Pediatric Nutrition Care Manual.pdf

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Welcome to the Pediatric Nutrition Care Manual ®
Pediatric Nutrition Practice Group
Academy of Nutrition and Dietetics
Content Release Date: May 7, 2012
The ADA Nutrition Care Manual ® (NCM) is a publication of the American Dietetic
Association.
Our goal is yours - Professional Excellence
Why go anywhere else?
For questions about materials to be included, or participating in future updates as a
contributor and/or reviewer, please contact the editor at [email protected].
The client education handouts in the ADA Pediatric Nutrition Care Manual ® are not
intended to substitute for nutrition counseling with a registered dietitian. The information is
meant to serve as a general guideline, and may not meet the unique nutritional needs of
individual patients. All medical professionals should consult with a registered dietitian
before providing handouts to clients or patients.
With the exception of adding patient-specific recommendations in the Notes section
clearly marked in the client education handouts, no part of the handouts may be
modified without prior written consent of the publisher.
Normal Nutrition 12
Normal Nutrition 12
Breastfeeding & Lactation Support 13
......Overview 14
......Criteria to Assign Risk 17
......Nutrition Assessment 18
......Feeding Recommendations 26
......Donor Milk 27
......Expression, Handling, and Storage of Human Milk 28
......Issues to Consider 31
Full-Term Infants 35
......Overview 36
......Nutrition Assessment 37
......Normal Laboratory Values 45
......Feeding Recommendations 46
......Fluid Needs or Limits 59
......Issues to Consider 60
Toddlers 67
......Overview 68
......Nutrition Assessment 69
......Normal Laboratory Values 71
......Feeding Recommendations 72
......Fluid Needs or Limits 75
......Issues to Consider 76
Preschool Children 77
......Overview 78
......Nutrition Assessment 79
......Normal Laboratory Values 80
......Feeding Recommendations 81
......Fluid Needs or Limits 84
......Issues to Consider 85
School-Age Children 87
......Overview 88
......Nutrition Assessment 89
......Normal Laboratory Values 92
......Issues to Consider 93
......Fluid Needs or Limits 96
......Feeding Recommendations 97
Adolescents 100
......Overview 101
......Nutrition Assessment 105
......Normal Laboratory Values 107
......Nutrient Recommendations 110
......Fluid Needs or Limits 114
......Issues to Consider 115
Child Athletes 121
......Overview 122
......Nutrition Assessment 123
......Normal Laboratory Values 128
......Nutrient Recommendations 129
......Fluid Needs or Limits 136
......Issues to Consider 139
Vegetarian Children 144
......Overview 145
......Nutrition Assessment 147
......Normal Laboratory Values 148
......Nutrient Recommendations 149
......Fluid Needs or Limits 153
......Issues to Consider 154
Preterm Infants 157
Preterm Infants 157
Condition Overview 158
Risk Screen 166
Nutrition Care 169
...Nutrition Assessment 170
......Anthropometrics 171
......Biochemical Data, Medical Tests and Procedures 175
......Comparative Standards 179
......Intake Assessment 180
......Nutrition-Focused Physical Findings 181
...Nutrition Diagnosis 186
...Nutrition Intervention 193
...Nutrition Monitoring & Evaluation 212
Parenteral Nutrition 214
Enteral Nutrition 234
Human Milk 257
Discharge/Follow-up 259
...Nephrotic Syndrome 272
Risk Screen 273
Risk Screen 273
......Comparative Standards 274
......Intake Assessment 275
......Nutrition-Focused Physical Findings 276
...Nutrition Monitoring & Evaluation 277
Anemia 279
...Iron Deficiency Anemia 280
...Sickle Cell Disease 284
Behavioral Health 287
...Eating Disorders 288
...Mood Disorders 299
Burns 301
Cardiology 304
...Congenital Heart Disease 305
Cleft Lip and Palate 307
Critical Care 308
Developmental Disabilities 310
Diabetes Mellitus 311
Disorders of Lipid Metabolism 313
Epilepsy 319
...Dietary Management 320
Failure to Thrive 322
Food Allergic Disorders 324
...Eosinophilic Esophagitis 325
...General Guidance 327
Gastrointestinal Diseases 328
...Celiac Disease 329
...Inflammatory Bowel Disease 331
...Diarrhea 332
...Gastroesophageal Reflux 333
...Irritable Bowel Syndrome 334
...Short Bowel Syndrome 336
Hepatic Diseases 337
HIV/AIDS 338
Inborn Errors of Metabolism 340
Oncology 341
Pulmonary Diseases 345
...Asthma 346
...Bronchopulmonary Dysplasia 347
...Cystic Fibrosis 348
...Ventilator Issues 350
Renal Diseases 351
...Chronic Kidney Disease 352
...Nephrotic Syndrome 353
Transplantation 354
...Organ Transplant 355
......Cardiac Transplant 356
......Kidney Transplant 359
......Liver Transplant 360
...Hematopoietic Stem Cell Transplant 363
Weight Management 367
...Overweight/Obesity 368
...Underweight 370
Conditions 372
Diseases/Conditions 372
......Comparative Standards 373
......Intake Assessment 374
......Nutrition-Focused Physical Findings 375
...Nutrition Monitoring & Evaluation 376
Anemia 378
...Iron Deficiency Anemia 379
...Sickle Cell Disease 384
Behavioral Health 390
...Eating Disorders 391
...Mood Disorders 398
Burns 401
Cardiology 407
...Congenital Heart Disease 408
...Extracorporeal Membrane Oxygenation (ECMO) 415
Cleft Lip and Palate 416
Critical Care 419
Developmental Disabilities 420
...Autism Spectrum Disorders 421
...Cerebral Palsy 424
...Down Syndrome 427
...Spina Bifida 429
...Prader-Willi Syndrome 431
Diabetes Mellitus 433
...Type 1 434
...Type 2 440
Disorders of Lipid Metabolism 444
Epilepsy 450
...Pharmacologic Management 451
...Dietary Management 455
......Classic Ketogenic Diet 456
......MCT Oil Ketogenic Diet 457
Failure to Thrive 458
Food Allergic Disorders 463
...Eosinophilic Esophagitis 464
...General Guidance 467
Gastrointestinal Diseases 471
...Celiac Disease 472
...Constipation 476
...Inflammatory Bowel Disease 478
...Diarrhea 481
...Gastroesophageal Reflux 483
...Irritable Bowel Syndrome 485
...Short Bowel Syndrome 488
Hepatic Diseases 490
HIV/AIDS 493
Inborn Errors of Metabolism 497
...General Guidance 498
...Phenylketonuria/PKU 504
Oncology 506
Pulmonary Diseases 508
...Asthma 509
...Bronchopulmonary Dysplasia 511
...Cystic Fibrosis 512
...Ventilator Issues 515
Renal Diseases 516
...Chronic Kidney Disease 517
...Nephrotic Syndrome 520
Transplantation 522
...Organ Transplant 523
......Cardiac Transplant 524
......Kidney Transplant 527
......Liver Transplant 532
...Hematopoietic Stem Cell Transplant 534
......Complications of HSCT 535
......General Information 538
Weight Management 544
...Overweight/Obesity 545
...Underweight 549
Nutrition Care 552
Nutrition Care 552
......Comparative Standards 553
......Intake Assessment 554
......Nutrition-Focused Physical Findings 555
...Nutrition Monitoring & Evaluation 556
Anemia 558
...Iron Deficiency Anemia 559
...Sickle Cell Disease 572
Behavioral Health 579
...Eating Disorders 580
...Mood Disorders 611
Burns 618
Cardiology 647
...Congenital Heart Disease 648
...Extracorporeal Membrane Oxygenation (ECMO) 661
...Prevention of Adult Cardiovascular Disease 663
Cleft Lip and Palate 665
Critical Care 673
Developmental Disabilities 695
...Autism Spectrum Disorders 698
...Cerebral Palsy 708
...Down Syndrome 723
...Spina Bifida 735
...Prader-Willi Syndrome 747
Diabetes Mellitus 757
...Carbohydrates and Other Nutrients 758
...Type 1 767
...Type 2 791
Disorders of Lipid Metabolism 809
Epilepsy 830
...Pharmacologic Management 831
...Dietary Management 842
......Classic Ketogenic Diet 843
......MCT Oil Ketogenic Diet 848
Failure to Thrive 855
Food Allergic Disorders 871
...Eosinophilic Esophagitis 872
...General Guidance 882
Gastrointestinal Diseases 901
...Celiac Disease 902
...Constipation 916
...Inflammatory Bowel Disease 923
...Diarrhea 933
...Gastroesophageal Reflux 943
...Irritable Bowel Syndrome 950
...Short Bowel Syndrome 957
Hepatic Diseases 966
HIV/AIDS 976
Inborn Errors of Metabolism 989
...General Guidance 990
...Phenylketonuria/PKU 998
Oncology 1005
...General Guidance 1006
...Medications for GI Problems 1037
...Survivorship 1047
...Treatment Modalities 1052
Pulmonary Diseases 1062
...Asthma 1063
...Bronchopulmonary Dysplasia 1068
...Cystic Fibrosis 1074
...Ventilator Issues 1087
Renal Diseases 1092
...Chronic Kidney Disease 1093
...Nephrotic Syndrome 1114
Transplantation 1120
...Organ Transplant 1121
......Cardiac Transplant 1126
......Kidney Transplant 1141
......Liver Transplant 1149
...Hematopoietic Stem Cell Transplant 1163
Weight Management 1188
...Overweight/Obesity 1189
...Underweight 1202
References 1214
References 1214
Modified Consistency Meal Plans 1215
......Comparative Standards 1217
......Intake Assessment 1218
......Nutrition-Focused Physical Findings 1219
...Nutrition Monitoring & Evaluation 1220
Normal Nutrition 1222
...Breastfeeding & Lactation Support 1223
...Full-Term Infants 1231
...Toddlers 1250
...Preschool Children 1252
...School-Age Children 1254
...Adolescents 1257
...Child Athletes 1263
...Vegetarian Children 1266
Anemia 1271
Behavioral Health 1282
...Eating Disorders 1283
...Mood Disorders 1287
Burns 1290
Cardiology 1298
Cleft Lip and Palate 1305
Critical Care 1308
Developmental Disabilities 1312
...Autism Spectrum Disorders 1314
...Cerebral Palsy 1317
...Down Syndrome 1321
...Spina Bifida 1324
...Prader-Willi Syndrome 1327
Diabetes Mellitus 1329
Disorders of Lipid Metabolism 1337
Epilepsy 1343
Failure to Thrive 1354
Food Allergic Disorders 1362
...Eosinophilic Esophagitis 1363
...General Guidance 1365
Gastrointestinal Diseases 1373
...Celiac Disease 1374
...Constipation 1380
...Inflammatory Bowel Disease 1383
...Diarrhea 1384
...Gastroesophageal Reflux 1387
...Irritable Bowel Syndrome 1389
...Short Bowel Syndrome 1391
Hepatic Diseases 1393
HIV/AIDS 1397
Inborn Errors of Metabolism 1403
Oncology 1407
Preterm Infants 1419
Pulmonary Diseases 1438
...Asthma 1439
...Bronchopulmonary Dysplasia 1440
...Cystic Fibrosis 1441
...Ventilator Issues 1445
Renal Diseases 1446
...Nephrotic Syndrome 1449
Transplantation 1450
...Organ Transplant 1451
......Cardiac Transplant 1453
......Kidney Transplant 1455
......Liver Transplant 1457
...Hematopoietic Stem Cell Transplant 1461
Weight Management 1470
...Overweight/Obesity 1471
...Underweight 1478
Nutrition Support 1481
Meal Plans 1498
Meal Plans 1498
Modified Consistency Meal Plans 1503
...General Guidance 1504
...Liquid Diet 1505
...Blenderized Diet 1510
...Pureed Diet 1515
...Mechanical Soft Diet 1521
......Comparative Standards 1527
......Intake Assessment 1528
......Nutrition-Focused Physical Findings 1529
...Nutrition Monitoring & Evaluation 1530
Normal Nutrition 1532
...Breastfeeding & Lactation Support 1533
...Full-Term Infants 1538
...Toddlers 1544
...Preschool Children 1549
...School-Age Children 1554
...Adolescents 1558
...Child Athletes 1561
...Vegetarian Children 1564
Anemia 1574
...Iron Deficiency Anemia 1575
...Sickle Cell Disease 1579
Behavioral Health 1582
...Eating Disorders 1583
...Mood Disorders 1585
Burns 1586
Cardiology 1588
Cleft Lip and Palate 1595
Developmental Disabilities 1597
...Autism Spectrum Disorders 1598
...Down Syndrome 1601
...Spina Bifida 1604
...Prader-Willi Syndrome 1607
Diabetes Mellitus 1610
Disorders of Lipid Metabolism 1615
Epilepsy 1633
...Dietary Management 1634
......Classic Ketogenic Diet 1635
......MCT Oil Ketogenic Diet 1640
Failure to Thrive 1646
Food Allergic Disorders 1650
...Eosinophilic Esophagitis 1651
...General Guidance 1660
Gastrointestinal Diseases 1694
...Celiac Disease 1695
...Constipation 1700
...Inflammatory Bowel Disease 1703
...Diarrhea 1709
...Gastroesophageal Reflux 1714
...Irritable Bowel Syndrome 1718
...Short Bowel Syndrome 1725
Hepatic Diseases 1729
HIV/AIDS 1733
Inborn Errors of Metabolism 1736
Oncology 1739
Preterm Infants 1750
Pulmonary Diseases 1751
...Asthma 1752
...Bronchopulmonary Dysplasia 1755
...Cystic Fibrosis 1756
...Ventilator Issues 1761
Renal Diseases 1762
...Chronic Kidney Disease 1763
...Nephrotic Syndrome 1773
Transplantation 1777
Weight Management 1798
...Overweight/Obesity 1799
...Underweight 1805
Resources 1808
Resources 1808
Contributors 1810
......Authors 1811
......Reviewers 1820
Nutrition Care Process (NCP) 1828
Nutrition Support 1837
......Pediatric Enteral Nutrition Support 1838
............Adult and Specialized Formulas for Use in Pediatrics 1848
............Infant Formulas 1853
............Pediatric Formulas 1864
............General Guidance 1868
......Pediatric Parenteral Nutrition Support 1895
Spanish Language Resources 1924
Arm Anthropometry 1927
Common Nutrient-Drug Interactions 1928
......Anti-inflammatory 1930
......Anticoagulant 1932
......Bisphosphonate 1934
......CYP450 1936
......MAOI 1938
......Non-Potassium-Sparing Diuretic 1940
......Potassium-Sparing Diuretic 1943
......Vitamin K 1945
Cultural Food Practices 1947
......African American 1948
......Asian Indian 1965
......Caribbean 1992
............Trinidad and Tobago 1993
......Chinese 2013
......Ecuador 2038
......Filipino 2053
......Hispanic 2066
......Jewish 2113
......Korean 2125
......Mormon 2143
......Muslim 2146
......Native American 2155
............Apache & Navajo 2156
............Alaska Native 2164
............Hopi 2173
............Ojibwe 2178
............Pima 2184
............Sioux 2189
............Tohono O'odham 2195
Dietary Guidelines for Americans, 2010 2200
Dietary Reference Intakes 2203
Fluoride Supplementation 2204
Growth Charts 2206
Malnutrition 2217
MyPlate Food Guidance System 2229
Physical Signs of Malnutrition 2231
Preterm Infants Terminology and Abbreviations 2238
Specialty Food Manufacturers 2241
Normal Nutrition
Welcome to the Normal Nutrition area of the Pediatric Nutrition Care Manual.
Information here deals with nutrition recommendations and related issues for the full
spectrum of pediatric life stages, plus specific recommendations for children with an
athletic or vegetarian lifestyle.
This content is appropriate for healthy children, so if your clients present with a specific
disease or condition, please refer to that topic under the Nutrition Care tab.
For more information, click on a topic in the left-hand navigation.
Normal Nutrition > Breastfeeding & Lactation Support
Breastfeeding & Lactation Support


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Overview
Composition of Human Milk

Human milk contains unique components to protect the infant from infection (Spatz, 2011).
These include immune cells, immunoglobulins, long-chain polyunsaturated fatty acids,
cytokines, oligosaccharides, nucleotides, hormones, bioactive peptides, glycans, and
lactoferrin.
Human milk composition varies among mothers and is constantly changing depending on
the time of day, the mother's diet, the stage of lactation, gestational age and whether it is
the beginning or end of the feeding.
Energy distribution in human milk is approximately 50% fat, 40% to 45% carbohydrate, and
6% protein.
Types of fat in the milk are determined by maternal diet and fat stores. Long-chain fatty
acids (docosahexaenoic acid and arachidonic acid) are important for brain and retinal
development and will be present in human milk in proportion to maternal intake. Fat content
of human milk increases during a feeding, so it is important for the breast to be emptied at
each feeding. Human milk contains cholesterol that is not present in infant formula. This
exposure may be significant for early programming and reduction of cholesterol synthesis
later in life (Horta, 2007).
The primary carbohydrate is lactose. Lactose is produced in the mammary gland
and enhances mineral absorption. It is not influenced by maternal diet.
Protein in human milk is low compared with that in other mammalian species, as human
growth occurs at a slower rate than growth in other mammals. Protein in human milk is
easier to digest and more efficiently utilized than protein in formula. In human milk, 25% of
the nitrogen is non-protein nitrogen compared with 5% in bovine milk (Lawrence, 2011).
Human milk contains the enzymes amylase, protease, and lipase to help digest
carbohydrate, protein, and fat in the milk.
Vitamins and minerals in human milk are highly bioavailable and change during the course
of lactation. Some are influenced by maternal diet whereas others are not. Maternal
supplementation with vitamin A (Lietz, 2001; Bahl, 2002), vitamin B-6 (Boylan, 2002),
vitamin B-12 (Deegan 2011), thiamin (Ortega 2004), riboflavin (Allen 2005), vitamin C
(Daneel-Otterbech, 2005), vitamin D (Wagner 2011), and iodine (Allen 2005) has been
shown to increase levels in human milk. Well-nourished mothers may have little or no
increase in levels of these nutrients in their milk, whereas women with low levels of
nutrients may benefit from dietary supplementation. Zinc (Ortega, 1997), copper (Chierici,
1999), iron (Hannan, 2009), and calcium (Ortega, 1998; Moser, 1988) in human milk do not
appear related to maternal serum levels or dietary intake.
Colostrum is the first milk produced. It is higher in protein and lower in fat and lactose than
mature milk and has high levels of IgA and other immune factors to protect the newborn
from infections. It is also higher in sodium, chloride, potassium, zinc, and vitamins A and E
than mature milk.
Human milk is 87% water. Nutrients are dispersed, suspended, or dissolved in water. In
general, infants need no other fluid other than breast milk, even in hot weather.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Indications and Contraindications for Breastfeeding

There are few contraindications to breastfeeding. Breastfeeding is recommended by the
American Academy of Pediatrics for all infants, including sick and preterm infants, with rare
exceptions (AAP, 2005; ADA, 2009).
Contraindications:
Galactosemia (infant)
Maternal active untreated tuberculosis
Maternal human-T lymphotropic virus type I or II positive
Maternal human immunodeficiency virus
Mothers receiving diagnostic or therapeutic radioactive isotopes
Mothers receiving antimetabolites or chemotherapeutic agents
Mothers using drugs of abuse
Mothers with herpes simplex lesion on the breast, near or on the nipple
A risk-benefit analysis should be utilized whenever maternal medications are considered.
Reducing infant exposure to maternal medications is desirable. Consideration should be
given to nondrug therapies or postponement of drug treatment when feasible. When drug
treatment is chosen, the following information should be collected:
Published/known information regarding absolute and/or relative infant dose using
appropriate resources such as Medication and Mother's Milk or LactMed
Toxicity of medication
Maternal dose
Duration of therapy
Infant's post-conceptual age
Any infant condition compromising drug clearance
Amount of human milk consumed daily
The physician and mother should work together to choose the best option for the mother
and infant so the mother can safely continue to breastfeed.
Medications that may reduce milk production include the following:
Estrogen
Progestin
Ethanol
Bromocriptine
Ergotamine
Cabergoline
Pseudoephedrine
Testosterone
Antiestrogen
Clomiphene
The following conditions are not contraindicated for breastfeeding:
Mothers who are hepatitis B surface antigen positive
Mothers infected with hepatitis C
Mothers who are febrile
Mothers exposed to low level environmental chemical agents
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mothers who are sero-positive carriers of cytomegalovirus
Mothers who use tobacco
Mothers who drink alcohol
Infants with jaundice
Mothers are advised to avoid smoking tobacco in the home and when in the same room as
the infant and make every effort to stop smoking. Alcohol concentrates in human milk and
consumption can inhibit milk production. Contrary to popular belief, drinking beer will not
increase milk supply (Mennella, 2005; Mennella, 1995). Mothers are advised to wait 2 to 3
hours before breastfeeding after drinking each unit of alcohol (12 oz beer, 6 oz wine, 1.5 oz
liquor) (Hale, 2010; AAP, 2006; Ho, 2001).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Criteria to Assign Risk
Criteria to Assign Risk

Late Preterm
Infants born between 34 and 37 weeks' gestation may have feeding difficulties resulting in increased risk of morbidity
and mortality. Sleepiness and weak, uncoordinated suck may lead to difficulties breastfeeding. Mothers may need extra
support and guidance to prevent dehydration, hypoglycemia, hyperbilirubinemia, and failure to thrive in the late preterm
infant (ABM, 2011).
Slow Weight Gain vs Failure to Thrive (Lawrence, 2011)
Slow to Gain Weight Failure to Thrive
Alert; healthy appearance Apathetic or crying
Good muscle tone Poor tone
Good skin turgor Poor skin turgor
At least 6 wet diapers per day
Few wet diapers (<1 wet diaper /day of life if less than 6 days old; <6 wet
diapers thereafter)
Pale, dilute urine Strong, dark urine
Frequent soft, seedy stool Infrequent, scanty stools (<3 per day after day 5)
8 or more feedings lasting 15-20
minutes
<8 feedings, often brief
Well-established milk ejection reflex No signs of functioning milk ejection reflex
Weight gain consistent but slow Weight erratic or weight loss
When evaluating the infant for failure to thrive, look for the following:
Poor intake (poor suck, infrequent feeds, structural abnormality)
Low net intake (vomiting and diarrhea, malabsorption, infection)
High energy requirement (neurologic disorders, congestive heart failure)
Low output (<1 wet diaper/day of life if less than 6 days old; <6 wet diapers and 3 soiled thereafter)
When evaluating the mother for failure to thrive, look for the following:
Poor production (anatomic, hormonal, nutritional, pharmacologic, stress, illness, fatigue)
Poor let-down (psychologic, pain, hormonal, pharmacologic, smoking)
Hyperbilirubinemia (ABM, 2010; AAP, 2005)
Physiologic jaundice is common in infants in the first week of life. Bilirubin levels normally peak on DOL5. Breastfed
infants may continue to have elevated unconjugated bilirubin levels into the second and third week of life. Starvation
jaundice, resulting from poor intake, increases intestinal bilirubin absorption in the breastfed infant. Recommendations
to minimize hyperbilirubinemia include the following:
Initiating breastfeeding early, in the first hour of life
Breastfeeding every 2 to 3 hours
Waking infant if still sleeping 3 hours from start of previous feed
Exclusive breastfeeding with supplements of expressed breast milk, pasteurized donor human milk, or formula
only when medically necessary
Optimal breastfeeding management
Educating mothers on early feeding cues
Identifying at-risk mothers and infants

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Nutrition Assessment
Assessment of the Breastfed Infant

Nutrition assessment of the breastfed infant includes birth history, anthropometric
measurements, physical findings, diet history, and breastfeeding assessment.
Birth History
Gestational age
Birth events
Medical history
Anthropometric Measurements
Birthweight
Current weight
Weight change
Physical Findings
Feeding tolerance
Emesis
Diarrhea
Colic
Irritability
Satiety
Sleep behaviors
Diet History
Timing of first feeding after birth
Breastfeeding attempts and success
Frequency of daytime and nighttime feedings
Average length of feeding
How feeding ends (eg, baby falls asleep, mother removes baby, baby releases nipple)
Formula supplementation
Bottles offered and volume consumed
Nasogastric supplements
Alternative feeding methods
Oral-motor skills/suck assessment
Assessment of oral intake
Urine and stool output
Number of feedings per day
Complementary food intake
Food allergies or intolerances
Feeding skills/age appropriate eating behaviors and patterns
Breastfeeding Assessment
Infant state and readiness to feed
Positioning
Latch
Audible swallows
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutritive suck and swallow
Milk transfer using before and after weights where applicable
Infant Risk Factors for Lactation Problems
Low birthweight or <38 weeks gestation
Multiples
Difficulty latching
Ineffective or unsustained suckling
Oral anatomic abnormalities (cleft lip/palate, micrognathia, macroglossia, tight
frenulum)
Medical problem (jaundice, hypogylcemia, respiratory distress, infection)
Neurologic problem (genetic syndrome, hypotonia, hypertonia)
Persistently sleepy baby
Mother-baby separation
Formula supplementation
Early pacifier use
(Lawrence, 2011)

Assessment of the Lactating Mother

Assessment of the lactating mother includes medical and reproductive history, maternal
diet, birth events, maternal medication, and psychosocial history.
Assess medical and reproductive history of the mother for the following:
Gravida and parity
Age
Health status
Hormonal disorders
Previous breast surgery
Previous breastfeeding experience
Pregnancy weight gain
Breast changes during pregnancy/post-delivery
Assess the mother's diet for the following:
Appetite
Number of meals and snacks per day
Alcohol
Caffeine
Dairy
Dietary restrictions
Assess birth events for the following:
Type of birth
Length of labor
Complications/interventions
Assess maternal medications for the following:
Prescription or over-the-counter medications, including birth control
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Herbals
Vitamin/mineral supplements
Assess psychosocial status of the mother for the following:
Maternal support system
Plans for employment
Breastfeeding goals
Maternal risk factors for lactation difficulties include the following:
Primiparity
Early intention to formula feed or both breastfeed and bottlefeed
Early intention to use pacifiers
Early intention to return to work
Previous history of breastfeeding problems or infant with slow weight gain
History of infertility or significant health problems including obesity, depression,
diabetes, untreated hypothyroidism
Lack of support
Perinatal complications including hemorrhage, hypertension, infection
Intended use of hormonal contraceptives before lactation is well established
Maternal medication use
Lack of breast enlargement during pregnancy
History of breast reduction or augmentation
Flat or inverted nipples
Marked breast asymmetry or hypoplastic or tubular breasts
Discharge from hospital using a nipple shield
(Lawrence, 2011)

Growth Assessment

Infant growth is best assessed using the World Health Organization (WHO) Child Growth
Standards. These standards show how every child in the world should grow when free of
disease and when their mothers follow healthy practices such as breastfeeding and not
smoking. These growth charts are unique in that they describe how a child should grow
rather than provide a reference that merely describes how infants grew at a particular point
in time. Deviations of the standards are evidence of abnormal growth.
In September 2010, the Centers for Disease Control and Prevention (CDC) recommended
that health care providers use the WHO growth standards to monitor growth for children
from birth to 24 months. In the WHO sample, all participants were predominantly breastfed
for at least 4 months and were still breastfeeding at 12 months (Grummer-Strawn, 2010),
compared with the CDC sample used for the 2000 National Center for Health Statistics
growth charts, where approximately 50% were ever breastfed and 33% were breastfeeding
at 3 months.
Healthy breastfed infants typically gain weight faster than formula-fed infants in the first few
months of life, then gain weight more slowly during the remainder of infancy. WHO growth
curves show a faster rate of weight gain in the first few months than those in the CDC
charts. Use of the WHO growth charts might lead to misperception of poor growth in the
formula-fed baby in the first few months. Beginning at age 3 months, the WHO growth
curves show slower rate of weight gain than the CDC charts in both weight for age and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
curves show slower rate of weight gain than the CDC charts in both weight for age and
weight for length. Infants continuing to breastfeed through 12 months are more likely to
maintain percentiles on the WHO chart while showing a downward trend when plotted on
the CDC chart.
Additional information and charts for length, weight, head circumference, arm
circumference, skinfolds, developmental milestones, and growth velocity can be found at
the following links:
http://www.who.int/childgrowth/standards/en/
http://www.cdc.gov/growthcharts/who_charts.htm
Also refer to Growth Assessment in the Full-Term Infants section for more information.

Nutrient Needs for the Infant

The World Health Organization and the American Academy of Pediatrics recommend
exclusive breastfeeding for 6 months followed by the introduction of complementary foods
and continued breastfeeding from 6 months until at least 1 year of age (WHO, 2006). No
other foods or liquids are necessary to meet the nutrition needs of the growing infant during
the period of exclusive breastfeeding. With the exception of vitamin D for all infants and
iron for preterm infants, no vitamin or mineral supplements are needed (AAP,
2005). Vitamin deficiencies are rare in exclusively breastfed infants but when maternal diet
is deficient, infants may have low intakes of vitamins A, B-6, and B-12 and
riboflavin. Improving the maternal diet or prescribing supplements to mothers is advised
(PAHO, 2003).
Human milk contains adequate fluoride when the mother drinks fluoridated water or
consumes adequate supplements. Infants older than 6 months may need fluoride
supplements if they are at high risk for developing dental caries and water is not
fluoridated. Supplementation with 0.25 mg/day fluoride in areas where community water is
<0.3 ppm is recommended. Assessing fluoride in local water is recommended to prevent
fluorosis (Rozier, 2010; CDC 2001).
The Dietary Reference Intakes (DRI) for infants are available on the US Department of
Agriculture's Dietary Guidance page. Recommended intakes for infants during the first 6
months are based on intakes of exclusively breastfed infants. For infants aged 6 to 12
months, recommended intakes are based on an average intake of 600 mL breast milk and
usual intake of age-appropriate complementary foods.

The equations for calculating the estimated energy requirement (EER) for infants are as
follows:
0-3 months: EER = (89 X weight [kg] – 100) + 175
4-6 months: EER = (89 X weight [kg] – 100) + 56
7-12 months: EER = (89 X weight [kg] – 100) + 22

The DRIs for protein are as follows:
0-6 months Average Intake (AI) = 1.52 g/kg
7-12 months
Estimated AI: 1.0 g/kg
Recommended Dietary Allowance (RDA): 1.0 g/kg

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(IOM, 2006)

Complementary feeding is the process of introducing liquids and foods other than breast
milk into the infant's diet to meet nutrition needs when breast milk alone is no longer
sufficient to do so. Infants may be at risk for nutritional deficiency during the period of
transition when complementary feeding begins (Pan American Health Organization). As
long as nutrient needs are met, there is no evidence that the order of introduction of
complementary foods is critical (Butte, 2004).
Developmental readiness for introduction of complementary foods varies among
infants. Infants learn to accept different textures when they are introduced gradually,
starting with smooth purees and advancing to lumpier textures and then to coarsely
chopped foods and bite-size pieces.
Children often eat small, frequent meals and snacks throughout the day. Portion sizes will
vary based on hunger and satiety. Parents should respond to the child's appetite cues and
developmental skills.
Complementary Feeding Guidelines
For age 6 to 8 months: eat 2-3 meals per day
For age 9 to 24 months: eat 3 meals and 1 to 2 nutritious snacks per day
Meat, poultry, fish, or eggs should be eaten daily
Vitamin A–rich fruits and/or vegetables should be eaten daily
Adequate fat to provide essential fatty acids facilitate absorption of fat-soluble
vitamins and provide energy
Adequate intake for infants younger than 1 year is 30 g/day based on intake of
healthy, breastfed infants
For children aged 1 to 3 years, fat should provide 30% to 40% of daily energy
(IOM, 2006)
Because of rapid growth in the first year of life, iron needs are relatively high. Infants
deplete birth iron stores during the first 4 to 6 months of life. Iron in human milk significantly
decreases over the first 6 months and will ultimately no longer meet iron requirements
(Rao, 2007; Domellof, 2002; Ziegler, 2009; Yang, 2009). Foods rich in iron should be
added to the child's diet. As 80% of iron stores are deposited during the third trimester,
preterm infants are at greatest risk for iron deficiency and should receive 2 mg/kg/day of
supplemental oral iron starting at 1 month and continuing through 12 months (Dee, 2008).
Maternal diabetes, hypertension, or anemia can result in decreased fetal stores and earlier
exhaustion of iron stores. See Nutrient Needs of Full-Term Infants.
Introduction of meat as an early complementary food is recommended (Krebs,
2006). Heme iron from meat, poultry, and fish is well absorbed and a good complement to
the low iron content in breast milk. Non-heme iron is present in all foods, including meat,
and absorption is enhanced with vitamin C and inhibited by phytates in legumes, unrefined
rice, and grains.
Along with iron deficiency, there is limited evidence indicating that breastfed infants may
become zinc deficient during the period of complementary feeding. In one study, 36% of
breastfed infants had mild to moderate zinc deficiency at 9 months (Krebs, 2006). Human
milk provides adequate zinc for the first 6 months but levels decline after 6 months and are
no longer sufficient to meet requirements (Krebs, 2006). Meat is an excellent source of zinc
for the breastfed infant. Other sources include whole grains, some shellfish, and some
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
fortified cereals. There is greater bioavailability of zinc in human milk than cow's milk.


Nutrient Needs for the Mother

Lactating women should continue to eat a well-balanced diet that includes a variety of
foods. Maternal nutritional status prior to and during pregnancy will influence nutrient
requirements during lactation. A well-nourished mother will have nutrient stores to draw
upon during lactation.
Breastfeeding mothers can safely consume foods that they enjoy without concern for effect
on the infant. Breastfeeding mothers should not restrict foods—including vegetables, spicy
foods, dairy products, or citrus—to prevent effects of these foods on their infants, as there
is no consistent scientific evidence to support this concern.
Caffeine and alcohol pass into human milk and may affect the baby. The level of caffeine
in human milk is low (1% of the level in the mother's blood) but caffeine can accumulate in
the infant leading to a wakeful, hyperactive infant (Lawrence, 2011). The effect of caffeine
via breast milk on the infant will decrease over time. The half-life of caffeine in a neonate is
97.5 hours; at age 3 to 5 months, it is 14 hours; and after age 6 months, it is 2.6
hours. Caffeine peaks in human milk 1 to 2 hours after maternal ingestion (Hale, 2010).
Refer to Indications and Contraindications for additional information on alcohol
consumption.
Energy
Energy needs increase during lactation due to the energy cost of milk production. Women
who exclusively breastfeed will gradually lose the weight they gained in pregnancy without
any additional energy expenditure. Prenatal weight gain includes deposition of fat stores,
which are drawn upon during lactation to provide some of the energy needed for milk
production. The costs of milk production in the first 6 months are estimated at 625 kcal per
day. Approximately 170 kcal may be drawn from body stores; therefore, 455 kcal per day
may be needed from maternal dietary intake. This amount will vary depending on the
actual volume of milk produced. As complementary foods are introduced, infant milk
consumption decreases, lowering maternal energy requirements (Hale, 2007; Butte, 2005).
Protein (IOM, 2006)
Protein needs are increased by 30% during the first 6 months of lactation and 25% after 6
months. Mothers are advised to consume 1.3 g/kg/day protein (compared to 0.8 g/kg/day
protein for nonlactating women).
Vitamins
Maternal requirements for vitamins is increased during lactation to compensate for milk
losses and to maintain maternal stores (IOM, 2006). The vitamin content in milk of
well-nourished mothers is only minimally influenced by maternal dietary intake. In
deficiency states, vitamin content in milk will readily increase with maternal
supplementation (Hale, 2007).
Women who follow a vegan diet may be at risk for vitamin B-12 deficiency. Cases of
neurologic impairment due to vitamin B-12 deficiency have been reported in breastfed
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
infants. Mothers may be asymptomatic, yet infants may show progressive lethargy,
hypotonia, loss of skills, and failure to thrive after just 4 months. Irreversible damage may
result from prolonged deficiency although most infants rapidly improve with vitamin B-12
supplementation (CDC, 2003).
Minerals
Most minerals in human milk are stable and not affected by maternal stores or
maternal diet. Selenium, iodine, and magnesium in human milk varies based on maternal
intake (Hale, 2007). There are no recommendations for increased maternal mineral intake
during lactation other than 150 mcg iodine (Picciano, 2009). Bone mineral density has not
been found to decrease during lactation and calcium supplementation above normal
requirements is not recommended (Paton, 2003).
Docosahexaenoic Acid (DHA)
DHA is an omega-3 long-chain fatty acid present throughout the central nervous system
and retina and is thought to be conditionally essential for the developing infant. Levels in
human milk are influenced by maternal dietary intake. Fatty fish is an excellent source of
DHA and populations with the highest fish intake have milk with the highest levels of DHA.
Recommendations vary from 200 mg/day to 500 mg/day DHA during lactation (Carlson,
2009). Lactating women should avoid eating shark, tilefish, king mackerel, and
swordfish because these fish have high mercury levels.
Vitamin D
Levels in human milk reflect maternal vitamin D status and can be improved with maternal
supplementation. A pilot study demonstrated that maternal supplementation of 6,400
IU/day vitamin D-3 was safe and effective in increasing infant vitamin D status to
recommended levels (Wagner, 2006). Further testing on a large cohort is needed to
determine safety. The Recommended Dietary Allowance for vitamin D was increased by
the Institute of Medicine in 2010 from 400 IU/day to 600 IU/day for adults. The increased
recommendation means that vitamin D in human milk is not considered sufficient, and the
infant will require 400 IU vitamin D supplementation daily (Wagner, 2011).
Fluid
Increasing fluid intake will not increase milk volume, and decreasing fluid intake does not
decrease milk production. Forcing fluid intake beyond normal thirst results in decreased
milk production (Dusdieker, 1985; IOM, 1991). Lactating mothers have increased thirst and
should drink to satisfy thirst. A prescribed fluid intake is not necessary (Lawrence, 2011).


Assessment of Adequate Breastmilk Provision

Assessment of the breastfed infant reflects the adequacy of milk intake. Milk intake is
determined by maternal milk production and the infant's ability to transfer milk from the
breast. It is important that the baby is well attached and positioned correctly in order to
receive milk available in the breast and not cause pain to mother's nipples. Poor drainage
of milk in the breast may result in insufficient weight gain, maternal engorgement or
plugged ducts, increased risk of mastitis, and decreased milk production. Early correction
of latching difficulties will improve outcomes (Lawrence, 2011; USDHHS, 2011). Examples
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
of different breastfeeding positions are illustrated at this link.
In the first few days of life, milk volume is low, yet adequate to meet infant needs at the
time. Infants receive small amounts of nutrient-rich colostrum. Urine output and stool will
increase as milk volume increases. There should be one wet diaper per day of life through
day 5 and at least six urinations per day by day 6. Adequate intake is indicated by yellow
bowel movements by day 5 and three to four stools per day by day 6.
According to the American Academy of Pediatrics and the Academy of Breastfeeding
Medicine, infants should be seen by a health care professional and weighed within 48 to 72
hours of discharge (by 3 to 5 days of age). Weight loss of more than 7% of birthweight may
indicate difficulties with breastfeeding and referrals should be made for assistance with
breastfeeding. Infants should regain birthweight by 14 days of age (AAP, 2005; ABM,
2007).
Frequent weight checks may be necessary until the infant demonstrates adequate weight
gain. Thereafter, weight should be monitored regularly and plotted on the World Health
Organization (WHO) growth standards. Refer to the Growth Assessment section.
Adequate breast milk intake will be reflected in appropriate growth. Measurements of
weight, height, and head circumference should be carefully measured and recorded on
the WHO growth chart. Growth velocity can be monitored on the WHO standards for
growth; the WHO velocity standards are available
at http://www.who.int/childgrowth/standards/w_velocity/en/index.html
Weight gain is more rapid in the first 3 months and decreases gradually throughout the first
year.
In the newborn period, infants are encouraged to eat frequently. Cue-based feeding is
recommended. Infants will need to feed 8 to 12 times per 24 hours in order to gain weight
as desired and allow the mother to sufficiently develop her milk supply. Waking a sleepy
baby every 2 to 3 hours may be necessary.
When breast milk intake appears to be inadequate, a thorough lactation evaluation by an
International Board-Certified Lactation Consultant (IBCLC) is recommended. This includes
breastfeeding observation, history of mother and baby, and measurement of pre- and
post-breastfeeding weights to evaluate milk transfer (Haase, 2009). Skilled assessment of
breastfeeding and recommendations for improvement when concerns arise should be done
prior to recommending use of non–breast milk supplements.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Feeding Recommendations
Feeding Recommendations

Breastfeeding is the most natural way to feed babies and is recommended for all infants
with few exceptions (AAP, 2005; Spatz, 2011; ADA, 2009). Infant cue–based, on-demand
feeding are suggested. Until lactation is well established and infants are demonstrating
adequate weight gain, infants should be fed every 2 to 3 hours and should receive 8 to 12
feedings in 24 hours. Thereafter, feeding frequency and length of feeds will depend on
maternal milk supply, maternal milk ejection reflex, and strength and effectiveness of infant
suck.
Exclusive breastfeeding is recommended for the first 6 months of life, followed by
continued breastfeeding with appropriate complementary foods beginning at 6 months
(WHO, 2003). Breastfeeding should continue for at least 1 year and as long as mutually
desired by mother and child.
Refer to Nutrient Needs for the Full-Term Infant for more detailed recommendations.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Donor Milk
Donor Milk

Human milk is preferred for all infants, including sick and premature infants. If a mother is
not able to provide her own milk for her infant, banked donor human milk should be
considered as the first alternative (WHO, 2003). Possible indications for use of donor
human milk include the following:
Prematurity
Allergies
Feeding intolerance
Immunological deficiencies
Postoperative nutrition
Parental preference
Maternal contraindications to breastfeeding
Donor human milk is available as term or preterm milk and is delivered frozen. Milk from
mothers of preterm infants is higher in sodium, protein, and antibodies for the first month
after delivery.
Donor human milk can be obtained from a milk bank that complies with the Human Milk
Banking Association of North America (HMBANA) guidelines. Contact information for
HMBANA milk banks is available on the HMBANA website. Although HMBANA milk banks
are not-for-profit organizations and mothers are not compensated for their milk, there is a
cost for the donor human milk to cover handling, processing, and shipping.
Donors are breastfeeding mothers of infants younger than 1 year who are in good
health and have surplus milk. These women are carefully screened for health behaviors
and have blood tests for human immunodeficiency virus, human T-cell leukemia virus type,
syphilis, and hepatitis B. Donors do not take regular medications (exceptions include some
oral contraceptives, insulin, synthroid, topical antibiotics, and topical steroids). Donors do
not take herbal supplements, do not drink alcohol, and do not smoke.
Milk from several donors is pooled together and then pasteurized by Holder pasteurization
to kill viruses and bacteria. It is then cultured for bacterial growth. Only milk with zero
bacterial growth is shipped to users. Pasteurization destroys B-cells, T-cells, and lipase
and reduces IgA. Other immune factors and nutrients are not affected.
A commercial milk bank, Prolacta, has developed technology to pasteurize and
concentrate human milk to create a human milk fortifier that increases the protein content
and energy density of human milk without use of bovine protein. The cost of this fortifier is
very high, and as a result, beyond the budget of many hospitals. The fortifier is
well-tolerated and may be beneficial to patients who do not tolerate standard bovine protein
human milk fortifiers (Sullivan, 2010).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Expression, Handling, and Storage
of Human Milk
Expression, Handling, and Storage of Human Milk

Proper handling and storage of human milk is vital to ensure the safety and quality of the
milk fed to vulnerable infants in the hospital setting. Whenever human milk is expressed,
there is potential for pathogen contamination, misadministration, and loss of nutrients that
could adversely affect health outcomes (Robbins, 2011; Gabrielski, 2011).
Mothers should be encouraged to express milk for their sick infants who are unable to
directly breastfeed.
Expression
To establish and maintain milk production, mothers should pump both breasts
simultaneously every 2 to 3 hours, using a hospital-grade electric breast pump and a
double expression kit.
Mothers should express milk at least 8 times in 24 hours, and continue each pumping
session until 2 minutes after flow ceases.
Milk expression should begin as soon as possible after birth.
To avoid contamination of milk, mothers should wash hands prior to pumping and use
clean pumping equipment and storage containers.
Each mother is given her own reusable sterile kit or clean, unopened kit with
instructions to sterilize prior to first use. The kit should be cleaned after each use with
soap and water and sterilized daily.
There is no need to wash breasts prior to pumping.
Milk can be expressed directly into appropriate size storage containers designed for
freezing human milk and closed with a tightly fitting lid. Milk should not be stored in
bottles with nipples attached.
Milk supply gradually increases over the first 1 to 2 weeks. Milk production may be 0
mL to 5 mL per pumping (30 mL to 35 mL per day) on day 1. By the end of the first
week, mothers should be producing 600 mL to 800 mL per day.
Nighttime pumping is important. Mothers should be encouraged to pump at least once
overnight and should not go more than 6 hours without pumping.
Mothers may choose to pump at the bedside, where they can see the infant as they
pump. This may reduce anxiety about having to leave the infant and help increase
milk production. Mothers may also choose to pump in a centrally located private
pumping room.
Storage Containers
Milk should be stored in hard plastic storage containers with lids (not with bottle
nipples).
Milk should be stored in approximate volumes used for each feeding.
Although convenient for home use, breast milk storage bags are not recommended
for use in the hospital setting because of the possibility of tearing, leaking, and
difficulty handling for milk preparation.
When filling containers, space should be left to allow for expansion of milk when
frozen.
Labeling Milk
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Bottles of milk should be labeled with the following information:
Patient name
Medical record number
Date and time of pumping
Maternal medications
Fortifiers added and energy density
To prevent misadministration, a check of the label on the milk compared to the baby's
identification, performed by two health care providers, is recommended prior to thawing,
preparing, and administering the milk.
Storage Guidelines for Hospitalized Infants (Robbins, 2011; Slutzah, 2010; Jones, 2011)
Room temperature, fresh milk 4 hours
Cooler with ice packs, fresh milk 24 hours
Refrigerator, fresh milk 4 days
Refrigerator, thawed milk 24 hours
Refrigerator, fortified milk 24 hours
Freezer, home unit combined
with refrigerator but with a
separate door
3 months
Freezer, separate unit
6-12
months
Milk should be stored in individual, labeled bins with lids in unit freezers and refrigerators.
Transporting Milk
Use insulated coolers with freezer packs to maintain cold temperatures during
transport.
Because ice freezes at a higher temperature than human milk, it may not maintain
temperatures to keep milk frozen during transport. Freezer gel packs are preferred.
When transporting human milk for longer distances, dry ice and styrofoam containers
may be used.
Milk that is partially thawed with ice crystals present can be refrozen (Jones, 2011).
Milk that is completely thawed should be used within 24 hours.
Preparation and Fortification
Fresh milk should be used whenever possible.
If fresh milk is not available, previously frozen milk that is now thawed can be used.
Thaw frozen milk in a warmer intended for use with human milk or thaw in the
refrigerator.
The entire bottle should be defrosted with no ice crystals present.
Swirl gently to mix components.
Do not use hot water or microwave to thaw or warm milk as nutrients may be
destroyed.
Aseptic technique should be used in milk preparation.
Powdered fortifiers are not sterile and have been associated with infections in
high-risk infants. Sterile liquid fortifiers are preferred.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Feeding
Colostrum, which is high in antibodies, should be the first food fed to the infant. It
should be fed in the order it was expressed. Mouth care should be considered when
the baby is nil per os (nothing by mouth) (Rodriguez, 2009).
A two person check of expressed milk against the infant’s identification must be
conducted before warming, preparing, and feeding to the infant.
Milk may be warmed in a warmer or warm water bath prior to bolus or oral feed.
Milk that is warmed and not used within 1 hour for oral or bolus feeds should be
discarded.
Milk for continuous feedings should not be warmed.
Continuous enteral feedings of human milk may result in loss of nutrients and
significant loss of fat that adheres to the tubing.
To minimize growth of bacteria, continuous feeds should be limited to 4 hours. The
syringe and tubing should be changed every 4 hours.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Breastfeeding & Lactation Support > Issues to Consider
Supplementation

Under normal circumstances, there is no indication for any feeding other than human milk
feeding for the first 6 months of life (AAP, 2005; WHO, 2003). With appropriate guidance
and support, mothers should be capable of meeting the nutrition needs of their growing
infant. It may take time for the mother's daily milk production to respond to the infant's
needs. Offering formula during this time will reduce demand and further reduce milk
production. Mothers may misinterpret the baby's need for frequent feedings of every 1 to 2
hours, day and night, as an indication of inadequate supply (AAP, 2006). As long as the
infant is gaining weight appropriately, the mother's supply is sufficient and there is no need
to introduce formula supplementation.
Early supplementation at the birth hospital is detrimental to breastfeeding and rarely
necessary, yet 24% of birth facilities routinely give formula to more than 50% of healthy,
full-term, breastfeeding newborns during the postpartum stay (CDC, 2011b). Furthermore,
providing mothers with discharge bags containing formula negatively affects breastfeeding
success and reduces exclusivity and duration of breastfeeding (Rosenberg, 2008).
If a mother experiences difficulties with breastfeeding, including inability to comfortably
latch the baby, persistent engorgement or plugged ducts, or infant with poor weight gain,
she should see an International Board-Certified Lactation Consultant (IBCLC) for
evaluation. Improved breastfeeding technique may be sufficient to resolve the problem.
Mothers may also need to pump and feed their expressed milk to the baby.
Infants with special needs such as prematurity or a history of cardiac or gastrointestinal
surgery may need to receive fortified breast milk for some or all of their feedings. Often
these fortified feedings can be gradually replaced with more direct feedings at the breast.
As the infant's weight gain and growth improves, the need for fortification will decrease.
The option of hindmilk feedings may also be considered.

Partial Breastfeeding

The evidence is strong that partial breastfeeding (breastfeeding and formula feeding)
increases the risk of illness in the child compared with exclusive breastfeeding (Ip, 2007;
Horta, 2007). Although mothers may choose this option for convenience or because they
believe it is desirable to breastfeed and formula feed, it should be discouraged. Families
need information and support to exclusively breastfeed.
For mothers with true milk insufficiency, human milk feeding (breastfeeding or expressed
human milk) and supplementation with an appropriate infant formula will improve infant
health outcomes compared with exclusive formula feeding. Efforts to improve maternal milk
supply are essential (ABM, 2007).


Galactogogues

Galactogogues are medications or other substances believed to enhance milk production.
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Typical indications for use include the following:
Adoptive nursing
Relactation (establishing a milk supply after weaning)
Increasing a faltering milk supply related to maternal or infant illness or separation
A common indication for galactogogues is to augment production in exclusively pumping
mothers whose infants are in an intensive care unit. Women employed outside the home
who are pumping at work may also see a decrease in milk production over time.
Milk production is complex and affected by many factors. The frequency and thoroughness
of milk removal should be evaluated and improved before galactogogues are considered.
Mothers should be referred to their physicians for evaluation of medical causes of low milk
supply.
Additional information on mechanism of action, transfer to human milk, effectiveness,
suggested dosage, and potential side effects is available for a variety of pharmaceutical
and herbal galactogogues.
(Zuppa, 2010; Anderson, 2007; ABM, 2011b; Ingram, 2011)

Return to Work

In 2010, 56.5% of women with children younger than 1 year were in the workforce, with the
majority working full time (BLS, 2011). Returning to work creates a barrier to continued
breastfeeding. According to the US Surgeon General, inflexible work hours, lack of privacy,
and limited maternity leave benefits are significant obstacles to breastfeeding (USDHHS,
2011). Part-time employment, increased maternity leave, and proximity to infant for direct
breastfeeding can increase breastfeeding success (Mandal, 2010; Fein, 2008).
In 2010, the Affordable Care Act was signed into law; it included the requirement that
employers provide reasonable break times for an employee to express milk for her nursing
child for 1 year in a space that is private, other than a bathroom (USDL, 2010). The
Business Case for Breastfeeding (available at womenshealth.gov), from the US
Department of Health and Human Services, provides employers with the tools needed to
create a breastfeeding-friendly worksite.

Obstacles

Women who choose to breastfeed continue to experience challenges and obstacles.
Despite awareness that the recommendation is exclusive breastfeeding for 6 months with
continued breastfeeding for more than 1 year, few women are successful in meeting this
goal. Although 75% of US mothers initiate breastfeeding, only 15% breastfeed exclusively
for 6 months and only 24% are still breastfeeding in any amount at 1 year (CDC, 2011).
Barriers include lack of knowledge, lack of support, promotion of formula, embarrassment
to breastfeed in public, difficulty overcoming lactation problems, and employment and
unsupportive hospital policies (USDHHS, 2011).

Weaning

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Weaning begins when the breastfed infant receives foods other than human milk. This can
occur after a few weeks of breastfeeding if the mother decides to offer formula
supplementation or it can begin when solid foods are introduced. During the weaning
process, the infant can continue to breastfeed along with other forms of nutrition. Gradual
weaning is recommended both for the mother's comfort and to allow the infant to adjust to
the transition. Abrupt weaning can have physical and psychological implications.
Occasionally weaning will occur as a result of maternal or child illness, maternal-infant
separation, or because the mother becomes pregnant.
When a mother takes the lead and decides to wean the infant, she can replace one
daytime feeding at a time with either a bottle, cup, or solid food feeding, depending on the
developmental stage of the infant. She will continue this process until the infant is only
breastfeeding in the morning and at nighttime. Breastfeeding can continue for many
months. The same process occurs naturally as complementary foods are introduced to the
diet. The child will show less interest in daytime breastfeeding as meals are offered 3 times
per day (Lawrence, 2011).
Mothers may experience some sadness or depression when weaning their child, as there is
both a physiologic and an emotional component to the weaning process.

Skim Milk for Chylothorax

Approximately 50% of the energy in human milk is derived from fat. This energy from fat is
a rich source of energy and important for brain development; yet, for the child with
chylothorax who is on a long-chain fat–restricted diet, human milk presents challenges. It is
a complex process to remove all the fat from expressed human milk, and certainly if the
child is directly breastfeeding, it is impossible. The most reliable method is to spin the milk
in a refrigerated centrifuge to completely separate the fat from the milk. Most institutions do
not have access to this equipment (Chan, 2007).
An alternative method for separation is to allow the expressed milk to sit for 48 to 72 hours
in the refrigerator. The mother can draw the milk into a 60 mL syringe as soon as she
expresses it and then place the syringe tip down in a bottle to keep it upright. The milk can
be placed undisturbed in the refrigerator and the fat will rise to the top of the syringe. The
lower portion will be fat free and can easily be removed by pressing on the plunger, leaving
the fat behind. This method may be acceptable for feeding some infants with chylothorax,
but this milk will likely still contain small amounts of long-chain fat (Lessen, 2009).

Hindmilk for Extra Calories

An option for increasing the fat and energy density in human milk is to fractionate milk into
foremilk (the first milk removed, which contains less fat) and hindmilk (the milk obtained at
the end, which contains more fat) during milk expression (Valentine, 1994; Saarela, 2005).
This technique involves having the mother pump for approximately 2 minutes after the milk
ejection reflex, which can either be felt as a tingling sensation in the breasts or observed
visually as forceful milk flow. She then removes the foremilk that she has expressed and
uses new containers to continue pumping until the breasts are drained. She should be
removing the first one-third to one-half of the normal milk volume she produces at that
pumping session.
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pumping session.
Massaging and compressing the breasts during milk expression also increases the fat
content of the milk. Mothers who directly breastfeed can have similar results by expressing
the foremilk prior to breastfeeding.

Relactation

A woman who has stopped breastfeeding a child, recently or in the past, can resume
production of breast milk. Due to the life-saving effects of human milk, this process is
particularly important in infant feeding in emergency situations to prevent diarrhea,
infections, and malnutrition (CAHD, 1998). There are reports of relactation by
grandmothers and mothers of adopted children. Many women who relactate will produce
adequate milk to exclusively breastfeed the child (CAHD, 1998; Muresan, 2011; Seema
1997).
The milk produced by relactation is not significantly different in composition from human
milk produced after giving birth. Relactation success is influenced by many factors,
including the motivation of the mother, providing sufficient nipple stimulation and a strong
support system for the mother. Milk often appears within a few days to a few weeks, partial
lactation may be achieved in 4 to 28 days, and full lactation may take 3 to 6 weeks. Not all
women achieve a full milk supply.
Strategies for inducing lactation include breastfeeding with a supplemental device and
frequent pumping with hand expression. Frequent day and night sucking at both breasts is
necessary. Feeding the baby with a cup or syringe and avoiding bottles may ease the
transition back to the breast (Muresan, 2011).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants
Full-Term Infants


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants > Overview
Overview

The Full-Term Infants section covers the nutrition needs and recommended feeding
practices to promote optimal growth and development for infants during the first 12 months
of life.
At no time during the life span is nutrition more important. Birthweight doubles by
approximately 5 months of age and triples by 1 year. Length increases 30% from birth by 5
months of age and 50% by 12 months (Holt, 2011; Chumlea, 2005). Rapid brain
development also occurs during this period. The brain is approximately 25% of adult size
at birth and reaches 75% of adult size by 1 year, having completed 50% of postnatal
growth.
Because of this rapid rate of growth, nutrient needs are higher per kilogram of body weight
than at any other time. Diet during infancy sets the stage for diet for the rest of the life
span. Early feeding experiences affect feeding behaviors later on.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants > Nutrition Assessment
Growth Assessment

Nutrition assessment of the infant includes evaluation of growth, dietary intake, biochemical
data, and client history.
Growth
The 2006 Expert Panel Review of World Health Organization (WHO) and Centers for
Disease Control and Prevention (CDC) Growth Charts recommended use of the
WHO growth charts to assess growth in children younger than 24 months, as they are a
standard for describing growth of infants in a healthy environment with adequate nutrition
(Grummer-Strawn, 2010). The charts are based on the premise that the growth and
development of the breastfed infant is considered the gold standard.
The WHO charts were derived from an international longitudinal sample of children in
optimal conditions who were predominately breastfed for at least 4 months, introduced to
complementary foods between age 4 to 6 months, and continued breastfeeding until 12
months of age. Downloadable copies and information on obtaining anthropometric
measurements, using and interpreting these charts, evaluating causes of growth problems,
and counseling caregivers are available in the Growth Charts area of the Resources
section.

Charts available for both sexes from birth to 24 months include the following:
Weight for age
Length for age
Weight for length
Head circumference for age
Considerations include the following:
It is recommended that the 2.3rd percentile and the 97.7th percentiles (or ±2 standard
deviations) on the WHO growths charts be used to screen for suboptimal growth
(Grummer-Strawn, 2010).
After 3 months of age, breastfed infants gain weight more slowly than formula-fed
infants but grow similarly in length and head circumference during the rest of the first
year of life (Dewey, 1992). Because only 33% of infants used to developed the
CDC growth charts were breastfed at 3 months, growth patterns will be different on
the CDC and WHO growth charts (Grummer-Strawn, 2010).
Head size is determined in part by genetics. It is the last anthropometric
measurement to decline when nutrition is inadequate. Microcephaly, or small head
size (less than the 5th percentile), may result from genetic factors or other
causes—including malnutrition. Macrocephaly, or large head (greater than the 95th
percentile)—does not reflect nutritional status but rather genetic factors or
neurological pathology (Leonberg, 2008).
Growth and appetite spurts are variable but typically occur at days 8 to 12, in weeks 3 to 4,
and in the third month (Piette, 2006).
Red flags for growth include the following (AAP, 2009e):
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Short stature
Length for age below 3rd percentile
Weight
Weight for length below 3rd percentile or above 97th percentile
Weight for age crosses more than 2 percentile channels upward or downward
on the growth chart
Weight is more than 10% below birth weight when younger than 2 weeks
Birth weight not regained by 2 to 3 weeks of age or newborn is not gaining a
minimum of 20 g per day
Obtaining anthropometric measurements is done as follows:
Weight (Leonberg, 2008)
Use a calibrated bean balance or electronic scale that can be easily "zeroed"
and periodically calibrated and is capable of weighing to the nearest 0.01 kg or
10 g or in ½-oz increments.
Spring balance scales, such as bathroom scales, are not appropriate for
obtaining weights.
Infant should be weighed nude or wearing only a clean, dry diaper.
Length (Leonberg, 2008)
Recumbent length should be the measurement of stature in an infant. Two
people are needed to obtain an accurate measurement.
Recumbent length may be measured to the nearest 1 mm (0.1 cm) or 1/8
inch, using a length board (infantometer) with an immovable, perpendicular
headboard and a movable, perpendicular foot board.
The measurement is taken from the top of the infant's head to the base of
the heel (without shoes) while the infant is lying flat on his or her back, chin
and toes pointing to the ceiling, with the head gently held in position
Head circumference (Leonberg, 2008)
Use a flexible, nonstretchable, ¼-inch to ½-inch wide plasticized measuring tape
or an insertion tape.
The tape should encircle the head, crossing the forehead just above the
eyebrows, continuing above the ears, and crossing the back of the head at
its widest point. The goal is to find the largest circumference of the head.
Pull the tape to compress the hair. Any braids, barrettes, or hair ties that
interfere with the measurement should be removed.
The following table lists expected weight and length gains for the first 12 months.
Gains in Weight and Length During the First Yeara
Weight (g/day) Length (cm/month)
0-3 months 28-33 3.5-3.8
3-6 months 16-17.5 2.0-2.1
6-9 months 10-11 1.5
9-12 months 8 1.3
(www.who.int/childgrowth/standards/en/)
a
based on the 50th percentile for girls and boys
Rapid weight gain in infancy may be predictive of the later development of obesity (Botton,
2008; Chomtho, 2008; Baird, 2005; Koletzko, 2009; Adair, 2009; Taveras, 2009; Yliharsila,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2008; Larnkjaer, 2010; De Lucia Rolfe, 2010; Wu, 2009; Mihrshahi, 2011; Ekelund, 2006;
de Hoog, 2011; Singhal, 2010; Taveras, 2011). Rapid weight gain is not associated with
better cognitive function in non–small for gestational age infants (Beyerlein,
2010). Johnson and colleagues (2011) report that whereas size and growth velocity are
genetically determined, timing of peak weight velocity, or the tempo of growth, is
environmentally determined and may be a determinant of later health.
In contrast, other studies report that weight gain during infancy is associated more with
increased lean body mass than fat mass during childhood and as an adult (Yliharsila, 2008;
Victora, 2007; Sachdev, 2005). The authors speculate that that the greater lean body mass
results in a higher body mass index, meeting the criteria for obesity.
Poor weight gain may result in less lean body mass, which may result in decreased insulin
sensitivity. Inadequate weight gain during the first 8 weeks of life is associated with lower
intelligence quotient at 8 years of age (Emond, 2007).

Diet Assessment

Following are questions to answer for the diet assessment.

Breastfed Infant
Are breastmilk feedings supplemented with formula feedings, and how are feedings
prepared?
Is the mother taking any vitamin or mineral supplements, medications, or
supplements to increase milk supply?
If concerns are identified, consider referral to a certified lactation consultant. See
the Breastfeeding section for additional information.
Formula Feeding
Is the formula mixed according to manufacturer's directions?
Is formula and food prepared in accordance with food safety and sanitation
guidelines?
Is the stiffness of the nipple appropriate and the nipple hole the correct size? The
nipple should be hard enough to force the baby to use the mouth muscles but soft
enough to enable the baby to consume an adequate volume (Piette, 2006).
Adequacy of Intake
Is the type and amount of formula appropriate? The table on this page provides
guidelines for expected amount of formula. The Formulary database and Types of
Infant Formula provide information on different types of formulas, their indications,
and their composition.
Are complementary foods developmentally appropriate in terms of amount, type, and
texture? More information is provided in the table and in the Complementary Foods
section. Development of Feeding Skills provides information on
age-appropriate feeding skills.
Are there sources of added energy that are part of the infant's usual intake (for
instance, the addition of rice cereal to formula for gastroesophageal reflux)?
How often does the baby feed and how long does a feeding last? A feeding that lasts
longer than 30 minutes is considered too long. The expected number of feedings per
day is provided in the table on this page.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
day is provided in the table on this page.
What is the interval weight gain between visits? See Growth Assessment for
expected weight gain.
Has the health care professional recommended special preparation of breast milk or
formula? If so, are the instructions being followed?
How much juice and extra water is the infant receiving?
How many wet and/or soiled diapers are changed daily? If there are 4 to 6 wet diapers
per day, this indicates adequate hydration. See Stool Patterns for information on the
expected stool characteristics and frequency.
Energy and protein intake recommendations are provided in the Nutrient Needs section.

Typical Portion Sizes and Daily Intake for Infants
a

Age
(months)

Food (Portion Size)
Feedings
Per Day
0-4
Breast milk or infant formula (2-4
oz)
8-12
4-6
Breast milk or infant formula (6-8
oz)
4-6
Infant cereal (1-2 Tbsp) 1-2
6-8
Breast milk or infant formula (6-8
oz)
3-5
Infant cereal (2-4 Tbsp) 2
Crackers (2), bread (½ slice) 1
Juice (0-3 oz) 1
Fruit or vegetable (2-3 Tbsp) 1-2
8-12
Breast milk or infant formula (6-8
oz)
3-4
Cheese (½ oz) or yogurt (½ cup) 1
Infant cereal (2-4 Tbsp), bread (½
slice), crackers (2), or pasta (3-4
Tbsp)
2
Juice (3 oz) 1
Fruit or vegetable (3-4 Tbsp) 2-3
Meat (3-4 Tbsp) or beans (¼ cup) 2

a
Typical portions are provided as a guideline only; individual needs may vary.
Feeding Environment
How is the baby fed? Is the feeding position correct?
Is the caregiver able to distinguish hunger from other needs?
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Does the caregiver respond appropriately to the infant’s signs of satiety and hunger?
Are distractions minimized during feeding?
Does the caregiver burp the infant during or after feeding?
Which feeding delivery items are being used? Bottle, sippy cup, spoon, fingers?
Client History
Is access to food and formula a concern?
Do the infant and mother exhibit signs of appropriate bonding? Are they affectionate,
comfortable, distant, anxious?
Has the infant been examined by a health care provider for well baby checks?
Is the infant displaying age-appropriate development and behaviors? See
Development of Feeding Skills. The Centers for Disease Control
and Prevention website includes "Learn the Signs, Act Early," which provides
information on developmental milestones to be achieved by age 3 months, 7 months,
and 1 year.
Do cultural or religious beliefs affect food selection?
Is the infant receiving any vitamin/mineral or other supplements?
Physical Assessment
Does the appearance of the infant's skin, hair, teeth, gums, tongue, and eyes indicate
nutritional concerns?


Nutrient Needs

The Dietary Reference Intakes (DRI) for infants are available on the Dietary Guidance
page. Recommended intakes for infants during the first 6 months are based on intakes of
exclusively breastfed infants. For infants aged 6 to 12 months, recommended intakes are
based on an average intake of 600 mL breast milk and usual intake of age-appropriate
complementary foods.
The equations for calculating the estimated energy requirement (EER) for infants are as
follows:
0-3 months: EER = (89 X weight [kg] – 100) + 175
4-6 months: EER = (89 X weight [kg] – 100) + 56
7-12 months: EER = (89 X weight [kg] – 100) + 22

The DRIs for protein are as follows:
0-6 months Estimated Average Intake (AI) = 1.52 g/kg
7-12 months
AI: 1.0 g/kg
Recommended Dietary Allowance: 1.0 g/kg

(IOM, 2006)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Breast milk is lower in protein than formula because cow's milk is higher in protein. Calves
require more protein than human infants because they grow much faster. However, breast
milk also contains nonprotein sources of nitrogen.
Nutrients of Interest
Fluoride
Fluoride supplementation is not recommended before 6 months of age. Beginning at 6
months of age, supplemental fluoride is recommended for breastfed infants and for
formula-fed infants living in locales with less than 0.3 ppm fluoride in the local water
supply ( AAP, 2009b). Nursery water, purchased by some parents, contains fluoride.
To determine whether a fluoride supplement is needed, complete a thorough evaluation of
all sources of fluoride and the risk for dental caries. For infants living in a nonfluoridated
community, adequate fluoride may be obtained from consumption of foods and beverages
prepared in communities with fluoridated water. Toxicity or fluorosis can cause mottling of
the teeth ( AAP, 2009b).
Vitamin D
The recommendation that infants receive 400 IU vitamin D from birth (Misra, 2008;
Wagner, 2008) takes on additional importance considering the high frequency of vitamin D
insufficiency or deficiency reported in pregnant women (Johnson, 2011; Ginde, 2010;
Mulligan, 2010). Maternal vitamin D status influences the vitamin D status of the infant.
Without supplementation, an infant born to a mother with vitamin D deficiency will be
become vitamin D deficient sooner than an infant born to a mother with adequate vitamin D
intake.
To reach the recommended intake, the following protocols are necessary (Misra, 2008;
Wagner, 2008):
All breastfed and partially breastfed infants should receive a supplement of 400 IU
vitamin D per day starting within days of birth
Formula-fed infants consuming less than 1 L formula should receive a supplement of
400 IU vitamin D per day
One milliliter of a multivitamin preparation or vitamin D drops contain 400 IU vitamin
D. Vitamin D-only supplements are available
Perrine and colleagues (2010) estimate that only 20% to 37% of infants in the United
States meet the recommendation for vitamin D intake.
Iron
Iron needs during infancy are high per unit of body weight. Iron deficiency during infancy
has long-term, irreversible, negative consequences on cognitive and motor development
(Beard, 2008; Lozoff, 2008; Lozoff, 2007; Shafir, 2008; Gunnarson, 2007; Georgieff, 2007;
Beard, 2007; Lozoff, 2006; Corapci, 2006; Collard, 2009; McCann, 2007; Lozoff,
2011). Therefore, the American Academy of Pediatrics (AAP) recommends that all
formula-fed infants receive only iron-fortified infant formula. Well-designed studies show no
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
evidence that the iron in iron-fortified formulas causes irritability, colic, constipation, reflux,
gas, or cramping (AAP 2009a; AAP, 2009c; Nelson, 1988; Singal, 2000; Oski, 1980;
Bradley, 1993; Baker, 2010). A review concluded that there is limited evidence that routine
iron supplementation could enhance psychomotor development but not behavior or
cognitive development (Szajewska, 2010)
Exclusively breastfed infants have adequate iron stores for approximately the first 4 to 6
months of life (Chaparro, 2008; Zeigler, 2009; Buchanan, 2009; Dewey, 2001; Baker,
2010). The AAP recommends that exclusively and partially breastfed infants receive 1 mg
iron per kg per day starting at 4 months of age until iron-containing complementary foods
have been introduced to account for infants born with low iron stores (Baker, 2010). A
double-blind study found that supplementing breastfed infants between age 1 and 6
months resulted in higher hemoglobin concentrations and mean corpuscular volume at
age 6 months, as well as better visual acuity and higher scores on the Bayley Psychomotor
Developmental Indices at 13 months, compared with unsupplemented infants (Friel, 2003).
Dietary prevention of iron deficiency includes the following (AAP, 2009f; CDC, 1998):
Iron-fortified formula only for formula-fed infants for the first year
Use iron-fortified formula for weaning or supplementing breast milk during the first
year
Introduction of iron-fortified cereal or meats at 4 to 6 months of age
One serving of vitamin C–rich foods approximately by age 6 months to enhance iron
absorption from nonheme sources

Assessment of Adequate Breastmilk Provision

Assessment and Recommendations for Infants
Weight pattern consistent with weight gain, such as 4 oz to 7 oz per week after the
4th day of life
Minimum of 6 wet diapers daily, several soaked (only after the first 3 to 5 days of life
when milk volume increases)
Minimum of 3 to 4 stools daily during the first few weeks (although usually with every
feeding and occasionally fewer than previously noted); after 6 weeks to 2 months, an
infant may continue to have several stools daily or the infant may go several days
without a stool
Minimum of 8 to 12 feedings daily during the first few weeks, lasting long enough to
ensure adequate hind milk removal (approximately 15 to 20 minutes, possibly less
than 15 minutes in women who hyperlactate)
Alert, healthy appearance of infant
No food or drink, other than breast milk, given to the breastfeeding infant unless
medically indicated
Advocacy for Lactating Mothers
Use a multidisciplinary approach in the promotion of breastfeeding
Foster the establishment of breastfeeding support groups, sharing nutrition expertise
with these groups and referring mothers to them upon discharge from the hospital or
clinic
Remove all commercial milk products and advertisements from patient care areas
Provide didactic and clinical training about breastfeeding and lactation to students in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
health care professions and to practicing professionals through continuing education
Promote breastfeeding to the public
Advocate for breastfeeding mothers in the workplace
Advocate for support of breastfeeding programs at the federal, state, and local levels
Evaluate and improve the quality of existing breastfeeding programs and services
Educate mothers on adequate food and fluid intake to support lactation; for maternal
concerns regarding allergy prevention, see this page

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants > Normal Laboratory Values
Normal Laboratory Values

Laboratory tests ordered will depend on the medical concerns. Normal values are generally
established by specific institutions or laboratories and may be different for infants than for
older children or adults.
Screening for Iron-Deficiency Anemia
Recommendations for screening for iron deficiency using hemoglobin or hematocrit differ.
The US Preventive Service Task Force recommendations are as follows (USPSTF, 2006):
There is insufficient evidence to recommend for or against screening
The Centers for Disease Control and Prevention (CDC) recommendations are as
follows (CDC, 1998):
At 9 to 12 months of age, screen infants with the following risk factors:
Preterm or low-birth-weight infants
Infants fed a diet of non–iron-fortified infant formula for longer than 2 months
Infants introduced to cow's milk before age 12 months
Breastfed infants who do not consume a diet adequate in iron after age 6
months (eg, who receive insufficient iron from supplementary foods)
The American Academy of Pediatrics recommendations are as follows (AAP, 2009f):
At 9 to 12 months of age
Universal screening of all infants or screening only at-risk infants. At-risk infants
include preterm infants, low-birth-weight infants, infants not receiving
iron-fortified formula, and breastfed infants older than 6 months who are not
consuming adequate iron.
Screening for iron-deficiency anemia before 1 year of age may not be appropriate for
infants receiving iron-fortified formula or foods, as there is not sufficient time to develop
anemia (Kohli-Kumar, 2001).
Screening for Elevated Lead Levels
Lead screening for children at risk should begin at 9 to 12 months of age (AAP, 1997)
The CDC recommendations are as follows:
Universal screening in communities with inadequate data on the prevalence of
elevated blood lead levels and in communities where 27% or more of the houses
were built before 1950
Targeted screening in communities where less than 12% of children's blood lead
levels are 10 mcg/dL or more, or where fewer than 27% of the houses were built
before 1950 (CDC, 1997)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants > Feeding Recommendations
General Guidelines

Feed with breast milk or iron-fortified formula for the first 12 months (AAP, 2009a;
AAP, 2009d). Any milk not specifically designed for an infant (such as rice milk, soy
milk, or goat's milk) is not recommended during the first 12 months (Basnet, 2010).
Exclusive breastfeeding is recommended for about 6 months (AAP, 2012).
Recommendations for human milk are based on recognized benefits to infant
nutrition and gastrointestinal and immune functions as well as potential impact
on neurodevelopment and development of chronic diseases of childhood ( AAP,
2009e; AAP, 2005).
Until approximately 9 months of age, cow's milk consumption is associated with
intestinal blood loss (Zeigler, 1999; Udall, 1999; AAP, 2009a, AAP, 1992;
ESPGHAN, 2008).
Cow’s milk provides inadequate iron, vitamin E, and linoleic acid and excessive
amounts of sodium, potassium, and protein (AAP, 2009a; ESPGHAN, 2008).
Proteins—especially casein, calcium, and phosphorus in cow's milk—inhibit iron
absorption. Cow's milk protein is 80% casein (Bondi, 2009).
Respond to the infant’s signs of hunger and satiety
Healthy breastfed newborns require no supplemental fluids, as partial satiety
may interfere with successful initiation of breastfeeding by the mother and baby
(AAP, 2009e).
Feeding frequency of the breastfed infants may differ from that of
the formula-fed infant secondary to increased gastric emptying times.
Infants have an innate ability to self-regulate intake (Farrow, 2006; Fox, 2006;
Johnson, 2002; Ounsted, 1975; Adair, 1984).
Responding to the first signs of hunger promotes a more positive feeding
experience. Crying is a late sign of hunger and may result in a tired infant who
has difficulty settling down to eat (Piette, 2006).
Introduce complementary foods when the infant is about 6 months of age and shows
signs of developmental readiness. See Complementary Foods for signs of
developmental readiness.
Proper position helps prevent choking, discomfort, and ear infections.
Typical Portion Sizes and Daily Intake for Infants
Age
(Months)

Food (Portion Size)
Feedings
Per Day
0-4
Breast milk or infant formula (2-4
oz)
8-12
4-6
Breast milk or infant formula (6-8
oz)
4-6
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Infant cereal (1-2 Tbsp) 1-2
6-8
Breast milk or infant formula (6-8
oz)
3-5
Infant cereal (2-4 Tbsp) 2
Crackers (2), bread (½ slice) 1
Juice (0-3 oz) 1
Fruit or vegetable (2-3 Tbsp) 1-2
8-12
Breast milk or infant formula (6-8
oz)
3-4
Cheese (½ oz) or yogurt (½ cup) 1
Infant cereal (2-4 Tbsp), bread (½
slice), crackers (2), or pasta (3-4
Tbsp)
2
Juice (3 oz) 1
Fruit or vegetable (3-4 Tbsp) 2-3
Meat (3-4 Tbsp) or beans (¼ cup) 2

Breastfeeding
Proper positioning of the infant at the breast should be comfortable and, regardless of
the position chosen, breastfeeding should be a pain-free experience when the baby is
latched correctly.
Traditional breastfeeding holds can be seen at this link.
Bottlefeeding
Recommended position for bottlefeeding for the first few months is the semi-upright
position. This is the same angle as in a car seat or infant carrier, but infants should be
held while feeding and not placed elsewhere (Isaacs, 2005).
Propping the bottle or placing the infant in a carrier or on a pillow can cause choking,
discomfort while eating, and ear infections (Isaacs, 2005).
Begin introducing the cup at approximately 6 months of age and complete weaning by
12 to 14 months of age. Use of the bottle at 24 months of age has been associated
with obesity at 5 years of age (Gooze, 2011).
Spoonfeeding
Sitting with good support for the back and feet facilitates control of the mouth and
head.
The feeder should be positioned in front of the infant; make eye contact with the
infant so that the infant does not need to turn his or her head.
In a high chair, the infant should sit with hips and legs at a 90º angle using the seat
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In a high chair, the infant should sit with hips and legs at a 90º angle using the seat
belt. Pressure on the stomach increases and spitting up is more frequent when the
infant is not seated in this position (Isaacs, 2005).
Feeding Relationship
During the first year of life, infants transition from an exclusive breast milk or formula-based
diet to a modified adult diet. The development of the feeding relationship and the execution
of the transition influences later food choices, diet quality, and weight status (Savage,
2007). During infancy, the key to establishing a positive feeding relationship is that "parents
are responsible for the what, when, and where of feeding, [and] children are responsible for
the how much and whether of eating" (Satter, 2000). In other words, parents are
not responsible for the quantity of food a child eats and whether food is eaten when
offered.
An understanding of infant cues and temperment is key to implementing this division of
responsibility (Satter, 2000). A positive feeding relationship in infancy sets the foundation
for developing healthful eating at future life stages. Paul and colleagues (2011) report that
teaching parents to discriminate between hunger and other causes of distress and respond
with nonfood interventions combined, as well as teaching parents how to combat rejection
of nutritious food via multiple exposure and to respond to signs of hunger and satiety, has
potential for preventing long-term obesity.

Types of Infant Formulas

Formula can be purchased in the following three forms:
Ready to feed
Concentrated liquid
Powder
Indication Comments
Intact Cow's Milk
Protein–Based
Formulas
Healthy-term infants who are
not breastfed or as a
supplement to breastfeeding
Vary in
Whey:casein ratio
Amount of
docosahexaenoic
acid/arachidonic acid
Available with added
prebiotics
Soy

Galactosemia
Hereditary lactase deficiency
Secondary lactose intolerance
Vegetarian alternative to breast
Promote similar growth
and bone mineralization
as cow's milk protein
formula
Not recommended for
preterm infants
Not recommended for
management of cow's
milk allergy
Not recommended for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
milk
Not recommended for
management of colic
Impact of phytoestrogens
on reproductive health
inconclusive
Partially hydrolyzed soy
protein formula available
Partially
Hydrolyzed

Gas, fussiness
Not recommended for
cow's milk allergy
Whey or whey and
casein hydrolysate
Vary in amount of lactose
Available with probiotic
Extensively
Hydrolyzed

Hypoallergenic formulas for
cow’s milk allergy
Malabsorption results from
gastrointestinal or hepatobiliary
disease
Differ in amount of
medium-chain
triglyceride (MCT) oil
Lactose free
Casein hydrolysate
Contain free amino acids
and peptides
Available with probiotic
Elemental

Hypoallergenic formulas for
malabsorption, severe food
allergies, short bowel
syndrome, or other conditions
requiring an amino acid–based
diet
Free amino acids
Differ in the amount of
MCT oil
Lactose free
Lactose Reduced

Lactose sensitivity
Not recommended for
infants with galactosemia
Thickened
Formula
Frequent spit up, reflux
Thickening agent is rice
starch
Eliminates the need to
pulverize rice cereal and
mix to the right viscosity
Does not alter the
macronutrient distribution
as adding rice cereal
does
Thickening occurs in the
stomach with gastric
juices
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Follow-Up
Formulas
Added nutrition for infants
transitioning off formula or
breast milk
Higher in protein and
minerals
Offer no advantage over
standard infant formula
(AAP, 2009a)
Formulas for premature infants are discussed in the premature infant section.
Specialized formulas—such as carbohydrate-modified formulas for gastrointestinal
disorders, protein-modified formulas for inborn errors of metabolism, electrolyte-altered
formulas for renal disease, and a calcium/vitamin D–modified formula for infants with
hypercalcemia—are available.
Some infant formulas have prebiotic or probiotic added. Prebiotics are added to more
closely mimic human milk oligosaccharides. Human milk oligosaccharides affect
development of intestinal microflora and may provide immunological benefits (Bode, 2009;
Sherman, 2009; Vael, 2009; Martinez, 2011; Bakker-Zierikzee, 2006; Scholtens,
2010). Infants on formula supplemented with prebiotics have softer stools and a microflora
like those of breastfed infants compared with infants on unsupplemented formulas (Hernot,
2009; Zeigler, 2007; Nakamura, 2009; Williams, 2009; Rao, 2009; Martinez, 2011; Ben,
2004; Moro, 2002; Castalos, 2008). Normal weight gain and good tolerance are reported in
infants on formula supplemented with prebiotics, probiotics, or symbiotics (Chouraqui,
2008; Rao, 2009; Castalos, 2008, ESPGHAN Committee on Nutrition, 2011).
The European Society for Paediatric Gastroenterology Hepatology, and Nutrition
Committee on Nutrition reviewed the evidence regarding the safety and health effects of
prebiotics and probiotics and concluded that are no adverse effects of the use of prebiotics
and probiotics but that insufficient data is available to recommend their routine use
(ESPGHAN Committee on Nutrition, 2011).
Docosahexaenoic acid (DHA) and arachidonic acid (ARA) and their precursors are added
in varying quantities to infant formula to promote visual acuity and cognitive development
similar to the breastfed infant (Agostoni, 2008; Birch, 2007; Uauy, 2003). Experts
recommend 0.2% to –0.4% DHA and 0.35% to 0.7% ARA (Mitmesser, 2007). The ability of
precursors to contribute to DHA in the brain has not been fully elucidated (Innis, 2007;
Hoffman, 2006; Lin, 2010). The DHA content of breast milk varies widely is dependent
on maternal diet, gestational parity, and smoking (Innis, 2007; Agostoni, 2008; Meldrum,
2011).
Long-chain fatty acids (LCFA) may promote lower blood pressure during childhood
(Forsyth, 2003). Research is not conclusive as to whether DHA supplementation of the
term infant affects development (Agostoni, 2010; Makrides, 2011; Guesnet,
2011). Confounding variables include DHA status at birth, maternal or family
characteristics, and genetic background (Agostoni, 2008; Meldrum, 2011; Gale,
2010). Studies differ in the amount, timing, and tests used to measure visual acuity and
development. LCFA supplementation improved visual acuity at 1 year in 2 studies (Birch,
2002; Birch, 2010). DHA supplementation of formula resulted in improved cognitive
development at 18 months in one study (Drover, 2011) but this was not the result in a meta
analysis of 4 large clinical trials (Beyerlein, 2010). Benefits of DHA and ARA
supplementation during infancy at 9 years have been reported in a study (de Jong,
2010) whereas other studies have reported no benefits at 39 months (Auestad, 2003) and
5 years (Jensen, 2010).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Some infant formulas may be advertised with claims, such as helping an infant sleep
through the night, that are not substantiated by research.
Frequent switching of formulas generally is not efficacious. Take into consideration
rationale for switching and allow sufficient time (several days) to see if the change is
effective in improving the infant's symptoms.
For additional information on infant formulas and names of formulas in each category, refer
to the Formulary.
(Turck, 2007; ESPGHAN, 2006; Osborn, 2005; Mimouni, 1993; Strom, 2001; Mendez,
2002; Bhatia, 2008; Greer, 2008; von Berg, 2003; Heine, 2008, Joeckel, 2009; Badger,
2009; AFP, 2008; Martinez, 2011; Vandenplas, 2011; Merritt, 2004)

Infant Formula Preparation and Storage

Mixing
Shake ready-to-feed formula and concentrated formulas before pouring into a bottle to
“resuspend any mineral sediment that may have settled during storage" ( AAP,
2009a).
Formula should not be warmed in a microwave, as uneven heating may lead to
hotspots that can cause burns and loss of nutrients (Robbins, 2011).
Feeds are traditionally warmed and may be preferred warm. However, warming the
feed will promote more rapid growth of bacteria (Robbins, 2011).
Continuous feeds do not need to be warmed as the feed will reach room
temperature or body temperature as it travels through the tube
Feeds for term infants may not need to be warmed but feeds for preterm infants
should be warmed
Feeds can be warmed using electric warming units, warm water baths, and
warm running water with care taken to prevent contamination
Devices that thaw and warm human milk safely are available
For infants with special nutrition needs, infant formulas can be concentrated beyond
the standard 20 kcal/oz.
Although the recipe for concentrating liquid formula is the same for all formulas,
recipes for concentrating powder formulas differ. Instructions can be obtained
from the manufacturer.
Increases in formula concentration should be made in increments of 2 kcal/oz.
Formula should not be concentrated beyond 30 kcal/oz.
Concentrating formula also increases the micronutrient content. Thus, an
evaluation of total nutrient intake for any excesses may be indicated.
Formulas for premature infants should not be used to provide additional energy
to a term infant.
Modulars may be used to provide additional energy and protein. Care should be
taken to maintain appropriate macronutrient distribution.
Hospital
Ready-to-feed and concentrated liquid products are commercially sterile. However,
powder formula is not sterile and may contain pathogenic bacteria (ESPGHAN, 2004;
Baker, 2002; AAP, 2009a; Robbins, 2011). Thus, it is recommended that powder
formulas be avoided for immunocompromised infants.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Liquids should be measured in graduated cylinders, beakers, liquid measuring cups,
syringes, or pitchers (Robbins, 2011).
Powder should be measured in grams (Robbins, 2011).
Home
Because scoop sizes vary, use only the scoop provided by the manufacturer to
measure powder.
Follow the manufacturer’s preparation directions, as mixing instructions differ. Note
whether the directions specify use of a packed or unpacked scoop.
Shake ready-to-feed formula and concentrated formulas before pouring into a bottle to
“resuspend any mineral sediment that may have settled during storage" ( AAP,
2009a).
Water
Prepare formula using water that is free of pathogenic microorganisms and low in
minerals that may be harmful should be used to prepare formula. Municipal water
supplies are generally free of pathogenic microorganisms. Well water needs to be
tested regularly. In some cases, bottled water may be the best alternative ( AAP,
2009a).
Recommendations differ as to whether water used to prepare infant formula should be
boiled and cooled before mixing (Askers, 2005; WHO, 2010; AAP, 2009a; Baker,
2002; ESPGHAN, 2004). Water should be brought to a rolling boil for 1
minute. Longer boiling time may concentrate minerals to an undesirable level.
Use of hot water (158°F) to prepare formula decreases the content of heat-labile
vitamins and can cause the formula to clump.
Boiled water used to prepare concentrated liquid should be cooled completely (AAP,
2009a).
Sanitary Procedures
Wash hands before preparing formula.
Clean area used to prepare the formula.
Wash reusable bottles, caps, and nipples in hot, soapy water or in the dishwasher
before each use.
Wash and dry the top of the infant formula container before opening.
Refrigerate formula immediately after preparation (Story, 2002; Askers, 2005).
Storage
Home (AAP, 2009a)
Prepared bottles should not be left out of the refrigerator for more than 2 hours.
Any formula remaining in the bottle after a feeding should be discarded within 1 hour.
Prepared formula refrigerated right after preparation can be stored in the refrigerator
for 48 hours.
Once opened, ready-to-feed and concentrated liquid formula can be covered with a
plastic overlap or aluminum foil and stored in the refrigerator for up to 48 hours.
Powdered formula should be stored in a cool, dry place. Once opened, powder
formula should be covered with the overlap and used within 1 month.
Hospital (Robbins, 2011)
Prepared formula can be stored in the refrigerator for 24 hours
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For tube feedings, the maximum time at room temperature is 4 hours for prepared
formula from powder or concentrate and 8 hours for sterile, ready-to-feed formulas.
Liquids should be measured in graduated cylinders, beakers, liquid measuring cups,
syringes, or pitchers.
Powder should be used when no liquid form is available and measured in grams.
Refer to the Academy of Nutrition and Dietetics publication Infant Feedings:
Guidelines for Preparation of Human Milk and Formula in Health Care Facilities for
more information regarding formula preparation and storage in the hospital setting.

Signs of Hunger and Satiety

Respond to the infant's signs of hunger and satiety.
Signs of Hunger
Breastfeeding or Bottlefeeding (Story, 2002)
Hand-to-mouth activity
Rooting
Pre-cry facial grimaces
Fussing sounds
Crying
Wakes and tosses
Spoonfeeding (Isaacs, 2005)
Watching the food being opened in anticipation of eating
Tight fist or reaching for the spoon as a sign of hunger
Showing irritation if the feeding pace is too slow or if the feeder temporarily stops
Signs of Satiety
Breastfeeding or Bottlefeeding (Story, 2002)
Turns head away from the nipple
Shows interest in things other than eating
Closes the mouth
Seals lips together
Decreases, slows rate of, or stops sucking
Spits out nipple or falls asleep when full
Spoonfeeding (Isaacs, 2005)
Starts to play with the food or spoon as the infant begins to get full
Slows the pace of eating or turns away from food when satiety is achieved
Stops eating or spits out food when infant has had enough to eat
During nonfeeding meal periods, comfort the infant by cuddling, rocking, and walking him
or her instead of feeding. Using food to comfort an infant may teach eating in response to
emotional needs rather than hunger (Story, 2002).


Complementary Foods

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Complementary foods should be introduced at about 6 months of age, when the infant
shows developmental signs of readiness, including extinction of the tongue thrust reflex,
movement of the center of the gag reflex to the back of the tongue, the ability to sit with
support, and the ability to indicate desire for food by opening the mouth or leaning in or
satiety by closing the mouth or leaning away (AAP, 2012; AAP, 2009d; Isaacs, 2005; Story,
2002; Butte, 2004; ESPGHAN, 2008; Michaelsen, 2010; Agostoni, 2008; Kramer, 2002;
Wu, 2009). The exact timing should be based on an infant's individual needs (Fewtrell,
2007; Cattaneo, 2011).
Early introduction of solid foods may result in more rapid weight gain during infancy and
increased risk of later obesity (Grote, 2011). The literature is not conclusive, however, as
timing of introduction of solid foods has been reported to not influence growth in some
studies (Forsyth, 1993; Mehta, 1998; WHO, 2002) but reported to influence growth in
others (Grote, 2011; Moorcroft, 2011; Huh, 2011). A 2011 study (Huh, 2011) reported that
introduction of solid foods before 4 months of age in formula-fed infants is associated with a
sixfold increased risk of obesity at 3 years of age. In breastfed infants, the timing of
introduction of solids did not increase the risk of obesity.
Grote and colleagues (2011) reported that solid foods introduced before 3 months of age
increased energy intake, resulting in more rapid growth in these infants compared with
infants introduced to solid foods later. However, introduction to complementary foods
in infants at 24 months of age did not influence anthropometric measures. Schack-Nielsen
and colleagues (2010) found that later introduction of solids between the ages 2 and 6
months, but not duration of breastfeeding, decreased the likelihood of obesity at age 42
years after controlling for duration of breastfeeding and other confounding variables.
Research by Mennella (2011) indicates that there are key times during early development
when acceptance of different flavors is established. Thus, flavors in breast milk may
familiarize the infant with flavors that the infant will experience and develop acceptance for
during weaning (Agostoni, 2008). Early exposure to salty foods may lead to a preference
for salt in infants and preschoolers (Stein, 2012).
The first foods offered should be good sources of calcium, vitamin B-6, phosphorus, iron,
and zinc. These nutrients are likely to be limited, especially in the diet of the breastfed
infant. Thus, pureed meats, beans, and legumes are excellent choices (AAP, 2009d;
Krebs, 2006; Hallberg, 2003; Dewey, 2001). Providing cereal before bed does not lead to
sleeping through the night (Macknin, 1989).
Introduce one single-ingredient food at a time. Wait 3 to 5 days before introducing another
new food to allow for the observation of an adverse reaction to a food. Feeding mixed
dishes containing two new foods makes it difficult to determine which food is responsible
for any adverse reaction.
Let the infant experience different food flavors.
Avoid mixing solid foods together when first offering solids. As noted in a book about
children who are picky eaters, “Let the infant experience each new flavor separately.
This makes eating more interesting and helps the infant enjoy a variety of food
flavors” (Piette, 2006).
Infants do display taste preferences (AAP, 2009d).
Introduce a variety of foods by the end of the first year to facilitate the development of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
healthful food habits. Once meats and cereals are well accepted, introduce fruits and
vegetables.
This approach sets the stage for healthful eating when the infant is older (Story, 2002).
If the infant refuses a food, try again. It can take 10 to 20 exposures before a food is
accepted (Story, 2002; Piette, 2006).
Infants who have been exposed to a variety of foods are more willing to try new foods
later in the first years, when neophobia is common.
Juice should not be introduced before 6 months of age (AAP, 2009d). When introduced,
juice (100% only) should be given in a cup, not a bottle, and limited to 4 oz per day.
Nutritionally, juice does not provide nutrients that are not provided by breast milk,
formula, or fruits and vegetables.
The Special Supplemental Nutrition Program for Women, Infants, and Children no
longer provides juice to infants.
Sugar-containing foods and beverages and the addition of salt to food are not
recommended for infants (Story, 2002; Glinnsmann, 1996; ESPGHAN, 2008).
Sugar decreases the nutrient density of foods.
Consumption of sweet and salty food enhances preference for these foods
(ESPGHAN, 2008).
The following foods are not recommended for infants because of the risk of choking
(Isaacs, 2005):
Popcorn
Peanuts
Raisins, whole grapes
Uncut, stringy meats
Hot dog pieces
Hard, raw fruits or vegetables such as apples and green beans
Pieces of food that the infant cannot completely masticate because of decreased
chewing skills and foods that can block the airway since voluntary coughing and the
ability to clear the throat has not yet developed (Isaacs, 2005)
Sticky foods, such as peanut butter, which can get stuck in the back of the mouth
(Isaacs, 2005)
Honey should not be given because of the risk of botulism spores
Milk such as cow's, goat, rice, or soy milk—other than those specifically designed for
infants—are not appropriate before 1 year of age.
Preparation and Storage of Baby Food
Commercial Baby Foods
Choose single-ingredient foods. Meat and vegetable mixtures contain fewer nutrients
than if the ingredients were bought separately and mixed as the infant was fed.
Avoid fillers such as modified food starch or tapioca.
Baby food desserts are not recommended because of the added sugar.
Do not feed the infant directly from the jar, as the infant's saliva can cause food
spoilage. Use a clean spoon to take food from the jar into a small feeding bowl. Then,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
if the infant does not finish the jar, it can be stored in the refrigerator for 2 days.
Homemade Baby Food
Homemade baby food is inexpensive and easy to make.
Use a baby food grinder or blender and formula, breast milk, or water to thin food as
needed for appropriate texture.
Extra quantities of pureed foods can be frozen in small freezer containers or ice cube
trays and kept in the freezer for 2 months.
See Home-Prepared Baby Food (from the US Department of Agriculture's Food
and Nutrition Service) for more detailed information.
Visit the Development of Feeding Skills page for information on milestones in feeding skills
development by age and appropriate foods at each milestone.
Visit the Diet Assessment page for information on appropriate number of servings and
serving sizes.


Development of Feeding Skills

Learning to Eat: Step by Step
When:
Appropriate Age
How:
Mouth and Body
Movement/Skills
What:
Typical Foods/Eating Behaviors
Birth through 5
months
Coordinates sucking, swallowing,
and breathing
Poor control of head, neck, and
trunk

Swallows liquids
4 months through
7 months
Begins up-and-down munching
movement
Opens mouth for the spoon
Closes the upper or lower lip
around the spoon
Moves food to the back of the
tongue to swallow
Sits with support
Good head control
Uses whole hand to grasp objects
Swallows liquids
Gums or mouths pureed foods
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
5 months through
9 months
Closes lip on spoon to remove
food
Positions food between the jaws
for chewing
Follows food with eyes
Begins to sit alone without support
Begins to use a pincer grasp to
pick up food
Gums and swallows crackers
Eats pureed/mashed foods
Drinks from a cup (dribbles) held
by adult
Begins self-feeding with hands
8 months through
11 months
Uses the tongue to move food
from side to side in the mouth
Begins to curve lips around the
rim of the cup
Begins to chew in rotary pattern
Sits alone easily
Transfers objects from hand to
mouth
Swallows with mouth closed
Bites and chews crackers
Licks food off a spoon
Eats mashed table foods
Finger-feeds small pieces of food
Begins to experiment with spoon
Drinks from a cup with less spilling
10 months
through 12 months
Rotary chewing
Begins to put spoon in the mouth
Begins to hold cup (enjoys
turning cup upside down)


Eats chopped foods and small
pieces of soft-cooked table foods
Begins self-spoonfeeding

12 months

Picks up foods with a refined
pincer grasp (thumb and
forefinger)
Picks up and drinks from a cup
(expect spills)

Bites nipples, spoons, and
crunchy foods
Prefers finger foods
Reprinted with permission from Piette L. Just Two More Bites: Helping picky eaters say yes
to food. New York: Crown Publishing; 2006: 43-44.
An infant may not display age-appropriate feeding skills or be resistant to advances in
food texture because of the following (Piette, 2006):
Lack of exposure to age-appropriate foods
Oral sensitivity
Lack of oral muscular strength and coordination to bite and chew age-appropriate
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
foods
Lack of ability to use fingers to self-feed
An infant should be referred to an occupational or speech therapist skilled in feeding
disorders if oral motor issues or sensitivity impair the development of feeding skills,
especially when combined with poor growth. Refer to the developmental disability section
for more information on feeding disorders.

Expression, Handling, and Storage of Breast Milk

At times, mothers and infants need to be separated; advance knowledge of this separation
allows mothers to decide how best to express and store their milk for future use. Some of
the common reasons for separation include returning to work or school, hospitalization of
the infant or the mother, or illness. Specific guidelines for expression, handling, and storage
of breast milk may be found in the Breastfeeding & Lactation section.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants > Fluid Needs or Limits
Fluid Needs or Limits

Fluid needs may be calculated using several different methods.
A basic method for calculating daily maintenance fluid requirements is as follows:
Body weight 1-10 kg = 100 mL/kg
Body weight 11-20 kg = 1,000 mL + 50 mL/kg for each kg >10 kg
Body weight >20 kg = 1,500 mL + 20 mL/kg for each kg >20 kg
According to the Dietary Reference Intakes, the recommended amount of water or fluids
that should be given is 0.7 L/day for infants aged 0 to 6 months and 0.8 L/day for infants
aged 7 to 12 months (IOM, 2006).
Individual fluid requirements may vary from the general guidelines; fluid intakes
significantly below or above the recommended amounts should be evaluated.Total fluid
needs may be met by all fluids the infant consumes, including breastmilk, infant formula,
and juice when appropriate.
Supplemental fluids can interfere with the establishment of lactation and thus are not
recommended (AAP, 2009g). The American Academy of Pediatrics states that there are
"no data basis for minimum or maximum usual water intake recommendations; water
intoxication not a discernable public health problem" (AAP, 2009d). Formula-fed infants
may need additional water beyond that supplied in formula in hot weather. For infants who
are exclusively or partially breastfed and eating complementary foods, offer water up to a
maximum of 225 mL/kg per day if there is dark or decreased urine output (AAP, 2009d).
Infants receiving nutrition support may require a more individualized approach to
calculating fluid requirements. See the Enteral Nutrition and Parenteral Nutrition sections
for more information.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Full > Term Infants > Issues to Consider
Allergy Prevention

Primary recommendation for prevention of allergies is exclusive breastfeeding for the
first 4 to 6 months of life (Greer, 2008; Ziegler, 2003; Prescott, 2008; Mihrshahi, 2007;
Heine, 2008; Herz, 2008; Du Toit, 2011; Wu, 2009, Host, 2004; Eigenmann, 2004;
Sampson, 2004).
Avoidance of common food allergens during lactation is unlikely to provide protection
from the development of food allergies according to some reports (Kramer, 2006;
Heine, 2008; Palmer, 2006; Greer, 2008; Du Toit, 2011; Dattner, 2010; Finch, 2010;
Sampson, 2004). However, other studies report that maternal diet restriction
reduces atopic disease in some cases (Dattner, 2010).
Infants who are at high risk for developing allergies (infants with at least one parent or
sibling with documented food allergy) and who are not exclusively breastfed for 4 to 6
months may benefit from the use of an extensively hydrolyzed formula. Soy formulas
provide no advantage in the prevention of allergies (Bhatia, 2008; Greer, 2008; von
Berg, 2003; Heine, 2008; Osborn, 2006; Osborn, 2005; AAP, 2009c; Herz, 2008; Du
Toit, 2011; Berg, 2010; Finch, 2010; Sampson, 2004).
Use of partially hydrolyzed formulas is controversial (AAP, 2009c). Several studies
and meta analyses support the use of partially hydrolyzed formulas (Hays, 2005;
Alexander, 2010; Szajewska, 2010; Alexander, 2010; Von Berg, 2007) whereas a
study published in 2011 does not (Lowe, 2011). The US Food and Drug
Administration has approved a qualified health claim that a partially hydrolyzed whey
formula in place of a cow's milk protein–based formula from birth to 4 months may
reduce the risk of developing atopic dermatitis throughout the first year of life
(Schneeman, 2011).
Probiotics and prebiotics may or may not play a role in allergy prevention
(Vanderhoof, 2008; Vael, 2009; Sherman, 2009; van der Aa, 2010; Kim, 2010,
Arslanoglu, 2010; Osborn, 2007; Moro, 2006; Dattner, 2010).
Long-chain polyunsaturated fatty acids play a role in the development and maturation
of the immune system and may provide protection from the development of atopic
disease (Thijs, 2011; Ganapathy, 2009; Finch, 2010).
Introduction of solid foods before 4 months of age may increase the risk of
development of eczema but not of other allergic conditions (Tarini, 2006; ESPGHAN,
2008; Wu, 2009).
Delaying or avoiding the introduction of common food allergens such as wheat,
peanuts, fish, or eggs beyond 6 months of age does not reduce allergies, regardless
of whether the child is at higher risk for development of allergies (ESPGHAN, 2008;
Greer, 2008; Prescott, 2008; Omari, 2008; Poole, 2006; Snijders, 2008; Zutavern,
2006; Zutavern, 2008; Filipiak, 2007; Mihrshahi, 2007; Nwaru, 2010; Koplin, 2010;
Wu, 2009).
For more information, see Food Allergies.

Management of Cow's Milk Hypersensitivity

Approximately 2% to 3% of infants have a cow's milk protein hypersensitivity. By 4 years of
age, 80% of children will outgrow this sensitivity. Symptoms include diarrhea, constipation,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
bloody stools, vomiting, eczema, atopic dermatitis, urticaria, allergic rhinitis, coughing,
wheezing, and anaphylaxis (Vandenplas, 2007; Ewing, 2005; AAP, 2009c; El-Hodhod,
2010; Carroccio, 2006; Garcia-Careaga, 2005; Kattan, 2011; Allen, 2009; Kneepkens,
2009).
Cow's milk sensitivity is rare in breastfed infants because there are few cow's milk
protein antigens in breast milk. If sensitivity occurs, the infant may benefit from
maternal elimination of cow's milk protein (Vandenplas, 2007; Ziegler, 2003; Ewing,
2005; Heine, 2008).A 2- to 4-week trial of a diet free of cow's milk protein is
recommended (Vandenplas, 2007).
Partially hydrolyzed formulas or other milk types such as goat's, rice, or oat are not
recommended for the management of cow's milk allergy (Vandenplas, 2007; Kemp,
2008).
Infants allergic to cow's milk protein who are not breastfed should be fed an
extensively hydrolyzed protein formula. Soy formulas are not recommended, as these
infants may also be allergic to soy, especially those with immunoglobulin E–mediated
symptoms (Ziegler, 2003; Bhatia, 2008; AAP, 2000; AAP, 2009c; ESPGHAN, 2006;
Vandenplas, 2007; Kattan, 2011; Allen, 2009; Kneepkens, 2009). Among infants
with cow's milk allergy, 10% to 35% are also allergic to soy (Vandenplas, 2007;
Bhatia, 2008; Allen, 2009). After 6 months, the rate decreases to 5% (Allen, 2009).
Risk of failure of an extensively hydrolyzed formula is 10% (Vandenplas, 2007). If
symptoms persist on an extensively hydrolyzed formula, use of an elemental (amino
acid) formula is indicated (Ewing, 2005; AAP, 2009c).
Extensively hydrolyzed formulas may have a different taste than elemental (amino
acid) formulas. Parents should be advised that the taste of the formula to their infant
may not be the same as the smell the parent perceives.
Soy formula may be introduced after 6 months of age except for infants with food
protein–induced protocolitis or eosinophilic esophagitis (Kemp, 2008; Vandenplas,
2007). Among infants with food protein–induced protocolitis, 30% to 64% also react to
soy (Bhatia, 2008; ESPGHAN, 2006).

Diarrhea

In children with mild to moderate dehydration, treat fluid and electrolyte losses with oral
rehydration therapy (ORT) (CDC, 1992; Duggan, 1997; Sandhu, 2001a; Sandhu, 2001b).
Infants without dehydration should be fed their regular diet, and infants requiring
rehydration should resume their normal diet after rehydration. Following these guidelines is
effective; conversely, an elimination diet or antidiarrheal medications may increase the
duration of the diarrhea (Albano, 2010). Furthermore, fasting delays healing of the
intestinal mucosa whereas feeding promotes healing (CDC, 1992; Duggan, 1997;
Provisional Committee, 1996; AAP, 2009e).
Dietary Tips
Breast milk or formula is well tolerated and maintains nutritional status and decreases
stool output (Duggan, 1997; CDC, 1992; Provisional Committee, 1996; Sandhu,
2001a; Sandhu, 2001b).
Recommended foods include complex carbohydrates such as rice, potatoes, bread,
and cereals; lean meats; yogurt; and fruits and vegetables (Duggan, 1997).
Avoid foods high in simple sugars, as their osmotic effects can make the diarrhea
worse (Duggan, 1997; CDC, 1992).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sports beverages are not recommended, as they are higher in sugar and lower in
sodium and potassium than the recommended ORT (Provisional Committee, 1996)
Avoid foods high in fat as they can delay gastric emptying (Duggan, 1997; CDC,
1992).
Lactose restriction or use of a lactose-free formula is not necessary unless the infant
shows signs of lactose intolerance (Duggan, 1997; Sandhu, 2001a; Sandhu, 2001b).
The "BRAT diet" (bananas, rice, applesauce, and toast) is low in energy, protein, fat,
fiber, vitamin A, vitamin B-12, and calcium (AAP, 2009e; Duo, 2007). This diet can
impair nutritional recovery and lead to malnutrition. Therefore, it is not recommended.
Probiotics may assist in the management of diarrhea depending on the pathogen and
probiotic preparation (Canani, 2007; Allen, 2010).

Stool Patterns

Great variation exists in stooling patterns (see Stool Frequency table below) (Clinical
Practice Guideline, 2006; Arias, 2001; Hyams, 1995). The newborn can have as many as 8
to 10 bowel movements per day or may go 1 or more days without a bowel movement. It is
possible for infants not to have a bowel movement for 1 week and then have a normal, soft
bowel movement (Clinical Practice Guideline, 2006). The number of daily bowel
movements decreases significantly by the end of the first year.
Stool Frequency

0-28 days
of age
1-12 months
of age
Number
stools/24 hrs
Mean: 2.2-4
Range 1-9
Mean: 1.8-4.2
Range:
0.3-9.6
(Arias, 2001)
Frequency of producing stools varies by type of feeding (Akers, 2005). Breastfed infants
and infants on hydrolyzed protein formulas may have twice as many stools as infants on
cow’s milk or soy-based formula (Akers, 2005).
Stool characteristics also differ by diet. Breastfed infants' stool is greenish-yellow and loose
in consistency, whereas formula-fed infants' stool is greenish-brown and paste-like in
consistency.
Constipation
It is recommended that constipation—"stools that are less frequent than normal for the
infant or extremely dry, hard, or small stool”—be considered a symptom and not a
diagnosis (Akers, 2005). Constipation rarely occurs in the breastfed infant (Akers, 2005).
Thus, reassurance and monitoring are appropriate for the breastfed infant who is healthy
and thriving unless there are signs of an obstruction, enterocolitis, or Hirschsprung disease
(Clinical Practice Guideline, 2006; Arias, 2001). Infants will grunt, strain, turn red in the
face, and make all sorts of hard working noises when passing a stool.
Causes of constipation include the following (Akers, 2005; Heine, 2006):
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Inappropriate fluid intake
Excessive fluid losses
Allergy
Medications
Recommended dietary intervention requires following the following steps in the order
shown(Akers, 2005):
Verify constipation through family interview 1.
Evaluate adequacy of fluid intake 2.
Provide additional water if indicated 3.
Confirm accurate preparation of formula if infant is bottle fed 4.
Provide 2 oz of prune, pear, or apple juice per day; the juice can be divided into two
servings
5.
Provide complementary foods high in fiber if appropriate, such as legumes, beans,
fruits, and vegetables
6.
Parents should be discouraged from changing formula unless advised by their health care
provider, as this can make it difficult to determine whether the problem is an allergic
response (Akers, 2005).
If there is no relief from these recommendations and the infant appears to be in pain or
cramping, a physician should be notified (Akers, 2005). Under the guidance of a physician,
medical Intervention may include the following (Clinical Practice Guideline, 2006):
Barley malt extract, corn syrup, lactulose, or sorbitol may be used as stool softeners
Glycerin suppositories can help
Enemas are not recommended
Mineral oil is not recommended for infants because of the risk of aspiration

Colic

Colic occurs in 5% to 30% of infants (Crotteau, 2006; Clifford, 2002b; Savino, 2007). The
most common criteria are the rule of three: An infant who is "otherwise healthy and well fed;
has paroxysms of irritability, fussing or crying lasting for a total of 3 hours per day; and
occurring more than 3 days in any 1 week" (Savino, 2007). Colic ceases by age 3 to 6
months (Lucassen, 2007; Clifford, 2002b; Savino, 2007).
The etiology of colic has not been elucidated, and many strategies, including the
following, have been suggested to alleviate symptoms (Clifford, 2002a; Lucassen, 2007):
Some infants respond to a partially hydrolyzed whey protein formula (Cohen-Silver,
2009; Lucassen, 2007).
Approximately 10% to 25% of infants with colic are sensitive to cow's milk protein and
may respond to an extensively hydrolyzed formula (Lucassen, 2007; Heine, 2008;
Savino, 2007; Heine, 2006; Vandenplas, 2007) or maternal elimination of common
allergens for breastfed infants (Hill, 2005; Savino, 2007; Heine, 2006).
Fennel extract, mixed herbal tea, and sugar solutions may be helpful, although the
studies have major limitations (Perry, 2011). Use of any of these should be with
caution as side-effects are not know.
Frequent switching of formula is not helpful, as frequently enough time has not
elapsed to evaluate whether the formula change is efficacious. It may take several
days to see a difference and if the infant will respond to the formula change.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
days to see a difference and if the infant will respond to the formula change.
The best intervention is parental reassurance and time (Savino, 2007; Crotteau, 2006;
Clifford, 2002b)
Although soy protein-based formulas are indicated for some infants unable to tolerate cow
milk protein-based formulas, they are not effective in the management of colic (Bhatia,
2008; ESPGHAN, 2006).

Reflux

Gastroesophageal reflux (GER) is defined as "the passage of gastric contents into the
esophagus" (Vandenplas, 2009). GER is a normal physiological process and may or may
not involve regurgitation or vomiting of gastric contents (Vandenplas, 2009). Regurgitation
is defined as "the passage of refluxed contents into the pharynx, mouth, or from the mouth"
and may be also known by the terms "spitting up," "posseting," and "spilling" (Sherman,
2009).

Regurgitation is common in infants, occurring in nearly half of all infants aged 2 to 4
months (Jadcherla, 2002; Vandenplas, 2009; Martin, 2002; Nelson, 1997, Bhatia, 2009). In
an otherwise happy and growing infant, regurgitation is not considered problematic and
resolves with time (Jadcherla, 2002; Vandenplas , 2009). In fact, time reassurance of the
caregivers are the primary interventions (Craig, 2004; Hegar, 2008).
Therapeutic interventions, if warranted, include the following:
Positioning
Supine posture, right lateral position, and infant car seat position (ie, upright
position in a car seat) can make reflux worse (Jadcherla, 2002; Craig, 2004;
Carroll, 2002 )
Prone position with a 30° elevation and left lateral position are associated with
lesser episodes of reflux (Jadcherla, 2002; Omari, 2008; Pediatric GE Reflux
Guidelines, 2001; Bhatia, 2009; BMJ, 2010).
Use the prone position for sleep only in rare cases where the risk of death from
complications of gastroesophageal reflux is greater than the risk of sudden infant
death syndrome (SIDS). When prone positioning is necessary, risk of SIDS can
be decreased by avoiding soft bedding (Pediatric GE Reflux Guidelines,
2001; Bhatia, 2009).
Dietary changes
Lower volume with more frequent feedings (Jadcherla, 2002)
Minimizing and reviewing use of oral medications that are hyperosmolar
(Jadcherla, 2002)
Reflux caused by a food allergy frequently responds to a hypoallergenic formula
or a maternal elimination diet (Heine, 2006; Hill, 2000)
15% to 21% of infants with reflux also have a cow's milk protein allergy
(Vandenplas, 2007)
In these infants the frequency of vomiting decreases substantially
within 2 weeks (BMJ, 2010)
Thickened feeds
Reduce regurgitation frequency and amount by reducing
nonacid gastroesophageal reflux episodes (Craig, 2004; Wenzl, 2003;
Horvath, 2008; Vanderhoof, 2003; Moukarzel, 2007; Hegar, 2008;
Vandenplas, 2009; Chao, 2007; Craig, 2010).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Do not reduce acid gastroesophageal reflux (Wenzl, 2003; Horvath,
2008)
Strengthen parental reassurance (Vandenplas, 2009)
Side effects include coughing and diarrhea (Craig, 2004)
Addition of rice cereal alters the macronutrient profile and increases energy
density (Chao, 2007; BMJ, 2010)
Formulas thickened with rice starch are available
Advantages
Standard thickening: It is easy to overthicken formula using rice
cereal so that it does not flow easily through the nipple;
enlarging the hole increases risk of choking
Alteration of macronutrient profile or increased energy density
Disadvantages
Medications to reduce acid reduce the thickening ability of the
formula as it is designed to thicken in an acidic environment
May not be available through the Special Supplemental
Nutrition Program for Women, Infants, and Children
Enzymes in breast milk break down the starch, so it is not recommended
to use rice cereal as a thickener for breast milk
Medical therapy: Side effects and lack of response are the main problems with the
use of these agents (Craig, 2004; Bhatia, 2009; van der Pol, 2011; Craig, 2010; BMJ,
2010; Hassall, 2011)
Prokinetic agents such as bethanechol and metochlopramide
Acid suppression agents such as H2 blockers or proton pump inhibitors; Chiaro
(2011) provides recommendation for use and safety of proton pump inhibitors
Acid-neutralizing agents
Facilitate healing in the presence of esophagitis in older infants
Routinely used in neonates because of constipation (calcium- and
aluminum-containing antacids) or diarrhea (magnesium-containing
antacids)
Orenstein and McGowan (2008) report that 78% of infants symptomatic for GER improved
and 24% became asymptomatic with conservative treatment of positioning and dietary
changes.

Early Childhood Caries

Early childhood caries is defined as “the presence of one or more decayed, missing, or filled
tooth surfaces in any primary tooth in a child between birth and 71 months of age” (ADA,
2000). Risk factors for early childhood caries include poverty, premature birth, infrequent
tooth brushing, recent fillings/extractions, dental plaque/pain, maternal caries,
Mexican-American ethnic status, maternal low educational level, and maternal smoking
(Iida, 2007; Marrs, 2011). Medications containing sugar may lead to dental caries (Marrs,
2011).

Recommended feeding practices to prevent early childhood dental caries include the
following:
Provide a balanced diet.
Breastfeeding and bottlefeeding should be limited to meal times. An infant should not
be put to bed with a bottle containing formula or juice after eruption of the first tooth
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(AAP, 2009b; ADA, 2000; Isaacs, 2005). The decrease in the flow of saliva during
sleep limits the clearance of sugar from any beverage.
Beverages offered in a bottle should be limited to pumped breast milk, formula, or
water.
An open cup should be introduced at age 6 to 8 months.
Juice may be offered from a cup beginning at 6 months of age, limited to 4 oz per day.
Weaning from a bottle should be complete by age 12 to 16 months.
Examine and clean the infant’s gums and teeth regularly using a clean, moist
washcloth or a toothbrush and water (Isaacs, 2005; Story, 2002).


Vegetarian Diet

A vegetarian diet can meet the nutrition needs of infants (Mangels, 2001; AAP,
2009h). See the Sample Menu provided for a vegetarian infant meal plan.
Special attention should be paid to sources of zinc, iron, vitamin D, and vitamin B-12
(Mangels, 2001; AAP, 2009h). Breastfed infants of vegan mothers may need vitamin D
supplementation if maternal intake is inadequate. Meat substitutes such as dried beans
and peas, meat analogs, and tofu will enable the infant to meet protein, iron, vitamin B-12,
and zinc needs. Energy-dense complementary foods should be emphasized (AAP,
2009h).
Macrobiotic diets require very careful planning to meet all nutrition needs (Mangels,
2001). Guidelines for other nutrient supplementation are the same as those for
nonvegetarian infants (Mangels, 2001). See Nutrient Needs for recommendations
regarding supplementation of vitamin D and fluoride. See Normal Nutrition for Vegetarian
Children for additional information on vegetarian diets.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers
Toddlers


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers > Overview
Overview

The toddler (aged 1 to 3 years) has distinct nutrition and developmental needs. After the
first year of life, the growth rate slows, yet there is a steady increase in body size (see
chart in Nutrition Assessment). Along with the reduction in growth rate comes a decrease
in appetite and an increased need for vitamins and minerals.
Toddlers are striving to be independent. Self-feeding is important, even though they may be
still learning to handle feeding utensils and cups. Meals have acquired a greater social
significance. The role of caregivers is to allow exploration and independence, to set up
mealtimes to promote pleasure and success, and to avoid succumbing to unreasonable
demands. Caregivers need to provide quality foods to meet nutrient needs and establish a
good eating environment with developmentally appropriate feeding utensils, cups, and food
textures, so that children can develop positive lifelong eating habits (Patrick, 2005; ADA,
2008; USDA, 2005).


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers > Nutrition Assessment
Nutrition Assessment

Many children in the toddler age group spend time in several venues during the day,
including home, day care, or a family member’s care. Input from all caregivers who are
feeding the child may be difficult to obtain; furthermore, the child may have different eating
behaviors with each caregiver. Parents are frequently challenged with the changing
preferences of the child from day to day and from day care to home. Special attention
needs to be given to the feeding environments the child is exposed to and to the concerns
of the caregiver present for the nutrition assessment.
During the nutrition assessment, first evaluate any objective measures that are
available. Simple anthropometric measures plotted on the growth chart accurately by
actual age can put some issues with growth and perceptions of the child’s body size into a
better perspective. For the toddler, recumbent length and weight for length are more
accurate, especially if you can also consider the body frame of the parents present and a
history of the family’s heights and frames. Do not assume that a child has a growth
problem by the growth chart alone, and measure the weight for length even if someone
else has measured and plotted the child. If the measures that were obtained don’t appear
visually accurate for the child you are counseling, redo them, especially if the caregiver
with the child thinks they are not correct or the child was uncooperative for the
measurements. Make sure the head circumference is likewise monitored through 36
months for a complete picture of the child’s developmental growth status. Compare
unusual or disproportionate measures to the parents’ head sizes.
If laboratory values are available, make note of them and compare them to the pediatric
standards. Lab standards and values or ranges are highly variable depending on the
method used by the lab, so keep in mind your hospital or practitioners sources and results.
If there is a discrepancy in the laboratory results, address appropriately according to
deficiency or excess guidelines (FNB, 2006).

Then, if the objective measures do not address the concerns of the caregiver, get a family
and child history of food preferences, locations of meals, and health issues (Samour, 2005).
The child may have been exposed to different circumstances at other child-care venues,
and may have developed different habits and preferences the family is unfamiliar with and
ill-equipped to understand. Exploring these differences and offering the family information,
tips, and suggestions for coping with or correcting the behavior will help the
family members become more aware of their concern and put it into a better perspective.
For example, if the child is not drinking milk, it may be necessary to determine if she/he or
family members are lactose intolerant. Lactose intolerance has a higher incidence in some
races and, therefore, needs to be treated with respect and evidence-based counseling
(NCMHD, 2010).
Average Growth Rates for Children Aged 1 to 3 Years
Growth Measurements
1-2
Years
2-3 Years
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Average weight gain
per year (kg)

2.5

2
Average height gain
per year (cm)

12

9
Average head
circumference
per year (cm)

2.5

1

(NCHS, 2000)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers > Normal Laboratory Values
Normal Laboratory Values

If lab values are available, make note of them and compare them to the pediatric
standards. Some labs do not have the values compared to the pediatric standards or no
pediatric standards exist, so keep your reference at hand. If there is a discrepancy in the
labs, address appropriately according to deficiency or excess guidelines (FNB 2006).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers > Feeding Recommendations
Macronutrients

Energy
The average energy requirement is 90 kcal/kg to 102 kcal/kg of body weight. After the first
year of life, the growth rate slows and appetite decreases. Energy needs are dependent on
growth rate, body size, and physical activity. The average daily energy requirement is 900
kcal/day to 1,400 kcal/day (USDA, 2012).
Protein
Recommended protein intake for the child aged 1 to 3 years is approximately 13 g/day, or
1.1 g/kg (FNB, 2006). Adequate protein intake may be difficult to achieve during oral motor
skill development and when milk or breast milk intake is minimal. Other protein sources
from MyPlate Daily Food Plan (USDA, 2012) should be considered to help achieve protein
requirements, including breast milk.
Dietary fat requirements change during the toddler years. With the introduction of table
foods, the percentage of energy from fat begins to decline, but it is recommended not to
restrict fat and cholesterol for children younger than 2 years for continued brain and nerve
development. This may be the opposite if the child is introduced to more fast foods and
snack foods. Do not overly restrict fat in the diet of young children to less than 30% total
daily energy from fat and less than 10% total daily energy from saturated fat, unless under
medical supervision (Daniels, 2008).
Please click here for more information on DRIs for macronutrients.

Vitamins and Minerals

All Dietary Reference Intakes (FNB, 2006) for vitamins and minerals can be met with a
varied diet from all the food groups. Vitamin A intake may be suboptimal in this age group,
mainly because of the common dislike of or difficulty eating certain vegetables, but
substituting fruits and vegetables high in beta carotene can alleviate this problem, even if it
causes the child's skin to turn a little orange (USDA, 2005). Recent increases of rickets in
breastfed children have prompted the supplemental injections of vitamin D in all
neonates. Continued monitoring of lactating mothers’ vitamin D levels and supplementation
will alleviate the need for supplementing that group, but children's regular intake of a
vitamin D supplement or foods high in vitamin D is recommended (Samour, 2005).
Because children in this age group may be having difficulties accepting meats or cow's
milk, intake of the minerals iron, zinc, and calcium may be deficient. Grinding lean meats,
especially beef, and mixing with a sauce or gravy can help with both the zinc and iron
intake. The use of a cast iron skillet can improve iron intake, especially when used to cook
acidic foods like spaghetti sauce. Lactose intolerance may be a more prominent issue in
some ethnic groups. In these cases, calcium-enriched juice, cheese, or other culturally
appropriate foods high in calcium can be increased in the diet to replace milk. A
vitamin/mineral supplement may be discussed with the caregivers if eating is inconsistent
(Trahms, 1997).
Supplements should also be addressed for the child who is hospitalized for a long time or
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
on certain medications for a prolonged time (Maber, 2007).
More information on DRIs for vitamins and DRIs for minerals is available at these links.

Development of Feeding Skills

Throughout the toddler years, a child's diet includes an increasing variety of foods of
different textures, tastes, and colors. This follows the child's developing hand, arm, and
chewing coordination or feeding skills. Meals with snacks or 6 small meals per day are
required to meet nutrient needs, since the toddler has a small stomach capacity and is very
active.
Checklist for Development of Feeding Skills
_ Begins rotary chew (accomplished by 36 months) 12-18 months
_ Helps hold cup during drinking with both hands; use a lid or
assist with a regular cup
_ Discards the bottle
_ Feeds self with spoon, spills frequently (offer thicker foods)
15 months
_ Handles regular cup well; lifts, drinks, replaces
_ Inhibits turning over of spoon before it reaches mouth
_ Mostly feeds self (increased food refusals)
_ Hands empty dish to caregiver when requested
18 months
_ Eats part of meal with fork 21 months
_ Feeds self neatly with spoon, spills little 24 months
_ Drinks from a small cup, one hand holding 24 months
_ Pours well from glass to glass 30 months
_ Sucks through a straw well 36 months
(Combined checklist from speech language development, oral motor development and a
notes sheet for clinical evaluation from Diana M. Miller, MPH, RD, LDN, CLC; August 2007)

Suggested Portion Sizes

Recommendations for Children Ages 1 to 3 Years
Foods Servings/day Serving sizes
Grains 6 = 5 oz
Bread, loaf
Bagel, bun
Ready-to-eat cereal
Cooked cereal
Rice, pasta
¼-½
¼-½
1/3-½ cup
¼-½ cup
¼-1/3 cup
Fruits 2-3 each = 1 to 1½ cups
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
High vitamin C 1
½ small
1/3 cup
1/3 cup
Whole or sliced (preferred)
Canned (in juice) or fresh chopped
Juice

Other fruits 1-2
Vegetables 2-3 each = 1 to 1½ cups
High vitamin A (red, orange, and green) 1
¼ cup
¼-1/3 cup
Cooked, canned or fresh chopped
Juice

Starchy, peas & beans 1

¼-½ piece
¼-1/3 cup
Whole or sliced
Cooked or canned

Other vegetables 1
Whole or sliced
Cooked, canned, or freshly chopped

¼-½ piece
¼-1/3 cup
Dairy 4-5 = 2 to 2½ cups
Milk or yogurt
Cheese
½ cup
½ oz
Meats 2 = 2 to 4 oz
Beef, pork, poultry, fish
Legumes, nuts
Egg, small
1-3 Tbsp
2-4 Tbsp
1
Fats, Added Sugars and Sodium
Solid fats and sugar
Oils
Sodium
< 120 kcal/day
4 tsp
<2.3 g/day


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers > Fluid Needs or Limits
Fluid Needs or Limits

The usual milk intake for toddlers is 24 oz/day. The toddler is usually weaned from formula
by bottle or breastfeeding during their second year; it is replaced with cow’s milk from a
cup. Many toddlers have a problem accepting formula or milk from a cup, however, and
their fluid intake may suffer.
Fruit juices should be diluted to as much as 50% with water or substituted with water if
toddlers are drinking from a bottle or sippy cup. Limiting juice to 4 oz/day to 6 oz/day is
recommended for a more balanced diet and reduces risk of the child substituting sweet
liquids for food during a busy day. Other sweet beverages should be considered treats or
eliminated from the diet of children with a strong sweet tooth (Satter, 2008; USDA, 2005).
More information regarding DRIs for electrolytes and water is available.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Toddlers > Issues to Consider
Issues to Consider

Oral Health
Good dental care is important in the toddler years. Certain diet elements have been found
to help prevent the formation of dental caries. Conversely, certain types of carbohydrate
foods can lower the pH in the mouth, providing an environment conducive to tooth decay.
For improved dental health, use only water in the bottle for nighttime feedings. The use of
fluoride supplements should be discussed with a dentist or physician. The need for fluoride
supplementation varies with the age of the child and the level of fluoridation in the water
supply (Nunn, 2009). For a discussion of fluoride supplementation, see Nutrition for the
Full-Term Infant.
Fiber
The consumption of dietary fiber in childhood has been associated with many health
benefits, such as promoting normal bowel habits. The Dietary Reference Intake
recommends 19 g fiber per day (FNB, 2006). Many foods on the market have been
improved to contain whole grains and fiber, especially soluble fiber, for improved bowel
health.

Tips to Prevent Choking
A child who is choking may not be able to make noise or attract attention. Always
supervise mealtimes.
Be aware if the child is eating in the car.
Discourage eating while walking or playing. Encourage the child to chew and swallow
his/her food before talking or laughing.
Avoid hard-to-chew foods or foods that increase the risk of choking. Some childhood
favorites can be given simply by changing the form in which they are served.
Cut hotdogs and link sausage lengthwise and grapes into quarters, no larger
than a half inch.
Cook or steam carrots and chop corn.
Serve peanut butter spread thinly with jelly or fruit sauce and not by the spoonful.
Coughing is a sign a child is removing an object naturally. (Shelov, 2009)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children
Preschool Children


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children > Overview
Overview

Normal nutrition for the preschool child (aged 4 to 5 years) should provide adequate and
varied nutrition for optimal growth and development.
The continued slowing of growth velocity, the maturation of fine and oral motor skills, and
the development of independence affect diet and feeding. A caregiver’s sensitivity to cues
given by the child can make mealtimes enjoyable and encourage positive lifelong eating
habits (Maber, 2007; Satter, 2008).
For the preschooler, oral motor skills have developed to tolerate most of the
difficult-to-chew foods, although some children may still be mastering them to be able
to consume plain cooked meats, fruit peelings, and some fresh vegetables. For
hospitalized children, to optimize nutrient intake, extra attention should be given to
providing meals and snacks that incorporate most of their food preferences.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children > Nutrition Assessment
Nutrition Assessment

Many children in this age group are in several venues during the day—including home,
preschool, day care, or a family member’s care. Input from all caregivers who are feeding
the child may be difficult to obtain, and the child may have different eating behaviors with
each caregiver. Parents are frequently challenged with the changing preferences of the
child from day to day and from day care to home. Special attention needs to be given to the
feeding environments the child is exposed to and to the concerns of the caregiver present
for the assessment (ADA, 2008; Samour, 2005; Trahms, 1997).
During the nutrition assessment, first evaluate any objective measures that are
available. Simple anthropometric measures plotted on a growth chart can put some issues
with growth and perceptions of the child’s body size into a better perspective. The body
mass index (BMI) chart for preschoolers is odd looking, but a good start if you can also
consider the body frame of the parent(s) present and a history of the family’s heights and
frames. Do not assume that a child has a growth problem based on the growth chart alone,
and measure the BMI even if another clinician has measured and plotted the child (NCHS,
2000). If the measures that were obtained don’t appear correct for the child you are
counseling, redo them, especially if the caregiver with the child thinks they are't correct or
if the child was uncooperative for the measurements.
For the normally developing preschooler, biochemical data are only necessary for
monitoring iron status. Other indices can be ordered if something is not easily explained or
treated with counseling. If lab values are available, make note of them and compare them
to the pediatric standards. Lab standards and values or ranges are highly variable
depending on the method used by the lab, so keep in mind your hospital or practitioners
sources and results. If there is a discrepancy in the laboratories or measures, address
appropriately according to deficiency or excess guidelines (Samour, 2005).
If the objective measures do not address the concerns of the caregiver, take a family and
child history of food preferences and health issues, taking into account anything out of the
normal range for age (Samour, 2005). The child may have been exposed to different
circumstances at other child-care venues on a regular basis, and may have developed
habits and preferences the family is unfamiliar with and ill-equipped to understand.
Exploring these differences and offering the family information, tips, and suggestions for
coping with or correcting the behavior will help the family members become more aware of
their concern and put it into a better perspective (Patrick, 2005; Satter, 2008).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children > Normal Laboratory Values
Normal Laboratory Values

For the normally developing preschooler, biochemical data is only necessary to monitor
iron status. Other indices can be ordered if something is not easily explained or treated
with counseling. If lab values are available, make note of them and compare them to the
pediatric standards. Some labs do not have the values compared to the pediatric
standards, so keep your reference at hand. If there is a discrepancy in the labs or
measures, address appropriately according to deficiency or excess guidelines (Samour
2005).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children > Feeding Recommendations
Suggested Portion Sizes

Recommendations for Children Ages 4 to 5 Years
Foods Servings/Day
Serving
Sizes
Grains (at least ½ whole
grains)
6 = 5 oz
Bread
Buns, bagels, muffins
Crackers
Dry cereal
Cooked cereal
Rice, pasta
1 slice
½
4-6
½ cup
½ cup
½ cup
Fruits 3 = 1½ cups
High Vitamin C 1
Other fruits 2
Whole
Chopped or chunks, fresh
Juice or canned in juice
½-1 small
½ cup
½ cup
Vegetables 3-5 = 2 cups
High Vitamin A (red, orange,
and green)
1
Cooked, canned, or chopped raw
Juice
¼-½ cup
½ cup
Starchy, peas and beans 1-2
Whole
Cooked or canned
½-1 piece
½ cup
Other vegetables 2-3
Cooked, canned, or chopped raw
Juice
¼-½ cup
½ cup
Dairy 3 = 3 cups
Milk, yogurt
Cheese
¾ cup
¾ oz
Meats 2 = 5 oz
Lean meat, chicken, fish
Dry beans and peas
Egg
1-3 Tbsp
4-5 Tbsp
1
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fats, Added Sugars and
Sodium

Solid fats and sugar
Oils
Sodium
< 120
kcal/day
4 tsp
<2.3 g/day

Macronutients

Energy
Energy needs vary with growth rate, body size, and physical activity of the preschool child.
The average caloric requirement is 1,300 to 1,600 kcal/day, equivalent to approximately 90
to 102 kcal/kg of body weight (FNB, 2006; USDA, 2012). At this age, appetites may vary
and the average should be considered from a 3-day diet record or the typical intake of the
child over a week’s time.
Protein
Protein is required to synthesize enzymes and hormones that regulate body processes and
to continue stimulating growth. Protein is also used to build tissues. Protein Daily
Recommended Intake (DRI) is approximately 13-19 g/day, or 0.95 g/kg for the 4- to
8-year-old (FNB, 2006). After age 2, children should gradually adopt a diet that contains no
more than 30% of total calories from fat, less than 10% of total calories from saturated fat,
and less than 300 mg of cholesterol per day (USDA, 2010; Daniels, 2008).
Please click here for more information on DRIs for macronutrients.

Vitamins and Minerals

All DRIs for vitamins and minerals can be met with a varied diet from all the food groups.
Vitamin A intake may be suboptimal in this age group, mainly because of the common
dislike of certain vegetables, but substituting high beta-carotene fruits and vegetables can
alleviate this problem, even if it causes the child's skin to turn a little orange (USDA, 2005).
Because children in this age group may not eat enough meats or drink enough milk, intake
of the minerals iron, zinc, and calcium may be deficient. The use of an iron skillet can
improve iron intake, especially when used to cook acidic foods like spaghetti sauce.
Lactose intolerance may be a more prominent issue in some ethnic groups. In these cases,
calcium-enriched juice, cheese, or other culturally appropriate foods high in calcium can be
increased in the diet to replace milk (NCMHD, 2010).
A vitamin/mineral supplement may be discussed with the caregivers if eating is inconsistent
(Trahms, 1997). Supplements should also be addressed for the child who is hospitalized for
a long time or on certain medications for a prolonged time.

Types of Food
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Each meal should contain a variety of colors, textures, and interesting shapes, and
can be arranged artfully on the plate.
Children this age may not try foods that are combined into one dish. Foods should be
separated rather than in a sandwich, casserole or mixed with gravies and sauces. If
these are served, the child may pick apart the individual ingredients (ie,
disassembling a sandwich).
Provide small portions and allow the child to ask for second helpings as desired.
(See Suggested Portion Sizes.) A quick rule of thumb for serving sizes is 1/4 of an
adult serving.
Low-nutrient foods, such as candy, cookies, cake, snack foods, fruit drinks, and
sweetened and carbonated beverages, can be given occasionally, but should not
take the place of a meal or displace other, more nutritious foods (Satter, 2008; USDA,
2005).
If the child has any issues with his/her head or neck, such as ear infections, chewing
patterns could be immature and choking a strong possibility. Please encourage
continued appropriate choking precautions (See Normal Nutrition for Toddlers: Issues
to Consider).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children > Fluid Needs or Limits
Fluid Needs or Limits

Set a limit on fluids—such as juices, fruit drinks, soda, sport drinks, and milk—between
feedings. These can interfere with appetite at regular meal and snack times. Water is a
better choice to help quench thirst between feedings. Active 4-year-olds have been known
to have accidents if they do not stop playing to toilet. It may happen only once while playing
with friends, but if it persists, limited fluids and frequent toilet breaks may help the
child. Referral to the pediatrician may be warranted.
The Dietary Reference Intakes (DRI) (Adequate Intakes) for fluid needs of the preschooler
is 1.3 L/day to 1.7 L/day (FNB, 2006). For more information, see DRIs for Electrolytes and
Water.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Preschool Children > Issues to Consider
Issues to Consider

Oral Health
Good habits for dental self-care can begin in the preschool years. Certain diet elements
have been found to help prevent the formation of dental caries. Conversely, certain types
of carbohydrate foods can lower the pH in the mouth, providing an environment conducive
to tooth decay.
Recommendations for good dental health include regular toothbrushing, limiting intake of
sweet or sticky sugars and starches to mealtimes, and limiting the number of snacks to 2 or
3 each day. The need for fluoride supplementation varies with the age of the child and the
level of fluoridation in the water supply (Nunn, 2009). For a discussion of fluoride
supplementation, see Nutrition for the Full-Term Infant.
Fiber
The consumption of dietary fiber in childhood has been associated with many health
benefits, such as promoting normal bowel habits. The National Academy of Sciences,
Nutrition Section, recommends 19 g fiber/day for children aged 1 to 3 and 25 g fiber/day for
children aged 4 to 6 years (FNB, 2006). Until the increase of fiber in more products over
the last decade and recent changes in the Special Supplemental Nutrition Program for
Women, Infants, and Children, it had been very difficult to meet these guidelines for
fiber (Kranz, 2006). Fiber sources include fresh fruit and vegetables, whole grain breads,
and cereals (see High-Fiber Foods).
Lead poisoning
Lead poisoning is another health issue for children in this age group. For children who are
exposed to lead, it is recommended that meals and snacks be given regularly to decrease
absorption of lead. Evidence has shown that a diet high in iron, low in fat, and adequate in
calcium and zinc has some protective and helpful effects (Wengrovitz 2009).
Obesity
A concern that has grown in the past couple decades is childhood obesity (see Weight
Management section). The number of children who are overweight has more than doubled
(ADA, 2008). Preschoolers who are overweight have an increased risk of health problems.
Attention should be given to type and amount of intake and physical activity patterns. It is
important to remember not to overly restrict food and fat intake of preschoolers, as this has
the potential to create psychosocial problems with overeating and an obsession with
food. If this problem exists in a given child, it may be revealed in the family food history
(Hornick, 2008).

Adequacy
When a variety of foods is consumed, the preschooler diet meets the Dietary Reference
Intakes (Food, 2006). Special attention may be required to ensure adequacy of vitamin A,
protein, calcium, iron, zinc, and energy, both for the hospitalized and the nonhospitalized
preschooler (Maber, 2007). The Meal Plans section provides a sample menu for preschool
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
preschooler (Maber, 2007). The Meal Plans section provides a sample menu for preschool
children.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children
School-Age Children


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children > Overview
Overview

The goals of nutrition management of the school-age child include the following:
Support optimal growth, development, and health
Establish healthful eating and physical activity behaviors that prevent immediate
health conditions (eg, iron-deficiency anemia, undernutrition, obesity, eating
disorders, dental caries)
Promote lifelong behaviors to reduce the risk for chronic diseases (eg, cardiovascular
disease, diabetes mellitus, hypertension, some forms of cancer, and osteoporosis)
A recommended normal diet for healthy children between 5-11 years of age should include
a variety of foods provided throughout the day and should be based on MyPlate, Dietary
Guidelines for Americans (2005), Healthy People 2010, and Bright Futures in Practice:
Nutrition.
Three meals each day with one to three planned snacks are recommended. When
children are of school age, it is the opportune time to teach the importance of food and
nutrition and model healthful eating habits so children can develop these good habits into
adulthood. It is important for the child to respond to his or her own internal cues of hunger
and fullness. Reinforcing the child’s ability to self-manage food intake is an important
component of successful, lifelong weight management (JADA 2008).
For more information, visit Nutrition Management of the Child Athlete, the Developmental
Disabilities section, and the Overweight and Obesity section.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children > Nutrition Assessment
Client History

To obtain a clearer picture of the nutrition history of the school-age child, the
following questions can guide the nutrition professional to identify the child's nutritional
status.
What is the child's weight and height? Where does the child appear on the clinical
growth charts? (CDC Growth Charts).
Is there a recent change in weight? If yes, describe.
How many meals does the child eat at home? Who prepares the meals at home?
How many meals does the child eat outside the home (such as via the school meals
program or at a friend's house or restaurant)?
Is there a recent change in appetite?
Does the child avoid any foods? If yes, why? Is the avoidance allergy related?
Has the child been advised to follow a special diet?
Does the child take vitamin/mineral supplements?
Does the child exercise? If yes, what type of exercise? How frequently does the child
exercise? How long is the duration of the exercise activity?
Does the child participate in organized sports?
What is the child's body image of himself or herself?
Availability of nutrition-related laboratory values may not be readily accessible yet can
direct the nutrition professional to guide the child and parents to more healthful eating
patterns that prevent nutrient deficiencies (anemia) and chronic diseases (hyperlipidemia)
and promote more healthful lifestyles.





Nutrition Standards for School Meals

When a child begins school, the daily routine may involve eating breakfast and lunch at
school. The US Department of Agriculture (USDA) has established meal plans to comply
with the applicable recommendations of the US Dietary Guidelines (Russell, 2000; SBP
2004). School lunch is designed to provide one-third of the Recommended Dietary
Allowances (RDA) for energy, protein, vitamins A and C, iron, and calcium during the lunch
meal. School breakfast is designed to provide one-third of energy and protein needs and
one-quarter of the RDA for the vitamins and minerals. The table on this page shows
the school lunch and breakfast distribution of nutrients, according to the updated nutrition
standards (IOM 2008), which are averaged over a period of a school week for verification
through nutritional analysis or food-based menu planning (CNP 1995).
School breakfast and lunch together contribute approximately 50% to 60% of the day’s
total intake of energy, protein, cholesterol, carbohydrate, and sodium (JADA 2008). Parents
and caretakers may underestimate how much food the children are getting, even if they are
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and caretakers may underestimate how much food the children are getting, even if they are
packing a lunch. Children in third grade generally have difficulties reporting what they have
eaten (Baranowki 1997). Parents and caretakers who are concerned that their child is at
risk for overweight may need to review school menus in advance and discuss the child’s
access to food while at school, since many children eat more at school than at home.
Families who do not participate in school meals may pack nutritious lunches at home. Use
of prepackaged items and convenience foods may make the packed lunch higher in fat and
sodium than what is recommended for school-age children. Food safety and storage of
home-packed lunches are important considerations at school. School-age children often
share or trade part of their meals at school and have classroom parties or snacks that
contribute to their intake.
Foods and beverages separate from the USDA school meals program are sold in schools,
regardless of nutritional quality. These foods, called competitive foods, are sold in a variety
of locations on school campuses nationwide (eg, canteens, school snack bars, vending
machines). School meals are required to meet federal nutrition standards, but competitive
foods are not held to these same standards. Most competitive foods have minimal
nutritional value and are high in fat, sodium, energy, and added sugar.
The American Dietetic Association position paper on nutrition integrity in schools
discourages sales of other food products and vended snacks of low nutritional quality
(JADA 2006). The Centers for Disease Control and Prevention also recommends offering
appealing and nutritious foods in school snack bars and vending machines and
discourages the sale of foods high in fat, sodium, and added sugars on school grounds or
as part of fundraising activities (CDC 2005).
There are federal regulations in place regarding the sale of foods and beverages in
schools; however, the rules vary from state to state. These regulations prohibit access to
foods of minimal nutritional value (FMNV) in foodservice areas during mealtimes. FMNV
are defined as foods providing less than 5% of recommended intakes for 8 key nutrients.
These foods include carbonated soda, gum, hard candies, and jelly beans. Potato chips,
chocolate bars, and doughnuts, however, are not considered FMNV and can be sold in the
cafeteria or elsewhere at any time (CDC 2005; USGA 2005).
To help in the promotion of improved nutritional outcomes in school-age children, Congress
passed a law placing responsibility at the local level for developing a wellness policy to
promote student health, prevent childhood obesity, and battle the risks associated with
poor nutrition and physical inactivity. The responsibility is placed on each educational
agency participating in the school lunch and breakfast programs. These agencies are to
set goals for nutrition education, physical activity, campus food provision, and other
school-based activities designed to promote student wellness (Russell, 2000).

Child Nutrition Program: Recommended Nutrient Targets for School Lunch and
School Breakfast by Age-Grade Group
Food
Component

Breakfast Lunch

Elementary
School
Middle
School
High
School
Elementary
School
Middle
School
High
School
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Calories 350-500 400-550 450-600 550-650 600-700 750-850
Fat (% of total
kcal) 25-35 25-35 25-35 25-35 25-35 25-35
Saturated fat
(% of Kcal) <10 <10 <10 <10 <10 <10
Protein (g) 10.2 21.6 21.8 15.2 32.2 32.5
Calcium (mg) 223 296 323 332 440 481
Iron (mg) 2.3 3.5 4 3.4 5.2 5.9
Vitamin A
(RAE) 129 162 186 192 241 277
Vitamin C 16 20 26 24 30 39
Note: g = grams; kcal = kilocalories (or calories as used to refer kilocalories); mg =
milligrams; RAE = retinol activity equivalents.
Source: Adapted from School Meals: Building Block for Healthy Children, Table 7-1.
Washington DC: National Academies Press; 2009.

Anthropometrics

Accurate measurement and interpretation of weight and height are key to the nutrition
assessment of school-age children.
Weight should be measured without shoes and outer clothing on a calibrated balance or
electronic scale. Privacy should be provided when the measurement is taken since weight
consciousness and body image concerns may begin at this age. Weight-for-age should be
plotted and interpreted using the CDC growth chart for children 2-20 years old.
Height should be measured without shoes using a wall-mounted stadiometer.
Height-for-age should be plotted and interpreted using the CDC growth chart for children
2-20 years old.
BMI-for-age should be calculated, plotted and interpreted using the CDC growth chart for
children 2-20 years old. BMI changes dramatically over this age range, reaching its lowest
point at 4-6 years of age and then steadily increasing in preparation for puberty (CDC
2007). This phenomenon is known as the adiposity rebound. As a result of this
physiological change in the proportion of weight to height, BMI can only be correctly
interpreted when plotted on the BMI-for-age growth chart.
Schools that participate in the federal School Lunch program are required to maintain a
school wellness policy. As part of the effort to stem the rising incidence of childhood
obesity, schools in this program are encouraged to weigh and measure all children,
calculate their BMI, and report this to their caregivers annually. An Excel spreadsheet tool
which can be used by school healthcare professionals to calculate student BMIs is
available on the CDC Website.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children > Normal Laboratory Values
Normal Laboratory Values

Laboratory Values
Age Laboratory Value

Hemoglobin
(g/dL)
Hematocrit
(%)
MCV
(mm
3
)
MCH
(g/L)
2-6 years 12.5 37 81 34
6-12
years
13.5 40 86 34
MCV = mean corpuscular value; MCH = mean corpuscular hemoglobin concentration
Total Cholesterol and Low Density Lipoprotein (LDL) Concentrations for
Children Aged 2-19 Years

Cholesterol
(mg/dL)
LDL
Cholesterol
(mg/dL)
Normal <170 <100
Borderline 170-200 100-130
High >200 >130

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children > Issues to Consider
Issues to Consider

School-age children have nutritional risks resulting from conditions identified in the age
range and as a result of national dietary trends. Attention deficit hyperactivity disorder, for
example, commonly occurs during these years and may be treated by medications that
may affect the child’s appetite and meal pattern (AAPCPG 2000).
Calcium Intake
Calcium intake has been documented to be low in the diet of school-age children (Baker
1999). In part, low calcium intake may be related to replacement of milk by fruit juice and
soft drink consumption in children and adolescents (Harnack 1999; JADA 2003). Some
school-age children have restricted diets because of food sensitivities that may also
contribute to inadequate nutritional intakes (Infante 2000). This decrease in intakes of
significant minerals can increase the risk of osteopenia or osteoporosis. Encouraging
children to continue to consume nonfat or low-fat calcium-rich or calcium-fortified foods and
beverages can promote skeletal growth and prevent bone disease (JADA 2003).
Vitamin D Intake
Historically, the risk for rickets caused by deficiency of vitamin D was a significant problem
in the pediatric population. The fortification of dairy products with vitamin D decreased the
rate of rickets in children. Sunlight exposure was also a recommendation made in the
prevention of vitamin D deficiency because vitamin D synthesis occurred naturally in the
skin after exposure to ultraviolet radiation from the sun.
However, the increasing concern for skin cancer later in life related to ultraviolet light
exposure during childhood caused major organizations (including the Centers for Disease
Control and Prevention, the American Academy of Pediatrics, and the American Cancer
Society) to launch a health campaign to encourage limited exposure to ultraviolet light and
use of sunscreen to help decrease the incidence of skin cancer.
Higher rates of vitamin D deficiency in children have been noted again. The current
recommendation is to provide vitamin D supplementation to all children and adolescents
who do not receive >200 IU/day of fortified foods (fortified dairy products, fortified cereals,
and juices and fatty fish) (Greer 2004).
Food Allergies
Food allergies are of concern with school-age children. Having multiple allergies places a
child at great risk for nutritional deficiency, leading to poor growth.
There is also concern for children with multiple food allergies who participate in the school
meals program. The school foodservice systems may make food substitutions for the child,
though there is no requirement to do so (USDA 2001). There are currently
no federal guidelines for food allergy management for schools. However, state guidelines
to help schools manage students with food allergies have been published in Arizona,
Connecticut, Maryland, Massachusetts, Mississippi, New Jersey, New York, Tennessee,
Vermont, Washington, West Virginia, Ohio, and Illinois (FAAN 2009).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Overweight and Obesity
One major issue is the alarming increase in the prevalence of overweight and obesity in
children and adolescents over the past 3 decades. Low activity and excess consumption
can increase the risk for overweight and cardiovascular disease (CVD) in adult life (Dietz
1998; Obarzanek 2001; Fisher 1997). Type 2 diabetes has also increased in school-age
children (ADA 2000).
Peers at school can influence the child's eating pattern and other nutrition-related issues
(eg, increased consumption of high-energy foods of low nutritional quality; limited intake of
fruit and vegetables; and increased concerns in body image, which could lead to eating
disorders). Although parents have less control than they did previously, they continue to
play a big role in training the child to make more healthful food-related choices.
Another issue that affects the school-age child is hyperlipidemia (elevated concentration of
any or all lipids circulating in the blood). Hyperlipidemia is a strong risk factor for
CVD. Other factors including genetics, environment, and presence of other disease, like
diabetes and hypertension, may lead to CVD.
The American Academy of Pediatrics recommends a child be screened for hyperlipidemia
after the age of 2 years and no later than the age of 10 years if there is a positive family
history of dyslipidemia or premature CVD (younger than age 55 for men, younger than age
65 for women) (Daniels 2008). Nutrition intervention includes promoting a healthful diet
following MyPyramid, including saturated fat at less than 7% of total energy, dietary
cholesterol less than 200 mg/day, and increased soluble fiber intake. Fiber needs can be
calculated using the formula of the child's age plus 5 g fiber per day, up to 20 g fiber per
day at 15 years of age (Daniels 2008).
Hunger and Malnutrition
Inadequate nutrition in childhood is also a significant problem, particularly in children with
insufficient or episodic hunger, such as those entering foster care as a result of neglect
(AAP 2000). Children from unstable environments, such as low-functioning families in
which primary caregivers are substance abusers, are at greatest nutritional risk. Federal
and state programs with a nutrition component for school-age children include
food-assistance programs; the Medicaid Early and Periodic Screening, Diagnostic, and
Treatment Program; and Aid to Dependent Children (Story 2000). The Children’s Health
Insurance Program is financed by federal and state governments and administered by the
states in an effort to ensure that children have access to health providers; it also has an
outreach component with the US Department of Agriculture, Food and Nutrition Service.
The growing population of homeless school-age children are at increased risk for food
insecurity and hunger. There are federal resources for feeding the homeless children. The
federal resources assist by providing full school year eligibility for free school meals,
Summer food service program, federal nutrition funds for shelters serving children and
youth, and supplemental nutrition assistance (formerly called food stamps) for children
and youth (FRAC).
Health Promotion
Childhood is an important time to establish healthful diet and exercise habits. Encouraging
physical activity for fitness and balancing food intake and activity in childhood can develop
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
social skills, self-confidence, and self-esteem (Story 2002; Birch 1998; Fischer 2000; JADA
2008). The Dietary Guidelines for Americans, has recommended an increase in physical
activity to 60 minutes per day for most days, preferably every day, for school-age children
and an increase in the consumption of nutrient-dense foods while maintaining energy
intakes within estimated ranges ( see Dietary Reference Intakes) to promote a healthy
lifestyle.
National efforts, such as the 5 A Day program (now called "Fruits-and-Veggies,
More Matters"), have shown effectiveness in increasing fruit and vegetable intake in
school-age children (Reynolds 2000). National programs targeted at lowering
cardiovascular risks in children are exemplified by the Dietary Intervention Study in
Children, which demonstrated adequate growth in 8- to 10-year-old children who received
a low-fat and low-cholesterol diet over a 7-year period (Obarzanek 2001).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children > Fluid Needs or Limits
Fluid Needs or Limits

The combination of addressing thirst and usual drinking behavior, especially the
consumption of fluids with meals, is sufficient to maintain normal hydration. Children who
are healthy, have access to fluids, and are not exposed to heat stress can consume
adequate water to meet their needs.
The Dietary Guidelines for Americans for fluids for children are as follows:
Children aged 4 to 8 years need 1,700 mL water per day
Boys aged 9 to 13 years need 2,400 mL water per day
Girls aged 9 to 13 years need 2,100 mL water per day


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > School > Age Children > Feeding Recommendations
Working with Parents

Most parents and caretakers of school-age children have a strong interest in their child’s
nutrition and growth and appreciate the reassurance that they are feeding their child a
healthful diet. They may request assistance in applying all the available nutrition
information to their child’s needs. When working with parents, literacy and health
literacy levels should be considered. Use of handouts, pictures, recipes, and so on should
be encouraged. Technology can also be a helpful way to reach out to parents (eg, Internet,
e-mail, or telephone).
Identifying individuals' parenting styles can help the health care professional guide the
parents to healthier outcomes. Parenting styles play a major role in the child's weight status
and outcome (Rhee 2006; Anzman 2009). One parenting style, for example, is to
respect the child's opinions but maintain boundaries and display sensitivity with
high expectation of the child's self-control. This parental characteristic has been associated
with increased self-regulatory ability and lower prevalence of overweight status later in
life. In contrast, children of parents who are emotionally uninvolved and have low
expectation of self-control are at increased risk for becoming overweight (Rhee
2006). Restrictive feeding practices have been associated with overeating, resulting
in higher weight statuses in children (Anzman 2009).
The balance of food intake and activity level is a key concept in chronic disease prevention
(Story 2000; ADA 2008). Parents can review and discuss MyPyramid and its importance in
promoting optimal growth and preventing vitamin and mineral deficiencies. MyPyramid can
guide both the parent and child to incoporate fruits and vegetables in to their daily food
intakes. Parents can be positive role models by practicing healthful eating
behaviors. Parents can also expose their children to nutritious foods by allowing them to be
active participants in creating the grocery list and in the grocery shopping.
If the overall dietary intake is balanced, specific vitamin and mineral supplements are
generally not necessary. If parents or caretakers are using alternative medicine or
over-the-counter supplementation for themselves, it is important to caution them that adult
dosages are not appropriate for children and to encourage them to discuss such
supplements with a registered dietitian and with the child’s physician.

Suggestions for Feeding the School-Age Child

Numerous factors influence the diet of the school-age child. Growing independence may
lead to resistance to certain foods and a gradual transfer of control of food selection from
the parent or caregiver to the child (MyPyramid). The school-age child may prepare or
purchase his or her own snacks and meals. Some children may be too involved in other
activities to respond to internal eating cues. Suggestions on eating environment, types of
food, and education and socialization can make meals more enjoyable and may encourage
healthful eating habits (Story 2000; Birch 2000; ADA 2008).

The Eating Environment

The eating environment plays a key role in establishing long-term habits that contribute to a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The eating environment plays a key role in establishing long-term habits that contribute to a
healthful lifestyle. Parents or caretakers are responsible for providing a quiet, pleasant
atmosphere for meals and snacks. School-age children can increasingly share this
responsibility. The following guidelines can be used to encourage a pleasant environment
for school-age children:
Serve meals and planned snacks at consistent times of day, allowing enough time for
the child to become hungry between meals and to eat at mealtimes. In addition,
allowing adequate time during meals can create a good eating environment that
provides ample time for the child to adequately chew and enjoy the food.
Eat meals while seated at a table and removed from distractions such as
watching television or movies and playing computer games. These activities may
encourage inappropriate snacking and lower activity, which contribute to the
development of obesity. Research has shown that there is an increased correlation
between family meals and psychosocial well-being and improved dietary intake
(Eisenberg 2004; Neumark-Sztainer 2003).
Provide opportunities for the child to participate in creating a pleasant meal
environment with age-appropriate activities, such as setting the table or choosing
seating arrangements.
Encourage positive social interaction by paying attention to the children during the
meal and by sitting together, talking together, and praising good table manners.
Do not use food as a reward or as punishment.


Types of Food

Parents or caretakers are the primary gatekeepers for selecting, procuring, and preparing
food brought into the home. School-age children should be encouraged to participate in
these decisions but should not be the primary decision makers. Offering the child a choice
of nutritious foods at meals and snacks is one way to assist a child in taking responsibility
for his or her own intake and learning to set limits on eating. Other guidelines include the
following:
Provide a variety of healthful foods. Make smart choices from every food group. Set
limits on low-nutrient snacks like candy, cookies, cakes, and carbonated/fruit-flavored
beverages. However, forbidding these foods can make them more desirable for the
child.
Provide a mix of favorite foods with new or less-liked foods to encourage acceptance.
Offering new foods repeatedly is usually necessary for acceptance.
Food textures may have to be soft when gums are tender, when deciduous teeth are
loose, when permanent teeth are first erupting, or with orthodontia treatment.
Serve milk with meals and limit access to sugar-sweetened beverages, such as juices
that are not 100% and carbonated/fruit-flavored beverages, between meals; excess of
these types of fluids may limit milk and food intake at meals.
Stress the importance of breakfast as part of the daily routine to school-age children.
Provide time for a variety of nutritious snacks, with portion sizes suitable for the
child’s age. Snacks can be a part of the daily routine, usually after school and after
sports activities. Healthful snacks include bread, crackers, cereals, fruit, raw
vegetables, low-fat cheese, lean meats, and dairy products such as pudding or
yogurt.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Limit sweet, sticky foods and foods that dissolve slowly in the mouth to decrease the
risk of tooth decay. Frequent snacks that contain simple sugars can also promote
tooth decay.


Education and Socialization

Parents or caregivers provide nutrition education, as role models, for their children.
Parental food likes and dislikes greatly influence children’s eating. Parents and caregivers
model portion sizes, the pace of the meal, and use of food as an emotional coping
mechanism. Working with parents regarding their own eating styles may be necessary to
improve the child’s nutrition. Some suggestions for parents for modeling healthful habits
are as follows:
Set a good example to promote healthful eating habits, table manners, and a positive
mealtime environment. Try to have one family meal together every day.
Model basic nutrition principles, such as accepting a variety of balanced foods in
moderation.
Use MyPyramid as a guide in menu planning for the child and for the family.
Involve the child in grocery shopping and in reading food labels. Encourage selection
of foods on the basis of nutrient content, such as fat or fiber.
Encourage the child’s participation in age-appropriate food-preparation activities while
providing adequate and safe supervision.
Allow the child to express hunger and fullness, and praise the child who appears to be
responding to his or her own internal cues. Children may be encouraged to select
their own portion sizes as part of learning to respond to personal cues, while avoiding
the "clean your plate" rule.
Allow the child to choose from a variety of foods within a meal and encourage the
child to select or refuse foods in a socially appropriate manner in public.
Use nonjudgmental behavioral approaches to mealtime problems, such as whining or
complaining at home and in public. Mealtime is usually not an appropriate time to
punish a child, although it may be necessary to have the child leave the table if
negative behavior continues.
Allow the child sufficient time (15 to 20 minutes) to finish the meal and encourage him
or her to remain seated at the table with others during mealtime. Distractions from the
telephone or television should be discouraged at mealtime.
Refrain from commenting about the child's food selection and the amount of food
consumed during the meal, as these comments can become harmful to the child's
sense of self-worth and self-esteem.
Nonfood rewards, such as special attention or an activity with the parent, are
recommended for acknowledging good behavior. Avoid using desserts or sweets as a
reward at mealtime, as this may make such foods more desirable and result in the
child’s preference for food rewards. Withholding food should not be used as
punishment.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents
Adolescents


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents > Overview
Bone Mass

In addition to height increases, approximately half of adult bone mass is accumulated
during adolescence. For most adolescents, 90% of bone mass has been gained by the
time they reach 18 years of age (Gong, 1994). Since the peak of bone mineral accrual
occurs during adolescence, it is vital to encourage optimal calcium consumption (Greer,
2006). The Dietary Reference Intake is 1,300 mg calcium per day (IOM, 2011). Several
factors may affect achievement of peak bone mass, including the following:
Hormonal fluctuations: estrogen, androgens, growth hormone, thyroid hormone,
parathyroid hormone (Loud, 2006). Use of depot medroxyprogesterone acetate
(DMPA) oral contraceptives may have a negative impact on bone mineral density in
young women (Cromer, 2004; Harel, 2010).
Amenorrhea: one component of the female athlete triad (ACSM, 2007)
Genetic potential
Weight-bearing activity, such as running or jumping for 10 to 20 minutes for at least 3
days per week (ACSM, 2004)
Tobacco use
Illnesses: such as intrinsic bone diseases, anorexia nervosa, cystic fibrosis,
inflammatory bowel disease (Loud, 2006)
Dietary substances that decrease retention of calcium (Greer, 2006)
Alcohol
Caffeine
Oxalates
Phytates
Vitamin and mineral intake, including vitamin D, calcium, phosphorus, and iron
Dairy consumption
Dairy products are the most common source of calcium in the western diet
(Greer, 2006)
Milk-drinking teens had higher bone mineral density compared to those who
drank little or no milk (Volek, 2003) (Du, 2002)
Milk fortified with vitamin D is one of the primary food sources of vitamin D in the
diet and vitamin D deficiency in youth may jeopardize attainment of peak bone
mass (Holick, 2005)


Physical Development

Puberty, which occurs during adolescence, is associated with myriad physical changes
and is defined as the physical transformation of a child into an adult. Puberty is
characterized by increases in height and weight, completion of skeletal growth, increases in
bone mass, changes in body composition, and sexual maturation.
Children enter adolescence and begin puberty at varying ages. The age of onset, duration,
and speed of puberty differ for each individual and therefore nutrition needs cannot always
be estimated based on chronological age alone. Research has shown differences among
girls of different ethnicities and race in terms of when they enter puberty (Stang, 2005).
Data indicate that African-American girls may enter puberty earlier than white girls and that
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
puberty lasts longer for African-American girls than it does for white girls (Herman-Giddens,
1997).
Tanner Staging, also known as sexual maturation ratings (SMR), is a scale based on
development of secondary sexual characteristics. SMR does not rely on chronological age
and therefore provides the best guidance for stages of development. Tanner stage ratings
start at 1(prepubertal) to 5 (adult). When available, SMR should be taken into consideration
for estimating nutrient needs (Stang, 2005).
Among girls, SMR is based on the appearance and growth of pubic hair and breast
development. For boys, SMR is based on appearance and growth of pubic hair as well as
genital development (Tanner, 1962). If sexual maturation stage is not identified, other
physical characteristics correspond to stages of sexual development for assessment. Girls
will begin their linear growth spurt at Tanner stage 2 and will have completed the majority
of growth by the onset of menarche at Tanner stage 4 (Spear, 2002). Boys may display
facial hair/mustache at the start of their growth spurt at Tanner stage 3 (Spear, 2002).

Linear Growth

Linear growth typically occurs at different times in development for boys and girls. Most
females begin the linear growth spurt during sexual maturity rating (SMR) stage 2, with
peak velocity of growth occurring at the end of stage 2 and during stage 3. This is typically
before the start of menarche. Approximately 15% to 25% of final adult height is achieved
during this growth spurt (Barnes, 1975; Tanner, 1962).

For males, the linear growth spurt will occur later in puberty, around SMR stage 4.
Males gain an average of 2.8 inches to 4.8 inches each year during their growth spurt
(Barnes, 1975; Tanner, 1962).

Teens with severely restricted energy intakes are likely to experience delayed or slow
linear growth.

Body Composition

In terms of changes in body weight, approximately half of adult ideal body weight is gained
during adolescence. Peak weight gain precedes linear growth spurt in girls and coincides
with growth spurt for boys (Spear, 2002). After menarche, most girls will gain no more than
2 inches to 3 inches in height; however, girls with early-onset menarche will have more
linear growth after menarche than girls who had later menarche (Spear, 2002).
On average, females gain 38.5 pounds during adolescence, with a slowdown in the rate of
weight gain around the time of menarche. Depending on the time of menarche, it is
possible for females to gain up to 14 pounds during the latter stages of adolescence. The
average age at which girls reach menarche in the United States is 12.5 years (Spear,
2002).
Adolescent males tend to experience a slightly greater average weight gain than females,
with approximately 52 pounds gained on average during adolescence (Barnes,
1975; Wong, 1995).
Although both males and females gain weight during adolescence, body fat and lean body
mass levels do not change in the same way for boys and girls. During adolescence,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
females will experience a fairly dramatic change in body fat and lean body mass:
Throughout adolescence, the average body fat levels increase from 16% to 27% and lean
body mass decreases from 80% to 74% (Frisch, 1983). (The opposite effect typically
occurs for boys, with increases in lean body mass and decreases in body fat.) These
changes in body composition are not always seen as positive among adolescent females
and, in some cases, can put adolescent girls at increased risk for disordered eating,
unhealthful weight-control behaviors, and body dissatisfaction.
For information on counseling overweight or obese adolescents, visit the Weight
Management section.

Psychosocial Development

Adequate nutrition during the adolescent years is crucial in order for teenagers to achieve
peak growth and development. Multiple factors—including the general psychosocial
development that occurs as a natural part of adolescence—contribute to whether adequate
nutrition is achieved during adolescence.
Emotional, cognitive, and social skills, which can affect food choices and nutritional intake,
are associated with the three stages of adolescence (Ingersoll, 1992):
Early adolescence (11-14 years): Teens are beginning to adjust to a new body image,
are strongly influenced by peers, and are still only able to think concretely for the most
part.
Middle adolescence (15-17 years): Teens begin to emotionally separate from their
parents and seek a greater degree of autonomy, to think more abstractly,
and possibly to engage in risky behaviors.
Late adolescence (18-21 years): Teens are further separating from parents and
establishing their own identity, completing the development of abstract and complex
thinking, and experiencing increased impulse control and a greater sense of social
autonomy.
The establishment of abstract thinking has a significant impact on nutritional decision
making as older teens are more likely to see the long-term implications of their food
choices. They may be able to relate a high intake of fast food and low intake of fruits and
vegetables with an increased risk for obesity, heart disease, and diabetes. On the other
hand, before the development of abstract thinking, teens often struggle with how their food
choices now will affect them later on in life. Health messages geared toward prevention of
chronic illnesses may not have the greatest impact on younger teens. Younger teens are
more receptive to messages that are aimed at what is currently occurring in their lives.
Nutrition interventions with teenagers need to be tailored to the developmental stage of the
individual adolescent. It is important when counseling a teenager to take adequate time to
determine his or her level of physical maturity and cognitive development. Taking the time
to determine these two aspects will allow the practitioner to best determine nutrient needs
and the most appropriate nutrition messages to be delivered during counseling.
The Dietary Guidelines for Americans are designed to prevent disease and promote health
through nutrition and physical activity recommendations. Specific recommendations for
adolescents are provided in the Dietary Guidelines. Additional sources of information on
adolescent nutrition and adolescent development include MyPyramid and Bright Futures in
Practice.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents > Nutrition Assessment
Nutrition Assessment

Multiple components are necessary for the most accurate nutrition screening and
assessment of an adolescent. Factors to consider when doing a nutrition assessment and
screening include the following:
Sexual maturity rating
Weight, height, body mass index (BMI)
Blood lipid values
Blood pressure
Food access
Specific dietary restrictions (food allergies, food intolerances, vegan, etc.)
Recent weight loss
Participation in competitive sports;
Substance abuse
Family medical history
Visual assessment (muscle wasting, acanthosis nigricans, swelling, mouth sores,
lanugo)
A nutrition assessment includes an accurate measure of height and weight and calculation
of BMI. Once BMI has been calculated, this should be plotted on the appropriate age- and
sex-specific growth chart. BMI categories are as follows (Barlow, 2007):
<5th percentile = Underweight
5th to 84th percentile = Healthy weight
85th to 94th percentile = Overweight
At or above 95th percentile = Obese
There is not a clear consensus on a definition of severe obesity in children. The Expert
Committee suggested identification in the 99th percentile; however, these cutoff points may
be imprecise. Adolescents with BMI at or above the 99th percentile have higher medical
risk and therefore intervention is more urgent (Freedman, 2007). The following table
displays the cutoff points for the 99th percentile for male and female adolescents based on
age (Barlow, 2007):
BMI (kg/m
2
) Cutoffs for the
99th Percentile
Age Males Females
11 30.7 31.5
12 31.8 33.1
13 32.6 34.6
14 33.2 36.0
15 33.6 37.5
16 33.9 39.1
17 34.4 40.8
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Underweight adolescents should be referred to a primary care physician to assess causes
for underweight, which could include metabolic disorders, eating disorders, or a chronic
disease. Similarly, adolescents who are overweight should be referred to a primary care
physician to assess any complications related to overweight. In some cases, a referral to a
comprehensive adolescent weight-management program may be needed. For more
information, see the Weight Management section.
An in-depth nutrition assessment should also include the following (Stang, 2005):
Medical history (any chronic diseases, previous illnesses, etc.)
Psychosocial history
Socioeconomic status (poverty, food insecurity, etc.)
Dietary recall (24-hour recall, food frequency, food records)
Meal and snack frequency
Supplement use
Food allergies
Food intolerances
Special dietary practices
Alcohol or substance use
Unhealthful weight-control behaviors/disordered eating practices
Physical activity level (eg, highly competitive sports)
Laboratory values (hemoglobin, serum lipids, blood pressure)
An accurate assessment of foods and beverages consumed is paramount in a nutrition
assessment. There are several options for gathering dietary history, including the 24-hour
recall, description of a typical day, and food records. The 24-hour recall may be the most
commonly used method in assessing intake, but it may be more challenging for teenagers
to recall what they ate during the past day. To help with this recall, starting with the most
recent thing they had to eat or drink may be beneficial. In an outpatient setting, a food
record may be a better option, if time allows. Typically food records are maintained for 3
days: 2 weekdays and 1 weekend day. This can be a good way to assess intake, but
teenagers may become more aware of what they are eating and make changes in usual
habits because they know their intake will be assessed by a dietitian. In most situations,
the 24-hour recall can provide a good overview of an adolescent’s eating habits and then a
food record could be completed later, if needed (Stang, 2005).
If food records are used for assessing nutritional status, being able to analyze the
information with a nutrient analysis software program provides additional benefits. Results
of the nutrient analysis should be reviewed with the adolescent and used as a counseling
tool. Discussing how his or her results compare with recommendations can be a starting
point for discussions regarding education and behavior change. Even without nutrient
analysis programs, intake from each food group can be compared with recommendations
as a way to simply and understandably interpret the adolescent’s intake. In addition,
providing the adolescent with a chance to assess his or her own intake can be empowering
and hopefully will lead to an increase in motivation to make changes. The MyPyramid
website provides a tool for assessing intake and comparing it to recommended intake.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents > Normal Laboratory Values
Normal Laboratory Values

Blood Pressure
Hypertension in children and adolescents is based on the normal distribution of blood
pressure in healthy children. Normal blood pressures are based on systolic and diastolic
pressures that are less than the 90th percentile for sex, age, and height. Hypertension is
defined as an average systolic or diastolic blood pressure greater than or equal to the 95th
percentile for sex, age, and height on three different readings (NHBPEPWG, 2004).

Systolic or Diastolic Blood
Pressure Percentilea
Normal <90th percentile
Prehypertension
90th to <95th percentile or if
blood pressure exceeds 120/80
even if <90th percentile up to
<95th percentile
Stage 1
Hypertension
95th-99th percentile plus 5 mm
Hg
Stage 2
Hypertension
>99th percentile plus 5 mm Hg
a
3 readings based on sex, age, and height
(NHBPEPWG, 2004)

Hemoglobin/Hematocrit
Hemoglobin and hematocrit values can be used to determine iron-deficiency anemia.
Females, once menarche has been reached, are at greater risk for iron deficiency than
males.
Normal Hemoglobin and Hematocrit
Values

Hemoglobin
(g/dL)
Hematocrit
(%)
Female
12-15
years
11.8 35.7
15-18
years
12.0 35.9
18+
years
12.0 35.9
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Male
12-15
years
12.5 37.3
15-18
years
13.3 39.7
18+
years
13.5 39.9
(CDC, 2002)
Higher altitudes as well as cigarette smoking raise the cutoff point for normal hemoglobin
and hematocrit values. Following are the adjustments for altitude and cigarettes for
hemoglobin and hematocrit (CDC, 2002).
Altitude
(feet)
Hemoglobin
(g/dL)
Hematocrit
(%)
3,000-3,999 +0.2 +0.5
4,000-4,999 +0.3 +1.0
5,000-5,999 +0.5 +1.5
6,000-6,999 +.7 +2.0
7,000-7,999 +1.0 +3.0
Cigarettes/Day
Hemoglobin
(g/dL)
Hematocrit
(%)
10-19 +0.3 +1.0
20-39 +0.5 +1.5
40+ +0.7 +2.0

Cholesterol
Criteria for total cholesterol levels and low-density lipoprotein (LDL) levels were developed
by the National Cholesterol Education Program (part of the National Heart, Lung, and Blood
Institute). The values are based on the average of two measurements (NCEP, 1992).
Cutoff Points of Total and LDL Cholesterol for
Individuals Aged 2 to 18 Years
Acceptable Borderline High
Total cholesterol
(mg/dl)
<170 170-199 =200
LDL cholesterol
(mg/dl)
<110 110-129 =130
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The American Academy of Pediatrics has developed population and individual approaches
to treat elevated cholesterol levels in adolescents (AAP, 2008).
In addition, the American Heart Association recommends that high-density lipoprotein
lower than 35 mg/dL and triglycerides higher than 150 should be considered abnormal for
adolescents (Kavey, 2003).


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents > Nutrient Recommendations
Energy

Energy needs vary depending on stage of maturation (Tanner stages) as well as level of
physical activity. Tanner stages use secondary sexual characteristics (pubic hair, breast
development, menarche, testicular development, and penile development) to assess the
level of pubertal maturation in an adolescent. By Tanner stage 5, full sexual maturation has
been reached. Level of sexual maturation corresponds well with linear growth, changes in
body weight and composition, and changes in hormone levels (Gong, 1994). The first signs
of puberty for males and females correspond with Tanner stage 2. Peak weight velocity
occurs before peak height velocity in girls but coincides with peak height velocity in boys
(Spear, 2002). Peak height velocity begins at Tanner stage 2 for girls and Tanner stage 3
for boys ( Spear, 2002).

The Dietary Reference Intake (DRI) for energy is known as the estimated energy
requirement (EER) and is based on calculations that account for an individual's energy
intake and expenditure, age, sex, weight, height, and physical activity level (PAL).
Estimated Average Energy Requirements
a
(kcal/day) for Boys Aged 9 to 18 Years
Age Sedentary PAL Low Active PAL Active PAL Very Active
PAL
9 1,530 1,787 2,043 2,359
10 1,601 1,875 2,149 2,486
11 1,691 1,985 2,279 2,640
12 1,798 2,113 2,428 2,817
13 1,935 2,276 2,618 3,038
14 2,090 2,459 2,829 3,283
15 2,223 2,618 3,013 3,499
16 2,320 2,736 3,152 3,663
17 2,366 2,796 3,226 3,754
18 2,383 2,823 3,263 3,804

a
EER calculated using "reference size" adolescents based on median height and weight
for ages.
Estimated Energy Requirements (kcal/day) for Girls Aged 9 to 18 Years
Age Sedentary PAL Low Active PAL Active PAL Very Active
PAL
9 1,415 1,660 1,890 2,273
10 1,470 1,729 1,972 2,376
11 1,538 1,813 2,071 2,500
12 1,617 1,909 2,183 2,640
13 1,684 1,992 2,281 2,762
14 1,718 2,036 2,334 2,831
15 1,731 2,057 2,362 2,870
16 1,729 2,059 2,368 2,883
17 1,710 2,042 2,353 2,871
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
18 1,690 2,024 2,336 2,858

See Nutrient Recommendations for more details on DRIs. EERs for individuals can be
calculated using the EER calculator available in the Calculators section of this site.

Protein

Protein intake during adolescence is used not only for maintenance of existing lean body
mass, but also for the new lean body mass that is gained during growth. Protein needs are
highest during the time of peak height gains, which typically occur between the ages of 11
to 14 years for females (Tanner Stage 2) and 15 to 18 years for males (Tanner Stage
3). Similar to energy needs, protein needs correlate closer with growth patterns than
chronological age (Spear, 2002).

The majority of adolescents consume more than the required amounts of protein, but there
are some adolescent populations where protein intake may be inadequate, including
individuals in the following situations where energy intake is inadequate:
Food insecurity
Eating disorders
General energy restriction
Vegan diets
Inadequate intakes of protein can result in decreased growth and decreased lean body
mass.


Dietary Reference Intakes (DRI) for Protein


DRI (g/kg/day) RDA
a
(g/day)
Boys and Girls aged 9-13 y 0.95 34
Boys aged 14-18 y 0.85 52
Girls aged 14-18 y 0.85 46
a
RDA = Recommended Dietary Allowance
Source: National Academy of Sciences, 2005

Minerals and Vitamins

Calcium
Because of the large increase in skeletal growth during adolescence, calcium needs are
greater than in childhood or during the adult years. Adequate calcium intake is critical for
reducing lifelong risk of fractures and osteoporosis resulting from poor bone mass (AAP,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1999). Many adolescents do not meet the recommendations for calcium intake. According
to data from the 2007-2008 What We Eat in America, National Health and Nutrition
Examination Survey, adolescent females had intakes of 878 mg/day and adolescent males
had calcium intakes of 1,173 mg/day—both lower than recommended intakes (NHANES,
2007).
Given the importance of calcium in the diet for bone health, supplemental calcium should
be considered an option if adolescents are not willing to increase intake through dietary
sources. Calcium carbonate contains the most elemental calcium of supplements
available, but calcium citrate and lactate are also options. Absorption is most efficient when
taken in doses of 500 mg or less and with food.
The Dietary Reference Intake (DRI) for calcium for males and females aged 9 to 18
years is 1,300 mg/day (IOM, 2011).
Iron
The requirement for iron increases in adolescence because of rapid growth and the
expansion of blood volume and muscle mass. Furthermore, with the start of menstruation,
girls have additional iron needs; thus, adolescent girls are more likely to have inadequate
intakes of iron compared with adolescent boys.
Iron deficiency is more common than full-blown anemia in the United States. Adolescent
females have higher rates of iron deficiency than males; minority females have some of the
highest rates (CDC, 2002). Poor iron status is linked to poor cognitive development among
children and adolescents.
Iron is found in animal and plant sources, but animal sources (heme iron) are much more
readily absorbed than plant sources (nonheme iron). To increase the absorption of
nonheme iron, sources of this nutrient should be consumed with a good source of vitamin
C.
The DRIs for iron are as follows:
Female
9-13 years: 8 mg/day
14-18 years: 15 mg/day
19-30 years: 18 mg/day
Male
9-13 years: 8 mg/day
14-18 years: 11 mg/day
19-30 years: 8 mg/day
Zinc
Zinc is important during adolescence because of its role in growth and sexual maturation.
Zinc is found naturally in red meat, shellfish, and whole grains; many foods are enriched
with zinc as well. Adolescents who follow a vegan diet or do not eat a lot of animal products
are at greatest risk for zinc deficiency.
Zinc and iron also compete for absorption, so higher intakes of one nutrient may reduce the
absorption of the other.
The DRIs for zinc are as follows:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Female
9-13 years: 8 mg/day
14-18 years: 9 mg/day
19-30 years: 8 mg/day
Male
9-13 years: 8 mg/day
14-18 years: 11 mg/day
19-30 years: 11 mg/day
Folate
Folate is necessary for protein synthesis and needs are increased during adolescence.
Many adolescents do not consume enough folate and should be encouraged to consume
increased amounts. Good sources of folate that adolescents typically consume include
fortified foods (breakfast cereal, bread), orange juice, milk, dried beans, and lentils.
Adolescent females who are sexually active need to pay special attention to consuming
adequate amounts of folate. Inadequate folate intake before pregnancy may increase the
risk of neural tube defects. All adolescents and women of child-bearing age (15 to 45
years) should consume 600 mcg of folate daily.
Vitamin D
Adequate vitamin D intake is needed for optimal bone health and the prevention of rickets.
Vitamin D can be produced through exposure of the skin to sunlight and through dietary
sources (although sources are limited). The use of sunscreen, which is recommended to
reduce risk of skin cancer, decreases the ability of the skin to synthesize vitamin D.
Individuals with darker-pigmented skin also have a decreased ability to synthesize vitamin
D.
Recent studies have shown that adolescents may be at risk for vitamin D deficiency
depending on skin pigmentation as well as location within North America. The new Dietary
Reference Intakes for vitamin D for children ages 9 to 18 years are 600 IU daily for good
bone health; the upper limit has been set at 4,000 IU per day to prevent risk for harm (IOM,
2011). Main dietary sources of vitamin D include vitamin D–fortified milk (100 IU vitamin D
per 8 oz) and fortified cereals or eggs (yolks).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents > Fluid Needs or Limits
Fluid Needs or Limits

Healthy adolescents are generally able to regulate their fluid intake and avoid dehydration
or overhydration. Adolescents should be encouraged to consume plenty of water as well as
other low-energy, nutrient-rich beverages, including skim or low-fat milk. Another option is
100% fruit juice but it should be limited to 8 oz to 12 oz per day (AAP, 2007).
One indicator teens can use to gauge hydration status is the color of their urine. When
adequately hydrated, urine should be straw or amber colored. Dark urine is a sign of
inadequate hydration and should be a signal to increase water intake. A general
recommendation to help adolescents meet their fluid needs is to consume 1 mL fluid per
kilocalorie expended.
One concern about fluid intake among teens is the high consumption of soft drinks and
other sweetened beverages. Although these beverages will help meet hydration needs,
they usually do not provide much, if any, nutritional value and usually contribute a
significant number of kilocalories to daily intake. Consuming large amounts of sweetened
beverages can cause unwanted weight gain (Malik, 2006). High consumption of energy
drinks and vitamin-enhanced beverages are also of concern, as these beverages may lead
to excessive intake of caffeine, sugar, and vitamins.
In addition, sugary beverages often take the place of more nutrient-rich beverages at meals
and between mealtimes. Therefore, when working with adolescents, it is important to
assess the amount of sweetened beverages being consumed and educate provide
education about increasing water consumption and decreasing sweetened beverage
intake.
Although water is the preferred beverage, exploring other substitutions for sweetened
beverages is often needed for adolescents who do not like the taste of water. Some
options to consider include adding sugar-free flavor packets to water; adding sliced
lemons, limes, or oranges to water; or choosing diet drinks instead of regularly sweetened
beverages.
Adolescent athletes are at particular risk for dehydration during activity. Further information
on fluid needs for athletes can be found in Issues to Consider: The Teen Athlete.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Adolescents > Issues to Consider
The Teen Athlete

Adolescents participating in vigorous activity and sports will have increased energy,
nutrient, and fluid needs compared with other adolescents. Most adolescent athletes do not
need to eat special foods to meet their increased needs but will need to eat more in
general to meet energy needs resulting from increased energy expenditure.
The types of foods adolescent athletes choose will likely have an impact on their athletic
performance, and therefore a well-balanced diet is essential. When working with teen
athletes, it is important to discuss the importance of balance and moderation and the
positive impact that eating a variety of foods will have on their performance. In general,
intake for most adolescent athletes should follow the general pattern of 55% of total energy
from carbohydrates, 12% to 15% from protein, and 25% to 30% from fat (Spear, 2005).
Hydration is important for athletes. During intense activities, sweating accounts for the
majority of fluid losses. Overhydration and underhydration can significantly impair athletic
performance. Adequate hydration is needed before, during, and after exercise to optimize
performance. A customized fluid replacement program is optimum and should consider
sweat rate, duration of activity, clothing and equipment, heat acclimatization, training, and
weather conditions (ACSM, 2007). General rehydration guidelines are as follows:
Fluid Intake Before, During, and After Exercise
1-2 hours before activity 10-14 oz of cool water
10-15 minutes before
activity
10-12 oz of cool water
During activity 4-6 oz cool water every 15-20 minutes
After activity
16-24 oz of cool fluids for every pound of weight
lost
Table adapted from: Spear B. Sports Nutrition. In: Stang J, Story M, eds. Guidelines for
Adolescent Nutrition Services. Minneapolis, MN: University of Minnesota; 2005. Available
at: www.epi.umn.edu/let/pubs/adol_book.shtm. Accessed October 15, 2010.
Adolescents may experiment with dietary supplements that claim to enhance performance,
but use of many of these supplements can lead to adverse effects. Anabolic steroids are
one supplement often used by teen athletes; adverse effects include menstrual
irregularities, testicular hypertrophy, hirsutism, hypertension, acne, lipid abnormalities, and
mood disturbances. Use of caffeine as a stimulant should be monitored and excess
intake—in the form of supplements, coffee, teas, sodas, or energy drinks—should be
discouraged, as it can lead to restlessness, insomnia, anxiety, hypertension, and cardiac
arrhythmia (Patrick, 2001).
Excessive intake of nutrients can also cause negative side effects. Adverse effects of
excessive supplementation of protein or amino acids (more than 2 g/kg/day) include
dehydration, gout, and impaired essential amino acid absorption (Patrick, 2001).
For more information, see the Child Athletes section.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Disordered Eating

Engaging in disordered eating is often seen among adolescents and can negatively affect
nutrient intake and overall nutritional status (Story, 1996; Neumark-Sztainer, 1997).
Incidence of the psychiatric disorders anorexia nervosa, bulimia nervosa, and binge eating
disorders among adolescent girls and young women are 1%,1% to 3%, and 3%
respectively (Lytle, 2002). A far greater percentage of adolescent girls (approximately
10% to 20%) exhibit some of the behaviors associated with anorexia and bulimia (Lytle,
2002). Many adolescents who don't meet the criteria for disordered eating still engage in
various potentially harmful behaviors such as self-induced vomiting, laxative use, binge
eating, and excessive exercise (Ackard, 2007). Adolescents who engage in disordered
eating behaviors are also at increased risk for developing eating disorders compared with
peers not engaging in these behaviors (Patton, 1990).
Unhealthful weight-control behaviors include skipping meals, fasting, taking laxatives,
vomiting, excessive exercising, and smoking cigarettes; data show that more than half of
adolescent girls and one-third of adolescent boys engage in these behaviors. In addition,
research has shown that, over time, dieting leads to weight gain, not weight loss, and that
both females and males who diet are more likely to binge eat than nondieting peers
(Neumark-Sztainer, 2005). Disordered eating can also include binge eating without
purging, as well as limiting or restricting types of foods eaten, and eating or not eating in
response to emotional or stressful situations.
It is important to assess the use of dieting, disordered eating, and unhealthful
weight-control behaviors when working with adolescents. Addressing these issues in a
nonjudgmental manner is important to gain trust from the adolescent, as there is often
shame or embarrassment caused by many of these behaviors. In counseling individuals
with disordered eating, using motivational interviewing techniques in addition to behavior
change strategies is often helpful.
Following is a list of topics that may be appropriate to address with adolescents engaging
in disordered eating behaviors:
Role of food in overall health (physical and mental effects of dieting)
Hunger and satiety cues
Portion sizes
Healthful eating and how all foods might fit into a healthful eating plan
Risks of using unhealthful weight-control behaviors
Basic nutrition information (roles of macronutrients and micronutrients)
Normalization of foods
Stress management and overall coping skills
For more information, visit the Eating Disorders section.

Adolescent Pregnancy

Pregnant adolescents have a higher likelihood of pregnancy complications and
low-birth-weight babies than older women primarily due to lack of early prenatal care
(ACOG, 2009). The additional nutrient and energy demands that occur during pregnancy
put a pregnant adolescent at increased nutritional risk. Early nutrition assessment and
intervention would provide for the best potential for successful pregnancy outcome.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Research has speculated on the competition for nutrients between the mother and the
growing fetus, especially among younger adolescents (Scholl, 1993; Scholl,
1994). Generally, when counseling pregnant adolescents, focus on providing well-balanced
meals and snacks that promote adequate weight gain and provide the following:
Adequate energy
Adequate protein
Typically increase protein needs by 25 g/day, so a 14-18 year old who
previously required 46 g/day now requires 71 g/day
Adequate carbohydrate
Encourage whole grains, fruits, vegetables, low-fat dairy, and fiber-rich foods
Moderate amount of dietary fat
Encourage monounsaturated and polyunsaturated sources
Adequate iron, calcium, folate, zinc, and vitamins A and D
Supplements should be provided when necessary
Dietary Reference Intakes for Pregnancy
Estimated Energy Requirement (EER) for Pregnant Adolescent by Trimester:
EER (kcal/day) = Nonpregnant EER + Pregnancy Energy Deposition
1st trimester: EER = Nonpregnant EER + 0
2nd trimester: EER = Nonpregnant EER + 340
3rd trimester: EER = Nonpregnant EER + 452

Equation for calculating EER for Nonpregnant Adolescents Aged 14–18:
EER (kcal/day) = Total Energy Expenditure + Energy Deposition
EER = 135.3 – (30.8 x age [y]) = PA x [(10.0 x weight [kg]) + (934 x height [m]) + 25

Physical Activity (PA) values:
Sedentary (typical daily living activities) = 1.0
Low Active (typical daily living activities plus 30 to 60 minutes of daily moderate
activity) = 1.16
Active (typical daily living activities plus at least 60 minutes of daily moderate
activity) = 1.31
Very Active (typical daily living activities plus at least 60 minutes of daily moderate
activity plus an additional 60 minutes of vigorous activity or 120 minutes of moderate
activity) = 1.56
Above equations reprinted with permission from Weight Gain During
Pregnancy: Reexamining the Guidelines, 2009 by the National Academy of Sciences,
Courtesy of the National Academies Press, Washington, D.C. (IOM, 2009)
Dietary Reference Intakes for Select
Nutrients for Pregnant Adolescents
Aged 14-18 Years
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Protein
EAR = 0.88
g/kg/day RDA =
71 g/day
Carbohydrate RDA = 175 g/day
Fiber AI = 28 g/day
Linoleic acid AI = 13 g/day
Alphalinolenic acid AI = 1.4 g/day
Iron RDA = 27 mg/day
Calcium AI = 1,300 mg/day
Folate RDA = 600 mcg/day
Zinc RDA = 12 mg/day
Vitamin A RDA 750 mcg/day
Vitamin D AI = 5.0 mcg/day
a
In the absence of adequate exposure to sunlight, and as cholecalciferol. 1 mcg/day
cholecalciferol = 40 IU vitamin D

EAR = Estimated Average Requirement
RDA = Recommended Dietary Allowance
AI = Adequate Intake
Reprinted with permission from Weight Gain During Pregnancy: Reexamining the
Guidelines, 2009 by the National Academy of Sciences, Courtesy of the National
Academies Press, Washington, D.C. (IOM, 2009)
Recommendation for Total and Rate of Weight Gain During Pregnancy, by
Prepregnancy Body Mass Index (BMI)
Prepregnancy
BMI
BMI
(kg/m2)
Total
Weight
Gain
Range
(lbs.)
Rates of Weight
Gain 2nd and 3rd
Trimester (Mean
Range in lbs/wk)
Underweight <18.5 28-40
1
(1-1.3)
Normal weight 18.5-25.9 25-35
1
(0.8-1)
Overweight 25.0-29.9 15-25
0.6
(0.5-0.7)
Obese (includes
all classes)
≥30.0 11-20
0.5
(0.4-0.6)
Reprinted with permission from Weight Gain During Pregnancy: Reexamining the
Guidelines, 2009 by the National Academy of Sciences, Courtesy of the National
Academies Press, Washington, D.C. (IOM, 2009)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Substance Abuse

Often the first exposure to potentially addictive substances occurs during the adolescent
years. Some teenagers will heed the messaging to abstain from drug, tobacco, and alcohol
use whereas others will experiment with perceived adult behaviors such as smoking
cigarettes, drinking alcohol, or taking drugs. Some adolescents will develop abusive
relationships with these substances or a true addiction, defined as “A chronic, relapsing
disease characterized by compulsive drug seeking and abuse and by long-lasting
neurochemical and molecular changes in the brain” (NIDA, 2009).
Health supervision of adolescents should promote risk reduction (tobacco, alcohol, or other
drugs) by discussing adverse health effects and providing anticipatory guidance to avoid
their use (Bright Futures, 2008). Using a nonjudgmental manner, ask the adolescent if he
or she has tried or is regularly using any addictive substances and offer help with
quitting. It will be paramount to clarify type, amount, and frequency of the substance when
interviewing the adolescent to determine if dependence exists and then determine the best
intervention strategies.
Cigarette use
According to the National Institute on Drug Abuse 2008 Future Trend Survey, there has
been a dramatic decrease in smoking trends for U.S. youth. Although promising, the
statistics show that approximately 7% of 8th graders, 12% of 10th graders, and 20% of 12th
graders had reported smoking cigarettes in the 30 days before the survey was completed
(NIDA,2009). Even if most teen smokers realize the potentially harmful effects of a regular
smoking habit, they have difficulty overcoming the addictive nature of nicotine and may be
more vulnerable than adults (NIDA, 2009). Nicotine has appetite-suppressing effects,
which may translate in decreased food intake, lower body weight, and the potential for
nutritional deficiencies in the adolescent (Jo, 2002). Smoking depletes plasma ascorbic
acid (Lykkesfeldt, 2000). The vitamin C needs of smokers increase by an additional 35
mg/day due to increased oxidative stress and metabolic turnover (NAS, 2000).
Smoking cessation, which requires an awareness of various treatment options to best
direct the client to the strategy that would be most successful for him or her, should be
advocated. Initial withdrawal from nicotine can cause unwanted symptoms such as
irritability, anxiety, sleep disturbances, increased appetite, and cognitive and attention
deficits. Some smokers, especially women, fear postcessation weight gain (typically 5
pounds to 10 pounds), which may deter attempts to quit. Some research shows that
addressing the concerns of weight gain with cognitive-behavioral therapy may enhance
successful treatment (NIDA, 2009).
Alcohol
True alcohol dependency is quite rare in adolescents but they are at higher risk for
alcohol-related accidents, deaths, and acute alcohol poisoning (SAMSHA, 1999). Alcohol
presents a dual threat to malnutrition. Alcohol contributes energy (7.0 kcal/g) and can
displace nutrient-dense foods in the diet and limit intake of essential nutrients. In addition,
alcohol can interfere with the digestion, absorption, and utilization of those
nutrients. Alcohol abuse is associated with deficiencies of many nutrients—including
carbohydrates; protein; fat; vitamins A, B-12, C, and E; pyridoxine; thiamine; and
folate—and minerals including magnesium, calcium, zinc, and iron (Lieber, 2000;
SAMSHA, 2006).
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Fluid and electrolyte imbalances should be addressed first during alcohol detoxification
(SAMSHA, 2006). Monitor for nausea, vomiting, diarrhea, and anorexia, which are common
in moderate to severe alcohol use. Provide 50 mg parenteral thiamine (Lieber, 2000) and
multivitamins (SAMSHA, 1999). Complete nutrition assessment and assess adequacy of
current diet for possible nutrient deficiency and correct with a balanced diet.
Other Drugs
Other drug substances—whether illicit, prescription, or over the counter—can lead to
abuse or addiction in the adolescent. In addition, use of these drugs can cloud good
judgment and lead to other risky behaviors such as unprotected sex or getting into a car
with someone under the influence. Drug use can impair ability to concentrate and retain
information and interfere with learning at school (NIDA, 2004), which is especially
problematic given that the long-term implications of poor school performance can
determine the trajectory of adolescents' futures.
Some drugs have a greater impact on nutritional status than others. For example,
marijuana can stimulate appetite, especially for sweet foods, and the effect is described as
having the "munchies" (Catalda, 2003). Cocaine is an appetite suppressant and can cause
anorexia and interfere with absorption of calcium and vitamin D (SAMSHA, 2006).
Withdrawal from stimulants such as cocaine can cause a voracious appetite initially
(SAMSHA, 1999). Methamphetamine is another stimulant that can suppress appetite and
lead to malnutrition and severe dental problems with long-term use (NIDA, 2006). In
addition, many drug addictions can lead to abnormal glucose tolerance.
Key Components of Nutrition Assessment for Substance Abuse
Assess laboratory values
Evaluate protein, vitamins, glucose, iron and electrolytes to determine scope of
deficits (SAMSHA, 2006)
Assess anthropometrics
Obtain a detailed weight history
Assess dentition and oral health
Adjust diet consistency as needed
Identify deficits using food-frequency or 24-hour recall
Determine food preferences and food tolerances, especially during the initial phases
of detoxification
Start providing well-balanced, attractive meals in a pleasant environment
If nausea and vomiting are present during initial detoxification, start with a clear
liquid diet and progress to solids as tolerated (SAMSHA, 2006)
Encourage nutrient-dense foods that provide adequate energy
Provide caffeine-free beverages (SAMSHA, 2006)
Provide healthful snacks and limit refined carbohydrates such as candy, cake,
cookies, and soda pop (SAMSHA, 2006)
This will help to prevent the substitution of sweets for the individual's drug of
choice (Escott-Stump, 2002)
Encourage whole grains and rich fiber sources to prevent constipation (SAMSHA,
2006; Escott-Stump, 2002)

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Normal Nutrition > Child Athletes
Child Athletes


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Normal Nutrition > Child Athletes > Overview
Overview

The term "youth sports" has been applied to various athletic programs that provide a
systematic sequence of practices and contests for children and youth. In reality, these
sports experiences differ greatly in competitive level, length of season, cost to competitors,
qualifications of coaches and officials, and skill levels of athletes.
In 2010, more than 7.6 million athletes participated in organized high school sports, the
largest group of participants ever (NFHS, 2011). In addition, more than 44 million child and
youth athletes play in recreational leagues each year in the United States. It is interesting
to note that females are the fastest-growing segment of youth athletes. The top 5 sports for
males are basketball, track and field, baseball, football, and cross country. For females, the
top 5 are basketball, track and field, volleyball, softball, and cross country. However, there
is also a growing trend among youth competing in sports such as skateboarding,
wakeboarding, surfing, bodyboarding, snowboarding, and inline skating.
Unfortunately, misinformation and heavy marketing by supplement manufacturers often
cause coaches and parents to recommend unhealthful and potentially dangerous nutritional
practices. Adequate intake of whole foods providing carbohydrate, protein, fat, and fluids is
essential for peak performance. Proper nutrition is one factor that can contribute to making
sports a positive experience for children and adolescents. If athletes are well hydrated and
adequately fueled, they will get more out of practice and competition than if they are not
nutritionally prepared.

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Normal Nutrition > Child Athletes > Nutrition Assessment
Physiologic Growth

When the puberty process begins, age is not a good indicator of nutrition
needs—especially for athletes. Until puberty, stature growth continues at an even pace.
Before puberty, children grow approximately 2 inches to 3 inches a year and gain
approximately 5 pounds a year. Adolescence is the only time following birth when the
velocity of growth actually increases.
Enormous variability exists in the timing of the onset of puberty and peak height velocity
(growth spurt). Adolescents of a given chronological age may vary widely in physiological
development and, therefore, energy and protein needs. An assessment of the degree of
maturation of secondary sexual characteristics is useful not only in evaluating physical
growth but also in determining nutrient needs. Sexual maturity ratings, often called Tanner
stages, are widely used to evaluate growth and developmental age during adolescence.
Stages are based on the development of secondary sexual development of breast and
pubic hair in females and genitalia and pubic hair in males. Following is an overview of
secondary sex characteristics and other developmental characteristics and how these
relate to nutrition needs for individuals who participate in sports and athletics.
Ratings of Sexual Maturation/Tanner Stage

Pubic
Hair/Genitalia
Corresponding
Physical
Changes
Relationship to
Sports
Boys
Stage
1
None Childhood High risk for heat
illness
Energy needs
increased slightly
Stage
2
Small amount of
pubic hair at
outer edges of
pubis, slight
darkening
Beginning penile
enlargement
Beginning
of enlargement
of testes
Scrotum
reddened and
changed in
texture
Increased activity
of sweat glands
Energy and
protein needs
increased only
slightly
Still not able to
add significant
muscle mass
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Stage
3
Pubic hair
covers pubis
Penis longer;
testes continue
to enlarge
Scrotum further
enlarged
Voice begins to
change
Faint
mustache/facial
hair develops
Axillary hair
present
Beginning of
peak
height velocity
(PHV) (growth
spurt 6-8 in)
Increased energy
and protein
needs for growth
and athletic
performance
Unhealthy
supplement
intake may
increase as a
result of desire
for competitive
edge
Increased fluid
needs
Stage
4
Pubic hair adult
type, does not
extend to the
thighs
Penis wider and
longer
Scrotal skin dark
End of PHV
Voice deepens
Acne may be
severe
Facial hair
increases
Hair on legs
becomes darker
and curly
Muscle mass
increases
significantly; if
athlete is in
strength sport,
protein needs
may be increased
Increased
supplement use
and risk for
misinformation
regarding diet
and supplements
possible
Increased fluid
needs
Stage
5
Adult type, hair
now spreads to
the thighs
Adult penis and
testes
Able to grow full
beard
Muscle mass
increases
significantly
Continue to add
muscle mass
Adult nutrition
standards apply
Increased fluid
needs
Girls
Stage
1
None Childhood High risk for heat
illness
Energy needs
increase slightly
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Stage
2
Small amount of
pubic hair,
downy on
medial labia
Small breast bud
Increased activity
of sweat glands
Beginning of
PHV (growth
spurt 3-5 in)
Increased energy
and protein
needs for growth
and athletic
performance
Dieting may
interfere
with PHV
Adequate
calcium intake
needed to
prevent stress
fractures
Increased fluid
needs
Stage
3
Pubic hair
increased,
darker, and curly
Breasts larger
but no
separation of
the nipple and
the areola
End of PHV
Beginning of acne
Axillary hair
present
Peak energy
needs decrease
Adequate
calcium intake
needed to
prevent stress
fractures
Increased fluid
needs
Stage
4
Pubic hair more
abundant,
coarse texture
Breast
increased size
Areola and
nipple form
secondary
mound
Acne may be
severe
Menarche begins
Energy and
protein needs
based on sport
Adequate
calcium intake
needed to
prevent stress
fractures
Increased fluid
needs
Increased risk of
eating disorders
and female
athletic triad
Increased risk for
iron-deficiency
anemia
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Low energy
intake or dieting
increases risk for
amenorrhea
Stage
5
Pubic hair adult,
spreads to
medial thighs
Adult distribution
of breast tissue,
continuous
outline
Increase in fat
and muscle mass
Adult nutrition
standards apply
Adequate
calcium intake
needed to
prevent stress
fractures
Increased fluid
needs
Increased risk of
eating disorders
and female
athletic triad
(Tanner, 1962)

Weight/Height and Body Mass Index

Assessment of weight in relationship to height, using the body mass index (BMI) growth
charts, enables evaluation of current nutritional status. BMI is a more sensitive index of
appropriate growth velocity than weight-for-age. The BMI should be used as a screening
tool and to track weight-for-height over time, not as a tool for recommending weight loss or
gain.
For optimal performance, BMIs should be between the 10th and 85th percentiles.
However, some adolescents have a high BMI because of a large, lean body mass resulting
from physical activity, high muscularity, or frame size. Triceps skinfold can differentiate
excess body fat from lean body mass in adolescents. For example, a low skinfold
measurement in an individual who is above the 85th percentile for BMI indicates a state of
being overweight, but not overfat. An assessment of muscle and arm circumference can
confirm the muscular composition. However, a skinfold at the 90th percentile or greater
with a BMI greater than the 95th percentile suggests overfat or true overweight/obesity.

Body Composition Assessment

Body composition assessment has important implications for health, fitness, and
performance. In the athlete, several factors affect the basis for estimating fat and lean
tissue. Before puberty, older children have higher body water and lower bone mineral
content and, therefore, a lower bone density (Nelson-Steen, 2000). Most skinfold equations
for children are based on adult or elite adolescent athletes and extrapolated for children
(Slaughter, 1988). Adult formulas may overestimate body fatness by 3% to 6% and
underestimate lean body weight. Other forms of body composition assessment (eg,
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underestimate lean body weight. Other forms of body composition assessment (eg,
bioelectric impedance) also may overestimate body composition.
Slaughter and Lohman have validated a formula that can be used for children and
adolescents 8 to 18 years of age (Slaughter, 1988). These equations are based on
research that shows that chemical maturity in humans does not occur until after adolescent
growth is complete (sexual maturity rating/Tanner Stage 5). Care must be taken to not use
body composition measurements for setting weight management or body composition
goals during these periods of change. Each athlete is different, and athletes perform better
at different body fat percentages (EAL, 2009).
Some sports rely on body composition for performance (eg, wrestling, gymnastics, and
track). The major concern for the child/adolescent athlete should be on health, not
performance. Often these recommendations can be at odds with the wishes of coaches
and parents. Nutrition education provided to coaches and parents is helpful in ensuring that
athletes are provided appropriate nutrition and avoid fads that make unrealistic
performance promises and may be dangerous.

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Normal Nutrition > Child Athletes > Normal Laboratory Values
Normal Laboratory Values

Laboratory values for child athletes are no different than for other children at a specific
age. Normal laboratory values are listed in the sections that deal with normal nutrition
across the life stages.

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Normal Nutrition > Child Athletes > Nutrient Recommendations
Energy

In all cases, athletes must consume adequate energy for growth. In determining energy
needs, it is important to assess the following:
Stage of development: Tanner stages or development stage is more critical to
determine energy needs than to make recommendations based on age.
Dietary Reference Intakes (DRI) for energy: The estimated energy requirements
(EER) are based on energy expenditure, requirements for growth, and level of
physical activity (IOM, 2006). Most athletes will be at the active or very active level
(See table below)
Macronutrient composition: 55% to 60% of total energy should come from
carbohydrates; 12% to 15%, from protein; and 25% to 35%, from fat (IOM, 2006).
It is important to note that variability exists for males and females in recommended EERs
because of variations in growth rate and level of physical activity. The table on this page
presents examples of EER based on age, reference heights and weights, and physical
activity level. The EERs for individuals whose heights and weights are higher or lower than
the reference heights and weights should be adjusted accordingly.
For the complete table and formulas to calculate energy needs, go to DRI energy table
(IOM, 2006).
Several factors may affect a young athlete's food intake, including socioeconomic status,
the actions of the individual responsible for food purchase and preparation, access
to adequate energy, intentional weight loss and body image disturbance, peer pressure,
and health problems (Dorfman, 2008).
Examples of EERs for Male and Female Children and Adolescents, Ages 8 to 18
Age

Reference
Weight
(kg [lbs])
Reference
Height (m [in])
Sedentary
PALab
Low Active
PALc
Active
PALd
Very Active
PALe
8 M
F
25.6 (56.4) 1.28 (50.4) 1,453 1,692 1,931 2,225
25.6 (56.4) 1.28 (50.4) 1,360 1,593 1,810 2,173
10 M
F
31.9 (70.3) 1.39 (54.7) 1,601 1,875 2,149 2,486
32.9 (72.5) 1.38 (54.3) 1,470 1,729 1,972 2,376
12 M
F
40.5 (89.2) 1.49 (58.7) 1,798 2,113 2,428 2,817
41.6 (91.6) 1.51 (59.4) 1,617 1,909 2,183 2,640
14 M
F
51.0 (112.3) 1.64 (64.6) 2,090 2,459 2,829 3,283
49.4 (108.8) 1.60 (63.0) 1,718 2,036 2,334 2,831
16 M
F
60.9 (134.1) 1.74 (68.5) 2,320 2,736 3,152 3,663
53.9 (118.7) 1.63 (64.2) 1,729 2,059 2,368 2,883
18 M
F
67.2 (148.0) 1.76 (69.3) 2,383 2,823 3,263 3,804
56.2 (123.8) 1.63 (64.2) 1,690 2,024 2,336 2,858
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(IOM, 2006)
a
PAL = Physical activity level
b
Sedentary PAL is rare in children
c
Low Active PAL = Less than 1 hour/day of physical activity
d
Active PAL = Approximately 1 hour/day of physical activity
e
Very Active PAL = More than 1 hour/day of physical activity (ADA, 2009; IOM, 2006)


For additional assistance with calculating EERs, go to the Calculators area of this site.

Carbohydrates

Although fat and carbohydrates provide energy for activity, carbohydrates are the most
efficient fuel for athletic performance. The energy from carbohydrate sources can be
released within exercising muscles up to 3 times faster than energy from fat. Therefore,
carbohydrate is the preferred fuel for working muscles. The only problem is that the body
can only store a limited amount of carbohydrate as glycogen primarily in the muscle
(muscle glycogen). Once used, glycogen must be replaced, or the athlete will have less
energy for endurance. The body uses carbohydrate mainly to provide energy for muscles to
do work. How much and what type of fuel (glycogen or fat) is used depends on how intense
the activity is and how long the exercise lasts (ADA, 2009).
Glucose converted from glycogen in the muscles is used for brief, intense exercise, such
as sprinting or jumping, as well as for sports that have intermittent aerobic activity, such as
basketball, football, or volleyball. Glycogen is used very quickly in intense exercise with as
much as 25% to 30% being used in first 30 seconds of activity. Endurance sports, such as
long-distance running or cycling, use glycogen stores initially and then those stores turn to
body fat for energy (ADA, 2009). As the intensity of the exercise increases, working
muscles have less oxygen available to them, and fat cannot be used as fuel. As the
intensity decreases and more oxygen is available (aerobic exercise), the body is able to
use more fat stores for energy and spare the glycogen (Steen, 1998).
Females may have less ability to increase muscle glycogen concentration with increased
carbohydrate consumption because they have less muscle mass than males. This
discrepancy is more evident when energy intake is insufficient (EAL, 2009).
Following are the daily ranges for carbohydrate based on weight and level of intensity
(ADA, 2009). The amount of carbohydrate required depends on the athlete’s age, sex, and
body weight; the intensity of the activity; total daily energy expenditure; and type of sport
(ADA, 2009).
Daily Ranges for Carbohydrate Based on Level of Training
Intensity of Activity Carbohydrate (g/kg/day)a
None/light training 3-5 g/kg/day
Moderate/heavy training 5-8 g/kg/day
Pre-event (24-48 hours) 8-9 g/kg/day
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Post-event (within 2-4
hours)
0.8-1 g/kg/hour for 4 hours after glycogen-depleting exercise
Adapted from ADA, 2009
a
Younger children need to eat at the lower levels, and adolescent male athletes need to
eat at the higher levels.
In addition to knowing the optimal amount of carbohydrate intake to maintain or build
glycogen stores, athletes should also be aware of the optimal timing of high-carbohydrate
meals and snacks (ADA, 2009). Since most children are dependent on parents for food,
educating parents along with the athletes on healthful options is critical to successful
performance.
Pre-Event
The goal of the pre-event meal is to prevent the athlete from feeling hungry before or
during the workout/competition as well as to maintain optimal blood sugar levels (Fink,
2009). The athlete is actually performing from glycogen stored in the muscles during the
24 to 48 hours before the event. In fact, a review performed by the American Dietetic
Association in 2009 showed that there was no significant effect of meal consumption 90
minutes to 4 hours before athletic performance (EAL, 2009).
The main dietary goal of the pre-event meal is to provide carbohydrate foods, especially
complex carbohydrates, along with moderate amounts of protein, small amounts of fat, and
extra fluids. The athlete’s food preferences should also be considered, particularly since
there is wide individual variation with regard to foods that might upset an athlete's stomach.
Some practitioners have recommended manipulating the Glycemic Index of foods and
meals to enhance carbohydrate availability and improve athletic performance. For example,
foods low on the Glycemic Index are often recommended before exercise to promote
sustained carbohydrate availability. Foods that are moderate to high on the Glycemic Index
are recommended during exercise to promote carbohydrate oxidation and following
exercise to promote glycogen repletion (Coleman, 2000). However, there is insufficient
evidence to recommend that all athletes consume foods low on the Glycemic Index before
exercise, but it may be helpful for some athletes who react negatively to pre-exercise meals
that are high on the Glycemic Index (Coleman, 2000). How much food to eat will depend on
how much time is available before the event/practice starts. The following table presents
suggested meal and snack timing.
Suggested Meal and Snack Timing for Athletes
Meal/Snack

Timing Examples
Snack (15-30 g
CHO
a
, < 5% fat)
½-1 hour before
Pretzels/fruit and fluids (eg, sports drink, water,
lemonade, 100% fruit juice)
Light meal
(30-40 g CHO,
5% to 15% fat)
2-4 hours before
Turkey sandwich, pretzels, fruit, fluids (eg,
sports drink, water, lemonade)
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Large meal
(50-60 g CHO,
15% to 25% fat)
4-5 hours
before (may need a
snack later to
prevent hunger)
Baked chicken, potatoes, fruit, bread, lemonade
and fluids, or peanut butter/jelly sandwich,
baked chips, fruit, and fluids (eg, sports drink,
water, lemonade/100% fruit juice, chocolate
milk)

a
CHO = Carbohydrate
Post-Event
Muscles are most receptive to storing glycogen during the 2 to 4 hours following exhaustive
exercise. During this time, there is a period, the first 2 hours after exercise, known as the
"muscle recovery window" or the "glycogen replacement window." This effect occurs
because the enzyme (glycogen synthase) responsible for storing glycogen is highly
elevated after exercise. Furthermore, after weight training, new muscle protein is being
synthesized. Eating or drinking carbohydrate immediately after the exercise or competition
and then again at 1-hour intervals may optimize the replenishment of glycogen in the
muscles (see the daily ranges for carbohydrate presented earlier on this page). This could
be accomplished by drinking a carbohydrate beverage immediately after the workout and
then eating a high-carbohydrate meal within the next 2 hours (EAL, 2009; Steen, 1998).
High glycemic carbohydrate sources may help during this post-recovery
period. Carbohydrate levels can be adjusted to meet the energy needs. The 2009
Evidence Analysis Library review suggests that athletes who consumed carbohydrate
during the recovery period of 4 hours after exhaustive exercise showed improvements in
athletic performance (EAL, 2009).
It has been proposed that small amounts of protein consumed during post-event eating
may enhance glycogen storage, improve recovery, and improve subsequent
performance (Ferguson, 2011; ACSM, 2007). Several studies have shown that athletes
who drank approximately 16 oz of fat-free chocolate milk had increased markers of muscle
protein repair. Chocolate milk was also shown to be superior to sports drinks and
carbohydrate solutions to help replenish glycogen stores (Ferguson, 2011). Others have
shown that endurance on subsequent exercise bouts was greatly improved with the
ingestion of fat-free chocolate milk as compared to carbohydrate replacement drinks (Karp,
2006).
Although the exact protein requirements for post-exercise will vary with the age and level of
intensity of the athlete, there remains questions about the optimal amount
post-exercise. However, most sports nutritionists agree that athletes need extra protein for
optimal performance and recovery. Furthermore, power athletes, or athletes wanting to
build muscle, may need slightly more protein than endurance athletes. On the other hand,
endurance athletes will need more carbohydrates with protein to replenish muscle
glycogen.
Carbohydrate Content of Common Foods
Milk shake (10 oz) 63 g
Bagel (1,
medium) 31 g
Crackers
(6) 15 g
Pretzels (1
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Dairy
Yogurt (8 oz) 42 g
Milk (8 oz) 12 g
Chocolate milk (8 oz) 27 g

Bread/Cereal
oz) 28 g
Cereal (1
cup) 15-25 g
Bread 1
slice 15 g
Potato 1 lg
50 g
Pasta ½
cup 22 g

Protein
Foods
Beans (½ cup) 17 g
Peanut butter (2 Tbsp) 6 g
Sunflower seeds (1 oz) 6 g
Macaroni and cheese (1 cup)
36 g

Fruits and
Vegetables
Raisins (4
Tbsp) 33 g
Apple (1,
medium) 21 g
Apple juice (½
cup) 14 g
Banana (1,
medium) 27 g
Orange (1,
medium) 16 g
Fruit salad (½
cup) 25 g


Sports
Drinks/
Other
Fluids
Gatorade (8 oz) 14 g
Propel (8 oz) 3 g
Powerade (8 oz) 19 g
Capri Sun Sport
a
(7 oz) 16 g
Lemonade
a
(8 oz) 25-30 g
100% fruit juice
a
25-30 g

a
Not for use during exercise but can be used after exercise for carbohydrate replacement.

Protein

Protein is an essential part of the adolescent athlete's diet. However, the key to protein's
successful role in the athlete's diet is moderation. The function of protein in youth is to
build, maintain, and repair muscle and other body tissue. The only way to build muscle is to
eat adequate amounts of protein and to exercise the muscles.
As with carbohydrate, protein recommendations are made in terms of grams of protein per
unit of body weight. Often parents, coaches, and athletes are drawn to protein supplements
(powders, bars, etc.) to increase protein intake, but almost all children receive adequate
protein from two servings of lean meats each day. It is important for parents and athletes to
understand that excessive protein will not lead to greater muscle mass development, but
may lead to more fat deposition and increase the risk for dehydration.

Protein Requirements
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The estimated average requirements for children and adolescents is 0.71 g/kg/day to
0.76 g/kg/day (IOM, 2006; BCM, 2009). The average teenager usually consumes
approximately 1.3 g/kg/day of protein.
Athletes who are just beginning a training program should consume adequate
energy with approximately 1.0 g/kg/day to 1.5 g/kg/day protein to reduce the loss
associated with increased protein turnover and nitrogen loss (ADA, 2009).
Endurance athletes may need 1.2 g/kg/day to 1.4 g/kg/day (ADA, 2009).
Athletes who chronically restrict energy require higher intakes of protein to allow for
adequate synthesis and repair of tissue. But it is more important to counsel these
athletes to increase energy to spare the protein rather than to increase protein above
1.7 g/kg/day (ADA, 2009).
Supplementation with specific amino acids will not increase muscle mass, decease
body fat, or improve endurance and should be discouraged (Dorfman, 2008; ADA,
2009).
Consuming excessive protein, whether from food or supplements, can lead to risk of
dehydration, stress on the kidney and liver, and possibly weight gain (if excessive
energy intake is consumed) (Dorfman, 2008).
Adding small amounts of protein, such as chocolate milk, to post-exercise eating can
improve subsequent exercise performance and proved increased protein synthesis
better than just carbohydrate beverages (Ferguson, 2011).

Vitamins and Minerals

Nutrients reported most often as less than adequate for school-aged children include
calcium; iron; and vitamins A, C, D (mostly for athletes during winter), E, and B-6
(Nelson-Steen 2000; Meyer 2007). Iron is important to maintain hemoglobin concentrations
as well as total iron stores during growth.
In adolescents, there are increased needs for growth, expansion of red blood cell volume,
and addition of lean body mass. Because iron-deficiency anemia can lead to poor stamina,
performance, and ability to learn, prevention should focus on regular consumption of
adequate sources of iron that are acceptable to the adolescent. Adequate intake of
B-vitamins is important to ensure optimal energy production and for building and repair of
muscle tissue (ADA, 2009).
Intake of calcium and vitamins A, C, and B-6 may be inadequate because adolescents
often avoid fruits, vegetables, and dairy products. The downside of high-intensity exercise
is the oxidative stress and body’s production of free radicals. Antioxidants are important for
athletes because they serve as scavengers for the free radicals and help prevent the
muscle damage. In addition, adequate vitamin C helps improve blood vessel integrity and
may help to reduce bruising in contact sports.
Calcium is especially critical in adolescents because the Dietary Reference Intake (DRI)
for calcium increases to 1,300 mg/day (IOM 2006; BCM 2009). Adolescence is when peak
bone growth and bone mineralization occurs. On average, an adolescent’s calcium intake
is one-half to two-thirds of the DRI. Inadequate consumption may place female athletes at
risk for stress fractures and osteopenia/osteoporosis (ADA, 2009).
Youth athletes should be encouraged to consume adequate vitamins and minerals by
eating a variety of foods. However, in rare occasions when food consumption is not
adequate or there is an increased nutrient need, then a simple multivitamin may be
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
warranted. The table presented in the Dietary Supplements section provides potential
adverse effects of consumption of vitamins and minerals above the DRI Upper Limit levels.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Child Athletes > Fluid Needs or Limits
Fluids Overview

Dehydration in athletics can be very dangerous. Fluids play a critical role in maintaining the
health and optimal performance of the pediatric athlete (Meyer, 2007). One of the most
important functions of water is to cool the body. As the athlete exercises, working muscles
generate heat, and this raises the temperature of the entire body. If the child/adolescent
athlete does not replace sweat by drinking fluids, he or she will become dehydrated. High
humidity impairs the body's ability to dissipate heat through sweating.
Prepubertal children/young adolescents are at even higher risk for overheating than
adolescents, who have begun the pubertal process (Meyer, 2007). A number of
physiologic differences, including the following, impair children's ability to thermoregulate,
particularly when ambient temperatures exceed skin temperature (ACSM, 2007):
Children have a proportionately larger body surface area than adults, so extreme
ambient temperatures have a greater effect on body temperature.
Children have lower sweating capacity than adults. Not until the onset of puberty does
sweating increase.
Lower sweating capacity means that children and young teens are less effective at
dissipating excess body heat.
Prepubertal children also have a lower cardiac output, which decreases transfer of
internal body heat to the body's surface and requires a longer time to acclimate to
warm temperatures (Casa, 2000; Bar-Or, 1994).
See the table under Physiologic Growth for more information.

Fluid Goals and Recommendations

The goals of fluid maintenance and hydration for athletes are to prevent dehydration and
optimize performance. Temperature, humidity, and type of sport may affect these
recommendations. It is often helpful to weigh athletes before and after practice and events
and replace fluids lost (16 oz to 24 oz for every pound lost). Athletes who lose more than
1% to 2% of total body weight in fluids are already dehydrated and will have decreased
performance. If an athlete has not regained the weight by the next practice or event, he or
she should be rested until totally rehydrated. This is especially critical in hot and/or humid
weather, when the risk for heat illness increases (Meyer, 2007; ADA, 2009; ACSM, 2007).
Following is essential information regarding hydration of athletes:
For activities lasting less than 60 minutes, water is all that is needed for hydration.
For activities longer than 60 minutes, other beverages, such as fluid-replacement
drinks, are helpful because of the additional carbohydrate and electrolytes (ADA,
2009).
Some studies suggest that the presence of flavoring, sodium, and carbohydrate in a
beverage enhances thirst and is effective in reducing or preventing voluntary
dehydration (Meyer, 2007; Otis, 1997).
With adolescents, carbohydrate-electrolyte beverages tend to elicit a greater fluid
intake in individuals than water alone. Therefore, drinking fluid-replacement drinks
may enhance fluid consumption even in events shorter than 60 minutes (Meyer,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2007).
Fluids consumed during exercise should provide 6% to 8% carbohydrate. Fluids
containing carbohydrate levels greater than this (eg, fruit juice, soda) may cause
delayed gastric emptying and may cause stomach cramping (Bar-Or, 1994; ACSM,
2007).
Beverages with high caffeine content may increase risk of dehydration.
Salt tablets provide excessive sodium and should never be used with children or
youth. Additional sodium may be needed for athletes playing in very hot and humid
conditions. If needed, the best solution is for children to eat salty snacks that will
satisfy increased sodium needs.
Heat-Related Illness: Signs, Symptoms, and Treatment



Signs and
Symptoms
Treatment
Heat
Cramps
Disabling muscular
cramps
Thirst
Chills
Rapid heart rate
Normal body
temperature
Alertness
Normal blood
pressure
Nausea
Make sure child/adolescent
avoids beverages that contain
caffeine
Give child/adolescent 4-8 oz of
cold water every 10-15
minutes (provide the lower
levels to younger children)
Move child/adolescent to
shade
Remove as much clothing and
equipment as possible
Heat
Exhaustion
Sweating
Dizziness
Headache
Confusion
Lightheadedness
Clammy skin
Flushed face
Shallow breathing
Nausea
Body temperature of
100.4ºF - 104ºF
Give child/adolescent 16 oz of
cold water for each pound of
weight lost
Move child/adolescent to a
cool place
Remove as much clothing and
equipment as possible
Cool child/adolescent with
whatever is available (eg, ice
baths, ice bags)
Heat Stroke
Shock
Collapse
Body
temperature higher
than 104ºF
Delirium
Hallucinations
Loss of
consciousness
Seizures
Call for emergency medical
treatment immediately
Cool child/adolescent with
whatever is available (eg, ice
packs, ice bags, immersion in
ice water) as much as possible
until emergency treatment
arrives
Intravenous fluids needed
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Inability to walk
Source: Adapted from Maughan, 1998

Hydration Recommendations
Timing Rehydration Amounts
1 to 2 hours before
event
12-22 oz of cool water (50°F-60°F) but always lower than the
ambient temperature
10 to 15 minutes before
event
10-20 oz of cool water (50°F-60°F)
During physical activity 4-6 oz cool water every 15-20 minutes
After physical activity
2-3 cups (16-24 oz) cool fluids (50°F-60°F) for every pound of
weight lost
Adapted from ACSM, 2007
Note: This is a consensus statement on youth football and heat stress and is based on
nonrandomized trials and observational studies and is a panel consensus judgment.
Younger children should drink amounts at the lower end of the range.
Tips to encourage young athletes to stay hydrated include the following:
Encourage athletes to stop at a water fountain between classes or, if allowed, to carry
water bottles and drink throughout the day.
Teach them to pack water bottle or sports drink in practice gearbag every day.
Explain that the body is dehydrated in the morning after sleeping and drinking extra
fluids in the morning can help to optimize performance later at practice.
Encourage them to drink extra fluids at lunch to help prepare for practice.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Child Athletes > Issues to Consider
Female Athlete Triad

An issue of major concern in female athletes is the interrelationship between disordered
eating, amenorrhea (absence of 3 consecutive menstrual periods), and osteoporosis—also
known as the female athlete triad (Patrick, 2001; Sanborn, 2000; Currie, 2005; ACSM,
2007). Physically active adolescents whose energy intake is not sufficient to provide the
energy needed to participate in physical activity are at risk for weight loss. This can lead to
menstrual irregularities, most often amenorrhea, and negative consequences for bone
health such as premature bone loss, decreased bone density, and increased risk of stress
fractures (Otis, 1997; ACSM, 2007).
Restricted food intake and poor body image can occur among adolescents of both sexes,
but those at greatest risk are females who participate in activities that focus on
appearance, size, body shape, or weight class (eg, ballet, gymnastics, figure skating,
running, crew). It is important to identify and treat individuals suffering from the female
athlete triad early because bone loss may be only partially reversible. Adolescents who
develop symptoms such as excessive weight loss, irregular menstrual periods, or frequent
injuries (including stress fractures) should be evaluated by a health care team, which
includes a physician, registered dietitian, and mental health providers (Otis, 1997; Sanborn,
2000; Currie, 2005, Dorfman, 2008). In addition to individual dietary treatment, nutrition
professionals should provide education to coaches, trainers, parents, and players about
signs and symptoms of disordered eating as well as where to refer for services.
Following is an overview of warning signs for eating disorders in young athletes.
Screening Elements and Warning Signs of Eating Disorder

Screening Areas Warning Signs
Body Image
Extreme dissatisfaction with body shape or weight
Profound fear of gaining weight or becoming fat
Eating Behaviors
Wide variation in energy intake
Always “on a diet”
Very low energy intake
Denial of hunger cues
Frequent comments such as “I already ate at home” to avoid
eating with teammates
Erratic meal patterns or frequent meal skipping
Difficulty eating in front of others
Avoidance of wide food groups (eg, meat, dairy, fats)
Food seen as good or bad
Physical Symptoms
Unexplained weight change or fluctuations
Body mass index less than 20th percentile
Irregular menses or amenorrhea
Constipation or diarrhea
Cold intolerance
Frequent lightheadedness
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Abdominal pain
Decrease in performance
Orthostatic hypotension (greater than 10 mm Hg after posture
changes)
Bradycardia (resting heart rate less than 60 beats/minute)
Physical Activity
Behaviors
Overtraining or compulsive attitude about physical activity
Psychosocial
Behaviors
Depressed affect
Frequent thoughts about food or weight
Withdrawal from friends, teammates, or team activities
Self-identity as an athlete only (ie, no identity outside of sports)
Worry about gaining weight or exhibition of anxiety if not
exercising
Adapted from Patrick K, Spear BA, Holt K, Sofka D. Bright Futures in Practice: Physical
Activity. Arlington, VA: National Center for Education in Maternal and Child Health; 2001.
Available at: http://www.brightfutures.org/physicalactivity/about.htm. Accessed February
15, 2012.

For more information, see Eating Disorders.

Dietary Supplements

In 2005, the American Academy of Pediatrics (AAP) published a policy statement, Use of
Performance-Enhancing Substances, which focused on athletes younger than 18
years (AAP, 2005). The recommendations included the following:
Use of performance-enhancing substances for athletic or other purposes should be
strongly discouraged.
Substances may pose a significant health risk to younger individuals.
Parents, coaches, and school and sports organizations should stress whole, nutritious
foods to young athletes.
Athletes should seek out appropriate professional and clinical resources regarding
this issue.
Athletes, coaches, and parents are often lured by promises to improve performance made
by over-the-counter dietary supplement manufacturers, particularly those marketed as
sports supplements. Claims of increased lean muscle mass, speed, endurance, fat loss,
and recovery appeal to athletes across all sports, and coaches often emphasize that
dietary supplements are a necessary training tool. In reality, little, if any, evidence suggests
that a healthy athlete in training needs to stray from the current recommended nutritional
requirements for active individuals. Among published reasons for use of these dietary
supplements, young athletes report improving performance, developing muscle, treating
illness, helping with growth, and combating tiredness. Influences on use by young athletes
consistently include parents, peers, coaches, the media, professional athletes, health food
stores, and health clubs or gyms.
Current levels of legislative oversight have allowed sport supplement products to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
flourish. In 1994, the Dietary Supplement Health and Education Act (DSHEA) was passed
and, with very few changes, it is still in effect today (DSHEA, 1994). A crucial outcome of
the DSHEA was that ingredients found in dietary supplement products were now exempt
from premarket evaluations for efficacy and safety that were required of new food
ingredients. Once products become available for consumer use, the US Food and Drug
Administration (FDA) is now tasked with addressing complaints and reports of adverse
effects. The burden of proof is placed on the FDA, not on the manufacturer, to identify
dietary supplement ingredients that may cause harm to the user. Until recently, consumers
of these products were asked to assume safety standards. Current Good Manufacturing
Practice (CGMP) regulations implemented in August 2007 are expected to help improve
the quality of ingredients in these products (FDA, 2007).
Concern remains regarding the scarcity of long-term clinical evidence to support dietary
supplement products in young athletes for performance reasons or otherwise. This not only
applies to products that are totally marketed for sports performance but also to suggestions
of use of high levels of vitamins, minerals, or protein. Following is an overview of
the adverse effects of high levels of certain vitamins and minerals.

Potential Adverse Effects of High Supplement Levels

Nutrient Potential Adverse Effects
Amino acid/protein
(>2 g/kg/d)
Dehydration, gout, gastrointestinal (GI)
upset, hepatotoxicity, renal toxicity,
hypercalciuria, impaired essential amino
acid absorption
Vitamin A
9-13 years: >1,700
mcg/d or 510 IU/d
a
14-18 years: >2,800
mcg/d or 840 IU/d
a
Fatigue, irritability, increased intracranial
pressure, GI upset, bone and joint pain,
hypercalcemia, skin and nail
abnormalities
Niacin
9-13 years: >20 mg/d
a
14-18 years: >30 mg/d
a
Flushing, GI upset, glucose intolerance,
hyperuricemia
Vitamin B-6
9-13 years: >60 mg/d
a
14-18 years: >80 mg/d
a
Headache, nausea, sensory neuropathy,
hepatocellular toxicity
Vitamin C
9-13 years: >1,200
mcg/d
a
14-18 years: > 1,800
mcg/d
a
GI upset, flushing
Vitamin D
9-18 years: >50 mcg/d
or 2,000 IU/d
a
Hypercalcemia, weakness, lethargy,
anorexia, nausea, vomiting, constipation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin E
9-13 years: >600 mg/d
a
14-18 years: >800
mg/d
a
GI upset, fatigue, weakness, lipid
abnormalities

a
Based on the DRI Upper Limit (IOM, 2006); adapted from Patrick, 2001.

Other Supplements
Creatine, the most popular dietary supplement today, has been shown to increase muscle
mass and strength in athletes who compete in strength or maximum effort activities lasting
short periods of time. It works by increasing the phosphorus in the muscles, which
increases adenosine triphosphate production and therefore more energy for maximal
exercision (eg, weight lifting). For endurance sports, however, it has been shown to reduce
performance. Side effects of creatine have not been shown in clinical trials but anecdotal
evidence from case reports, coaches, trainers, and athletes have shown potential kidney
problems and increased risk of dehydration and injury.
Increased fluids are recommended when taking creatine; children and teens already have
trouble getting adequate fluids in the absence of this supplement. This supplement then
can increase the risk for dehydration. Although creatine is currently not banned by any
organized sports agency and athletes are not tested for use, there are concerns regarding
its use by young athletes. Almost all experimental studies have been on adult athletes; few
clinical trials exist for healthy athletes younger than 18 years (AAP, 2005). The Position of
the AAP, Sport Medicine Section, is that creatine should not be used by athletes younger
than 18 (AAP, 2005). The AAP also states that children under 18 should not be given
supposed "performance-enhancing" supplements, but providers need to assure a healthy
nutrition intake. Sadly, there are products that are targeted to “athletes” as young as 4
years of age. Dietetics practitioners can recommend foods that contain natural creatine to
improve performance.
Caffeine intake has also been proposed as a sports supplement based on its supposed
ergogenic effect on athletes. Its proposed effects include the following:
May improve performance in steady-state endurance activities
Appears to reduce the perception of fatigue, thus allowing for further performance
Adverse effects of caffeine include the following:
Restlessness, nervousness, insomnia, hyperesthesia, and diuresis
Excessive doses increase sympathomimetic stimulation, which can interfere with
performance
However, many children and adolescents already consume large amounts of caffeine, and
adding more to affect athletic performance may induce unwanted side effects. Caffeine is a
substance that is part of drug testing by the International Olympic Committee and the
National Collegiate Athletic Association, although it is rarely tested in athletes. Ingestion in
amounts greater than 300 mg/day to 500 mg/day may place an athlete over the legal
limit. This is the equivalent to 3 cups of coffee or 6 to 8 sodas. Following is information
regarding the caffeine content of certain groups of products.
Caffeine Content of Selected Products
Product Caffeine Content
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Product Caffeine Content
Coffee 100-200 mg/cup
Tea 30-120 mg/cup
Cola 25-35 mg/can
High-caffeine cola 50-70 mg/can
Energy drinks 75-160 mg/8 oz can
Chocolate bar 30 mg/serving
Stay-awake pills Average 200 mg/pill
Information regarding caffeine content of popular drinks is available at
http://www.mayoclinic.com/health/caffeine/AN01211.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children
Vegetarian Children


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children > Overview
Types of Vegetarian Diets

A vegetarian diet does not include meat, poultry, seafood, or products containing those
foods (Craig 2009). Within this broad definition, there are several different types of
common vegetarian diets that are classified based on foods included and excluded.
Lacto-ovo vegetarian diet: Includes dairy products and eggs
Lacto vegetarian diet: Includes dairy products but not eggs
Vegan diet: Does not include dairy products, eggs, or other animal-derived foods
Because of the wide variety of these diets, it is important for nutrition professionals to
determine specific foods that are used and avoided by individuals who are following some
form of vegetarian diet.
Nutrition professionals may also encounter the following types vegetarian or
near-vegetarian diets.
Fruitarian diet: Vegan diet based on fruits, nuts, seeds, and vegetables classified
botanically as fruits (Mangels 2011)
Raw foods diet: Mainly or exclusively consists of uncooked and unprocessed foods
including fruits, vegetables, nuts, seeds, and sprouted grains and beans; rarely
includes unpasteurized dairy products and raw meat and fish (Koebnick 2005)
Macrobiotic diet: Based largely on grains, legumes, and vegetables; fruits, nuts, and
seeds are used to a lesser extent, and some practitioners will eat fish
Semi-vegetarian diet: An inexact term that encompasses occasional or regular
consumption of fish, poultry, and possibly meat
Note that the safety of extremely restrictive diets such as fruitarian and raw foods diets has
not been studied in children. These diets can be very low in energy, protein, and some
vitamins and minerals and cannot be recommended for infants and children.

Reasons for Vegetarianism

A number of reasons for choosing vegetarian diets have been identified (Lea 2006a; Lea
2006b), including the following:
Health
Environmental considerations
Animal rights/animal welfare
Concerns about world hunger
Nonviolent philosophy
Economics
Religious beliefs or practices
Dislike for taste of meat
Peer pressure
In addition, children and adolescents may choose vegetarian diets to emulate celebrities,
family or community members, or peers.

Health Benefits and Risks for Children
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Health Benefits and Risks for Children

Vegan, lacto-vegetarian, and lacto-ovo-vegetarian diets can be developed to meet
the nutrient needs of infants, children, and adolescents and promote normal growth (Craig
2009; Hebbelinck 2001; Mangels 2001; Messina 2001; Rosell 2005a).
Health benefits of vegetarian diets in childhood and adolescence include the following:
Promotion of lifelong healthful eating patterns (Craig 2009)
Lower intakes of cholesterol, saturated fat, and total fat (Larsson 2005; Perry 2002)
Higher intakes of fruits, vegetables, and fiber than nonvegetarians (Larsson 2005;
Perry 2002).
Leaner body mass in vegetarian children than non-vegetarians (Hebbelinck 2001)
Lower mean serum cholesterol levels (Krajcovicova-Kudlackova 1997)
Some children will continue to follow a vegetarian diet in adulthood. Health benefits
of vegetarian diets in adulthood include the following:
Lower risk of death from ischemic heart disease (EAL 2009)
Reduced risk for hypertension (Appleby 2002; Fraser 2009)
Reduced risk for type 2 diabetes (Tonstad 2009)
Reduced risk for the metabolic syndrome (Rizzo 2011)
Lower body mass index (Newby 2005; Spencer 2003)
Potential health risks of vegetarian diets in childhood and adolescence include the
following:
Poor growth reported in children on very restricted diets (Van Dusseldorp 1996)
Vitamin B-12 deficiency in unsupplemented vegan diets (Herrmann 2003)
Vitamin D deficiency in unsupplemented vegan diets with limited sunlight exposure
(Dagnelie 1990)
Lower bioavailability of zinc and iron (Food and Nutrition Board 2001)
Vegetarian or near-vegetarian diets may be used to camouflage an existing eating
disorder (Martins 1999; O'Connor 1987)


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children > Nutrition Assessment
Nutrition Assessment

Growth
Growth of vegetarian infants and children would be expected to be similar to that of
nonvegetarian infants and children (Hebbelinck 2001; Sabate 1991; Nathan 1997; Sanders
1988; Drake 1998). Assessment techniques are identical to those used for nonvegetarians
(see Nutrition Assessment headings in other Normal Nutrition sections). Although older
studies suggest that vegetarian girls may have a slightly later onset of menarche and the
adolescent growth spurt ( Sanchez 1981), newer studies report that, if nutrient and energy
needs are met, age at menarche is similar in vegetarian and nonvegetarian adolescents
(Rosell 2005a; Barr 2001).

Dietary Assessment
Dietary assessment should include:
Type and duration of vegetarian diet
Specific foods eaten and foods avoided
Food allergies and intolerances
Dietary supplements and herbs
Nutrient intake assessment based on dietary intake
Health issues requiring dietary modification
Activity level
Assessment of dietary adequacy can be based on the appropriate Dietary Reference
Intakes. Iron is the only nutrient for which there is a different RDA for vegetarians.

For adolescents who have recently become vegetarian, and who have other risk factors for
eating disorders, a screening assessment is indicated.


Food guides have been developed specifically for vegetarians (Mangels 2011; Messina
2003; Messina 2001) and these can be useful in dietary assessment and planning.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children > Normal Laboratory Values
Normal Laboratory Values

Well-nourished vegetarian children will have laboratory values that fall within the normal
ranges for age. If dietary and physical assessment by a registered dietitian identifies risk
for specific deficiencies, these deficiencies should be monitored through laboratory
assessment.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children > Nutrient Recommendations
Protein

If energy intake is adequate (See the section on Energy of the specific Normal Nutrition life
stage you are interested in) and a variety of protein-containing foods are chosen, plant
protein sources alone or in conjunction with dairy products and/or eggs can provide
adequate amounts of essential and nonessential amino acids ( Craig 2009). A variety of
protein-containing foods should be eaten over the course of the day.
Because of the amino acid composition and digestibility of plant proteins, vegan children
may have protein needs that are higher than the Recommended Dietary Allowances. One
estimate has called for 30% to 35% more protein for children aged 1 to 2 years, 20% to
30% more for children aged 2 to 6 years, and 15% to 20% more for children older than 6
years (Messina 2001). The following table is based on these estimates for protein needs of
vegan children.
Age/Gender
Weight
(kg)
Adjusted Protein
Recommendation
(g/kg)
Adjusted Protein
Recommendation
(g/d)
1-2 y M/F 11 1.4-1.5 15-16
2-3 y M/F 13 1.3-1.4 17-18
4-6 y M/F 18 1.1-1.2 20-22
6-8 y M/F 23 1.1 25
9-13 y M/F 36 1.1 40
14-18 y M 61 1.0 61
14-18 y F 54 1.0 54
Protein for Vegan Children and Adolescents

Protein sources for vegetarian infants include the following:
Breast milk or infant formula
Well-cooked and pureed legumes
Blended or mashed tofu
Cottage cheese and yogurt
Cooked eggs
Protein sources for vegetarian children and teens include the following:
Legumes (such as kidney beans, pinto beans, lentils, chickpeas)
Soy products (including tofu, tempeh, and meat analogues)
Nuts and nut butters, seeds and seed butters
Grains and grain products
Dairy products
Cooked eggs


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Omega-3 Fatty Acids

The omega-3 fatty acids are essential dietary nutrients. Docosahexaenoic acid (DHA), an
omega-3 fatty acid, plays a role in growth and function of nervous system tissue. A primary
source of dietary DHA is fish; thus, it is not surprising that lacto-ovo vegetarians and
vegans have been shown to have lower blood concentrations of DHA than nonvegetarians
(Sanders 2009; Rosell 2005b).
Some bioconversion of alpha-linolenic acid (ALA)—a plant-based omega-3 fatty acid
provided by foods including flaxseeds, flaxseed oil, canola oil, soybeans, tofu, and
walnuts—to the omega-3 fatty acids eicosapentaenoic acid (EPA) and DHA does
occur. The bioconversion of ALA to EPA and DHA is quite low, however (Williams 2006;
Plourde 2007). In addition, the dietary fat levels seen in some children may lead to low
intakes of ALA. DHA and EPA supplements derived from microalgae are a
non-animal–derived source suitable for vegetarians and vegans. These supplements are
well absorbed and positively influence blood levels of DHA (Conquer 1996; Arterburn
2007).

Iron

Iron bioavailability is estimated to be lower with a vegetarian diet than a nonvegetarian diet
as a result of the lower absorption of nonheme iron. The Dietary Reference Intake for iron
is 1.8 times higher for vegetarians (Food and Nutrition Board 2001).
Good iron sources for vegetarian infants and children include the following:
Whole and enriched grains and grain products
Iron-fortified, ready-to-eat breakfast cereals
Iron-fortified meat analogues
Legumes
Green vegetables, including kale, spinach, broccoli, and bok choy
Blackstrap molasses
Potatoes
Iron-fortified infant formula and cereal
Consuming foods rich in vitamin C along with good sources of iron enhances nonheme iron
absorption.
Recommended Dietary Allowance for Iron for Vegetarians
a

Age
Iron
(mg)
0-6 months
b
0.27
7-12 months 11
1-3 years 12.6
4-8 years 18
9-13 years 14.4
Boys, 14-18 years 19.8
Girls, 14-18 years 27
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Oral contraceptive
users,14-18 years
20.5
Pregnant
adolescents, 14-18
years
48.6
Breastfeeding
adolescents, 14-18
years
18
a
Values calculated based on 1.8 times the Recommended Dietary Allowance for
nonvegetarians of all ages except 0-12 months.
b
AI

Zinc

The bioavailability of zinc is reduced by phytate, found in whole grains and
legumes. Vegetarian children eating a diet high in phytate may need 50% more zinc than
the Dietary Reference Intake (DRI) (Food and Nutrition Board 2001). Zinc supplementation
may be indicated if dietary zinc is marginal and the child’s diet is based on high-phytate
cereals and legumes (Allen 1998). Dietary plus supplemental zinc for children whose diet
is based on high-phytate cereals and legumes should provide a level equivalent to 150% of
the DRI for zinc (Food and Nutrition Board 2001).

Good sources of zinc include the following:
Legumes
Dairy products
Wheat germ
Fortified and whole grain breads and cereals
Nuts and nut butters
Tofu and other soy products
Zinc absorption can be enhanced by the following (Gibson 1988):
Choosing yeast-leavened breads instead of quick breads
Choosing fermented soy products (tempeh and miso)
Emphasizing foods that are good sources of zinc and protein, like soy foods and dried
beans

Calcium

Children following lacto-ovo vegetarian diets tend to have adequate calcium intakes (Thane
2000; Perry 2002). However, lower calcium intakes have been seen in vegan children
(Mangels 2011). Dietary calcium intake should be included in the nutrition assessment.

Calcium sources include the following:
Dairy products
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Calcium-fortified soy milk and other nondairy milks
Calcium-fortified fruit juice
Dark green, leafy vegetables low in oxalic acid, including kale, collard greens,
mustard greens, bok choy, and Chinese cabbage
Broccoli, okra
Calcium-set tofu
Soybeans, tempeh
Figs
Calcium-fortified breakfast cereal
Although calcium supplements are an option for children with inadequate calcium intakes,
food sources of calcium are preferred because they supply additional nutrients such as
protein, vitamins A and C, and iron.

Vitamin D

Cutaneous vitamin D production can be affected by factors such as sunscreen use, skin
pigmentation, season, time of day, and geographic location. A dietary or supplemental
source of vitamin D is recommended for all children (Wagner 2008). Foods that are fortified
with vitamin D include the following:
Cow’s milk
Some brands of soymilk and other nondairy milks
Some brands of ready-to-eat cereal
Some brands of orange juice

Vitamin B12

Vitamin B-12 is of special concern for infants and children following vegan diets. Because it
is only found in animal products, vegans and other vegetarians who do not consume dairy
products or eggs regularly must get vitamin B-12 from supplements or fortified
foods. Breast milk from women with adequate vitamin B-12 intake is a good source of
vitamin B-12 for breastfed infants.
Foods fortified with vitamin B-12 include the following:
Some brands of soymilk and other nondairy milks
Some meat analogues
Some ready-to-eat breakfast cereals
Some energy bars
Nutritional yeast (Red Star Vegetarian Support Formula)
Infant formula


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children > Fluid Needs or Limits
Fluid Needs or Limits

Fluid needs of vegetarian children are the same as those for nonvegetarian children. In
children whose diets are especially high in fiber, inclusion of adequate fluid should be
emphasized. Refer to the Fluid Needs or Limits heading of the specific Normal Nutrition life
stage you are interested in learning more about.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Normal Nutrition > Vegetarian Children > Issues to Consider
Feeding Progression for Infants

The American Academy of Pediatrics recommends that solid foods should not be
introduced until 4 to 6 months of age (American Academy of Pediatrics 2009b). Although
there is no evidence of benefits of introducing any particular food first, many practitioners
recommend that single-ingredient, iron-fortified infant cereals be introduced first, followed
by pureed fruits and vegetables. Vegetarian infants can follow this same progression with
tofu, pureed legumes, yogurt, and other protein-rich foods introduced at the age when
strained meat would be introduced for nonvegetarian infants. One possible scheme for
introducing foods to vegetarian infants is as follows.
Iron-fortified infant cereal (4-6 months)
Strained fruit and vegetables, fruit and vegetable juice (6-8 months)
Crackers, toast, unsweetened dry cereal (6-8 months)
Tofu, pureed legumes, yogurt, cheese, cooked egg yolks (7-10 months)
Soft or cooked fruit; cooked and mashed vegetables (9-10 months)
Rice, pasta (11-12 months)
Mashed legumes, bite-size pieces of meat analogues (11-12 months)
Guidelines for nonvegetarian infants for timing between each new food and home
preparation of food for the infant should be followed.


Breastfeeding vs Bottle Feeding

Many vegetarian women choose to breastfeed, a practice that should be supported.
Breastfeeding women should be screened for adequacy of usual diet and for use of
supplements.

The benefits of breastfeeding are numerous (see Breastfeeding & Lactation Support). Only
iron-fortified commercial infant formula should be used by infants who are not breastfed or
who are weaned before their first birthday. Lacto-ovo and lacto vegetarian families who do
not breastfeed can use an iron-fortified cow’s milk–based formula. Vegan families who do
not breastfeed should choose a soy formula (Bhatia 2008). Homemade formulas based on
plant milks (such as soy milk or rice milk), cereal gruels, or fruit or vegetable juices are not
nutritionally adequate for infants (Mangels 2001).


Weaning

As solid foods become a larger part of the diet, it is important that energy intake is
adequate to support growth and development. If the vegetarian diet is based primarily on
whole grains, legumes, fruits, and vegetables, it can be quite high in fiber. If early satiety
results, energy intake can be inadequate. In these cases, use of some refined products and
concentrated energy sources can lead to a higher energy intake. For example, use of
applesauce or peeled apples in place of unpeeled apples, or refined pasta in place of
whole-grain pasta, can reduce the fiber content of the diet. Concentrated energy sources
include avocado, tofu and other soy products, and bean spreads. Plant-based oils and
margarine can be used in cooking and added to foods to provide additional
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
energy. Cheese, mayonnaise, and butter are additional concentrated energy sources for
children who follow a lacto-ovo vegetarian diet.
Small, frequent meals and snacks can be used to promote energy intake.
Honey and corn syrup should not be given to infants younger than 1 year of age, because
these products can contain spores of Clostridium botulinum, which can cause infant
botulism (Cox 2002).
Whole cow’s milk is commonly introduced at the end of the first year as the primary
beverage (Greer 2006). At this time, vegan children can begin using a fortified, full-fat soy
milk as their primary beverage, provided that the following factors exist (Mangels 2001):
Growth is appropriate
Weight and height for age are appropriate
The child is eating a variety of table foods, including soy products, dried beans,
grains, fruits, and vegetables
Because of the lower fat content of soy milk compared with whole cow’s milk, other foods
that provide fat should be added to the child’s diet to promote adequate energy intake. Rice
milk, nut milks, hemp milk, and other plant-based milks are not recommended as primary
beverages for young children because of their low protein and energy content.

Supplement Use by Vegetarian Infants and Children

Vegetarian infants should follow standard recommendations for supplements:
All infants should have a minimum intake of 400 IU vitamin D daily starting soon after
birth (Wagner 2008; Food and Nutrition Board 2011).
Healthy full-term infants usually can obtain adequate iron from breast milk and from
stores for 6 to 9 months (Bueche 2009). Iron-fortified infant cereal should be started at
approximately 6 months of age to supplement the diet (American Academy of
Pediatrics, 2009). Infants who are not breastfed should receive iron-fortified infant
formula, though it is not essential that iron-fortified cereal be their first food at age 4 to
6 months (American Academy of Pediatrics 2009a).
In addition, a breastfed infant of a vegan mother should receive supplements that provide
100% of the Recommended Dietary Allowance for vitamin B-12 unless the mother has a
daily, adequate, and reliable source of the nutrient. Some experts recommend zinc
supplements when complementary foods are introduced if the infant’s diet is low in zinc or
if many high-phytate foods are used (Allen 1998).
Individual nutrition assessment can be used to determine if vegetarian children and
adolescents require supplements. Pediatric supplements that contain no animal products
are available. The nutrient content varies and should be evaluated while considering the
child’s needs.

Pregnant Adolescents

Lacto-ovo, lacto, and vegan diets that are nutritionally adequate for pregnant adolescents
can be developed. Key nutrients to consider include the following:
Iron: supplemental iron is likely to be required to meet the higher Recommended
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dietary Allowances for iron for vegetarians (Food and Nutrition Board 2001)
Zinc
Vitamin B-12
Calcium and vitamin D
Docosahexaenoic acid
For more information, see Adolescent Pregnancy.

Eating Disorders

Choosing to follow a vegetarian diet does not appear to increase the risk of developing an
eating disorder (O’Connor 1987; Janelle 1995; Barr 1999). Adolescents, however, who
already have symptoms of eating disorders may choose a vegetarian diet as a way to
further restrict their food intake in a socially acceptable fashion (Barr 1999; Martins 1999;
Curtis 2006). Several studies suggest that self-described vegetarian diets—especially diets
that do include chicken, fish, or both—are somewhat more common among adolescents
with eating disorders (Neumark-Sztainer 1997; Perry 2001; Robinson-O’Brien 2009). In
addition, adolescents who describe themselves as lapsed vegetarians seem more likely to
use extreme weight-control measures (Robinson-O’Brien 2009). Adolescents following
vegetarian or near-vegetarian diets, whose main motivation for their dietary choice is
weight loss, are more likely to develop an eating disorder than adolescents with motivations
such as concern for animals or personal health (Perry 2001; Janelle 1995). If an adolescent
exhibits symptoms of an eating disorder and describes herself or himself as vegetarian or
as a lapsed vegetarian, additional assessment is recommended.
For more information, see the Eating Disorders section.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants home page
Increasing numbers of preterm, very low-birth-weight infants survive to discharge from the
hospital (Lemons, 2001). The smallest infants are at significant risk for growth failure,
developmental delay, infectious disease, and rehospitalization. The goal of nutrition
management is for the discharged preterm infant to achieve the body composition and rate
of growth of a term infant of the same postconceptional age, although opinion and practice
vary on how to achieve this (Greer, 2007). Information under the Preterm Infants tab
includes general care as well as nutrition care for common diseases and conditions specific
to prematurity.
Parenteral nutrition is used during the neonatal period, initially to prevent negative energy
and protein balance, and subsequently to support normal growth until adequate enteral or
oral feedings can be established. Enteral nutrition is preferred for nourishing all infants, but
for high-risk newborns it is usually introduced when transitioning from parenteral nutrition.
Human milk is the gold standard for infant feeding and is preferred for nearly all high-risk
newborns. Benefits of using human milk are numerous. Although human milk is preferred
to infant formula, for preterm infants, it is inadequate in protein; many vitamins; and most
minerals, including calcium, phosphorus, zinc, and iron (Sapsford, 2000a). Fortifying
human milk can minimize these nutrient deficiencies. For babies whose mothers choose
not to provide human milk or for when the supply of human milk is exhausted, commercial
infant formulas designed for preterm infants are available and highly recommended
(Sapsford, 2000a).


Preterm Infants > Condition Overview
Prematurity

Prematurity is defined as a birth before 37 weeks of gestation. In the United States, more
than 12% of all births are preterm (Nock, 2006). The preterm birth rate has risen
significantly over the last several decades and is higher in Hispanic and non-Hispanic black
women than in non-Hispanic white women. Prematurity is the leading cause of infant
mortality in the developed world, after congenital malformations (Swamy, 2008).
Significant long-term sequelae are disproportionately more prevalent among infants born
very early but even late-preterm infants (34 to 36 weeks gestation) are at heightened risk
when compared with infants delivered at term. Preterm infants stay in the hospital for about
13 days on average whereas uncomplicated newborns have average hospital stays under
2 days. Infants with extreme prematurity (< 28 weeks gestation) can have hospital stays of
approximately 6 weeks or more (Russell, 2007).
Most preterm infants are cared for in neonatal intensive care units. Adequate weight gain is
associated with shorter hospital stays and improved outcome (Olsen, 2002). Variation in
nutritional intake explains much of the difference in growth among preterm infants, and
growth is significantly improved when there is a neonatal nutritionist on the medical team
(Olsen, 2002; Ehrenkranz, 1999).
Classification
Newborn infant maturity and intrauterine growth are classified by gestational age (GA),
birth weight, and weight-for-gestational age.
GA: GA can be estimated by maternal dates and by early (first/early second trimester)
ultrasound exam (if available). GA is also determined in the neonatal intensive care
unit by examining the infant’s physical and neurological development on a reliable
standardized instrument called the New Ballard score (formerly the Dubowitz score)
(Ballard, 1991). The GA classifies the infant as preterm, term, or postterm.
Birth weight: The infant’s birth weight is used to categorize the infant as (a) normal
weight, (b) low birth weight, (c) very low birth weight, (d) extremely low birth weight,
or (e) micropremie.
Classification: The infant’s weight is plotted on an intrauterine growth chart to
determine size for length of gestation, defined as (a) small for gestational age (SGA),
(b) appropriate for gestational age (AGA), or (c) large for gestational age (LGA).
For specific definitions of SGA, AGA, and LGA, refer to Terms and Abbreviations
Corrected Age
Chronological age is age from the date of birth. Corrected age, sometimes called "adjusted
age," is defined as age from estimated term birth and is used in nutrition assessment of
infants born prematurely (Theriot, 2000). For example, an infant born on May 1, 2009, at 27
weeks’ gestational age (GA) had a corrected age of 3 months when she reached 6 months
of chronological age on November 1, 2009. This is calculated as follows:
GA of 27 weeks when born on May 1, 2009: 13 weeks before estimated term date of
August 1, 2009 (40 weeks – 27 weeks = 13 weeks, or 3 months preterm)
Chronological age of 6 months on November 1, 2009: 26 weeks past actual date of
birth
Corrected age of 3 months on November 1, 2009: 13 weeks past expected term date
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Corrected age of 3 months on November 1, 2009: 13 weeks past expected term date
of birth (26 weeks – 13 weeks = 13 weeks, or 3 months)
Corrected age is used for preterm infants for at least the first year (LaHood, 2007).

Congenital Anomalies of the Alimentary Tract

Feeding and nutrition implications deal with three sections of the infant’s alimentary tract:
(a) upper alimentary tract (from mouth through stomach), (b) small intestine, and (c) large
intestine. See Table for specific anomalies associated with these sections. Surgical
treatment, required for most of these conditions, is followed by a gradual return of
alimentary tract function. It is speculated that infants divert protein and energy from growth
to tissue repair, thus avoiding the catabolism and hypermetabolism seen in adults. (See
sections on Necrotizing Enterocolitis and Short Bowel Syndrome.)
Infants’ energy and protein requirements seem to be minimally affected by major surgeries
(Pierro, 2006). Severity of the metabolic response to injury is reflected in serum C-reactive
protein (CRP) levels. When CRP levels are elevated, overfeeding can increase
complications and delay recovery (Alaedeen, 2004).
Prealbumin levels are inversely correlated with CRP levels and can be used to gauge
return to anabolic metabolism (Alaedeen, 2004; Ambalavanan, 2005). Perioperative
anesthesia and postoperative analgesia help blunt the metabolic stress response (Thureen,
2005).
See Nutrition Care for more information.

Congenital Heart Disease

Congenital heart disease (CHD) occurs in 1% of newborns, who are typically born at full
term. Poor energy intake, increased total energy expenditure, malabsorption, and additional
medical conditions may be seen depending on specific defect. Preoperative nutrition and
growth is emphasized if the infant needs to reach goal weight before surgery (Barry, 2006).
See Nutrition Care for more information. The Cardiology section includes more details on
CHD and related conditions.

Endocrine Disorders

Endocrine disorders requiring nutrition management generally involve glucose or calcium
metabolism. Deficiencies in thyroid, growth, or pituitary hormone often present with poor
feeding and poor growth. Hormone replacement therapy obviates dietary management
beyond monitoring feeding progression and growth recovery (Acosta, 2001; Tsang, 2005;
Sunehag, 2002; Cornblath, 2000; Meites, 1989; Kao, 2006; Farrag, 2000; Peters, 2007;
Sisto, 2004; DiGiacomo, 1991; Hooy, 2000; Cowett, 1991).
Hypoglycemia
There is controversy regarding the specific serum glucose level that defines hypoglycemia:
proposals have included levels below 35 mg/dL, 40 mg/dL, and 50 mg/dL (less than 1.94
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
mM/L, less than 2.2 mM/L, and less than 2.8 mM/L, respectively) all have been proposed
as the defining level (Tsang, 2005; Sunehag, 2002; Cornblath, 2000; Meites, 1989; Kao,
2006; Farrag, 2000; Peters, 2007; Sisto, 2004).
Risk factors for hypoglycemia include the following:
Endocrine disorders: hyperinsulinism (transient: infant of diabetic mothers,
Beckwith-Wiedemann syndrome, asphyxia, and intrauterine growth retardation;
persistent: nesidioblastosis, islet cell adenoma), cortisol or growth hormone
deficiencies, panhypopituitarism, hypothyroidism
Sepsis, polycythemia
Inborn errors of carbohydrate metabolism: galactosemia, glycogen storage disease,
fructose intolerance, glucose-6-phosphate deficiency
Disorders of fatty acid oxidation: medium-chain acyl-CoA or other fatty acid
dehydrogenase deficiency, carnitine deficiency (characterized by decreased
production of ketones)
Amino acid disorders: maple syrup urine disease, proprionic acidemia, methylmalonic
acidemia hereditary tyrosinemia
Iatrogenic causes: hypothermia, delayed feeding, abruptly discontinuing glucose
infusions, exchange transfusions
Hyperglycemia
Hyperglycemia is most often encountered in extremely-low-birth-weight infants receiving
parenteral nutrition and is thought to be related to inefficient insulin secretory ability and
relative tissue insensitivity to insulin. There is controversy regarding the specific serum
glucose level that defines hyperglycemia: definitions include levels greater than 144 mg/dL
(> 8 mM/L), 158 mg/dL (> 8.8 mM/L), 178 mg/L (> 10 mM/L), 216 mg/dL (>12 mM/L), and
239 mg/dL (> 13.3 mM/L) (75-78). Severe hyperglycemia (≥ 180 mg/dL [≥ 10 mM/L]) may
be associated with increased risk of sepsis, dehydration, and electrolyte losses (Sunehag,
2002; Meites, 1989).
Transient neonatal diabetes mellitus may present in the first 6 weeks of life, usually
resolving by 3 to 6 months of age. Neonatal onset of permanent diabetes mellitus may be
caused by pancreatic agenesis or other rare congenital disorders.
Hypocalcemia
Declining serum calcium levels after birth reflect the infant’s loss of maternal source of
calcium. Prematurity, asphyxia, and maternal diabetes may be associated with pathologic
hypocalcemia. Endocrine-related causes include hypoparathyroidism, either transient (as
in premature infants) or permanent (as in DiGeorge syndrome),
pseudohypoparathyroidism, or maternal vitamin D deficiency.
Hypercalcemia
The endocrine cause of hypercalcemia is primary neonatal hyperparathyroidism.
See Nutrition Care for more information.

Gastroesophageal Reflux

Gastroesophageal reflux (GER) is the return of gastric contents into the esophagus. It is a
common physiologic condition in infancy that is benign and self-limiting, typically resolving
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
common physiologic condition in infancy that is benign and self-limiting, typically resolving
by 1 year. Reflux can be occult (remaining in the esophagus without evident signs or
symptoms) or regurgitant (manifesting as spit-up or vomiting). Incidence is similar in
breastfed and formula-fed infants.
GER is generally considered pathologic if accompanied by failure to thrive, esophagitis, or
particular respiratory disorders--although cause-and-effect relationships are uncertain
(Poets, 2011; Jadcherla, 2011). Pathologic GER frequently accompanies
neurodevelopmental disabilities and some surgical alimentary tract anomalies (Poets,
2004; Thompson, 2000b; Rudolph, 2001; Salvatore, 2002).
The gold standard for diagnosis is a 24-hour pH probe recording. Because preterm infants
have less gastric acidity than do term infants, multiple intraluminal impedance is an
emerging diagnostic modality (Poets, 2004).
See Nutrition Care for more information.

Hyperbilirubinemia

Hyperbilirubinemia is a symptom, not a specific disease. Unconjugated (indirect) bilirubin
levels may become elevated within the first week of life as a result of increased breakdown
of red blood cells or enhanced enterohepatic recirculation of bilirubin caused by decreased
intestinal motility or intestinal obstruction, or a combination of both. Medical treatment is
not required unless serum bilirubin concentration reaches levels that place the infant at
increased risk for neurologic damage (kernicterus). Breastfed infants may present with a
second or late form of unconjugated hyperbilirubinemia, which occurs beyond the first or
second week of life, particularly if stools are infrequent.
Elevated levels of conjugated (direct) bilirubin indicate compromised liver function.
Conjugated hyperbilirubinemia occurs with diseases that prevent excretion of bile from the
liver by obstruction or hepatic tissue injury, including neonatal hepatitis, biliary atresia,
primary biliary cirrhosis, metabolic disorders, or cholestasis associated with prolonged
parenteral nutrition.
Please see Nutrition Care for more information.

Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is an acquired, life-threatening gastrointestinal disease
often associated with feeding. Overall incidence is 7% in very-low-birth-weight infants and
is inversely related to gestational age (Srinivasan, 2008). Pathophysiology is believed to be
multifactorial (Lin, 2006). Risk factors include prematurity, enteral feedings, bowel
ischemia, and abnormal bacterial colonization.
Manifestations include the following:
Systemic: Temperature instability, lethargy, apnea, bradycardia
Gastrointestinal: Poor feeding, increasing residuals, emesis, abdominal distension
and/or tenderness, occult or grossly bloody stools (no fissure)
Infants are categorized by stages for NEC (Bell, 1978):
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Stage I: suspected
Stage II: definite
Stage III: advanced disease
See Nutrition Care for more information.

Neurologic Impairment

Neurologic impairment may be caused by the following (Nevin-Folino, 2000):
Genetic factors:
Chromosomal abnormalities
Inherited neurometabolic disorders (inborn errors of metabolism)
Neuromuscular disorders
Congenital disorders/birth defects:
Drug exposure
Fetal alcohol syndrome
Hydrocephalus
Spina bifida
Intrauterine growth retardation
Intrauterine infections
Uncontrolled maternal neurometabolic conditions during pregnancy
Perinatal trauma:
Asphyxia (ischemic hypoxic encephalopathy)
Intraventricular hemorrhage
Meconium aspiration
Septic shock
See Nutrition Care for more information.

Osteopenia

Osteopenia of prematurity is defined as reduced bone mass of infants who were born
before or during maximal mineral accretion—80% of which occurs in the third trimester
(Demarini, 2005). Incidence is inversely related to gestational age and birth weight—up to
30% in very-low-birth-weight (VLBW) infants; 50% in extremely-low-birth-weight infants
(Sharp, 2007). Enteral nutrition is preferred over parenteral nutrition (PN) for providing
recommended mineral intake.
Osteopenia of prematurity is clinically silent and is diagnosed by 6 to 12 weeks postnatal
age when biochemical tests indicate the combination of low serum phosphorus (< 5.6
mg/dL [1.8 mmol/L]) and elevated alkaline phosphatase (> 900 U/L) (Backstrom, 2000).
Although not done routinely in clinical practice, radiographic evidence using dual energy
x-ray absorptiometry may be used for bone mineral assessment and monitoring.
Risk Factors
Preterm birth (< 34 wk gestational age)
VLBW infant (< 1,500 g)
Prolonged PN (> 4 wk)
Enteral feedings with low mineral content/bioavailability: unfortified human milk; infant
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
formulas with mineral levels designed for term infants; soy-based infant formulas
Chronic use of medications that increase mineral excretion (eg, diuretics, steroids)
Low activity levels (lack of mechanical stimulation of muscles and bones)
Chronic disease/prolonged sedation (restricted fluid/mineral intakes; low activity
levels)
See Nutrition Care for more information.

Renal Dysfunction

Causes of Dysfunction
Renal function may be compromised during the neonatal period for the following reasons:
Prerenal clinical conditions: dehydration, excessive gastrointestinal fluid loss, blood
loss, perinatal asphyxia, hypotension, sepsis, or patent ductus arteriosus
Intrinsic renal disease: acute tubular necrosis or congenital abnormalities
Postrenal obstructions: congenital anomalies or fungal infections within the urinary
tract
Functional renal immaturity in preterm infants, which increases risk for dehydration,
hyponatremia, metabolic acidosis, mild azotemia, hyperkalemia, and increased losses
of glucose, zinc, and some water-soluble vitamins
Nephrocalcinosis, which is more common in preterm infants because of immature
renal function, hypercalciuria, low glomerular filtration rate, low citrate excretion,
alkaline urine, excessive vitamin D intake, phosphorus depletion, and acid/base
imbalances—but resolves over time
Assessment of Renal Function
Prerenal failure may be differentiated from acute renal insufficiency by measuring fractional
sodium excretion (Haycock, 2003):
RFI = [U
Na
× P
Cr
]/U
Cr
where RFI is renal failure index, U
Na
refers to urine sodium in mg/dL, P
Cr
refers to plasma
creatinine in mg/dL and U
Cr
refers to urine creatinine in mg/dL. RFI above 8 indicates
renal insufficiency.
Acute renal insufficiency (ARI) is characterized by urine output < 1 mL/kg/hr and elevations
of serum creatinine, potassium, and phosphorus levels; edema; and altered electrolyte and
acid/base balance. Nonoliguric renal insufficiency is characterized by an increase in serum
creatinine. To calculate creatinine clearance (Edelmann, 1992):
CrCl (mL/min/1.73 m
2
) = [K × Length (cm)]/P
Cr
Where CrCl is creatinine clearance; K is a constant = 0.34 in preterm infants up to 34
weeks’ gestational age (GA); K = 0.44 in infants 35 weeks’ GA to term; P
Cr
= plasma
creatinine in mg/dL.
Plasma creatinine of 1.5 mg/dL (or 132.5 mcmol/L) for longer than 24 hours, consistent
with a 50% reduction in creatinine clearance, is often used to define renal insufficiency.
Chronic renal insufficiency includes the same biochemical changes that occur in ARI but
may also include anemia, renal osteodystrophy, anorexia, and poor growth.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Edelmann, 1992; Moghal, 2006; Haycock, 2003; Hein, 2004)
Please see Nutrition Care for more information.

Respiratory Disease

Respiratory distress syndrome (RDS) is characterized by cyanosis in room air, nasal
flaring, grunting, retracting, and tachypnea. RDS may develop in preterm infants as a result
of immaturity of lung tissue and a lack of alveolar surfactant. Other causes of respiratory
distress are meconium aspiration, pneumonia, lung hypoplasia, transient tachypnea,
pneumothorax, or chylous pleural effusion.
RDS may progress to bronchopulmonary dysplasia (BPD), also called chronic lung disease
of prematurity. BPD may be defined by oxygen dependency for 28 days or longer or
beyond 36 weeks’ gestational age (GA) for infants below 32 weeks’ GA at birth. It may be
mild, moderate, or severe depending on the amount of oxygen support required and
presence of other lung function abnormalities. Lung tissue continues to grow and remodel,
resulting in gradual improvement, although symptoms may continue into adolescence
(Baraldi, 2007; Biniwale, 2006; Sweet, 2007).
Infants with respiratory disease may have difficulty achieving adequate oral intake because
of increased respiratory rate; difficulty coordinating an efficient and sustained suckle,
swallow, and breathing pattern; or early fatigue with feedings. Infants requiring mechanical
ventilation or constant positive airway pressure ventilation for prolonged periods of time
may develop feeding aversion, refuse oral feedings, or have difficulty with gag reflex or
accepting foods with different textures.
Infants with BPD may have associated gastroesophageal reflux, which may result in
microaspiration, esophagitis, or episodic bronchospasm—each of which may contribute to
feeding aversion (Baraldi, 2007; Biniwale, 2006; Sweet, 2007).
See Nutrition Care for more information.

Short Bowel Syndrome

Short bowel syndrome (SBS) is defined functionally as malabsorption in conjunction with a
shortened bowel length. Intestinal failure can result even with normal or near-normal
absorptive surface area if obstruction or dysmotility complicates the diagnosis.
The most common reasons for SBS in the neonatal intensive care unit are congenital
malformations and necrotizing enterocolitis (Wessel, 2007). Overall, incidence of SBS is 25
per 100,000 live births and is much more common in preterm infants. Mortality can
approach 40% (Wales, 2004).
The following estimates of bowel length are used to guide and anticipate response to
treatment (Wessel, 2007):
Term infants: 240 cm small bowel (about five times birth length) and 40 cm colon
Preterm infants (19 to 27 weeks): 150 cm total small and large bowel
At 1 year of age: 380 cm average small bowel length
Survival has been reported in patients with 15 cm small bowel or smaller if the ileocecal
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
valve is intact and in patients with larger than 15 cm small bowel but no ileocecal valve
(Wessel, 2007).
See Nutrition Care for more information. The Gastrointestinal Diseases section also
provides coverage of SBS in children.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Risk Screen
Nutritional Risk Screen

A nutrition screen—often completed by a neonatal intensive care nurse or dietetic
technician, registered—may be used to focus registered dietitian (RD) resources.
Screening should be completed within 24 hours of admission (JCAHO, 2006; Wessel,
2005a). The following table provides example screening criteria (Thompson, 2000a). An
RD then completes an assessment on infants meeting designated criteria.
Ohio Neonatal Nutritionists’ Screening Criteria for Identifying Hospitalized Infants at
Highest Nutritional Risk
< 1 week of age

> 15% weight loss from birth weight
< 1 kg at birth
1-2 weeks of age

< 60 kcal/kg/day
Any continued weight loss
> 2 weeks of age











Intake below expected energy requirement

< 60 kcal/kg/d (all IV)
< 70 kcal/kg/d (IV/enteral)
< 80 kcal/kg/d (all enteral)

< 10 g/kg/d weight gain (< 38 weeks’ gestational
age) or
< ½ expected g/d weight gain (> 38 weeks’
gestational age)

Prealbumin
a
< 8 mg/dL or albumin < 2.5 g/dL
Direct bilirubin > 2 mg/dL
Serum phosphorus < 4 mg/dL
Alkaline phosphatase > 600 U/L
> 2 months of age


Any of the above for > 2 weeks of age plus:
No source of dietary iron
Continued total parenteral nutrition
Any infant with newly diagnosed necrotizing enterocolitis, bronchopulmonary
dysplasia, osteopenia, cardiac disorders, neurologic problems, gastrointestinal
surgical anomalies, or metabolic aberrations.
Any infant with birth weight < 1.5 kg (and current weight < 2.0 kg) on full feedings,
but not receiving fortified human milk or preterm formula



a
Include as criteria only if screening can be done in a time-efficient manner for entire unit;
use values only as a guide—compare to institutional normal ranges.

(Source: Adapted from Thompson M. Establishing and developing the position of neonatal
nutritionist. In: Groh-Wargo S, Thompson M, Cox JH, eds. Nutritional Care for High-Risk
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Newborns. Chicago, IL: Precept Press; 2000:605. Used with permission.)

Rationale for Nutrition Consult

Most infants who receive care in a neonatal intensive care unit (NICU) have altered
nutrition. All infants born before they have completed term gestation prematurely lose their
intrauterine supply of nutrients, amniotic fluid, and their temperature-controlled
environment. Their gastrointestinal tracts must take on the roles of digestion and
absorption before they are physiologically ready to do so. Human milk and formula do not
necessarily match the nutrients provided by the placenta and amniotic fluid. Infants born
with various conditions or diseases may need different amounts of nutrients or they may
need nutrients delivered enterally or parenterally.
NICUs may typically employ collaborative care strategies to meet the nutrition needs of
most infants admitted to their care. Nutrition screening serves to identify infants whose
nutrition needs may not be met by standard nutrition care protocol. These infants are
referred to the dietitian for further nutrition assessment, identification of specific nutrition
diagnoses or problems, and nutrition intervention.
When nutrition screening identifies an infant who meets designated critera for nutritional
risk, a nutrition assessment should include all of the following:
Anthropometric assessment: Obtain accurate measurements of weight, length, and
head circumference. Plot on appropriate growth curves. Consider infant’s
classification (ie, gestational age, birth weight, and weight for gestational age).
Interpret/analyze growth pattern or trend.
Biochemical assessment: Review appropriate biochemical data. Interpret in light of
patient’s condition.
Clinical assessment: Look at the patient and medical record; make clinical
observations.
Dietary intake assessment: Evaluate intake (parenteral and enteral) to assess what
and how much is administered. Calculate intake—at least fluids, energy, and protein,
all per kilogram per day.

Classification

Newborn Classification of Gestational Age and Birth Weight
Newborn infant maturity and intrauterine growth are classified by gestational age, birth
weight, and weight-for-gestational age.
Gestational age can be estimated by maternal dates and by early (first/early second
trimester) ultrasound exam (if available). The gestational age is also determined in the
neonatal intensive care unit by examining the infant’s physical and neurological
development on a reliable standardized instrument called the New Ballard score
(formerly the Dubowitz score) (Ballard, 1991). The gestational age classifies the infant
as preterm, term, or postterm.
The infant’s birth weight is used to categorize the infant as (a) normal weight, (b) low
birth weight (LBW), (c) very low birth weight (VLBW), (d) extremely low birth weight
(ELBW), or (e) micropremie.
The infant’s weight is plotted on an intrauterine growth chart to determine size for
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length of gestation—defined as (a) small for gestational age (SGA), (b) appropriate for
gestational age (AGA), or (c) large for gestational age (LGA). For specific definitions
of SGA, AGA, and LGA, refer to Terms and Abbreviations. These classifications can
help to guide or anticipate clinical care needs. For example, babies who are postterm
and/or SGA or LGA are more likely to have hypoglycemia, polycythemia, birth
asphyxia, and specific syndromes/anomalies than are term AGA babies. Being
preterm is associated with a host of potential morbidities, many of which are
discussed in this Preterm Infants section.

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Preterm Infants > Nutrition Care
Nutrition Care


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Preterm Infants > Nutrition Care > Nutrition Assessment
Nutrition Assessment


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Preterm Infants > Nutrition Care > Nutrition Assessment > Anthropometrics
Overview and Growth Assessment

Postnatal growth—with consistent and comprehensive monitoring—is an important health
care outcome measure for high-risk infants (Kuzma-O'Reilly, 2003). Anthropometric
measurements are rapid, inexpensive, and noninvasive to obtain.
Measurement of body weight, length, and head circumference is the predominant method
used to monitor infant growth, detect growth abnormalities, and assess nutritional status in
infants. Measurements are plotted on percentile growth curves for comparison against
established reference data. Serial measures of growth are helpful in assessing response to
nutrition support in hospitalized infants. Satisfactory postnatal growth is associated with
shortened lengths of hospitalization and improved cognitive development (Moyer-Mileur,
2007; Anderson, 2002).

Weight

Method
The nude infant is weighed on a regularly calibrated digital gram scale.
Uses and Interpretation
Body weight comprises the total mass of the infant’s lean tissue, fat, and extracellular
and intracellular fluid compartments.
As gestational age increases, extracellular fluid volume decreases and lean tissue
and fat mass increase.
Initial postnatal weight loss is attributed to contraction of body water compartments
and catabolism of endogenous stores before energy and nutrient needs are met
(Moyer-Mileur, 2007).
Expected initial postnatal weight loss ranges between 8% and 15%, with greater loss
found in the smallest, most immature infants (Bell, 2008).
Initial weight loss reaches its nadir by approximately 4 to 6 days of life (Moyer-Mileur,
2007).
Birth weight is usually regained by 2 to 3 weeks (Moyer-Mileur, 2007; Anderson,
2002).
Daily body weights allow assessment of fluid status.
Limitations
Weight gain does not accurately reflect lean body mass changes, especially when edema
or dehydration is present (Moyer-Mileur, 2007; Anderson, 2002).
Weight Assessment
Weight gain is evaluated to identify infants with mean weight gains that are less than or
more than desired growth (specifically, less than 10 g/kg/day or more than 35 g/day) during
a week’s period of time (Anderson, 2002).
Infants at high risk for poor weight gain include those with extreme prematurity, chronic
lung disease, severe intraventricular hemorrhage, necrotizing enterocolitis, and late-onset
sepsis (Moyer-Mileur, 2007; Anderson, 2002). Factors that may contribute to poor weight
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gain include the following (Moyer-Mileur, 2007; Anderson, 2002):
Insufficient fluid, energy, or nutrient intake
Improper preparation of feeding
Feeding intolerance
Acidosis
Hypoxia
Anemia
Chronic diuretic administration
Factors that may contribute to excessive weight gain include the following (Moyer-Mileur,
2007; Anderson, 2002):
Excessive fluid, energy, or nutrient intake
Improper preparation of feeding
Chronic steroid administration
In addition to excessive weight gain, this may contribute to the loss of lean mass
and decreased linear growth

Length

Method
Ideally, length is measured on an infant length board. In some clinical settings, however,
infant length is estimated using a tape measure.
Uses and Interpretation
Weekly length measurements have the following advantages over the measurement
of weight (Roche, 2003):
Length more accurately reflects lean tissue mass.
Length is not influenced by fluid status.
Length is a better indicator of long-term growth.
Expected incremental gain in crown-heel length in low-birth-weight infants is
approximately 0.9 cm/week (Moyer-Mileur, 2007; Anderson, 2002).
Limitations
Length is often more difficult to accurately determine—requiring a length board and two
measurers—than weight or head circumference (Moyer-Mileur, 2007; Anderson, 2002).

Head Circumference

Method
The largest occipital-frontal circumference is measured with a flexible tape measure.
Uses and Interpretation
During the first postnatal week, head circumference may decrease by approximately
0.5 cm due to extracellular fluid space contraction (Moyer-Mileur, 2007).
Head circumference is monitored weekly; mean weekly gain in low-birth-weight
infants is 0.9 cm/week (Moyer-Mileur, 2007; Anderson, 2002).
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More frequent assessment may be indicated for infants with microcephaly or
macrocephaly or with suspected abnormal increases in head circumference (>1.25
cm/week) (Moyer-Mileur, 2007).
Limitations
Cerebral edema, hydrocephalus, compression due to the administration device for nasal
continuous positive airway pressure, or the addition or removal of external apparatus may
interfere with accuracy of head circumference measurements.

Weight for Length

Method
Using the growth chart, ideal weight-for-length is identified by finding the weight that is
approximately on the same percentile as the infant's length measurement percentile.
Uses and Interpretation
Determining ideal weight-for-length is helpful in assessing symmetry of growth.
Current weight expressed as a percentage of ideal weight-for-length can be used to
identify infants at risk for undernutrition or overnutrition (Moyer-Mileur, 2007).

Regional Anthropometry

Regional anthropometry is not routinely assessed. It is used primarily in research settings.
Uses and Interpretation
Triceps skinfold (TSF), mid-arm circumference, and the ratios and formulas derived
from these measurements are reported to be good predictors of infant body
composition, growth, and metabolic complications for infants who are overgrown or
undergrown during gestation (Roche, 2003).
Standards are available for infants between 24 to 41 weeks’ gestation and can be
used to compare measurements of an individual infant to reference values or to
assess individual change over time (Moyer-Mileur, 2007).
Limitations
Examiner measurement technique variability—as well as critical illness, hydration
status, and positioning of infants—can make these measurements invalid or
unreliable (Moyer-Mileur, 2007).
The use of calipers to measure TSF may not be feasible in extremely immature
infants who have delicate, easily punctured skin.
Weight, length, and head circumference have been found to be the most reliable
measurements and are highly predictive of both fat and lean mass (Moyer-Mileur,
2007).

Growth Charts

Growth charts provide the basis for growth and nutrition assessment of high-risk infants by
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presenting a comparison of an infant’s actual size and growth trajectory to reference data
(Moyer-Mileur, 2007; Anderson, 2002).
Two types of charts are presently available for growth assessment:
Charts developed using intrauterine growth data
Charts developed using postnatal growth data
In most neonatal intensive care units, the infant’s measurements are plotted sequentially
on both an intrauterine and a postnatal growth chart.
Intrauterine Growth Charts
Intrauterine growth charts are based on a compilation of cross-sectional measurements of
birth weight, length, and head circumference from infants of varying gestational ages at
birth (Moyer-Mileur, 2007; Anderson, 2002). They represent fetal growth and are presented
as the goal for preterm infant growth (Moyer-Mileur, 2007; Anderson, 2002).
Intrauterine growth charts based on precise measurements of gestational age have been
developed within the past decade (see the Fenton Intrauterine Growth Chart and the Olsen
Growth Chart) (Fenton, 2003; Olsen, 2010). The infant’s weight, length, and head
circumference can be plotted weekly on these curves.
Limitations
The following are limitations to the use of intrauterine growth charts:
Intrauterine growth charts do not allow for the initial postnatal weight loss seen in
newborn infants; body weight at 1 week of age will often be less than the birth
percentile (Moyer-Mileur, 2007; Anderson, 2002).
Variability among the intrauterine charts limits the generalizability of these data.
Charts vary in terms of the following: the years data were collected, geographic
location of the infants as related to elevation, ethnicity, estimation of gestational age,
and sample size (Moyer-Mileur, 2007; Anderson, 2002).
Typically, the preterm infant’s growth will parallel and not exceed the intrauterine
growth curve of a fetus of similar gestational age (Moyer-Mileur, 2007; Anderson,
2002).
Postnatal Growth Charts
Postnatal growth charts based on a large sample of infants (from a broad geographic area
in the United States) receiving current neonatal care have been published. These charts
provide a reference for expected weight, length, and head circumference changes starting
at various birth weights. Because they were developed from postnatal growth data, they
reflect the initial weight loss that occurs in infants during the first week of life (Moyer-Mileur,
2007; Anderson, 2002).
The following are limitations to the use of postnatal growth charts (Moyer-Mileur, 2007):
Postnatal growth charts do not show an infant’s growth velocity or “catch-up” growth
relative to the fetus.
Postnatal growth charts were likely influenced by the medical and nutrition support
practices used for the sample infants.

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Preterm Infants > Nutrition Care > Nutrition Assessment > Biochemical Data, Medical Tests
and Procedures
Overview

Biochemical (laboratory) data can be useful markers of nutritional status. Specific
laboratory tests may help detect nutritional deficiency or toxicity prior to the appearance of
clinical symptoms.
Many factors not related to nutrition can alter serum nutrient levels, however, and must be
considered when interpreting laboratory results (Moyer-Mileur, 2007). These factors
include the following:
Storage and processing of the specimen
Type of laboratory method used
Technician accuracy
Disease state or medical treatment, including blood transfusions
Laboratory tests are interpreted with caution and used to complement other nutrition
assessment data (Moyer-Mileur, 2007).

Parenteral Nutrition

Regular assessment of laboratory data is necessary for infants receiving parenteral
nutrition (PN). Early detection of metabolic complications of PN is facilitated by analysis of
arterial blood gases and levels of electrolytes, blood urea nitrogen, creatinine, calcium,
magnesium, phosphorus, glucose, liver enzymes, visceral proteins, and triglycerides.
Daily monitoring of acid/base balance, glucose, electrolytes, calcium, magnesium,
phosphorus, and triglycerides is required as PN solutions are initiated and adjusted to meet
the specific energy and nutrient needs of individual infants. Once stable, laboratory
monitoring every 7 to 14 days is sufficient (Moyer-Mileur, 2007).
Suggested Monitoring Schedule for Infants Receiving Parenteral Nutrition Support
Initial Phase
a
Stable Phase
b
Growth:

Weight Daily Daily
Length Baseline Weekly
Head circumference Baseline Weekly
Intake and output Daily Daily
Glucose:

Serum As indicated
As
indicated
Urine 1-3 times/d
As
indicated
Electrolytes 1-3 times/wk Every 1-2 wks
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Calcium, magnesium,
phosphorus
2-3 times/wk Every 1-2 wks
Triglycerides
Daily during
dose increase
Every 1-2 wks
Blood urea
nitrogen/creatinine
2-3 times/wk Every 1-2 wks
Serum proteins Baseline Every 2-3 wks
Liver enzymes Baseline Every 2-3 wks
Alkaline phosphatase Baseline Every 2-3 wks
Blood cell count Baseline Every 2-3 wks
Vitamin and trace mineral
status or other specific tests
As indicated As indicated
a
Initial phase is the phase as parenteral nutrition solutions are adjusted to meet the
specific energy and nutrient needs of individual infants. This period generally lasts less
than 1 week for parenteral support.
b
Stable phase is the phase when the infant is in a metabolically steady state. For clinically
stable infants receiving an adequate nutrient intake with desired growth, the interval
between laboratory measurements may be increased beyond the recommendations
provided in the table.
Source: Data are from Moyer-Mileur, 2007.

Enteral Nutrition

Biochemical assessment of the infant receiving enteral nutrition is not well delineated. In
medically unstable infants, it may be desirable to follow serial parameters of hematologic,
protein, mineral, electrolyte, and acid/base status. Routine laboratory monitoring, however,
is not indicated for medically stable infants receiving enteral nutrition at advised levels and
achieving adequate growth (Moyer-Mileur, 2007).
Suggested Monitoring Schedule for Infants Receiving Enteral Nutrition Support
Initial Phase
a
Stable Phase
b
Growth:


Weight Daily Daily
Length Weekly Weekly
Head circumference Weekly Weekly
Intake and output Daily Daily
Glucose:


Serum Baseline
As
indicated
Urine Baseline
As
indicated
Electrolytes Baseline Every 2-3 wks
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Calcium, magnesium,
phosphorus
Baseline Every 2-3 wks
Triglycerides As indicated As indicated
Blood urea nitrogen/creatinine Baseline Every 2-3 wks
Serum proteins Baseline Every 2-3 wks
Liver enzymes Baseline Every 2-3 wks
Alkaline phosphatase Baseline Every 2-3 wks
Blood cell count Baseline Every 2-3 wks
Vitamin and trace mineral status
or other specific tests
As indicated As indicated
a
Initial phase is the phase as enteral nutrition feedings are adjusted to meet the specific
energy and nutrient needs of individual infants. This period generally lasts 7-10 days for
enteral support.
b
Stable phase is the phase when the infant is in a metabolically steady state. For clinically
stable infants receiving an adequate nutrient intake with desired growth, the interval
between laboratory measurements may be increased beyond the recommendations
presented in the table.
(Moyer-Mileur, 2007)

Normal Laboratory Values

Small preterm infants cannot afford to lose much blood volume for biochemical tests. The
laboratory performing the tests must be capable of using techniques that require only
microliters of blood (Moyer-Mileur, 2007). The cost, relative usefulness, and turnaround
time of a complex laboratory test should be considered before the test is done
(Moyer-Mileur, 2007).
Although it is best to use the individual laboratory’s reference ranges, the following table
gives rounded average ranges of reference laboratory values for infants beyond the first
week of life.
Reference Laboratory Values
a
for Term and Preterm Infants
Test Reference Range
a
Glucose 60-100 mg/dL
Electrolytes
Sodium 130-145 mEq/L
Potassium 3.5-6 mEq/L
Chloride 100-110 mEq/L
Calcium 6-12 mg/dL
Magnesium 1.5-2.5 mg/dL
Phosphorus
Term: 4-8 mg/dL
Preterm: 5.6-11 mg/dL
Triglycerides < 200 mg/dL
Blood urea nitrogen 5-20 mg/dL
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Creatinine 0.2-1 mg/dL
Albumin 3-5 g/dL
Prealbumin 10-25 mg/dL
Direct bilirubin < 0.2 mg/dL
Alkaline phosphatase 100-500 U/L
Hemoglobin 10-15 g/dL
Hematocrit 30%-45%
a
Rounded average ranges to use beyond the first week of life.
(Nock, 2006; Pesce 2007; Siparsky, 2007; Table is used by permission of Melody
Thompson)

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Preterm Infants > Nutrition Care > Nutrition Assessment > Comparative Standards
Comparative Standards

See Parenteral Nutrition Nutrient Requirements and Enteral Nutrition Nutrient Requirements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Nutrition Care > Nutrition Assessment > Intake Assessment
Intake Assessment

Data Collection
To assess dietary intake, review the medical record or nursing flow sheets to determine
nutrient sources—parenteral nutrition (PN); intravenous solutions; human milk; human milk
fortifier; infant formula; and vitamin, mineral, or other modular supplements.
Data Analysis
The dietary intake assessment should include both qualitative and quantitative analyses.
In the qualitative analysis, consider whether current nutrient solutions are appropriate
for the patient’s gestational age, size, tolerance issues (if any), and diagnoses.
In the quantitative analysis, calculate nutrient intakes (at least mL/kg/day, kcal/kg/day,
and grams of protein/kg/day).
PN calculations (including dextrose, crystalline amino acids, and intravenous fat
grams per kilogram per day) are done in the same way for infants as they are for
other populations.
Dextrose and/or electrolytes in intravenous drip medications often contribute
substantially to an infant’s intake and are calculated.
Occasionally, even medication flushes influence the small infant’s glucose or
electrolyte status.
A more detailed, targeted nutrient intake analysis may be done on intakes of
infants with certain diagnoses or conditions (eg, assessing calcium, phosphorus,
and vitamin D intake for infants with osteopenia).
Calculating Nutrient Intakes
Calculations of nutrient intakes are compared with recommended intakes (see Parenteral
Nutrition and Enteral Nutrition for recommendations) and interpreted in light of the baby’s
medical condition and growth. Following is an example of how to calculate nutrient intake.
Sample Nutrient Intake Calculation for 1,500-g Preterm Infant
Intake
Maternal milk fortified to 24 kcal/fl oz with human milk fortifier, taking 28 mL every 3 hours
Calculations
28 mL × 8 feedings/day = 224 mL/d ÷ 1.5 kg = 149 mL/kg/d
149 mL/kg/d × 0.8 kcal/mL
a
= 119 kcal/kg/d
149 mL/kg/d × 0.024 g protein/mL
a
= 3.6 g protein/kg/d
a
For most precise calculations, consult the specific manufacturer’s literature.

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Preterm Infants > Nutrition Care > Nutrition Assessment > Nutrition > Focused Physical
Findings
Apgar Score

Apgar scores—an assessment of heart rate, respiratory effort, muscle tone, reflex
irritability, and color observed at birth and immediately after—should be recorded in the
medical record (Hockenberry, 2007).
Scores range from 0 to 10.
Total scores of 0 to 3 indicate profound distress.
Scores of 4 to 6 show moderate distress.
Scores of 7 to 10 represent normal adaptation to extrauterine life.
Low Apgar scores with no improvement warrant a cautious approach to enteral
feeding initiation and advancement.

Skin

Carefully observe the infant’s skin (see table below), as skin color is an important indicator
of cardiorespiratory function. Notice any devices for respiratory, feeding, or excretory
assistance that may influence feeding (such as ventilator tubing, nasal continuous positive
airway pressure, feeding tube, pacifier, urinary catheter, ostomy).
Infant Clinical Assessment: Skin
Observation Possible Clinical Significance
Color
Pallor (washed-out,
whitish)
Shock (altered perfusion)
Anemia (iron and/or vitamin
deficiency)
Chronic disease
Plethora (deep, rosy
red)
Polycythemia
Overoxygenated
Overheated
Jaundice
Yellowish: indirect
hyperbilirubinemia
Greenish: direct
hyperbilirubinemia
Central cyanosis
(bluish skin, tongue,
lips)
Low oxygen saturation, may be
congenital heart disease or lung
disease (concern about gut
perfusion)
Acrocyanosis (bluish
hands and feet only)
Cold stress
Hypovolemia
Mottling (lacy red
pattern)
Normal variation
Cold stress
Hypovolemia
Sepsis
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Fluid Status
Periorbital or
generalized edema;
bulging fontanel
Overhydration
Protein deficiency
Dry mucous
membranes; sunken
fontanel; lack of tears;
poor skin turgor
Dehydration
Integrity
Dermatitis
EFA, B-vitamin, or zinc
deficiency
Flaky paint dermatitis Protein deficiency
Poor wound healing
Zinc, vitamin C, energy, or
protein deficiency
Texture
Scaly, dry EFA, vitamin A, or zinc deficiency
Excessive initial peeling Postterm: normal variant
EFA = essential fatty acid.
(Hockenberry, 2007; Pesce-Hammond, 2005; Gomella, 2004. Table is used by permission
of Melody Thompson.)

Vital Signs, Urine and Stool Output, and Feeding Intolerance

Review the infant’s vital signs and urine and stool output (see tables on this page)
(Hockenberry, 2007; Gomella, 2004). Also note signs of feeding tolerance or intolerance
(see Bedside Tool for Evaluating Feeding Intolerance in the Preterm Infant under Enteral
Nutrition>Feeding Methodology).

Medical Records
Review the medical record for the following:
Potential drug–nutrient interactions
Radiology reports—note any evidence of osteopenia (see Osteopenia)
Neurology reports—note any evidence of neurologic problems (see Neurologic
Impairment)
Maternal history of relevance: intent to breastfeed, weight gain during pregnancy,
illnesses (including gestational diabetes), family history of food allergies, and use of
alcohol or drugs
Infant Clinical Assessment: Vital Signs
Reference
Range
Alterations with Possible
Significance to Nutrition
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Temperature,
skin
36°C-36.5°C
(96.8°F-97.7°F)
Hypothermia and
hyperthermia
associated with
increased basal
metabolic rate,
-increased oxygen
consumption,
decreased weight gain
Respiratory
rate
40-60
breaths/min
Tachypnea (> 60
breaths/min) is a
contraindication for
nipple feeding
Apnea (absence of
breathing for > 20
seconds) and/or
bradycardia suggest
cardiorespiratory
instability: feed
cautiously, if at all
Heart rate
120-160
beats/min
a
Tachycardia (> 180
beats/min) associated
with increased energy
consumption
Bradycardia (< 100
beats/min) and/or
apnea suggest
cardiorespiratory
instability; feed
cautiously, if at all
a
Heart rate may be lower when sleeping, higher when crying.
(Sources: Hockenberry, 2007; Pesce, 2007; Gomella, 2004. Table is used by permission of
Melody Thompson.)
Infant Clinical Assessment: Urine Output
Reference
Range
Alterations with Possible
Significance to Nutrition
Urine volume
1-3 mL/kg/hr
(5-7
mL/kg/hr
with diuresis)
< 1 mL/kg/hr = oliguria
No urine output = anuria
If oliguria or anuria,
consider volume and
potential renal solute
load (PRSL) of feeding
with conservative
treatment of acute renal
failure
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Urine-specific
gravity
1.001–1.020
> 1.020 may be
associated with
increased feeding
concentration,
-increased PRSL, or
decreased fluid intake
Urine-reducing
substances
Negative
Glucosuria associated
with intravenous glucose
load above renal
threshold—or rule out
galactosemia
(Sources: Hockenberry, 2007; Gomella, 2004. Table is used by permission of Melody
Thompson.)
Infant Clinical Assessment: Stool Output
Reference
Range
Alterations with Possible
Significance to Nutrition
Timing of first
Within 48 hours
of birth
No stool: consider bowel
obstruction, imperforate
anus
Frequency
(when enteral
feedings are
established)
From every
feeding to every
3 days
Excessive watery stools:
consider hydration status
Infrequent stools:
consider strictures
Color
Initially: tarry,
dark
(meconium);
later: yellow to
green to brown
Black stools: may be
associated with occult
blood
Clay-colored stools: may
indicate cholestasis or
decreased bile flow
Blood None
Blood present: consider
necrotizing enterocolitis,
swallowed maternal
blood, nasogastric tube
trauma, anal fissure,
ulcer, feeding
intolerance (protein
allergy), colitis
pH 5-7
pH <5 suggestive of
carbohydrate
malabsorption
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Reducing
substances
None after first
week of life
Unabsorbed sugars (>
¼%) suggest
carbohydrate
malabsorption
(Source: Data are from Hockenberry, 2007; Gomella, 2004. Table is used by permission of
Melody Thompson.)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Nutrition Care > Nutrition Diagnosis
Prematurity

Registered dietitians who care for infants in a variety of settings—including neonatal
intensive care units, intermediate neonatal care units, normal newborn nurseries, newborn
follow-up clinics, or pediatricians’ offices—use the parameters described in the Nutrition
Assessment section of this manual to determine whether or not a nutrition diagnosis is
present. The following list, while not exhaustive, represents nutrition diagnoses commonly
used in these settings.

Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Predicted suboptimal energy intake (NI-1.6)
Inadequate oral intake (NI-2.1)
Less than optimal enteral nutrition infusion (NI-2.5)
Less than optimal parenteral nutrition (NI-2.7)
Increased nutrient needs (specify) _____________ (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein intake (NI-5.7.1)
Inadequate mineral intake (specify) ____________ (NI-5.10.1)
Predicted suboptimal nutrient intake (NI-5.11.1)
Swallowing difficulty (NC-1.1)
Breastfeeding difficulty (NC-1.3)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) ___________ (NC-2.2)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
Overweight (NC-3.3)
Unintended weight gain (NC-3.4)

Sample Problem, Etiology, Signs and Symptoms or Nutrition Diagnostic Statements:

Increased nutrient needs (protein, vitamins and minerals) (NI-5.1) related to growth
requirements of very-low-birthweight preterm infant as evidenced by birthweight of 1
kg at 28 weeks’ gestational age.
Swallowing difficulty (NC-1.1) related to medical diagnosis of paralyzed vocal cords as
evidenced by aspiration of thin liquids during swallow study.
Inadequate protein intake (NI-5.7.1) related to intake of breast milk without human
milk fortifier at 1 kg as evidenced by intake of 2.5 g protein/kg/d compared to standard
of 4 g/kg/d.
Malnutrition (NI-5.2) related to intrauterine growth retardation as evidenced by weight
that plots below the 10th percentile for gestational age and weight for length index
that plots below the 10th percentile.

Note: Terminology in the examples above is from the third edition of the International
Dietetics and Nutrition Terminology (2011). Code numbers are inserted to assist in finding
more information about the diagnoses, their etiologies, and signs and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
symptoms. Registered dietitians should not include these numbers in routine clinical
documentation.

Congenital Anomalies of the Alimentary Tract

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have congenital anomalies of the alimentary
tract should diagnose nutrition problems based on nutritional signs and symptoms.
Nutrition diagnoses from the list below as well as other diagnoses may be present.
Increased nutrient needs (specify) (NI-5.1)
Swallowing difficulty (NC-1.1)
Breastfeeding difficulty (NC-1.3)
Altered GI function (NC-1.4)
Sample PES or Nutrition Diagnostic Statement(s)
Breastfeeding difficulty (NC-1.3) related to cleft lip and palate as evidenced by
measured breast milk intake--before and after breastfeeding weights--of 150 mL/kg/d
with low weight gain
Swallowing difficulty (NC-1.1) related to tracheo-esophageal fistula repair and
narrowing of esophagus on x-ray as evidenced by average daily intake of 100 mL/kg/d
Altered GI function (NC-1.4) related to delayed gastric emptying as evidenced by
gastric residuals of >30 mL documented 3 hrs after feedings, and inability to progress
feedings to 130 mL/kg/d.
Increased nutrient needs related to cystic fibrosis, meconium ileus, and resection of
20 cm of small bowel, as evidenced by steatorrhea and weight gain less than
expected.
Altered GI function (NC-1.4) related to surgical repair of Hirschsprung's Disease and
lack of anal sphincter function as evidenced by stool frequency greater than 12 per
day, stools with loose to watery consistency, and skin breakdown on buttocks.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Congenital Heart Disease

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have congenital heart disease should diagnose
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Impaired nutrient utilization (NC-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Predicted suboptimal nutrient intake (NI-5.11.1)
Sample PES or Nutrition Diagnostic Statement(s)
Impaired nutrient utilization (NC-2.1) related to compromised lymphatic function on
formula containing 75% of fat as long-chain triglycerides as evidenced by chylous
fluid accumulation in the lungs.
Predicted suboptimal nutrient intake (NI-5.11.1) related to fluid restriction of 120
mL/kg/d medical treatment for patent ductus arteriosus as evidenced by total nutrient
intake of 80% of that recommended for age and weight.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Endocrine Disorders

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have endocrine disorders should review
diagnose nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses
from the list below as well as other diagnoses may be present.
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Sample PES or Nutrition Diagnostic Statement(s)
Impaired nutrient utilization (NC-2.1) related to prematurity and a glucose infusion rate
of 12 mg/kg/min as evidenced by hyperglycemia (serum glucose 250 mg/dL)
Impaired nutrient utilization (NC-2.1) related to extreme prematurity and lack of
enteral feedings containing carnitine as evidenced by serum glucose of 30 mg/dL
coincident with negative urine ketones.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Gastroesophageal Reflux Disease

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have gastroesophageal reflux should diagnose
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Altered gastrointestinal function (NC-1.4)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Altered gastrointestinal function (NC-1.4)
Inadequate oral intake (NI-2.1)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to gastroesophageal reflux as evidenced by
frequent regurgitation and weight gain of 15 g/d despite feedings of 120 kcal/kg/d.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Hyperbilirubinemia

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have hyperbilirubinemia should diagnose
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Increased nutrient needs (specify) (NI-5.1)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Sample PES or Nutrition Diagnostic Statement(s)
Increased nutrient needs (vitamins A, D, E, and K) (NI-5.1) related to cholestasis,
decreased bile secretion, and fat malabsorption as evidenced by low serum levels of
vitamins A, D, and E, and prolonged prothrombin time.
Impaired nutrient utilization (NC-2.1) related to cholestasis as evidenced by increased
stool fat content (malabsorption) and a weight gain of 15 g/d.
Altered nutrition-related laboratory values (vitamins A, D, E, and K) (NC-2.2) related
to cholestasis as evidenced by plasma retinol level 18 mcg/dL, plasma
25-hydroxycholecalciferol level 15 ng/mL, serum vitamin E level 0.5 mcg/mL, and
prolonged prothrombin time.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Necrotizing Enterocolitis

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have necrotizing enterocolitis should diagnose
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Predicted suboptimal nutrient intake (NI-5.11.1)
Altered gastrointestinal function (NC-1.4)
Sample PES or Nutrition Diagnostic Statement(s)
Altered gastrointestinal function (NC-1.4) related to necrotizing enterocolitis as
evidenced by increased gastric residuals, emesis, abdominal distension and bloody
stools.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Neurological Impairment

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have neurological impairment should diagnose
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Inadequate oral intake (NI-2.1)
Less than optimal enteral nutrition (NI-2.5)
Decreased nutrient needs (specify) (NI-5.4)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to neurological compromise and delayed
feeding skills as evidenced by recorded oral intake of 100 mL/kg/d infant formula.
Decreased nutrient needs (energy) (NI-5.4) related to low muscle tone as evidenced
by accelerated rate of weight gain.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Osteopenia

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have osteopenia of prematurity should
diagnose nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses
from the list below as well as other diagnoses may be present.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Altered nutrition-related laboratory values (NC-2.2)
Inadequate mineral intake (specify) (NI-5.10.1)
Sample PES or Nutrition Diagnostic Statement(s)
Altered nutrition-related laboratory values (NC-2.2) related to use of inappropriate
formula as evidenced by elevated serum alkaline phosphatase and low serum
phosphorus.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Renal Dysfunction

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants with renal dysfunction should diagnose nutrition
problems based on nutritional signs and symptoms. Nutrition diagnoses from the list below
as well as other diagnoses may be present.
Decreased nutrient needs (specify) (NI-5.4)
Excessive protein intake (5.7.2)
Sample PES or Nutrition Diagnostic Statement(s)
Decreased nutrient needs (protein, phosphorus, and fluid) (NI-5.4) related to renal
insufficiency as evidenced by urea nitrogen 35 mg/dL, phosphorus 7.6 mg/dL (high
normal), urine output of 80 mL/kg/d, and presence of edema.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Respiratory Disease

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have respiratory diseases should diagnose
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Increased nutrient needs (specify) (NI-5.1)
Increased energy expenditure (NI-1.2)
Sample PES or Nutrition Diagnostic Statement(s)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Increased nutrient needs (energy) (NI-5.1) related to increased work of breathing
associated with respiratory disease as evidenced by weight gain lower than expected.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Short Bowel Syndrome

More information from the Neonatal Nutrition Toolkit on applying the Nutrition Care
Process to the NICU and ADA's standard terminology is available in the Resources area.
An additional table of common NICU Nutrition Diagnoses is also included for reference.
Dietitians working with preterm infants who have short bowel syndrome should diagnose
nutrition problems based on nutritional signs and symptoms. Nutrition diagnoses from the
list below as well as other diagnoses may be present.
Impaired nutrient utilization (NC-2.1)
Altered gastrointestinal function (NC-1.4)
Increased nutrient needs (NI-5.1)
Sample PES or Nutrition Diagnostic Statement(s)
Altered GI function (NC-1.4) related to decreased functional bowel length as
evidenced by steatorrhea, frequent loose stools, and weight gain less than expected.
Increased nutrient needs (fat-soluble vitamins) (NI-5.1) related to steatorrhea and
decreased functional bowel length as evidenced by plasma retinol level 18 mcg/dL,
plasma 25-hydroxycholecalciferol level 15 ng/mL, serum vitamin E level 0.5 mcg/mL,
and prolonged prothrombin time.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Nutrition Care > Nutrition Intervention
Prematurity

Nutrition intervention is designed to resolve or at least improve the nutrition problem or problems
identified in the neonatal patient. The intervention comprises both planning and implementation.
Planning may require the following:
Prioritizing nutrition diagnoses more than one diagnoses are determined or prioritizing the
nutrition diagnosis within the framework of the patient's total care plan
Referring to evidence-based practice guidelines, expected outcomes, and comparative
standards
Conferring with other members of the health care team, including the patient's family
Defining the steps and strategies for implementation of intervention
Defining the time and frequency of care and follow-up to ensure desired outcome
Implementation may require the following:
Communication of the nutrition care plan to those who are directly involved in implementing
the nutrition intervention, including physicians, nurses, and the patient's family
Carrying out or facilitating the implementation of the plan
Nutrition intervention strategies may include the following:
Food and/or nutrient delivery: Changes in parenteral or enteral nutrient delivery to meet
evidence-based practice guidelines or comparative standards—for example, individualized
recommendations for human milk or infant formulas, parenteral or enteral nutrition, or nutrient
supplements
Nutrition education: Educating families to be able to procure, prepare, and administer
adequate and appropriate nutrition, whether the infant requires breast, bottle, parenteral or
enteral feedings with or without fortification, or supplements to support normal growth,
development, and optimal health
Coordination of nutrition care: Consultation with other members of the neonatal staff and the
infant's family, referral to community resources or agencies, and coordination of care with
primary care providers to monitor and evaluate nutrition-related outcomes after hospital
discharge


Congenital Anomalies of the Alimentary Tract

The nutrition regimen for infants after alimentary tract surgery (summarized in the Table below)
includes the following:
Start parenteral nutrition (PN) soon after surgery. In the acute phase after surgery, while
C-reactive protein (CRP) levels are ≥ 2 mg/dL, provide maintenance PN (eg, CAA, 2.5 to 3
g/kg/day; dextrose, 8.5 g/kg/day to 10 g/kg/day; and IFE, 1 g/kg/day to 2 g/kg/day) (B)
(Alaedeen, 2004).
When CRP decreases (indicating reduced metabolic stress) and prealbumin increases
(indicating resumption of anabolism), advance nutrient intake as tolerated to promote growth
(B) (Alaedeen, 2004). After surgical stress, anabolic recovery frequently occurs more rapidly
in preterm than in term infants (B) (Tueting, 1999).
For infants expected to be on long-term PN, minimize PN–associated cholestasis by avoiding
excessive energy and providing balanced regimens (see Parenteral Nutrition) (C).
When evidence of intestinal motility returns following surgery, start minimal enteral nutrition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(MEN) (C).
The optimal composition of enteral feedings after alimentary tract surgery is unknown. See
options in the Table, which are based on accumulated clinical experience of practitioners (C).
For preterm infants on protein hydrolysate or amino acid–based formulas, consider a
transition to fortified human milk or preterm formula for improved nutritional adequacy (C)
(Koo, 2005).
If feeding progression for infants (especially for those with small intestinal anomalies)
becomes complicated by significant malabsorption, consider suggestions made for Short
Bowel Syndrome.
Congenital Alimentary Tract Anomalies and Feeding/Nutrition Implications
Upper Alimentary Tract Small Intestine Large Intestine
Specific anomalies
Cleft lip/cleft palate
Esophageal
atresia/tracheoesophageal
fistula
Pyloric stenosis
Omphalocele
Gastroschisis
Congenital
diaphragmatic
hernia
Congenital
obstruction
(atresia,
malrotation,
and/or
volvulus)
Hirschsprung’s
disease
Meconium plug
Meconium ileus
Feeding/nutrition
challenges
Ingesting and retaining feedings
Digesting and
absorbing feedings
Excreting intestinal
waste products
Digestion/absorption
affected?
No Yes
No (unless infant
has cystic
fibrosis—often
associated with
meconium ileus)
Long-term PN
expected?
No
Yes—provide
central venous
access early
No
Enteral product(s)
Preterm: human milk
(+HMF when 100 mL/kg/d)
and/or preterm formula
Term: human milk (+direct
breastfeeding when
tolerated) and/or standard
term formula
Preterm and
term: human
milk, protein
hydrolysate,
or amino
acid–based
formulas
Fortification
will be
needed for
preterm
infants
Preterm:
human milk
(+HMF when
100 mL/kg/d)
and/or preterm
formula
Term: human
milk (+direct
breastfeeding
when
tolerated)
and/or
standard term
formula
MEN rate 10-20 mL/kg/d 10-20 mL/kg/d 10-20 mL/kg/d
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Progressive feeding
rate
≤ 35 mL/kg/d
Individualized;
MEN may be
maintained for
weeks; progressive
feedings usually
advance slowly (10
mL/kg/d).
≤ 35 mL/kg/d
Feeding
methodology
Bolus enteral or oral; infants
with cleft lip and/or palate may
require feeding
evaluation/treatment
Continuous
nasogastric (or
gastrostomy if > 2
mo); provide
nonnutritive
sucking on pacifier
Bolus enteral or oral
Time to reach full
feedings
Rapid: ~1 wk
Slow: weeks to
months; PN
maintained
Rapid: ~1 wk
Abbreviations: PN = parenteral nutrition; HMF: human milk fortifier; MEN = minimal enteral nutrition
Table used by permission of Melody Thompson.

Evidence classification system

Congenital Heart Disease

Nutrition intervention cannot prevent congenital heart defects. In some cases, fluid restriction (120
mL/kg/day or less) may prevent congestive heart failure in infants with CHD.
Preoperative Nutrition
Prevent catabolism with sufficient parenteral nutrition (PN) energy, protein, and nutrients (see
Parenteral Nutrition):
If the infant is edematous, determine a “dry weight” (often the weight appropriate for length) to
calculate nutrition needs (C).
Infuse drip medications in concentrated glucose solutions. Concentrate PN substrates
(glucose, crystalline amino acids, intravenous fat emulsion [IFE], and other nutrients) as much
as possible (C) (Barry, 2006; Kleinman, 2004; Wessel, 2005).
Initiate minimal enteral nutrition (MEN). Provide 10 mL/kg/day to 20 mL/kg/day as MEN unless
cyanosis and gut hypoperfusion contraindicate enteral stimulation (C).
Advance enteral nutrition (EN) as tolerated with concomitant weaning from PN. Cautious advances
in EN are advised for infants whose cardiac lesions are associated with decreased intestinal blood
flow (risk factor for NEC) (B) (Barry, 2006).
Promote normal growth for age/size, and promote oral feeding skills:
Average enteral energy requirements to support growth are 145 kcal/kg/day (or 115
kcal/kg/day for ideal body weight for length). Recommended protein intake is approximately
3.5 g/kg/day (B,C) (Kleinman, 2004).
Allow breastfeeding as tolerated. If needed, provide pumped breast milk with hind milk and/or
nutrient supplements (eg, concentrated liquid formula for term babies) via supplemental
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrient supplements (eg, concentrated liquid formula for term babies) via supplemental
nursing system (C).
If formula-fed, concentration of the base formula typically needs to be 24 kcal/fl oz to 30 kcal/fl
oz. Optimal growth is achieved with 24-hour continuous nasogastric tube feeding (B), which
precludes oral feeding. Nonnutritive sucking can be offered to encourage oral-motor
development (Kleinman, 2004).
Postoperative Nutrition
Fluid volume is initially restricted (often to 50 mL/kg/day to 80 mL/kg/day); therefore, glucose in
drip medications and PN should be concentrated. When evidence of bowel function returns, start
with MEN and advance to progressive feedings as tolerated.
Rapid postoperative advancement in caloric density of enteral feedings (daily increases from 24
kcal/fl oz to 27 kcal/fl oz to 30 kcal/fl oz) has shown improved energy intake and weight gain, and
resulted in earlier hospital discharge compared with slower advancement using lower
energy-density goals (A) (Pillo-Blocka, 2004).
Chylothorax
Chylothorax (lymphatic fluid in the chest cavity from operative trauma) is treated nutritionally by
limiting the intake of enteral long-chain fatty acids in favor of medium-chain triglycerides (MCTs).
Continue PN, with IFE as the source of essential fatty acids.
It may be possible to remove fat from the mother's milk and feed the “skimmed” milk to infants
with chylothorax (Chan, 2007).
Infant formulas with high MCT content (up to 84% of fat as MCT) are often used.
No ideal enteral formula exists for all infants with chylothorax. Meet the infant’s nutrient needs
(often through a combination of PN and EN) in a safe manner while minimizing chylous drainage.
Nutritional treatment duration is quite variable (average approximately 1 month) and should be
managed on a case-by-case basis (C) (Chan, 2007; Chan, 2005; Densupsoontorn, 2005).
Congenital chylothorax is treated in the same manner as postoperative chylothorax. Regardless of
etiology, refractory cases may require medication, surgery, and/or use of PN exclusively until
chylous drainage subsides (Chan, 2005; Densupsoontorn, 2005).
Patent Ductus Arteriosus
The ductus arteriosus is a fetal vascular connection that diverts blood from the pulmonary artery to
the aorta and placenta for oxygenation. The ductus normally constricts shortly after full-term birth.
If it remains open—as it frequently does after preterm birth—it is termed a patent (open) ductus
arteriosus (PDA).
Incidence is inversely proportional to birth weight and gestational age and occurs in up to 80% of
extremely low-birth-weight infants. PDA has the potential to lead to congestive heart failure,
pulmonary edema, progressive development of pulmonary vascular resistance, and failure to thrive
(Poole-Napp, 2000).
PDA may close unaided in days or weeks or may require medical or surgical closure. Infants with
hemodynamically significant PDA are managed nutritionally with fluid restriction (~120 mL/kg/day
to 130 mL/kg/day) and concentrated PN.
PDA and related medications are associated with abnormal intestinal blood flow and concomitant
risk for NEC. MEN may or may not be used—the luminal need for trophic feedings is weighed
against NEC risks (C) (Thureen, 2005). When the PDA closes, the infant’s enteral feeding plan can
be normalized.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Evidence classification system

Endocrine Disorders

Hypoglycemia
Use screening protocol to identify hypoglycemia, particularly for infants at increased risk (B).
If medically stable and feedings may be given, provide 10 mL/kg of human milk or infant formula
per feeding. Encourage enteral/oral feeding within the first 6 hours of life or within the first 30 to 60
minutes of life for infants at higher risk for developing hypoglycemia. If feedings are precluded by a
medical condition, initiate intravenous dextrose at 4 mg/kg/min to 6 mg/kg/min (normal rate of
hepatic production of glucose) (C).
Hyperglycemia
Amino acid administration within the first hours of life may help stimulate endogenous production
and secretion of insulin, reducing the need for insulin infusion, particularly in
extremely-low-birth-weight infants, whose endogenous protein stores are low (B).
(Tsang, 2005; Meites, 1989; Kao, 2006; Farrag, 2000)

Gastroesophageal Reflux Disease

The following nutrition interventions have shown some efficacy in infantile gastroesophageal reflux
(GER):
Small, frequent (or continuous) feedings are less associated with GER than are larger,
infrequent feedings (B,C) (Poets, 2004; Thompson, 2000).
In some infants, reflux may be a manifestation of a hypersensitivity reaction to cow’s milk
protein, treatable by hypoallergenic feedings (Rudolph, 2001; Salvatore, 2002). If the lactating
mother chooses a trial (of several weeks) of cow’s milk protein avoidance, provide nutrition
counseling to ensure nutritional adequacy of her adjusted diet. If her infant’s condition does
not improve, her dietary restrictions should be discontinued (C). Changing from a cow’s
milk–based formula to amino acid–based or casein hydrolysate formula decreases spitting
up/vomiting in as many as half of formula-fed infants with GER. A 1- to 2-week trial of a
hypoallergenic formula is recommended (A) (Rudolph, 2001). Continue if efficacy is noted.
These products are formulated with nutrient levels for full-term infants; if used for more than 1
week in preterm infants, assess adequacy of nutrient intake. Nutrient supplementation,
particularly minerals, is often indicated (C).
Thickened feedings reduce regurgitation (symptomatic reflux) but not reflux index (the
amount of time that the esophagus is bathed in acidic fluid) and may also increase coughing
(A) (Rudolph, 2001; Craig, 2004). Thickened feedings are not possible or desirable with direct
breastfeeding. Pumped, fresh breastmilk cannot be thickened with cereal or starches
(presumably because of the amylase activity in the milk) (C). In the United States, formulas
have traditionally been thickened with dry infant rice cereal in the neonatal intensive care unit
(NICU). Recent concerns about safety of dried or powdered products in the NICU may
preclude the use of dry cereal or other powdered thickeners (Lin, 2007). SimplyThick® – a
xanthan gum gel – is sometimes added in the NICU to feedings as a thickener. The FDA is
now warning against the use of SimplyThick for preterm infants (those born before 37 weeks
gestational age). The use of SimplyThick in this population has been associated with the risk
of necrotizing enterocolitis (FDA, 2011). Commercial infant formulas containing part of their
carbohydrate as rice starch, which thickens at gastric pH, are now available in the United
States. Similar products have been used for many years in Europe, where they have been
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
shown to decrease the amount and severity of regurgitation (Rudolph, 2001; Salvatore, 2002).
The concomitant use of acid-suppressant medications likely diminishes the efficacy of these
formulas (C). The nutrient profiles of these formulas are not appropriate for preterm infants.
Additional (Nonnutrition) Treatment Options
Nonnutrition treatment options include prone or left-lateral positioning in the NICU. At home,
because of sudden infant death syndrome concerns, infants should lie supine when sleeping and
supine or prone after feedings or when awake (A) (Rudolph, 2001; Craig, 2004). Acid-suppressant
and prokinetic medications may be beneficial (A,B,C) (Rudolph, 2001; Craig, 2004). Surgery may
be indicated for severe cases (C) (Pacilli, 2005).

Hyperbilirubinemia

Prevention of Unconjugated Hyperbilirubinemia
Encourage 9 to 12 feedings per day of human milk or formula to promote adequate hydration and
intestinal motility. Supplementation of breastfed infants with water does not prevent or improve
elevated bilirubin levels (A) (Askin, 2003; Gourley, 2000; Hartline, 2000; Venigalla, 2004;
Francavilla, 2003; Acosta, 2001).
Prevention of Conjugated Hyperbilirubinemia
Although nutrition strategies to prevent the occurrence of inborn errors of metabolism do not exist,
nutrition therapies for prevention of hepatic damage due to inborn errors of metabolism have been
described elsewhere (Acosta, 2001). Nutrition-related strategies that may decrease risk or severity
of cholestasis associated with parenteral nutrition (PN) include the following:
Provide adequate but not excessive macronutrients. Meet protein needs for age and clinical
condition, providing 60% to 70% of nonprotein energy as carbohydrate and 30% to 40% of
nonprotein energy as fat (B) (Gourley, 2000; Hartline, 2000; Venigalla, 2004; Francavilla,
2003; Acosta, 2001)
Consider cyclic administration of PN (C).
Use pediatric amino acid preparations containing taurine, especially for preterm infants or
infants in whom necrotizing enterocolitis develops (B) (Gourley, 2000; Hartline, 2000;
Venigalla, 2004; Francavilla, 2003; Acosta, 2001).
A new parenteral lipid emulsion, Omegavan (Freseniu Kabi, Germany), containing primarily
n-3 fatty acids and made from fish oils, may be a promising alternative product to prevent
cholestasis (C). Omegavan is currently approved for use in Europe but only compassionate
use in the United States. Research is currently under way to seek US Food and Drug
Administration approval of this product (Gura, 2006)
Introduce and advance enteral feedings as soon as possible (A) (Gourley, 2000; Hartline,
2000; Venigalla, 2004; Francavilla, 2003; Acosta, 2001).
Unconjugated Hyperbilirubinemia
If bilirubin levels increase to more than 20 mg/dL in infants with breast milk jaundice, temporarily
discontinue breastfeeding and provide casein hydrolysate or standard cow’s milk protein formula
for 1 to 2 days. Counsel the mother about how to promote maintenance of breast milk supply and
when to resume breastfeeding (C) (Gourley, 2000; Hartline, 2000).
Conjugated Hyperbilirubinemia
Consider the following during administration of parenteral nutrition (PN):
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tactics to prevent cholestasis should be continued (see above) (Gourley, 2000; Hartline,
2000; Venigalla, 2004; Francavilla, 2003; Acosta, 2001).
When enteral feedings are tolerated, consider use of ursodeoxycholic acid, which has been
shown to reduce cholestasis by increasing bile flow (B) (Venigalla, 2004; Francavilla, 2003).
Although copper is excreted in bile, hepatic levels of copper decrease as liver disease
progresses, and copper deficiency has developed in pediatric patients when copper is
removed from parenteral solutions. Reduce or remove copper only if evidence of copper
toxicity is present (C) (Zambrano, 2004; Hurwitz, 2004).
Manganese is also excreted primarily in bile, but blood manganese levels are elevated in
patients with cholestatic jaundice and are directly correlated to level of cholestasis. At this
time, it seems appropriate to remove manganese from PN when direct bilirubin is greater than
2 mg/dL. Excessive intakes of parenteral manganese may induce PN–associated liver
disease and neurotoxicity (C) (Fok, 2001).
Case reports using a new parenteral lipid emulsion containing primarily n-3 fatty acids made
from fish oils (Omegavan; not currently approved for use in the United States) also show
resolution of cholestatic jaundice (C) (Gura, 2006).
Following are considerations with enteral feedings:
Energy needs may be 125% of the normal recommended amounts based on ideal body
weight (Gourley, 2000; Hartline, 2000; Venigalla, 2004; Francavilla, 2003).
Medium-chain triglycerides (MCT) do not require bile salts for absorption. Formula with MCT
oil may be used, but the formula should also provide adequate amounts of oils rich in linoleic
and linolenic acids to prevent essential fatty acid (EFA) deficiency (Gourley, 2000; Hartline,
2000; Venigalla, 2004; Francavilla, 2003). Preterm infant formulas and preterm discharge
formulas contain a substantial amount of MCT oil as well as oils rich in EFAs (C).
If stools appear acholic (without bile—usually white, grey, or clay-colored) or if fat
malabsorption is present, obtain serum levels of fat-soluble vitamins A, D, and E and
prothrombin time to assess vitamin K status (C). Specific recommendations for
supplementation of fat-soluble vitamins appear later on this page (Gourley, 2000; Hartline,
2000; Venigalla, 2004; Francavilla, 2003; Sippel, 1991).
Recommended oral intake of water-soluble vitamins is twice the Recommended Dietary
Allowance (C).
Maintain optimal intake of calcium, phosphorus, and zinc (C).
Recommendations for Vitamins A, E, D, and K in Enteral Nutrition Therapy for
Conjugated Hyperbilirubinemia
Vitamin A
Supplement with enteral/oral doses of 5,000 IU/day to 25,000 IU/day in water-miscible form
as needed to prevent deficiency. Serum levels below 20 mcg/L indicate deficiency.
Monitor for signs of toxicity. Serum levels greater than 100 mcg/dL identify potential toxicity.
Vitamin E
Supplement with enteral/oral doses of 50 IU/day to 400 IU/day in water-miscible form or 15
IU/kg/day to 25 IU/kg/day as d-alpha-tocopherol polyethylene glycol-1,000 succinate to
prevent deficiency. Serum levels below 0.5 mg/dL indicate deficiency.
Pharmacologic doses are associated with an increased incidence of necrotizing enterocolitis,
possibly resulting from the high osmolality of the preparation, and may cause diarrhea or
exacerbate vitamin K deficiency coagulopathy.
Serum levels greater than 5 mg/dL are associated with increased incidence of sepsis.
Vitamin D
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Vitamin D levels below 20 ng/mL may be considered evidence of vitamin D deficiency, and
levels between 21 ng/mL to 29 ng/mL may be considered evidence of insufficiency.
Hypophosphatemia (serum phosphorus < 4) may also be present, as may hypocalcemia
(serum calcium level below 8 mg/dL).
For infants with cholestasis, provide enteral/oral dose of 200 IU/day to 1,000 IU/day of vitamin
D if serum levels are normal.
Supplement with enteral/oral doses of 2,500 IU/day to 8,000 IU/day of D-2 cholecalciferol or 3
mcg/kg/day to 5 mcg/kg/day of 25-hydroxyvitamin D if there is evidence of insufficiency or
deficiency.
Calcium (25 mg/kg/day to 100 mg/kg/day) and phosphorus (25 mg/kg/day to 50 mg/kg/day)
supplements may also be needed if rickets or osteomalacia is present.
Evidence of vitamin D toxicity may include vomiting, hypercalcemia, hypercalciuria,
nephrocalcinosis, and failure to thrive.
Vitamin K
2.5 mg to 5 mg every 2 to 3 days.
Coagulation studies are used to monitor vitamin K status, rather than serum vitamin levels.
Source: Data are from references (Gourley, 2000; Hartline, 2000; Venigalla, 2004; Francavilla,
2003; Sippel, 1991)

Necrotizing Enterocolitis

Although enteral nutrition is a risk factor for development of necrotizing enterocolitis (NEC), not all
infants in whom NEC develops have been fed enterally (Srinivasan, 2008). The decision to
withhold feedings in an effort to prevent NEC should be carefully weighed against the positive
effects of luminal nutrients on gastrointestinal development (Reynolds, 2007). Common nutrition
practices proposed to reduce the incidence of NEC include the following (A) (Srinivasan, 2008;
Reynolds, 2007; NEC, 2007; Boyd, 2007; Schanler, 2005; Kuschel, 2004; Patole, 2007):
Human milk: widely accepted as the most effective way to reduce NEC; experts do not agree
on whether human milk from a donor is as protective as an infant’s own mother’s milk. There
is no evidence that commercial human milk fortifiers increase the incidence of NEC.
Fluid restriction: ~60 mL/kg to 120 mL/kg during the first week; avoid dehydration.
Minimal enteral nutrition: 10 mL/kg/day to 35 mL/kg/d for more than 4 days.
Rate of feeding advancement: 35 mL/kg/d or less.
Feeding practices likely to have no effect on occurrence of NEC include the following (A) (NEC,
2007; Morgan, 2011a):
Early (younger than 5 days of life) vs late (day of life 5 to 14) initiation of feeding
Transpyloric vs gastric feeding
Bolus vs continuous feeding
Feeding with high vs low umbilical artery catheter placement
A potentially harmful nutrition practice that may increase NEC is pharmacological supplemental
vitamin E that results in serum levels greater than 3.5 mg/dL (A) (Brion, 2003). Evidence for
treatment with the probiotics lactobacilli and/or bifidobacteria is conflicting and their safety in
newborns is undetermined (B) (Lin, 2006; NEC, 2007; Patole, 2007; AlFaleh, 2011; Thomas, 2010).
Efforts to increase the availability of fresh “own mother’s milk” are perhaps the best strategy to
minimize the risk of NEC. Careful initiation of feeding within the first week of life followed by
advancement at rates approximately 20 mL/kg/d is within the scope of recommended clinical
practice (Kuzma-O'Reilly, 2003; Morgan, 2011b).
Management of necrotizing enterocolitis (NEC) includes antibiotic therapy and support of
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Management of necrotizing enterocolitis (NEC) includes antibiotic therapy and support of
physiological homeostasis. There is no known optimal nutrition management during active or
recovering NEC, but consider the following strategies (C):
Bowel rest with cessation of enteral nutrition, ranging from 1 to 3 weeks, with balanced and
complete total parenteral nutrition (TPN) (See Parenteral Nutrition)
Gradual reintroduction of enteral feedings as tolerated: increase by 10 mL/kg/day to 35
mL/kg/day with human milk (preferred), donor human milk or preterm formula (if mother’s own
milk is not available), or protein hydrolysate or amino acid–based formula (if evidence of
intolerance to intact protein is present)
After NEC resolves, preterm infants who resume feedings with human milk require
fortification; options include gradual introduction of commercial powdered human milk fortifier
to a concentration of 1 packet per 25 mL (goal), combination with high–nutrient density
formula (if volume of human milk is insufficient), or fortification with specific nutrients (if
intolerant to commercial fortifier options) (See Enteral Nutrition)
Bowel injury and prolonged gut rest may precipitate secondary intestinal enzyme deficiencies;
anticipate and treat feeding intolerance with individualized enteral feedings and/or feedings
built from modular products
If bowel resection is necessary, carefully review nutrients that may be
maldigested/malabsorbed
Monitor for late complications such as cholestatic jaundice (when TPN is administered for
more than 2 weeks), bowel strictures (manifested by sudden or increasing gastric residuals
and/or emesis), and osteopenia (See Osteopenia).

Evidence classification system

Neurologic Impairment

Specific nutrition-related strategies to prevent neurologic diseases are generally not known, other
than the following (B) (Acosta, 2001; Nevin-Folino, 2000; Acosta, 2005; Cloud, 2005):
Spina bifida has a genetic etiology, but considerable evidence suggests that adequate
maternal intake of folic acid (400 mcg/day) throughout childbearing years and pregnancies
can significantly reduce risk.
Dietary treatment of neurometabolic disorders during pregnancy is generally recommended to
reduce risk of neurologic compromise in the infant.
Abstinence from alcohol throughout pregnancy is recommended to prevent fetal alcohol
syndrome.
Many neurometabolic disorders are amenable to nutrition therapy, but nutrition treatment
modalities for infants with other neurologic conditions relate primarily to problems of altered growth
and energy needs, abnormal muscle tone, delayed feeding skills, dysphagia, gastroesophageal
reflux (GER), constipation, and/or drug-nutrient interactions (Acosta, 2001; Nevin-Folino, 2000;
Acosta, 2005; Cloud, 2005).
Infants may require several complex nutrition strategies to provide treatment and prevent
neurologic dysfunction. Specific nutrition treatment strategies are beyond the scope of this manual,
but generally involve one or more of the following approaches (B) (Acosta, 2001; Nevin-Folino,
2000; Acosta, 2005; Cloud, 2005):
Prevent catabolism by avoiding fasting and providing adequate energy to meet metabolic
demands for normal growth and development, especially during periods of illness or stress
when oral intake may be limited.
Restrict dietary intake of specific nutrient(s) to prevent toxic accumulation due to lack of
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enzymes or blocked/impaired metabolic pathways.
Supplement nutrients that help drive alternate metabolic pathways, that become essential due
to lack of endogenous production or blocked metabolic pathways, that replace deficient
cofactors or induce normal enzyme production, and that are inadequately absorbed or not
available metabolically.
Growth Assessment
Growth may be altered in infants with neurologic compromise (C). Head circumference may be
disproportional to length and weight on growth charts. Normal head-to-length proportion is
described by the following equation:
Head circumference (cm) = (0.5 length [cm] + 9.5) ± 2.5 cm
Infants with intrauterine growth retardation associated with drug or alcohol exposure, intrauterine
infection, or microcephaly may not experience catch-up growth.
Energy
Although not specifically predictable, variations in energy needs may be expected (C). Resting
metabolic rate may be lower, decreasing energy needs if brain tissue mass or function is below
normal.
Energy needs may be increased to accommodate increased muscle tone, seizure activity,
irritability, or spasticity/involuntary movement. Energy needs may be decreased when muscle tone
or movement is below normal. Energy needs for growth may be decreased for specific diagnoses
and syndromes associated with decreased growth potential.
When energy needs are less than 75 kcal/kg/d, protein, electrolyte, vitamin, and mineral
supplements may be required to meet Dietary Reference Intakes.
Delayed Feeding Skills/Dysphagia (C)
Hunger/satiety cues may be subtle or absent in infants with neurologic disorders, and families may
need help interpreting cues.
If oral feedings take longer than 20 to 30 minutes, consider supplemental tube feedings to prevent
fatigue and feeding aversion. If energy-dense formula is used to provide adequate nutrition in a
tolerated volume, ensure that adequate fluid intake (100 mL/kg/day free water) is provided.
Educate the family about the signs and symptoms of dehydration.
Tube-feeding recommendations include the following:
For short-term (less than 2 months) tube feeding, use a nasogastric feeding tube. An
orogastric feeding tube may be needed to prevent airway obstruction in a younger infant, but
this may also interfere with oral skill development. Either type of tube may stimulate gag and
contribute to feeding aversion. Feeding therapy should start to promote and develop oral
skills.
For long-term (more than 2 months) tube feeding, a gastrostomy tube is recommended
because it is safer for continuous feedings and diminishes noxious facial stimulation
associated with nasogastric or orogastric feeding tubes. Gastrostomy feedings may increase
GER. Oral therapy at planned intervals is recommended.
For infants with absent gag reflex or recurrent pneumonia, a jejunal tube may be needed.
If tube feedings are required at the time of discharge:
Provide family with expected weight gain and volume progression to support normal weight
gain until nutrition follow-up can be scheduled.
Ensure adequacy of intake for all nutrients, including fluid and electrolytes.
Educate family to use hunger and satiety cues as much as possible to facilitate eventual oral
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feeding; do not force feed.
Provide family with guidelines to make feedings as normal as possible: holding infant,
pleasant facial stimulation, social interaction, temperature of feeding, duration of feeding, and
so forth.
Individualize feeding plan to meet needs of both infant and family. Some infants may be able
to take part of a feeding by nipple, or several feedings each day with supplemental tube
feeding given simultaneously with oral feeding, as a bolus after the oral feeding, or as a
continuous feeding at night.
For oral-motor skill development, indwelling nasogastric tubes are generally preferred over
orogastric tubes, but either may be used if tube feedings will be required for a short time (up
to 2 to 3 months). If tube feedings are required for longer periods of time, gastrostomy
feeding tube placement is generally recommended to reduce risk of oral aversion.
If thickened liquids are needed to facilitate swallowing:
Ensure feeding recommendations meet all nutrient needs without providing excess energy;
instruct family about accurate preparation of feedings.
Rice starch–containing formulas that are used for GER have a higher viscosity than standard
formulas and may be of nearly nectar consistency without providing excessive carbohydrate
intake.
Starch-based thickeners are quickly inactivated by breast milk amylase. Xanthan gum–based
thickeners may be used effectively to thicken breast milk (Chamberlin, 2000).
Gastroesophageal Reflux
See Gastroesophageal Reflux for preterm infants.
Constipation
Constipation is often associated with decreased bowel motility, alterations in abdominal muscle
tone, decreased activity, low fluid intake, frequent vomiting, and/or medications (C).
Ensure adequate fluid intake—free water of at least 100 mL/kg/d. Additional water may be
needed to replace increased losses.
Avoid chronic use of laxatives or enemas to prevent dependency and/or nutrient loss,
particularly vitamins A, D, E, and K with use of mineral oil.
Provide 1 tsp to 2 tsp (5 mL to 10 mL) of prune juice/day or 1 oz to 2 oz (30 mL to 60 mL) of
water, pear, or apple juice per day if infant is beyond term age.
Consult an occupational or physical therapist for abdominal massage techniques and
range-of-motion exercises for lower extremities.
Drug-Nutrient Interactions
Drugs commonly used in the treatment of neurologically compromised infants include
anticonvulsants, antibiotics, drugs that reduce gastric acid or enhance gastric motility, stool
softeners, and laxatives.

Osteopenia

The goal for preventing osteopenia of prematurity is to match intrauterine bone mineral accretion
rates by optimizing energy, protein, and general nutrient intakes (for bone matrix formation) and
mineral intake (for mineralization of the matrix) (Demarini, 2005; Sharp, 2007; Backstrom, 2000;
Lapillonne, 2004; Atkinson, 2005; Kleinman, 2004).
Optimize calcium and phosphorus intakes—at least 15 mmol/L each of calcium and phosphorus
(60 mg/dL calcium and 46 mg/dL phosphorus)—from parenteral nutrition while avoiding mineral
precipitation. Consider consulting a clinical pharmacist to individualize and maximize calcium and
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phosphorus intakes using solubility curves (C).
Initiate minimal enteral nutrition at 10 mL/kg/day to 20 mL/kg/day as soon as cardiorespiratory
stability is achieved (C).
Human milk supplemented with commercially available multinutrient human milk fortifier, or a
preterm formula results in greater long-term linear growth, weight gain, bone mineral content, and
avoidance of fractures compared with the use of term formulas (A,B) (Lapillonne, 2004; Atkinson,
2005; Kleinman, 2004). Recently, the American Academy of Pediatrics recommended that all
infants have a minimum daily intake of 400 IU of vitamin D per day beginning shortly after birth to
prevent rickets (Wagner, 2008). Although osteopenia of prematurity is primarily a mineral
deficiency disorder, whereas rickets is a vitamin D deficiency disease, all infants should receive
400 IU of vitamin D daily.
Enteral nutrient intake recommendations are as follows.
Enteral Nutrient Intake Recommendations
Nutrient
Enteral
Recommendation
Reference
Calcium 175 mg/100 kcal
Kleinman,
2004
Phosphorus 91.5 mg/100 kcal
Kleinman,
2004
Calcium:Phosphorus ratio (by
weight)
1.7:1
a
to 2:1
Atkinson,
2005
Vitamin D 400, IU/d
Wagner,
2008
a
Assuming phosphorus needs are met and calcium source is highly bioavailable.

Monitor laboratory values approximately every 2 weeks when osteopenia is suspected or being
treated.
Wean from parenteral nutrition (PN) if possible. If not, maximize calcium and phosphorus in PN.
Start minimal enteral nutrition if possible (C) and advance to or continue fortified human milk or
preterm formula (A,B) (Lapillonne, 2004; Atkinson, 2005). If these feedings are not tolerated or not
medically indicated for longer than 1 week, supplement feedings with calcium and phosphorus.
Select supplements based on availability, osmolality, mineral bioavailability, and fluid limitations
(C).
Consider a physical therapy program (passive range of motion) to promote weight gain and bone
mineralization (B) (Schulzke, 2007).
Continuing Care
Infants discharged from the neonatal intensive care unit at a period of rapid growth may still be at
risk for osteopenia, particularly if breastfed without fortification or if fed term formulas. Inhospital
fortifiers with human milk or inhospital preterm formulas could be continued until the infant reaches
term weight, followed by the use of preterm discharge formula until 9 to 12 months (C) (Demarini,
2005; Carlson, 2005).

Evidence classification system
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Renal Dysfunction

In prerenal cases of renal failure, provide adequate fluid and electrolytes to maintain normal
hydration and electrolyte and acid/base status (C)*.
In cases of nephrocalcinosis, the following is advised:
Maintain acid/base balance; prevent hypophosphatemia (C).
Ensure adequate fluid, protein, and energy intake when providing increased amounts of
calcium and phosphorus to support intrauterine rates of linear growth (C).
Vitamin D: doses of 160 IU/day to 400 IU/day are adequate (B).
Consider assessment of urine calcium-to-creatinine ratio in infants who require chronic
diuretic or steroid medications, when mineral supplements are given to treat osteopenia, or
when vitamin D is given in doses > 400 IU/day. Urine calcium-to-creatinine ratios greater than
0.2 mg to 0.35 mg calcium/mg creatinine may indicate excessive calcium excretion and
increased risk of nephrocalcinosis (B).
(Edelmann, 1992; Moghal, 2006; Haycock, 2003; Hein, 2004; Spinozzi, 2000)
Fluid and Electrolytes
In oliguria and anuria, fluid intake = urine output + insensible losses (generally 25 mL/kg/day
to 30 mL/kg/day for most infants, but may be higher for infants who are less than 26 weeks’
gestational age). As fluids may be restricted to < 100 mL/kg/day, considerable effort may be
needed to provide adequate amounts of nutrients. Sodium (1 mEq/kg/day to 3 mEq/kg/day)
and potassium (1 mEq/kg/day to 2 mEq/kg/day) intake may need to be restricted. Bicarbonate
supplementation of 1 mEq/kg/day to 2 mEq/kg/day may be needed to achieve acid/base
balance and prevent hyperkalemia.
In high-output renal failure, fluid needs may be 150 mL/kg/day to 200 mL/kg/day.
Supplements of sodium and/or bicarbonate of 5 mEq/kg/day to 10 mEq/kg/day may be
needed.
For urinary, stool, or dialysate losses, replace fluids and electrolytes as needed to maintain
homeostasis.
Energy
Calculation of energy needs is often based on length rather than weight. Provide 8 kcal/cm/day to
12 kcal/cm/day or that which is necessary to promote normal growth/anabolism and to prevent
catabolism (Spinozzi, 2000).
Peritoneal dialysate solutions provide substantial amounts of energy as dextrose and must be
included when assessing energy intake.
Anorexia associated with azotemia and limited fluid intake may require use of a nutrient-dense
formula, modular additives, and/or supplemental tube feedings (see

Feeding Methodology).
Carbohydrate or fat modular additives may be added to human milk or infant formulas to achieve
adequate intake and growth, especially if protein, phosphorus, and/or potassium intake must be
restricted (see Formulas).
Increase energy density of feedings gradually to help ensure tolerance. Additional carbohydrate
(35% to 65% of total energy) and/or fat (30% to 55% of total energy) may be needed to meet
energy needs (meet protein, mineral, and vitamin needs before adding modular sources of
additional energy).
Protein
In cases of chronic renal insufficiency (CRI), for infants ages 0 to 6 months, limit protein to (Hein,
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2004).
For peritoneal dialysis, protein needs may be more than the RDI for age, or 2.4 g/kg/day to 4
g/kg/day. For hemodialysis, protein needs are
Calcium
In CRI, calcium needs are 400 mg/day for age 0 to 2 months and 500 mg/day for age 2 to 6
months.
In hypocalcemia, dihydrotachysterol or calcitriol forms of vitamin D and additional calcium
supplements as calcium carbonate liquid suspension in doses of 0.2 mL/kg/day to 0.8 mL/kg/day
may be needed (250 mg calcium carbonate or 100 mg elemental calcium per 1 mL). Avoid calcium
gluconate due to its higher aluminum content.
In nephrocalcinosis, provide the RDI or recommended intake for age for phosphorus, fluid, protein,
energy. Avoid excess vitamin D intake.
Phosphorus
In CRI, phosphorus needs are 200 mg/d for age 0 to 2 months and 400 mg/d for age 2 to 6 months.
In hyperphosphatemia, decrease phosphorus by 30% to 50% when parenteral nutrition is provided.
For enteral nutrition, use formula with reduced phosphorus content or human milk. When serum
phosphorus levels have been reduced to the normal range, calcium carbonate may be given as a
phosphorus binder to increase phosphorus excretion and maintain normal serum levels. (See
recommendations for calcium on this page; adjust dose to maintain normal serum levels.) Avoid
use of aluminum hydroxide binders because ofrisk of aluminum neurotoxicity.
In hypophosphatemia, use standard infant formula; supplement human milk with standard infant
formula or sodium phosphate.
Iron
Standard iron doses of 2 mg/kg/day to 6 mg/kg/day (based on specific infant’s iron status) are
recommended.
Trace minerals (Greene, 1988)
Zinc: High-output renal failure may require up to 600 mcg/kg/d parenterally. Dialysis may
incur increased losses and require supplementation.
Chromium, molybdenum, and selenium: Normal excretion may be decreased in renal failure;
decrease or omit from parenteral solutions if creatinine > 1 mg/dL.
Vitamins
Standard dose of infant liquid multivitamins is recommended. Add 1,000 mcg folic acid/day for
infants receiving dialysis.
(Edelmann, 1992; Moghal, 2006; Haycock, 2003; Hein, 2004; Spinozzi, 2000; Zioni, 2007; Greene,
1988)

Evidence classification system
Notes

Respiratory Disease
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Prevention
Energy and Protein
Inadequate nutrient intake in very low-birth-weight infants decreases nutrient reserves and may
adversely affect surfactant production; respiratory muscle function; and lung tissue growth,
maturation, and repair.
Fluids and Electrolytes
Limit fluids initially to 70 mL/kg/day to 80 mL/kg/day; adjust daily, based on individual needs. Allow
diuresis to occur as evidenced by a 2.4% to 4% daily weight loss, up to 8% to 15% of initial weight
during the first few days of life, to prevent pulmonary edema (C).
Restrict sodium to 0 to 1 mEq/kg/day during first few days. Provide 1 mEq/kg/day to 2 mEq/kg/day
after the onset of diuresis, and then increase as needed to maintain fluid and electrolyte balance
(A).
Vitamin A
Low serum and tissue vitamin A levels and low serum retinol-binding protein levels in extremely
low-birth-weight (ELBW) infants are associated with decreased clearance of lung secretions,
abnormal tracheobronchial epithelium water homeostasis, loss of cilia, decreased ability to repair
lung tissue injury, and increased incidence of bronchopulmonary dysplasia.
For ELBW infants, intramuscular administration of vitamin A—5,000 IU 3 times per week for 4
weeks for a total of 12 doses—is recommended (A).
Vitamin E
Vitamin E deficiency may be associated with increased oxygen toxicity. Human milk provides 0.6
mg/100 kcal to 1.6 mg/100 kcal or 5.3 mg/100 kcal to 7.4 mg/100 kcal with fortifier added; preterm
infant formulas provide 5.3 mg/100 kcal to 6.3 mg/100 kcal.
Research shows no benefit for supplementing vitamin E intake beyond sustaining normal serum
levels. Parenteral doses of 2.8 mg/kg/day to 3.5 mg/kg/day using standard dose regimens sustain
serum vitamin E levels within the recommended range (see Parenteral Vitamins) (C).
Enteral recommendations vary from 3.5 IU/kg/day to 6 IU/kg/day to 12 IU/kg/day, with a maximum
dose of 25 IU/kg/d (see Enteral Supplements) (B).
Pharmacologic doses may be associated with increased risk of sepsis and necrotizing enterocolitis
(NEC) (B).
Inositol
Human milk contains 22 mg/100 kcal; preterm formulas contain 40 mg/100 kcal to 44 mg/100 kcal.
Human milk fortifiers do not contain a significant amount of inositol.
Inositol plays a role in surfactant synthesis and epithelial cell growth and may play a role as an
antioxidant (B).
Doses of 120 mg/kg/day to 160 mg/kg/day are reported to increase serum levels and improve
surfactant synthesis and may improve respiratory outcomes (B).
Lipids
Meta-analysis shows no statistically significant benefits or adverse effects of early lipid
administration on morbidity or mortality (B).
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administration on morbidity or mortality (B).
General recommendations are to start lipids at 0.5 g/kg/day and increase to no more than 3
g/kg/day (or 0.15/kg/hour) within 4 to 6 days (B).
(Baraldi, 2007; Biniwale, 2006; Sweet, 2007; Keller, 2000; Atkinson, 2001)

Treatment
Energy
Initial energy intake should be 40 kcal/kg/day to 60 kcal/kg/day. Increase by day 6 to levels that
support tissue accretion: 85 kcal/kg/day to 115 kcal/kg/day parenterally or 90 kcal/kg/day to 130
kcal/kg/day enterally (C).
Subsequent intakes of 100 kcal/kg/day to 120 kcal/kg/day parenterally or 120 kcal/kg/day to 150
kcal/kg/day enterally may be needed to accommodate increased metabolic rate (work of breathing
and stress associated with compromised lung function) (B).
Protein
Initial recommended parenteral protein intake is 1.5 g/kg/day to 2 g/kg/day; increase to 3 g/kg/day
to 4 g/kg/day by day 6 to 10 (C). Maintain adequate intake during stress or steroid use to maintain
protein stores (C).
Preterm infant formula or human milk with human milk fortifier is recommended for infants
weighing less than 1.8 kg at birth until they reach 3.6 kg; preterm discharge formula is
recommended after 37 weeks’ gestational age through 6 to 9 months corrected age to provide
adequate protein, calcium, phosphorus, and zinc to support better linear growth, lean tissue, and
bone mass accretion (B).
Lipids
If parenteral nutrition (PN) is required, provide 0.5 g/kg/day to 1 g/kg/day on days 1 and 2;
advance to 3 g/kg/day to provide adequate energy for growth, including growth of lung tissue (C).
Lipids may improve fat-soluble vitamin bioavailability and decrease carbon dioxide production by
limiting conversion of carbohydrate to fat (C).
Infants with chylothorax may require enteral feedings that limit or omit long-chain fatty acids. (See
Congenital Heart Disease.)
Fluid Restriction
Beyond the initial 7 to 10 days of life, fluid tolerance may range from 120 mL/kg/day to 150
mL/kg/day to prevent fluid retention, patency of the ductus arteriosus, pulmonary edema, and
congestive heart failure (A).
Supplementation with carbohydrate or fat additives to achieve adequate energy intake may
decrease intake of other nutrients. To achieve adequate nutrient intake, 24-kcal/oz to 30-kcal/oz
concentrations of appropriate infant formula are recommended (B).
Human milk fortifiers and concentrated liquid formulas may be used to increase nutrient density of
human milk (C).
Feeding Problems
Increase nutrient density of formula or human milk to meet nutrition needs within tolerated feeding
volume (C).
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Enlist the support of a feeding therapist, who can provide care plans that reduce noxious oral-facial
stimulation and recommend ways to enhance oral-motor development (C).
Many infants with compromised respiratory function require prolonged use of tube feedings.
Encourage flexible schedules for feedings to accommodate hunger and satiety cues (C).
For postdischarge tube feedings, provide family and physician with expected weight gain and
feeding guidelines to accommodate growth but prevent overfeeding (C).
Drug–Nutrient Interactions
Drugs commonly used in the treatment of neonatal respiratory diseases include corticosteroids,
diuretics, bronchodilators, and potassium replacement.
Infants who demonstrate growth delay due to postnatal corticosteroid administration may
experience better growth recovery of lean tissue with higher protein intake (C). Use of
corticosteroids may cause hyperglycemia. If the patient receives PN, monitor serum glucose
levels and modify glucose infusion as needed to maintain euglycemia.
Use of chlorothiazide diuretics may cause delayed growth due to decreased serum levels of
sodium, potassium, and chloride, requiring supplementation of these electrolytes. Use of
spironolactone may elevate serum potassium but may increase urinary sodium and chloride
excretion. All diuretics increase renal phosphorus excretion causing negative phosphorus
balance and increasing the risk for osteopenia ( Ramanathan, 2008). Provide adequate
phosphorus with the appropriate calcium-to-phosphorus ratio (C). When providing calcium
supplements to infants receiving diuretics, use caution as this may cause nephrocalcinosis.
Bronchodilators may cause hypokalemia.
Potassium supplements may be irritating to the gastrointestinal tract, causing vomiting,
diarrhea, and bleeding.
(Biniwale, 2006; Sweet, 2007; Keller, 2000; Atkinson, 2001; Cox, 2000; Puangco, 2000; Brunton,
1998; Ramanathan, 2008)

Evidence classification system

Short Bowel Syndrome

Goals are to establish fluid and electrolyte balance, maintain growth and nutritional status, and
maximize the process of intestinal adaptation. This is accomplished through well-conceived
parenteral nutrition (PN) regimens, individualized enteral support, strict adherence to procedures
designed to minimize risk of infection, and experienced medical/surgical management.
Specific nutrition therapy guidelines are primarily based on accumulated clinical experience of
practitioners (lowest level of evidence-based practice) (C) (Wessel, 2007; Bhatia, 2010; Olieman,
2010; Kocoshis, 2010).
Parenteral Nutrition
Goals for PN are as follows (more information is available in Parenteral Nutrition):
Provide energy and macronutrients to support expected growth and maintain biochemical
measures of nutritional status (eg, prealbumin).
Maximize calcium and phosphorus to prevent osteopenia.
Prevent sepsis through scrupulous care of intravenous lines.
Minimize total PN–associated cholestasis by avoiding excessive energy and providing
balanced regimens.
Consider PN cycling
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Monitor trace elements, including the following:
Copper: Consider reducing to 10 mcg/kg/day if direct bilirubin is greater than 2 mg/dL;
monitor with ceroplasmin levels.
Manganese: Remove completely if direct bilirubin is greater than 2 mg/dL
Zinc: Consider more than 400 mcg/kg/day if significant ostomy or stool losses are
present
Enteral Nutrition
Goals for enteral nutrition include the following:
Schedule: Initiate feedings at 10 mL/kg to 20 mL/kg per day as soon as possible; slowly
increase in volume as tolerated.
Composition: Include colostrum from human milk (donor milk not known to offer same
advantages of mother’s own milk) (Wessel, 2007), protein hydrolysate formula (traditional
feeding for malabsorption), or amino acid–based formula (preferred over protein hydrolysate
formulas by some because of significant risk of secondary non–IgE-mediated intestinal
allergic disease in patients with short bowel syndrome). Ideal feeding composition has not yet
been determined (Schaart, 2007).
Route of administration: Initially use continuous tube feeding by orogastric/nasogastric
(short-term), gastrostomy (long-term), or transpyloric (patients with poor gastric emptying),
and gradually transition to bolus/intermittent feedings. Offer nonnutritive sucking and
small-volume oral feedings several times per day, as tolerated, to avoid feeding aversion
(Hwang, 2002).
Micronutrients: Monitor micronutrient status with special attention to fat-soluble vitamins A, D,
E, and K (if fat malabsorption is present); trace elements (especially iron and zinc); calcium,
phosphorus, and magnesium (particularly in preterm infants); and vitamin B-12 after ileal
resection (Serrano, 2002). Supplement routinely with multivitamins; consider water-miscible,
fat-soluble vitamins if fat malabsorption and/or cholestasis are present; consider
intramuscular delivery of vitamins B-12 and K.
Response to Treatment
The goals of treatment are little or no vomiting, growth at expected rate for age, and normal
nutritional biochemical levels. The presence of reducing substances in the stool and/or acidic stool
contents suggest carbohydrate malabsorption. Thus, stool/ostomy output guidelines include the
following (Serrano, 2002):
Volume ≤ 50 mL/kg/day
Negative reducing substances in the stool
Stool pH ≤ 5.5 (intact colon only)
Negative or trace stool fat
Monitor fluid and electrolyte status and replace losses from feeding tubes, ostomies, or stool if
output is greater than 50 mL/kg/d (see Table) (Wessel, 2000). Consider measuring zinc content of
stool or ileostomy fluid and replace zinc if losses are significant. Zinc content of stool output is
approximately 12 mg/L to 17 mg/L (Wessel, 2000).
Gastrointestinal Electrolyte Losses
Sodium, mEq/LPotassium, mEq/LChloride, mEq/LBicarbonate, mEq/L
Gastric 140 15 155 -
Ileostomy 80-140 15 115 40
Colostomy 50-80 10-30 40 20-25
Secretory 60-120 – – –
Diarrhea 30-40 10-80 10-110 30
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Normal stool 5 10 10 0
Source: Adapted with permission from Wessel JJ: Short bowel syndrome. In: Groh-Wargo S,
Thompson M, Cox JH, eds. Nutritional Care of High Risk Newborns. Chicago, IL: Precept Press;
2000:469.
Additional Treatment Options
Refeeding of proximal enterostomy effluent into a mucous fistula can stimulate bowel
adaptation (Richardson, 2006).
Soluble fiber may reduce diarrhea and enhance intestinal adaptation. Sources include liquid
fruit pectin (eg, Certo, Kraft Foods, Northfield, IL) (1% to 3% or 1 mL to 3 mL per 100 mL
formula) (Wessel, 2007) or partially hydrolyzed guar gum (1 g per 40 mL formula). Use
cautiously in the presence of bacterial overgrowth.
Consider probiotics, but use with extreme caution because of risk of secondary bacteremia
(Kunz, 2004).
Gastric acid controllers such as ranitidine may prevent hypersecretion. Motility agents such
as loperamide may slow intestinal transit. Antimicrobial drugs (metronidazole) are indicated to
treat bacterial overgrowth. Additional medications that may be indicated include octreotide to
decrease stool output, ursodiol to decrease cholestasis, and cholestyramine to decrease bile
acids in the colon (Hwang, 2002).
Continuing Care
Sudden, unexplained abdominal distention and/or vomiting may signal the development of
intestinal strictures requiring surgical intervention (Hwang, 2002). Introduction of solid foods is
usually recommended after 4 months' corrected age and helps to maintain oral-motor skills. Simple
sugars, fruit juices, and lactose-containing foods are more likely to be poorly tolerated than
starches, vegetables, and meats. Green beans as a source of fiber may improve bowel function
(Wessel, 2007; Serrano, 2002).

Evidence classification system

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Preterm Infants > Nutrition Care > Nutrition Monitoring & Evaluation
Nutrition Monitoring & Evaluation

The purpose of nutrition monitoring and evaluation in neonatal intensive care units,
intermediate neonatal care units, normal newborn nurseries, newborn follow-up clinics, or
pediatricians’ offices is to assess progress toward nutrition goals and expected
outcomes. Goals and expected outcomes are defined by reference standards or an
improvement in nutrition care indicators and may be categorized using the nutrition
assessment terminology categories as follows:
Food/Nutrition-Related History Outcomes (FH)
Food and Nutrient Intake (1)
Food and Nutrient Administration (2)
Breastfeeding (7.1)
Anthropometric Measurement Outcomes (AD)
Length
Weight
Weight change
Growth pattern indices/percentile ranks for corrected age for prematurity
Head circumference
Weight-for-age
Length-for-age
Head circumference-for-age
Weight-for-length
Bone density and bone age
Biochemical Data, Medical Tests and Procedure Outcomes (BD)
Laboratory data
Electrolyte
Essential fatty acid
Gastrointestinal measures
Glucose
Mineral
Nutritional anemia
Protein
Vitamin profiles
Nutrition-Focused Physical Finding Outcomes (PD)
Overall appearance
Extremities, muscles, bones
Digestive system
Skin
Vital signs
Critical thinking is necessary when completing the following step of the nutrition care
process*:
Select the appropriate indicators or measures to monitor and evaluate the impact of
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nutrition intervention on the patient’s/client’s progress toward defined goals.
Examples include the following:
Grams per day weight gain
Grams per kilogram per day protein intake
Serum alkaline phosphatase level
Use current and age-specific/disease-specific reference standards for comparison.
Examples include the following:
120 kcal/kg/d and 4 g protein/kg/day for infants 0.9 kg to 1.2 kg (Ziegler, 2007)
400 mcg zinc/kg/day parenteral zinc requirement for preterm infants (Tsang,
2005)
Define progress toward goals in terms of expected outcomes. Examples include the
following:
Increase in head circumference of 0.6 cm/week compared with standard 0.9
cm/week (Moyer-Mileur, 2007).
Compared to a norm of less than 550 IU/L, and a previous level of 850 IU/L,
alkaline phosphatase is now 750 IU/L after mineral intake was increased.
Explain any variance from expected outcomes. Examples include the following:
Increase in head circumference is less than expected, which may be related to
use of steroid medication
Less than expected weight gain, which may be related to temperature instability
during weaning from isolette to open crib
Identify factors that enhance or impede progress and ways to address these factors.
Examples include the following:
Frequent episodes of vomiting are impeding progress toward full enteral
feedings; giving gavage feedings over longer duration(eg, over 60 minutes
instead of 10 minutes) may prevent vomiting and allow continued progression to
full enteral feedings
Interrupting parenteral nutrition for antibiotic administration is preventing
adequate parenteral nutrition intake; increase parenteral nutrition hourly rate
during the 20 hours of parenteral nutrition administration to accommodate 4
hours of antibiotic infusion
Identify when follow-up will occur, or if nutrition care can be discontinued. Examples
include the following:
Follow-up in 5 days
Nutrition goals are met; no nutrition care follow-up is necessary at this time
*Adapted from Pocket Guide for International Dietetics & Nutrition Terminology Reference
Manual. 3rd edition. Chicago, IL: American Dietetic Association; 2011: 314.

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Preterm Infants > Parenteral Nutrition
Overview

Indications for Use of Parenteral Nutrition
Parenteral nutrition (PN) is used during the neonatal period, initially to prevent negative
energy and protein balance, and subsequently to support normal growth until adequate
enteral or oral feedings can be established. Indications for PN include the following
(Groh-Wargo, 2000):
Functional immaturity of the gastrointestinal (GI) tract or gestational age at birth less
than 30 to 32 weeks: use PN as supplemental nutrition while enteral feeds advance
Necrotizing enterocolitis (NEC)
Congenital GI anomalies requiring surgical repair (gastroschisis, omphalocele, bowel
obstruction, bowel atresia)
Malabsorption syndromes (short bowel syndrome, cystic fibrosis with meconium ileus)
Impaired GI motility (prematurity, ileus from surgery or sepsis, after surgical repair of
gastroschisis, Hirschsprung’s disease)
Impaired GI perfusion that decreases GI motility and increases risk for NEC
(congenital heart disease, patent ductus arteriosus, hypotension) or use of
medications that may impair GI perfusion
If it is anticipated that feedings may not be started or adequately advanced to meet
nutritional needs, PN is started within the first 1 to 2 days for preterm or
low-birth-weight infants (< 1.5 kg) or within the first 3 to 5 days for term infants.

Starter PN Solution
Starter PN solution is a standardized premixed bag of nutrients for initial parenteral feeding
to be infused immediately after birth (Denne, 2007a). To increase flexibility for use and
extend shelf life of this solution, the product typically does not include lipids, electrolytes,
trace elements, or vitamins, although some institutions do include calcium gluconate at 5
mEq/L to 20 mEq/L.
Starter PN solution is infused at 50 mL/kg/day to 75 mL/kg/day and provides maintenance
carbohydrate and 1.5 g/kg/day to 3 g/kg/day amino acids. It is initiated as soon as
intravenous (IV) access is placed and continues until total PN is ordered.

Infants born fewer than 26 weeks’ gestation often show alterations in fluid, glucose, and
electrolyte tolerance in the first few days of life. To ensure prescribed doses of amino acids
and minerals are infused, it may be beneficial to use a more concentrated solution at 50
mL/kg/day to 75 mL/kg/day. Provide additional IV fluids as needed for hydration for rapid
adjustment as glucose, fluid, and electrolyte status changes. As fluid, glucose, and
electrolyte needs stabilize, PN can be advanced to supply all IV fluid needs.
Transitional doses are the doses used during the 2 to 5 days of life when extracellular fluid
volumes continue to contract, but may be used well into the second week of life for infants
< 750 g, if fluid and electrolyte balance is difficult to manage, and/or tolerance to adequate
dextrose and lipid doses are limited.

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Access Methods

Access Methods for Parenteral Nutrition
Peripheral Intravenous (IV) Line
Short-term use, generally 1 to 4 weeks.
Maintain osmolality of solution in the range of 300 mOsm/kg to 900 mOsm/kg water.
Limit dextrose concentration to no more than 12.5 g/dL in peripheral IVs.
Limit calcium dose to 8 mEq/L to 20 mEq/L.
Use of IV lipids help protect integrity of the IV site (Pineault, 1989).

Peripherally inserted central venous catheter
Most often used for infants who need parenteral nutrition (PN) for several weeks.
Catheter is inserted into a peripheral vein, but threaded into the central circulation,
allowing safe administration of solutions with greater osmolality and dextrose
concentration.
Catheter may kink, occlude, or migrate over time. Monitor catheter tip location weekly
to ensure central venous placement, and adjust osmolality and dextrose concentration
if tip is no longer centrally placed.
Addition of heparin is beneficial to minimize risk of developing thrombus.
Central venous catheters
Access to central venous circulation allows infusion of greater osmolality and greater
dextrose concentrations. Although recommendations vary, maximum dextrose
concentration recommended is 20 g/dL to 30 g/dL.
Percutaneous central venous catheters allow direct and immediate access to central
venous circulation, but pose a high risk of septicemia.
Central venous catheters may be tunneled to provide increased distance between the
skin at the insertion site and the tip of the catheter in the central venous system.
These catheters are ideal for infants who are likely to require PN for extended periods
of time.
Umbilical artery catheter (UAC) and umbilical venous catheter (UVC)
Not all institutions use UACs or UVCs to deliver PN. Approximately 35% of hospitals
surveyed report never using UACs or UVCs to administer total PN (TPN) (Kanarek,
1991). Safety of using these catheters to administer TPN is not widely
studied/reported.
UACs and UVCs are usually saved for lab and blood pressure monitoring (Kanarek,
1991).
Dextrose concentrations of more than 12.5 g/dL may be used, but may increase risk
of glucosuria and dehydration depending on position and placement in relation to
renal vessels.

Aluminum Toxicity
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Aluminum Toxicity

Aluminum toxicity may occur from aluminum contamination of additives in parenteral
nutrition (PN). Calcium and phosphorus are the greatest sources, but multivitamin and
trace element additives also contain appreciable amounts. Other sources of aluminum
include heparin, albumin, and some intravenous medications (Gura, 2006). Aluminum
toxicity may be associated with metabolic bone disease, hypochromic microcytic anemia,
and neurotoxicity (Klein, 1998; Gura, 2006). The US Food and Drug Administration has
established guidelines for aluminum content of both small-volume (additives) and
large-volume (amino acids/dextrose) parenteral components and recommends maintaining
aluminum intake to less than 5 mcg/kg/day (Young, 2004).
Risk Factors
Extended period of PN
Increased needs for calcium and phosphorus
Renal failure
Iron deficiency
Methods to Reduce Aluminum Intake
Encourage enteral intake to reduce need for PN.
Monitor aluminum content of parenteral additives, selecting products that contain the
lowest aluminum content.
Use sodium phosphate instead of potassium phosphate.
Calcium gluconate is one of the greatest sources of aluminum in total PN admixtures,
but alternative calcium sources (calcium chloride, calcium glubionate) containing
lesser amounts of aluminum have limited solubility when infused with phosphorus,
thereby increasing risk of osteopenia.
Most additives are packaged in glass containers. Glass naturally contains aluminum
and over time, aluminum is leached into the additive solution. Package labeling
indicates the maximum aluminum content that is expected at the product’s expiration
date. Therefore, to reduce aluminum exposure, use products well before the
expiration date or select additives packaged in plastic containers.

Amino Acids

Amino Acid Solutions
The amino acid profile in pediatric amino acid solutions mirrors the serum amino acid
profile of breastfed term infants. Solutions contain a small amount of taurine, which may be
an essential amino acid for preterm infants. These solutions have lower pH than adult
amino acid solutions, which improves solubility of calcium and phosphorus (Lenz, 1988).
Pediatric amino acid solutions may reduce risk of cholestasis when compared with
standard solutions (Heird, 1987). They are indicated for use in preterm infants and infants
at risk for osteopenia.
Initiation and Advancement
Early administration of amino acid intake (within the first 24 hours of life) is safe, promotes
positive nitrogen balance, and improves glucose tolerance in preterm infants (Denne,
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2007a; Ehrenkranz, 2007).
Initiate amino acid intake at a minimum of 1.5 g/kg/day to 2 g/kg/day to prevent catabolism.
Initiation of amino acids at rates as high as 3 g/kg/day has been shown to be safe and
promote positive nitrogen balance (Denne, 2007a).
Advance amino acid intake as energy intake increases to meet estimated needs as shown
in the table.
Estimated Required Parenteral Energy and Protein Intakes for Preterm Infants
Body Weight (g)
500
-
700
g
700
-
900
g
900 -
1200
g
1200
-
1500
g
1500
-
1800
g
1800
-
2200
g
2200
-
2500
g
Protein (g/kg) 3.5 3.5 3.5 3.4 3.2 3.0 2.8
Energy
(kcal/kg)
89 92 101 108 109 111 108
Protein/Energy
(g/100 kcal)
3.9 3.8 3.5 3.1 2.9 2.7 2.6
(Adapted from Ziegler, 2002; Ziegler, 2007).

Monitoring
Routine monitoring of amino acids is not indicated unless doses given are in excess of
recommended intake or if the infant has renal dysfunction (elevated serum creatinine)
(Ridout, 2005; Ehrenkranz, 2007).
Blood urea nitrogen is not an effective monitor of protein tolerance in preterm infants
because amino acids are partly used for protein synthesis and partly oxidized as a source
of energy, reflecting intrauterine metabolism (Ridout, 2005).

Calcium and Phosphorus

Dose Recommendations
Estimated requirements for calcium and phosphorus are provided in the table.
Initial
Dose
Transitional
Dose*
Premature
Infants
Term
Infants
Maximum
Dose
Calcium,
mEq/kg/d
1-3 2-3 3 2 4
Phosphorus,
mmol/kg/d
0-0.6 1.3-2 1.3-2 1-1.5 2
*Transitional doses are the doses used during the few days (usually around days 2-5)
when extracellular fluid volumes continue to contract, but may last well into the second
week for infants less than 750 g.
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(Tsang, 2005)
The ideal calcium-to-phosphorus ratio to promote optimal mineral retention and tolerance is
in the following ranges:
1.3 mg to 1.7 mg calcium:1 mg phosphorus weight ratio
1 mM calcium to 1.3 mM Ca:1 mM phosphorus molar ratio
2.2 mEq to 2.6 mEq Ca:1 mM phosphorus (units frequently used in total parenteral
nutrition [PN] compounding)
Mineral wasting or alterations in mineral homeostasis may be caused by alternate-day
infusions of calcium and phosphorus or ratios less than the following:
1 mg calcium:1 mg phosphorus
0.8 mM calcium:1 mM phosphorus
1.6 mEq calcium:1 mM phosphorus
Increased urinary calcium losses resulting from medications such as diuretics (eg,
furosemide), theophylline, and steroids may increase calcium needs (Aladangady, 2004).
Phosphorus needs may be increased in infants born small for gestational age to prevent
refeeding syndrome resulting from rapid growth and increases in lean tissue.
Barriers to Mineral Provision
Calcium and phosphorus intake is limited in neonatal PN because of limitations in solubility.
Factors that increase calcium and phosphorus solubility include the following:
Acidity of neonatal amino acid solutions (compared with standard solutions)
Cysteine hydrochloride (added 40 mg per 1 g of amino acids)
Higher concentrations of amino acids and dextrose
Lipids given separately
Factors that decrease calcium and phosphorus solubility include the following:
Higher concentrations of calcium and phosphorus
Lower concentrations of protein or dextrose or lack of cysteine
Higher temperatures
Lipids administered as total nutrient admixture
Check with your pharmacist to determine solubility limits for specific parenteral solutions.
Monitoring
Infants on PN for more than 2 weeks should be monitored for signs of osteopenia (see
Osteopenia of Prematurity). Hepatic sources of alkaline phosphatase may be elevated
when cholestasis is present, which may confound interpretation of serum levels of this
enzyme. Levels may be fractionated or assessed for isoenzymes to determine bone (heat
stable) and hepatic (heat labile) contributions to total serum levels of alkaline phosphatase.

Carnitine

Blood carnitine levels decrease rapidly in preterm infants during the first 2 weeks of
parenteral nutrition (PN) (Penn, 1981). However, current studies have not shown a clinical
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
benefit to routine carnitine supplementation of neonatal PN (Cairns, 2000).
Carnitine supplementation may be beneficial for infants receiving nutrition solely via PN for
an extended period of time. Estimated requirement is 2 mg/kg/day to 10 mg/kg/day
(Groh-Wargo, 2000).

Chronic Complications

Parenteral Nutrition–Associated Liver Disease (Cholestatic Jaundice)
Risk Factors
Risk factors for parenteral nutrition (PN)–associated liver disease or cholestatic jaundice
(direct bilirubin >2 mg/dL) include the following:
Extended period of NPO (nil per os, or nothing by mouth) (Zambrano, 2004;
Krawinkel, 2004; Teitelbaum, 1997)
Sepsis, particularly gram-negative bacteria (Shamir, 2000)
Small for gestational age (Zambrano, 2004; Baserga, 2004)
Overfeeding of parenteral nutrients, particularly dextrose and lipids (Krawinkel, 2004;
Teitelbaum, 1997)
Intravenous lipids rich in phytosterols (soy) (Oshita, 2004; Clayton, 1988)
Prevention/Treatment
Initiate trophic enteral feeds.
Provide adequate but not excessive macronutrients to meet protein needs for age
and clinical condition; provide 60% to 70% of nonprotein energy as carbohydrate and
30% to 40% of nonprotein energy as fat.
Consider cyclic administration of PN (see Cyclic Administration).
When enteral feedings are tolerated, consider use of ursodeoxycholic acid, which has
been shown to reduce cholestasis by increasing bile flow (Levine, 1999).
Use pediatric amino acid preparations that contain taurine, especially for preterm
infants or infants in whom necrotizing enterocolitis develops (Spencer, 2005).
Use of a new parenteral lipid emulsion, Omegavan, containing primarily n-3 fatty
acids made from fish oils, is not yet approved in the United States but seems to be a
promising alternative product to prevent cholestasis (Gura, 2006a).
Metabolic Bone Disease (Osteopenia of Prematurity)
Metabolic bone disease, also referred to as osteopenia of prematurity, is evidenced by
reduced bone mineralization on x-ray, or an alkaline phosphatase greater than 900 IU/L
and a serum phosphorus lower than 5.6 mg/dL (Klein, 1998; Backstrom, 2000).
Risk Factors
Extended period of PN
Extended use of unfortified breast milk or term infant formulas
Chronic use of diuretics or steroids, which increases urinary loss of calcium
Chronic use of phenobarbital, which may impair vitamin D status
Treatment
Optimize mineral content of PN by using pediatric amino acid solutions and cysteine
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Optimize mineral content of PN by using pediatric amino acid solutions and cysteine
hydrochloride.
Solubility of calcium and phosphorus is affected by many factors. Collaborate with
pharmacy personnel to establish policies and procedures that maximize mineral
content of PN.
Optimize mineral content of enteral feedings by using human milk fortifier, preterm
formulas, or calcium and phosphorus supplements when indicated. (See Calcium and
Phosphorus and Trace Elements.)
Supplementation of vitamin D typically is not required except for infants receiving
chronic phenobarbital therapy.

Cyclic Administration

In cyclic administration, total parenteral nutrition (TPN) is infused for fewer than 24 hours
each day. TPN is interrupted from 4 to 18 hours per day or longer as enteral feedings fulfill
a greater proportion of total nutritional intake.
To prevent hypoglycemia when interrupting TPN, the infusion is tapered for a period of
time, usually at half the full rate, for 30 minutes to 1 hour. Infusion is restarted gradually,
usually at half the full rate, for 30 minutes to 1 hour to prevent hyperglycemia when
resuming TPN.
Young infants may not be able to tolerate periods without TPN unless enteral feedings
provide a substantial amount of nutrition.
Providing a diurnal cycle of TPN delivery may help decrease circulating levels of insulin and
may protect hepatocytes from excessive glycogen and lipid deposition. In addition, by
allowing physical freedom from intravenous lines and infusion pumps, cyclic TPN offers
opportunities for increased activity levels.

Cysteine

Whether cysteine is an essential amino acid for preterm infants remains somewhat
controversial, but it is often added to parenteral solutions. Although the addition of cysteine
does not improve growth, serum levels of taurine may normalize (Heird, 1987).
Cysteine reduces parenteral solution pH, enhancing the solubility of calcium and
phosphorus (Lenz, 1988). Cysteine supplementation may reduce the incidence of
parenteral nutrition (PN)–associated liver disease (Kelly, 2006).
Recommended dose for cysteine hydrochloride is 40 mg/g amino acids (Tsang, 2005).
Metabolic acidosis may be increased in infants receiving the current recommended dose of
cysteine. Acid/base status should be closely monitored after initiation of cysteine-containing
PN and the acetate content of solution increased as needed to prevent metabolic acidosis
(Laine, 1991).

Dextrose

Initiation and Advancement
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Initiation and Advancement
Begin carbohydrate intake as follows:
Preterm infants: 6 g/kg/d to 8 g/kg/d (approximately 4 mg/kg/min to 6 mg/kg/min)
Term infants: 11 g/kg/d to 12 g/kg/d (8 mg/kg/min)
Advance carbohydrate intake daily by 1.5 g/kg/d to 3.0 g/kg/d (1 mg/kg/min to 2 mg/kg/min)
to goal rate of 8 g/kg/d to 20 g/kg/d (5 mg/kg/min to 15 mg/kg/min) as long as blood glucose
remains below 120 mg/dL. Infants with hypoglycemia may require more dextrose initially to
maintain euglycemia, although maximum dose recommendations are generally 25 g/kg/d
(18 mg/kg/min).
Consider reducing dextrose infusion by 1.5 g/kg/d to 3.0 g/kg/d (1 mg/kg/min to 2
mg/kg/min) whenever blood glucose is moderately elevated (120 mg/dL to 180 mg/dL) or
consider providing insulin, particularly when blood glucose is markedly elevated (above 180
mg/dL) or when the dose of dextrose must be restricted to less than 6 mg/kg/min to
maintain euglycemia (Kao, 2006).
Dextrose is usually the greatest contributor to osmolarity in parenteral nutrient solutions.
Solutions with osmolarity higher than 1,000 mOsm/L, when delivered through peripheral
venous access, increase risk of tissue damage. Peripheral venous access requires limiting
dextrose to 12.5% concentration. Central venous access allows up to 25% dextrose
solutions.
Monitoring
Although it has been common practice to define a wide range of blood glucose as
acceptable for preterm infants (that is, 50 mg/dL to 200 mg/dL), blood glucose levels higher
than 180 mg/dL may be associated with increased morbidity and mortality (Kao, 2006).
Elevated blood glucose is a common complication of preterm infants on parenteral nutrition.
Studies evaluating the impact of tight glucose control on neonatal outcomes have not been
done to date.
Monitoring recommendations are as follows:
Monitor blood glucose at least 4 times per day in the first 24 hours.
Monitor blood glucose at least twice per day in subsequent days as glucose infusion
rate is advanced to goal.
When blood glucose is within normal limits for 48 hours on goal glucose infusion rate,
frequency of glucose monitoring may be reduced to once daily for infants weighing
less than 1 kg or 2 to 3 times per week for infants weighing more than 1 kg.
Frequency of glucose monitoring should be increased whenever infant is at risk for
glucose intolerance (eg, sepsis, surgery, necrotizing enterocolitis, steroid
administration).
Common Causes of Hypoglycemia and Hyperglycemia in Preterm Infants (Hosono,
1999)
Causes of Hypoglycemia
Small for gestational age
Large for gestational age (especially macrosomic infants of diabetic mothers)
Indomethacin therapy
Rapid discontinuation of IV dextrose
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Causes of Hyperglycemia
Sepsis
Extreme prematurity
Surgery/stress
Malnutrition
Renal disease
Excessive dextrose infusion
Glucocorticoid therapy
Thiazide diuretic therapy


Electrolytes

General Dose Recommendations for Parenteral Electrolytes
Initial
Dose
Transitional
Dose
±
Premature Infants
Term
Infants
Maximum
Dose
Sodium, mEq/kg/d 0-1 2-5 2-4 2-4 20
Potassium, mEq/kg/d 0 0-2 2-3 2-3 9
Chloride, mEq/kg/d 0-1 2-5 2-7 2-7 *
Acetate, MEq/kg/d as needed as needed as needed as needed 6
*Hyperchloridemic acidosis may occur with high chloride intake; adjust electrolytes by
including sodium or potassium as acetate if needed.
±
Transitional doses are the doses used during the few days (usually around days 2-5)
when extracellular fluid volumes continue to contract, but may last well into the second
week for infants less than 750 g.
Sodium
Sodium restriction (0 mEq/kg/day to 1 mEq/kg/day) during the first few days of life has
been associated with a reduced incidence of bronchopulmonary dysplasia (Baumgart,
2000).
Sodium should be limited to 0 mEq/kg/day to 1 mEq/kg/day until postnatal diuresis has
been achieved. Advance sodium intake to 2 mEq/kg to 3 mEq/kg when infant begins to
regain birth weight.
Extremely preterm infants may require higher sodium intakes due to limited renal tubular
sodium reabsorption (Baumgart, 2000). If hydration is within normal limits, adjust sodium
intake by 1 mEq/kg/day to 2 mEq/kg/day as needed to maintain normal serum sodium
values. Late-onset hyponatremia may require 5 mEq/kg/day to 7 mEq/kg/day.
Sodium may be present in total parenteral nutrition (TPN) solutions as chloride, acetate,
and/or phosphate. Sodium phosphate has substantially less aluminum than does
potassium phosphate.
Potassium
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Nonoliguric hyperkalemia is a common early complication of extremely preterm infants.
Although the cause of nonoliguric hyperkalemia is unknown, factors that may exacerbate
this condition include the following:
Extreme prematurity
Bruising
Catabolism
Metabolic acidosis
Potassium intake
Provide potassium-free parenteral nutrition (PN) until urine output is well established (more
than 1 mL/kg/hour) and serum potassium is within normal limits. Advance potassium intake
to 2 mEq/kg/day to 3 mEq/kg/day and adjust as needed based on changes in renal function
or changes in serum values, particularly with use of diuretic medication.
Potassium may be present in TPN solutions as chloride and acetate, and less often as
phosphate. Potassium phosphate products currently available contain substantially more
aluminum than sodium phosphate products.
Chloride and Acetate
Pediatric amino acid solutions contain approximately 1 mEq acetate/g protein equivalent.
Chloride and additional acetate intake should be restricted until the neonate is ready for the
addition of sodium and potassium to PN.
Limit chloride to 2 mEq/kg to 3 mEq/kg to prevent hyperchloremic acidosis. If sodium
requirement is more than 5 mEq/kg, higher intakes of chloride may be given, up to 7
mEq/kg/d. Sodium and additional potassium may also be given as acetate, but total acetate
intake (including the acetate present in the amino acid base solution) should generally not
exceed 6 mEq/kg/day.
The presence of acetate in PN reduces the incidence of hyperchloremic metabolic acidosis
(Peters, 1997).
Recommended Frequency of Electrolyte and Acid/Base (Blood Gas) Monitoring
During PN
Conditions
Frequency of
Monitoring
Postnatal diuresis (age ~3-8 d) and/or advancement to
goal PN
Daily
At goal PN with stable, normal electrolytes and
acid/base status
1-2 times per wk
PN > 3 wks duration with normal electrolytes and
acid/base status
Every 1-2 wks

(Tsang, 2005)


Filters

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Parenteral nutrition line filters have been suggested to minimize risk of both bacterial
contamination and infusion of intravenous particulates. A recent meta-analysis of filters
found no significant effect of the use of inline filters on morbidity or mortality of neonates;
however, the studies were few and limited in size (Foster, 2006). At this time,
recommendations are to use a 1.2-micron filter only in circumstances when total parenteral
nutrition is infused via a total nutrient admixture (Driscoll, 1996).

Fluids

Fluid Initiation and Advancement
Initial Phase
Postnatal fluid restriction during the first 1 to 3 days of life is associated with reduced
incidence of chronic lung disease (Oh, 2005; Bell, 2008). Fluid intake should be restricted
to promote normal postnatal diuresis (of approximately 10% to 15% of birth weight) while
maintaining electrolyte homeostasis (Tsang, 2005; Bell, 2008). Postnatal weight loss may
be minimal in infants born small for gestational age, reflecting a more mature body
composition (Groh-Wargo, 2000; Tsang, 2005; Grünhagen, 2002; Wadhawan, 2007).
Although fluid needs may vary widely depending on skin, lung, and renal maturity; clinical
condition; and environmental factors such as radiant warmers or double-walled isolettes,
fluids are usually limited as follows:
Infants weighing less than 1 kg: 50 mL/kg/d to 120 mL/kg/d (more if medically
necessary)
Infants weighing 1 kg to 1.5 kg: 70 mL/kg/d to 90 mL/kg/d
Infants weighing more than 1.5 kg: 60 mL/kg/d to 120 mL/kg/d
Fluid needs may be higher in infants with the following conditions (Grünhagen, 2002):
Less than 28 weeks’ gestational age
Have abdominal wall defects such as gastroschisis
Have high-output renal failure
Receiving care under a radiant warmer or receiving phototherapy
Fluid needs may be lower in infants with the following conditions:
Maintained in a humidified environment
Have a patent ductus arteriosus or oliguric renal failure
Transitional Phase
As renal function improves, skin integrity matures, and postnatal diuresis is complete, fluid
intake may be liberalized as tolerated to promote nutrient intake. The exact duration of this
phase varies, but occurs within the first 1 to 2 weeks of life (Tsang, 2005):
Infants weighing less than 1 kg may require 90 mL/kg/d to 140 mL/kg/d
Infants weighing 1 to 1.5 kg may require 90 mL/kg/d to 140 mL/kg/d
Infants weighing more than 1.5 kg may require 120 mL/kg/d to 150 mL/kg/d
During the transitional phase, fluid needs may be higher in infants remaining on
phototherapy. Fluid needs may be lower in infants with patent ductus arteriosus,
oliguria/anuria, or significant lung disease.
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Growth Phase
Providing nutrients parenterally generally requires 120 mL/kg/d to 150 mL/kg/d. If fluid
tolerance is lower as a result of patent ductus arteriosus, oliguria/anuria, edema, or chronic
lung disease, adequate nutrient delivery may require use of more concentrated parenteral
nutrient solutions.
Monitoring of Fluid Status
Fluid status should be monitored by evaluating weight changes, fluid intake, urine output,
and serum sodium levels.
Normal urine output is 1 mL/kg/hr to to 2 mL/kg/hr.
Markers of overhydration include weight gain (in excess of that expected for age and
intake), reduced urine output, or normal urine output with hyponatremia.
Markers of dehydration include weight loss in excess of anticipated postnatal diuresis,
decreased urine output, and hypernatremia.
Hypernatremia may also reflect increased sodium intakes (see Electrolytes).

Heparin and Insulin

Infusion of Heparin
Heparin has been shown to reduce risk of catheter thrombosis in arterial lines (Randolph,
1998). Studies have not shown conclusive benefits to the addition of heparin to peripheral
intravenous catheters or peripherally inserted central venous catheters (Shah, 2005a;
Shah, 2005b).
Increased dosages of heparin (83.5 units/kg vs 59.4 units/kg) were associated with an
increased risk of intraventricular hemorrhage (Malloy, 1995).
Infusion of Insulin
Insulin is not recommended as a routine additive to parenteral nutrition, although
hyperglycemia may be associated with increased morbidity (Ziegler, 2002; Ng, 2005;
Alaedeen, 2006). Insulin may be indicated for infants who are unable to tolerate nutrient
intakes of 50 kcal/kg/day to 60 kcal/kg/day (or glucose infusion of 4 mg/kg/hour) without
elevations in serum glucose levels (Tsang, 2005; Poindexter, 1998). Because the initial
dose of insulin may be different than the maintenance dose, insulin should be infused
separately until dose is consistent. Using insulin solely to provide nutrient intakes that
exceed normal requirements requires further study.

Iron

Iron is not recommended as a routine additive to neonatal parenteral nutrition (PN)
because of concerns about iron toxicity and oxidative injury. The addition of 0.1 mg/kg/day
to 0.2 mg/kg/day of parenteral iron may be indicated for infants on sole source PN more
than 2 months or for those infants in whom iron deficiency develops (Tsang, 2005).
Parenteral iron is not recommended for infants who have received more than 180 mL of
transfused blood (Ng, 2001; Shaw, 1982).
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Erythropoietin therapy trials reported no adverse effects when iron was given concurrently
in doses of 1 mg/kg/d over short time periods (up to 1 month) (Greene, 1988a; Shaw,
1982). However, evidence of iron overload is difficult to monitor.

Laboratory Monitoring

Suggested Laboratory and Physical Monitoring Schedule for Infants Receiving
Parenteral Nutrition Support
Initial Phase
a
Stable Phase
b
Growth:
Weight
Length
Head circumference
Daily
Baseline
Baseline
Daily
Weekly
Weekly
Intake and output Daily Daily
Glucose:
Serum
Urine
As indicated
1-3 times/d
As
indicated
As
indicated
Electrolytes 1-3 times/wk Every 1-2 wks
Calcium, magnesium,
phosphorus
2-3 times/wk Every 1-2 wks
Triglycerides
Daily during
dose increase
Every 1-2 wks
Blood Urea
Nitrogen/creatinine
2-3 times/wk Every 1-2 wks
Serum proteins Baseline Every 2-3 wks
Liver enzymes Baseline Every 2-3 wks
Alkaline phosphatase Baseline Every 2-3 wks
Blood cell count Baseline Every 2-3 wks
Vitamin and trace mineral
status or other specific tests
As indicated As indicated
a
Initial phase is the phase as parenteral nutrition solutions are adjusted to meet the
specific energy and nutrient needs of individual infants. This period generally lasts less
than 1 week for parenteral support.
b
Stable phase is the phase when the infant is in a metabolically steady state. For clinically
stable infants receiving an adequate nutrient intake with desired growth, the interval
between laboratory measurements may be increased beyond the recommendations
presented in the table.
(Moyer-Mileur, 2007)

Lipids
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Intravenous Fat Emulsions (IFE)
IFEs at 20% are cleared more rapidly than 10% IFE. (Groh-Wargo 2000; Tsang 2005). When
administered separately over hang-time periods of longer than 12 hours, infusions may be
associated with coagulase-negative staphylococcal bacteremia, possibly because IFEs
contain glycerol and are relatively isotonic and pH neutral, which provides a favorable
medium for bacterial growth (Putet, 2000). Transfer of IFE from the original container to the
administration device should be done aseptically under class “A” laminar flow hood by
trained pharmacy personnel.
To reduce occurrence of coagulase-negative staphylococcal infections, consider limiting
lipid hang-times to 12 hours, although this may require two separate administration sets to
allow 24-hour infusion and adequate energy intake within hourly rate tolerance when total
parenteral nutrition provides more than 50% of total nutritional intake (Putet, 2000; Driscoll,
2003).
When administered as a component of total nutrient admixtures (TNAs), lipid association
with bacteremia is no longer evident. However, stability of lipids in TNAs is decreased by
the hypertonic, acidic, and high mineral content of neonatal admixtures, and the presence
of precipitates or other particulates may be masked by the opacity of TNAs (Driscoll, 2003):
Administer over 24 hours
1.2-micron filters are recommended to maintain physical stability and minimize risk of
infection (Driscoll, 1996)
Use of a new parenteral lipid emulsion, Omegavan (Freseniu Kabi, Germany), containing
primarily n-3 fatty acids made from fish oils is approved for use in Europe and only for
compassionate use in the United States; however, it seems to be a promising alternative
product to prevent cholestasis (Gura, 2006).
Initiation and Advancement
IFE may be initiated at 0.5 g/kg/day to 1 g/kg/day within the first 24 hours to meet essential
fatty acid needs and provide energy (Groh-Wargo 2000; Tsang 2005; Putet, 2000; Gura,
2006). Advance lipids in 0.5 g/kg/day to 1 g/kg/day increments daily as listed in the table or
as needed to meet energy goals. IFE should be infused over 20 to 24 hours to promote
optimal clearance; maximum hourly infusion rate recommendations are 0.12 g/kg/hour to
0.15 g/kg/hour.
Recommendations for Parenteral Lipid Dosing
Initial
Dose
Transitional
Dose
Premature
Infants
Term
Infants
Maximum
Safe Dose
Fat,
g/kg/d
a
0.5—1 1—3 0.5—3 0.5—3 4
a
Minimum fat dose to meet essential fatty acid requirements varies depending on fat
source and total energy needs.
Doses up to 2 g/kg/day of IFE do not displace bilirubin from albumin and may be given to
infants with hyperbilirubinemia (Koo, 2005). IFE may exacerbate pulmonary hypertension.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Consider avoiding IFE or using a minimal dose and advance cautiously in infants with this
condition (Koo, 2005). IFE help protect peripheral veins from the hypertonicity of PN (Driscoll,
2003; Driscoll, 1996; Gura, 2006; Koo, 2005; Adamkin, 2007; Pineault, 1989).
During periods of acute stress or sepsis, if fat tolerance is impaired, rates of administration
less than 0.08 g/kg/hr (2 g/kg/day) should be well-tolerated (Tsang 2005).
Monitoring
Routine monitoring of serum triglyceride levels is not indicated if the dose of IFE is less
than 2 g/kg/day. Monitor triglyceride levels in infants receiving more than 2 g/kg/day IFE. If
serum triglyceride level exceeds 200 mg/dL, reduce IFE by 0.5 g/kg/day to 1 g/kg/day.

Magnesium

Estimated requirements for magnesium are listed in the table. Magnesium may be omitted
from initial and/or transitional total parenteral nutrition when serum levels are elevated,
which may occur if the mother received significant amounts of magnesium sulfate to
prevent premature labor or to treat preeclampsia.
Initial
Dose
Transitional
Dose
Premature
Infants
Term
Infants
Maximum
Dose
Magnesium,
mEq/kg/d
0 0.3-0.6 0.5-1 0.25-1 1
(Groh-Wargo, 2000; Tsang, 2005)

Osmolality

Osmolality of Parenterally Administered Solutions
Minimal evidence has been published regarding the effect of osmolality on tolerance of
parenteral nutrition solutions in neonates. In animal models, thrombophlebitis seems to be
associated with low pH and increased osmolality, both common characteristics of neonatal
total parenteral nutrition (Kuwahara, 1998). For this reason, it seems prudent to limit
parenteral osmolality to less than 1,000 mOsm/kg and co-infuse lipids in infants with
peripheral access to further dilute osmolality (Pineault, 1989) (see Access Methods and
Dextrose).

Trace Elements

Dose Recommendations
Trace mineral requirements for neonates are less researched than for other age groups.
However, specific parenteral dose recommendations are available for zinc, copper,
manganese, chromium, selenium, and iron. Recommendations are based on gestational
age, postnatal age, and clinical condition—they are listed in the table below.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Estimated Parenteral Trace Element Requirements for Preterm Infants
Dosing
Category
Zinc
mcg/kg/d
Copper
mcg/kg/d
Manganese
mcg/kg/d
Chromium
mcg/kg/d
Selenium
mcg/kg/d
Initial
stabilization
period
a
150 0-10 0-1 0-0.1 0-1.3
Growing
preterm
infant, birth
to term
400 20 1.0 0.1 1.5-2
b
Growing
term infant,
birth to 3 mo
250 20 1.0 0.1 2
b
Cholestasis,
direct
bilirubin > 2
Preterm:
400
Term:
250
3 mo:
100
20 0 0.1 2
b
Renal
insufficiency,
creatinine >
1 mg/dL
(undialyzed)
Preterm:
400
Term:
250
High
output
failure:
600
20 1.0 0 0
Specific
Products
Multitrace
Neonatal
c
dose: 0.2
mL/kg/d
300 20 5 0.17 0
Multitrace
Pediatric
c
dose: 0.2
mL/kg/d
200 20 5 0.2 0
Multitrace
Pediatric
c
dose: 0.1
mL/kg/d
100 10 2.5 0.1 0
a
Stabilization period varies by reference: Day 0-7, Day 0-10, or Day 0-14.
b
For infants older than 28 days.
c
Nutrient content listed is per manufacturer’s label (American Regent, Inc, Shirley, NY).
Always check current product information before administering.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Groh-Wargo, 2000; Tsang, 2005; Greene, 1988a)
None of the commercially available neonatal or pediatric trace mineral "packages" meets
the needs of every age or clinical condition, and manganese content may be five times the
recommended dose when other trace minerals are at recommended doses. Trace
elements are available individually and may be dosed individually.
Individual Trace Mineral Dose Recommendations for Various Clinical Conditions
Zinc
Deficiency has been described in neonates of various birth weights and gestational ages.
Low serum levels of zinc (normal = 74 mcg/dL to 146 mcg/dL) provide diagnosis, though
zinc levels may be falsely normal or elevated during tissue catabolism or increased bone
tissue turnover. Symptoms of zinc deficiency may include the following:

Anorexia
Failure to thrive
Weight loss
Decreased linear growth
Dermatitis (particularly around mucous membranes)
Alopecia
Increased susceptibility to infection
Impaired wound healing
Hypoproteinemia with generalized edema
Increased renal losses resulting from high-output renal failure may require 600 mcg
zinc/kg/day.
Because zinc is primarily absorbed in the proximal small bowel, and enterohepatic
recirculation of zinc is considerable in the distal small bowel, short bowel syndrome with
increased stool/ostomy losses may increase zinc requirements to as much as 800
mcg/kg/day.
Copper
Although copper is excreted in bile, hepatic tissue levels of copper decrease as liver
disease progresses, possibly indicating a protective role for copper. Copper deficiency has
developed in pediatric patients when copper is removed from parenteral solutions
(Zambrano, 2004; Hurwitz, 2004). Although previous recommendations have been to
reduce or remove copper from parenteral solutions if cholestasis is present, current
practice is to reduce or remove copper only if evidence of copper toxicity is present. If
copper is removed, serum ceruloplasmin and copper levels should be monitored to ensure
sufficient copper status.

Manganese
Manganese is also excreted primarily in bile, but blood manganese levels are elevated in
patients with cholestatic jaundice and are directly correlated to the severity of cholestasis.
At this time, it seems appropriate to remove manganese from parenteral nutrition (PN)
when direct bilirubin is greater than 2 mg/dL. Excessive intakes of parenteral manganese
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
may induce PN–associated liver disease and neurotoxicity (Fok, 2001; Erikson, 2007).
Selenium and Chromium
Requirements may be decreased in patients with chronic (undialyzed) renal failure.
Selenium may be reduced to 1 mcg/kg/day or omitted, and chromium may be omitted (
(Greene, 1988a).
Monitoring
Routine monitoring of trace element status is not indicated. Infants with cholestasis benefit
from monthly monitoring of serum copper, ceruloplasmin, and whole blood manganese to
identify toxicity or, if these trace elements have been removed or reduced, to identify
deficiency.

Vitamins

Dose Recommendations
Goals for vitamin intakes are shown in the table.
Estimated Daily Parenteral Vitamin Requirements and Dose
a
Recommendations for
Preterm Infants
Delivered Amount/kg/d Using Various Dose
Recommendations
Vitamin Recommended
Amount/kg/d
30%
Dose/d
for
Infants
0.5-1 kg
65%
Dose/d
for
Infants
1-2.5 kg
40%
Dose/kg/d
for
Infants ≤
2.5 kg
b
One
5-mL
b
Dose
Vitamin A
IU
700-1500 700-1,400 600-1,500 920 2300
Vitamin D

IU
40-160 120-240 100-260 160 400
Vitamin E
IU
2.8-3.5 2.1-4.2 1.8-4.5 2.8 7
Vitamin K

mcg
10-100 60-120 50-130 80 200
Thiamin
mcg
200-350 360-720 312-780 480 1,200
Riboflavin
mcg
150-200 420-840 364-910 560 1,400
Niacin

mg 4-6.8 5-10 4.4-11 6.8 17
Vitamin B-6
mcg
150-200 300-600 260-650 400 1,000
Folate

mcg 56 42-84 36-90 56 140
Vitamin
B-12

mcg
0.3 0.3-0.6 0.3-0.6 0.4 1
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
d-Panthenol
mg
1-2 1.5-3 1.3-3.3 2 5
Biotin mcg 5-8 6-12 5-13 8 20
Vitamin C
mg
15-25 24-48 21-52 32 80
aAmounts listed are for both pediatric multivitamin preparations: Pediatric MVI Injection or Unit Vial (Astra USA, Inc,
Westboro, MA) and INFUVIT Pediatric (Sabex Inc, Boucherville, QC, Canada).
bMaximum dose not to exceed 1 full 5-mL dose per day.

(Groh-Wargo, 2000; Tsang, 2007; Greene, 1988b)
Currently available pediatric multivitamin solutions, although high in water-soluble vitamins
and low in vitamin A, should be used because they provide more appropriate levels of
vitamins than adult multivitamin preparations.
Water-soluble vitamins are photosensitive and may degrade and oxidize upon exposure to
light (Laborie, 2000; Chessex, 2001). Although the clinical significance of this effect is still
being evaluated, protecting parenteral nutrition (PN) bags and tubing from light exposure
seems to minimize this process.
Monitoring
Routine monitoring of vitamin levels is not usually recommended. As PN is being weaned
and enteral feedings provide a greater proportion of total vitamin intake, fat-soluble vitamin
levels, vitamin B-12, and/or prothrombin times may be monitored depending on clinical
condition.

Nutrient Requirements

Daily Dose Recommendations for Parenteral Macronutrients, Electrolytes, and
Minerals
Initial
Dose
Transitional
Dose
Premature
Infants
Term
Infants
Maximum
Dosea
Basal Energy,
kcal/kg/d
b
35-50 35-50 46-55 55
Total Energy,
kcal/kg/d
c
35-50 60-85 90-115 90-108
Dextrose,
mg/kg/min
d
5 5-10 5-15 5-15 18
Carbohydrate,
g/kg/d
7 8-15 10-20 8-210 25
Protein, g/kg/d
e
2-3 3.5-4 3.2-3.8 2.5-3 4
Fat, g/kg/d
f
0.5-1 1-3 0.5-3 0.5-3 4
Sodium, mEq/kg/d 0-1 2-5 2-4 2-4 20
Potassium,
mEq/kg/d
0 0-2 2-3 2-3 9
Chloride,
mEq/kg/d
g
0-1 2-5 2-7 2-7
as as
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Acetate, mEq/kg/d
as
needed
as needed as needed
as
needed
6
Calcium,
mEq/kg/d
1-3 2-3 3 2 4
Phosphorus,
mmol/kg/d
0-0.6 1.3-2 1.3-2 1-1.5 2
Magnesium,
mEq/kg/d
0 0.3-0.6 0.5-1 0.25-1 1
Iron, mg/kg/d
h
— — (0.2 ) (0.1) 1
a
Individual tolerance varies based on many factors. See individual nutrient sections for
detailed information.
b
Basal energy needs (usually equated with resting energy expenditure) assume a
thermoneutral environment. Thermal losses during care may increase energy expenditure
by 7 kcal/kg/day to 8 kcal/kg/day. During periods of acute stress, as in sepsis or major
surgery, when C-reactive protein (CRP) levels are elevated, energy expenditure may
increase by 8 kcal/kg/day to 10 kcal/kg/d, although tolerance to carbohydrate and fat may
decrease. Basal energy needs may be used in the absence of measured energy
expenditure to prevent overfeeding until CRP levels are 2 or lower.
c
Total parenteral energy needs listed include basal energy needs plus energy for growth
(tissue synthesis and stored energy) and activity. Additional energy is not required for
digestion or to replace losses in stool that occur with enteral feeding, but additional energy
may be needed during recovery periods after sepsis or surgery or during catch-up growth.
d
Dextrose is usually the greatest contributor to osmolarity in parenteral nutrient solutions.
Peripheral venous access requires limiting dextrose to 12.5% concentration. Solutions with
osmolarity > 1,000 mOsm/L, when delivered through peripheral venous access, increase
risk of tissue damage. Central venous access allows up to 25% dextrose solutions. Infants
with hypoglycemia may require more dextrose initially to maintain euglycemia.
e
Protein needs may vary with diagnoses: 0.8 g/kg/day to 2 g/kg/d for renal failure and 3
g/kg/day to 4 g/kg/d for necrotizing enterocolitis, major surgery, and sepsis.
f
Minimum fat dose to meet essential fatty acid requirements varies depending on fat source
and total energy needs. See Lipids.
g
Hyperchloridemic acidosis may occur with high chloride intake; adjust electrolytes by
including sodium or potassium as acetate if needed.
h
Many institutions do not routinely include iron in parenteral admixtures because of
incompatibility with other nutrients, contraindication during sepsis, and risks associated
with overdose with multiple blood transfusions. See Iron.
(Groh-Wargo, 2000; Tsang, 2005; Pierro, 2002; Chwals, 2008)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Enteral Nutrition
Overview

Enteral nutrition is preferred for nourishing all infants, but for high-risk newborns, it is
usually introduced when transitioning from parenteral nutrition. The goal of this section is to
provide health care professionals who work with neonates with evidence-based information
about human milk and commercial enteral products for infants and suggestions for
introducing and progressing with enteral feedings. General guidelines include the following:
Human milk is the preferred feeding for all newborns. Human milk fed to infants who
are at or less than 34 weeks’ gestational age or weigh 1,500 g or less at birth should
be fortified with a commercial human milk fortifier.
Commercial infant formulas are used if human milk is not available. Preterm infants
are fed with preterm infant formulas unless those products are not tolerated.
Vitamin/mineral supplements may be indicated in selected situations and are most
commonly fat-soluble vitamins, especially vitamin D, and the minerals calcium,
phosphorus, iron, zinc, and fluoride.
Enteral feedings are delivered to preterm infants by gavage with transition to breast or
bottle at approximately 34 to 36 weeks’ gestational age.
Noncommercial enteral feedings must be carefully designed for nutritional adequacy,
prepared using strictly controlled policies and procedures and delivered in a timely
fashion to ensure safety and efficacy.
Enteral Nutrient Requirements
Enteral nutrient requirements for infants vary by body weight and age (Tsang, 2005;
Agostoni, 2010). Preterm infant nutrient needs are greater than those of term infants
because of decreased nutrient stores, altered gastrointestinal absorption, and rapid rates of
weight gain. Nutrients of particular interest in the preterm infant include protein, calcium,
iron, phosphorus, and zinc. Recommended intakes can typically be achieved by feeding
fortified human milk or premature infant formulas. Vitamin and mineral supplements and/or
modular macronutrient products are needed when commercially available formulas do not
meet the needs of the infant. In practice, clinicians use recommendations for
low-birthweight infants up to approximately term age and weight and then transition to the
Recommended Dietary Allowances and Adequate Intakes.

Human Milk, Human Milk Fortifiers, and Infant Formulas: Availability, Indications,
and Macronutrient Sources
Type/Availability Indications Carbohydrate Protein Fat
Human milk
From mothers who
wish to breastfeed
or who pump to
provide expressed
milk; from human
milk banks
Preterm infants;
infants birth to 1
year and beyond
Lactose Human milk Human milk
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Human milk
fortifiers
Powder; liquid
Multinutrient
supplement to be
added to human
milk to meet
nutrient needs for
premature or low-
birthweight infants
Corn syrup
solids; lactose
(liquid only)
Cow’s milk
protein
Variety of
vegetable oils,
and/or
medium-chain
triglycerides
(MCT)
(70%-100%)
Preterm formulas
Ready-to-feed
liquid in a variety
of energy densities
Contain higher
amounts of
nutrients including
protein, vitamins,
and minerals to
meet the needs of
growing premature
infants; suitable for
use as human milk
fortifier
Corn syrup
solids or
maltodextrin,
and lactose
(50%)
Cow’s milk
protein
Variety of
vegetable oils,
and MCT
(40%-50%)
Preterm discharge
formulas
Ready-to-feed
liquid; powder
For the continued
feeding of preterm
infants with
nutrient density
between preterm
and most standard
milk protein–based
formulas
Corn syrup
solids or
maltodextrin,
and lactose
(40%-70%)
Cow’s milk
protein
Variety of
vegetable oils,
and MCT
(20%-25%)
Standard milk
protein–based
formulas
Ready-to-feed
liquid; liquid
concentrate;
powder
Infants birth to 1
year
Variety of
sources,
including
lactose ranging
from 0%-100%
Cow’s milk
protein
Variety of
vegetable oils
Soy protein–based
formulas
Ready-to-feed
liquid; liquid
concentrate;
powder
Infants birth to 1
year with
immunoglobulin
E–mediated
allergy or
sensitivity to cow's
milk protein;
lactose free for
disorders such as
galactosemia
Corn syrup
solids, corn
maltodextrin,
sucrose ranging
from 0%-40%
Soy protein
isolate,
L-methionine
Variety of
vegetable oils
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Semi-elemental
formulas
Liquid concentrate
and/or
ready-to-feed
liquid and powder
Hypoallergenic
formula for infants
birth to 1 year
sensitive to intact
protein found in
milk and
soy-based formulas
Variety of
sources
(lactose free)
Casein
hydrolysate,
L-cystine,
L-tyrosine,
and
L-tryptophan
Variety of
vegetable oils,
MCT (0%-55%)
Elemental formulas
Powder
Note: Product is
not packaged as
ready-to-use in
hospital patients
Amino acid–based
formula for infants
and young children
with severe allergy
to intact protein
Corn syrup
solids and/or
modified corn
starch
Free amino
acids
Variety of
vegetable oils,
MCT (0%-33%)
Formulas for older
babies
Ready-to-feed
liquid
Total or
supplemental milk
protein–based
nutritionally
complete beverage
for children ages
1-13 years
Variety of
sources with
and without
added fiber,
sucrose ranging
from 25%-85%
Cow’s milk
protein
and/or soy
protein isolate
Variety of
vegetable oils,
and MCT
(15%-21%)
Oral electrolyte
maintenance
solutions
Ready-to-feed
liquid, bottles and
freezer pops
Oral electrolyte
solution for infants
and children to
replace fluids and
electrolytes lost
during diarrhea
and vomiting
Rice syrup
solids or
dextrose
None None
Note: Product information is subject to change. Consult manufacturer Web sites, product
handbooks, and product labels for specific information on ingredients.
Typical Value Ranges for Selected Nutrients in Human Milk, Human Milk Fortifiers,
and Infant Formulas
a
Energy,
kcal/dL
Protein,
g/dL
Sodium,
mg/dL(mEq/dL)
Calcium,
mg/dL
Phosphorus,
mg/dL
Osmolality,
mOsm/kg
H
2
0
Human milk,
term
70 0.9 18 (0.8) 28 15 290
Human milk,
preterm
b
67 1.4 25 (1.1) 25 13 290
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Human milk
fortifier (HMF):
Composition for
4 packets of
powder
14-15 1.0-1.1 15-16 (0.7) 90-117 50-67 Powder
HMF mixed with
preterm human
milk (1 packet
per 25 mL)
79 2.4-2.5 39-41 (1.7-1.9) 115-138 63-78 325-385
Preterm
formulas: 20
kcal/oz
67-68 2 29-39 (1.3-1.7) 112-122 56-68 235-240
Preterm
formulas: 24
kcal/oz
81 2.4 35-47 (1.5-2) 133-146 67-81 275-300
Preterm
formulas: 30
kcal/oz
101 3 44 (1.9) 183 101 325
Preterm
discharge
formulas
73-74 2-2.1 25-26 (1.1) 78-88 46-48 250-300
Milk
protein–based
formulas
67 1.4-1.7 16-27 (0.7-1.2) 45-57 26-38 180-300
Soy
protein–based
formulas
67 1.7-1.8 24-30 (1.0-1.3) 70-71 42-56 170-240
Semi-elemental
formulas
67 1.9 30-32 (1.3-1.4) 63-71 35-51 290-370
Elemental
formulas
67 1.9-2.1 25-32 (1.1-1.4) 63-83 42-62 350-375
Formula for
older babies
100-106 3 37-57 (1.6-2.5) 97-101 80-85 335-560
a
See Electrolyte Solutionsfor information about oral electrolyte maintenance solutions
b
Composition summary from Abbott Nutrition (Columbus, OH)
Note: Information varies from product to product. Consult manufacturer Web sites, product
handbooks, and specific product labels for specific information on nutrients and osmolality.

Nutrient Requirements

Fluids, Energy, and Macronutrients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Growing RDA/AI
a
Nutrient ELBW (< 1,000 g) VLBW (< 1,500 g) Age 0-6 mo Age 7-12 mo
Fluid 160-220 mL/kg 135-190 mL/kg 0.7 L/d 0.8 L/d
Energy 130-150 kcal/kg 110-130 kcal/kg 555 kcal/d 694 kcal/d
Carbohydrate 9-20 g/kg 7-17 g/kg 60 g/d 95 g/d
Protein 3.8-4.4 g/kg 3.4-4.2 g/kg 9.1 g/d 11 g/d
Fat 6.2-8.4 g/kg 5.3-7.2 g/kg 31 g/d 30 g/d
Linoleic acid 700-1680 mg/kg 600-1440 mg/kg 4.4 g/d (14%) 4.6g/d
Alphalinolenic acid 0.7-2.1% kcal 0.7-2.1% kcal 0.5 g/d (1.6%) 0.5 g/d
DHA ≥ 21 mg/kg ≥ 18 mg/kg – –
ARA ≥ 28 mg/kg ≥ 24 mg/kg – –
Abbreviations: DHA = docosahexaenoic acid; ARA = arachidonic acid; ELBW = extremely
low birth weight; VLBW = very low birth weight
a
Recommended Dietary Allowances (RDAs) in bold and Adequate Intakes (AIs) may both
be used as goals for individual intake. RDAs are set to meet the needs of almost all (97%
to 98%) individuals in a group. For healthy infants fed human milk, the AI is the mean
intake.
(Tsang, 2005; IOM, 2005)
Fortifed human milk and preterm formulas, when fed at adequate volume, approximate the
protein requirement of the preterm infant. Extremely low-birth-weight infants may have
protein needs above that provided by fortified human milk or preterm formula. A
high-protein preterm formula is available (see Formulary) and provides increased protein at
normal fluid volumes. Additional protein can also be provided by a modular protein
supplement. The protein powder is weighed under sterile conditions in an amount that can
be added to 100 mL of human milk or formula. Strict adherence to clean procedures is
essential to minimize the growth of bacteria.
For nutrient composition of selected enteral feedings, see Table: Human Milk, Human Milk
Fortifiers, and Infant Formulas: Availability, Indications, and Macronutrient Sources.
Trace Elements

RDA/AI
a
Trace Element
Growing ELBW (< 1,000 g)
or
VLBW (< 1,500 g)
Age 0-6 moAge 7-12 mo
Zinc 1,000-3,000 mcg/kg 2 mg/d 3 mg/d
Copper 120-150 mcg/kg 200 mcg/d 220 mcg/d
Iron 2-4 mg/kg 0.27 mg/d 11 mg/d
Chromium 0.1-2.25 mcg/kg 0.2 mcg/d 5.5 mcg/d
Molybdenum 0.3 mcg/kg 2 mcg/d 3 mcg/d
Manganese 0.7-7.5 mcg/kg 0.003 mg/d 0.6 mg/d
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Iodine 10-60 mcg/kg 110 mcg/d 130 mcg/d
Fluoride – 0.01 mg/d 0.5 mg/d
Selenium 1.3-4.5 mcg/kg 15 mcg/d 20 mcg/d
Abbreviations: ELBW = extremely low birth weight; VLBW = very low birth weight.
a
Recommended Dietary Allowances (RDAs) in bold and Adequate Intakes (AIs) may both
be used as goals for individual intake. RDAs are set to meet the needs of almost all (97%
to 98%) individuals in a group. For healthy infants fed human milk, the AI is the mean
intake.
(Tsang, 2005; IOM, 2005)
Fluoride
Ready-to-feed formula and most bottled water do not contain fluoride; if formula is not
reconstituted with fluoridated water or sufficient fluoridated water is not consumed in some
other way, a fluoride supplement of 0.25 mg/day from 6 months to 3 years is recommended
(AAP, 1999).
Iron
Preterm, very low-birth-weight infants fed fortified human milk or preterm infant formulas do
not usually need vitamin or mineral supplementation. Possible exceptions exist (Kleinman,
2004). Iron supplementation may be indicated for infants needing more than the
approximately 2 mg/kg/day of iron provided by iron-fortified formulas or who are receiving
human milk fortified with a commercial human milk fortifier that does not contain iron
(Baker, 2010). Iron supplementation should begin no later than 2 months. Preterm infants
receiving erythropoiten require at least 6 mg/kg/day.
Term infants and older preterm infants may require more iron than what is provided in
breast milk or commercially prepared infant formulas. Supplementation should be
considered in the hospital and at discharge, depending on the baby’s age and feeding type.
For infants receiving human milk, an iron supplement is recommended by 4 to 6 months of
age. Two servings per day of ½ oz or 15 g of dry infant cereal or a supplement providing 1
mg/kg/day of elemental iron is recommended (Kleinman, 2009).
Vitamins
AI
a
Vitamin
Growing ELBW (< 1,000 g)
or
VLBW (< 1,500 g)
Age 0-6 moAge 7-12 mo
Vitamin A 700-1500 IU/kg 400 mcg/d
b
500 mcg/d
b
Vitamin D 150-400 IU/d 5 mcg/d
c
5 mcg/d
c
Vitamin E 6-12 IU/kg 4 mg/d
d
5 mg/d
d
Vitamin K 8-10 mcg/kg 2 mcg/d 2.5 mcg/d
Vitamin C 18-24 mg/kg 40 mg/d 50 mg/d
Thiamin 180-240 mcg/kg 0.2 mg/d 0.3 mg/d
Riboflavin 250-360 mcg/kg 0.3 mg/d 0.4 mg/d
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Niacin 3.6-4.8 mg/kg 2 mg/d 4 mg/d
Pyridoxine 150-210 mcg/kg 0.l mg/d 0.3 mg/d
Vitamin B-12 0.3 mcg/kg 0.4 mcg/d 0.5 mcg/d
Folic acid 25-50 mcg/kg 65 mcg/d 80 mcg/d
Pantothenic acid1.2-1.7 mg/kg 1.7 mg/d 1.8 mg/d
Biotin 3.6-6 mcg/kg 5 mcg/d 6 mcg/d
Choline 14.4-28 mg/kg 125 mg/d 150 mg/d
Abbreviations: ELBW = extremely low birth weight; VLBW = very low birth weight.
a
For healthy infants fed human milk, the Adequate Intake (AI) is the mean intake.
b
As retinol activity equivalents (RAEs). 1 RAE = 1 mcg retinol, 12 mcg beta carotene.
c
As cholecalciferol. 1 mcg = 40 IU vitamin D.
d
As alpha tocopherol.
(Tsang, 2005; IOM, 2005)

Minerals
AI
a
Mineral
Growing ELBW (< 1,000 g)
or
VLBW (< 1,500 g)
Age 0-6 moAge 7-12 mo
Calcium 100-220 mg/kg 210 mg/d 270 mg/d
Phosphorus60-140 mg/kg 100 mg/d 275 mg/d
Magnesium 7.9-15 mg/kg 30 mg/d 75 mg/d
Sodium 3-5 mEq/kg (69-115 mg/kg) 120 mg/d 370 mg/d
Potassium 2-3 mEq/kg (78-117 mg/kg) 400 mg/d 700 mg/d
Chloride 3-7 mEq/kg (107-249 mg/kg) 180 mg/d 570 mg/d
Abbreviations: ELBW, extremely low birth weight; VLBW, very low birth weight.
a
For healthy infants fed human milk, the Adequate Intake (AI) is the mean intake.
(Tsang, 2005; IOM, 2005)
See Table: Typical Ranges for Selected Nutrients in Human MIlk, Human Milk Fortifiers,
and Infant Formulas.
Preterm, very-low-birth-weight infants fed fortified human milk or preterm infant formulas do
not usually need vitamin or mineral supplementation. For exceptions, see Supplements.
Infants with respiratory disease may benefit from supplemental vitamins A and E. See
Nutrition Care: Respiratory Disease.
Older preterm infants not on fortified human milk or preterm formula and term infants
require additional vitamin D. For infants receiving unfortified human milk or less than 1
qt/day of commercial nonpreterm infant formula a daily supplement of 400 IU of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
qt/day of commercial nonpreterm infant formula a daily supplement of 400 IU of
supplemental vitamin D is recommended (Gartner, 2003). A 1 mL daily dose of either a
tri-vitamin or a multi-vitamin drop for infants meets this recommendation.

Electrolyte Solutions

Oral electrolyte solutions help to prevent dehydration following diarrhea and vomiting. Use
for longer than 24 hours is rarely needed. Occasionally, oral electrolyte solutions are
prescribed as the initial feeding in preterm infants.
Typical Value Ranges for Oral Electrolyte Maintenance Solutions
Nutrient Typical Value Range
Energy 10-13 kcal/dL
Carbohydrate 2.5-3 g/dL
Sodium 104-115 mg/dL (4.5-5 mEq/dL)
Potassium 78-98 mg/dL (2-2.5 mEq/dL)
Chloride 124-160 mg/dL (3.5-4.5 mEq/dL)
Osmolality 170-270 mOsm/kg H20
Note: Information varies from product to product. Consult manufacturer Web sites, product
handbooks, and product labels for specific information on nutrients and osmolality.
For sodium composition of selected enteral feedings, see the Table: Typical Value Ranges
for Selected Nutrients in Human Milk, Human Milk Fortifiers, and Infant Formulas on the
Enteral Nutrition Overview page.

Feeding Methodology

Although breastfeeding or bottle-feeding is the ultimate goal for high-risk newborns, most
infants begin and progress to their enteral nutrition goals by tube feeding. Feeding tubes
should meet the following criteria:
Radio-opaque for visualization on radiography
Made of either polyurethane or silicone (indwelling for up to 30 days) or
polyvinylchloride (for intermittent feedings; cannot be left in place)
Larger than 5 French in size but smaller than 8 French for satisfactory flow
Products containing the plasticizer di (2-ethylhexyl) phthalate are not recommended (FDA,
2009).
Nasogastric and orogastric tube feedings are commonly used for preterm infants with
feedings delivered either continuously or intermittently (bolus). Less commonly used are
transpyloric (nasoduodenal and nasojejunal), jejunal, or gastrostomy feedings. The
following table reviews considerations when choosing among feeding methods.

Review of Enteral Feeding Methodologies
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Feeding Methodology
Advantages and
Disadvantages/Contraindications
Potential Problems
NG or OG Bolus
Indicated for:
Premature
Immature oral
motor skills
Advantages
Simple
Minimal equipment
Feedings can be initiated in
infants unable to orally feed
Minimize total parenteral
nutrition
Can be done at home if
parents can be taught to insert
tube and confirm placement
Disadvantages/Contraindications
Unsafe for gastric feeding
Inexperienced personnel
Unable to check placement
Possible inability to protect
airway such as absent gag
reflex or aspiration
Increased gastric
residuals
Malabsorption
Dumping syndrome
Aspiration
Emesis
Tube misplacement
(too high or too low) or
dislodgement
Nasal erosion (NG)
Palatal grooves (OG)
Bradycardia due to
vagal stimulation
NG or OG Continuous
Indicated for:
Malabsorption
Premature
Immature oral
motor skills
Reflux
Aspiration
Advantages
Well tolerated
Alternative to bolus feedings
Increased absorption for infant
with intestinal disease
Disadvantages/Contraindications
Same as for NG or OG bolus
Proximal ostomy
Pump malfunction
Antireflux system
should be considered
Aspiration potential if
tube is pulled into
esophagus
Decreased cyclic
enteric hormone
response
ND or NJ
Indicated for:
Gastric aspirates
without ileus
Severe
gastroesophageal
reflux
Must always be
continuous
Advantages
Typically well tolerated
Alternative when gastric feeds
not tolerated
Less risk of aspiration
Disadvantages/Contraindications
Unsafe for enteral feeding
Bolus feeding
Inexperienced personnel
Proximal ostomy
Perforation
Dumping syndrome
Diarrhea
Pump
malfunction—consider
use of a pop-off system
Decreased cyclic
enteric hormone
response
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Jejunal
Indicated for:
Infant not able to
be fed into the
stomach requiring
stable access
Must always be
continuous
Advantages
Well tolerated if access can be
maintained
Alternative method for infant
not able to be fed otherwise
Disadvantages/Contraindications
Access
Inexperienced personnel
Proximal ostomy
Unable to maintain
access
Perforation of the
bowel wall
Diarrhea
Dumping syndrome,
especially with
hyperosmolar feeds
G tube
Indicated for:
Anatomical
malformations
Neurological
damage
Severe feeding
aversion
Need for
long-term
continuous
feeding (longer
than 2-3 mo)
Advantages
Allows for easier care at home
Less feeding aversion than
with long-term nasoenteric
tube
Safer for continuous feeding at
home
Disadvantages/Contraindications
Potential for transition to full
nipple feedings in a short time
Tube displacement
causing gastric outlet
obstruction
Site infections
Leaking at the site
Abbreviations: NG = nasogastric; OG = orogastric; ND = nasoduodenal; NJ = nasojejunal;
G tube = gastrostomy tube
(Kleinman, 2009; Parker, 1987; Heyman, 2004)

Feeding Initiation and Advancement
Sample Guidelines for Feeding the Preterm Infant
Birth
weight, g
Feeding
Type
Schedule,
C/I
Initial
Rate,
mL/kg/d
Volume
Increase,
mL/kg/d
Full
Feeding
Volume,
mL/kg/d
< 750
Human
milk
a
/PF
12, then
24
C
b
/I every
2 h
c
≤10 × 1
week
10-15 150
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
750-1,000
Human
milk
a
/PF
24
C/I every
2 h
10 15-20 150
1,001-1,250
Human
milk
a
/PF
24
C/I every
2 h
10 20 150
1,251-1,500
Human
milk
a
/PF
24
Every 3 h 20 20 150
1,501-1,800
Human
milk/PF 24
Every 3 h 30 30 150
1,801-2,500
Human
milk/PDF
Every 3 h 40 40 165
> 2,500
Human
milk/Term
infant
formula
Every 4 h 50 50 180
Abbreviations: C = continuous; I = intermittent; PF = preterm formula 12 kcal/oz or 24
kcal/oz; PDF = preterm discharge formula.

a
Fortify human milk to meet nutrient needs.
b
Continuous feeding is not recommended for human milk due to potential for milk
separation.
c
Some units begin with 1 mL every 12 hours and progress gradually to every 2 to 3 hours.
(Source: Division of Neonatology, MetroHealth Medical Center, Cleveland, OH. Copyright
© 2009 MetroHealth Medical Center. Adapted with permission.)

Early enteral feedings and a standardized approach to feeding have been shown to
improve intestinal motility, stimulate hormonal response, improve feeding tolerance,
promote earlier achievement of full feeds, and decrease problems related to prolonged
parenteral nutrition in the very-low-birth-weight (VLBW) infant (Meetze, 1992;
Schanler,1999; Ramirez, 2006; Patel, 2007; Patole, 2005; McCallie, 2011; Ehrenkranz,
2011). A bedside tool based on red flags for evaluating feeding intolerance ensures a
consistent approach to feeding the VLBW infant. To develop the bedside tool, Bell’s
criteria for staging necrotizing enterocolitis was used (Bell, 1978), studies of feeding
tolerance were evaluated (Meetze, 1992; Schanler,1999; Ramirez, 2006; Patel, 2007;
Berseth, 2003; Patole, 2005; Mihatsch, 2002; Kenton, 2004), and expert opinions were
reviewed (Ziegler, 2002; Jadcherla, 2002).
Bedside Tool for Evaluating Feeding Intolerance in the Preterm Infant
Evaluate infant if gastric residual greater than half of feeding volume, abdominal distension
above 2-cm increase in 24 hours, bloody stool, or report of clinical instability
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
If physical examination is normal:
Reduce feeds by 20% if infant is on trophic feeds, or space feeds longer (eg,
every 6 or every 8 hours)
Consider rectal stimulation followed by glycerin
If bloody stool but no clinical problem, consider discontinuing cow’s milk
additives
If physical examination is abnormal:
Request babygram (whole body x-ray)
If babygram is normal:
Hold feeds for 12 to 24 hours, then reinitiate at half volume
If babygram is abnormal:
Check for ileus, pneumatosis, or perforation
Perform sepsis workup (blood and catheterized urine cultures; consider lumbar
puncture if clinically stable)
Prescribe at least 7 to 10 days of antibiotics (Vancomycin and Gentamicin) and
order nothing by mouth (NPO)
Follow with serial x-rays (every 6 to 12 hours depending on condition)
If pneumatosis or perforation is suspected, assess serial complete blood count and
platelets (every 6 to 12 hours depending on condition); if perforation is suspected,
order surgical consult and add clindamycin.
Upon resolution, NPO and antibiotics for 48 hours and slowly restart feeds
(Source: Adapted with permission from Valentine CJ and Nationwide Children’s Hospital
Neonatal. Feeding intolerance algorithm. Copyright © 2007.)

Transition to Oral Feeding
In addition to knowing what is fed, the neonatal dietitian is knowledgeable about how the
baby is fed. The neonatal dietitian works closely with the feeding experts in the neonatal
intensive care unit (NICU), including nurses and speech and occupational therapists. Many
infants benefit from tastes of human milk or formula via pacifier in preparation for oral
feedings of larger volume. Skin-to-skin contact at the breast is beneficial for babies who
will be nursing. Four major criteria determine readiness for nutritive oral feeding (Shaker,
2001; Lemons, 2001). Successful achievement in all four areas is important.
Criteria to Determine Readiness for Nutritive Feeding
Signs of Readiness for Nutritive Feeding
Age
32-34+ weeks’ gestation: the typical age
infants begin to demonstrate coordination of
suck-swallow-breathe
Physiological
Tolerates feeding into stomach
Maintains consistent weight gain with tube
feeding
On ≤ 2 L oxygen due to concern that with
increased flow, infants may be less able to
protect their airway. If > 2 L, may be a
candidate for introduction of tastes via
pacifier dipped in human milk or formula
Respiratory rate between 20 to 50 breaths
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
per minute (bpm) but no more than 70 bpm;
respiratory rate that is consistently more
than 60 bpm may lead to reduced
coordination of suck-swallow-breathe
Stable work of breathing (no retractions,
head bobbing, etc)
State
Ability to reach and maintain a quiet alert
state
Maturational
Tolerates handling and transitions without
excessive signs of stress
Root and nonnutritive suck emerging or
established
(Source: Copyright © 2008 Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.
All Rights Reserved. Used with permission. Data are from Shaker, 2001; Lemons, 2001.)
Infants attempting oral feeds who are exhibiting behaviors or clinical signs that are of
concern for aspiration or safety with feeding may need further evaluation. Two common
tests to assess swallow function are the video swallow study (Arvedson, 1998; Logemann,
1998) and the fiber optic evaluation of swallow study (Leder, 2000; Hartnick, 2000), both of
which are done by experienced physicians and therapists. A dye test is not supported as
reliable for assessment of swallow function in patients with a tracheostomy (O'Neil-Pirozzi,
2003). Thickening of formula must be a team decision due to its impact on the hydration
and nutrition of the infant. Also, the effect of thicker intake on the infant's oral transfer skills
and pharyngeal and esophageal peristalses is questionable.
Nipples and Bottles
Nipples and bottles vary in pliability; shape; size; and, in the case of nipples, flow rate and
type, size, and number of holes. No nipple should be cut or otherwise altered. The following
table compares nipples and bottles commonly used in the NICU.
Comparison of Nipples and Bottles
Brand Name
and
Specifications
Advantages Disadvantages
Slow-Flow Soft
Nipple and Ring
Latex free
Slow flow
Not readily
available after
discharge
Easy to collapse
during feeding
Infant Nipple
and Ring
(yellow
standard nipple)
Latex free
Shape
promotes
tongue
cupping to
control bolus
Not readily
available after
discharge
Easy to collapse
during feeding
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Similac
Premature
Nipple and
Ring
a
(red fast-flow
nipple)
Reduced effort
required to
obtain liquid
Latex free
Fast flow rate
Does not
encourage
activation of oral
musculature for
progression of
nutritive skills
Orthodontic
nipple
May work well
with infants
with cleft lip
and palate
Larger nipple
surface for oral
sensory input
Available in
silicone, latex
free, and latex
Does not support
tongue cupping
Requires greater
lip closure for seal
Pigeon Bottle
b
Crosscut
nipple with
pliable
underside of
nipple for
compression
One-way valve
decreases air
intake
Bottle is pliable
Large nipple
Mead Johnson
Cleft Lip/Palate
Nurser
c
Unit with firm,
long nipple
with crosscut
Can use any
nipple with the
system
Inexpensive
Supports
feeders with
inadequate
suction
Assistive squeeze
done with the
bottle—difficult to
regulate the
consistency of the
squeeze
Haberman
Bottle/Nipple
d
Allows
sensitive flow
regulation
Soft nipple
(two sizes)
Nipple slit/lines
control flow
One-way valve
decreases air
Expensive
Can be difficult to
learn
Multiple parts for
assembly and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
intake
Supports
infants with
inadequate
suction
cleaning
a
Abbott Nutrition (http://www.abbottnutrition.com)
b
Children’s Medical Ventures (http://www.childmed.com)
c
Mead Johnson (http://www.meadjohnson.com)
d
Medela (http://www.medela.com).
(Source: Copyright © 2008 Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.
All Rights Reserved. Used with permission. Data are from Franker 2004.)
Patient Safety
The Joint Commission issued a Sentinel Event Alert regarding tubing misconnections in
2006 (Joint Commission, 2006). Among the other misconnections, intravenous (IV) feeding
infusions have been connected to nasogastric tubes and enteral feedings have been
administered into IV lines (Ryan, 2006). Risk-reduction strategies suggested by the Joint
Commission include design of the systems to be incompatible, and reengineering work
practices (Joint Commission, 2006). The implementation process of an enteral-only system
in a NICU for nutrition and medications has been described (Joint Commission, 2008;
Copelan, 2006; Robbins, 2011).
Powdered formulas are not commercially sterile and should not be used in the NICU setting
or in infants who are immunocompromised unless there is no nutritionally appropriate
alternative available. If a formula must be made using a powder, care must be taken to
minimize the risk of bacterial contamination and proliferation.
Manufacturers have specific recommendations related to the handling of their products as
well as the recommended amount of time their products should be kept at room
temperature once reconstituted. Guidelines have been developed to promote the safest
feeding preparation and storage practices (Robbins, 2011).
When available, a sterile, ready-to-feed or concentrated liquid formula is recommended for
use with all formula-feeding infants. See Table: Human Milk, Human Milk Fortifiers, and
Infant Formulas: Availability, Indications, and Macronutrient Sources.
Formulas made in the hospital should be stored in food-grade materials, such as glass,
plastic, or milk cartons. A variety of suitable bottles and lids are available from dairies,
formula manufacturers, and container companies. See Human Milk.
When medically appropriate, enteral feedings are initiated by 3 to 5 days after birth
(Meetze, 1992; Schanler,1999; Ramirez, 2006; Patel, 2007). Low-volume feedings of 20
mL/kg/day or less (variously called minimal enteral nutrition [MEN], gut stimulation, or
priming, trophic, and hypocaloric feedings) are continued for 3 to 5 days for extremely
low-birth-weight and sick VLBW infants. MEN can be full-strength expressed human milk
or half- or full-strength preterm formula and fed either continuously or intermittently. Infants
weighing less than 750 g with slow motility may benefit from MEN for a minimum of a week
(Meetze, 1992; Berseth, 2003). Feedings are advanced at ≤20 mL/kg/day to 35 mL/kg/day,
depending on the size of the infant and severity of illness (Schanler,1999; Berseth, 2003;
Kennedy, 2005; Krishnamurthy, 2010). Infants have been safely fed despite the presence
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
of umbilical lines (Meetze, 1992); however, each infant must be assessed by the attending
physician. In addition, caution is recommended when beginning feedings in severely
asphyxiated infants (pH < 7.1) with poor perfusion and when pressors are used.

Formulas

For babies whose mothers choose not to provide human milk, or when the supply of human
milk is exhausted, commercial infant formulas designed for preterm infants are available.
Formulas designed for preterm infants are preferred over other formulas (Sapsford, 2000a).
Preterm infants fed formulas designed for preterm infants have better growth, nitrogen
retention, and bone mineral content than preterm infants fed standard formulas (Sapsford,
2000a).
A variety of soy, protein hydrolysate, and amino acid–based elemental formulas are
available when preterm infants do not tolerate preterm infant formulas. Although
satisfactory for term infants, these products may not be nutritionally adequate for growing
preterm infants (Bhatia, 2008; Mihatsch, 2002). Preterm infants not on fortified human milk
or a commercial preterm formula should be closely monitored and considered for
enrichment with modular products and/or vitamin/mineral supplements. A gradual transition
back to fortified human milk or preterm formula is suggested if the baby’s condition allows
it.
For composition, indications, and availability of enteral products fed to infants, see the
Tables in the Enteral Nutrition Overview heading.
A description of modular formula products by macronutrient source is as follows:
Protein
Common sources are whey protein isolate or amino acids.
Typically provide 0.8 g to 0.9 g protein and 3.2 kcal/g to 3.6 kcal/g of powder.
Typically provide 7 g powder/scoop, 4.7 g powder/Tbsp or 9.5 g powder/Tbsp; 200 g
to 227 g per can.
Carbohydrate
Common source is glucose polymers from hydrolyzed corn starch.
Per gram of powder, provide 0.94 g carbohydrates, 3.8 kcal.
Provide 6 g powder/Tbsp; 349 g per container.
Fat
Common sources are coconut oil, 100% safflower oil, and vegetable/corn oils.
Provide 0.5 g to 1 g fat (4.5 kcal to 8 kcal) per milliliter.
Amount per container varies.
Carbohydrate and fat
Typically provide 4.9 kcal (0.73 g carbohydrates as hydrolyzed corn starch, 0.22 g fat
as corn/coconut/medium-chain triglyceride [MCT] oil) per gram of powder.
Provide 5 g powder per scoop, 8.5 g powder/Tbsp; 400 g per container.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Carbohydrate, protein, and fat
Typically provide 6.25 kcal (0.12 g carbohydrate as lactose, 0.13 g protein as milk
protein, 0.62 g fat as 97% MCT) per gram of powder.
Available as 16 g sachets (100 per carton).
Note: Powdered supplements are not commercially sterile.

Hypercaloric Feedings

Neonatal dietitians are challenged with providing optimal feedings to support proportional
growth for infants who require fluid restriction or have nutrition needs more than what can
be supplied with ready-to-feed formulas or concentrated liquids or powder products made
according to manufacturers’ directions.
High-energy feedings can be made by concentrating the formula and using less water,
thereby keeping all nutrients in balance. High-energy formulas can also be made using
modular products, such as individual supplements of carbohydrate, protein, or fat, or a
combination of carbohydrate and fat. Using modular supplements may alter the original
balance of nutrients but may be desired for clinical reasons. When altering formula
concentration, it is very important to analyze nutrient composition to ensure desired nutrient
intake, to monitor tolerance and clinical status of the infant, and to limit hang time to 4
hours (Robbins, 2011).
Options for increasing the energy density of human milk include the following:
Use of a commercially available human milk fortifier up to 24 kcal/oz (most common)
Addition of preterm discharge formula (PDF) powder to expressed human milk. See
Feeding Progression for more information.
Use of Similac Special Care 30 (Abbott Nutrition, Columbus, OH) mixed with human
milk or mixed with fortified human milk to make desired concentration
Use of hind milk; estimate energy density using the Creamatocrit technique (Meier,
2002); special equipment is available but not required (The Creamatocrit Plus;
Medela, Inc; McHenry, IL)
Use of powdered formula, concentrated liquid formula, or modular products that add
carbohydrate, protein, and/or fat
The examples in the following table are for illustration purposes only. Consult
manufacturers’ Web sites, product handbooks, and product labels for possible changes in
nutrient composition.
Intake of Key Nutrients from Selected Hypercaloric Enteral Mixtures When Fed at 120
kcal/kg to a Hypothetical 1.5-kg Infant

Feeding
Volume,
mL/kg
Macronutrients,
g/kg
Calcium,
mg/kg
Zinc,
mg/kg
Vitamin
D, IU/d
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
PHM +
SHMF
(24 kcal/oz
[120
kcal/kg])
152
CHO: 13
Protein: 3.6
Fat: 6.3
210 2 267
Human
milk +
SHMF = 24
+
Beneprotein
(26 kcal/oz
[120
kcal/kg])
138
CHO: 12
Protein: 4.3
Fat: 6.2
187 1.4 270
PHM:SSC
30 1:1
(25 kcal/oz
[120
kcal/kg])
140
CHO: 11
Protein: 2.8
Fat: 7.7
148 1.2 218
EPF 24 +
Polycose
(26 kcal/oz
[120
kcal/kg])
138
CHO: 15
Protein: 3.6
Fat: 5.6
183 1.7 447
Pregestimil
24 + MCT
oil
(28 kcal/oz
[120
kcal/kg])
131
CHO: 10
Protein: 2
Fat: 7.7
118 1 92
Neocate
(26 kcal/oz
[120
kcal/kg])
138
CHO: 14
Protein: 3.7
Fat: 5.4
149 2 156
Abbreviations: CHO = carbohydrate; PHM = preterm human milk; SHMF = Similac Human
Milk Fortifier (Abbott Nutrition, Columbus, OH); SSC = Similac Special Care (Abbott
Nutrition, Columbus, OH); EPF = Enfamil Premature Formula (Mead Johnson, Evansville,
IN); MCT = medium-chain triglyceride.

Preparation of High-Energy Feedings
Consider the following factors when preparing feedings high in energy:
Desired energy density and desired final volume
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Availability of equipment to measure ingredients precisely for hospitalized infants
(gram scale for powders; milliliter precision for liquids)
Concentrated liquid formulas are packaged in 13 fl oz cans (390 mL) and provide 1.33
kcal/mL (40 kcal/oz)
Infant formula powders vary from 4.2 kcal/g to 5.2 kcal/g; when mixed with liquids,
they range in volume displacement from 6.1 mL to 7.4 mL per scoop (for formulas
prepared, 1 scoop per 2 oz water) (Kuzma-O'Reilly, 2000); measuring instructions
may indicate packed or unpacked powder
Conversion to recipes using scoops and household measurements for preparation at
home

Monitoring

Suggested Monitoring Schedule for Infants Receiving Enteral Nutrition Support
Initial
Phase
a
Stable Phase
b
Growth:
Weight
Length
Head circumference
Daily
Weekly
Weekly
Daily
Weekly
Weekly
Intake and output Daily Daily
Glucose:
Serum
Urine
Baseline
Baseline
As
indicated
As
indicated
Electrolytes
Baseline Every 2-3 wks
Calcium, magnesium,
phosphorus
Baseline Every 2-3 wks
Triglycerides As indicated As indicated
Blood urea nitrogen/creatinine Baseline Every 2-3 wks
Serum proteins Baseline Every 2-3 wks
Liver enzymes Baseline Every 2-3 wks
Alkaline phosphatase Baseline Every 2-3 wks
Blood cell count Baseline Every 2-3 wks
Vitamin and trace mineral status
or other specific tests
As indicated As indicated
a
Initial phase is the phase as enteral nutrition feedings are adjusted to meet the specific
energy and nutrient needs of individual infants. This period generally lasts 7 to 10 days for
enteral support.
b
Stable phase is the phase when the infant is in a metabolically steady state. For clinically
stable infants receiving an adequate nutrient intake with desired growth, the interval
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
stable infants receiving an adequate nutrient intake with desired growth, the interval
between laboratory measurements may be increased beyond the recommendations
provided in the table.
(Moyer-Mileur, 2007)

Osmolality

Osmolality is a measurement of the concentration of solutes in solution. Values are
expressed as mOsm/kg water. The osmolality of blood is approximately 300 mOsm/kg
water. Hyperosmolar feedings may cause intolerance and diarrhea. Carbohydrate as
monosaccharides and disaccharides are major contributors to osmolality.
Medications and vitamin/mineral supplements in syrups are extremely hyperosmolar (Jew,
1997). The final osmolality of formula-medication mixtures can be calculated (Jew, 1997).
To reduce the osmolality of feedings with added syrup-based medications, divide the
medication dose or use another form of the medication, such as intravenous. The upper
limit of osmolality for infant feedings is 450 mOsm/kg water (as estimated from an
osmolarity of 400 mOsm/L) (AAP, 1976).
Typical Value Ranges for Selected Nutrients in Human Milk, Human Milk Fortifiers,
and Infant Formulas
a
Energy,
kcal/dL
Protein,
g/dL
Sodium,
mg/dL(mEq/dL)
Calcium,
mg/dL
Phosphorus,
mg/dL
Osmolality,
mOsm/kg
H
2
0
Human milk,
term
70 0.9 18 (0.8) 28 15 290
Human milk,
preterm
b
67 1.4 25 (1.1) 25 13 290
HMF:
Composition for
4 packets of
powder
14-15 1.0-1.1 15-16 (0.7) 90-117 50-67 Powder
HMF mixed
with preterm
human milk (1
packet per 25
mL)
79 2.4-2.5 39-41 (1.7-1.9) 115-138 63-78 325-385
Preterm
formulas: 20
kcal/oz
67-68 2 29-39 (1.3-1.7) 112-122 56-68 235-240
Preterm
formulas: 24
kcal/oz
81 2.4 35-47 (1.5-2) 133-146 67-81 275-300
Preterm
formulas: 30
kcal/oz
101 3 44 (1.9) 183 101 325
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm
discharge
formulas
73-74 2-2.1 25-26 (1.1) 78-88 46-48 250-300
Milk
protein–based
formulas
67 1.4-1.7 16-27 (0.7-1.2) 45-57 26-38 180-300
Soy
protein–based
formulas
67 1.7-1.8 24-30 (1.0-1.3) 70-71 42-56 170-240
Semi-elemental
formulas
67 1.9 30-32 (1.3-1.4) 63-71 35-51 290-370
Elemental
formulas
67 1.9-2.1 25-32 (1.1-1.4) 63-83 42-62 350-375
Formula for
older babies
100-106 3 37-57 (1.6-2.5) 97-101 80-85 335-560
Abbreviation: HMF = human milk fortifier.
a
See Electrolyte Solutions for information about oral electrolyte maintenance solutions.
b
Composition summary from Abbott Nutrition (Columbus, OH).
Note: Information varies from product to product. Consult manufacturer Web sites, product
handbooks, and product labels for specific information on nutrients and osmolality.

Renal Solute Load

Potential renal solute load (PRSL) is the amount of nitrogen from protein plus the sum of
sodium, potassium, chloride, and phosphorus that a feeding contains (Fomon, 2000).
PRSL is expressed as mOsm/L or mOsm/100 kcal. Equations to calculate PRSL are
available (Fomon, 1993; Sapsford, 2000b). Actual renal solute load can be calculated
assuming not all RSL is presented to the kidney when the infant is growing. Urine
osmolality can be estimated from actual RSL (Fomon, 1993; Sapsford, 2000b).
Feedings with a high PRSL could increase the risk of dehydration. The upper limit of PRSL
for infant feedings is 277 mOsm/L or 30 mOsm/100 kcal to 35 mOsm/100 kcal (Fomon,
1993; Fomon, 1999; J Nutr 1998).

Supplements

Preterm, very-low-birth-weight (VLBW) infants fed fortified human milk or preterm infant
formulas do not usually need vitamin or mineral supplementation. Preterm infants who may
need a vitamin and/or mineral supplement include the following (Kleinman, 2009; Baker,
2010):
Extremely low-birth-weight infants able to tolerate full enteral feeding at weights of
approximately 1 kg (may need additional fat-soluble vitamins until they are bigger and
the volume of their intake increases)
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Preterm, VLBW infants receiving unfortified human milk or nonpreterm formula (eg,
soy, protein hydrolysate, or amino acid–based products)
Preterm infants with malabsorption or cholestasis
Iron supplementation may be indicated for infants needing more than the
approximately 2 mg/kg/day of iron provided by iron-fortified formulas or who are
receiving human milk fortified with a commercial human milk fortifier that does not
contain iron. Iron supplementation should begin no later than 2 months. Preterm
infants receiving erythropoiten require at least 6 mg/kg/day.
Term infants and older preterm infants may require additional vitamin D, iron, and/or
fluoride other than what is provided in breast milk or commercially prepared infant formulas.
These nutrients should be considered in the hospital and at discharge, depending on the
baby’s age and feeding type.
Vitamin D
For infants receiving human milk or less than 1 qt/day of commercial infant formula, a daily
supplement of 400 IU vitamin D is recommended (Wagner, 2008). A 1 mL daily dose of
either a tri- or a multi-vitamin drop for infants meets this recommendation.
Iron
For infants receiving human milk, an iron supplement is recommended by 4 to 6 months of
age. Two servings per day of ½ oz or 15 g of dry infant cereal or an iron supplement
providing 1 mg/kg/day of elemental iron is recommended (Kleinman, 2009; Baker, 2010).
Fluoride
Ready-to-feed formula and most bottled water do not contain fluoride; if formula is not
reconstituted with fluoridated water or sufficient fluoridated water is not consumed in some
other way, a fluoride supplement of 0.25 mg/day from 6 months to 3 years is recommended
(AAP, 1999).
Available vitamin and mineral supplement types include the following:
Vitamins
Vitamin A (retinol) (injection)
Vitamin B-6 (pyridoxine) (injection)
Vitamin B-12 (cyanocobalamin) (injection)
Vitamin C (ascorbic acid) (drops)
Vitamin D (cholecalciferol) (drops)
Vitamin D (1,25 dihydroxycholecalciferol) (drops)
Vitamin D-2 (ergocalciferol) (drops)
Vitamin E (d-alpha tocopherol) (drops)
Vitamin K-1 (phytonadione) (injection or crushable tablet)
Minerals
Iron (drops)
Fluoride (drops)
Calcium: as calcium glubionate (syrup) or calcium carbonate (suspension)
Magnesium sulfate (intravenous source used orally)
Sodium chloride or sodium phosphate (intravenous source used orally)
Potassium chloride (intravenous source used orally)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Potassium phosphate (intravenous source used orally; powder for oral solution)
Sodium citrate (drops)
Potassium and sodium citrate (drops)
Zinc sulfate (intravenous source used orally)
Tri-vitamins (drops, with and without iron)
Each 1 mL typically contains 1,500 IU vitamin A, 35 mg vitamin C, 400 IU vitamin D,
and up to 10 mg iron (for multivitamins that specify “with iron”)
Lactose-free, gluten-free, no artificial sweeteners
Multivitamins (drops, with or without iron)
Each 1 mL typically contains 1,500 IU vitamin A, 35 mg vitamin C, 400 IU vitamin D,
5 IU vitamin E, 0.5 mg thiamin, 0.6 mg riboflavin, 8 mg niacin, 0.4 mg vitamin B-6, 2
mcg vitamin B-12, and 10 mg iron (for multivitamins that “specify with iron”).
Available as lactose-free, gluten-free, with no artificial sweeteners.
Multivitamins with water-miscible formulation of fat-soluble vitamins (drops)
Contain 3,170 IU to 5,751 IU vitamin A (53% to 87% as beta carotene), 45 mg to 46
mg vitamin C, 400 IU vitamin D, 50 IU vitamin E, 300 mcg to 400 mcg vitamin K, 0.5
mg to 0.6 mg thiamin, 0.6 mg vitamin riboflavin, 6 mg niacin, 0.6 mg vitamin B-6, 15
mcg biotin, 3 mg pantothenic acid, and 5 mg zinc.
Some products contain vitamin B-12 and selenium.

Formula Safety Issues

Safety Issues
Powdered formulas are not commercially sterile and should not be used in the neonatal
intensive care setting or in infants who are immunocompromised unless there is no
nutritionally appropriate alternative available. If a formula must be made using a powder,
care must be taken to minimize the risk of bacterial contamination and proliferation.
Manufacturers have specific recommendations related to the handling of their products as
well as the recommended amount of time their products should be kept at room
temperature once reconstituted. Guidelines have been developed to promote the safest
feeding preparation and storage practices (Robbins, 2004).
When available, a sterile, ready-to-feed or concentrated liquid formula is recommended for
use with all formula-feeding infants. See Table: Human Milk, Human Milk Fortifiers, and
Infant Formulas.
Formulas made in the hospital should be stored in food-grade materials, such as glass,
plastic, or milk cartons. A variety of suitable bottles and lids are available from dairies,
formula manufacturers, and container companies. See Human Milk.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Human Milk
Composition

Human milk composition varies during gestation, within a feeding, diurnally, throughout lactation, and based
on the mother’s diet. Macronutrient sources include whey-predominant protein, lactose, and long-chain
triglycerides. For several weeks postpartum, human milk from mothers of preterm infants is known to
contain greater amounts of protein and sodium than human milk from mothers of term infants (Lawrence,
2005; Sapsford, 2000a; Wojcik, 2009).
For composition of and indications for human milk, see Tables in the Enteral Nutrition Overview.

Breastfeeding Considerations

Human milk is the gold standard for infant feeding and is preferred for nearly all high-risk newborns.
Benefits of using human milk include improved developmental outcomes and decreased incidence of
necrotizing enterocolitis (NEC) and late-onset sepsis (AAP, 2005).
Conditions compatible with breastfeeding or using human milk include the following (AAP, 2005; CDC,
2009; Lawrence, 2005):
Mothers who are hepatitis B surface antigen–positive
Mothers infected with hepatitis A or C
Mothers who are febrile
Mothers exposed to low-level environmental chemical agents
Mothers who are seropositive for cytomegalovirus (CMV)
Mothers who smoke tobacco (mother should be advised to quit smoking)
Mothers who drink a single, small alcoholic beverage (avoid breastfeeding or pumping for 2 hours)
Hyperbilirubinemia in the baby
Contraindications to breastfeeding or using breast milk include the following (AAP, 2005; Lawrence, 2005;
AAP, 2009; Pickering, 2006):
Infants with classic galactosemia or some inborn errors of protein metabolism
Mothers with herpes simplex lesions on the breast; with active, untreated tuberculosis; or who are
positive for human immunodeficiency virus
Mothers receiving radioactive isotopes, chemotherapeutic agents, and some medications
Mothers using drugs of abuse

Donor Milk

Donor human milk is available for infants whose mothers are unable to express their own milk or have
inadequate milk supply. Use of donor human milk may reduce the risk of necrotizing enterocolitis in
low-birth-weight (LBW) infants (Schanler, 2005; Lucas, 1990; CCHMC, 2007; Arslanoglu, 2010a). Some are
using donor human milk as a bridge for feeding infants in the first few days of life or for up to 2 weeks.
Others use it when a mother wants her baby to receive only human milk but her supply is inadequate.
Use of donor human milk may be associated with poor growth (Schanler, 2005; Arslanoglu, 2010a). The
Human Milk Banking Association of North America (http://www.hmbana.org) and the Food and Drug
Administration
(http://www.fda.gov/ScienceResearch/SpecialTopics/PediatricTherapeuticsResearch/ucm235203.htm) have
established guidelines for safe and consistent handling of donor human milk (HMBA, 2006). This site also
provides access to a list of donor milk banks in North America.
Concentrated donor milk enriched with minerals is available as a frozen liquid fortifier from Prolacta
Bioscience (http://prolacta.com).

Fortifiers
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Although human milk is preferred to infant formula, for preterm infants, it is inadequate in protein; many
vitamins; and most minerals, including calcium, phosphorus, zinc, and iron (Sapsford, 2000a). Fortifying
human milk can minimize these nutrient deficiencies. Commercial human milk fortifiers (HMF) are available
as powders and liquids and are indicated for infants who meet the following criteria (Sapsford, 2000a):
≤ 34 weeks’ gestation
≤ 1,500 g at birth
On total parenteral nutrition more than 2 weeks
> 1,500 g at birth with suboptimal growth
> 1,500 g at birth with limited ability to tolerate increased volume
The addition of HMF to expressed human milk increases the osmolality. Tolerance may be improved by
starting with 1 packet of HMF mixed with 50 mL of expressed human milk (22 kcal/oz) and progressing to 1
packet to 25 mL (24 kcal/oz) as tolerated. When the supply of expressed human milk is inadequate or if the
baby does not tolerate the addition of a HMF, a nutrient dense, 30 kcal/oz preterm formula can be mixed
with the expressed human milk in a 1:1 or other ratio. A human milk-based HMF is available
(http://prolacta.com; Sullivan, 2010). "Targeted fortification" and "adjustable fortification" are other options to
improve the nutrient intake of VLBW infants fed human milk (Arslanoglu, 2010b). For other suggestions for
increasing the energy density of human milk, see Hypercaloric Feedings.

Labeling and Storage

Labeling
Guidelines have been developed for management of human milk delivery in the neonatal intensive care unit
(NICU) (Sapsford, 2011). Human milk is labeled with two identifiers, including name and medical record
number (Joint Commission, 2008). The mother records on the label the date and time the milk was
expressed, and nurses double-check the milk before feeding to avoid the risk of feeding an infant another
mother’s milk.
In addition, the label notes when the milk expires and whether it was fresh or frozen then thawed. Some
NICUs use basic labels with key information written on them; others use computerized labels, including
those with bar code capabilities or those that can be placed in the chart for further documentation (Sapsford,
2011; HMBA, 2006).
Storage
Human milk is stored in containers suitable for food, such as those made from polypropylene, polyethylene
teraphthalate, and high-density polyethylene (Sapsford, 2011; HMBA, 2006). Containers or bottles made of
polycarbonate contain bisphenol A, which may pose health risks (Kang, 2006). Manufacturers that make
storage containers include the following:
Medela (http://www.medela.us; 800/435-8316)
Ross/Abbott Nutrition (http://www.abbottnutrition.com; 800/227-5767)
Capitol Vial (http://www.capitolvial.com; 800/772-8871)
Snappies (http://www.snappiescontainers.com; 800/772-8871)
Once expressed, human milk should be stored in a refrigerator (4°C or 39°F to 40°F) if it will be used within
the next 96 hours for hospitalized infants; otherwise, it should be frozen immediately. Milk stored in a deep
freezer (–20°C or –4°F) will last 6 to 12 months.
Thawed human milk should be used within 24 hours. Milk should not be kept at room temperature for more
than 4 hours for hospitalized infants. Detailed storage guidelines for human milk are available (Sapsford,
2011; HMBA, 2006).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Discharge/Follow > up
Breastfeeding and Human Milk

Human milk is the preferred feeding for all infants. Hospitalization and prematurity
complicates the newborn breastfeeding period because (a) separation requires the mother
to pump and frequently leads to diminished milk supply, and (b) prematurity of 1 month or
more requires tube feeding in the hospital and a period of transition to the breast that often
includes some bottle feeding. Many preterm infants cannot or will not be able to breastfeed
exclusively at the time of discharge. Preterm infants exclusively fed human milk are known
to have slower growth than preterm infants fed preterm or enriched formula, but they
benefit from enhanced development and protection against infection (Schanler, 1999;
O'Connor, 2003).
Nutrition Goals
Nutrition goals for the breastfeeding mother and her baby at discharge are as follows:
Promote adequate weight gain, including necessary catch-up growth.
Ensure good nutritional status of protein, calcium, phosphorus, and other
micronutrients.
Maintain or build breast milk supply.
Sustain or improve feedings at the breast.
Limit bottle and formula feeding to what is required for the first and second goals.
Goals are individualized based on the condition of the baby at discharge, the supply of
breast milk, and the wishes of the mother. The following table suggests management
options for two common scenarios at discharge.
Breastfeeding Management for Prematurely Born Infants at Discharge
Exclusive Human Milk Human Milk and Formula
Requirements
Good supply of expressed human milk
(could be stored), and a baby who can
latch correctly, elicit letdown, sustain
suckling for the entire breastfeeding,
and/or take adequate volume of
expressed human milk from a bottle
Some human milk (could be
stored), and a baby who is
learning to take feedings at the
breast and can take adequate
volume of expressed human
milk and formula from a bottle
Issues to
consider
Monitor growth; screen/monitor for osteopenia (See Discharge Nutrition
Assessment); consider fortification or enrichment (see below); consider
multivitamin, iron, and zinc supplementation (See Discharge Supplements)
Fortification and Enrichment of Human Milk
Continued fortification of expressed human milk using a commercial human milk fortifier
(HMF) may be indicated at discharge for infants who have significant osteopenia and/or
poor protein nutriture. Extremely low-birth-weight (ELBW) and very sick infants are the
most likely to fall into this category (O'Connor, 2008; Aimone, 2009).
Enrichment of expressed human milk using a preterm discharge formula (PDF) powder is
common clinical practice for somewhat larger, healthier infants who need energy-dense
feedings. Although soy, protein hydrolysate, and amino acid–based formulas are not
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
recommended for preterm infants, enrichment of expressed human milk with these
formulas may be needed for infants who do not tolerate milk-based products such as
human milk fortifier (HMF) or PDF.
Fortification and Enrichment of Expressed Human Milk for Prematurely Born Infants
Fortification
Consider for ELBW infants
Continued commercial HMF mixed with expressed human milk 1:25 if severe
osteopenia, protein, and/or other micronutrient deficiency, or 1:50 if mild to moderate
nutrient deficiency
Requires that at least part of the daily volume be fed from a bottle
Caution: Monitor serum calcium and phosphorus; limit fortification at the 1:25 level to
infants taking less than 500 mL/day and who weigh less than 3.5kg to avoid possible
hypervitaminosis A and other nutrient excesses
More nutrient-dense than enrichment; compare nutrient intake with other options (see
Table (below): Various Human MIlk Feeding Regimens for a 2-kg Preterm Infant at
Discharge)
Vitamin supplement not usually needed
Iron supplement: may be needed if fortifier is not iron-fortified and/or iron needed is
more than 2 mg/kg/d
Enrichment
Combine ½ tsp PDF powder with 45 mL expressed human milk or alternate
breastfeeding with feedings of enriched expressed human milk and/or PDF from the
bottle
Requires that at least part of the daily volume be fed from a bottle
Less nutrient-dense than fortification; compare nutrient intake with other options (see
Various Human Milk Feeding Regimens for a 2-kg Preterm Infant at Discharge table
on this page)
Vitamin/mineral supplement: individualized based on amount of unaltered human milk
and level of enrichment (see Table in section Supplements)
Individualized
Consider if intolerance to commercial HMF and PDF powder is present
Soy, protein hydrolysate, and amino acid–based formula powders can be added to
expressed human milk to boost energy density but do not add adequate protein and
micronutrients
Consider modular products for additional energy and protein
Assess all micronutrient levels and compare with recommendations for age; consider
multivitamin and iron supplements (see Table in Supplements)
The following table compares the intake of selected nutrients provided by exclusive human
milk, human milk enriched with PDF, human milk alternated with PDF, and human milk
fortified with two different levels of a commercial HMF with recommendations for preterm
infants (Tsang, 2005; Lawrence, 2005). The regimens increase in nutrient density from left
to right in the table.
Various Human Milk Feeding Regimens for a 2-kg Preterm Infant at Discharge:
Comparison of Selected Nutrients at ~ 120 kcal/kg
Human
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Human Milk
without
Fortification
or
Enrichment
(Lawrence,
2005)
Human
Milk
Enriched
with
PDF
a

tsp
formula
powder +
45 mL
human
milk)
Breastfeeding
or Human
Milk
Alternated
with 22
kcal/oz PDF
b
HMF
Plus
Human
Milk, (1
pkt to
50
mL)
c
HMF
Plus
Human
Milk, (1
pkt to
25 mL)
c
Recommendations
for Stable/Growing
Preterm Infants
(Tsang, 2005)
Volume,
mL/kg
175 150 165 155 150 135-220
Energy,
kcal/kg
122 122 119 119 120 110-150
Protein, g/kg 1.6 1.9 2.5 2.2 2.9 3.4-4.4
Calcium,
mg/kg
49 64 92 124 197 100-220
Phosphorus,
mg/kg
26 35 52 69 110 60-140
Sodium,
mEq/kg
1.4 1.4 1.6 1.8 2.2 3-5
Vitamin D,
IU/d
4 36 95 216 411 150-400
d
Iron, mg/kg trace 0.4 1.1 0.3
e
0.67 2-4
Zinc, mcg/kg 210 412 848 852 1470 1000-3000
a
PDF composition is derived from human milk mixed with the mean of two products:
NeoSure (unpacked, level ½ tsp) and EnfaCare (packed, level ½ tsp). Neosure is a
manufactured by Ross Products Division (http://www.abbottnutrition.com; product
information, July 2007); EnfaCare is manufactured by Mead Johnson
(http://www.meadjohnson.com; product information, October 2007).
b
Composition is derived from the mean of two products: NeoSure and EnfaCare.
c
Composition is derived from human milk mixed with the mean composition of two
products: Similac HMF (Ross Products Division; product information, July 2007) and
Enfamil HMF (Mead Johnson; product information, October 2007).
d
Goal of 400 IU/day.
e
Products vary substantially; information in table is for Similac HMF; iron for Enfamil HMF
1:50 = 1.2 mg/kg and 1:25 = 2.2 mg/kg.
(Source: Data are from product handbooks; Tsang, 2005; Lawrence, 2005)
Summary
Most mothers of preterm infants can be encouraged to provide milk for their babies during
the acute phase of care but will need help in the transition from tube feeding and/or the
bottle if they want to breastfeed. Special attention to protein and minerals, such as calcium,
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phosphorus, and zinc, can ensure adequate nutrition. Continued fortification with a
commercial HMF can be cautiously considered for ELBW infants until they reach
approximately 3.5 kg. Larger preterm babies may benefit from some level of enrichment
with a PDF. Multivitamin, iron, and zinc supplements can be used until a sufficient volume
of human milk is taken as the baby approaches term size. As with the term breastfed baby,
vitamin D, iron, and fluoride are important to consider throughout the first year of life for the
older prematurely born baby who is fed human milk. See Enteral Nutrition Supplements .

Corrected Age

Chronological age is age from the date of birth. Corrected age, sometimes called "adjusted
age," is defined as age from estimated term birth and is used in nutrition assessment of
infants born prematurely (Theriot, 2000). For example, an infant born on May 1, 2009, at 27
weeks’ gestational age (GA) had a corrected age of 3 months when she reached 6 months
of chronological age on November 1, 2009. This is calculated as follows:
GA of 27 weeks when born on May 1, 2009: 13 weeks before estimated term date of
August 1, 2009 (40 weeks – 27 weeks = 13 weeks, or 3 months preterm)
Chronological age of 6 months on November 1, 2009: 26 weeks past actual date of
birth
Corrected age of 3 months on November 1, 2009: 13 weeks past expected term date
of birth (26 weeks – 13 weeks = 13 weeks, or 3 months)
Corrected age is used for preterm infants for at least the first year (LaHood, 2007).

Discharge Criteria

Criteria for discharge readiness include the following (Carlson, 2005):
Attainment of a specific weight (such as 2 kg)—this is often less important than the
subsequent criteria listed
Respiratory stability—usually in-room air but sometimes on oxygen by nasal cannula;
with a tracheostomy in rare cases
Ability to take sufficient enteral feedings—usually by breast and/or bottle; by
nasogastric tube, gastrostomy tube, or intravenously in certain cases
Maintenance of normal body temperature outside the isolette
Availability of an appropriate home environment and prepared caregivers
Scheduled follow-up care such as home visits, special developmental follow-up clinic,
well child care, and appointments with the Special Supplemental Nutrition Program
for Women, Infants and Children

Feeding Progression

Anticipatory guidance about feeding progression should be offered to all caregivers as
soon as the infant is evaluated in follow-up. Corrected age and developmental assessment
are used to determine readiness for advancement. An overview of the first year is as
follows (Kleinman, 2009):
Human milk/breastfeeding or infant formula provides the primary source of nutrition
for the entire first year.
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Solid foods are introduced from a spoon when infants are developmentally ready or at
approximately 4 to 6 months corrected age; new foods are introduced at a rate no
faster than approximately one every 5 days (Sullivan, 1994).
Solid foods with more texture (Stages 2 and 3), finger foods, and cup feeding are
introduced after 6 months corrected age or when developmentally ready.
Consumption of cow’s milk is delayed until 12 months corrected age.
Common problematic feeding behaviors include resistance to new flavors/textures; picky
eating; and constant nibbling, snacking, and/or sipping from bottle—often called “cruising”
or “grazing.” Ineffective responses to problematic feeding behaviors include forced feeding,
persistent/constant coaxing, and offering rewards for eating. Many helpful suggestions for
health care professionals caring for preterm infants can be found at Gaining and Growing:
Assuring Nutritional Care of Preterm Infants.

Formula Choices

If breastfeeding is stopped and expressed human milk is not available before age 1 year
(corrected age), the preterm infant is transitioned to commercial infant formula.
Products
Continued feeding of preterm formula may be indicated at discharge for infants who have
significant osteopenia and/or poor protein nutriture. Extremely low-birth-weight (ELBW) and
very sick infants are the most likely to fall into this category.
Transition to preterm discharge formula (PDF) is recommended for somewhat larger,
healthier infants. Although soy, protein hydrolysate, and amino acid–based formulas are
not recommended for preterm infants, these formulas may be needed for infants who do
not tolerate milk-based products such as preterm formula or PDF. (See Enteral Nutrition
Formulas.)
Infant Formula Choices
a
for Prematurely Born Infants at Discharge
Preterm
Formula
a
Preterm
Discharge
Formula
a
Other
Formula
a
Examples
Enfamil
Premature
Lipil
b
; Similac
Special Care
c
Enfamil EnfaCare
Lipil
b
; Similac
NeoSure
c
Soy, protein
hydrolysate,
and amino
acid–based
formulas
Availability
Individual
ready-to-feed
bottles in
20-kcal/oz and
24-kcal/oz
strengths with
and without iron
Ready-to-feed and
powder; usual
concentration of
22 kcal/oz but
reconstitution of
powder can be
individualized;
iron-fortified
Powders, liquid
concentrates,
and/or
ready-to-feed;
usually
iron-fortified
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Likely
candidates
Infants < 1 kg
at birth who are
< 2 kg at
discharge
and/or have
osteopenia
and/or protein
deficiency
Infants born, or
ready for
discharge, at
approximately 1.8
kg
Infants
intolerant to the
intact protein in
preterm or PDF
Duration
of use
3.5 kg weight
or 500 mL/d is
approximate
upper limit for
safe use due to
high
concentration
of fat-soluble
vitamins in
preterm
formula;
transition to
PDF when
weight is > 3.5
kg or when
intake exceeds
500 mL/day
Recommended by
AAP until 9
months’ corrected
age (Kleinman,
2004) and by
ESPGHAN until
40-52 weeks’
postconceptional
age (ESPGHAN,
2006); consider
longer use option
for smaller babies,
especially if
preterm formula is
stopped before
infant weight
reaches 3 kg
( LaHood, 2007)
Until 1 year
corrected age
Evidence
When fed in
the early
postdischarge
period,
facilitates
faster
nutritional
repletion than
standard
formula
(Carlson, 2005)
May promote
better weight and
length gain, and
improved bone
mineral content
especially in
infants < 1,250 g
at birth (Brunton,
1998; Carver,
2001; Lucas,
2001) although
this is
controversial
(Greer, 2007;
Koo, 2006)
Last choice;
inadequate
levels of some
micronutrients,
especially
calcium,
phosphorus,
and zinc
(Bhatia, 2008;
Mithatsch,
2002)
Vitamins
d
None usually
needed
Multivitamin drop until infant weight
of approximately 4 kg, when the
volume of formula becomes
sufficient to meet most vitamin
needs
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Iron
2 mg/kg provided by iron-fortified formula; consider
iron supplement to total 4 mg/kg if at risk for iron
deficiency or 5-6 mg/kg if iron deficiency is present
and/or on Epogen (Taketomo, 2007; Aher, 2006)
Abbreviations: PDF = preterm discharge formula; AAP = American Academy of Pediatrics;
ESPGHAN = European Society of Pediatric Gastroenterology, Hepatology and Nutrition.
a
See Enteral Nutrition Formulas for more detailed formula information.
b
Mead Johnson, Evansville, IN
c
Abbott Nutrition, Columbus, OH
d
See Discharge Supplements for more detailed vitamin and iron supplement information.
Safety Issues
To ensure safety when feeding formula:
The US Food and Drug Administration recommends mixing infant formula “using
ordinary cold tap water that’s brought to a boil and then boiled for one minute and
cooled” (USDA, 2004). For most infants older than 3 months' corrected age, water no
longer needs to be boiled and formula prepared with water directly from the tap is
satisfactory (Dietz, 1999).
Because of the risk of contamination from the bacterium Enterobacter sakasakii
(CDC, 2002), powdered formula should be handled with care. Safe handling practices
include mixing the smallest batch practical so that storage time is limited to fewer than
24 hours.
All mixing and measuring equipment and all bottles and nipples should be thoroughly
cleaned and air-dried before use.
All caregivers should be given thorough mixing and measuring instructions prior to
discharge. Techniques should be periodically reviewed after discharge.
Bottled and spring water are not sterile unless labeled as such.
"Nursery" water intended to be used for mixing infant formula is sterile.
Use of the microwave for warming infant formula is strongly discouraged.
Formula left in the bottle at the end of a feeding should be discarded.
Product expiration dates should be noted and expired formula discarded.
Summary
ELBW infants who are discharged weighing less than 3.5 kg may benefit from continued
premature formula; however, the most common formulas fed to preterm infants at
discharge are PDF. Although controversy exists about the efficacy of PDF to improve
growth and outcomes for preterm infants, the American Academy of Pediatrics along with
other noted experts recommend their use (Lucas, 2005; Kleinman, 2004). There have been
no obvious problems when they are used until 1 year corrected age (LaHood, 2007). The
duration of use of PDF is usually inversely related to birth weight—the smallest babies
receive these formulas for the longest time. Until the preterm infant reaches full-term size
and takes sufficient volume of formula, a multivitamin with iron may be indicated. Formulas
not intended for preterm infants, such as soy, protein hydrolysate, and amino acid–based
products, are inadequate in micronutrients and require additional supplementation.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Assessment

Nutrition follow-up of the infant discharged from the neonatal intensive care unit (NICU) is
recommended (Vohr, 2001). The registered dietitian assesses growth, interprets laboratory
results, reviews feeding tolerance, performs qualitative or quantitative intake analysis, and
offers anticipatory guidance.
Growth
Expected Velocity
Infants born during the third trimester of pregnancy are expected to gain approximately 15
g/kg per day in weight, 0.9 cm/week in length, and 0.5 cm/week to 0.9 cm/week in head
circumference (see Anthropometric Assessment). After reaching an adjusted age of 40
weeks, growth should approximate the velocities of term infants, as shown below (Guo,
1991).
Velocity of Weight and Length Gain After Term
Age (months)
Weight, g/d Length, cm/wk
Males Females Males Females
Up to 2 33 ± 7 28 ± 6.5 0.8 ± 0.1 0.7 ± 0.1
2-4 23 ± 4.7 22 ± 5.4 0.6 ± 0.5 0.6 ± 0.1
4-6 16 ± 2.9 15 ± 4.6 0.5 ± 0.1 0.4 ± 0.1
6-9 13 ± 2.4 13 ± 4.6 0.4 ± 0.03 0.4 ± 0.04
9-12 11 ± 2.3 11 ± 4.3 0.3 ± 0.03 0.3 ± 0.03
12-15 9 ± 2.3 9 ± 4.1 0.3 ± 0.03 0.3 ± 0.03
15-24 7 ± 2.2 8 ± 3.7 0.2 ± 0.03 0.2 ± 0.03
(Guo, 1991)
Catch-up Growth and Growth Charts
Definitions of catch-up growth vary (Theriot, 2000; LaHood, 2007). A weight that plots
above the 5th to 10th percentile on a growth chart for term infants may be considered
adequate catch-up by some. Others expect growth to retrack along the birth percentile
before declaring the achievement of catch-up growth.
To achieve catch-up growth, the velocity of weight gain must be higher than what is
expected for age for a period of time. Growth charts are used to visually monitor progress.
See Anthropometric Assessment for more information and some commonly used charts.
Advantages and Disadvantages of Selected Growth Charts
Chart (Reference) Advantages Disadvantages
Fenton, 2003
Starts at 22 weeks; most
frequent choice of NICU
follow-up programs
To 50 weeks only
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Babson and
Benda, 1976
26 weeks to 12 months Data > 30 years old
Infant Health and
Development
Program, 1996,
1997
Longitudinal data of preterm
infants 32 weeks’ gestational
age to 38 months; only charts
available to compare growth to a
group of preterm infants
Use with caution; measurements
plot higher than when compared to
term longitudinal data, possibly
leading to a false impression that
growth is adequate
Centers for
Disease Control
and Prevention,
2000
US data birth to 20 years Graphs start at term corrected age
World Health
Organization, 2006
Worldwide standard birth to 5
years
Graphs start at term corrected age
Laboratory Assessment
The frequency of laboratory assessment decreases after discharge and is individualized to
each patient’s condition. The following table lists some common conditions requiring
continued surveillance.
Laboratory Surveillance After Hospital Discharge
Parameter Indication(s)
Phosphorus and alkaline
phosphatase
Osteopenia
Liver function tests including direct
bilirubin
Cholestasis
Complete blood count
Anemia; screening for iron deficiency at 9 to 12 months
corrected age
Albumin, prealbumin Poor nutrition history, slow growth, edema
Feeding Tolerance
Prematurely born infants are at increased risk for poor feeding and growth failure,
especially those with neurologic deficits, developmental delay, or visual and/or auditory
impairment. Physical, cognitive, motor, neurologic, visual, and auditory assessments offer
insight into feeding tolerance (Carlson, 2005). Common feeding problems include vomiting,
constipation, and poor feeding.
Vomiting
Some minor spitting up is expected in young infants. However, vomiting that is projectile,
substantial, and occurring after most feedings or resulting in poor growth is not normal.
Possible causes are overfeeding, improper mixing of formula, uncontrolled reflux (see
Gastroesophageal Reflux), or bowel stricture/obstruction (especially following necrotizing
enterocolitis). Conservative treatment includes education about formula preparation and
expected volume of feedings.
Constipation
Constipation is defined as pebble-like, hard stools or firm stools two or fewer times per
week (Benninga, 2004). Constipation is rare in infants fed human milk. On average, stool
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
production is as follows (Baker, 1999; Malacaman, 1985):
Breastfed infants 0 to 3 months have three yellow stools per day.
Formula-fed infants 0 to 3 months have two yellow, brown, or green stools per day.
Infants 6 to 12 months have one to two stools per day.
Possible causes of constipation include improper mixing of formula, milk protein allergy,
developmental delay/neurologic disease, and adverse effects of medication.
Possible treatments for constipation are 1 oz to 2 oz per day of prune, pear, or apple juice
full-strength or diluted 1:1 with water or a stool softener such as lactulose (1 mL/kg to 3
mL/kg once or twice daily) (Benninga, 2004; Malacaman, 1985).
Poor Feeding
Vague descriptions of poor feeding or refusal to eat are often reported by caregivers.
Possible causes include fatigue in the recovering preterm infant, poor oxygenation in the
infant with cardiorespiratory disease, constipation, neurologic disease, and infection.
Feeding specialists, such as occupational and speech therapists, can develop
individualized treatment plans to improve the feeding skills of the caregivers and the
endurance of the baby. Schedules with defined limits to feeding sessions (usually 30
minutes or less per feeding) and daily goals for amounts of solids and/or milk can be
helpful (Klein, 1994).
Intake Assessment
Assessment of enteral intake is quantitative or qualitative based on anthropometric data.
Qualitative if growth is adequate: what is fed, general feeding schedule
Quantitative if growth falters: what and how much is fed, details of feeding schedule,
calculation of estimated energy intake and other nutrients as appropriate
Although there is no universally accepted convention, a gradual transition from intake
recommendations for preterm infants (Tsang, 2005) to the Dietary Reference Intakes is
made based on either attainment of term corrected age and/or catch-up in weight on an
appropriate growth chart. Daily energy and protein recommendations for infants past term
are only available as Adequate Intakes (AIs) and have been set using estimated intakes of
human milk (IOM, 2005). Reference body weights are available for the two age categories
in infancy. Estimated daily energy (mean kcal ± 2 standard deviations) and protein (g) AIs
are as follows:
Birth to 6 months (6 kg): 90 (72-108) kcal/kg and 1.5 g protein/kg
7 to 12 months (9 kg): 80 (64-96) kcal/kg and 1.2 g protein/kg
Note that these AIs should be used cautiously, in conjunction with growth assessment, in
prematurely born infants.

Goals

Increasing numbers of preterm, very-low-birth-weight (VLBW) infants survive to discharge
from the hospital (Lemons, 2001). The smallest infants are at significant risk for growth
failure, developmental delay, infectious disease, and rehospitalization. The goal of nutrition
management is for the discharged preterm infant to achieve the body composition and rate
of growth of a term infant of the same postconceptional age, although opinion and practice
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
vary on how to achieve this (Greer, 2007).
High-risk newborns deserve careful nutrition assessment at discharge and close follow-up
after discharge. Do the following to ensure optimal growth and development:
Use corrected age for nutrition assessment and recommendations.
Calculate velocity of weight gain and compare with what would be expected for age.
Plot serial anthropometric measurements on an appropriate growth chart.
Evaluate quality of dietary intake for all infants. Quantitative analysis is indicated for
infants with growth failure.
Encourage breastfeeding and/or continued use of expressed human milk, but
evaluate nutritional adequacy. Consider fortification or enrichment.
For formula-fed infants, recommend preterm or postdischarge formulas, especially for
the smallest and most preterm infants.
Monitor intake of all micronutrients—especially vitamin D, calcium, phosphorus, zinc,
and iron—and ensure adequate intake.
Anticipate difficulty with feeding transitions, especially for the smallest babies and
those with continuing medical/surgical problems.
Offer anticipatory nutrition guidance to caregivers.

Supplements

Vitamin and/or mineral supplements may be indicated for some preterm infants at
discharge. The table below lists common feeding regimens at discharge, micronutrients
that will likely fall below recommendations for preterm infants (Tsang, 2005), and
suggested infant vitamin/mineral drops. Iron supplementation recommendations are based
on a goal of 2 mg/kg/ day to 4 mg/kg/day (Tsang, 2005; Baker, 2010).
Suggested Vitamin and Mineral Supplements at Discharge for a 2-kg Infant
Consuming Various Feeding Regimens
Feeding
Micronutrients Less
Than
Recommendations
Supplement
Example, mL/d
Human milk
Exclusive human
milk
All water- and fat-soluble
vitamins; most minerals,
including calcium,
phosphorus, zinc, and
iron
AqaADEKs 0.5
mL
a
plus
Fer-in-sol 0.3
mL until infant
weighs 4 kg
Enriched human
milk: 45 mL human
milk mixed with ½
tsp PDF powder
All water- and fat-soluble
vitamins; most minerals,
including calcium,
phosphorus, zinc, and
iron
AqaADEKs 0.5
mL
a
plus
Fer-in-sol 0.3
mL until infant
weighs 4 kg
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fortified human
milk: 1 packet
HMF:50 mL
expressed human
milk or human milk
alternated with PDF
Some fat-soluble
vitamins; iron
Poly-Vi-Sol
b
with iron 0.5 mL
until infant
weighs 4 kg
Fortified human
milk: 1:25
Iron if fortifier does not
contain iron or infant
needs > 2.5 mg/kg/d
provided by the
iron-fortified product
Fer-In-Sol
b
0.15-0.3 mL
(1.9-3.8 mg/kg)
Formula
Preterm formula 24
kcal/oz with iron
Iron if infant needs > 2
mg/kg/d provided by
formula
Fer-In-Sol
b
0.2
mL (2.5 mg/kg)
PDF 22 kcal/oz
with iron
Some vitamins; iron if
infant needs > 2 mg/kg/d
provided by formula
Poly-Vi-Sol
b
with or without
iron 0.5 mL until
infant weighs 4
kg
Soy, protein
hydrolysate, or
amino acid
based–formula with
iron
Products vary; many
vitamins and minerals;
iron if infant needs > 2
mg/kg/d provided by
iron-fortified formula
Poly-Vi-Sol
b
with or without
iron 1 mL until
infant weighs 4
kg
Abbreviations: PDF = preterm discharge formula; HMF = human milk fortifier.
a
AqaADEK (Yasoo Health Inc, Johnson City, TN) contains zinc, substantial vitamin A (87%
as beta carotene), but no calcium or phosphorus; consider additional mineral
supplementation if osteopenia exists.
b
Mead Johnson, Evansville, IN
(Data are from product handbooks and Tsang, 2005)
The need for supplements decreases when the infant reaches full-term size (approximately
4 kg) and makes the transition from recommendations for preterm infants (Tsang, 2005) to
the Dietary Reference Intakes (IOM, 2009). This is assuming all problems of prematurity,
such as osteopenia, have resolved. The three micronutrients that most often continue to be
needed as supplements are vitamin D, iron, and fluoride.
Vitamin D: For infants receiving human milk or less than 1 qt/day of commercial infant
formula, a daily supplement of 400 IU vitamin D is recommended (Wagner, 2008). A 1
mL daily dose of either a trivitamin or multivitamin infant drop meets this
recommendation. A single-source infant vitamin D drop is available and has 400 IU
vitamin D3 in 1 mL ( D-Vi-Sol, Mead Johnson, Evansville, IN)
Iron: The need for iron supplementation may remain for older preterm infants who are
exclusively breastfed (AAP, 1997; Baker, 2010). Two servings per day of ½ oz or 15 g
of dry infant cereal or an iron supplement providing 1 mg/kg per day is recommended
(IOM, 2009; Kleinman, 2009). Iron-fortified commercial infant formulas fed at
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(IOM, 2009; Kleinman, 2009). Iron-fortified commercial infant formulas fed at
adequate volumes to support growth provide approximately 2 mg/kg per day of iron.
Trivitamin or multivitamin infant drops with iron provide 10 mg elemental iron in 1 mL.
A single source infant iron drop is available and has 15 mg elemental iron in 1 mL
(Fer-In-Sol, Mead Johnson, Evansville, IN). Infants with confirmed iron deficiency
anemia need treatment with 3 mg/kg/day to 6 mg/kg/day of oral elemental iron for 4
weeks (Kleinman, 2009).
Fluoride: A daily supplement of 0.25 mg of fluoride is recommended for infants older
than 6 months (corrected age) who are exclusively breastfed, are significantly
volume-restricted, or who receive either ready-to-feed formula or formula
reconstituted with nonfluoridated water (Kleinman, 2009). Several single source
fluoride supplement drops are available (1.1 mg fluoride per mL).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Preterm Infants > Renal Diseases > Nephrotic Syndrome
Nephrotic Syndrome

This section is blank.

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Risk Screen
Welcome to the Nutritional Risk Screen home page.
The Risk Screen area is to support nursing services since they are usually responsible for
screening patients in the first 24 hours after admission to a healthcare facility or during a
clinic visit. Risk Screen contains the nutritional indicators or criteria (by disease or
condition) that should prompt a nutrition consult order for a dietitian (RD) to provide
nutrition care (nutrition assessment, nutrition diagnosis, nutrition intervention, nutrition
monitoring and evaluation).
For more information, select a disease or condition in the navigation on the left side of this
page.
Risk Screen > Nutrition Care > Nutrition Assessment > Comparative Standards
Comparative Standards

See Parenteral Nutrition Nutrient Requirements and Enteral Nutrition Nutrient Requirements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Nutrition Care > Nutrition Assessment > Intake Assessment
Intake Assessment

Data Collection
To assess dietary intake, review the medical record or nursing flow sheets to determine
nutrient sources—parenteral nutrition (PN); intravenous solutions; human milk; human milk
fortifier; infant formula; and vitamin, mineral, or other modular supplements.
Data Analysis
The dietary intake assessment should include both qualitative and quantitative analyses.
In the qualitative analysis, consider whether current nutrient solutions are appropriate
for the patient’s gestational age, size, tolerance issues (if any), and diagnoses.
In the quantitative analysis, calculate nutrient intakes (at least mL/kg/day, kcal/kg/day,
and grams of protein/kg/day).
PN calculations (including dextrose, crystalline amino acids, and intravenous fat
grams per kilogram per day) are done in the same way for infants as they are for
other populations.
Dextrose and/or electrolytes in intravenous drip medications often contribute
substantially to an infant’s intake and are calculated.
Occasionally, even medication flushes influence the small infant’s glucose or
electrolyte status.
A more detailed, targeted nutrient intake analysis may be done on intakes of
infants with certain diagnoses or conditions (eg, assessing calcium, phosphorus,
and vitamin D intake for infants with osteopenia).
Calculating Nutrient Intakes
Calculations of nutrient intakes are compared with recommended intakes (see Parenteral
Nutrition and Enteral Nutrition for recommendations) and interpreted in light of the baby’s
medical condition and growth. Following is an example of how to calculate nutrient intake.
Sample Nutrient Intake Calculation for 1,500-g Preterm Infant
Intake
Maternal milk fortified to 24 kcal/fl oz with human milk fortifier, taking 28 mL every 3 hours
Calculations
28 mL × 8 feedings/day = 224 mL/d ÷ 1.5 kg = 149 mL/kg/d
149 mL/kg/d × 0.8 kcal/mL
a
= 119 kcal/kg/d
149 mL/kg/d × 0.024 g protein/mL
a
= 3.6 g protein/kg/d
a
For most precise calculations, consult the specific manufacturer’s literature.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Nutrition Care > Nutrition Assessment > Nutrition > Focused Physical
Findings
Nutrition-Focused Physical Findings

Observe the infant’s general condition, bedside nursing documentation, feeding tolerance,
and medical status. Additional information on physical observations is included under the
following headings.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Nutrition Care > Nutrition Monitoring & Evaluation
Nutrition Monitoring & Evaluation

The purpose of nutrition monitoring and evaluation in neonatal intensive care units,
intermediate neonatal care units, normal newborn nurseries, newborn follow-up clinics, or
pediatricians’ offices is to assess progress toward nutrition goals and expected
outcomes. Goals and expected outcomes are defined by reference standards or an
improvement in nutrition care indicators and may be categorized using the nutrition
assessment terminology categories as follows:
Food/Nutrition-Related History Outcomes (FH)
Food and Nutrient Intake (1)
Food and Nutrient Administration (2)
Breastfeeding (7.1)
Anthropometric Measurement Outcomes (AD)
Length
Weight
Weight change
Growth pattern indices/percentile ranks for corrected age for prematurity
Head circumference
Weight-for-age
Length-for-age
Head circumference-for-age
Weight-for-length
Bone density and bone age
Biochemical Data, Medical Tests and Procedure Outcomes (BD)
Laboratory data
Electrolyte
Essential fatty acid
Gastrointestinal measures
Glucose
Mineral
Nutritional anemia
Protein
Vitamin profiles
Nutrition-Focused Physical Finding Outcomes (PD)
Overall appearance
Extremities, muscles, bones
Digestive system
Skin
Vital signs
Critical thinking is necessary when completing the following step of the nutrition care
process*:
Select the appropriate indicators or measures to monitor and evaluate the impact of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition intervention on the patient’s/client’s progress toward defined goals.
Examples include the following:
Grams per day weight gain
Grams per kilogram per day protein intake
Serum alkaline phosphatase level
Use current and age-specific/disease-specific reference standards for comparison.
Examples include the following:
120 kcal/kg/d and 4 g protein/kg/day for infants 0.9 kg to 1.2 kg (Ziegler, 2007)
400 mcg zinc/kg/day parenteral zinc requirement for preterm infants (Tsang,
2005)
Define progress toward goals in terms of expected outcomes. Examples include the
following:
Increase in head circumference of 0.6 cm/week compared with standard 0.9
cm/week (Moyer-Mileur, 2007).
Compared to a norm of less than 550 IU/L, and a previous level of 850 IU/L,
alkaline phosphatase is now 750 IU/L after mineral intake was increased.
Explain any variance from expected outcomes. Examples include the following:
Increase in head circumference is less than expected, which may be related to
use of steroid medication
Less than expected weight gain, which may be related to temperature instability
during weaning from isolette to open crib
Identify factors that enhance or impede progress and ways to address these factors.
Examples include the following:
Frequent episodes of vomiting are impeding progress toward full enteral
feedings; giving gavage feedings over longer duration(eg, over 60 minutes
instead of 10 minutes) may prevent vomiting and allow continued progression to
full enteral feedings
Interrupting parenteral nutrition for antibiotic administration is preventing
adequate parenteral nutrition intake; increase parenteral nutrition hourly rate
during the 20 hours of parenteral nutrition administration to accommodate 4
hours of antibiotic infusion
Identify when follow-up will occur, or if nutrition care can be discontinued. Examples
include the following:
Follow-up in 5 days
Nutrition goals are met; no nutrition care follow-up is necessary at this time
*Adapted from Pocket Guide for International Dietetics & Nutrition Terminology Reference
Manual. 3rd edition. Chicago, IL: American Dietetic Association; 2011: 314.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Anemia
Anemia


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Anemia > Iron Deficiency Anemia
Nutritional Risk Screen

The risk screen for iron-deficiency anemia should include factors that might indicate low
iron intake or iron deficiency, including the following:
Dietary intake
Lifestyle factors that may affect iron intake or need
Laboratory measures
Iron-deficiency anemia has been decreasing in the United States. As a result, a lower
percentage of cases of anemia are the result of iron deficiency. This has implications for
screening—it is becoming more important to target screening for iron deficiency to persons
who are at risk rather than screening indiscriminately (AAP, 2009).
The signs and symptoms of anemia include the following (PNPG, 2003):
Fatigue
Weakness
Pallor
Tachycardia
Palpitations
Sensitivity to cold
Shortness of breath
Altered learning
Loss of appetite
Typically a low hemoglobin or hematocrit value is used as a screening tool for identifying
patients with anemia. However, these tests are not sensitive to low iron status prior to
development of anemia and are not adequate screening measures for all populations.
Medical and lifestyle factors also place some children at increased risk.
Risk factors for iron-deficiency anemia vary depending on the age of the child. Risk for iron
deficiency is highest for infants born with low iron stores, children aged 1 to 3 years, and
menstruating adolescent females. Risk is increased for preterm infants, infants born to
mothers with diabetes, low-birth-weight infants, and children with increased iron needs or
increased iron loss (AAP, 2009; PNPG, 2003).
Universal screening is recommended at approximately 1 year of age. Children with history
of or risk factors for iron-deficiency anemia may require more frequent screening and
monitoring of iron status. Selective screening may be performed at any age when risk
factors for iron deficiency or iron-deficiency anemia are identified (Baker, 2010).

Nutritional Indicators

Screening for Iron Deficiency Anemia by Age
Infants
Universal screening should be performed at approximately 1 year of age
Screening should include hemoglobin determination and assessment of risk factors
associated with iron deficiency and iron-deficiency anemia
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Prematurity or low birth weight
Lead exposure
Exclusive breastfeeding without iron supplements after 4 months of age
Weaning to whole milk or complementary foods that are not rich in iron
Poor growth
Feeding problems
Inadequate nutrition
Low socioeconomic status
Infants or toddlers with hemoglobin below 11.0 mg/dL or significant risk of iron
deficiency or iron-deficiency anemia should also have serum ferritin and reticulocyte
hemoglobin concentration to improve the sensitivity and specificity of the diagnosis
Toddlers
Routine screening is not indicated between 2 to 5 years of age
School-Aged Children
Routine screening of preadolescent children is not usual practice in the United
States, as they are not at high risk for iron deficiency.
Vegetarian children and those with risk factors for iron deficiency should be screened.
Adolescents
Males: Screen for anemia at routine exams during peak growth
Females: Screen during routine physical exams

Risk Factors for Iron-Deficiency Anemia
Anthropometric risk factors for iron-deficiency anemia include the following:
Weight for height below the 5th percentile
Weight for age below the 5th percentile
Weight loss of ≥10% of usual body weight in 6 months
Laboratory values of hemoglobin less than 11 g/dl or hematocrit less than 33% may
indicate iron deficiency and should be explored further.

Special Considerations
Premature Infants
Anemia is associated with preterm birth (less than 37 weeks of gestation). Signs of iron
deficiency in the premature infant include pallor and tachycardia. Laboratory findings may
include hypochromic, microcytic red blood cells. Risk factors the dietitian should assess in
the neonatal intensive care unit include the following:
Feeding problems
Diarrhea
Frequent vomiting or reflux
Malabsorption
Short bowel
Prolonged use of total parenteral nutrition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Special Considerations for Infants and Children
Risk factors to assess for infants and toddlers include the following:
History of preterm birth or growth restriction
Poor intake of iron-rich food after 4 months of age
Cow’s milk consumption before 12 months of age
Use of a low-iron infant formula
Infants of diabetic mothers may also be at increased risk for low iron stores.
Special Considerations for Adolescents
In adolescents, risk factors to consider include increased physical activity (athletes), and
disordered or restriction food intake patterns. Adolescent females who are pregnant or
have heavy menstruation coupled with low intake of iron-rich foods are also at increased
risk for iron deficiency.
The following factors present in an adolescent, lactating mother indicate increased risk:
Younger than 17 years
Financially deprived
Nutritionally restrictive
Heavy smoker
Drinks 2 or more alcoholic beverages daily
Had a multiple gestation
Had poor weight gain during pregnancy
Weighs less than 85% of desirable body weight
Is pregnant while breastfeeding
Has a hemoglobin of less than 12 g/dL or hematocrit of less than 36

Additional Risk Factors for Iron Deficiency
Physical Difficulties or Medical Conditions
Anorexia nervosa/bulimia
Cancer
Celiac disease
Congenital heart disease
Crohn’s disease
Developmental disability
Draining abscesses, wounds, or decubiti
Extensive burns, infection, trauma
Failure to thrive
Feeding problems
Human immunodeficiency virus/acquired immune deficiency syndrome
Inborn error of metabolism
Malabsorption
Nil per os (nothing by mouth) or hypocaloric for more than 3 to 5 days
Short bowel syndrome, fistulas, gastrointestinal problems
Sickle cell disease
Status post–organ transplant
Ulcerative colitis
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ulcerative colitis
Poor Food Intake Pattern
Exclusion of iron-containing foods
Frequent dieting
Irregular meal patterns, skipping meals
Restricted food intake pattern or energy restriction
Vegetarianism
Low Socioeconomic Status
Limited income and/or education
Use of supplemental food program
Living in older housing (risk of lead exposure in peeling, lead-based paint)

(PNPG, 2003; AAP, 2009; Baker, 2010)



Rationale for Nutrition Consult

The dietitian should work with the child, family, and health care team to ensure the child is
consuming appropriate foods that meet his or her iron needs. The dietitian listens to the
family; evaluates the child’s feeding skills (with the rest of the care team, as appropriate);
and helps the family understand how to provide appropriate foods or supplements in a
supportive, family-centered way.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Anemia > Sickle Cell Disease
Nutritional Risk Screen

Sickle Cell Disease Risk Factor Scoring
Factor
Risk
Points
A. Weight or body mass index (BMI)
>90% of recommended body weight or BMI 0
81% to 90% of recommended body weight or BMI 1
<80% of recommended body weight or BMI 2
B. Weight loss or no gain in weight or height
over 6 months

Weight loss in children, adolescents, and infants:
<5% loss (children and adolescents) or 1% loss
(infants)
1
5% to 10% loss (children and adolescents) or 1%
loss (infants)
2
>10% loss 3
No gain in weight or height in children and
adolescents

Stayed the same weight or height for 6 months
(depending on age)
2
Gained height or weight at a rate of 25% of the
normal rate for age
2
Weight loss in adults:
5% to 10% 1
11% to 20% 2
>20% 3
C. Visceral protein stores (albumin, g/dL)
>3.5 0
3.2 to 3.5 1
<3.2 2
D. Hemoglobin <9 mg/dL 1
E. Consistently poor quality and frequency of
food intake; less than 50% of Recommended
Dietary Allowance (RDA) in at least 2 food groups or
the presence of pica.
2
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
F. Change in growth percentile curve (if younger
than 18 years); any decrease in the growth
percentile curve of 2 or more channels (height/age,
weight/age, weight/height)
2
G. Frequent hospitalizations (>2 per year) for
acute chest syndrome, pain crisis, infection, fever, or
other reason
2
H. The patient has chronic disease: renal,
pancreatic, gastrointestinal, or liver dysfunction;
renal protein wasting, diabetes, hypertension,
respiratory dysfunction, pulmonary hypertension, or
chronic constipation.
3
(Clinical Practice Guidelines 2002)
After calculating a patient's risk, compare the risk total with the risk factor scoring
categories.
Adapted from Nutrition Care Manual, www.nutritioncaremanual.org.

Nutritional Indicators

Nutritional risk indicators in sickle cell disease (SCD) are characterized by at least one of
the following:
Degree of malnutrition
Disease complications or other factors that increase energy and protein expenditure
Presence of neurologic damage from stroke, resulting in impaired ability or desire to
eat
The degree of malnutrition can be classified according to National Center for Health
Statistics (NCHS) growth parameters in children and according to percentage of
recommended body weight in adults. Wasting or reduced weight for height is characterized
by a weight for length below the 5th percentile. Stunting is characterized by a reduced
height for age. Malnutrition is further classified as follows:
Mild (81% to 90% of reommended weight)
Moderate (70% to 80%)
Kwashiorkor (edematous malnutrition)
Marasmus (<70% of recommended weight)
One study that evaluated growth in SCD described the importance of comparing
anthropometric measures of children with SCD with those of children of similar ethnic
origin. The study found that children with SCD had similar weight to white controls but
weighed significantly less than the African/Caribbean controls. Children with SCD had
similar body mass index (BMI) to the BMI of whites but had significantly lower BMI than
African/Caribbean controls. As current NCHS growth curves describe a mixed population,
this study would seem to support anthropometric comparisons with groups of similar ethnic
origin (Patey, 2002).
Disease complications in SCD that can increase energy expenditure include the following:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Disease complications in SCD that can increase energy expenditure include the following:
Pulmonary disease
Chronic inflammation/infection such as osteomyelitis
Anemia also requires additional energy, presumably because the constant production of
new cells and increased protein turnover causes increased cardiac output.
Biochemical risk indicators include reduced vitamin and mineral levels. Reduced bone
density, found in SCD, is another nutritional risk factor.
Triceps skinfold measurement, subscapular skinfold measurement, mid-arm muscle area
measurement, or mid-arm circumference measurement can be used to determine
nutritional risk. Measurements should be compared with standards for African-American
males and females.

Adapted from Nutrition Care Manual, www.nutritioncaremanual.org

Rationale for Nutrition Consult

Patients with sickle cell disease can be assigned a risk category based on the Sickle Cell
Disease Risk Factor Scoring screening tool. The need for nutrition intervention is
determined by the patient's risk category. Persons with a moderate or high risk should
have a nutrition consultation ordered.
Sickle Cell Disease Risk Factor Scoring Categories:
Degree of Risk Risk Points Action
1st (low risk) 3-4 Rescreen in 6 months
2nd (moderate risk) 5-7 Order a nutrition consultation
3rd (high risk) 7+ Order a nutrition consultation
(Clinical Practice Guidelines 2002)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Behavioral Health
Behavioral Health


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Behavioral Health > Eating Disorders
Nutritional Risk Screen

A diagnosed eating disorder will show nutrition-related complications as a key feature of
the disease, most of which will be reversed upon refeeding. Screens used in identifying
eating disorders will prompt an assessment for specific nutrition risks.
GENERAL SCREENING INFORMATION
Screen for the eating disorder, unless this task has been performed already. If you suspect
an eating disorder, refer to an eating disorder specialist or notify the child's family and
physician about the possibility of an eating disorder, then screen for the following:
Vitamin deficiencies
Mineral deficiencies
Electrolyte imbalances
Dieting behavior, even if the child may have needed to lose weight, can be a gateway
to an eating disorder
Evaluate the growth chart (weight and height over time). Has the child deviated from
expected growth and weight gain? Has there been a sudden drop in weight? Has the child
had a downward trend or crossed two percentiles which could indicate growth failure
secondary to nutritional compromise?
Dietary Intake: Check the overall deficit or imbalance of macronutrients. This will be
present in anorexia nervosa and may not be present in bulimia nervosa. In binge-eating
disorder, macronutrient imbalance may be present. In other words, the intake of
macronutrients may not reflect current recommendations. A 24-hour recall or 3-day diet
history, using the parents/caregivers as respondents, can reveal details about present
intake.
Screening for an eating disorder
There have been many questionnaires developed that can help in the task of screening for
an eating disorder. A simple questionnaire is the SCOFF questionnaire (Rosen 2010).
In young children and even adolescents one can obtain answers from the
parents/caregivers that will be more useful than in asking the child.
See American Academy of Pediatrics: Specific Screening Questions to Identify the Child,
Adolescent, or Young Adult with an Eating Disorder (Rome, 2003) and the history
questions suggested by Rosen.(Rosen 2010)
Another link with a questionnaire that is helpful is "Could This Be
an Eating Disorder?" by Janet Treasure of the South London and Maudsley
NHS Foundation Trust, and Institute of Psychiatry at King's College London.
Components of the medical screening questionnaire can be used to identify nutrition risks.
The 24-hour or 3-day diet history can help to pinpoint specific foods not consumed and
therefore possible nutrient deficiencies.
According to Lock and Le Grange, signs such as refusing to eat with family or
friends, amenorrhea (in girls), excessive exercise (more than 1 hour/day), and extreme
l
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
calorie counting indicate that a child should be evaluated sooner rather than later for an
eating disorder, ruling out any other possible causes of the behaviors and symptoms (see
differential diagnosis) and then seeking treatment (Lock, 2005).

See also Criteria to Assign Risk and Laboratory sections for additional information
on when to consider an emergency situation.
It is often very difficult for families to find health care providers who are familiar with eating
disorders, even for evaluation and diagnosis.
The nonprofit group FEAST (Families Empowered and Seeking Treatment for Eating
Disorders) maintains a list of treatment centers and providers. It also promotes evidenced
based treatment and has a wealth of information about eating disorders for families as well
as professional.

Risk Screen for refeeding syndrome
See Khan, 2011

Nutritional Indicators/Criteria to Assign Risk

Anorexia nervosa danger signs include the following:
significant weight loss
continual dieting (even if the patient is already thin)
feelings of fatness by the patient even after weight loss
fear of weight gain
lack of menstrual periods
preoccupation with food, calories, nutrition, and/or cooking
a preference to eat in isolation
compulsive exercise
insomnia
brittle hair or nails
social withdrawal
Bulimia nervosa danger signs include the following:
uncontrollable eating (binge eating)
purging by self-induced vomiting
vigorous exercise
abuse of laxatives or diuretics (water pills) to lose weight
frequent use of the bathroom after meals
reddened fingers (from induced vomiting)
swollen cheeks or glands (from induced vomiting)
preoccupation with body weight
depression or mood swings
irregular menstrual periods
dental problems such as tooth decay (from induced vomiting)
heartburn and/or bloating
(American Academy of Pediatrics, 2003 and 2010)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
For children and adolescents with suspected eating disordered behavior:

Anthropometrics
Look at trend in weight over time. Look at the lifetime growth chart and see if weight
has deviated at all from the expected course.
Look for sustained weight loss or failure to gain weight during a longitudinal growth
spurt. Weight loss in a growing child or adolescent is not normal and needs to be
evaluated by a pediatrician. Assess for overall body adiposity using bioelectrical
impedance analysis or skinfold measurements.
Be aware that use of body mass index (BMI) to assess body adiposity in children
is problematic. In adolescents a change in the BMI may not reflect a change in body
adiposty. (Royal College of Psychiatrists, 2005) Note that caloric restriction initiated
before growth is complete can stunt growth and therefore reduce height, which
causes underestimation of the degree of weight loss.

Parental Report

The information obtained from parents and caregivers of children suspected to have an
eating disorder is very important. Ask parents and caregivers about eating behaviors and
other behaviors around food.

Examples include:
What was eating behavior like before you became concerned about your child?
Concern is raised if child has eaten "normally" and suddenly changes eating
behavior. Concern is raised if the child seems preoccupied with the "challenge of
eating" rather than simply enjoying the act of eating.
Describe current eating behaviors. Concern is raised if the child is often stating they
"want to eat healthfully" or if the child wants to become vegetarian in a household
where the family is not vegetarian. Concern is raised if the child is noticeably
restricting, ie, eating smaller and smaller amounts of food.
Describe behaviors around food and meal preparation. Concern is raised if the child
wants to participate in meal preparation and then does not wish to eat what he or she
has prepared. Concern is raised if the child pays undue attention to labels, calories,
fat grams and so on. Concern is raised if the child does not want to eat with family
and friends. Concern is raised if the child gets up from the table numerous times
during a meal (possibility of purging behaviors and/or throwing away food). Concern
is raised if the child appears to be "playing" with food rather than eating it.
Ask about exercise behaviors. Concern is raised if the child is exercising excessively.
"Excessive" is more than previously, more than the child is consuming adequate
calories for (taking into consideration calories necessary for growth), and "odd"
exercise such as running frantically around the house after a meal, or dropping to do
sit-ups. If the parents think the exercise is odd, it may very well be.

Risk of Nutrient Deficiencies
A child or adolescent who has been restricting calories is at risk of multiple nutrient
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
deficiencies. One may be able to calculate intake of macro- and micronutrients and come
up with likely nutrients not present in adequate amounts, depending on the nature of the
restriction. It is best, once an eating disorder has been diagnosed by a knowledgeable
physician or psychologist, to assume multiple nutrient deficiencies and work with the team
toward refeeding. Nutrient deficiencies are corrected with adequate and aggressive
refeeding, which includes a high-calorie diet with plenty of food variety. Exceptions are
those nutrients which need to be replenished prior to refeeding those at risk of refeeding
syndrome.
Risk of Complications
Anticipate these individuals to be at risk for refeeding syndrome:
Those with anorexia nervosa
Any child with prolonged undernutrition over weeks and months
Individuals with a rapid and significant weight loss prior to hospital admission
regardless of current weight. This includes individuals who are still clinically
overweight but have recently lost a lot of weight.
Chronic diuretic users
Those who have engaged in severe purging behavior such as vomiting or laxative
misuse.
Those with a concurrent medical condition such as sepsis or diabetes.
Criteria for Hospital Admission
This is a medical call, but all health care professionals should know these criteria. A list of
criteria for hospital admission in anorexia nervosa and bulimia nervosa is available through
the American Academy of Pediatrics Web site (AAP 2003). Also see Rosen, 2010 for
warning signs and criteria for hospitalization.

Role of the RD

Since eating disorders are illnesses with serious nutrition consequences the goals of
nutrition management in children and adolescents with eating disorders are primarily to
initiate nutrition rehabilitation that supports growth, maturation, and those mental and
physical functions that were compromised by malnutrition and nutrient deficiencies.

Best evidence supports the fact that this task is not wholly taken on by registered dietitians
(RDs) but by a knowledgeable team, led by a medical professional familiar with eating
disorders. This is because the malnutrition seen in eating disorders is not brought about by
only a lack of nutrition knowledge or lack of will to simply eat better. The team may
minimally consist of a medical practitioner and a therapist, both of whom need to be
experienced in eating disorder treatment. An RD may be asked to provide consultation to a
team or may be an integral part of a team. The role of the RD will vary dependent on the
setting, whether inpatient, intensive outpatient, residential or in-home refeeding.

Role of the RD in various treatment settings - Overview

TYPES OF TREATMENT SETTINGS
inpatient
outpatient or day treatment programs
residential
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
family based home feeding
individual counseling
The role of the RD will vary depending on what type of treatment is offered and where the
RD is working. Keep in mind that in the treatment of the pediatric population, family
inclusion is now considered a best practice and that nutrition education alone to the sick
child is never sufficient to create motivation to eat or change eating behaviors. Nutrition
education to the child can create anxiety and thus be counterproductive. The RD has to
bear in mind their scope of practice and be realistic about initiating behavioral therapies for
which they are not trained (ADA, 2006).
Inpatient settings
Inpatient settings are used primarily for medically fragile persons (see Criteria to Assign
Risk). In this setting an RD may be asked to provide nutrition advice about refeeding
syndrome, supplements, high calorie supplements, calorie target, and weight targets. Often
the RD will supply this information, on request, to the medical team. Current evidence does
not support the efficacy, in terms of long term weight maintenance, of simply feeding until a
person is no longer medically fragile and then discharging with no follow-up care. Some
inpatient settings may employ nasogastric tube feedings, if necessary, to promote weight
gain, and the RD may be asked to calculate rate of feeds and recommend formulas (Baran,
1995).
Outpatient settings
If a person is not medically fragile then often they will be enrolled in an outpatient
treatment program. Some inpatient programs offer a step-down unit or next-step outpatient
program as follow-up to the inpatient setting. This can take the form of individual therapy,
an organized program where multiple therapies are used (eg, art therapies, relaxation
programs, cognitive behavioral therapy). These programs vary considerably. Therapy may
be aimed at normalization of cognitive distortions about body image and food, resolution of
family relationship issues, resolution of feelings related to trauma, or other personal issues.
Not all of these therapeutic approaches are based on evidence but on assumptions about
eating disorder etiology.
Food selection and preparation is often done for the patients. The RD may be involved in
menu preparation, food selection for individuals, group nutrition classes, family nutrition
classes, and providing nutrition information to the rest of the treatment team (supplements,
height/weight info, anthropometric info, monitoring of nutrient intake). The RD might also
work directly with patients, providing them with education about how to eat healthfully and
giving strategies about how to eat throughout the day.

Residential treatment programs
These are long-term programs where the patientis usually separated from family members
and lives at the treatment facility. Therapy may again be aimed at resolution of personal
issues, management of stress, finding appropriate coping skills. Goals toward
normalization of eating and weight gain are set and the pt is moved toward those goals
using various therapeutic methods, often behavioral in nature. Individual and group
therapy, medical monitoring, nutrition education can all be part of these programs. In these
programs, the RD may be asked to develop menus, set target weights, monitor weights and
anthropometrics, teach nutrition and food prep, and provide nutrition education to staff and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
to the family (if the family is included as part of treatment).

Individual Counseling
Some children with eating disorders are referred for individual counseling with someone
trained in psychotherapy, social work, or psychiatry. The question of why the eating
disorder developed is often central in this type of therapy with the idea being that if the
“why” is discovered, then the patient will be able to work on the “why” and start to separate
disordered eating behaviors from other issues in their life. Resolution of issues that
precipitate the eating disorder and reduction in anxiety are often goals, along with weight
gain and stopping binging and purging behaviors. Many therapists do not use an RD but at
times an RD is called upon to give nutrition information to the therapist or client and maybe
create an eating plan. Current evidence does not support long term psychotherapy alone in
treating eating disorders, especially without cessation of eating disorder behaviors. In fact
it is dangerous and irresponsible to continue to allow a child to starve while trying to figure
out why the eating disorder developed.
At times RDs have performed individual nutrition counseling to children with eating
disorders. Often, the child with an eating disorder will be referred to an RD, utilizing the
logic that because the disorder is an “eating” problem a food and nutrition expert should be
consulted. While this may seem reasonable, there is no evidence that this is an effective
approach done alone, in the absence of other therapies (Lock, 2005). If we accept that
eating disorders are diseases, attempting to change behavior by educating about nutrition
does not seem likely to be an effective intervention.
Quite often, children with eating disorders are already preoccupied with food, calories, and
nutrition details so providing more information can be a source of stress rather than helpful
to them. It is prudent to listen to the family’s assessment of how the child is responding to
various forms of therapy and make adjustments if needed. All professionals who work with
eating disorder patients need to receive special training about these disorders. Families
should not have to be subjected to non-evidence-based care.

The role of the RD may be:
to assist and support the family and caregivers in feeding the child and support the
child as they become healthy and begin to take over the task of age-appropriate food
selection and feeding. Assistance and support may be in the form of advice regarding
food selection, menu planning, supplement selection, recipes, and nutrition education.
to support the treatment team by providing nutrition and dietary assessment of the
patient when needed, provide recommendations about calories and macronutrients,
provide advice about food and supplement selection, nutrition support regimens, and
lab values and, if diets are prescribed, to modify the diet as needed throughout the
treatment.
Various tasks the RD may be responsible for in support of the above:
Evaluating, calculating, and monitoring caloric and macronutrient intake to assure
weight goals are met. (Weight gain should be achieved in an appropriate time frame,
and once weight is restored, food intake is adjusted to maintain weight.)
Providing counsel on refeeding syndrome and other issues related to malnutrition.
Usually the RD provides this information to the medical staff and the medical team
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
signs off on it (the MD has the final call but they can sometimes lack nutrition
specifics).
Helping the family and other caregivers with food selection to take into account family
and individual preferences, physical factors, food availability, family health history,
and family resources as needed. The RD helps the family select foods to create a
very high-calorie diet for the recovering patient, assessing the degree of
hypermetabolism.
Monitoring nutrient supplement intake or providing counsel to the team about
supplements to ensure maximum absorption, minimizing drug nutrient interactions,
and adjusting as necessary to ensure that improper and unnecessary intake of
supplements does not occur.
Educating the family (not the patient) as necessary about nutrition fundamentals
related to how eating disorders affect overall nutrition and health so the family is
better able to implement feeding. Education of the patient may take place as
determined by the rest of the health care team. Older teens and young adults may
need basic nutrition information as they start to make food selections for themselves,
after weight restoration. They will need to know how to adjust calories as they are
cleared to engage in physical activity. Sometimes it is not productive to focus on
nutrition facts and figures as these can cause stress for the person undergoing initial
refeeding. Members of the health care team can focus on these numbers (calories,
weights, grams of this or that) but for the patient this is often not helpful and they may
not have the cognitive ability in early refeeding to make use of these numbers.
Evaluating overall diet quality over time. Providing this information to the family and
the treatment team. Being a resource to families. Adjusting calories as physical
activity changes.
RDs maybe able to coach the family in family based therapy (FBT) if they have
advanced training to do so.
RDs might find themselves to be the only health care provider in an area who has
knowledge, if any, concerning eating disorders. Sometimes in smaller towns a
pediatric patient might be referred to an RD in the hopes that the RD alone can
change the course of the illness. In this case it is important to be a resource to other
health care professionals and to the family, provide education about eating disorders
and advocate for the best evidence-based treatment. Best evidence based
treatment currently takes a team approach, with medical supervision. The RD alone
should not take the lead or be solely responsible for an eating disorder patient's care.
Even if the RD is very well educated in regards to eating disorders, he or she should
insist on medical supervision, including regular labs, prescribing medications, and
checking vitals to make sure the patient is medically stable and if not, referred to
in-hospital care. In addition, the involvement of a mental health specialist in the
team is recommended.


Diagnostic Criteria

Current DSM-IV Criteria for Diagnosis of Eating Disorders
Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
height (eg, weight loss leading to maintenance of body weight less than 85% of that
expected; or failure to make expected weight gain during period of growth, leading to body
weight less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue
influence of body shape on self-evaluation, or denial of the seriousness of the current low
body weight.
D. In postmenarcheal females, amenorrhea (ie, the absence of at least three consecutive
menstrual cycles).
Type: Restricting Type vs. Binge-Eating/Purging Type.
Proposed change: These subtypes will either be eliminated or changed in the new DSM-V
criteria.

Bulimia Nervosa
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of
the following:
A. Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that
is significantly larger than most people would eat during a similar period of time and under
similar circumstances.
B. A sense of lack of control over eating during the episode (ie, a feeling that one cannot
stop eating or control what or how much one is eating).
C. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting;
or excessive exercise.
D. The binge eating and inappropriate compensatory behaviors occur, on average, at least
twice a week for three months.
E. Self-evaluation is unduly influenced by body shape and weight.
F. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Provisional research criteria for diagnosing BED in children
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both
of the following:
Food seeking in absence of hunger (eg, after a full meal) 1.
A sense of lack of control over eating (eg, a sense that when the patient starts to eat, 2.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A sense of lack of control over eating (eg, a sense that when the patient starts to eat,
they can’t stop)
2.
B. Binge episodes are associated with one or more of the following:
Food seeking in response to negative affect (eg, sadness, boredom, restlessness) 1.
Food seeking as a reward 2.
Sneaking or hiding food 3.
C. Symptoms persist over a period of 3 months
D. Eating is not associated with the regular use of inappropriate compensatory behaviors
(eg, purging, fasting, excessive exercise) and does not occur exclusively during the course
of anorexia or bulimia nervosa (Marcus, 2003).

Diagnostic criteria reprinted with permission from the Diagnostic and Statistical Manual of
Mental Disorders, Text Revision, Fourth Edition, (Copyright 2000). American Psychiatric
Association.

Problems with Using Current Diagnostic Criteria in Pediatrics
The Diagnostic and Statistical Manual (DSM) classification system is used in the United
States both for research classification purposes and as a diagnostic tool for mental
disorders. The DSM-IV criteria are being revised for eating disorders with the DSM-V
classification system expected in 2012. In addition to the DSM classification system the
Ormond Street criteria and the ICD10 World Health Organization Classification have been
used to classify childhood eating disorders.
The DSM-IV is being revised for a number of reasons, one being because it has limitations
when applied to the pediatric population. Diagnostic criteria that include absence of
menses do not apply to very young children or male patients. Even when applied to the
female population, due to developmental variations, some adolescents may reach a target
weight yet not resume menses while others may be below target weight and have menses.
The developmental variation in children and their immaturity as compared to adults makes
a classification system used for adults imperfect for use in the pediatric population.
Children have a different capacity to reflect upon, report, describe, and place into context
their symptoms or fears when compared to adults. For example, the criteria in DSM-IV for
anorexia nervosa (AN) requires verbalization of fear of gaining weight and verbalization
about disturbances in body image. These verbalizations would be difficult if not
impossible to elicit from a child, due to their emotional and cognitive maturity level (Rosso,
2004). Newly proposed age-adjusted criteria would eliminate the need for verbal
expression of these fears and disturbances.
Many children, because they do not fully fit the current diagnostic criteria, are diagnosed
with Eating Disorders Not Otherwise Specified (EDNOS) for that reason. If a child fits into
this classification it is not a reason to assume that their eating disorder is less serious. A
developing eating disorder may be overlooked or minimized because a child does not fit
the current diagnostic criteria and when this happens, an important opportunity to initiate
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treatment can be missed (Nicholls, 2000). Recently, children with EDNOS were found to be
as seriously ill, from a medical and psycological perspective, as those who met full
diagnostic criteria for anorexia nervosa or bulimia nervosa (Peebles, 2010).
Weight criteria for diagnosis are also problematic. The criteria for AN of weight being less
than 85% of expected, and refusal to maintain weight, may be adjusted to state that any
clinically significant weight loss, in the absence of a medical condition where weight loss
could be easily explained, would be suspect. This is because any weight loss in childhood
is not normal when the priority of childhood is growth and maturation. It also would help
clinicians identify a pediatric patient who starts out overweight, loses weight quickly (yet is
still considered overweight according to weight criteria), but is still tending toward an eating
disorder and may be medically fragile.
In bulimia nervosa (BN) part of the criteria in DSM-IV state that self-evaluation is overly
influenced by body shape and weight. The frequency of binge episodes and compensatory
behaviors must be at least twice per week for 3 months. In children, self-evaluation is
cognitively different than in older adolescents and adults, so use of this criteria is
problematic. The frequency of binging and purging may be less in younger children and the
intent to perform such behaviors may be as important in pinpointing eating disorders as the
actual execution of the behaviors (Bryant-Waugh, 1996).
Binge-eating disorder (BED) has been identified as a valid disorder in that it is similar to
AN and BN in terms of the degree of shape and weight concerns, psychopathology,
functional impairment and health care utilization. Individuals with BED have been shown to
differ from individuals who are obese but who have not been diagnosed with BED in terms
of the level of eating psychopathology, overall quality of life, and, social and work
impairment. Studies of familes have demonstrated that BED aggregates in families, and
twin studies have shown an additive genetic influence in BED development. The criteria for
diagnosing BED will change as the DSM-V is developed.
Concerns about the defining features of BED, namely the recurrent binging without
compensatory purging, are similar to the concerns about binging in BN. Frequency and
duration cutoffs are not based on clinically meaningful criteria at the present time.
Current frequency and duration cutoffs are at least 2 binges a week for a minimum of 6
months.
DSM-V- New Diagnostic Criteria
The new criteria will include variations of the classic eating disorders AN and BN, as well
as further classifications of entities such as food phobias (functional dysphagia) , selective
eating, pervasive refusal syndrome, and food avoidance emotional disorders.
The EDNOS category is being revised so cases that currently fall into that category would
be given a more distinct diagnosis. Many children fall into the EDNOS category and being
in this category makes both insurers and health care providers think that the illness is not
as serious, or residual. This creates a delay in treatment which is associated with poorer
prognosis. EDNOS does not describe the temporal alterations that can take place in an
eating disorder and in some cases may represent an earlier stage of a serious disease.
Parental reports would become very important in a new classification system. A parental
report of restricting food, exercise, purging behavior, or preoccupation with body shape and
size would be considered valid.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Behavioral Health > Mood Disorders
Nutritional Risk Screen

Nutritional risk, in terms of the pediatric population with mood disorders, is defined as
the presence of conditions in which altered nutritional status and alteration in mental
status may coexist.
Adverse nutritional effects may be related to an inadequate or excess intake of
macronutrients or micronutrients.
Medication effects may include weight gain, weight loss, or drug–nutrient interactions.
Few, if any, validated measures for nutritional risk have also been validated for
psychiatric populations (Gordon, 2001).
A pediatric nutritional risk screen should include the following elements:
Weight for age
Height for age
Body mass index (BMI) percentile for age
Weight status: Registered dietitians and other health care providers should
classify the weight status of a child or adolescent by calculating the person’s
BMI, plotting the BMI on the sex-specific and age-appropriate growth charts of
the Centers for Disease Control and Prevention, and then comparing the
person’s BMI percentile to the weight classifications from the expert panel
recommendations presented after this list (Barlow, 2007).
Recent weight change (loss or gain)
Intake of calcium/vitamin D
Medications
Supplements
Nutritional needs for adolescent pregnancy
Assess dentition status that may be related to an inadequate intake of macronutrients
or micronutrients.
Assess food intolerances or food allergies that may be related to inadequate or
excess intake of macronutrients or micronutrients.

Weight Classifications from the Expert Panel Recommendations (Barlow, 2007)
Classification BMI Percentile for Age
Underweight <5th
Healthy weight 5th to 84th
Overweight 85th to 94th
Obesity >95th

Nutritional Indicators/Criteria to Assign Risk

Indicators of potential nutritional risk include the following:
Depressed mood with unplanned weight change
Depressed mood with significant change in appetite and intake
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Body mass index (BMI) greater than the 85th percentile for age and sex
BMI less than the 5th percentile for age and sex
Persistent somatic complaints
Prescription for one or more psychiatric medication
Comorbidity of eating disorder or alcohol or substance abuse
Food insecurity
Food intolerances
Food allergies
Adolescent pregnancy
Elevated lipid profiles, HgA1c


Rationale for Nutrition Consult Order

A nutrition consultation is recommended for the following reasons:
To assess the nature of significant, unplanned weight change
To assess the nutritional consequences of significant changes in appetite or intake
To assess overweight status with body mass index (BMI) greater than the 85th
percentile for age and sex
To assess underweight status with BMI less than the 5th percentile for age and sex
To evaluate the probable nutritional adequacy of reported dietary intake
To address food insecurity leading to poor food intake (Whitaker, 2006)
To review possible nutritional effects of medications (Dubovsky, 2007)
To assess the nature of somatic complaints that affect nutrition/hydration
To determine if comorbidities of alcohol abuse, drug abuse, or eating disorders are
present
To assess the management of coexisting medical conditions (e.g., diabetes,
hypertension, renal failure)
To assess nutrition needs for adolescent pregnancy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Burns
Nutritional Risk Screen

All pediatric patients admitted with a burn injury should receive a nutritional screen within
24 hours of admission. Nutritional risk is determine both by preexisting nutritional
status and the metabolic risk imposed by the degree of injury.

Nutritional risk screen criteria indicating need for a full nutrition assessment include the
following:

Admitted for acute burn greater than 15% total body surface area
Infants admitted for burn greater than 10% total body surface area
Admitted with any burn size and accompanying inhalation injury
Delayed admission (more than 3 weeks postburn injury) with burn exceeding 10%
Malnutrition
Special dietary needs
Modified diet due to surgery or medical history (includes
high-energy/high-protein, blenderized, soft)
Ethnic food practices
Food allergy or intolerance
Weight or height decreased by 2 or more percentiles since burn injury
History of recent fracture
History of unplanned weight loss
Difficulty chewing or swallowing
Reliance on supplemental nutrition (tube feeding/parenteral nutrition)
Altered nutritional status resulting from newly diagnosed chronic or metabolic disease






Nutritional Indicators/Criteria to Assign Risk

Level of Risk
All patients are screened within 24 hours of admission. A nutrition consult is made if any of
the criteria are met. The registered dietitian completes a full nutritional assessment within
the timeframe indicated by the risk criteria. Once the patient has been evaluated, based on
additional information, level of risk may be reassigned by the registered dietitian to guide
future nutrition monitoring and intervention.
Level 3 (Nutrition Assessment within 24 hours)
Acute burn injury of more than 30% total body surface area (TBSA)
Requirement of parenteral nutrition or enteral tube feeding
Ventilator dependent
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Ventilator dependent
History of recent burn injury and significant malnourishment based on the following:
Severe weight loss
Clinical malnutrition by appearance
Biochemical data consistent with prolonged malnutrition

Level 2 (Nutrition Assessment within 48 Hours)
Burn of more than 15% to 30% TBSA
Burn of 1% to 10% TBSA and any of the following:
Intake below 80% of estimated requirement for more than 3 days
Weight/height less than 5th percentile on NCHS growth charts
history of suboptimal nutrition

Level 1 (Nutrition Assessment within 72 hours)
Burn of 1% to 10% TBSA
Weight/height below 5th percentile growth on NCHS growth charts
Body mass index greater than 95 percentile on NCHS growth charts
Weight more than 130% of ideal body weight
Patient appears significantly overweight
Significant recent weight changes or shifts in percentile growth detected
in follow-up outpatient visits (more than 2 percentile channels in height or weight)
Diet history indicating lack of major food group
Special dietary modification required due to surgical procedure or medical history
Specific ethnic practices
Significant food allergies or intolerances
Identified need for patient/parent nutrition education
Potential for food–drug interactions




Rationale for Nutrition Consult Order

Patients who meet the risk criteria should have a comprehensive nutrition assessment by a
registered dietitian within 24 to 72 hours of admission depending on level of risk. In general,
patients admitted with an acute burn of more than 30% total body surface area are likely to
require aggressive nutrition therapy to support the inflammatory response and increased
energy expenditure associated with evaporative water losses. In infants, whose body
surface area is much greater per unit of body weight (hence increased risk of insensible
water loss), burns exceeding 10% are considered to impose a high risk and may require
nutrition intervention.
In rehabilitative burn care, children with growth failure or persistent weight loss should
receive a nutrition consult to promote anabolism. Because burn injury and prolonged
bedrest are associated with altered bone physiology, bone mineral density may need to be
measured during this phase with subsequent therapy instituted as needed. In
addition, patients with factors or limitations resulting from their initial injury that may impair
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
addition, patients with factors or limitations resulting from their initial injury that may impair
adequate nutrition or impede growth should be evaluated.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Cardiology
Cardiology


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Cardiology > Congenital Heart Disease
Nutritional Risk Screen

Following are the signs and symptoms that a patient may be at risk for malnutrition.
Growth Parameters
Weight or height for age below the 5th percentile on appropriate growth chart
Weight for length below the 3rd percentile on the fetal infant growth chart for preterm
infants
Body mass index for age above the 95th percentile in children aged 2 to 20 years
Weight for length below the 5th percentile or above the 95th percentile in individuals
from birth to age 36 months.
Deviation from established curves of weight for age by 2 or more percentile channels
Feeding History
Poor oral intake
Fatigue while feeding
Inefficient feeding or increased duration of oral feeding
Poor coordination of feeding and respiration
Medical History
Medical diagnosis: type of congenital heart disease or cardiac lesion
Surgical history: repaired vs unrepaired cardiac lesion, stage of surgical repair
Degree of malnutrition and growth failure


Nutritional Indicators/Criteria to Assign Risk

After completion of the nutritional risk screen, the following indicators may require a
nutrition consult or nutrition support:
Initiation of or alterations to enteral feeding regimen
Initiation of parenteral nutrition
Recent weight change (eg, unintentional weight loss)
Reduced food intake
Gastrointestinal symptoms (eg, anorexia, nausea, bowel disturbances) present for
more than 2 weeks
Reduced immune function
Poor wound healing
Physical observations (eg, loss of subcutaeneous fat, muscle wasting, growth
stunting)
Deviation from established growth curve (Marshall, 2008)
Lack of caregiver understanding for home feeding preparation
Lack of caregiver education on feeding techniques


Rationale for Nutrition Consult Order

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Infants and children with congenital heart disease require intense nutrition care and
follow-up to ensure optimal growth. If the screen for nutrition risk identifies an infant or child
with a cardiac history, a nutrition consult order can ensure specific medical nutrition
therapy to prevent a decline in nutrition status (Marshall, 2008).
A comprehensive evaluation by a registered dietitian (RD) is essential for an accurate
assessment of the pediatric cardiac patient's nutritional status. Individuals in this
population often require the use of fortified breast milk, concentrated formulas, intensive
education on proper feeding techniques, and/or nutrition support in order to achieve
adequate growth and development. The registered dietitian, as part of a multidisciplinary
team, is invaluable for continued care of the infant or child in the hospital and outpatient
setting. RDs can provide close monitoring of growth trends, nutritional intake, feeding
patterns, feeding tolerance, and caregiver understanding of home breast milk fortification or
formula concentration.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Cleft Lip and Palate
Nutritional Risk Screen

The identification of a cleft lip and/or cleft palate indicates a need for nutrition screening
and ongoing nutrition follow-up.
Cleft lip and/or cleft palate conditions have several distinct periods where the children are
at highest risk:
newborn through first surgery
post-surgery feeding issues
Due to a high incidence of chronic ear infections and respiratory infections, children with
cleft lip and/or palate may need nutrition interventions at other times.
Children with cleft lip and/or palate associated with other syndromes may need nutrition
interventions at other times in their lives, since some cleft palates may require multiple
surgeries well into the child's teen years.

Criteria to Assign Risk

Below are specific criteria indicating health risks in a newborn infant:
Cleft lip, cleft palate, or cleft lip and palate
Dehydration/poor feeding/failure to gain during the first 4-10 days of life
Failure to gain weight at any time throughout the first 2 years (Montagnoli, 2005)
Feeding issues of vomiting, loss of milk around mouth while feeding from breast or
bottle
Feeding times of greater than 20-30 minutes per feeding after the first week
An infant not receiving breastmilk is more likely to experience infections, respiratory
illness, and enteric disease (Stepans, 2006).

Rationale for Nutrition Consult Order

Failure to gain weight that maintains a weight for height of between 25th and 75th
percentile may lead to failure to thrive or other growth issues (Beaumont, 2008).
About half of all infants with cleft lip and palate have a diagnosis that is part of a syndrome
or sequence such as Pierre Robin, Sicklers, Cornelia deLange, or another syndrome. Early
nutrition intervention may promote fewer illnesses.
Nutrition support for breastfeeding or the use of breastmilk can reduce illness.
There is often evidence of parental distress/frustration when caring for a CLP infant
(Young, 2001). Nutrition support for feeding may help reduce stress on caregivers and
child.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Critical Care
Nutritional Risk Screen

The nutritional risk screen proactively identifies and stratifies patients with or at risk for
malnutrition or obesity. This initial patient information serves to indicate whether more
formal nutrition assessment is necessary. Interventions as part of the nutrition care plan are
developed based on the initial nutrition screen (JADA 2008). Because critically ill children
with a history of malnutrition have worse outcomes, it is important to screen all children
admitted to the pediatric intensive care unit to identify those at greatest risk (Mehta 2009).
It is not necessary for the initial screen to be completed by a nutrition practitioner.
Information obtained by the admitting nurse as part of the admission profile
typically includes recent changes in weight, appetite, diet intake, feeding issues, and the
need for non-oral nutrition support. Results of the screen are communicated to the nutrition
practitioner so that the admission data can be interpreted, elaborated, and prioritized for
the development of an appropriate nutrition care plan.

Criteria to Assign Risk

Risk criteria quantify the degree to which a patient’s specific nutrition indicators differ from
established norms or standards. Assigning risk is a crucial step in the nutrition assessment
process. By stratifying nutrition risk, the practitioner can prioritize goals and interventions
as part of the nutrition care plan.
Some criteria that place a critically ill child at high nutrition risk include the following:
Weight for length/height below the 85th percentile for ideal body weight for
length/height
Body mass index greater than the 95th percentile for age and sex
History of recent weight loss or gain
Admission diagnosis
Nil per os (nothing by mouth)/intravenous fluids only for 3 days or more for children,
and 2 days or more for infants
History of chronic illness
History of premature birth
History of enteral or parenteral nutrition requirement

Rationale for Nutrition Consult Order

The nutrition support order is written following the completion of nutrition assessment. It
should be safe, adequate, appropriate, effective, and timely. It should also consider the
disease state or medical diagnosis, meet nutrition requirements, and avoid complications.
This necessitates that the nutrition practitioner work closely and communicate frequently
with the entire health care team.
The nutrition practitioner documents recommendations for a nutrition care plan in the
medical record, prioritizing nutrition diagnoses. It is then the responsibility of the physician
to write the nutrition order. However, some medical centers permit nutrition order writing by
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
qualified registered dietitians. Orders written by dietitians appear to have improved
outcomes compared to those written by physicians in certain adult populations (Braga
2006). Regardless, nutrition support should be initiated as quickly as possible to avoid
untoward effects of delayed or inadequate nutrition support.
The goals of nutrition support in the critically ill child include maintenance of lean body
mass and gut integrity, support of the immune system, facilitation of wound healing, and
reduction of mortality. Delivery of nutrients should occur in the safest and most
cost-effective manner. A registered dietitian trained in pediatrics and nutrition support is
best prepared to achieve these goals.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Developmental Disabilities
Nutritional Risk Screen

In most institutions, developmental disabilities (or conditions, syndromes, and so on,
associated with developmental disabilities) indicate nutrition risk and the need for referral
to a registered dietitian. In other institutions (eg, tertiary pediatric hospitals), additional
criteria are required to trigger a nutrition consult.
Tools for screening include the PEACH survey (Campbell, 1994), and A Look at Nutrition
(Baer, 1997). Two other resources that include screening tools are:
Nutrition Strategies for Children with Special Health Care Needs (available for
purchase and/or download at http://uscucedd.org)
Nutrition Interventions for Chidren with Special Health Care Needs (available for
download at http://here.doh.wa.gov/materials/nutrition-interventions)

Criteria to Assign Risk

Nutrition risk criteria for children without developmental disabilities apply as well. One or
more of the following indicators may be used to designate nutrition risk and the need for a
nutrition consult:
Underweight (eg, indicated by weight-for-length below the 5th percentile for age, slow
rate of weight gain, or undesired weight loss)
Overweight (eg, indicated by weight-for-length or BMI-for-age at or above the 85th
percentile, accelerated or undesired weight gain)
Laboratory indicators (eg, low hematocrit, low ferritin, low serum 25-OH-vitamin D)
Inadequate intake (eg, protein, energy, and/or vitamin and mineral intake that is lower
than estimated needs) due to difficulty obtaining food and/or feeding problems
Behavior issues related to food and eating

Rationale for Nutrition Consult Order

Children with identified nutrition risk should be referred to an registered dietitian (RD) for a
comprehensive nutrition assessment. The RD can also help to develop interventions that
address the nutrition- and health-related needs of the individual child and his or her family
(ADA 2010). Nutrition services have been shown to be effective in improving growth and
overall health of children with developmental disabilities (Gilliam 2006; Lucas, 2004;
Herman 1999).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Diabetes Mellitus
Nutritional Risk Screen

Inpatient Nutrition Screening:
Screen performed on all patients within 24 hours of admission
Patient’s weight and height assessed on appropriate growth chart
Patients at nutritional risk include those with the following circumstances:
Special diet
Tube feedings
Intravenous nutrition
Weight less than 5% on a growth chart
Decrease in usual intake for the last 5 days
Unintentional weight loss = 10% body weight
Ambulatory Nutrition Screening:
Utilize patient’s growth parameters (height/length, weight, and head circumference for
patients younger than 24 months) as the nutrition screen at an initial visit
Patients at nutritional risk include those with the following circumstances:
Weight or height less than 5% on a growth chart
Body mass index greater than 95% in children aged 2-20 years
Weight for length less than 5% or greater than 95% in infants and children birth
to 36 months.


Nutritional Indicators

Nutritional indicators for persons with diabetes would be the same as those for patients
without diabetes.

Rationale for Nutrition Consult Order

Medical nutrition therapy (MNT) is effective to prevent and/or delay diabetes and
its complications (Franz 2008). MNT has been shown to decrease the patient’s hemoglobin
A1c (HbA1c) by approximately 1% to 2%, depending on the type and duration of diabetes.
MNT is recommended as a series of three to four encounters with a registered dietitian,
each lasting 45 to 90 minutes. This should be provided at the patient’s initial diagnosis,
within 3 to 6 months and at least annually thereafter (American Diabetes Association 2009).
MNT should be provided by a registered dietitian experienced with the changing nutritional
requirements of the growing child and identifying risk for disordered eating (American
Diabetes Association, 2008).
The MNT goals for pediatric patients with type 1 and type 2 diabetes include the following
(American Diabetes Association, 2008):
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Maintain optimal blood glucose levels by balancing food, activity, and medication.
Achieve normal blood lipid and lipoprotein profile that reduces the risk for vascular
disease.
Prevent and/or delay acute and chronic complications of diabetes.
Maintain blood pressure levels in the normal range or as close to the normal.
Maintain a normal growth and development pattern and slow the rate of weight gain
or promote weight loss in overweight or obese children.
Limit food choices only as indicated by scientific evidence.
Meet nutrition needs by taking into account personal and cultural preferences and
willingness to change.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Disorders of Lipid Metabolism
Nutritional Risk Screen

The following medical diagnoses may underscore the need for a nutrition consult:
Inherited disorders of lipid metabolism
Familial hypercholesterolemia
Familial combined hyperlipidemia
Rarer inherited disorders
Homozygous familial hypercholesterolemia
Familial defective apoprotein B-100
Autosomal recessive hypercholesterolemia
Sitosterolemia
Mutations in PCSK9 (proprotein convertase subtilisin-like/kexin type 9)
Primary dyslipidemias
Elevated cholesterol
Elevated low-density lipoprotein (LDL) (type IIa)
Elevated triglyceride (type IV)
Elevated LDL and elevated triglyceride (type IIb)
Low high-density lipoprotein (hypo-)
Hyperlipoproteinemias
Hyper-apobetalipoproteinemia (hyper-apoB) with normal LDL
Secondary dyslipidemias (associated with endocrine, renal, hepatic, storage
diseases)
Metabolic syndrome
Hypertension
Obesity
Coronary artery disease is well documented with the following conditions:
Familial hypercholesterolemia
Diabetes mellitus, types 1 and 2
End-stage renal disease
Kawasaki disease with aneurysms
Heart transplantation
Premature coronary artery disease may be present in the following conditions:
Kawasaki disease without aneurysms
Human immunodeficiency virus
Post-cancer treatment
Chronic inflammatory disease (rheumatoid arthritis, systemic lupus)
Certain congenital heart diseases:
Coarctation of the aorta
Single coronary anomalies
Transposition corrected by arterial switch procedure (Zappalla, 2009)



Nutritional Indicators

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutritional risk factors for dyslipidemias include the following:
Family history of cardiovascular disease
Hypertension
Obesity
Diabetes
Diet rich in saturated and trans fats
Excessive energy intake
Metabolic syndrome

Metabolic syndrome predicts cardiovascular risk two to three decades later. There is
no consensus on the definition of metabolic syndrome. According to the Third National
Health and Nutrition Examination Survey, the presence of 3 or more of the following factors
in adolescents indicates metabolic syndrome:
Triglycerides 110 mg/dL or higher
High-density lipoprotein cholesterol 40 mg/dL or lower
Waist circumference at the 90th percentile or higher
Fasting glucose of 110 mg/dL or higher
Blood pressure at the 90th percentile or greater (for age, sex, and height)


Criteria to Assign Risk

Pediatric dyslipidemias result from elevated or depressed levels of lipoproteins (cholesterol
esters, triglycerides, phospholipids, and apolipoproteins). Lipoproteins facilitate the
passage of water-insoluble lipids in the plasma. Elevated levels of particular lipoproteins
suggests the initiation of therapy that targets the specific components such as cholesterol
and triglyceride.
Fredrickson and Lee's classification system can be used to classify dyslipidemias into
phenotypes on the basis of their clinical sequelae (see Table) (Ridker, 2001). Once a
phenotype is identified, diet therapy addresses the specific laboratory abnormality. For
example, phenotype IIa would be treated by targeting diet changes needed to decrease
low-density lipoprotein (LDL) and cholesterol.
The apoproteins, found on the surface of the lipid core, play a significant role in heart
disease by enabling recognition of the lipoproteins by the different organs and cells,
activating enzymes such as lipoprotein lipase (LPL), which facilitate uptake of lipid into the
cells or enable actual binding with cell receptors. Apoproteins also act as cofactors for
different enzymes in lipoprotein metabolism (Kwiterovich, 1994; Khachadurian, 1989). Diet
is not known to affect the apoproteins in a lipoprotein but seems to affect the number of
receptors on a cell or organ as well as the quantity of lipoprotein that is synthesized.
Dyslipoproteinemia Phenotype Definitions and Their Association with Genetic and
Other Disorders
Fredrickson
and Lee's Laboratory Definition
Association with
Genetic Disorders
Conditions
Associated with
Secondary
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Phenotype
Genetic Disorders Secondary
Dyslipoproteinemia
Type I
Hyperchylomicronemia
and absolute
deficiency of LPL
Cholesterol normal
Triglycerides greatly
increased
Familial LPL
deficiency
Apo C-II deficiency
Dysglobulinemia,
pancreatitis, poorly
controlled diabetes
mellitus
Type IIa
LDL increased
Cholesterol increased
Triglycerides normal
Familial
hypercholesterolemia
LDL receptor abnormal
Familial combined
hyperlipidemia
Polygenic
hypercholesterolemia
Hypothyroidism,
acute intermittent
porphyria,
nephrosis,
idiopathic
hypercalcemia,
dysglobulinemia,
anorexia nervosa
Type IIb LDL increased
Very-low-density
lipoprotein (VLDL)
increased
Cholesterol increased
Triglycerides increased
Familial
hypercholesterolemia
Familial combined
hyperlipidemia
Diabetes mellitus,
hypothyroidism,
dysglobulinemia
(monoclonal
gammopathy)
Type III Floating beta
lipoproteins
VLDL cholesterol:
VLDL triglyceride ratio
> 0.35
Apo E-II homozygote
on isoelectric focusing
Cholesterol increased
Triglycerides increased
Familial
dysbetalipoproteinemia
Glycogen storage
disease,
hypothyroidism,
disseminated lupus
erythematosus,
diabetes mellitus,
nephrotic syndrome,
renal failure,
ethanol abuse
Type IV VLDL increased
Cholesterol normal or
increased
Triglycerides increased
Familial
hypertriglyceridemia
Familial combined
hyperlipidemia
Poorly controlled
diabetes mellitus,
glycogen storage
disease,
hypothyroidism,
nephrotic syndrome,
dysglobulinemia,
pregnancy,
estrogen
administration
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(either contraceptive
or therapeutic) in
women with familial
hypertriglyceridemia
Type V
Chylomicrons and
VLDL increased

LDL present but
reduced
Cholesterol increased
Triglycerides greatly
increased
Familial
hypertriglyceridemia
Familial multiple
lipoprotein type
hyperlipidemia
Poorly controlled
diabetes mellitus,
glycogen storage
disease,
hypothyroidism,
nephrotic syndrome,
dysglobulinemia,
pregnancy,
estrogen
administration
(either contraceptive
or therapeutic) in
women with familial
hypertriglyceridemia
Data are from Krummel, 2000 and Ridker, 2001.
Elevation of total homocysteine is an independent risk factor for cardiovascular disease
(CVD). When there is a family history of CVD in a child with familial hypercholesterolemia,
total homocysteine should be checked. If elevated, nutrition therapy with fruits and
vegetables, especially foods high in folate, should be considered (Tonstad, 1997). Vitamins
B-6 and B-12 and folate are needed to metabolize homocysteine. Cholestyramine can also
increase homocysteine levels by decreasing folate absorption (Tonstad, 1998). Consider
folate supplementation when a child is taking cholestyramine. Diet analysis of this subset of
children needs to be assessed to determine whether these nutrients are adequate.
Serum Cholesterol and Lipoprotein Screening
Children and adolescents with the following familial history should be screened for elevated
serum cholesterol levels (NCEP, 1992):
A parent or grandparent, age 55 or younger, who has premature CVD, as evidenced
by any of the following:
Coronary atherosclerosis
Myocardial infarction
Angina pectoris
Peripheral vascular disease
Cerebrovascular disease
Sudden cardiac death
At least one parent has hypercholesterolemia (>240 mg/dL)
Children may also be screened when additional risk factors—such as cigarette smoking,
hypertension, obesity, or diabetes mellitus—are present (NCEP, 1992).
Measurement of total cholesterol should be included in the screening of children and
adolescents with strong familial history of CVD. If this level is found to be high (> 200
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
mg/dL), a fasting lipoprotein analysis should be completed (NCEP, 1992). If the
measurement is borderline (170 mg/dL to 199 mg/dL), a second measurement should be
made, and if the average of the two values is borderline or high, a fasting lipoprotein
analysis should be completed to measure high-density lipoprotein (HDL) and LDL.
Children and adolescents with a documented history of premature CVD should have a
fasting lipoprotein analysis in their initial screening process. It can also be helpful or
diagnostic to measure apoproteins B and A-I, although these measurements are generally
not routine (NHANES, 1994).
A disorder of increased production of VLDL by the liver results in an increased number of
LDL that is enriched with a higher proportion of apoprotein B. Hyper-apoB is prevalent in
adults with atherosclerosis and is thought to be inherited by their children (Kafonek, 1989).
Low levels of apo A-I and HDL cholesterol have been found in children of parents with
coronary artery disease (Kwiterovich, 1994; Srinivasan, 1994). Measuring apo E and Lp(a)
did not predict which children will respond to diet intervention (Dixon, 1997).
Abnormal Apoprotein Levels Used for Screening
Apoprotein Child Young Adults
B

A-1
=110 mg/dL =120 mg/dL

=80 mg/dL
Sex differences exist for children with dyslipoproteinemia. Girls aged 5 to 9 years tend to
have higher cholesterol levels than boys but have only one third the risk of premature CHD
(Newman, 1995). Girls do, however, show a stronger correlation with cholesterol values
and nutritional status, whereas boys’ values of cholesterol and triacylglycerol seem to be
most related to familial aggregation (Guillaume, 2000).
When a lipoprotein analysis is completed, it should be repeated to obtain the average LDL
cholesterol level. This average will determine the recommended course of treatment, as
outlined below:
Acceptable LDL cholesterol (< 110 mg/dL): Provide basic education on a
recommended eating pattern, based on MyPyramid or MyPlate and the Dietary
Guidelines for Americans; repeat lipoprotein analysis in 5 years.
Borderline LDL cholesterol (110 mg/dL to 129 mg/dL): Provide risk factor reduction
advice; initiate nutrition therapy (see Meal Plans); reevaluate in 1 year.
High LDL cholesterol (> 130 mg/dL): Evaluate for secondary causes and familial
disorders (thyroid, liver, and renal disorders); screen all family members; initiate
nutrition therapy; reevaluate regularly.

Rationale for Nutrition Consult Order

Nutrition consultation and intervention for dyslipoproteinemia is recommended to prevent
premature atherosclerosis and the risk of developing heart disease. Nutrition consultation is
necessary for those children with inherited disorders of lipid metabolism (primary
dyslipidemias) and secondary dyslipidemias. These dyslipidemias are defined as follows:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Primary dyslipidemias (Kwiterovich, 2008) include the following:
Most Common Dyslipidemias
Familial hypercholesterolemia
Autosomal dominant disorder with defects in low-density
lipoprotein (LDL) receptor gene
Familial combined hypercholesterolemia (3 times more prevalent than familial
hypercholesterolemia)
Overproduction of very-low-density lipoprotein (VLDL), intermediate-density
lipoprotein (IDL), and LDL
Hyper apolipoprotein B
Overproduction of VLDL, IDL, and LDL
Rarer Primary Dyslipidemias
Homozygous familial hypercholesterolemia
Familial defective apolipoprotein B-100
Autosomal recessive hypercholesterolemia
Sitosterolemia
Mutations in proprotein convertase subtilisin-like/kexin type 9
Primary High-Density Lipoprotein Disorders
Familial hypoalphalipoproteinemia
Apolipoprotein A-1 mutations
ABCA1 variants, including Tangier disease
Lecithin cholesterol acyltransferase deficiency
Primary Triglyceride Disorders
Lipoprotein lipase deficiency
Results in pancreatitis
Defective Apolipoprotein C-II
Secondary dyslipidemias include those resulting from exogenous sources, such as alcohol
or oral contraceptive use; endocrine and metabolic disorders; renal or hepatic diseases;
storage diseases; acute and transient causes such as burns or hepatitis; and multiple other
causes ranging from anorexia nervosa to heart transplantation (Kwiterovich, 2008).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Epilepsy
Epilepsy


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Epilepsy > Dietary Management
Nutritional Risk Screen

A complete nutrition assessment—which includes client, food, and nutrition history;
nutrition-focused physical findings; and laboratory biochemical index—is used to assess
the nutritional risk of a child on the ketogenic before initiation and every 1 to 6 months once
it has been initiated.

Rationale for Nutrition Consult Order

The ketogenic diet (KD) is used for the treatment of difficult-to-manage epilepsy, and may
be started before a patient's epilepsy becomes medically refractory. In addition, it is the
primary treatment for the following specific conditions (Kossoff, 2009):

Glucose transporter 1 deficiency
Pyruvate dehydrate dehydrogenase deficiency
Myoclonic-astatic epilepsy (Doose syndrome)
Tuberous sclerosis complex
Rett syndrome
Severe myoclonic epilepsy of infancy (Dravet syndrome)
Infantile spasms
Children only receiving formula (infants or enterally fed patients)
Preliminary experience also shows that some beneficial effects of the KD have been
reported in the following symptomatic epilepsies (Kossoff, 2009):
Glycogenosis type V
Landau-Kleffner syndrome
Lafora body disease
Subacute sclerosing panencephalitis
Selected mitochondrial disorders
However, there are contraindications to the use of the ketogenic diet. Epilepsy patients with
the following conditions should not be considered candidates for the ketogenic diet
(Kossoff, 2009):
Primary carnitine deficiency
Carnitine palmitoyltransferase (CPT) I or II deficiency
Carnitine translocase deficiency
Pyruvate carboxylase deficiency
Porphyria and beta-oxidation defects, which includes medium-chain acyl
dehydrogenase deficiency, long-chain acyl dehydrogenase deficiency, short-chain
acyl dehydrogenase deficiency, long-chain 3-hydroxyacyl-CoA deficiency, and
medium-chain 3-hydroxacyl-CoA deficiency
Inability to maintain adequate nutrition, surgical focus identified by neuroimaging and video
electroencephalography monitoring, and parent or caregiver noncompliance are also
considered factors that make a patient a poor candidate for starting the ketogenic diet
(Kossoff, 2009). All other children with intractable epilepsy that have failed two
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
anticonvulsant medications can be referred for ketogenic diet consultation.


Nutritional Indicators/Criteria to Assign Risk

Nutritional indicators and criteria to assign risk for children on the ketogenic diet are the
same as children not following a ketogenic diet.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Failure to Thrive
Nutritional Risk Screen

Failure to thrive (FTT) is a decline from accepted growth standards over time, usually as a
result of energy insufficiency or deprivation. It can occur at any time during childhood but
most commonly describes growth failure during the first 2 to 3 years of life.
There is no single, universally accepted definition of FTT (Olsen, 2006; Olsen, 2007). It is
considered a symptom rather than a diagnosis, yet it does have a billable code (783.41) in
the International Classification of Diseases, Ninth Revision, as a diagnosis under
symptoms, signs, and ill-defined conditions. It presents as a clinically stable infant or child
with one or all of the following symptoms:
Weight loss
Failure to gain weight
Suboptimal growth

Nutritional Indicators

Patients with failure to thrive will meet one or more of the following criteria:
Weight for age is less than 5th percentile on a standard World Health Organization
(WHO) growth chart (children up to 24 months) or Centers for Disease Control and
Prevention (CDC) growth chart (children older than 24 months), with normal
height/length
Weight for length less than the 5th percentile (children up to 24 months) on a
standard WHO growth chart and/or body mass index (BMI) (children older than 24
months) is less than the 5th percentile on a standard CDC growth chart
Weight is less than 80% of expected weight for height/length
Deceleration of growth velocity across two major percentile lines and/or decrease of
more than 2 standard deviations on a CDC or WHO growth chart over a period of 3 to
6 months
(Corrales, 2005; Olsen, 2007; Hughes, 2007; Grummer-Strawn, 2010)
The US Department of Health and Human Services developed the following table for their
Maternal and Child Health Bureau training module to summarize the different parameters
used for defining poor growth among children:
Criteria to Identify Poor Growth
Source Indices Cutoff Point Reference
Institute of
Medicine
Length-for-age,
height-for-age,
weight-for-length,
or weight-for-height
5th
percentile

Institute of
Medicine, 1996
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Special
Supplemental
Nutrition
Program for
Women,
Infants, and
Children

Length-for-age,
height-for-age,
weight-for-length,
BMI-for-age
10th
percentile

US
Department of
Agriculture
CDC BMI-for-age 5th
percentile
BMI Module
WHO

Height (or
length)-for-age,
weight-for-height,
weight-for-age
2.3
percentile
(–2 SD)*
WHO, 1995
Medical
Practice

Weight-for-age,
weight-for-length,
length-for-age
5th
percentile

Kessler and
Dawson, 1999
Medical
Practice
Weight-for-age,
length-for-age or
height-for-age
Dropping
downward
across
percentiles
Kessler and
Dawson, 1999


(USDHHS, 2009)

Rationale for Nutrition Consult Order

Nutrition assessment and nutrition therapy are necessary for all patients with failure to
thrive to achieve the following:
Determine the need for nutrition support
Establish an adequate nutrient intake
Promote catch-up growth and development
Foster appropriate behavior patterns for the child and caregiver(s) regarding
food-related issues
Correct any nutrient deficiencies
Normalize weight

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Food Allergic Disorders
Food Allergic Disorders


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Food Allergic Disorders > Eosinophilic Esophagitis
Nutritional Risk Screen

Poor growth and weight loss are commonly noted in pediatric patients with eosinophilic
esophagitis (EoE). Other common symptoms, such as abdominal pain, feeding dysfunction,
emesis, and dysphagia, can lead to decreased oral intake. Nutritional indicators of risk
include, but are not limited to, the following:
Decreased oral intake as a consequence of symptoms caused by EoE
Failure to demonstrate appropriate weight or linear gains
Body mass index for age below the 5th percentile in a child older than 2 years
Weight for length below the the 15th percentile in a child younger than 2 years
Weight loss
Children with EoE are at increased risk for other atopic diseases. Because of this, as many
as 46% of these children have a documented food allergy and will already be following an
allergen elimination diet (Noel, 2004). Children with food allergies are at greater nutritional
risk because of the potential limitation of nutrients provided by the elimination diet.
Treatment of EoE often involves elimination diets (or further limitations to the diets of
patients with documented food allergy). The degree of nutritional risk posed by elimination
diets depends on factors such as the following:
The number of foods that need to be removed
The nutrient content of the foods to be eliminated
Any other factor that may affect dietary intake of allowed foods
Gastrointestinal symptoms
Food refusal
Feeding delays

Nutritional Indicators/Criteria to Assign Risk

Dietary elimination diets are often employed independently or in combination with
pharmacologic therapy (topical or systemic corticosteroids) to treat eosinophilic esophagitis
(EoE). Diets that eliminate major foods or food groups (such as wheat, milk, egg, or soy) or
diets that eliminate two or more foods or food groups put the pediatric patient at nutritional
risk (Christie, 2002).
In addition, ineffective allergen avoidance may lead to treatment failure. The First
International Gastrointestinal Eosinophil Research Symposium report strongly encourages
consultation with a registered dietitian when applying any diet therapy in the treatment of
EoE (Furuta, 2007).
Children with EoE who will be treated exclusively with pharmacologic therapy may still
require medical nutrition therapy to correct underlying nutritional deficiencies resulting from
symptoms of active EoE. Patients with EoE often experience poor weight gain or weight
loss and should be evaluated for protein–energy malnutrition and other associated
nutritional deficiencies. Ideally, every patient with a diagnosis of EoE will receive medical
nutrition therapy from a registered dietitian.

Rationale for Nutrition Consult Order
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Nutrition consult is indicated for all children with eosinophilic esophagitis (EoE) who will
receive diet therapy as part of management of the condition. Diet therapy can treat EoE
independent of or in conjunction with medical management and may include the following:
Successful elimination of the targeted allergen(s)
Adequate intake of nutrients within the confines of the elimination diet
Appropriate management of the elimination diet to adapt to patient/family lifestyle
Resources to ensure dietary adherence
Education regarding the following topics:
Successful grocery shopping
Developmentally and age-appropriate meal and snack planning and preparation
How to ensure a safe restaurant meal
How to ensure a safe and appropriate school or day care environment
If the patient will be treated with medical management alone, a nutrition consult may still be
required to identify and correct poor nutritional status commonly associated with EoE.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Food Allergic Disorders > General Guidance
Nutritional Risk Screen

Food allergy is a medical condition for which treatment entails dietary elimination of the
identified food allergen. Children with a diagnosed food allergy would benefit from medical
nutrition therapy with regular monitoring to ensure a safe, allergen-free diet that supplies all
nutrients required for adequate growth and development (Christie, 2002). Diets that
eliminate major foods or food groups (wheat, milk, egg, soy, etc.) place the pediatric patient
at nutritional risk. In addition, ineffective allergen avoidance may lead to chronic allergic
symptoms such as atopic dermatitis or acute, potentially life-threatening, food-allergic
reactions. The US Food Allergy Guidelines recommend nutrition counseling and regular
growth monitoring for all children with a food allergy (Boyce, 2010).

Rationale for Nutrition Consult

Nutrition consult is indicated for all children with food allergy to ensure the following:
Successful elimination of the allergen(s)
Adequate intake of nutrients within the confines of the allergen-restricted diet
Appropriate management of the food allergy to adapt to daily living to ensure dietary
adherence and patient safety; for example, the dietitian should provide education
regarding the following concerns:
Successful grocery shopping
Developmentally appropriate and age-appropriate meal and snack planning and
preparation
How to ensure a safe restaurant meal
How to ensure a safe and appropriate school or day care environment
The registered dietitian may also remind families to have the food allergy action plan and
all emergency medications available to the child with food allergies at all times as well as
ensure that all child care providers understand how to recognize and treat a food-allergic
reaction. The US Food Allergy Guidelines recommend nutrition counseling and regular
growth monitoring for all children with food allergy (Boyce, 2010).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases
Gastrointestinal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases > Celiac Disease
Nutritional Indicators

Signs and symptoms of undiagnosed celiac disease or consumption of gluten in diagnosed
patients vary from one individual to the next.
Gastrointestinal (GI) symptoms can include the following:
Diarrhea
Vomiting
Constipation
Abdominal distention
Abdominal pain
Failure to thrive
Irritability
Symptoms related to malabsorption (that may not be associated with GI symptoms) include
the following:
Dental enamel defects
Nutritional anemias
Pubertal delay
Short stature
Osteopenia/osteoporosis
Ataxia
Epilepsy with intracranial calcifications
Fatigue
Skin abnormalities
Elevated serum antiendomysial antibody or tissue transglutaminase or a positive
small intestinal biopsy
If a previously diagnosed patient experiences any of the above symptoms or
complications, he or she is at increased nutritional risk because of the damage to the small
intestine.
Newly diagnosed patients are also at nutritional risk.


Rationale for Nutrition Consult

All patients with celiac disease or dermatitis herpetiformis should be referred to a registered
dietitian. Lifelong adherence to a gluten-free dietary pattern is essential for the
management of these diseases (NIH, 2004). Consultation with a registered dietitian as part
of a team-based approach results in improved self-management (EAL, 2009).
A patient may be following a gluten-free dietary pattern without a diagnosis of celiac
disease or dermatitis herpetiformis for a variety of reasons, such as intolerance to gluten
despite a negative diagnosis for celiac disease (gluten sensitivity), behavior disorders, and
autism. Currently the evidence that a gluten-free dietary pattern is beneficial for autism or
behavior disorders is weak; however, an investigation of potential benefits is under way
(Marcason, 2009). The incidence of gluten sensitivity in this population is also currently
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Marcason, 2009). The incidence of gluten sensitivity in this population is also currently
being investigated (Verdu, 2009).
Regardless of the reason for following a gluten-free dietary pattern, a registered dietitian
should be consulted because it can result in a diet that is low in iron, folate, niacin, vitamin
B-12, calcium, and iron (EAL, 2009).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases > Inflammatory Bowel Disease
Nutritional Risk Screen

Growth failure can occur in 50-70% of pediatric patients who have inflammatory bowel
disease (IBD). Symptoms such as abdominal pain, diarrhea, and nausea can lead to
decreased nutritional intake, thus putting the patient at risk for further growth failure.

Nutritional Indicators

Ideally, every patient with a diagnosis of inflammatory bowel disease (IBD) will be followed
regularly by a dietitian. Some of the nutritional indicators that will indicate the patient is at
additional risk include, but are not limited to, the following:
< 5th percentile Body Mass Index for age
> 10% body weight loss over the past month
Significantly increased output or stooling
Current gastrointestinal surgery (resection)
IBD patients on parenteral nutrition with electrolyte abnormalities

Rationale for Nutrition Consult Order

Early intervention with an inflammatory bowel disease (IBD) patient’s nutritional status may
help prevent further growth failure and malnutrition. Helping the patient and family find a
diet that is more easily tolerated and do-able, combined with medical treatment, may help
the patient find the state of remission. Failure to address nutritional issues caused by IBD
could ultimately set the patient up for continued poor nutritional state leading to
vitamin/mineral deficiencies, linear growth stunting, and so on.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases > Diarrhea
Nutritional Risk Screen

Diarrhea is one of the most common symptoms in pediatrics. In newborns and infants,
diarrhea can be dangerous because it can quickly lead to dehydration. Depending on the
institution, it may or may not be a nutritional risk indicator on standard nutritional screening
tools. However, patients with protracted diarrhea should be placed at moderate to high
nutritional risk due to the increased risk of dehydration and inadequate nutrient intake. A
nutrition consult should be ordered.
Nutrition screening information should focus on:
Signs and symptoms of dehydration
Signs and symptoms of malabsorption
Evaluation of growth parameters and growth history
Food intake/intolerances
Food preparation/infant formula preparation
History of recurrent infections
Review of acid-base balance

Nutritional Indicators, Criteria to Assign Risk

Nutritional indicators that should stimulate nutrition consultation and more in depth
investigation after the initial nutrition screen include:
NPO = 2-3 days
Weight loss of = 5% in a month or 1% in infants
Nutrition support (enteral or parenteral nutrition)
Weight/height below 5th percentile
Height/age below 5th percentile
Dysphagia
Difficulty chewing, sucking/swallowing
Other standard indicators dictated by institutional policy


Rationale for Nutrition Consult Order

Nutrition therapy is necessary to correct nutritional deficiencies associated with
diarrhea. Nutrition therapy can be a crucial component of the medical care used to treat
diarrhea. Inappropriate food or formula choices may complicate the symptoms of diarrhea.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases > Gastroesophageal Reflux
Nutritional Risk Screen

Although gastroesophageal reflux (GER) is benign and most infants outgrow it by age 12
months, GER disease (GERD) may affect nutritional status if significant vomiting or
regurgitation accompanies feeding. Vomiting or regurgitation may lead to inadequate
nutrient intake and may possibly result in dehydration. There are many conditions that
increase the risk of GERD, including the following (Vandenplas, 2009):
Neurologic impairment
Obesity
Cystic fibrosis
Hiatal hernia
Repaired achalasia
Esophageal atresia repair
Lung transplantation
Any congenital esophageal disease
Family history of esophageal disease
A nutrition consult is warranted if the patient exhibits poor growth.


Nutritional Indicators/Criteria to Assign Risk

The following nutritional indicators suggest the need for a nutrition consult for further
evaluation of the patient:
Weight loss of 5% in 1 month for children or 1% in 1 month for infants
Weight for age below the 5th percentile
Weight for length or body mass index for age below the 5th percentile
Difficulty swallowing or sucking
Dysphagia
Vomiting with feeding

Rationale for Nutrition Consult Order

A nutrition consult may be necessary in children if gastroesophageal reflux disease
(GERD) symptoms have led to inadequate growth. Speech or occupational therapists may
request a consult as part of an interdisciplinary health care plan. A nutrition consult may
also be necessary with a change or modification in formula type, delivery, or preparation in
the treatment of GERD.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases > Irritable Bowel Syndrome
Rationale for Nutrition Consult

Clinical studies suggest that irritable bowel syndrome (IBS) symptoms may be caused or
exacerbated by one or more dietary components in 25% of affected individuals (Heizer,
2009).
Children who tested positive for fructose malabsorption via breath hydrogen analysis have
been reported to experience a sustained reduction in IBS symptoms (abdominal pain and
bloating) on a fructose-restricted diet (Chiou, 2010).
More recent research supports short-term elimination of poorly absorbed, fermentable
carbohydrates and polyols (FODMAPs) as an emerging dietary strategy in IBS symptom
management (Heizer, 2009).
Until definitive therapies for IBS are elucidated, limited trials (2 to 3 weeks) of dietary
restrictions based on individual clinical presentation may prove beneficial (Chiou, 2010).

Nutritional Risk Screen

Anthropometric Data (Bessler, 2005):
Height for age: <5th percentile
Weight for age: <5th percentile or at the 85th percentile or higher
Weight changes: Weight loss/gain of 10% in 6 months or fewer
Body mass index: <5th percentile or at the 85th percentile or higher
Height and weight discrepancy of 2 or more % bands
Oral Intake:
Fasting or skipping meals on a regular basis to control symptoms of irritable bowel
syndrome
Excessive intake or avoidance of a specific food or food group in the belief it will help
symptoms



Nutritional Indicators/Criteria to Assign Risk

Food/Nutrition-Related History
Anxiety about eating; social withdrawal; school absenteeism
Restrictive or erratic eating patterns (eg, exclusion of multiple foods or entire
food groups, frequent skipped meals)
Inadequate nutritional intake
Multiple food intolerances
Anthropometric data
Weight for age or weight for height below 3% to 5%
Poor growth velocity (weight falls more than 2 major percentiles over 3 to 6
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Poor growth velocity (weight falls more than 2 major percentiles over 3 to 6
months)
Physical findings suggestive of malnutrition

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Gastrointestinal Diseases > Short Bowel Syndrome
Nutritional Indicators

Patients with a diagnosis of short bowel syndrome (SBS) should be followed by a
registered dietitian. Some of the nutritional indicators that indicate additional risk include,
but are not limited to, the following:
weight/length less than the 5th percentile
Not tolerating enteral/po feeds
Excessive output or significantly increased stooling/output
Diagnosis of failure to thrive or current gastrointestinal surgery
SBS patients receiving parenteral nutrition with abnormal electrolytes

Rationale for Nutrition Consult Order

All patients with short bowel syndrome should receive a nutrition consult, as these patients
almost always have feeding intolerances, enteral and/or parenteral dependence, electrolyte
disturbances, and poor growth. The earlier the registered dietitian can intervene with these
patients, the better the outcome will be for overall growth and nutrition status.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Hepatic Diseases
Criteria to Assign Risk

Criteria to assign risk for hepatic diseases include the following:
Cholestatic disorders
Biliary atresia
Alagille syndrome
Progressive familial intrahepatic choletstasis (types 1 and 2)
Byler disease and syndrome
Idiopathic neonatal hepatitis
Cystic fibrosis (see Pulmonary Diseases)
Alpha-1 antitrypsin deficiency
Neonatal iron storage disease
Metabolic diseases/disorders (see Inborn Errors of Metabolism)
Wilson’s disease
Urea cycle disorders
Tyrosinemia
Galactosemia, fructosemia, glycogen storage disease type 1a
Hepatitis
Autoimmune
Viral B and C
Primary sclerosing cholangitis
Non-alcoholic fatty liver disease
Fulminant liver failure
Malignancies (hepatoblastoma)
Parenteral nutrition–associated liver disease

Rationale for Nutrition Consult Order

Moderate to severe malnutrition is a common finding in patients with advanced liver
disease. Assessments should be performed at initial presentation of any cholestasis and
monitored (Feranchak, 2007). The extent of the damage to the liver, the progressive nature
of the insult, and the presence of cholestasis determine the dietary modifications required.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > HIV/AIDS
Nutritional Risk Screen

Human immunodeficiency virus (HIV) infection can impair the nutritional status of infected
children early in life (WHO, 2009); thus, nutrition assessment and intervention should begin
soon after diagnosis (ADA, 2010). Every infected child should receive a complete baseline
nutrition assessment with regular follow-up, depending on the child’s age, nutritional status,
and nutritional risk (Heller, 1997; ASPEN, 2009; ADA, 2010).

Nutritional abnormalities, including malnutrition and obesity, are highly prevalent among
HIV-infected children and adults and can independently contribute to declines in health and
increases in mortality. HIV-associated wasting syndrome, a leading manifestation of
progressive disease in HIV-infected children in the United States, has long been identified
as the fourth most common indicator of acquired immunodeficiency syndrome (AIDS) in
children (CDC, 2010). Moreover, inability to achieve a normal weight-for-height, failure to
thrive (FTT), impaired cognitive development, obesity, and cardiometabolic problems are
potential adverse nutrition-related outcomes in pediatric HIV (Majaliwa, 2009 ).



Nutritional Indicators/Criteria to Assign Risk

Nutritional risk factors for human immunodeficiency virus (HIV)/acquired immune deficiency
syndrome include the following:
Underweight: indicated by weight-for-length or body mass index (BMI)–for-age
(children older than 2 years) below the 5th percentile for age or slow rate of weight
gain
Inadequate growth rate
Recent weight change: unintentional weight loss or excessive weight gain
Overweight: indicated by weight-for-length or BMI-for-age (children older than 2
years) at or above the 85th percentile
Deviation from established growth curve
Deviation from established skinfold and circumference measurements
Inadequate dietary intake
Gastrointestinal symptoms
Anorexia
Nausea
Diarrhea
Advanced HIV disease with severe immune suppression
Physical observations
Loss of subcutaneous fat
Muscle wasting
Signs of HIV lipodystrophy
Alterations in nutrition-related laboratory values
Albumin
Transthyretin
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Hemoglobin
Hematocrit
Lipid panel
Other metabolic parameters
Cardiometabolic problems


Rationale for Nutrition Consult Order

The American Dietetic Association’s position paper on Nutrition Intervention and Human
Immunodeficiency Virus Infection notes that a complete baseline nutrition assessment
should be performed as part of the multidisciplinary care plan, with regular follow-up care
as appropriate to achieve care plan goals. For optimal care, it is recommended that a
registered dietitian should perform the nutrition evaluation and follow-up (ADA, 2010).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Inborn Errors of Metabolism
Nutritional Risk Screen

In most institutions, diagnosis of a metabolic disorder indicates high nutritional risk.
See Newborn Screening for more information.

Rationale for Nutrition Consult Order

Each inborn error of metabolism requires unique treatment based on the enzyme activity
that is affected. In addition, each individual with an inborn error of metabolism requires
unique family-centered therapeutic considerations. Nutrition interventions managed by a
registered dietitian with training and experience in working with metabolic disorders are key
to the treatment of many metabolic disorders.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Oncology
Nutritional Risk Screen

Standard screening is the identification of nutritional, health, functional, and behavioral
information that would quickly identify individuals who are at nutritional risk (Lacey, 2003).
Early identification of nutritional risk is paramount to providing excellent nutrition care and
can often prevent the need for more aggressive nutrition support later in the patient’s
treatment course (Bechard, 2006). Nutritional risk screening is important to the initiation of
the nutrition assessment, which is the first step of the nutrition care process (McCallum,
2006).
Screening should be an ongoing process that begins at diagnosis and continues
throughout the treatment course in order to ensure that interventions are timely and
effective (Bechard, 2006; Trujillo, 2005; Kleinman, 2004).
Several unique tools have been developed for screening and assessing; they are well
documented in the literature. Two tools that warrant review include the subjective global
assessment (SGA) and the St. Jude Children's Research Hospital Screening and Risk
Stratification Protocol.
St. Jude Children's Research Hospital (SJCRH) has implemented screening for all children
with cancer upon admission to the hospital, in the clinic setting at diagnosis, and
continuously at 6-month intervals. The screening protocol that SJCRH clinicians use is
presented in Criteria to Assign Risk. Nurses and dietitians utilize this screening protocol to
identify at-risk patients—children who are identified as being of moderate to high risk are
evaluated by the clinical dietitians and undergo an in-depth nutrition assessment.
SGA is a simple, easy-to-use approach that assists in identifying individuals at nutritional
risk. It was first described and tested by Detsky et al (1984) in the early 1980s. Since its
development, the tool has been utilized as a screening method in many patient
populations, including oncology (Shopbell, 2001; Shirodkar, 2005; Sacks, 2000; Mutsert,
2009). A scored, patient-generated SGA was developed by Ottery and includes issues
specific to the adult oncology population (McCallum, 2006; Ottery, 2000).
In 2003, a pediatric version of the scored, patient-generated SGA (PED-SGA) was
developed by Ringwald-Smith, Sacks, and Ladas. The PED-SGA includes questions that
the patient/caregiver answers in five domains: weight history, food intake, nutritional
impact symptoms, recent treatment, and activity level. The tool includes scoring the first
five domains, scoring for disease type and stage, and scoring the individual's
nutrition-related physical exam.
The PED-SGA also includes a training manual that is used to teach health care
professionals how to conduct a nutrition physical exam and how to score the exam in the
pediatric population. Once the tool is complete, a referral can be made to initiate the
appropriate nutrition intervention. The PED-SGA can also be used to assign patients to
three nutrition assessment categories: Stage A: well-nourished, Stage B: moderately
malnourished, and Stage C: severely malnourished. This method of screening is new and
may be able to identify at-risk patients better than some standard methods (Sacks, 2010).
A pdf of the PED-SGA is provided with permission of Nancy Sacks, MS, RD here.
PED-SGA Scoring and Triage information
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Criteria to Assign Risk

Screening guidelines have been established by the Joint Commission for all accredited
health care organizations. The Elements of Performance standards require that nutrition
screening is completed within 24 hours of a patient’s admission (Joint Commission, 2004)
and that it is conducted in ambulatory, home care, and sub-acute care on a routine
basis. Because of this admission screening time frame stipulation, many nutrition
departments have shifted the screening responsibility to nursing staff or have developed
automated screening that assigns risk and generates a nutrition consult by collecting
diagnostic, demographic, and anthropometric and laboratory data (Chima, 2003).
Whereas the Joint Commission guidelines for inpatient screening are well defined, the
guidelines for ambulatory and other health care settings are not. In addition, the guidelines
for assessment time frames are not well established (Chima, 2003).
A review of the literature supports that both objective and subjective measures are utilized
in the early identification of individuals at nutritional risk (Smith, 2006; McCallum, 2006;
Trujillo, 2006; NCI). Yet, a study conducted by the Cancer Oncology Group (COG)
indicates that there is no uniform approach to screening and assessing among pediatric
cancer facilities (Ladas, 2005). Although a lack of consistency was observed among the
institutions surveyed, the survey did indicate that a significant number of the participating
institutions reported use of screening parameters to trigger a nutrition consult (Ladas,
2005). Since there is no consistency in the tools or parameters being utilized, it is
recommended that each institution develop institution-specific screening and assessment
guidelines that meet the needs of the patients they serve and that are in compliance with
state, local, and accreditation processes within the institution.
A good screening tool should be one that a variety of clinicians can use, including a dietetic
technician, a nurse, or a physician. Characteristics of nutrition screening should be simple
and easy to complete, cost effective, effective in identifying nutritional problems, reliable,
and valid. The COG survey reported that the most commonly used criteria for assessing
the need for nutrition intervention included the following (Ladas, 2005):
Weight for height
<90% ideal body weight for height
>120% ideal body weight for height
<10th percentile
Weight for age
<10th percentile
<5th percentile
Height for age
<10th percentile
<5th percentile
Body mass index
<5th percentile
>90th percentile
Nutrient intake
<80% nutrient needs

St. Jude Children’s Research Hospital Nutrition Screening System
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Used with permission)
I. Risk Factors and Assigned Points
a. Ideal body weight
=90% (0 risk points) 1.
81% to 90% (2 risk points) 2.
=80% (3 risk points) 3.
b. Weight Loss in 1 month
<5% (0 risk points) 1.
5% to 10% in children or 1% in infants (2 risk points) 2.
>10% (3 risk points) 3.
c. Serum albumin (g/dL) (indicator of visceral protein stores)
>3.5 g/dL (0 risk points) 1.
3.2 g/dL to 3.5 g/dL (1 risk point) 2.
<3.2 g/dL (2 risk points) 3.
d. Impending therapy/treatment side effects (2 risk points/each)
Surgery involving the gastrointestinal (GI) tract. 1.
Radiation therapy to the GI tract or central nervous system 2.
Bone marrow transplant 3.
GI problems including but not limited to typhlitis, ileus, mucositis (= grade 3 based on
National Cancer Institute common toxicity criteria)
4.
Radiation enteritis and dumping syndrome 5.
e. Oral intake less than 50% of assessed needs, = 3 days (2 risk points)
f. Change in growth percentile curve. Any decrease in the curve by 2 or more growth
percentile channels (stature-for-age percentiles, weight-for-age percentiles,
weight-for-stature percentiles) (2 risk points)
g. High nutritional risk cancer diagnosis
Wilms’ tumor (stages III and IV, unfavorable histology, and relapsed) 1.
Neuroblastoma (stages III and IV) 2.
Metastatic solid tumors 3.
Non-Hodgkin’s lymphoma (stages III and IV and relapsed) 4.
Acute myelogenous leukemia and chronic myelogenous leukemia (newly diagnosed,
relapsed)
5.
Acute lymphocytic leukemia with poor prognosis (high-risk categories and relapsed) 6.
Medulloblastoma and other brain tumors 7.
h. Lower nutritional risk cancer diagnosis (0 risk points)
Acute lymphocytic leukemia with good prognosis 1.
Nonmetastatic solid tumors 2.
Advanced diseases in remission during maintenance treatment 3.
II. Categories of Risk and Point Destination
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
0-1 risk factor points…1st degree: low risk a.
2-3 risk factor points…2nd degree: moderate risk b.
3+ risk factors points…3rd degree: high risk c.


Rationale for Nutrition Consult Order

In addition to the criteria outlined under Criteria to Assign Risk, several other screening and
assessment parameters may be used to trigger a nutrition consult:
Use of complementary/alternative medication
Swallowing/chewing/sucking difficulties
Nausea/ vomiting/ or diarrhea lasting more than 3 days
Allergies to food
Modified/restrictive diet
Use of enteral or parenteral nutrition support

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Pulmonary Diseases
Pulmonary Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Pulmonary Diseases > Asthma
Nutritional Risk Screen

A nutritional risk screen should include the following elements:
Weight for age
Height for age
Weight for length in younger children
Body mass index for age
Intake of calcium/vitamin D
Medication

Rationale for Nutrition Consult

There are several nutritional implications related to the diagnosis of asthma. Issues to
consider include the following:
Overweight
Underweight
Drug–nutrient interactions
Potential avoidance or elimination of certain food groups


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Pulmonary Diseases > Bronchopulmonary Dysplasia
Nutritional Risk Screen

Infants and children with bronchopulmonary dysplasia are at high risk for growth failure due
to their underweight status at birth, delay in starting and advancing to full feeds after
delivery, interruptions in nutrition support due to concomitant illnesses and complications,
and increased needs due to respiratory insufficiency and growth requirements.
Weight-for-age, length-for-age, head-circumference-for-age and weight-for-length may all
be less than expected for gestational age.

Nutritional Indicators

Infants with bronchopulmonary dysplasia are often at very to extremely low birth weight due
to their prematurity. They are frequently underfed in the neonatal intensive care unit (NICU)
early in their disease process and remain small for their gestational age. Upon discharge
from the NICU some infants may continue to experience growth failure. See
the Premature Infants section for more information.

Criteria to Assign Risk

Other criteria that would be important to assess for risk include prolonged underfeeding,
prolonged use of total parenteral nutrition (TPN), potential drug-nutrient interactions, and
feeding difficulties.

Rationale for Nutrition Consult Order

Adequate nutrition to allow normal growth and development is key to the resolution
of bronchopulmonary dysplasia. Growth of new lung tissue can occur in humans up to 8
years of age; therefore, it is important to continue to encourage good nutrition to provide
adequate linear velocity.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Pulmonary Diseases > Cystic Fibrosis
Nutritional Risk Screen

A diagnosis of cystic fibrosis (CF) places a patient at nutritional risk and warrants referral to
the registered dietitian for nutrition assessment. Risk for nutritional deficiencies are due to
increased energy needs, which is caused by cough; work of breathing; inflammation; and,
for patients who are pancreatic insufficient, malabsorption. Nutritional deficiencies are
evident through suboptimal weight and/or height and abnormal fat-soluble vitamin levels.
Patients who have CF require supplemental salt. Inadequate salt supplementation can
result in loss of appetite and poor growth (Laughlin, 1981; Haycock, 1993). Zinc deficiency
may also result in poor growth (Borowitz, 2002). Poor bone health is another complication
of CF (Aris, 2005). In addition, uncontrolled blood sugar levels and/or other complications,
such as liver disease, can increase the risk of developing nutritional deficits (Moran, 1999;
Sokol, 1999).
The CF Foundation recommends management by a multidisciplinary team that includes a
registered dietitian, who should assess each patient at least annually (Borowitz, 2009).

Rationale for Nutrition Consult

The registered dietitian (RD) is responsible for monitoring the nutritional status, and
providing nutrition intervention as indicated, for all individuals who have cystic fibrosis (CF).
Growth, weight, fat-soluble vitamin levels, food intake, supplemental vitamin use, salt
intake, eating behaviors, and enzyme use are routinely assessed. Using data collected
during the assessment, the RD determines nutritional risk and identifies causes of
suboptimal nutritional status (Borowitz, 2009; Borowitz, 2002; Stallings, 2008).
Nutritional risk may reflect severity of disease and/or social issues, such as inadequate
financial resources to purchase food, energy supplements, and vitamin supplements or
challenges in dealing with a child’s school in terms of providing supplemental pancreatic
enzymes prior to snacks and meals.
The RD provides anticipatory guidance to promote optimal weight gain, linear growth, and
nutritional status. Knowledge of developmental issues, particularly those related to CF, is
important when assessing and providing nutritional guidance to individuals with CF and
their families.
Problematic eating behaviors are frequently encountered in toddlers with CF, often
exaggerated from the usual picky eating "food jags" that are seen in many preschool-age
children (Crist, 1994). Nutritional risk may be increased in patients with feeding delay due
to oral motor deficits or sensory aversions and in patients with food allergies and/or
associated gastrointestinal conditions, such as celiac disease. RDs guide parents in
methods to identify and overcome these behaviors while encouraging a high-kilocalorie,
well-balanced diet (Powers, 2003).
As school-age children become more independent eaters in general, meals may become
challenging for the parent. Adolescents who have CF are no different from their peers in
their desire for the “perfect” body and can struggle with body image concerns and feelings
of being different due to CF. A pediatric RD is well-suited to manage nutrition-related issues
in the context of these developmental stages.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Nutritional Indicators

Assess the following nutritional factors for a patient diagnosed with cystic fibrosis (CF).
See also the Biochemical and Nutrient Factors; Biochemical Data, Medical Tests and
Procedures; and Laboratory sections.
Body mass index (BMI), or weight-for-length in children younger than 2 years,
calculated every visit
Fat-soluble vitamins assessed yearly
Annual oral glucose tolerance test for patients 10 years and older (Moran, 2010)
Prealbumin obtained in the absence of pulmonary exacerbation (to minimize
confounding effect of inflammation).
Criteria to Assign Risk
Promotion of optimal growth and nutritional status is integral to effective treatment of
children and adolescents with CF. Prevention of growth failure is preferred. Early detection
of inadequate growth and treatment is recommended (Borowitz, 2009).
The 2005 CF Patient Registry Report reveals that 43% of girls and 44% of boys in the 117
CF centers and 48 affiliate programs in the United States met the recommendation for a
BMI at or above the 50th percentile (Stallings, 2008). Previously, weight-for-stature was
used to assess nutritional status. To determine the best method of assessment, a
comparison was made between BMI percentile, percentage of ideal body weight (IBW),
and association to forced expiratory volume (FEV
1
) (Zhang, 2004). BMI is a more accurate
indicator of CF-related lung health due to its correlation with FEV
1
(Stallings, 2008). FEV
1
is an indicator of CF-related lung disease, and better FEV
1
status—that is, at or greater
than 80% predicted—was associated with BMI at the 50th percentile and higher. The CF
Foundation Subcommittee on Growth and Nutrition reviewed these data and now
recommends using age-appropriate BMI as an indicator of nutritional health (Stallings,
2008).
In summary, the risk criteria has changed due to newer research and findings described in
the 2006 CF Patient Registry (CFF, 2008). Nutritional risk is now defined as BMI below
than the 50th percentile or weight-for-length below than the 50th percentile.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Pulmonary Diseases > Ventilator Issues
Nutritional Risk Screen

Children requiring mechanical ventilation are at nutritional risk due to their altered nutritional
needs secondary to mechanical ventilation and their inability to consume food or liquids
orally.

Nutritional Indicators

Children on mechanical ventilation may be over- or underweight.

Criteria to Assign Risk

The following criteria may be used to assign risk:
weight, length/height, and weight for length or BMI < 10th or > 90th percentile for age
inadequate oral intake


Rationale for Nutrition Consult

Most ventilator-dependent children require tube feedings for their source of nutrition. Their
energy requirements may be higher or lower than the Dietary Reference Intake standards
depending on their underlying diagnosis.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Renal Diseases
Renal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Renal Diseases > Chronic Kidney Disease
Nutritional Risk Screen

Children with chronic kidney disease are at high nutritional risk as a result of
biochemical/metabolic abnormalities that affect nutrition needs, bone development and
growth, and general development. Any child with impaired kidney function needs to be
screened for nutritional concerns at the time of diagnosis and regularly thereafter (Norman,
2000; Rees, 2007).

Nutritional Indicators

A diagnosis of chronic kidney disease is a nutritional risk indicator itself. Abnormalities in
weight gain, growth, or biochemical indices (see Laboratory) are all further indicators of
nutritional risk.

Rationale for Nutrition Consult Order

Medicare has guidelines for nutrition screening and assessment for all individuals with
chronic kidney disease (CKD) who are on dialysis. The Kidney Disease Outcomes Quality
Initiative guidelines give specific parameters for frequency of nutrition assessment for
infants and children with CKD stages 2 through 5 before dialysis as well as for the
requirements for those with CKD stage 5D (on dialysis) (NKF, 2009). (See the table in
Nutrition Assessment.)
A pediatric patient with CKD before initiation of dialysis may fail to receive the nutrition
assessment, intervention, and monitoring necessary for optimal health. Although children
with CKD who live far from a major medical center or who do not have access to a pediatric
nephrology team may be at greater risk for insufficient nutrition care, it may be possible for
these clients to receive state-of-the-art nutrition care with the advent of distance medical
assessment and monitoring via a combination of written information and video/web
conferencing.
If growth and metabolism are not monitored and treated as necessary, the child with CKD
is at risk for poor weight gain and growth retardation, developmental delay, and metabolic
abnormalities that could cause morbidity and mortality.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Renal Diseases > Nephrotic Syndrome
Nutritional Risk Screen

Growth and weight gain (see Anthropometric Measurements)
Obtain a diet history and information about typical intake; families of children whose
food intakes can be described as follows will need more nutrition counseling and help
in meeting nutrition needs than others
Children who typically eat a diet high in sodium (high in processed foods)—they
are at higher risk for edema
Children who typically eat a high-fat, high-sugar diet—they are at higher risk for
side effects of prednisone
Children who typically do not meet calcium and vitamin D needs—they are at
higher risk for poor bone mineralization effects of prednisone
Children from families who are economically challenged and must rely on food
stamps and food banks—they may have a harder time meeting
recommendations for diet for nephrotic syndrome

Rationale for Nutrition Consult Order

Nephrotic syndrome causes fluid retention and edema; thus, a low-sodium diet is
necessary as soon as a diagnosis is made. Also of concern is hyperlipidemia that results
from nephrotic syndrome as well as the medications used to treat it (corticosteroids).
Treatment with corticosteroids also puts the patient at risk for hyperglycemia,
derangements in calcium and vitamin D metabolism, and excessive weight gain resulting
from increased appetite. Assessment of nutritional status and diet followed by nutrition
education is essential (ACR, 1996; McDonough, 2008; Leonard, 2004).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Transplantation
Transplantation


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Transplantation > Organ Transplant
Organ Transplant


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Transplantation > Organ Transplant > Cardiac Transplant
Nutritional Risk Screen

A pediatric patient that needs a heart transplant is at high nutritional risk because
nutritional status prior to transplant significantly affects morbidity and mortality. Often these
patients have nutritional abnormalities and become malnourished due to organ failure and
associated issues.
Adults with cachexia and obesity pretransplant have significantly decreased early and late
survival posttransplant compared with patients of normal weight. Children are at increased
risk for malnutrition and wasting relative to adults due to the high energy demands
associated with growth and increased metabolic rate (Kaufman, 2008).
A nutritional risk screen should be done within 24 hours of admission by a well-trained
dietetic technician following the screening criteria adopted by each medical center.





Nutritional Indicators/Criteria to Assign Risk

Pediatric cardiac transplant patients are at increased risk for preoperative and
postoperative nutritional complications. Malnutrition decreases posttransplant survival
rates and increases the risk of complications such as infection. The factors listed below
may affect patients more seriously or more quickly, depending on the type and severity of
cardiac lesion and associated disease conditions and medications (Nydegger, 2006;
Hasse, 2001).
Common criteria to assign risk vary between medical centers but may include the following:
Age (all kids below 1 year in the cardiac intensive care unit [CICU] are considered
high nutritional risk)
Weight/height below 5th %ile
npo >3 days
Other factors that may influence the development of malnutrition and growth failure in
cardiac patients (Nydegger, 2006; Hasse, 2001):
Disturbances in energy metabolism
Increased energy expenditure
Cardiac hypertrophy
Abnormal body composition
Increased activity of sympathetic nervous system
Increased hematopoietic tissue
Increased basal temperature
Recurrent infection
Pharmacologic agents
Decreased energy intake
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Decreased energy intake
Anorexia and early satiety
Pharmacologic agents
Decreased gastric volume caused by hepatomegaly
Disturbances in gastrointestinal function
Malabsorption
Edema and chronic hypoxia of the gut
Drug-nutrient interactions
Delayed gastrointestinal development
Compressive hepatomegaly
Decreased gastric volume
Increased gastroesophageal reflux
Poor nutrient delivery to tissues due to impaired waste removal secondary to
decreased circulatory function
Cardiac cachexia
Inadequate nutrient intake
Poor gastrointestinal absorption
Abnormal stool and urine loss
Increased cardiac and pulmonary energy expenditure




Rationale for Nutrition Consult Order

Before being listed for a heart transplant, each child needs to have a heart
transplant evaluation. This evaluation period is critical in determining whether a patient
needs a heart transplant or if he or she will be referred to other programs for treatment.
Upon completion of the evaluation, the patient's medical, social, and financial information is
presented to a medical review board. The responsibility of the board is to review each
patient’s case and determine whether this child is a candidate for transplantation. The
members of the board come from many disciplines within the hospital and health care
community.

The preoperative evaluation involves 2 to 3 days of testing, as inpatient or outpatient
depending on the patient's situation. The steps include the following:
Physical examination and cardiac tests
Cardiologist's evaluation
Medical history
Nutrition evaluation
Social worker evaluation
Insurance evaluation
Additional medical tests
Child life specialist
Dental evaluation
The nutrition evaluation should be done by a registered dietitian. While patients await
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
transplantation, physical and nutritional status may decline. Nutrition support should be
optimized during the pretransplant waiting period. The goal during this period is to maintain
or improve the patient's nutritional status as much as possible (Hasse, 2001).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Transplantation > Organ Transplant > Kidney Transplant
Nutritional Risk Screen

The child who has had a kidney transplant is at high risk for nutrition-related problems. Risk
factors include the following:
Increased nutrition needs for healing immediately after transplant
Medication–nutrient interactions associated with immunosuppressant medications
Issues associated with the child’s stage of chronic kidney disease (See Chronic
Kidney Disease section) (NKF, 2009).


Nutritional Indicators/Criteria to Assign Risk

Abnormalities in weight gain, growth, and biochemical indices are all indicators of nutritional
risk.

Rationale for Nutrition Consult Order

Immediately after transplant, monitoring of fluid and electrolyte status and treatment of
common drug nutrient interactions is crucial to prevent hypophosphatemia,
hypomagnesemia, hyperkalemia, hyperglycemia, and hypertension.
Nutrition care to promote anabolism and healing from surgery is important.
Long-term issues include medication-associated hyperlipidemia, excessive weight
gain (NKF, 2009).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Transplantation > Organ Transplant > Liver Transplant
Nutritional Risk Screen

Liver transplant recipients are inherently at increased nutritional risk because of a past
history of liver failure and current nutrition-related complications of transplantation and
immunosuppressive drugs. Risk is especially high in the immediate postoperative period
but persists throughout the recipient's life because of ongoing treatment with
immunosuppressive drugs.

Nutrition screening should be performed within 24 to 48 hours of admission. Screening can
be done by a well-trained nutrition professional or other members of the health care team
using established criteria (refer to Criteria to Assign Risk).


Nutritional Indicators

Following are specific indicators of increased nutritional risk in pediatric transplant
recipients:
Dietary Intake
Poor appetite
Feeding aversion
Early satiety
Restricted meal plans (eg, low potassium for hyperkalemia related to calcineurin
inhibitor administration)
Continued need for nutrition support (total parenteral nutrition or tube feeding)
Gastrointestinal Symptoms
Nausea
Delayed gastric emptying
Vomiting and gastroesophageal reflux
Diarrhea
Physical Observations
Wasting
Excess fat deposition
Bruising and ecchymosis (vitamin K deficiency)
Dry skin (vitamin A and essential fatty acid deficiency)
Bitot spot and xerophthalmia (vitamin A deficiency)
Sparse or brittle hair (malnutrition, zinc deficiency)
Enlargement of epiphyses, bowed legs, beading of ribs (rickets)
Delayed eruption of teeth (calcium and vitamin D deficiencies)
Frontal bossing and persistent open anterior fontanelle (rickets)
Delayed wound healing (inadequate energy and protein intake, zinc deficiency)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Laboratory Values
If liver and kidney function are normal and fluid retention is absent, hepatic proteins
such as albumin and prealbumin may be useful as nutrition screening tools
Serum glucose level and/or glycosylated hemoglobin to screen for new-onset
diabetes or transient glucose intolerance
Serum lipid levels to screen for hyperlipidemia
Serum blood urea nitrogen and creatinine to screen for renal dysfunction
(Sutton, 2002; Rand, 2003; Hasse, 2009)


Criteria to Assign Risk

Specific criteria for determining risk level should be assigned by each hospital or clinic. In
addition, the assignment of a patient to a registered dietitian or dietetic technician,
registered, must be in accordance with the institution's guidelines. A general guideline that
will trigger nutrition assessment will be the need for nutrition support or the presence of 2
or more of the following risk factors.
Food/Fluid Intake
Poor appetite for 1 week or longer
Restricted diets (eg, low potassium for hyperkalemia related to calcineurin inhibitor
administration)
Multiple food allergies
Being on nutrition support (tube feeding or total parenteral nutrition)
Gastrointestinal Symptoms
Vomiting for 3 days or longer
Diarrhea for 3 days or longer
Physical Observations
Weight change (not caused by fluid retention or diuresis) of 1% to 2% in past week,
5% in past month, 7.5% in past 3 months, 10% in past 6 months
Decrease in length or height by 2 or more percentile curves in 6 months
Presence of edema or ascites
Laboratory Values
Hemoglobin less than 10.5 g/dL in an infant and less than 11.5 g/dL in a child;
hematocrit below 33% in an infant and less than 34% in a child
Serum albumin level below 3.5 g/dL (if liver and kidney function are normal and fluid
retention is absent)
Serum prealbumin level below 17 mg/dL (if liver and kidney function are normal and
fluid retention is absent)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Serum glucose level above 180 mg/dL for toddlers, preschoolers, and school-aged
children (younger than 13 years) and above 130 mg/dL for adolescents (aged 13 to
19 years); or glycosylated hemoglobin between 7.5% to 8.5% for toddlers and
preschoolers, below 8% for school-aged children (age 6 to 12 years), and below 7.5%
for adolescents (age 13 to 19 years)
Fasting serum cholesterol level above 200 mg/dL
Fasting serum low-density lipoprotein cholesterol level above 130 mg/dL
Fasting serum triglyceride above 200 mg/d
Other Metabolic Abnormalities
Graft dysfunction
Renal impairement
Osteopenic bone disease
(American Diabetes Association, 2009; Fischbach, 2009; Robertson, 2005; Sutton, 2002;
Hasse, 2009)


Rationale for Nutrition Consult Order

Malnutrition and growth failure in pediatric patients with liver disease is common; therefore,
children with liver disease should be monitored by a registered dietitian and receive
appropriate intervention upon initial diagnosis of disease. Improvement in nutritional status
during the pretransplant period maximizes success of the liver transplant and
posttransplant growth (Ramaccioni, 2000; Pikul, 1994; Figueiredo, 2000).

All patients being admitted for transplantation should also be referred to a registered
dietitian for a complete assessment. Every patient who has previously undergone
transplantation should be screened to identify level of nutritional risk and need for nutrition
intervention. Some transplant-specific, high-risk medical conditions include recurrent organ
failure, renal failure, bone disease, infection, glucose intolerance, obesity, and
hyperlipidemia. Each of these comorbidities increase a patient's risk status.

Nutrition referral for consult can assist in the following:
Maximize nutritional intake
Correct fluid, electrolyte, and acid-base imbalance
Minimize symptoms and prevent anticipatory nausea, vomiting, diarrhea
Provide anticipatory drug–nutrient interaction guidance
Address learned food aversions


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Transplantation > Hematopoietic Stem Cell Transplant
Nutritional Risk Screen

Screening is usually a prelude to nutritional assessment, which may consist of several
parts, including data collection, evaluation, and interpretation, followed by estimation of
nutritional risk.

Screening should be performed within 24-48 hours of admission for every patient and
repeated regularly depending on the patient’s age, diagnosis, treatment, and other
risk factors.
Nutritional screening can be performed by any personnel from the multidisciplinary
team by following a careful selection of parameters to screen.
Nutritional screening should include growth history; usual body weight; and a
subjective history of current symptoms that includes, but is not limited to, nausea,
vomiting, diarrhea, and appetite.
Such screening can identify children who are malnourished or at risk of malnutrition
and need a more comprehensive nutritional assessment (see the screening list on
the Nutritional Indicators page).
Subjective global assessment (SGA) is a simple screening tool for readily identifying
who is at risk and, hence, who needs a full assessment, but it is not commonly used
in pediatrics. However, it may be useful in some hospital settings. It is an inexpensive
and valuable tool and was validated recently for assessing nutritional status in a
preoperative pediatric population and identifying patients at higher risk for
nutrition-associated complications and prolonged hospitalization (Secker, 2007). The
patient or caregiver will complete the first part of the SGA, and a well-trained
professional practiced in nutrition assessments will complete the second part, which
assesses physical appearance.

Nutritional Indicators

Nutritional indicators for risk are as follows:
Changes in dietary intake
Food allergies
Changes in weight
Nausea/vomiting
Receiving nutrition support
Problems chewing, swallowing, sucking
Requirements for modified diet
Dietary restrictions
Breastfeeding
Complementary alternative medicine or practices
When assessing dietary intake, resting metabolic rate should be calculated using the
Expert Consultation for Human Energy requirements of the Food and Agriculture
Organization, World Health Organization, and United Nations University (Food and
Nutrition Technical Report Series, 2001) and adding the activity quotient. A patient is
considered at nutritional risk if he or she consumes less than 80% of recommended
intake for more than 3 days (Children's Oncology Group, 2004).
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intake for more than 3 days (Children's Oncology Group, 2004).
See the box below for a sample of a nutrition screen used at St. Jude Children’s Research
Hospital in Memphis, TN.

Nutrition screening for nurses: inpatient done at admission; outpatient done at
diagnosis and every month (Courtesy St Jude Children's Research Hospital,
Memphis, TN)

Are you currently being seen by the clinical nutrition service?
Nutrition Screen
Allergies to food
Weight loss = 5% over 1 month
Weight loss = 2 % over 1 month for infants
Recent unexpected weight gain (please comment)
Nausea/vomiting = 3 days
Nil per os or poor oral intake = 3 days
Total parenteral nutrition/Tube feedings
Problems or pain with chewing, swallowing, sucking
Modified diet/dietary restrictions (please comment)
Currently being breastfed
Currently taking complementary alternative medications (please comment)
Other
Nutrition Consult
No nutrition needs identified at this time
Nutrition consult requested
Comments
Nil per os = nothing to eat or drink by mouth

Rationale for Nutrition Consult Order

The nutrition consult order will depend on the result of the nutrition screen. If any field is
marked in the nutrition screen, a dietitian should meet with the patient and decide if a
detailed nutrition assessment is necessary.
Autologous and allogeneic transplant patients should follow a similar diet because of
their extreme immunosuppressed state posttransplant. In many hospitals, it is
recommended that autologous and allogeneic transplant patients follow low-bacteria
diet—for autologous transplant patients, the diet should be followed for the first 3 months
posttransplant, and for allogeneic transplant patients, the diet should be followed until all T
cells are within the normal range.

Nutrition preevaluation for allogeneic and autologous transplant patients may include any
or all of the following:
Education on guidelines for eating safely
Education on recording food and energy intake
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Education on recording food and energy intake
Review of patient's previous use, if any, of oral supplements, appetite stimulants,
enteral nutrition, and/or parenteral nutrition
Assessment of current nutritional status
Assessment of food allergies

Criteria to Assign Risk

Weight for Age (Bunting 2008)
< 5th or > 85th percentile
5% weight loss in 1 month
Current percentile for weight or height fallen by 2 channels or more
Length or Height for Age (may indicate chronic malnutrition) (Bunting 2008; CDC, 2000a;
CDC, 2000b)
< 5th percentile height-for-age
Weight for Length or Height (may indicate acute malnutrition)
< 5th percentile underweight (indicator of inadequate weight gain)
95th percentile is indicator of obesity
Body Mass Index (BMI) (CDC, 2000a; CDC, 2000b; Zhang, 2004)
<15th percentile or >85th percentile BMI-for-age (>3 years of age)
>85% = overweight
>95th percentile = obese
<15th percentile = undernutrition
< 5th percentile = severe undernutrition
Estimated desired weight calculated from weight for length or weight for height
(Zhang, 2004)
< 90% or >110% 50th percentile weight-for-height
85% to 89% = mild undernutrition
>75% to 84% = moderate undernutrition
<75% = severe undernutrition
Estimated desired weight calculated from BMI (Ringwald-Smith, 2000)
<90% or >120% of 50th percentile weight-for-height or -age
>120% = overweight
80% to 89% = mild undernutrition
70% to 79% = moderate undernutrition
< 70% = severe undernutrition
Head circumference for age (Bunting 2008; CDC, 2000a; CDC, 2000b)
< 5th percentile and >95th percentile
< 5th percentile may indicate microcephaly or chronic malnutrition during fetal life or
early childhood
Arm Anthropometry
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Assessment of subcutaneous fat and muscle mass for signs of
underweight/overweight
Triceps skinfold estimation of energy stores: compare to reference values
Mid-upper arm circumference: indicator of lean body mass
Nutrient Intake
< 80% of estimated energy needs for a longer period of time
< 50% of estimated energy needs for more than 3 days


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Weight Management
Weight Management


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Weight Management > Overweight/Obesity
Nutritional Risk Screen

Registered dietitians and other health care providers should classify the weight status of a
child or adolescent by calculating the person’s body mass index (BMI), plotting the BMI on
the sex-specific and age-appropriate growth charts of the Centers for Disease Control and
Prevention, and then comparing the person’s BMI percentile to the weight classifications
from the expert panel recommendations presented below (Barlow, 2007).

Weight Classifications from the Expert Panel Recommendations
Classification BMI Percentile for Age
Underweight <5th
Healthy weight 5th to 84th
Overweight 85th to 94th
Obesity >95th

Nutritional Indicators

The body mass index (BMI) expressed as body weight in kilograms divided by the square
of the height in meters (kg/m
2
) should be calculated for every child and adolescent
beginning at 2 years of age (see Growth Charts in Resources). Children and adolescents
are identified as overweight with a BMI between the 85th and 94th percentiles. Children
and adolescents with a BMI in the 95th percentile or a BMI higher than 30 are considered
obese.
Measure the height of the child using a stadiometer with a fixed right angle.
Measure weight while the child is wearing a gown. Make note if it is a morning,
afternoon, or evening weight. Indicate stage of menstrual cycle for adolescent girls.
Both these conditions can cause weight fluctuations at subsequent visits.
Plot the height and weight on the growth charts of the Centers for Disease Control
and Prevention.
Skinfold thickness measures and waist circumference are not currently recommended
as indexes of body fat in this population (Barlow, 2007).
To see a pattern of BMI change, obtain previous heights and weights from primary
health care provider, calculate BMIs, and plot on appropriate CDC BMI curve to see
pattern of BMI change.


Rationale for Nutrition Consult Order

Order a nutrition consult for children and adolescents who meet the following criteria:
Overweight (>85th % for BMI based on age and sex)
Obese (>95th % for BMI based on age and sex)or have a body mass index (BMI) of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
30
Exhibit a pattern of BMI increases crossing BMI percentiles unexpectedly
Have risk factors including obesity-related medical conditions (such as
hyperlipidemia, high blood pressure, hyperinsulinemia)
Positive family history for type 2 diabetes mellitus, insulin resistance, and
cardiovascular disease and cardiovascular disease risk factors


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Risk Screen > Weight Management > Underweight
Nutritional Risk Screen

Children of all races are at similar risk for short stature and underweight between the ages
of one to five years. However, infants of non-hispanic white or black descent are at higher
risk than other defined races and ethnicities (CDC Pediatric Nutrition Surveillance, 2007).
Income alone is a poor indicator of pediatric and adolescent underweight. But when linked
to a larger system of influences, such as maternal and child characteristics, and overall
family resources, low income takes on a new level of risk and deserves discussion (Wachs,
2008). While the prevalence of food-insecure households remained relatively unchanged
from 2005-2006, the number of children experiencing very low food security increased
slightly in 2007 from a rate previously stable since 1999 (USDA ERS, 2007). Compared to
young children, adolescents in very low food-secure households are more likely to
experience inadequate food and a disruption in eating patterns. Since 16% of children in
the United States live in households with low or very low food security, families and
patients should be screened for indicators of food insufficiency when determining etiologies
for underweight. Especially at risk are children in households: headed by a single parent;
with a parent of Hispanic descent; and, where the income is <185% of the poverty level.
Practitioners can ask leading questions regarding food availability, such as:
Are you ever concerned about food running out?
Have you ever experienced a time when buying enough food for a balanced diet was
difficult?
Have you or your child ever had to cut down the size of your meal or skip a meal?
Have you or your child ever had to not eat for a day?
Have you or your child ever eaten less than you wanted to save food?
Inquiring about food purchasing and preparation habits may also reveal ways for a family to
stretch the food dollar.
Where are foods purchased?
Grocery or mega-store (often provides the most cost-effective option)
Local food mart
Restaurant
Farmer's market (may offer better prices)
Bulk purchasing decisions are more cost effective when:
Used or portions frozen for later use
Compared to sale items and unit purchase price
Are seasonal and sale items included?
Are leftovers used?
Is a garden feasible and would the harvest be consumed?


Nutritional Indicators

Growth, more than any other assessment tool, reliably indicates the nutritional status of a
pediatric patient (Leonberg, 2008). For this reason, changes in weight gain velocity (see
Anthropometrics section) deserve a nutrition assessment. Risk of low weight increases with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
confounding factors, such as a change in eating patterns negatively influencing nutrition
intake, onset or progression of a disease state, or fear of eating.

Rationale for Nutrition Consult

Any instance of poor growth, such as underweight, substantiates the need for a nutrition
consultation. Whether the underlying problem relates to a nutritional diagnosis, the
treatment for underweight requires a modification in nutritional intake. Determining the
nutritional intervention requires a case-by-case nutrition assessment.

Criteria to Assign Risk

The following is a list of potential risks leading to underweight status:
Delayed introduction of solids
Distractions at mealtimes
Excessive beverage intake for young children
Incorrect formula preparation
Low family income
Maternal depression leading to neglect
High anxiety, anger, or violence in home
Low maternal education level
Child characteristics perceived as difficult by the caregiver
Insufficient caregiver supervision
Controlling behavior on the part of caregiver or child
Taste perceptions
Medical problems interfering with digestion or absorption, increasing metabolism, or
making oral intake difficult
Delay or impairment of normal feeding skills
Health and nutrition beliefs of the family

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions home page
Welcome to the Diseases/Conditions home page.
Information under this tab includes general overview and background information for each
disease or condition listed in the left-hand menu. This general information will help you
understand the context in which a patient presents for nutrition counseling, and major
issues to be aware of when considering proper care.
Please click on a disease or condition in the left-hand navigation to learn more.
Diseases/Conditions > Nutrition Care > Nutrition Assessment > Comparative Standards
Comparative Standards

See Parenteral Nutrition Nutrient Requirements and Enteral Nutrition Nutrient Requirements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Nutrition Care > Nutrition Assessment > Intake Assessment
Intake Assessment

Data Collection
To assess dietary intake, review the medical record or nursing flow sheets to determine
nutrient sources—parenteral nutrition (PN); intravenous solutions; human milk; human milk
fortifier; infant formula; and vitamin, mineral, or other modular supplements.
Data Analysis
The dietary intake assessment should include both qualitative and quantitative analyses.
In the qualitative analysis, consider whether current nutrient solutions are appropriate
for the patient’s gestational age, size, tolerance issues (if any), and diagnoses.
In the quantitative analysis, calculate nutrient intakes (at least mL/kg/day, kcal/kg/day,
and grams of protein/kg/day).
PN calculations (including dextrose, crystalline amino acids, and intravenous fat
grams per kilogram per day) are done in the same way for infants as they are for
other populations.
Dextrose and/or electrolytes in intravenous drip medications often contribute
substantially to an infant’s intake and are calculated.
Occasionally, even medication flushes influence the small infant’s glucose or
electrolyte status.
A more detailed, targeted nutrient intake analysis may be done on intakes of
infants with certain diagnoses or conditions (eg, assessing calcium, phosphorus,
and vitamin D intake for infants with osteopenia).
Calculating Nutrient Intakes
Calculations of nutrient intakes are compared with recommended intakes (see Parenteral
Nutrition and Enteral Nutrition for recommendations) and interpreted in light of the baby’s
medical condition and growth. Following is an example of how to calculate nutrient intake.
Sample Nutrient Intake Calculation for 1,500-g Preterm Infant
Intake
Maternal milk fortified to 24 kcal/fl oz with human milk fortifier, taking 28 mL every 3 hours
Calculations
28 mL × 8 feedings/day = 224 mL/d ÷ 1.5 kg = 149 mL/kg/d
149 mL/kg/d × 0.8 kcal/mL
a
= 119 kcal/kg/d
149 mL/kg/d × 0.024 g protein/mL
a
= 3.6 g protein/kg/d
a
For most precise calculations, consult the specific manufacturer’s literature.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Nutrition Care > Nutrition Assessment > Nutrition > Focused
Physical Findings
Nutrition-Focused Physical Findings

Observe the infant’s general condition, bedside nursing documentation, feeding tolerance,
and medical status. Additional information on physical observations is included under the
following headings.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Nutrition Care > Nutrition Monitoring & Evaluation
Nutrition Monitoring & Evaluation

The purpose of nutrition monitoring and evaluation in neonatal intensive care units,
intermediate neonatal care units, normal newborn nurseries, newborn follow-up clinics, or
pediatricians’ offices is to assess progress toward nutrition goals and expected
outcomes. Goals and expected outcomes are defined by reference standards or an
improvement in nutrition care indicators and may be categorized using the nutrition
assessment terminology categories as follows:
Food/Nutrition-Related History Outcomes (FH)
Food and Nutrient Intake (1)
Food and Nutrient Administration (2)
Breastfeeding (7.1)
Anthropometric Measurement Outcomes (AD)
Length
Weight
Weight change
Growth pattern indices/percentile ranks for corrected age for prematurity
Head circumference
Weight-for-age
Length-for-age
Head circumference-for-age
Weight-for-length
Bone density and bone age
Biochemical Data, Medical Tests and Procedure Outcomes (BD)
Laboratory data
Electrolyte
Essential fatty acid
Gastrointestinal measures
Glucose
Mineral
Nutritional anemia
Protein
Vitamin profiles
Nutrition-Focused Physical Finding Outcomes (PD)
Overall appearance
Extremities, muscles, bones
Digestive system
Skin
Vital signs
Critical thinking is necessary when completing the following step of the nutrition care
process*:
Select the appropriate indicators or measures to monitor and evaluate the impact of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition intervention on the patient’s/client’s progress toward defined goals.
Examples include the following:
Grams per day weight gain
Grams per kilogram per day protein intake
Serum alkaline phosphatase level
Use current and age-specific/disease-specific reference standards for comparison.
Examples include the following:
120 kcal/kg/d and 4 g protein/kg/day for infants 0.9 kg to 1.2 kg (Ziegler, 2007)
400 mcg zinc/kg/day parenteral zinc requirement for preterm infants (Tsang,
2005)
Define progress toward goals in terms of expected outcomes. Examples include the
following:
Increase in head circumference of 0.6 cm/week compared with standard 0.9
cm/week (Moyer-Mileur, 2007).
Compared to a norm of less than 550 IU/L, and a previous level of 850 IU/L,
alkaline phosphatase is now 750 IU/L after mineral intake was increased.
Explain any variance from expected outcomes. Examples include the following:
Increase in head circumference is less than expected, which may be related to
use of steroid medication
Less than expected weight gain, which may be related to temperature instability
during weaning from isolette to open crib
Identify factors that enhance or impede progress and ways to address these factors.
Examples include the following:
Frequent episodes of vomiting are impeding progress toward full enteral
feedings; giving gavage feedings over longer duration(eg, over 60 minutes
instead of 10 minutes) may prevent vomiting and allow continued progression to
full enteral feedings
Interrupting parenteral nutrition for antibiotic administration is preventing
adequate parenteral nutrition intake; increase parenteral nutrition hourly rate
during the 20 hours of parenteral nutrition administration to accommodate 4
hours of antibiotic infusion
Identify when follow-up will occur, or if nutrition care can be discontinued. Examples
include the following:
Follow-up in 5 days
Nutrition goals are met; no nutrition care follow-up is necessary at this time
*Adapted from Pocket Guide for International Dietetics & Nutrition Terminology Reference
Manual. 3rd edition. Chicago, IL: American Dietetic Association; 2011: 314.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Anemia
Anemia


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Anemia > Iron Deficiency Anemia
Overview

Anemia is defined as a hemoglobin concentration 2 standard deviations below the mean in
a normal population of the same age and sex (Baker, 2010). Anemia has multiple causes; it
is marked by a deficiency in the size or number of erythrocytes, or by the amount of
hemoglobin (a conjugated protein containing four heme groups and globin, the
oxygen-carrying pigment of the erythrocytes) in the erythrocytes.
Anemia classification is based on the following:
Cell size
Macrocytic (large)
Normocytic (normal)
Microcytic (small)
Hemoglobin content
Hypochromic (pale color)
Normochromic (normal color)
Most anemias are caused by a lack of nutrients required for normal erythrocyte synthesis,
principally, iron, vitamin B-12, and folic acid. Others result from a variety of conditions,
such as hemorrhage, genetic abnormalities, chronic disease states, drug toxicity, and
elevated blood lead levels.
Treatment and nutrition recommendations depend on the type of anemia. The
appropriate provider to treat the anemia also varies, but anemia often requires a team
approach.
Iron-deficiency anemia results from low iron intake, increased iron need, or increased loss
of iron. It is characterized by the production of small (microcytic) erythrocytes and a
diminished level of circulating hemoglobin. This microcytic anemia is the last stage of iron
deficiency, and it represents the end-point of a long period of iron deprivation.
Nutrition care for a child with anemia depends on the age of the child; the type of anemia;
and the social, developmental, and medical context. The goal of nutrition care is to provide
nutrients required for growth and development in a supportive environment.
Recommendations should take each child’s and family’s needs into account. When a
family is concerned about a child’s health status, it is helpful to keep in mind that as much
as they are able, caregivers should still offer nutritious foods at regularly scheduled meals
and snacks and allow the child to choose whether and how much to eat (Satter, 2000).

Iron Intake: Avoidance of Iron-Deficiency Anemia
Iron is an essential nutrient required for growth and development. Inadequate iron intake
leads to iron-deficiency anemia. There has been increasing evidence that low iron stores
before onset of iron-deficiency anemia may have long-term neurological consequences.
For this reason, it is important to ensure that infants and children consume adequate
amounts of iron to become and remain iron replete (AAP, 2009). Both iron deficiency and
excess are harmful; it is the role of the dietitian and the health care team to help ensure the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
child receives an appropriate amount of iron.


Disease Process

Pathophysiology
Iron-deficiency anemia results when iron intake does not meet iron needs. There are many
possible causes of iron-deficiency anemia. The condition can arise from the following:
Inadequate iron intake secondary to a poor diet (such as a vegetarian lifestyle with
insufficient heme iron)
Inadequate absorption resulting from diarrhea, achlorhydria, H. pylori, intestinal
disease, atrophic gastritis, partial or total gastrectomy, or drug interference (antacids;
cholestyramine; cimetidine [Tagamet]; pancreatin; ranitidine [Zantac]; tetracycline;
and antiretroviral medications, especially the nucleoside reverse transcriptase
inhibitors, Combivir, Epivir, Retrovir, Zerit, and the protease inhibitor Crixivan)
Inadequate utilization secondary to chronic gastrointestinal disturbances
Increased iron requirement for growth of blood volume, which occurs during infancy,
adolescence, pregnancy, and lactation
Increased excretion because of excessive menstrual blood (in females); hemorrhage
from injury; or chronic blood loss from a bleeding ulcer, bleeding hemorrhoids,
esophageal varices, regional enteritis, ulcerative colitis, parasites (hookworm
disease), or malignant disease
Defective release of iron from iron stores into the plasma and defective iron utilization
owing to a chronic inflammation or other chronic disorder
Disease Progression
Stages of Deficiency
An individual’s iron status can range from iron overload to iron-deficiency anemia. Routine
measurement of iron status is necessary because approximately 6% of Americans have a
negative iron balance, approximately 10% have a gene for positive balance, and
approximately 1% have iron overload.
Deviations from normal iron status have been summarized as follows (Herbert, 1992):
Stages I and II negative iron balance (ie, iron depletion): In these stages, iron stores
are low and there is no dysfunction. In stage I negative iron balance, reduced iron
absorption produces moderately depleted iron stores. Stage II negative iron balance
is characterized by severely depleted iron stores. More than 50% of all cases of
negative iron balance fall into these two stages. When persons in these two stages
are treated with iron, they never develop dysfunction or disease.
Stages III and IV negative iron balance (ie, iron deficiency): Iron deficiency is
characterized by inadequate body iron, causing dysfunction and disease. In stage III
negative iron balance, dysfunction is not accompanied by anemia; however, anemia
does occur in stage IV negative iron balance.
Stages I and II positive iron balance: Stage I positive iron balance usually lasts for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Stages I and II positive iron balance: Stage I positive iron balance usually lasts for
several years with no accompanying dysfunction. Supplements of iron or vitamin C
promote progression to dysfunction or disease, whereas iron removal prevents
progression to disease. Iron overload disease develops in persons with stage II
positive balance after years of iron overload have caused progressive damage to
tissues and organs. Again, iron removal stops disease progression.
Iron status has a variety of indicators. Serum ferritin levels are in equilibrium with body iron
stores. Very early (stage I) positive iron balance may best be recognized by measuring
total iron-binding capacity (TIBC) (transferrin IBC). Conversely, measurement of serum
(plasma) ferritin levels may best reveal early (stages I and II) negative iron balance,
although serum TIBC may be as good an indicator.

Short-Term Consequences of Iron Deficiency
In the short term, physical signs of iron deficiency include fatigue, pallor, weakness,
shortness of breath, heart palpitations, sensitivity to cold, and loss of appetite. These
symptoms are largely reversed when iron is status is normalized.
Long-Term Consequences of Iron Deficiency
Long-term consequences of iron deficiency before development of anemia (as indicated by
hemoglobin or hematocrit) are of concern, as these may not resolve with iron
supplementation. This is an area of ongoing research, as investigators work to identify
screening tools for identification of iron deficiency prior to development of anemia and
quantify the effects of iron deficiency during critical periods of development.
Iron deficiency during the late fetal or neonatal period may have long-term consequences
on neurological development and memory, as iron is required for brain development
(Georgieff, 2007; Georgieff, 2005; Siddappa, 2004; Lozoff, 2006; Lozoff, 2006a; Yu, 1986;
deUngria, 2000; Kwik-Uribe, 2000; Beard, 2003), and iron deficiency in infancy may have
lasting impacts on cognitive, social-emotional, and motor function (Lozoff, 2006; Beard,
2007).
The effect of iron deficiency in infancy on function later in life has been reviewed by Lozoff
and colleagues (2006). Preschool children with iron deficiency have had poorer intelligence
quotient (IQ) scores, motor development, perceptual speed, and visual matching (Lozoff,
2006a), as well as altered sleep-wake cycles (Peirano, 2007).
School-aged children with iron deficiency were clumsy, hyperactive, and
inattentive and had lower IQs and less positive task orientation. Children and adolescents
who had iron deficiency in infancy had increased referrals for special education and poorer
math and writing skills and were rated by parents and teachers as more anxious and
depressed (Lozoff, 2006a). Although these differences are compelling, the studies cited in
this review are primarily case control and cannot be used to demonstrate whether
iron-deficiency anemia causes these effects.
Iron deficiency at preschool age has been associated with wary behavior, slower
demonstration of positive affect (laughing, smiling, etc.), and less social looking (visually
checking in with an adult for how to respond to a novel item) than iron-replete peers (Lozoff
2007a).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Iron deficiency is the most common nutritional deficiency in adolescence and is of special
concern for menstruating athletes. Iron-deficiency anemia in the adolescent athlete may
be the result of increase in skeletal mass, hemodilution (which is not true anemia, as blood
volume increases but red blood cell mass does not), increased gastrointestinal iron losses,
hematuria, and iron loss in sweat (AAP, 2009).
Disease progression of iron-deficiency anemia is affected by the severity of iron deficiency
and the timing of deficiency and supplementation. The consequences of iron deficiency
may also be augmented by other medical conditions, such as feeding problems or chronic
disease.

Biochemical and Nutrient Factors

Iron-deficiency anemia results when iron intake does not meet iron needs. Iron is found in
the body in two forms—functional and stored. Functional iron is primarily in the heme
groups of hemoglobin and myoglobin. It is also essential in a variety of enzymes. Iron is
stored primarily as ferritin and hemosiderin (Andrews, 2007). The balance of stores, intake,
and loss indicate risk for iron deficiency (AAP, 2009).
Several factors influence the bioavailability of dietary iron. The rate of absorption depends
on the iron status of the individual, as reflected in the level of iron stores. The lower the iron
stores, the greater the rate of iron absorption. Individuals with iron-deficiency anemia
absorb approximately 20% to 30% of dietary iron compared with the 5% to 10% absorbed
by those without iron deficiency.
The form of iron in the diet also influences absorption. Heme iron (approximately 15%
absorbable)—present in meat, fish, and poultry (MFP)—is much better absorbed than
nonheme iron, which can also be found in MFP as well as in eggs, grains, vegetables, and
fruits. The absorption rate of nonheme iron varies between 3% and 8%, depending on the
presence of absorption-enhancing factors—specifically, ascorbic acid and MFP. Ascorbic
acid is not only a powerful reducing agent, but it also binds iron to form a readily absorbed
complex.
The mechanism by which MFP potentiates the absorption of nonheme iron in other
foodstuffs is unknown. MFP digestion may lead to the release of amino acids (particularly
cysteine) and polypeptides in the upper small bowel, which then chelate with nonheme iron
to form soluble, absorbable complexes (Mulvihill, 1998).
Iron absorption can be inhibited to varying degrees by a number of factors that chelate
iron, including carbonates, oxalates, phosphates, and phytates (unleavened bread,
unrefined cereals, and soybeans). Factors in vegetable fiber may inhibit nonheme iron.
Taken with meals, tea and coffee can reduce iron absorption by 50% through the formation
of insoluble iron compounds with tannin. Iron in egg yolk is poorly absorbed because of the
presence of phosvitin.
Patients should be counseled to take the following steps to maximize iron absorption and
prevent iron-deficiency anemia:
Improve food choices to increase total dietary iron intake
Include a source of vitamin C at every meal
Include heme-containing meat, fish, and/or poultry at every meal, if possible
Avoid drinking large amounts of tea or coffee with meals
For women of childbearing age who may become pregnant, eat foods high in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
For women of childbearing age who may become pregnant, eat foods high in
heme-iron and/or consume iron-rich plant foods or iron-fortified foods with an
enhancer of iron absorption (ie, vitamin C–rich foods)
Infant iron stores are proportional to birth weight. For healthy term infants, stores are
typically adequate until 4 to 6 months of age. The bulk of iron transfer to the fetus occurs
during the third trimester. Preterm infants are typically born with appropriate iron stores for
their weight, but since they are smaller and have not had full benefit of the third trimester
iron transfer, their total iron stores are less than that of term infants (Rao, 2009). Because
of rapid growth, blood volume expansion, and phlebotomy losses, preterm infants deplete
their iron stores faster than term infants (Rao, 2009), possibly by 2 to 3 months of age, if
supplemental iron is not provided (AAP, 2009).
Quick Facts of Iron Absorption and Loss
These “quick facts” are as reported by the American Academy of Pediatrics. Values are
approximate; absorption varies between individuals and is significantly affected by gut
maturity, foods consumed with the iron-containing food or supplement, iron needs, and
other factors.
Iron Absorption:
Infants absorb ~0.8 mg/day. One-fourth of this iron is used to replace losses, and the
balance is used for growth. By adulthood, iron absorption in the male is approximately
1 mg/day, which is appr oximately equal to skin and intestinal losses.
Absorption from a single food ranges from 1% to 50% of amount consumed
Vegetable iron sources are poorly absorbed; meat sources are best absorbed
~ 4% of iron in fortified formulas and cow's milk is absorbed
~ 10% of iron in unfortified formulas is absorbed
~ 50% of iron in breast milk is absorbed
~ 4% of iron in infant cereal is absorbed
~ 10% to 20% of iron in meat is absorbed
Preterm infants absorb ~33% of dietary iron
Overall, typically 5% to 20% of iron consumed is absorbed
Tea, bran, and milk reduce absorption
Vitamin C increases absorption
Iron Loss:
Unregulated
Losses include: sloughing of intestinal mucosa, menstruation, and blood loss
(including fecal blood loss from ulcers or inflammatory bowel disease)
Consumption of cow’s milk may cause increased fecal blood loss in infants sensitive
to the proteins contained in the milk
Drinking cow’s milk before 12 months of age may reduce iron intake and
increase iron loss
(AAP, 2009)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Anemia > Sickle Cell Disease
Overview

Sickle cell disease (SCD), an inherited condition, is the most common hemoglobinopathy in
the United States, where approximately 80,000 people are affected. About one in 12
African Americans and about one in 100 Hispanic Americans carry the sickle cell trait,
which means that they are carriers of the disease (NHGRI 2009). The cause of SCD is the
substitution of glutamic acid with valine at the sixth position of the beta-globin chain of
hemoglobin.
Following are four common types of SCD, named according to the specific type of
hemoglobin by which they are characterized:
Homozygous sickle cell disease SS
Sickle cell-hemoglobin C disease SC
Sickle cell B
o
thalassemia SB
o
thal
Sickle cell B
+
thalassemia SB
+
thal
The immediate consequence of the mutation is that deoxygenated hemoglobin S
polymerizes and distorts the red blood cell into a sickle shape. The deformed cells are
fragile and increase hemolysis through blood vessels, which results in the following:
Severe anemia
Pain crises
Impeded blood flow
Organ damage
Possibly death
Studies indicate that the incidence of pain crises may be reduced by optimizing nutritional
status. In addition, some studies indicate suboptimal vitamin/mineral and amino acid status
in patients with SCD. Research is being conducted to determine benefits and safety of
nutrient supplementation in SCD.
Poor growth need not be accepted as untreatable in SCD. High-energy/high-protein
nutrition therapy is used to provide energy and nutrients to meet the higher-than-normal
nutrient needs of the sickle cell patient and to prevent malnutrition. Weight gain and
catch-up growth are desirable and attainable goals in this population. Nutrition regimens of
high energy and nutrient density can be used to meet the increased nutrient needs,
resulting from acute or chronic illness.
Normalizing nutritional status has the potential to optimize a person’s ability to respond to
treatment modalities as well as reduce the incidence of pain crises. The goal of nutrition
therapy is always to prevent malnutrition from occurring or to improve nutritional status in
patients who have nutritional deficiencies common in sickle cell disease.

Disease Process

Sickle cell disease (SCD) is a genetic hematological disease that arises from the
substitution of valine for glutamic acid in the sixth position of the beta-globin chain. SCD is
distributed in areas throughout the world that have falciparum malaria. Persons with sickle
cell trait infected with malaria have resistance to malaria. Since the distribution of sickle cell
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trait is related to malaria and not to race, it is associated with persons of Mediterranean
descent as well as regions of Africa (Heeney 2009).
Among African Americans, 1 in 600 have the disease, and 1 in 12 have the trait for the
disease. It is charactized by unpredictable and intense vso-occlusive pain episodes, which
frequently result in hospital admissions (Mitchell 2009). It causes development of acute and
chronic organ impairment, acute chest syndrome, stroke, and priapism. All of the chronic
conditions described as follows can worsen over time.
There are two primary manifestations of SCD:
Hemolytic anemia
Vaso-occlusion
Hemolytic manifestations of SCD include the following:
Chronic anemia
Jaundice
Aplastic crisis
Gallstones
Vaso-occlusion results in the following:
Recurrent acute pain
Functional asplenia
Splenic sequestration
Acute chest syndrome
Stroke
Hyposthenuria and enuresis
Chronic nephropathy
Priapism
Avascular necrosis
Proliferative retinopathy
Leg ulcers
SCD is most common in people with ancestors from the following geographic locations:
Africa
Central America (especially Panama)
South America
Caribbean countries
Mediterranean countries
India
Near Eastern countries
Homozygous SCD and sickle B thalassemia are generally more severe than hemoglobin
sickle cell and hemoglobin SB
+
thalassemia. The deleterious effects of SCD arise from the
sickled shape of the red cells, as they block the microvasculature and are more likely to
adhere to the vascular endothelium. Both of these factors contribute to the pathophysiology
of the vaso-occlusion. Vaso-occlusive pain events represent the most common
manifestation of SCD. Infants are prone to dactylitis, or painful swelling of the hands and
feet. As the child ages, the hematopoiesis moves to more central locations. Thus, older
children and adults are more prone to pain in the arms, legs, chest, and ribs. Severity of
painful episodes increases dramatically with age. Since intracellular dehydration can
increase red cell sickling, patients at home or in the hospital are taught to maintain
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hydration between 1.0 and 1.25 times maintenance fluid (Fixler 2002).
The infant with SCD is at high risk for infection. This is because the sickled red cells infarct
the spleen. SCD patients become functionally asplenic and are particularly prone to
bacterial infections from encapsulated organisms like streptococcus pneumonia,
salmonella, and haemophilus (Fixler 2002; Serjeant 2001a, Gill 1995). Patients take
prophylactic penicillin throughout childhood. Every fever in a patient with SCD is evaluated.
Parents are taught to monitor spleen size at home because of the risk of splenic
sequestration in SCD. This is a serious event and a common cause of morbidity in infants
and young children with SCD. Splenic sequestration results in a rapid drop in hemoglobin
as sickle cells are rapidly removed from circulation and sequestered in the spleen. This
eventually leads to hypovolemia and shock, requiring red cell transfusion and fluid
resuscitation. (Fixler 2002).
The vascular complications of SCD have now been grouped as being related to two
phenotypes of vasculopathy: (1) a viscosity-vaso-occlusion subphenotype that is
associated with vaso-occlusive crisis and acute chest syndrome (ACS), and (2) a
hemololysis-endothilial dysfunction subphenotype that is associated with pulmonary
hypertension, systemic hypertension, priapism, leg ulceration, stroke, sudden death, and
asthma. Pulmonary hypertension occurs in about one-third of adults and children with SCD
(Morris 2008, Kato 2006).
Changes in vascular endothelium in SCD are caused by hemolysis and release of
hemoglobin into plasma. This causes changes in the availability of nitric oxide (NO) and
arginine. This dysregulated arginine metabolism leads to deficiency of arginine, which is
accompanied by a decrease in NO (Morris 2005). Arginine decreases further during
vaso-occlusive crises and ACS (Morris 2008). The NO decreases platelet activation and
limits injury from ischemia, as well as being a potent vasodilator. Oxidative stress is a
prominent feature of SCD, with increased concentrations of reative oxygen species in
sickle cell erythrocytes compared to normal (Morris 2008). This is accompanied by
alterations in the glutathione buffering system so that sickle erythrocytes cannot handle the
increased oxidant burden.
Glutamine is important for glutathione homeostasis, and is depleted in sickle cell
erythrocytes. Glutamine is a precursor for arginine production in the citrulline-arginine
pathway in the kidneys, so researchers have included arginine and glutamine as
therapeutic interventions that could improve the vasculopathy of SCD (Morris 2008; Kaul
2008; Niihara 2005).
The leading cause of death in SCD is acute pulmonary injury. ACS is the combination of
fever, chest pain, respiratory symptoms, and a new pulmonary infiltrate. Because of ACS,
pneumonia in SCD is more severe than in the general population. In one study, half of the
patients with ACS had originally been admitted for pain and went on to develop ACS. This
happens especially in patients who have pulmonary fat embolism, which is thought to result
from bone marrow necrosis. Necrotic bone marrow is released into the blood and the bone
marrow fat travels to the lung (Vichinsky 2000). Because of the seriousness of ACS, a
chest X-ray is performed on all febrile children with SCD. Repeated episodes of ACS can
lead to pulmonary hypertension and cor pulmonale. Transfusions are often initiated to stop
the progression of pulmonary hypertension (Fixler 2002).
Cerebral infarction and hemorrhage are common in SCD. Among SCD patients, 30% show
evidence of asymptomatic cerebral infarction on magnetic resonance imaging. Of these,
10% to 12% suffer a symptomatic stroke in childhood (Miller 2001).
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10% to 12% suffer a symptomatic stroke in childhood (Miller 2001).

Biochemical and Nutrient Factors

People with sickle cell disease (SCD) are often smaller and leaner than their healthy
counterparts.
Research has found that people with SCD experience the following:
Increased resting energy expenditure (REE)
Increased protein turnover
Increased bone turnover
Decreased bone mineral density (Badaloo, 1989; Barden, 2000; Borel, 1998; Brinker,
1998; Buchowski, 2001; Buchowski, 2002a; Buchowski, 2002b; Kopp-Hoolihan, 1999;
Salman, 1996; Singhal, 1993; Williams, 2002)
There are also reports of amino acid deficiencies in SCD. Of the 13 amino acids known to
be low in the plasma of sickle cell patients (Enwonwu, 1990; Van der Jagt, 1997), 3 have
been supplemented: glutamine (Niihara, 1998; Storm, 2003), citrulline (Waugh, 2001), and
arginine (Morris, 2000; Morris, 2003a). Supplementation with glutamine resulted in
decreased REE, improved nutritional parameters, and improved muscle strength (Williams,
2004). Another study showed that supplementation with glutamine improved minute
ventilation and exercise endurance of sickle cell patients (Macan, 2007). Citrulline
supplementation (chosen for its ability to raise arginine and, hence, nitric oxide levels),
resulted in improvement in well-being, increased arginine levels, and reductions in high
total leukocyte and high segmented neutrophil counts. Arginine is a precursor to nitric
oxide, which is in increased demand during vaso-occlusive events.
Nitric oxide, also known as "endothelial relaxing factor," is a potent vasodilator and has
been found to decrease vaso-occlusion in sickle cell patients. It also limits platelet
aggregation and reduces adhesion of sickle red blood cells to activated endothelium
(Space, 2000). Arginine is known to be deficient in sickle cell anemia (Enwonwu, 1990).
Arginine supplementation of 0.1 g/kg to 0.5 g/kg in sickle cell patients resulted in increased
nitric oxide production in patients having a vaso-occlusive event. Researchers believed that
the decreased nitric oxide production observed during vaso-occlusion may be corrected by
supplementation with arginine (Morris, 2000). and that arginine therapy would show great
promise as a therapy for sickle cell patients. However, a trial of either 0.05 g/kg/day or 0.1
g/kg/day in patients with sickle cell anemia did not show a change in arginine levels. The
study concluded that oral arginine therapy did not provide a clinical benefit for pediatric
patients with SCD, in regard to the outcomes they measured. The authors speculated that
the dose of arginine used in the study may not have been sufficient (Styles, 2007).
Arginine is also being used successfully to reduce pulmonary hypertension, a common
sequellae of sickle cell disease (Morris, 2003a).
Zinc has been supplemented in sickle cell patients despite conflicting results with plasma
zinc levels being low in sickle cell patients (Abshire, 1988; Fung, 2002; Prasad, 1999;
Prasad, 1988, Zemel, 2002; Leonard, 1998). Zinc supplementation is warranted in SCD
when there is low plasma zinc or growth deficiency in the presence of normal plasma zinc
status because of the insensitivity of plasma zinc in predicting zinc status. Significant
increases in growth were observed in sickle cell patients supplemented with 10 mg zinc
daily, even though plasma zinc levels remain unchanged (Fung, 2002), suggesting that
zinc supplementation should be considered in any sickle cell patient with poor growth,
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regardless of plasma zinc status.
Growth hormone levels, specifically insulin-like growth factor (IGF)-1, is dependent on zinc
for its action (MacDonald, 2000). IGF-1 levels increase during trials of zinc
supplementation (Ninh, 1996; Siklar, 2003; Nakamura, 1993). Therefore, treatment with
growth hormone may be ineffective in the presence of poor zinc status. As above, plasma
zinc status should not be the determinant of zinc status in the individuals in the SCD
population who respond positively to zinc supplementation regardless of plasma zinc status.
Magnesium is also found to be deficient in the sickle cell population. When magnesium
was supplemented for 4 weeks in sickle cell patients, hydration of the red blood cell
improved, resulting in a reduction in the number of dense sickle cell erythrocytes, which are
problematic in the vaso-occlusion events of sickle cell disease. Magnesium inhibits
potassium chloride cotransport that controls cell volume (Brugnara, 1986). When
intracellular magnesium is low, as in SCD, this promotes potassium chloride cotransport,
which results in increased potassium efflux and cellular dehydration (DeFranceschi, 1997;
DeFranceschi, 1998). Supplementing magnesium inhibits potassium chloride cotransport,
which decreases potassium efflux and restores red blood cell hydration.
Magnesium deficiency in SCD may be a significant factor in the disease because of
increased losses or decreased intake (Zehtabchi, 2004).When magnesium was
supplemented for 6 months, a significant reduction in the number of painful episodes was
observed as well as the reduction of the number of dense sickle cell erythrocytes
(DeFranceschi, 1997; DeFranceschi, 2000). Serum magnesium values are insensitive and
a normal value does not always reflect optimum status (Arnaud, 2008). Magnesium levels
are lower in the African-American population (Resnick, 1997; Fox, 1999) and are known to
be low in children with SCD (Altura, 2002). Ionized magnesium and ionized
calcium-to-magnesium ratios were measured in adults with SCD. The SCD patients had
significant hypomagnesemia compared to healthy controls. Lower magnesium levels in
SCD compared to healthy African Americans were only found by measuring ionized
magnesium versus total serum magnesium (Zehtabchi, 2004).
As with zinc, magnesium should be supplemented if a low serum value is obtained. If a
patient has a normal serum magnesium level, magnesium deficiency may still exist.
Magnesium supplementation should be considered whenever a patient is not growing well
or having frequent pain crises. Sulfates of magnesium should be avoided. Magnesium
oxide, at a level of 7 mg/kg/day, is generally well-tolerated.
Sickle cell patients have suboptimal vitamin A status. One study found 66% of children with
sickle cell disease had suboptimal vitamin A status; these children had higher overall risks
of hospitalization for fever and pain than sickle cell patients with normal vitamin A status
(Schall, 2004).
Vitamin E levels have been measured in several studies and are found to be suboptimal in
patients with SCD (Sindel, 1990). One study determined that transfusion therapy lowers
vitamin E–type antioxidant capacity (Marwah, 2002). Another study found normal VItiamin
E levels (Broxson, 1989).
There are several reports of vitamin B-6 deficiency in SCD. One report links this deficiency
to poor riboflavin status (Adelekan, 1987). Several reports associate increased plasma
homocysteine in SCD patients with low vitamin B-6 levels or low folate or vitamin B-12
status (van der Dijs, 1998; Balasa, 2002; Nelson, 2002; Al-Momen, 1995), as well as poor
riboflavin, zinc, and vitamins A and E status. (Sindel, 1990; Leonard, 1998, Zemel, 2002)
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Vitamin D status and intake are often low in children with SCD; status was lowest during
spring (Buison, 2004). One study looking at bone status before, during, and after vitamin D
repletion found increased CTx levels in the SCD patients before and after treatment. The
researchers speculate that bone resorption may be one of the mechanisms of low bone
mineral density in SCD patients and that the chronic inflammation present in SCD may
contribute to this (Adewoye, 2007). The study's repletion regime consisted of 50,000 IU
ergocalciferol weekly for 8 weeks, followed by 50,000 IU ergocalciferol every other week for
44 weeks. A dose of 1,000 mg calcium carbonate was given daily throughout the treatment
period. An interesting finding was that parathyroid hormone (PTH) levels remained
unchanged. Researchers believed this was the result of the effects of hypomagnesemia,
which blunts the PTH response, and is common in SCD (Sahota, 2006, DeFranceschi,
1997). The authors of the vitamin D repletion study state that long-term vitamin D and
calcium therapy is likely to be required "given the chronicity of SCD and its relentless
vasoocclusive, hemolytic, and inflammatory complications" (Adewoye, 2007).
Bone density in children with SCD was found to be low in 64% of 25 SCD patients aged 9
to 19 years, including the youngest children in the study. This indicated that deficits in bone
mineralization start early in SCD. These patients also had low vitamin D status but did not
have increased bone resorption as measured by serum NTX levels (Lal, 2006).
There is one report of poor vitamin C status in sickle cell patients (Chiu, 1990).
One study determined optimal dosage amounts of B-vitamins based on plasma
homocysteine normalization. The recommended daily dosages of vitamins in this study
were 1 mg folate, 6 mcg B-12, and 6 mg B-6 for children aged 7 to 16 years (van der Dijs,
2002).
Frequency of pain episodes in SCD patients was decreased by approximately half in
subjects receiving supplementation with 3 g menhaden fish oil capsules daily. There was
no associated increase in prothrombin time (Tomer, 2001). Other researchers have found
that leukocytes from sickle cell patients have high levels of two adhesion molecules and
that they had significantly lower amounts of omega-3 fatty acids in erythrocytes and
plasma. This deficiency of omega-3 fatty acids was significantly greater in patients with
complications of SCD in comparison to those who had none (Okpala, 2007).
Some patients also may have iron deficiency anemia, which should be positively
diagnosed before iron therapy is initiated. However, patients with SCD can have low
hemoglobin, which may not be caused by iron-deficiency anemia (Ekvall, 1993). Because
of potential risks of iron overload, supplementation with iron should be approached with
caution in children with SCD. The anemia that is present is not typically because of iron
deficiency, but simply the result of increased hemolysis (Stettler, 2001).
Patients may need additional folate because of the red cell turnover (Ekvall, 1993;
Kennedy, 2001).
Supplementation should be discussed with the patient’s physician.
Transfusion therapy is becoming a more common treatment for some patients with
numerous vaso-occlusive crises and acute chest syndrome. Iron supplementation should
not be used in these patients.


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Diseases/Conditions > Behavioral Health
Behavioral Health


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Behavioral Health > Eating Disorders
Overview

The Academy for Eating Disorders (AED) has recently published a position paper stating
that eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and Eating
Disorders Not Otherwise Specified (EDNOS) are biologically based, serious mental
illnesses (Klump, 2009). The AED position is based on current scientific evidence that
eating disorders are heritable, neurobiological illnesses that pre-dipose sufferers to the
illness, perhaps in the presence of environmental triggers.

This new paradigm in thinking about eating disorders will have a profound impact on
treatment of the diseases. Health care providers from many disciplines have not had
effective treatment models to use or evidence pointing to approaches that work well; thus
many families with a child suffering from an eating disorder are left with few options for
effective care. Compounding this is the fact that many insurance companies still do not
cover treatment for eating disorders or coverage is inadequate, and families often find
themselves going from treatment center to treatment center, exhausting resources, yet still
caring for a child who is medically unstable and nutritionally compromised.
This section provides a brief review of current literature on eating disorders, including
theories about causation- and evidence-based treatment modalities. Medical nutrition
therapy in eating disorder treatment and ideas about the role of dietetics professionals is
reviewed. Medical nutrition therapy and nutrition counseling in treating pediatric eating
disorders needs to be evaluated and brought in line with emerging science about eating
disorders. It is essential that anyone who endeavors to work with families caring for a child
with an eating disorder understand these disorders thoroughly, be up to date about and
know what the best evidenced-based treatment options are, and understand their scope of
practice and best contribution to a treatment team (ADA, 2006).

Brief descriptions of AN, BN, BED, EDNOS
The numbers of children and adolescents with diagnosed anorexia nervosa and bulimia
nervosa has steadily increased from the 1950s to the present (AAP, 2003). Eating
disorders are the third most common chronic illness seen in adolescent females, affecting
approximately 5% of this age group (SAM, 2003).
AN affects approximately 0.5% to 1% of any population and does not discriminate on the
basis of gender, socioeconomic group, or ethnic background. Key features of this illness
are the persistent restriction of adequate kilocalories and excess physical activity, leading
to the medical complications associated with starvation.
Individuals with BN regularly binge or consume large quantities of food and may state that
they feel out of control during a binge. To compensate for binging, inappropriate and
dangerous compensatory behaviors are used, which include excessive physical activity,
laxative and diuretic use, and induced vomiting.
Binge-eating disorder (BED) is a provisional category of EDNOS, and is characterized by
recurrent binge eating, with a sense of not being in control of one’s eating behavior.
Compensatory purging behavior is not used. BED is associated with obesity.
Individuals who do not meet the Diagnostic Criteria for AN or BN are diagnosed as having
l
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EDNOS. Many younger patients fall into this category because the diagnostic criteria are
adult focused. If a patient falls into this category, it does not mean that the illness is not
serious.
Current estimates are that 40 to 60% of children with eating disorders end up diagnosed
with EDNOS (AAP, 2003) or 0.8 to 14% of the total adolescent population (Rosen,
2010). Many treatment programs will not accept individuals for treatment until they meet
full diagnostic criteria for AN or BN, so a child diagnosed with EDNOS is at risk for the
disorder becoming worse and an important opportunity for early treatment is missed.
Children and adolescents are often placed into the EDNOS category because they do not
fit the criteria for full AN or BN. For example, in one retrospective study of almost 400
patients admitted to an eating disorder unit, 30% of those patients had been diagnosed
with EDNOS. Of those nearly half were anorexic without amenorrhea, 28% were anorexic
but had an ideal body weight greater than 85% even though many had lost more than 20%
total body weight, and 3% had BN but did not meet frequency or duration criteria (Wilfley,
2007).
Children participating in sports, such as running, or performance activities, such as dance
or gymnastics, where a lean body type is promoted, are at increased risk for development
of an ED (Rosen, 2010).

Etiology

The classic eating disorders, anorexia nervosa (AN) and bulimia nervosa (BN), frequently
emerge during adolescence. There has been little understanding about the development of
these disorders which in turn has resulted in few effective treatments or interventions, and
very little to offer in prevention of relapse.
Current research on eating disorders has revealed that these disorders are heritable,
neurobiological disorders that result in serious mental illness. Results of twin studies have
shown that 50 to 83% of the variance in anorexia nervosa, bulimia nervosa and
binge-eating disorder (BED), considered a form of Eating Disorder Not Otherwise Specified
(EDNOS), can be accounted for by genetic factors. Chromosomes 1, 4 and 10 may contain
risk genes for AN and BN and chromosomal regions are being identified that may be
involved in the serotonin, brain-derived neurotrophic factor (BDNF), and opioid systems,
implicated in risk for AN. In both AN and BN there are alterations in brain serotonin,
neuropeptide systems and also brain neurocircuitry which are present when the disease is
in its active state as well as in apparent recovery (AMC, 1998). Neuroimaging studies have
shown abnormalities in brain structure and that an area of the brain housing the insula is
poorly perfused in AN, an alteration that persists after weight restoration (Nunn, 2008).
Evidence exists that alteration in brain serotonin function plays a role in the odd appetite,
mood, and impulse control observed in eating disorders.
Consistent personality traits seen in AN and BN such as perfectionism, obsessive
compulsiveness, and dysphoric mood, sometimes seen in a child before the eating
disorder sets in and remaining after weight restoration, offering the intriguing suggestion
that biologically determined personality traits may be indication of a predisposition to an
eating disorder (Kaye, 2008).
From the early starvation study by Ancel Keys came the knowledge that starvation itself
produces many of the symptoms, personality disturbances, and odd behaviors seen in AN.
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produces many of the symptoms, personality disturbances, and odd behaviors seen in AN.
Others have noted that the psychopathology is a consequence of the starvation, instead of
a cause of the starvation, seen in anorexia nervosa (Bergh, 2002). From this knowledge
many have correctly observed that until weight is restored and physical disturbances
corrected in any eating disorder, cognitive therapies are rarely effective, because the
starved brain cannot process thoughts normally (Kalm, 2005).
ETIOLOGY-REFEEDING SYNDROME
Severe caloric restriction over a long period of time leads to reduction in both adipose and
lean tissue mass. Cardiac mass and output are decreased and respiratory function is
reduced which can lead to carbon dioxide retention.
In uncomplicated starvation, serum protein levels remain normal and are not a good
indicator of the degree of malnutrition.
Adaptation to starvation includes lower metabolic rate and metabolic shift to free fatty acids
and ketones as fuel. Overall poor nutrient intake results in depleted vitamin and mineral
status, including zinc, folic acid, thiamin, phosphorus, magnesium, and potassium.
Serum levels of electrolytes may be normal during starvation, while total body stores are
low. If feeding is initiated too quickly and carbohydrates fed especially aggressively, there
is a shift of electrolytes into cells, initiation of glycolysis and other carbohydrate metabolic
events, and a rapid depletion of serum phosphate and other electrolytes.
With carbohydrate feeding, insulin secretion can cause sodium and fluid retention due to
renal tubule retention of sodium.
In patients adapted to starvation, it is clearly dangerous to give calories, especially
carbohydrate, and fluids too quickly. See also the Refeeding Syndrome section.
The main biochemical findings in refeeding syndrome are as follows:
Hypophosphatemia
Hypomagnesemia
Hypokalemia
Glucose intolerance
Fluid overload
Thiamin deficiency

Biochemical and Nutrient Issues

Medical Complications Resulting From Purging
Persistent purging can lead to fluid and electrolyte imbalance, hypokalemia,
hyponatremia, and hypochloremic alkalosis.
Vomiting, laxative and diuretic abuse can lead to hypochloremic, hypokalemic
metabolic alkalosis.
Use of ipecac can lead to irreversible myocardial damage and a diffuse myositis.
Chronic vomiting can lead to esophagitis, dental erosions, Mallory-Weiss tears, rare
esophageal or gastric rupture, or rare aspiration pneumonia.
Use of laxatives can lead to depletion of potassium bicarbonate, causing metabolic
acidosis; increased blood urea nitrogen concentration and predisposition to renal
stones from dehydration; hyperuricemia; hypocalcemia; hypomagnesemia; or chronic
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
dehydration. With laxative withdrawal, patient may get fluid retention (may gain up to
10 pounds in 24 hours).
Women may experience amenorrhea (can be seen in normal or overweight
individuals with bulimia nervosa) or menstrual irregularities.
Osteopenia
Medical Complications From Caloric Restriction
Cardiovascular Electrocardiographic abnormalities: low voltage; sinus bradycardia
(from malnutrition); T wave inversions; ST segment depression (from electrolyte
imbalances). Prolonged corrected QT interval is uncommon but may predispose
patient to sudden death. Dysrhythmias include supraventricular beats and ventricular
tachycardia, with or without exercise. Pericardial effusions can occur in those
severely malnourished. All cardiac abnormalities except those secondary to emetine
(ipecac) toxicity are completely reversible with weight gain.
Gastrointestinal system: delayed gastric emptying; slowed gastrointestinal motility;
constipation; bloating; fullness; hypercholesterolemia (from abnormal lipoprotein
metabolism); abnormal liver function test results (probably from fatty infiltration of the
liver). All are reversible with weight gain.
Renal: increased blood urea nitrogen concentration (from dehydration, decreased
glomerular filtration rate) with increased risk of renal stones; polyuria (from abnormal
vasopressin secretion, rare partial diabetes insipidus). Total body sodium and
potassium depletion caused by starvation; with refeeding, 25% can get peripheral
edema attributable to increased renal sensitivity to aldosterone and increased insulin
secretion (affects renal tubules).
Hematologic: leukopenia; anemia; iron deficiency; thrombocytopenia.
Endocrine: euthyroid sick syndrome; amenorrhea; osteopenia.
Neurologic: cortical atrophy; seizures (AAP, 2003).
Patients with anorexia nervosa often manipulate water intake and may drink too much
water to falsely elevate weight, or too little water so they weigh as little as possible.
Hypo- or hypernatremia can result.

MEDICAL COMPLICATIONS IN REFEEDING SYNDROME
The main biochemical findings in refeeding syndrome are:
Hypophosphatemia
Hypomagnesemia
Hypokalemia
Glucose intolerance
Fluid overload
Thiamin deficiency
See the Refeeding Syndrome section for more details.


Anorexia Nervosa

Anorexia nervosa (AN) affects approximately 0.5% to 1% of any population and does not
discriminate on the basis of gender, socioeconomic group, or ethnic background. Key
features of this illness are the persistent restriction of adequate kilocalories and excess
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
physical activity, leading to the medical complications associated with starvation.
A clinician working with anorexia nervosa needs to understand the nature of this illness. AN
is not an illness one chooses. It is a genetically based, biological illness that is maintained
by certain environmental factors. There are often co morbid illnesses such as anxiety and
depression, which some medications can help manage.

The general course of treatment for anorexia nervosa is:

Ensure medical stability with the aid of a knowledgeable medical team, experienced in
the early feeding of patients at risk for refeeding syndrome. Identify those at risk and
feed according to an established protocol to avoid complications from re-feeding
syndrome (see criteria for hospitalization).
1.
Once patient is medically stable gradually increase macronutrients so that weight gain
is achieved. In pediatrics the evidence is strong that this part of treatment can be
done in the home, under medical supervision, coaching the family in the supportive
role of refeeding.
2.
Monitor for micronutrient deficiencies and correct if suspected or present. 3.
Monitor and stop exercise in the initial phases to allow for weight gain and return of
normal physical functions. Excess exercise is seen as a purging behavior, as it rids
one of unwanted calories.
4.
Once target weight is achieved then ensure that weight remains stable. This is an
important step to avoid relapse. Monitoring of food intake and exercise is needed until
the patient shows an improvement in attitude about eating, is comfortable with age
appropriate feeding skills.
5.
Criteria for Hospitalization (AAP, 2003)
<75% recommended weight or ongoing weight loss despite intensive management
refusal to eat
body fat <10%
heart rate < 50bpm daytime
<45 bpm night
systolic bp <90
orthostatic changes in pulse>20 bpm or bp > 10 mm Hg
temperature <96 degrees
arrhythmia

Bulimia Nervosa

In bulimia nervosa (BN), individuals regularly binge or consume large quantities of food.
They may state that they feel out of control during a binge. To compensate for binging,
inappropriate and dangerous compensatory behaviors are used, which include excess
physical activity, laxative and diuretic use, and induced vomiting.
The current DSM-IV criteria for BN are:
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by the
following:
Eating, in a discrete period of time (eg, within any 2 hour period) an amount of food
that is significantly larger than most people would eat during a similar period of time
and under similar circumstances
A sense of lack of control over eating during the episode (ie, a feeling that one cannot
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A sense of lack of control over eating during the episode (ie, a feeling that one cannot
stop eating or control how much one is eating)
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting;
or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors occur, on average, at least
twice a week for three months.
D. Self evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
(APA, 2000)
Criteria for Hospitalization (AAP, 2003)
Syncope
Serum potassium < 3.2 mmol/L
Serum chloride < 88 mmol/L
Esophageal tears
Cardiac arrhythmias including prolonged QTc
Hypothermia
Suicide risk
Intractable vomiting
Hematemesis
Failure to respond to outpatient treatment

Binge Eating Disorder

Research Criteria for Binge Eating Disorder (BED)
Recurrent episodes of binge eating, characterized by both of the following:
Eating in a discrete period of time (eg, within any 2-hour period) an amount of food
that is significantly larger than most people would eat in a similar period of time under
similar circumstances
A sense of lack of control over eating during the episode (ie, a feeling that one cannot
stop eating or control what or how much one is eating)
The binge-eating episodes are associated with three (or more) of the following:
Eating much more rapidly than normal
Eating until uncomfortably full
Eating large amounts of food when not feeling physically hungry
Eating alone because of being embarrassed by how much one is eating
Feeling depressed, disgusted with oneself, or very guilty after overeating
Marked distress regarding binge-eating
Note that the method of determining frequency differs from that used for bulimia nervosa;
future research should address whether the preferred method of setting a frequency
threshold is counting the number of days on which binges occur or counting the number of
episodes of binge eating.
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The binge eating occurs on an average at least 2 days a week for 6 months.
The binge eating is not associated with regular inappropriate compensatory behaviors (eg,
purging, fasting, excessive exercise) and does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa.

Provisional research criteria for diagnosing BED in children:
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both
of the following:
Food-seeking behavior in absence of hunger (eg, after a full meal)
A sense of lacking control over eating (eg, feeling that when one starts to eat, they
can't stop)
B. Binge episodes are associated with one or more of the following:
Food-seeking in response to negative affect (eg, sadness, boredom, restlessness)
Food-seeking as a reward
Sneaking or hiding food
C. Symptoms persist over a period of 3 months
D. Eating is not associated with regular inappropriate compensatory behaviors (eg,
purging, fasting, excessive exercise) and does not occur exclusively during the course of
anorexia or bulimia nervosa (Marcus, 2003).

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Diseases/Conditions > Behavioral Health > Mood Disorders
Overview

Mood disorders or disturbances are a prolonged display of feelings that color the whole
emotional life. Affective disorders are a temporary expression of feelings or state of mind
(Jarvis, 1992). Mood disorders may be a short-term episode or may persist for weeks or
years.
Mood disorders may be associated with a positive family history, substance abuse, eating
disorders, medications, and suicide attempts. They may be accompanied by symptoms
such as the following:
Depression
Anxiety
Agitation
Irritability
Phobias
Sleep and appetite disturbances
Physical symptoms
Fatigue
Headaches
Abdominal pain
Diverging opinions continue for and against using the same criteria for adults in the DSM
IV to diagnose mood disorders in children and adolescents, thus a need to improve criteria
for diagnosis and early intervention (Farias 2011).
While major depression is comparatively rare in children, up to 25% of adolescents
experience at least one major depressive episode by the end of adolescence. Mania in
adolescence is less common, with less than a 2% lifetime prevalence after adolescence
(Kessler, 2001).
From 1987 to 1996, the overall rate of psychotropic medication use by children increased
from 1.4 to 3.9 per 100 persons. Significant increases were found in stimulant use
(especially common in children aged 6 to 14 years), antidepressant use (common is
children aged 15 to 18 years), and co-prescription of different classes (especially stimulants
and antidepressants) (Olfson, 2002).
There are increasing rates of bipolar diagnoses in children, but this is controversial, as
children rarely meet full criteria, as detailed in the fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders, for bipolar disorder (Biederman, 2004; Parens,
2010).
Some medications given for mood disorders have food–drug interactions.

Disease Process

Mood disorders are characterized by a disturbance in mood as a prominent feature. Mood
disorders include major depressive disorder, dysthymic disorder, bipolar disorder, and
cyclothymic disorder. Mood episodes serve as the building block for the diagnosis, and
include major depressive episode, manic episode, mixed episode, and hypomanic episode.
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There may also be a developmental association in the disease process; for example,
adolescent females with depressive symptoms may be more likely to develop eating and
substance abuse disorders (Measelle, 2006). Comorbidities are also possible. For
example, children and adolescents with autism spectrum disorders may be managed with
medications for mood difficulties.
A registered dietitian (RD) participates in the health care team for patients with mood
disorders to address food insecurity or inadequate food/nutritional intake; the nutritional
consequences of mood episodes, such as appetite changes or unplanned weight changes;
possible nutritional effects of medications; or the presence of comorbidities with nutritional
consequences, such as eating disorders or substance abuse.
Mental health workers most often use a multi-axial system to assess a client.
There are five axes included in the multi-axial classification system published in the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders:
Axis I - Clinical disorders; Other conditions that may be a focus of clinical attention
Axis II – Personality disorders; developmental disorders
Axis III – General medical conditions
Axis IV – Psychosocial and environmental problems
Axis V - Global assessment of function (GAF: a scale from 1-100)
The GAF scale considers only the psychological, social, and occupational function on a
hypothetical continuum of mental health/illness. The GAF scale does not include
impairment in functioning due to physical or environmental limitations. It may provide the
RD with an indicator of the patient’s learning readiness and ability to manage self-care
(DDPD, 2006).

Neurobiology Review (from Nutrition Care Manual)
Neuron (a nerve cell): The axons, or main body, of nerve cells (<1 mm to 3 feet in
length) relay biochemical messages from one nerve cell to another, crossing the
synapse between dendrites (the branches at the end of each axon).
Neurotransmitter: Electrical stimulation of the neuron causes the release of chemical
compounds called neurotransmitters, which flow across the synapse to deliver the
“message” to the receiving dendrite. At least 70 neurotransmitters have been
identified that regulate such functions as memory, appetite, cognition, emotion, and
sleep. Neuropeptides such as histamine, neuropeptide-Y, beta-endorphin, and others
are thought to be probable neurotransmitters.
Five neurotransmitters are directly linked to food commonly consumed: serotonin,
dopamine, norepinephrine, histamine, and acetylcholine.
Reuptake: Once the neurotransmitter has delivered its message, it is dismantled
down or resorbed back into the cells’ storage space to be used again. (SSRI
medications are selective serotonin reuptake inhibitors.)
Blood brain barrier (BBB): The BBB maintains a constant environment for the brain. It
allows some molecules to cross into the neurons. Like other cell membranes, some
substances enter directly, some by special carrier.
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(Somer, 1999)
Nutrients and Neurons
Amino acids: Building blocks of neurotransmitters.
Vitamins and minerals: Assist in the production of neurotransmitters (as precursors
and catalysts), enhance neurotransmitter activity, or protect neurotransmitters from
damage.
Neurotransmitters and diet: Food and nutrients directly influence nerve cell function,
mood and behavior. Activity of some neurotransmitters is enhanced or limited by diet.
Overconsumption or severe restriction of a macronutrient such as carbohydrate or fat
can trigger imbalances, which contribute to mood swings, irritability, altered cognition,
and food cravings.

Biochemical and Nutrient Factors

Activity of some neurotransmitters is enhanced or limited based on diet. Tables of
neurotransmitters made from food and neurotransmitter influences on food consumption
can be found in Psychiatric Nutrition Therapy: A Resource Guide for Professionals
Practicing in Behavioral Health Care (DDPD, 2006). The greater concern for patients with
mood disorders is diet quality, with a focus on nutrient-dense calories from vegetables,
fruits, whole grains, and fewer saturated fats and added sugars (Guenther, 2007).
Although research in this area is in the early stages and results are largely correlational, it
points to potential effect of diet, nutrient intake, and nutritional status. One example from
the Third National Health and Nutrition Examination Survey indicated that food-insufficient
adolescents (aged 15 and 16 years) were significantly more likely to have had dysthymia,
thoughts of death, and a desire to die and have attempted suicide (Alaimo, 2002).

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Diseases/Conditions > Burns
Overview

Nutrition support of the pediatric burn patient requires an understanding of the physiologic
and metabolic alterations that accompany traumatic injury. The inflammatory response that
characterizes burn injury is virtually identical in adults and children, as are many aspects of
medical and surgical management of burns. However, nutrition therapy must
be tailored to accommodate differences in energy and protein metabolism, substrate
utilization, micronutrient requirements, and alterations in body composition that
are inherent to the pediatric patient. In addition, in order to facilitate growth, nutrition care
often extends well into convalescence. Nutrition care planning for the pediatric burn
patient, therefore, often proceeds in phases from the acute to rehabilitative phase of
recovery.
Acute Phase
Burn injury sets off an inflammatory cascade characterized by whole body protein
breakdown, thus diminishing body cell mass, specifically skeletal cell mass. Therefore, the
goal of nutrition support during this acute phase is monitoring and preservation of this body
cell mass via adequate energy, protein, electrolytes, and vitamin/mineral supplementation.
Aggressive nutrition support for the burn patient is a necessary intervention to
counterbalance hypermetabolism and protein hypercatabolism during the acute phase of
injury. The need for continual nutrition assessment remains paramount, as patients
progress from the ebb phase into the flow phase (height of energy surge). Energy and
protein needs may be altered as the surface area of wounds change related to closures or
increased number of donor sites.
Rehabilitative Phase
Marked nutritional wasting may occur despite aggressive nutritional support. This is
sometimes only recognized after the patient's wounds have healed. Hence, at the time of
entry into the crucial period of rehabilitation where muscle strengthening, endurance, and
performance of daily activity is the focus, many patients have suboptimal nutritional status.
Thus, the nutrition focus is on promoting anabolism as opposed to minimizing breakdown.
A combination of nutritional supplementation and continuation of nutritional pharmacology
can achieve this goal.
Convalescence
Although some patients may still be hypermetabolic at the time of discharge, most have
normalized with respect to muscle breakdown. As children return to their daily lives, they
are challenged by the normal activities of eating, playing, and socializing. Moreover, they
must return to the hospital for periodic stays for additional surgeries and care. This can
often affect growth. Nutrition care shifts to monitoring growth and the promotion of further
gains in weight and stature.

Disease Process

The most severe form of stress the human body can endure is a major burn. Severe stress
is characterized by the following:
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Hypermetabolism
Metabolic disarray
Hemodynamic instability
Background Information
Burns are classified by 1) burn depth: how deeply the injury penetrates the skin and
underlying tissue; and 2) burn size or area: the percent of total body surface area (TBSA)
that is burned.
Burn depth is categorized as follows:
First-degree, or superficial, burns affect the epidermis layer of the skin, are red/pink in
color, and are painful.
Second-degree, or partial-thickness, burns involve both the epidermis and the dermis
and are extremely painful as nerve endings are exposed. These partial-thickness
burns are blistery, wet, and red in appearance.
The most severe burn is third degree, or full thickness, which affects the epidermis,
dermis, and subcutaneous tissues. These burns are yellow, white, or charred with the
presence of eschar and destroy the underlying nerves. Full-thickness burns will not
heal independent of grafting.
Burn size or area is determined using burn charts such as the following:
Rule of Nines: This diagram divides the body into 11 portions, with each part
representing 9% or a multiple of 9% (i.e., 18%).
Lund & Browder: These charts are similar to the Rule of Nines; however, this chart
takes the different proportions of body parts in children and adults into consideration.
Minor burns are considered to represent less than 30% of total body surface area, whereas
major burns represent more than 30%. Regardless of size or depth, burns of 10% TBSA in
children and 15% TBSA in adults will require hospitalization, as fluid resuscitation is
needed.
Once the injury is sustained, the response to a burn injury follows the classic ebb-and-flow
physiologic phases. With recent medical advances and greater survival rates, more
pediatric burn patients enter a rehabilitation period and prolonged convalescence in which
nutritional status still has the potential to greatly affect outcome (Prelack, 2007).
Ebb Phase
Directly after the initial trauma, the body enters the ebb phase. For burn patients, the
primary treatment is fluid resuscitation. This phase can last from 12 to 72 hours and is
significant for the following:
Increased secretion of cytokines and stress hormones (namely, cortisol,
catecholamines, and glucagon)
Limited tissue profusion
Low intravascular volume
Decreased oxygen consumption
Decreased cardiac output
Increased third-spacing related to capillary permeability (Sheridan, 2003; Herndon,
2004)

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Flow Phase
In an attempt to reestablish homeostasis, the body has increased substrate mobilization
and oxygen transport and thereby enters the flow or hypermetabolic phase. This phase
can last for several months postinjury, as excision and biological closure of wounds
occur. Biological closure consists of allografts in which donor skin is used to cover burn
wounds. The risk of infection during this phase is great, given depressed immunity that
accompanies acute injury, coupled with the loss of skin as a defense barrier (Sheridan,
2003, Prelack, 2007, Herndon, 2001).
Energy and protein needs are greatly increased related to the metabolic stress the body is
now under. Unique to this physiological phase is the protein catabolism that occurs in an
effort to make acute phase proteins and glucose. Protein loss from skeletal muscle is
substantial, and the goal of nutrition support in this phase is to minimize the breakdown of
the body cell mass (Prelack, 2007). It should be noted that the inflammatory response is
approximately proportional to the size and extent of the injury--further mitigated by
anatomy, sex, age, and preexisting conditions.
In addition to increased needs in the flow phase, the following metabolic and physiologic
changes also occur:
Enhanced rate of glucose production coupled with decreased insulin sensitivity
(Sheridan, 1998)
Increased cortisol and increased body cell mass degradation, which equate to high
energy expenditure in these patients (Wolfe, 1996)
Enhanced lipolysis and increased recycling of fatty acids and triglycerides
Fluid retention
Depression of the immune system (Calum, 2009)
Rehabilitative Phase
The rehabilitative phase takes place following definitive closure of wounds with autografts
(from the patient’s own skin, either from donor areas of the body or cultured cells) and
is marked by intensive physical therapy, much of which takes place during
hospitalization. Once definitive closure is achieved, these patients no longer require the
acuity of care provided in an intensive care unit. However, their energy and protein needs
remain high, particularly since the focus can shift to nutrition for growth and development
and increased activity related to physical rehabilitation (Sheridan, 2003). Some aspects of
nutritional care during this phase are as follows:
Promoting weight gain: Weight loss can still occur despite the closure of wounds.
Research suggests that basal energy expenditure remains high at discharge; thus
weight loss is seen in these patients. Possible reasons for weight loss in pediatric
burn patients can be related to a hypermetabolic state that still persists despite wound
healing, or to an increase in energy requirements from increased mobility and
physical activity (Mittendorfer, 1995; Hart, 2000; Prelack, 2007).
Monitoring intake and output: With the help of the hospital staff, it is important not only
to monitor the patient’s intake, but also to determine the adequacy of the oral diet in
meeting estimated needs. Kilocalorie counts can also be calculated by the dietitian.
Transitioning to oral diet: Enteral nutrition given either nocturnally or on a sliding scale
may also be indicated if these patients are not consuming adequate energy and
protein to promote wound healing and recovery.
Treating bone disease and hypovitaminosis D: Related to extended immobilization,
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calcium and phosphorus are pulled from bones to perform necessary functions in the
body, which greatly affects bone health. A major role of vitamin D is to aid with
intestinal absorption of these minerals, which are essential for building bone mineral
density. In fact, bone mineral density is directly proportional to the depth as well as
percentage of the burn injury. Further exacerbating this problem, prolonged
hospitalization and improper synthesis of vitamin D from skin grafts may warrant
repletion therapy in this population (Dylewski, 2006; Sullivan, 2010).

Convalescent Phase
This is the phase marked by reconstructive surgeries and adaption to life outside the
hospital. Patients are frequently seen for treatment, and adequate energy, protein,
electrolytes, and vitamins/minerals remain necessary from a healing standpoint as well as
from a growth and development standpoint (Sheridan, 2003; Prelack, 2007).

Biochemical and Nutrient Factors

Upon admission, baseline values of pertinent nutrition-related laboratory values are
important to establish or trend the progress or regression of a patient; they are also useful
for a nutrition assessment. At a minimum, the vital laboratory studies that should be
required include the following:
Complete Blood Panel
Due to the nature of the injury and the need for central access, pediatric burn patients are
more prone to infection as this is a common comorbidity directly linked to mortality
rates. This broad screening test is a useful tool in determining the degree of infection as
well as a patient’s postoperative recovery. These laboratory values can also be helpful in
determining an underlying deficiency, for example, iron or vitamin B-12. The following
values are included in a complete blood panel:
White blood cells
White blood cell differential
Red blood cells
Mean corpuscular volume
Hemoglobin
Hematocrit
Platelet count
Blood Chemistries
A complete blood chemistry analysis allows for a broad perspective on the whole
body. The following are included among these laboratory tests:
Plasma proteins
Albumin
Prealbumin
C-reactive proteins
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General chemistries
Serum enzymes and electrolytes
Sodium
Potassium
Chloride
Blood urea nitrogen
Creatinine
Calcium
Ionized calcium
Phosphorus
Magnesium
Plasma proteins are influenced by changes in hydration, renal function, and the acute
phase response. Prealbumin responds quickly to changes in protein status; however, its
synthesis is downregulated during the inflammatory response to burn injury. Therefore,
values of prealbumin and c-reactive protein (as an indicator of inflammation) are useful
together for trending nutritional adequacy over a longer period of time.
Electrolyte imbalances occur commonly with burn patients, particularly with sodium and
potassium. The following electrolyte abnormalities are common in burned patient and
warrant monitoring of laboratory values:
Hyponatremia. During burn care, the application of wound dressings (such as silver
nitrate soaks) can be sodium leeching, resulting in a true sodium deficiency. In
addition, increased insensible losses and changes in hydration and intravenous
fluids frequently result in hyponatremia (Mahan, 2008)
Hypokalemia, hypophosphatemia, hypomagnesiumia. Low levels of these
electrolytes can be incurred during preliminary resuscitation. In addition, with the
onset of aggressive nutritional support, a surge in insulin can result in intracellular
shifts of these electrolytes, resembling a refeeding-like syndrome. This is particularly
prominent in patients who have had thier nutritional support delayed following burn
injury (Bankhead, 2009; Prelack, 2007).
Calcium and vitamin D. These nutrients are of particular concern, as they are
needed for proper bone health. Vitamin D physiology is altered, and becomes
depleted during the acute phase response (Gottschlich, 2004; Dylewski, 2006).
Blood glucose. This trends toward hyperglycemia during times of stress. Up-to-date
laboratory values help to determine insulin requirements as exogenous sources of
insulin are needed for normoglycemia (Sheridan, 1998). Chronic hyperglycemia
impedes wound healing. Also during times of stress, insulin sensitivity is decreased.
Blood urea nitrogen and creatinine. Renal values help to establish the adequacy of
kidney function, which may confound nitrogen balance studies. In addition, these
values can provide information on protein solute load and hydration during nutrition
support.
Blood Gases
Blood gas tests evaluate the efficiency of pulmonary gas exchange and ventilation and aids
with the interpretation of cause in acid–base imbalance.
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Measures of blood gas include the following:
Partial pressure of oxygen in the blood
Partial pressure of carbon dioxide in the blood
pH
Bicarbonate
Sulfamylon is sometimes used to exercise more control over bacterial colonization when
applied to wound dressings. This pharmacological agent requires close monitoring of
acid–base balance, as sulfamylon can potentially exaggerate carbonic anhydrase inhibition
and would require the use of bicarbonate (Castellano, 2007).

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Diseases/Conditions > Cardiology
Cardiology


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Cardiology > Congenital Heart Disease
Overview

Congenital heart defects are the most common major congenital malformations among
newborns, with a reported incidence at 6 to 8 per 1,000 live births in the United States
(Sadowski, 2009). This rate increases with prematurity and advanced maternal age. Many
infants with congenital heart defects do not survive past the first year of life, and infants
who survive often require multiple surgeries, prolonged hospitalizations, and a lifetime of
treatment for related disabilities.
Infants and children with cardiac conditions may need special nutritional considerations
and often require increased energy intake. Growth disturbances are a common clinical
feature in infants and children with congenital heart defects. The magnitude of the cardiac
defect's effect on growth, development, and nutritional status depends on the particular
lesion and its severity (Carlson, 2000). As malnutrition develops in this population, children
can experience adverse effects on weight, linear growth, and head circumference, as well
as disturbances in normal development. In hospitalized pediatric patients with congenital
heart defects and congestive heart failure, there is an increase in the frequency and
severity of acute and chronic malnutrition (Cameron, 1995).
Causes of Growth Failure in Congenital Heart Disease
The association of congenital heart defects and growth failure is well documented (Barton,
1994; Davis, 2008; Day, 1989; Kelleher, 2006; Leitch, 2000; Mehrizi, 1962; Nydegger,
2006; Rosenthal, 1993; Vaidyanathan, 2008). The causes of abnormal growth and
development are multifactorial.
Factors that may influence the development of malnutrition and growth failure in infants
with congenital heart disease include the following:
Type and clinical impact of cardiac disease
Cyanotic vs acyanotic defects i.
Shunts ii.
Congestive cardiac failure iii.
Operative status
Age at time of surgery
Type of surgery
Complications
iv.
1.
Disturbances in energy metabolism
Increased energy expenditure
Cardiac hypertrophy
Abnormalities in body composition
Increased activity of sympathetic nervous system
Increased hematopoietic tissue
Increased basal temperature
Recurrent infections
Pharmacologic agents
i.
2.
Decreased energy intake
Anorexia and early satiety i.
Pharmacologic agents ii.
Decreased gastric volume caused by hepatomegaly iii.
3.
Disturbances in gastrointestinal function 4.
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Malabsorption
Edema and chronic hypoxia of the gut
Interference with drugs
i.
Delayed gastrointestinal development ii.
Compressive hepatomegaly
Decreased gastric volume
Increased gastroesophageal reflux
iii.
Prenatal factors
Chromosomal disorders i.
Intrauterine factors ii.
Birth weight iii.
5.
(List reprinted with permission from Elsevier: Nydegger A, Bines JE. Energy metabolism in
infants with congenital heart disease. Nutrition. 2006;22:697-704. Journal homepage)
The combination of chronic disease and malnutrition in the pediatric population can have a
detrimental effect on growth, development, and disease-related morbidity (Steltzer, 2005).
Corrective operations for congenital heart disease have become increasingly common at
an earlier age and can improve the nutritional status of infants with this condition by
eliminating cardiac factors that contribute to failure to thrive (Leitch, 2000).
If early cardiac surgery is not an option for a neonate, then aggressive nutrition
intervention—often including enteral and parenteral nutrition support—is vital to prevent
outcomes associated with malnutrition (Leitch, 1998). Failure to thrive in infants with
cardiac heart disease, either preoperatively or postoperatively, results in more frequent
hospital admissions, with longer lengths of stay, which ultimately increases the cost of their
care (Silberbach, 1993). A registered dietitian is vital in obtaining a complete nutrition
assessment of the pediatric cardiac patient’s nutritional status to prevent or correct
malnutrition.

Disease Process

Nutrition needs vary from child to child, depending on the type and severity of the heart
defect, so documentation of the medical diagnosis is an important component of the
evaluation. Cardiac defects can be anatomically classified into cyanotic and acyanotic
malformations.
Growth failure is a well-recognized consequence of severe cardiac disease. There are
various factors that contribute to growth disturbances. Research indicates that
hypermetabolism plays a role, particularly in the presence of congestive heart failure
(Barton, 1994; Mitchell, 1994). Increased metabolic rate is likely related to the increased
metabolic demands of the cardiac and respiratory muscles to ensure adequate ventilation
in the presence of decreased lung compliance (Pittman, 1964). An elevated basal
metabolic rate has been reported 3 to 5 times more frequently in this population than
in infants without heart disease (Abad-Siden, 1991). Resting oxygen consumption has
been reported to be higher in infants with persistent cardiac failure and/or pulmonary
hypertension (Krauss, 1975).
In combination with low energy intakes, high energy requirements may lead to insufficient
energy for normal growth. Increasing the energy intakes of infants with congenital heart
disease may be a way of improving their growth. Several studies have been done to
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determine baseline energy needs; however, there is a general consensus to provide these
infants and children with more than the recommended energy intake for age, usually using
a baseline of 120 kcal/kg for infants, which may need to be increased to 150 kcal/kg to 175
kcal/kg or more (Blecker, 2000; Leitch, 2000; Dooley, 2002; Smith, 2001; Kelleher, 2006;
Wessel, 2005; Carlson, 2000). High-energy breast milk and formulas as well as tube
feedings are common methods to assist with meeting the higher energy demands of this
population.
The type of cardiac lesion can affect the pattern of growth failure. Patients with cyanotic
heart disease frequently have delays in weight gain and linear growth. Acyanotic lesions
with a degree of left-to-right shunting typically affect weight rather than height in the early
stages prior to surgical repair (Mehrizi, 1962).



Biochemical and Nutrient Issues

Biochemical data used by the registered dietitian to evaluate a patient are the typical
laboratory data collected and evaluated by the critical care team:
Electrolytes (basic metabolic panel)
Renal profile
Hepatic panel
Blood gas analysis
Oxygen saturation
Complete blood count
These data, in combination with clinical findings and patient history, are used to assess
fluid status, renal and liver function, adequacy of glucose control, need for electrolyte
supplementation or restriction, and respiratory status, among other functions.
B-type natriuretic peptide is tested to assess the degree of heart failure.
The following laboratory data may be tested to further investigate nutritional status if
malnutrition is suspected.

25-hydroxy vitamin D
Prealbumin
Serum zinc
Iron studies
Other micronutrients, as warranted


Chylothorax

Chylothorax is the collection of lymphatic fluid in the pleural or mediastinal space caused
by injury to the thoracic duct or one of its main tributaries. Symptoms of a chylous effusion
include pleural effusions, dyspnea, or tachypnea. Diagnosis may be confirmed through
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thoracentesis revealing opaque, milky white fluid, as well as biochemical analysis of the
effusions (Suddaby, 2004).
Background of Chyle
Chyle is composed of lymphatic fluid and chylomicrons and consists of protein, fat,
lymphocytes, and electrolytes.
It plays an important role in absorption of fat-soluble vitamins and reabsorption of
proteins lost through capillary leakage.
Chyle flow originates in the gut and increases after enteral intake. During a fasting
state, flow is ~1 mL/min. After a high-fat meal, flow may increase to >200 mL/min.
Biochemical Analysis of Chyle (Merrigan, 1997)
Total lipid content 0.4-4.0 g/dL
Triglycerides 150-1,100 mg/dL (or more)
Cholesterol <220 mg/dL
Lymphocytes 80%-90%
Total protein >3 g/dL
pH Alkaline
Adverse Effects of Chlye Loss
Electrolyte imbalances: hyponatremia, hypocalcemia, hypokalemia
Hypovolemia
Metabolic acidosis: pH of chyle >7 (7.4-7.8)
Hemodynamic instability
Hypoproteinemia
Chyle contains >30 g/L protein (albumin, fibrinogen, immunoglobulins, enzymes)
Transcapillary fluid shifts may cause problems with maintenance of intravascular
volume
Loss of protein and fat may be accompanied by an increase in metabolic demand
Immunological Effects
95% of the cellular content of chyle is lymphocytes: 90% of these are T cells
Symptoms include anergy, lymphocytopenia, hypoalbuminemia, and decreased
serum levels of antibodies and gamma-globulins
Increased risk of bacterial and viral sepsis
Goals of Nutrition Therapy
Decrease production of chyle fluid through dietary intervention to avoid aggravation of
the effusions or chylous drainage
Replace fluid and electrolytes
Maintain or replete nutritional status and prevent malnutrition
Nutrition Management
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Management involves a very low long-chain triglyceride (LCT), high medium-chain
triglyceride (MCT) oral/enteral regimen.
The primary purpose of chyle is the absorption and transportation of LCTs in the
intestines. Chyle is formed in the lacteals of the intestine during digestion in response
to the presence of intraluminal fat. The chyle binds with LCT to form chylomicrons,
which are then absorbed and transported by the intestinal lymphatics to the
bloodstream.
MCTs are absorbed directly into the portal system as are carbohydrates and amino
acids and thus do not stimulate an increase in lymphatic flow (Jensen, 1989).
Commercially prepared formulas containing 80% or more MCT content should be
used for infants and children to meet protein and energy needs.
Parenteral Nutrition
Nutrition support that bypasses the intestines may be required if oral intake is
insufficient or clinical symptoms (eg, no decrease in chest tube output with
high-MCT/low-LCT enteral feedings) persist
Fasting decreases intestinal blood flow, which results in a secondary reduction in
lymphatic flow
Intravenous lipids do not stimulate lymph flow or chylous effusions (Büttiker, 1999)
Fat-Soluble Vitamins
Fat-soluble vitamins are carried by the lymphatic system
With increased losses and decreased absorption, these patients may be at risk for
nutrient deficiencies; thus, careful monitoring of serum levels is warranted
Multivitamin/mineral supplement may be recommended for patients on a restricted
oral/enteral regimen
Water-soluble forms of vitamins A, D, E, and K may be better utilized
Essential Fatty Acid Deficiency
This deficiency may develop within 2 to 4 weeks of initiation of a fat-free/low-fat diet
(IOM, 2002)
Diagnosis: serum triene to tetraene ratio >0.4
The American Academy of Pediatrics recommends 2% to 4% of total energy from
essential fatty acids to avoid a deficiency (AAP, 2004)
MCT oil does not provide significant essential fatty acids
Intravenous fat emulsion may be required if patient is unable to tolerate any
oral/enteral fat


Cyanotic Heart Disease

Cyanotic heart disease is a congenital disorder that changes the way blood flows through
the heart and lungs. Cyanosis occurs when there is mixing of pure oxygen-rich blood with
venous blood and results in low blood oxygen levels through the rest of the body. Cyanosis
is evidenced by a bluish discoloration of the mucous membranes, lips, skin, and nail beds.
Cyanotic heart disease may include a combination of defects. The defects affect the
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Cyanotic heart disease may include a combination of defects. The defects affect the
structure or function of the heart or vessels and can be further classified as
ductal-dependent pulmonary blood flow, ductal-dependent systemic blood flow, and
ductal-independent mixing lesions (Suddaby, 2001). Some of these lesions may require
surgical palliation in the neonatal period. These surgical procedures may require the use of
cardiopulmonary bypass, which places the infant at risk for postoperative morbidity,
including extracardiac organ dysfunction and possible organ failure (Madhok, 2006;
Owens, 2009).
Open-heart surgery for infants diagnosed with congenital heart defects is used for a variety
of heart defects. Some cardiac lesions may be repaired with one surgical intervention,
whereas more complex lesions, such as hypoplastic left heart syndrome, may require
staged reconstruction.
Infants with Tetralogy of Fallot, who have critically low oxygen levels soon after birth, will
usually require surgical intervention in the neonatal period. Infants with normal oxygen
levels or only mild cyanosis are usually able to go home in the first week of life. Complete
repair is typically done electively when the children are approximately 6 months of age, as
long as the oxygen levels remain adequate. Progressive or sudden decreases in oxygen
saturation may prompt earlier corrective repair.
Infants with hypoplastic left heart syndrome require staged reconstruction in which a series
of operations, usually 3, are performed to reconfigure the child's cardiovascular system to
be as efficient as possible despite the lack of an adequate left ventricle. These surgeries do
not correct the lesion and are instead considered palliative. The first operation in the
staged approach is known as the Norwood procedure and is typically performed in the first
week of life. Because of the extensive reconstruction, this operation is one of the most
challenging heart surgeries in pediatrics. The subsequent operations in the staged
reconstruction plan are the bidirectional Glenn procedure, typically done at 3 to 6 months of
age, and the Fontan procedure, typically done in children older than 2 or 3 years.
For a complete overview of pediatric congenital heart anomalies, refer to the Weblinks.
Infants and children with cyanotic defects tend to have greater growth compromise, which
can be the result of the severity of cyanosis, the presence of congestive heart failure,
and/or pulmonary hypertension. Patients with unrepaired cyanotic defects typically exhibit
lower weight and smaller length (Davis, 2008; Kogon, 2007; Jadcherla, 2009;
Medoff-Cooper, 2010; Tokel, 2010).
Types of cyanotic cardiac lesions include the following:
Hypoplastic left heart syndrome
Transposition of the great arteries
Tetralogy of Fallot
Pulmonary atresia
Tricuspid atresia
Truncus arteriosus
Total anomalous pulmonary venous connection

Acyanotic Heart Disease

An acyanotic heart defect is any congenital cardiac malformation in which all of the blood
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returning to the right side of the heart passes through the lungs and pulmonary vasculature
in normal fashion and is not accompanied by cyanosis. The common forms of acyanotic
congenital heart defects are when there is a defect in one of the walls separating the
chambers of the heart or an obstruction to or a narrowing of a valve or artery. These
lesions include ventricular septal defect, patent ductus arteriosus, and atrioventricular
septal defect and are usually repaired within the first year of life (Suddaby, 2001).
Types of acyanotic cardiac lesions include the following:
Obstructive malformations
Pulmonary stenosis
Aortic stenosis
Coarctation of the aorta
Left-to-right shunt malformations
Patent ductus arteriosis
Ventricular septal defect
Atrial septal defect
Atrioventricular canal defect

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Diseases/Conditions > Cardiology > Extracorporeal Membrane Oxygenation (ECMO)
Overview

Extracorporeal membrane oxygenation (ECMO) is an advanced form of life support used in
pediatric patients with persistent pulmonary hypertension, congenital diaphragmatic hernia,
septic shock (Jadcherla, 2005), and respiratory and/or cardiac failure and as a bridge to
heart transplantation in children with cardiomyopathy and patients who have not had
significant recovery of cardiac function postoperatively (Lequier, 2008).
The physiologic goal of ECMO is to improve tissue oxygen delivery, remove carbon
dioxide, and allow normal aerobic metabolism to continue while lung "rest" take place.
ECMO is achieved by draining venous blood, removing carbon dioxide, and adding oxygen
through an artificial lung and returning the blood to the circulation via a vein (veno-venous)
or an artery (veno-arterial) (ECMO, 1999).

Types of ECMO
Veno-arterial (V-A): Cardiac and pulmonary support
Veno-venous (V-V): Pulmonary support only
Note: There is no difference in nutrition support for V-A and V-V ECMO.
More than 80% of infants who receive ECMO now survive their acute illness, but they often
sustain significant morbidity. Complications that can arise after initiation of ECMO support
include the following:
Capillary leak syndrome at the initiation of ECMO
Can cause severe edema (50% to 75% weight increase in neonates) and
inflammatory mediator release
Release of inflammatory cytokines at ECMO initiation or circuit change
Hemodynamic instability
Cholestasis
Resolves without hepatic complications (Abbasi, 2008)
Feeding problems
Lack of coordination of feeding
Frequent regurgitation and emesis
Gastroesophageal reflux
Delayed gastric emptying
Slow transit (Jaksic, 2005)

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Diseases/Conditions > Cleft Lip and Palate
Overview

Cleft lip and/or palate occurs at a rate of about 1 in every 700 newborn infants. About 50%
of children with a cleft palate are associated with a syndrome; only 25% of those with a cleft
lip and palate have a related syndrome. There can be a genetic component, and a family
history may reveal the likelihood of the occurence (Saal, 2002).
There are now 626 genetic syndromes associated with clefting. The cleft lip/palate may be
a characteristic of one or a group of anomalies. Children with a cleft lip and/or palate also
have other associated medical conditions, such as chronic otitis media, hearing loss, and
dental and orthodontic problems (Coy, 2002).
A cleft is diagnosed in the neonate and may be a unilateral or bilateral cleft of the lip
without palate involvement; a unilateral or bilateral cleft of the soft and/or hard palate with
or without a cleft lip defect; or a submucous cleft palate. A submucosal cleft involves the
muscles of the soft palate and part of the hard palate. Feeding is usually not a major
problem, although an infant who displays milk running through its nose during a feeding
may indicate a submucous cleft palate and, therefore, should be evaluated appropriately
(Farnan, 1993).
Cleft Lip and Palate (CLP)

This is diagnosed by visual observation of the face and oral cavity during the newborn
exam by nurses and pediatricians. It may be a unilateral or bilateral cleft lip and palate.

Cleft Palate Isolated (CPI)
This must be diagnosed from an oral cavity exam, and the extent of the cleft can be widely
varying from a large bilateral cleft to a small soft palate cleft.

Cleft Lip Isolated (CLI)
This is diagnosed by a visual exam, and may be extensive or small. This may or may not
interfere with breastfeeding; only a large cleft lip tends to interfere with breastfeeding or
bottle-feeding, since the sucking effort may not be sufficient.
Successful feeding of a child with cleft lip and/or palate is not always about calories and
nutrients. When an infant is born with cleft lip, the baby may look less than perfect to the
parents. Cleft-palate infants may also make parents feel inadequate due to the many
considerations needed for feeding, and the mother may feel disappointment in not being
able to breastfeed. These infants, however, have the same need for maternal cuddling and
skin-to-skin care that all infants have (Taveras, 2003).

In hospital/newborn
During the initial hospital stay the clinical nursing staff including lactation consultants and
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physicians usually manage the feedings. Infants requiring lengthy hospital stays, and
infants who have cleft lip and/or palate as well as a related syndrome may require the input
of a dietitian to help with the feeding plan. Studies support the use of colostrum for oral
support in the first days of life (Rodriguez, 2009; Sullivan, 2010).
Post discharge
The physician may refer to the dietitian as a part of the feeding team to help with issues
such as poor weight gain or other feeding difficulties. The dietitian may be a part of the
early intervention team.

Disease Process

Most infants with cleft lip isolated (CLI), cleft palate isolated (CPI), or cleft lip and palate
(CLP) go home in the usual discharge time of 2-4 days of age. Successful feeding in the
first few days does not mean the feedings will go well in the weeks or months to come;
therefore, plans should be in place to have these infants frequently assessed for growth
issues, and caregivers should be connected with the nearest craniofacial clinic that
specializes in CLI, CPI, and CLP.
Initial involvement of the dietitian (and a lactation consultant if the mother is breastfeeding
or pumping) with the newborn is important to establish a relationship with the parents to
make appropriate recommendations for clinic followup, and information regarding the need
to closely follow for adequate nutrition. These infants are at risk for poor intake during
feedings due to CLP interfering with the ability to suck efficiently.
The dietitian may be called in as a part of the CLP team, or if the infant is re-admitted after
birth, or as a part of an early intervention team. Dietitians who are also lactation
consultants and who work in hospitals may get a chance to help with these infants as they
are born.
Cleft lip repair occurs during the period when the infant is either breastfeeding and/or bottle
feeding. Cleft lip repair may occur at 6 weeks of age, or about 3 months of age.
Cleft palate repair occurs when the infant is older and has begun spoon feeding (6 months
or, more commonly, 9 to 12 months). Feeding regimens and recommendations depend on
the surgical protocol. Some surgical protocols depend on weight for the first procedure (eg,
10 pounds).
Families should check with the physician regarding when breastfeeding can begin
post-operatively. After repair of the cleft(s), a liquid diet by cup feeding and purees are
necessary until surgical healing, or as advised by surgical team/clinic. However, a child may
continue to have difficulty chewing particular foods, because of malocclusion, dental
crowding, or other dental abnormalities. As the child grows, food textures can be modified
until dental adjustments are made. Older children may experience chronic dry mouth from
mouth breathing, if a reduced nares airway is present after surgical repair. The child may
also experience reduced tastes related to a diminished sense of smell.

Biochemical and Nutrient Issues

Nutrition needs are the same for infants with cleft lip and palate (CLP) as for any other
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infant of the same gestational age and weight/height.
If the CLP infant or child also has a syndrome, then the related nutritional needs of that
syndrome should be taken into account. For example, infants with Pierre Robin Sequence
often have respiratory issues which will require higher calories.
Biochemical data is not different for CLP infants and children, unless there is a related
syndrome or condition which impacts biochemistry of the individual.

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Diseases/Conditions > Critical Care
Overview

The pediatric nutrition practitioner is faced with numerous challenges when caring for
critically ill children. The dearth of population-specific research leaves those who care for
children in the intensive care unit to rely on literature from studies in adults for guidance,
which is far less desirable.
In adults, the metabolic response to illness or trauma has been described as occurring in
stages: The initial response lasts approximately 24 to 48 hours and is characterized by
hyperglycemia, hypovolemia, and hypometabolism. Following fluid resuscitation and the
restoration of tissue perfusion, there is a shift toward hypermetabolism, protein catabolism,
and hyperglycemia. Negative nitrogen balance predominates, and, if left unchecked, the
development of malnutrition will be rapid (Plank 2000; Moriyama 1999; Chiolero 1997). The
stress response results in alterations in energy requirements as well as substrate
utilization. This catabolic response is in proportion to the magnitude of the insult.
These processes have not been well documented in children, but they have been
assumed to be similar (Jaksic 2002).
Younger and smaller pediatric patients are at highest risk of developing morbidities as a
result of metabolic stress (Skillman 2008). Their muscle and fat mass are reduced while
their resting metabolic rate is higher when compared to adults (Cunningham 1995). At
particular risk are those children with preexisting illness or malnutrition. For purposes of
screening and assessment, children who are obese or overweight should be considered
malnourished and at similar risk as critically ill children with malnutrition ( Bailey 2010;
Brown 2006). These children tend to have greater physiologic instability and longer length
of hospital stays and are more likely to develop multisystem organ failure with a higher rate
of mortality (Hulst 2004; Pollack 1985; Pollack 1981; Pollack 1982; Briasoulis 2001).
When developing a nutrition care plan, the nutrition practitioner must consider the
metabolic instability associated with the stress response including the transient suspension
of growth (Gardelis 2005) and subsequent medical therapies necessary to treat the
critically ill child. Each aspect of stress response and treatment can affect nutrition
requirements and substrate utilization and care must be taken to avoid overfeeding and
underfeeding. Provision of nutrition that is appropriate, timely, and consistent may have an
impact on patient outcome.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Developmental Disabilities
Developmental Disabilities


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Diseases/Conditions > Developmental Disabilities > Autism Spectrum Disorders
Overview

Autism spectrum disorders (also called pervasive developmental disorders) are a group of
disorders that include autism disorder, Asperger’s syndrome, and pervasive developmental
disorders not otherwise specified. In recent years, estimates of the prevalence of autism
have increased to approximately 1 in 110 (Rice 2009).
Autism spectrum disorders (ASDs) are characterized by three key manifestations (Rapin
2008):
Impaired sociability, empathy, and ability to read other people’s moods and intentions,
with resulting inadequate or inappropriate social interactions
1.
Rigidity and perseveration, including stereotypies (purposeless repetitive movements
and activities), the need for sameness, and resistance to change
2.
Impaired language, communication, and imaginative play 3.
Treatment strategies include a variety of behavioral, developmental, and educational
approaches, including applied behavior analysis, communication-focused interventions (eg,
sign language training), social skills development intervention (eg, Social Stories
TM
), and
integrative programs. For many children, a variety of approaches are combined to meet
individual needs (Ospina 2008). Early intensive intervention results in improvement for
many preschoolers; families and children receive services through early intervention
programs (ie, birth-to-three centers) and specialized preschool education. Many families
also receive therapy through private therapists and educators (Rapin 2008; Ospina 2008).
The primary nutrition and feeding concern reported by parents is “picky” eating. Many of
the behaviors associated with autism can contribute to a selective food pattern (see Table)
(Feucht 2010).
Many families use special diets (eg, gluten- and/or casein-free) and/or supplements.
Ensuring that a child’s intake is nutritionally adequate is another common nutrition-related
issue.
Many children with ASDs (especially young children) are followed by a team of therapists
who are familiar with autism spectrum disorders as well as with the individual needs of the
child and his or her family. Consultation with these teams is essential. Collaboration
between specialists, families, and local/community health-care providers enhances care.
Standards of Practice and Standards of Professional Performance have been developed
for the fields of Pediatrics and Behavioral Health Care (which includes developmental
disabilities). These standards define the practice-specific role of the RD (Emerson 2006;
Charney 2009).
Possible Selective Food Patterns Related to Autism-Associated Behaviors
Behavior associated
with ASDs
Possible effects on eating
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Need for routine, difficulty
with transitions
Problems with changes in
mealtime routines
Refusal of an unfamiliar
food, dish, or location
Limited number of accepted
foods
Increased sensitivity to
texture, taste,
temperature, and smell
Easily overwhelmed or
overstimulated
Restricted intake due to
hypersensitivity
Restricted intake due to
refusal of specific color,
texture, temperature
Difficulty in making
transitions to new textures or
tastes
Possible gagging, vomiting
Short attention span
Loses interest in eating after
only a few minutes
Impaired social interaction
Less responsive to positive
eating behaviors modeled by
others
Adapted from Feucht S, Ogata B, Lucas B. Nutrition concerns
of children with autism spectrum disorders. Nutrition Focus.
2010;25(4).

Disease Process

Autism spectrum disorders (ASDs) appear to be a group of disorders with similar
manifestations – though the severity of symptoms varies widely, and not all children exhibit
all symptoms. No single biological cause for ASDs has been identified, and it is believed
that there are numerous etiologies, including a strong genetic component. Other identified
differences include immunology, structural and functional brain differences, and
neurological abnormalities (Rapin 2008).
Many children with autism develop typically during infancy, and symptoms present when
the child is a toddler or preschooler. Often, speech and communication regress. Clinical
deficits that may be present in some individuals with autism are described by Rapin and
Tuchman (2008), and include impairments in or problems with cognition, executive
function, attention, mood/affect, expressive language, language comprehension, play,
taste/olfaction, and motor skills.

Biochemical and Nutrient Issues

Specific biochemical and nutrient issues will depend on the individual child. Factors
affecting nutrient metabolism, absorption, and utilization can include drug-nutrient
interactions.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

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Diseases/Conditions > Developmental Disabilities > Cerebral Palsy
Overview

Cerebral palsy (CP) is a group of motor dysfunctions that result from nonprogressive brain
damage early in life. The incidence of CP is approximately 2.5 per 1,000 live births (Dodge,
2008).
The American Academy for Cerebral Palsy and Developmental Medicine defines cerebral
palsy (Rosenbaum, 2007) as follows:
[CP] describes a group of permanent disorders of the development of movement
and posture, causing activity limitation, that are attributed to nonprogressive
disturbances that occurred in the developing fetal or infant brain. The motor
disorders of cerebral palsy are often accompanied by disturbances of sensation,
perception, cognition, communication, and behaviour, by epilepsy, and by
secondary musculoskeletal problems.
Issues common among people with cerebral palsy include the following (Dodge, 2008):
Seizures (in approximately 30% of individuals with CP)
Cognitive impairment (in approximately half of individuals with CP)
Issues with muscle tone (spasticity, dystonia)
Growth impairments (more likely to be underweight and short in stature, likely due to
nutrition-related issues)
Dysphagia (with or without aspiration)
Gastroesophageal reflux, delayed gastric emptying
Constipation (in approximately 80% of individuals with CP)
Orthopedic problems
Additional issues can include vision, hearing, urologic problems, dental, drooling, sleep,
and pain-related problems.
Management of CP requires an appreciation for the context of family and community and
an approach that is family centered. Many children with CP receive therapy services
through early intervention programs and/or the school system, in addition to specialized
care through a neurodevelopmental clinic. Specialists are familiar with CP as well as with
the long-term care of the individual children and their families. Consultation with these
teams is essential. Collaboration among specialists, families, and local/community health
care providers enhances care.
Therapies typically focus on the individual’s symptoms (eg, posture and mobility, verbal
and nonverbal communication, feeding). Adjunct therapies can include aquatic exercise
and hippotherapy (horse therapy).
Children with cerebral palsy are at increased nutritional risk. Potential problems include the
following (Lucas, 2004; Sullivan, 2002; Dodge, 2008; Bandini, 2005):
Altered growth (eg, underweight, overweight, short stature)
Inadequate intake (eg, energy and/or micronutrients)
Altered (increased or decreased) energy needs
Feeding problems (eg, related to oral-motor and/or behavioral issues)
Medication–nutrient interactions
Chronic constipation
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In addition to issues that are overtly linked to nutrition, many problems influence an
individual’s nutritional status.
Standards of Practice and Standards of Professional Performance have been developed
for the fields of pediatrics and behavioral health care (which includes developmental
disabilities). These standards define the practice-specific role of the registered dietitian
(Emerson, 2006; Charney, 2009).

Disease Process

The disease process and nutrition-related implications vary, depending on the specific
conditions and the individual child.
Common causes of cerebral palsy (CP) include the following (Dodge, 2008):
Prenatal
Brain malformations
In utero stroke
Congenital cytomegalovirus infection
Perinatal
Hypoxic ischemic encephalopathy
Viral encephalitis
Meningitis
Postnatal
Accidental head trauma
Anoxic insult
Child abuse
CP is often classified based on movement disorder and the pattern of limb involvement
(Krick, 2003; Dodge, 2008):
Spastic or pyramidal, increased muscle tone, difficult to control movement
Hemiplegia: affects arm and leg on same side
Diplegia: affects legs more than arms
Quadriplegia: affects all four limbs, legs more than arms
Double hemiplegia: affects all four limbs, arms more than legs
Monoplegia: affects one limb, usually an arm
Triplegia: affects one arm and both legs
Non-spastic or extrapyramidal, lack of ability to coordinate movement
Athetosis: slow, writhing movements
Dystonia: contortions of limb or trunk
Rigid: stiff and clumsy movement
Ataxia: unbalanced walking
Hypotonia: low postural tone
Mixed CP: Characteristics of both pyramidial and extrapyramidial (eg, rigidity in upper
extremities and spasticity in lower)

Biochemical and Nutrient Issues

Specific biochemical and nutrient issues will depend on the individual child. Factors
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
affecting nutrient metabolism, absorption, and utilization can include drug–nutrient
interactions as well as factors that are related to conditions associated with cerebral palsy
(eg, delayed gastric emptying). See the Gastrointestinal disease topics for more information
about the implications of reflux, delayed gastric emptying, and other gastrointestinal
conditions.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Developmental Disabilities > Down Syndrome
Overview

Down syndrome (trisomy 21) is one of the most common chromosomal abnormalities, and
occurs in approximately 1 in 733 live births (NDSS). Down syndrome is a result of extra
genetic material on chromosome 21. It is associated with developmental delays,
hypotonia, and short stature as well as physical characteristics (features of the face and
hands). The specific developmental delays vary, but generally include problems with
language. Mild to moderate intellectual disability is usually present (Davidson 2008;
Lucas 2008).
Many children with Down syndrome are born with congenital anomalies such as heart
defects (approximately 44%) and gastrointestinal malformations (approximately 5%). Other
medical concerns may include pulmonary hypoplasia, upper respiratory tract and
middle-ear infections, vision and joint problems, and tooth abnormalities (Davidson 2008;
Lucas 2008). Some children with Down syndrome have a dual diagnosis that can include
Pervasive Developmental Disorder, or other autism spectrum disorders (Lucas 2008).
Nutrition-issues related to Down syndrome can include the following (Davidson 2008;
Lucas 2008; Capone 2005; Bandini 2005):
Feeding concerns for some, especially early in life
Overweight and obesity if not addressed/prevented early – decreased stature,
decreased physical activity, decreased energy needs
Cardiac defects
Endocrine dysfunction (eg, hypothyroidism, diabetes mellitus)
Celiac disease
Possible malabsorption due to gastrointestinal malformations
Constipation related to decreased gut motility
Seizures
Table 1 summarizes general nutrition-related concerns associated with selected
developmental disabilities, including Down syndrome.
Many children with developmental disabilities, including Down syndrome, are followed by a
team of specialists, who are familiar with disorders as well as with the long-term care of the
individual children and their families. Consultation with these teams is essential.
Collaboration between specialists, families, and local/community health care providers
enhances care.
Standards of Practice and Standards of Professional Performance have been developed
for the fields of Pediatrics and Behavioral Health Care (which includes developmental
disabilities). These standards define the practice-specific role of the registered dietitian
(Emerson 2006; Charney 2009).

Disease Process

Down syndrome is a genetic condition, so it is present at birth. The disease process and
nutrition-related implications vary, depending on the individual. Down syndrome is
sometimes diagnosed prenatally. Infants with Down syndrome usually have hypotonia and
short stature and may have cardiac issues that require immediate repair and/or ongoing
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monitoring. Developmental milestones are often delayed, and delays are usually apparent
in the first year of life.
Obesity is a major issue, and early intervention to prevent obesity is most effective. Other
issues throughout the life cycle include:
Surveillance for cardiac problems
Occupational and physical therapy to address motor skill deficits, including feeding
problems
Screening for celiac disease
Monitoring for endocrine disorders (eg, hypothyroidism, diabetes mellitus)
Monitoring for and treatment of orthopedic problems (eg, dysplasia)
Addressing issues related to transition (ie, through adolescence and adulthood)


Biochemical and Nutrient Issues

Specific biochemical and nutrient issues will depend on the individual child. Factors
affecting nutrient metabolism, absorption, and utilization may include drug-nutrient
interactions and the presence of malabsorptive disorders.

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Diseases/Conditions > Developmental Disabilities > Spina Bifida
Overview

Spina bifida is a neural tube defect that results when the fetal spinal column does not close
completely during the first month of gestation.
Major nutrition-related issues associated with spina bifida include obesity, urinary tract
infections, constipation, and feeding problems. A major contributor to obesity is lack of
ambulation, depending upon the location of the spinal lesion. Obesity in these children also
contributes to musculoskeletal deformities, cardiopulmonary problems, and a poor fit with
equipment prescribed to help with ambulation (Ekvall 2005).
Many children with developmental disabilities, including spina bifida, are followed by a team
of specialists who are familiar with such disorders as well as with the long-term care of the
individual children and their families. Consultation with these teams is essential.
Collaboration between specialists, families, and local/community health care providers
enhances care.
Standards of Practice and Standards of Professional Performance have been developed
for the fields of Pediatrics and Behavioral Health Care (which includes developmental
disabilities). These standards define the practice-specific role of the registered dietitian
(Emerson 2006; Charney 2009).

Disease Process

The incidence of neural tube defects ranges from one to seven per 1000 live births
(McLone 2009). Since the fortification of many grains in the US with folic acid, the
incidence of neural tube defects has decreased 20-30% (Grosse 2005). In addition,
advances in medical care have dramatically increased the survival rate for individuals with
spina bifida.
Three common types of spina bifida are:
Myelomeningocele –the spinal cord and the meninges protrude from an opening in
the spine; the severest and most common form
Meningocele – the meninges protrudes from a spinal opening
Occulta – one or more vertebrae are malformed and covered by a layer of skin; the
mildest form
Complications associated with spina bifida can include the following:
Paralysis (complete or partial, depending on the level of the spinal lesion) of the legs,
requiring assistive devices (eg, braces, crutches, wheelchairs)
Learning difficulties, including poor executive skills, attention deficits, and memory
problems
Bladder dysfunction (neurogenic bladder), may progress to urinary tract deterioration
and renal disease; bowel dysfunction (affects about 97% of individuals)
Bowel problems
Hydrocephalus
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Hydrocephalus
Hydromelia – accumulation of fluid within the central canal of the spinal cord; occurs
because of untreated hydrocephalus or a shunt malfunction
"Tethered cord" – progressive deterioration in lower extremity function, changes in
urinary tract function, progressive scoliosis, pain
Orthopedic problems, congenital skeletal deformities, scoliosis
Most children with myelomeningocele have the Chiari II malformation (incorrectly called
the Arnold-Chiari malformation, type II). This involves herniation of the cerebellum and
medulla and leads to progressive dysfunction, which can include the following:
swallowing difficulties
vocal cord paresis causing stridor, or apneic episodes
neck pain, strabismus, facial weakness
progressive weakness in the lower extremities, increase in incontinence
altered cognitive function
Surgical closure of the spinal lesion is generally done within 72 hours of birth (if not
repaired in utero). Hydrocephalus may require a shunt. Management of spina bifida
involves addressing the associated medical conditions. For example, individuals with
neurogenic bladder may require clean intermittent catheterization, antibiotic prophylaxis
and other interventions. Bowel management programs, including use of laxatives and other
treatments, are common as well.
Optimal management requires specialized care, and individuals should be followed by a
multidisciplinary team with expertise in neurosurgery, orthopedics, neurology, urology, and
rehabilitation. Team members often include physicians, physical and occupational
therapists, dietitians, social workers, wound specialists, and psychologists (McLone 2009).

Biochemical and Nutrient Issues

Specific biochemical and nutrient issues will depend on the individual child. Factors
affecting nutrient metabolism, absorption, and utilization can include drug-nutrient
interactions.

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Diseases/Conditions > Developmental Disabilities > Prader > Willi Syndrome
Overview

Prader-Willi syndrome is a genetic disorder that is estimated to occur in 1 in 10,000-25,000
births in the US (Nativio 2002). It is characterized by hypotonia, growth retardation, genital
hypoplasia, developmental delays, small hands and feet, and other physical and behavioral
conditions that result in obesity (Goldstone 2008).
Many infants initially require tube feeding. Food seeking, sneaking, and gorging begin
during early childhood. If unmanaged, morbid obesity can result. Early intervention and
ongoing nutrition management (including transition to adult care) is critical (Goldstone
2008).
Many children with Prader-Willi syndrome are followed by a team of specialists who are
familiar with disorders as well as with the long-term care of the individual children and their
families. Consultation with these teams is essential. Collaboration between specialists,
families, and local/community health care providers enhances care.
Standards of Practice and Standards of Professional Performance have been developed
for the fields of Pediatrics and Behavioral Health Care (which includes developmental
disabilities). These standards define the practice-specific role of the registered dietitian
(Emerson 2006; Charney 2009).

Disease Process

Prader-Willi syndrome is a genetic condition that results from a paternal deletion or
maternal disomy on the 15th chromosome. It is generally identified based on clinical
presentation, and diagnosis is confirmed through genetic testing.
Clinical features of Prader-Willi syndrome include the following (Goldstone 2008; Nativio
2002):
Infancy: hypotonia with poor suck
Early childhood: hypotonia, global developmental delay, short stature and/or growth
failure
School-age: hypotonia, global developmental delay, excessive eating (hyperphagia,
obsession with food), obesity if uncontrolled
Adolescence: cognitive impairment, excessive eating, hypogonadism, behavior
problems (eg, temper tantrums, obsessive-compulsive features)
Other features may include characteristic facial features, hypopigmentation, small/narrow
hands, eye abnormalities, speech articulation defects, and thick, viscous saliva (Nativio
2002).
Neuroanatomic and endocrine abnormalities that are responsible (at least in part) for many
of the features of Prader-Willi syndrome have been identified. Examples include structural
brain defects and elevated ghrelin concentrations (Goldstone 2008; Nativio 2002).
Prader-Willi syndrome has been described as having distinct phases and subphases (eg,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
hypotonia during infacy; hyperphagia leading to obesity). In light of the recent use of growth
hormone therapy, it is being recognized that the progression through the subphases may
be delayed for some individuals, and not all children go through each subphase (Goldstone
2008).
Medical and nutritional management of Prader-Willi syndrome address the issues of the
individual child, and often include the following (Goldstone 2008; Nativio 2002; Goldberg
2002):
Feeding therapy and nutrition supervision during infancy to ensure an adequate
intake; many infants with Prader-Willi syndrome receive tube-feeding early in life
Motor therapy (often provided by physical and/or occupational therapists) because of
hypotonia and motor delays
Education of parents, families, care givers, and other health professionals, to optimize
social, psychological and educational support
Management of hyperphagia, prevention/management of obesity, and management of
complications of obesity
Growth hormone therapy, with or without growth hormone deficiency; results in
increased adult height and improved body composition
Transition to adulthood, including health care setting and providers, concerns about
autonomy, and social, behavioral, psychological, and financial concerns; group home
placements are often necessary
Management of behavior and psychiatric problems, including management of temper
outbursts and skin picking
An interdisciplinary (often inter-agency) team is essential to effective management of
Prader-Willi syndrome (Goldstone 2008; Pereira 2009).

Biochemical and Nutrient Issues

Specific biochemical and nutrient issues will depend on the individual child. Factors
affecting nutrient metabolism, absorption, and utilization can include drug-nutrient
interactions as well as condition-specific factors that are related to associated conditions.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Diabetes Mellitus
Diabetes Mellitus


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Diabetes Mellitus > Type 1
Insulin Regimens

Children with type 1 diabetes require insulin to survive. Insulin is categorized based on
onset of action, peak action, and duration of action (American Diabetes Association, 2008).
These insulin regimens include the following:

Type of
Insulin
Brand
Name
Onset Peak Duration
Timing of
Dose
Rapid Acting (Prandial and Correction)
Lispro Humalog
15-30
min
30-90
min
3-4 hrs
Take within
15 minutes
before meals
or
immediately
after meals
Aspart NovoLog
15
min
45-90
min
3-5 hrs
Take 5-10
minutes
before meals
Glulisine Apidra
20
min
50-60
min
5-6 hrs
Take 15
minutes
before meals
or up to 20
minutes after
meals
Short Acting (Prandial and Correction)
Human
Regular
Humulin
R
30
min
1-3
hrs
8 hrs
Take 30
minutes
before meals
Intermediate Acting (Basal)
Human
Isophane
(NPH)
NovoLin
N
Humulin
N
1-2
hrs
4-12
hrs
24 hrs
Take either 1
to 3 times daily
Long Acting (Basal)
Detemir Levemir
1-3
hrs
3-14
hrs
5-23 hrs
Take once
daily before
evening meal
or bedtime or
one every 12
hours
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Glargine Lantus
1-3
hrs
No
peak
24 hrs
Take once
daily at the
same time
Cannot be
mixed with
any other type
of insulin but
can be used
in
combination
with other
insulins
Premixed Combinations (Prandial and Basal)
70%
Aspart
protamine,
30% Apart
NovoLog
70/30
10-20
min
2-4
hrs
Up to 24
hrs
Take 5-10
minutes
before meals
70% NPH,
30%
Regular
Humulin
70/30
30
min
2-12
hrs
24 hrs
Take 30
minutes
before meals
50% NPH,
50%
Regular
Humulin
50/50
30
min
2-12
hrs
24 hrs
Take 30
minutes
before meals
75%
Lispro
protamine,
25% Lispro
Humalog
75/25
15
min
1-4
hrs
14-24
hrs
Take 15
minutes
before meals
50%
Lispro
protamine,
50% Lispro
Humalog
50/50
15
min
1-4
hrs
14-24
hrs
Take 15
minutes
before meals
Guidelines for rapid-acting insulin:
Typically begins to work within 15 minutes after injection, peaks within an hour and
continues to work for 2 to 4 hours.
Rapid-acting insulin or bolus insulin should be administered before meals to match
the amount of carbohydrate eaten at meals or snacks. It can also be given to correct
for high blood glucose levels.
Young children may benefit from postprandial bolus insulin because their
carbohydrate intake can be unpredictable. Meals should have been eaten within 20
minutes, if postprandial insulin is administered, to best control blood glucose levels
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(American Diabetes Association, 2008).
Insulin pumps only use rapid-acting insulin.
Guidelines for regular or short-acting insulin:
Begins to work within 30 minutes after injections, peaks within 2 to 3 hours and is
effective approximately 3 to 6 hours after injection.
Can be used to cover the amount of carbohydrates eaten (prandial) and to correct for
high blood glucose (correction).
Guidelines for Intermediate-acting insulin:
Begins to work 2 to 4 hours after injection, peaks 4 to 12 hours later, and is effective
for approximately 12 to 18 hours.
It is often used in combination with rapid or short-acting insulins.
Typically peaks during the lunch meal in school-aged children if given at breakfast.
Can be administered 1 or 3 times daily.
Guidelines for long-acting insulin:
Provides continuous, “peakless” action; called basal (background) insulin.
Manages blood glucose levels between meals and snacks, as well as overnight and
fasting morning blood glucose levels.
Glargine cannot be mixed with any other type of insulin.
Insulin duration of action ranges from 5.7 to 23.2 hours and may need to be
administered either once or twice daily.
Guidelines for premixed insulin:
Convenient premixed dose of insulin, often in a prefilled pen.
Helpful for patients having difficulty administering multiple insulin injections to manage
blood glucose levels.
Administered twice daily, before breakfast and dinner meals.

Guidelines for fixed insulin:
A fixed amount of insulin, premixed insulin, or set insulin doses, is appropriate for children
who eat on scheduled mealtime and snack schedules. Day-to-day consistency in the timing
and amount of carbohydrate eaten in a meal is recommended.
Guidelines for flexible Insulin:
Intensive or flexible insulin regimens allow the patient to eat at flexible mealtimes as well as
eat an amount of food based on hunger rather than a predetermined amount of
carbohydrate. Patient’s use of basal/bolus insulin therapy and the total carbohydrate
amount at meals and snacks is the primary determinant of bolus insulin doses and blood
glucose response (American Diabetes Association, 2008).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Overview

Type 1 diabetes is a chronic illness characterized by the immune destruction of pancreatic
B-cells, slow and progressive loss of endogenous insulin production, and subsequent
hyperglycemia (American Diabetes Association, 2008).
All children and adolescents with type 1 diabetes require exogenous insulin to survive. At
diagnosis, they and their families are presented with different insulin regimens that are
determined by their eating habits and school, family, and physical activity schedules. It is
important for the registered dietitian to tailor the meal plan based on a patient’s insulin
regimen.
The American Dietetic Association Type 1 Diabetes Evidence-Based Practice Guidelines
state the following (EAL 2008):
In persons using fixed insulin doses, meal and snack carbohydrate intake should be
kept consistent daily to improve glycemic control.
In persons with type 1 diabetes who adjust their mealtime insulin or who are on insulin
pump therapy, insulin doses should be adjusted to carbohydrate intake
(insulin-to-carbohydrate ratios). This can be accompanying comprehensive nutrition
education and counseling on interpretation of blood glucose patterns, nutrition-related
medication management, and collaborating health care team.
The registered dietitian should encourage consumption of macronutrients according to
the Dietary Reference Intakes for infants, children, and adolescents (FNIC)

Disease Process

Immune-mediated diabetes
Type 1 diabetes, previously called "insulin-dependent diabetes" or "juvenile-onset
diabetes," is an autoimmune disease that results from beta-cell destruction. It accounts for
5% to 10% of all diagnosed cases of diabetes (American Diabetes Association 2009).
The antibodies against proteins in the islets can be found months to years before the onset
of diabetes. They include islet cell autoantibodies, insulin autoantibodies, autoantibodies to
glutamic acid decarboxylase, and autoantibodies to the tyrosine phosphatases (IA-2 and
IA-2ß) (American Diabetes Association-Diagnosis Classification, 2009). Usually one or
more of these autoantibodies are found in 85% to 90% of individuals when fasting
hyperglycemia is present. Type 1 diabetes also has strong human leukocyte antigen
associations with DQA and DQB genes and is influenced by the DRB gene. Different
versions of these genes can put people at risk for, or prevent them from, developing type 1
diabetes. Other autoimmune diseases such as celiac and autoimmune thyroiditis are
associated with type 1 diabetes.
The onset can be rapid in infants and children, whereas it is more gradual in adults. It is
typically characterized by the abrupt onset of clinical signs and symptoms: substantial
weight loss, polyuria, and polydipsia, associated with marked hyperglycemia leading to
ketoacidosis. Or, it may present as modest fasting hyperglycemia leading to severe
hyperglycemia and ketoacidosis when stressed or an infection is present. This beta-cell
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
destruction leads to absolute insulin deficiency, causing hyperglycemia. Exogenous insulin
is required to sustain life.
Common characteristics of individuals with type 1 diabetes include the following:
Northern European descent
Youth, although it can occur at any age
Healthy weight (BMI for age of 5th to 85th percentile)
Positive insulin autoantibodies (Rosenbloom 2008)
"Honeymoon" Phase
The honeymoon period in newly diagnosed type 1 diabetes is characterized by a transient
restoration of the beta-cell function after the initiation of insulin therapy. During this period,
exogenous insulin requirements are reduced or discontinued while maintaining good blood
glucose control. Insulin therapy at this time can slow down or even stop the destruction
process of the beta-cells and preserve endogenous insulin secretion. The incidence of
remission can vary between 25% to 100%; however, total remission is rare in children with
type 1 diabetes (Abdul-Rasoul 2006).
Maturity Onset Diabetes of the Young (MODY)
MODY is a type of diabetes that is found in approximately 2% of people with diabetes. It is
often not recognized and is treated as type 1 or type 2 diabetes. There are six known
genes that cause MODY, but each gene will produce different forms of diabetes (Timsit
2005). Knowing the type of MODY a person has influences the type of treatment and how
their diabetes will progress in the future.
The main characteristics of MODY include:
Usually occurs in youth (younger than age 25)
Is inherited through several generations (autosomal dominant inheritance); all
children of an affected parent with MODY have a 50% chance of inheriting affected
gene and developing MODY themselves
Insulin is not always required and can be treated with type 2 diabetes oral
medications to maintain blood glucose control
Persons with MODY do not produce enough insulin
Idiopathic diabetes
The etiology of type 1 diabetes occasionally is not known. These patients do not have
autoimmunity but may be prone to ketoacidosis. A minority of patients, including those
of African or Asian ancestry, fall into this category (American Diabetes
Association-Diagnosis Classification, 2009). Insulin therapy during this type of diabetes
may be more transient with varying degrees of insulin deficiencies.

Biochemical and Nutrient Issues

Adequate Insulin Metabolism
Insulin is essential for maintaining glucose levels and regulating carbohydrate, lipid, and
protein metabolism.
Insulin facilitates the entry of glucose into the cell, stimulates glycogen synthesis in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
the liver and muscle cells, and increases triglycerides stores.
Insulin lowers blood amino acids, facilitates incorporation of amino acids into tissue
protein, and decreases gluconeogenesis.
Insulin promotes lipogenesis by activating lipoprotein lipase, inhibiting lipolysis, and
stimulating hepatic lipogenesis.
Inadequate Insulin Metabolism
Hyperglycemia occurs when insulin is deficient as a result of increased
gluconeogenesis, accelerated glycogenolysis, and impaired glucose utilization by
peripheral tissues (Kitabchi 2001).
Hepatic glucose production is increased as a result of higher availability of amino
acids, lactate, and glycerol.
Counterregulatory hormones (glucagon, catecholamines, cortisol, and growth
hormone) cause insulin to be less effective and lead to the development of diabetic
ketoacidosis.
Ketogenesis occurs in the liver, causing fatty acid release in adipose tissue.
Triglyceride levels increase as a result of a decreased uptake of triglycerides.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Diabetes Mellitus > Type 2
Pharmacotherapy

Pharmacologic therapy for children with type 2 diabetes is used to decrease insulin
resistance, increase insulin secretion, or slow postprandial glucose absorption
(Rosenbloom 2008).
Metformin (glucophage) and insulin are approved for use in children and adolescents
(Rosenbloom 2008). Other classes of oral medications for type 2 diabetes—which include
glitazone, sulfonylurea, meglitinide, amylin, a glucagon-like peptide-1 (GLP-1) mimetic, or a
dipeptidyl peptidase-IV inhibitor—are approved for young adults 18 years of age and older
(Fonseca 2008).
Biguanide (Metformin)
Initial medication used that acts on insulin receptors in liver, muscle, and fat tissue
Reduces hepatic glucose production
Increases glucose uptake in muscle and fat
May promote weight loss
Reduces hemoglobin A1c (HgbA1c) by 1% to 2% with long-term use
May cause intestinal side effects (abdominal pain, diarrhea, and nausea); doses
should be titrated slowly over 3 to 4 weeks and should be taken with food; maximum
dose is 2,000 mg/day
Risk of lactic acidosis is low; however, metformin should not be given to patients with
renal impairment, hepatic disease, or cardiac or respiratory insuffiency
May normalize ovulation abnormalities in girls with polycystic ovarian syndrome and
increase pregnancy risk
Insulin
If blood glucose control is not effective using metformin, a long-acting insulin can be added
to improve HgbA1c. If postprandial hyperglycemia exists using metformin and a long-acting
insulin, a rapid-acting or short-acting insulin (bolus insulin) may be added. Refer to the type
1 diabetes Insulin Regimens section for different insulin descriptions.
Non-Insulin Injectables
Exenatide (Byetta)
After eating, GLP-1 is secreted by the L-cells in the small intestine. This causes insulin
secretion to increase in proportion to blood glucose levels, suppressing glucagon,
prolonging gastric emptying, and increasing satiety (Rosenbloom 2008; American Diabetes
Association 2008).
Byetta is used for those individuals with type 2 diabetes
Given as a twice-daily subcutaneous injection, typically with breakfast and dinner
Reduces fasting and postprandial blood glucose levels
Decreases hepatic glucose production
May suppress appetite and promote weight loss
May cause nausea and vomiting
Approved only in young adults (18 years and older)
Pramlintide acetate (Symlin) (Amylin)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Amylin peptide is secreted in conjunction with insulin by the pancreatic beta-cells. It can
lower blood glucose levels by decreasing glucagon, slowing gastric emptying, and
decreasing food intake (Rosenbloom 2008; American Diabetes Association 2008).
Amylin is used only in individuals with type 1 or type 2 diabetes who take mealtime
insulin (bolus insulin).
It is administered by subcutaneous injection before meals containing at least 250 kcal
or more than 30 g carbohydrate.
It cannot be mixed with insulin and should be taken as a separate injection.
Adverse effects are hypoglycemia and nausea; therefore, it is recommended to
decrease the insulin dose by 50% when treatment with amylin is initiated.
Modest weight loss or weight stabilization can be seen.

Overview

Type 2 diabetes, previously referred to as "non-insulin-dependent diabetes," "type II
diabetes," or "adult-onset diabetes," is a non-immune–mediated disease that involves a
complex picture of metabolic defects. It accounts for 90% to 95% of persons with diabetes.
Common characteristics of children with type 2 diabetes include the following:
Mean age of diagnosis is 13.5 years
Found in all races, but there is a greater prevalence in individuals of nonwhite,
non-European descent
Associated with body mass index greater than 85th %ile for age and sex
Ketoacidosis is usually not present, but one-third or more cases present with ketosis
Negative islet cell autoimmunity and without human leukocyte antigen (HLA)
More than 75% of cases among youth in the United States are associated with a first-
or second-degree family history of type 2 diabetes
Increased risk for developing macrovascular and microvascular complications
May occasionally present with severe dehydration (hyperosmolar hyperglycemic state
and hypokalemia), which can be fatal
In children with type 2 diabetes, medical nutrition therapy (MNT) is most effective when
provided early and consistently throughout the disease.
Lifestyle intervention should be focused on the following:
Weight maintenance or loss
Increase in exercise capacity
Normalization of glycemia
Control of comorbidities, including hypertension, dyslipidemia, nephropathy, and
hepatic steatosis (Rosenbloom 2008)
Overall, nutrition recommendations should be realistic to meet the patient’s and familiy's
lifestyle. Such recommendations for type 2 diabetes include the following:
Implement lifestyle modifications to reduce intakes of energy, saturated and trans
fatty acids, cholesterol, and sodium and to increase physical activity
Self-monitoring of blood glucose should be performed regularly to determine whether
adjustments in foods and meals will be sufficient to achieve blood glucose goals or if
medication(s) need to be combined with MNT (Rosenbloom 2008; American Diabetes
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Association, 2008)
Metformin and insulin are the only medications approved for use in children/adolescents in
most countries. Sulfonylureas may be approved for use in children in some countries
(Rosenbloom 2008).
The American Dietetic Association Type 2 Diabetes Evidence-Based Practice Guidelines
state the following (EAL 2008):
In persons receiving MNT alone or in combination with glucose-lowering medications,
meal and snack carbohydrate intake should be consistent each day to improve
glycemic control
In persons with diabetes who adjust their mealtime insulin, insulin doses should be
adjusted to carbohydrate intake (insulin-to-carbohydrate ratios). This can accompany
comprehensive nutrition education and counseling on interpretation of blood glucose
patterns, nutrition-related medication management, and collaborating with the health
care team.
The registered dietitian should encourage consumption of macronutrients according to
the Dietary Reference Intakes for infants, children and adolescents (IOM 2002).

Disease Process

Type 2 diabetes, previously referred to as "non-insulin-dependent diabetes," "type II
diabetes," or "adult-onset diabetes," is a non-immune–mediated disease that involves a
complex picture of metabolic defects. It accounts for 90% to 95% of persons with diabetes.
Type 2 diabetes is associated with insulin resistance, as well as hyperlipidemia,
hypertension, acanthosis nigricans, ovarian hyperandrogenism, and non-alcoholic fatty liver
disease (Rosenbloom 2008). Insulin secretion can be delayed, elevated, or diminished
depending on the status and duration of the disease. Initially, there is an increase in insulin
secretion to maintain blood glucose levels; however, as the disease progresses, insulin
production declines, resulting in hyperglycemia (Gungor 2005).
Autoimmune Type 2 Diabetes
It is known that approximately 15% of children with type 1 diabetes are obese; therefore,
distinguishing between type 1 and type 2 diabetes may be more difficult because of the rise
in obesity and insulin resistance in children. Furthermore, it has been found in the United
States and Europe that 15% to 40% of children with type 2 diabetes, including those who
are not taking insulin, have type 1 diabetes–associated autoantibodies (Rosenbloom 2008).
According to the International Society for Pediatric and Adolescent Diabetes Clinical
Practice Consensus Guidelines, the recommendations for autoantibody testing with
diagnoses and treatment of type 2 diabetes include the following:
Diabetes autoantibody testing should be considered in all pediatric patients with
clinical diagnosis of type 2 diabetes because of the high frequency of islet cell
autoimmunity in otherwise “typical” type 2 diabetes.
Antibodies will indicate an earlier need for insulin.
Antibodies will indicate the need to check for thyroid autoimmunity and to
consider other associated autoimmune disorders.
Diabetes autoantibody testing should be considered in overweight/obese children
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diabetes autoantibody testing should be considered in overweight/obese children
older than 13 years with a clinical presentation of type 1 diabetes (weight loss and
ketosis/ketoacidosis), some of whom may have type 2 diabetes.
C-peptide measurements should be considered in overweight/obese children older
than 13 years who have worsening levels of control on oral agents to identify those
requiring insulin therapy and to reconsider the diabetes classification (Rosenbloom
2008).

Biochemical and Nutrient Issues

Insulin resistance is defined as an inadequate response by skeletal muscle, liver, and
adipose tissue to the physiologic effects of circulating insulin. Impaired insulin sensitivity, as
seen in type 2 diabetes, decreases insulin-stimulated glucose uptake into skeletal muscle,
impairs insulin inhibition of hepatic glucose production in the liver, and reduces the ability of
insulin to inhibit lipolysis in adipose tissue (Schenk 2008).
Disturbances in carbohydrate and fat metabolism are important factors in the development
and maintenance of increased triglyceride storage and accumulation of lipids within adipose
tissue and skeletal muscle, leading to insulin resistance and type 2 diabetes (Blaak 2003).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Disorders of Lipid Metabolism
Overview

Disorders of lipid metabolism include the hyperlipidemias of elevated cholesterol and triglycerides,
and hypolipidemia, which includes low levels of high-density lipoprotein (HDL). These disorders in
children can occur from hereditary and/or environmental factors. When parents have disorders of
lipid metabolism, their children are screened according to the American Academy of Pediatrics and
the American Heart Association guidelines for screening (Kavey, 2006).
Universal screening with a fasting lipid profile is recommended for all children between the ages of
9 and 11 years with the aim to diagnose dyslipidemia before affected children begin puberty when
lipid levels naturally rise and it is difficult to diagnose. Universal screening will also allow treatment
before atherosclerosis is detected (Daniels, 2011). For those with a family history, screening
should occur as early as age 2 years.
Environmental factors that most contribute to disorders of lipid metabolism include inappropriate
nutrition and inadequate physical activity. If these factors are not corrected with changes in
lifestyle, the atherogenic process begins in childhood and presents as dyslipidemia in childhood
and adolescence.
Children aged 2 years or older consume 16% of their daily energy as added sugars. Although the
percentage of total energy at which sugar kilocalories would be detrimental to children is not
known, a recent study relating percentage of sugar intake to higher triglyceride levels and lower
HDL levels in adults needs to be noted. Adults who consumed 10% or more of daily energy as
added sugar had a 50% to 300% greater incidence of low HDL, compared with those consuming
<5% of energy as added sugar. Increased intake of caloric sweeteners increased triglyceride and
low-density lipoprotein levels (Welsh, 2010). As food habits are learned in childhood, it seems that
a low-sugar diet should be advocated in children. Less than 5% of total intake could be equivalent
to 60 kcal to 90 kcal from added sugar each day (based on average intake of 1,200 kcal to 1,800
kcal).
Nutrition therapy for children with disorders of lipid metabolism includes both a population
approach and an individual approach. The population approach emphasizes a healthy lifestyle with
a goal of preventing abnormal lipid levels. The previously recommended Step 1 diet is no longer
used. The individualized approach is for children at high risk who already have abnormal lipids and
whose family history reveals cardiovascular disease. The individual approach is directed at
reducing saturated fat, trans fat, and dietary cholesterol and encouraging a healthy lifestyle along
with specific cholesterol-lowering strategies, including increasing soluble fiber, docosahexaenoic
acid, and stanols and sterols.

Disease Process

Atherosclerosis is an adult disease that begins in childhood. For certain familial dyslipidemias,
children experience the morbidity in childhood. The process of the disease relates to cholesterol
that is found most abundantly in the low-density lipoprotein (LDL) cholesterol. LDL can be taken up
into blood vessels where it can be oxidized, which makes it atherogenic. When oxidized,
macrophages, which are part of the immune system, are thought to recognize the oxidized fat in
the lipoprotein as foreign. The macrophages ingest the fat, and this gives the macrophage a foamy
appearance; thus, they are called foam cells. The foam cells are the precursor to fatty
streaks. They also release chemical mediators to call in additional macrophages.
LDL cholesterol accumulates under the vascular endothelial cells, which are proliferated by the
cascade of macrophage signals. The macrophages also stimulate smooth muscle cells to become
more fibroblast-like, releasing more collagen and connective tissue proteins. This results in filiform
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
fatty deposits within the vascular intima, which is covered by a fibrous coat called plaque. The
thickened and fibrotic vessel wall with plaques prevents nutrient delivery, cells die, and the
contents are released into the plaque; cholesterol crystallizes and the lumen of the vessel is
decreased. The plaque can cause coronary heart disease or myocardial infarction, most often in
adults. Other factors contribute to the severity of the disease, such as age, sex, high-density
lipoprotein (HDL), triglycerides, smoking, blood pressure, insulin resistance, and
obesity ( McMahan, 2006). The liver is the only organ that can catabolize cholesterol. Once
catabolized, the cholesterol is secreted into the bile.
There are 5 classes of lipoprotein: HDL, LDL, intermediate-density lipoprotein (IDL),
very-low-density lipoprotein (VLDL), and chylomicrons. In order to be soluble in the plasma, they
are coated with an outer core of cholesterol, phospholipids, and apoproteins. Not only do the
apoproteins make the lipoprotein soluble, they activate some enzymes that are important to
releasing the inner core of triglyceride and cholesterol. Some dysipidemias are caused by genetic
mutations in the apoproteins (Rohrs, 2010). A disorder of increased production of VLDL by the liver
results in an increased number of LDL that is enriched with a higher proportion of apoprotein B.
Hyper-apoB is prevalent in adults with atherosclerosis and is thought to be inherited by their
children (Kafonek, 1989).
Low levels of apo A-I, the primary apolipoprotein component of HDL cholesterol, have been found
in children of parents with coronary artery disease (Kwiterovich, 1994; Srinivasan, 1994).
Measuring ApoE and lipoprotein A, did not predict whether children's cholesterol levels responded
to diet intervention (Dixon, 1997). Insulin resistance has also been shown to decrease apo A-I and
the secretion of HDL.
The Fredrickson phenotypes are used to classify dyslipidemias:
Frederickson Classification of Dyslipidemias
Phenotype Elevated
Particles
Major lipid
increased
Frequency
I Chylomicron TG Very Rare
IIA LDL LDL
cholesterol
Common
IIB LDL and VLDL LDL
cholesterol,
triglycerides
(TG)
Common
III IDL and
remnants
TC, TG Rare
IV VLDL TG Common
V Chylomicron
and VLDL
TG Uncommon

The children of parents with premature cardiovascular disease (CVD) can be grouped into the
following 7 dyslipidemia categories (Kwiterovich, 2008):
Elevated LDL-cholesterol (C) (type IIa) 1.
Elevated LDL-C combined with high triglyceride (type IIb) 2.
Elevated triglyceride (type IV) 3.
Low HDL-C (hypo-a) 4.
Type IIa, IIb, IV with additional low HDL-c 5.
Hyper-apobetalipoproteinemia (hyper-apoB) with normal LDL 6.
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Hyper-apobetalipoproteinemia (hyper-apoB) with normal LDL 6.
Apo-B and apoA-I levels are stronger predictors of parental CVD than LDL and HDL. All
apo-B particles are atherogenic. In adults, high levels of apo-B are a predictor of severe
coronary atherosclerosis.
7.
The size and density of the LDL particle can increase atherogenicity. Subclass A is large, buoyant,
and less atherogenic. Small, dense LDL, subclass B, with diameter of <255 has been shown to
have increased atherogenic properties. It is thought that these particles do not bind well with
receptors, are more prone to oxidative stress, and have a prolonged half-life. They seem to
penetrate the arterial wall more effectively (Raitakari, 2005). Others classify LDL in four
subclasses, with LDL1 being large and the most buoyant and LDL4 being the smallest and most
dense (Engler, 2005).
HDL is also divided into subcategories. HDL2 and HDL3 fractions have been identified according to
density. HDL2 is more saturated with lipid and therefore is more important in protecting from
atherosclerosis. Another parameter that can be assessed is non-HDL cholesterol, which is derived
from subtracting HDL from total cholesterol. It reflects the amount of cholesterol carried by the
atherogenic apoB-containing lipoproteins (VLDL, IDL, LDL, and lipoprotein A); in children, it
predicts future dyslipidemia as well as LDL. The Bogalusa Heart studies provided guidelines on
non-HDL; acceptable levels are <123 mg/dL (Kwiterovich, 2008; Srinivasan, 2002).
Familial hypercholesterolemia (FH) is an autosomal dominant disorder, a type of IIa or IIb defect,
and occurs in 1 in 500 people. FH presents with a LDL >160 mg/dL and normal triglycerides. A
deficiency of the liver cell membrane receptors (LDL-R gene) results in the elevated LDL. The
LDL-R also clears IDL, and VLDL may be elevated because it is the precursor to IDL. FH can
manifest as cardiovascular disease in adolescents.
FH is characterized by the number of gene alleles affected. If there are 2 alleles affected, it is
called homozygous FH, which is characterized with the highest levels of LDL, resulting in severe,
premature atherosclerosis. Before age 10, xanthomas can appear. These fatty deposits can be
found on the achilles tendons and the extensor tendons of the hands or on the cornea of the
eye. Fortunately, it occurs in 1 in 1 million children. Death from myocardial infarction has been
reported in children as young as 3 years who have homozygous FH.
Another presentation of IIA is an apoprotein B-100 defect. It results in elevated LDL levels.
Familial combined hyperlipidemia is an inherited autosomal dominant trait. It is an overproduction
of apoprotein B–containing particles VLDL, LDL or both. It is three times more prevalent than FH,
occurring in 1 in 200 to 1 in 300 people. Familial combined dyslipidemia has elevated triglyceride
and elevated cholesterol (both LDL and VLDL will be elevated). HDL cholesterol is low. Elevated
apolipoprotein B will be noted. These laboratory results are consistent with metabolic syndrome
(Zappalla, 2009).
Other causes of type IIA or IIB are hypothyroidism, in which the LDL-R expression is reduced,
leading to elevated LDL cholesterol levels.
In patients with nephrosis, lipoprotein production is elevated causing elevations in LDL cholesterol.
In patients with diabetes, apoprotein B is glycosylated and results in increased VLDL synthesis.
Type III (Fredrickson phenotype), also called remnant removal disease, involves elevations of IDL
and remnants and is rare in children.
Type IV and V (Fredrickson phenotype) result from hypertriglyceridemia. Hypertriglyceridemia is
more common in children with obesity and diabetes. Insulin resistance is present in children with
type 2 diabetes mellitus and obesity. Insulin regulates lipoprotein lipase activity, so less triglyceride
is taken up by the cells. Hypothyroidism has a similar outcome. FH rarely presents in childhood.
HDL cholesterol disorders include low apoprotein A-1 levels and lecithin-cholesterol
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acyltransferase deficiency, wherein cholesterol esters that typically move into the core of the HDL
particle cannot be formed and therefore circulating cholesterol increases.
Several studies involving children—including the Bogalusa Heart Study, the Pathological
Determinants of Atherosclerosis in Youth, the Muscatine Study, and the Cardiovascular Risk in
Young Finns Study—helped to support the correlation of elevated total cholesterol, LDL, and
triglycerides and low HDL with increased carotid intimal medial thickness and atherosclerotic
lesions ( Raitakari, 2003; Srinivasan, 2002; McMahan, 2006; Magnussen, 2009). The presence of
risk factors in adolescence predict carotid intima-media thinness in adults.
Cholesterol and lipoproteins increase from infancy and have levels similar to those of adolescents
by age 2 years. Cholesterol levels generally peak at age 9 to 11 years at 171 mg/dL ( Hickman,
1998). During puberty, levels decrease while growth escalates. Females tend to have higher
cholesterol levels than males, which is also accompanied by a higher HDL cholesterol level. Black
children have higher HDL and lower triglyceride levels than Hispanic children and non-Hispanic
white children ( Daniels, 2008).
More recently, the increase of pediatric obesity has been shown to result in insulin resistance and
metabolic syndrome, which is an additional risk factor for developing fatty streaks and fibrous
plaques in the aorta and coronary arteries. Diet and lifestyle factors contribute to the progression of
cardiovascular disease. Medical management of this condition via drug therapy in children with FH
who are older than 8 years has been approved by the American Academy of Pediatrics (Kavey,
2006).

Biochemical and Nutrient Issues

Pediatric dyslipidemias result from elevated or depressed levels of lipoproteins (cholesterol esters,
triglycerides, phospholipids, and apolipoproteins). There are 5 major lipoproteins, classified by
percentage of composition of cholesterol ester, triglyceride, protein, and phospholipid. The table
below summarizes the components of lipoproteins, which can enable both classification of the
dyslipidemia and therapy. For example, if low-density lipoprotein (LDL) is elevated, consideration
needs to be given to modifying cholesterol amount and use in the body, since it is the major
component of LDL. Lipoproteins facilitate the passage of water-insoluble lipids in the plasma.
Elevations in a certain lipoprotein suggest therapy that targets the specific components such as
cholesterol and triglyceride.
Content of 5 Classifications of Lipoproteins
Composition
(%)

Chylomicron VLDL IDL LDL HDL
Triglyceride 90 60 40 10 5
Cholesterol 5 12 30 50 20
Phospholipid 3 18 20 15 25
Protein 2 10 10 25 50
Physiological
Role
Transport of
dietary
triglyceride
Transport of
endogenous
triglyceride
LDL
precursor
Cholesterol
transport
Reverse
cholesterol
transport
VLDL = very-low-density lipoprotein; IDL = intermediate-density lipoprotein; HDL = high-density
lipoprotein
(Data are from Kris-Etherton, 1988)
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Fredrickson and Lee's classification system can be used to classify dyslipidemias into phenotypes
on the basis of their clinical sequelae (see table in Criteria to Assign Risk) (Ridker, 2001). Once a
phenotype is identified, nutrition therapy addresses the specific laboratory abnormality. For
example, phenotype IIa would be treated by targeting diet changes needed to decrease LDL and
cholesterol.
The apoproteins, found on the surface of the lipid core, play a significant role in heart disease by
enabling recognition of the lipoproteins by the different organs and cells, and activating enzymes
such as lipoprotein lipase, which facilitate uptake of lipid into the cells or enable actual binding with
cell receptors. Apoproteins also act as cofactors for different enzymes in lipoprotein metabolism
(Kwiterovich, 1994; Khachadurian, 1989). Most of the apoproteins in LDL are apo B-100, and are
referred to as apo B. As LDL increases, so does apo B; they are both atherogenic. Apo A-I and apo
A-II are primarily in HDL. Apo B, apo A-I, and apo A-II are affected by diet; Apo E is not.
Measurement of fasting insulin provides information on risk of developing cardiovascular risk
factors. High fasting insulin is associated with weight gain and blood pressure levels. Insulin
should not be measured during puberty, as it is elevated during that time (Steinberger, 2009).
Classification of Dyslipidemia in Childhood
Note: Lipid cutoffs vary between different panels. These are reflected by the references noted.
Lipid Type
Protective
Level(mg/dL)
Optimal
Level
(mg/dL)
Borderline
Level
(mg/dL)
Elevated
Level
(mg/dL)
Low
(mg/dL)
Extreme,
Gene-Related
Abnormality
(mg/dL)
Total Cholesterol 170 170-199 >200
LDL-Cholesterol 40-60
<100
a
<110
b
100-129
a
110-129
b
> 130 > 160
HDL-Cholesterol >80
>60
a
45
b
40-59
a
35-45
b


<40
a
35
b
<30
Non-HDL-Cholesterol
c
<120 123
c
120-144
f
144
c
>145
e
>190
e
Triglycerides <100
<100
a
75
b
100-200
a
0-9
yr: 75-99;
10-19
yr: 90-129
b
>200
a
0-9
yr: 100;
10-19 yr:
130
b
>400
Apo B
d
90
d
90-109
d
110
d

Apo AI 120
d
110-120
d
110
d

a
Source: Zappalla, 2009
b
Source: NCEP, 1992
c
Source: Srinivasan, 2002
d
Source: Hickman, 1998
e
Source: Daniels, 2011

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Diseases/Conditions > Epilepsy
Epilepsy


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Diseases/Conditions > Epilepsy > Pharmacologic Management
Overview

Epilepsy is a condition of recurrent seizures. Children with epilepsy may exhibit completely
normal function, growth, and development, but some may be severely, even
catastrophically, incapacitated by seizures. Most children with epilepsy achieve control with
the first antiepileptic drug (AED) selected (McAbee, 2000; Pellock, 1999); however, 30%
will be resistant to medication (Wheless, 1999; Lefevre, 2000; Stafstrom, 2004). In these
cases, the epilepsy is termed "medication or drug resistant” (Fisher, 2005).
Surgeries such as lobectomy and hemispherectomy remove or isolate a localized section of
brain tissue from which seizure activity originates. Although only a fraction of children with
intractable seizures meet the criteria for surgical intervention, studies report that the vast
majority enjoy dramatic postoperative improvements in function, leading to sharp
reductions in seizures and need for AEDs (Rutka, 2010; Skirrow, 2011).
The guidelines of nutrition therapy for patients on pharmacologic management are for
children who are not on any ketogenic diet therapy and only require treatment with AEDs,
vagus nerve stimulation therapy, or epilepsy surgery. An algorithm for determining whether
a patient is a candidate for ketogenic diet therapy or alternative therapies is available here.
For related information, see the Developmental Disabilities topic, specifically
Cerebral Palsy.

Biochemical and Nutrient Issues

Cytochrome P450 (CYP) isoenzymes are responsible for oxidative metabolism of many
drugs, including antiepileptic drugs (AEDs). CYP isoenzymes are a group of
heme-containing enzymes embedded primarily in the lipid bilayer of the endoplastic
reticulum of hepatocytes (liver cells). CYP metabolism also occurs, to a lesser extent, in
the small intestine, kidney, lung, and brain.
Induction or inhibition of microsomal CYP enzymes can alter drug and nutrient metabolism,
produce reactive and cytotoxic metabolic byproducts, and instigate drug–drug or
drug–nutrient interactions and nutrient deficiency syndromes. Studies suggest that the
ability of AEDs to induce or inhibit these enzymes may be the basis for some of their
associated adverse effects and toxicity syndromes (Wheless, 1999; Zhou, 1996; Cupp,
1998; Tanaka, 1999; Baer, 1997; Chung, 1994; Kishi, 1997; Chapman, 1997; Lewis, 1995).
Because the impact occurs at the subcellular level, both intravenous and oral forms of
AEDs are implicated.
Moderate to severe hepatic and renal dysfunction can affect biotransformation and
disposition of several AEDs (Bazil, 1998). Dialysis reduces levels of phenobarbital,
primidone, and ethosuximide (Bazil, 1998).
Significant interactions between grapefruit and carbamazepine have been reported (Garg,
1997; Pronsky, 2000). Grapefruit juice inhibits CYP isoenzymes in the intestinal wall,
leading to increased absorption, increased serum drug levels, and a greater risk of adverse
effects and toxicity (Garg, 1997; Elbe, 2001). Children on carbamazepine should avoid
grapefruit and its juice (Garg, 1997; Pronsky, 2000).
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Low levels of serum proteins, particularly albumin, can alter pharmacokinetics of some
AEDs and increase risk of drug toxicity (Lewis, 1995). Many AEDs (eg, diazepam,
phenytoin, valproic acid) are highly protein bound for transport into cells for metabolism
(Lewis, 1995; Pronsky, 2000). When bound to protein, AEDs are less pharmacologically
active than when they are unbound (free). When serum albumin levels are below 3 g/dL,
the total proportion of free AED to bound AED is higher; therefore, the pharmacological
action is greater, yet total serum drug concentrations are not altered. For these AEDs,
monitoring of free serum drug levels is more reliable in preventing toxicity than total serum
drug levels.
Vitamin D is used to maintain skeletal calcium balance by promoting calcium absorption in
the intestines, promoting bone resorption by increasing osteoclast number, maintaining
calcium and phosphate levels for bone formation, and allowing proper functioning of
parathyroid hormone to maintain serum calcium levels. Vitamin D deficiency can result in
lower bone mineral density and an increased risk of bone loss as osteoporosis or bone
fracture because a lack of vitamin D alters mineral metabolism in the body. Anticonvulsants
such as phenytoin and phenobarbitol can lead to a deficiency in vitamin D. These
medications increase the activity of enzymes in the liver, which causes vitamin D to be
more rapidly broken down into inactive forms. Anticonvulsants may induce bone disease
(Pack, 2004a; Mikati, 2003).
Adverse Effects
Common to nearly all AEDs is some degree of neurotoxicity, gastrointestinal distress,
teratogenicity, and drug–nutrient interaction. Drowsiness may negatively affect oral intake.
Gastrointestinal dysfunction can alter nutrient ingestion, absorption, digestion, and
elimination. Several AEDs are associated with weight loss (Pellock, 1999; Wheless, 1999;
Bazil, 1998; Pronsky, 2000; Bergen, 1995; Holland, 2000); in children, this may manifest as
flattened weight-related growth curves (Bergen, 1995). Other AEDs, such as valproate, are
associated with weight gain (Demir, 2000; Novak, 1999). Teratogenicity is of special
concern, particularly in the adolescent female, as teen pregnancy is almost always
unplanned. Adverse effects associated with selected AEDs are outlined in the table that
follows.
Nutrition-Related Adverse Effects Associated with Selected AEDs


Potential Adverse Effects
Name
Nutrients
Affected
Oral
a
Weight Gastrointestinal
b
Liver
c
Renal
Calculi
Bone
d
Carbamazepine
Calcium,
vitamin D,
folate,
carnitine
Y Gain Y Y N
Y
Ethosuximide
Calcium,
vitamin D
Y Loss Y N N Y
Felbamate – N Loss Y Y N N
Gabapentin – Y Gain N N N N
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Phenobarbital
Calcium,
vitamin D,
folate,
carnitine
N – Y Y N Y
Phenytoin
Calcium,
vitamin D,
folate,
carnitine
Y – Y Y N Y
Stiripentol
(Diacomit)
– Y Loss Y Y Y N
Topiramate – N Loss Y N Y N
Valproate
Calcium,
vitamin D,
carnitine
N Gain Y Y N Y
Zonisamide – N Loss Y N Y N
Lamotrigine – Y Loss Y Y N N
ACTH
Phosphate,
calcium,
sodium,
potassium
N Gain N N N N

a
Dry mouth, hypersalivation, gingival hyperplasia
b
Nausea, vomiting, diarrhea, constipation
c
Elevated liver function tests, hepatotoxicity
d
Impaired osteoid synthesis and calcification, osteoporosis, fractures, rickets

(McAbee, 2000; Pellock, 1999; Zhou, 1996; Baer, 1997; Chung, 1994; Kishi, 1997;
Chapman, 1997; Lewis, 1995; Bazil, 1998; Pronsky, 2000; Bergen, 1995; Holland, 2000;
Demir, 2000; Novak, 1999; Pavlakis, 1998; Akin, 1998; Kubota, 2000; De Vivo, 1998;
Raskind, 2000; Freeman, 2000; Oommen, 1999; Perez, 1999; Chiron, 2000)
For more information on nutrition interventions for nutrients that are affected by AEDs, refer
to the sections listed under Nutrition Interventions.

Disease Process

Seizure disorders are myriad and complex, and each disorder’s etiology and treatment
have a unique impact on function and nutritional status. Seizure frequency does not always
correlate with function (McAbee, 2000). Because of these variations, dietary modifications
for children with seizure disorders must be individualized for each child, based on a
comprehensive nutrition assessment. This assessment should include an evaluation of the
child’s food intake, growth pattern, activity level, motor and cognitive function and
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development, and the nutritional impact of medical interventions for seizure control.
The child with poorly controlled or intractable seizures is at a significantly greater risk for
feeding problems; gastrointestinal dysfunction; and malnutrition secondary to delayed,
stagnant, or regressed physical and/or cognitive development (Thommessen, 1991) (see
Developmental Disabilities). Multidisciplinary assessment by rehabilitation therapists, along
with the registered dietitian, may be warranted. Oral-motor dysfunction and prolonged
feeding times can significantly decrease energy intake, but conscientious efforts by
caregivers to improve intake are effective in reducing the risk (Duncan, 1999). Occupational
therapy and adaptive equipment may help increase nutrient intake if self-feeding is
hampered by fine-motor deficits. Speech therapy and a modified-consistency diet (see
Meal Plans) may be required if oral-motor skills are impaired.
Age-appropriate nutritional supplements or enteral nutrition (see Enteral Nutrition Support)
may be required if the child chronically or increasingly demonstrates the inability to eat
enough to sustain optimal nutritional status. To prevent deleterious effects on the physical
growth and health of children with disabling epilepsy, caregivers need nutrition counseling
to optimize energy, protein, and micronutrient intakes.

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Diseases/Conditions > Epilepsy > Dietary Management
Dietary Management


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Epilepsy > Dietary Management > Classic Ketogenic Diet
Overview

The ketogenic diet consists of approximately 70% to 90% of energy from fat, with the
remaining energy coming from protein and carbohydrate (Huttenlocher, 1976). The classic
ketogenic diet produces ketosis by limiting intake of carbohydrate and protein to 10% to
30% of energy combined.

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Diseases/Conditions > Epilepsy > Dietary Management > MCT Oil Ketogenic Diet
Overview

The ketogenic diet consists of approximately 70% to 90% of energy from fat, with the
remaining energy from protein and carbohydrate (Huttenlocher, 1971; Huttenlocher,
1976). The medium-chain triglyceride diet allows a larger intake of carbohydrate and
protein but still is limited to approximately 29% of energy with 10% coming from protein and
19% coming from carbohydrate (Liu, 2008).


Disease Process

Because medium-chain triglycerides (MCT) (C6-C12) are more ketogenic than long-chain
triglycerides, Huttenlocher introduced a variant of the classic ketogenic diet (KD) to allow
more carbohydrate than the classic 4:1 ratio KD to make it more palatable (Huttenlocher,
1971).
Efficacy of this variant was excellent, with a similar success rate to that achieved with the
classic KD. The MCT ketogenic diet (MCTKD) successfully suppressed a similar spectrum
of seizures as the classic KD (eg, minor motor, akinetic and myoclonic seizures) (Liu,
2008). This efficacy was verified in several subsequent retrospective, prospective, and
randomized studies (Huttenlocher, 1971; Trauner, 1985; Sills, 1986; Schwartz, 1989; Sell,
2005; Liu, 2008; Neal, 2009).
However, the MCTKD has been frequently associated with gastrointestinal side effects
including diarrhea, vomiting, bloating, and cramps. For this reason, the MCTKD has been
underutilized in children with intractable epilepsy (Liu, 2008). Liu (Liu, 2008) used MCT as
40% to more than 60% of daily energy intake, with estimated 100% compliance from
2005-2008 (n=43); approximately 7% of the cohort experienced gastrointestinal problems
and discontinued the diet before 2005. With careful monitoring and management of the
MCTKD, gastrointestinal side effects can be minimized (Liu, 2008).

Biochemical and Nutrient Factors

Without nutrition supplementation, nutritional risks within the diet can occur. A study of 25
children on the classic and MCT ketogenic diets, including daily multivitamin and mineral
supplements, met or exceeded the Dietary Reference Intakes for all nutrients except
phosphorus and folate (Liu, 2003). Both diets would have been inadequate in most
micronutrients (including vitamins A, B-1, B-2, B-3, B-6, B-12, C, D, and E; folate; calcium;
phosphate; magnesium; iron; zinc; and selenium) without the addition of vitamin and
mineral supplements (Liu, 2003).

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Diseases/Conditions > Failure to Thrive
Overview

Failure to thrive (FTT) is a physical sign of undernutrition, characterized by growth rates
that do not meet expected standards for infants and toddlers under 3 years of age
(Gahagan, 2006; Jaffe, 2011; Olsen, 2007; Corrales, 2005).
Historically, “Primary” or “Nonorganic” FTT was a term used to describe poor growth of a
child in the absence of any medical diagnosis. This type of FTT was most commonly
associated with delayed development, abnormal behavior, and altered infant-caregiver
interaction. Nonorganic FTT was thought to be largely environmental (Chatoor, 1998). It is
now known that many of these children may have specific developmental or psychological
problems including oromotor or sensory disorders, feeding disorder of infancy, and/or
environmental factors such as parental neglect and family relationship problems (Gahagan,
2006).
Conversely, “Secondary” or “Organic” FTT has been associated with a chronic disease
process or disability. This included conditions that affect digestion or absorption, or prevent
adequate nutritional intake.
FTT is often multifactorial. There is no universally accepted definition, and it has been
proposed that “inadequate growth” and “undernutrition” may more accurately describe all
types of FTT (Gahagan, 2006, Jaffe 2011).

Disease Process

FTT is a symptom of a child receiving inadequate nutrition for optimal growth (Jaffe, 2011).
It is often multifactorial (Gahagan, 2006). FTT can be classified based on pathophysiology:
inadequate energy intake, inadequate absorption, excess metabolic demand, or defective
nutrient utilization. Following is a description of conditions frequently associated with
FTT. In addition to the conditions that will be presented, stress and psychosocial factors in
the home can also contribute to FTT (Krugman, 2003).

Possible Causes of Failure to Thrive in Children
Inadequate energy intake resulting from the following:
Behavior problems affecting eating
Developmental delay
Disturbed parent-child relationship
Gastroesophageal reflux
Incorrect formula preparation
Infantile feeding disorders (Levine, 2011)
Lead poisoning
Mechanical feeding difficulties (oromotor dysfunction, congenital anomalies, central
nervous system damage)
Mercury poisoning (Koh, 2009)
Neglect
Neurological impairment or deficit
Prader-Willi syndrome (Miller, 2011)
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Unsuitable feeding habits (food fads, excessive juice intake)
Inadequate nutrient absorption resulting from the following:
Bartter syndrome (Purnima, 2011)
Biliary atresia
Celiac disease
Chronic diarrhea
Cow’s milk protein allergy
Cystic fibrosis
Malabsorption
Short gut syndrome
Increased metabolic demands resulting from the following:
Acquired immunodeficiency virus
Cerebral palsy
Chronic lung disease
Congenital heart defects
Fetal alcohol syndrome
Hyperthyroidism
Kidney disease
Malignancy
Obstructive sleep apnea (Chang, 2010)
Severe combined immunodeficiency (Cole, 2011)
Defective nutrient utilization resulting from the following:
Cornelia de Lange syndrome
Chromosomal abnormalities (Down syndrome, Hurler syndrome, Russell syndrome)
Inborn errors of metabolism
Williams syndrome
Trisomy 13 and 18
Vitamin B-12 deficiency (Banka, 2010; Chalouhi, 2008; Dror, 2008; Ide, 2011 )
Vitamin D deficiency (Haggerty, 2011)
Lack of expected growth in children is a problem. Children with FTT are at increased risk
for growth deficiency or short stature. In addition to increased susceptibility to childhood
disease, these children may be at increased risk for later heart disease (Fall, 1995). There
are conflicting data regarding the effect of early FTT on cognitive development and
intelligence quotient; however, it has been shown that undernutrition during critical periods
of brain development causes retardation of brain growth, as well as a variety of functional
abnormalities in the neurons, especially in the dendritic synaptic apparatus
(Benitez-Bribiesca, 1999). Fortunately, these same infants appear to catch up with
cognitive development when cared for in a nurturing environment (Mackner, 2003; Boddy,
2000; Chatoor, 2004; Black, 2007).

Factitious FTT
Not all healthy children follow the standard growth curves. Familial short stature,
constitutional growth delay, and abnormal intrauterine growth affect the rate of weight gain
and linear growth. These conditions should be ruled out during an evaluation of suspected
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
FTT (Krugman, 2003).

Familial Short Stature
The child who is genetically small grows at a rate parallel to the standard growth curves but
below the 5th percentile. This child maintains normal weight for height and appropriate
skinfold measures. The genetically small child tends to be small at birth, and mid-parental
height is below average. Mid-parental height can be assessed as follows (Tanner, 1970):
Girls: (Father's height – 5 inches + Mother's height)/2
Boys: (Mother's height + 5 inches + Father's height)/2
It is important to note that mid-parental height may not be a good predictor for certain
populations, such as those parents who experienced suboptimal nutrition during their own
childhood.
Bone age is consistent with chronological age in this population (Satter, 1986; Daniel,
2008).

Constitutional Growth Delay
Familial patterns of growth delay contribute to the appearance of FTT in an otherwise
healthy infant or child. Frequently in such cases, the parents are of average height and
describe themselves as “late bloomers” who were short as children but continued to gain in
height for a longer period of time than their peers. As with familial short stature, the child
experiencing constitutional growth delay should maintain a normal weight for height and
skinfold measures, but bone age will be delayed (Satter, 1986; Daniel, 2008).

Intrauterine Growth
Intrauterine conditions affect the birth size of an infant. For example, poorly controlled
maternal diabetes is associated with infants who are large for gestational age. A downward
shift to the child’s true genetic growth potential is expected for infants determined to be
large for gestational age at birth if caused by gestational diabetes or another cause not
related to parental height. Upon reaching the expected percentile for growth potential, the
child’s growth pattern should follow the standard curves. Conversely, a child who
experienced intrauterine growth retardation or was small for gestational age at birth may
experience difficulty in achieving sufficient catch-up growth to reach the standard curves
(Satter, 1986; Daniel, 2008).

Premature Infants
Growth deficiency may be overestimated in infants or children who were born prematurely
if the age at measurement is not corrected for the number of weeks the child was
premature (the difference between 40 weeks and gestational age at birth). For consistent
evaluation of growth, correction for prematurity should be continued until age 3 years or
after 2 years if the child can be plotted within normal limits on the Centers for Disease
Control and Prevention (CDC) growth curve for 2- to 20-year-olds (NCHS, 2009). No
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
correction for prematurity is indicated when the child’s growth pattern can be evaluated on
the CDC growth chart for 2- to 20-year-olds. However, it is important to note the degree of
prematurity in the medical history.

Breastfed Infants
Infants who are breastfed tend to gain weight at a slower rate than formula-fed infants after
age 3 months (NCHS, 2009). Gains in length and head circumference are similar in both
groups. The slower growth rates and lower energy intakes of breastfed infants are not
associated with any increase morbidity, decreased activity, or delayed development (WHO,
2006). The World Health Organization child growth standards are available at
http://www.who.int/childgrowth/en/.


Biochemical and Nutrient Issues

Carbohydrate
Nutrient analysis of intake records for the child with failure to thrive (FTT) may reveal either
an overabundance of simple carbohydrate as a strategy to increase energy intake or a strict
limitation of all sucrose or sucrose-containing foods because of concerns regarding health
or hyperactivity.
Fat
Many parents perceive dietary fat as undesirable and unhealthful. Inadvertent or
well-intentioned fat restriction by parents attempting to promote a healthy lifestyle can
severely limit the energy intake in a young child who is unable to consume sufficient
quantities of low-kilocalorie foods (McCann, 1994; Pugliese, 1987). These parents may be
reluctant to increase dietary fat, especially saturated fats, as a means of promoting weight
gain (Lifshitz, 1989).
Fluid
Excessive consumption of fruit juice, soda, punch, fruit-flavored beverages, sweetened tea,
and/or water may displace more energy-dense and nutrient-dense foods. In addition, some
juices, especially apple juice, may induce fructose and sorbitol malabsorption (Smith, 1994;
AAP, 2001). Milk consumption should be limited to 24 oz per day for children between the
ages of 1 and 5 years to promote adequate intake of other nutrient-dense foods and
to prevent iron-deficiency anemia.
Iron
Iron deficiency may occur with FTT due to suboptimal intake or inadequate nutrient
absorption. Excessive milk consumption in the absence of other iron-rich foods can also
lead to iron deficiency in this population. Furthermore, iron-deficiency anemia may impair
appetite and weight gain. A complete blood count (CBC) to identify iron-deficiency anemia
is indicated when the dietary history is consistent with a deficient iron intake or possible
iron losses and/or a positive physical examination (Zenel, 1997; Corrales, 2005; Christian,
2003). If the CBC is consistent with anemia, a serum ferritin may be obtained to give a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
more specific measurement of iron deficiency.
Vitamin B-12
Vitamin B-12 deficiency during infancy includes FTT, movement disorders, developmental
delays, and megaloblastic anemia (Monsen, 2003). Vitamin B-12 deficiency may occur with
FTT due to inadequate intake by the child or nursing mother. Inadequate intake is most
commonly seen among strict vegetarian and/or vegan children and nursing mothers.
Deficiency is diagnosed through serum vitamin B-12 laboratory values (Banka, 2010;
Chalouhi, 2008; Dror, 2008).
Zinc
Zinc deficiency is associated with growth failure. Physical signs and symptoms of zinc
deficiency include specific skin lesions, alopecia, irritability, and anorexia. Low serum zinc
levels may not reflect cellular zinc status but may be considered along with physical
status. Risk factors for the development of zinc deficiency include prematurity, diarrhea or
malabsorption, a poor dietary intake of zinc, and the relatively low concentration of zinc in
breast milk. Zinc deficiency, in conjunction with these risk factors, is diagnosed through
clinical signs, symptoms, and laboratory values. Low serum alkaline phosphatase activity in
the presence of one or more of the stated risk factors is suggestive of zinc deficiency (King,
2005; Kasarskis, 1980; Weismann, 1985).

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Diseases/Conditions > Food Allergic Disorders
Food Allergic Disorders


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Diseases/Conditions > Food Allergic Disorders > Eosinophilic Esophagitis
Overview

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated disease of the
esophagus characterized clinically by symptoms related to esophageal dysfunction and
histologically by eosinophil-predominant inflammation (Liacouras, 2011). EoE has been
increasingly identified and diagnosed over the past 10 years (Furuta, 2007). The
prevalence of EoE in the pediatric population is greater in males (66%) than in females
(Straumann, 2008). Approximately two-thirds of patients diagnosed with EoE have other
allergic disorders, including 46% of children with documented immunoglobulin E–mediated
food allergies (Noel, 2004). EoE appears to be chronic without spontaneous resolution
(Straumann, 2003).
Symptoms of EoE may include abdominal pain, emesis, heartburn, poor appetite, early
satiety, food aversions, failure to thrive (FTT), swallowing difficulties, and bolus food
impactions. Age-related differences in symptoms are often reported (Chehade, 2010). The
most common signs of EoE in infants and young children are emesis, FTT, food refusal,
and other nonspecific feeding disorders. Abdominal pain and GERD-like symptoms are
often verbalized by older children. In adolescents and adults, the most common symptoms
appear to be dysphagia and esophageal food impactions (Chehade, 2010).
Diagnosis
EoE is a clinicopathologic disease (Liacouras, 2011). Clinically, EoE is characterized by
symptoms of esophageal dysfunction. Pathologically, EoE is characterized
by eosinophil-predominant inflammation in the esophageal mucosa upon examination
of biopsy specimines obtained via esophagogastroduodenoscopy (Liacouras,
2011). Diagnosis is based on a finding of at least 15 intraepithelial eosinophils/high power
field in at least one esophageal mucosal biopsy specimen. Other causes of esophageal
eosinophilia should be excluded, specifically GERD. Typically the absence of GERD
is proven by either negative pH probe or unresponsive treatment with high-dose PPI
(Furuta, 2007).
Other eosinophilic disorders—such as eosinophilic gastritis, gastroenteritis, and
colitis—are generally treated with similar dietary regimens (Chehade, 2006). These
disorders are less common and little research on treatment approaches is available.

Disease Process

Dietary antigens are strongly implicated in causing the allergic response in eosinophilic
esophagitis (EoE) (Furuta, 2007). The removal of dietary antigens has clearly been
demonstrated to successfully treat EoE, with both a symptomatic and histologic
response (Kelly, 1995; Markowitz, 2003; Spergel, 2005). There is some evidence that
environmental antigens may also play a role (Onbasi, 2005; Fogg, 2003).
The role of food antigens was first described by Kelly et al (1995); these researchers were
able to demonstrate remission of the disease using a predominantly amino acid–based
formula diet. Ten children with a diagnosis of refractory EoE were placed on a diet of
amino acid–based formula in addition to clear liquids; for those old enough to
eat solid foods, foods made from apple and corn were added. Eight of the 10 children had
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complete resolution of symptoms whereas the remaining two children had significant
improvement. Mean eosinophil counts decreased from 41/HPF (range 15 to 100) to
0.5/HPF (range 0 to 22). With reintroduction of foods, active EoE returned.
The findings of the study by Kelly et al were later confirmed by Markowitz (2003) with a
larger study group (n=51) of children who were placed on an amino acid–based formula
and either apple or grape. Among the 51 children, 49 showed significant clinical and
histological response .
Food Allergy
Although the cause of EoE is unknown at this time, there appears to be a genetic
component. The food allergic mechanism in EoE may involve both immunoglobulin E
(IgE)– and non-IgE–mediated immune mechanisms (Furuta, 2007). Often, patients with
EoE cannot associate their gastrointestinal or esophageal symptoms with the ingestion of
a specific food because of the delayed allergic response typically seen in
non-IgE–mediated food hypersensitivity. Several reports have demonstrated that it may
take several days for symptoms to occur (or recur on challenge) with ingestion of antigens
that cause EoE (Kelly, 1995; Liacouras, 1999)
IgE– and Non-IgE–Mediated Food Allergy
Food allergy occurs when the immune system fails to develop tolerance to harmless food
proteins and responds as if they were harmful. One way in which the immune system
responds is with IgE antibodies (Sicherer, 2006). During sensitization or the first exposure
to the allergen, the immune system produces protein-specific IgE antibodies. These
food-specific antibodies bind to the surfaces of mast cells, basophils, macrophages,
monocytes, lymphocytes, eosinophils, and platelets (Scurlock, 2005). Each subsequent
exposure to the specific food protein will result in cross-linking of the IgE on the cell surface
and signal the release of pro-inflammatory mediators such as histamine, leukotrienes, and
prostaglandins, resulting in allergic symptoms (Scurlock, 2005). A cascade of symptoms,
ranging from mild to severe, may occur; these symptoms involve the cutaneous (urticaria,
angioedema, atopic dermatitis), respiratory (acute rhinoconjunctivitis, bronchospasm,
asthma), gastrointestinal (pollen food allergy syndrome, gastrointestinal anaphylaxis),
and/or cardiovascular systems (hypotension, cardiac dysrhythmia) (Sicherer, 2006).
The immune system may respond in other ways to food antigens. In non-IgE–mediated
food allergic reactions, other inflammatory cells such as lymphocytes, eosinophils, and
mast cells play a role. There is considerable evidence that EoE is associated with T helper
cell 2 (Th2) type immune response (Furuta, 2007). Eosinophil-active Th2 cytokines as well
as mast cells are present in the esophagus of patients with EoE. Non-IgE–mediated
reactions typically have delayed symptoms, often those that affect the gastrointestinal tract
(chronic or episodic vomiting, abdominal pain, nausea, diarrhea) or skin (atopic dermatitis);
these symptoms may appear hours to days after allergen ingestion. Although this type of
cell-mediated reaction is not responsible for life-threatening anaphylaxis, the symptoms of
a non-IgE–mediated allergy may be chronic and have a significant impact on the quality of
daily life.

Biochemical and Nutrient Factors

Children with eosinophilic esophagitis have increased nutritional risk and poor growth
because of decreased intake, emesis or dietary elimination diets. Analysis of the dietary
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records may reveal specific nutritional inadequacies in the provided diet. Rickets,
micronutrient deficiencies, shorter stature, and failure to thrive have been associated with
allergen-elimination diets (Henriksen, 2000; Isolauri, 1998; Jensen, 2004; Christie, 2002).

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Diseases/Conditions > Food Allergic Disorders > General Guidance
Overview

Food allergy is defined as an adverse health affect arising from a specific immune
response that occurs reproducibly on exposure to a given food (Boyce, 2010). Other types
of adverse reactions to food, such as lactose intolerance, are not immune-mediated and
therefore are not related to food allergies. Although almost any food protein can cause an
abnormal immune-mediated response, 90% of all food-allergic reactions in the United
States are caused by 8 foods or food groups: milk, egg, wheat, soy, peanut, tree nut, fish,
and shellfish (Sampson, 2004).
The most common food allergens in early childhood are milk, egg, wheat, soy, and peanut
(Sampson, 2004). Food allergy in childhood has been shown to be on the rise, with an 18%
increase in prevalence between 1997 and 2007 (Branum, 2008). The natural course of
allergy to specific foods varies and many children lose their allergy to milk, egg, wheat, and
soy after several years. There is recent evidence to suggest that milk allergy may be more
persistent, with resolution occurring in the teenage years rather than early childhood
(Skripak, 2007). Peanut allergy tends to be lifelong, with only approximately 20% of
individuals eventually outgrowing their allergy to peanut (Skripak, 2008; Fleischer, 2007;
Fleischer, 2003; Sicherer, 2002). In addition to the specific food allergen, the type of food
allergic disorder may also influence how quickly tolerance is developed. For example, in
milk protein–induced proctocolitis, tolerance is often achieved by 1 year of age (Ravelli,
2008).
Promising immunotherapeutic treatment options for food allergy are being investigated.
Clinical trials exploring anti-immunoglobulin E (IgE) antibody therapies, Chinese herbal
medicines, and oral and sublingual immunotherapy for various food antigens are under
way (Chehade, 2007; Nowak-Wegrzyn, 2006; Nowak-Wegrzyn, 2004; Pons, 2005;
Srivastava, 2009; Lemon-Mule, 2008, Nowak-Wegrzyn, 2011). Preliminary peanut oral
immunotherapy research indicates that clinical desensitization can be induced (Jones,
2008). The term "desensitization" refers to a change in threshold of ingested allergen
needed to cause allergic symptoms while the patient continues to receive ongoing
therapy. Tolerance, on the other hand, indicates the ability to ingest the food without
symptoms and without ongoing therapy. The ability of oral immunotherapy to induce
long-term clinical tolerance (as opposed to desensitization) is now being studied (Jones,
2008).
However, at this time, avoidance of the identified allergen is the only therapeutic treatment
approach that has been consistently shown to prevent food-allergic reactions. Food
elimination diets may pose a challenge to providing adequate nutrition; therefore, they
should be applied appropriately for the treatment of a properly diagnosed food allergy or
for diagnostic purposes on a short-term basis.
Allergen elimination diets may affect nutrient intakes and growth (Henriksen, 2000; Isolauri,
1998; Jensen, 2004; Christie, 2002). Christie and colleagues (2002) found that children
with two or more food allergies were shorter, based on height-for-age percentiles, than
those with only one food allergy. Furthermore, children with cow’s milk allergy or multiple
food allergies consumed dietary calcium less than age- and gender-specific
recommendations compared with children without cow’s milk allergy and/or one food
allergy (Christie, 2002). Overall, children with food allergy are reported to have lower
intakes of vitamins D and E, iron, calcium, and zinc, although, depending on the food
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avoided, certain nutrients may be at greater risk of inadequacy.

Disease Process

IgE-Mediated Allergic Disorders
The immune system is vast and employs many systems to detect and destroy harmful
bacteria, viruses, and parasites. Food allergy occurs when the immune system fails to
develop tolerance to harmless food proteins and responds as if they were harmful. One
way in which the immune system responds is with immunoglobulin E (IgE) antibodies.
During sensitization or the first exposure to the allergen, the immune system produces food
protein–specific IgE antibodies. These food-specific antibodies bind to receptors on the
surface of mast cells and basophils (Sampson, 2004; Scurlock, 2005). Each subsequent
exposure to the specific food protein will result in cross-linking of the IgE on the cell surface
and signal the release of pro-inflammatory mediators such as histamine, leukotrienes, and
prostaglandins, resulting in allergic symptoms (Scurlock, 2005).
A variety of symptoms, ranging from mild to severe, may occur and can involve the
cutaneous (urticaria, angioedema, atopic dermatitis), respiratory (throat
tightness/laryngoedema, cough, wheezing, dyspnea), gastrointestinal (nausea, vomiting,
diarrhea), and/or cardiovascular systems (hypotension, cardiac dysrhythmia). Once a
reaction begins, there is no way to predict how serious it will become (Sampson,
2004). The severity of allergic reactions is variable, will depend on many factors, and
cannot be predicted by previous allergic reactions or food-specific IgE levels. The
coexistence of asthma is a factor most commonly associated with severe
reactions (Boyce, 2010).
Anaphylaxis is a serious allergic reaction that is rapid in onset, occurring minutes to
several hours after contact with an allergen, and may cause death (Sampson, 2006). Food
allergy is the most common cause of anaphylaxis in emergency rooms in the United States,
with an estimated 200 deaths each year. The foods most commonly associated with
anaphylaxis are peanut, tree nut, fish, and shellfish, although anaphylaxis can occur as a
result of other allergens such as milk, egg, soy, wheat, and others. Food-allergic individuals
with concomitant asthma are at greater risk for anaphylaxis. Teenage children are also
more likely to experience an anaphylactic reaction, as they eat more frequently away from
home, do not always have their emergency medications on hand, and may not recognize
or might even ignore symptoms of an allergic reaction.
Epinephrine, available as an auto-injector (EpiPen or Twinject), is the required treatment
for anaphylaxis and patients at risk for anaphylaxis should carry epinephrine with them at
all times (Sampson, 2004; Wang, 2007); it is also essential that all caregivers
(babysitters, family, school personnel) understand how to recognize and treat a food
allergy reaction. In some cases, the symptoms may initially resolve but return 2 to 3 hours
later; this is called a biphasic reaction. Any patient experiencing anaphylaxis should
receive epinephrine and be transported to the hospital's emergency department and remain
under observation for several hours because of the risk of a biphasic reaction (Sicherer,
2006).
Not all food-allergic reactions will result in anaphylaxis. Certain IgE-mediated food-allergic
disorders are less likely to lead to anaphylaxis. For instance, pollen-food allergy syndrome,
also known as oral allergy syndrome, is characterized by oral itching and swelling and
rarely progresses to a systemic reaction (Hofmann, 2008). It is caused by sensitization to
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plant proteins such as birch, grass, and ragweed pollens, which cross-react with food
allergens. Patients with birch allergy may have oral symptoms upon ingestion of raw apple,
pear, peach, carrot, or hazelnut, for example. Those with ragweed allergy may present oral
symptoms caused by raw melons or banana, and those with grass pollen allergy may react
to raw tomato or melons.
Oral allergy symptoms may be worse during the specific pollen allergy season although
that is not always the case and symptoms may persist regardless of season. These food
proteins are heat-labile and susceptible to gastric digestion. Therefore, patients with
pollen-food allergy syndrome generally experience symptoms localized in the mouth or
throat. Because these proteins are easily denatured with heat, individuals who experience
oral symptoms from fresh apples, for example, generally have no symptoms upon
ingestion of cooked apple (Hofmann, 2008).
Non-IgE–Mediated Food-Allergic Disorders
The immune system may respond in other ways to food antigens. T cells and eosinophils
are pro-inflammatory leukocytes that can be “called” to a specific site and cause
inflammation. Although this type of cell-mediated reaction is not responsible for
life-threatening anaphylaxis, the symptoms of a non-IgE–mediated allergy may be chronic
or severe and have a significant impact on the quality of daily life. In addition, some
food-allergic disorders, such as allergic eosinophilic esophagitis or atopic dermatitis, may
have mixed immune-mediated responses—in other words, they may involve both IgE- and
non-IgE–mediated immune mechanisms.

Food Protein-Induced Enterocolitis Syndrome

Food protein–induced enterocolitis syndrome (FPIES) is a non-immunoglobulin
E–mediated allergic disorder generally seen before 3 months of age, but the onset may be
delayed in breastfeeding infants. The most common foods that cause hypersensitivity are
milk and soy, although other foods, such as grains and poultry, have been implicated
(Nowak-Wegrzyn, 2003). Proteins that have been associated with FPIES in some children
include grains (rice, oats, barley), meat and poultry (beef, chicken, turkey), vegetables and
fruit (sweet potato, squash, string beans, banana), legumes (peas, lentils), fish, and the
probiotic Saccharomyces boulardii.
Affected infants typically demonstrate significant gastrointestinal symptoms (repetitive
vomiting and diarrhea) within 1 to 3 hours after ingestion of the offending food
(Nowak-Wegrzyn, 2003). FPIES can also present with chronic symptoms of vomiting and
diarrhea while the antigen is being ingested regularly. This can be followed by an acute
phase if the antigen is removed from the diet and subsequently reingested, with symptoms
occurring within 1 to 3 hours after ingestion. Symptoms disappear once the allergen is
removed from the diet and the vast majority of children outgrow this type of
allergy. Symptoms can be severe enough to cause dehydration and shock
(Nowak-Wegrzyn, 2003; Sicherer, 2006).
FPIES generally resolves in early childhood, but oral food challenges should always be
performed in a hospital setting, as there is a 15% risk of hypotension with this type of
allergic reaction (Sampson, 2004; Nowak-Wegrzyn, 2003).

Food Protein-Induced Proctocolitis
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Food protein–induced proctocolitis syndrome generally presents in the first few months of
life in response to milk or soy formula or food proteins passed through the breast milk and
is characterized by gross or occult blood in the stool (Ravelli, 2008). Symptoms resolve
once the identified food is removed from the infant diet or the maternal diet of breastfed
infants. Proctocolitis usually resolves at approximately 1 year of age (Ravelli, 2008;
Sicherer, 2003).
The World Health Organization's Diagnosis and Rationale for Action against Cow's Milk
Allergy Guidelines recommend an extensively hydrolyzed hypoallergenic milk-based
formula (as opposed to intact cow's milk or soy-based formula) for formula-fed infants for
treatment of proctocolitis (Fiocchi, 2010). Symptoms typically resolve 72 hours after milk is
removed from the diet but may continue for as long as 2 weeks. In the breastfed infant,
strict removal of cow's milk protein from the maternal diet is recommended. If symptoms do
not resolve, removal of soy from the diet is also recommended, followed by egg.

Eosinophilic Esophagitis

Information on eosinophilic esophagitis is available here.

Celiac Disease

Celiac disease is an autoimmune disorder caused by an immune-mediated response to a
food protein, in which the lining of the small intestine becomes damaged. Intake of gluten in
wheat products and analogous proteins present in barley and rye trigger the immune
response.
Celiac disease, which is not classified as a food allergy, is discussed separately in the
Pediatric Nutrition Care Manual and will not be covered in this section.

Biochemical and Nutrient Issues

The pediatric population with food allergies does not generally have altered nutrient needs
when compared with the pediatric population without food allergies. Patients with severe
atopic dermatitis are an exception, however, as they may have increased energy and
protein needs associated with skin repair (Cho, 2011; Mofidi, 2003).
Children with food allergies are at increased risk for inadequate nutrient intakes and poor
growth due to dietary restrictions. Rickets, vitamin and mineral deficiencies, shorter stature,
and failure to thrive have all been associated with allergen-elimination diets (Henriksen,
2000; Isolauri, 1998; Jensen, 2004; Christie, 2002; Noimark, 2008; Kirby, 2009; Hays,
2011; Cho, 2011). The elimination diet must be carefully planned to ensure adequate
substitution of the macronutrients and micronutrients inherent in the eliminated
food(s). The US Food Allergy Guidelines recommend nutrition counseling and close growth
monitoring for all children with food allergies (Boyce, 2010).

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Diseases/Conditions > Gastrointestinal Diseases
Gastrointestinal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Gastrointestinal Diseases > Celiac Disease
Overview

Celiac disease, an autoimmune disease of the small intestine, is characterized by damage
to the villus epithelial cells in response to ingestion of gluten in genetically susceptible
individuals. Gluten is a protein found in some cereal grains, including wheat. The damage
to the small intestine resolves when gluten is removed from the diet (Murray, 1999;
Fasano, 2001).
Celiac disease was once thought to be rare; however, epidemiological studies in Europe
and in the United States indicate that the prevalence of celiac disease in both geographic
locations is approximately 1 in 130 to 1 in 300, making it one of the most common
genetically based diseases (Fasano, 2003). The prevalence in children is estimated to
range from as few as 1 in 300 to as many as 1 in 80 (Hill, 2005).
The prevalence of celiac disease is higher among individuals who fall within the scope of
the following (Hill, 2005; Fasano, 2003):
First- and second-degree relatives of individuals with history of celiac disease
Insulin-dependent diabetes mellitus
Autoimmune thyroiditis
Down syndrome
Turner syndrome
Williams syndrome
IgA deficiency
Dental enamel defects
Osteoporosis
Iron-deficiency anemia resistant to iron therapy
Short stature
Delayed puberty
Dermatitis herpetiformis, often called skin celiac disease, is a variant of celiac disease in
which the skin is the major organ affected. Skin symptoms such as blister-like papules
(which have IgA deposits), severe itchiness, and burning are usually the most prominent
manifestations. Individuals with dermatitis herpetiformis usually do not have
gastrointestinal symptoms; however, some degree of damage to the small intestine is found
in almost all patients with dermatitis herpetiformis (Murray, 1999; Fasano, 2001; Caproni,
2009). Dermatitis herpetiformis affects 10% to 20% of patients with celiac disease and can
be diagnosed at any age; however, it is rarely seen in children (Reunala, 1998; Fasano,
2005).
Management of this chronic disease is dependent on lifelong, strict adherence to a
gluten-free diet. Patients with celiac disease who do not follow a strict, gluten-free diet may
have increased prevalence of other autoimmune diseases. In addition, there is an
increased mortality rate among this population as a result of neoplasms (Fasano, 2001;
Murray, 1999; Green, 2007). Children diagnosed for 2+ years with elevated antibodies
indicating noncompliance have lower bone densities than those who have negative
antibodies (Blazina,2010). A gluten-free diet initiated during childhood and adolescence
allows complete recovery of fat, lean, and bone mass, and a long-term, gluten-free diet
maintains normal body composition in young adults (Barera, 2000).

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Disease Process

Celiac disease requires the ingestion of the protein gluten and the presence of human
leukocyte antigen DQ2 or DQ8 to produce the inflammatory reaction characterized by the
infiltration of the small intestine with chronic inflammatory cells and a cascade of
proinflammatory cytokines. The result is atrophy of the villi, crypt hypertrophy, and damage
to the microvilli, which leads to malabsorption (Fasano, 2001; Murray, 1999; Green, 2007).
The National Institutes of Health Consensus Development Conference Statement (NIH,
2004) classifies celiac disease in the following four categories:
Classic–Gastrointestinal 1.
Atypical–Nongastrointestinal 2.
Silent (asymptomatic with positive serology/positive biopsy) 3.
Latent (asymptomatic with positive serology/negative biopsy but may later develop
symptoms/positive biopsy)
4.
Symptoms in infants and toddlers usually appear within weeks to a few months after the
introduction of gluten-containing food. Children younger than 3 usually present with
classical celiac disease with symptoms of growth delays, protuberant abdomens,
decreased subcutaneous fat, decreased bone mineral content, and a reduction in muscle
mass (Fasano, 2001; Barera, 2000). Their stool is usually pale, loose, and foul smelling. If
symptoms occur in an infant, he or she may exhibit frank watery diarrhea with dehydration.
Some infants develop what has been termed a “celiac crisis,” in which they have severe
hypoproteinemia and edema and present in a shock-like state (Fasano, 2001).
Celiac disease can be diagnosed at any age and the average age of diagnosis is
increasing. Children diagnosed when they are older than 3 usually present with atypical
celiac disease or silent celiac disease (Fasano, 2001).
Environmental factors, such as breastfeeding and the timing of the introduction of gluten to
an infant, may play a role in the development and presentation of celiac disease. Children
who are breastfed for the first 6 months of life have been shown to present with celiac
disease later in life and with more atypical symptoms and fewer classic symptoms
(D'Amico, 2005). The slow introduction of gluten into the diet of a breastfed infant may
prevent or delay the development of celiac disease (Ivarsson, 2002).
Infants in high-risk groups have been shown to develop celiac autoantibodies when gluten
was introduced before 3 months of age or after 7 months of age when compared
to those who had gluten introduced between the ages of 4 and 6 months (Norris, 2005).
The effect of breastfeeding and the introduction of gluten-containing solid foods continue to
be investigated; one current study is researching the introduction of gluten-containing
solids in high-risk groups after the first year of life to take advantage of a more mature
immune system (Fasano, 2009).
Classic Symptoms of Celiac Disease
Weight loss
Vomiting
Diarrhea and/or constipation
Gas
Bloating
Distention
Abdominal pain
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Abdominal pain
Failure to thrive
Chronic fatigue/pain
Atypical Symptoms of Celiac Disease
Iron-deficiency anemia
Macrocytic anemia
Migraines
Neurological changes
Seizures
Delayed puberty
Short stature
Kidney stones
Bone disease
Bone fractures
Recurrent miscarriages
Infertility
Hepatic steatosis
Angular chelitis
Recurrent aphtous ulcers
Delayed motor development
Concentration alterations
Hypothyroidism/hyperthyroidism
Dental enamel hypoplasia
Hyposplenism
Primary biliary cirrhosis
Isolated hypertransaminasemia
Myasthenia gravis
Psoriasis
Alopecia universalis
High-Risk Groups
Type 1 diabetes
Autoimmune thyroiditis
Sjögren syndrome
Addison's disease
Down syndrome
Turner syndrome
First- and second-degree relatives of individuals with celiac disease


Biochemical and Nutrient Factors

Nutrient issues will vary among children upon diagnosis of celiac disease. Nutrients of
concern are B-vitamins; zinc; folate; iron; and the fat-soluble vitamins A, D, E, and K
(Barker, 2008). Initiation of a gluten-free dietary pattern and healing of the small intestinal
mucosa result in normalization of these nutrient deficiencies.
Bone density in children can be low at diagnosis but usually returns to normal after
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following the gluten-free dietary pattern (Jatla, 2009; Mora, 2008; Tau, 2006).However
calcium and vitamin D intake can be low and should be evaluated (Blazina, 2010).

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Diseases/Conditions > Gastrointestinal Diseases > Constipation
Overview

Constipation is a common pediatric problem. The most common cause of constipation is
functional and is often referred to as idiopathic constipation, functional fecal retention, and
fecal withholding. Functional constipation is most commonly caused by painful bowel
movements which results in the child voluntarily withholding defecation to avoid unpleasant
and painful bowel movements. Some of the more common events that can lead to painful
defecation include toilet training, changes in routine or diet, stressful events, illnesses, and
the postponement of defecation.
Caregivers are instructed to pay close attention to the frequency and characteristics of an
infant's bowel movements. So it is not surprising that when a caregiver notes a deviation
from the normal bowel habit of their child they call a pediatrician. Approximately 3% of all
general pediatric outpatient visits are related to perceived defecation disorder, as
are approximately 25% of all pediatric gastroenterology evaluations (Afzal, 2011).
Infants have a mean stool output of 4 per day during the first week of life. This gradually
declines to an average of 1.7 by age 2 and 1.2 by age 4. After 4 years of age the stool
frequency is unchanged.
The Rome III criteria for pediatric functional constipation are as follows:
Two or fewer defecations per week
At least one episode of fecal incontinence per week
Stool-retentive posturing
Painful or hard bowel movements
Presence of a large fecal mass in the rectum
Large diameter stools that may obstruct the toilet
Infants through 4 years of age must meet two or more criteria for 1 month and children >4
years should meet two or more criteria for at least 2 months (Tabbers 2011).
Constipation may also be a secondary symptom of many other conditions or diseases,
including those listed below (Leung 2007; Müller-Lissner 2005):
Obesity
Hypotonia
Inactivity
Irritable bowel syndrome
Inadequate fiber intake (in some individuals)
Inadequate fluid intake
Dietary changes (switching from breastmilk to infant formula, introduction of solids)
Spinal cord injuries
Certain diseases, including the following:
Neuromuscular disorders
Cerebral palsy
Diabetes
Certain medications, including the following:
Anti-seizure
Diuretics
Pain medications with codeine
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Antidepressants
Antihistamines
Iron supplements
Calcium supplements
*Adapted from Nutrition Care Manual: Constipation

Disease Process

Normal physiology of the large intestine allows for residual chyme to move in both
directions within the colon, allowing for adequate absorption of fluid and electrolytes. Mass
movements occur when there is a substantial contraction of a large portion of the colon.
This generally occurs several times a day and will accomplish moving a large portion of
intestinal contents along the colon. Finally, defecation occurs when distention of the rectum
relaxes the anal sphincter. As a result of pathophysiology or dietary intake, or as a side
effect of medication, this process can be interrupted and cause constipation. Further
classifications of constipation describe the condition as normal-transit constipation, pelvic
floor dysfunction, and slow-transit constipation (Leung 2007; Ternent 2007).

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Diseases/Conditions > Gastrointestinal Diseases > Inflammatory Bowel Disease
Overview

Inflammatory bowel disease (IBD) encompasses two different conditions: Crohn’s disease
and ulcerative colitis (UC). It is thought that there are 1 million people in the United States
with IBD, and approximately 25% of those cases are under the age of 21 years old; with
the incidence rising, especially of Crohn’s disease. Crohn’s disease is more common than
UC, but both can equally affect a patient’s nutritional status.
Crohn's and UC are two of the most significant chronic gastrointestinal diseases and are
associated with high morbidity and decreased quality of life (Kappelman 2008; Cohen
2002; McLeod 1991). A recent study showed that the health care costs for children with
IBD tend to be significantly higher than for adults, costing an average of approximately
$10,000 per year for hospitalizations, medications, and outpatient services as opposed to
$4,300 for adults (Kappelman 2008).
IBD patients can face a multitude of nutritional issues such as protein and electrolyte
losses, growth failure, and vitamin/mineral deficiencies. Optimal growth can ultimately be
synonymous with optimal management of their IBD (Heuschkel 2008). Overall, diet therapy
combined with medical treatment is recommended for IBD.

Disease Process

Ulcerative colitis (UC) and Crohn’s disease are both chronic inflammation conditions of the
gastrointestinal tract. The exact causes of both UC and Crohn’s disease have not been
identified but tend to be multi-faceted, including genetics, inability of the immune-host
response to regulate inflammation, environmental factors (stress/toxins) and bacterial
overgrowth. Crohn’s and UC are generally defined on the basis of clinical, radiological,
endoscopic and histological features.
UC is commonly confined to mucosal inflammation that affects the rectum and either all or
part of the colon. The pattern of inflammation is usually continuous in distribution (Walker
2000). In contrast, Crohn’s disease is a panenteric inflammatory process that involves the
full thickness of the bowel and mesentery. It typically presents in segments separated
by unaffected areas. It may affect anywhere from the mouth to the anus, but the terminal
ileum tends to be the most commonly affected site (Walker 2000). There is no cure for
Crohn’s disease but prolonged remissions may occur with diet, surgical intervention, and
medicinal treatment. UC can be cured by a total colectomy.
Patients with inflammatory bowel disease (IBD) may be normal height and weight, but may
also be underweight or malnourished. Growth failure may occur in up to 50% of patients
with IBD. Malnutrition could be attributed to many causes including: abdominal pain;
nausea and diarrhea resulting in anorexia and inadequate energy intake; altered digestive
function; reduced absorptive area; excessive loss of nutrients; intestinal malabsorption;
drug-nutrient interactions; and, increased nutritional requirements (AAP 1998; Teitelbaum
2009). Many of the consequences suffered by a malnourished patient with IBD are growth
stunting, pubertal delay, bone disease, post-operative morbidity, and psychosocial stress
(Teitelbaum 2009).
Malabsorption tends to be more common in Crohn’s disease than in UC. Carbohydrate
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
malabsorption may be seen in 30-40% of patients with Crohn's, likely secondary to small
bowel inflammation, decreased bowel length, enterocyte damage, or bacterial overgrowth
(Teitelbaum 2009). Fat malabsorption may also occur due to bacterial overgrowth, bile acid
deficiency secondary to resection of the ileum, and use of medications (Teitelbaum 2009).
The mucosal damage and inflammation caused by Crohn’s and UC can result in protein
loss and mineral deficiencies. Often, this is associated with diarrhea which can lead to loss
of water, electrolytes, minerals, and trace elements. Fat-soluble vitamin deficiency can
occur with fat malabsorption and/or if the ileum has been affected.
When a patient has severe active inflammation, this is called a flare. There are different
hypotheses as to what can cause a patient to flare, including infections, antibiotics,
physical or emotional stress, and noncompliance with medication regimen.
Active inflammation, sepsis, fistulas, and repletion can contribute to a need for increased
nutritional requirements.
Other manifestations can occur from IBD and the patient should be screened by the
medical team on a regular basis for the following: peripheral and axial arthritis, skin
disorders (erythema nodosum, skin tags, fissures, enterocutaneous fistulas), eye
disorders, primary sclerosing cholangitis, gallstones, pancreatitis, cancer, depression, and
osteoporosis (Ferry). IBD patients are prone to malabsorbing calcium, and many
medications can further exacerbate inadequate calcium absorption. Sixty-eight percent of
the IBD population has been found to be deficient in Vitamin D which could also intensify
bone disease (CCFA 2009).

Biochemical and Nutrient Issues

Biochemical and nutrient issues may be present for each patient depending on which
part(s) of their intestines is affected by inflammatory bowel disease (IBD).
Bowel
Segment
Main function
Complications of
Disease or
Resection
Duodenum
Absorption of CHO,
FAT, PRO
Micronutrient
absorption iron,
calcium,
phosphorus,
magnesium, folic
acid, copper
Decreased
macronutrient
digestion
Acidosis, anemia,
osteopenia
Jejunum
Primary site of
CHO & PRO
absorption
Water-soluble
vitamin absorption,
zinc
Macronutrient and
water soluble
vitamin
malabsorption
Fluid and
electrolyte losses
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ileum
Primary site of
vitamin B
12
and
bile salt absorption
Absorption of
fat-soluble
vitamins,
magnesium
Unable to absorb
B
12
Loss of fat soluble
vitamins
Decreased
absorption trace
elements
Increased risk of
renal oxalate
stones
Colon
Fluid & magnesium
absorption
Na, Cl, K and fatty
acid reabsorption
Dehydration
Electrolyte
abnormalities
Reduce ability to
absorb bile salts
Medications can also cause concerns for biochemical and nutrient issues. IBD patients are
at risk for osteoporosis. The risk occurs not only because of malabsorption of calcium and
vitamin D, but mainly due to the high dose of steroid therapy many of the patients require to
reduce inflammation. Long-term steroid therapy, combined with decreased physical
activity, malabsorption, malnutrition, possible lactose intolerance, and intestinal resections,
puts this population at risk of developing osteoporosis or osteopenia (CCFA; Ferry).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Gastrointestinal Diseases > Diarrhea
Overview

Diarrhea is considered a common symptom of many gastrointestinal disorders, such as
Crohn's disease or irritable bowel syndrome, as well as a symptom of many infectious
diseases. It is also a common side effect of many medications. Diarrhea is defined as an
increase in frequency of bowel movements and/or an increase in water content of stools,
which affects either consistency or volume of fecal output. It is one of the most common
symptoms seen in pediatrics. In newborns and infants, diarrhea can be dangerous
because it can quickly lead to dehydration.
Incidence of infectious diarrhea is estimated at approximately 99 million new cases each
year, resulting in 3,100 deaths each year in the United States (Nahikian-Nelms, 2007).
Foodborne illness is a major cause of these cases.
Diarrhea is an important public health issue throughout the world. Millions of children die
from dehydration secondary to diarrhea each year. Understanding the role of oral
rehydration therapy, as well as prevention of diarrhea, is a cornerstone in preventing
deaths from diarrhea (Steffen 2010).
*Adapted from Nutrition Care Manual: Diarrhea

Disease Process

Diarrhea can be classified as either acute (short term) or chronic. Diarrhea lasting several
weeks is considered chronic and is usually associated with more health concerns (Spiller
2007). It can be described as one of the following:
Osmotic
Secretory
Osmotic
When there is an increase in osmotically active particles in the intestine, the body reacts
by pulling water into the lumen in an attempt to normalize osmolality. When this occurs,
increased fluid results in osmotic diarrhea. Osmotic diarrhea can be caused by
maldigestion of nutrients (such as lactose), excessive sorbitol (found in many liquid
medications) or fructose intake, enteral feeding, and some laxatives. In general, when the
causative agent is removed, osmotic diarrhea will also stop.
Secretory
Secretory diarrhea results from excessive fluid and electrolyte secretions into the intestine.
The difference in the underlying disease is the factor causing the excessive secretions.
Secretory diarrhea does not resolve when the patient is indicated as having nil per os, or
nothing by mouth, status. Bacterial infections often produce enterotoxins that result in this
type of diarrhea. These are commonly related to foodborne illnesses. Protozoa, viruses,
and other infections can also cause secretory diarrhea.
Traveler's diarrhea, a variety of secretory diarrhea, is a common health problem affecting
those who travel to other countries and is caused by the following (Leung 2006):
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Enterotoxigenic Escherichia coli
Enteroaggregative E. coli
Shigella spp
Salmonella
Campylobacter
Yersinia
Aeromonas
Plesiomonas spp
Norwalk virus
Giardia
Other causes of secretory diarrhea include the following:
Medications including antibiotic-associated diarrhea (Nelson 2007)
Hormone-producing tumors
Excessive prostaglandin production
Excessive amounts of bile acids or unabsorbed fatty acids in the colon
Rotavirus or clostridium difficile ova and parasites
A symptom of other gastrointestinal diseases such as the following:
Crohn's or Celiac disease (Imanzadeh, 2005)
Acquired immune deficiency syndrome (Siddiqui, 2007).
Pancreatic insufficiency
Antibiotics will be used to treat diarrhea of infectious origin. Zinc supplementation has been
used to treat childhood diarrhea with a positive effect on overall duration of the condition
(Bajait, 2011; Dutta, 2011; Aggarwal, 2007; Fischer, 2007). Other medications work either
to decrease motility or to thicken consistency of the stool and can be used to treat the
symptoms of diarrhea.
*Adapted from Nutrition Care Manual: Diarrhea

Biochemical and Nutrient Issues

Nutrition implications are determined by the diarrheal volume and the length of the illness.
Large volume losses can quickly lead to the following:
Dehydration
Electrolyte imbalance
Acid-based imbalance
Metabolic acidosis
Infants are at high risk as their systems are much more sensitive to rapid shifts in both
fluids and electrolytes. Chronic diarrhea can also result in malnutrition and specific nutrient
deficiencies. Diarrhea can affect appetite and impair adequate ingestion. It also results in
decreased transit time, which interferes with the ability of the gastrointestinal tract to
perform adequate digestion and absorption (Nahikian-Nelms 2007).
*Adapted from Nutrition Care Manual: Diarrhea

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Gastrointestinal Diseases > Gastroesophageal Reflux
Overview

Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus
(Vandenplas, 2009). GER is a normal physiological process and may or may not involve
regurgitation or vomiting of gastric contents (Vandenplas, 2009). Regurgitation is defined
as "the passage of refluxed contents into the pharynx or mouth, or from the mouth"; it
may also be known by the terms "spitting up," "posseting," and "spilling" (Sherman, 2009).
GER disease (GERD) occurs when the reflux of gastric contents causes complications or
symptoms (Vandenplas, 2009). Studies indicate that reflux occurs most often in the first 5
months of age and usually resolves by 12 months of age (Campanozzi, 2009).
For more information, see the GER topics for Preterm Infants and Full-Term Infants.

Disease Process

Gastroesophageal reflux (GER) is a normal process that happens several times per day
and is not associated with vomiting or regurgitation (Vandenplas, 2009). A person is not
diagnosed with GER disease (GERD) unless GER becomes associated with symptoms or
complications (Vandenplas, 2009). Both voluntary and autonomic motor responses may be
responsible for vomiting related to reflux, leading to the development of
GERD (Vandenplas, 2009). Reflux can also become GERD when there is an alteration in
one of the body's protective mechanisms, such as delayed gastric emptying (Vandenplas,
2009).
It was originally thought that lower esophageal sphincter (LES) hypotonia was the primary
mechanism for GER, but studies have shown that LES tone is well developed even in the
premature infant. Currently, transient LES relaxation (TLESR) is believed to be the main
mechanism of GER. Certain factors, such as the supine and slumped positions assumed
frequently in infancy, put gastric contents at the posterior gastroesophageal junction,
promoting reflux during LES relaxation. TLESR is responsible for 94% of reflux episodes in
children and for 50% of reflux episodes in infants and children up to 1.5 to 2 years of
age (Tsou, 1998; Orenstein, 1999; Orenstein, 1997).
Clinical manifestations of pathological GER may include the following (Vandenplas, 2009):
Recurrent regurgitation with or without vomiting
Weight loss or poor weight gain
Recurrent pneumonia
Irritability in infants
Wheezing
Cough
Stridor
Feeding refusal
Apnea spells
Esophageal stricture
Anemia
There are many conditions that increase the risk of GERD, including the following
(Vandenplas, 2009):
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Neurologic impairment
Obesity
Cystic fibrosis
Hiatal hernia
Repaired achalasia
Esophageal atresia repair
Lung transplantation
Chronic lung diseases
Prematurity
Diagnostic studies include combined multiple intraluminal impedance and pH monitoring,
esophageal manometry, and endoscopy with biopsy (Vandenplas, 2009).
When medical management fails to control the symptoms and consequences of GERD,
surgical intervention should be considered. Gastric fundoplication (wrapping the gastric
fundus around the distal esophagus below the diaphragm) is performed to help prevent
reflux (Tsou, 1998). Children with respiratory or life-threatening complication or those who
require long-term medical therapy for GERD may benefit the most from fundoplication
surgery (Vandenplas, 2009). However, more research is needed, as most studies have
focused on adults and there are known complications with fundoplication surgery, such as
dumping syndrome, retching and gagging, and early satiety (Vandenplas, 2009).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Gastrointestinal Diseases > Irritable Bowel Syndrome
Overview

Irritable bowel syndrome (IBS), characterized by abdominal pain associated with an altered
pattern of bowel elimination, is one of 4 subtypes of chronic/recurrent abdominal
pain (RAP) of childhood (Boyle, 2004). Its presentation is usually categorized as either
diarrhea-predominant or constipation-predominant (IBS-D or IBS-C, respectively), but
some individuals with IBS experience an alternating pattern of these symptoms (IBS-A)
(Escott-Stump, 2012).
Other symptoms that further define this disorder include excessive intestinal gas, nausea,
and abdominal distention or bloating. IBS is considered a functional gastrointestinal
disorder (FGID), in that the diagnosis is usually made following a medical evaluation that
fails to identify a structural, infectious, inflammatory, or biochemical etiology for symptoms
(Boyle, 2004). However, IBS has begun to be recognized as a primary medical condition
rather than a diagnosis of exclusion. Recent application of the biopsychosocial model of
illness in IBS research continues to further define the complexities of this condition (Chiou,
2010).
IBS and other FGIDs carry a significant morbidity and are associated with high health care
costs. FGIDs have been estimated to account for 50% of consultations in pediatric
gastroenterology practices and 2% to 4% of all general visits to a pediatric office (Nurko,
2008). It has been suggested that 25% to 30% of school-age children experience RAP,
including 10% to 15% who never seek medical care for their symptoms (Boyle, 2004).
Some studies have suggested an association between functional abdominal pain in
childhood and multiple long-term comorbidities including depression, anxiety, and other
behavioral and psychiatric disorders among the 33% to 50% of individuals in whom
symptoms persist into adulthood (Nurko, 2008).






Disease Process

Diagnosis
There are no specific biological markers for irritable bowel syndrome (IBS) (Nurko,
2008). Therefore, childhood IBS is currently defined by the following symptom-based
diagnostic criteria, known as the Rome III Diagnostic Criteria for IBS (Chiou, 2010):
Abdominal discomfort or pain associated with 2 or more of the following, at least 25%
of the time:
Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in the form (appearance) of stool
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No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that
explains the subject's symptoms
Etiology and Pathophysiology
Current theory regarding the etiology of IBS suggests that the disorder develops as
a result of physiologic and psychological factors (eg, intestinal motility, inflammation, and
stress) as well as genetic-environmental interactions (Nurko, 2008; Chiou, 2010). The
pathophysiology underlying IBS symptoms is believed to be centered in the complex
interrelationship of the gastrointestinal and autonomic nervous systems—that is, the
brain-gut axis—and likely involves alterations in sensitivity, perception, transmission, and
responses to pain (Boyle, 2004; Chiou, 2010).
Examples of multiple risk factors that have been linked to development of IBS include the
following (Nurko, 2008):
Family history
Low birthweight
Pain and stress in early childhood
Food hypersensitivity
Alterations in gut flora
Immunologic response to acute gastroenteritis
Treatment
Management of IBS has evolved to include a combination of nutrition and pharmaceutical
interventions, psychological therapies, and complementary or alternative strategies.
Traditional nutrition therapy for IBS has included the following:
Strategies to maintain a normal intestinal caliber (regular, frequent meals including
fiber-containing foods and supplements)
Avoidance of gas-forming foods and caffeine
Reduction in intake of specific fermentable carbohydrates (lactose, fructose) and
sorbitol
Elimination of specific food allergens and intolerances
Inclusion of food sources of probiotics such as yogurt, kefir, and aged cheeses
According to recent reviews, the effectiveness of several of these strategies in children with
IBS—including lactose restriction, fiber supplementation, and probiotic use—are
unsubstantiated (Huertas-Ceballos, 2009; Chiou, 2010). Intake of insoluble fiber may
actually worsen symptoms of IBS (Heizer, 2009). However, studies of adults with
IBS have demonstrated positive results with both soluble fiber and Lactobacillus
supplementation, suggesting that larger, well-designed pediatric trials may yield similar
findings. Until more data are available, selective and limited trials (2 to 3 weeks) of these
relatively benign interventions may be reasonable, based on the specific clinical
presentation of the individual (Chiou, 2010).
Restriction of fructose in children with documented fructose malabsorption has resulted in
significant and sustained improvement in IBS symptoms (Chiou, 2010). Recently, a
growing number of studies has demonstrated improvement in IBS symptoms with dietary
restriction of fermentable, poorly absorbed carbohydrates and polyols (FODMAPs)
(Heizer, 2009; Yao, 2011; Staudacher, 2011).
Effective pharmacotherapy for pediatric IBS has yet to be elucidated. Multiple classes of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
medications that have been utilized or considered thus far include the following:
Antidepressants (tricyclic, selective serotonin reuptake inhibitors)
Antispasmodics
Prokinetics (for constipation-dominant IBS [IBS-C])
Other specific medications that have been used in treatment of IBS include the following:
Cyproheptadine
Lubiprostone (for IBS-C)
Loperamide (for diarrhea-dominant IBS)
Neomycin and rifaximin (for bacterial overgrowth causing increased abdominal gas
production and bloating)
Among complementary and alternative therapies, peppermint oil has been shown in one
pediatric study to reduce IBS symptom severity, presumably due to its effect on ileal and
colonic smooth muscle function. However, its profile for side effects (rectal burning,
esophageal pain or heartburn, and allergic reactions) may limit its application (Chiou,
2010).
Meta-analyses have shown that psychological therapies are effective in both adults and
children with functional gastrointestinal disorders. Cognitive behavioral therapy used alone
or in combination with other techniques—for example, relaxation therapy, guided imagery,
and hypnotherapy—has been shown to directly affect somatic symptoms and support the
ability of the individual to self-manage symptoms (Chiou, 2010).
Prognosis
It has been reported that 30% to 50% of children with IBS experience resolution of
symptoms without treatment within 2 to 6 weeks after diagnosis. Yet, symptoms may
persist into adulthood in a significant number of children with IBS, particularly those who
exhibit passive, avoidant, or dependent coping styles (Nurko, 2008). IBS does not increase
risk for development of other gastrointestinal diseases or malignancies (Boyle, 2004;
Escott-Stump, 2012).

Biochemical and Nutrient Issues

Most individuals with irritable bowel syndrome (IBS) appear to maintain adequate and
balanced macronutrient and micronutrient intake when compared to Dietary Reference
Intakes (Williams, 2011). However, perception of specific foods or food groups as triggers
for IBS symptoms may result in restrictive dietary practices in some individuals with IBS.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Gastrointestinal Diseases > Short Bowel Syndrome
Overview

Short bowel syndrome (SBS) is a condition that is characterized by a functional or
anatomical loss of more than 50% of the small intestine, which may cause functional
incapacity of the bowel to absorb adequate nutrients (Vanderhoof, 1995). SBS patients can
have difficulty maintaining appropriate development and growth (Wessel, 2005).

Disease Process

Short bowel syndrome (SBS) can occur as a result of either a congenital malformation or
surgery. The most common etiologies of SBS include necrotizing enterocolitis resulting in
surgical resection, intestinal atresia, gastroschisis, midgut volvulus, and trauma or
complications from inflammatory bowel disease (IBD) (Walker 2000; Vanderhoof
1996). Initially, nutrition therapy is provided with parenteral nutrition. Factors that can affect
dietary modifications and thus determine how long the infant or child is on parenteral
nutrition include the length of the remaining bowel, the site of the remaining bowel, and the
condition of the remaining bowel. Modifications to the diet may be only for a short time due
to quick adaptation and growth in length; however, it is important to note that some children
may be on parenteral and enteral nutrition for months or even years.
In addition to malabsorptive nutritional issues, the SBS patient can have a variety of
complications such as small bowel bacteria overgrowth, liver disease (total parenteral
nutrition-associated cholestasis), and central line infections (Hwang, 2002; Carter, 2009).
In the process of rehabilitating the intestines, the patient may need additional surgical
intervention to help maximize the intestines' absorptive capability (Ching, 2007). There are
two procedures that can be done to help lengthen the intestines: the longitudinal intestinal
lengthening and tailoring (LILT) procedure, and serial transverse enteroplasty (STEP)
(Ching, 2007). The STEP procedure is becoming more widely used as it does not interrupt
the mesenteric blood supply as the LILT procedure does (Ching, 2007). If the patient’s
intestines are unable to be rehabilitated, small bowel transplantation is an option, and the
patient should be referred early on in the process.

Biochemical and Nutrient Issues

Biochemical and nutrient issues vary with each patient depending on which part(s) of the
intestines have been resected.
The main function of the duodenum is absorption of macronutrients along with some
micronutrients such as iron, calcium, magnesium, copper, and folic acid. Complications of
resection can include acidosis, anemia, and osteopenia, as well as macronutrient digestion
(DiBaise, 2004a).
The jejunum is where the absorption of carbohydrate, protein, and water-soluble vitamins
takes place. Resecting the jejunum can cause fluid and electrolyte losses as well as
malabsorption of macronutrients and water-soluble vitamins (DiBaise, 2004b).
The ileum primarily absorbs bile salts and fat-soluble vitamins. Resection of the ileum can
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cause vitamin B
12
deficiency and fluid and electrolyte losses (DiBaise, 2004b).
Bowel
Segment
Main function
Complications of
Resection
Duodenum
Absorption of CHO, FAT, PRO
Micronutrient absorption (iron,
calcium, phosphorus,
magnesium, copper, folic acid)
Decreased macronutrient
digestion
Acidosis, anemia,
osteopenia
Jejunum
Primary site of CHO & PRO
absorption
Water-soluble vitamin
absorption
Macronutrient and
water-soluble vitamin
malabsorption
Fluid and electrolyte
losses
Ileum
Primary site of vitamin B
12
and bile salt absorption
Absorption of fat-soluble
vitamins
Unable to absorb B
12
Loss of fat-soluble
vitamins
Decreased absorption
trace elements
Increased risk of renal
oxalate stones
Colon
Fluid absorption
Na, Cl, K, and fatty acid
reabsorption
Dehydration
Electrolyte abnormalitites
Reduce ability to absorb
bile salts
The ileocecal valve (ICV) is located between the jejunum and ileum. This serves as the
“brake” to slow the release of nutrients and fluid into the colon. This valve also serves as a
barrier to prevent reflux of colonic bacteria into the terminal ileum. Studies have shown that
the presence of the ICV was a postitive predictor in weaning off of total parenteral nutrition
(Spencer, 2005).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Hepatic Diseases
Overview

Children with liver disease face many nutrition-related issues as the liver plays a primary
role in both nutrient and energy metabolism (Nightingale, 2009). Children with chronic liver
disease are at an increased risk for malnutrition, fat-soluble vitamin deficiencies, and
growth failure (Kockochis, 2009). Overall nutrition management is crucial in children with
chronic liver disease and collaboration among the members of the medical team is critical
(Kockochis, 2009).
The most common pediatric liver disease is biliary atresia (1 in 8,000 to 15,000 live births)
(Shneider, 2002), which is frequently associated with malabsorption of fat and fat-soluble
vitamins (Roy, 1995). The Kasai procedure may be used to surgically restore bile flow,
significantly reducing the consequences of biliary atresia, but it is not a cure. As a result,
extrahepatic biliary atresia is the most common indication for pediatric liver transplant
(Balisteri, 2000). A less common cholestatic liver disease is Alagille syndrome, which is
present in 1 in 30,000 births (Kamath, 2003). Compared to patients with biliary atresia,
these children have other manifestations such as cardiac disease and facial characteristics
(Emmerick, 1999).
In addition to the cholestatic liver diseases, the prevalence of nonalcoholic fatty liver
disease (NAFLD) is rising similar to childhood obesity (Nobili, 2009). The incidence among
the general population is ~2.6%, but it increases significantly among obese children
(Patton, 2006).
Additional causes of liver disease in children include the following:
Cholestatic disorders
Biliary atresia
Alagille syndrome
Progressive familial intrahepatic choletstasis (types 1 and 2)
Byler disease and syndrome
Idiopathic neonatal hepatitis
Cystic fibrosis
Alpha-1 antitrypsin deficiency
Neonatal iron storage disease
Metabolic diseases/disorders (see Inborn Errors of Metabolism)
Wilson’s disease
Urea cycle disorders
Tyrosinemia
Galactosemia, fructosemia, glycogen storage disease type 1a
Hepatitis
Autoimmune
Viral B and C
Primary sclerosing cholangitis
NAFLD
Fulminant liver failure
Malignancies (hepatoblastoma)
Parenteral nutrition–associated liver disease

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Biochemical and Nutrient Issues

Carbohydrate
The liver plays a primary role in carbohydrate metabolism, which places pediatric patients
at increased risk for hypoglycemia in chronic liver disease (Nightingale, 2009). Alterations
in insulin, glucagon, cortisol, and epinephrine contribute to difficulty with glucose control,
often leading to hypoglycemia. Although adults with cirrhosis metabolize fat in preference
to glucose, children with chronic liver disease preferentially oxidize carbohydrate (Shetty,
1999). Fasting hypoglycemia can occur because of the decreased availability of glucose
from glycogen (Taylor, 2006). Adequate carbohydrate intake is therefore necessary for
adequate energy as well as for prevention of hypoglycemia.
Protein
As a result of altered carbohydrate metabolism in chronic liver disease, amino acids are
used as an alternative source for gluconeogenesis (Nightingale, 2009; Feranchak, 2007).
Protein metabolism in liver disease is frequently impaired. Biochemical indicators of protein
status—such as albumin, transferrin, prealbumin, and retinol-binding protein—may be
lowered, owing to a decrease in liver synthetic capacity and hydration status ( Ramaccioni,
2000). Excessive protein intake or increased catabolism leads to increased nitrogenous
waste, including ammonia, which may lead to hyperammonia. Protein restriction in the
presence of elevated ammonia or encephalopathy has been suggested but in children this
may not hold true as growth is the primary goal (Nightingale, 2009).

Fat
Fat malabsorption is not present in all forms of liver disease (Taylor, 2006). However, in
cholestatic liver disease, such as biliary atresia and Alagille syndrome, fat absorption is
impaired secondary to decreased bile acid concentration in the intestinal tract (Roy, 1995).
Under certain conditions, pancreatic insufficiency and portal hypertension may also
contribute to decreased utilization of dietary fat (Roy, 1995). Although long-chain fatty
acids are incompletely metabolized in liver failure, medium-chain fatty acids can replace
long-chain fatty acids as an alternative fuel source, as medium-chain triglycerides do not
require bile acids for absorption (Nightingale, 2009). However, medium-chain fatty acids do
not provide essential fatty acids (EFAs). Therefore, care must be taken to ensure that
adequate amounts of EFAs are provided to prevent deficiency. It is well accepted that 3% to
4% of daily energy should be provided as linoleic acid and linolenic acid (Feranchak,
2007).

Fat-Soluble Vitamins
Risk of fat-soluble vitamin deficiency is also common in cholestatic liver disease due to
poor intestinal absorption (Feranchak, 2007). Deficiency of fat-soluble vitamins has been
found in all types of liver disease but is most prevalent in cholestatic liver diseases where
malabsorption and cholestasis are evident. The liver is the storage site for the fat-soluble
vitamins A, E, and K. Furthermore, the liver is involved in the conversion of vitamin D to
25-dihydroxycholecalciferol, the first step in the formation of the active form of vitamin D.
Malabsorption of the vitamins can result in full-blown deficiencies, including hyperkeratosis
and xerophthalmia (vitamin A), rickets (vitamin D), neurological abnormalities (vitamin E),
and hemorrhagic disease (vitamin K).

Minerals
Mineral nutriture is also altered in liver disease. Wilson's disease is a rare, genetic disorder
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
of abnormal copper metabolism. The defect in copper metabolism lead to excess copper is
stored in various organs, mainly the liver, and causes severe damage (Pefeil, 1999).
Additionally, calcium, magnesium, and zinc may be malabsorbed when steatorrhea is
present ( Shetty, 1999). Increased loss of calcium resulting from fat malabsorption and lead
to poor vitamin D status as well. Furthermore, medications commonly used in liver disease
can cause abnormal bone mineral density.

Disease Process

Liver disease in infants and children can arise from a variety of etiologies, including
infectious, metabolic, genetic, and structural abnormalities or long-term use of parenteral
nutrition. The extent of the damage to the liver, the progressive nature of the insult, and the
presence of cholestasis determine the dietary modifications required and whether a
transplant would be warranted. Nutritional disturbances are common and often severe in
chronic liver disease. Chronic liver disease is often associated with protein–energy
malnutrition and growth failure. Malnutrition may arise from a variety of issues, including
decreased intake, increased energy needs, impaired hepatic metabolism, and fat
malabsorption (Ramaccioni, 2000; Shetty, 1999; Roggero, 1997).
The presence of cholestasis frequently results in malabsorption, with attendant loss of
energy and essential nutrients, including essential fatty acids and fat-soluble vitamins.
Maldigestion and malabsorption play a major role in the malnutrition associated with liver
disease. Impaired digestion, specifically of fat, is due to decreased delivery of bile acids,
ultimately leading to malabsorption (Feranchak, 2007; Nightingale, 2009). Steatorrhea is
common in cirrhosis, especially in disease involving bile duct injury and obstruction
(Feranchak, 2007). Diuretics, bile acid sequestrants, neomycin, and lactulose are examples
of medications commonly used in liver disease that may also cause specific malabsorptive
losses (Munoz, 1991).
Impaired metabolism of carbohydrates, fat, and protein in the liver occurs with most types
of liver disease. Both fat and protein are used as a source of fuel due to decreased
glycogen stores (Protheroe, 1998). In addition, growth may be negatively affected in
patients with chronic liver disease, possibly as a result of growth hormone resistance or
reduced synthesis and release by the liver of insulin-like growth factor 1 (Leonis, 2008).
In chronic liver disease, individuals have increased energy needs resulting from
hypermetabolism and infection. Resting energy expenditure may be increased by as much
as 30% in infants and children with extrahepatic biliary atresia, the most common form of
chronic liver disease (Sokol, 1990a; Greer, 2003). In addition to increased needs,
decreased oral intake occurs because of nausea, vomiting, and anorexia. Unpalatable
feeds have been considered to be a cause of anorexia (Protheroe, 1998).
In addition, ascites and hepatomegaly have been shown to lead to decreased gastric
emptying and capacity (Aquel, 2005). Altered taste perceptions have been noted as a
cause of decreased intake, possibly the result of zinc or magnesium deficiency
(Nightingale, 2009). The effect of decreased intake in addition to increased energy needs
leads to an overall energy and protein deficit.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > HIV/AIDS
Overview

Human immunodeficiency virus (HIV) is a retrovirus that compromises the immune system
and causes acquired immunodeficiency syndrome (AIDS). From the initial infection, viral
replication is a continuous phenomenon. HIV disorders the immune system primarily
through depletion of CD4+ T lymphocytes that are fundamental in the development of
specific immune responses toward infectious agents. HIV infection results in a wide array
of clinical manifestations and varied course, dependent on host immunity and adherence to
treatment (AAP, 2009), beginning from seroconversion to disease progression.

Childhood infections are usually the result of trans-mission of the virus from the mother to
the child prenatally or postnatally (vertical transmission). Infants can be infected in utero,
during delivery, or during breastfeeding. Implementation of effective preventive strategies
during pregnancy has reduced the risk of mother-to-child transmission (MTCT) of HIV in
the United States to approximately 1% (CDC, 2006; UNAIDS, 2009). A smaller proportion
of children become infected through contaminated blood products or sexual abuse.
New-onset HIV infection in adolescents is typically acquired horizontally through sexual
intercourse or intravenous drug use (NIAID, 2010).
Despite advances in the treatment of HIV and AIDS, the disease continues to be a global
problem. As of December 2008, the World Health Organization (WHO, 2010) estimated
that 33.4 million persons, including 2.1 million children (UNAIDS, 2009), were living with
HIV or AIDS worldwide. Nutritional problems in patients with HIV/AIDS may be due to
several mechanisms working independently or synergistically. The causes are described in
Disease Process.

Disease Process

Range and severity of illness are defined by the Centers for Disease Control and
Prevention according to clinical categories. These categories are based on signs,
symptoms, or diagnoses related to human immunodeficiency virus (HIV) infection—and
immunologic categories—established to classify children by the severity of
immunosuppression attributable to HIV infection. The immunologic and clinical categories
have been defined to provide a staging classification and have been described elsewhere
(CDC, 1992; CDC, 1994).
Since the introduction of highly active antiretroviral therapy (HAART) in developed nations,
HIV infection has transitioned from an almost uniformly fatal illness to a chronic disease
(Powderly, 1998), with current therapies targeted at maximal and durable suppression of
viral replication and restoration and/or preservation of immune function (WGATMM, 2009).
Significant advances have been made in the management of HIV infection but despite this
progress, nutritional deficits remain a challenging issue for HIV-infected children and adults
in the HAART era and can often contribute to both morbidity and mortality of those infected
with HIV. Weight loss, lean tissue depletion, lipoatrophy, anorexia, nutrient malabsorption,
diarrhea-induced nutrient losses, and a hypermetabolic state increase risk of death.
Causes of nutritional deficiencies and wasting in HIV/acquired immune deficiency
syndrome (AIDS) are summarized in the table on this page (Miller, 2003).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In addition, metabolic problems such as changes in body fat, serum lipid abnormalities,
and insulin resistance—many leading to an increased risk for cardiovascular
diseases—have emerged since the introduction of HAART. Protease inhibitors and
nucleoside reverse transcriptase inhibitors are both implicated in the development of
lipodystrophy. However, all HIV patients may present with lipodystrophic changes
regardless of receiving HAART treatment. Fat redistribution varies phenotypically from
peripheral wasting of fat (lipoatrophy) in the face, extremities, and buttocks to fat
accumulation (lipohypertrophy) in the abdominal and dorsocervical spine regions (buffalo
hump). The manifestation of these and other metabolic features, whether independently or
concomitantly, defines one component of lipodystrophy syndrome. Compared with adults,
lipodystrophy in children is more difficult to assess because of growth and puberty
(Leonard, 2004). Lipodystrophic changes in children can be subtle and less severe than in
adults and are often associated with puberty.
In adults with HIV, there has been a shift in cause of death from acute opportunistic
infections to metabolic consequences, such as diabetes and heart disease. In children,
mortality has improved significantly, yet the complications associated with cardiometabolic
abnormalities have yet to be fully realized. However, these trends indicate the need for a
more comprehensive approach to healthy living for people with HIV (Vining, 2009).
Causes of Nutritional Deficiencies and Wasting in HIV/AIDS

Decreased nutrient
intake

Primary anorexia
Opportunistic infections of
upper gastrointestinal tract
(candida, cytomegalovirus,
herpes simplex virus)
Idiopathic apthous ulcers
Dysgeusia (zinc deficiency)
Encephalopathy
Medications

Gastrointestinal
malabsorption

Mucosal disease
Infectious
Inflammatory
Disaccharidase deficiency
Protein-losing enteropathy
Fat malabsorption

Hepatobiliary
Sclerosing cholangitis
Chronic pancreatitis
Co-infection with hepatitis B
virus/hepatitis C virus
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Increased nutrition
requirements or
tissue catabolism
Protein wasting
Increased energy expenditure
Futile metabolic
cycling secondary to fever,
infections, sepsis
Release of catabolic factors
(cytokines, tumor necrosis
factor)
Psychosocial factors

Poverty
Illness in biological family
members
Limited access to health care

(Miller, 2003)

Biochemical and Nutrient Issues

Chronic human immunodeficiency virus (HIV) infection places children in a perpetual
proinflammatory state. Inflammation and other immune responses alter nutritional status
through sequestration of minerals (eg, iron and zinc), impaired absorption, increased
nutrient loss, or altered nutrient utilization (Semba, 1999; Drain, 2007). Low serum levels of
retinol, alphatocopherol, selenium, and zinc can be persistent in the highly active
antiretroviral therapy (HAART) era and may accelerate the progression of HIV to acquired
immune deficiency syndrome and death (Jones, 2006). These alterations in
nutrition-related laboratory values may reflect inflammatory responses rather than
nutritional compromise alone.
Some indicators of nutritional compromise that are associated with prognosis include levels
of albumin, transthyretin (originally called prealbumin), hemoglobin, hematocrit, creatinine,
urea nitrogen, transferrin, glucose, vitamin B-12, c-reactive protein, and others (Feldman,
2003). During physical stress, acute phase reactants such as zinc and albumin may fall
rapidly and increase quickly thereafter when the infection resolves. Iron may be shunted to
a storage form during inflammation (ADA, 2010).
Advanced HIV clinical disease, severe immune suppression, increased viral burden,
increased interleukin-6 activity, decreased total serum protein, and decreased insulin-like
growth factor-1 levels are more likely to be found in HIV-infected children with growth
impairment than those with normal growth (Johann-Liang, 2000).
Various types of anemia occur with chronic HIV infection and can sometimes include
anemia associated with nutrient deficiencies, but more often the presence of anemia may
be the result of chronic disease and related to medication interactions (Eley, 2002;
Northrop-Clewes, 2008). Anemia should be evaluated to determine the role of nutrition
intervention in treatment, such as dietary iron and supplementation of folate or vitamin
B-12.
Children are at a significant risk for lipodystrophy as a metabolic effect of HAART.
Biochemical changes associated with the fat redistribution syndrome may include higher
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
fasting insulin, cholesterol, and triglyceride levels. All HIV-infected children and adolescents
should be closely monitored at regular intervals for nutritional, metabolic, and cardiac
problems (Miller 2008).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Inborn Errors of Metabolism
Inborn Errors of Metabolism


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Inborn Errors of Metabolism > General Guidance
Overview

The focus of this topic in the Pediatric Nutrition Care Manual is for providers who have
been asked to provide a basic nutrition assessment for an individual with a metabolic
disorder. It is not meant as a management tool for advanced practitioners.
Inborn errors of metabolism are inherited metabolic disorders caused by genetically
determined changes that disrupt biochemical pathways in the body. These changes in
biochemical pathways may be caused by altered activity of essential enzymes, deficiencies
of the cofactors (activators) for the enzymes, or faulty transport compounds. These altered
pathways are involved in amino acid, carbohydrate, or fat metabolism. Clinical signs are
usually related to the type and toxicity of the metabolites that accumulate or to deficiencies
of the products of the reaction that is impaired.
Inborn errors of metabolism are individually rare and are generally autosomal recessive in
nature. This means that for an affected child, each parent is a genetic carrier for the
disorder (or has the disorder themself). Each individual has two copies of a gene. If one
copy of the gene is unaltered and one copy is altered, the person is called a carrier for the
disorder. When two carriers for the same disorder have a child, that child has a 25%
chance of inheriting both copies of the altered gene; such children will manifest the
disorder. Each disorder presents a physiological spectrum from mild to severe; thus,
treatment must be individualized for each patient. For many of these disorders, treatment is
investigational. For others, treatment is rapidly changing and improving as research
outcomes are incorporated into clinical practice (Fernandes, 2006; Valle, 2009; Nyhan,
2005).
Inborn errors of metabolism are often complex disorders that affect neurological and
physical status as well as nutritional wellbeing if not carefully monitored and managed. The
team approach to management of inborn errors of metabolism has been demonstrated as
effective. The metabolic care team consists of several experts, often including the
following, all with training in and experience with metabolic disorders:
A specialty or advanced practice–level registered dietitian to ensure nutritional
adequacy, monitor adherence to therapy, and promote appropriate food-related
behaviors ( Charney, 2009)
A physician/geneticist to monitor medical and physical aspects of the disorder
A medical social worker to help individuals with social barriers to adherence and
problem solving related to insurance and formula issues
A psychologist to document psychological and neuropsychological status
For more information on inheritance, see
Genetics Resources
on the
National Newborn Screening & Genetics Resource Center Web site
.

Disorders of Amino Acid Metabolism
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

There are many disorders of amino acid metabolism. Phenylketonuria (PKU) is the most
common disorder, affecting approximately 1 in 15,000 newborn infants. Less frequently
occurring disorders include maple syrup urine disease (MSUD), tyrosinemia, and
homocystinuria.
Treatment for these disorders requires dietary restriction of the affected amino acids.
Formulas or medical foods that do not contain the affected amino acids are used to ensure
an adequate intake of protein and other nutrients and to provide 75% to 90% of an infant's
or young child's protein needs. Malnutrition is often the result of restricting the affected
amino acids by restricting protein solely from natural food sources. As a supplement to
specialized metabolic formulas or medical foods, natural foods are prescribed to meet the
metabolic requirement of the individual for the affected amino acids but not support the
accumulation of toxic levels in the blood.
Selected disorders and their nutritional management are briefly discussed below. For
additional details, see Laboratory.
Phenylketonuria (PKU)
PKU (phenylalanine hydroxylase deficiency) is identified by newborn screening in all
states. Without early identification, treatment would not be initiated until neurological
damage had already occurred. Without the benefit of identification in the early newborn
period and prompt diagnosis and treatment, children with PKU have profound intellectual
disability. It is estimated that the average intelligence quotient (IQ) of an individual with
PKU who has not had the benefit of treatment is 40.
Children who are identified by newborn screening and are promptly, consistently, and
appropriately treated will have IQs equivalent to that of their siblings. The PKU Consensus
Conference (PKU Consensus) suggested treatment guidelines in which blood
phenylalanine levels should be maintained consistently at less than 6 mg/dL (360
mcmol/L). Effective treatment for PKU requires the restriction of phenylalanine (to meet the
individual’s requirements) and supplementation of tyrosine.
Tyrosinemia type I
Tyrosinemia type I (fumarylacetoacetate hydrolase deficiency) causes liver and kidney
problems and peripheral neuropathy. There is a wide range of clinical manifestations.
Dietary treatment is aimed at minimizing the precursor amino acids from the affected
metabolic pathway. Treatment for tyrosinemia type I includes the following:
The administration of NTBC
[2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione] (Orfadin) prevents death
from fulminant liver failure in the first few months of life. The data suggest reversal of
liver disease and normal growth and cognitive development (Sniderman King, 2008).
A low-protein diet limited in phenylalanine and tyrosine is necessary to lower plasma
tyrosine levels. (Elevated tyrosine levels are a side effect of NTBC use.) Adequate
tyrosine-free and phenylalanine-free protein is provided through the use of a
specialized formula.
MSUD
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
MSUD, or branched-chain ketoaciduria, is the result of abnormal metabolism of leucine,
isoleucine, and valine. In MSUD, the first step of branched-chain amino acid (BCAA)
metabolism (transamination) occurs normally, but the next step (oxidative decarboxylation)
is impaired. If untreated, severe MSUD leads to metabolic acidosis, cerebral edema,
central nervous system damage, and death.
Intake of the BCAAs leucine, isoleucine, and valine is restricted, to normalize plasma levels
of these amino acids. Specialized metabolic formula, free of BCAAs but including other
essential amino acids, is necessary. Plasma alloisoleucine levels are also monitored, as an
indicator of metabolic control. During episodes of acute illness, BCAA-free parenteral
solutions have proven to be valuable in restoring metabolic balance. During recovery from
metabolic insult, valine and isoleucine normalize before leucine. Thus, supplementation
with these amino acids is often necessary to prevent amino acid imbalance (Strauss,
2006).

Disorders of Carbohydrate Metabolism

Disorders of carbohydrate metabolism include galactosemia and the glycogen storage
disorders. Disorders of fructose metabolism include hereditary fructose disorder and
fructose 1,6 biphosphatase deficiency (very rare).
Galactosemia
Galactosemia (galactose-1-phosphate uridytransferase deficiency) results in failure to
grow, liver disease, cataracts, and renal tubular dysfunction in the newborn period. A diet
restricted in lactose/galactose leads to reversal of these symptoms in galactosemia but
may not prevent later manifestations of developmental delay, speech abnormalities, and, in
females, ovarian failure. Despite strict elimination of galactose from the diet, the outcome is
variable. The underlying pathophysiology is not clearly understood, but may be related to a
chronic self-intoxication with galactose as a result of endogenous synthesis from
secondary metabolic pathways (Elsas, 2007).
Glycogen storage diseases
The glycogen storage diseases are caused by deficiencies of enzymes that regulate the
synthesis or degradation of glycogen. The most common of these disorders, glycogen
storage disease type 1, represents a deficiency in the enzyme glucose-6-phosphatase. The
enzyme defect between glucose-6-phosphate and glucose blocks both glycogenolysis and
gluconeogenesis. Hypoglycemia results when exogenous sources of glucose are
exhausted. In addition to life-threatening hypoglycemia, the symptoms of this disorder are
elevated lactic acid, lipid, and uric acid levels.
The goal of medical nutrition therapy is to prevent hypoglycemia and to normalize
secondary metabolic abnormalities as much as possible. The following two approaches
(individually or in combination) are used:
Nocturnal drip feedings of a carbohydrate-containing solution
Raw cornstarch therapy
Raw cornstarch therapy has demonstrated a decrease in glycogen storage in the liver for
types Ia, Ib, and III (Bali, 2008). Neutropenia caused by neutrophil dysfunction is a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
characteristic of glycogen storage disease type Ib. Low lactose, fructose, and sucrose food
patterns are usually recommended to minimize glycogen production.
Other types of glycogen storage diseases exist. They may present differently and require
different treatment.

Disorders of Fatty Acid Metabolism

Disorders of fatty acid oxidation include the following:
Glutaric acidemia type II
Short-chain acyl-CoA dehydrogenase deficiency
Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency
Long-chain acyl-CoA dehydrogenase (LCAD) deficiency
Very-long-chain acyl-CoA dehydrogenase (VLCAD) deficiency
MCAD is the most common of these disorders. MCAD deficiency has been reported to be
as common as PKU (about 1 in 10,000 - 15,000).
Severely affected infants have sudden death, cardiac disorders, neurological distress, or
metabolic disturbances (Morris, 2000; Matern, 2005). Milder forms of the disorders may not
be physically evident in the newborn period. This is because fatty acid oxidation does not
play a major role in energy production until later infancy, when the child is sleeping through
the night or meals are spaced, resulting in a prolonged fasting period when fats are used
as the primary energy source. Symptoms often include vomiting, lethargy, and
hypoglycemia. Infants can also present during illness, when they become catabolic.
Treatment includes avoiding fasting and catabolism, suppressing lypolysis. Some centers
also provide carnitine supplementation. The aim of long-term medical nutrition therapy is to
prevent periods of fasting and to restrict the fatty acids that are not metabolized, and
supplement with those that are metabolized (Matern, 2005; Rohr, 2009; Frazier, 2009).
Essential fatty acid levels should be monitored when fat intake is restricted.
Medium-chain triglyceride oils (medium-chain triglyceride–containing oils, containing
C6–C8 fatty acids) are frequently used as an energy source for the longer-chain fatty acid
oxidation disorders (LCAD, LCHAD, VLCAD, and trifunctional protein disorder), but are
inappropriate for individuals with blocks in medium- and short-chain defects.

Disorders of Organic Acid Metabolism

Disorders of organic acid metabolism are a diverse group of metabolic disorders, each
caused by a defect in a different enzyme involved in amino acid oxidation. In this group of
disorders, specific nonamino organic acids accumulate in plasma and are excreted in
urine. Disorders of organic acid metabolism include the following:
Propionic acidemia
Methylmalonic acidemia
Isovaleric acidemia
Ketone utilization disorders
Glutaric acidemia type I
Disorders of organic acid metabolism present in many ways. A severely affected newborn
may have hyperammonemia, ketosis, or hypoglycemia. Medical nutrition therapy involves
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
restriction of the substrates of the defective enzyme or enzymes to the level required to
support normal plasma levels.

Disorders of Urea Cycle Metabolism

The urea cycle serves to convert unused dietary nitrogen into urea and thus prevents the
accumulation of ammonia and glutamine. The five major disorders of the urea cycle are
well described, and each has a significant degree of genetic and phenotypic variability. The
disorders are carbamyl phosphate synthetase deficiency, ornithine transcarbamylase
deficiency, argininosuccinic acid synthetase deficiency, argininosuccinase deficiency, and
arginase deficiency.
Severely affected infants present with lethargy, vomiting, hyperventilation,
hyperammonemia, and seizures, which quickly accelerate to coma. Because all these
disorders reflect the inability to synthesize urea (the principal waste nitrogen product)
therapy is directed at reducing the need for urea synthesis and at enhancing other
pathways for synthesis and excretion of other waste nitrogen products. Treatment typically
includes the following:
Protein restriction, often to age-appropriate requirement levels that will support
growth; to minimize the requirement for urea synthesis, a minimum age-appropriate
protein intake that will support growth is prescribed (Acosta, 2005)
Specialized formulas that provide protein as essential amino acids only are used to
minimize the amount of waste nitrogen.
Supplemental arginine and/or citrulline (except for arginase deficiency), since these
amino acids are conditionally essential
Other compounds to enhance urea excretion (eg, sodium phenylbutyrate and sodium
benzoate)
Despite these treatments, individuals with urea cycle disorders are at a constant risk for
life-threatening and/or brain-damaging hyperammonemia (Summar, 2005; Berry, 2001).

Disease Process

Newborns with inborn errors of metabolism typically seem normal at birth, but they may
quickly develop metabolic decompensation or other notable symptoms. Screening of
newborns can identify infants with these disorders before they become ill. Newborn
screening is a nationally recognized and state-mandated effort to ensure the best outcome
for the nation’s newborn population by early identification of potentially devastating
disorders. Early identification, diagnosis, and treatment of inborn errors of metabolism lead
to substantial reductions in mortality and in physical and mental impairment. Appropriate
treatment and compliance with prescribed management improves chances for newborns to
develop normally.
The goals of nutrition intervention for infants and children with inborn errors of metabolism
are to modify or avoid the affected metabolic pathways, to prevent neurological damage,
and to promote physical growth and development. Outcomes of treatment for inborn errors
of metabolism are variable and depend on early diagnosis and intensive monitoring
(Fernandes, 2006; Valle, 2009; Nyhan, 2005; GeneClinics).
Metabolic disorders can be devastating if appropriate treatment is not initiated promptly and
monitored closely. Without intervention, many inborn errors of metabolism interfere with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cognitive development, physical growth, and/or the functioning of organ systems. Many of
these disorders are life threatening if treatment is not initiated in the early neonatal period,
and several are life threatening if treatment is discontinued at any time. Each inborn error
of metabolism requires unique treatment based on the enzyme activity that is affected. In
addition, each individual with an inborn error of metabolism requires unique,
family-centered therapeutic considerations.

Newborn Screening

Although inborn errors of metabolism were previously identified through clinical symptoms
(which were often catastrophic), new technology allows identification of these disorders
through newborn screening.
Expanded newborn screening has changed the expected outcomes for many
infants. Universal newborn screening has enabled infants with metabolic disorders to be
identified before they become seriously ill or die. Outcomes for affected infants are
improved with early identification and treatment. Newborn screening is a dynamic,
programmatic approach to preventing mortality and morbidity.
The American Academy of Pediatrics, the March of Dimes, and other groups have
suggested that 29 disorders be included as “core conditions” in expanded screening
programs and that 25 additional disorders be considered secondary target conditions. All
states screen for the conditions labeled "core conditions" or have plans to implement
screening. Individual states, however, may have individual laws and mandates to guide
their screening programs. Check the National Newborn Screening and Genetics Resource
Center at Genes-R-US to view screening protocols and guidelines for your state. Use this
information to determine the following:
Who to contact if a positive result is identified
Whether there is screening for a specific disorder in your state
What resources are available to families
Effort has gone into development of protocols for immediate follow-up of newborn
screening results. These protocols emphasize the need for a timely, organized public
health system. Often, several steps are required to establish a diagnosis. Once diagnosis
is completed and treatment is started, long-term care and monitoring continue the process.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Inborn Errors of Metabolism > Phenylketonuria/PKU
Overview

Phenylketonuria (PKU) is an inherited disorder of phenylalanine metabolism that occurs in
approximately 1 in 10,000 to 15,000 live births in the United States. The metabolic error
stems from the absence or inactivity of phenylalanine hydroxylase, a liver enzyme that
catalyzes hydroxylation of the essential amino acid phenylalanine to tyrosine. As a result,
phenylalanine and its metabolites accumulate in the blood. Because phenylalanine is an
essential amino acid, it cannot be eliminated entirely from the diet, but it needs to be
restricted to maintain serum levels within an acceptable range. Tyrosine becomes an
essential amino acid in PKU, and adequate quantities must be provided to promote growth
and repair of body tissue.
Adequate phenylalanine, protein, and energy must be provided to prevent breakdown of
body tissues, which can lead to elevated blood phenylalanine levels. Frequent monitoring
of blood phenylalanine (at least monthly after levels are stabilized in infancy) is necessary
to ensure adequacy of treatment. Overprescription of dietary phenylalanine or consumption
of greater amounts of dietary phenylalanine than required, suboptimal intake of metabolic
foods, or catabolic states during illness can result in elevated blood phenylalanine levels.
Underprescription of phenylalanine, reduced consumption of phenylalanine from foods, or
increased phenylalanine need because of accelerated growth may cause reduced blood
phenylalanine levels.
There is no safe age when dietary phenylalanine restriction can be discontinued. Decline in
intelligence quotient, poor school achievement, behavior problems, and neurological
deterioration have been documented after discontinuation of treatment (Mitchell, 2007;
Waisbren, 2007; Anastasoaie, 2008).
Recent treatment options that have been explored include tetrahydrobiopterin (BH4),
phenylalanine ammonia lyase (PAL), and large neutral amino acids (LNAAs) as methods to
mediate blood phenylalanine levels and the rigidity currently required in nutrition therapy.
These newer aspects of treatment for PKU require the support of a metabolic genetics
team with expertise in PKU treatment (Blau, 2009).
Females of childbearing age with PKU who have elevated blood phenylalanine
concentrations at conception and during pregnancy have a high incidence of offspring with
microcephaly and other birth defects as well as increased incidence of spontaneous
abortions. This damage is the result of teratogenic effects of phenylalanine in maternal
circulation during gestation. Treatment for pregnancy must be initiated before conception
and maternal phenylalanine levels are maintained at < 4 mg/dL (Koch, 2003; Waisbren,
2003). The Maternal PKU Collaborative Study developed a nutrition support protocol for
treatment of pregnant women with PKU (Acosta, 1993). They recommend that blood
phenylalanine levels should be maintained between 2 - 6 mg/dL throughout pregnancy,
monitored weekly.

Disease Process

Phenylketonuria (PKU), a phenylalanine hydroxylase deficiency, is identified by newborn
screening in all states. Without early identification, treatment would not be initiated until
neurological damage had already occurred.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Without the benefit of identification in the early newborn period and prompt diagnosis and
treatment, children with PKU have profound intellectual disability. Other possible outcomes
include growth delay and seizures. It is estimated that the average intelligence quotient
(IQ) of an individual with PKU who has not had the benefit of treatment is 40. Children who
are identified by newborn screening and are promptly, consistently, and appropriately
treated will have IQs within the normal range of functioning. The PKU Consensus
Conference (PKU Consensus) suggested treatment guidelines in which blood
phenylalanine levels are maintained consistently at less than 6 mg/dL (360 mcmol/L).
Effective treatment for PKU requires the restriction of phenylalanine to the tolerance
requirement level and supplementation of tyrosine.

Biochemical and Nutrient Issues

Nutrition management of phenylketonuria is designed to reduce blood phenylalanine levels
to between 120 mcmol/L and 360 mcmol/L (2 mg/dL to 6 mg/dL) and to supplement
tyrosine, which becomes conditionally essential. Tyrosine levels should be maintained
within the normal range, as specified by the laboratory where the analysis is being done, to
promote normal cognitive development by reducing the toxic effects of increased
concentrations of phenylalanine and its metabolites while providing adequate nourishment
for growth (Waisbren, 2007; Mitchell, 2007; Anastasoaie, 2008). Without treatment,
phenylalanine levels may exceed 1,200 mcmol/L (> 20 mg/dL).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Oncology
Overview

One in 7,000 children aged 14 years and younger are diagnosed with cancer each year. This translates into 12,400
new cases annually for individuals younger than 20 years of age (Gurney, 2006). There is a 1 in 300 chance that a
newborn child will be diagnosed with cancer by the time he or she reaches 20 years of age (Ries, 1998).
Death from cancer totals 1,400 annually for children younger than 15 years of age and 700 per year for individuals aged
15 to 19 years (Gurney, 2006). In 2000, cancer was the third leading cause of death among children aged 1 to 4 years,
and the second leading cause of death among children aged 5 to 14 years (Minino, 2000).
Although the number of deaths reported in the pediatric cancer population is high, the death rate has decreased
dramatically in the past 30 years (NCI, 2009). Advances in treatment, including supportive care, have led to increased
cure rates and long-term remission and thus resulted in improved overall prognosis for children with cancer (Kalinyak,
2005; NCI, 2009). The following table highlights the 5-year relative survival rates by primary cancer site and year of
diagnosis.

5-Year Relative Survival Rates (Percent)
By Selected Primary Cancer Site and Year of Diagnosis
All Races, Males and Females, Ages 0-19
Site 1975-1977 1978-1980 1981-1983 1984-1986 1987-1989 1990-1992 1993-1995 1996-1998 1999-2005
All Sites, All
Races
61.6 65.3 68.3 70.6 73.5 76.2 77.8 79.6 81.0
All Sites, Whites 61.5 65.9 69.1 72.5 75.0 77.5 78.6 80.9 82.2
All Site, Blacks 59.5 60.0 62.5 58.3 64.3 68.6 74.0 73.6 74.4
Bone and Joint 50.4 48.1 51.2 56.6 64.0 68.4 68.7 66.8 68.5
Brain and Other
Nervous System
58.8 58.0 58.0 63.9 66.0 66.4 71.4 75.6 74.2
Hodgkin's
lymphoma
86.0 88.7 85.5 90.9 89.0 94.3 93.9 94.9 95.5
Leukemia 45.5 53.5 58.1 60.6 67.6 71.3 72.0 76.5 78.7
Acute
Lymphocytic
Leukemia
54.1 62.3 67.1 70.3 75.0 79.8 81.4 84.2 85.1
Acute Myeloid
Leukemia
18.7 26.2 26.4 31.4 37.6 41.0 39.4 46.2 55.0
Neuroblastoma 52.7 57.0 53.4 52.5 60.7 76.1 67.3 65.7 73.9
Non-Hodgkin's
Lymphoma
44.6 53.4 63.8 67.7 70.4 72.2 77.9 81.4 84.4
Soft Tissue 65.2 69.3 68.4 72.7 67.4 69.5 74.3 71.7 75.6
Wilms’ Tumor 72.6 78.4 86.7 91.0 92.1 91.3 91.7 91.7 91.2
Source: SEER 9 areas (San Francisco, Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, and Atlanta).
Rates are based on follow-up of patients into 2006. (Data are from the SEER program, National Cancer Institute.)
There are 12 major types of childhood cancers, with leukemias and cancers of the brain and central nervous system
accounting for more than half of the new cases (NCI, 2009). According to the National Cancer Institute, one-third of all
childhood cancers are leukemias (NCI, 2009). The most common type of leukemia diagnosed in pediatrics is acute
lymphoblastic leukemia and the most common solid tumors are brain tumors such as gliomas and medulloblastomas
(NCI, 2009).

Disease Process

The potential causes and risk factors associated with childhood cancers are not clear, some cancers are associated
with certain conditions such as Down syndrome and other chromosomal and genetic abnormalities, and others are
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associated with environmental factors such as ionizing radiation exposures, exposures to toxins (pesticides, solvents,
household chemicals), and exposures to infectious agents (Gurney, 2006).



Biochemical and Nutrient Issues

Children receiving treatment for cancer are at high risk for altered nutritional status for many reasons. Often the
treatment protocols involve intensive chemotherapy, radiation, surgery, and, in some instances, hematopoietic stem
cell transplantation, all of which can negatively affect nutritional status. Side effects from these therapies may include
nausea, vomiting, diarrhea, taste changes, pancreatitis, hyperglycemia, typhlitis,and/or mucositis throughout the GI
tract.
Disease location can also affect nutritional status; for example, intra-abdominal disease may result in digestive
problems, and disease involving the head and neck region can result in reduced oral intake.
Cancer treatment can often alter the patient’s sense of taste or smell, thus making food unpalatable and leading to
decreased appetite or anorexia. In addition to treatment- and disease-related complications that result in altered
nutritional status, practitioners must address the higher nutrition needs of the growing child.
A patient education handout is available in the Client Education section to help clients manage side effects.


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Diseases/Conditions > Pulmonary Diseases
Pulmonary Diseases


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Diseases/Conditions > Pulmonary Diseases > Asthma
Overview

Asthma is the leading serious chronic illness in children in the United States.
Approximately 6 million children are affected by this condition (NHLBI, 2007).
Asthma is an inflammatory condition of the bronchial airways. This inflammation causes the
normal function of the airways to become excessive and overreactive, thus producing
increased mucus, mucosal swelling, and muscle contraction. The National Asthma
Education and Prevention Program Expert Panel's Guidelines for the Diagnosis and
Treatment of Asthma provides a "working diagnosis" of asthma as follows (NHLBI, 2007):
Asthma is a chronic inflammatory disorder of the airways in which many cells
and cellular elements play a role: in particular, mast cells, eosinophils,
neutrophils (especially in sudden onset, fatal exacerbations, occupational
asthma, and patients who smoke), T lymphocytes, macrophages, and epithelial
cells. In susceptible individuals, this inflammation causes recurrent episodes of
coughing (particularly at night or early in the morning), wheezing,
breathlessness, and chest tightness. These episodes are usually associated
with widespread but variable airflow obstruction that is often reversible either
spontaneously or with treatment.
Children with asthma are at risk for undernutrition or overnutrition. Children who are
overweight have been found to have more asthma symptoms (Belamarich, 2000). Infants
who have high birth weights and children who are overweight during middle childhood are
at higher risk of receiving the diagnosis of asthma later in life (Flaherman, 2006).
Parents of children with asthma often report reducing dairy products in their asthmatic
children's diets (Dawson, 1990), possibly because of the common misconception that fluid
milk leads to increased mucus production (Wuthrich, 2005). This misconception remains
pervasive in the asthma community and requires education and intervention to ensure
adequate calcium, phosphorus, and vitamin D intake (Wuthrich, 2005). Parents and
caregivers often use alternative therapies to treat their child's asthma (Dawson, 1990).

Disease Process

Asthma is a common chronic disorder of the airways that is complex and characterized by
variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and
an underlying inflammation. The interaction of these features of asthma determines the
clinical manifestations and severity of the asthma and the response to treatment. Asthma is
characterized by two primary processes: constriction of the smooth muscles surrounding
the airways and inflammation causing increased mucus production in the lumen of the
airways. These processes lead to the following classic symptoms:
Cough, particularly worse at night
Wheezing
Shortness of breath
Chest tightness
Sputum production
Decreased exercise tolerance
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Factors that trigger the symptoms of asthma include the following:
Environmental allergens: House dust mites, animal allergens (especially cat and dog),
cockroach allergens, and fungi are most commonly reported
Viral respiratory tract infections
Exercise, hyperventilation
Gastroesophageal reflux disease
Chronic sinusitis or rhinitis
Aspirin or nonsteroidal anti-inflammatory drug hypersensitivity, sulfite sensitivity
Use of beta-adrenergic receptor blockers (including ophthalmic preparations)
Environmental pollutants, smoke (tobacco and other types)
Occupational exposure
Irritants such as household sprays and paint fumes (NHLBI, 2007)
Exposure to cold air
A small percentage (6% to 8%) of children with food allergies and asthma have their
asthma triggered by their food allergens (Ozol, 2008).

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Diseases/Conditions > Pulmonary Diseases > Bronchopulmonary Dysplasia
Overview

Bronchopulmonary dysplasia (BPD) is a chronic pulmonary condition found primarily in
premature infants who receive supplemental oxygen and mechanical ventilation. Infants
with BPD are often of very low to extremely low birth weight due to their
prematurity. They often remain small for their gestational age and frequently have feeding
difficulties. Some infants with BPD who are very inactive and/or are on mechanical
ventilation at home may be at risk for overweight due to decreased energy requirements.

Disease Process

Premature infants born before 30 weeks gestation may develop respiratory distress
syndrome (RDS). As a result, these infants are given supplemental oxygen and
mechanically ventilated.
Most infants with RDS will improve within 2 to 4 weeks. Those who get worse and need
more oxygen and/or breathing assistance from a machine have developed
bronchopulmonary dysplasia (BPD). The lungs of the infants who are born with RDS and
who go on to develop BPD are less developed than those of babies with RDS who recover.
There is some controversy on the diagnostic criteria for BPD, but it is generally accepted to
be present in those infants who are oxygen-dependent at day 28 of life (Bancalari, 2006).

BPD results from a complex variety of factors that can injure the lungs. Damage to the
lungs during a critical stage of lung growth can result in ongoing lung disease. The lungs,
heart, and brain are the major organs affected. Common outcomes include abnormal
long-term neurologic and muscular development, chronic pulmonary morbidity, and slow
growth (Ambalavanan, 2011). Nutritional concerns include increased energy and protein
requirements, fluid balance, drug-nutrient interactions, oral-motor skill development,
micronutrient excesses and deficiencies, and reflux.

Biochemical and Nutrient Issues

Infants with bronchopulmonary dysplasia have increased needs for energy and protein
(Zerzan, 2006). Biochemical indices to evaluate include hemoglobin/hematocrit, serum
calcium and phosphorus, serum vitamin D and vitamin A, alkaline phosphatase, serum
albumin, and prealbumin.

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Diseases/Conditions > Pulmonary Diseases > Cystic Fibrosis
Overview

Cystic fibrosis (CF) is an autosomal recessive genetic disease that affects approximately
30,000 people in the United States and 70,000 people worldwide (CFF, 2008). CF occurs
in approximately 1 out of every 2,500 live births. The gene, which is on chromosome 7, is
called the CF transmembrane conductance regulator and controls the flow of sodium and
chloride ions across the cell membrane. Abnormal flow results in thickened secretions. It
affects both the respiratory and gastrointestinal tracts, causing bacterial infection and
scarring in the lungs, and pancreatic insufficiency in approximately 85% of persons who
have CF. Persons who are pancreatic insufficient may experience pancreatitis (Michel,
2009b). Persons who have CF are at risk for liver disease, reproductive complications, and
CF-related diabetes.
All states and several countries now conduct newborn screening, which can lead to
diagnosis early in life, often prior to any evidence of the disease. Life expectancy for
persons with CF has improved significantly with a predicated median survival age of 37
years (CFF, 2008) due to improved therapies, including attention to the nutrition needs of
each patient. Most children with CF are expected to live to adulthood.


Disease Process

Cystic fibrosis (CF) is a genetic disease that affects the exocrine glands of the body. It is
caused by mutations in the CF transmembrane conductance regulator gene. In the
respiratory tract, this results in thick, sticky secretions, which attract bacteria in the lungs
and sinus cavities. Respiratory symptoms include cough, excessive sputum production,
and progressive scarring in the lungs (CFF, 2008). The bacteria that colonize the lungs can
be spread among individuals with CF; therefore, camps and other joint activities that can
lead to close contact are discouraged.
Some individuals, particularly at a young age, have only
intermittent infections with organisms such as staphylococcus aureas and pseudomonas
aeroginosa. Infections are treated with oral, inhaled, and/or intravenous antibiotics. With
intermittent infections, the goal of treatment is usually eradication of the infection. Once
colonization occurs, the goal of treatment is usually eradication of symptoms and
improvement in lung function.
Prednisone, high-dose ibuprofen, and/or other antibiotics and medications are also
occasionally used to treat the inflammation associated with CF. Hypertonic saline and
dornase alpha are used via nebulization to thin mucus secretions. All of these therapies are
used in conjunction with airway clearance techniques such as chest physiotherapy (which
may include manual clapping, acapella, therapy vests, flutter, or other methods) to
decrease the amount of thick secretions in the airways.
Lung function is monitored with pulmonary function testing starting at approximately age 6
years (dependent on the patient's ability to perform the testing). Normal lung function is
usually maintained in younger children and sometimes through teen and adult years;
however, slow progressive loss of lung function is the leading cause of mortality in CF.
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There is considerable variability in the severity of the disease among individuals with CF.
Lung transplantation can be a life-saving option for some who have end-stage lung disease.
In the digestive tract, thick secretions block the pancreatic duct, which leads to scarring in
the pancreas and impaired secretion of pancreatic enzymes (lipase, amylase, and
protease) as well as bicarbonate into the small bowel. Thick secretions in the large bowel
can lead to meconium ileus (MI) in newborns or distal intestinal obstruction syndrome in
children and adults. MI occurs in approximately 15% of newborns and is characterized by
failure to pass meconium and bowel obstruction. Thickened secretions in the liver can
decrease bile flow and lead to damage to the liver. Damage to the islet cells in the
pancreas and insulin resistance significantly increases the risk of developing diabetes. All
of these complications of cystic fibrosis can lead to malnutrition, including fat-soluble
vitamin deficiency.

Biochemical and Nutrient Factors

Most individuals with cystic fibrosis (CF)—approximately 85% to 90%—are pancreatic
insufficient (PI), which increases the risk of poor weight gain, growth, and vitamin and
mineral deficiencies. Individuals who are pancreatic sufficient have increased risk of
recurrent pancreatitis, which may eventually lead to PI (Michel, 2009b).
PI is usually diagnosed by checking the fecal elastase level (Daftary, 2006; Borowitz,
2004). Fecal elastase should be measured on all patients at diagnosis, and if normal, on a
regular basis—especially in the first 2 years of life for infants with a PI genotype—to
monitor for development of PI (Borowitz, 2009). A false positive can occur if the stools are
watery. The 72-hour fecal fat study is a quantitative measurement of fat absorption but can
be fraught with error since for 72 hours, all bowel movements must be collected and all
food/fluid intake recorded. The coefficient of fat absorption is calculated to determine how
much energy is lost from fat in the stool.
Individuals with CF and PI are at risk for deficiency of the fat-soluble vitamins A, D, K, and
E. Levels should be monitored on an annual basis (more frequently if a deficiency is
detected). Vitamin K is monitored indirectly using protein-induced in vitamin K absence or
prothrombin time. Zinc deficiency can occur in individuals who have CF, including
breastfed infants. Serum zinc levels are a poor indicator of zinc status. Supplemental zinc
is indicated with evidence of poor growth and/or appetite (Borowitz, 2009; Borowitz, 2002).
Intravenous aminoglycoside antibiotics can lead to urinary losses of magnesium and
magnesium deficiency, requiring supplementation. Essential fatty acid deficiency is quite
common, especially in individuals who have a late diagnosis of CF (Michel, 2006).
Liver function tests are obtained annually to assess liver status but aren't always sensitive
or specific when monitoring development or progression of liver disease in CF (Sokol,
1999; Michel, 2009c). Serum albumin and retinol-binding protein levels are used to assess
visceral protein status, but these stores can be well-preserved in those with mild to
moderate chronic malnutrition.
Individuals with CF should be monitored for development of CF-related diabetes (CFRD)
with an annual random glucose level in those younger than 10 years. Patients aged 10
years and older should be monitored annually with an oral glucose tolerance test (Moran,
2010). Symptoms may include unexplained weight loss/suboptimal growth, polyuria,
polydipsia, and more frequent pulmonary infections; however, some patients have no
symptoms. Hemoglobin A1C is not useful in screening for CFRD but should be monitored
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
in those patients (along with fingerstick glucose testing) who have been diagnosed with
CFRD (Moran, 1999).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Pulmonary Diseases > Ventilator Issues
Overview

Children may require intubation and mechanical ventilation for a variety of medical
conditions that may include respiratory and/or cardiovascular failure, central nervous
system disease, or unstable airway (Kendirli, 2006).
Children on mechanical ventilation may be in the pediatric intensive care unit (PICU) or
living at home. Most children on mechanical ventilation at home will have a tracheostomy
tube for breathing and a gastrostomy feeding tube. Children who receive mechanical
ventilation have specific nutritional needs to aid their growth. The nutritional concerns for
children on mechanical ventilation include energy balance, growth, and micronutrient
deficiencies. Inactivity can lead to constipation issues.

Disease Process

Respiratory insufficiency can be fatal if not corrected. An endotracheal or tracheostomy
tube and the use of a mechanical ventilator may be necessary to provide adequate gas
exchange. The use of a mechanical ventilator may be short term or permanent, depending
on the primary disease. Premature infants with bronchopulmonary dysplasia may improve
with age and no longer require mechanical ventilation, while those with progressive
neuromuscular dysfunction (Duchenne's muscular dystrophy) will require increasing
support with age.

Biochemical and Nutrient Factors

Children requiring mechanical ventilation are often unable to feed orally. Most have either
nasogastric/nasojejunal feeding or gastrostomy feeding tubes. Biochemical and nutrient
factors to consider are as follows:
Biochemical factors
Total protein/albumin
Hemoglobin, hematocrit
Serum or urine osmolality
Serum vitamin levels (A, D)
Nutrient factors
Energy and protein requirements
Fluid needs
Vitamin and mineral needs
Fiber

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Renal Diseases
Renal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Renal Diseases > Chronic Kidney Disease
Overview

Chronic kidney disease (CKD) is classified into stages 1 through 5 (see Table in Disease
Process), 5D (dialysis), and 5T (kidney transplant). Although the majority of adult-onset
CKD is caused by diabetes or hypertension, that is not the case in pediatric CKD patients.
CKD in a child may be congenital resulting from an anatomical defect, inherited disease, or
inborn error of metabolism, or may be acquired as a result of untreated kidney infections,
physical trauma to kidneys, exposure to nephrotoxic chemicals, or illness that damages the
kidneys.
CKD is a very complex disease with very complex nutritional issues. Without regular
nutrition assessment, intervention, and follow-up, a child with CKD is likely to have
problems with growth and development, electrolyte and metabolic processes, and bone
development. The registered dietitian (RD) must evaluate weight gain and growth, feeding
issues, and laboratory values to develop an individualized nutrition plan. The RD must take
into account all of the other medical and socioeconomic issues associated with CKD.
To provide optimal nutrition care for a pediatric patient with CKD, the RD must work with a
team that addresses all of the patient's needs.

Disease Process

In a typical situation, a child presents with a condition that causes a mild decrease in
kidney function (chronic kidney disease [CKD] stage 1 or 2), which progresses over
months or years to end-stage renal disease (CKD stage 5), when renal replacement
therapy is needed (dialysis or transplant). In some cases, an infant or child presents with
stage 5 CKD and needs replacement therapy right away.

5 Stages of Chronic Kidney Disease

Stage Description
Glomerular
Filtration Rate (GFR)
At
increased
risk
Risk factors for kidney disease (eg, diabetes, high
blood pressure, family history, older age, ethnic
group)
More than 90
1
Kidney damage (protein in the urine) and normal
GFR
More than 90
2 Kidney damage and mild decrease in GFR 60 to 89
3 Moderate decrease in GFR 30 to 59
4 Severe decrease in GFR 15 to 29
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5 Kidney failure (dialysis or kidney transplant needed) Less than 15
National Kidney Foundation

Biochemical and Nutrient Issues

Nutrition issues and nutrient needs are based on the individual, depending on etiology
and/or stage of chronic kidney disease (CKD). Thus, there is no one diet plan for all
pediatric patients with CKD at a particular stage.
Depending on the cause of renal insufficiency, a patient may be polyuric or
oliguric/anuric. The patient with polyuria may “waste” electrolytes (sodium, potassium,
and/or phosphorus), whereas the patient with oliguria or anuria may retain
electrolytes. Many children with CKD have concurrent medical problems (eg, heart, lung, or
liver problems). The patient with CKD who was born premature may have lung disease and
be on steroids and diuretics. In all cases, treatment must be individualized depending on
weight gain and growth, laboratory values, hydration status, and other patient-specific
issues.
The kidneys have many functions, including the following:
Fluid and electrolyte balance—excretion of waste products, including excess acid,
sodium, potassium, phosphorus, urea, and fluid
Production of erythropoeitin, which is necessary for red blood cell production
Conversion of 25-OH vitamin D to 1,25-OH vitamin D (the active form), which
is necessary for calcium and phosphorus metabolism and bone mineralization
Metabolism of growth hormone
Two common scenarios of children with CKD are as follows:
A child born with kidney dysplasia:
He has growth and feeding issues as well as metabolic issues starting shortly
after birth and spends a lot of time in the hospital. He is breastfed but feeds
poorly, so he receives nasogastric feedings of a combination of breastmilk and
formula to meet his needs. Within months, he has a peritoneal dialysis catheter
placed and is started on dialysis. In the meantime, the parents need to care for
their older children and work to meet financial needs as well as maintain health
care insurance and learn a tremendous amount of information about how to care
for this infant with complex health issues. The mother is trying to do the right
thing by breastfeeding and pumping her milk, but she is exhausted and grieving
that her infant is not healthy. As the infant grows, the registered dietitian (RD) is
monitoring him and encouraging the parents to provide oral stimulation and
feeding and to make sure he is getting 100% of his formula prescription. The
infant is very spitty (it is common for babies and children with CKD to have
substantial gastroesophageal reflux). Having a child with CKD is extremely
stressful. Without lots of support and encouragement, it is impossible for parents
to do everything they need to do to keep the infant in optimal health.
A teenager diagnosed with stage 5 CKD:
A teenage girl has been ill with flu-like symptoms for months; she has lost a lot
of weight and feels terrible. Finally, her physician checks laboratory results and
her creatinine is 20 mg/dL and blood urea nitrogen is 200 mg/dL. She is
admitted to the hospital intensive care unit; a hemodialysis catheter is placed
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
admitted to the hospital intensive care unit; a hemodialysis catheter is placed
and dialysis started within a couple days of this diagnosis. She starts to feel
better as her metabolism is stabilized. Urine output has dramatically decreased.
It is determined that she has stage 5 CKD and will need chronic dialysis until a
kidney transplant can be performed. The RD needs to instruct her and her
parents about following a low-sodium, low-potassium, low-phosphorus, low-fluid,
increased-energy, increased-protein diet. While on this diet, the patient must
come to the outpatient dialysis center 3 to 4 times per week for 3 to 4 hours at a
time (it can take 5 to 8 hours per dialysis session when travel time is included;
this can amount to 15 to 32 hours per week). Both her parents work. The RD
may need to be very creative in helping this family address complex diet
requirements, such as when they will be able to do the shopping and food
preparation for this complex diet, especially if no one in the family likes to cook.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Renal Diseases > Nephrotic Syndrome
Overview

Nephrotic syndrome (NS) is a serious disease that has significant nutritional implications. A
registered dietitian who has expertise in pediatric nutrition and knowledge of NS is an
integral part of the team treating a child with NS. Early nutrition assessment, intervention,
and education will help promote the best outcome for NS, especially if a child has several
relapses.
The incidence of NS in children in Europe, North America, and New Zealand is 2 in
100,000 (Hodson, 2008). The nutritional issues associated with NS are caused by the
disease itself as well as the medications used to treat it.
The most important diet therapy is to decrease sodium intake in order to decrease edema
associated with low serum albumin. In addition, low intakes of simple carbohydrates and fat
and high intakes of calcium and vitamin D are needed to combat the effects of prednisone
therapy.
Prednisone increases appetite, often resulting in excess weight gain. At the same time, it
causes muscle breakdown and increased fat deposition; it is important to make sure that
protein intake meets the Dietary Reference Intakes (DRI) for age (usually not a problem in
children). Prednisone increases blood glucose levels and can actually cause diabetes
when administered at high levels for long periods of time. Thus, consuming high-fiber
complex carbohydrates can help prevent hyperglycemia. Keeping both fat
and simple carbohydrates low can help prevent excessive energy intake and, in turn,
excess weight gain and hyperglycemia.
Hyperlipidemia is a secondary effect of NS as well as of prednisone therapy; low fat
intake—especially saturated fat intake—may help keep lipid levels down.
Prednisone causes increased excretion of calcium in the urine and can lead to decreased
bone mineralization when given long term. Consider calcium and 25-OH vitamin
D supplements if the diet is not meeting these DRIs for age.
NS is characterized by proteinuria of more than 3 g per day. Serum albumin decreases
significantly and patients become very edematous. Infection risk increases significantly
because of loss of proteins used by the immune system.
The most common type of NS in children is “minimal change NS,” which generally resolves
in adolescence without long-term kidney problems. The cause of minimal change NS is
unknown. First-line treatment is oral corticosteroids (ie, prednisone). Most patients respond
well to prednisone but may relapse whenever they have other illnesses (eg, cold, flu, etc.).
Some patients are “steroid dependent”; they respond to prednisone but relapse whenever
prednisone is weaned to very low doses or discontinued. In these cases, patients may be
treated with noncorticosteroid immunosuppressants such as cyclophosphamide,
chlorambucil, tacrolimus (FK506), or cyclosporine with the goal of getting nephrotic
syndrome into a long-term remission without the use of prednisone (Hodson, 2008).
NS can be caused by other kidney abnormalities, which may result in long-term/chronic
renal disease. These patients may also be treated with prednisone as well as the other
drugs mentioned in the previous paragraph.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Disease Process

Proteinuria causes a decrease of protein in the blood, resulting in decreased oncotic
pressure in blood vessels, which allows water to go from the bloodstream into tissues,
resulting in edema. If sodium intake is high, edema is increased. If left untreated, levels of
proteins in the blood become dangerously low; in such cases, edema can become life
threatening and risk of infections, such as peritonitis, become high (NKF, 2009). Nephrotic
syndrome (NS) also can lead to hyperlipidemia, which typically resolves as the disease
resolves.
There are several types of NS that result in progressive chronic kidney disease (CKD);
examples of these are focal segmental glomerular sclerosis, congenial NS, and rapidly
progressive glomerular nephritis. See the guidelines for these within the CKD topic.

Biochemical and Nutrient Issues

Nutrient issues with nephrotic syndrome (NS) stem from both the disease itself and the
medications used to treat it.
Sodium
High sodium intake exacerbates edema associated with proteinuria and low blood proteins.
Prednisone, the first-line treatment for NS, causes increased sodium retention, which can
lead to hypertension. Low serum sodium levels may occur when a patient is very
edematous.
Calcium
Calcium excretion is increased and absorption is decreased with prednisone treatment.
Since it isn't possible to predict how long or how often a patient will be on high-dose
prednisone when he or she first presents with NS, it is prudent to discuss adequate
calcium intake with caregivers.
Vitamin D
In 2010, the Institute of Medicine recommended an increase in vitamin D intakes for
healthy children. The child with nephrotic syndrome may need a higher dose of vitamin D
supplement than is recommended for healthy children. It is prudent to discuss adequate
vitamin D intake and normal levels, especially when a child is taking prednisone
(IOM, 2011)
Weight Gain, Glucose, and Lipid Abnormalities
Increased appetite associated with prednisone can lead to excessive weight gain not
associated with edema. Weight gain along with impaired glucose tolerance associated with
prednisone can occasionally cause type 2 diabetes mellitus, which may or may not resolve
when prednisone is discontinued. Lipid abnormalities associated with NS and prednisone
typically resolve when NS resolves but can lead to atheroslcerosis in children who have
frequent relapses over several years.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation
Transplantation


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Organ Transplant
Organ Transplant


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Organ Transplant > Cardiac Transplant
Overview

Heart transplantation has been a treatment for end-stage pediatric heart disease since the
late 1960s. In the 1980s, cyclosporine-based immunosuppression regimens—which made
heart transplantation more applicable to pediatric patients with intractable heart
failure—were developed. Neonatal transplantation was initially performed in 1985 using a
baboon heart for an infant with hypoplastic left heart syndrome. Although the patient died
21 days after the controversial procedure, subsequent efforts at allograft cardiac
transplants in neonates saw increased success as factors such as the following became
better understood (Bailey, 2009; Chinnock, 2008; Gandhi, 2007):
Growth of the patient and the heart
Relative risk of rejection and infection
The risk of coronary vasculopathy
How patients might adapt to a normal environment involving family, school, and the
complexity of medical therapy required after heart transplantation
Transplantation became the treatment of choice in infants with hypoplastic left heart
syndrome, as conventional surgical palliation tended to have an extraordinarily high
mortality rate; and treatments and outcomes continue to improve as new pharmacology
and technology become available (Canter, 2007).
Nutrition care for postoperative cardiac transplant patients is nearly identical to that for
cardiac surgical patients, except for the need to address the effects of the
immunosuppressive regimen. The primary goals are as follows:
Provide adequate and appropriate nutrition to promote wound healing
Reduce the risk of infection
Replenish nutritional stores
Help patient regain strength to enable participation in cardiac rehabilitation (Hummell,
2003)
Consider the nutrient needs in the metabolic changes and transplant-specific
conditions (graft rejection) (Hasse, 2001)

Disease Process

Disease Processes That Lead to Consideration of Heart Transplantation (Canter,
2007)
Pediatric cardiomyopathies
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Congenital heart disease
Retransplantation in pediatric heart transplant recipients
Growth failure secondary to congenital heart disease and severe congestive heart failure
unresponsive to conventional medical treatment are other indications for heart
transplantation (Canter, 2007). The cause of growth failure is multifactorial and might
include any or all of the following (Vogt, 2007):
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Poor nutrition
Increased metabolic requirements
Endocrine factors
Impaired hemodynamic status
Hypoxemia

Biochemical and Nutrient Factors

Nutrients and Roles in Cardiac Transplant Patients (adapted from Miller 2007)
Calories
Calories provide energy for all metabolic processes and to support growth. Increased
metabolic rates occur secondary to recurrent infections, increased muscle activity,
and need for rapid growth.
Protein (g/d)
Protein serves as the major structural component of all cells in the body and functions
as enzymes in membranes, as transport carriers, and as some hormones.
Protein catabolic rate is increased as a result of surgical stress and high-dose
corticosteroids.
Adequate amounts of protein are required for wound healing and to prevent infection.
Additional losses from surgical drains, fistulas, wounds, and dialysis should be
considered (Hasse, 2001).
Carbohydrate (g/d)
Carbohydrate is a source of energy to maintain body weight and is the primary energy
source for the brain.
Serum glucose levels may be increased because of medications (eg, corticosteroids,
cyclosporine, tacrolimus), metabolic stress, or infection.
Fat (g/d)
Fat is an energy source and increases absorption of fat-soluble vitamins.
Fat oxidation is decreased following transplantation.
Hyperlipidemia is common in the recovery phase and can lead to vasculopathy.
n-3 polyunsaturated fatty acids (linolenic acid) (g/d)
n-3 fatty acids may induce long-term functional transplant tolerance and may enhance
immunosuppression.
n-3 fatty acids have a possible favorable effect on the left ventricular function.
n-6 polyunsaturated fatty acids (linoleic acid) (g/d)
n-6 fatty acids are an essential component of structural membrane lipids and
precursor of eicosanoids.
Fluids (mL/d)
Fluids are essential for maintaining vascular volume.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fluid balance is a key factor in the medical management of most infants with coronary
heart disease (CHD).
Insensible losses may be increased as much as 10% to 15% above normal. Fluid
losses occur secondary to high ambient temperature, fever, diuretic therapy, and
tachypnea. Despite increased fluid losses, most infants with CHD show symptoms of
fluid overload and are fluid restricted to prevent excess fluid accumulation (Carlson,
2000).
Sodium (g/d or mEq/d), Potassium, Phosphorus, Magnesium (mg/d), Calcium (mg/d)
Sodium restriction prevents exacerbation of heart failure and can reduce the dose of
diuretic therapy.
Chronic use of diuretics results in increased urinary excretion of sodium, potassium
chloride, magnesium, and calcium.
In addition to bone metabolism, calcium plays a role in muscle contraction.
Vitamin D (µg/d)
Vitamin D is essential for calcium absorption from the intestine.



© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Organ Transplant > Kidney Transplant
Overview

Kidney transplant is a treatment option for chronic kidney disease (CKD), but it is not a
cure. A child may receive a living related, living nonrelated, or cadaveric transplant.
There are some nutritional issues specific to kidney transplant (see Disease Process);
otherwise, a kidney transplant patient has nutritional issues similar to any patient with
CKD, depending on stage of CKD/kidney function.

Disease Process

Immunosuppression drugs are started immediately after transplant to prevent rejection of
the transplanted organ. The dietitian works with the medical team to stabilize phosphorus,
magnesium, potassium, and blood glucose levels.
The newly transplanted kidney "wastes" phosphorus, and several of the
immunosuppressive drugs (tacrolimus, mycophenolate, cyclosporine, and sirolimus) cause
wasting of phosphorus and/or magnesium; most patients require both phosphorus and
magnesium supplementation. These are both cathartics, so supplementation must be
balanced with risks of associated diarrhea.
Cyclosporin and tacrolimus (most patients will be taking one of these) are associated with
retention of potassium. Patients typically need some degree of dietary potassium restriction
in the first few months after transplant
Hypertension is a common problem after transplant and may be multifactorial (Kew, 2000):
Factors Associated with Posttransplant Hypertension
Pretransplant hypertension
Immunosuppressive medications: cyclosporine, tacrolimus, prednisone
Chronic allograft dysfuntion
Recurrent or de novo glomerulonephritis
Transplant renal artery stenosis
Vasoconstrictive hormone synthesis by native kidneys
Diet (excessive sodium) and obesity
Hypertension in donor’s family
Reprinted from Kew C, Curtis J. The best way to manage hypertension after Renal
Transplantation. J Renal Nutrition. 2000;10:3-6 with permission of Elsevier. Journal
available at: http://www.sciencedirect.com/science/journal/10512276
Low-sodium diet, weight reduction, and exercise can help decrease hypertension in many
cases, but medical or surgical management is necessary when hypertension is the result of
anatomical or hormonal causes.
Long-term issues for transplant patients are hyperlipidemia and hypertension, as well as
decreased bone density and obesity (especially if on glucocorticoid therapy) (Cohen, 2003;
Holley, 1990; Pagenkemper, 1999). The most important way to deal with these issues is a
heart-healthy diet and exercise. Several studies have shown marked improvement in lipid
levels and/or weight gain when early, regular nutrition intervention is provided (Patel, 1998;
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Barbagallo, 1999; Lopes, 1999; Hines, 2000). Exercise has been shown to be very
beneficial for children after renal transplant, decreasing cardiovascular risks and improving
muscle mass and overall fitness. (Feber, 1997; Painter, 1986; Painter, 1997). However,
care must be taken to gradually increase exercise, with a goal of submaximal aerobic
activity, especially for those with hypertension (Calzolari, 1997; Feber, 1997; Krull, 1994).

Biochemical and Nutrient Issues

Biochemical and Nutrient Issues Specific to Kidney Transplant Patients
Nutrient or
Biochemical
Indice
Associated Issues Treatment
Energy Energy needs are
increased in the
immediate
posttransplant period to
allow for healing. In the
long term, obesity is a
common problem,
especially for those on
corticosteroids (Holley,
1990; Pagenkemper,
1999).
Risk of obesity has
been reduced with use
of steroid-free
immunosuppresion
protocols.
Provide 100% of
estimated energy
requirements for
chronological age,
weight, height and
physical activity level.
Adjust as needed to
maintain appropriate
rate of weight gain for
age (NKF, 2009).
Protein Protein needs are
increased in the
immediate
posttransplant period to
allow for healing.
Long-term protein
needs are equal to the
Dietary Reference
Intake (DRI) for age.
Provide at least 100%
of the Recommended
Dietary Allowance for
protein for age. (Most
children exceed this
when they are eating
enough to meet energy
and micronutrient
needs.)
Fats Hyperlipidemia is a
major side effect of
several of the
immunosuppressant
medications given to
transplant patients.
Studies of pediatric
kidney transplant
Diet should be heart
healthy—rich in fruits,
vegetables, and whole
grains. Fats should be
kept to <30% of energy
intake and should
consist of mainly
monounsaturated and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
patients in the 1990s
showed that 72% to
84% had increased
low-density lipoprotein
cholesterol levels
(>100 mg/dL).
polyunsaturated
oils. Saturated fats and
trans fats should be
less than 10% of total
energy intake (NKF,
2009; Hines, 2000;
Lopes, 1999;
Barbagallo, 1999)
Phosphorus Low levels due to high
renal phosphorus
output. Usually
resolves over 1-3
months as medications
are reduced.
Supplement with
potassium and/or
sodium phosphate (both
potassium and sodium
can be problematic;
need to assess blood
pressure and potassium
levels when deciding
what form of
phosphorus supplement
to use).
Phosphorus has a
laxative effect and may
cause diarrhea.
Magnesium Low levels due to high
urinary magnesium
output. Usually
resolves over 1-3
months.
Supplement with
magnesium protein
complex (pill form, 133
mg) or magnesium
gluconate (Magonate)
liquid (54 mg/5 mL);
many other
supplements are
available.
Magnesium salts have
a laxative effect and
may cause diarrhea.
Potassium High levels due to
drug–nutrient
interactions. Becomes
less of an issue as
medication levels are
reduced over time.
Low potassium diet.
Calcium Poor bone
mineralization is a side
effect of corticosteroid
therapy, as well as of
chronic kidney disease
(CKD). Adequate
Ensure that all children
are receiving at least
100% to a maximum of
200% of the DRI for
calcium for age.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
calcium intake is
essential for all
transplant patients. For
those on corticosteroid
regimen, a higher
calcium intake is
warranted.
For those on
corticosteroids, ensure
150 to 200% of the DRI
for calcium (ACR, 1996)
Vitamin D Same issues as for
calcium. Recent
research suggests that
vitamin D needs are
much higher than the
current DRI, thus a
higher level of intake is
recommended for
transplant patients
(EURODIAB, 1999;
Holick, 2007; NKF,
2009; Roth, 2005)
Ensure and intake of
800-1,000 IU vitamin D
with foods for transplant
patients with less than
stage 3 CKD. For those
with CKD stages 3 to
5T, follow CKD
guidelines (NKF, 2009).
Sodium High sodium intake
exacerbates
hypertension.
For patients with
hypertension, limit
sodium intake to 1-2
mEq/kg body
weight/day (1 mEq = 23
mg sodium)
Fluid Dehydration can result
in damage to
transplanted kidney.
Special attention
must be taken to
ensure adequate water
intake (fluid minimums
will be set by kidney
transplant team).
Ensure that patient
takes in prescribed fluid
each day (prescription
will vary depending on
body size, urine
production from native
kidneys, and other
patient-specific factors).
Sugar Hyperglycemia is a
side effect of several of
the
immunosuppressant
medications given to
transplant patients.
Diet should be low in
simple sugars (avoid
sugared drinks and fruit
juices, candies, dessert
items). Encourage
whole grains and high
fiber, complex
carbohydrates, fruits
and vegetables, and
protein foods. Spread
consumption of meals
and snacks out over the
day to help avoid high
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
day to help avoid high
glucose levels. In rare
cases, insulin is
necessary until
immunosuppressant
medications are
decreased.
Food borne
pathogens
Due to
immunosuppression,
the transplant patient is
at high risk for serious
illness due to
foodborne pathogens.
Families should be
given guidelines for
safe/hygenic food
preparation in order to
avoid contamination of
foods with pathogens.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Organ Transplant > Liver Transplant
Overview

Liver transplantation in children has been the standard of care for liver failure for more than
20 years. Current 1-year survival rates from experienced liver transplant centers are
greater than 90%, and 5-year survival rates are above 85% (Magee, 2008).

The goal of nutrition therapy in patients with liver transplant is to reestablish normal growth
and development and to minimize nutrition-related side effects of immunosuppressive
drugs, including hyperlipidemia, hypertension, obesity, osteopenia, renal dysfunction, and
glucose intolerance (Ng, 2008; Varo, 2002; Perez, 2009; Fernandez, 1999; Scolapio, 2001;
Everhardt, 1998; Helenius, 2006; Giannini, 2000; Stratta, 2005; Araki, 2006).

Please note that some information in this topic has been adapted from the adult Nutrition
Care Manual's section on Organ and Liver Transplantation. For an overview of liver
transplantation, see How the Liver Works and History of Pediatric Liver Transplantation.

Disease Process

Indications for pediatric liver transplantation are as follows:
Extrahepatic biliary atresia
Sclerosing cholangitis (secondary to cystic fibrosis, Langerhan’s cell histiocytosis)
Nonsyndromic bile duct paucity
Neonatal hepatitis
Byler’s disease
Alagille syndrome
Tyrosinemia
Hemochromatosis
Wilson's disease
Glycogen storage disease
Alpha-1 antitrypsin deficiency
Liver tumors
Fulminant liver failure
(Sutton, 2002; Rand, 2003)
In addition to organ-specific indications for transplantation, which include growth failure
among other variables, transplant centers have guidelines for transplant acceptability.
Some of those guidelines include other medical comorbidities and patient–family
psychosocial criteria.
For information on the liver transplant procedure, see Transplant Living: During the
Transplant.

Posttransplant Immunosuppression

Transplant recipients must be maintained on immunosupressive drugs indefinitely to
prevent rejection of the transplanted organ. Immunosuppressive Medications and Side
Effects summarizes transplant immunosuppressive drugs, their mechanism of action, and
side effects. Additional information on transplant medications can be found at Transplant
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Living: Medications: Protecting Your Transplant.
Overimmunosuppression increases transplant recipients' risk for developing opportunistic
infections and posttransplant lymphoproliferative disease. Side effects of many of the
immunosuppressive medications contribute to risk factors for heart disease, hypertension,
renal impairment, diabetes mellitus, osteoporosis, and other chronic conditions (Ng, 2008;
Varo, 2002; Perez, 2009; Fernandez,1999; Scolapio, 2001; Everhardt, 1998; Helenius,
2006; Giannini, 2000; Stratta, 2005; Araki, 2006; Millonig, 2005).
Tacrolimus has also been associated in the initiation of food allergies leading to
eosinophilic gastroenteritis (Saeed, 2006).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Hematopoietic Stem Cell Transplant
Hematopoietic Stem Cell Transplant


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Hematopoietic Stem Cell Transplant >
Complications of HSCT
Graft-Versus-Host Disease

Graft-versus-host disease (GVHD) is a potential complication following allogeneic
transplantation. The donor's infection-fighting cells attack the patient's organs, impairing
their ability to function and increasing their susceptibility to infection. To increase the odds
of engraftment and minimize the risk of GVHD, the donor and patient are matched as
closely as possible based on human leukocyte antigen typing.
There are two types of GVHD: acute and chronic. Traditionally, the presence of GVHD
beyond 100 days after hematopoietic stem cell transplant was called "chronic GVHD."
However, the National Institutes of Health currently recommends that that acute and
chronic GVHD should be distinguished by clinical manifestations and not by time after
transplantation. The new classification includes late-onset acute GVHD (after 100 days)
and an overlap syndrome with features of both acute and chronic GVHD (Filipovich, 2005).
Acute GVHD occurs in the first 100 days following the allogeneic hematopoietic stem cell
transplant. The signs of acute GVHD may be a skin rash appearing on the patient's hands
and feet. Cramping, nausea, and watery or bloody diarrhea are other signs of GVHD in the
stomach or intestines. A rising bilirubin with jaundice may be a sign that acute GVHD has
affected the liver. Chronic GVHD occurs more than 100 days posttransplant.
Chronic GVHD can be multisystemic, involving the skin, gastrointestinal tract, liver,
musculoskeletal system, and the immune system. To date, there has been no effective
means to prevent chronic GVHD. The most successful treatment of patients with chronic
GVHD is a systematic approach to management with a multidisciplinary team.
Two means of treating GVHD have been found effective: extracorporeal photopheresis and
psoralen and ultraviolet A (PUVA) irradiation therapy.
Extracorporeal photopheresis involves removing the blood from the body and then treating
it with a combination of ultraviolet light and certain drugs that become active on exposure to
light. Once the blood has been treated, it is then returned to the body of the patient. PUVA
therapy is a photodynamic therapy that is used to treat GVHD specifically affecting the
skin. During PUVA therapy, the patient will receive the drug psoralen, which becomes
activated in the presence of light, either by mouth or by applying it to the skin. The
patient then undergoes ultraviolet A radiation.

Veno-Occlusive Disease

Veno-occlusive disease (VOD) is a potentially serious liver problem caused by high doses
of chemotherapy or radiation given to the individual before transplant. The blood vessels
carrying blood to the liver become swollen or obstructed, impairing the liver's ability to
remove toxins, drugs, and other waste products from the bloodstream. Fluid accumulates
in the liver, causing swelling and tenderness of the liver. The nutrition intervention for VOD
is to limit fluid intake to maintenance level or less. Patients with VOD may require
aggressive fluid restriction to prevent a buildup of fluid that could cause respiratory and
renal complications. The symptoms of VOD are noted in the first 4 weeks after the
conditioning regimen.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
VOD is referred to as "sinusoidal obstruction syndrome" specifically for cases resulting
from chemotherapy or bone marrow transplantation.

Renal Complications

Patients may have preexisting renal dysfunction from their underlying disease and/or
previous therapy.
High-dose chemotherapy and radiation administered in the preparative regimen also
may directly cause renal damage.
Rapid cytolysis of tumor and normal marrow can cause tumor lysis syndrome with
renal injury resulting from hyperphosphatemia.
Post-transplantation infections can lead to acute renal dysfunction because they may
be accompanied by hypotension and renal hypoperfusion.
Antimicrobials used for prophylaxis and treatment of infections are also commonly
nephrotoxic.
A patient with renal dysfunction may require reduced volume of fluid, decreased
amount of protein or amino acids, or adjustment in electrolytes. During renal
dysfunction, parenteral nutrition is usually concentrated to maximum concentration to
provide maximum energy with restricted volume.

Mucositis

Mucositis is common in hematopoietic stem cell transplant (HSCT) patients. Mucositis is a
painful inflammation and ulceration of the mucous membranes lining the digestive tract. It
occurs as a result of the conditioning regimen of chemotherapy, radiation, and/or total body
irradiation. Mucositis reduces an individual’s ability to eat and drink adequately. Pain
medications manage mucositis; intravenous infusions may be necessary to prevent
dehydration and malnutrition. Oral glutamine supplementation has been shown to
decrease mucositis severity in children undergoing HSCT (Aquino, 2005).

Infection

The risk for bacterial, viral, and fungal infections are high in hematopoietic stem cell
transplant (HSCT) patients, as the conditioning regimen destroys normal hematopoiesis for
neutrophils, monocytes, and macrophages. The most critical time period is the 2 to 4
weeks after the transplant because of the individual's depleted immune system. Complete
recovery of immune function may take up to several months for autologous transplant
patients and 1 to 2 years for allogeneic or syngeneic transplant patients.
Common side effects of infection include diarrhea, nausea, and vomiting. Food safety
guidelines are recommended during this post-transplant period. Typically, a low-bacteria
meal plan may be indicated during this period. If the patient on antibiotic medication shows
symptoms of decreased production of lactase, a low-lactose meal plan may be
needed. Probiotics such as Lactobacillus can also be administered to modify the enteric
flora. However, limited evidence exists on the safety or efficacy of a direct influence on the
immune system and the outcome of HSCT patients (Thompson, 2008).

Pancreatic Insufficiency
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Pancreatic insufficiency occurs when the pancreas does not secrete enough digestive
enzymes for normal digestion to occur.
Pancreatic insufficiency can be caused by high doses of chemotherapy or radiation given to
the patient before transplant. In severe cases, malabsorption may occur, resulting in
deficiencies of essential nutrients and loose, fatty stools (steatorrhea). Abnormal values for
coefficient of fat absorption values are below 85% for infants and below 93% for older
patients and can be used to define steatorrhea (Ramsey, 1992).
An easier and more effective method for determining maldigestion and malabsorption
resulting from pancreatic insufficiency is a fecal elastase test. This test is a much more
sensitive method of determining pancreatic insufficiency and the need for pancreatic
enzyme replacement therapy than a fecal fat test.

Hemorrhagic Cystitis

Hemorrhagic cystitis is diffuse inflammation of the bladder leading to dysuria, hematuria,
and hemorrhage.
Hemorrhagic cystitis occurs in patients undergoing hematopoietic stem cell transplant as a
result of the conditioning regimen of chemotherapy (eg, cyclophosphamide, methotrexate),
radiation, or increased infection. Fluid intake and output need to be monitored in patients
with hemorrhagic cystitis. Fluid intake may need to be increased.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diseases/Conditions > Transplantation > Hematopoietic Stem Cell Transplant > General
Information
Overview

Hematopoietic stem cell transplant (HSCT) is used to treat individuals with leukemia,
myelodysplastic syndrome, non-Hodgkin’s lymphoma, Hodgkin's disease, severe aplastic
anemia, thalassemia, sickle-cell disease, metabolic disorders, and immune deficiency
disorders. The purpose of HSCT is to replace an individual’s diseased or nonfunctional
bone marrow with healthy stem cells from a donor. Stem cells in the bone marrow produce
the body's blood cells throughout a lifetime (red blood cells [erythrocytes], white blood cells
[leukocytes], and platelets).
There are two types of HSCT: allogeneic HSCT and autologous HSCT. Some patients
may also receive only partial infusions of additional cells or infusion of natural killer cells.
An allogeneic HSCT means that another person is donating stem cells for the affected
patient. The donor may be a family member such as a father, mother, or sibling or a
matched unrelated donor. Stem cells may come from the bone marrow or stem cells of the
donor or from the umbilical cord. Before the new stem cells are given, the patient must first
undergo a conditioning regimen to prepare the marrow for the transplant. The conditioning
or preparative regimen may last from 7 to 10 days, depending on the disease being treated
and the protocol. The regimen may consist of chemotherapy, radiation, and/or total body
irradiation. The conditioning regimen destroys the patient’s bone marrow and malignant
cells and makes room for the new bone marrow to develop. The new bone marrow will
eventually replace the patient’s immune system. Side effects of the conditioning regimen
include nausea, emesis, diarrhea, taste alterations, mucositis, and overall malaise. These
side effects decrease an individual’s ability to eat adequately. Throughout conditioning and
in the posttransplant period, medications, including antinausea and pain medications, can
be given to diminish the side effects.
The patient's dietary intake is closely monitored during the conditioning period. In some
patients, a nutrient analysis may be used to determine the need for nutrition support, which
can be initiated before stem cell infusion or after. Enteral nutrition is preferred over
parenteral nutrition (PN). PN is used when conditioning side effects such as severe
mucositis and uncontrollable nausea and vomiting does not allow for enteral nutrition.
One or two days following completion of the conditioning or preparative regimen, the
infusion of stem cells or marrow occurs. The stem cells are infused into the individual
intravenously through the central venous line. Individuals are closely monitored for signs of
fever, chills, hives, and chest pain while the infusion is occurring. The most critical time
period is the 2 to 4 weeks after the transplant because of the individual's depleted immune
system. The individual will be more susceptible to bacterial and viral infections. Food safety
guidelines are recommended during this posttransplant period. In some hospitals, a
low-bacteria diet (LBD) is indicated during this time period because of the decreased ability
to fight infection (refer to Meal Plans). The benefit of following a LBD instead of just food
safety protocols is not supported by research in developing countries. However, if LBD is
indicated, the individual should remain on the diet for the duration of the
immunosuppressive therapy because of the weakened immune system and development
of T cells.
If the individual is still receiving immunosuppressive therapy such as steroids or
cyclosporine or has graft-versus-host disease, he or she will need to follow the doctor’s
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cyclosporine or has graft-versus-host disease, he or she will need to follow the doctor’s
directions as to how long he or she should remain on the diet.
An autologous HSCT is when the individual is both the donor and the recipient of purged
bone marrow. Autologous transplants may be beneficial for individuals with high-risk
disorders such as Hodgkin’s disease, non-Hodgkin’s lymphoma, acute myelogenous
leukemia, medulloblastoma, pineoblastoma, neuroblastoma, Wilms’ tumor, retinoblastoma,
osteosarcoma, and Ewing sarcoma.
Before undergoing high-dose chemotherapy and/or radiation, stem cells are collected or
harvested from the individual. These cells are cryopreserved until the time of
transplant. The procedure for harvesting stem cells is called stem cell apheresis. Special
medications called growth factors are usually administered before the harvest to mobilize
the stem cells from the bone marrow into the circulating blood. Sometimes sufficient cells
can not be collected via this method and a bone marrow harvest is necessary. A bone
marrow harvest is a surgical procedure, extracting bone marrow from the hip bone with a
needle syringe. The harvested bone marrow is cryopreserved until the day of transplantation.
The preparative or conditioning regimen can be radiation or high-dose chemotherapy that
is administered to the individual during the 5-to 10-day period immediately preceding the
autologous transplant. The types of chemotherapy given depend on the protocol and the
disease.
Common chemotherapeutic agents:
vincristine
cisplatin
busulfan
carboplatin
melphalan
etoposide
topotecan
cyclophosphamide


Disease Process

Disease process differs by diagnosis (reason for transplantation), type of transplant
(allogeneic or autologous), treatments, and by individual complications or side effects of
treatment.

Biochemical and Nutrient Issues

The biochemical and hematological data will analyze blood glucose levels and lipid profiles
and sometimes visceral proteins, hemoglobin, hematocrit, and lymphocyte count although
these last four indicators listed are not often used because of their tendency to be falsely
high or falsely low as a result of dehydration or chemotherapy rather than malnutrition.
Many medications used for supportive care during transplant have nutrient interactions
worthy of attention when implementing nutrition care. Antimicrobials are often nephrotoxic
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
with effects on electrolyte and mineral balance. Immunosuppressives may have many
nutrition-related side effects. Many drugs commonly used to treat other symptoms during
transplant may have drug-nutrient or drug-drug interactions as well and should be
considered when examining nutrient requirements.

Antimicrobials Frequently Used in HSCT: Drug-Nutrient Interactions
Antibacterial Agents Frequently Used in Hematopoietic Stem Cell Transplant (HSCT)
Drug Nutritional Implications
Vancomycin Nausea
Cefepime Dyspepsia, diarrhea, nausea, vomiting, pseudomembranous colitis
Meropenem Nausea, vomiting, diarrhea, constipation, melena, oral moniliasis
Tobramycin Nausea, vomiting
AzithromycinDiarrhea, nausea, abdominal pain, vomiting, anorexia, oral candidiasis
(Lexi-Comp, 2007)

Antiviral Agents Frequently Used in HSCT
Drug Nutritional Implications
Acyclovir Nausea, vomiting, diarrhea
GanciclovirNausea, vomiting, diarrhea, pancreatitis
Foscarnet Hypocalcemia, hypomagnesemia, hypokalemia, weight loss, nausea, diarrhea,
vomiting, anorexia, constipation, colitis, dysphagia
Cidofovir Metabolic acidosis, hyperglycemia, hyperlipidemia, hypocalcemia, hypokalemia,
dehydration, hypomagnesemia, hyponatremia, hypophosphatemia, nausea,
vomiting, diarrhea, anorexia, abdominal pain, constipation, colitis, dysphagia
(Lexi-Comp, 2007)

Antifungal Agents Frequently Used in HSCT
Drug Nutritional Implication(s)
Micafungin Nausea, vomiting, diarrhea, abdominal pain
Voriconazole Hypokalemia, hypomagnesemia, nausea, vomiting, diarrhea, abdominal
pain, anorexia, constipation, mucositis, dysphagia
Posaconazole Hypokalemia, nausea, vomiting, diarrhea, abdominal pain, mucositis,
dyspepsia
Amphotericin
B
Hypokalemia, bilirubinemia, hypomagnesemia, hyperglycemia,
hypocalcemia, hyperphosphatemia, nausea, vomiting, diarrhea, abdominal
pain
Fluconazole Hypokalemia, hypercholesterolemia, hypertriglyceridemia, nausea,
abdominal pain, vomiting, diarrhea, dysguesia
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Lexi-Comp, 2007)

Drug-Nutrient Interactions of Immunosuppressive Agents Commonly Used in
Preventing or Treating GVHD
Drug Nutritional Implications
Cyclosporine
(CSA)
Hypomagnesemia, hyperkalemia, hyperglycemia, hypertriglyceridemia,
nausea, abdominal pain, vomiting, diarrhea, dysgeusia
Tacrolimus Similar to CSA, greater incidence of hyperglycemia
Siroliumus Hyperlipidemia, hypokalemia, diarrhea; avoid grapefruit juice
Methotrexate Mucositis, esophagitis, elevated liver function test
Mycophenolate Diarrhea, constipation, nausea, dyspepsia, hypercholesterolemia,
hypophosphatemia, hypokalemia
Corticosteroids Hyperglycemia, hypokalemia, increased appetite, dyspepsia,
hypertension, edema; long-term therapy associated with muscle
catabolism, osteoporosis, growth suppression
Rituximab Hyperglycemia, nausea, vomiting, abdominal pain, diarrhea
(Chan, 2002; Lexi-Comp, 2007)

Allogeneic HSCT
The complications following allogeneic HSCT are graft failure, GVHD, organ damage from
chemotherapy toxicity, and infection in the neutropenic and follow-up phases. The risk for
bacterial, viral, and fungal infection secondary to immunosuppression is high. Therefore, it
is very important for the individual to follow a low-bacteria diet and safe
eating guidelines during the conditioning period and after transplant, until instructed to
discontinue them post-allogeneic HSCT (usually at least 100 days posttransplant). Refer to
Meal Plans for these diet guidelines.

Nutritional Implications
During chemotherapy, radiation and HSCT patients can experience any or all of the
following side effects:
Nausea
Vomiting
Mouth sores
Constipation
Altered taste
Loss of appetite
Any of these side effects could result in undesirable weight loss. For more information on
management of treatment-related nutritional complications, see the Nutrition Intervention
section. In addition, as mentioned above, this patient population is at increased risk for
GVHD and veno-occlusive disease (VOD). If an individual develops GVHD, he or she can
experience any or all of the following side effects:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dry mouth
Decreased secretion of saliva, making swallowing difficult
Difficulty eating acidic foods because of burning and discomfort
GVHD may also cause a lack of glands that lubricate the stomach and intestines, which
interferes with the body's ability to properly absorb nutrients from foods. Other symptoms
may include heartburn, stomach pain, nausea, diarrhea, vomiting, and malabsorption of
macronutrients from food and weight loss. Patients with GVHD often require
immunosuppressive medications such as cyclosporine, mycophenolate, and
steroids. Dietary guidelines are to follow a low-bacteria, lactose-free, low-fat, and/or
GVHD bland diet. View the Meal Plans area for samples of low-bacteria and GVHD diet.

A patient with VOD may experience any or all of the following symptoms:
Jaundice
Enlarged liver
Pain and tenderness in the area of the liver
Rapid weight gain
Edema
Accumulation of fluid in the abdominal cavity (ascites)
The nutritional intervention for VOD is to limit fluid intake to maintenance level or less.
These patients may require aggressive fluid restriction to prevent a buildup of fluid that may
cause respiratory and renal complications. This may compromise energy intake for a short
time. Parenteral nutrition is usually concentrated to maximum concentration to provide
maximum energy with restricted volume.

Autologous HSCT
Nutritional Implications
During chemotherapy and after autologous HSCT, patients can experience any or all of the
following side effects:
Nausea
Vomiting
Mouth sores
Constipation
Altered taste
Loss of appetite
Any of these complications can result in undesirable weight loss. For more information on
the management of treatment-related complications, visit the Nutrition Intervention
section. There is essentially no risk of GVHD and a decreased risk of infections with
autologous HSCT as compared to an allogeneic HSCT. Autologous HSCT patients rarely
develop lymphocytic gastritis ("pseudo"-GVHD). For those patients who are unable to
maintain their body weight with oral intake and oral supplements, appetite stimulants are
often used. Enteral nutrition can be used either proactively before HSCT or after attempts
to increase oral intake of energy and protein have failed, a patient experiences excessive
nausea and vomiting, and/or a patient has lost an excessive amount of weight.
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Diseases/Conditions > Weight Management
Weight Management


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Diseases/Conditions > Weight Management > Overweight/Obesity
Overview

The prevalence of pediatric obesity is increasing at alarming rates; since 1980, it has tripled
in children and adolescents, aged 6 to 19 years. According to data from the National Health
and Nutrition Examination Survey 2003-2006, a significant percentage of all Americans
aged 2 to 19 years is overweight and obese with higher prevalence rates in non-Hispanic
blacks and Mexican Americans, as shown in the table that follows (Ogden 2010):
Prevalence of Overweight (Body Mass Index >85th Percentile) Among US Children
and Adolescents
Age (yrs) All (%)
Non-Hispanic
White (%)
Non-Hispanic Black (%) Hispanic (%)
2-5 21.2 17.4 26.0 27.7
6-11 35.5 34.5 37.6 41.7
12-19 34.2 31.3 39.5 44.1
In 2007, the Expert Committee Recommendations Regarding the Prevention, Assessment
and Treatment of Child and Adolescent Overweight and Obesity: Summary Report (Barlow,
2007)—a consensus document using evidence to recommend strategies for the
prevention, identification, and treatment of pediatric overweight and obesity—was
published.
The Pediatric Weight Management (PWM) Guidelines of the Evidence Analysis Library
(EAL, 2007) also were published in 2007. While the Evidence Analysis Library is an
ADA member benefit, links to PWM evidence-based guidelines that are publicly available
are listed below:
Pediatric Weight Management (PWM) Major Recommendations
Overview
PWM: Comprehensive Multicomponent Weight Management Program for Treating
Childhood Obesity
PWM: Obesity in Children Ages 2-5
Assessment
PWM: Assessing Foods and Pediatric Overweight
PWM: Assessing Child and Family Diet Behaviors in Pediatric Obesity
PWM: Assessing Physical Activity and Sedentary Behaviors
PWM: Determination of Total Energy Expenditure
PWM: Assessing Family Climate Factors
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Intervention:
Nutrition Prescription
PWM: Nutrition Prescription in the Treatment of Pediatric Obesity
Energy Restriction
PWM: Energy Restricted Diets
Altered Macronutrient Diets
PWM: Reduced Glycemic Load Diet
PWM: Very Low Carbohydrate Diet
PWM: Using Protein Sparing Modified Fast Diets for Pediatric Weight Loss
PWM: Very Low Fat Diet (<20% Daily Energy Intake from Fat)
Nutrition Education
PWM: Nutrition Education in the Treatment of Pediatric Obesity
Nutrition Counseling
PWM: Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Obesity in
Children and Adolescents
PWM: Family Participation in Treating Pediatric Obesity in Children and Adolescents
PWM: Nutrition Counseling: Setting Weight Goals with Patient and Family
Coordination of Nutrition Care
PWM: Coordination of Care in Pediatric Weight Management
Physical Activity and Inactivity
PWM: Decreasing Sedentary Behaviors in Children and Adolescents
PWM: Physical Activity in the Treatment of Childhood and Adolescent Obesity
Adjunct Therapies
PWM: Adjunct Therapies: Use of Weight Loss Medications in Treating Obesity in
Adolescents
PWM: Adjunct Therapies: Weight Loss Surgery and Adolescent Obesity
Treatment Format Options
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PWM: Treatment Format Options: Group vs. Individual Intervention
Monitoring and Evaluation
PWM: Optimal Length of Weight Management Therapy in Children and Adolescents


Disease Process

Pediatric overweight and obesity can affect all of the organ systems of the human body
especially the endocrine, gastrointestinal, pulmonary, cardiovascular, renal, orthopedic,
and nuerologic systems. Obesity in children and adolescents has been linked to
psychosocial consequences and discrimination as well (Richardson, 1961; Gortmaker,
1993).

Biochemical and Nutrient Issues

Pediatric obesity can elevate serum lipid levels (Srinivasan, 2004), hepatic functions
(Patton, 2006), and blood pressure (Freedman, 2001). It also can impair glucose tolerance
(Weiss, 2004) and renal function (Adelman, 2001). Severely overweight children and
adolescents can develop type 2 diabetes mellitus (Fagot-Campagna, 2000); sleep apnea
(Wing, 2003); and orthopedic complications, such as Blount's disease (Dietz ,1982) or
slipped capital femoral epiphysis (Manoff, 2005). Obesity in children and adolescents has
been linked to psychosocial consequences and discrimination as well (Richardson, 1961;
Gortmaker, 1993). Polycystic ovary syndrome, occurring in adolescent females with
oligomenorrhea or amenorrhea, is associated with obesity in this population.
Cardiovascular risk factors, especially elevated blood pressure and lipid abnormalities, are
frequently present with overweight and obesity. Disorders of lipid metabolism can be
identified by laboratory results of fasting serum lipid profiles based on recommendations
from the Report of the Expert Panel on Blood Cholesterol Levels in Children and
Adolescents of the National Cholesterol Education Program (NCEP, 1991), the American
Academy of Pediatrics (Daniels, 2008), and norms from the Lipid Research Clinics
Population Studies Data Book (NHLBI, 1980). The National Heart, Lung, and Blood
Institute has made available pediatric blood pressure tables based on age, sex, and height
percentiles for use in screening, diagnosing, and treating elevated blood pressure and
hypertension (NIH, 2004).
Food intake may have a role in the development of overweight and obesity when it meets
the following criteria (EAL, 2007):
Increased total dietary fat intake
Increased intake of calorically sweetened beverages
A dietary factor that may be associated with a decrease in the risk of overweight is an
increased intake of fruits and vegetables (EAL, 2007).
Dietary factors that may or may not be related to the development of pediatric overweight
include the following:
Reported total energy intake
100% fruit juice intake
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Observational research indicates that an inadequate intake of dairy and calcium may be
related to an increase in the risk of pediatric overweight (EAL, 2007).

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Diseases/Conditions > Weight Management > Underweight
Overview

Despite the growing burden of overweight issues (Centers for Disease Control and
Prevention, 2009) and the trend for dietary guidelines to focus well beyond nutrient
under-consumption (Nicklas, 2008), concerns regarding underweight remain integral to a
thorough discussion of weight management.
In fact, many of the etiologies attributed to overweight also underlie underweight problems,
but differ in the child’s response to the causal factor (Wachs, 2008). Parents and children
with underweight problems deal with negative social stigma, family power struggles,
miscommunications, problems in balancing physical activity with oral intake, and
frustrations in making food choices, just as parents and children with overweight problems.
Many etiologies cause underweight. No matter the cause, underweight in the early years
may result in overweight problems later in childhood (Plagemann, 2008; Caballero, 2006).
For this reason, underweight children require ongoing growth monitoring for years beyond
normalization of their growth.


Disease Process

Etiologies of underweight status include:
Gastrointestinal disturbances
Food allergies and intolerances
Inflammatory bowel processes
Irritable bowel syndrome
Cancer
Reflux
Celiac disease
Malabsorption
Hypermetabolic states
Pulmonary compromise (cystic fibrosis)
Spastic cerebral palsy
Chronic infection or disease
Other diagnoses
Congenital heart disease
HIV/AIDS
Metabolic or chromosomal abnormalities
Oral intolerances
Sucking problems
Swallowing problems
Texture hypersensitivity
Severe dental caries
Emotional concerns
“Picky" eating
Restrictive eating
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Anorexia nervosa
Fear (of specific foods, textures, or smells), or “neophobia”
Individual characteristics and family dynamics
Temperament interferences or differences between child and adult (eg, miscues
for hunger and satiety signals, depression or anxiety of caregiver, mood
instability interrupting perception of hunger cues, or negative temperament in
the child)
Distractions
Anxiety associated with meal times
Taste differences between child and adult
Compromised food supply due to caregiver inabilities or practices, lack of food
resources, unsafe food, lack of food preparation equipment, or lack of healthy
and accepted foods
Anorexia and appetite suppression
ADD/ADHD medications
Cancer treatment
Post organ-transplant
Bipolar disorder
Medication side effects
Anorexia and appetite suppression
ADD/ADHD medications
Cancer treatment
Post-organ transplant
Bipolar disorder
Check other medications for side effects in the presence any of the following
symptoms which may reduce interest in or ability to consume food:
Nausea
Upset stomach
Swollen gums
Mouth sores
Constipation


Biochemical and Nutrient Issues

An underweight child is at risk for malnutrition. If a nutrition assessment reveals the
likelihood of the presence of nutrient deficiencies, the appropriate work-up is indicated.
Nutrient analyses can reveal deficiencies in macro- or micronutrients, in addition to caloric
deficiencies. Depending on preparation time available, an analysis can be conducted using
a food diary completed ahead of time or a dietary recall conducted during a nutrition
assessment. Technologies chosen to analyze the nutrient intake range from specialized
software or on-line resources to manual calculations based on exchanges or specific
nutrient information.
Biochemical analysis of blood and urine (Leonberg, 2008) can reveal protein, electrolyte,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Biochemical analysis of blood and urine (Leonberg, 2008) can reveal protein, electrolyte,
vitamin, and mineral deficiencies associated with underweight and malnutrition. (Refer to
Laboratory section.)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care home page
Welcome to the Nutrition Care home page.
All the information in this section of the site deals directly with specific nutrition care
recommendations for the various diseases and conditions listed in the left-hand navigation.
These recommendations follow the Nutrition Care Process for assessment, diagnosis,
intervention, and monitoring & evaluation. Some diseases and conditions include subtopics
to help you find more specific recommendations for your clients' individual situations.
NOTE: The Nutrition Diagnosis, and some Nutrition Intervention headings, offer examples
of nutrition diagnoses and related interventions from the International Dietetics and
Nutrition Terminology (IDNT) Reference Manual. These diagnoses and sample PES
statements are intended as samples only and are NOT intended to be the definitive
or final list of diagnoses that may apply to children with a specific disease or
condition. The Nutrition Care Process should be applied on an individual basis and should
take into account all aspects of a client's condition and situation. For more information,
see Nutrition Care Process under the Resources tab.
Click on your topic of interest for more information.
Nutrition Care > Nutrition Care > Nutrition Assessment > Comparative Standards
Comparative Standards

See Parenteral Nutrition Nutrient Requirements and Enteral Nutrition Nutrient Requirements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Nutrition Care > Nutrition Assessment > Intake Assessment
Intake Assessment

Data Collection
To assess dietary intake, review the medical record or nursing flow sheets to determine
nutrient sources—parenteral nutrition (PN); intravenous solutions; human milk; human milk
fortifier; infant formula; and vitamin, mineral, or other modular supplements.
Data Analysis
The dietary intake assessment should include both qualitative and quantitative analyses.
In the qualitative analysis, consider whether current nutrient solutions are appropriate
for the patient’s gestational age, size, tolerance issues (if any), and diagnoses.
In the quantitative analysis, calculate nutrient intakes (at least mL/kg/day, kcal/kg/day,
and grams of protein/kg/day).
PN calculations (including dextrose, crystalline amino acids, and intravenous fat
grams per kilogram per day) are done in the same way for infants as they are for
other populations.
Dextrose and/or electrolytes in intravenous drip medications often contribute
substantially to an infant’s intake and are calculated.
Occasionally, even medication flushes influence the small infant’s glucose or
electrolyte status.
A more detailed, targeted nutrient intake analysis may be done on intakes of
infants with certain diagnoses or conditions (eg, assessing calcium, phosphorus,
and vitamin D intake for infants with osteopenia).
Calculating Nutrient Intakes
Calculations of nutrient intakes are compared with recommended intakes (see Parenteral
Nutrition and Enteral Nutrition for recommendations) and interpreted in light of the baby’s
medical condition and growth. Following is an example of how to calculate nutrient intake.
Sample Nutrient Intake Calculation for 1,500-g Preterm Infant
Intake
Maternal milk fortified to 24 kcal/fl oz with human milk fortifier, taking 28 mL every 3 hours
Calculations
28 mL × 8 feedings/day = 224 mL/d ÷ 1.5 kg = 149 mL/kg/d
149 mL/kg/d × 0.8 kcal/mL
a
= 119 kcal/kg/d
149 mL/kg/d × 0.024 g protein/mL
a
= 3.6 g protein/kg/d
a
For most precise calculations, consult the specific manufacturer’s literature.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Nutrition Care > Nutrition Assessment > Nutrition > Focused Physical
Findings
Nutrition-Focused Physical Findings

Observe the infant’s general condition, bedside nursing documentation, feeding tolerance,
and medical status. Additional information on physical observations is included under the
following headings.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Nutrition Care > Nutrition Monitoring & Evaluation
Nutrition Monitoring & Evaluation

The purpose of nutrition monitoring and evaluation in neonatal intensive care units,
intermediate neonatal care units, normal newborn nurseries, newborn follow-up clinics, or
pediatricians’ offices is to assess progress toward nutrition goals and expected
outcomes. Goals and expected outcomes are defined by reference standards or an
improvement in nutrition care indicators and may be categorized using the nutrition
assessment terminology categories as follows:
Food/Nutrition-Related History Outcomes (FH)
Food and Nutrient Intake (1)
Food and Nutrient Administration (2)
Breastfeeding (7.1)
Anthropometric Measurement Outcomes (AD)
Length
Weight
Weight change
Growth pattern indices/percentile ranks for corrected age for prematurity
Head circumference
Weight-for-age
Length-for-age
Head circumference-for-age
Weight-for-length
Bone density and bone age
Biochemical Data, Medical Tests and Procedure Outcomes (BD)
Laboratory data
Electrolyte
Essential fatty acid
Gastrointestinal measures
Glucose
Mineral
Nutritional anemia
Protein
Vitamin profiles
Nutrition-Focused Physical Finding Outcomes (PD)
Overall appearance
Extremities, muscles, bones
Digestive system
Skin
Vital signs
Critical thinking is necessary when completing the following step of the nutrition care
process*:
Select the appropriate indicators or measures to monitor and evaluate the impact of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition intervention on the patient’s/client’s progress toward defined goals.
Examples include the following:
Grams per day weight gain
Grams per kilogram per day protein intake
Serum alkaline phosphatase level
Use current and age-specific/disease-specific reference standards for comparison.
Examples include the following:
120 kcal/kg/d and 4 g protein/kg/day for infants 0.9 kg to 1.2 kg (Ziegler, 2007)
400 mcg zinc/kg/day parenteral zinc requirement for preterm infants (Tsang,
2005)
Define progress toward goals in terms of expected outcomes. Examples include the
following:
Increase in head circumference of 0.6 cm/week compared with standard 0.9
cm/week (Moyer-Mileur, 2007).
Compared to a norm of less than 550 IU/L, and a previous level of 850 IU/L,
alkaline phosphatase is now 750 IU/L after mineral intake was increased.
Explain any variance from expected outcomes. Examples include the following:
Increase in head circumference is less than expected, which may be related to
use of steroid medication
Less than expected weight gain, which may be related to temperature instability
during weaning from isolette to open crib
Identify factors that enhance or impede progress and ways to address these factors.
Examples include the following:
Frequent episodes of vomiting are impeding progress toward full enteral
feedings; giving gavage feedings over longer duration(eg, over 60 minutes
instead of 10 minutes) may prevent vomiting and allow continued progression to
full enteral feedings
Interrupting parenteral nutrition for antibiotic administration is preventing
adequate parenteral nutrition intake; increase parenteral nutrition hourly rate
during the 20 hours of parenteral nutrition administration to accommodate 4
hours of antibiotic infusion
Identify when follow-up will occur, or if nutrition care can be discontinued. Examples
include the following:
Follow-up in 5 days
Nutrition goals are met; no nutrition care follow-up is necessary at this time
*Adapted from Pocket Guide for International Dietetics & Nutrition Terminology Reference
Manual. 3rd edition. Chicago, IL: American Dietetic Association; 2011: 314.

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Nutrition Care > Anemia
Anemia


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Anemia > Iron Deficiency Anemia
Nutrition-Focused Physical Findings

Iron-deficiency anemia is the last manifestation of chronic, long-term iron deficiency. The
symptoms reflect a malfunction of a variety of body systems. Inadequate muscle function is
reflected in decreased work performance and exercise tolerance.
Neurologic involvement is manifested by behavioral changes, such as fatigue; anorexia;
and pica, especially pagophagia (ice eating). Abnormal cognitive development in children
suggests the presence of iron deficiency before it has developed into overt anemia (Nokes,
1998; Pollitt, 1986). Growth abnormalities, epithelial disorders, and a reduction in gastric
acidity are common. A possible sign of early iron deficiency is reduced
immunocompetence, particularly defects in cell-mediated immunity and the phagocytic
activity of neutrophils, which may lead to an increased propensity for infection.
As iron-deficiency anemia becomes more severe, defects arise in the structure and
function of the epithelial tissues, especially of the tongue, nails, mouth, and stomach. The
skin may appear pale, and the inside of the lower eyelid may be light pink instead of red.
Fingernails can become thin and flat, and eventually koilonychia (spoon-shaped nails) may
be noted. Mouth changes include atrophy of the lingual papillae; burning; redness; and, in
severe cases, a completely smooth, waxy, and glistening appearance to the tongue
(glossitis). Angular stomatitis and a form of dysphagia (difficulty swallowing) may occur.
Gastritis occurs frequently and may result in achlorhydria. Progressive, untreated anemia
results in cardiovascular and respiratory changes that can eventually lead to cardiac failure.

Some behavioral symptoms of iron deficiency seem to respond to iron therapy before the
anemia is cured, suggesting they may be the result of tissue depletion of iron-containing
enzymes rather than the result of a decreased level of hemoglobin.
Because physical signs may not appear until stage III negative iron balance or stage IV
iron-deficiency anemia (see Disease Process), it is important to screen those individuals
who are at risk. The signs and symptoms of negative iron balance and iron-deficiency
anemia may include the following:
Fatigue
Decreased concentration
Slow cognitive and social development in children
Difficulty maintaining body temperature
Decreased immune function, which increases susceptibility to bruising and infection
Glossitis (inflamed tongue)
Pallor
Weakness
Dyspnea
Palpitations
Sensitivity to cold
Loss of appetite


Biochemical Data, Medical Tests and Procedures
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No single laboratory test is diagnostic of iron-deficiency anemia. Rather, a detailed client
history and/or carefully chosen laboratory panel should be used to determine whether a
child has iron-deficiency anemia. Hemoglobin and hematocrit are used both for screening
and diagnosis of anemia (PNPG, 2003), but a low hemoglobin or hematocrit value is not
specific for iron-deficiency anemia. For infants younger than 6 months, laboratory tests for
iron status must be interpreted with caution; normal hematopoietic changes occur and
hemoglobin falls and serum ferritin increases.
Anemia is defined as a hemoglobin concentration 2 standard deviations below the mean
for a healthy reference population of the same age and sex. However, this provides an
incomplete picture of iron status. For diagnosis of iron deficiency in a child with a
low hemoglobin concentration, serum ferritin and c-reactive protein or reticulocyte
hemoglobin concentration provide discriminatory information. Serum ferritin measures iron
stores but may be falsely elevated during inflammation. The hemoglobin reticulocyte
concentration indicates iron availability in newly produced erythrocytes and is a good
predictor of development of iron-deficiency anemia (Baker, 2010).
Iron deficiency in children with positive screen for anemia via low hemoglobin or hematocrit
can also be diagnosed based on the child’s response to treatment. An increase in
hemoglobin of 1 g/dL or increase of hematocrit of 3% or more 1 month after initiation of oral
iron treatment indicates that iron deficiency was present (AAP, 2009).

Laboratory

Iron-deficiency anemia is best diagnosed by a panel of laboratory tests; no single test will
characterize a child's iron status. Anemia is defined as a hemoglobin concentration 2
standard deviations below the mean for age and sex, but this is not sensitive or specific for
iron-deficiency anemia (Baker 2010).
Laboratory tests to consider in assessment of iron status are presented in the following
table (Carley, 2003; AAP, 2009; Baker 2010).

Laboratory Tests to Consider for Assessment of Iron Status
Usual
Abbreviation
Function Direction
of Effect
on Iron
Deficiency
Red Blood
Cell Count
RBC Number of RBCs
per volume blood
Decreased
Hemoglobin Hb Hemoglobin per
unit blood
Decreased
Hematocrit Hct % RBCs per
volume blood
Decreased
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Mean Corpuscular
Volume
MCV Average RBC
size; used to
classify anemias
as macrocytic,
normocytic, or
microcytic
Decreased
Mean Corpuscular
Hemoglobin
MCH Average amount
of hemoglobin
per RBC
Decreased
Mean Corpuscular
Hemoglobin
Concentration
MCHC Average
concentration of
hemoglobin in
RBC
May be
decreased
with
reduced
Hb
Reticulocyte
Hemoglobin
Concentration
CHr Hemoglobin
content of
reticulocytes
Decreased
Absolute
Reticulocyte Count
Rct (abs) Number of
immature RBCs
per volume blood
Decreased
Reticulocyte Count
(%)
Rct (%) (Number of
reticulocytes
/number of
RBCs) X 100 per
volume blood
Decreased
Red Cell
Distribution Width
RDW Variation in RBC
size
Increased
Serum Ferritin Ferritin Measurement of
iron stores,
proportional to
liver ferritin
Decreased
Zinc-Protoporphyrin
to Heme Ratio
ZnPP/H Proportion of
zinc to iron
incorporated into
porphyrin IX
during heme
synthesis
Increased
Soluble Transferrin
Receptor
sTfR Receptors for
transferrin-bound
iron produced by
iron-deficient
cells
Increased
Serum iron Iron Blood iron level Decreased
Total Iron-Binding
Capacity
TIBC Availability of
proteins to bind
free iron
Increased
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Transferrin
Saturation
sTf Ratio of serum
iron to TIBC x
100
Decreased
Blood Lead Level Lead Blood lead level Iron
deficiency
may
increase
risk of
lead
poisoning
Some laboratory measures for iron status vary with age. Hemoglobin and hematocrit are
higher at birth, fall during the first few weeks of life, and then climb to adult levels (AAP,
2009). Similarly, the zinc protoporphyrin to heme ratio is higher in newborns than in older
children and adults (Soldin, 2003). The child’s age, medical diagnosis, and diet history may
affect choice and interpretation of laboratory parameters.
For diagnosis of iron deficiency anemia in children with a low hemoglobin concentration
(<2 standard deviations below the mean), measurement of serum ferritin and c-reactive
protein or measurement of the reticulocyte hemoglobin concentration are discriminatory for
iron deficiency. Serum ferritin may be falsely elevated in inflammation. The reticulocyte
hemoglobin concentration is a less common test, but it is a good predictor of development
of iron deficiency (Baker 2010).
Lead poisoning is an independent cause of microcytic, hypochromic anemia. Iron
deficiency may increase risk of lead poisoning, whereas good iron status may be protective
against lead poisoning. In the United States, lead is typically encountered in the peeling
paint in older houses. In developing countries, it may also be found in leaded gasoline and
industrial pollution. Children living in older, urban areas in the United States and children
living in (or who have just moved from) developing countries are at increased risk for lead
poisoning (Kwong, 2004).

Food/Nutrition-Related History

A food history can be obtained in a number of ways. When evaluating a child with
iron-deficiency anemia, it is important to assess iron intake and the overall adequacy of the
child's food intake pattern.
Exclusively breastfed term infants and term infants receiving more than half of their intake
as breast milk should receive an iron supplement of 1 mg/kg/day beginning at 4 months of
age until iron-rich complementary foods are introduced (Baker 2010).
Signs that may indicate poor iron intake include the following:
Before 1 year of age:
Intake of cow’s milk or low-iron infant formula
Exclusive breastfeeding without iron supplementation after 4 months of age
Low intake of of iron-containing foods without iron supplementation after 4 months of
age
After 1 year of age:
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After 1 year of age:
Low intake of meats, vitamin C, or iron-fortified foods
Medical conditions that may affect iron intake, absorption, or needs, such as the
following:
Feeding or swallowing problems
Chronic diarrhea
Picky eating/restrictive food intake
High intake of cow's milk
Food insecurity
The Centers for Disease Control and Prevention recommend that an infants aged 12 to 24
months should not consume more than 24 oz cow's milk each day; after 2 years of age,
daily intake of 16 oz is sufficient. Increased intake of cow's milk can replace intake
of iron-containing foods; cow’s milk is not a good source of iron (Lozoff, 2007; CDC, 1998).



Comparative Standards

To determine whether an individual child’s iron intake meets his or her needs, iron intake
can be calculated and compared to the Dietary Reference Intake (DRI) for age. Iron
content of foods can be obtained from tables or using a computerized dietary analysis
program.

The appropriateness of the DRI for a child should be evaluated on an individual basis; for
treatment of iron-deficiency anemia, a child may need more iron than the
DRI recommendation. An infant or child who has received multiple transfusions may not
need supplemental iron.
DRIs for Iron Based on Age
Age Iron (mg/day)
Infant 0-6 mo 0.27 (AI)
Infant 7-12 mo 11
Child 1-3 yr 7
Child 4-8 yr 10
Child 9-13 yr 8
Male 14-18 yr 11
Female 14-18 yr 15
Pregnancy ≤18 yr 27
Lactation ≤18 yr 10
(IOM, 2001)
Fluid Needs or Limits
Fluid needs of children with iron-deficiency anemia do not differ from those of healthy
children. Fluid needs may be estimated based on body size or energy expenditure using
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
standard methods.

Nutrition Diagnosis

Dietitians working with patients who have iron-deficiency anemia should review the signs
and symptoms obtained in the nutrition assessment and use them as the basis to diagnose
nutrition problems. Nutrition diagnoses may include, among others, the following:
Inadequate protein intake (NI-5.7.1)
Inadequate vitamin intake (specify) (NI-5.9.1)
Inadequate mineral intake (specify) (NI-5.10.1)
Sample Problem, Etiology, Signs and Symptoms (PES) or Nutrition Diagnostic
Statements
Inadequate vitamin intake (vitamin C) (NI-5.9.1) related to reduced availability
of citrus fruits as evidenced by consumption of two citrus fruit servings per week.
Inadequate mineral intake (iron) (NI-5.10.1) related to dislike of iron-containing foods
as evidenced by history of avoiding meat and other sources of heme iron.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology (3rd ed). Code numbers are inserted to
assist in finding more information about the diagnoses, and their etiologies, signs, and
symptoms. Dietitians should not include these numbers in routine clinical documentation.


Nutrition Intervention

The nutrition intervention will vary depending on the type of anemia, medical diagnosis,
nutrition diagnosis, and dietary intake. Nutrition interventions in the domains of Food and
Nutrient Delivery, Nutrition Education, Nutrition Counseling, and Coordination of Nutrition
Care may be appropriate.
Dietary Reference Intakes
Dietary Reference Intakes (DRI) have been established for iron. The Adequate Intake (AI)
has been set for infants younger than 6 months of age; Recommended Dietary Allowances
(RDA) have been established for older infants and children (IOM, 2001). A DRI has not yet
been established for preterm infants. The RDA is based on absorption rate of 10% and
assumes the body has some iron stores (AAP, 2009).
Dietary Reference Intakes for Iron Based on Age
Age Iron (mg/day)
Infant 0-6 mo 0.27 (AI)
Infant 7-12 mo 11
Child 1-3 yr 7
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Child 4-8 yr 10
Child 9-13 yr 8
Male 14-18 yr 11
Female 14-18 yr 15
Pregnancy ≤18 yr 27
Lactation ≤18 yr 10
(IOM, 2001)
Avoidance of Iron-Deficiency Anemia: Recommendations for Preterm and Term
Infants
Iron stores are difficult to asses in infants younger than 6 months, as stores are used
for growth and iron parameters are in flux during this time. The DRI assumes the
infant has accrued adequate stores before birth to last until 4 to 6 months of age.
Premature infants (less than 37 weeks' gestation at birth) fed human milk should
receive 2 mg/kg/day supplemental iron beginning by 1 month through 12 months of
age
Exclusively breastfed term infants should receive supplemental iron of 1 mg/kg/day
by 4 months of age until iron-rich complementary foods are introduced (Baker, 2010).
Low-iron infant formulas should not be used in healthy infants (AAP, 2009).
Formula-fed preterm infants should receive 2 mg/kg/day to 4 mg/kg/day of iron by 1
month of age. For an infant drinking 150 mL/kg/day, infant formula typically provides
1.8 mg/kg/day of iron. Thus, an additional 1 mg/kg/day of supplemental iron (as a
liquid preparation) may be needed (AAP, 2009).
Diagnosis and Treatment of Iron-Deficiency Anemia in Children
For a child with anemia (defined as hemoglobin concentration 2 standard deviations below
the healthy population mean for age and sex), serum ferritin and c-reactive protein or
reticulocyte hemoglobin concentration can be used to better determine whether a child has
iron deficiency (Baker, 2010).
Children Younger Than 3 Years (AAP, 2009)
Confirm anemia based on hemoglobin or hematocrit with a second laboratory
measurement. If low, treat with 3 mg/kg/day of oral elemental iron for 4 weeks.
Repeat the hemoglobin or hematocrit measure after 4 weeks of supplementation. A
hemoglobin increase of at least 1 g/dL or hematocrit increase of at least 3% indicates
iron-deficiency anemia. If deficient, continue treatment for 2 months and recheck.
Check hemoglobin or hematocrit again 6 months after treatment.
If no increase in hematocrit is seen after 4 weeks of iron treatment and the child does
not have an illness that would depress these measures (such as diarrhea, an ear
infection, or an upper respiratory tract infection), follow up with further laboratory tests
A low mean corpuscular volume (MCV) (<70 fL) and low red blood cell (RBC)
count (<4.0 x 10
12
/L ) may indicate iron deficiency
Low MCV (<70 fL) and high RBC count (>4.8 x 10
12
/L) may indicate hereditary
anemia such as thalassemia
Seurm ferritin <15 mcg/L confirms iron deficiency. If serum ferritin is >15 mcg/L,
it is likely the anemia is not the result of iron deficiency
School-Aged Children (AAP, 2009)
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Iron deficiency is rare in school-aged children.
For children with anemia diagnosed by low hematocrit or hemoglobin, supplement
with oral elemental iron for 4 weeks; if no increase in hemoglobin or hematocrit is
detected, further laboratory tests should be performed (same as for younger children).
Special Considerations
Vegetarian Children
Good sources of iron for vegetarian children include the following (PNPG, 2003):
Whole or enriched grains and grain products
Iron-fortified cereal
Legumes
Green, leafy vegetables
Blackstrap molasses
Dried fruit
Consuming vitamin C with these foods will improve absorption. Iron bioavailability is
approximately 10% from a vegetarian diet and 18% from nonvegetarian diet.
Postpartum and Lactating Adolescents (PNPG, 2003)
Iron may be depleted postpartum—a vitamin/mineral supplement or iron
supplementation should be prescribed if iron deficiency is documented by laboratory
measures
Milk iron concentrations in lactating mothers are not significantly affected by maternal
iron intake

Nutrition Therapy Efficacy

If the cause of the anemia is iron deficiency, replacement of iron should result in improved
iron status. In this case, although the nutrition therapy is expected to produce the desired
effect, long-term consequences of iron deficiency during development may not be reversed
(AAP, 2009; Lozoff, 2007; Lozoff, 2000; Lozoff, 2006a; Peirano, 2007).

Goal Setting

The goal of iron intake is to achieve optimal iron status. Specific goals must be tailored to
meet the needs of the individual child and family.

Please see the Nutrition Intervention and Overview for recommendations.

Oral Intake

Iron should be supplemented if the child is deficient.
An iron-rich diet with supplements can be followed
Iron absorption varies with form of supplement
Iron absorption from supplements is highest on an empty stomach
Iron supplements may cause constipation, diarrhea, or upset stomach; this can be
minimized by taking supplements with food
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An iron-rich food intake pattern is recommended for children at risk for iron deficiency
and those who have iron-deficiency anemia or increased iron needs (PNPG, 2003).
Iron-Rich Food Pattern (PNPG 2003)
Include one iron-rich food and one food to promote iron absorption at most meals and
snacks.
Introduce an iron-rich food (such as iron-fortified rice cereal) at age 4 to 6 months for
most infants.
In addition to pairing vitamin C with iron-rich foods, combining heme and nonheme
foods at the same meal or including foods with citric acid or cysteine may improve
absorption. Bile acids also improve absorption of nonheme iron.
Cooking in iron or stainless steel cookware may increase the amount of bioavailable
iron in foods.
Most dietary iron sources are meat based. Careful planning is required for developing
an iron-rich diet without meat sources.
Foods that hinder iron absorption include the following:
Coffee
Tea
Whole grains
Bran
Soy products
Other high-fiber foods
Serve these foods apart from meals that include iron-rich foods to maximize absorption.

Enteral or Tube Feeding

Enteral intake should meet nutrient requirements and provide adequate energy for growth
as appropriate. Enteral feeding requirements are not different from the Dietary Reference
Intake (DRI), other than to note that a child requiring enteral feeds may have a medical
diagnosis that affects nutrition needs or nutrient delivery.
DRIs for Iron Based on Age
Age Iron (mg/day)
Infant 0-6 mo 0.27 (AI)
Infant 7-12 mo 11
Child 1-3 yr 7
Child 4-8 yr 10
Child 9-13 yr 8
Male 14-18 yr 11
Female 14-18 yr 15
Pregnancy ≤18 yr 27
Lactation ≤18 yr 10

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(IOM, 2001)
Preterm infants fed human milk should receive 2 mg/kg/day to 4 mg/kg/day supplemental
iron by 1 month through 12 months of age (Baker, 2010). Formula-fed preterm infants
should receive 2 mg/kg/day to 4 mg/kg/day. Only iron-fortified infant formulas should be
used for term and preterm infants (AAP, 2009). Preterm infants receiving multiple
transfusions may not require supplemental iron (Baker, 2010).

Parenteral Nutrition

Parenteral Iron
Use of parenteral iron is a subject of ongoing research. It should be used with caution, and
only when oral iron supplementation is not possible or effective (Greene, 1988; Kumpf,
2003).

As early as 1966, parenteral iron has been associated with fatal anaphylaxis (Becker,
1966). Iron dextran is available for iron-deficient patients who are unable to receive oral
iron, but a test dose should be provided before administration; the US Food and Drug
Administration (FDA) recommends that resuscitation equipment and practitioners trained to
identify anaphylactic reactions be present during infusion (FDA, 2009).
Follow the FDA recommendations for provision of a test dose of iron dextran.
Parenteral Iron Recommendations (PNPG, 2003; Kumpf, 1996; Kumpf, 2003).
Use parenteral iron only when clearly indicated and patient is not responsive to oral
iron therapy.
Use enteral iron whenever possible.
Use iron dextran only in growing children with serum ferritin less than 12 mcg/L
Intramuscular injections should not be used in patients with low muscle mass.
Regulation of parenteral iron supplementation by the body is not possible; therefore,
the risk of iron overload is greater than with enteral supplementation.
Candidates for parenteral iron supplementation have iron-deficiency anemia and are
unable to tolerate or absorb oral iron. These individuals may have short bowel
syndrome, Crohn’s disease, radiation enteritis, and other diseases of the small bowel.
Parenteral Iron Requirements (Kumpf, 1996; PNPG, 2003)
Parenteral iron may be used to either replace iron because of blood loss or to replete
iron stores in the patient with iron-deficiency anemia.
Low iron caused by blood loss: Replace iron lost due to blood loss
Low iron caused by iron-deficiency anemia: Provide iron to bring hemoglobin to
desired level and replete stores
Follow package instructions for dosage calculation and administration
Parenteral iron requirements are estimated to be 0.1 mg/kg/day to 1.0 mg/kg/day
intravenous iron
The usual dose for infants and children is 0.1 mg/kg/day intravenous iron; needs may
increase with exclusive total parenteral nutrition for longer than 2 months
The oral Dietary Reference Intake for iron is based on a 10% absorption rate; thus,
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The oral Dietary Reference Intake for iron is based on a 10% absorption rate; thus,
parenteral recommendations are 10% of the enteral recommendations


Nutrition Monitoring & Evaluation

Nutrition monitoring and evaluation are key steps in the Nutrition Care Process. Nutrition
care outcomes, which are markers for the dietitian to focus on, have been defined.
Outcomes are affected directly by nutrition care and are measureable.
The four outcomes are as follows:
Food/nutrition-related history
Food and nutrient intake
Medication and herbal supplement intake
Knowledge/beliefs
Access to food and food/nutrition-related supplies
Physical activity and function
Nutrition quality of life
Anthropometric measurements
Biochemical data, medical tests, and procedures
Nutrition-focused physical findings
Any outcome may be applied to anemia, depending on the type of anemia, medical
diagnosis, and intervention chosen by the dietitian and health care team. An appropriate
outcome choice for a child who has iron-deficiency anemia might be "intake inconsistent
with estimated, or measured, or recommended needs,” as the dietitian helps the child
increase consumption of iron-rich foods. If iron is supplied as a supplement, the an
outcome under the heading of “medication and herbal supplement intake” might be an
appropriate choice for monitoring. For a child showing clinical signs of anemia, such as
pallor or fatigue, an outcome under the “nutrition-focused physical findings” heading may
be an appropriate choice to monitor. The outcome measurement most appropriate for the
situation should be chosen.
The nutrition monitoring step for a child with anemia would vary, depending on the needs of
the particular client and family. It might include constructing a 24-hour food recall with a
patient, education on high-iron foods and consumption of foods containing iron and vitamin
C at the same meal, or assessment of the patient's comprehension of the nutrition
intervention. The measuring step might include calculation of a patient’s iron intake. In the
evaluation step, the nutritional indicator is compared to a standard. For the child with
anemia, this might include comparing the child’s iron intake to the Dietary Reference
Intakes.

Nutrition Care FAQs

What foods are high in iron?
Iron is best absorbed into our bodies from “heme” iron sources—that is, iron from animal
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sources, especially meats. Good choices to improve iron status are beef and chicken. Pork
and fish are also good choices, although they are lower in iron.
Iron is also found in plants, but it is more difficult for the body to use the iron in plants.
Good sources of iron from plants include dried beans (such as kidney beans or navy
beans) and dried fruits.
How can I improve iron absorption?
There are two good ways to improve iron absorption.
Eat heme iron and plant-based iron sources together, for example, pork with a sauce
of dried cranberries or a burrito that contains both beef and beans. The heme iron will
help your body absorb the nonheme iron from plants.
Eat foods high in vitamin C at the same time as iron-rich foods, such as beef and
broccoli at the same meal or orange juice with an iron-fortified breakfast cereal.

Nutrition Prescription

The nutrition prescription should indicate the patient’s recommended energy intake and
any additional specific recommendations as appropriate (ADA, 2009). For a child with
iron-deficiency anemia, the nutrition prescription may include specific recommendations
about iron supplementation or iron-rich foods.
Nutrition intervention should always be individualized to meet the needs of a particular
infant or child. Special cases—such as premature infants, children with special health care
needs, and infants and children with feeding difficulties—require careful assessment and
individualized recommendations.

Client History

The pertinent client history should be collected as part of the nutrition assessment and may
include the following:
Age
Anthropometrics
Weight for height
Body mass index for age
Prior diagnosis and evidence of anemia
Any current/past anemia treatment
Food intake pattern with focus on iron-rich foods
Medical conditions that may affect iron intake, absorption, or needs, such as the
following:
Feeding or swallowing problems
Chronic diarrhea
Heavy menstrual flow in adolescent females
Client history that may indicate poor iron intake may include the following:
Poverty
Food insecurity
Picky eating/restrictive diet
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High intake of cow’s milk in infants/toddlers
Intake of cow’s milk or low-iron infant formula before 12 months of age
Vegetarian/restricted meat food pattern

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Anemia > Sickle Cell Disease
Nutrition-Focused Physical Findings

Children with sickle cell disease (SCD) have distinct physical characteristics, including the following (Gee, 1994; Henderson, 1994; Modebe, 1993;
Serjeant, 2001; Barden, 2002):
Frequently shorter in stature than other children their age
Delayed onset of puberty and appear to be younger than their actual age.
As adults, individuals with sickle cell disease have the following traits:
Abnormal physical build with long limbs
Decrease in the upper-to-lower body segment ratio
Yellow sclera caused by excess bilirubin from chronic hemolysis
In addition, individuals with sickle cell disease have the following traits:
Increased anterior-to-posterior chest diameter
Narrow pectoral and pelvic girdles
Thinner-looking appearance
Thinner skinfolds and reduced body fat

Laboratory

Although many nutrients are deficient in sickle cell disease, laboratory indices are not always helpful in defining the deficiencies. For example, zinc
has been shown to be beneficial for growth in sickle cell disease (SCD), yet plasma zinc levels in these patients are usually normal (Fung, 2002).
Magnesium supplementation in sickle cell patients has been shown to reduce the number of pain episodes (DeFranceschi, 1997). However,
extracellular magnesium represents only approximately 1% of total body magnesium and appears to be homeostatically regulated (Groff, 2009).
Normal serum values may be found despite severe intracellular deficit. Therefore, serum magnesium is of limited use in determining magnesium
status. However, if a low serum magnesium value is present, magnesium deficiency is a certainty.
Sickle cell patients have been found to have deficiencies in several vitamins that do have reliable laboratory indices. Serum vitamin A has been found
to be low in SCD. Serum retinol level can be used as an initial screen. If it is low, it should be followed by a modified, oral relative dose response
test (Feranchak, 2005) to confirm existence of vitamin A deficiency. Leukocyte vitamin C levels are a sensitive index of vitamin C status. Serum
25-hydroxyvitamin D is a reliable marker of vitamin D status. Vitamin E status can be evaluated by measuring serum vitamin E concentration and
total serum lipids, then calculating the ratio of serum vitamin E in milligrams to total serum lipids in grams (Groff, 2009). Riboflavin can be assessed by
measurement of erythrocyte glutathione reductase activity (Groff, 2009). Vitamin B-6 is assessed by measurement of serum pyridoxal 5-phosphate
concentration.
It should be noted (see Biochemical and Nutrient Issue) that the growth hormone IGF (insulin-like growth factor)-1 requires zinc to function. For this
reason, a patient's zinc status needs to be optimized before growth hormone treatment begins. IGF-1 levels can respond to zinc supplementation
(Ninh, 1996). Plasma zinc levels are not always indicative of true zinc status (Fung, 2002). It is possible for patients to have a "functional" deficiency
of zinc if growth improves with modest supplementation while serum zinc remains normal.
The most basic laboratory value for sickle cell nutrition assessment is the average hemoglobin concentration (Brown, 1994). The patients with the
lowest hemoglobin levels most frequently are the patients who have the most growth deficits. Hemoglobin is also used in the calculation of resting
energy expenditure developed for sickle cell patients (Williams, 2002).
The multisystem nature of SCD guarantees that numerous abnormalities in common laboratory tests are often present. These abnormalities need to
be understood in the context of hemoglobin genotype, age, and sex. Laboratory values beyond the expected abnormal range may signify accelerated
organ damage or a new disease complication.
Sickle Cell Disease Laboratory Test Results
Hemoglobin
Type
Hematocrit Hemoglobin
White
Blood
Cell
Count
Reticulocyte
Count
Platelets
Mean
Corpuscular
Volume
Bilirubin Creatinine Zinc
Homozygous
sickle cell
disease
Decreased Decreased Increased
Increased;
decreases
with age
Increased
Normal or
increased
Increased Decreased
Decreased
or normal*
Sickle
cell-hemoglobin
C disease
Mildly
decreased
Normal Normal Normal Normal
Normal or
decreased
Increased Decreased Not studied
Sickle cell Bo
thalassemia
Decreased Decreased Increased
Increased;
descreases
with age
Increased
Normal or
increased
Increased Decreased **
Sickle cell B+
thalassemia
Mildly
decreased
Normal Normal Normal Normal
Normal or
decreased
Increased Decreased **
Steinberg, 1994
*Normal value not indicative of adequate zinc status (Fung, 2002).
**
Although not studied in sickle-beta thalassemia, zinc is deficient in SCD and in thalassemia (Nasr, 2002, Bekheirnia, 2004), so evaluation of zinc
status seems warranted in these patients.


Client History

Growth history
Problem list
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History of surgeries/procedures
Social history
Hemoglobin and presence of anemia
Presence of vitamin levels

Food/Nutrition-Related History

Although vitamin D needs to be monitored in all sickle cell patients, those who avoid milk are at higher risk for deficiency. Likewise, zinc deficiency is
prevalent but individuals with a low intake of meat are at higher risk and likely to need supplementation. A patient with sickle cell disease who has low
antioxidant intake may benefit from antioxidant vitamin supplementation.
Fluid Needs or Limits
It is especially important for people with sickle cell disease (SCD) to stay hydrated because dehydration can precipitate a pain crisis. Dehydration can
occur for a number of reasons, including the following:
Diarrhea
Severe vomiting
Excessive sweating
Inadequate fluid intake
Water is the best fluid to drink, but adequate water can be obtained from other good sources, such as the following:
Milk
Juice
Soup
Sport drinks
Popsicles
Fruits
Vegetables
Patients with SCD should avoid or limit their intake of drinks that contain caffeine (cola beverages, coffee), alcohol, or methylxanthine (tea), because
these agents promote excretion of water as urine, which contributes to dehydration.
Following is a guideline for how much fluid patients with SCD should drink each day. Remember, this list includes water from other sources such as
milk, juice, soup, fruits, and vegetables.
Fluid Recommendations for Persons with Sickle Cell Disease
Body Weight (pounds) Daily Recommendations (8-oz Servings/Day)
10-24 2-3
25-29 4-6
30-44 5-8
45-54 6-9
55-75 7-10
75-99 8-11
100-129 9-13
130-149 10-15
150-174 11-17
>175 12-18
Source: Clinical Practice Guidelines 2002
Fluid needs may increase during periods of fever, exercise, hot weather, and pain crisis, so patients should drink the highest recommended amount
during these times.
Symptoms of Dehydration
Mild to moderate dehydration:
Dry mouth
Few or no tears when crying
Fussy behavior in infants
Fewer than 6 wet diapers/day in an infant (>4 hours without a wet diaper in an infant younger than 6 months)
No urination for 6 to 8 hours in children
Fontanel (the soft spot on the top of an infant’s head) looks flatter than usual or somewhat sunken
Despite dehydration, the patient still has a strong pulse and normal heart rate (especially in an older child)
Severe dehydration:
Very dry mouth (looks "sticky" inside)
Dry, wrinkled, or doughy skin (especially on the abdomen, upper arms, and legs)
Inactivity or decreased alertness
Appearance of weakness or limpness
Sunken eyes
Sunken fontanel in an infant
Excessive sleepiness or disorientation
Muscle cramps
Deep, rapid breathing
No urination for several hours (more than 6 hours in infants, more than 8 hours in children)
Fast or weakened pulse

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Comparative Standards

Because hemoglobin is the oxygen-carrying component of blood, anemia leads to increased cardiac output as a compensatory mechanism of the
body to provide more oxygen to body tissues. Increased cardiac output increases resting energy expenditure (REE), so anemia leads to increased
REE. The use of hemoglobin as a variable in the following modified energy equations allows for a more accurate prediction of the energy needs in
sickle cell disease (Williams 2002).
REE Calculation for Children with Sickle Cell Disease
Modified Harris-Benedict Equation (kcal/day)
Boys Girls
Modified REE = (66.5 + [13.75 × weight in kg] + [5 ×
height in cm] – [6.76 × age in years]) × (1.3278 –
[0.0242 × Hgb])
Modified REE = (655 + [9.56 × weight in kg] + [1.85 ×
height in cm] – [4.68 × age in years]) × (1.3595 –
[0.0242 × Hgb])
Modified World Health Organization Equation (kcal/day)
Boys Girls
Age 3-10 years:
Modified REE = (22.7 × weight in kg+ 495) × (1.3074
– 0.0309 × Hgb)

Modified REE = (22.5 × weight in kg + 499) × (1.4775
– 0.0309 × Hgb)
Age 10-18 years:
Modified REE = (17.5 × weight in kg + 651) × (1.3074
– 0.0309 × Hgb)

Modified REE = (12.2 × weight in kg + 746) × (1.4775
– 0.0309 × Hgb)
(Williams 2002)
REE Calculation for Adolescents with Sickle Cell Disease
Boys Girls
U.S.
REE (kcal/d) = 1305 + 18.6 × weight (kg) – 55.7 ×
Hgb (g/dL)
REE (kcal/d) = 1100 + 13.3 × weight (kg) – 30.2 ×
Hgb (g/dL)
E.U.
REE (kj/d) = 5461 + 77.7 × weight (kg) – 233.2 ×
Hgb (g/dL)
REE (kj/d) = 4603 + 55.6 × weight (kg) – 126.2 ×
Hgb (g/dL)
(Buchowski 2002)

Nutrition Diagnosis

Dietitians working with patients who have sickle cell disease should review the signs and symptoms obtained in the nutrition assessment and
diagnose nutrition problems based on these signs and symptoms. Nutrition diagnoses from the list below as well as other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate oral intake (NI-2.1)
Inadequate protein intake (NI-5.7.1)
Inadequate mineral intake (specify) (NI.5.10.1)
Inadequate vitamin intake (specify) (NI.5.9.1)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to pain crisis as evidenced by food recall.
Note: Terminology in the examples above is from the American Dietetic Association's International Dietetics and Nutrition Terminology, 3rd edition.
Code numbers are inserted to assist in finding more information about the diagnoses, their etiologies and signs and symptoms. Dietitians should not
include these numbers in routine clinical documentation.



Nutrition Intervention

Nutrition intervention in SCD is typically requested for growth issues. Hospitalization is seldom a good time for educational intervention since pain is
severe, and pain treatment can make the patient somnolent. Intake is usually poor during hospitalization until pain is resolved, so it is not a good time
to try out nutritional supplements. If the patients have received several days of narcotic analgesia, it is prudent to have a bowel regimen ordered.
This can be overlooked during pain crises.
One study (Fuggle 1996) has indicated that sickle cell pain occurs on average once every 14 days. Vaso-occlusive pain can be debilitating, and this
study found there was a sevenfold increased risk of not attending school, thereby disrupting social and recreational activities. Among the activities
disrupted is eating. Jacob (2006) evaluated 27 children aged 5 to 19 years who were hospitalized for vaso-occlusive pain. The pain started on
average 4.5 days before admission and mean length of hospital stay was 5.9 days. Children reported that severe pain decreased only by 5% during
the course of hospitalization, which the authors attributed to suboptimal pain management.
Since it is known that sickle cell pain episodes may increase energy expenditure, decrease the amount of food intake, and lead to an energy deficit
(Modebe 1993; Fung, 2002), hospitalization is likely a significant contributor to poor nutritional status in this population. In the Jacob study (2006), the
mean score for the amount of eating on a scale of 0–10 was 2.6, corresponding to "ate a little bit." Intervention during hospitalizations does not
typically include nutrition support. Patients hospitalized for vaso-occlusive pain are usually quite somnolent from pain medications until ready for
discharge. Nutrition intervention typically takes place in the outpatient setting in follow-up visits.
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Nutrition Intervention codes based on the earlier sample diagnoses and PES statement could include the following (IDNT, 2011):
General/healthful diet (ND-1.1)
Modify distribution, type, or amount of food and nutrients within meals or at a specified time (ND-1.2)
Commercial beverage supplement (ND-3.1.1)
Multivitamin/mineral supplement (ND-3.2.1)
Vitamin supplement (ND-3.2.3)
Mineral supplement (ND-3.2.4)
Nutrition relationship to health/disease (E-1.4)
Recommended modifications (E-1.5)
Motivational interviewing (C-2.1)


Nutrition Therapy Efficacy

The nutrition therapy should provide at least 120% to 150% of both the Estimated Energy Expenditure and Recommended Dietary Allowance for
energy and protein. This nutrition therapy supplies all the Dietary Reference Intakes if sufficient foods from all of the food groups are eaten.
In a study of 62 children with homozygous sickle cell disease (SCD), where intake and growth were evaluated over 4 years, patients had overall poor
growth evidenced by negative z-scores for height, weight, and body mass index (Kawchak 2007). Intake of vitamins D and E, folate, calcium, and
fiber was suboptimal. In the study, 63% to 85% of the children fell below the estimated average requirement or Adequate Intakes. There was a decline
in protein and micronutrients as the children aged, so that by adolescence, intakes of protein, vitamin C, riboflavin, vitamin B-12, and magnesium
were significantly lower in the oldest children, showing a drop of Recommended Dietary Allowances of 28%, 80%, 40%, 57%, and 73%, respectively.
Because SCD patients may require more than the Dietary Reference Intakes of many nutrients (see Biochemical and nutrient issues), and there is a
dropoff in micronutrient adequacy of many nutrients during the school-age years, patients need regular follow-up for nutrition assessment during
childhood and adolescence. Kawchak and colleagues (2007) recommended "Children with SCD-SS may benefit from comprehensive treatment
incorporating nutrition and food-related behavior support to improve nutritional status."
In another study, patients with SCD were evaluated to determine food habits in relation to the Food Guide Pyramid (now called MyPlate). Two-thirds
of the patients ate the recommended servings from the meat group; 20% to 31% of the recommended servings from each of the other food groups was
consumed. Homozygous sickle cell patients ate significantly less from the bread and milk categories than the sickle cell hemoglobin-C patients.
Among families participating in this study, 59% had incomes below poverty level and 79% participated in a food assistance program (Williams,
1997).
Therefore, the following is recommended for effective nutrition therapy:
Patients who have SCD should know how much fluid to drink and what specific fluids are or are not recommended.
The nutrition care plan should outline all of the patient’s nutrition needs while providing details of the specific nutrition intervention required,
instruction materials for the patient, follow-up monitoring, and evaluation.
If the patient has problems or conditions besides SCD that require nutrition intervention, these should be addressed as well.


Goal Setting

Patients who have sickle cell disease should know how much fluid to drink and what specific fluids are or are not recommended (see Food and
Feeding Issues).
The nutrition care plan should outline all of the patient’s nutrition needs while providing details of the specific nutrition therapy required,
instructional materials for the patient, follow-up monitoring, and evaluation.
If the patient has problems or conditions besides sickle cell disease that require nutrition therapy, these should be addressed as well.

Food & Feeding Issues

There are several reports of increased pica behavior in individuals with sickle cell disease (SCD); reference information for these studies can be
found in Ivascu (2001). Other concerns about chronic eating patterns and frequent hospitalization issues in SCD are discussed under the Nutrition
Intervention heading.
Fluids
It is especially important for people with sickle cell disease (SCD) to stay hydrated because dehydration can precipitate a pain crisis. Dehydration can
occur for a number of reasons, including:
Diarrhea
Severe vomiting
Excessive sweating
Inadequate fluid intake
Water is the best fluid to drink. Other fluids are also good sources from which to obtain adequate water, such as the following:
Milk
Juice
Soup
Sport drinks
Popsicles
Fruits
Vegetables
Patients with SCD should avoid or limit their intake of drinks that contain caffeine (cola beverages, coffee), alcohol, or methylxanthine (tea), because
these agents promote excretion of water as urine, which contributes to dehydration.
Below is a guideline to how much fluid to drink each day. Remember, this list includes water from other sources such as milk, juice, soup, fruits, and
vegetables.
Fluid Recommendations for Persons with Sickle Cell Disease
Body
Weight
Daily Recommendations
(Number of 8-oz
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(pounds) Servings/Day)
10-24 2-3
25-29 4-6
30-44 5-8
45-54 6-9
55-75 7-10
75-99 8-11
100-129 9-13
130-149 10-15
150-174 11-17
>175 12-18
Source: Clinical Practice Guidelines. Memphis, Tenn: St. Jude Children's Research Hospital Clinical Nutrition Services; 2002.
Fluid needs may increase during periods of fever, exercise, hot weather, and pain crisis, so patients should drink the highest recommended amount
during these times.
Symptoms of dehydration
Mild to moderate dehydration:
Dry mouth
Few or no tears when crying
Fussy behavior in infants
Fewer than 6 wet diapers/day in an infant (>4 hours without a wet diaper in an infant younger than 6 months of age)
No urination for 6 to 8 hours in children
Fontanel (the soft spot on the top of an infant’s head) looks flatter than usual or somewhat sunken
Despite dehydration, the patient still has a strong pulse and normal heart rate (especially in an older child)
Severe dehydration:
Very dry mouth (looks “sticky” inside)
Dry, wrinkled, or doughy skin (especially on the abdomen, upper arms, and legs)
Inactivity or decreased alertness
Appearance of weakness or limpness
Sunken eyes
Sunken fontanel in an infant
Excessive sleepiness or disorientation
Muscle cramps
Deep, rapid breathing
No urination for several hours (>6 hours in infants; >8 hours in children)
Fast or weakened pulse

Enteral or Tube Feeding

Meeting nutrition needs with regular foods is more cost efficient than using enteral supplements; however, often people cannot increase their food
intake sufficiently to meet nutrition therapy goals and must drink enteral supplements. It also allows feeding to be a normal function and not a
medical treatment. Enteral supplements may be useful in accomplishing or augmenting the nutrition goals and may help avoid the need for more
invasive and costly techniques such as tube feedings. Enteral supplements may be indicated in situations where nutritional requirements are
significantly elevated or altered because of metabolic stress or losses from malabsorption, or when appetite or intake is depressed.
Supplements range from single substrate sources (protein, fat, carbohydrate) to nutritionally complete products, which can vary from simple,
homemade recipes to commercially prepared, ready-to-use formulas. Product recommendations should be based on individual requirements, nutrition
therapy, tolerance, patient preference, clinical symptoms, and socioeconomic considerations. Use of a variety of enteral products may help avoid
taste fatigue and improve adherence.
While patients are taking enteral supplements, tolerance and progress toward nutrition therapy goals should be monitored. In addition, when using
modular supplements, extra precautions must be taken. Consideration should be given to osmotic load and renal solute load when adding
carbohydrate or protein modules. Fat modules can cause delayed gastric emptying.
One study examined nasogastric tube feedings in 5 male patients with sickle cell disease (Heyman 1985). Of the 5 patients in the study, only 2
received tube feedings.
These 2 patients experienced accelerated growth and a reduction in the incidence and severity of complications. A third patient received nightly oral
supplements. Two patients received dietary counseling plus supplemental iron, zinc, folate, and vitamin E. Although there were no benefits seen with
supplementation of these vitamins/minerals, the combination of zinc with iron or zinc with folate is problematic. It is not recommended that zinc be
administered with other mineral supplements (Gropper 2009), and iron is known to interfere with zinc absorption.
Little can be concluded about the mineral supplementation's efficacy in this study. However, tube-fed subjects did respond favorably with improved
growth rate, reduced incidence of infection, and reduced complications. Though growth acceleration was not seen in the patient receiving oral
supplementation, he still did not require admission to the hospital for infection or pain during the period of supplementation. Given the excellent overall
response of the 2 tube-fed patients, the study, although extremely small in size, does raise the question of why tube feedings are rarely used in a
population known to be undernourished.

Nutrition Monitoring & Evaluation

The patient's nutritional status should be monitored and the nutrition care plan modified if necessary, depending on the response to nutrition therapy.
The exact timing of follow-up assessments depend on the nutrition care plan. Patients' nutritional status should be reassessed whenever their
disease condition changes or they start a new medical therapy or treatment regimen. Patients who are not under the care of a dietitian should have
their nutritional status screened every 6 months.
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The decision to initiate a follow-up nutrition intervention should be based on the patient’s original nutrition care plan. If the patient’s nutritional status
is not responding positively (lack of weight gain or additional weight loss) or the patient’s condition has changed significantly, then the nutrition care
plan should be revised.

Nutrition Care FAQs

Question: What is the minimum nutrition therapy target for a high-energy/high-protein nutrition therapy?
Answer: The nutrition therapy should provide enough energy and protein to meet the elevated needs documented in sickle cell disease (SCD), at
least 120% of normal (see Biochemical and Nutrient Issues). At a minimum, based on the studies in this section, energy and protein intakes should
be increased to 120% of normal. This could extend to 150% as needed for failure to thrive.
Question: Why do sickle cell patients need to consume a high-energy/high-protein meal plan?
Answer: Numerous studies measuring energy expenditure and protein turnover in SCD, as well as studies documenting suboptimal intake
(discussed in Biochemical and Nutrient Issues and Nutrition Intervention sections) demonstrate the need for a high-energy and high-protein meal
plan. This nutrition therapy will support them from becoming more malnourished while improving their nutritional status.
Question: How does consuming a high-energy/high-protein meal plan help sickle cell patients improve their nutritional and growth status?
Answer: A high-energy/high-protein meal plan will provide their body with energy and nutrients in excess of their weight-maintenance needs to help
them with weight gain and catch-up growth.
Question: What types of foods contain a high content of energy and protein?
Answer: Nutrient-dense and protein food sources include whole milk and milk products, peanut butter, tree nuts, seeds, red meats, poultry, fish,
eggs, and cheese. High-energy food sources include margarine and butter, mayonnaise, avocado, gravy, oil, coconut, cream, dried fruit, sauces, and
sugar.
Question: What is the actual amount of energy and protein appropriate in the meal plan to give to sickle cell patients?
Answer: A registered dietitian will determine the actual amounts of energy and protein depending on the patient’s age, height, weight, medical
status, and nutrition therapy goals.
Question: Are patients with sickle cell disease at particular risk for deficiencies in certain nutrients?
Answer: There are some nutrients in which these patients frequently are deficient. Increased overall intake of nutrient-dense foods is best, but the
increased requirements may still not be fully addressed. A registered dietitian and physician can best determine if supplements are indicated.


Anthropometrics

Results of anthropometric studies of SCD patients are typical of a population whose nutrition needs are not being met. They have lower z-scores for
the following:
Weight
Height
Arm circumference
Upper arm fat and muscle areas
Bone age in patients with SCD is also delayed. Prepubertal children and pubertal boys with SCD have significantly lower fat mass and all groups have
significantly lower fat-free mass (Barden, 2002; Phebus, 1984). This indicates that children with SCD have the following:
Impaired growth
Delayed puberty
Deficits in fat stores
Muscle wasting
Low protein stores
In one study that separated ethnic groups for analysis, SCD children had similar weight to whites but weighed significantly less than
African/Caribbean controls. The African/Caribbean control group had greater height, weight, and body mass index (BMI) than whites. The SCD
patients had a significantly lower BMI than the African/Caribbean controls, although their BMI was similar to that of whites. This could suggest that
SCD negatively impacts acheiving genetic potential. Of note is that the body proportion ratio—the sitting height divided by the standing height—was
lower in the SCD group than in whites. However, the African/Caribbean control group had lower body proportion ratios than the white group, indicating
that the African/Caribbean ethnic group has lower upper body proportion in general (Patey, 2002).
Although SCD patients are plotted on Centers for Disease Control and Prevention (CDC) growth curves, upper arm and subscapular anthropometry
are best compared using standards for African-American children (Frisancho, 1981).
Patients in the Stroke Prevention Trial for Sickle Cell Anemia Study who received long-term transfusion had improved height, weight, and BMI (Wang,
2005).
A study of 133 sickle cell patients aged 6 to 18 years found that in comparison to CDC norms, males were three times more likely to be underweight
in adolescence, and females were three times more likely to be obese in adolescence. The study also found that the BMI attained in adolescence
could be predicted by sex, average weight in childhood, and the number of emergency department visits (Mitchell, 2009). This was the largest study to
address the rising issue of obesity in a disease where malnutrition has been the prevalent growth concern.
Osteoporosis, according to one study, "may be one of the major public health problems in SCD patients" (Sarrai, 2007). The study observed a 79.6%
prevalence of low bone mineral density (BMD) in a group of 103 SCD patients. The liklihood of developing low BMD decreased with increasing BMI.
The researchers also observed that low hemoglobin levels were the strongest predictor of low BMD in SCD. Other factors associated with low BMD
in SCD were sex (female) and smoking (Sarrai, 2007). Another study found a 72% incidence of low BMD in 32 SCD patients, including 13 with
osteoporosis and 10 with osteopenia. In this study, a higher percentage of men had osteopenia or osteoporosis than women. It was speculated that
this was the result of low testosterone and delayed puberty. The patients with low BMD had low vitamin D and serum zinc levels. Accelerated
hematopoiesis and bone infarction may contribute to low BMD in this population (Miller, 2006).

Metabolic Rate Profile (Indirect Calorimetry)

There have been numerous studies measuring energy expenditure in sickle cell patients using indirect calorimetry. Increased protein turnover and
energy expenditure compensating for a hyperactive marrow in chronic hemolysis is thought to be responsible for a decreased body mass index
(BMI) in sickle cell disease (SCD) (Singhal, 1997; Singhal, 1993; Badaloo, 1989; Borel, 1998; Kopp-Hoolihan, 1999; Salman, 1996; Barden, 2000;
Williams, 2002).
Indirect calorimetry measurements show energy expenditure to be elevated in patients with SCD. Resting energy expenditure (REE) for sickle cell
patients have been measured at 6% to 22% higher than REE measurements for controls. Protein turnover in sickle cell patients was 44% to 100%
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higher than that of controls.

Nutrition Prescription

Patients with sickle cell disease (SCD) need to eat a well-balanced, nutritious meal plan and drink plenty of fluids. If there are other health problems
such as the following, the patient will need to follow a specific nutrition therapy appropriate to these conditions as well:
Weight loss
Poor growth
Constipation
High cholesterol
Diabetes
People with SCD are often shorter and thinner than their healthy peers. There is evidence that people with SCD have protein turnover two times that
of controls (Borel 1998; Badaloo 1989; Salman 1996). In addition, there are reports that people with SCD have deficiencies of the following nutrients:
Magnesium (De Franceschi, 2000)
Zinc (Fung, 2002)
Iron (Stettler, 2001)
Vitamin E (Sindel, 1990)
Vitamin D (Buison, 2004)
Vitamin B-6 (Nelson, 2002)
Vitamins B-6 and B-12, Folate (van der Dijs, 2002)
Riboflavin (Adelekan, 1987)
Vitamin C (Chiu, 1990)
Vitamin A (Kawchak, 1999)
The following resources discuss vitamin deficiency, and several have documented normal intake of the nutrient in question, so that increased
utilization of these nutrients is likely: Schall 2004; Flores 1988; Essien 1995; Chiu 1982; Al-Momen 1995; Leonard 1998.
There are multiple reports documenting poor food intake in children with SCD and another report documenting decreased intake during hospitalization
(Williams 1997; Malinauskis 2000; Jacob 2006; Modebe 1993; Fung 2002). With the average pain crisis occuring every 14 days, according to one
study (Fuggle 1996), it seems prudent to consider nutrient-dense diets for pain-free periods. There is some evidence that people with SCD need
additional folate because of red blood cell turnover. There has been a number of studies documenting increased REE and increased protein turnover
in children, adolescents, and adults with SCD (Badaloo 1989; Buchowski 2002a; Buchowski 2002b; Enwonwu 1990; Kopp-Hoolihan 1999; Salman
1996; Singhal 1993).
These findings, coupled with the short stature and thinness of people with SCD, indicate that a high-energy, high-protein nutrition therapy is warranted
for children with growth issues. However, weight and growth should be monitored as nutrition therapy depends on these measurements. At the very
least, patients should be encouraged to follow a nutritious, balanced meal plan.
The high-energy/high-protein nutrition therapy can be used for people with conditions that have increased needs or to maximize these nutrients in
patients with poor intake (Nevin-Folino 2003; St. Jude Children's Research Hospital 2003) to promote weight gain and/or catch-up growth. It may also
be used to meet increased nutrient needs resulting from acute or chronic illness and/or to optimize a person’s ability to respond to treatment
modalities. The expected outcome is to prevent malnutrition, optimize growth in children, and improve nutritional status.
This nutrition therapy consists of foods that are energy and protein dense. Because fats are often added to increase energy density of foods, the
nutrition therapy often exceeds the recommended maximum of 30% of total energy from fat (see Dietary Guidelines for Americans, 2010). It is
important that unsaturated fats be encouraged, especially to prevent development of cardiovascular disease as an adult. Small, frequent feedings of
energy- and protein-dense foods are encouraged to increase intake. Generally, the nutrition therapy should provide at least 120% to 150% of the
Dietary Reference Intake for energy and protein with consideration for the person’s age, height, weight, medical status, and nutrition goals.

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Nutrition Care > Behavioral Health
Behavioral Health


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Nutrition Care > Behavioral Health > Eating Disorders
Nutrition Assessment

An initial nutrition assessment for a child or adolescent with a diagnosed eating disorder
would include:
Changes in eating habits over time
Rate of weight loss and up-to-date growth charts with historical growth charts and
growth information
History of binging
History of purging including exercise purging, use of diuretics and laxatives and
vomiting
Gastrointestinal function
Hydration status and water and fluid intake daily
Food intolerances, allergies, preferences, restrictions
Other conditions that might require dietary management
Other conditions that affect nutrient requirements (growth, infection)
Drug and/or alcohol use
Anthropometric data-height, weight, BMI, growth
Resting energy expenditure (REE), using indirect calorimetry (REE will change as
feeding a starved individual progresses)
Glucose tolerance
Dietary Assessment/Food history

Another Nutrition Assessment Protocol
Patient and parents/caregivers are all excellent sources of assessing the nutrition status
and behaviors both current and past. When listed as patient/client it implies the inclusion of
families and other caregivers.
Note the date and time of the interview.
Note those present at interview: patient and those present may include parents or
other caregivers.
Growth and health measurements (current and historical): Compare to standardized CDC
growth charts and standardized values:
height
weight-current, lowest and highest at this height
Body mass index
blood pressure
menstrual periods – regularity, absence
laboratory results – i.e. glucose, lipids
Dexa scan
allergies, sensitivities, intolerances
Oral health and dental history:
dental visit/year
number of times patient brushes per day
number of times patient flosses per day
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disease
Sleep patterns:
average number of hours
restful/number of times awake
non sleep hours description - rested/fatigued/energetic
Medical history past and current–physical and psychiatric diagnosis (eg, diabetes,
obsessive-compulsive disorder, gastrointestinal health):
patient/client
parents
siblings
grandparents
Dieting history:
types experienced
period of time – client’s age and duration of diet
success
Current medications or herbal remedies:
prescribed or over the counter
start date
quantity
side effects and interactions
History of feeding as infant/child
Physical signs and symptoms:
hair
skin
nail
eyes
Current and past food/beverage (all types of fluids) intake: assessment includes but is not
limited to:
adequacy
quantity
quality – reduced fat, light version
reason ate/drank
eating speed
meal patterns
place (eg, table, in car, standing) they eat or drink
hunger acknowledgement
Changes in eating and eating behaviors:
rituals – (eg, cutting foods into small pieces)
habits
avoidance
food fears
appetite – reasons for loss/increase
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appetite – reasons for loss/increase
eliminate food groups
change in fluid habits
consumption of non-foods – (eg, gum, pica)
Behavior history
restricting
binging # days per week
purging # days per week
compensatory behaviors (eg, laxatives, diuretics, excessive use of fiber or one food)
caffeine consumption – amount/day
Food intolerances, allergies, preferences, restrictions
cultural, lifestyle, or ethnic factors
compulsiveness
addiction
Behaviors and thinking process - current and changes related to eating disorder. Note: this
type of information may likely be taken by the therapist and so does not need to be
repeated by the dietitian. The RD can discuss with the therapist and use this information to
inform direction of nutrition education with parents, food decisions with family.
understand health condition
perceptions
self esteem
body image
body checking
attitude
self control
obsessions
readiness to change
Environmental
support system
ethnic, cultural beliefs and customs – limitations
socioeconomic
values
access to care
food availability
Physical Activity – current and past
school, home or gym/facility
compulsive
length in minutes/day
intensity
consistency

Nutrition-Focused Physical Findings

Danger Signs
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Anorexia danger signs include
significant weight loss
continual dieting (even though the child is already thin)
feelings of fatness by the child even after weight loss
fear of weight gain
lack of menstrual periods
preoccupation with food, calories, nutrition, and/or cooking
a preference to eat in isolation
compulsive exercise
insomnia
brittle hair or nails
social withdrawal
Other physical signs can include:
blue tone to the skin
coldness (complaints of feeling cold or wearing an extra layer of clothes)
loss of hair
prominent veins on arms and legs
lanugo
unstable vital signs
Bulimia nervosa danger signs include:
uncontrollable eating (binge eating)
purging by self-induced vomiting
vigorous exercise
abuse of laxatives or diuretics (water pills) to lose weight
frequent use of the bathroom after meals
reddened fingers (from inducing vomiting)
swollen cheeks or glands (from induced vomiting)
preoccupation with body weight
depression or mood swings
irregular menstrual periods
dental problems, such as tooth decay, caused by induced vomiting
heartburn and/or bloating

Biochemical Data, Medical Tests and Procedures

The diagnostic tests to determine whether a person has an eating disorder are applied by
those trained in psychiatry and psychology and include, but are not limited to, the Eating
Disorder Examination (EDE) and the Development and Well Being Assessment (DAWBA).
The EDE is the most widely accepted standardized diagnostic tool for eating disorder
identification (House, 2008). Registered dietitians are usually not trained to administer
these tests.
A complete medical history and differential diagnosis by a medical doctor familiar with
eating disorders needs to be done to rule out other causes of weight loss or symptoms. The
differential diagnosis can rule out hyperthyroidism, malignancy, inflammatory bowel
diseases, immunodeficiency, malabsorption, chronic infections, Addison's disease, and
diabetes. A key feature of eating disorders is that most patients who have involuntarily lost
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weight express concern about this while those with an eating disorder display ambivalence
toward their weight loss (Pritts, 2003).
Diagnostic tests for specific nutrient deficiencies include the standard vitamin and mineral
assessments, as well as a complete blood count to screen for anemias. Anemia is often
present in anorexia nervosa due to depletion of folate and/or iron. See the Laboratory
section for comprehensive list of tests often performed to assess degree of malnutrition
and physical compromise.

Laboratory

Lab Values to watch
The lab values listed below are for adolescents and adults. Children younger than age 10
may have different alert levels based on laboratory normal ranges.

Anorexia Nervosa or Bulimia Nervosa
Test
Raised
Concern
Alert/Action
Level
Weight loss per
week
>0.5 kg >1.0 kg
Purpuric rash Present
Systolic blood
pressure
<90 <80
Diastolic blood
pressure
<70 <60
Pulse rate <50 <40
Temperature <35 C <34.5 C
Arrythmia Present
Orthostasis Present
Hemoglobin <11 <9.0
Acute Hb drop Present
Neutrophil count <1.5 x 103 <1.0
White cell count <4.0 x 103 <2.0
Platelets <130 x 103 <110

Electrolytes – mmol/L
Test Raised concern Alert/Action Level
Potassium <3.5 <3.0
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Sodium <135 <130
Magnesium <0.5 – 0.7 <0.5
Phosphate <0.5 – 0.8 <0.5
NOTE: Phosphate levels can be temporarily elevated due to use of laxatives containing
sodium phosphate (can be seen in bulemia nervosa). Elevated phosphate can last 5-6
hours after laxative use. Oral laxative use can elevate blood phosphorus by as much as
1.6 mmol/L 2 to 3 hours after intake.
Liver Function
Test
Raised
Concern
Alert/Action Level
Bilirubin >20 >40
Alkaline
phosphatase
>110 >200
AsT >40 >80
ALT >45 >90
GGT >45 >90
Albumin* <3.5 <3.0
Urine specific
gravity
<1.010
% Body fat
<13% women, <8%
men
This list is adapted from that created by professor Janet Treasure at King's College London
and is used with permission.

Comparative Standards

Use the patient’s actual weight, not their goal weight, to estimate calories at this phase. In
malnourished states such as anorexia nervosa (AN), basal metabolic rate slows and then,
upon refeeding, increases.
Reported resting energy expenditure (REE) in the starved state can be 50 to 70% of the
values obtained using predictive equations such as Harris-Benedict or WHO. These
equations overestimate caloric needs in AN patients, so for programs that want to know
REE for purposes of determining energy needs, indirect calorimetry is the better method
for obtaining REE.
With metabolic recovery, REE increases to well over that predicted by Harris-Benedict or
WHO equations. One study measured REE after refeeding and found values of 120 to
156% of those predicted, indicating a higher calorie need once anabolism was initiated
(Trocki, 1997). Energy intakes of 130% of those predicted should be prescribed, with
values of 3500-4000 kcal/day often necesary for weight gain.
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Practically speaking, many programs simplify operations by feeding a high-calorie diet,
continuing to add calories until weight gain is seen.
In bulimia nervosa and binge-eating disorder, individuals with a history of bulimic symptoms
and a higher body weight before the onset of the illness often need fewer calories for
weight maintenance. REE determination can help with calorie estimates (Salisbury, 1995).
Food intake needs to be normalized.
Use of Body Mass Index (BMI)
Changes in BMI (kg/M
2)
do not always correlate well with changes in adiposity in children,
especially male adolescents and children with low BMI (Demerath, 2006). A BMI of less
than 22.4 is typically too low for a male adolescent.
Other measures of adiposity, such as multisite skinfold measurements or bioelectrical
impedance analysis need to be used in assessment of body fatness, especially since
adiposity is positively correlated with better outcome in anorexia nervosa (Mayer, 2007).
Calculations to Assess Diet
In weight-restored patients with anorexia nervosa, greater dietary energy density and
greater dietary variety, measured by the diet energy density score (DEDS) and diet variety
score (DVS), are associated with better outcome (Schebendach, 2008).
Energy density is defined as caloric intake (in kcal) divided by the total weight (in g) of food
and beverages consumed.
Dietary Variety score is defined as the cumulative number of different foods and beverages
consumed divided by the total number of food record days (see Schebendach, 2008 for
exact methodology).
Fluid Needs or Limits
Issues related to fluids and re-feeding
Refeeding, cessation of laxative and diuretic use, and/or too rapid fluid replacement
can cause a transient peripheral edema.
Weight gain of more than 2 pounds per week is likely due to fluid retention. Usually
this resolves within 10 days.
Patients with anorexia nervosa often manipulate water intake and may drink too much
water to falsely elevate weight, or too little water so they weigh as little as possible.
Hypo- or hypernatremia can result.
Vomiting, laxative, and diuretic abuse can lead to hypochloremic, hypokalemic
metabolic alkalosis.
Correct electrolyte and fluid imbalances prior to refeeding the starved patient. Initiate
replacement therapy for electrolytes as needed (Solomon, 1990). Monitor electrolytes
(K, P, Ca, Mg) every 6 hours at the beginning of refeeding for 3 days (some
recommend 7 days) and replace low levels as needed. Usually resumption of oral
feeding will replace minerals and vitamins naturally but if serum levels fall then
replacement is warranted.
A form of purging called "stomach washing" has been reported by some patients. This
practice involves the affected person drinking a lot of water, then inducing vomiting,
drinking water again and inducing vomiting again and repeating this until the stomach
contents expelled are clear in color. This practice can result in severe hyponatremia
and hypochloremia. If a patient exhibits these conditions persistently, they need to be
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monitored closely to make sure this behavior has not been adopted.
Patients who binge/purge often will drink a lot of water with a meal to "float" the food,
making it easier for them to induce vomiting. Monitor to make sure excess water
consumption is not occuring during a meal.


Nutrition Diagnosis

Dietitians working with patients who have eating disorders should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate energy intake (NI-1.4)
Excessive energy intake (NI-1.5)
Inadequate oral intake (NI-2.1)
Excessive oral intake ((NI-2.2)
Excessive fiber intake (NI-5.8.6)
Inadequate vitamin intake (NI-5.9.1)
Predicted suboptimal intake (NI-5.11.1)
Predicted excessive nutrient intake (NI-5.11.2)
Altered gastrointestinal function (NC-1.4)
Predicted food-medication interaction (NC-2.4)
Harmful beliefs/attitudes about food- or nutrition-related topics (NB-1.2)
Disordered eating pattern (NB-1.5)
Undesirable food choices (NB-1.7)
Excessive physical activity (NB-2.2)
Poor nutrition quality of life (NB-2.5)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate energy intake (NI-1.4) related to anorexia nervosa as evidenced by
inappropriate weight loss (may wish to describe growth velocity or weight loss in
terms of percentiles) and by parental report 24 hr recall
Poor nutrition quality of life (NB-2.5) related to bulimia nervosa as evidenced by
parental report of patient's bingeing and purging
Inadequate vitamin intake (specify which) (NI-5.9.1) related to inadequate dietary
intake and anorexia nervosa as evidenced by dietary history and (specify which)
laboratory values.
Excessive energy intake (NI-1.5) related to binge-eating disorder as evidenced by
_____pound weight gain over ___ period of time.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Prescription

Anorexia Nervosa
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Anorexia Nervosa
Nutrition prescription is usually a high-calorie, moderate protein and fat diet.
Supplementation when indicated
Occasionally a supplemental nasogastric tube feeding is used for weight gain. This is a
rare occurence. See Nutrition Support section. Refer to section on Refeeding for specific
pertaining recommendations.
Bulimia Nervosa
Nutrition prescription is a normal, balanced oral diet.
Supplementation as indicated.
Binge-eating Disorder
The nutrition perscription is a normal, balanced oral diet.
Kilocalorie reduction if necessary to avoid inappropriate weight gain.
Supplementation as indicated.

Nutrition Intervention

Nutrition intervention is one of the key elements of rehabilitation in overall treatment of
eating disorders; however, this task is not usually taken on by the registered dietitian (RD)
alone.
The medical staff will assess the patient as to whether or not they are medically fragile, as
well as how well they are progressing toward health, or if they are developing medical
problems along the way during treatment. Psychologists and therapists will address family
and individual concerns, the patient's ability to stay on target toward rehabilitation, and
work toward elimination of barriers to eating and delusional thinking about body image and
food.
The RD will either be asked to address specific food questions or estimate components of
treatment such as estimation of necessary calories, diet questions related to family
preferences, food allergies or intolerances, resting energy expenditure (REE) assessment
and other nutrition-related aspects of care. Occasionally nutrition support is necessary (see
Nutrition Support section) and the RD will be asked to calculate feeding protocol.
Some treatment teams may request development of meal plans or menus while others will
be against this intervention. Since controlled clinical trials are finally beginning to present
meaningful data on what treatment modalities work well, the components of nutrition care
are somewhat in a state of flux with respect to eating disorders.
Nutrition intervention will be different depending on what disorder is being addressed and
what phase of treatment a patient is in. Refer to the Stages of Illness section. Below are
general guidelines for anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating
disorder (BED).
Practice guidelines from the American Psychiatric Association are available online.

Anorexia Nervosa
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The general course of treatment regarding nutritional rehabilitation for anorexia nervosa is
as follows:

Ensure medical stability with the aid of a knowledgeable medical team, experienced in
the early feeding of patients at risk for refeeding syndrome. Identify those at risk and
feed according to an established protocol to avoid complications from refeeding
syndrome (see Criteria to Assign Risk).
1.
Once patient is medically stable, gradually increase macronutrients so that weight
gain is achieved. In pediatrics the evidence is strong that this part of treatment can be
done in the home, under medical supervision, coaching the family in the supportive
role of refeeding.
2.
Monitor for micronutrient deficiencies and correct if suspected or present. 3.
Monitor and stop exercise in the initial phases to allow for weight gain and return of
normal physical functions. Excess exercise is seen as a purging behavior (it rids one
of unwanted calories).
4.
Once target weight is achieved then ensure that weight remains stable. This is an
important step to avoid relapse. Monitoring of food intake and exercise is needed until
the patient shows an improvement in attitude about eating and is comfortable with
age-appropriate feeding skills.
5.

Refeeding Syndrome in the Anorexic Patient
A detailed account of what the anorexic patient’s “typical” intake has been, often provided
by the parents, is useful in estimating where to start the caloric intake. This will be an
unreliable method of estimating typical caloric intake if the diet history is taken from the
patient. If the caregivers have had the opportunity to observe meals taken by the child,
obtain the diet history from them.
Starting at this level, one may add 200 kcal and remain at this level for 3 to 4 days.
Increase intake by 200 kcal per day from this point, monitoring for electrolyte and fluid
disturbances. If there is no nutrition history or intake information available or if parents are
clearly unsure of what the child has been eating then start with a conservative amount of
calories, 800 to 1000 orally per day. Use the patient’s actual weight (adjusted weight if
obese), not their goal weight, in estimating calories at this phase. See the Refeeding
section.
General guidelines for feeding conservatively to avoid refeeding syndrome include:
Feed 20 kcal/kg initially; start at 15 kcal/kg if a patient is severely malnourished. 1.
Do not feed at more than 20% above REE (McCray, 2005). 2.
Feed 60% to 75% of recommended energy level for actual body weight. 3.
The American Academy of Pediatrics recommends a daily gain, during the medically
fragile phase of refeeding of 0.3 to 0.4 lbs per day (Rome, 2003).
4.
Increase calories in stepwise fashion, adding 200 kcal/day, monitoring fluid and
electrolyte balance and correcting as needed.
5.
Monitor glucose: Those with hyperglycemia who require exogenous insulin are at risk
for development of refeeding syndrome upon receipt of insulin because then the
sequence of events leading to influx of electrolytes and glucose into cells will begin.
6.
Feeding an Anorexic Patient after Risk of Refeeding Syndrome
High-calorie diet; regular, oral meal plan
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Increase calories until weight gain is seen, usually after the first 5 to 7 days of
refeeding. This initial time is the time necessary for the body to shift from a catabolic
state to an anabolic state.
1.
To minimize volume in a high-calorie diet, increase calories from fats. This is
advantageous because a high-volume diet can be overwhelming to the anorexic
patient.
2.
Add calories with liquid supplements such as Boost Plus. 3.
Instruct family in high-calorie recipes or how to add calories to recipes they already
use at home.
4.
Monitor to make sure calories are consumed by the patient. 5.
Bulimia Nervosa
The general course of treatment emerging for BN is similar except that far fewer individuals
are hospitalized with BN or BED. Therapy in BN involves maintenance of weight and
cessation of extreme dieting and purging behaviors. Evidence is strong for use of
antidepressants in this population along with therapy to stop binging and purging. The
family is involved in normalization of feeding, monitoring food intake and closely watching
the child after eating to ensure purging behaviors are not maintained (Lock, 2005).
Nutrition concerns in BN are related to out-of-balance eating and the resultant purging
behaviors resulting in an overall poor nutrition quality of life, in addition to the medical
complications that arise from binging and purging.
Families need to be strongly encouraged to monitor the adolescent with bulimia so that
binging does not take place and purging does not occur. Watching the adolescent after
meals and snacks for at least one hour, to make sure purging does not occur, is one
strategy. The mental health professional may be able to identify favorite binge foods so that
the family can eliminate these from the home and focus on creating a balnced diet.
Regular meals and snacks are encouraged. Understand that there are philosophical
differences regarding keeping binge foods in the house. Some therapists are in favor of
eliminating favorite binge foods at the start of treatment and then gradually bringing them
back in as the patient becomes better able to resist the desire to binge. Other therapists
feel it is best to keep favorite binge foods in the home and have the patient learn to deal
with them (distress tolerance; exposure therapy). The RD often has to adapt to the
treatment philosophy of the location/clinic where they practice. As research documents the
effectivenes of various techniques, practitioners will be able to rely on evidence to support
their treatment philosophy.
Educate the family and the patient (depending on patient age and recommendations from
the therapist) about frequency of eating, diet composition, and calorie needs. The therapist
may work with the family to empower them to monitor food consumption and ensure that
food eaten is retained. Similarly, for BED, the family will be encouraged to limit binge
trigger foods and help their child achieve a normal eating pattern.
Binge-Eating Disorder
For BED, the RD can help the family identify appropriate amounts of foods, so they can
help the child or adolescent achieve a balanced, energy-appropriate diet. In cases of BED,
a low-energy eating pattern may be helpful as energy dilute diets containing the required
nutrients have been associated with weight loss or maintenance (Mendoza, 2006).
Mandometer method for treatment of AN and BN
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The Mandometer method is a computer-assisted method of training individuals with AN
and BN to recognize hunger and satiety. A randomized controlled trial of the efficacy of this
method showed very good results (Bergh, 2002).
Nutrition Support
Supplemental nocturnal nasogastric refeeding has been advocated for some anorexic
patients (Robb, 2002). Patients who received this support were below 85% of ideal body
weight and highly resistant to oral feeding during the day and/or very uncomfortable with
oral feeding due to gastrointestinal distress. Nocturnal nasogastric refeeding was used to
supplement, not entirely replace, daytime oral feeding.

Goal-Setting/Target Weight

Goals of Nutrition Therapy
Nutrition rehabilitation, eating management and normalization of eating
behaviors are central in treatment of anorexia nervosa (AN), bulimia nervosa (BN), and
binge-eating disorder (BED). Psychological goals to reduce delusional thinking and anxiety
around food, eating, and body image are ultimately aimed at preserving nutritional and
therefore physical health and function.
General Goals - Anorexia Nervosa
Golden and Meyer (Golden, 2004) defined several specific goals in rehabilitation from AN:
1. Metabolic recovery
2. Weight restoration
3. Reversal of medical complications
4. Improved psychological functioning
5. Improvement in eating behaviors
Specific goals of refeeding the anorexic patient are to achieve and maintain a healthy
weight, maintain physical functioning and correct any nutrient deficiencies. Usually, nutrient
deficiencies are corrected as the diet improves and weight is gained.

Weight Goals
Inpatient programs' weight gain goals of 2 to 3 pounds per week (0.9 to 1.4kg) have been
recommended (Golden, 2004).
Weight gain goals of 1 to 2 lbs (0.5 to 1.0 kg) per week are recommended in an outpatient
setting with calories added until this goal is met.
Better prognosis is seen with consistent weight gains of >0.8 kg/week during treatment.
Frequent evaluation of calories and dietary intake is sometimes needed when goal weights
are not achieved. Evaluation of calorie needs has to be evaluated in terms of how
well careful monitoring of eating behaviors has been achieved. Often in anorexia as well as
bulimia, patients will not eat the necessary amount of food unless watched very closely, so
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before recommending more food and calories it is wise to make certain that what is
currently given to a child is actually being consumed and retained. Family-based
therapy (FBT) is especially useful for training caregivers to monitor food intake and ensure
that food is eaten and retained.
Predictors of outcome following weight restoration
Numerous variables have been suggested as predictors of treatment outcome including
serum cortisol and leptin levels, body mass index (BMI), waist to hip ratio, and percent
body fat. One study found only % body fat (measured by total body dual-energy X-ray
absorptiometry) was predictive of treatment success. Lower body fat at discharge from an
in-hospital program was associated with poorer outcome (Mayer, 2007). This study
examined serum cortisol and leptin, BMI, and waist to hip ratio in comparison to % body fat.
Predictors of successful weight maintenance after treatment and attainment of weight
within normal limits have been higher BMI at discharge from a treatment program and rate
of weight lost in the 28 days after treatment. Again, the trend is to achieve higher total body
adiposity, within the normal weight range and keep the weight on after treatment (Kaplan,
2009).
General Goals - Bulimia Nervosa
In BN the child or adolescent has to be monitored for adequate food intake, cessation of
bingeing behaviors and cessation of purging behaviors. Goals are thus similar to those for
AN, except in BN weight maintenance rather than weight gain is often the goal in addition
to correction of medical complications and nutrient deficiencies related to poor intake,
purging behaviors.
There is often purging behavior seen in BN, following what is seen by the patient as too
much food being consumed. During refeeding in BN, the patient has to be closely watched
to make sure purging behaviors do not start.
General Goals - Binge-Eating Disorder
Goals for the child with BED are to normalize eating behavior and maintain an appropriate
weight for age and height. Some but not all adolescents with BED are overweight, so
attention to weight over time is necessary to guard against dentition. This does not mean
keeping weight steady through the adolescent period but to allow gains to accommodate
height and mass increases.
Additional goals for BED patients are to help the child or adolescent understand body cues
for satiety and understand how to choose portions and diet variety so a balanced diet is
achieved.
Family members may be enlisted to support the child or adolescent by monitoring meals,
monitoring food in the household so favorite binge foods are not brought into the house,
and by monitoring overall intake by the child. Watchfulness about foods within the house,
watching for large amounts of food missing or being consumed more quickly than expected
can suggest the occurrence of possible binge episodes.
Weight/setting target weight
Setting a target weight is a difficult process for growing children and adolescents.
Depending on when the eating disorder started, the length of time it persisted before
intervention, the age of the child, and the degree of malnutrition, weight goals will need to
be adjusted as the child goes through treatment. Often in anorexia nervosa after feeding
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be adjusted as the child goes through treatment. Often in anorexia nervosa after feeding
has started, the child may experience a growth spurt and so the target weight would need
to be re-evaluated. The common practice of settling for a minimum target weight (a “low
normal” weight in the weight range), is not recommended because weight at discharge is
associated with the best outcome. One study found that best prognosis was associated
with total body adiposity of 25% to 30% in young women recovering from anorexia
nervosa, which provides evidence that setting target weights too low is not advisable
(Mayer, 2007). Target weights of 95% to 100% of normal or expected are necessary for
normal bone development, hormone levels, growth, and brain function.
Some clinicians state that 85% to 90% of expected weight is considered acceptable for
discharge from a structured treatment program. While this might be acceptable for
discharge, it does not mean the child is well or ready to take up self-feeding. Teaching the
family to monitor feeding until the child is able to prepare, choose, and consume foods
independently is crucial at this point so that weight gained is not immediately lost upon
discharge. Some programs have structured step-down units for patients after discharge.
Follow-up after discharge from an inpatient setting is crucial for maintaining the weight
gained and for continuing to gain weight up to an appropriate level.
Use of the BMI can provide inaccurate information in children and adolescents. If anorexia
has started before growth is complete, growth may be stunted and height reduced. Body
mass loss and weight loss will be underestimated if based on BMI alone. Even if weight
holds steady during a period of expected growth and growth is stunted due to caloric
restriction, weight loss will not appear to be a problem and BMI can appear within normal
limits.
Bulimia Nervosa and Binge Eating Disorder
Weight goals for BN and BED need to be age appropriate. Sometimes these patients may
actually need to lose weight but this practice needs to be avoided until cessation of
purging, bingeing, and weight cycling have stopped. Frequent weighing gives the clinician
feedback about how well the family has made adaptations that are productive in terms of
stopping bingeing and purging behaviors. Weight goals in this pediatric population have to
be regularly adjusted to account for growth and maturation.
In patients who have misused laxatives or induced vomiting frequently, refeeding edema
may occur. This can result in rapid weight gain but usually resolves within 10 days.
Anticipate this, and monitor weight daily. If edema is present serum electrolytes need to be
monitored.

Measurement of Height and Weight
Height and weight in growing children and adolescents needs to be checked twice daily in
the hospitalized patient to monitor progress and check for fluid retention and edema.
Weight is measured at least weekly in medically stable outpatients. The frequent weighing
gives feedback about compliance to refeeding, provides valuable feedback to the parents
and the rest of the treatment team. Persons younger than 20 years old might experience a
growth spurt when refeeding is started and then target weights would need to be
recalculated.
Weight should be taken gowned with only undergarments to ensure that the patient has not
hidden objects in an attempt to make weight appear elevated.
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Many patients with eating disorders are very upset by knowing their weight, especially as
they gain weight. The treatment team needs to evaluate this aspect of care and consider
whether or not "blind weighing" ought to be done, where knowledge of the weight is kept
from the patient. With a beam scale the patient is turned facing away from the beam
and care is taken to not verbalize or write down the weight so the patient is aware of it.
Digital scales are sometimes easier to blind weigh patients as some digital scales have
readouts that can be moved away from the scale.

Other Feeding Issues in Childhood

There are feeding issues that present in early childhood that are not considered "eating
disorders." These include infantile anorexia, sensory food aversions, and post-traumatic
eating disorder, among others. These have been described recently (Chatoor, 2004a).
The role of the registered dietitian (RD) in treatment of these feeding issues in early
childhood could be to support the family as they attempt to resolve issues around feeding.
Additionally, diet analysis to identify specific nutrients that may be lacking due to selective
eating behaviors is useful.
Infantile anorexia
Children do not appear to have normal appetite or appetite cues and therefore eating is
diminished. They fail to gain weight and height at the expected rate. Onset is before 3 years
of age. Occurs in both genders at the same frequency.
Treatment is first a complete differential diagnosis, including psychiatric workup. This is
followed by working with the family, setting regular meals and snacks, not praising or
punishing for eating behaviors, not drawing excess attention to the eating, not allowing
snacks in between planned meals and snacks, and not allowing distractions during
meals. Children are encouraged to learn about hunger and fullness cues. The RD may be
able to assist the family in mealtime behaviors that are helpful as well as track nutrient
intake so supplements can be recommended if necessary.
Sensory Food Aversions
This is a spectrum of feeding issues that can be more or less severe. Many children are
somewhat "food neophobic" but some children develop significant aversions to foods based
on taste or texture of the food, or some other aspect inherent in the food. Sensory food
aversions can become problematic if entire food categories are avoided so much so that
nutrient deficiencies occur (eg, iron, folate, zinc, or calcium). If children avoid "hard to
chew" foods their oral motor and language developmental milestones may be missed,
resulting in impairment. Food aversions can cause severe family conflict and even social
anxiety due to embarrassment about food intake.
Treatment consists of helping the child feel less fearful of new foods, by a variety of
therapeutic techniques. A skilled therapist will likely not encourage "making the child
hungry," punishment or threatening actions, or coaxing to encourage eating more variety.
These methods can make the child feel more, not less, anxious. Because of the possibility
of nutrient deficiencies, a diet analysis may be done to pinpoint specific nutrients to
supplement. The doctor may do a workup for anemias as well, which is very helpful in
determination of specific nutrient deficiencies (eg, iron, folate, copper, and vitamin B
12
).
Post-traumatic Eating Disorder
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This disorder was described by Chatoor (Chatoor,1988) as pertaining to several cases of
children who had choked or gagged on solid foods and then later did not want to eat any
solid foods, preferring only soft, pureed or liquid foods. Generally these children lost weight.
In addition to the food restriction, these children were fearful around mealtimes, and
reported thoughts and dreams of dying or choking.
There are no studies for treatment of this type of disorder, but therapists have tried
variations of cognitive behavioral therapy and desensitization therapies. Some children
need medication to help manage their anxiety and allow them to eat. Again, using parental
report of foods eaten, an RD can analyze the diet and pinpoint specific nutrients missing
that will need to be supplemented.

Nutrition Support

Enteral feeding is sometimes, although rarely, considered in hospitalized children and
adolescents when they are very medically compromised and unable to accept oral feeding.
A nutritionally complete, isotonic formula, supplying 1 kcal/ml is generally recommended
when starting enteral feeding (Royal College of Psychiatrists, 2005). This is not intended to
completely replace oral food intake but be a complement to it when weight gain is elusive.
Usually an energy amount equivalent to the amount of energy being taken in by oral route
can be administered by nasogastric route. Rate and volume are adjusted according to the
amount of oral intake.
The recommendation is that initial enteral feeding be at a rate of 20 ml/hour and
progress by 10 ml/hour until 120 ml/hour is achieved. Increases of 200 to 300 kcal can be
made once or twice per week until a rate of weight gain of 1 to 2 pounds (0.5 to 1.0 kg) per
week is attained. In children and adolescents that are compromised to a point where
enteral feeding is considered, monitoring for refeeding syndrome has to be done. See
Refeeding Syndrome section for recommendations to avoid refeeding syndrome.
Oral feeding should be continued so the enteral nutrition support is viewed as an adjunct to
feeding, not a replacement.
One study looked at rate of weight gain in hospitalized teenage girls and found that rate of
weight gain was more rapid and weight at discharge higher in those with supplemental
nocturnal nasogastric tube feeding (Robb, 2002).


Nutrient Exceptions to DRI

There are major exceptions to recommended energy intakes for anorexia nervosa (AN).
People diagnosed with restricting anorexia tend to have higher energy needs than those
with binge/purging type anorexia (Kaye, 1986; Weltzin, 1991).
Initially the recommendation is for reduced energy intake, to avoid refeeding syndrome.
Guidelines for feeding conservatively to avoid refeeding syndrome are:
Feed 20 kcal/kg initially; start at 15 kcal/kg if a patient is severely malnourished. 1.
Do not feed at more than 20% above resting energy expenditure (REE) (McCray,
2005).
2.
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Feed 60 to 75% of recommended energy level for actual body weight. 3.
The American Academy of Pediatrics recommends a daily gain, during the medically
fragile phase of refeeding of 0.3 to 0.4 lbs per day (Rome, 2003).
4.
Increase calories in stepwise fashion, adding 200 kcal/day, monitoring fluid and
electrolyte balance and correcting as needed.
5.
Monitor glucose: Those with hyperglycemia who require exogenous insulin are at risk
for development of refeeding syndrome upon receipt of insulin because then the
sequence of events leading to influx of electrolytes and glucose into cells will begin.
6.
After the initial week or two of refeeding in AN, when the risk of refeeding has passed, the
need for energy greatly exceeds that which is expected for anabolism. REE can increase to
120-150% of that determined by predictive equations. Kilocalorie needs have to be met so
protein is spared and used for tissue synthesis.
Anticipate that calories will need to be added, step wise, until weight gain is seen at the
recommended 1 to 2 lb per week (0.45-0.9 Kg/week) in the outpatient setting and 0.3 to
0.4 pounds per day (0.14-0.2 kg per day) in an inpatient setting. Notice the difference in
time frame with outpatient weight gains measured per week and inpatient measured on a
per day basis.
In a healthy population the post-prandial increase in REE is on the order of 10%. In
recovering anorexic individuals this value can be as high as 30% and it is not clear why the
value is so high. This also contributes to the increased need for energy in this population
(Golden, 2004).
Protein during initial refeeding of the starved patient
Feed high biological value protein. Start with 0.6 to 0.8 gm/kg actual weight, while
monitoring for signs of acidosis, hypernatremia, azotemia, hypertonic dehydration, and
uremia. Once the patient is medically stable, increase protein to recommended value for
weight and age.
Monitor kilocalorie intake and make sure weight is gained so protein is not used for energy.
Thiamin in initial refeeding of starved patients
Give dose of thiamin (1 to 2 mg/kg) intramuscularly 30 minutes prior to the initiation of
feeding (Cape Town Metropole Paediatric Group 2007).
Calories from Fat, in weight gain diet
Often due to the hypermetabolism that takes place after initial refeeding in AN, the patient
needs a very high calorie diet in order to continue gaining weight. Persons with AN also do
not prefer high-volume diets as these can take an unusually long time to eat (this interferes
with timing of meals) and/or they cause gastrointestinal distress. The meals may also look
"too big" to a person with an eating disorder. For these reasons many weight-gain diets are
higher in fat than is recommended.

Nutrition Monitoring & Evaluation

Special Considerations in Anorexia Nervosa
After the acute phase, many anorexic patients become hypermetabolic and require a high
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
number of kilocalories in order to continue to gain weight. In anorexia nervosa, the number
of kilocalories required for weight gain increases as weight increases and more than half of
the increased weight gained in refeeding will be adipose tissue (Salisbury, 1995). This is
normal in feeding after starvation.

The registered dietitian (RD) should resist the temptation to expect “normal” body
composition attained upon initial refeeding because of the high proportion of adipose tissue
gained during this phase. In addition, there is a disproportionate amount of adipose tissue
deposited centrally during refeeding after semi-starvation.

Measurement of Height and Weight, Factors Affecting Weight
Weight in growing children and adolescents needs to be measured twice daily in the
hospitalized patient to monitor progress and check for fluid retention and edema. Weight is
checked at least weekly in medically stable outpatients. The frequent weighing provides
feedback about compliance to refeeding and provides valuable feedback to the parents and
the rest of the treatment team. Persons younger than 20 years might experience a growth
spurt when refeeding is started and then target weights would need to be recalculated.
Measure height monthly to check for additional growth.
Weight should be measured gowned with only undergarments to ensure that the patient
has not hidden objects in an attempt to make weight appear elevated.
Urine-specific gravity is frequently measured by the physician as a check on water
consumption. Water loading is done by some patients in order to falsely elevate weight.
Monitoring Food Intake
If family-based therapy (FBT) is used, the parents and caregivers will be trained to monitor
every meal and every bite of food. In the true Maudsley FBT method, the family is not
given a specific meal plan but allowed to feed their child as they know how, increasing
kilocalories in meals and snacks in order to affect weight gain. Some programs use
elements of FBT and insist on providing a meal plan for the family to follow. In either
situation, the family will be watching the food intake and can give the RD facts about food
intake. The RD will be able to adjust energy if needed or give the family nutrition
information as requested, in order to support weight gain by the child/adolescent. Food
intake information is also helpful in determining which nutritional supplements to
recommend.
Evidence strongly supports that early and aggressive treatment, with quick restoration of
weight and cessation of restricting and purging behaviors, is associated with the best
prognosis. Evidence also supports involvement of the family in treatment of pediatric eating
disorders. Specifically, the Maudsley FBT model has been studied and emerged as
effective in comparison to other forms of treatment for the pediatric population (Keel, 2008;
Rosen, 2010). More details about the FBT approach appear in the table at the following link.
Key Aspects of Nutritional Care for Eating Disorders in Adolescents
Monitoring for Purging Behaviors
In adolescents who have history of purging behaviors, first the medical team needs to
identify the behaviors, such as laxative abuse or self-induced vomiting, and instruct family
members on how to make sure the behaviors do not continue. With self-induced vomiting,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
the family will have to monitor the child for at least 1 hour after meals, sometimes for up to
2 hours, to make sure this behavior does not continue. Monitoring shopping behavior and
bathroom use can help identify laxative abuse.
The RD can teach individuals who abuse laxatives about the dangers of abuse, what to
expect as they withdraw from laxatives, and how to correct bowel function.
Tips for Dealing with Laxative Abuse
1. Drink at least 6 to 10 cups of water or decaffeinated beverages daily. Restricting fluid
intake dehydration and worsens constipation.
2. Include some physical activity in the regular daily pattern to regulate bowel function,
although the intensity and type of activity needs to be monitored and approved by the
health care provider.
3. Eat foods at regular intervals during the day.
4. Eat foods that promote normal bowel function such as whole grains and produce.
Prunes and prune juice are not recommended because the ingredient in prunes that
promotes bowel movements is actually an irritant laxative, and long-term use of prunes and
prune juice can result in the same problem as long-term use of laxatives. Ground flaxseed
(2 Tbsp/day) can aid in bowel function.
5. If a person is truly constipated or has very irregular bowel movements, discuss with the
physician to determine other possible causes.
Symptoms of laxative withdrawal include the following (these can be short term (several
days) or longer term (3 months):
Constipation
Fluid retention
Feeling bloated
Temporary weight gain



Nutrition Care FAQs

Nutrition care and the input of registered dietitians (RDs) will vary depending on the setting
where treatment is occuring. Inpatient, outpatient residential, and home refeeding
programs all utilize RDs to a varying degree.
Some Eating Disorder Basics
Pediatric patients should not be left on their own to make decisions about food. This
includes choosing which foods to eat (with very minor exceptions such as "do you
want this cereal or that cereal") and how much food to eat. Food decisions can cause
undue anxiety.
The pediatric patient does not have a say in the course of treatment or how much
weight they are willing to gain. This is a medical decision.
Better prognosis is seen with early diagnosis and aggressive refeeding to a healthy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
physical condition which includes weight to a mid-range of recommended body
weight, not the lowest possible weight for age/height that is still in the recommended
range.
Better prognosis is seen in weight-restored patients who have more food variety
and more energy-dense diets.
Use indirect calorimetry as opposed to predictive equations to estimate resting energy
expenditure.
Nutrition education alone is never an effective means of treating an eating disorder in
the pediatric population and is not a best practice.
Frequently Asked Questions (by both families and RDs)
Why can't my child make decisions about what food he/she wants to eat during refeeding?
Making decisions about food is very difficult for a child/adolescent in recovery from an
eating disorder. Making decisions about food adds to their stress level and makes it more
difficult for them to stay on task and eat what they need to become healthy. Often, once
children have had to eat "normally" or in a manner designed to gain weight, they start to
relax about eating and after awhile they can start to make decisions about what to eat. The
therapist can determine when anxiety is to a level where the child can start to make
food-related decisions.
Why is it not appropriate for the RD to teach the child about healthy eating?
This really depends on what stage of refeeding the child/adolescent is in. In the early
stages, the patient is usually so ill that instruction about nutrition is misinterpreted. It adds
to anxiety and it fuels eating disorder behaviors. Quite often with eating disorders and
especially in anorexia nervosa, the patient has become obsessed with calories, fat grams,
and other nutrition facts, so adding to this obsession is not in the best interest of the
child/adolescent. In family-based therapy (FBT), responsibility for food is taken from the
child and given to the family to help minimize the anxiety and obsessions around food.
In later, post-refeeding stages of the eating disorder, food decisions are handed back
gradually to the child/adolescent (appropriate for developmental stage) and nutrition
education might then be appropriate. However, this needs to be cleared with the health
care team to make sure nutrition facts do not add to the anxiety of the patient.
If an RD is asked to provide nutrition education or information in the care of an eating disordered child, who
receives and implements this information?
For inpatients, the medical team and the parents are the main receivers of diet information,
including kilocalorie estimations.
In the outpatient setting (where FBT is used), the RD can continue to coach caregivers, in
line with the therapist, presenting a unified approach to care. The RD is able to answer
nutrition questions from the family about adding calories, recipes, nutrient dense foods,
and supplements. Support for the family is crucial if the family has chosen to refeed at
home so any information the RD can provide to ease the burden on the caregivers is
usually appreciated. Generally the RD's role is to support the medical team and therapist
and provide operational nutrition advice to parents.
Is it OK for children who are overweight to diet?
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Children in general should not diet; they may be watched by a medical team if they are
severely overweight, and may be encouraged to adopt behaviors that might assist with
attaining more appropriate weight. The RD who is well educated about eating disorders
would first ask about family history related to eating disorders. Children with relatives
diagnosed with eating disorders are at increased risk of developing an eating disorder, and
dieting should be discouraged. These children may be assisted in development of good
eating habits and sound exercise habits; focus on body weight, appearance, and active
dieting needs to be discouraged and parents educated about this.

Family Based Therapy

While it may seem simple enough to feed a child, feeding an anorexic child or stopping
purging behaviors in a child with bulimia is not simple. The delusional thinking creates a
very real fear of foods and weight gain and these fears will emerge during feeding and
cessation of purging behaviors.

Evidence-based approaches to treatment of childhood eating disorders have not been
widely available until recently. There is evidence to support the use of the Maudsley
approach or family based therapy (FBT) in treatment of childhood eating disorders (Keel,
2008). Lock and LeGrange have conducted clinical trials of FBT, documenting good
results, and have written several books on the subject (Lock, 2005; LeGrange, 2009).
"Addressing" fears does not mean the child will be subjected to intense scrutiny about how
they feel about foods. Addressing fears will take the form of making sure the child eats. It
will be the family who stands up to the eating disorder. In traditional Maudsley approach
the family is taught to separate the child from the eating disorder. When the child resists
eating the family is taught to see the resistance as coming from the disorder, not their
child. The child is seen as having an illness that makes it very difficult for them to eat
normally. This stance takes the blame away from the child. The deception that often goes
along with an eating disorder (hiding foods, throwing away food, hiding weights in clothes,
excess water drinking to elevate weight, hidden purging, excess exercise) is seen as being
something the disorder does, not as something the child is doing to be difficult. Their
disorder is difficult, they are not. In FBT or Maudsley, the family is taught how to take a
stand against the disorder.
True Maudsley or FBT typically does not use registered dietitians (RDs) as part of the front
line team. RDs might be used for their nutrition knowledge as secondary team members.
Sometimes RDs may have additional training in the basic techniques of coaching a family
through home refeeding. This may be valuable since there is a shortage of FBT-trained
professionals and Maudsley/FBT professionals are not available in every location. Any
clinicians who want to work with people with eating disorders have to obtain additional
training from experts in this field.
True Maudsley progresses through three distinct phases with the last phase being the
return of eating and feeding tasks to the child, and it does not take an inordinate amount of
time. Many forms of traditional therapy for eating disorders have taken years, but FBT is
accomplished in 20 sessions or less (Lock, 2005).
It is essential that all members of a treatment team, if they are using this or another
approach, collaborate and form a consistent approach to treatment, for the sake of the
family and their ill child. The child will need at least weekly medical monitoring for weight
and vital signs. The family may find it very helpful to have family therapy to help with the
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tension that can arise anytime a family is taking care of an ill child. Individual therapy for
the child may also be prescribed, to alleviate anxiety and address co-morbid conditions that
are frequently present. The treatment team needs to frequently comunicate and make sure
everyone on the team is giving consistent messages to the family. It is also essential that
treatment providers are very aware of evidence-based treatments and not rely on
anecdotal treatments.
Basic assumptions and practices of FBT and home refeeding for the pediatric
population
The child is not choosing to have the illness and they most likely will not choose to
alter the eating behavior on their own, so the intervention will now include the family,
refeeding the child sooner rather than later. Refeed to a healthy goal weight, and
ensure that the weight is kept on for six months or longer to allow the neuroendocrine
system to return to normal (Kaye, 1986).
1.
One should make no assumptions about the role of the family in the etiology of the
illness. The family is seen as part of the treatment team with the necessary
knowledge to refeed their child and monitor eating behaviors.
2.
Train the caregivers to refeed. This often includes institution of family meals, three
meals and two to three snacks per day in a high-calorie, high-nutrient diet. Honor
family traditions and allow diet alterations to accommodate allergies and food
preferences (when possible).
3.
Make sure food preferences are not eating disorder behaviors. With anorexia
nervosa, any foods are fine as long as calorie, macronutrient, and weight gain goals
are met. Suspend talk about healthy foods.
4.
To treat bulimia nervosa and binge-eating disorders, learn which foods are favorite
binging foods and avoid those. Feed well balanced meals at regular intervals.
Maintain weight unless the child is underweight.
5.
A child with bulimia nervosa has to be watched after eating for at least 45 min to 1
hour. The child cannot leave the table during meals or leave too quickly following a
meal. if the child needs to use the restroom, for example, a parent must accompany
them and stand outside the door to ensure that the meal is retained.
6.
Exercise has to be suspended until goal weight is achieved and the doctor has stated
that physical functioning has returned to normal. Some programs will have light
exercise as part of the program (eg, yoga or walking for 15 minutes), but exercise
activity often has to be monitored so it does not become another purging behavior.
7.
The RD can take an active role in FBT, if they have had additional training in this
method. They can support the family in meal planning, if the family needs this
support. Some families do ask for calorie-dense food plans and recipes and the RD
can readily provide help in this area. An RD with additional training may be able
to coach the family in the mechanics of home refeeding.
8.
Have a backup plan in case home refeeding does not meet stated goals of weight
gain or cessation of purging behaviors. These goals need to be met within a short
time period: within two weeks generally, or another plan has to be adopted. Close
medical monitoring (weekly appointments) has to continue throughout home
refeeding to ensure that the child is not becoming medically fragile. If the child's
condition is worsening or if the child's behavior become too difficult for the family, or if
stated weight goals are not being met then the child will need to be referred to a
specialized treatment center. (For a list of treatment centers go to
www.FEAST-ED.org.)
9.

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Refeeding

REFEEDING: ANOREXIA NERVOSA
Refeeding in anorexia nervosa usually proceeds through stages, with the initial stage being
a conservative, low-energy diet to ensure that refeeding syndrome does not occur and then
proceeding to a high-energy, high-food-variety diet.
Initial refeeding for the anorexic patient
Initial refeeding may take place in a hospital setting if the patient meets criteria for hospital
admission. If a patient diagnosed with anorexia nervosa meets hospitalization criteria then
they may also be at risk for refeeding syndrome. Even if the patient does not necessarily
meet criteria for hospital admission, the medical team needs to assess for risk of refeeding
syndrome.
Risk of refeeding syndrome is highest in persons who are less than 70% of ideal weight
and in situations where enteral or parenteral nutrition is given, but refeeding syndrome can
also occur with aggressive oral feeding, and the danger is highest in the first week of
refeeding the anorexic patient. When there is a risk of refeeding syndrome, conservative
refeeding in the initial phases is necessary.
Estimating energy needs at the start of refeeding
At the start of refeeding the anorexic patient who has adapted to low-energy intakes will
have a resting energy expenditure (REE) typically lower (by 50 to 70%) than predicted, if
using predictive equations (Golden, 2004).
After approximately one week of refeeding the REE will increase dramatically. It can be
120 to 150% of values using predictive equations (Trocki, 1997). Use of indirect calorimetry
is recommended for this reason. REE remains high until several weeks following complete
weight restoration.
One method of estimating initial energy intake is to obtain a record from caregivers, using
24 hr recall or diet history, of what the patient has been eating. Then, starting at this level
of caloric intake, one may add 200 kcal and remain at this level for 3 to 4 days. Increase
calories by 200 kcal per day until weight gain is achieved. If there is not nutrition history or
intake information available, or if caregivers are clearly unsure of what the child has been
eating, then start with a conservative amount of calories, such as 800 to 1000 orally per
day. Use the patient’s actual weight, not their goal weight, in estimating calories at this
phase.
Other guidelines for management of refeeding syndrome are:
Feed 20 kcal/kg initially; starting at 15 kcal/kg if a patient is severely malnourished. 1.
Do not feed at more than 20% above REE (McCray, 2005). 2.
Feed 60 to 75% of recommended energy level for actual body weight. 3.
The American Academy of Pediatrics recommends a daily gain, during the medically
fragile phase of refeeding, of 0.3 to 0.4 lbs per day (Rome, 2003).
4.
Monitor glucose: Those with hyperglycemia who require exogenous insulin are at risk
for development of refeeding syndrome upon receipt of insulin, because the
5.
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sequence of events leading to influx of electrolytes and glucose into cells will begin.
Monitor electrolytes: Often, when first diagnosed and before refeeding starts, the
metabolic panel will appear normal, only to become abnormal once feeding
begins. Monitor electrolyes (K, P, Ca, Mg) every 4 to 6 hours at the beginning of
refeeding for up to 2 weeks and replace low levels as needed.
6.
Phosphorus drops to its lowest point in the first week of refeeding the starved patient.
Recommendations are to monitor serum phosphorus daily and supplement as
necessary during the first week of refeeding the severely starved (Less than 75%
ideal body weight) (Ornstein, 2003).
7.
Other recommendations are to correct electrolyte and fluid imbalances prior to
refeeding. Initiate replacement therapy for electrolytes as needed (Solomon, 1990).
Monitor electrolyes (K, P, Ca, Mg) every 6 hours at the beginning of refeeding for 3
days (some rec 7 days) and replace low levels as needed. Usually resumption of oral
feeding will replace minerals and vitamins naturally but if serum levels fall then
replacement is warranted.
8.
For an up to date review on refeeding syndrome see Khan, 2011. 9.
Specific Nutrients to Monitor when Refeeding Anorexic Children/Adolescents
Thiamin
Thiamin has a half-life of 9.5 to 18.5 days and thiamin deficiency can develop within 28
days of inadequate intake. Patients at risk for refeeding syndrome should receive adequate
thiamin and magnesium (McCray, 2005, Khan, 2011)). Thiamin levels are frequently low in
the anorexic patient and thiamin requirements will increase with refeeding as thiamin
derived intermediates (thiamin pyrophosphate), used in carbohydrate metabolism are
synthesized. This metabolic intermediate requires magnesium to function, so magnesium
should also be given with thiamin. Various guidelines for repletion doses of thiamin exist,
ranging from 50 mg given intramuscularly daily for adults to a 24 hour infusion of 1 gram of
the vitamin. Guidelines for the pediatric population state thiamin at 1-2 mg/kg,
intramuscularly at least 30 minutes prior to the start of refeeding is recommended. A
multiple vitamin/mineral supplement is often given at the start of refeeding and represents
a conservative approach to supplementation.
Protein
During initial refeeding of children with anorexia ages 8 to 18 years of age, protein intake of
0.6 to 1.0 gm/kg/day is recommended. 0.8 to 1.0 gm/kg/day is required for anabolism.
During initial refeeding high intake of protein can cause hyperammonemia and/or metabolic
acidosis due to renal capacity for excretion of hydrogen ion and phosphate being
exceeded.
Zinc
Numerous reports have documented low zinc in both anorexia nervosa and bulimia
nervosa patients (McClain, 1992). Zinc supplementation is often recommended.
Iron, folic acid
Often patients with eating disorders are anemic due to deficiencies of iron and folate.
Refeeding can correct this but if severe anemia is present then replace using
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supplementation appropriate for age. In children who have become vegetarian/vegan also
check vitamin B
12
levels and supplement as necessary.
Calcium and Vitamin D
Osteopenia is evident in up to 90% of adolescents with anorexia nervosa. If the diet is low
in calcium, provide a supplemental form to reach the current Dietary Reference Intake for
age and gender. Vitamin D status of many individuals is low due to lack of sun exposure
and lack of dietary vitamin D, so providing supplemental vitamin D is warranted.

Other Feeding Complications and possible solutions:
Constipation
Ensure adequate fiber intake and fluids. Monitor that fluid intake is not excessive. One
suggestion for adding fiber: use ground flaxseed. It should be kept refrigerated. Whole
flaxseed has a longer shelf life; if the patient has a home coffee grinder and is willing to
grind small amounts at a time, this may be an effective method. Start with one teaspoon a
day, and gradually increase the dose (about 1 tsp every other day) up to three tablespoons
a day.


Delayed gastric emptying
Reassure family and patient that this is common. Use of small meals more frequently
helps. Allowing the child to eat slowly, although not too slowly, can help. Many patients
with eating disorders eat very slowly, and programs often enforce time limits on meals so
slower eating has to be cautiously suggested. Once the patient has started to gain weight
and has been eating well for a few weeks this problem usually resolves.

Intestinal lipase and lactase reduction
These may cause temporary gastrointestinal distress upon initial refeeding in patients
who have severe malnutrition.

Step-down and outpatient settings
After the acute phase many anorexic patients become hypermetabolic and require high
calories in order to continue to gain weight. In anorexia nervosa, the number of calories
required for weight gain increase as weight increases and over half of the increased weight
gained in refeeding will be adipose tissue (Salisbury, 1995). This is normal in feeding after
starvation. The registered dietitian should resist the temptation to have “normal” body
composition attained upon initial refeeding because of the high proportion of adipose tissue
gained during this phase.

Additionally, several investigators have shown the distribution of adipose tissue attained
during refeeding is disproportional and located in the abdomen and trunk
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during refeeding is disproportional and located in the abdomen and trunk
regions. Compared to controls, refed anorexic patients had more fat mass in the truncal
area (Golden, 2004).

Weight gain goals of 1 to 2 lbs (0.5 to 1.0 kg) per week are recommended in an outpatient
setting with calories added until this goal is met. Frequent evaluation of calories and dietary
intake is sometimes needed when goal weights are not achieved. Evaluation of calorie
needs is set against careful monitoring of eating behaviors, which the team, including
parents, can contribute to. Often in anorexia as well as bulimia, patients will not eat the
necessary amount of food unless watched very closely, so before recommending more
food and calories it is wise to make certain that what is currently given to a child is actually
being consumed and retained. Family Based Therapy is especially useful for training
caregivers to monitor food intake and ensure that food is eaten and retained.

In anorexia nervosa, refeeding to a weight that restores physical and mental functioning
and is 100% of ideal body weight or determined weight for age and height (see Julie
O'Toole's determination of target weight) is associated with better prognosis.
Higher percent body fat is associated with better outcome in anorexia nervosa
patients (Laurel, 2007) and greater dietary variation as well as greater dietary energy
density are predictive of more favorable outcome in anorexia nervosa (Schebendach,
2008).
In some patients, after weight restoration, and with consideration for the amount of physical
activity the patient is allowed (restoration of physical activities also proceeds gradually and
is determined by the medical team based on medical stability), the diet has to be modified
again to account for physical activity and growth. Consult with the medical professional
about growth potential to determine whether calories need to be adjusted for potential
growth.


Stages of Illness

Two related concepts need to be appreciated in order to understand eating disorders:
illness severity and the stage of the illness.
Eating disorders manifest themselves as an interplay between psychological, behavioral,
and physical symptoms that vary in terms in terms of type and intensity. While the primary
disorder is psychological, the psychological distortion drives the behaviors and
the resultant physical deterioration.
Recent work on standardizing the stages of eating disorders could be helpful to clinicians in
terms of how to orient therapy and communicate with one another (Maguire, 2008). The
severity of anorexia nervosa is often presented in terms of the degree of medical
compromise using markers of health such as Body Mass Index; however, several
researchers have proposed developing a staging system based on symptom severity,
similar to the staging system used in staging cancers (Maguire, 2008).
Historically, three stages have been described for anorexia nervosa. The first stage is
characterized by feelings of uneasiness after eating or uneasiness with certain foods. The
next stage is characterized by more severe food restriction, increased physical activity, and
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the oft-described mental state of denying of the illness, along with a sense of
accomplishment when weight loss and restriction are achieved. The third stage displays
increased debility, emaciation, and physical deterioration.
Eating disorders vary in terms of severity (Maguire, 2008). Severity generally increases as
a person with an eating disorder progresses through the stages of the illness, as described
above. Some patients do not seem to enter into later stages of the illness; they may have a
form of eating disorder that never becomes very severe. These patients might get well
almost on their own, or respond very well to simple instruction, including information about
how to eat appropriately, in combination with behavioral approaches like cognitive behavior
therapy (CBT) or dialectical behavioral therapy (DBT). Other people with eating disorders
go through all stages of the illness, from preoccupation with food and body image, to
severe restriction. They are more resistant to interventions and require careful monitoring
to ensure that they are eating.
Depending on the severity and stage of the illness a person with an eating disorder will
receive care in one of several settings, including inpatient settings (for those who meet
criteria for hospital admission), outpatient settings and day treatment units, residential
treatment programs, home based refeeding, or traditional individual therapies.
Refer to the Treatment Philosophies section for more information regarding why one may
be chosen over another.

TYPES OF TREATMENT
inpatient
outpatient or day treatment programs
residential
family based home feeding
individual counseling
The role of the registered dietitian (RD) will vary depending on what type of treatment for
eating disorders is offered and where the RD is working. Keep in mind that in the treatment
of the pediatric population, family inclusion is now considered a best practice, and that
nutrition education alone for a sick child is rarely sufficient to change eating behaviors.
Nutrition education can create anxiety in the child and thus be counterproductive. The RD
has to bear in mind their scope of practice and be realistic about initiating behavioral
therapies for which they are not trained. (ADA, 2006)
Inpatient settings
Inpatient settings are used primarily for medically fragile persons (see criteria for
hospitalization for AN and BN). In this setting an RD may be asked to provide nutrition
advice about refeeding syndrome, supplements, high calorie supplements, and calorie and
weight targets. Current evidence does not support the efficacy, in terms of long-term
weight maintenance, of simply feeding a patient until they are no longer medically fragile
and then discharging them without follow up care. Some inpatient settings may employ
nasogastric tube feedings, if necessary, to promote weight gain, and the RD may be asked
to calculate rate of feeds and recommend formulas (Baran, 1995).
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to calculate rate of feeds and recommend formulas (Baran, 1995).
Outpatient programs
If a person is not medically fragile then often they will be enrolled in an outpatient
treatment program. Some inpatient programs offer a step-down unit or next-step outpatient
program as follow-up to the inpatient setting. This can take the form of individual therapy,
or an organized program where multiple therapies are used (eg, art therapies, relaxation
programs, or cognitive behavioral therapy). These programs vary considerably. Therapy
may be aimed at normalization of cognitive distortions about body image and food,
resolution of family relationship issues, resolution of feelings related to trauma, or other
personal issues. Not all of these therapeutic approaches are based on evidence but on
assumptions about eating disorder etiology.
Food selection and preparation is often done for the patients. The RD may be involved in
menu preparation, food selection for individuals, group nutrition classes, family nutrition
classes, and providing nutrition information to the rest of the treatment team (including
supplements, height/weight info, anthropometric info, and monitoring of nutrient intake).
The RD might also work directly with patients, educating them about how to eat healthfully
and giving strategies about how to eat throughout the day.
Residential treatment programs
These are long-term programs where the patient is usually separated from family members
and lives at the treatment facility. Therapy may again be aimed at resolving personal
issues, management of stress, or finding appropriate coping skills. Goals toward
normalizing eating and weight gain are set, and the patient is moved toward those goals
using various therapeutic methods, often behavioral in nature. Individual and group
therapy, medical monitoring, and nutrition education can all be part of these programs. In
these programs, the RD may be asked to develop menus, set target weights, monitor
weights and anthropometrics, teach nutrition and food preparation, and provide nutrition
education to staff and family (if the family is included as part of the treatment).
Individual Counseling
Some children with eating disorders are referred for individual counseling with someone
trained in psychotherapy, social work, or psychiatry. The question of why the eating
disorder developed is often central in this type of therapy, with the idea being that if the
“why” is discovered, then the patient will be able to work on the “why” and start to separate
disordered eating behaviors from other issues in their life. Resolving issues that precipitate
the eating disorder and reduction in anxiety are often goals, along with weight gain and
cessation of binging and purging behaviors. Many therapists do not use an RD, but at
times an RD is called upon to give nutrition information to the therapist or client and
possibly create an eating plan. Current evidence does not support long-term
psychotherapy alone in treating eating disorders, especially without physical restoration.

Treatment Philosophy and Modalities

Some invalid assumptions about eating disorders have driven various ineffective forms of
treatment. Given the emerging science about eating disorders, these assumptions will be
replaced with factual information.
Some invalid assumptions have included:
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A person with an eating disorder is choosing the behaviors for some reason and that
they can willfully control aspects of their dysfunctional eating.
Families and family pathology is central to the development of an eating disorder.
Families need to be excluded from treatment or therapy for their child.
With psychotherapy the patient will discover underlying causes for their eating
disorder and can then work toward overcoming it.

When treatment is based on inappropriate assumptions about causality, the medical
condition of an affected child generally deteriorates. Due to the effects of starvation on
brain function, treatment consisting of only nutrition education, or cognitive therapies aimed
at determining causal factors while not restoring weight, are ineffective and often
counterproductive. Today this approach is considered against current best practice (Lund,
2009).

Nutrition intervention alone is not considered best practice, especially if it only consists of
nutrition education. It is even less effective to only provide nutrition counseling or education
to a child or adolescent alone, without involvement of the family and caregivers.

Traditional individual psychotherapy has assumed that one must first change the mind or
mental state of the patient, or teach them appropriate ways to eat, and then weight and
health will be restored. In actuality, the reverse has proven to be true. When weight is
restored the mental state is able to return to normal, and then the pati is able to learn,
eventually, how to eat healthfully and with less anxiety.


What is effective treatment?

Research about effective treatments for eating disorders has revealed the following:

Any treatment needs to be effective within a short time frame in reversing weight loss
and stopping purging behaviors, with resultant weight gains and restoration of
physical functioning. Any treatment that does not accomplish this should be
considered ineffective.
1.
When weight and physical functioning are restored, then the person can make better
progress in psychotherapy, the mental state is able to recover and the person can
learn how to eat appropriately.
2.
There is no evidence to warrant excluding parents from their child during therapies or
to assume that parents play no role in treatment. In fact, strong evidence now
supports the practice of including the parents or other caregivers and siblings, which
addresses the needs of the whole family and utilizes the family as a resource in
treatment (Le Grange, 2009).
3.
Evidence strongly supports the fact that early and aggressive treatment, with quick
restoration of weight and cessation of restricting and purging behaviors, is associated with
the best prognosis. Evidence supports involvement of the family in treatment of pediatric
eating disorders. Specifically, the Maudsley model or Family Based Therapy (FBT) has
been studied and emerged as most effective in comparison to other forms of treatment for
the pediatric population (Keel, 2008). More details about the FBT approach follow in the
section on Family Based Therapy.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

The general course of treatment regarding nutritional rehabilitation for anorexia nervosa is:

Ensure medical stability through a knowledgeable medical team, experienced in the
early feeding of patients at risk for refeeding syndrome. Identify those at risk and feed
according to an established protocol to avoid complications from re-feeding syndrome
(see criteria for hospitalization).
1.
Once the patient is medically stable, gradually increase macronutrients so that weight
gain is achieved. In pediatrics the evidence is strong that this part of treatment can be
done in the home, under medical supervision, coaching the family in the supportive
role of refeeding.
2.
Monitor for micronutrient deficiencies and correct if suspected or present. 3.
Monitor and stop exercise in the initial phases to allow for weight gain and return of
normal physical functions. Excess exercise is seen as a purging behavior, as it rids
one of unwanted calories.
4.
Once target weight is achieved, ensure that weight remains stable. This is an
important step to avoid relapse. Monitoring of food intake and exercise is needed until
the patient shows an improvement in attitude about eating, is comfortable with age
appropriate feeding skills.
5.

The emerging course of treatment for bulimia nervosa (BN) is similar except that far fewer
individuals are hospitalized with BN or binge eating disorder. Therapy in BN involves
maintenance of weight and cessation of extreme dieting and purging behaviors. Evidence
is strong for use of antidepressants in this population along with therapy to stop binging
and purging. The family is involved in normalization of feeding, monitoring food intake and
closely watching the child after eating to ensure purging behaviors are not maintained
(Lock, 2005).
Evidence exists for therapies for bulimia nervosa that include pharmacologic therapy and
cognitive behavioral therapy (Shapiro, 2007).



Anthropometric Measurements

Anthropometric measurements include height, weight, and body mass index (BMI). This
might have been already done by the doctor; if so, do not repeat as this kind of
measurement can provoke anxiety. However, height and weight need to be
measured accurately in order to determine correct BMI, which many clinicians use as part
of the assessment of a person's degree of starvation and which is used to make decisions
about patient management, such as whether or not to hospitalize. Height cannot be
estimated or taken by report but needs to be measured using a stadiometer. Weight needs
to be measured on a medical quality beam or digital scale. Compare BMI to standards: If
low, raise concern for the patient.
History of weight loss
Note that a child might have weight and BMI within normal limits but may have recent
history of rapid weight loss, and so could be severely compromised in terms of vitals.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Presentation of a nomal weight does not mean an eating disorder has not emerged.
The referring physician may have done Tanner staging on the child, which is helpful in
assessing potential for growth and therefore caloric needs or changes to caloric needs over
time. For example, if a child has yet to go through an adolescent growth spurt then one can
anticipate that this will happen, then monitor growth over time and adjust calories
accordingly.
Measure the percentage of target weight based on lifetime growth charts (see
Growth Charts).
The percentage of body fat is measured with skinfold calipers, multi-site if recommended
by the team. This kind of measurement can provoke much anxiety in a child with an eating
disorder so only perform this type of analysis if absolutely necessary and recommended by
the medical and psychological team.

Food/Nutrition-Related History

Factors to consider in the food history of a patient with an eating disorder:
Fluid intake
Current food intake: Assess by parental report of current foods eaten and
approximate measure of volume.
Dietary assessment: Pinpoint specific nutrients that may be low. Use 5 pass method
or 24 hour recall with information supplied by parents/caregivers.
Physical activity
Menstrual history
Purging behaviors present or not
Caffeine consumption
Food rituals
Foor beliefs; "good food/bad food" or food phobic beliefs
Departure from family food norms
Body image thoughts, beliefs

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Nutrition Care > Behavioral Health > Mood Disorders
Nutrition Assessment

A thorough nutrition assessment should be performed for every child who is identified to be
at nutritional risk. Follow the age-appropriate guidelines. Adequacy of the diet for
macronutrients and micronutrients, as well as potential food or nutrient and
drug interactions with any medications or supplements taken, should be assessed.

Client History

History from patient or caregiver:
Weight, height, and pattern of growth
Usual activity level and/or exercise routine
Usual/typical food and beverage intake
Meals
Snacks
Water
Sport drinks
Milk
Sodas
Juice
Coffee
Tea
Alcohol
Changes in appetite, presence of nausea/vomiting
Medications or supplements taken
Any allergies, intolerances, or negative reactions to previous medications
Drug or alcohol use or abuse
Thirst, constipation, diarrhea
Food allergies or intolerances/omissions
Dental problems influencing eating
Perceived energy level, mental energy level (ILSI, 2006)
Any personal or family nutrition/health goals
Cultural, ethnic, religious, and/or personal preferences
Questions regarding food or foodservice
History from medical record:
Psychiatric diagnosis
Medical history
Laboratory assessments
Medications or supplements prescribed
Living situation
Possible food insecurity of patient and/or family
Functional level/ability of patient and/or family (caregiver) to prepare food

Biochemical Data, Medical Tests and Procedures

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Laboratory work may be indicated when nutrient–drug interactions are indicated, such as
electrolytes for a patient taking lithium.
With some of the newer antipsychotics, which may cause weight gain in patients,
hemoglobin A1c may be indicated.
Consider diet intake records and activity levels as related to weight gain, HgA1c, and/or
elevated triglycerides for patients taking antipsychotic medications.

Anthropometric Measurements

Increases or decreases in appetite, along with weight gain or loss caused by medication,
indicate a need to monitor weight and growth.
Follow standards of care for age: Length or height; weight; and, depending on age, weight
for height or body mass index should be measured at initial assessment and follow-up
visits, and should be plotted on the appropriate growth chart of the Centers for Disease
Control and Prevention.

Food/Nutrition-Related History

A complete food history, food frequency, and/or a 24-hour recall should be completed to
assess adequacy of the diet, including macronutrients and micronutrients, and balance of
the diet from a variety of foods and food groups. If the patient is taking any medications or
supplements, this should be correlated with any food–drug interactions. Results from this
assessment may indicate a need for laboratory tests.

Nutrition Diagnosis

Dietitians working with patients who have mood disorders should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Excessive energy intake (NI-1.5)
Inadequate oral food/beverage intake (NI-2.1)
Excessive oral food/beverage intake (NI-2.2)
Excessive alcohol intake (NI-4.3)
Inappropriate intake of types of carbohydrates (NI-5.8.3)
Inadequate fiber intake (NI-5.8.5)
Predicted suboptimal intake (NI-5.11.1)
Predicted excessive nutrient intake (NI-5.11.2)
Food- and nutrition-related knowledge deficit (NB-1.1)
Harmful belief/attitudes about food or nutrition-related topics (NB-1.2)
Not ready for diet/lifestyle changes (NB-1.3)
Self-monitoring deficit (NB-1.4)
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Limited adherence to nutrition-related recommendations (NB-1.6)
Undesirable food choices (NB-1.7)
Physical inactivity (NB-2.1)
Inability or lack of ability to manage self-care (NB-2.3)
Impaired ability to prepare foods/meals (NB-2.4)
Limited access to food (NB-3.2)
Unintended weight loss (NC-3.2)
Unintended weight gain (NC-3.4)
Sample PES or Nutrition Diagnostic Statement(s)
Unintended weight gain (NC-3.4) related to initiation of new prescription for ___ as
evidenced by gain of __ lbs in past 2 months.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition Intervention is the third step in the Nutrition Care Process. Nutrition interventions
are based on the nutrition diagnosis.
Nutrition therapy often includes the following:
Determining meal structure/timing/composition for stabilizing mood and controlling
hunger
Recommending nutrient-dense foods for nutritional adequacy while minimizing the
risk of weight gain
Planning for fiber and fluid intake adequate for bowel regularity while taking
psychotropic drugs
Planning for appropriate low-energy fluid choices to counteract dry mouth and prevent
excess intake of energy and caffeine
Nutrition interventions should address the following, as appropriate:
Nutrient–drug interactions such as constipation or inadequate or excessive fluid
intake, or a need for tyramine restriction. It is advisable to focus on minimizing the
consequences of any side effects of medications, while recognizing the value of such
drugs in treatment of the mood disorder.
Weight changes, with goals for energy intake and exercise accompanied by an
individualized eating guideline and sample meal plan. Inclusion of appropriate snacks
will help address alterations in appetite. Regular follow-up is recommended. Referral
to a nutrition education and exercise group, when available, is helpful.
Access to adequate and acceptable meals in the hospital, at home, or in a residential
facility or other living situation.
Education and instructions should accommodate the individual’s emotional and
mental status; education level; interest; and other personal factors such as religious
beliefs, cultural habits, and food preferences. The age of the child will affect the focus
of individual or family education and instructions.
Commonly used nutrition interventions include the following:
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ND—Food or Nutrient Delivery
Meal and snacks: Regular eating event (meal); food served between regular meals
(snack)
1.
ND 1.1 General/healthful diet
ND 1.2 Modify distribution, type, or amount of food and nutrients within meals or at
specified time
ND 1.3 Specific foods/beverages or food groups
3.2 Vitamin/mineral supplements
ND 3.2.1 Multivitamins/minerals
ND 3.2.2 Multitrace elements
ND 3.2.3 Vitamin: specify
ND 3.2.4 Mineral: specify
E—Nutrition Education Content and Nutrition Education Application
Initial/brief nutrition education: Build or reinforce basic or essential nutrition-related
knowledge.
1.
E 1.1 Purpose of the nutrition education
Comprehensive nutrition education instruction or training leading to in-depth,
nutrition-related knowledge or skills.
2.
E 2.1 Purpose of the nutrition education
E 2.2 Recommended modifications
C—Nutrition Counseling
Theoretical basis/approach: The theories or models used to design and
implement an intervention
1.
C 1.2 Cognitive-Behavioral Theory
C 1.3 Health Belief Model
C1.4 Social Learning Theory
C1.5 Transtheoretical Model/Stages of Change
Strategies: Selectively applied evidence-based methods or plans of action
designed to achieve a particular goal
2.
C 2.1 Motivational interviewing
C 2.2 Goal setting
C 2.3 Self-monitoring
C 2.4 Problem solving
C 2.5 Social support
C 2.6 Stress management
C 2.7 Stimulus control
C 2.8 Cognitive restructuring
C 2.9 Relapse prevention
C2.10 Rewards/contingency management
RC—Coordination of Nutrition Care
Coordination of other care during nutrition care: Facilitating services with other
professionals, institutions, or agencies during nutrition care
1.
RC 1.1 Team meeting
RC 1.2 Referral to registered dietitian with different expertise
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RC 1.2 Referral to registered dietitian with different expertise
RC 1.3 Collaboration/referral to other providers
RC 1.4 Referral to community agencies/programs


Nutrition Prescription

The nutrition prescription may include any of the following principles:
Sodium: A consistent, moderate, intake of sodium is required for maintaining a stable,
effective level of blood lithium from a given dose of medication (Pronsky 2006).
Grapefruit juice: Omit from the diet, as it interacts with many psychotropic drugs;
intake can inhibit normal breakdown of the drug and increase active blood levels
(Wiens, 2000). Other beverages may contain grapefruit juice, including Sunny
Delight and Squirt (carbonated soft drink).
Monoamine oxidase inhibitors (MAOIs) are not typically prescribed for children or
adolescents. A diet providing minimal tyramine is recommended if a monoamine
oxidase inhibitor medication is prescribed (Hazell, 2009).
Offer meals/snacks with the recommended percentage fat to improve absorption of
antipsychotic medication (Ziprasidone HCL [Geodon])

Goal Setting

The overall goal is to promote optimal nutritional status for growth and development.
Depending on the age of the child or adolescent, goals may be designed for the patient
and/or the family or caregivers to implement.
Structuring time and composition of meals and snacks for mood stability and hunger
control
Bipolar manic phase: Often persons in the manic phase of bipolar disorder will
expend significant energy with increased activity and decreased sleep, which are
common symptoms of this phase. They also may either not acknowledge hunger
or may not be able to focus on specific tasks long enough to obtain a meal.
Cues (such as alarm clocks) to remind these individuals to take time to eat may
be necessary.
Depression: A written plan removes the need for those with depression to make
a decision to eat. The family of a child with depression may create an
incentive program for appropriate food intake.
Psychotropic medications: A planned schedule for eating can help counteract
appetite stimulation, food cravings, and dry mouth
Adequacy of nutrient intake
Nutrient-dense foods for nutritional adequacy while minimizing the risk of
unwanted weight gain or weight loss
Inclusion of all food groups each day
A moderate-level, complete multivitamin supplement daily
Adequate fiber and fluid intake for bowel regularity
Omission of foods or beverages that may cause an unwanted nutrient–drug
interaction
Lithium requires a consistent, moderate intake of fluid and sodium.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Grapefruit juice inhibits cytochrome 450 and affects the metabolism of many
psychotropic drugs; it is prudent to omit grapefruit juice when taking these drugs
(Wiens, 2000). Also check ingredients of other beverages; some fruit drinks and
sodas contain grapefruit juice.
Alcohol is contraindicated with many psychotropic medications.
Tyramine intake should be restricted with monoamine oxidase inhibitors
(although this is not typically prescribed for children or adolescents).

Nutrition Support

Nutrition support guidelines for children with mood disorders are the same as those for
other children. For detailed information on pediatric enteral and parenteral nutrition, go to
the following sections (available on the Resources tab):
Enteral Nutrition
Parenteral Nutrition

Nutrition Monitoring & Evaluation

Nutrition monitoring may include tracking growth patterns and dietary intake. Nutrition
goals and interventions should be adjusted when the goals are met or when an intervention
is determined to be ineffective.
If the intervention is not being implemented as prescribed, the registered dietitian works
with the family and other members of the health care team to identify barriers to
implementation. Addressing these issues may include arranging for additional resources,
referring to other professionals, and collaborating with other care providers (Charney,
2009).

Nutrition Therapy Efficacy

If adequate guidance, support, and motivation are provided, psychiatric patients of any age
may be expected to be successful with weight gain, loss, or maintenance and meeting their
nutrient needs. For the pediatric population, the parents or caregivers will most likely need
to be involved for successful changes to be made.
According to observations regarding adult patients made by Allison et al (2009), “Many of
the weight-management strategies used in the general population may be applicable to
those with mental disorders, but little is known about the effects of these strategies on this
patient population or how these strategies may need to be adapted for the unique needs of
those with mental disorders. The minimal research on weight-management programs for
those with mental disorders indicates that meaningful changes in dietary intake and
physical activity are possible.”
“Adequate” guidance and support may be influenced by an individual’s mental state.
Depression and bipolar disorder alter motivation to change and ability to concentrate,
as well as appetite and activity level, often in opposite directions.
A food intake using the described nutrition prescription and goals can meet nutrient
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
recommendations if high-nutrient foods are selected and energy level is sufficient.
An individual with a history of poor intake may benefit from a complete
vitamin-mineral supplement to restore tissue levels while eating habits are improving.
(Allison, 2009)


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Burns
Nutrition Assessment

Nutrition assessment is the first of four steps in the Nutrition Care Process. Nutrition
assessment includes use of nutrition-focused physical findings; client history; biochemical
and laboratory analysis; anthropometrics; and diagnostic measurements such as indirect
calorimetry and dual energy x-ray absorptiometry.
Fundamental to the application of this process in assessing pediatric burn patients is the
understanding that many conventional indicators of nutritional status are altered by the
physiologic response to trauma or by the various aspects of burn care
management. Following are a number of confounding elements that are typically
encountered when evaluating pediatric burn patients:
Nutrition-Focused Physical Exam
Visual inspection of muscle and fat stores is hindered and difficult to observe,
particularly in patients with extensive burn injury.
Subtle signs of micronutrient deficiency can be obscured by the physical trauma of
the burn injury itself.
Anthropometric Measurements
Initial assessment of growth status is complicated by aggressive fluid
resuscitation immediately following burn injury and the inability to obtain a
standing height.
Body weight fluctuates with changes in extracellular water during both resuscitation
and mobilization of fluid during the stress response (Prelack, 2004).
The effect of burn escharatomies, particularly in larger children, can account for
significant weight loss, despite nutritional adequacy.
Biochemical Data
Downregulation in the synthesis of visceral and carrier proteins during the acute
phase response invalidates measures of albumin; prealbumin; and plasma measures
of specific nutrients such as calcium, vitamin D, and zinc.
Nitrogen balance studies can be flawed by incomplete urine collections, difficulty
estimating total losses, and an upward shift in the ammonia component of total urinary
nitrogen.
Certain biochemical endpoints (including nitrogen balance and serum protein levels)
do not clearly relate to clinical outcome (Carlson, 1991)
Client and Food-Related History
Although children generally have a less extensive medical history as compared to
adults, useful information related to a patient's diet, food, and social history may
be lacking at the time of admission.
Because of limitations in the client history, a greater reliance on burn-related proxies
such as wound healing and graft take—along with critical evaluation of nutritional
indices, particularly in the context of which they are obtained—is necessary for an
assessment to be practical.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Nutrition-Focused Physical Findings

A physical exam in pediatric burn patients is best accomplished during wound dressing
changes, when patients can be fully visualized. Most children are well nourished prior to
the injury. For them, physical observation can help distinguish between children who are
small in size but well nourished as opposed to children who may be nutritionally
compromised.
Because height is often unavailable (and measures of length can be flawed), calculated
body mass index may be misleading whereas a patient's general appearance is useful.
Parental stature is also useful to note when evaluating the size of the child. Patients who
are overweight should have edema or increased lean body mass ruled out before
confirming the presence of obesity and making adjustments in energy or substrate intake.
In patients who are past 3 weeks from their initial injury or are suspected of experiencing
malnutrition, temporal and extremity wasting may be already apparent. An overall
inspection of hair loss and nails in these patients is done when possible to determine if
micronutrient losses have occurred.
Physical inspection should continue throughout the patient's hospital stay. Observation of
donor wounds and their healing provides some indication of nutritional adequacy. In
addition, as patients begin to mobilize their fluid, the extent of muscle wasting due to
increased catabolism can be appreciated, particularly given their prolonged length of stay.
As the patient transitions to the rehabilitative phase, be mindful of particular factors that
may be contributing to the child's ability to take in adequate intake, such as the location of
the wound, oral dentition, and burns to the hands or contractures that may make it difficult
for the patient to self-feed. In addition, factors that may limit the child's physical activity long
term are important, as they may impede physical activity and growth during convalescence.


Client History

Medical and Surgical History
Most children admitted with an initial acute burn injury do not have extensive pre-burn
medical or surgical history. However, review of their burn-related history and current
problem list is useful in identifying hemodynamic stability, priorities in nutrient and
electrolyte management, metabolic risk factors, and anticipated problems with feeding.
Respiratory Status
Inhalation injury augments inflammation and imposes additional nutritional risk. In general,
any patient requiring ventilatory support will likely require nutrition therapy altered with
respect to the following:
Fluid intake
Restriction may be required
Energy intake and diet composition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Overfeeding should be avoided
Enteral products designed for respiratory distress may be useful
Diets high in omega-3 fatty acids, antioxidants with moderate carbohydrate
intake may be beneficial (Pacht, 2003; Marin, 2009)
Mode of ventilatory support and progress with weaning
Monitoring helps determine feasibility of indirect calorimetry measurements and
work of breathing
Wounds and Grafting
Initial wound size and depth are always included in nutrition assessment and planning. The
magnitude of the inflammatory response in burn injury increases with burn size until it
plateaus after reaching 50% total body surface area. Following are factors related to wound
size and surgical grafting that may affect nutrition assessment and intervention:
Most patients with initial burn injuries of more than 30% total body surface area will have
the following:
Requirement of artificial nutrition support to meet nutrition needs
Some element of lean tissue loss and muscle wasting
Possible hyperglycemia and electrolyte imbalances
Repeated operative visits
Extended length of hospital stay
Impaired growth during convalescence
Current open wound size (including donor wounds) should be routinely assessed due to
the following:
Hypermetabolic response may correlate with percent open wound (Cone, 1988)
Protein breakdown (whole body and skeletal) decreases with wound closure (Prelack,
2010)
Due to the presence of other factors such as infection, sepsis, and inflammation,
energy expenditure and muscle breakdown do not completely abate with wond
closure (Hart, 2000; Demling, 1991)
Donor wound wounds should heal in 7 to 10 days. Poor healing of donor wounds could
be the result of compromised nutrition. Weight loss due to amputation should be noted and
goals reassessed as indicated.
Gastrointestinal
Information that should be gathered to determine appropriate route and timing of feeding
include the following:
Gastric output and residuals
Bowel history
Abdominal girth
Feeding access (gastric and enteral tubes)
Medications
Following are pertinent medications in burn therapy that affect nutrition care:
Hemodynamic stability and the need for inotropes and vasopressors can be used as
a proxy for determining the appropriateness of aggressive enteral feeding. In these
instances, trophic feeds may be a better alternative until the patient stablizes. In one
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
study of burn patients receiving early enteral feedings, a small number of patients
experienced adverse outcomes including bowel necrosis to aggressive enteral
support. Some common characteristics included the requirement for high dose
inotropes and vasopressors, abdominal distention and other symptoms of septic
onset (Gottschlich, 2002). There are also case reports of small bowel necrosis in
patients receiving early enteral support during critical illness with these similarities
(Munshi, 2000). The incidence of small bowel necrosis to date is rare, however, given
the high mortality rate associated with it, cessation of enteral feedings during
episodes of sepsis, hypoperfusion, or prior to the completion of fluid resuscitation is
advised.
Sedatives and pain medications can minimize total energy requirement either
metabolically or by minimizing energy expenditure related to pain, anxiety, and
physical activity
Patients who are on insulin protocols should have diet therapy coordinated to protocol
guidelines
Anabolic steroids or beta blockers diminish muscle and protein breakdown and
minimize losses body cell mass (Wolf, 2003)
Medications with potential drug–nutrient interactions such as anticonvulsants,
anticoagulants, and antibiotics should be identified so that nutrition education
or dietary adjustments can occur.
Chronic Disease
Patients with history of disease who have metabolic or endocrine implications—such as
diabetes, cystic fibrosis, failure to thrive, or other chronic disorders—will require alterations
in macronutrient intake and composition as well as electrolyte and micronutrient
management.
Social History
Familiarity with the circumstances of a child's home environment is useful particularly for
discharge planning.
Parental/family structure
Long-term outcomes in burn patients with a stable family network is improved
(Sheridan, 2008)
Income, ethnicity, and global region can influence food sources and accessibility
and obstacles to food procurement, particularly protein sources once discharged
Emotional disposition and attitudes about food and body image may effect nutrient
intake, physical activity, and the growth process
Diet History
Post-burn diet: Patients who are transferred from another facility, or who have gone for an
extended period of time without adequate nutrition are at high risk for malnutrition and
refeeding syndrome (an insulin-induced intracellular shifting of phosphorus, potassium, and
magnesium due to rapid introduction of feeds, and related consequences). Information on
dietary intake (enteral tube feedings or oral intake), feeding regimen, or issues related
to intolerance of the feeding regimen from the admitting hospital or unit will allow for
continuity in the nutrition care plan, and prevent intolerance or metabolic complications.
Pre-burn diet: Information on a child's normal nutritional intake is useful in assessment of
nutritional status as well as future goal setting. Immediate screening for food allergies or
intolerances is required, as this may need to be incorporated into nutrition interventions.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Factors to consider include the following:
Usual appetite
Food allergies/intolerances
Ethnic food practices
Difficulty chewing or swallowing
Nutritional supplement intake
Developmental stage feeding



Biochemical Data, Medical Tests and Procedures

Biochemical and Laboratory Analysis
Review of laboratory indices in nutrition care of the burn patient is useful to assess fluid and
electrolyte balance, metabolic acidosis, and organ function, as well as potential
complications that may respond to nutrition support including hyperglycemia, refeeding
syndrome, and altered bone physiology. Most critically ill children will have laboratory
analysis done as part of their routine medical management that is sufficient for the purpose
of nutrition assessment and support monitoring. It occasionally becomes necessary to
request additional biochemical indices for patients in the following circumstances:
Patients initiated on parenteral nutrition with or without lipids
Patients at risk for refeeding syndrome
Patients at risk for metabolic bone disease
Patients on medications with potential metabolic/nutrient interactions such as
insulin, anabolic steroids
Laboratory Assessment of Electrolyte and Organ Function During Nutrition Support
Electrolytes are altered in response to aggressive nutrition support, particularly during the
initiation of feeds. Burn wound losses and leaching due to dressing solutions can also
aggravate fluid and electrolyte homeostasis (Prelack, 2004). Other prominent burn related
changes in physiology and organ function include alterations in bone metabolism,
burn-induced pancreatitis (Ryan, 1995; Dylewski, 2008), and liver dysfunction.
Specific to burn patients are the following electrolyte and nutrient aberrations:
Sodium depletion resulting from silver-based dressing solutions
Renal losses of potassium and magnesium related to antibiotic therapy
Intracellular shifts in phosphorus with aggressive feeding
Elevated amylase and lipase due to burn-associated pancreatitis
Altered liver function tests with parenteral nutrition and oxandralone therapy
Alterations in vitamin D, calcium, and parathyroid hormone due to bone
demineralization
Laboratory Monitoring Schedule
This schedule reflects the basic level of monitoring for patients on metabolic support to
prevent complications and for monitoring of efficacy:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Measurement Monitoring Schedule
Electrolytes, Phosphorus,
Magnesium, Ionized
Calcium
Baseline, every 6 hours after
then initiation of nutrition support;
then twice daily
Glucose
Twice daily
Requires more frequent
monitoring when insulin used
Liver Function Tests Weekly
Triglycerides Weekly
Serum Albumin Weekly
Serum Prealbumin, Weekly
Urinary Urea
Nitrogen (UUN)
Weekly
C-Reactive Protein Weekly
Complete Blood Count Daily
BUN, Creatinine Daily
Amylase, Lipase Weekly
Vitamin D Weekly

Patients at risk for refeeding syndrome may require electrolyte, phosphorus, and
magnesium monitoring every 4 hours with feeding advancement
Patients receiving intravenous lipids: Baseline triglyceride level prior to initiating lipids,
then weekly. Intralipid administration should be held for patients at greater than 350
mg/d.
Bone Mineral Density
Studies have shown that bone mineral density can be negatively altered following severe
burn injury, resulting in osteopenia and increased risk of fracture. In some instances,
persistent bone demineralization can hamper growth for up to 7 years post–burn injury.
The degree of bone loss and growth delay appears to be related to burn size (Klein,
1998). Optimally, children with severe burn injury should be assessed for ostepenia and
bone mineral status. Dual energy x-ray absorptiometry is the gold standard for bone
assessment. In its absence, other diagnostic tools that can be used include computerized
tomography or x-ray of bone age. Patient risk criteria for bone depletion are as follows:
Older than 4 years of age
Major burn injury of more than 30% total body surface area (once wounds are
healed and patient enters rehabilitative stage)
History of severe burn injury (more than 50% of total body surface area) within the
past 7 years
Growth deceleration (a drop of 2 or more percentile channels)
History of fractures
For patients who receive dual-energy x-ray absorptiometry measures, values for bone
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
For patients who receive dual-energy x-ray absorptiometry measures, values for bone
mineral content are best interpreted using z-score values. It is imperative that z-scores are
determined with the appropriate reference population based on a patient's race, age, and
body size. In cases where patients are small for their age, z-scores should be determined
using height for age. Patients with z-scores equal to or less than –1 should be referred to
the physician. Patients may have additional biochemical indices measured for 25-hydroxy
and 1,25 hydroxy vitamin D, total and ionized calcium, osteocalcin, alkaline phosphatase,
and parathyroid hormone.





Indirect Calorimetry

Indirect calorimetry (IC) allows determination of energy expenditure by measurement of
respiratory gas exchange. Although there are limited data to determine if routine use
improves outcome in pediatric burns, IC is particularly useful for patients who require
extended periods of nutrition support, who fall outside of norms for weight or body mass
index, or who are not responding as expected to nutrition intervention.
The implications of underfeeding are intuitive, but the likelihood of overfeeding in critical
care is as great and has many deleterious effects, including increased ventilatory work,
impaired liver function, and hyperglycemia. Despite enhanced metabolism with critical
illness, mechanically ventilated children can have significant reductions in their resting
energy expenditure as a result of sedation, decreased activity, or reduced work of
breathing. The American Society for Parenteral and Enteral Nutrition recommends that
patients who are critically ill have their energy expenditure routinely measured whenever
feasible (Mehta, 2009). Patient subgroups particularly likely to benefit from IC include the
following:

Mechanically ventilated patients
Patients with conditions that may exacerbate energy expenditure such as sepsis,
pancreatitis, and long bone fracture
Patients who are malnourished
Patient with dramatic or persistent weight loss
Patients with lack of weight gain during rehabilitation
Obese patients
Patients with a history of chronic disease
Patients on oral diets ideally should be measured when fasting early in the morning. During
times when this is not possible, testing conditions should be documented and incorporated
into the final interpretation of the measurement. Patients receiving continuous enteral or
parenteral nutrition do not need to fast for IC as the measurement will include the thermic
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
effect of feeding and hence represent the current state of the patient. Other factors to
consider include the following:
Hemodynamic state
Febrile state
Degree of sedation
Ventilator settings
Nutritional state, including fasting or type of feeding
Patient movement and/or anxiety
Time of last wound dressing change, procedure, or physical therapy or operative
procedure
Patients should be hemodynamically stable, with fractions of inspired oxygen less than
50%. Measurements should not be completed within 2 hours of their last physical or
stressful procedure, or within 24 hours of an operative procedure.
Under these conditions, the measured energy expenditure (as opposed to resting energy
expenditure) is obtained and an activity factor is added. Typically 20% to 30% of the
measured energy expenditure is used to determine total energy expenditure (Goran, 1990;
Mayes, 1996). However, if the patient has had recent activity, more can be used. Likewise,
for patients who are extremely sedated, and are not receiving notable physical therapy or
painful procedures throughout the day, the addition of an activity factor is not necessary. In
these cases, total energy expenditure is equal to the measured energy expenditure.
The respiratory quotient (RQ) is used to determine the adequacy of intake and/or substrate
composition given. Typical guidelines for RQ are given below:
RQ >1 = overfeeding or high-carbohydrate diet
RQ 0.85-0.9 = standard mixed diet
RQ <0.7 = underfeeding or increased fat oxidation.
Measurements should be performed weekly or whenever there is a substantial change in
clinical status such as wound closure, extubation from the ventilator, sepsis, or change in
nutrition therapy.



Anthropometric Measurements

Anthropometry is an important tool for assessing nutritional status and growth in pediatric
burn patients. During the acute phase of injury, initial weight can be used to assess
preexisting nutritional status. Subsequently, serial measures of weight can serve as a proxy
for lean body mass loss despite confounding factors of fluid shifts and escharatomies if the
following simple guidelines are employed:
If patient has received fluid resuscitation prior to admission, obtain preburn weight by
history (if possible) for nutrition goal setting.
Note that significant loss in weight during the first week of admission may represent
diuresis from resuscitation vs lean tissue losses. This weight may provide a better
estimate of dry weight.
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Because further diuresis occurs with wound closure, upon entry into rehabilitation
phase, obtain a "new weight" for future goal setting.
Since admission height is unavailable, obtain a standing height following wound
closure. This can be assumed to be the patient's preinjury height since linear growth
is unlikely during acute phase of burn recovery.
Because the incidence and severity of growth retardation following burn injury are high,
longitudinal changes in height and weight are helpful for assessing growth problems
(Prelack, 2007). The use of a reference population makes it possible to compare growth in
children of different ages. Growth status if often expressed as a percentage of the
reference median, or percentile, or as a proportion of the standard deviation (z score).
Height-for-age, weight-for-age, and weight-for-height z scores are used internationally for
classifying child malnutrition. The following describe typical postburn growth phenomenon
in pediatric burn patients:

Severe burn injury results in wasting, as defined by a normal height-for-age but a low
weight-for-height z score. At the time of wound closure (despite aggressive support),
patients may appear to have wasting and can be expected to have dropped in weight
percentiles on the growth curve.
Catch-up growth in burn patients is delayed or absent; therefore, growth recovery
may not be apparent during the initial admission or subsequent follow-up visits.
Stunting—defined by a low height-for-age but a normal weight-for-height z score—is
often the result of chronic malnutrition and demonstrates longer recovery time
following illness or injury
Moderate stunting has been noted in the natural recovery of pediatric burn patients,
particularly those with large burn injury.

Food/Nutrition-Related History

Nutritional intake should be monitored closely to evaluate nutritional adequacy, tolerance to
diet, and efficacy of nutritional planning. Daily energy count and meal rounds are
fundamental until the patient achieves definitive wound closure and is reaching established
goals for weight maintenance. The following data should be collected:
Daily energy and protein intakes (patients during acute injury should achieve more
than 85% of their estimated energy requirement and 100% of their protein goal).
Free water intake to prevent suboptimal protein intake and aggravating
hyponatremia (high juice consumption is a common pitfall for children on oral diets)
Progress in efficient transition of diet (parenteral to enteral, enteral to oral) to ensure
patients are on the best mode of therapy given their clinical state.
Interruptions in nutrition therapy for dressing changes, operative procedures, or trials
of extubation.
Use and consumption of high-energy/high-protein supplements
Tolerance to diet with regard to the following:
Stool patterns
Gastric residuals
Nausea
Vomiting
Abdominal distention
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
.


Comparative Standards

Energy Requirements
Although energy expenditure in burns corresponds to initial burn wound size and
associated trauma, it is driven by many medical, surgical, and physiological aspects of burn
care. Individualized assessment of energy requirements is essential, making use of indirect
calorimetry preferable whenever possible. However, ease and practicality make predictive
equations extremely useful in determining nutrition for pediatric burn patients. Of greater
importance than the tools or methods applied to determine energy needs is recognition that
energy goals should not be static. Rather, they need to accommodate changes that take
places throughout the patient's course of care and need to be scrutinized based on
outcome indicators such as weight, wound healing, and recovery time as well as
biochemical indicators of nutritional status. The following table presents clinical factors that
influence energy requirements:
Factors that Influence Total Energy Expenditure in Burn Patients
Increase Decrease
Sepsis
Fever
Work of breathing
Substrate utilization
Evaporative water loss
Heated environment
Early excision and grafting
Pain control and sedation
Infection control

Predictive Equations
Historically, numerous equations have been developed for use in pediatric burn patients.
Although these equations have been shown to be inaccurate (Suman, 2006; Mayes, 1996;
Liusuwan, 2005), they provide a basis for launching nutrition support in most clinical
settings. In general, predictive equations in children utilize some estimate of basal
metabolic rate (BMR) or resting energy expenditure (REE) with stress factors that may or
may not incorporate wound size. Occasionally, in older children who are large in size, the
Harris-Benedict equation may be used.
Equations for Predicting REE in Children Older Than 3 Years
Author
Population
Age (Years)
Equation for Predicting
REE
FAO/WHO/UNU
a
3-18
Female (3-10 years):
REE = 22.5W + 499
Male (3-10 years): REE
= 22.7W + 495
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(WHO, 1985) Female (10-18 years):
REE= 12.2W + 746
Male (10-18 years): REE
= 17.5W + 641
Schofield
(Schofield, 1985)
3-18
Female: (3-10 years):
REE = 16.97W + 1.618H
+ 371.2
Male: (3-10 years): REE
= 19.6W + 1.303H +
414.9
Female: (10-18 years):
REE = 8.365W + 4.65H +
200
Male: (10-18 years): REE
= 16.25 + 1.372H + 515.5
Harris-Benedict
equation
(Harris, 1919)
Adults, some
children
Female: REE =
655.10+9.56W + 1.85H –
4.68A
Male: REE = 66.47 +
13.75W + 5.0H – 6.76A

a
FAO = Food and Agriculture Organization; WHO = World Health Organization; UNU =
United Nations University
BMR of Infants and Children (Altman, 1968)
Age 11-36 Months Age 3-16 Years
Weight
(kg)
Metabolic Rate
(kcal/hr)
Weight
(kg)
Metabolic Rate
(kcal/hr)
Male Female Male Female
9.0 22.0 21.2 15 35.8 33.3
9.5 22.8 22.0 20 39.7 37.4
10.0 23.6 22.8 25 43.6 41.5
10.5 24.4 23.6 30 47.5 45.5
11.0 25.2 25.2 35 51.3 49.6
11.5 26.0 26.0 40 55.2 53.7
12.0 26.8 26.9 45 59.1 57.8
12.5 27.6 27.7 50 63.0 61.9
13.0 28.4 28.5 55 66.9 66.0
13.5 29.2 28.5 60 70.8 70.0
14.0 30.0 29.3 65 74.7 74.0
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14.5 30.8 30.1 70 78.6 78.1
15.0 31.6 30.9 75 82.5 82.2
15.5 32.4 31.7
16.0 33.2 32.6
16.5 34.0 33.4
Stress/activity factors can be added, ranging between 1.3 to 1.75. Wound healing and
minimization of weight loss can be achieved in patients receiving amounts in this range,
given that sufficient protein intake is provided (Prelack, 1997). The large range emphasizes
the variation in stress and activity seen in pediatric burn patients. Contrary to common
belief, a lower stress factor may be appropriate for patients who are critically ill, but highly
sedated, in a heated environment, with little activity throughout the day. On the other hand,
total energy expenditure may be equally high in the rehabilitative phase due to an increase
in physical therapy and other daily activity.
Formulas have been developed to estimate energy requirements based on wound size.
They must be revisited and adjusted as the patient proceeds through surgical grafting. The
change in energy expenditure with weekly grafting may be subtle and overshadowed other
clinical changes that affect energy expenditure as mentioned above. This may partially
explain why energy requirements do not always correlate to open wound size area.
Equations Based on Open Burn Wound Size

Age
(Years)
% Body
Surface
Area
Formula Based on
Total Body Surface
Area Burn (TBSAB)
Curreri Junior
(Day, 1986)
0-1
1-3
4-15
< 50
Basal + (15 x
%TBSAB)
Basal + (25 x
%TBSAB)
Basal + (40 x %
TBSAB)
Revised
Galveston
(Mittendorfer,
1988)
<12 > 30
1,800 kcal/m
2
BSA +
1,300 kcal/m
2
%TBSAB
Davies and
Liljedahl
(Davies, 1971)
<12 Any 60W + (36 x TBSAB)

Indirect Calorimetry
Use of measured energy expenditure is useful and recommended in pediatric burn
patients. Because measured energy expenditure captures the stress of disease, a stress
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patients. Because measured energy expenditure captures the stress of disease, a stress
factor is not necessary; however, a factor should be incorporated to account for increased
activity throughout the 24-hour period. Dressing changes, physical therapy, and
positioning all contribute to this factor. Typically, this activity factor is 20%–30% of the
measured energy expenditure. The total energy expenditure is derived by adding the
activity factor to the measured resting energy expenditure (Mayes, 1996; Goran, 1990).
Although indirect calorimetry is useful in patients who are in rehabilitation and not gaining
weight to rule out persistent hypermetabolism, it is limited in establishing goals for weight
gain.
Protein Requirements
As opposed to energy requrements, clinical interventions often exacerbate protein
breakdown and losses. Factors that contribute to increased protein requirements include
the following:
Catabolic state
Wound losses
Atrophy from bed rest
Medication effect
Reliance on conditional amino acids
A high protein intake in children improves wound healing and infection control (Alexander,
1980). The following intakes have been shown to promote positive protein balance and
wound healing (Prelack, 1997):
For children aged 0 to 6 years: 3 g to 4.5 g protein per kilogram
For children older than 6 years: 2.5 g to 3 g protein per kilogram
These amounts can be adjusted downward with the completion of wound closure.
However, it should be noted that muscle protein breakdown slowly abates over the course
of rehabilitation as indicated by 3 methyl-histidine (Prelack, 2010). Therefore, a high
protein intake should be maintained throughout hospitalization in pediatric burn patients.

Nutrition Diagnosis

Dietitians working with patients who have burn injuries should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnosis in pediatric burn care is dynamic and will
vary throughout the phases of burn recovery.
During the acute phase of burn injury, the following nutrition diagnoses as well as
other diagnoses may be present:
Increased energy expenditure (NI-1.2)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein-energy intake (NI-5.3)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
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Food–medication interaction (NC-2.3)
Underweight (NC-3.1)
Overweight/obesity (NC-3.3)
Sample PES (problem, etiology, signs and symptoms) statements include the
following:
Inadequate enteral nutrition infusion (NI-2.3) related to energy delivery less than
130% of measured resting energy expenditure, as evidenced by respiratory quotient
of less than 0.69 with 10% weight loss.
When progressing from the acute to the rehabilitation and convalescent phase of injury, in
addition to the diagnoses above, the following diagnoses may be typically used:
Swallowing difficulty (NC-1.1)
Biting/Chewing (Masticatory) difficulty (NC-1.2)
Breastfeeding difficulty (NC-1.3)
Unintended weight loss (NC-3.2)
Overweight/obesity (NC-3.3)
Unintended weight gain (NC-3.4)
Food- and nutrition-related knowledge deficit (NB-1.1)
Physical inactivity (NB-2.1)
Self-feeding difficulty (NB-2.6)
Sample PES statements during this phase include the following:
Self-feeding difficulty (NB-2.6) related to hand burn injury as evidenced by oral intake
at meal times of less than 75% of recommended intake.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition intervention in pediatric burn patients is closely linked to clinical state and phase
of burn injury. During the first 24 to 48 hours, initiation of nutrition support and the mode of
feeding depend on hemodynamic stabilization and adequacy of blood perfusion to the
gut. Once a patient enters the flow phase, and for the duration of the acute phase of injury,
nutrition intervention focuses on metabolic support of the inflammatory response. Some
aspects of this intervention include the following:
Safe and timely administration of nutrition support based on nutrition assessment as
soon as clinically feasible
Utilization of appropriate mode of therapy given the patient's clinical status
Advancement of nutrition therapy in 1 to 3 days to meet set goals
Assessment of gastric and metabolic tolerance to diet regimen with proper adjustment
in therapy as indicated
Monitoring of weight and other nutritional indices to ensure efficacy of diet
Precision and accuracy in intake of energy and fluid intake and substrate composition
to minimize overfeeding and facilitate extubation from mechanical ventilation
Provision of sufficient micronutrient intake to counter losses from wounds and
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increased utilization for wound healing and infection control with supplementation as
indicated
Prevention of bone demineralization with appropriate intakes of calcium, vitamin D,
and other micronutrients
Routine assessment and reassessment of energy and protein intakes and
requirements to ensure nutritional adequacy
Control and management of hyperglycemia and other electrolyte disturbances
Planning for transition to oral diet by coordinating appropriate medical tests and
consults to assess eating and swallowing ability, establish intermittent feedings, and
provide proper diet
Adherence to dietary practices and food preferences

Sample PES (problem, etiology, signs and symptoms) statement with an associated
intervention:
PES: Inadequate energy intake from enteral nutrition related to energy delivery less than
130% of measured resting energy expenditure and evidenced by respiratory quotient
of less than 0.69 and 10% weight loss
Intervention: Increase standard enteral tube feedings to meet total energy requirement as
estimated above by increasing hourly rate to 60 mL per hour
Once the patient progresses into the rehabilitation phase and convalescence, nutrition
intervention goals change as the patient becomes less catabolic and more anabolic. During
this time, goals may include the following:
Sufficient energy and protein intake to promote weight gain and support physical
therapy intervention goals
Promote oral intake to transition from enteral tube feeding to volitional feedings
Enhance bone mineral accrual from diet and pharmacologic interventions
Begin diet education on adequate energy and protein intake for continued recovery
and growth upon discharge
Sample PES statement with intervention:
PES: Self-feeding difficulty related to hand burn injury as evidenced by oral intake at meal
times less than 75% of recommended intake
Intervention: Provide nutrient-dense foods and high-energy/high-protein supplements to
maximize nutritional value of foods consumed


Nutrition Prescription

Acute Phase
Provide aggressive nutrition support to meet full energy and protein
requirements—preferably via enteral nutrition—to address wound healing, infection,
and minimization of lean body mass wasting.
Incorporate use of nutritional pharmacology to hamper hypermetabolic response and
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stimulate anabolic processes for wound healing, positive protein balance, and bone
accrual.
Monitor weight and protein indices to ensure nutritional adequacy.
Follow, correct, and support metabolic aberrations and electrolyte imbalances
associated with burn injury and its clinical course.
Establish plan to overcome obstacles for transition to normal diet related to burn injury
such as swallowing difficulties and mechanical difficulties that affect chewing and
self-feeding.

Rehabilitative Phase
Transition from enteral tube feeding to oral feeding while promoting anabolism and
weight gain.
Coordinate use of nutritional supplements to offset increased energy needs
associated with increase physical activity.
Promote skeletal muscle uptake of amino acids through high-protein drinks following
physical therapy sessions.
Promote bone accrual through increased high-calcium diet, nutritional pharmacology,
and promotion of physical activity.
Monitor weight gain and muscle strength as indicators of nutritional efficacy.
Convalescent Phase
Provide education regarding a diet appropriate for enhancing catch-up growth.
Ensure that appropriate foods are available to the child for continuation of healing and
skeletal muscle growth.
Monitor growth—both height and weight—over time.


Goal Setting

By setting appropriate and realistic goals for nutritional intervention in pediatric burn
patients, ineffective use of of diet therapy and potential complications are avoided. For
example, growth is not a realistic goal for children during the acute phase of injury; hence,
energy and protein intakes should not be too ambitious, nor should feedings be escalated
to promote weight gain. In fact, overzealous feedings are likely to promote accumulation of
fat tissue as opposed to lean body mass (Hart, 2002). Similarly, achieving total energy
requirements when using parenteral nutrition may not be possible, as substrate utilization
is inefficient under these circumstances, and ceilings are in place for maximal intakes
particularly of carbohydrate and fat (Sheridan, 2000; Mehta, 2009). The following are
considered realistic goals for metabolic support of the pediatric burn patients:
Acute Phase of Injury
Minimization of total body weight loss to less than 10% of preinjury weight
Adequate nutrition to support graft take and and timely wound closure including donor
wound healing in 7 to 10 days
Proper mode of nutrition therapy to support wound healing and nutritional status while
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minimizing complications associated with both enteral and parenteral nutrition,
including lack of bowel stimulation, metabolic aberrations associated with intravenous
feedings, excessive fluid volume, aspiration, and bowel necrosis
Minimization of protein losses and erosion of body cell mass through diet and
nutritional pharmacology
Accurate energy and fluid intake and substrate composition to minimize overfeeding
and facilitate extubation from mechanical ventilation
Sufficient micronutrient intake to counter losses from wounds and increased utilization
for wound healing and infection control
Reduce bone demineralization with appropriate intakes of calcium, vitamin D, and
other micronutrients
Rehabilitation Phase
Transition to oral diet without weight loss
Increase in weight to within 10% of preinjury weight
Self-feeding
Sufficient energy and stamina for physical therapy sessions
Convalescent Phase
Gradual increase in weight and height-for-age percentiles
Increased bone mineral density

Oral Intake

Oral Diets
Patients with burns on greater than a 10% total body surface area, or patients who have
been identified as having increased nutrient requirements should be placed on a
high-energy, high-protein diet that is age appropriate. Children should also receive snacks
throughout the day; this provides an additional opportunity to incorporate nutrient-dense
foods.
Patients on oral diets should receive diet education on high-energy/high-protein foods (see
Client Education).
Familiar foods are useful for optimizing intake. Patients with cultural food preferences
should be accommodated.
Transition Diets from Tube Feedings to Oral Intake
(1) When the patient is able to achieve 50% of estimated energy and protein goals, the first
step in transitioning to normal diet is changing to nocturnal feedings (eg, 7 pm-7 am) at
same hourly rate.
(2) The tube-feeding schedule can be altered according to oral intake on a daily basis.
Following is an example of sliding scale tube feedings designed to promote transition off
enteral tube feeding. This example is based on an energy goal of 1200 kcals and utilizes a
1 kcal/ml polymeteric enteral formula.

Example of Sliding Scale Tube Feedings
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If energy intake at 7pm
is:
Then run tube feeding (at 50
mL/hour):
< 600 kcal 7 pm-7 am
< 700 kcal 7 pm-5 am
< 800 kcal 7 pm-3 am
< 900 kcal 7 pm-1 am
< 1,000 kcal Hold tube feedngs, offer snack

Note: The intent of the sliding scale is to end tube feedings early in the morning of the
following day to stimulate appetite.
(3) Once a patient demonstrates ability to eat more than 85% of requirements for at least 3
days, feedings may be discontinued (This may vary based on the goals set for the patient.
Some patients may have difficulty gaining weight after wound closure and as a result may
need prolonged supplemental nutrition.)



Enteral or Tube Feeding

Enteral nutrition is the gold standard and should be utilized when possible. Overwhelming
research dictates that enteral nutrition is the preferred means of nutrition support for
patients requiring acute levels of care with an intact gastrointestinal system. Enteral
nutrition may help achieve the following (Grossie, 2001; Pacht, 2003; Andel, 2001;
Conejero, 2002; Kiyama, 2001):
Improve gut profusion and gastrointestinal integrity
Minimize the risk of nosocomial infection and inflammatory response
Lower production of acute phase proteins
Promote weight maintenance
Expedite wound healing

Initiation of Enteral Feedings
The American Burn Association practice guidelines state that enteral feedings should be
initiated as soon as practical. Many patients, even those with moderate burns, are capable
of tolerating enteral tube feedings within 24 hours post burn. The tendency to practice early
enteral feeding is supported in part on animal studies demonstrating decreased gut
permeability and a reduction in the hypermetabolic response with immediate post burn
enteral feedings (Mochizuki, 1984; Dominioni, 1985). However, in humans, a consensus
lacks. In one study, early (within 24 hours of injury) versus late (7 days after injury) did not
improve mortality or decrease daily energy expenditure (Peck, 2004). While adult
burn patients fed early had shorter ICU length of stay and improved wound healing
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(Mosier, 2010), in pediatric burn patients, the safety and benefit of early feeding with
respect to hypermetabolism, nutritional status, or morbidity could not be affirmed. In fact,
a higher incidence of adverse effects, including bowel necrosis were reported with early
versus delayed enteral feedings. Increased incidence in bowel necrosis appeared to be
related to the extent of burn injury, need for greater resuscitation volumes, and the need
for inotropic agents among these children (Gottschlich, 2002).
Based on this body of evidence, the following recommendations are
made for administration of enteral tube feedings in burned children:
1) Upon admission, all patients with burns over more than 30% total body surface area
(TBSA) or patients with inhalation injuries requiring ventilatory support (regardless of burn
size) should be evaluated for the initiation of enteral nutrition support.
2) Tube feedings may commence following successful fluid resuscitation, which can occur
within the first 24 hours after injury in patients who meet the following criteria (McDonald,
1991; Gottschlich, 2002):
Fluid resuscitation completed
Hemodynamically stable
Not receiving vasoconstrictor such as levophed, dopamine, or phenylephrine
Absence of severe abdominal distention
It is not recommended to maintain full enteral nutrition support during periods of severe
hemodynamic instability.

Formula Selection
Standard Polymeric
There is minimal evidence-based research on specialized formulas that contain
conditionally essential amino acids or other select nutrients, and therefore standard
polymetric formulas are appropriate in burned children (Prelack, 2007). Standard polymeric
feedings (1.0 kcal/mL) are most likely sufficient for supporting wound healing and lean
body mass.
Because adult formulas contain more protein (~40 g/L to 60 g/L) compared with pediatric
formulas (~30 g/L) they may be more practical for meeting the high protein demands of
children (older than 1 year) with burn injuries. Use of adult formulas in children also allows
a higher baseine electrolyte and micronutrient intake, potentially reducing the need for
supplementation (Prelack, 2001; Prelack, 2007).

Immune-enhancing formulas
Immune-enhancing formulas, although costly, are now commonly used in intensive care
units in hopes of reducing infection rates and enhancing the immune response. Main
constituents of these formulas include the following:
Arginine
Glutamine
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n-3 fatty acids
Nucleic acids

Published literature examining the efficacy of immunonutrition is inundated with
controversy and conflicting results, particularly among the critical care population
(Gottschlich, 1990; Saffle, 1997; Kieft, 2005). Evidence-based analysis by the American
Dietetic Association shows that utilization of immune-enhanced formulas in critically ill
patients does not significantly affect mortality, length of stay, or days on mechanical
ventilation (EAL, 2006).
A recent review in burn patients revealed insuffcient data to support the routine use of
arginine, omega-3 fatty acids, and combined nutrient feedings. However, enteral
glutamine supplementation was associated with the following outcomes (Kurmis, 2010;
Zhou, 2003):
Improved wound healing
Reduced morbidity
Shortened length of stay
The evidence suggests that patients with > 20% TBSA burn may benefit from
suppementation. Ideal dosing, timing and length of supplementation requires further study;
however, positive outcomes were associated with the following:
Dose of at least 0.3 gm/kg/day or greater
Split bolus supplementation (seperate from tube feeding)
10 or more consecutive days
Infant formula should be provided to children with burns during the first year of life. The
formula should be concentrated to meet increased energy and protein needs. Protein
modulars may be added to provide additional protein, if warranted.

Mode of Feeding
Continuous feedings are traditionally accepted as better tolerated in the pediatric burn
population. Guidelines for initiation and advance of continuous feedings are listed in the
table below.

Weight (kg) Initial volume
(mL/hr)
Advancement
<10 1 mL/kg 5 mL every 4 hours
< 50 10 10 mL every 4 hours
>50 20 10 mL every 4 hours

Small Bowel vs Gastric Feeds
Controversy continues over the most effective route of gastrointestinal support: intragastric
tube feedings or small bowel tube feedings. There currently is no convincing evidence to
suggest that tube position influences incidence of aspiration. Gastric tube feedings are well
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tolerated when begun early after injury. These tubes are simple to administer and provide
an easy way to monitor tolerance via gastric residuals (Prelack, 2007).
When relying on intragastric feedings, infusions must be stopped perioperatively to avoid
aspiration. During these intervals, children with large burns may be supplemented with
parenteral nutrition (Prelack, 2007).
A small bowel tube may be placed if high residuals are noted with gastric
feedings. Postpyloric feeding tubes, beyond the ligament of Treitz, allow for uninterrupted
enteral nutrition during surgery, a practice that is used successfully in some burn units.
Placement of small bowel feeding tubes is technically more challenging. This can be done
blindly with a weighted tube, although endoscopy or fluoroscopy is often required.

Monitoring Tolerance of Enteral Feedings
Keep head at 30° angle or higher in bed to decrease risk of aspiration.
Monitor residuals. For patients with gastric feeding tubes: check gastric residuals
every 4 hours. If the amount of residual is equal to or exceeds the hourly volume, the
residual should be refed and the feedings suspended (ASPEN, 2009).
Monitor abdominal distention: abdominal girth is measured prior to initiating feedings,
at each advancement of feeds, then daily as clinically necessary. Patients
demonstrating significant distention should have feedings suspended. A kidney,
ureter, and bladder x-ray may be ordered to rule out obstruction.


Parenteral Nutrition

General Indications for Parenteral Nutrition
Patient is >50% total body surface area burn (TBSAB) and requires frequent
(>2/week) interruption of feedings for clinical procedures
Patient does not tolerate advancement to goal feeding volume within 96 hours of
admission
Patient previously tolerating enteral feedings develops signs of sepsis with
comcommittent abdominal distention
Ileus by KUB
Dependent on high requirement of vasopressor support

PN Formula Considerations
Macronutrients
Energy Requirements
Achieving total energy requirements may be difficult when providing PN as the sole
component of nutrition support. In general, parenteral nutrition can be administered at rates
that approximate basal energy requirements. This level of intake has been proven effective
for wound healing provided that protein targets are met (Prelack, 1997). A combination of
PN and trophic enteral nutrition may also be utilized to reduce the energy deficit associated
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PN and trophic enteral nutrition may also be utilized to reduce the energy deficit associated
with PN (Prelack, 2010).

Carbohydrate Administration
Studies of glucose oxidation rates in burned adults and children suggest a glucose infusion
rate of 5-7 mg per kilogram per minute (Burke, 1979 ; Sheridan, 1998). Exceeding this level
may lead glucose to enter non-oxidative pathways and fatty infiltration. TPN can be initiated
at goal rate without aggravating hyperglycemia (Prelack, 1997).

Protein Administration
Amino acid provision should meet 100% of estimated protein requirements. Protein goals
set at 2.5-4.0 grams per kg support wound closure and diminish infection in burned children
(Alexander, 1980; Matsuda, 1983; Prelack, 2010). A standard adult amino acid
admixture can be used as the nitrogen source in PN. This admixture does not
accommodate the special amino acid requirements for growth, however reprioritization of
protein metabolism for wound healing at the expense of growth is presumed to occur in this
population. A high amino acid content in PN, which provides a non-protein calorie to
nitrogen ratio of 85:1, enables protein needs to be met without excessive volume infusion
rates.
Fat Administration
IV lipid solutions are not provided to patients during initial stages of burn treatment due to
potential complications associated with their administration (Prelack, 2006). These include
cholestasis, hepatomegaly, fat overload syndrome, impaired clotting, and
immunosuppression (Samuelsson, 1972; Weyman, 1975; Sheldon, 1978; Belin, 1976;
Allardyce, 1982; Campbell, 1984; Heyman, 1981; Rodgers, 1976). Since most exogenous
lipid provided during critical illness functions to maintain peripheral lipid stores, rather than
as an energy source, their ommission may be inconsequential (Wolfe, 1996).
Intravenous lipids may be added if the patient is unable to tolerate enteral feedings for a
prolonged period of time. Essential fatty acid deficiency can develop in infants within 7 days
and in children within 3 to 5 weeks of lipid-free nutrition (Paulsrud, 1972; McCarthy,
1978). A dose of 0.5-1.0 g fat/kg/day is sufficient to prevent deficiency (Barness, 1981).
The table below shows an example of a parenteral solution for use in burn children. This
central formulation is unique in its fluid-restricted composition; electrolytes and additives
are higher than in most typical parenteral formulations to accomodate wound losses and
leaching. This, in addition to its high amino acid content, ensures that optimal protein and
basal energy requirements are met with minimal fluid volumes. Fluctuations in fluid and
electrolyte balance can (and should) be managed independently of the nutritional support
regimen.

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Parenteral Solution for Burned Children
Nutrient
Concentration mEq/L
(unless specified)
Amino Acids 74 gm
Dextrose 200 gm
Sodium 100
Potassium 50
Calcium 9
Magnesium 18
Phosphate 15 mMol
Acetate 120
Chloride 70.65
Ascorbic Acid 500 mg
Multivitamins 10 ml
Trace elements** 0.5ml
*Vitamin K is added to TPN weekly as one weight-based dose:
<10kg = 1mg; 10-50kg = 2mg; >50 kg = 4mg
**Micronutrient Amounts: Zn = 2500 mcg; Cu = 500 mcg;
Selenium = 30 mcg

Laboratory monitoring with PN is included elsewhere (see Biochemical Data, Medical Tests
and Procedures).
Provision of adequate protein and energy immediately or soon after injury is needed to
maintain protein synthesis and prevent protein-energy malnutrition (Demling, 2009).
Occasionally, clinical circumstaces prevent prompt initiation of enteral feeding. When used
appropriately, parenteral nutrition (PN) can be a safe and effective way to administer
nutrition when complete enteral nutrition is not possible (Woodcock, 2001; Thibault, 2010).
Total parenteral nutrition delivered through a central venous catheter can sustain healing
even in the most severe burns, and prevents major calorie deficits when eneteral nutrition
is not clinically suitable (Prelack,1994; Prelack, 2010). When properly administered it is not
associated with mortality in burned children (Sheridan, 2000).
Complications associated with TPN use in this population (hepatomegaly, fatty infiltration,
and cholestasis) are often seen in the context of overfeeding intravenous
calories (Herndon, 1989). In order to prevent such complications, it is imperitive that
parenteral nutrition be formulated to provide basic metabolic support. That is, the provision
and proportion of nutrients should be based on what is known about substrate utilization
and protein-sparing macronutrients following burn injury (Wolfe, 1996; Sheridan, 1998).

Complications of Nutrition Support
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Diarrhea
Most cases of diarrhea are primarily caused by antibiotic therapy which alters gut flora, and
hypertonic medications (eg, potassium chloride).
Clostridium difficile is the most common cause of infectious diarrhea in the intensive care
unit (ICU), although patients from developing countries are also at high risk for parasitic and
bacterial enteric pathogens.
Noninfectious diarrhea can be alleviated by using a fiber-containing formula to add bulk to
stool. If clostridium difficile is diagnosed or parasites identified, a fiber-containing formula
can be added following treatment.

Refeeding Syndrome
Malnourished patients are at high risk for refeeding syndrome, a serious condition that can
rapidly cause cardiac arrhythmias, multisystem organ failure, and death. Symptoms result
from fluid and electrolyte imbalances that occur when the body attempts to switch from a
state of catabolism to a state of anabolism (Fuentebell, 2009).
Provision of carbohydrate to a malnourished patient, with a corresponding insulin surge,
stimulates an influx of glucose, phosphorus, potassium, and magnesium into the cells,
resulting in depleted serum levels. High levels of insulin also increase sodium retention,
which leads to fluid retention and expansion of the extracellular fluid volume (Kerner, 2009).
Hypophosphatemia is the hallmark of refeeding syndrome and can occur within 24 to 72
hours of introducing nutrition (Dunn, 2003).
Recommendations for preventing refeeding syndrome are as follows (Dylewski, 2010):
Obtain baseline electrolytes and replete as needed. 1.
Slowly initiate nutrition support
Enteral: Initiate at 5 mL/hour and advance by 5 mL/hour to 10 mL/hour every 6
hours
Parenteral: Initiate at 30% of goal rate and advance by 5 mL/hour to 10 mL/hour
every 6 hours
2.
Monitor electrolytes every 6 hours for the first 24 to 48 hours. Subsequently check
daily.
3.
It is important to note that despite conservative measures, refeeding hypophosphatemia
can still occur (Miller, 2008; Dylewski, 2010). Therefore, aggressive repletion protocols
should be followed.

Hyperglycemia
Hyperglycemia is common in the pediatric burn ICU, presumably due to the
hypermetabolic response to injury. Nutrition support should never be withheld due to
hyperglycemia. Instead, insulin therapy should be initiated.
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In pediatric burn patients, intensive insulin therapy decreases the incidence of infections
and sepsis (Jeschke, 2010). An ideal glucose target is 130 mg/dL and can be achieved by
utilizing strict insulin protocols (Jeschke, 2010).

Nutrition Therapy Efficacy

A high-energy, high-protein diet is required to supply sufficient energy, protein, and
micronutrients to support wound healing and immune function and to minimize lean body
mass catabolism. During later stages of recovery, adequate energy and protein intake is
necessary to recoup growth.

Suggested Monitoring Parameters and Recommendations

Accurate monitoring of nutritional status during acute burn injuries remains a challenge.
Most parameters of nutritional status are confounded by the physiological elements of the
inflammatory response and are therefore not reliable. However, parameters of nutritional
status, when trended or used collectively, can help the clinician in monitoring day-to-day
efficacy of diet therapy.
The laboratory monitoring schedule is located elsewhere (See Biochemical Data, Medical
Tests and Procedures).
The parameters presented in the following table should be followed closely during the
acute phase of injury or until wound closure (Prelack, 2007). Subsequently, monitoring
schedules can be relaxed so that parameters are assessed only when clinically necessary.

Elements of
Nutrition
Assessment

Monitoring
Schedule
Comments/
Recommendations
Weight Biweekly
Monitor trends to reduce
erroneous values due to
discrepancies across
scales or due to fluid
shifts
Indirect
Calorimetry
Weekly
Prevents underfeeding or
overfeeding
Tolerance to
Nutrition
Support
Daily
Adjust tube feeding
formula type, rate, and
schedule as needed
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Energy and
Protein Intake
Daily
Energy and protein
counts are required to
ensure adequate intake
and determine need for
additional supplements
or nutrition support
Although hepatic synthesis of most carrier proteins is downregulated, trended values or
prealbumin in conjunction with CRP are predictive of nutritional adequacy (Prelack, 2001;
Devoto, 2006; Mayes, 2005; Gottschlich, 1992). Similarly, although nitrogen balance
studies are imprecise, UUN does correlate with whole body protein balance as indicated by
leucine kinetic studies (Prelack, 1997). The table belows illustrates how these biochemical
indices can be utilized to evaluate nutritional adequacy in the context of energy and protein
intakes.
Energy
Protein
Intake
(%
goal)
Prealbumin

CRP UUN Interpretation Action
100% D I I Increased
inflammation
accompanied by
increased
catabolic rate
Prealbumin is
not reflective of
nutritional
adequacy
Continue
monitoring
protein
intake >1.5
times UUN
to cover
obligatory
losses
<100% D D I, D Inadequate
intake based on
decreased
prealbumin with
decreased
inflammation
Check
weight
Look for
obstacles to
meeting
nutrition
plan/revise
accordingly
>100% I D I, D Inadequate
intake based on
goal
achievement
and increased
prealbumin
Reevaluate
protein goal
in relation to
changing
wound and
clinical
status for
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Increased UUN
may be due to
excessive
protein intake
potential
need to
decrease
Check total
protein,
blood urea
nitrogen,
creatinine
100% D D I Prealbumin
should trend
upwards as
inflammatory
state subsides
UUN may
reflect
increased
gluconeogenesis
Reevaluate
energy and
protein
goals, may
need to
increase
Check
weight,
energy
expenditure,
donor site
healing
I = increased; D = decreased

Nutrition Care FAQs

Question: Should pediatric burn patients receive micronutrient supplementation?
Answer: Currently there is insufficient evidence to support a generalized practice of large
dose micronutrient supplementation. Common nutrients of interest in burns include zinc,
selenium, vitamin A, vitamin D, and vitamin C. It is generally recommended not to
supplement these nutrients unless the patient is deficient. Unfortunately micronutrient
status is difficult to assess. Biochemical indices are confounded by the acute phase
reaction and inflammation. Actual signs of deficiency are often obscured in burns. Because
children (particularly those receiving adult formulas) are likely to receive larger intakes of
these nutrients when feedings are based on elevated energy or protein needs, it is often
unnecessary to give additional supplementation. Patients requiring an individualized
approach include larger children, children who are malnourished, with poor wound healing,
or transitioning onto an oral diet (Prelack, 2001).

Question: Should parenteral nutrition include selenium?
Answer: Selenium stores are depressed among pediatric patients with burns. Although the
amount of selenium required to optimize stores is unknown, selenium should be included in
all forms of nutrition support (Dylewski, 2010).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Question: Are immune-enhancing products safe and recommended for use in children?
Answer: Currently, in the burn population, insufficient information exists to support the use
of immune-enhancing formulas, with the exception of possibly glutamine (Kurmis,
2010). Safety and efficacy of an anti-inflammatory, pulmonary enteral feeding formula in
burned children with acute respiratory distress has been demonstrated (Mayes, 2008).

Question: Are pediatric burn patients at a higher risk for obesity?
Answer: Following recovery from a large burn injury, children are at high risk for becoming
overweight or obese. Although the etiology is unknown, several factors may relate to this
weight gain: difficulty moderating oral intake, social isolation, emotional overeating, and
decreased physical activity due to functional limitations (Mayes, 2010).
Question: Should energy goals in burned children take growth into consideration?
Answer: During the acute phase of injury, growth is not possible in burned children.
Energy goals at this time shoud be geared towards preservation of lean body
mass. Intakes above this will promote fat vs lean body mass acrual (Hart, 2002). However,
following acute recovery, increased intakes to promote anabolism and support growth are
suggested since catch up growth can be prolonged or absent in children with larger burns
(Prelack, 2007)


Nutrition Pharmacology

Oxandrolone Therapy
Aggressive dietary protein delivery coupled with oxandrolone therapy can improve protein
economy by increasing the rate of protein synthesis. Current kinetic data show that
oxandrolone (0.2 mg/kg/day) significantly improves net protein balance in the muscle (via
enhanced protein synthesis) among pediatric burn patients, both acute (Hart, 2001) and
delayed admissions (Wolf, 2003).
Additional data, aside from protein kinetics, indicate that oxandrolone supplementation
during the acute phase of injury increases body weight and muscle strength and decreases
length of hospital stay in pediatric burn patients (Jeschke, 2007). Oxandrolone initiated at
discharge also increases lean body mass, bone mineral content, and muscle strength after
12 months of therapy among pediatric burn patients (Przkora, 2005). Oxandrolone therapy
among pediatric patients with large burns may achieve the following:
Improve muscle protein synthesis and subsequent protein balance during the acute
phase of injury
Minimize weight loss and potentially maintain fat-free mass during the acute phase
Promote fat-free mass accrual during the convalescent phase
Nutritional and pharmaceutical objectives will vary according to clinical status. The
following patients are considered eligible for oxandrolone therapy:
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Pediatric acute patients with burns of more than 50% total body surface area who
present with an inhalation injury or primarily third degree burns
Pediatric acute or convalescent burn patients who are clinically malnourished (as
determined by the clinical team), visibly wasted, or have poor wound healing
Length of stay in the hospital or in local housing anticipated to be longer than 1 month
For well-nourished patients, oxandrolone therapy can start any time after initial fluid
resuscitation. For malnourished patients, oxandrolone therapy should not start until after
nutrition support (parenteral nutrition or tube feedings) is at goal rate. The recommended
dose is 0.1 mg/kg to 0.2 mg/kg.
Exclusion Criteria
Children at least 2 years of age or younger
Hypercalcemia (ionized calcium greater than 1.4 mmol/L for more than 1 week)
Nephrosis
Pregnancy
Precautions
Cardiac, renal, or hepatic disease
Concomitant warfarin (“Coumadin”) therapy
Concomitant bupropion (“Wellbutrin”) therapy
Monitoring
Weights: Biweekly
Prealbumin/c-reactive protein: Weekly
Liver function tests (alanine aminotranferease [ALT] and aspartate aminotransferase
[AST]): Baseline and monthly
Potential Side Effects
Side effects that should be monitored include the following:
Increased AST, ALT
Edema
Deepening of voice
Acne, oily skin,
Menstrual irregularities
Facial hair

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Nutrition Care > Cardiology
Cardiology


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Cardiology > Congenital Heart Disease
Client History

The client history provides information on factors that may influence growth, such as the
ability to orally feed and tolerate feeds, degree of edema, and respiratory rate. It is thought
that growth is negatively affected by a multifactorial process. Factors to consider when
initially assessing a patient with congenital heart disease (CHD) include the following:
Type of cardiac lesion: The degree of the effect of the cardiac disease on growth,
development, and nutritional status depends on the particular lesion and magnitude of
severity and cardiac failure (Greecher, 2002). Cardiac defects and characteristics that
increase the risk of growth failure in infants with CHD include the following:
Cyanotic lesions
Prematurity
Intrauterine growth retardation/small for gestational age
High-complexity cardiac disease/multiple anomalies
Single ventricle physiology
Associated genetic syndromes
Later age at time of surgical repair (especially seen in Tetralogy of Fallot and
ventricular septal defects)
Presence of congestive heart failure or pulmonary hypertension
Plan for surgery now vs later; timing and stages of surgeries (also length of stay
during previous admissions)
Institutional policies regarding preoperative enteral feedings; presence of umbilical
arterial catheter precluding feeding enterally; administration of prostaglandins and
enteral nutrition; extracorporeal membrane oxygentation and enteral nutrition;
introduction and type of enteral feeding after necrotizing enterocolitis
Postoperative course
Recurrence of infections
Route of nutrition support postoperatively: total parenteral nutrition, enteral feeding,
oral feeding
Fluid balance is a vital component in the medical management of infants and children
with CHD. Insensible fluid losses may be increased by 10% to 15% above normal
secondary to fever, diuretic therapy, and tachypnea. Despite higher fluid losses, many
infants with CHD show signs of fluid overload and are often fluid restricted
(Heymsfield 1987). Fluid shifts may make observing growth trends more challenging
as weight may fluctuate secondary to fluid more so than true weight gain or loss.
Clinical signs of fluid overload include the following:
Presence of edema around the eyes, buttocks, or extremities
Ascites
Decreased urine output
Evidence of rapid weight gain with poor nutritional intake
Clinical symptoms of fluid overload include the following:
Tachypnea
Lethargy
Tachycardia
Cool and clammy skin
Early satiety
Diaphoresis
Poor color
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Respiratory status and support with oral feeding or nothing by mouth (nil per os) with
feedings via tube
If poor oral feeding skills or aspiration are suspected, consider speech language
pathology and/or occupational therapy consults
Review of Medications
Current medications should be included as part of the nutrition assessment of the infant or
child with cardiac disease.
Antiarrhythmic agents
Anticoagulants: Potential drug–nutrient interactions
Cardiac glycosides
Diuretics: Electrolyte imbalances; chronic therapy may cause renal wasting of
calcium, which may alter bone mineralization; thiazide diuretics can raise calcium
levels in the blood; loop diuretics can decrease calcium levels
Inotropics: Gastrointestinal (GI) distress is a common side effect
Pain medications: Pain medications, such as morphine, may slow gastric motility
Prokinetic agents: Enhance GI motility, treat gastroesophageal reflux disease
Prostaglandins: Gastric outlet obstruction has been reported in association with
prolonged prostaglandin infusion of more than 120 hours
Steroids: Known to cause glucose instability; are often given postoperatively, further
worsening already noted metabolic issues


Nutrition-Focused Physical Findings

Physical observations are critical to assessing the overall nutritional status of the patient, as
well as determining if visual findings are consistent with anthropometric measurements.
Successful completion of a nutrition assessment is dependent on appropriate selection
and accuracy of anthropometric measurements.
Physical indications of malnutrition, including macronutrition and micronutrition deficiencies,
can be observed via the following:
Skin
Hair
Nails
Head
Mouth
Eyes
Abdomen
Musculoskeletal system
Clinical symptoms of heart failure, which may increase risk for malnutrition, include the
following:
Tachypnea
Lethargy
Tachycardia
Cool and clammy skin
Early satiety
Diaphoresis
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Diaphoresis
Cyanosis
Chronic hypoxia
Delayed gastrointestinal motility (including gastroesophageal reflux)
Compromised absorption
Congestive heart failure (CHF) and pulmonary hypertension
Frequent respiratory infections
Infant chest retractions
Vaidyananthan (2008) cited the following as predictors of malnutrition: presence of CHF,
lower growth potential (small for gestational age, low birthweight), and older age at
corrective (surgical) intervention.

Medical Tests and Procedures

Some common medical tests and procedures performed to diagnose patients with cardiac
conditions are described below. As surgical interventions and followup are complex and
individualized, they are not covered here; however, physiological responses to these
interventions that affect nutrition may include the following:
Increased protein catabolism and down regulation of visceral protein stores
Skin breakdown
Increased risk for infection
Anemia
Poor weight gain and linear velocity
Delayed oral motor skills
Feeding aversion associated with prolonged intubation
Chylothorax resulting in disrupted feeding, NPO status, TPN initiation, enteral feeding
changes, etc.
These effects may lead to a variety of nutrition diagnoses and interventions.
Tests and Procedures
Chest x-ray
The chest x-ray is the most common radiologic procedure. The x-ray is
projected toward the chest to show the heart and lungs, bones, and soft tissues
and helps the physician determine if the heart is enlarged, if there is pneumonia,
and if there is fluid in the lungs, as well as exact placement of lines, tubes,
and/or wires.
Echocardiogram
An echocardiogram is an ultrasound test that uses high-frequency sound waves
(nonradioactive) for viewing the heart. It is the best test to demonstrate the
structure of the heart; it is used for measuring the size and thickness of the heart
chambers, blood flow through the chambers and valves, and overall cardiac
function. The echocardiogram can detect structural abnormalities of the heart
(holes between the chambers, fluid around the heart, mass inside the heart,
etc.) and show valve shape, motion, narrowing, or leaking.
Electrocardiogram (EKG)
The EKG is a test that records the changes in the electrical activity of the heart
on graph paper. An EKG helps identify heart rhythm abnormalities. It can also
provide information about the size or thickness of the heart chambers and the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
relative position of the heart in the chest.
Magnetic resonance imaging (MRI)
An MRI uses a powerful magnet, radio waves, and a computer to acquire
pictures of the body. A cardiac MRI is able to provide detailed measures of
certain heart parameters unavailable by other means.
Cardiac catheterization
In the cardiac catheterization procedure, an artery or vein is punctured so that a
small, long, flexible tube (the catheter) can be guided into the heart and major
vessels around it. The catheter is moved through the heart with the aid of
fluoroscopy (x-ray machine). This is usually performed to help in providing a
diagnosis of heart disease and pressure measurements of the cardiac chambers
and blood vessels around the heart as it allows calculations of detailed
information about the heart's function. Interventions can also be performed
during a catheterization, including balloon catheters that can open up narrowed
valves or arteries and catheters where devices to close extra vessels or certain
holes in the heart can be deployed.


Anthropometric Measurements

Accurate measurements of weight and length or height are essential to any nutrition
assessment.
Anthropometrics to note include the following:
Weight for age
Length or height for age
Weight for length
Head circumference (younger than 2 years)
Body mass index
Weight history, if available
Arm anthropometrics are useful for long-term monitoring of fat and muscle stores
Edema—if present, use estimated dry weight
For complete information on assessing degree of malnutrition and linear stunting, see
Comparative Standards in Failure to Thrive.
It is well recognized that children with congenital heart disease (CHD) have compromised
growth. This growth failure is often apparent at birth. Infants with CHD have an increased
risk (1.8 to 3.6 times) of being small for gestational age (<10th percentile for birth
weight–gestation age curve) (Kramer, 1990; Malik, 2007). Furthermore, it has been
reported that patients with acyanotic lesions have a lower birthweight corrected for
gestational age than those with cyanotic defects (Naeye, 1965). Currently, there are no
established growth parameters for infants with hemodynamically significant CHD.


Food/Nutrition-Related History

A thorough diet history is an integral component of a nutrition assessment. It is beneficial in
assessing the adequacy of a patient’s nutritional intake, assisting in confirmation of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutritional status, gathering evidence of nutrient deficiencies, determining any food
intolerances, and establishing a baseline nutritional intake before admission.
Food/nutrition-related history may include the following:
Duration and frequency of breastfeeding
Recipe used at home to prepare high-energy breast milk or formula from the parents
or primary caregiver
Any additives parents may be adding to formula or breast milk
For infants fed by mouth, obtain information on the typical volume consumed per
feeding, duration of feedings, and number of feedings per day
For older infants, children, and adolescents, obtain a 3-day food record to evaluate
nutritional intake
Developmental feeding progression (including food textures)
Positioning during feeding
Parent perception of feeding behavior, problems, and expectations
Determine if patients skip meals or have limited food selection/picky eating habits
Note usage of multivitamin and mineral supplements, herbal supplements, and
prebiotics/probiotics
Obtain detailed information on child’s physical appearance during mealtimes
Infants with congenital heart disease often have poor coordination of feeding
and respiration
Observe breathing patterns by monitoring respiratory rate and oxygen saturation
Other signs of potentially inadequate nutrient consumption in infants and children with
cardiac conditions include increased work of breathing; fatigue; diaphoresis; and poor
perfusion with evidence of cyanosis, coughing, wheezing, grunting, vomiting, tachycardia,
and/or desaturations when feeding.


Nutrition Intervention

Interventions based on sample nutrition diagnoses include the following:
NI-1.2: PES (problem, etiology, signs and symptoms): Increased energy expenditure
related to cardiac failure as evidenced by failure to gain weight with normal energy
intake
Intervention (ND-1.2): Modify distribution, type, or amount of food and nutrients
within meals or at specified times.
Recommendation: Provide additional energy by increasing energy density
of breast milk to 24 kcal/oz using addition of human milk fortifier in all
feedings.
ND-2.3: PES: Inadequate enteral nutrition (EN) infusion as evidenced by intolerance
of EN trition due to gut ischemia.
Intervention (ND-2.2): Initiate parenteral nutrition (PN)
Recommendation: Start PN to provide 100% of nutritional requirements
NC-1.3: PES: Breastfeeding difficulty related to lethargy/sleepiness, as evidenced by
lack of weight gain, fewer than 6 wet diapers per day, and laboratory evidence of
dehydration.
Intervention (ND-2.1): Initiate En feeding using expressed mother’s milk to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
supplement oral intake.
NI-3.1: PES: Inadequate fluid intake related to congenital heart defect as evidenced
by tachycardia, diaphoresis, and early satiety.
Intervention (ND-2.1.2): Nasogastric tube placement providing x amount of
breast milk with specific timing schedule.


For information on interventions for more specific situations, see the following sections:
Goal Setting
Gastrointestinal and Feeding Issues
Nutrition Support
Enteral or Tube Feeding
Parenteral Nutrition

Nutrition Diagnosis

Registered dietitians (RDs) working with patients who have congenital heart disease should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the following list,
as well as other diagnoses, may be present.
Increased energy expenditure (NI-1.2)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Breastfeeding difficulty (NC-1.3)
Inadequate fluid intake (NI-3.1)
Sample PES (Problem, Etiology, Signs, and Symptoms) or Nutrition Diagnostic
Statement(s)
Increased energy expenditure (NI-1.2) related to cardiac failure as evidenced by
failure to gain weight with normal energy intake
Inadequate oral intake (NI-2.1) related to difficulty feeding and coordinating
suck/swallow with breathing as evidenced by documented oral intake
Inadequate enteral nutrition infusion (NI-2.3) related to gut ischemia as evidenced by
intolerance of enteral nutrition
Breastfeeding difficulty (NC-1.3) related to lethargy/sleepiness as evidenced by lack
of weight gain and fewer than 6 wet diapers per day with laboratory evidence of
dehydration
Inadequate fluid intake (NI-3.1) related to congenital heart defect as evidenced by
tachycardia, diaphoresis, and early satiety
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd ed. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies, and signs and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
symptoms. RDs should not include these numbers in routine clinical documentation.

Goal Setting

Nutrition goals for infants and children with congenital heart disease include the following:
Provide adequate energy and protein to account for high energy expenditure
Support vital organ function
Minimize loss of lean body mass
Aim for weight gain and growth velocity similar to that of normal infants
Promote development of oral feeding skills as medically able in light of chronic illness
and prolonged hospitalization, in order to minimize potential oral feeding aversions
Manage symptoms of fluid retention
Maintain normal electrolyte levels and adequate hydration while on highly
concentrated enteral feeding regimen


Gastrointestinal and Feeding Issues

Feeding and gastrointestinal (GI) problems are common in infants and children with
congenital heart disease (CHD). Many factors in an infant's or child's course of CHD may
influence feeding milestones.
Gastroesophageal Reflux
Infants and children with CHD can experience early satiety, nausea, vomiting, and poor
appetite as a result of delayed gastric emptying and gastroesophageal reflux. It may be
caused by decreased motility or the use of highly concentrated formulas, especially those
with higher fat content, which is known to reduce gastric transit time. Certain medications,
such as electrolyte supplements, may irritate the GI tract and contribute to reflux or
diarrhea. In addition, reflux may increase risk for aspiration in the pediatric cardiac
population (Forchielli, 1994). Alterations in intestinal absorption and gastric emptying may
also be related to reduced splanchnic flow, hepatomegaly, and venous engorgement
secondary to congestive heart failure (Forchielli, 1994; Cavell, 1981). Impaired
gastrointestinal function may further compromise energy and nutrient intake.
Reflux can be managed with medications and/or adjustments to the infant's feeding
regimen. Dysmotility is often a common side effect with narcotic medications. A bowel
regimen with medication may be appropriate to improve the motility of the GI tract.
Pancreatitis can also arise during low cardiac output, and pancreatic enzymes should be
monitored along with clinical symptoms before enteral feeding begins.
Dysphagia
In neonates with CHD, the development of feeding and swallowing related difficulties are
frequent concerns (Jadcherla, 2009). The estimated incidence of dysphagia varies
depending on the risk factors, which include preoperative acuity, duration of intubation,
nature of CHD, vocal cord injury, growth, or type of surgical procedure (Einarson, 2003;
Kogon, 2007). For instance, laryngopharyngeal dysfunction has been reported after
Norwood procedure in approximately 48% of patients, with effects characterized as
dysphagia, aspiration, and left recurrent laryngeal nerve injury (Skinner, 2005).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Research has reported dysphagia in children undergoing cardiac surgery. Risk factors for
dysphagia have included preoperative intubation and age younger than 3 years (Kohr,
2003). Other potential risk factors that could contribute to feeding difficulties include
abnormal swallowing, gastroesophageal reflux, and splanchnic hypoperfusion related to
surgery or underlying heart disease.
Vocal Cord Dysfunction
Vocal cord dysfunction is also a complication of undergoing cardiovascular surgery,
primarily in children younger than 1 year. Vocal cord paresis is defined as incomplete
abduction or adduction of the cord. Vocal cord paralysis is defined as complete immobility
of the cord. Etiologies include operative injury to the laryngeal nerve (common in aortic
arch reconstruction), association of the cardiac lesion with a congenital laryngotracheal
anomaly, and prolonged intubation with direct vocal cord trauma. Vocal cord dysfunction
may predispose a child to aspiration by impairing the ability to protect the airway and cause
potential pulmonary injury. One common symptom of vocal cord dysfunction and aspiration
is stridor caused by inflammation of the vocal cords. Research has indicated that it is also
associated with significant feeding problems, including abnormal swallow study results
(Sachdeva, 2007).
GI Defects
GI malformations such as duodenal atresia, malrotation, pyloric stenosis, and even severe
defects such as gastroschisis may be present in patients with CHD. These defects must be
surgically corrected before enteral feeding can be administered. Infants with heterotaxy
syndrome are often prone to gastrointestinal obstruction due to partial malrotation of the
small intestine. A comprehensive GI work-up may be indicated, depending on each
individual child’s severity of symptoms.
Protein-Losing Enteropathy (PLE)
The etiology of PLE in pediatric cardiac patients with Fontan physiology is poorly
understood but thought to be associated with prolonged elevated pressures in the superior
vena cava, hindering drainage of the lymphatic system through the thoracic duct (Rychik,
2007; Braamskamp, 2010). With elevated venous pressures and the subsequent
impairment of lymphatic drainage, this can cause an abnormal protein loss from the GI
tract (Rychik, 1998; Jacobs, 1996; Mertens, 1998; Thorne, 1998). Research has found that
the development of PLE occurs in approximately 13% of patients with Fontan physiology
by age 10 (Feldt, 1996). Mertens and colleagues (1998) found a 50% 5-year survival rate
and 50% mortality in patients who were part of a multicenter study.
In CHD patients, the diagnosis of PLE is based on clinical symptomatology, such as edema
and diarrhea, as well as biochemical parameters, including serum protein counts (Rychik,
1998). Treatment options vary with the diagnosis of PLE. Management may include
diuretics, afterload reduction, steroids, surgical fenestration, protein infusions, and/or diet
therapy (Rychik, 1998; Mertens, 1998).
Literature is limited regarding the dietary treatment of PLE. Some literature describes
dietary treatment as low in fat, specifically long-chain triglycerides, and high in protein (Lin,
2006). The rationale behind dietary therapy is similar to that for patients with chylothorax or
malabsorption. To alleviate and prevent symptoms such as diarrhea, hypoproteinemia, and
lymphocyte loss, the use of medium-chain triglycerides as an energy source is suggested.
However, Lin and colleagues (2006) also noted that diet intervention was associated with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
only transient relief of clinical symptoms with limited overall success.

Nutrition Support

In infancy, nutrition support is essential during the stages of diagnosis and initial
postoperative and rehabilitation periods. The provision of early nutrition support is crucial
to the preservation of lean body mass. The initial goals of nutrition support are to minimize
loss of lean body mass and to maintain electrolyte balance and vital organ function. Many
factors influence the decision regarding which method of nutrition support to initiate
following cardiac surgery. The medical team must clinically assess the neonate's cardiac
output and decide whether to initiate parenteral or enteral nutrition (Owens, 2009).
When a neonate, child, or adolescent presents for surgical repair or palliation, the patient
receives nothing by mouth following surgery. Patients who are malnourished are prone to
both infectious and noninfectious complications, resulting in longer duration of hospital
stay. Providing adequate energy and nutrients improves postoperative outcomes. Meeting
metabolic and nutritional demands during this critical period of medical instability may
assist in reducing the metabolic stress and loss of lean body mass (Nydegger, 2006).
Parenteral nutrition can be initiated usually on postoperative day one until adequate enteral
intake can be reliably maintained. For patients who are severely fluid restricted, parenteral
nutrition provides a more concentrated form of nutrition compared to enteral nutrition, which
requires larger volumes of fluid to provide comparable nutrition (Owens, 2009).
Ideally, nutrition support should be provided via the enteral route unless there are
contraindications to enteral feeding. Patients may have decreased cardiac output following
surgery, elevating the concern of hypoperfusion to vital organs. This concern is further
amplified in hemodynamically unstable patients requiring inotropic support. In the presence
of low cardiac output, blood is shunted away from the splanchnic system to the heart and
brain, increasing risk for gut ischemia (Zaloga, 2003). Patients with pulmonary
overcirculation and poor systemic output may also be at risk for compromised blood flow to
the gastrointestinal system.
Although parenteral nutrition may be the primary mode of nutrition support in the early
postoperative period, trophic feeding, also known as minimal enteral nutrition, may be
initiated in conjunction with parenteral nutrition. Minimal enteral nutrition does not provide
sufficient energy for growth but may be beneficial in promoting gut integrity, gut motility,
and enhancement of immune function (Schanler, 2005; Mishra, 2008). It may also help in
facilitating a smooth and rapid transition from parenteral to complete enteral
nutrition. Feedings can be initiated at the discretion of the medical team based on the
diagnosis and condition of the patient. Timing of extubation postoperatively can also affect
the decision to begin enteral feeds.

Enteral or Tube Feeding

Enteral nutrition in the form of tube feedings can deliver partial or complete alimentation for
the pediatric cardiac patient as short-term or long-term therapy. Indications for tube
feedings include the following:
Inability to voluntarily consume adequate nutrition
Failure to thrive when oral intake has been maximized
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Prolonged postoperative course
Vocal cord paralysis/paresis, where there is an increased risk of aspiration
Minimal enteral nutrition to promote gut integrity
Studies have demonstrated that tube feedings have improved growth in infants with
congenital heart disease (Schwarz, 1990; Bougle, 1986; Vanderhoof, 1982, Natarajan,
2010; Medoff-Cooper, 2010). Delivery of nutrients through the enteral route is dependent
on patient tolerance and amount of oral intake. If the pediatric cardiac patient has
gastrointestinal problems, such as reflux, a continuous infusion may be better tolerated
than a bolus feeding (Cox, 1997). A bolus schedule can provide a physiologic feeding
regimen. Nocturnal or cyclic feedings allow for oral intake during the day, with
supplementation during the night while the child is asleep. Growth parameters need to be
carefully monitored and energy needs reassessed to ensure enteral feedings are adequate
even post–cardiac surgery (Schwalbe-Terilli, 2009).

Parenteral Nutrition

Infants, children, and adolescents in the cardiac intensive care unit often require parenteral
nutrition (PN) support. The goals of PN are to promote growth and development as well as
tissue repair until oral or enteral nutrition is tolerated. In some pediatric cardiac patients,
there are relative contraindications to providing oral and enteral feeds. Feeding the gut
during these circumstances may cause an intestinal catastrophe, such as necrotizing
enterocolitis. PN should be initiated immediately for conditions in which enteral feedings
are contraindicated until the medical situation allows for safe initiation of enteral feedings.
Indications for PN include the following:
Poor gut perfusion that could be caused by decreased cardiac output, an open patent
ductus arteriosus either naturally or on prostaglandins, arch obstruction, or severe
aortic regurgitation
The presence of an umbilical arterial line (UAC); note, however, that this is
controversial, as new research indicates it may be safe to feed when a UAC is
present
Intestinal malabsorption
Postoperative ileus
Necrotizing enterocolitis
Gastrointestinal malformations
Extracorporeal membrane oxygenation
Premature birth
For cardiac patients, PN orders are driven by the total fluid limit. Maintenance fluids are
usually provided preoperatively and postoperatively, but further restrictions may be
necessary, depending on the medical condition. Providing adequate energy and protein is
often difficult secondary to the multiple medication infusions and line carriers that are
included in the total fluid limit. This limits the amount of fluid that can be used for PN.
Infusions and carriers should be concentrated and run at the lowest rate possible to
maximize the fluid available for PN. These parameters must be monitored daily so
adjustments to the total PN (TPN) can be made to maximize energy and protein.
PN can be administered through a peripheral vein as peripheral PN (PPN). In critically ill
patients, nutrient requirements often cannot be met with PPN because of fluid restriction
and a recommended limit of dextrose concentration of 10% to 12.5% with a final osmolarity
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
<900 mOsm/L (ASPEN, 2004). PPN is intended for short-term use or supplementation. In
most instances, it is used to maintain a previously well-nourished, nonhypermetabolic
patient or to serve as a bridge to centrally administered infusions or enteral feedings until
more suitable nutrition can be provided. In some cases, inappropriate use may result in
infusion phlebitis, infiltration, or inadequate nutrient intake (Gura, 2009).
TPN requires central venous access with the catheter tip terminating in the superior vena
cava or the right atrium of the heart. TPN allows for administration of a solution with an
osmolarity greater than 900 mOsm/L. X-ray confirmation of central line placement is
essential before administration of a parenteral solution with a high osmolarity to determine
the maximum dextrose concentration that can be safely infused (ASPEN, 2004).


Supplementation

Numerous cardiac medications—such as diuretics, calcium channel blockers, blood
pressure medications, and cardiac glycosides—have known drug–herbal interactions that
can alter the effect of the conventional medical therapy. Registered dietitians have an
essential role in educating families about the risks and benefits of herbal therapies (Buck,
2000; Miller, 1998). Furthermore, patients who require warfarin (Coumadin) for
anticoagulation need to be educated that fluctuations in dietary vitamin K intake can have a
significant effect on the degree of anticoagulation (see the Client Education Materials for
this section).
As with any other pediatric patients, dietary supplements should be considered and
recommended as an adjunct to the diet under the advice of a health care professional. The
feeding and diet history will assist in determining the need for micronutrient
supplementation in infants, children, and adolescents with cardiac conditions. If there is
concern regarding a nutrient deficiency, serum levels of these nutrients or their associated
enzymes should be obtained before supplementation. Additional supplementation may be
required for the following:
Protein-losing enteropathy and biliary atresia: Fat-soluble vitamins and zinc,
depending on the degree of malabsorption, may be needed.
Chylothorax: As fat-soluble vitamins are carried by the lymphatic system,
supplementation of vitamins A, D, E, and K (note: water-soluble forms may be better
utilized) and zinc, depending on the degree of chyle loss; a multivitamin/mineral
supplement and/or additional essential fatty acid supplements may also be
recommended for patients on a restricted oral/enteral regimen.
Iron deficiency: This deficiency occurs as a result of prolonged total parenteral
nutrition administration, postoperative blood loss, and chronic blood draws. Iron
supplementation, especially for infants, can be provided at 2 mg/kg to 4 mg/kg daily.
For those with severe anemia and during erythropoietin therapy, 4 mg/kg to 6 mg/kg
iron daily is recommended (Taketomo, 2008).


Nutrition Monitoring and Evaluation

The following are examples of Monitoring and Evaluation measures based on sample
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition diagnoses. Goals for weight gain, growth velocity, and energy concentration will
vary from patient to patient. Check with your institution for presence of established criteria
based on surgical protocols or collaborative standards.
ND-2.3: PES: Inadequate intake from enteral nutrition (EN)/parenteral nutrition (PN)
as evidenced by intolerance of EN due to gut ischemia.
Intervention (ND-2.1): Initiate PN
Recommendation: Start PN to provide 100% of nutritional requirements
Monitoring/Evaluation: (AD-1.1.4) Indicator: weight gain goal of 25 g/day to 35
g/day; monitor electrolytes until stable.
NC-1.3: PES: Breastfeeding difficulty related to lethargy/sleepiness, as evidenced by
lack of weight gain, fewer than 6 wet diapers per day, and laboratory evidence of
dehydration.
Intervention (ND-2.1): Initiate EN feeding using expressed mother’s milk to
supplement oral intake.
Monitoring/Evaluation: (AD-1.1.4) Indicator: weight gain goal of 25 g/day to 35
g/day.
NI-1.2: PES: Increased energy expenditure related to cardiac failure as evidenced by
failure to gain weight with normal energy intake
Intervention (ND-1.2): Modify distribution, type, or amount of food and nutrients
within meals or at specified times.
Recommendation: Provide additional energy by increasing energy density
of breast milk to 24 kcal/oz using addition of human milk fortifier in all
feedings.
Monitoring/Evaluation: (AD-1.1.4) Indicator: Weight gain goal of 25 g/day to 35
g/day.
NI-3.1: PES: Inadequate fluid intake related to congenital heart defect as evidenced
by tachycardia, diaphoresis, and early satiety.
Intervention (ND-2.1.2): Nasogastric tube placement providing x amount of
breast milk with specific timing schedule.
Monitoring/Evaluation: (AD-1.1.4) Indicator: weight gain goal of 25 g/day to 35
g/day; (FH-1.2.3.1) specific mL/ounces of breast milk consumed in 24 hours

Nutrition Care FAQs

Question: How much energy does an infant with congenital heart disease (CHD)
require?
Answer: Weight trends, growth velocity, and diagnosis are all factors that contribute to
estimated energy needs. Several studies have been done to determine baseline energy
needs; however, there is a general consensus to provide these infants and children with
more than the recommended energy for age, usually using a baseline of 120 kcal/kg for
infants, which may need to be increased to 150 kcal/kg to 175 kcal/kg or more. (See
Nutrition Intervention.) Growth trends should be closely monitored to assess adequacy of
energy intake to better estimate changing needs.
Question: Why are estimated energy needs often higher in the cardiac population,
and why is failure to thrive (FTT) prevalent?
Answer: Increased energy requirements and the resulting FTT often seen in patients with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Answer: Increased energy requirements and the resulting FTT often seen in patients with
CHD may be related to multiple factors, including type of cardiac disease, disturbances in
energy metabolism (increased energy expenditure), decreased energy intake, and
disturbances in gastrointestinal function.
Question: How do you provide additional energy to prevent FTT?
Answer: To improve nutritional status and growth in infants with CHD, increase the energy
density of feedings beyond the standard 20 kcal/oz provided by human milk and formula to
a range of 22 kcal/oz to 30 kcal/oz or provide supplemental or complete tube feedings to
ensure adequate energy and protein intake.

Suggested Monitoring Parameters and Recommendations

Nutrition reassessment in patients with cardiac conditions should include the following:
Current medical condition and medical treatment plans
Current laboratory values
Current dietary intake and output
Evaluation of oromotor skills (ability to chew, swallow, and consume adequate
nutrients)
Weight and weight changes
Linear growth and growth patterns
Physical activity patterns
Assessment of readiness for education
Developmental milestones
Follow-up nutrition intervention in cardiac patients should include adjustment of nutrition
goals and treatment plans according to the patient's response to the current treatment. The
curative solution for children with cardiac conditions and congenital heart disease is
corrective surgery.
Nutrition support is often necessary for children with inoperable cardiac lesions or for those
in poor nutritional states preoperatively and postoperatively.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Cardiology > Extracorporeal Membrane Oxygenation (ECMO)
Nutrition Care

Nutrition during ECMO
At first, nutrition support for the patient receiving extracorporeal membrane oxygenation
(ECMO) is provided as parenteral nutrition because of the risk of gut ischemia. Depending
on individual patient status and duration of ECMO support, enteral nutrition has been
documented as a safe and effective route for alimentation.

General principles for providing nutrition support during ECMO include the following:
Fluid restriction
Total fluid limit may be 80 mL/kg to 100 mL/kg
Energy requirements: 70 kcal/kg to 80 kcal/kg (see table on this page)
No growth expected
Resting energy expenditure difficult to measure
Minimal activity
Metabolic stress
Minimize catabolism (Brown, 1994; Jaksic, 2001; Keshen, 1997)
Specific substrates: Parenteral nutrition goals
Carbohydrates
Limit glucose infusion rate to ~7 mg/kg/min (~10 g/kg/day) as excess
carbohydrate may increase carbon dioxide production and increase
respiratory quotient
Protein
Patients are in negative nitrogen balance; worsens with higher energy
intake
Fat:
Intravenous lipid should not be infused through the ECMO circuit, since
this can cause problems with agglutination of the fat emulsion and
malfunction of the membrane. It may be infused through a peripheral
intravenous access or other central/peripheral access. Check for
compatibility of lipids and other medication infusions.
Less carbon dioxide production than carbohydrate
Lowers respiratory quotient
2.5 g/kg/day 3 g/kg/day
Decreases hyperglycemia
Able to meet energy needs
Enteral feeding while on ECMO
Gut perfusion on ECMO
Pressors
Risk of necrotizing enterocolitis
Barrier function/translocation
More studies needed (both parenteral and enteral nutrition)
Post-ECMO
Oral intake after extubation
Speech-language pathology consult
Monitor weight trends, protein intake
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Estimated Energy Requirements for Neonates, Children, and Nonobese Adolescents on
ECMO
Age (years)
Estimated Energy
Requirement
(kcal/kg/day)
0 to 3 90
> 3 to 6 80
> 6 to 8 70
> 8 to 10 60
> 10 to 12 50
>12 to 14 40
15 and
older
30
(Jaksic, 2005; Jaksic, 2001)
Estimated Protein Requirements for Neonates, Children, and Nonobese Adolescents on ECMO
Age
(years)
Estimated protein
requirement
(g/kg/day)
0 to 2 2-3
> 2 to 13 1.5-2
14 and
older
1.5
(Jaksic, 2005; Jaksic, 2001)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Cardiology > Prevention of Adult Cardiovascular Disease
Prevention of Adult Cardiovascular Disease

It is clear that cardiovascular health behaviors are as important for children and
adolescents as for adults. In fact, they are perhaps even more important for children and
adolescents, because it is the establishment of those behaviors in childhood that translates
into maintenance of ideal cardiovascular health status in young adulthood and later life
(AHA, 2010). Early nutrition lessons, especially for children with existing cardiac
conditions, can help develop heart-healthy habits that last a lifetime. Interventions should
be targeted to parents and caregivers, as they are the main decision makers when it comes
to the nutrition, physical activity, and health needs of their children.
Dietetics is an integral part of cardiovascular patient risk management. As part of the
nutrition intervention, all patients and their families should receive advice about food
choices that are associated with lowered risk of cardiovascular disease. High-risk patients
should receive special dietary advice. See the Meal Plans section for more information on
specific foods to recommend or limit in this population.
The American Heart Association (AHA) currently recommends a diet low in fat and
cholesterol. The dietary guidelines of the US Department of Agriculture and the AHA are
designed to be preventive in nature but are also appropriate for patients in whom
cardiovascular disease is already present (AHA, 2010). In cases of severe congestive heart
failure, sodium may be restricted along with total fluid intake.
Historically, dietary recommendations regarding fat, sodium, and total energy were thought
to be pertinent to adults only. However, current research supports the implementation of
low-fat, moderate-sodium diets for children older than 2 years (AHA, 2010). The current
adult dietary recommendations should be applicable with moderation in children but should
not affect the consumption of high-quality protein, iron, calcium, and minerals that are
needed for growth. It is important to note that a diet with less than 30% of the total energy
from fat is not recommended for children younger than 2 years of age, as fat is an
important source of energy for growth and development (Murray, 1991; Graham, 2007).
The frequently prescribed sodium-restricted and fluid-restricted diets can limit energy and
nutrient intakes, but such restrictions may be negotiable. For example, easing the fluid
restriction to allow oral liquid supplements for a poor eater is preferable to tube feeding.
Patients with cardiac conditions who are in the hospital for a long time can become bored
with menu selections, and it may require considerable time and creativity from the
registered dietitian and dietetic technician, registered, to satisfactorily address this
complaint in patients. One solution may be the elimination of as many diet restrictions as
possible to increase menu options and palatability; however, stable patients with lengthy
hospital stays frequently have no diet restrictions. Family members sometimes are invited
to bring favorite foods or fresh fruits that are not available at the hospital. Passes to the
hospital cafeteria are another option.
Some patients are too depressed to eat well. Other factors that affect appetite include
fatigue—which worsens as the day progresses, potentially making breakfast the highest
quality meal eaten—and cardiac polypharmacy, which may cause taste changes.
Administration of appetite stimulants is an option for addressing appetite
concerns (Hummell, 2003).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Cleft Lip and Palate
Nutrition-Focused Physical Findings

Physical appearance should be evaluated as it is with any nutrition assessment. In
addition, the health care team should observe a feeding alongside a feeding specialist from
a speech language therapy department. The following should be monitored (Garcez, 2005):
Milk loss around the mouth while feeding
Suck/swallow rhythm and organization
Spitting up or vomiting
The skill of the caregiver in feeding. For example, the caregiver should be aware that
the position of an infant with cleft palate should be relatively upright to prevent liquid
from flowing into the open cleft and nasal cavity; or that a too-rapid feeding flow may
overwhelm the infant and cause them to stop feeding or to indicate distress.

Biochemical Data, Medical Tests, and Procedures

Careful assessment by the hospital pediatric exams usually discover large or small cleft
palate, but smaller clefts or laryngomalatial clefts may be harder to initially detect. Frequent
vomiting which flows from both the mouth and nose may indicate a less obvious cleft.
The caregivers should be referred to a cleft lip and palate or craniofacial clinic for
diagnostic tests for feeding and swallowing as necessary.
See the Nutrition-Focused Physical Findings heading for further information.

Laboratory

Laboratory values should be reviewed if available, or requested if clinical signs of
nutritional deficiencies are observed or milk/food intake is less than normal for
age/gestation and weight/height.
Otherwise, there are no special laboratory values that are indicative of cleft lip and palate.

Client History

Below are some factors to assess for a client history of an infant with cleft lip and palate:
Evaluate family history with respect to anthropometrics.
Record birth history details, eg, deep suction at birth, need to resuscitate at birth,
early feeding issues, whether birth weight was regained after 2 weeks.
If breastfeeding or pumping, assess mother's experience with prior breastfeeding,
assess for risks regarding breastfeeding such as appropriate changes in breasts
during pregnancy, milk in by day 3-5 postpartum, or any drug use (prescription or
recreational). Refer to a lactation consultant or hospital lactation center for further
evaluation and support.
Illness since birth
Isolated cleft lip or palate, or possible syndrome
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Take at least a 24-hour recall of feedings including any water used in tube feedings,
or otherwise.
Record stooling and wetting for 24 hours.
Ask about past and recent illness/hospitalizations.
Record any medications/supplements taken.
Ask about any vomiting, spittiness, gagging, and choking episodes; record frequency.
Ask about any particular concerns the parents/caregivers have.

Food/Nutrition-Related History

Review food intake items and food-related concerns below, and do a nutrient analysis.
For infants less than 6 months of age, assess the following:
use of breastmilk or formula
how breastmilk or formula is stored
any need for increased caloric density
any concerns regarding the change to formula from breastmilk
special formula use, any problem getting or mixing formula
thickeners used
if caregivers are skilled and comfortable with feeding techniques given
if any special bottles are used, (four special bottles are often required)
volume and frequency of feeds
if a breastfeeding mother is on a special diet or dietary restrictions
Infants on breastmilk should have their nutrition supplemented with vitamin D, per
American Academy of Pediatrics recommendations, at 2 months of age.
After one year, assess diet for need for any supplementary vitamins, iron, or vitamin D.
Introduce a cup by 5-6 months. This should be a simple flowing cup, not a sippy cup that
requires the infant to suck. Skilled cup feeding will greatly facilitate feeding post-surgery for
cleft palate.
For children older than 6 months old who are on solids:
solids should be purees or very soft, tiny pieces of food spoon fed and finger fed
use a cup for sips of water or milk daily to help with post-surgery feeding
rinse mouth with water after eating by giving 1/2 to 1 ounce of water by cup or bottle
begin with one meal per day at 6 months, and over the next 2-3 months increase the
frequency of meals to 3 per day
juice is not necessary but if desired, use only 1-2 ounce per day of diluted juice in a
cup


Anthropometrics

Anthropometrics are to be reviewed as part of the nutrition assessment, and inconsistent
height measurements re-measured by the dietitian if necessary.
Children with cleft lip and/or palate, without a related syndrome, can be expected to grow
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
according to their genetic potential (Montagnoli, 2005). Use specific growth charts for a
particular syndrome, provided one exists; otherwise chart on CDC growth charts.

Nutrition Diagnosis

Dietitians working with children with cleft lip and/or palate should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.2)
Inadequate fluid intake (NI-3.1)
Swallowing difficulty (NC-1.1)
Biting/chewing (masticatory) difficulty (NC-1.2)
Breastfeeding difficulty (NC-1.3)
Underweight (NC-3.1)
Self-feeding difficulty (NB-2.6)
Sample PES or Nutrition Diagnostic Statement(s)
Swallowing difficulty (NC-1.1) related to cleft lip/palate as evidenced by
videofluoroscopic swallow study (VFSS) results.
Self-feeding difficulty (NB-2.6) related to inability to form suction as evidenced by
need for a special bottle for successful feeding.
Increased energy expenditure (NI-1.2) related to increased work of breathing as
evidenced by poor growth with typical intake.
Breastfeeding difficulty (NC-1.3) related to inability to form suction as evidenced by
need for a special bottle for successful feeding.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

In general, to ensure adequate intake for optimal growth, children with cleft lip and palate
require more comprehensive nutrition intervention (Brooks, 1988).
Initial intake immediately after birth should be as with other newborns, with feedings of
colostrum or breastmilk given in approximately 10-mL increments every 2-3 hours.
Formula can be used if no colostrum or breastmilk is available.
Infants with cleft lip isolated (CLI) can generally breastfeed since the lips are not essential
for breastfeeding to occur. Ability to breastfeed should be expected until proven
otherwise. Mother and infant should be kept together as much as possible to encourage
bonding (Montagnoli, 2005; Coy, 2002).
Cleft palate isolated (CPI) makes it difficult to provide adequate suction for efficient feeding
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
at breast or with a standard bottle (Montagnoli, 2005).
For the first 1-2 days the infant can be put to breast. Colostrum should be expressed for
initial trophic feeds and given by finger or syringe, providing ½ to 1 teaspoon every 2-3
hours (Montagnoli, 2005). After the first 24 hours of skin-to-skin care with expressed
colostrum given, breastmilk or formula can be given using a Pigeon or SpecialNeeds
®
(formerly Haberman) feeder.
Successful modifications of usual breastfeeding and bottle-feeding techniques allow the
family and infant to achieve goals without expensive, odd-in-appearance feeding systems.
The feeding systems should appear as normal as possible and should be safe, readily
available, reasonably inexpensive, and easy to clean. If infant is to be bottle-fed, bottles
which do not require suction to release milk are necessary (see the Weblinks section).
Modifications in foods provided will vary with the child's age, modality of feeding, degree of
cleft(s), and surgical protocol. An individualized diet should be provided as the child grows
and undergoes periodic surgical repair (Brooks, 1988; Dunning, 1986; Brine 1994; Klein,
1994; Weatherly-White, 1987).
Nutrition management in the acute surgical repair period is important to avoid disruption of
the sutures. The key for successful feeding in the initial period after surgery is one-on-one
feeding instruction, with frequent monitoring of hydration status, weight gain, and home
feeding practices (Brooks, 1988; Fisher, 1987; Klein, 1994; Weatherly-White, 1987).
Preoperative and postoperative evaluations and education are important. Follow-up
instructions for after the infant goes home should be clearly communicated to parents and
pediatrician. An appointment should be made for the local cleft lip and palate or craniofacial
clinic.

Nutrition Therapy Efficacy

Expected nutrition-related outcomes include:
Growth at expected rate per genetics of parents, taking into account any related
syndrome (Montagnoli, 2005). Chart on an appropriate growth chart (eg, CDC,
premature, or special growth chart) that exists for some special
conditions/syndromes.
Feedings should match the expected number of feedings for a healthy child of the
same age, and the feeding should be finished within a normal range of time
Developmental feeding milestones should be reached within normal limits. For
example, solids should be started at 6 months of age and weaning from bottles to a
regular cup at about 12-14 months.
Use of a cup should begin at about 6 months of age so that child has cup feeding
skills well developed by the time palate surgery takes place.

Goal Setting

Goals for the infant or child with cleft lip and palate include:
normal growth and development for age or adjusted age or syndrome
meeting nutrient requirements
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
establishment of parental bonding (not a measurable goal, but can be facilitated by
nutrition support and referrals)
maintenance of nutritional status and growth throughout the surgical repair process
(Brooks, 1988; Dunning, 1986; Fisher, 1987)
Minimization of physical difficulties associated with the cleft (eg, choking, excessive
air swallowing, and nasal regurgitation)

Food & Feeding Issues

Infants with cleft lip need assistance with lip closure to form a tight seal to suck. Infants
with cleft palate have further difficulty, since the suction is broken by the opening between
the oral cavity and nasal passages. Assisted feeding techniques promote a coordinated
suck, swallow, and breath cycle, while minimizing parental and infant feeding frustration
(ADA, 2010).
Feeding a child with a cleft lip and/or palate may be stressful and often requires extra time,
individualized techniques, and patience. For some children, improved nutrition is the factor
most critical for survival; for others, it can reduce the potentially debilitating effects of their
conditions (ADA, 2010). In addition to promoting growth and development, good nutrition is
essential to enable the infant to build up resistance to infection, to acquire the necessary
weight needed for surgery, to build up strength for the stress of surgery, to promote healing
after surgery, and to develop and maintain healthy oral structures (Farnan, 1993).
Not only do functional issues of an infant with a cleft lip and/or palate affect nutritional
intake and physical growth, they also affect psychosocial variables such as:
parent-feeding interaction
infant temperament
maternal social support
family socioeconomic status
Feeding methods should be assessed for efficiency and adequacy. Evaluate issues such
as spittiness, vomiting, nasal regurgitation, or reflux.

Comparative Standards

Provided the infant does not have other issues such as a related syndrome, prematurity, or
other birth trauma, infants born with CLP or isolated cleft lip or palate have nutrition needs
that are the same as any other infant. During the first 6 months of life this is approximately
102 kilocalories/kg and 2.2 grams protein/kg as provided by breastmilk or formula.

Fluid needs are the same as those for children without cleft lip and palate, and are to be
evaluated on basis of age/weight.


Oral Intake

Below are some guidelines for feeding an infant with cleft lift and palate (CLP):
If infant is to be bottle-fed, bottles which do not require suction to release milk may
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
If infant is to be bottle-fed, bottles which do not require suction to release milk may
be necessary (see Nutrition Intervention for use of pigeon bottles or Haberman
feeders).
If infant is feeding at least part of the time at the breast, or mother is using pumped
breastmilk, referral to lactation support and mother-to-mother support groups (eg, La
Leche League) should be included. See Weblinks for mothers' milk pumping sites and
other support info.
It is very important that as soon as the infant is born the caregivers be allowed to do
as many feedings as possible so that they feel confident in doing so. They can be
observed by the health care team, who can help assess feeding efficiency.
Tube feeding with nasogastric or g-tube may sometimes be necessary if the infant
has CLP as part of a syndrome. These are not usually needed if there is no
neurological impairment with the cleft lip or palate.

Nutrient Exceptions to DRI

Calorie needs before surgical repair may be higher than normal if the infant has an
extensive defect, such as bilateral cleft lip with cleft of the hard palate. Calorie provision is
also influenced by the time required to feed the child, the ability to establish effective
sucking, and formula or breastmilk losses through the cleft (Brooks, 1988; Dunning, 1986).
In some cases, caloric density of breastmilk or formula may be increased to meet a greater
caloric expenditure, in order to promote a weight gain of 25 to 30 grams per day until 3
months of life and to allow for a decreased volume needed for successful oral feeding.
The guidelines for vitamin and mineral supplementation are consistent with standard
recommendations for infants. Vitamin and mineral supplements may be indicated if
macronutrient intake is consistently inadequate.

Suggested Monitoring Parameters and Recommendations

Routine monitoring to prevent failure to thrive should be the standard of care. General
infant feeding practices should also be incorporated into instructions for caregivers.

Follow-up instructions once the infant goes home should be clearly communicated to
caregivers and pediatrician.
Pre- and post-surgery evaluations and education should be provided.
Connection to the local cleft lip and palate or craniofacial clinic should be ascertained.
The pediatrician should see the infant within a few days of discharge, and at 2 weeks. The
child should be evaluated for additional visits every 2 to 3 weeks, or interventions such as a
weekly visiting nurse, The child should be evaluated for possible early nutrition
interventions.

Nutrition Care FAQs

How can I be sure this child will receive follow-up at a craniofacial clinic or cleft lip
and palate (CLP) clinic?
Develop a relationship with the clinic so that you can alert the clinic. Acquire a release from
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
the parent while they are still in the hospital. Find out how your state or local area follows
children with CLP.

Who will teach the parents/caretakers to feed this baby (either if breastfed, or fed
breastmilk or formula by bottle)?
The hospital may have a speech pathologist or a nurse with experience with CLP, or may
not have anyone who is really accustomed to helping with CLP. Since only 1 baby in 700 to
1000 is born with this anomaly, hospital staff may not have experienced personnel.
Refer to the CLP or craniofacial clinic for follow-up within a few days or weeks of discharge
for continuing observation/support.
Recommend to pediatrician or hospital staff that a home visiting nurse be a part of the
discharge arrangements to follow for the first month with weight checks, at least for the first
month until weight gain is established as normal. Pediatricians can also perform this
service.

Where can I refer these patients to in my state?
Go to your state’s health department for information about your state’s specific
clinic(s). The Cleft Palate Foundation has good information for parents on feeding, the
clinic team members, and support for these anomalies.
What websites would be helpful for parents?
See the Weblinks section.


Nutrition Assessment

Due to the lack of suction, infants with cleft lip and palate (CLP) are at risk for failure to
thrive. It is important to monitor the infant very closely in the first few weeks for feeding
issues and appropriate weight gain.
Referrals to CLP clinics should be made before the infant leaves the hospital so that
caregivers can receive the most up-to-date information regarding the surgery and the CLP
support team, as well as to be reassured. The hospital social worker or pediatrician may be
able to help with the referral.
Support can be given to mothers who are breastfeeding or pumping breastmilk by making
referrals to lactation consultants, La Leche League, or mothers' groups. Breast- or
bottle-fed infants and their families may find local support groups for CLP by contacting
their state health department (Garcez, 2005).
Parents of an infant with CLP may have a variety of reactions, including concern about the
infant's feeding and fear of the reactions from family and friends. Methods such as
providing reassurance by giving the infant early skin-to-skin care, helping parents learn
about kangaroo care for infants, and allowing the infant to have rooming in will go a long
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
way in normalizing the early relationship (Strathearn, 2009).
Nutrition Assessment
A 24-hour record of intake should be recorded for the first week to two weeks,
depending on how well the infant is gaining weight.
Include in the 24-hour record the intake in ounces if using a bottle of breastmilk or
formula, record of wet and soiled diapers, any spillage while drinking, spitting up or
vomiting, amount and frequency of feeds, and the infant's contentment or excessive
crying.
Normal output in the first week: Usually the minimum requirement for wet and/or
soiled diapers match the days of life. For example, on day 1, there should be one wet
or soiled diaper; day 2 will show at least one soiled diaper and one wet; and so on,
with at least one soiled diaper each day and the remainder wet for a total that
matches days of life until 7 days old. Breastfed babies tend to have more soiled
diapers per day, but the total number of wet and/or soiled is the same for breastfed or
bottle-fed.
The ultimate assessment is weight gain, and infants with CLP should be monitored
more closely due to the possibility of inefficient suck or swallowing. Upon discharge
they should be seen within 1 to 2 days by the pediatrician, which is now the American
Academy of Pediatrics' normal recommended protocol in pediatric offices. These
infants should be seen again in 1 week for a weight check, and at 4 weeks for weight
check and physical.
Based on weight gain and feeding efficiency in the first 4 weeks, a plan can be made
to monitor the infant's progress more or less frequently than normal.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Critical Care
Nutrition Assessment

Nutrition assessment of the critically ill child is a dynamic process that occurs throughout
the child’s admission. Nutrition assessment details are discussed in the following sections:
Laboratory
Client History
Food/Nutrition-Related History
Anthropometrics

Laboratory

The metabolic response to stress and its many treatments make interpretation of laboratory
values difficult.
There is a shift in hepatic synthesis from normal circulating binding proteins such as
albumin, prealbumin, etc. to acute phase proteins. Use of serum albumin in particular as a
nutritional marker is useless in this population. Serum prealbumin (transthyretin,
thyroxine-binding protein) is also of little use as an indicator of nutrition status early in the
course of critical illness without the context given by c-reactive protein (CRP). A low level of
prealbumin in the context of the stress response and an elevated CRP cannot be utilized
as an indicator of nutrition status. However, if the CRP is normal and the prealbumin is low,
it suggests that current nutrition therapy is insufficient. Please see the list below.
Other laboratory measures including electrolytes, blood urea nitrogen, creatinine, and
glucose can have broad fluctuations and must be interpreted carefully in the context of
nutrition therapy.
Considerations for use of serum-binding proteins for nutrition assessment include the
following:
Albumin
Large pool
Longer half-life (14 to 20 days)
Affected by albumin infusion, dehydration/diuresis, trauma, sepsis, liver disease
Poor marker of protein status during illness
Prealbumin
Smaller pool
Shorter half-life (24 to 48 hours)
Affected by inflammation, liver disease, renal failure, administration of
steroid medication
C-reactive protein
Acute phase protein
Marker of inflammation
Inversely related to prealbumin
Normalizes as acute phase response resolves
Level below 2 mg/dL suggests return to anabolism (increases in energy
expenditure and return of growth)

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Client History


Past medical history is an important consideration during the initial assessment of a patient
admitted to the pediatric intensive care unit.
Considerations include the following:
Pregnancy complications
History of prematurity
Birth weight and length
History of congenital or chronic disease
Medical history
Nutrition history
History of nutrition support, malnutrition, or obesity
Surgical history
Social history

Food/Nutrition-Related History

Food and nutrition history is another important component of the initial nutrition
assessment.
For infants, type, frequency, and amount of breast or formula feeding, history of food
allergy or sensitivity, and use of supplements or alternative therapies should be
documented. For older infants, age at introduction to solids, as well as type, frequency, and
amount, should also be noted. The food intake of toddlers and children should also be
reviewed with the primary caregiver(s).
For patients who receive enteral nutrition at baseline, it is important to obtain the home
feeding regimen (formula, volume, rate, free water) that may be adapted while in the
pediatric intensive care unit. Similar information should be obtained for children who
receive home parenteral nutrition.
Detailed diet histories may be most useful for children with severe malnutrition, growth
faltering, or obesity at admission.

Energy Requirements

Each component of total energy expenditure should be evaluated at each
assessment.
Careful assessment begins with the evaluation of each portion of total energy expenditure
(TEE) within the context of age and sex: basal metabolic rate (BMR), resting energy
expenditure (REE), thermic effect of feeding (TEF), and physical activity. Once each
component has been evaluated, a more accurate assessment of energy requirements can
be made.
BMR
BMR is the amount of energy necessary to maintain normal metabolic function while at rest
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after a 12-18 hour fast in a thermoneutral environment. BMR is most closely related to lean
body mass.
A number of treatments used in the management of sick children may affect BMR,
including use of heating or cooling blankets to change body temperature and numerous
medications used to treat fever, for deep sedation, and to increase cardiac output. A review
of these treatment effects on BMR would be too cumbersome for this publication, but it is
recommended that the clinician working with this population become familiar with them to
assist in making recommendations for energy requirements.
It has also been demonstrated that children suspend growth during periods of critical
illness and that this may explain the relative lack of hypermetabolism observed in this
population (Gardelis, 2005). That is, these children reprioritize energy ordinarily used for
growth for use in the metabolic response to illness. However, in children older than 1 year,
this is equivalent to less than 2% of total energy requirements (Hommes, 1980).
REE
REE reflects an "awake and alert" state while remaining in bed in a thermoneutral
environment after an overnight fast. This change in level of alertness raises energy
expenditure by approximately 10% over BMR (Kleiber, 1975).
TEF
TEF describes the increase in metabolic rate necessary for the digestion, absorption, and
assimilation of nutrients from food consumed. For most individuals who are consuming
nutrients in the form of several meals, such as boluses, TEF accounts for an additional
10% above REE (Kleiber, 1975).
For children receiving bolus enteral nutrition, TEF may be a potential component of energy
requirements. However, provision of nutrition therapy as an enteral formula may not result
in a similar rise in metabolic rate, as formulas require less metabolic effort to digest as a
large meal of multiple food sources. Use of continuous enteral or parenteral nutrition is less
likely to result in a significant increase in metabolic rate; however, this has not been
studied in children.
Physical activity
In healthy children, the contribution of physical activity to total energy requirements varies
widely. Physical activity accounts for the main difference between resting and total energy
expenditure in the healthy pediatric population.
Limited information is available regarding the contribution of physical activity to TEE in the
critically ill child. Physical activity in this population includes not only spontaneous
movement of the individual but also movement related to medical and nursing care. Failure
to account for this component of TEE will result in a cumulative energy deficit, increasing
risk of malnutrition-related morbidities and mortality.
Critical illness and its subsequent treatment result in poor accuracy of prediction
equations. Existing prediction equations were developed from populations of healthy
children. It is not surprising, therefore, that they do not provide accurate estimates of
energy requirements for sick children. Numerous studies have shown that use of prediction
equations for critically ill children result in both overestimates and underestimates of actual
energy requirements determined by indirect calorimetry. One equation has been developed
specifically for use in the pediatric intensive care population (White 2000); unfortunately,
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efforts to validate this equation by independent authors have been unsuccessful (Taylor
2003; Havalad 2006; Framson 2007).
When estimating energy requirements, consideration should be given to all aspects
of a child’s illness and its treatment. Elements that may contribute to increased energy
expenditure vs normal expenditure for age include, but are not limited to, the following:
Increased lean body mass vs fat mass
Persistent fever
Increased movement/physical activity
Certain medications (vasoactive) and their dosages
Use of bolus feeds

Elements that may contribute to reduced energy expenditure include, but are not limited to,
the following:
Increased fat mass vs lean body mass
Mechanical ventilation
Certain medications
Deep sedation and induced paralysis
Decreased movement/physical activity
Growth cessation
Risks of Overfeeding
Overfeeding critically ill children can increase their risk of morbidity and mortality. Increased
energy can place additional stress on organ systems, increase risk of infection, delay
weaning from mechanical ventilation, or even induce respiratory failure.
Risks of Underfeeding
The provision of energy less than required will result in underfeeding. Common causes of
underfeeding include incorrect estimates of needs, frequent interruption of nutrition therapy
(perceived or real intolerance, procedures), and fluid restriction. Persistent delivery of
inadequate nutrition will result in rapid onset of protein–energy malnutrition and its related
complications; wasting of skeletal muscle, including those necessary for optimal ventilation;
and increased risk of infection.
Estimating Energy Requirements
In the past, the addition of a stress factor has been advocated when estimating energy
needs for hospitalized patients. However, application may be arbitrary, inconsistent, and
often unnecessary and its use in this population may increase the risk of overfeeding
substantially.
Estimating energy needs of children who are overweight or obese pose a particular
challenge to the pediatric nutrition practitioner. Recent recommendations include the use of
indirect calorimetry whenever possible, but in its absence, using the same approach to
estimating energy needs as in other children in the pediatric intensive care unit.
Calculating REE with the use of two prediction equations and comparing the results can
provide guidance in estimating energy requirements. Use of serial measurements of
prealbumin and c-reactive protein and calculating their ratio may serve as an accurate
indicator of return to anabolism and when to advance energy intake. See Calculations for
Assessment for specific equations.
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Assessment for specific equations.

Nutrition Diagnosis

Dietitians working with children admitted to the pediatric intensive care unit should review
the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the list below as
well as other diagnoses may be present.
Inadequate energy intake (NI-1.4)
Excessive energy intake (NI-1.5)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Inadequate parenteral nutrition infusion (NI-2.6)
Inadequate fluid intake (NI-3.1)
Excessive fluid intake (NI-3.2)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein-energy intake (NI-5.3)
Imbalance of nutrients (NI-5.5)
Inadequate carbohydrate intake (NI-5.8.1)
Excessive carbohydrate intake (NI-5.8.2)
Inadequate mineral intake (specify) (NI-5.10.1)
Predicted suboptimal nutrient intake (NI-5.11.1)
Predicted excessive nutrient intake (NI-5.11.2)
Swallowing difficulty (NC-1.1)
Altered gastrointestinal (GI) function (NC-1.4)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Unintended weight loss (NC-3.2)
Unintended weight gain (NC 3.4)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate energy intake (NI-1.4) related to use of a 5% dextrose intravenous
solution only as evidenced by 3 days without nutritional intake.
Excessive energy intake (NI-1.5) related to energy delivery greater than estimated
energy needs as evidenced by a respiratory quotient greater than 1.0.
Inadequate oral intake (NI-2.1) related to continued use of sedation as evidenced by
frequent sleeping through meal times.
Increased nutrient needs (zinc) (NI-5.1) related to excessive losses as evidenced by
persistent, watery diarrhea.

Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.


Nutrition Intervention
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Nutrition Intervention

Nutrition intervention involves the planning and implementation of treatment that is aimed
at the nutrition diagnosis. Planning nutrition intervention for critically ill children requires the
close interaction between the nutrition professional and the intensive care team.
Nutrition interventions should first target the nutrition diagnoses of the highest priority, such
as providing nutrition to the patient who has been without intake for several days.
Sample PES (problem, etiology, signs and symptoms) statements with corresponding
intervention recommendations are as follows.
Inadequate energy intake (NI-1.4) related to use of a 5% dextrose intravenous solution only
as evidenced by 3 days without nutritional intake.
Establish a nutrition plan that includes age-appropriate estimates of energy and
protein needs with recommendations for achievement of these recommendations
(such as polymeric, 1 kcal/mL formula with rate goal of 30 mL/hour for 24 hours).
(ND-2.2)
Excessive energy intake (NI-1.5) related to energy delivery greater than estimated needs
as evidenced by a respiratory quotient > 1.0.
Document indirect calorimetry results and estimated energy requirements from
calorimetry; compare to energy delivered with recommendation to reduce volume of
energy from enteral or parenteral nutrition to that which was measured.
Inadequate oral intake (NI-2.1) related to continued use of sedation as evidenced by
frequent sleeping through meal times.
Document energy balance for 48 to 72 hours with comparison to goal of nutrition
therapy. Recommend placement (or replacement) of feeding tube with formula goal to
meet estimated needs. (ND-2.1/2.2)
Increased nutrient needs (zinc) (NI-5.1) related to excessive losses as evidenced by
persistent watery diarrhea.
Document stool output and relationship between diarrhea and elevated zinc loses.
Provide recommendation for supplemental zinc based on age and volume of stool
losses. (ND-3.2.4)

Nutrition Therapy Efficacy

Delay in provision of enteral or parenteral nutrition and provision of inadequate nutrition
were associated with development of malnutrition in one group of patients in the pediatric
intensive care unit (de Neef 2008).
Avoidance of underfeeding through the use of early enteral nutrition that meets energy
needs may reduce the development of infections and protein–energy malnutrition (Villet
2005; Hulst 2004).

Intravenous lipids are a necessary component of parenteral nutrition to decrease carbon
dioxide production, minute ventilation, and fat storage from excess carbohydrate (Bresson
1989). They also assist in protein retention and prevent essential fatty acid deficiency (Van
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1989). They also assist in protein retention and prevent essential fatty acid deficiency (Van
Aerde 1994).

There is no evidence to support the practice of incremental increases in amino acids or
lipids in parenteral nutrition (Shulman 2003; Koletzko 2005; Mehta 2009).

Use of a feeding protocol results in improved utilization of enteral nutrition and achievement
of energy goal more quickly with fewer interruptions in enteral delivery (Gurgueira 2005).

Goal Setting

Nutrition intervention goals allow the practitioner to develop a reference point for
monitoring progress and measuring outcomes. The categories that contain the most
appropriate interventions for this patient population are Food and/or Nutrient Delivery (ie,
enteral or parenteral nutrition therapy) and Coordination of Nutrition Care (ie, with other
health care providers).
Goals for each nutrition diagnosis should be established with the development of a clear
plan for intervention, evaluation of outcomes, and reassessment.
General goals for patients in the pediatric intensive care unit include the following:
Individualized assessment of energy and nutrient requirements
Timely delivery of nutrition
Utilization of the proper route
Optimal response to illness
Minimized complications of overfeeding or underfeeding
Regular reassessment
For example, if the problem, etiology, signs and symptoms of a patient were, "Inadequate
energy intake related to three days without nutritional intake as evidenced by the use of a
5% dextrose intravenous solution only," the goal of the nutrition prescription (see Nutrition
Diagnosis) would be the initiation of either enteral or parenteral nutrition support that would
meet the estimated energy and nutrient needs of this particular patient.

Fluid and Electrolyte Requirements

Fluid requirements of the critically ill child are dependent on size, diagnosis, and treatment
and can be quite variable. It is not unusual for these patients to receive multiple
simultaneous intravenous fluids or blood products, frequently in amounts that far exceed
what is typically considered "maintenance." Traditional maintenance fluids are derived from
estimates of water evaporation and energy expenditure in healthy children (Holliday 1957).
Since critically ill children usually do not have normal rates of water evaporation and energy
expenditure, it would follow that they do not have the same maintenance fluid
requirements. It has been suggested that fluid requirements are reduced by as much as
40% to 50% from standard maintenance estimates (Choong 2007), which would be in line
with adjusted estimates of energy requirements in this population.
Fluid available for nutrition support may be minimal by virtue of the use of multiple
intravenous lines and fluids to manage the presenting illness or injury, thus preventing the
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intravenous lines and fluids to manage the presenting illness or injury, thus preventing the
provision of adequate nutrition. A creative approach may be necessary if the patient is to
receive parenteral nutrition with a concentrated solution of a reduced volume. Use of
enteral nutrition support in these patients may be contraindicated, especially if there is
concern for decreased perfusion to the gut. However, it is important to attempt a slow
enteral drip, possibly using a semi-elemental formula, to maintain gut integrity as a
component of treatment whenever possible. It may be possible not only to use enteral
nutrition in patients receiving inotropic agents, but also to reach the energy goal in some of
these patients.
Regardless of route, the nutrition practitioner must work closely with the intensive care
team to determine optimal nutrition support for each patient within the context of available
fluid.
Calculations for maintenance fluids are as follows:
< 1kg: weight (kg) x 125 mL/kg/d
1 kg to 10 kg: weight (kg) x 100 mL/kg/d
11 kg to 20 kg: 50 mL/kg/day for each kg over 10 kg + 1,000 mL
> 20 kg: 20 mL/kg/day for each kg over 20 kg + 1,500 mL
Electrolytes
Serum electrolytes can fluctuate rapidly and to extremes in critically ill children as a result
of the inciting event or medical management. Management of electrolytes using either
enteral or parenteral nutrition should be avoided and is best done using other intravenous
fluids by the intensive care team.
The electrolyte requirement for sodium, potassium, and chloride in children younger than 3
is 3 mEq/kg/day to 5 mEq/kg/day; for children older than 3, the requirement is 2
mEq/kg/day to 5 mEq/kg/day. Acetate, a bicarbonate precursor, may be required to
maintain acid-base balance.


Enteral or Tube Feeding

Children who require intensive care have a greater need for nutrition support by virtue of
their need for aggressive medical interventions (respiratory failure, select medications,
etc.). However, the frequent fluctuations in medical status that occur during admission,
especially early in the hospital course, can make implementation and consistent provision
of nutrition support extremely challenging (Mehta 2010).
Following nutrition assessment, the first step in developing a nutrition support plan is to
determine the most appropriate enteral route of delivery. To date, there are no data
available in the critically ill pediatric patient population to support the use of enteral over
parenteral nutrition. However, the enteral route remains preferred in critically ill children
with a functioning gastrointestinal (GI) tract (Skillman 2008; Mehta 2009). Enteral nutrition
(EN) exerts a protective effect on the gut by promoting mucosal growth and function,
reducing bacterial translocation, and improving nutrient utilization with fewer hepatobiliary
and infectious complications when compared to parenteral nutrition.
Indications for EN are as follows:
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Functioning GI tract
Supplementation of oral diet
Prolonged period nil per os (nothing by mouth)
Oromotor dysfunction
Altered neurological status
Respiratory failure
Contraindications for EN are as follows:
GI obstruction
Prolonged ileus
Peritonitis
Severe vomiting or diarrhea
Enterocutaneous fistula
Extreme hemodynamic instability
The goal of EN support should be to meet estimated nutrition requirements in the safest
and timeliest manner. Unfortunately, these goals are often unmet because of frequent
interruptions resulting from perceived intolerance, fluid restrictions, or the need for medical
tests and procedures (Mehta 2010). The resulting sustained energy imbalance may explain
the lack of any observed beneficial effect of EN in the literature. The nutrition practitioner
must monitor energy balance closely and communicate any failure to meet estimated
needs to the health care team.
Once it has been determined that EN will be utilized, the nutrition practitioner must decide,
in consultation with the medical team, which route (gastric vs postpyloric) is the most
appropriate. To date, there are little data to support one route over the other in critically ill
children. However, children may be able to achieve and maintain target EN sooner and
more consistently when fed using the postpyloric (PP) route (Sanchez 2007). Further study
is necessary to determine whether one approach (gastric vs. postpyloric) is more
advantageous than the other. Shortcomings with the PP route include the need for
specially trained staff for tube placement and the risk of tube dislodgement. These issues
can result in similar delays and interruptions in feeding as use of the gastric route. Careful
consideration of needs, goals, and anticipated duration must be considered when choosing
which enteral route to use, but a trial of gastric EN should be considered before attempting
PP tube placement.
Early initiation of EN is usually safe and well tolerated, improving protein metabolism and
minimizing energy deficits. Many pediatric centers initiate EN within 48 to 72 hours
following admission (with initial nutrition screening and assessment occurring by 24 hours
post-admission). Further delay in initiating and advancing EN will contribute to the
development of significant energy imbalance. The approach to initiating EN will be
determined in large part by the patient’s medical status.
As the nutrition care plan begins to materialize, the appropriate choice of formula must be
made. The majority of patients will tolerate a polymeric, age-appropriate formula. However,
the nutrition practitioner working in the pediatric intensive care unit (PICU) must have a
strong understanding of the various disease or illness states for which a specialized
formula is indicated.
Decisions must also be made regarding the choice of bolus or continuous drip feeds. Some
children will tolerate bolus feeds, but if the patient is hemodynamically unstable, vomiting,
or experiencing gastric discomfort or distension, a continuous drip is preferred. Use of a
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continuous infusion may also facilitate reaching energy goal more quickly. For these
patients, EN may be initiated at 0.5 mL/kg/hour to 1 mL/kg/hour (typically not higher than
25-30 mL/hour) and advancing by the same volume every 4 to 6 hours to final energy and
volume goal.
For some critically ill children, use of the GI tract for complete nutrition support is not
possible. In these patients, use of minimal, or trophic, enteral nutrition supplemented
with parenteral nutrition to provide balance of nutrient requirements may be the best option.
The volume of formula necessary to achieve the desired trophic effects has not been well
studied, including in critically ill children. However, the general consensus of practitioners is
that use of the GI tract is preferred in an attempt to obtain even minimal benefit.
Trophic feeding may be used to stimulate the GI tract in patients who have been without
enteral nutrition for a prolonged period of time, beginning with a smaller volume and
advancing to goal more slowly. For these children, feeds may be initiated at the more
conservative rate of 0.5 mL/kg/hour and advanced slowly over several days, while
providing the balance of nutrition via the parenteral route.
As the patient’s clinical status improves, it may be possible to begin weaning from EN to an
oral diet. Success may vary, based on the age of the patient, the length of time without oral
intake and stimulation, the presence of neurological deficits, and overall condition of the GI
tract. If the patient demonstrates that it is safe to begin an oral diet, EN can continue over
several hours during the night and oral intake can be encouraged during the day.
Another option is to provide a small bolus of formula immediately following a meal to
contribute to the development of more typical hunger/satiety patterns. Careful assessment
of energy intake via oral and EN routes will aid in the further reduction in EN as oral
intake improves. In some situations, it may be necessary to discharge the patient home on
supplemental EN either via nasogastric tube or a percutaneously placed gastrostomy tube.
Regardless of route of nutrition support, inconsistent delivery of nutrition support and
subsequent energy imbalance contribute to worse PICU outcomes (Gurgueira 2005). The
American Society for Parenteral and Enteral Nutrition recently revised nutrition guidelines
for the management of the critically ill child (Mehta, 2009). The authors of these guidelines
acknowledge the important role of EN in optimizing PICU patient care and outcomes but
also recognize the frequent failure to achieve identified nutrition goals. It is suggested that
the development of specific EN protocols, possibly generated by a dedicated nutrition
support team, may result in the optimization of EN delivery and maintenance, particularly if
implemented early. In addition, they recognize the lack of data in this area and recommend
the design and implementation of prospective studies to examine the efficacy and impact
on outcomes specifically in this population.


Nutrient Exceptions to DRI

To date, there are no data to support the routine use of individual nutrients in amounts that
exceed the current Dietary Reference Intakes via enteral or parenteral nutrition. However,
supplementation for specific clinical cases may be warranted. It is the role of the nutrition
practitioner to be aware of such clinical situations and how to supplement safely, if at all.
Clinical situations that may benefit from nutrient supplementation include the following:
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Burns
Severe, protracted diarrhea
Cholestasis
Acute or chronic kidney injury

Nutrition Monitoring & Evaluation

Nutrition monitoring and evaluation is used to assess progress towards the previously
established nutrition goals or outcomes.These outcomes are related to the nutrition
diagnosis and intervention. They are measurable and occur as an important component of
reassessment throughout the clinical course.
Outcomes are generally organized into the following four categories (NCP 2008):
Food and Nutrition History Outcomes: These outcomes have limited application in
the pediatric intensive care unit, but could include such considerations as whether a
patient had a history of receiving nutrition support prior to admission.
Biochemical Data, Medical Tests, and Procedure Outcomes: Results of laboratory
tests—such as prealbumin, c-reactive protein, and electrolytes—can provide
important information when assessing a patient's progress or lack thereof. Results of
medical tests such as barium swallow and procedures such as postpyloric tube
placement can also provide important information when determining whether nutrition
goals have been achieved or the degree to which they have not been accomplished.
Anthropometric Measurement Outcomes: These outcomes include both standard
and less common measures, including height, weight, body mass index, and skinfold
measures.
Nutrition-Focused Physical Finding Outcomes: Information obtained from visual
and standard physical examination can provide information for comparison to
baseline and intermediate data. Routine monitoring of serum electrolytes, minerals,
and liver enzymes can provide additional information that can be considered when
reassessing each patient’s nutrition status throughout the hospital course.
Information from these categories provides the nutrition practitioner with data necessary to
determine the success or failure of various nutrition intervention strategies. From these
data, the practitioner will determine if goals have been achieved, new goals should be
developed, care should continue, or the patient should be discharged from care.
Example:
Problem, etiology, signs and symptoms: Inadequate oral intake related to continued use of
sedation as evidenced by frequent sleeping through meal times.
A possible approach to monitoring is to document energy balance for 48 to 72 hours with
comparison to goal of nutrition therapy. Recommend placement (or replacement) of feeding
tube with formula goal to meet estimated needs.
Evaluation: Medical team agrees to replace feeding tube; initiate then advance feeds to
recommended rate/volume. Repeat prealbumin improved.

Nutrition Care FAQs

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Question: How much energy does a critically ill child need?
Answer: Energy requirements of critically ill children are usually quite different from those of
healthy children. If indirect calorimetry is not available, energy needs can be determined by
using the World Health Organization equations or Schofield equations to estimate resting
energy expenditure (REE) or basal metabolic rate (BMR) multiplied by a correction factor of
1.2 or 1.3, depending on the patient’s level of alertness. The application of a stress factor
may be unnecessary in children who are mechanically ventilated, deeply sedated, or
without physical activity.
Question: How do I know if the patient is receiving adequate energy?
Answer: Regular monitoring of serum c-reactive protein, prealbumin, weight, and skinfold
measures can aid in determining whether the nutrition provided is adequate for a patient.
Question: Once the patient is out of the critical illness phase, do energy
requirements increase?
Answer: Children who are no longer sedated will have increased physical activity and an
associated increase in energy expenditure. Normalization of elevated serum c-reactive
protein level signals a return of anabolism and increased energy requirements for growth.
Question: How do I evaluate obese patients' energy requirements?
Answer: Indirect calorimetry is recommended to assess energy needs of obese pediatric
critically ill patients; however, in its absence, calculate REE or BMR with actual body
weight using the World Health Organization equations or Schofield equations.
Question: When is the best time to begin nutrition support in the critically ill child?
Answer: Enteral or parenteral nutrition should be implemented as soon as is feasible in the
critically ill child, following resuscitation and placement of the appropriate nutrition support
access device.
Question: What is the preferred route and regimen for administration of enteral
nutrition in the critically ill child?
Answer: There are insufficient data to support gastric over postpyloric feeding, or
continuous versus intermittent bolus administration of enteral nutrition in critically ill
children. Most pediatric patients will tolerate gastric feeding. A continuous administration is
required for the postpyloric route.

Anthropometrics

Changes in body composition occur rapidly during the stress response. Unfortunately,
equipment to accurately measure body composition at the bedside is currently unavailable.
As a result, standard anthropometry continues to be the only reliable measure of body
composition in this patient population.
Each child in the pediatric intensive care unit should receive careful evaluation of growth
parameters (weight, length or height, head circumference) soon after admission to assess
baseline nutrition status. This will aid in identifying children with existing malnutrition or
those at risk of its development.
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Regular measurement (twice weekly for infants and once weekly for older children and
adolescents) of weight parameters can and should be supplemented with other
anthropometric measures. These measures, when performed by an experienced
practitioner, can provide important information regarding the effectiveness of nutrition
support as a component of critical care. Measurements should include triceps skinfold and
mid-arm circumference with calculation of mid-arm muscle circumference. Reference
standards are available for comparison of results.
Fluid status must be considered when interpreting any anthropometric measures. Fluid
shifts that occur during the stress response, fluid resuscitation, and intravenous therapies
can contribute to increases in weight and tissue edema. Diuresis that occurs as the stress
response abates, as well as diuretic therapy, can result in weight loss and a reduction in
anthropometric measures. Therefore, all anthropometric measures must be interpreted in
the context of fluid status and location in the clinical course. This requires a strong
understanding of the time course and treatment of the metabolic response to illness.

Macronutrient Requirements

Once energy requirements have been estimated, the distribution of energy among the
macronutrients can be determined.
Protein
In critical illness there is an increase in whole body protein synthesis and breakdown.
However, the rate of protein degradation exceeds synthesis, resulting in negative nitrogen
balance. Accelerated degradation of protein, primarily from lean body mass (muscle),
continues until the stress response resolves. The achievement of positive nitrogen balance
is challenging in these circumstances. It is necessary to provide optimal nonprotein energy
as well as protein to allow the body to utilize this exogenous protein to support the stress
response as much as possible and later for anabolism.
Most enteral formulas provide protein in an appropriate ratio to nonprotein energy. In the
majority of situations, if energy requirements are met using the enteral route then the
amount of protein being provided should be sufficient. In some cases supplemental protein
must be added to the formula using a protein modular to meet a patient’s needs.
For patients who require parenteral nutrition, protein requirements are less clear.
Evidence-based data are inadequate to provide specific recommendations for protein
intake in critically ill children. Several studies have examined nitrogen balance at different
levels of nonprotein energy and protein intake in populations of critically ill children
(Coss-Bu 1998b; Joosten 1999; Coss-Bu 2001). Results suggest that current
recommended protein intakes might be insufficient. All three studies indicate that, on
average, the children studied were able to achieve positive nitrogen balance at a protein
intake of 2.5 g/kg/day to 3 g/kg/day. Recent guidelines, however, recommend protein
intakes of 2 g/kg/day to 3 g/kg/day in children aged 0 to 2 years, 1.5 g/kg/day to 2 g/kg/day
for children aged 2 to 13 years, and 1.5 g/kg/day for children aged 13 to 18 years (Mehta
2009).
Carbohydrate
Once protein requirements have been determined, carbohydrate and fat can be estimated
to provide the balance of energy needs.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
As stated above, protein catabolism during the stress response continues unabated until
the source of stress is removed or resolves. The amino acids liberated during catabolism of
lean mass are transported to the liver for gluconeogenesis. Provision of excess
carbohydrate does not attenuate this process and may result in hyperglycemia and its
related complications. Therefore, nonprotein energy should be supplied in an amount that
minimizes muscle catabolism while avoiding hyperglycemia and hepatic steatosis. Studies
have found that provision of glucose at a rate of 5-6 mg/kg/minute achieves these desired
effects (Coss-Bu 2001; Sheridan 1998). Alternatively, providing approximately 60% of
nonprotein energy as glucose will result in an infusion rate within the recommended
parameters.
Fat
One study in critically ill children found that the most stressed patients have an elevated
rate of fat oxidation when compared to those who were less stressed and stressed adults
(Coss-Bu 2001). When a fat source is omitted from nutrition therapy, the risk of developing
essential fatty acid deficiency is increased. Small, stressed children have reduced adipose
stores and can develop essential fatty acid deficiency in as little as two days (Friedman
1976)
A source of fat provides lipid for use in the oxidation processes, prevents essential fatty
acid deficiency, and minimizes carbon dioxide production from excessive carbohydrate
delivery. Essential fatty acid deficiency can be avoided by providing a minimum of 5% of
total energy as intravenous lipids; provision of approximately 40% of nonprotein energy as
fat is sufficient to reduce carbon dioxide production from carbohydrate overfeeding.

Micronutrient Requirements

The stress response imposes many additional demands on micronutrient stores. These
demands are difficult to predict but remain important considerations in the management of
critically ill children to avoid potential short- and long-term effects on outcome and nutrition
status.
Vitamins
The rapid cellular turnover that occurs during the stress response places a high demand on
micronutrients required as cofactors in a wide range of reactions. Other micronutrients
appear to have potent antioxidant properties. Few studies have been conducted in this
patient population and more are needed. Data are insufficient to make recommendations
for specific micronutrient supplementation. Patients with high stress states (sepsis, burns,
or on renal replacement therapy), or with lengthy stay in the pediatric intensive care unit
(10-14 days) should be monitored closely for the development of vitamin deficiencies and
repleted as necessary (Skillman 2008).
Minerals
Like vitamins, little information is available regarding the need to provide supplementation
of minerals in amounts that exceed recommendations for healthy children. Mineral status
should be monitored closely and specific minerals supplemented based on laboratory
results.

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Comparative Standards

There are several equations available to predict basal metabolic rate (BMR) or resting
energy expenditure (REE). There are two sets of Schofield equations: one set uses weight
only; the other incorporates weight and height (Schofield 1985). Both sets of equations are
divided by age and sex. If an accurate height is available, the set of equations that include
both weight and height should be used for optimal accuracy. The equations used by the
World Health Organization (WHO) Committee from which the most recent
recommendations on energy requirements were created are based on the Schofield
equations, but estimate REE (Torun 2005).
Schofield Equations Using Weight and Height to Estimate BMR
Boys
Age
< 3 years 0.167W + 15.174H – 617.6
3-10 years 19.59W + 1.303H + 414.9
10-18
years
16.25W + 1.372H + 515.5
W = weight in kg; H = height in cm
Girls
Age
< 3 years 16.252W + 10.232H – 413.5
3-10 years 16.969W + 1.618H + 371.2
10-18
years
8.365W + 4.65H + 200.0
W = weight in kg; H = height in cm
Schofield Equations Using Weight Only to Estimate BMR
Boys
Age
< 3 years 59.48W – 30.33
3-10 years 22.7W + 505
10-18
years
13.4W + 693
W = weight in kg
Girls
Age
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< 3 years 58.29W – 31.05
3-10 years 20.3W + 486
10-18
years
17.7W + 659
W = weight in kg
WHO Equations to Estimate REE
Boys
Age
< 3 years 60.9W – 54
3-10 years 22.7W + 495
10-18
years
17.5W + 651
W = weight in kg
Girls
Age
< 3 years 61W – 51
3-10 years 22.5W + 499
10-18
years
12.2W + 746
W = weight in kg

Parenteral Nutrition

In certain children, enteral nutrition (EN) cannot or should not be utilized and parenteral
nutrition (PN) must be implemented to meet nutrition needs. The nutrition goals remain
unchanged, but are delivered via the venous route.
Indications for parenteral nutrition include the following:
Nonfunctioning gastrointestinal (GI) tract
GI obstruction
Prolonged ileus
Peritonitis
Severe vomiting or diarrhea
Enterocutaneous fistula
Extreme hemodynamic instability
Short gut syndrome/Intestinal failure
Other congenital anomalies of the GI tract
Inability to deliver adequate EN
Inability to tolerate adequate EN
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Contraindications for PN include the following:
Functioning GI tract
Lack of safe and appropriate access
Macronutrients
PN should be initiated as early as possible when it is clear that the enteral route cannot be
utilized for nutrition support, or must be delayed indefinitely. For children admitted to the
pediatric intensive care unit (PICU), this should occur within 3 to 5 days following
admission (Skillman 2008).
Once proper venous access has been secured, a PN order can be composed for the
patient. Historically PN has been initiated at a "starting dose" for each of the
macronutrients. However, there are no data to support this practice in the majority of
critically ill children, especially those with a noncontributory past medical history. Therefore,
most children can be started at or close to goal energy via PN (Skillman 2008). It must be
kept in mind that many critically ill children have energy requirements that are lower than
those of normal, healthy children and provision of goal energy at the outset should not
present any untoward risk.
Steps in calculating a PN order are as follows:
Estimate energy needs utilizing indirect calorimetry or prediction equations 1.
Calculate protein requirement 2.
Calculate energy from protein (4 kilocalories/g) 3.
Subtract protein energy from energy goal 4.
Calculate contribution of energy from fat (30% to 40% of total energy) 5.
Determine volume and g/kg dose of 20% lipid emulsions to provide desired energy
from fat (2 kilocalories/ml, 10 kilocalories/g)
6.
Subtract fat kilocalories from remaining energy goal 7.
Calculate grams of carbohydrate by dividing remaining kilocalories by 3.4 8.
Calculate dextrose concentration by dividing grams of dextrose by fluid volume to be
utilized for PN
9.
Calculate glucose infusion rate: 10.
grams dextrose ÷ 1440 (minutes in a day) ÷ weight (kg) x 1000
General energy distribution is as follows:
Protein: 15% to 25% of total energy
Fat: 30% to 40% of total energy
Carbohydrate: 50% to 60% of total energy
Animal data suggest that parenteral protein requirements are lower in children receiving PN
than in children receiving EN. The gut utilizes a significant proportion of enteral protein;
thus, when the gut is bypassed by providing PN, this process is omitted. However, there
are insufficient data to recommend provision of reduced protein via PN. In addition, critically
ill children have substantially altered metabolism as well as potential increased losses from
wounds, fractures, burns, and so on.
Recommended Minimum Amino Acid Requirements for Pediatric PN

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Age Amino Acid
(g/kg/day)
Neonate 1.5-3
1 month - 3 years 1.5-2.5
4 years - 18 years 1-2
(ESPEN 2005)
Lipids
Intravenous lipid emulsion is an important component of the PN order. Critically ill children
have a higher rate of lipid turnover and fat oxidation, which, combined with limited fat stores
in this age group, further increases the risk of developing essential fatty acid deficiency
when administered PN is fat free (Coss-Bu 2001; Friedman 1976). Data also indicate that
fatty acids are the prime source of energy in critically ill children. Lipid emulsion serves to
provide energy from fat and reduce the amount of carbohydrate necessary to meet
estimated nonprotein energy requirements.
Lipid emulsion must be provided to avoid development of essential fatty acid deficiency,
which can occur rapidly in a critically ill child with preexisting malnutrition and delayed
introduction of nutrition support. Provision of lipid emulsion at a minimum dose of 0.5 g/kg/d
is sufficient to avoid development of essential fatty acid deficiency (Friedman 1976).
At the time of this writing, the choices of intravenous lipid emulsions in this country remain
limited. Those that are available are composed predominantly of soybean or safflower oil
and, as a result, contain primarily omega-6 fatty acids, with small (and perhaps insufficient)
amounts of omega-3 fatty acids. Studies published in the recent years have suggested that
lipid emulsions that are composed predominantly of omega-3–rich oils are more
advantageous and perhaps safer than those presently in use (deMeijer 2010).
Unfortunately, these products are not commercially available in the United States.
Glucose
Glucose is the sole energy source for brain, renal medulla, and red blood cells. It also
functions as the primary fuel for muscle, heart, liver, kidneys, and gut.
Glucose, in the form of dextrose, must be provided in sufficient amounts in the PN solution
to meet the needs of glucose oxidation by the various tissues and maintain euglycemia, as
well as for ongoing energy expenditure. Care must be taken, however, to avoid
carbohydrate overfeeding and its negative consequences.
Provision of a glucose infusion in excess of what can be directly oxidized results in excess
carbon dioxide production, lipogenesis, hepatic steatosis, and increased risk of infectious
complications, all of which can result in adverse patient outcomes.
Calculation of glucose infusion rate assists in determining appropriate glucose delivery.
Critically ill children may have altered glucose oxidation and utilization rates. Infants have
the highest oxidation rates, which decrease with age. Infusions should be adapted to the
clinical situation.
Careful assessment of energy requirements with appropriate distribution of energy among
the three macronutrients will result in optimal nutrition support with minimal risk of
complications.
Maximal Glucose Infusion Rates (GIR) by Weight
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Maximal Glucose Infusion Rates (GIR) by Weight

Weight GIR (mg/kg/min)
< 3kg 13
3-10 kg 12
10-15 kg 8.5
15-20 kg 7
20-30 kg ≤ 9
> 30 kg ≤ 7
(Adapted from ESPEN 2005)
Specialized PN Components
There is a growing list of nutrients that have been identified as providing a potential
advantage to patients receiving PN. Many are intended to function as immunomodulators to
ultimately improve patient outcome. Most, however, have been the subject of limited study
in pediatrics, including parenteral use and cannot be recommended for routine use in
critically ill children. Two exceptions are as follows.
Cysteine is a conditionally essential amino acid in neonates. It functions in calcium
homeostasis and in oxidation-reduction reactions. Cysteine should be added to infant PN
solutions in a dose of 30 mg/day to avoid depletion of body stores. However, supplemental
cysteine does not appear to confer any benefit in older children or adolescents.
Carnitine plays a role in lipid oxidation. Low levels of carnitine can result in alterations in
lipid metabolism. Patients receiving short-term PN without carnitine are not likely to
develop sufficiently low levels to affect lipid metabolism. However, if a patient is to receive
PN for at least 4 weeks, or if there is a sudden change in lipid clearance (rising triglyceride
levels), it would be advisable to add 2 mg/kg/day to 5 mg/kg/day carnitine to the
PN solution (ESPEN 2005).
Cycling PN
A continuous infusion of glucose results in the constant stimulation and release of insulin in
response. During an extended PN course, that is, longer than 2 weeks, this constant
release of insulin results in the development of steatosis, contributing to the development of
liver dysfunction, elevated liver enzyme levels, and hepatomegaly (Btaiche 2002; Lloyd
2007).
If PN is to continue for an extended period of time, it is of benefit to begin to cycle the PN
infusion over 10 to 16 hours as tolerated by the patient. Infants and young children may
require a longer infusion time to maintain euglycemia and avoid episodes of hypoglycemia,
whereas older children and adolescents can tolerate a longer period of time off their
infusion.
Cycling PN for children requiring long-term infusions can confer both physiologic and
quality of life advantages. For children who are ambulatory, having an opportunity to be
separated from the PN and related equipment can give the child a needed break from
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
medicalization.
Physiologic benefits include a period of fasting that limits the constant first pass exposure
of nutrients to the liver. It has also been suggested that cycling long-term PN may delay or
prevent the development of PN-associated liver disease (PNALD). To accomplish the
desired effects of cycling PN, it is important to withhold any intravenous source of glucose,
including the provision of maintenance fluids with 5% dextrose while holding the PN
infusion. This defeats the purpose of placing the patient into a fasted state to minimize
hepatotoxic effects.
Critically ill children are generally not candidates for cycling PN. First, many children in the
PICU are too metabolically unstable to tolerate periods of high-glucose infusion rates
followed by periods of no glucose. Second, many critically ill children require PN for a
shorter duration, during which time no benefit will be realized. Cycling PN in an ICU setting
can be more labor intensive for those providing care at the bedside as well.
Weaning Patients from PN to EN or Oral Diet
Weaning patients from PN as quickly as possible should be the goal of all nutrition
practitioners. Weaning children in the ICU setting usually follows two paths.
Many children are able to transition back to an oral diet quickly and easily. In these children,
PN can be discontinued once the patient is tolerating at least 50% of estimated needs
orally.
Other children require a transition to EN as an intermediate step. These children should
first begin with a slow continuous drip of an age-appropriate enteral formula. As the patient
begins to tolerate a higher infusion rate, the PN infusion can be reduced kilocalorie for
kilocalorie. This can be a trial-and-error process, with several days of progress followed by
some days of formula intolerance and a return to a rate previously tolerated. Once the child
is tolerating a continuous enteral drip at energy goal, the care plan can be adjusted to
transition to bolus feeds or possibly an oral diet similar to the process of children weaning
from PN to an oral diet.
Use of Standardized Protocols/Nutrition Support Teams
The use of aggressive feeding protocols in the PICU may increase the utilization of EN and
shorten the time to attain energy goal.
The implementation of a dedicated nutrition support team (NSTs) also appears to be
gaining favor with many medical centers and professional organizations (ASPEN 2009;
ESPEN 2005). These teams can serve to reduce the use of inappropriate PN, reduce
metabolic and catheter-related complications, and facilitate safe and effective weaning from
PN (Briasoulis 2001; Gurgueira 2005; Petrillo-Albarano 2006). Ultimately the NST can
serve to optimize the timing and delivery of nutrition support with the ultimate goal of
reducing complications and improving outcomes in the PICU.

Metabolic Rate Profile (Indirect Calorimetry)

When available, indirect calorimetry provides a more accurate estimate of energy
expenditure. It can reflect changes in clinical course or treatment response in as few as 15
minutes. Unfortunately, this procedure requires significant monetary and personnel
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
investments, which limit its widespread use.
Indirect calorimetry utilizes sophisticated equipment to measure the oxygen concentration
of each inspired breath and the carbon dioxide concentration of each expired breath, and
calculates 24-hour energy expenditure using a regression equation. The practitioner must
be aware that the measurement results reflect the energy expended in the state in which
the patient is measured (such as sedated, mechanically ventilated, and so on). If a patient’s
clinical course changes in any way from when the measurement was made, the results are
no longer valid and the process should be repeated.
Indirect calorimetry can provide important information regarding the adequacy of nutrition
therapy (overfeeding or underfeeding), and the presence of hypermetabolism or
hypometabolism compared to age and sex standards.
Application of this technology is not without its limitations. Patients cannot be measured
accurately with air leaks around their endotracheal tubes, with chest tubes, with inspired
oxygen concentrations greater than 60%, and while receiving renal replacement therapy or
dialysis.
In an ideal situation, indirect calorimetry is available for periodic reassessment in a
subpopulation of critically ill children. See list below.
Suggested Criteria for Selecting Patients for Indirect Calorimetry in the Pediatric
Intensive Care Unit
Underweight (body mass index [BMI] <5th percentile for age and sex), overweight
(BMI >85th percentile for age and sex), or obese (BMI >95th percentile for age and
sex)
Greater than 10% weight gain or loss during medical-surgical intensive care unit stay
Failure to consistently meet prescribed caloric goals
Failure to wean or an escalation in respiratory support
Need for muscle relaxants for >7 days
Neurologic trauma (traumatic, hypoxic, and/or ischemic) with evidence of
dysautonomia
Oncologic diagnoses (including stem cell or bone marrow transplantation)
Need for mechanical ventilatory support >7 days
Suspicion of severe hypermetabolism (status epilepticus, hyperthermia, systemic
inflammatory response syndrome, dysautonomic storms) or hypometabolism
(hypothermia, hypothyroidism, pentobarbital or midazolam coma)
Intensive care unit length of stay >4 weeks
Adapted with permission from Mehta NM, Bechard LJ, Leavitt K, Duggan C. Cumulative
Energy Imbalance in the Pediatric Intensive Care Unit: Role of Targeted Indirect
Calorimetry. JPEN J Parenter Enteral Nutr 2009; 33; 336. Online at
http://pen.sagepub.com/cgi/content/abstract/33/3/336.

Oral Intake

It is unusual for a child in the pediatric intensive care unit to be able to consume an
adequate oral diet spontaneously. It is more likely that enteral or parenteral nutrition will be
initiated to meet a child’s nutrition needs. The nutrition intervention of choice must also take
into account the multiple medical therapies that are employed.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
During the first 24 to 48 hours following admission, nutrition intervention may be limited
because of other urgent aspects of care (mechanical ventilation, sedation, fluid
resuscitation). Feeding tube placement or intravenous access for parenteral nutrition can
be addressed once the child has been stabilized.
Early in the hospital course, it is unlikely that the child will require energy above the basal
metabolic rate, especially if the patient is mechanically ventilated and sedated. Provision of
exogenous glucose alone will not interrupt the stress response and the gluconeogenesis
that results from catabolism of skeletal muscle and adipose tissue. Therefore, energy
delivery should include adequate protein for age, with carbohydrate and fat providing
remaining energy (see Macronutrient Requirements).
As the stress response begins to abate, as indicated by reductions in serum c-reactive
protein levels, total energy can begin to be liberalized with a shift in focus from metabolic
support toward age-appropriate nutrition support.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Developmental Disabilities
Tables for Developmental Disability topics

Table 1. General Nutritional Concerns Associated with Selected Developmental
Disabilities

Cerebral
Palsy
Spina Bifida Autism
Down
syndrome
Prader-Willi
syndrome
Altered
growth
X X X X
Risk for
obesity
X X X X
Underweight X
failure-to-thrive
in infancy
Altered
energy needs
-increased
with
athetosis;
decreased
with low
tone, limited
mobility
related to
short stature
and limited
mobility

related to
short stature,
limited activity
X
Drug-nutrient
interactions
X X X X
Feeding
problems
oral-motor
problems
swallowing
problems
caused by
Chiari
malformation
limited
food
selection;
strong
food
dislikes
poor suck in
infancy
poor suck in
infancy;
abnormal
food-related
problems
Constipation X X X
Others
seizures;
orthopedic
problems
urinary tract
infection
pica
gum disease;
risk of heart
disease;
osteoporosis
risk of diabetes
mellitus
References: ADA Position Statement, 2004; Lucas et al, 2004

Table 2. Development of Eating and Drinking Skills in Typically Developing Children
Developmental Age
(developmental ages are
approximate and skills
vary between children)
Oral-motor and self-feeding
skills and behaviors
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2 months
Coordinated
suck-swallow-breathe pattern
Moving hand to mouth
Expecting feedings at regular
intervals
2-4 months
Increasing head control
Mouth opening in anticipation
of feeding
Visually recognizing bottle
Beginning to reach for objects
4-6 months
Voluntary sucking
Showing an interest in food
Up-and-down munching and
biting
Sitting unassisted
Mouthing objects
6-8 months
Reaching for objects
Tongue starting to shift
laterally
Beginning vertical chewing
Holding bottle occasionally
Closing lips around spoon
8-10 months
Transferring food laterally
Voluntarily biting on foods and
objects
Closing lips briefly on cup
Finger-feeding primarily with
palmar grasp
Beginning to feed self with
spoon
Holding bottle
10-12 months
Bringing spoon to mouth
Beginning to pick up and hold
cup
Rotary chewing beginning
Beginning to finger-feed with
pincer grasp
12-18 months
Continuing to develop
self-feeding skills (eg, picking
up cup, finger-feeding with
pincer grasp)
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18-24 months
Feeding self (with spilling)
Finger-feeding discrete
objects of food
Placing food in spoon with
free hand, then lifting spoon to
mouth
Using a controlled bite for
hard foods (eg, apple)
Beginning to be able to lick
food off the upper lip
Holding cup well, spilling if too
full
Grasping spoon with a radial
grasp
Tongue clearing upper and
lower lips
Using a rotary motion for
chewing
References:
Nardella MT, Owens-Kuehner A. Feeding and eating. In:
Lucas BL, Feucht SA, Grieger LE, eds. Children with Special
Health Care Needs: nutrition care handbook. Pediatric
Nutrition Practice Group and Dietetics in Developmental and
Psychiatric Disorders, American Dietetic Association. 2004.
Morris SE, Klein MD. Pre-Feeding Skills: A Comprehensive
Resource for Mealtime Development, 2nd ed. San Antonio X:
TSB Harcourt. 2000.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Developmental Disabilities > Autism Spectrum Disorders
Anthropometrics

Careful evaluation of growth, including weight, length or stature, and head circumference
should be made. Accurate, serial measurements are important in assessing an individual’s
growth, as many conditions are associated with alterations in growth. The Centers for
Disease Control and Prevention Growth Charts (see Resources) are used to evaluate
growth.
Length or stature. Recumbent length (measured with a length board) is plotted on the
Infant (birth to 24months) chart. Stature (standing height, measured with a stadiometer)
should be plotted on the charts for 2-20 year olds (CDC, NCCDPHP).
Weight. Weight should be measured on calibrated equipment that weighs in 10 gram
(infants) or 100 gram (children and adolescents) increments. Weight should be measured
on a regular basis, recorded on the growth chart, and followed sequentially for changes
(CDC, NCCDPHP).
Head circumference. For children birth to 24 months of age, head circumference should
be measured in centimeters and plotted on the WHO Growth Charts. Serial measurements
should be taken and may help to identify microcephaly or macrocephaly (CDC, NCCDPHP).
Weight-for-length. Weight-for-length should be plotted on the Infant chart and is often the
best indicator of the child’s nutritional status. This is especially important for the child who
is small for his or her age.
Body Mass Index. Body Mass Index (BMI = weight [kg] / height [m]
2
) is used for children
ages two years and older. BMI-for-age can be plotted on the CDC Growth Charts. BMI is
used as a screening tool for obesity (CDC, NCCDPHP). The risk of obesity and overweight
among children with developmental disabilities seems to be at least the same as the risk in
the general population (Bandini 2005).
Resources. Additional information about assessment of growth, including measurement
techniques for children with developmental disabilities and interpretation of growth data is
available under Weblinks.

Feeding Skills

Children with autism spectrum disorders may have feeding problems. These feeding
problems are generally sensory in nature and related to hypersensitivities to textures,
smells, temperatures, or tastes. Aversions can lead to impairments in self-feeding skills
and slowed progression of feeding development. Table 2
Considerations When Assessing Feeding Skills (Cloud, 2005)
Age versus developmental level of child
Previous feeding experiences – method, variety, feeder position
Position
Texture/consistency of food and drink
Previous food challenges
Mouth movement and head position: jaw, lip, cheek, tongue movement
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mouth movement and head position: jaw, lip, cheek, tongue movement
Sensory aspects of feeding and tactile defensiveness
Visual/auditory stimuli
Smell of food
Temperature of food
Taste of food
Utensils used
Fluid intake
Dental hygiene and oral health



Oral Health

Developmental disabilities and other special health care needs can increase a child’s risk
of developing oral health problems. Secondary conditions and some therapies can also
increase the risk of problems with oral health. Some contributors to poor oral health that
are common among children with developmental disabilities include the following (Faine
2001; Boyd 1988):
Prolonged use of the nursing bottle – if a child sips on a bottle throughout the day, he
or she is at greater risk for caries
Extended eating time – if frequent meals and snacks are needed, or if mealtime is
longer than usual, teeth are exposed to acid for a greater period of time
Low fluid intake
Oral hypersensitivity – may make good oral hygiene difficult and may also limit the
types and textures of foods eaten
Inability or refusal to consume specific foods or groups of foods – nutrients needed for
development and remineralization of teeth may be unavailable
Limited or inconsistent dental hygiene due to behaviors, sensory problems, or
caregiver constraints
Toothbrushing and good oral hygiene may be difficult for some children with autism
spectrum disorders. Good oral hygiene is essential and may help with oral desensitization.
Therapists (eg, physical, occupational, or speech) should be consulted for techniques to aid
in oral-facial desensitization. In addition, dental care by specialists with experience with
children with autism and related disorders may be needed.
The clinician should consider the following questions:
Does the child have oral health problems that affect his or her nutritional status?
Is the child at risk for oral health problems?
How does the disorder (or treatment for the disorder) affect:
frequency of eating?
types of foods consumed?


Constipation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Constipation may result from decreased activity, decreased fluid intake, low fiber intake,
vomiting, or medications (Isaacs 2004). Evaluating and modifying the child’s food, fluid,
and/or enteral formula intake can have a significant impact on treating and preventing
constipation. Addition of bran or raw fruits or vegetables may be helpful. To prevent gas or
bloating, parents should be instructed to introduce high-fiber and/or bran cereals slowly.
Probiotics are sometimes recommended for children with autism spectrum disorders,
because of reports of altered intestinal microflora.
SEE CONSTIPATION IN GI DISORDERS CHAPTER.

Medical Tests and Procedures

A number of diagnostic tools are available to aid in the diagnosis of autism. These include:
(Levy 2008; Augustyn 2009)
Autism Behavior Checklist (completed by a parent or teacher)
Gilliam Autism Rating Scale (GARS)
Autism Diagnostic Interview-Revised (2-3 hour clinical interview)
Childhood Autism Rating Scale (CARS – clinician-administered, based on
observation)
Autism Diagnostic Observation Schedule – Generic (ADOS-G – the “gold standard” in
research and many clinical settings, used with other clinical information and
experience)
Additional diagnostic tests will vary depending on the individual child and the specific
syndrome or condition.
The nutrition assessment may include evaluation of how the test itself might affect
nutritional status (eg, need for fasting because of procedure). More often, the results of the
test can be used to identify nutrition problems (eg, nutrient deficiency) or potential
problems (eg, need for modified intake because of a medical condition).

Laboratory

Laboratory data will vary depending on the individual child and the specific syndrome or
condition, and may include nutrition-related biochemical data when indicated by risk factors
or therapy (eg, hematocrit/ferritin/other indicators to evaluate iron status).

Client History

Medical/health
The individual’s medical/health history should be reviewed. Identify issues that influence
nutrient needs and ability to meet estimated needs, as well as current and past issues that
may affect eating and feeding, including the feeding relationship.
Secondary conditions that may occur as a result of the primary condition should also be
included in the assessment (Cricco 2007).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
included in the assessment (Cricco 2007).
Medications
Types of medications used (including prescription, over-the-counter, and herbal
medications), and the duration of their use should be included in the nutrition assessment.
Examples of drug-nutrient interactions include effects on appetite, dryness of the mouth,
and interference with vitamin and mineral absorption. In addition, medications can lead to
practical issues with food and eating (eg, issues related to timing of medications and meals)
or interfere physically (eg, acidic medicine may curdle milk or formula) (Brizee 2006). See
Common Nutrient-Drug Interactions in the Resources section for more information.
Increasing numbers of parents are purchasing megadoses of vitamins and other nutrients
as a treatment for their child with autism spectrum disorders. This information and
information about other supplements should be documented in the nutrition assessment.
Social
The social history should be reviewed. Relevant questions may include the following:
Where does the child live? Who else lives in the household? Who provides care,
including food/feeding?
Is access to food reliable? Do caregivers have access to food preparation and
storage? What are the barriers to adequate food access (eg, homelessness,
transportation, finances, language)
What public resources do the child and family utilize? (eg, Supplemental Nutrition
Program for Women, Infants, and Children [WIC], Early Head Start/Head Start,
National School Breakfast and Lunch Program, Supplemental Food and Nutrition
Program [SNAP - formerly known as the food-stamp program], Medicaid/State
Children’s Health Insurance Program, Early Intervention)
Transition to adulthood
Transition is used to describe the process of moving from youth to adulthood in all areas of
life, including health care. Considerations during nutrition assessment include access to
adult-based health care and services, health insurance, issues related to independent living
(eg, meal preparation, access to food, food choices). Activities include identifying potential
issues, anticipating the need for transition, and providing the individual and family with
information and resources (Lanier 2005).

Food/Nutrition-Related History

A complete nutrition evaluation will include a review of the individual’s feeding history,
including feeding during infancy (eg, breastfeeding, bottle-feeding), need for specialized
foods or formulas, introduction of solids, and any problems, past or present, with feeding.
Dietary intake should be carefully assessed through a diet history, 24-hour recall, or written
diet record of 3 or more days. Many parents and caregivers may be providing only one
meal for the child; therefore, complete information should be obtained from other places
where food is provided (eg, child-care providers, Head Start programs, and school lunch
programs). The dietary information should include the serving size, the duration of time
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
spent eating, the number of snacks, and the times of day meals and snacks are served.
Many families are using special diets (eg, gluten- and/or casein-free) and/or supplements
(eg, vitamin B
6
, magnesium, dimethylglycine [DMG]) as adjunct therapies for autism
spectrum disorders. Registered dietitians should include the use of these therapies in the
nutrition assessment. A comprehensive review of therapies has been published (Levy
2008).
Despite many anecdotal reports, the efficacy of special diets and supplements for
treatment of autism spectrum disorders has not been proven in reproducible studies
(Elder 2008; Millward 2008; Nye 2005). A collaborative, family-centered approach is
recommended (Peregrin 2007; Elder 2008):
Find out why the family is using the specific therapy
Identify potential risks (eg, potential nutrient deficiencies, toxicities, lack of resources,
effect of a restricted diet on an already-restricted food pattern)
Work with the family to develop a thoughtful plan to address potential risks, and to
monitor the effectiveness of the therapy


Nutrition Diagnosis

Dietitians working with patients who have autism spectrum disorders should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Because of the wide range of autism spectrum
disorders, nutrition diagnoses from the list below as well as a number of other diagnoses
may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Excessive energy intake (NI-1.5)
Limited food acceptance (NI-2.9)
Inadequate protein intake (NI-5.7.1)
Inadequate mineral intake (specify)(NI-5.10.1)
Inadequate vitamin intake (specify)(NI-5.9.1)
Swallowing difficulty (NC-1.1)
Biting/chewing (masticatory) difficulty (NC-1.2)
Unintended weight loss (NC-3.2)
Self-monitoring deficit (NB-1.4)
Self-feeding difficulty (NB-2.6)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate mineral intake (iron) (NI-5.10.1) related to food selectivity and
hypersensitivities, as evidenced by food record analysis (iron intake < 3 mg/day) and
low hematocrit.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Nutrition Intervention

Nutrition interventions should be individualized based on the child’s nutritional, medical,
and other needs. Plans should be developed with input from the family and other members
of the health-care team. Examples of Nutrition Intervention codes and related strategies are
described below (Feucht, 2010; IDNT, 2010).
Theoretical Basis/Approach: Cognitive-Behavioral Theory (C-1.1)
Behavior-based interventions may be the most effective when addressing “picky” eating
and selective food habits.
Avoid overwhelming a child. Keep mealtimes constant, or make small gradual changes.
For example, if a new food is being introduced, offer it along with foods the child already
likes. Offer age-appropriate portions.
Introduce foods in forms that are similar to foods the child already eats, and make
gradual changes. For example, move from accepted crackers to toast; gradually lighten
the toast until bread is accepted.
Expect slow changes, but do expect changes. Progress toward food acceptance may
require a greater number of intervention-based steps for a child with autism, than for a
child without. It can be helpful to adjust expectations and to be patient as the child makes
slow progress.
Design interventions that are consistent with other effective approaches for the
individual. With coordination between the family, registered dietitian, and school,
nutrition-related goals can be incorporated into a child’s educational plan (eg,
Individualized Family Service Plan [IFSP] or Individualized Education Program [IEP]).
Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)
Modifying portion sizes and/or adjusting the meal and snack schedule. For some
children, the amount of food offered at meals and the meal and snack schedule can
prevent an adequate intake. Children may become overwhelmed with the task of eating a
large, full plate of food, and actually eat a larger amount when only a small (but
appropriate) amount of food is presented. For many children, decreasing portion sizes and
increasing the frequency of feedings may help. See Normal Nutrition sections for specific
age groups for more information and feeding tips.
Feeding Assistance--Feeding position (ND-4.2) or Meal setup (ND-4.3); Feeding Environment--Distractions
(ND-5.3)
Modifications to the feeding environment. The feeding environment for the child with
developmental disabilities, including autism spectrum disorders, requires the following:
Structure
Appropriate feeding equipment
Age-appropriate portion sizes
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Avoidance of distractions (eg, television and radio)
Meals and snacks should be offered at the same time each day. Chairs that ensure proper
positioning should be used.
Serving sizes should be small, so that the child can easily eat what is served. Additional
servings can be given if the child indicates wanting more.
Feeding time should not extend beyond a reasonable time limit, and children should not be
force-fed.
Feeding behaviors should be monitored and noted to follow for the potential development
of negative feeding behaviors (Nardella 2004).
Referral to community agencies/programs (specify) (RC-1.4)
Nutrition-related issues may require referral to and collaboration with community resources.
Early Intervention Programs. All states have Early Intervention Programs, which provide
health services, including nutrition services, to children up to three years of age who have
developmental delays. These services, mandated under Part C of the Individuals with
Disabilities Education Act (IDEA), 2007, are available to all children and are provided in the
least restrictive environment for the family.
Descriptions of and links to additional resources can be found in the following:
Nutrition issues facing children with special health care needs at school and in early
intervention programs, Nutrition Focus (Obara 2011)
Chapter 6 of Children with Special Health Care Needs: nutrition care handbook (Willis
2004)
Nutrition for Children with Special Health Care Needs, Module 5 – A self-study
module about integrating community services and programs into nutrition care plans
for children with special health care needs.

Nutrition Therapy Efficacy

Several reports document the efficacy and cost-effectiveness of nutrition services for
children with special health care needs, including children with developmental disabilities
(Gilliam 2006; Lucas 2004; Herman 1999).

Goal Setting

The goal of nutrition care for a child with a developmental disability is to promote optimal
nutrition status – growth and development consistent with expectations, based on the
child’s history and disorder. This requires an approach that is comprehensive,
collaborative, and family-centered (Lucas 2004; ADA 2010).

Food & Feeding Issues

Delayed physical development and motor-skill delays may limit the child’s ability to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
advance his or her feeding skills and appropriately self-feed. Modification of foods offered
and/or adaptive equipment may be necessary. Occupational therapists and physical
therapists familiar with available feeding equipment should be consulted. See Feeding
Skills, and Modifications to the Feeding Environment, under Nutrition Intervention.

Comparative Standards

Fluid needs will depend on the individual’s medical condition(s). In general, the fluid needs
of a child with autism spectrum disorders are the same as a child who is developing
normally.

Enteral or Tube Feeding

Some children may require enteral tube feeding. Examples of circumstances leading to
initiation of tube feeding include insufficient intake, weight loss due to illness, and poor
weight gain. Common routes for tube feeding may be gastrostomy, percutaneous
endoscopic gastrostomy (PEG), or jejunostomy. Enteral tube feedings can be used to
augment oral intake or may be the sole source of nutrition. If possible, bolus feedings are
preferred; however, gut function of some children may necessitate a continuous feeding
schedule. A physical therapist or speech pathologist should be consulted to recommend a
program for oral-facial stimulation and regular oral hygiene, so that facial sensitivities do
not interfere with the reintroduction of food.
Enteral formula intake should be adjusted according to age, tolerance, and desired rate of
weight gain. Fluid intake should be assessed, and a formula containing fiber should be
recommended for children with constipation. Some possible complications related to tube
feeding are nausea, vomiting, diarrhea, constipation, dehydration, tube obstruction,
gastroesophageal reflux (GER), excessive and rapid weight gain, and infection.
The decision to place a gastrostomy tube is often a complex one. Families whose children
need feeding tubes need information and support that includes an appreciation for the
psychosocial/emotional aspects (eg, feelings of loss, feelings of failure, emotional
meanings of food and eating) as well as consideration for practical aspects (eg,
incorporating tube feedings into daily life, going on vacation) (Petersen 2006; Craig 2003).

Nutrient Exceptions to DRI

In general, the nutrient needs of children with autism spectrum disorders do not differ from
children who are developing typically.
Nutrient intakes of 113 children with autism were recently compared with those of typical
children as obtained through the National Health and Nutrition Examination Survey
(NHANES). The majority of children with autism had inadequate (<80% Dietary Reference
Intake) intakes of calcium, vitamin D, and vitamin K (Depasquale 2009).

Nutrition Monitoring & Evaluation

Nutrition monitoring may include following growth patterns and dietary intake, as well as
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition monitoring may include following growth patterns and dietary intake, as well as
evaluating feeding skills and eating-related behaviors. Nutrition goals and interventions
should be adjusted when the goals are met or when it is determined that an intervention is
not effective.
If the intervention is not being implemented as prescribed, the registered dietitian works
with the family and other members of the health care team to identify barriers to
implementation. Addressing these issues may include arranging for additional resources,
referring to other professionals, and collaborating with other care providers (Charney 2009).

Nutrition Care FAQs

Question:
What are some strategies to offer to families who are trying to address “picky eating”?
Answer:
Children with autism spectrum disorders may have “picky” eating habits, and accept only a
few foods. These issues are quite different from the typical "food jags" of toddlers and
young children. It is not unusual for a child to accept a very limited number (<10) of foods.
Families are working hard to address other behaviors, so it may also be helpful to enlist the
help of others. Educators, childcare providers, and others may be able to help implement
some of the suggestions below.
The following suggestions were adapted from a handout published in Nutrition Focus
(Feucht 2010).
Avoid overwhelming the child with too many changes
Keep mealtimes constant. Use the same plates and utensils. Eat at the same place
and at the same time.
Offer small servings of a few (2-3) foods at one time. Avoid offering too much food
and too many choices.
Offer new foods along with foods the child already likes to eat.
Introduce foods in forms that are similar to foods your child eats, and make changes
gradually. For example, if a child eats crackers, but not sandwiches:
Offer sandwiches made with crackers 1.
Offer sandwiches made on toast 2.
Offer sandwiches made with bread 3.
Expect slow changes. Follow your child through the steps of the process…set realistic
goals. For example:
Child will let peas stay on plate 1.
Child will pick up peas, but not put in mouth 2.
Child will lick peas 3.
Child will take a bite of peas 4.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Encourage families to ask others for help.
Pick one “goal food” to offer at snack time and/or lunch. Offer this same food at home. 1.
Use non-food reinforcers. Using food as a reinforcer teaches your child to value this
food and can teach your child not to value other foods.
2.
Incorporate eating behaviors into your child’s token reward system; a token for a “goal
behavior,” such as leaving peas on plate. Remember NOT to use food as the end
reward!
3.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Developmental Disabilities > Cerebral Palsy
Medical Tests and Procedures

Diagnostic tests will vary depending on the individual child and the specific syndrome or
condition, and may include the following:
Video fluoroscopic swallow study (or, modified barium swallow study) to evaluate risk
for aspiration and/or safety of oral intake
pH probe to identify gastroesophageal reflux
Dual energy x-ray absorptiometry and/or estimation of bone age may be
recommended for some individuals with developmental disabilities
The nutrition assessment may include evaluation of how the test itself might affect
nutritional status (eg, need for fasting because of procedure). More often, the results of the
test can be used to identify nutrition problems (eg, nutrient deficiency) or potential
problems (eg, need for modified intake because of a medical condition).

Laboratory

Laboratory data will vary depending on the individual child and the specific syndrome or
condition and may include the following:
Nutrition-related biochemical data when indicated by risk factors or therapy (eg,
evaluation of vitamin D status when anti-seizure medications are used or based on
diet and/or sun exposure, hematocrit/ferritin/other indicators to evaluate iron status)
Laboratory testing for conditions associated with specific syndromes
Identification of other conditions, as indicated (eg, blood lead levels, pH and
electrolytes, serum urea nitrogen and creatinine, drug levels)

Client History

Medical/Health
The individual’s medical and health history should be reviewed. Identify issues that
influence nutrient needs and ability to meet estimated needs, as well as current and past
issues that may affect eating and feeding, including feeding relationships.
Secondary conditions that may occur as a result of the primary condition should also be
included in the assessment (Cricco, 2007).
Medications
Types of medications used (including prescription, over-the-counter, and herbal
medications), and the duration of their use should be included in the nutrition assessment.
Examples of drug–nutrient interactions include effects on appetite, dryness of the mouth,
and interference with vitamin and mineral absorption. In addition, medications can lead to
practical issues with food and eating (eg, issues related to timing of medications and meals)
or interfere physically (eg, acidic medicine may curdle milk or formula) (Brizee, 2006). See
Common Nutrient–Drug Interactions in the Resources section for more information.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Common Nutrient–Drug Interactions in the Resources section for more information.
Information about vitamins and other supplements should be documented in the nutrition
assessment.
Social
The social history should be reviewed. Relevant questions may include the following:
Where does the child live? Who else lives in the household? Who provides care,
including food/feeding?
Is access to food reliable? Is access to food preparation and storage reliable? What
are the barriers to adequate food access (eg, homelessness, transportation, finances,
language)?
What resources do the child and family utilize (eg, Supplemental Nutrition Program
for Women, Infants, and Children, Early Head Start/Head Start, National School
Breakfast and Lunch Program, Supplemental Nutrition Assistance Program [formerly
known as the food stamps program], Medicaid/State Children’s Health Insurance
Program, Early Intervention)?
Transition to Adulthood
Transition is used to describe the process of moving from youth to adulthood in all areas of
life, including health care. Considerations during nutrition assessment include access to
adult-based health care and services, health insurance, and issues related to independent
living (eg, meal preparation, access to food, food choices). Activities include identifying
potential issues; anticipating the need for transition; and providing the individual and family
with information and resources, including a referral to a registered dietitian who works with
adults, if needed (Lanier, 2005).

Food/Nutrition-Related History

Dietary intake should be carefully assessed through a diet history, 24-hour recall, or written
diet record of 3 or more days. Many parents and caregivers may be providing only one
meal for the child; therefore, complete information should be obtained from
representatives other venues where food is provided (eg, child care, Head Start, and
school lunch programs). The dietary information should include the serving size, the length
of time eating, the number of snacks, and the time meals and snacks are served.
Modifications to textures should be noted. Questions about the amount of food lost through
spillage can also provide valuable information about an individual's intake.
Because the energy needs of individuals with cerebral palsy vary greatly, registered
dietitians must use clinical judgment when evaluating intake. Routine follow-up to evaluate
energy and other nutrient needs is usually necessary.

Anthropometrics

Careful evaluation of growth—including weight, length, or stature, and head
circumference—should be included in the nutrition assessment. Accurate, serial
measurements are important in assessing an individual’s growth, as many conditions are
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
associated with growth alterations (see Table 1). In general, evaluation of growth is done
using the growth charts published and recommended by the Centers for Disease Control
and Prevention (CDC) (CDC, 2007).
Several sets of growth charts for children with cerebral palsy (CP) have been developed
(Stevenson, 2006; Day, 2007; Krick, 1996). The charts published by Day (2007) are more
specific to individual effects on growth than other charts and illustrate the variety of
influences on growth and growth expectations. The charts describe growth of children in
the following groups:
Walks independently
Walks with support
Crawls, creeps, or scoots but does not walk
Is not ambulatory, does not feed self, is not fed by gastrostomy tube
Is not ambulatory, is fed by gastrostomy tube
The authors urged that clinicians be cautious about using the charts to predict growth and
added caveats about the difficulty in obtaining accurate measurements for many children
with CP (Day, 2007).
Length or Stature
Recumbent length (measured with a lengthboard) is plotted on the chart for infants (birth to
24 months). Stature (standing height, measured with a stadiometer) should be plotted on
the charts for 2- to 20-year-olds (CDC, 2007).
Joint contractures, scoliosis, muscle spasms, and poor cooperation can interfere with
obtaining an accurate measurement. In these cases, alternative estimators of stature (eg,
crown-rump length, sitting height, or segmental lengths) are sometimes used.
Techniques and tables for comparison for alternative measurements—including
crown-rump length, sitting height, armspan, and knee height)—have been described in the
literature (Chumlea, 1994; Lohman, 1988; Frisancho, 1981; Hamill, 1973). Some
adjustments to these measurements may be required to apply them to the CDC growth
charts. These measurements should be made by trained practitioners who understand the
methods as well as the limitations of the techniques. If alternate methods are used, they
should be documented so that they can be replicated over time.
Weight
Weight should be measured on calibrated equipment that weighs in 10-g or 100-g
increments (for infants and children/adolescents, respectively). Weight should be measured
on a regular basis, recorded on the growth chart, and monitored sequentially for changes
(CDC, 2007).
In some instances, it may be difficult to obtain an accurate weight measurement. For
example, some children may not be able to maintain stability on a scale and a specialized
scale (eg, with handrails or a scale that can accommodate a wheelchair) may be needed.
Chair scales, bucket scales, and bed scales are used in some facilities.
Head Circumference
For children aged birth to 24 months, head circumference should be measured in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
centimeters and plotted on the WHO growth charts. Serial measurements should be taken
and may help to identify microcephaly or macrocephaly (CDC, 2007).
Weight-for-Length
Weight-for-length should be plotted on the infant (birth to 24 months) chart and is often the
best indicator of the child’s nutritional status. This is especially important for the child who
is small for age.
Body Mass Index
Body mass index (BMI = weight [kg] / height [m]
2
) is used as a screening tool for obesity
for children aged 2 years and older (CDC, 2007). BMI-for-age can be plotted on the CDC
growth charts. The risk of obesity and overweight among children with developmental
disabilities seems to be at least the same as the risk in the general population
(Bandini, 2005).
When evaluating weight-for-length or BMI-for-age, it is important to consider the
individual's body composition. These parameters are often at the low end because of
reduced lean body mass.
Skinfold Measurements
Standard methods for measurement can be used for triceps and subscapular skinfold
measures. Available reference data are based on healthy developing children, which limits
the application to children with developmental disabilities (Najar, 1987). Serial skinfold
measurements may be useful for monitoring changes in body composition. Triceps and
subscapular skinfold measurements and midarm muscle circumference are most
representative of body fat stores in this population.
Skinfold measurements (especially when compared to such measurements of children
without CP) may not be a reliable measure of body fatness because of differences in body
composition (Arrowsmith, 2006). In fact, single anthropometric measurements (BMI,
mid-upper arm circumference, triceps skinfold, and mid-upper arm fat rea) were found to be
poor predictors of body fat in children with CP (Kuperminc, 2010).

Nutrition Diagnosis

Dietitians working with patients who have cerebral palsy should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate oral intake (NI-2.1)
Less than optimal enteral nutrition (NI-2.5)
Inadequate protein intake (NI-5.7.1)
Inadequate vitamin intake (specify)(NI-5.9.1)
Inadequate mineral intake (specify)(NI-5.10.1)
Swallowing difficulty (NC-1.1)
Altered gastrointestinal function (NC-1.4)
Unintended weight loss (NC-3.2)
Unintended weight gain (NC-3.4)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Inability or lack of desire to manage self-care (NB-2.3)
Impaired ability to prepare foods/meals (NB-2.4)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to gastroesophageal reflux as evidenced by
24-hour recall 75% of estimated intake needs and 2 episodes of emesis.
Inadequate oral intake (NI-2.1) related to oral-motor dysfunction as evidenced by
3-day food record energy intake at 75% estimated needs.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition interventions should be individualized based on the child’s nutrition, medical, and
other needs. Plans should be developed with input from the family and other members of
the health care team. Examples of Nutrition Intervention codes and related strategies that
can be used for issues common to children with developmental disabilities are briefly
described below (IDNT, 2010).
Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)
Increasing energy intake. When a child is unable to consume an adequate amount of
food to meet energy needs, energy intake is often increased by adding energy boosters to
foods (Van Ripper 2010). Examples include powdered nonfat milk, undiluted evaporated
milk, cheese, wheat germ, vegetable oil, mayonnaise, butter or margarine, and gravy. Note
that each of these foods adds substantial energy to the diet without adding bulk or
increasing portion sizes. Commercial liquid supplements are also used to increase energy
intake (see below). Additional suggestions for increasing energy intake can be found in
the Failure to Thrive and Underweight sections and in Children with Special Health Care
Needs: Nutrition Care Handbook (Lucas, 2004).
The decision to modify the nutrient composition of foods should include consideration of the
effect of overall nutrient intake (eg, vitamin and mineral intake, fluid intake,
fat-protein-carbohydrate content).
Decreasing energy intake. A decrease in energy intake may be needed when rate of
weight gain is excessive. When decreased energy is recommended, the registered dietitian
(RD) should work to ensure that the meals contain an appropriate balance of protein, fat,
and carbohydrate. Strategies to decrease energy intake may include adjusting portion
sizes, modifying food preparation techniques, and limiting sugar-containing beverages.
When overall ener gy intake is decreased, assessing the adequacy of vitamin and mineral
intake is increasingly important.
Modifying portion sizes and/or adjusting the meal and snack schedule. For some
children, the amount of food offered at meals and schedule for meals and snacks can
prevent adequate intake. Children can become overwhelmed by the task of eating a large
full plate of food and actually eat a larger amount when only a small (but appropriate)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
amount of food is presented. For many children, decreasing portion sizes and increasing
the frequency of feedings may help. See feeding recommendations for specific age groups
in the Normal Nutrition section.
Medical Food Supplements: Commercial beverage (ND-3.1.1); Vitamin and Mineral Supplements (ND-3.2)
Nutritional supplements. For children who do not respond adequately to the suggestions
provided above, adding liquid or powdered nutritional supplements may be necessary.
There are several options, including pediatric liquid nutrition formulations; adult-strength
liquid nutritional supplements; powdered, tasteless, carbohydrate-based nutritional
supplements; powdered protein supplements; and fat supplements. The decision to modify
the nutrient composition of foods should include consideration of the effect of overall
nutrient intake (eg, vitamin and mineral intake, fluid intake, fat-protein-carbohydrate
content).
Feeding Assistance: Adaptive equipment (ND-4.1); Feeding position (ND-4.2); Meal set-up (ND-4.3)
Feeding Environment: Distractions (ND-5.3); Table height (ND-5.4); Table service/set up (ND-5.5)
Modifications to the feeding environment. The feeding environment for the child with
developmental disabilities requires the following:
Structure
Appropriate feeding equipment
Age-appropriate portion sizes
Avoidance of distractions (eg, television and radio)
Meals and snacks should be offered at the same time each day. Chairs that ensure proper
positioning should be used.
To encourage communication and eye contact during the meal, the person who is helping
the child with the meal should sit across from the child and be at eye level. This position
facilitates communication and the child’s anticipation of eating. For children who do not
feed themselves, the feeder should be at eye level with the child to prevent the child from
extending his or her neck while eating and, hence, the risk of choking.
Serving sizes should be small, so that the child can easily eat what is served. Additional
servings can be given if the child indicates wanting more.
Feeding time should not extend beyond a reasonable time limit, and children should not be
force-fed. Feeding behaviors should be monitored and noted to follow for the potential
development of negative feeding behaviors (Nardella, 2004).
Referral to Community Agencies/Programs (specify) (RC-1.4)
Nutrition-related issues may require referral to and collaboration with community resources.
Two resources are described below.
Early Intervention Programs. All states have early intervention programs, which
provide health services, including nutrition services, to children up to 3 years of age
who have developmental delays. These services, mandated under Part C of the
Individuals with Disabilities Education Act (IDEA) 2007, are available to all children
and are provided in the least restrictive environment for the family.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Child Nutrition Programs. Children with developmental disabilities who are enrolled
in the child nutrition programs at school are entitled to a modification of meals to meet
their particular nutrition needs (McCary, 2006). For example, a child with cerebral
palsy and oral-motor difficulties can receive a texture-modified meal once a
prescription has been sent to the school by a physician, nurse, or RD. This is the
result of Public Law 192-119, IDEA, which requires a prescription form.
Additional resources include the following:
Nutrition issues facing children with special health care needs at school and in early
intervention programs, Nutrition Focus (Obara 2011)
Chapter 6 of Children with Special Health Care Needs: Nutrition Care Handbook
(Willis, 2004)
Nutrition for Children with Special Health Care Needs, Module 5 (a self-study module
about integrating community services and programs into nutrition care plans for
children with special health care needs)

Nutrition Therapy Efficacy

Recent reports have documented that nutrition services for children with special health
care needs, including children with developmental disabilities, have been found to be
efficient and cost effective (Gilliam, 2006; Lucas, 2004; Herman, 1999).
Exceptions to DRI
Energy needs vary widely among individuals with cerebral palsy (CP), and commonly used
predictive equations may not be accurate (Dickerson, 1999). Close monitoring of an
individual’s intake and growth rates is needed to make accurate estimates. See
the Comparative Standards heading for more information.
The energy needs of many children with CP are higher or lower than the estimated energy
requirements for their age and size (Nowak-Cooperman, 2007). The following table
describes how CP characteristics have an impact on energy needs.
Influence of CP Characteristics on Energy Needs
Characteristic
Effect on Energy
Needs
Comments
Increase Decrease
Hypotonia X Related to:
Lower
resting
energy needs
Decreased
activity level
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Hypertonia/spasticity X Related to
increased
movement
Seizure Disorders X Related to seizure
activity and
increased muscle
tone
X Related to low
muscle tone or
sedation from
medications
One study used the doubly labeled water technique to measure energy expenditure in 16
children with mild CP and 16 children who were developing typically. Total energy
expenditure was lower in children with CP because of lower physical activity levels.
However, children with CP expended more energy while walking than children without CP
(Bell, 2010).
Nutrient needs can change as therapies change. For example, intrathecal administration of
baclofen is used to treat severe spasticity. As tone is reduced, energy needs may be
reduced too, and adjustments in intake needed.
Protein, fat, vitamins, and minerals should meet the Dietary Reference Intakes for age.
Vitamin/mineral supplementation may be indicated for children taking medications known to
affect or interact with certain nutrients and can be useful for correcting inadequate dietary
intake. Pediatric- and adult-strength liquid and powdered vitamin/mineral supplements are
available for individuals who have swallowing difficulties or who are tube fed.

Goal Setting

The goal of nutrition care for a child with a developmental disability is to promote optimal
nutrition status and growth and development consistent with expectations based on the
child’s history and disorder. This goal requires an approach that is comprehensive,
collaborative, and family centered (Lucas, 2004; ADA, 2010).

Food & Feeding Issues

Feeding
Children with cerebral palsy (CP) may have feeding problems including oral-motor
problems, such as weak suck, poor lip closure, tongue thrust, drooling, bite reflex, oral
tactile sensitivity, choking, hyperactive gag reflex, and swallowing difficulties (including
silent aspiration). Children with CP may also have delayed acquisition of feeding skills. For
the usual timetable for feeding development, see Normal Nutrition sections. Feeding
problems often have behavioral components.
Children with CP are often included in early intervention programs in which feeding
problems can be addressed. Children with severe oral-motor deficits consume a limited
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variety of foods; take longer to eat; and lose food through drooling, coughing, and choking.
Assessment of feeding problems requires a team-based approach. Teams may include
occupational therapists, speech pathologists, physical therapists, registered dietitians,
psychologists, nurses, and/or educators. An effective assessment of feeding will include an
observation of the parent or caregiver feeding the child, which allows the team to observe
positioning, parent/child interaction, and any oral motor problems that may exist.
General factors that affect feeding and eating should be evaluated, including the following
(Krick, 2003; Dodge, 2008):
Neuromotor performance, perceptual deficits, vision, and hearing
Cognitive and communication skills
Behavior/interactions
Growth
Overall health concerns
Constipation
Amount of physical and verbal assistance required to eat; physiologic support needed
for eating
Oral-motor skills and swallowing status, coordination of breathing and eating
Medication
Dental and gum disease
Orthopedic and other surgeries
Family/psychosocial supports and stresses
It is important to periodically evaluate an individual’s readiness for transition to the next
feeding stage. Evaluation of feeding skill development, acceptance of textures, and
acquisition of self-feeding skills will help families and clinicians anticipate the appropriate
next step for an individual child.
Gross and Fine Motor Skills
Delayed physical development, poor coordination, and contractures may limit the child’s
ability to advance feeding skills and appropriately self-feed. Specialized feeding equipment
is available for those children unable to use regular-shaped and regular-sized utensils,
dishes, and cups. Occupational therapists and physical therapists familiar with available
feeding equipment should be consulted.

Enteral and Tube Feeding

Many children with cerebral palsy require enteral tube feeding. Examples of circumstances
leading to initiation of tube feeding include insufficient intake, weight loss due to illness,
poor weight gain, dysphagia, or aspiration. Common routes for tube feeding may be
gastrostomy, percutaneous endoscopic gastrostomy, or jejunostomy.
Enteral tube feedings can be used to augment oral intake or may be the sole source of
nutrition. If possible, bolus feedings are preferred; however, gut function of some children
may necessitate a continuous feeding schedule. A physical therapist or speech pathologist
should be consulted to recommend a program for oral-facial stimulation and regular oral
hygiene, so that facial sensitivities do not interfere with the reintroduction of food.
Enteral formula intake should be adjusted according to age, tolerance, and desired rate of
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weight gain. For children with low energy needs, vitamin and/or mineral supplements may
be needed, in addition to formula. Fluid intake should be assessed, and a formula
containing fiber should be recommended for children with constipation. Some possible
complications related to tube feeding are nausea, vomiting, diarrhea, constipation,
dehydration, tube obstruction, gastroesophageal reflux, excessive and rapid weight gain,
and infection.
The decision to place a gastrostomy tube is often a complex one. Families whose children
need feeding tubes need information and support that includes an appreciation for the
psychosocial/emotional aspects (eg, feelings of loss and failure, emotional meanings of
food and eating) as well as consideration for practical aspects (eg, incorporating tube
feedings into daily life, going on vacation) (Petersen, 2006; Craig, 2003; Mahant 2009).
Guidelines for nutrition support for critically ill children have been published (Mehta, 2009).

Suggested Monitoring Parameters and Recommendations

Nutrition monitoring may include following growth patterns and dietary intake and
evaluating feeding skills and eating-related behaviors. Nutrition goals and interventions
should be adjusted when the goals are met or when it is determined that an intervention is
not effective.
If the intervention is not being implemented as prescribed, the registered dietitian works
with the family and other members of the health care team to identify barriers to
implementation. Addressing these issues may include arranging for additional resources,
referring to other professionals, and collaborating with other care providers (Charney,
2009).

Nutrition Care FAQs

Question:
I am concerned about the feeding skills of a child aged 2½ years with cerebral palsy (CP).
How do I make sure it is safe for her to eat orally?
Answer:
Feeding problems are common among children with CP. Talk with the girl's medical team
and her family about concerns regarding feeding and safety of oral eating. Two potential
actions include the following:
Depending on indications, referral for a videofluoroscopic swallow study may be
needed; discuss concerns with the child’s physician, who will make the referral
1.
Feeding evaluation at a local early intervention program (also called a Birth-to-Three
program) may be needed
Many early intervention programs have feeding therapists (usually a speech,
occupational, or feeding therapist). A feeding team that includes an registered
dietitian (RD) is ideal. Health care providers (including RDs) and families can
make referrals to early intervention programs.
2.
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If the child is not eligible for early intervention services (eg, older than age 3 years) or
feeding therapy is not available, resources may include feeding teams/services through
public health departments, children’s hospitals, and private therapy agencies. School
districts sometimes employ feeding teams as well.

Nutrition-Focused Physical Findings

Children with cerebral palsy (CP) are more likely to be underweight and have short stature;
many problems with growth are nutrition related. Factors that can affect the growth of
children with CP include the following (Krick, 2003; Kuperminc, 2008; Bell 2010):
Central nervous system abnormalities
Alteration in muscle tone, affecting limbs and torso
Limited physical activity level
Abnormal endocrine function
Orthopedic surgery and lack of weight-bearing activity
Orthopedic surgery may require periods of immobility and may interfere with
bone formation and longitudinal growth

Feeding Skills

Assessment of feeding problems requires a team-based approach. Teams may include
occupational therapists, speech pathologists, physical therapists, registered dietitians,
psychologists, nurses, and/or educators. An effective assessment of feeding will include an
observation of the parent or caregiver feeding the child. This allows the team to observe
positioning, parent-child interaction, and any oral-motor problems that may exist.
The following list identifies important considerations in the assessment of feeding. More
information can be found in the Food & Feeding Issues section.
Considerations When Assessing Feeding Skills
Age vs. developmental level of child
Previous feeding experiences
Method
Variety
Feeder position
Position
Texture/consistency of food and drink
Previous food challenges
Mouth movement and head position: jaw, lip, cheek, tongue movement
Sensory aspects of feeding and tactile defensiveness
Visual/auditory stimuli
Smell of food
Temperature of food
Taste of food
Utensils used
Fluid intake
Dental hygiene and oral health
Self-feeding ability
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Self-feeding ability
Time required for meals/snacks
(Cloud, 2005)

Swallowing Disorders

A high incidence of pneumonia hospitalizations in a patient with cerebral palsy should
serve as a red flag for potential swallowing disorders. Any incidence of pneumonia or
frequent coughing during feedings, especially when liquids are ingested, is a clue to
potential swallowing abnormalities, including aspiration or gastroesophageal reflux (see
Gastroesophageal Reflux Disease). "Silent" aspiration (aspiration without cough) is
common in these patients. Children with swallowing dysfunction may refuse food and fluids
and/or limit their intakes as a protective mechanism. Therefore, food refusal, limited intake,
or a combination of the two may be indicative of the need for a feeding evaluation.
Some children may not be able to safely swallow certain foods (eg, thin liquids or mixed
textures). The need for thickened liquids is generally identified by a modified barium
swallow test (also called videofluoroscopic swallow study). Sometimes liquids (eg, infant
formula or breast milk) thickened with rice cereal and/or commercially available thickeners
are recommended. The effects on the child’s nutrient intake must be included as part of the
nutrition assessment.
Indicators of problems with feeding and swallowing dysfunction may include the following
(Krick, 2003; Arvedson, 2008):
Facial weakness, decreased sensation
Congestion, noisy “wet” sounds
Coughing/choking/gagging before, during, or after a swallow
Food refusal
History of upper respiratory infections
Poor intake
Inefficient and lengthy mealtimes
Inappropriate progression of feeding skills

Oral Health

Cerebral palsy (CP) and associated conditions can increase a child’s risk of developing oral
health problems. Some factors that contribute to poor oral health and that may be common
among children with CP include the following (Ogata, 2003; Faine, 2001; Boyd, 1998):
Forward tongue thrust, which causes an open bite
Drooling, chewing, or swallowing disorders
Malocclusion if tongue in abnormal position
Abnormal or depressed movement of the tongue, lip, and cheek, causing food
particles to remain lodged in the teeth, contributing to caries
Difficulty performing adequate hygiene
Prolonged use of the nursing bottle
If a child sips on a bottle throughout the day, he or she is at greater risk for caries
Extended eating time
If frequent meals and snacks are needed, or if mealtime is longer than usual,
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If frequent meals and snacks are needed, or if mealtime is longer than usual,
teeth are exposed to acid for a greater period of time
Low fluid intake
Gastroesophageal reflux
As the acidic gastric contents are regurgitated, primary and permanent teeth
can be eroded
Oral hypersensitivity
May make good oral hygiene difficult and may also limit the types and textures
of foods eaten
Inability or refusal to consume specific foods or groups of foods
Nutrients needed for development and remineralization of teeth may be
unavailable
Oral health problems that can be common among children with developmental disabilities
include the following:
Dental caries, an infection that can compromise a child’s health and can lead to
inappropriate speech and other problems with communication; missing or decayed
teeth can prevent a child from eating certain foods
Malocclusion, a condition in which the teeth are misarranged or do not meet normally,
making it difficult to bite and chew food
Abnormal dentition: Abnormalities in the number and/or size of teeth may be
important in the child’s ability to chew and to consume specific foods
Bruxism, which can cause tooth abrasion and loss of enamel from the chewing
surface; may lead to headaches, facial pain, or periodontal disease
Toothbrushing and good oral hygiene may be difficult for some children with developmental
disabilities. Good oral hygiene is essential and may help with oral desensitization.
Therapists (eg, physical, occupational, or speech) should be consulted for techniques to aid
in orofacial desensitization.
The clinician should consider the following questions:
Does the child have oral health problems that affect his or her nutritional status?
Is the child at risk for oral health problems?
How does the disorder (or treatment for the disorder) affect the following:
Development of oral structures?
Saliva production?
Frequency of eating?
Types of foods consumed?


Constipation

Constipation may result from decreased activity, hypotonia, decreased bowel function,
inadequate fluid intake, low fiber intake, vomiting, or medications (Isaacs, 2004) and is
estimated to occur in approximately 80% of individuals with cerebral palsy (Dodge, 2008).
Evaluating and modifying the child’s food, fluid, and/or enteral formula intake can have a
significant impact on treating and preventing constipation. Liquid nutrition supplements are
available with or without added fiber. For children who consume solid foods, addition of
bran or raw fruits or vegetables may be helpful. To prevent gas or bloating, parents should
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be instructed to introduce high-fiber and/or bran cereals slowly. See Constipation for more
information.

Comparative Standards

Energy Needs
For some children, it may be more appropriate to estimate energy needs based on length
instead of weight (ie, kilocalories per centimeter of length vs. kilocalories per kilogram of
weight). General guidelines for some conditions (including cerebral palsy) are available to
provide perspective; however, it is always best to estimate an individual’s needs based on
his or her growth and intake history.
Several equations have been published to guide clinicians in estimating an individual’s
energy needs. See the tables below.
Alternative Method of Estimating Daily Energy Needs for
Children with Low Energy Needs
Lower 7-9 kcal/cm
Moderate 9-11 kcal/cm
High 12-15 kcal/cm
Source: Holland, 2004
Proposed Formula to Estimate Energy Needs for
Children with Cerebral Palsy
Equation Resting energy expenditure x Muscle tone
factor x Activity factor + Growth factor(s) =
kcal/day
Muscle Tone
Factors
Add 10% for high tone
Subtract 10% for low tone
No adjustment for normal tone
Activity Factors Add 15% for bedridden state
Add 20% for wheelchair dependent
Add 30% for ambulation
Growth Factors Add 5 kcal/g of expected, desired, or
catch-up growth
Source: Krick, 2003
See the Calculators within the Resources area for more information on catch-up growth
and estimated energy requirements.
Fluid Needs or Limits
Fluid needs will depend on the individual’s medical condition. For example, fluid needs can
be increased with excessive drooling, medications, or as part of a constipation
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management plan.
Estimation of fluid needs should be individualized. However, a starting estimate based on
body weight can be used (Krick, 2003):
Body weight < 10 kg: 100 mL fluid/kg
Body weight 11-20 kg: 50 mL fluid/kg
Body weight > 21 kg: 25 mL fluid/kg
Monitoring urine-specific gravity can be helpful for evaluating adequacy.

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Nutrition Care > Developmental Disabilities > Down Syndrome
Medical Tests and Procedures

Diagnostic tests will vary depending on the individual child and his or her specific issues;
they may include the following:
Testing for celiac disease (blood collected for screening test, small bowel biopsy for
diagnosis)
Surveillance for cardiac issues
Monitoring for endocrine disorders (eg, hypothyroidism, diabetes mellitus)
Video fluoroscopic swallow study (VFSS, or modified barium swallow study) to
evaluate risk of aspiration and/or safety of oral intake
pH probe to identify gastroesophageal reflux
The nutrition assessment may include evaluation of how the test itself might affect
nutritional status (eg, need for fasting because of procedure). More often, the results of the
test can be used to identify nutrition problems (eg, nutrient deficiency) or potential
problems (eg, need for modified intake because of a medical condition).

Laboratory

Laboratory data will vary depending on the individual child and his or her specific issues,
and may include the following:
Nutrition-related biochemical data when indicated by risk factors or therapy (eg,
evaluation of vitamin D status when anti-seizure medications are used or based on
diet and/or sun exposure, hematocrit/ferritin/other indicators to evaluate iron status)
Laboratory testing for conditions associated with Down syndrome (eg, thyroid
screening, screening for celiac disease for children with Down syndrome) (Davidson
2008; Hill 2005; Cassidy 1997)
Identification of other conditions, as indicated (eg, blood lead levels, pH and
electrolytes, serum urea nitrogen and creatinine, drug levels)

Client History

Medical/health
The individual’s medical and health history should be reviewed. Identify issues that
influence nutrient needs and ability to meet estimated needs, as well as current and past
issues that may affect eating and feeding, including the feeding relationship. For example, it
is common for children who have had many medical procedures (especially around the
face and mouth) to develop sensitivities and aversions.
Secondary conditions that may occur as a result of the primary condition should also be
included in the assessment (Cricco 2007).
Medications
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Children with Down syndrome may take a variety of medications. Types of medications
used (including prescription, over-the-counter, and herbal medications), and the duration of
their use should be included in the nutrition assessment. Examples of drug-nutrient
interactions include effects on appetite, dryness of the mouth, and interference with vitamin
and mineral absorption. In addition, medications can lead to practical issues with food and
eating (eg, issues related to timing of medications and meals) or interfere physically (eg,
acidic medicine may curdle milk or formula) (Brizee 2006). Some medications commonly
used by children with developmental disabilities and related nutrient/food interactions are
listed in Common Nutrient-Drug Interactions in the Resources section.
A number of supplements and other alternative therapies have been marketed to families
of children with Down syndrome. An example is NuTriVene-D, which is a combination of
vitamins, minerals, amino acids, phytochemicals, and other compounds. Despite anecdotal
reports of improvements, there is no good evidence to support its use (Lucas 2008).
Feeding history
A complete nutrition evaluation will include a review of the individual’s feeding history,
including feeding during infancy (eg, breastfeeding, bottle-feeding), need for specialized
foods or formulas, introduction of solids, and any problems (past or present) with feeding.
Social
The social history should be reviewed. Relevant questions may include the following:
Where does the child live? Who else lives in the household? Who provides care,
including food/feeding?
Is access to food reliable? Access to food preparation and storage? What are the
barriers to adequate food access (eg, homelessness, transportation, finances,
language)
What resources do the child and family utilize? (eg, Supplemental Nutrition Program
for Women, Infants, and Children [WIC], Early Head Start/Head Start, National School
Breakfast and Lunch Program, Supplemental Nutrition Assistance Program [SNAP -
formerly known as the food stamps program], Medicaid/State Children’s Health
Insurance Program, Early Intervention)
Transition to adulthood
Transition is used to describe the process of moving from youth to adulthood in all areas of
life, including health care. Considerations during nutrition assessment include access to
adult-based health care and services, health insurance, issues related to independent living
(eg, meal preparation, access to food, food choices). Activities include identifying potential
issues, anticipating the need for transition, and providing the individual and family with
information and resources (Lanier 2005; Davidson 2008).

Food/Nutrition-Related History

Dietary intake should be carefully assessed through a diet history, 24-hour recall, or written
diet record of three or more days. Many parents and caregivers may be providing only one
meal for the child; therefore, complete information should be obtained from other places
where food is provided (eg, child care providers, Head Start programs, and school lunch
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
programs). The dietary information should include the serving size, the length of time
eating, the number of snacks, and the time meals and snacks are served.


Anthropometrics

Careful evaluation of growth, including weight, length or stature, and head circumference,
should be included in the nutrition assessment. Accurate, serial measurements are
important in assessing an individual’s growth.
Length or stature
Recumbent length (measured with a lengthboard) is plotted on the Infant (birth to
24months) chart. Stature (standing height, measured with a stadiometer) should be plotted
on the charts for 2 to 20 year-olds (CDC, NCCDPHP).
In some instances, it may be difficult to make an accurate measurement. For example,
some children may be unable to stand for a measure of stature. Alternative estimators of
stature (eg, sitting height, armspan, or segmental lengths) are sometimes used. For older
children, recumbent length might be measured (instead of standing height). This should be
noted on the growth chart.
Weight
Weight should be measured on calibrated equipment that weighs in 10 gram (infants) or
100 gram (children and adolescents) increments. Weight should be measured on a regular
basis, recorded on the growth chart, and followed sequentially for changes (CDC,
NCCDPHP).
Head circumference
For children birth to 24 months of age, head circumference should be measured in
centimeters and plotted on the WHO Growth Charts. Serial measurements should be taken
and may help to identify microcephaly or macrocephaly (CDC, NCCDPHP).
Weight-for-length
Weight-for-length should be plotted on the Infants (birth to 24 months) chart.
Body Mass Index
Body Mass Index (BMI = weight [kg] / height [m]
2
) is used for children ages 2 years and
older. BMI-for-age can be plotted on the CDC Growth Charts. BMI is used as a screening
tool for obesity (CDC, NCCDPHP). Obesity and overweight is a significant concern for
children with Down syndrome (Bandini 2005).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Skinfold measurements
Standard methods for measurement can be used for triceps and subscapular skinfold
measures. Available reference data are based on healthy developing children, which limits
the application to children with Down syndrome (Najar 1987). Serial skinfold
measurements may be useful for monitoring changes in body composition. Triceps and
subscapular skinfold measurements and midarm muscle circumference are most
representative of body fat stores in this population. These measures may not be useful for
children with atypical body composition, such as those with Down syndrome.

Nutrition Diagnosis

Dietitians working with patients who have Down syndrome should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
Decreased nutrient needs (specify)(NI-5.4)
Inadequate protein intake (NI-5.7.1)
Breastfeeding difficulty (NC-1.3)
Altered gastrointestinal function (NC-1.4)
Underweight (NC-3.1)
Overweight/obesity (NC-3.3)
Unintended weight gain (NC-3.4)
Impaired ability to prepare foods/meals (NB-2.4)
Intake of unsafe food (NB-3.1)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to gastroesophageal reflux as evidenced by
24-hour recall 75% estimated needs and two episodes of emesis.
Obesity (NC-3.3) related to excessive energy intake and decreased energy needs
(associated with Down syndrome) as evidenced by weight gain and rapid increase in
Body Mass Index-for-age/sex.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition interventions should be individualized based on the child’s nutritional, medical,
and other needs. Plans should be developed with input from the family and other members
of the health care team. Examples of Nutrition Intervention codes and related strategies
that can be used for issues common to children with Down syndrome are briefly described
below (IDNT, 2010).
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General/healthful diet (ND-1.1)
General strategies for promoting healthy eating behaviors and weight management include
the following (Lucas 2008):
Establish early acceptance of a variety of foods
Develop and maintain a predictable pattern of eating with regular meals and snacks
Eat together as a family as often as possible; do not expect children to eat alone
Limit access to non-nutritious foods early on to establish good habits
Carry lower energy items, eg, vegetable juice, in the car for pick-me-ups when on the
road
Have water readily available at home and away from home
Provide cut-up fruit and vegetables for snacks during and after physical activity
Avoid the use of food reinforcers in educational settings or for behavior management
Time spent in physical activity limits between-meal snacking while increasing energy
expenditure (note: to prevent aspiration, children should not be engaged in physical
activity while eating).

Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2); Specific
foods/beverages or groups (ND-1.3)
Increasing energy intake. When a child is unable to consume an adequate amount of
food to meet energy needs, energy intake is often increased by adding “calorie boosters” to
foods (Van Ripper 2010). Examples include powdered nonfat milk, undiluted evaporated
milk, cheese, wheat germ, vegetable oil, mayonnaise, butter or margarine, and gravy. Note
that each of these foods adds substantial energy to the diet without adding bulk or
increasing portion sizes. Additional suggestions for increasing energy intake can be found
in the Failure to Thrive and Underweight sections, and in Children with Special Health
Care Needs: Nutrition Care Handbook (Lucas 2004a).
The decision to modify the nutrient composition of foods should include consideration for
the effect of overall nutrient intake (eg, vitamin and mineral intake, fluid intake,
fat-protein-carbohydrate content).

Decreasing energy intake. A decrease in energy intake may be needed when rate of
weight gain is excessive. When decreased energy is recommended, the registered dietitian
(RD) should work to ensure that the meals contain an appropriate balance of protein, fat,
and carbohydrate, and that vitamin and mineral needs are met. Strategies to decrease
energy intake may include adjusting portion sizes, modifying food preparation techniques,
and limiting sugar-containing beverages.

Medical Food Supplements: Commercial beverage (ND-3.1.1); Vitamin and Mineral Supplements (ND-3.2)
Nutritional supplements. For children who do not respond adequately to the above
suggestions, adding liquid or powdered nutritional supplements may be necessary. There
are several options, including pediatric liquid nutrition formulations; adult-strength liquid
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutritional supplements; powdered, tasteless, carbohydrate-based nutritional supplements;
powdered protein supplements; and fat supplements. The decision to modify the nutrient
composition of foods should include consideration for the effect of overall nutrient intake
(eg, vitamin and mineral intake, fluid intake, fat-protein-carbohydrate content).

Feeding Environment: Distractions (ND-5.3); Table height (ND-5.4); Table service/set up (ND-5.5)
The feeding environment for the child with developmental disabilities requires the following:
structure
appropriate feeding equipment
age-appropriate portion sizes
avoidance of distractions (eg, television and radio).
Meals and snacks should be offered at the same time each day. Chairs that ensure proper
positioning should be used.
To encourage communication and eye contact during the meal, the person who is helping
the child with the meal should sit across from the child and be at eye level. This position
facilitates communication and the child’s anticipation of eating. For children who do not
feed themselves, the feeder should be at eye level with the child to prevent the child from
extending his or her neck while eating and, hence, the risk of choking.
Serving sizes should be small, so that the child can easily eat what is served. Additional
servings can be given if the child indicates wanting more. Feeding time should not extend
beyond a reasonable time limit, and children should not be force-fed.
Feeding behaviors should be monitored and noted to follow for the potential development
of negative feeding behaviors (Nardella 2004).

Referral to Community Agencies/Programs (specify) (RC-1.4)
Nutrition-related issues may require referral to and collaboration with community resources.
Two resources are described below.
Early Intervention Programs. All states have Early Intervention Programs, which provide
health services, including nutrition services, to children up to 3 years of age who have
developmental delays. These services, mandated under Part C of the Individuals with
Disabilities Education Act (IDEA), 2007, are available to all children and are provided in the
least restrictive environment for the family.
Child Nutrition Programs. Children with developmental disabilities who are enrolled in the
child nutrition programs at school are entitled to a modification of meals, to meet their
particular nutritional needs (McCary 2006). For example, an overweight child with Down
syndrome can receive an energy-restricted meal, once a prescription has been sent to the
school by a physician, nurse, or RD. This is the result of PL 192-119, IDEA, which requires
a prescription form.
Additional resources include the following:
Nutrition issues facing children with special health care needs at school and in early
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
intervention programs, Nutrition Focus (Obara 2011)
Chapter 6 of Children with Special Health Care Needs: Nutrition Care
Handbook (Willis 2004)
Nutrition for Children with Special Health Care Needs, Module 5 (a self-study module
about integrating community services and programs into nutrition care plans for
children with special health care needs).

Nutrition Therapy Efficacy

Several reports document the efficacy and cost-effectiveness of nutrition services for
children with special health care needs, including children with developmental disabilities
(Gilliam 2006; Lucas 2004b; Herman 1999).
Exceptions to DRI
Children with Down syndrome may have energy needs that are higher or lower than the
Dietary Reference Intake (DRI)/Estimated Energy Requirement (EER) for their age and
size.
Factors that may decrease energy needs
low resting energy needs
slower growth rates
decreased activity levels
Factors that may increase energy needs
congenital heart disease
feeding difficulties
tachypnea and tachycardia
Recommended energy intake may be estimated by considering the EER for age, weight
history, dietary intake history, and previous feeding method. However, the EER is not
always appropriate for all children. The EERs for older children include factors for height
and physical activity level. The EERs for infants and young children do not include these
factors. See EER Calculators.
For some children, it may be more appropriate to estimate energy needs based on length,
instead of weight (eg, kilocalories per centimeter of length vs. kilocalories per kilogram of
weight). For children with Down syndrome, ages 5-11 years, one starting estimate is 16.1
kcal/cm (males) and 14.3 kcal/cm (females) (Lucas 2008).
Protein, fat, vitamins, and minerals should meet the DRIs for age (see Resources).
Nutrients of concern (possibly related to food and energy restriction) include calcium, iron,
copper, zinc, and vitamins A, C, and E (Lucas 2008).
Vitamin/mineral supplementation may be indicated for those children taking medications
known to affect or interact with certain nutrients and can be useful for correcting inadequate
dietary intake. Pediatric- and adult-strength liquid and powdered vitamin/mineral
supplements are available for those who have swallowing difficulties or who are tube fed.

Goal Setting

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The goal of nutrition care for a child with a developmental disability is to promote optimal
nutrition status – growth and development consistent with expectations, based on the
child’s history and disorder. This requires an approach that is comprehensive,
collaborative, and family-centered (Lucas 2004a; ADA 2010).

Food & Feeding Issues

Feeding difficulties often occur during early years (infant, toddler, preschool), including:

Problems coordinating suck and swallow
Oral-motor issues
Refusal to progress and/or chew more textured foods
Delayed physical development, delayed motor skills, and poor coordination may limit the
child’s ability to advance feeding skills and appropriately self-feed. Modification of food
offered may be needed. Specialized feeding equipment is available for those children
unable to use regular-shaped and –sized utensils, dishes, and cups. Occupational
therapists and physical therapists familiar with available feeding equipment should be
consulted.
See "Feeding Skills" and "Modification to the Feeding Environment" in Nutrition
Intervention. A team approach to feeding issues is often needed.

Comparative Standards

Individuals with Down syndrome grow more slowly and are shorter than their typically
developing peers (Lucas 2008; Davidson 2008; Capone 2005). Children with Down
syndrome may be at risk for inadequate weight gain in the first year, related to hypotonia,
early feeding difficulties, or the presence of cardiac or gastrointestinal issues. After cardiac
repair, weight gain usually normalizes. Later, the child with Down syndrome may be at risk
for obesity, because of lack of exercise, low muscle tone, and some joint involvement.
In general, the CDC Growth Charts are used to evaluate growth. Growth charts have been
developed, based on a sample of children with Down syndrome (see Resources). These
charts are useful in comparing the growth of an individual to others with Down syndrome,
but they have significant limitations. They are based on a small sample (400 children) with
data collected between 1960 and 1966, include some children with congenital heart
disease, and reflect a tendency for overweight. If used, these charts should be used along
with the CDC Growth Charts, and the practitioner should understand their limitations
(Lucas 2008).
Fluid needs will depend on the individual’s medical condition(s). For example, a child with
cardiac complications may require a fluid restriction. A child with constipation may require
additional fluid.

Enteral or Tube Feeding

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Some children with Down syndrome require enteral tube feeding, especially during infancy
and early childhood. Examples of circumstances leading to initiation of tube feeding include
insufficient intake, weight loss due to illness, poor weight gain, dysphagia, or aspiration.
Common routes for tube feeding may be gastrostomy, percutaneous endoscopic
gastrostomy (PEG), or jejunostomy. Enteral tube feedings can be used to augment oral
intake or may be the sole source of nutrition. If possible, bolus feedings are preferred;
however gut function of some children may necessitate a continuous feeding schedule. A
physical therapist or speech pathologist should be consulted to recommend a program for
oral-facial stimulation and regular oral hygiene, so that facial sensitivities do not interfere
with the reintroduction of food.
Enteral formula intake should be adjusted according to age, tolerance, and desired rate of
weight gain. For children with low energy needs, vitamin and/or mineral supplements may
be needed, in addition to formula. Fluid intake should be assessed, and a formula
containing fiber should be recommended for children with constipation. Some possible
complications related to tube feeding are nausea, vomiting, diarrhea, constipation,
dehydration, tube obstruction, gastroesophageal reflux, excessive and rapid weight gain,
and infection.
The decision to place a gastrostomy tube is often a complex one. Families whose children
need feeding tubes need information and support that includes an appreciation for the
psychosocial/emotional aspects (eg, feelings of loss, feelings of failure, emotional
meanings of food and eating) as well as consideration for practical aspects (eg,
incorporating tube feedings into daily life, going on vacation) (Petersen 2006; Craig 2003).
Guidelines for nutrition support for critically ill children have been published (Mehta 2009).

Suggested Monitoring Parameters and Recommendations

Nutrition monitoring may include following growth patterns and dietary intake, as well as
evaluating feeding skills and eating-related behaviors. Nutrition goals and interventions
should be adjusted when the goals are met or when it is determined that an intervention is
not effective.
If the intervention is not being implemented as prescribed, the registered dietitian works
with the family and other members of the healthcare team to identify barriers to
implementation. Addressing these issues may include arranging for additional resources,
referring to other professionals, and collaborating with other care providers (Charney 2009).

Nutrition Care FAQs

Question:
How do I estimate energy needs for an infant with Down syndrome?
Answer:
Energy needs will vary from individual to individual, and estimating needs will require
clinical judgment.
Evaluate the infant’s growth – is his or her current intake adequate to support growth?
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Estimate his or her current intake.
If the current intake is not supporting appropriate growth, use clinical judgment to estimate
a goal intake. Using the Estimated Energy Requirement (EER) as a starting point can be
helpful. Adjust the EER for medical factors (eg, cardiac conditions) as well as for physical
activity. If following a child long-term, monitor growth and adjust estimated energy needs
(and recommendations for intake) accordingly.
Question:
What do I tell parents about the use of NuTriVene-D?
Answer:
NuTriVene-D is a part of the "TNI" (Targeted Nutrition Intervention) supplements, currently
promoted for children with Down syndrome. It is a combination of vitamins, minerals, amino
acids, phytochemicals, and other compounds.
Considerations in the nutrition assessment include:
• Is the supplement safe? Evaluate safety depending on the specific product (and dose)
provided to the individual child, other supplements he or she may take, and any medical
conditions. Compare intake to the tolerable upper limits (outlined in the Dietary Reference
Intake) for age.
• Does it work? Despite anecdotal reports of improvements, there is no good evidence to
support its use
• What is the cost to the family?
• Is the supplement preventing attention to diet, feeding and/or growth concerns?
A discussion with the family that includes the considerations above may be helpful.
Information should be presented in a thoughtful, family-centered manner.

Feeding Skills

Children with Down syndrome are at high risk for feeding problems. These feeding
problems may include oral-motor problems, such as weak suck, poor lip closure, tongue
thrust, choking, and swallowing difficulties (Davidson 2008; Nardella 2004). Children with
Down syndrome may also have delayed acquisition of feeding skills. Table 2
It is important to periodically evaluate an individual’s readiness for transition to the next
“feeding stage.” Evaluation of feeding skill development, acceptance of textures, and
acquisition of self-feeding skills will help families and clinicians anticipate the appropriate
“next step” for an individual child.
Assessment of feeding problems requires a team-based approach. Teams may include
occupational therapists, speech pathologists, physical therapists, registered dietitians,
psychologists, nurses, and/or educators. An effective assessment of feeding will include an
observation of the parent or caregiver feeding the child. This allows the team to observe
positioning, parent/child interaction, and any oral motor problems that may exist.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Considerations When Assessing Feeding Skills
Age versus developmental level of child
Previous feeding experiences – method, variety, feeder position
Position
Texture/consistency of food and drink
Previous food challenges
Mouth movement and head position – jaw, lip, cheek, tongue movement
Sensory aspects of feeding and tactile defensiveness
Visual/auditory stimuli
Smell of food
Temperature of food
Taste of food
Utensils used
Fluid intake
Dental hygiene and oral health
(Cloud 2005)

Swallowing Disorders

A high incidence of hospitalizations for pneumonia in a patient with developmental
disabilities should serve as a red flag for potential swallowing disorders. Any incidence of
pneumonia or frequent coughing during feedings, especially when liquids are ingested, is a
clue to potential swallowing abnormalities, including aspiration or gastroesophageal reflux.
"Silent" aspiration (aspiration without cough) can occur. Children with swallowing
dysfunction may refuse food or fluids and/or limit their intake as a protective mechanism.
Therefore, food refusal and/or limited intake may be indicative of the need for a feeding
evaluation.
Some children may not be able to safely swallow certain foods (eg, thin liquids or mixed
textures). The need for thickened liquids is generally identified by a modified barium
swallow test (also called videofluoroscopic swallow study). Recommendations for
thickening liquids (eg, infant formula or breastmilk) with rice cereal and/or commercially
available thickeners are sometimes made. The effects on the child’s nutrient intake must
be included as part of the nutrition assessment.
Indicators of problems with feeding and swallowing dysfunction may include the following
(Krick 2003):
Facial weakness, decreased sensation
Congestion, noisy “wet” sounds
Coughing/choking/gagging before, during or after a swallow
Food refusal
History of upper respiratory infections
Poor intake
Inefficient and lengthy mealtimes
Inappropriate progression of feeding skills

Oral Health
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Children with Down syndrome have delayed dental development, with primary teeth
erupting later than among children without Down syndrome. Some permanent teeth may
be missing as well, and teeth may have thin enamel or be hypoplastic. These problems,
along with the potential for feeding problems and reflux, make oral care for children with
Down syndrome especially important (Ogata 2003).
Other issues related to oral health include the following (Ogata 2003; Lucas 2008):
Abnormalities in the number and/or size of teeth may be important in the child’s ability
to chew and to consume specific foods
Small oral cavity with a normal-sized tongue that appears to be large may lead to
malocclusion; children may also maintain open mouth and breathe through the mouth
Dry mouth, because of decreased saliva and/or open mouth and mouth breathing
increases risk of caries
Tooth eruption may be delayed, and some children may lack secondary teeth
Enamel abnormalities can cause pitting and retention of food
Bruxism occurs frequently and may cause tooth abrasion and loss of enamel from the
chewing surfaces

Constipation

Constipation may result from decreased activity, hypotonia, decreased bowel function,
inadequate fluid intake, low fiber intake, or medications (Isaacs 2004). Evaluating and
modifying the child’s food, fluid, and/or enteral formula intake can have a significant impact
on treating and preventing constipation. Liquid nutrition supplements are available with or
without added fiber. For children who consume solid foods, addition of bran or raw fruits or
vegetables may be helpful. To prevent gas or bloating, parents should be instructed to
introduce high-fiber and/or bran cereals slowly.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Developmental Disabilities > Spina Bifida
Nutrition-Focused Physical Findings

For a description of some of the complications sometimes associated with spina bifida, see
the Disease Process section.

Medical Tests and Procedures

Diagnosis of spina bifida is often made prenatally through ultrasound. Other complications
are diagnosed through physical examination (eg, other congenital structural anomalies,
neurologic function).
Diagnostic tests will vary depending on the individual child and his or her specific issues.
The nutrition assessment may include evaluation of how the test itself might affect
nutritional status (eg, need for fasting because of procedure). More often, the results of the
test can be used to identify nutrition problems (eg, nutrient deficiency) or potential
problems (eg, need for modified intake because of a medical condition).

Laboratory

Laboratory data will vary depending on the individual child and his or her specific issues:
Nutrition-related biochemical data when indicated by risk factors or therapy (eg,
evaluation of vitamin D status when anti-seizure medications are used or based on
diet and/or sun exposure, hematocrit/ferritin/other indicators to evaluate iron status)
Identification of other conditions, as indicated (eg, blood lead levels, pH and
electrolytes, serum urea creatinine and nitrogen, drug levels)

Client History

Medical/health
The individual’s medical and health history should be reviewed. Identify issues that
influence nutrient needs and ability to meet estimated needs, as well as current and past
issues that may affect eating and feeding, including the feeding relationship. For example, it
is common for children who have had many medical procedures (especially around the
face and mouth) to develop sensitivities and aversions.
Secondary conditions that may occur as a result of the primary condition should also be
included in the assessment (Cricco 2007).
Medications. Children with developmental disabilities often take a variety of medications.
Types of medications used (including prescription, over-the-counter, and herbal
medications) and the duration of their use should be included in the nutrition assessment.
Examples of drug-nutrient interactions include effects on appetite, dryness of the mouth,
and interference with vitamin and mineral absorption. In addition, medications can lead to
practical issues with food and eating (eg, issues related to timing of medications and meals)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
or interfere physically (eg, acidic medicine may curdle milk or formula) (Brizee 2006). Some
medications commonly used by children with developmental disabilities and related
nutrient/food interactions are listed in Common Nutrient-Drug Interactions in the Resources
section.
It is not uncommon for children with spina bifida to take supplements related to bladder
function (eg, cranberry supplements to potentially reduce urinary tract infections). This
information should be included in the nutrition assessment.
Increasing numbers of parents are purchasing mega doses of vitamins and other nutrients
as a treatment for their child with a special need. This information and information about
other supplements should be documented in the nutrition assessment.
Feeding history
A complete nutrition evaluation will include a review of the individual’s feeding history,
including feeding during infancy (eg, breastfeeding, bottle-feeding), need for specialized
foods or formulas, introduction of solids, and any problems (past or present) with feeding.
Social
The social history should be reviewed. Relevant questions may include the following:
Where does the child live? Who else lives in the household? Who provides care,
including food/feeding?
Is access to food reliable? Access to food preparation and storage? What are the
barriers to adequate food access (eg, homelessness, transportation, finances,
language)?
What resources do the child and family utilize (eg, Supplemental Nutrition Program
for Women, Infants, and Children [WIC], Early Head Start/Head Start, National School
Breakfast and Lunch Program, Supplemental Nutrition Assistance Program [SNAP -
formerly known as the Food Stamps program], Medicaid/State Children’s Health
Insurance Program, Early Intervention)?
Transition to adulthood. Transition is used to describe the process of moving from youth
to adulthood in all areas of life, including health care. Considerations during nutrition
assessment include access to adult-based health care and services, health insurance,
issues related to independent living (eg, meal preparation, access to food, food choices).
Activities include identifying potential issues, anticipating the need for transition, and
providing the individual and family with information and resources (Lanier 2005).

Food/Nutrition-Related History

Dietary intake should be carefully assessed through a diet history, 24-hour recall, or written
diet record of 3 or more days. Many parents and caregivers may be providing only one
meal for the child; therefore, complete information should be obtained from other places
where food is provided (eg, child care providers, Head Start programs, and school lunch
programs). The dietary information should include the serving size, the length of time
eating, the number of snacks, and the time meals and snacks are served.

Comparative Standards

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fluid needs will depend on the individual’s medical condition(s). Provision of adequate fluid
is critical, especially when bowel and/or bladder problems exist. Bowel and bladder
dysfunctions are common among children with spina bifida, so fluid is an important issue.
Renal disease, if present, may also affect fluid needs.
Energy needs for children with spina bifida may be significantly lower than energy needs
for typically developing children. For some children, as little as 50% of the Estimated
Energy Requirement (EER) may support adequate growth. See EER calculators.
For some children, it may be more appropriate to estimate energy needs based on length,
instead of weight (eg, kilocalories per centimeter of length vs. kilocalories per kilogram of
weight). General guidelines for some conditions are available to provide perspective,
however, it is always best to estimate an individual’s needs based on their growth and
intake history.
One alternative method of estimating energy needs for children with spina bifida is
described in the table below.
Alternative method of estimating daily energy needs for
children with spina bifida
For children >8 years old who are minimally active:
To maintain weight 9-11 kcal/cm
50% fewer kcal than recommended for
a child of the same age without the
condition
To promote
weight loss
7 kcal/cm
Source: Holland 2004

Anthropometrics

Careful evaluation of growth, including weight, length or stature, and head circumference,
should be included in the nutrition assessment. Accurate, serial measurements are
important in assessing an individual’s growth, as many conditions are associated with
alterations in growth (see Table 1). In general, the CDC Growth Charts are used to
evaluate growth.
Weight. Weight measurements should be made using a calibrated beam balance scale or
a digital scale with a "strain-gauge" mechanism. If the child is unable to stand unassisted,
there are several options:
A pan-type or bucket seat-type pediatric scale may work for a young child.
A platform scale (on which a wheelchair can be placed) is the best option for children
who cannot stand unassisted and are too large for the pan- or bucket-seat scale (the
weight of the wheelchair alone should be subtracted from the weight of the child in the
wheelchair).
A bed scale, if available, is also an option.
If the specialty equipment listed above is not available, one alternative is to weigh the child
being held by his/her caregiver and then subtract the weight of the caregiver alone.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
being held by his/her caregiver and then subtract the weight of the caregiver alone.
The method used to measure weight should be noted on the child's growth chart.
Recumbent length (measured with a lengthboard) is plotted on the Infant (birth to
24-months) chart. Stature (standing height, measured with a stadiometer) should be
plotted on the charts for 2- to 20-year olds (CDC, NCCDPHP).
Height/length measurements for a child with spina bifida can be difficult, depending on the
level of the spinal lesion.
A lengthboard should be used to measure the length of children younger than 24 months of
age; length can be plotted on WHO length-for-age charts
For children who are older than 24 months and who are unable to stand unassisted, there
are several options:
A lengthboard can be used to measure length (it should be noted on the child's
growth chart that the measurement is length and not height).
Sitting height measurements can be used and plotted on height-for-age charts.
Arm span can be measured and plotted on height-for-age charts.
The best method of stature measurement will depend on the individual child and the
equipment and training available to the clinician. Careful interpretation of measurements is
critical. For example, because of the effects of weight-bearing activity on growth of long
bones, a child with spina bifida who is not ambulatory will likely be shorter than a child
whose lesion does not affect ambulation. (For this reason, estimators of stature such as
knee height are often inappropriate for children with spina bifida.) (Cialone 2004)
It is important to note which measurement method(s) were used. Because the most
valuable growth information is longitudinal, care should be taken to replicate measurement
techniques over multiple visits.
Techniques and tables for comparison for alternative measures (eg, crown-rump length,
sitting height, armspan, knee height) have been described (Chumlea 1994; Lohman 1988;
Frisancho 1971; Hamill 1973). Some adjustments to these measurements may be required
to apply them to the CDC Growth Charts. These measurements should be made by trained
practitioners, who understand the methods as well as the limitations of the techniques. If
alternate methods are used, they should be documented so that they can be replicated
over time.

Head circumference. For children birth to 24-months of age, head circumference should
be measured in centimeters and plotted on the WHOGrowth Charts. Serial measurements
should be taken and may help to identify microcephaly or macrocephaly (CDC, NCCDPHP).
Weight-for-length. Weight-for-length should be plotted on the Infants (birth to 24-months)
chart and is often the best indicator of the child’s nutritional status. This is especially
important for the child who is small for age.
Body Mass Index. Body Mass Index (BMI = weight [kg] / height [m]
2
) is used for children
ages 2 years and older. BMI-for-age can be plotted on the CDC Growth Charts. BMI is
used as a screening tool for obesity (CDC, NCCDPHP). The risk of obesity and overweight
among children with developmental disabilities seems to be at least the same as the risk in
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the general population (Bandini 2005), and obesity is a major issue for children with spina
bifida.
Skinfold measurements. Standard methods for measurement can be used for triceps and
subscapular skinfold measures. Available reference data is based on healthy developing
children, which limits the application to children with developmental disabilities (Najar
1987). Serial skinfold measurements may be useful for monitoring changes in body
composition. Triceps and subscapular skinfold measurements and midarm muscle
circumference are most representative of body fat stores in this population.
For more information: Additional information about assessment of growth, including
measurement techniques for children with developmental disabilities (including spina
bifida) and interpretation of growth data is available:
MCHB (Maternal and Child Health Bureau) Growth Charts Training - Self-study
material, including modules about equipment, measurement technique, and using the
CDC Growth Charts with children with special health care needs.
Nutrition for Children with Special Health Care Needs, Module 1 - A self-study module
about growth (measurement and interpretation) for children with special health care
needs.
Nutrition for Interventions for Children with Special Health Care Needs - A publication
by the Washington State Department of Health, includes a chapter on anthropometry
and growth assessment.

Nutrition Diagnosis

Dietitians working with patients who have spina bifida should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
Decreased nutrient needs (specify)(NI-5.4)
Inadequate protein intake (NI-5.7.1)
Inadequate vitamin (NI-5.9.1) or mineral (NI-5.10.1) intake (specify)
Swallowing difficulty (NC-1.1)
Breastfeeding difficulty (NC-1.3)
Overweight/obesity (NC-3.3)
Unintended weight gain (NC-3.4)
Impaired ability to prepare foods/meals (NB-2.4)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to swallowing difficulties as evidenced by 3-day
food record 75% estimated needs.
Obesity (NC-3.3) related to excessive energy intake and decreased energy needs as
evidenced by immobility and decreased energy expenditure.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition interventions should be individualized based on the child’s nutritional, medical,
and other needs. Plans should be developed with input from the family and other members
of the health care team. Examples of Nutrition Interventions and related strategies that can
be used for issues common to children with developmental disabilities are briefly described
below (IDNT, 2010).
Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)
Increasing energy intake. When a child is unable to consume an adequate amount of
food to meet energy needs, energy intake is often increased by adding “calorie boosters” to
foods (Van Ripper 2010). Examples include powdered nonfat milk, undiluted evaporated
milk, cheese, wheat germ, vegetable oil, mayonnaise, butter or margarine, and gravy. Note
that each of these foods adds substantial energy to the diet without adding bulk or
increasing portion sizes. Additional suggestions for increasing energy intake can be found
in Failure to Thrive and Underweight sections, and in Children with Special Health Care
Needs: Nutrition Care Handbook (Lucas 2004).
The decision to modify the nutrient composition of foods should include consideration for
the effect of overall nutrient intake (eg, vitamin and mineral intake, fluid intake,
fat-protein-carbohydrate content).
Decreasing energy intake. A decrease in energy intake may be needed when rate of
weight gain is excessive. When decreased energy is recommended, the registered dietitian
(RD) should work to ensure that the meals contain the recommended pattern of protein, fat,
and carbohydrate. Strategies to decrease energy intake may include adjusting portion
sizes, modifying food preparation techniques, and limiting sugar-containing beverages. See
the Nutrition Intervention heading under Overweight/Obesity.
Feeding Assistance: Adaptive equipment (ND-4.1); Feeding position (ND-4.2)
Feeding Environment: Distractions (ND-5.3)
The feeding environment for the child with developmental disabilities requires the following:
structure
appropriate feeding equipment
age-appropriate portion sizes
avoidance of distractions (eg, television and radio)
Meals and snacks should be offered at the same time each day. Chairs that ensure proper
positioning should be used.
For children who do not feed themselves, the feeder should be at eye level with the child to
prevent the child from extending his or her neck while eating and, hence, reduce the risk of
choking.
Serving sizes should be small, so that the child can easily eat what is served. Additional
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
servings can be given if the child indicates wanting more. Feeding time should not extend
beyond a reasonable time limit, and children should not be force-fed.
Feeding behaviors should be monitored and noted to follow for the potential development
of negative feeding behaviors (Nardella 2004).
Referral to Community Agencies/Programs (specify) (RC-1.4)
Nutrition-related issues may require referral to and collaboration with community resources.
Two resources are described below.
Early Intervention Programs. All states have Early Intervention Programs, which provide
health services, including nutrition services, to children up to 3 years of age who have
developmental delays. These services, mandated under Part C of the Individuals with
Disabilities Education Act (IDEA), 2007, are available to all children and are provided in the
least restrictive environment for the family.
Child Nutrition Programs. Children with developmental disabilities who are enrolled in the
child nutrition programs at school are entitled to a modification of meals, to meet their
particular nutritional needs (McCary 2006). For example, an overweight child can receive
an energy-restricted meal, once a prescription has been sent to the school by a physician,
nurse, or RD. This is the result of PL 192-119, IDEA, which requires a prescription form.
Additional resources include the following:
Nutrition issues facing children with special health care needs at school and in early
intervention programs, Nutrition Focus (Obara 2011)
Chapter 6 of Children with Special Health Care Needs: Nutrition Care
Handbook (Willis 2004)
Nutrition for Children with Speical Health Care Needs, Module 5 (a self-study module
about integrating community services and programs into nutrition care plans for
children with special health care needs)

Nutrition Therapy Efficacy

Several reports document the efficacy and cost-effectiveness of nutrition services for
children with special health care needs, including children with developmental disabilities
(Gilliam 2006; Lucas 2004; Herman 1999).
Exceptions to DRI
Energy needs for children with spina bifida may be significantly lower than energy needs
for typically developing children. For some children, as little as 50% of the Estimated
Energy Requirement (EER) may support adequate growth. See Calculations for
Assessment and EER Calculators.
Protein, fat, vitamins, and minerals should meet the Dietary Reference Intake standards for
age. Vitamin/mineral supplementation may be indicated for those children taking
medications known to affect or interact with certain nutrients and can be useful for
correcting inadequate dietary intake. Pediatric- and adult-strength liquid and powdered
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
vitamin/mineral supplements are available for those who have swallowing difficulties or who
are tube-fed.

Goal Setting

The goal of nutrition care for a child with a developmental disability is to promote optimal
nutrition status: growth and development consistent with expectations, based on the child’s
history and disorder. This requires an approach that is comprehensive, collaborative, and
family-centered (Lucas 2004; ADA 2010).

Food & Feeding Issues

Delayed physical development, poor coordination, and contractures may limit the child’s
ability to advance feeding skills and appropriately self-feed. Modification of foods offered
and/or adaptive equipment may be necessary. Specialized feeding equipment is available
for those children unable to use regular-shaped and -sized utensils, dishes, and cups.
Occupational therapists and physical therapists familiar with available feeding equipment
should be consulted. See Feeding Skills and Modification to the Feeding Environment.
An additional concern for the child with spina bifida is the occurrence of latex allergy.
Children with spina bifida are at increased risk for latex allergy, owing to multiple surgeries
for closure of the lesion, placement of cranial shunts, hip surgery, and spinal cord surgery
to treat scoliosis. When latex allergy exists, it is recommended that bananas, water
chestnuts, kiwi, and avocados be avoided. Mild reactions can occur from apples, carrots,
celery, tomatoes, papaya, and melons (see Food Allergies).

Enteral or Tube Feeding

Some children with spina bifida require enteral tube feeding. Examples of circumstances
leading to initiation of tube feeding include insufficient intake, weight loss due to illness,
poor weight gain, dysphagia, or aspiration. Common routes for tube feeding may be
gastrostomy, percutaneous endoscopic gastrostomy (PEG), or jejunostomy. Enteral tube
feedings can be used to augment oral intake or may be the sole source of nutrition. If
possible, bolus feedings are preferred; however gut function of some children may
necessitate a continuous feeding schedule. A physical therapist or speech pathologist
should be consulted to recommend a program for oral-facial stimulation and regular oral
hygiene, so that facial sensitivities do not interfere with the reintroduction of food.
Enteral formula intake should be adjusted according to age, tolerance, and desired rate of
weight gain. For children with low energy needs, vitamin and/or mineral supplements may
be needed, in addition to formula. Fluid intake should be assessed, and a formula
containing fiber should be recommended for children with constipation. Some possible
complications related to tube feeding are nausea, vomiting, diarrhea, constipation,
dehydration, tube obstruction, gastroesophageal reflux, excessive and rapid weight gain,
and infection.
The decision to place a gastrostomy tube is often a complex one. Families whose children
need feeding tubes need information and support that includes an appreciation for the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
psychosocial/emotional aspects (eg, feelings of loss, feelings of failure, emotional
meanings of food and eating) as well as consideration for practical aspects (eg,
incorporating tube feedings into daily life, going on vacation) (Petersen 2006; Craig 2003).
Guidelines for nutrition support for critically ill children have been published (Mehta 2009).

Suggested Monitoring Parameters and Recommendations

Nutrition monitoring may include following growth patterns and dietary intake, as well as
evaluating feeding skills and eating-related behaviors. Nutrition goals and interventions
should be adjusted when the goals are met or when it is determined that an intervention is
not effective.
If the intervention is not being implemented as prescribed, the registered dietitian works
with the family and other members of the health care team to identify barriers to
implementation. Addressing these issues may include arranging for additional resources,
referring to other professionals, and collaborating with other care providers (Charney 2009).

Nutrition Care FAQs

Question:
Is latex allergy consistent with spina bifida? What is the relationship with food?
Answer:
Anyone can develop a latex allergy, but certain individuals have been identified to be at a
higher risk, including those with spina bifida. (Others at risk include those with congenital
urinary tract problems, health care workers, and patients who have had multiple surgeries.)
There are many different lists of foods that contain some of the same protein found in
natural latex and are cross-reactive. Foods with a high degree of association include
bananas, avocados, and chestnuts. Moderate associations have been found with apples,
carrots, celery, papayas, kiwi, potatoes, tomatoes, and melons. This doesn't mean that all
those identified as having a latex allergy are allergic to all the above mentioned foods, but
families should be aware of potential risk and cross-reactivity.

Feeding Skills

Children with developmental disabilities are at high risk for feeding problems. These
feeding problems may include oral-motor problems, such as swallowing difficulties
(Nardella 2004). Acquisition of feeding skills may also be delayed. Table 2
Feeding problems in the child with spina bifida may be associated with the Chiari II
malformation, which makes swallowing difficult. As a result, the child may selectively
choose foods that require little chewing and swallowing. Their food choices may be low in
fiber, which is contraindicated in the prevention of constipation.
It is important to periodically evaluate an individual’s readiness for transition to the next
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“feeding stage.” Evaluation of feeding skill development, acceptance of textures, and
acquisition of self-feeding skills will help families and clinicians anticipate the appropriate
“next step” for an individual child.
Assessment of feeding problems requires a team-based approach. Teams may include
occupational therapists, speech pathologists, physical therapists, registered dietitians,
psychologists, nurses, and/or educators. An effective assessment of feeding will include an
observation of the parent or caregiver feeding the child. This allows the team to observe
positioning, parent/child interaction, and any oral motor problems that may exist.
Considerations When Assessing Feeding Skills
Age versus developmental level of child
Previous feeding experiences – method, variety, feeder position
Position
Texture/consistency of food and drink
Previous food challenges
Mouth movement and head position: jaw, lip, cheek, tongue movement
Sensory aspects of feeding and tactile defensiveness
Visual/auditory stimuli
Smell of food
Temperature of food
Taste of food
Utensils used
Fluid intake
Dental hygiene and oral health
Reference: Cloud HH. Feeding problems for children with developmental disorders. In:
Ekvall S and Ekvall V. Pediatric Nutrition in Chronic Diseases and Developmental
Disorders, 2ed. Oxford Press, 2005.


Swallowing Disorders

A high incidence of hospitalizations for pneumonia in a patient with developmental
disabilities should serve as a red flag for potential swallowing disorders. Any incidence of
pneumonia or frequent coughing during feedings, especially when liquids are ingested, is a
clue to potential swallowing abnormalities, including aspiration or gastroesophageal reflux
(GER).
"Silent" aspiration (aspiration without cough) is common. Children with swallowing
dysfunction may refuse food and fluids and/or limit their intakes as a protective mechanism.
Therefore, food refusal and/or limited intake may be indicative of the need for a feeding
evaluation.
Some children may not be able to safely swallow certain foods (eg, thin liquids or foods
with mixed textures). The need for thickened liquids is generally identified by a modified
barium swallow test (also called videofluoroscopic swallow study). Recommendations for
thickening liquids (eg, infant formula or breastmilk) with rice cereal and/or
commercially-available thickeners are sometimes made. The effects on the child’s nutrient
intake must be included as part of the nutrition assessment.
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Gross and Fine Motor Skills

Delayed physical development, poor coordination, and contractures may limit the child’s
ability to advance feeding skills and appropriately self-feed. Specialized feeding equipment
is available for those children unable to use regular-shaped and –sized utensils, dishes,
and cups. Occupational therapists and physical therapists familiar with available feeding
equipment should be consulted.

Oral Health

Developmental disabilities and other special health care needs can increase a child’s risk
of developing oral health problems. Secondary conditions and some therapies can also
increase the risk of problems with oral health. Some contributors to poor oral health that
are common among children with developmental disabilities include the following (Faine
2001; Boyd 1988):
Prolonged use of the nursing bottle – if a child sips on a bottle throughout the day, he
or she is at greater risk for caries
Extended eating time – if frequent meals and snacks are needed, or if mealtime is
longer than usual, teeth are exposed to acid for a greater period of time
Low fluid intake
Gastroesophageal reflux – as the acidic gastric contents are regurgitated, primary
and permanent teeth can be eroded
Oral hypersensitivity – may make good oral hygiene difficult and may also limit the
types and textures of foods eaten
Inability or refusal to consume specific foods or groups of foods – nutrients needed for
development and re/mineralization of teeth may be unavailable
Limited or inconsistent dental hygiene due to behaviors, sensory problems, or
caregiver constraints
The clinician should consider the following questions:
Does the child have oral health problems that affect his or her nutritional status?
Is the child at risk for oral health problems?
How does the disorder (or treatment for the disorder) affect:
development of oral structures?
saliva production?
frequency of eating?
types of foods consumed?

Constipation

Constipation is a major concern for children with spina bifida because of issues related to
bowel innervation, including dysmotility and poor sphincter control. Most children require
bowel management programs for regular stool elimination, prevention of constipation and
impaction, and prevention of incontinence. Programs generally involve use of laxatives, in
addition to adequate fiber and fluid intake.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

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Nutrition Care > Developmental Disabilities > Prader > Willi Syndrome
Nutrition-Focused Physical Findings

Clinical features of Prader-Willi syndrome include the following (Goldstone 2008; Nativio
2002):
Infancy: hypotonia with poor suck
Early childhood: hypotonia, global developmental delay, short stature and/or growth
failure
School-age: hypotonia, global developmental delay, excessive eating (hyperphagia,
obsession with food), obesity if uncontrolled
Adolescence: cognitive impairment, excessive eating, hypogonadism, behavior
problems (eg, temper tantrums, obsessive-compulsive features)
Other features may include characteristic facial features, hypopigmentation, small/narrow
hands, eye abnormalities, speech articulation defects, and thick viscous saliva (Nativio
2002).

Medical Tests and Procedures

Diagnostic tests will vary depending on the individual child and the specific syndrome or
condition, and may include the following:
Video fluoroscopic swallow study (VFSS, or modified barium swallow study) to
evaluate risk of aspiration and/or safety of oral intake
pH probe to identify gastroesophageal reflux
Dual energy x-ray absorptiometry (DXA) and/or estimation of bone age may be
recommended for some individuals with developmental disabilities
Additional testing specific to Prader-Willi syndrome may include genetic testing to
confirm the diagnosis, and growth hormone levels (if growth hormone therapy is
started).
The nutrition assessment may include evaluation of how the test itself might affect
nutritional status (eg, need for fasting because of procedure). More often, the results of the
test can be used to identify nutrition problems (eg, nutrient deficiency) or potential
problems (eg, need for modified intake because of a medical condition).

Laboratory

Laboratory data will vary depending on the individual child and the specific syndrome or
condition, and may include the following:
Nutrition-related biochemical data when indicated by risk factors or therapy (eg,
hematocrit/ferritin/other indicators to evaluate iron status)
Laboratory testing for conditions associated with specific syndromes (eg, glucose
tolerance tests for children with Prader-Willi syndrome and previously impaired
glucose tolerance or a family history of diabetes) (Goldstone 2008; Cassidy 2009)
Identification of other conditions, as indicated (eg, blood lead levels)

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Client History

Medical/health
The individual’s medical and health history should be reviewed. Identify issues that
influence nutrient needs and ability to meet estimated needs, as well as current and past
issues that may affect eating and feeding, including the feeding relationship.
Secondary conditions that may occur as a result of the primary condition should also be
included in the assessment (Cricco 2007). Secondary complications can include type 2
diabetes (Goldstone 2008). Cardiorespiratory failure, cor pulmonale, apnea, pneumonia,
and septicemia due to skin infections are not uncommon among adults with Prader-Willi
syndrome (Goldstone 2008).
Physical activity is reduced, related to obesity and hypotonia (Goldstone 2008).
Medications. Children with developmental disabilities often take a variety of medications.
Types of medications used (including prescription, over-the-counter, and herbal
medications), and the duration of their use should be included in the nutrition assessment.
Examples of drug-nutrient interactions include effects on appetite, dryness of the mouth,
and interference with vitamin and mineral absorption. In addition, medications can lead to
practical issues with food and eating (eg, issues related to timing of medications and meals)
or interfere physically (eg, acidic medicine may curdle milk or formula) (Brizee 2006). Some
medications commonly used by children with developmental disabilities and related
nutrient/food interactions are listed in Common Nutrient-Drug Interactions.
Increasing numbers of parents are purchasing megadoses of vitamins and other nutrients
as a treatment for their child with a special need. This information, and information about
other supplements, should be documented.
Feeding history
A complete nutrition evaluation will include a review of the individual’s feeding history,
including feeding during infancy (eg, breastfeeding, bottle-feeding), need for specialized
foods or formulas, introduction of solids, and any problems (past or present) with feeding.
Social
The social history should be reviewed. Relevant questions may include the following:
Where does the child live? Who else lives in the household? Who provides care,
including food/feeding?
Is access to food reliable? Access to food preparation and storage? What are the
barriers to adequate food access (eg, homelessness, transportation, finances,
language)
What resources do the child and family utilize? (eg, Supplemental Nutrition Program
for Women, Infants, and Children [WIC], Early Head Start/Head Start, National School
Breakfast and Lunch Program, Supplemental Nutrition Assistance Program [SNAP -
formerly known as the food-stamps program], Medicaid/State Children’s Health
Insurance Program, Early Intervention)
Is the family connected to support organizations for Prader-Willi syndrome?
What type of structure is in place (or planned) to address the child’s food-seeking
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behaviors?
Transition to adulthood. Transition is used to describe the process of moving from youth
to adulthood in all areas of life, including health care. Considerations during nutrition
assessment include access to adult-based health care and services, health insurance,
issues related to independent living (eg, meal preparation, access to food, food choices).
Activities include identifying potential issues, anticipating the need for transition, and
providing the individual and family with information and resources (Lanier 2005).

Food/Nutrition-Related History

Dietary intake should be carefully assessed through a diet history, 24-hour recall, or written
diet record of 3 or more days. Many parents and caregivers may be providing only one
meal for the child; therefore, complete information should be obtained from other places
where food is provided (eg, child care providers, Head Start programs, and school lunch
programs). The dietary information should include the serving size, the length of time
eating, the number of snacks, and the time meals and snacks are served. It is also helpful
to identify access (and potential access) to food throughout the day.
The food/intake history should also include questions about eating non-food items,
including toothpaste, lotion (especially scented lotion), erasers (eg, shaped like food), etc.

Comparative Standards

Most young children with Prader-Willi syndrome receive growth hormone therapy. Growth
hormone therapy influences growth expectations; children with Prader-Willi syndrome who
receive growth hormone therapy are taller and have more lean body mass than children
who do not receive growth hormone therapy. Guidelines for management during growth
hormone therapy include regular (every 3-6 months) assessment of height, weight, BMI,
and body composition (Goldstone 2008).
In general, the CDC Growth Charts are used to evaluate growth. Growth charts (stature for
age) have been developed, based on a sample of children with Prader-Willi syndrome (see
Resources). These charts are useful in comparing the growth of an individual to others with
Prader-Willi syndrome, but they have significant limitations. They are based on a small
sample of children who did not receive growth hormone therapy. If used, these charts
should be used along with the CDC Growth Charts, and the practitioner should understand
their limitations.
For weight maintenance within the current growth chart channel, the preschool and
school-age child may need as few as 10 to 11 calories per centimeter of height. For the
child placed on a weight-reduction program, a diet of 8 to 9 calories per centimeter of
height may be needed (Holland 2004).
Fluid needs will depend on the individual’s medical condition(s). In general, children with
Prader-Willi syndrome have the same fluid needs as children without Prader-Willi
syndrome.

Anthropometrics

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Careful evaluation of growth, including weight, length or stature, and head circumference,
should be included in the nutrition assessment. Accurate, serial measurements are
important in assessing an individual’s growth, as many conditions are associated with
alterations in growth (see Table 1).
Length or stature. Recumbent length (measured with a lengthboard) is plotted on the
Infant (birth to 24-months) chart. Stature (standing height, measured with a stadiometer)
should be plotted on the charts for 2- to 20-year olds (Centers for Disease Control, National
Center for Chronic Disease Prevention and Health Promotion).
Children with Prader-Willi syndrome are shorter than their age-matched peers without
Prader-Willi syndrome.
Weight. Weight should be measured on calibrated equipment that weighs in 10 gram
(infants) or 100 gram (children and adolescents) increments. Weight should be measured
on a regular basis, recorded on the growth chart, and followed sequentially for changes
(CDC, NCCDPHP).
Head circumference. For children birth to 24-months of age, head circumference should
be measured in centimeters and plotted on the WHO Growth Charts. Serial measurements
should be taken and may help to identify microcephaly or macrocephaly (CDC, NCCDPHP).
Weight-for-length. Weight-for-length should be plotted on the Infants (birth to 24-months)
chart and is often the best indicator of the child’s nutritional status. This is especially
important for the child who is small for age.
Body Mass Index. Body Mass Index (BMI = weight [kg] / height [m]
2
) is used for children
ages 2 years and older. BMI-for-age can be plotted on the CDC Growth Charts. BMI is
used as a screening tool for obesity (CDC, NCCDPHP). Children with Prader-Willi
syndrome are at increased risk for obesity and overweight (Bandini 2005). Individuals with
Prader-Willi syndrome have increased body fat and decreased muscle (Goldstone 2008).
Skinfold measurements. Standard methods for measurement can be used for triceps and
subscapular skinfold measures. Available reference data are based on healthy developing
children, which limits the application to children with Prader-Willi syndrome (Najar 1987).
Serial skinfold measurements may be useful for monitoring changes in body composition.
Triceps and subscapular skinfold measurements and midarm muscle circumference are
most representative of body fat stores in this population. These measures may not be
useful for children with atypical body composition, such as those with Prader-Willi
syndrome.

Nutrition Diagnosis

Dietitians working with patients who have Prader-Willi syndrome should review the signs
and symptoms obtained in the nutrition assessment and diagnose nutrition problems based
on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Excessive energy intake (NI-1.5)
Predicted excessive energy intake (NI-1.7)
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Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
Inadequate fluid intake (NI-3.1)
Excessive bioactive substance intake (NI-4.1)
Increased nutrient needs (specify)(NI-5.1)
Inadequate protein-energy intake (NI-5.3)
Imbalance of nutrients (NI-5.5)
Inadequate fiber intake (NI-5.8.5)
Food-medication interaction (NC-2.3)
Overweight/obesity (NC-3.3)
Inability or lack of desire to manage self-care (NB-2.3)
Self-feeding difficulty (NB-2.6)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to feeding difficulties with weak suck, as
evidenced by 24-hour recall 75% estimated needs with insufficient growth velocity.
Obesity (NC-3.3) related to excessive energy intake and decreased energy needs, as
evidenced by weight gain and BMI for age >97th %ile.

Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition interventions should be individualized based on the child’s nutritional, medical,
and other needs. Plans should be developed with input from the family and other members
of the health care team. Examples of Nutrition Interventions and related strategies that can
be used for issues common to children with Prader-Willi syndrome are briefly described
below (IDNT, 2010). See also the Failure to Thrive and Weight Management sections.
General/Healthful Diet (ND-1.1)
Theoretical Basis/Approach: Cognitive-Behavioral Theory (C-1.1)
Strategies: Stimulus Control (C-2.7)
Prevention of obesity and obesity management. Obesity management involves
environmental control with early institution of a low-calorie, well-balanced diet, with regular
exercise, rigorous supervision, restriction of access to food and money with appreciation of
legal and ethical obligations, and appropriate psychological and behavioral counseling of
the patient and family (Goldstone 2008).
Early intervention to control food-seeking behavior and to prevent excessive weight gain in
the first years of life has proven to be the most successful approach to weight control.
When the child enters school, excessive weight gain may occur. Environmental controls
are recommended but are difficult to maintain. Special prescriptions for modification of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
school breakfast and lunch are also recommended.
Increasing physical activity in daily routines, by adaptive physical education in the school
and referral to Special Olympics, is also recommended. Developing a weight-monitoring
program is essential.
Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)
Increasing energy intake. Infants with Prader-Willi syndrome generally have feeding
problems (eg, weak suck) during infancy. Nutrition intervention strategies may include
concentrating infant formula or fortifying breastmilk. Tube feeding may also be necessary.
The decision to modify the nutrient composition of foods should include consideration for
the effect of overall nutrient intake (eg, vitamin and mineral intake, fluid intake,
fat-protein-carbohydrate content).
Decreasing energy intake. A decrease in energy intake may be needed when rate of
weight gain is excessive. When decreased energy is recommended, the registered dietitian
(RD) should work to ensure that the meals contain the recommended pattern of protein, fat,
and carbohydrate. Strategies to decrease energy intake may include adjusting portion
sizes, modifying food preparation techniques, and limiting sugar-containing beverages.
Access to food needs to be limited, including at home (eg, locking cabinets and the
refrigerator and freezer), at school (eg, restricting access to vending machines), and in the
community.
A Prader-Willi Food Pyramid has been developed that is more consistent with energy
needs of these individuals than MyPyramid.
Collaboration/Referral to Other Providers (RC-1.3)
Referral to Community Agencies/Programs (RC-1.4)
Nutrition-related issues may require referral to and collaboration with community resources.
Two resources are described below.
Early Intervention Programs. All states have Early Intervention Programs, which provide
health services, including nutrition services, to children up to 3 years of age who have
developmental delays. These services, mandated under Part C of the Individuals with
Disabilities Education Act (IDEA), 2007, are available to all children and are provided in the
least restrictive environment for the family.
Child Nutrition Programs. Children with developmental disabilities who are enrolled in the
child nutrition programs at school are entitled to a modification of meals, to meet their
particular nutritional needs (McCary 2006). For example, an energy-restricted meal can be
provided, once a prescription has been sent to the school by a physician, nurse, or RD.
This is the result of PL 192-119, IDEA, which requires a prescription form.
Additional resources include the following:
Nutrition issues facing children with special health care needs at school and in early
intervention programs, Nutrition Focus (Obara, 2011)
Chapter 6 of Children with Special Health Care Needs: Nutrition Care Handbook
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chapter 6 of Children with Special Health Care Needs: Nutrition Care Handbook
(Willis, 2004)
Nutrition for Children with Special Health Care Needs, Module 5 (a self-study module
about integrating community services and programs into nutrition care plans for
children with special health care needs)

Nutrition Therapy Efficacy

Several reports document the efficacy and cost-effectiveness of nutrition services for
children with special health care needs, including children with developmental disabilities
(Gilliam 2006; Lucas 2004b; Herman 1999).
Exceptions to DRI
Individuals with Prader-Willi syndrome have a reduced resting metabolic rate, so overall
energy needs are lower than those of the general population (Goldstone 2008). It has been
estimated that the energy needs of children with Prader-Willi syndrome are 37% to 77% of
the energy needs of typically developing children of the same age and sex.
Protein, fat, vitamins, and minerals should meet the Dietary Reference Intake standards for
age. Vitamin/mineral supplementation may be indicated, especially if energy intake is
significantly reduced.

Goal Setting

The goal of nutrition care for a child with a developmental disability is to promote optimal
nutrition status: growth and development consistent with expectations, based on the child’s
history and disorder. This requires an approach that is comprehensive, collaborative, and
family-centered (Lucas 2004a; ADA 2010).
Goals specific to individuals with Prader-Willi syndrome will likely include an adequate
intake during infancy, and prevention or management of obesity during childhood and
adolescence.

Food & Feeding Issues

Feeding
Delayed physical development and poor coordination may limit the child’s ability to
advance feeding skills and appropriately self-feed. Specialized feeding equipment is
available for those children unable to use regular-shaped and -sized utensils, dishes, and
cups. Occupational therapists and physical therapists familiar with available feeding
equipment should be consulted.
See Feeding Skills and Nutrition Intervention.
Gross & Fine Motor Skills
Gross motor skills may delay some types of physical activity beyond what would be typical
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
for age. Physical activity is important for children with Prader-Willi syndrome, and a daily
activity pattern with the family, based on the child's skill level, should be instituted early.

Enteral or Tube Feeding

Some infants with Prader-Willi syndrome may require enteral tube feeding, when
hypotonia, weak suck, and/or other feeding problems interfere with an adequate intake.
Enteral tube feedings can be used to augment oral intake or may be the sole source of
nutrition. If possible, bolus feedings are preferred; however, gut function of some children
may necessitate a continuous feeding schedule. A physical therapist or speech pathologist
should be consulted to recommend a program for oral-facial stimulation and regular oral
hygiene, so that facial sensitivities do not interfere with the reintroduction of food.
Enteral formula intake should be adjusted according to age, tolerance, and desired rate of
weight gain. Some possible complications related to tube feeding are nausea, vomiting,
diarrhea, constipation, dehydration, tube obstruction, gastroesophageal reflux, excessive
and rapid weight gain, and infection.
The decision to place a gastrostomy tube is often a complex one. Families whose children
need feeding tubes need information and support that includes an appreciation for the
psychosocial/emotional aspects (eg, feelings of loss, feelings of failure, emotional
meanings of food and eating) as well as consideration for practical aspects (eg,
incorporating tube feedings into daily life, going on vacation) (Petersen 2006; Craig 2003).
Guidelines for nutrition support for critically ill children have been published (Mehta 2009).

Suggested Monitoring Parameters and Recommendations

Nutrition monitoring may include following growth patterns and dietary intake, as well as
evaluating feeding skills and eating-related behaviors. Nutrition goals and interventions
should be adjusted when the goals are met or when it is determined that an intervention is
not effective.
If the intervention is not being implemented as prescribed, the registered dietitian works
with the family and other members of the health care team to identify barriers to
implementation. Addressing these issues may include arranging for additional resources,
referring to other professionals, and collaborating with other care providers (Charney 2009).


Nutrition Care FAQs

Question:
Where can I find more information to support families with Prader-Willi syndrome?
Answer:
The Prader-Willi Syndrome Association website has a wealth of information about
Prader-Willi syndrome (PWS). It includes information about medical issues associated with
PWS, practical information for families, and opportunities for families to get involved.
Educational materials include background about PWS, resources related to nutrition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
management, information about growth hormone, and strategies for transition to adult care.

Feeding Skills

Children with Prader-Willi syndrome generally have feeding problems (eg, weak suck)
during infancy. Feeding therapy, modifications to formula/breastmilk (eg, concentration,
fortification), and tube feeding may be necessary. Children with Prader-Willi syndrome may
also have delayed acquisition of feeding skills. Table 2
It is important to periodically evaluate an individual’s readiness for transition to the next
feeding stage. Evaluation of feeding skill development, acceptance of textures, and
acquisition of self-feeding skills will help families and clinicians anticipate the appropriate
next step for an individual child.
Assessment of feeding problems requires a team-based approach. Teams may include
occupational therapists, speech pathologists, physical therapists, registered dietitians,
psychologists, nurses, and/or educators. An effective assessment of feeding will include an
observation of the parent or caregiver feeding the child. This allows the team to observe
positioning, parent/child interaction, and any oral motor problems that may exist.
Considerations When Assessing Feeding Skills
Age versus developmental level of child
Previous feeding experiences – method, variety, feeder position
Position
Texture/consistency of food and drink
Previous food challenges
Mouth movement and head position: jaw, lip, cheek, tongue movement
Sensory aspects of feeding and tactile defensiveness
Visual/auditory stimuli
Smell of food
Temperature of food
Taste of food
Utensils used
Fluid intake
Dental hygiene and oral health
Reference: Cloud HH. Feeding problems for children with developmental disorders. In:
Ekvall S and Ekvall V. Pediatric Nutrition in Chronic Diseases and Developmental
Disorders, 2ed. Oxford Press, 2005.

Swallowing Disorders

A high incidence of hospitalizations for pneumonia in a patient with Prader-Willi syndrome
should serve as a red flag for potential swallowing disorders. Any incidence of pneumonia
or frequent coughing during feedings, especially when liquids are ingested, is a clue to
potential swallowing abnormalities, including aspiration or gastroesophageal reflux (GER).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Gross and Fine Motor Skills

Gross motor skills may delay some types of physical activity beyond what would be typical
for age. Physical activity is important for children with Prader-Willi syndrome (PWS) and a
daily activity pattern with the family, based on the child's skill levels, should be instituted
early. This activity could be as simple as walking. Children with PWS often are reluctant to
be active so trying a variety of activities may be beneficial. They may need to be
encouraged to be active as they get older.

Oral Health

Developmental disabilities and other special health care needs can increase a child’s risk
of developing oral health problems. Secondary conditions and some therapies can also
increase the risk of problems with oral health.
Oral health problems that can be common among children with developmental disabilities
include:
Dental caries – an infection that can compromise a child’s health and can lead to
inappropriate speech and other problems with communication; missing or decayed
teeth can prevent a child from eating certain foods
Malocclusion – a condition in which the teeth are misarranged or do not meet
normally, making it difficult to bite and chew food
Abnormal dentition – abnormalities in the number and/or size of teeth may be
important in the child’s ability to chew and to consume specific foods
Bruxism – can cause tooth abrasion and loss of enamel from the chewing surface;
may lead to headaches, facial pain, or periodontal disease
Toothbrushing and good oral hygiene may be difficult for some children with developmental
disabilities. Good oral hygiene is essential and may help with oral desensitization.
Therapists (eg, physical, occupational, or speech) should be consulted for techniques to aid
in oral-facial desensitization.
The clinician should consider the following questions:
Does the child have oral health problems that affect his or her nutritional status?
Is the child at risk for oral health problems?
How does the disorder (or treatment for the disorder) affect:
development of oral structures?
saliva production?
frequency of eating?
types of foods consumed?
Children with Prader-Willi syndrome may also eat toothpaste.

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Nutrition Care > Diabetes Mellitus
Diabetes Mellitus


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Diabetes Mellitus > Carbohydrates and Other Nutrients
Carbohydrate Amounts and Types

Carbohydrate is the main nutrient influencing blood glucose after meals. Carbohydrates
should not be restricted, since they are an important source of fiber, vitamins, minerals,
and energy. However, it has been found that both the amount and type of carbohydrate
found in foods affect the postprandial blood glucose level (American Diabetes Association
2008).
Amount of Carbohydrate
The amount of carbohydrate should be based on the child’s usual eating habits, blood
glucose goals, and lipid goals.
The percentage of carbohydrate can vary from 45% to 65% of total calories from
carbohydrates (http://fnic.nal.usda.gov).
The Recommended Dietary Allowance average minimum requirement is 130 g
carbohydrate/day.
Controlling the amount of carbohydrate can aid attainment of optimal blood glucose
control. Carbohydrate counting allows for increased flexibility with meal planning.
There are a variety of methods to determine the amount of carbohydrate eaten.
If using a flexible insulin regimen, use bolus insulin to match the amount of
carbohydrate eaten at the meal or snack.
Eat a consistent amount of carbohydrates throughout the day if not adjusting insulin
(Wolever 1999).
For children following a basal bolus regimen (use insulin-to-carbohydrate ratios), the
following carbohydrate ranges are recommended:
Average Carbohydrate
Recommendations per Meal
for Optimal Growth and Development
a
< 5 years
old
5-12
years old
Teens
Girls 30-45 g 45-60 g 45-75 g
Boys 30-45 g 45-60 g 45-75+ g
a
Carbohydrate amount must be
individualized based on energy needs,
preferences, and activity levels. Snacks are
not always needed. Usual snack ranges are
0 g to 30 g of carbohydrate.
Source: Evert 2007
Carbohydrate Counting
Carbohydrate counting allows patients with diabetes to plan meals and snacks based on
the total amount of carbohydrate eaten. This method of meal planning allows for increased
variety in food choices and incorporates food preferences while maintaining glycemic
control (Kawamura 2007).
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control (Kawamura 2007).
Insulin-to-Carbohydrate Ratios
Insulin-to-carbohydrate ratios determine the amount of rapid-acting insulin needed to cover
the amount of carbohydrate eaten at meals or snacks. For individuals using an insulin
pump or basal/bolus insulin regimens, approximately half of the insulin dose is used for
bolus or mealtime insulin.
Example:
Insulin-to-carbohydrate ratio:
1 unit rapid-acting insulin for every 15 g carbohydrate
If 60 g carbohydrate is eaten at the meal, 4 units of rapid-acting insulin will be required to
cover the amount to maintain postprandial blood glucose goals.
The following table shows the typical insulin-to-carbohydrate ratios for children on flexible
insulin regimens.
Age
Insulin (units):
carbohydrate (gram)
ratio
Toddler (0-3
years)
½ to 1 unit: 30-40 g
carbohydrate
Preschool (3-5
years)
½ to 1 unit: 20-40 g
carbohydrate
School-age (6-12
years)
1 unit: 15 g carbohydrate
Teenage (13-19
years)
1 unit: 5-15 g
carbohydrate
Overweight teen
(13-19 years)
1 unit: 5-10 g
carbohydrate
Source: Evert 2005
Types of Carbohydrate
The type of carbohydrate can affect the postprandial glycemic response. There are a
variety of factors that affect the type of carbohydrate, including the following:
Type of starch (amylose versus amylopectin)
Style of preparation (cooking time, amount of heat or moisture)
Ripeness
Degree of processing


Glycemic Index and Glycemic Load

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The glycemic index of a food compares the postprandial response to different types of
carbohydrates (American Diabetes Association 2009). It measures the blood glucose
response over 2 hours after eating 50 g carbohydrate compared with a reference food
(typically white bread or glucose).
The glycemic load of food is calculated by multiplying the glycemic index of the food by the
amount of carbohydrate in each food. The glycemic load of a portion of food = (glycemic
index x g carbohydrate per serving)/100.
For example, the glycemic index of watermelon is 72 and a 1 cup serving has 11
g carbohydrate, so the glycemic load of watermelon is (72 x 11)/100 = 8.
Foods are listed to either having low, medium, or high glycemic index/glycemic load values.
It is speculated that consuming high glycemic index/glycemic load foods will increase blood
glucose more rapidly than low glycemic index/glycemic load foods.
Food Rating GI GL
High >70 ≥20
Medium 55-70 11-19
Low <55 ≤10
Following are the glycemic index/glycemic load values for certain foods.
Food Values: Glycemic Index and Glycemic Load

Low Glycemic
Index (<55)
Medium Glycemic
Index (55-70)
High Glycemic Index
(>70)
Low Glycemic
Load
(≤10)
Apples
Carrots
Peanuts
Oranges
Corn
Ice cream
Sugar (sucrose)
Pineapple
White bread
Watermelon
Popcorn
Waffles
Medium Glycemic
Load
(11-19)
Bananas
Low-fat yogurt
Spaghetti
Orange juice
Quick oats (1 minute)
New potatoes
Shredded wheat
Cheerios
Instant oatmeal
Jelly beans

High Glycemic
Load
(≥20)
Potato chips
Cake with frosting
Snickers bar
Brown rice
Raisins
White rice (long grain)
Baked potato
Glucose
Bagel
French fries
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sources: http://www.nutritiondata.com/topics/glycemic-index; www.glycemicindex.com
Overall, several studies have reported that low-glycemic index diets have reduced blood
glucose levels in subjects with diabetes, but further studies are needed to confirm this
effect (Franz 2002; Rovner 2009).


Fiber

The American Diabetes Association (ADA) recommends that children with diabetes should
eat a fiber-rich diet to meet the Dietary Reference Intake (American Diabetes Association
2009). Even though there is insufficient evidence to support this suggestion, eating
fiber-rich foods (more than 5 g fiber/serving) may improve lipid and blood glucose levels
(Wheeler 2008).
Dietary Reference Intake Levels for Fiber in
Infants, Children, and Adolescents
Age Adequate Intake
0-6 months None set
7-12 months None set
1-3 years 19 g/day
4-8 years 25 g/day
Boys 9-13 years 31 g/day
Boys 14-18 years 38 g/day
Girls 9-13 years 26 g/day
Girls 14-18 years 26 g/day
Source: FNIC
The benefits to eating whole grains include the following (Grabitske 2008):
They add texture and flavor to foods
They contain essential nutrients-including vitamins, minerals, and fiber
They are digested more slowly, which may increase satiety between meals
They may improve blood glucose and lipid levels
Dietary fiber is counted as part of the total carbohydrate amount found on the Nutrition
Facts listed on the food label. However, the dietary fiber does not elevate blood glucose
as much as refined carbohydrate foods.
For patients who are matching insulin to the carbohydrate grams or carbohydrate choices
consumed, the ADA guidelines are as follows:
If a food contains 5 g dietary fiber or more per serving, subtract half the grams of fiber from
the total grams of carbohydrate to determine the number of carbohydrate grams you will
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“count” for that food (Evert, 2005).
For example, if a food contains 42 g total carbohydrate and 8 g dietary fiber:
42 g total carbohydrate – 4 g dietary fiber (½ the total amount) = 38 g total carbohydrate
Check your blood glucose before eating and two hours after to see the effect the
whole grain you have just eaten has on your blood glucose levels.

Note: This dietary fiber subtraction rule is only a guideline and can be used at the diabetes
educator's discretion.

High Fructose Corn Syrup

High-fructose corn syrup is used frequently as an added sugar. It is structurally similar to
sucrose (half glucose and half fructose). Research has shown no association between the
increased intake of high-fructose corn syrup and increased prevalence of type 2 diabetes
(Wheeler 2008). However, it is recommended to consume high-fructose corn syrup with
caution, as similar guidelines are established for sucrose. Refer to Sucrose for more
details.

Fructose

Foods that naturally contain fructose, such as fruit and vegetables, are recommended.
These foods are a good source of dietary fiber, vitamins, and minerals. Fructose yields a
smaller increase in plasma glucose despite having the same amount of energy as sucrose
and other carbohydrates. However, according to the American Diabetes Association, it is
not recommended to use fructose as a sweetener because it may alter plasma lipid levels
(American Dietetic Association 2008; Lê 2006).

Sugar Alcohols

Sugar alcohols are carbohydrates that chemically resemble sugar and alcohol but do not
contain ethanol. Sugar alcohols approved by the US Food and Drug Administration include
erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, tagatose, and hydrogenated
starch hydrolysates. Sugar alcohols are incompletely absorbed and metabolized,
therefore cause a lower postprandial blood glucose response than glucose or sucrose
(American Diabetes Association 2008; Kroger 2006). They contain approximately 50% less
energy than sucrose (2 kcal/g). See table on net energy of sugar alcohols (Wheeler 2008).
Net Energy per Gram for Various Sugar Alcohols
Sugar Alcohol Kcal/gram
Erythritol 0.2
Hydrogenated starch hydrolysate 3.0
Isomalt 2.0
Lactitol 2.0
Maltitol 2.1
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Mannitol 1.6
Sorbitol 2.6
Xylitol 2.4
Average sugar alcohol 2.0
Source: Wheeler 2008
Excessive consumption of sugar alcohols may have a laxative effect, especially in
children; however, this effect has not been found with erythritol (Kroger 2006).
For patients counting carbohydrate grams, when eating foods containing sugar alcohols,
subtract half the sugar alcohol grams from the total carbohydrate grams.
For example:
Total carbohydrate grams: 45
Sugar alcohol grams: 8
Subtract ½ sugar alcohol grams from total carbohydrate grams:
Total carbohydrate (45 g) – ½ sugar alcohol grams (4 g) = 41 g carbohydrate

Nonnutritive Sweeteners

The US Food and Drug Administration has approved six nonnutritive sweeteners:
acesulfame potassium, aspartame, neotame, saccharin, sucralose, and rebaudioside A
(stevia) (ADA Nutrition Recommendations 2008; Kroger 2006; IFIC 2009). All of the
sweeteners have been tested for safety and an acceptable daily intake, the amount that
can be safely consumed on a daily basis without any adverse side effects, has been
determined.
Low-Calorie Sweeteners Currently Approved for Use in the United
States
Sweetener kcal/g
Date
Approved
Acceptable
Daily Intake
Potency
(times
sweeter
than
sucrose)
Brand
Names
Acesulfame-K 0 1988
15 mg/kg of
body
weight/day
200
Sunett,
Sweet One
Aspartame
a
0 1981
50 mg/kg of
body
weight/day
180
NutraSweet,
Equal
Neotame 0 2002
18 mg/kg of
body
weight/day
7,000
b
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Saccharin 0
In use for
decades
before
the Food
Additives
Amendment
of 1958
500 mg/day
for children;
1,000
mg/day for
adults
300
Sweet and
Low, Sweet
Twin
Sucralose 0 1998
5 mg/kg of
body
weight/day
300 Splenda
Rebaudioside
A
0 N/A 200
Truvia,
Pruvia
a
Individuals with phenylketonuria should avoid using products sweetened with aspartame.
b
Currently there is no brand name for neotame.
Source: Kroger 2006

Protein

There is insufficient evidence to suggest that people with diabetes with normal renal
function should limit dietary protein. It is recommended to consume a usual amount of
protein (15% to 20% of energy) (ADA Nutrition Recommendations 2008). The development
of diabetic nephropathy has not been associated with consuming more than 20% of energy
as protein (Franz 2002).
The Recommended Dietary Allowance (RDA) for dietary protein varies depending on the
child’s age. It is suggested to consume high-quality proteins from meat, poultry, fish, eggs,
milk, cheese, and soy. Other sources of protein found in cereals, grains, nuts, and
vegetables should not be counted as part of the RDA to account for mixed protein in foods.
RDAs for Protein
Infants Protein
0-6 months 1.52 g/kg/d (Adequate Intake)
7-12 months 1.5 g/kg/d
1-3 years 1.10 g/kg/d
4-8 years 0.95 g/kg/d
9-13 years 0.95 g/kg/d
14-18 years 0.85 g/kg/d
High-protein diets are not recommended to achieve weight loss. It has not been
established that consuming protein in the amount of 20% of energy will result in long-term
benefits of weight loss or improve blood glucose.
Effect of Protein on Blood Glucose Levels
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Evidence suggests that dietary protein does not slow the absorption of
carbohydrate. Evidence also indicates that combining dietary protein and carbohydrate
does not raise plasma glucose postprandially more than carbohydrate alone (Franz 2002).
However, protein requires insulin for metabolism and studies have shown that circulating
amino acids stimulate insulin as well as glucagon secretion (Gannon 2001; Kahn 1992).
Overall, insulin deficiency and insulin resistance may cause abnormal protein metabolism,
but this is corrected when blood glucose levels are normalized (Gougeon 2000).

Dietary Fat and Cholesterol

The percentage of energy from fat should be individualized based on blood glucose, lipid,
and weight goals, as well as cardiovascular family history. Children with type 1 and type 2
diabetes have a high risk of cardiovascular disease; therefore, the type and amount of fat
are important to maintain good cardiovascular health and achieve lipid goals (Kavey 2006).
Research has shown that normal growth and development are not affected in children
aged 2 years and older by consuming a low-fat diet (Gidding 2005).
Amount of Fat and Type of Fat
In general, children aged 1 to 3 years should consume 30% to 40% of total energy from fat,
whereas children aged 4 to 18 years should consume 25% to 35% of total energy from fat
(American Dietetic Association, 2008). However, because individuals with diabetes have
the same cardiovascular risk as those with preexisting cardiovascular disease, the dietary
goals should include the following:
Limit saturated fat to less than 7% of total energy
Intake of trans fat should be minimized and represent less than 1% of total energy/day
Dietary cholesterol should be limited to less than 200 mg/day (American Diabetes
Association, 2008)
Two or more servings of fish per week (not fried) is recommended to provide n-3
polyunsaturated fatty acids and cardioprotective effects (Riediger 2009)
Children should avoid fish high in mercury (shark, mackerel king, swordfish, and
tilefish (http://www.cfsan.fda.gov/~frf/sea-mehg.html)
Effects of Fat on Blood Glucose
Consuming high-fat meals delays gastric emptying, which may delay elevations in
postprandial blood glucose levels.
Elevations in plasma-free fatty acid concentrations may cause insulin resistance by
inhibiting glucose transport or phosphorylation with a subsequent reduction in rates of
glucose oxidation and muscle glycogen synthesis (Roden 1996).
Children and adolescents using the insulin pump may achieve blood glucose control using
extended or combination bolus when eating a meal or snack high in fat. The combination
bolus delivers an immediate normal premeal insulin bolus, followed by a bolus that is
evenly delivered over several hours (Lee 2004). The extended bolus can be released over
a period of time (3 to 12 hours) to reduce postprandial hyperglycemia caused by the
delayed gastric emptying of a high-fat meal (Jones 2005).

Sucrose

Research shows that eating foods containing sucrose as part of the total carbohydrate
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Research shows that eating foods containing sucrose as part of the total carbohydrate
content does not impair blood glucose control in individuals with type 1 or type 2 diabetes
(Wheeler 2008). The American Diabetes Association recommends that “sucrose-containing
foods can be substituted for other carbohydrates in the meal plan or, if added to the meal
plan, covered with insulin or other glucose-lowering medications” (American Diabetes
Association 2008). Including small amounts of sucrose may increase the palatability of the
meal plan. This may lead to improved dietary adherence, since the child will be able to eat
in a manner similar to his or her family and peers.
The Dietary Reference Intake for added sugars is to limit them to less than 25% of total
energy intake.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Diabetes Mellitus > Type 1
Nutrition-Focused Physical Findings

Unexplained weight loss before diagnosis of type 1 diabetes is a common physical
observation. Weight loss is the result of insufficient endogenous and/or exogenous insulin
causing hyperglycemia, dehydration, and the utilization of fat stores and muscle mass, as
glucose is unavailable as an energy source to the cells. Once appropriate insulin is
administered, rapid weight gain and normal linear growth is observed and measured.
Weight gain occurs following insulin therapy as a result of the following (Daly 2007):
Energy retention resulting from improved glycemic control
Excess energy intake
Decreased energy expenditure
Improved hydration
Unphysiologic action of conventional insulin formulations
Skin examination should be performed at each clinic visit to include the following:
Self-monitoring blood glucose testing sites
Insulin injection sites/lipohypertropy

Biochemical Data, Medical Tests and Procedures

The fasting plasma glucose (FPG) test is the easiest and least expensive test to diagnose
diabetes (American Diabetes Association 2009). However, in 2010 the American Diabetes
Association recommended the use of the hemoglobin A1C test to diagnose diabetes, with a
threshold of >6.5%. This test should be done using a method certified by the National
Glycohemoglobin Standardization Program (NGSP) and standardized to the Diabetes
Control and Complications Trial (DCCT) reference assay (American Diabetes Association
2011).
The following criteria are used to diagnose diabetes (American Diabetes Association 2011):
A1C >6.5%. The test should be performed in a laboratory using a method that is
NGSP certified and standardized to the DCCT assay.
1.
FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no energy intake for at least 8
hours.
2.
Symptoms of hyperglycemia and a casual (random) plasma glucose ≥200 mg/dl (11.1
mmol/l). "Casual (random)" is defined as any time of day without regard to time since
last meal. The classic symptoms of hyperglycemia include polyuria, polydipsia, and
unexplained weight loss.
3.
2-hour plasma glucose =200 mg/dL (11.1 mmol/l) during an oral glucose tolerance
test. The test should be performed as described by the World Health Organization
using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in
water or 1.75 g/kg body weight if weight is less than 40 pounds (18 kg) (Rosenbloom
2008).
4.
In the absence of unequivacol hyperglycemia, these criteria should be confirmed by repeat
testing on a different day. The oral glucose tolerance test is not recommended for routine
clinical use. However, it may be required in the evaluation of patients with diabetes still
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suspected despite a normal fasting plasma glucose (Silverstein 2005).
Laboratory Overview
Laboratory tests in patients with type 1 diabetes mellitus are numerous and are used to
diagnose or assess the following:
Celiac disease
Diabetic ketoacidosis and hyperosmolar hyperglycemia state
Hemoglobin A1c
Lipid profile
Microalbuminuria
Thyroid-stimulating hormone levels

Laboratory Overview


Client History

Symptoms related to diagnosis of diabetes
Recent or current infections or illnesses
Growth, development and pubertal maturation
Family history of diabetes and other endocrine disorders
Current use of medications that will affect blood glucose:
Type of insulin
Glucocorticoids
Chemotherapeutic agents
Atypical antipsychotics
History and treatment of other conditions:
Endocrine disorders
Eating disorders
Secondary causes of diabetes: steroid induced, cystic fibrosis
Lifestyle, cultural, psychosocial, educational, and economic factors that will influence
the management of diabetes
Physical activity and exercise patterns
Risk factors for atherosclerosis:
Smoking
Hypertension
Obesity (body mass index for age >95th percentile)
Dyslipidemia
Family history (early coronary artery disease or myocardial infarction before age
55)


Food/Nutrition-Related History

When obtaining food history from a client, note the following:
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24-hour recall or typical intake on most days of the week
Meal and snack times (at school/day care and on weekends)
Travel frequency
Frequency of eating out
Food choices when eating out
Portion sizes
Types and amount of beverages
Appetite/gastrointestinal issues
Food allergies/intolerances
Who prepares the meals and what are the cooking methods
Who purchases the food
Food preferences (likes and dislikes)
Socioeconomic factors, including participation in the Special Supplemental Nutrition
Program for Women, Infants, and Children; supplemental nutrition assistance
program (SNAP, formerly called food stamps); and financial constraints
Psychosocial issues, including family dynamics and family schedule
Barriers to lifestyle changes
Use of tobacco, alcohol, and/or recreational drugs,
Carbohydrate goals at meals/snacks or daily carbohydrate goal.
Other concerns regarding physical activity may include the following:
Physical education (gym class) days and times
Extracurricular activities during and after school and on weekends
Seasonal changes in activity
Daily screen time, including television viewing, video games, and computer time


Comparative Standards

Energy needs
Energy requirements for patients with type 1 diabetes should be based on the child's
usual intake and level of physical activity, which can be obtained through a diet
history and/or actual food intake.
If this information cannot be obtained, energy needs may be also derived by the
following:
Dietary Reference Intakes (DRI) for Energy, Carbohydrate, Fiber, Fatty Acids,
Cholesterol, Protein, and Amino Acids (2002/2005)
Estimated energy requirements calculator, found under the Calculators
tab (above)
It is important to provide enough energy so that the child maintains consistent growth
within the normal parameters of the Centers for Disease Control and Prevention
growth charts and an appropriate body mass index for age (see CDC Growth Charts).
Estimated Energy Requirements (in kilocalories) for Both
Sexes in Each Age Group at Three Levels of Physical
Activity
a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Activity
Level
bcd
Age
(years)
Sex
Sedentary
b
Moderately
Active
c
Active
d
2-3
Males and
Females
1,000 1,000-1,400 1,000-1,400
4-8
9-13
14-18
Females
1,200
1,600
1,800
1,400-1,600
1,600-2,000
2,000
1,400-1,800
1,800-2,200
2,400
4-8
9-13
14-18
Males
1,400
1,800
2,200
1,400-1,600
1,800-2,200
2,400-2,800
1,600-2,000
2,000-2,600
2,800-3,200
a
These levels are based on estimated energy requirements from the Institutes of Medicine
(IOM) Dietary Reference Intakes macronutrients report, 2002, calculated by sex, age, and
activity level for reference-sized individuals. “Reference size,” as determined by IOM, is
based on median height and weight for up to 18 years of age.
b
"Sedentary" refers to a lifestyle that includes the light physical activity associated with
typical day-to-day life.
c
Moderately active means a lifestyle that includes physical activity equivalent to walking
approximately 1.5 miles to 3 miles per day at 3-4 miles per hour, in addition to the light
physical activity associated with typical day-to-day life
d
Active means a lifestyle that includes physical activity equivalent to walking more than 3
miles per day at 3-4 miles per hour, in addition to the light physical activity associated with
typical day-to-day life.
Fluid Needs or Limits
Dehydration and sodium depletion in diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemia state (HHS) result from increased urinary output and electrolyte losses
(Kitabchi 2001). Hyperglycemia leads to osmotic diuresis in both DKA and HHS. Fluids,
sodium, potassium, and chloride must be replaced in the initial hours of treatment for DKA.
Treatment of moderate or severe DKA requires adequate fluid replacement for lowering
glucose concentrations. Hyperglycemia will persist even with appropriate insulin therapy, if
fluid replacement is inadequate.
The deficits of water and electrolytes in DKA and HHS are as follows (Kitabchi 2001).
DKA HHS
Total water (liters) 6 9
Water (ml/kg)* 100 100-200
Na+ (mEq/kg) 7-10 5-13
Typical total body deficits of water and
electrolytes in DKA and HHS
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Cl- (mEq/kg) 3-5 5-15
K+ (mEq/kg) 3-4 4-6
PO4 (mmol/kg) 5-7 3-7
Mg2+ (mEq/kg) 1-2 1-2
Ca2+ (mEq/kg) 1-2 1-2
In a hospitalized patient, initial fluid replacement usually begins with an initial fluid
replacement made with one-half normal (0.45%) or normal (0.9%) saline. For children, the
usual calculation for fluid replacement is 10 mL/kg to 20 mL/kg of body weight in the first
hour. If no urination occurs, 20 mL/kg of body weight of fluid is given during the second and
third hours as well, followed by routine fluid replacement calculated on maintenance plus
deficit (Davidson 2003).
Normal Fluid Requirements in Infants, Children and Adolescents
1 kg to 10 kg: 100 mL/kg
10 kg to 20 kg: 1,000 mL + 50 mL for each kg over 10 kg
>20 kg: 1,500 mL + 20 mL for each kg over 20 kg


Nutrition Diagnosis

Dietitians working with patients who have type 1 diabetes mellitus should review the signs
and symptoms obtained in the nutrition assessment and diagnose nutrition problems based
on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Altered nutrition-related laboratory values (specify) (NC-2.2)
Unintended weight loss (NC-3.2)
Inappropriate intake of fats (specify) (NI-5.6.3)
Excessive carbohydrate intake (NI-5.8.2)
Inconsistent carbohydrate intake (NI-5.8.4)
Food- and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Limited adherence to nutrition-related recommendations (NB-1.6)
Physical inactivity (NB-2.1)
Inability or lack of desire to manage self-care (NB-2.3)
Impaired ability to prepare foods/meals (NB-2.4)
Sample PES or Nutrition Diagnostic Statements
Excessive carbohydrate intake (NI-5.8.2) related to lack of knowledge of carbohydrate
content of foods as evidenced by elevated hemoglobin A1c with self-report of high
carbohydrate intake.
Inappropriate intake of fats (NI-5.6.3) related to lack of knowledge as evidenced by
high intake of saturated and trans fatty acids.
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Altered blood glucose values (NC-2.2) related to inconsistent carbohydrate intake as
evidenced by hyperglycemia.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.


Nutrition Intervention

Nutrition Prescription
A nutrition prescription integrates an insulin regimen with an individual’s appetite,
preferred foods, and usual meal and physical activity schedule (Daly, 2007).
Individuals using rapid-acting insulin (injection or insulin pump) should adjust the food
bolus dose based on the carbohydrate content.
Individuals using fixed-insulin doses should be consistent with the timing of meals and
the amount of carbohydrates eaten at each meal and snack.
For planned exercise, insulin doses should be adjusted.
For unplanned exercise, extra carbohydrate may be needed to prevent hypoglycemia.
The Evidence-Based Nutrition Practice Guidelines for Type 1 Diabetes include the
following nutrition intervention recommendations (EAL 2008):
The registered dietitian should implement medical nutrition therapy (MNT), selecting
from a variety of interventions (reduced energy and fat intake, carbohydrate counting,
simplified meal plans, healthful food choices, individualized meal-planning strategies,
exchange lists, insulin-to-carbohydrate ratios, physical activity, and behavioral
strategies).
Nutrition education and counseling should be sensitive to the personal needs,
willingness to change, and ability to make changes of the individual with diabetes.
Studies reporting on effectiveness of MNT note a variety in the number and type of
MNT sessions that lead to improved outcomes.
Although total carbohydrate content of meals and snacks is the first priority,
macronutrient content and total energy intake cannot be ignored, as excessive energy
intake may lead to weight gain even if glycemic control is maintained.
Diets too low in carbohydrate eliminate many foods that are important sources of
vitamins, minerals, fiber, and energy.
According to the American Dietetic Association (ADA 2008), a nutrition intervention is a
planned action to change a nutrition behavior, risk factor, environmental condition, or
aspect of health status. It consists of two components: planning and intervention.
Planning Strategies
Prioritize nutrition diagnoses
Write a nutrition prescription based on patient’s recommended dietary intake
according to current reference standards and dietary guidelines
Collaborate with the patient and the patient’s family to identify goals on the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
intervention for each diagnosis
Select specific intervention strategies focused on the etiology of the problem based
on current evidence
Define timing and frequency of care
Implementation Strategies
Collaborate with a patient and his or her family to carry out the plan
Communicate the plan
Modify the plan as needed
Follow up and verify the plan is implemented
Revise strategies based on changes in condition or response to intervention
Examples of Nutrition Interventions
General/healthful diet (ND-1.1)
Modify distribution, type, or amount of food and nutrients within meals or at specified
time (ND-1.2)
Specific foods/beverages or groups (ND-1.3)
Initiate/change nutrition-related medication (ND-6.1 and ND-6.2)
Nutrition education content (E-1.1, E-1.2, E-1.3, E-1.4, E-1.5)
Nutrition education application (E-2.1, E-2.2, E-2.3)
Nutrition counseling (C-1.2, C-1.3, C-1.4, C-1.5)
Strategies (C-2.1, C-2.2, C-2.3, C-2.4, C-2.5, C-2.6, C-2.7, C-2.8, C-2.9, C-2.10)
Coordination of other care during nutrition care (RC-1.1, RC-1.2, RC-1.3, RC-1.4)
(IDNT 2010)


Nutrition Therapy Efficacy

Children with diabetes should be able to meet the Dietary Reference Intake goals and
normal growth rates if consuming a diet adequate in energy based on age, weight, and
height.
Medical nutrition therapy (MNT) has been documented as effective for diabetes (Franz
2008). MNT is most effective at the initial diagnosis and should be provided at least
annually. MNT should focus on the nutrition needs of the growing child and behavioral
issues that affect adolescent diets, including assessing the risk for disordered eating
(American Diabetes Association 2008).
Clinical studies of MNT have reported decreases in HbA1C of approximately 1% in
type 1 diabetes (American Diabetes Association 2008).
MNT reduces low-density lipoprotein cholesterol by 15 mg/dL to 25 mg/dL or up to
16%.
Low-carbohydrate diets (<130 g/day) are not recommended to manage blood glucose
levels. Diets that restrict carbohydrates can eliminate important foods containing
vitamins, minerals, and fiber (Daly, 2007).
Low-fat diets are effective for lowering low-density lipoprotein cholesterol levels and
will not affect normal growth in children 2 years and older. Children 2 years and
younger should not follow a low-fat diet.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Low-protein diets are not recommended for preventing hypoalbuminemia.


Goal Setting

The medical nutrition therapy goals for pediatric patients with type 1 and type 2 diabetes
include the following (American Diabetes Association, 2008):
Maintain optimal blood glucose levels by balancing food, activity, and medication.
Achieve normal blood lipid and lipoprotein profile that reduces the risk for vascular
disease.
Prevent and treat acute and chronic complications of diabetes.
Maintain blood pressure levels in the normal range or as close to the normal range as
possible.
Maintain a normal growth and development pattern and slow the rate of weight gain
or promote weight loss in overweight or obese children.
Limit food choices only as indicated by scientific evidence.
Meet nutrition needs by taking into account personal and cultural preferences and
willingness to change.


Food & Feeding Issues

Infants
Infants newly diagnosed with type 1 diabetes are not able to communicate signs of
hypoglycemia; therefore, the risk of severe hypoglycemia with seizures is highest in this
age (Silverstein 2005). Parents have difficulty balancing the risk of long-term complications
associated with diabetes versus the risk of severe hypoglycemia.
Energy requirements for infants with diabetes are the same as an infant without diabetes.
Breastfeeding or formula is recommended, with the usual introduction of solids.
Carbohydrate counting can be initiated once the infant is consuming an amount that can be
matched to the amount of rapid-acting insulin dose recommended.
Toddlers and Preschoolers (1-4 years)
Hypoglycemia remains a primary fear for parents raising toddlers with type 1 diabetes.
Toddlers are often unpredictable with the amount of food and the timing of meal/snacks,
which can make it difficult to maintain glycemia.
It is not unusual for individuals in this population to experience food jags and swings in
appetite. Therefore, it is important for parents to establish a meal and snack schedule to
provide adequate energy while controlling blood glucose levels. Carbohydrate counting and
postmeal dosing of rapid-acting insulin is often recommended to reduce the risk of
hypoglycemia and to allow the child to eat based on hunger rather than a predetermined
amount.
School-Aged Children (5-11 years)
School-aged children can begin to take on more of the daily tasks involved with diabetes
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management; however, they will continue to need their caregiver’s support and
supervision. The fear of hypoglycemia, experienced by the parents as well as the patient,
continues with this age group. This fear often results in overtreating hypoglycemic
symptoms, resulting in maintaining higher blood glucose control.
School-aged children will need to set their diet and insulin regimen to meet their school
schedule. Reviewing the school lunch menu, recess, and snack schedule with the child’s
teacher or school nurse will help identify appropriate carbohydrate goals and insulin doses.
Adolescents (12-19 years)
Adolescents have the fine motor control to manage their diabetes independently of their
parents, but it is important that the parents continue to help with the insulin adjustments to
continue with better glycemic control. The challenge is finding the balance of parental
involvement with the adolescent’s diabetes management. The diabetes team can help
assist families during this transition period.
Flexible insulin regimens, such as using basal long-acting insulin with bolus rapid-acting
insulin or the insulin pump, may be beneficial for adolescents to maintain blood glucose
control. Adolescents often miss meals, increase their intake of fast foods, consume large
snacks after school, and experience appetite changes with growth spurts. It is important at
this time that the registered dietitian monitor weight changes and screen for eating
disorders.
Although is it illegal for an adolescent to consume alcohol in the United States, it is
important to discuss the effects alcohol has on blood glucose levels as well as safe
consumption.

Nutrition Support

The nutrition support guidelines are the same for patients without diabetes, except that
insulin may be necessary to control blood glucose levels. See the Nutrition Support section
under Resources for more information and guidelines on nutrition support.

Nutrition Monitoring & Evaluation

The fourth step in the Nutrition Care Process is Nutrition Monitoring and Evaluation.
According to the American Dietetic Association, this step identifies the amount of progress
made and whether the goals were met (ADA 2008).
Nutrition monitoring and evaluation includes three processes:
1. Monitor progress
Check the patient’s understanding of and compliance with the plan
Determine whether the intervention is being implemented
Provide evidence that the plan strategy is or is not changing the patient’s behavior
Identify other positive or negative outcomes
Gather information indicating reasons for lack of progress
Support conclusions with evidence
2. Measure outcomes
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Select outcome indicators that are relevant to the nutrition diagnosis or signs and
symptoms, nutrition goals, medical diagnosis, and outcomes and quality management
goals.
3. Evaluate outcomes
Compare current findings with previous status, intervention goals, and/or reference
standards.
The registered dietitian should monitor and evaluate food intake, medication, metabolic
control (glycemia, lipids, and blood pressure), anthropometric measurements, and physical
activity.
Blood glucose monitoring results are effective for evaluating the achievement of medical
nutrition therapy (MNT) goals. Glucose results can be used to determine whether
adjustments in foods and meals will be sufficient to achieve blood glucose goals or if
medication adjustments need to be combined with MNT.

Nutrition Care FAQs

Question: How many grams of carbohydrates should my child eat each day?
Answer: The amount of carbohydrate depends on your child’s usual intake, activity level,
and growth. The percentage of energy from carbohydrates can vary from 45% to 65%. For
most healthy-weight children, approximately 50% to 55% of energy from carbohydrates is
appropriate to promote normal growth and development.
If your child is on a fixed-insulin regimen, he or she will need to eat a set amount of
carbohydrates (grams) at each meal and snacks at around the same time daily to best
control blood glucose levels. However, if your child is on a flexible insulin regimen, he or
she can eat a varied amount of carbohydrate at each meal and snack and eat at varied
times.

Question: Can my child eat sugar or foods containing sugar now that he has been
diagnosed with diabetes?
Answer: Having diabetes does not mean that your child cannot eat birthday cake or his or
her favorite foods. Sugar is one type of carbohydrate and can be incorporated into your
child's meal plan within moderation. However, it is recommeded to eat less than
25% of total energy from sugar.
If your child is carbohydrate counting, it is important to count the total amount of
carbohydrate grams on the food label. The sugar grams listed on the food label are part of
the total carbohydrate grams. If you are concerned about your child's intake of sugars,
make sure that added sugars are not listed on the food label as one of the first few
ingredients. Other names for added sugars include corn syrup, high-fructose corn syrup,
fruit juice concentrate, maltose, dextrose, sucrose, honey, and maple syrup. As with any
child, it is recommended to eat healthful foods from the www.choosemyplate.gov to ensure
he or she is receiving adequate energy, vitamins and minerals.
Question: What types of carbohydrate are best for my child to eat?
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Question: What types of carbohydrate are best for my child to eat?
Answer: Carbohydrates are found in a variety of foods such as fruits, vegetables, breads,
cereals, rice, pasta, juice, crackers, and other sweets and desserts. It is recommended to
eat carbohydrates containing whole grains (high fiber) because they contain vitamins and
minerals, help your child feel more full, and may help reduce blood glucose and cholesterol
levels.
Question: Should we follow the glycemic index list?
Answer: The glycemic index of foods was developed to compare the postprandial
responses to constant amounts of different carbohydrate-containing foods. Foods with low
glycemic indexes include oats, barley, bulgur, beans, lentils, legumes, apples, oranges,
milk, and yogurt. Furthermore, fiber, fructose, lactose, and fat tend to lower the glycemic
response. Several clinical trials using low-glycemic index diets resulted in reduced blood
glucose levels; however, other studies have had mixed results and cannot confirm this
effect.

Hemoglobin A1c

Glycemic goals vary depending on the age of the child or adolescent with type 1 diabetes.
Risk of hypoglycemia should be considered when maintaining blood glucose control.
Children younger than 6 years have hypoglycemic unawareness because their
counterregulatory mechanisms do not recognize and respond to hypoglycemic symptoms.
This places them at higher risk for severe hypoglycemia (American Diabetes Association
2009).
The glycated hemoglobin (A1C) reflects the average glycemia over the past 2 to 3 months.
Hemoglobin, found in the red blood cells, attaches to blood glucose, measuring the
percentage of A1C in the blood. A1C testing should be performed quarterly in patients to
determine if blood glucose goals have been met.
Limitations to using the A1C test include conditions that affect erythrocyte turnover,
specifically when the A1C result does not correlate with the patient's blood glucose
records. Furthermore, the A1C does not measure glycemic variability or
hypoglycemia. Therefore, insulin adjustments should be based not only on the A1C
percentage, but in combination with self-monitoring blood glucose testing.
Relationship Between A1C Level and Mean Plasma Glucose Levels
A1C 6% → 135 mg/dL
A1C 7% → 170 mg/dL
A1C 8% → 205 mg/dL
A1C 9% → 240 mg/dL
A1C 10% → 275 mg/dL
A1C 11% → 310 mg/dL
A1C 12% → 345 mg/dL
Source: Goldstein 2004
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Age-specific glycemic and A1C goals are listed as follows: (American Diabetes
Association 2009):
Toddlers and preschoolers (0-6 years of age)
Blood glucose goal before meals: 100-180 mg/dL
Bedtime/overnight blood glucose goals: 110-200 mg/dL
A1C goal: <8.5%, but >7.5% due to high risk and vulnerability to hypoglycemia
School age (6-12 years of age)
Blood glucose goal before meals: 90-180 mg/dL
Bedtime/overnight blood glucose goals: 100-180 mg/dL
A1C goal: <8% (lower risk of hypoglycemia and complications)
Adolescents and Young Adults (13-19 years of age)
Blood glucose goal before meals: 90-130 mg/dL
Bedtime/overnight blood glucose goals: 90-150 mg/dL
A1C goal: <7.5% (lower goal of <7.0% is acceptable if it can be achieved without
repeated hypoglycemia)
Glycemic goals should include the following:
Glycemic goals should be individualized. A lower goal can be achieved as long as an
increased risk of hypoglycemia is not present.
Children with frequent hypoglycemia or hypoglycemic unawareness should have a
higher blood glucose goal.
Postprandial blood glucose values should be measured if there is a difference
between preprandial blood glucose values and A1C levels to determine appropriate
basal/bolus insulin regimen adjustments.

Self-Monitoring of Glucose

Self-monitoring of blood glucose (SMBG) allows patients with diabetes and their families to
measure blood glucose levels quickly and accurately to maintain blood glucose control.
Patients with diabetes who measure their blood glucose levels frequently are able to
determine patterns of glucose variability.
According to the American Diabetes Association (Silverstein 2005), children with type 1
diabetes should test their blood glucose level four or more times per day to achieve optimal
blood glucose control. Children in preschool or those who are early school-aged may have
to test blood glucose levels more frequently because they are unable to verbalize
hypoglycemia episodes.
SMBG can be used to adjust insulin doses as follows:
Preprandial blood glucose levels are used to determine the dose of rapid-acting
insulin required to cover the amount of carbohydrate (grams) eaten at the meal or
snack (insulin-to-carbohydrate ratio) as well as the dose of rapid-acting insulin to
correct for a high blood glucose level (correction factor/sensitivity factor).
Fasting or preprandial SMBG is also used to dose the appropriate basal or
background insulin (American Diabetes Association 2009).
Testing blood glucose levels 2 hours from the start of the meal can be used to
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determine if the premeal insulin dose was appropriate. It is recommended the
preprandial and postprandial blood glucose level should be within 50 mg/dL of each
other.
Recommendations:
SMBG should be performed at least three or more times daily for patients using
multiple insulin injections or insulin pump therapy.
For patients using fewer insulin injections or medical nutrition therapy, SMBG can be
a helpful guide for therapy.
Postprandial target goals can be achieved by using SMBG.
A continuous glucose monitoring system (CGMS) allows patients with diabetes to see
blood glucose trends and can be used in conjunction with SMBG to help lower
hemoglobin A1C levels in patient with type 1 diabetes.
CGMS can also be used with SMBG in patients with hypoglycemia unawareness or
frequent hypoglycemic episodes (American Diabetes Association 2009).
Continuous Glucose Monitoring Systems
A CGMS uses a tiny sensor inserted under the skin to measure blood glucose levels in
fluid. The sensor can be over several days to a week. A small tranmitter worn on the body
connects to the sensor to display the blood glucose levels and trends. Blood glucose levels
can be measured in real time, displaying glucose levels at 5-minute or 1-minute intervals.
Alarms can be set to alert the user if glucose levels are too high or too low. Furthermore,
downloaded data from the device can be used to analyze glucose trends and patterns.
However, because CGMS is not as accurate as a blood glucose meter, it is recommended
that users confirm glucose levels with a meter before making any insulin changes (NDIC
2008).

Lipid Profile

According to the American Heart Association (AHA), children with diabetes are at high risk
for early cardiovascular disease (Kavey 2007; Gidding 2009). The AHA categorizes
children with type 1 diabetes in the highest tier (tier l) for cardiovascular risk.
The American Diabetes Association suggests the following screening criteria for
hypercholesterolemia:
If there is a family history of hypercholesterolemia (total cholesterol >240 mg/dL) or a
cardiovascular event before age 55 years, or if family history is unknown, a fasting
lipid profile should be performed on children older than 2 years soon after diagnosis
(after glucose control has been established). If family history is not of concern, then
the first lipid screening should be performed at puberty (approximately age 10). All
children diagnosed with diabetes at or after puberty should have a fasting lipid profile
performed soon after diagnosis (after glucose control has been established).
If lipids are abnormal, annual monitoring is recommended. If low-density lipoprotein
(LDL) cholesterol values are within the accepted risk levels (<100 mg/dL [2.6 mmol/L],
a lipid profile should be repeated every 5 years (American Diabetes Assocation
2009).
Lipid Goals for Children with Diabetes:
Fasting Total Cholesterol: <170 mg/dL (4.42 mmol/L)
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Fasting LDL Cholesterol: <100 mg/dL (2.6 mmol/L)
Fasting Triglyceride: <150 mg/dL (1.695 mmol/L)
Fasting High-Density Lipoprotein Cholesterol: >35 mg/dL (0.91 mmol/L)

Microalbuminuria

Microalbuminuria is defined as an elevated urine albumin level and is an early sign of
diabetic nephropathy. Annual screening allows for early detection of microalbuminuria so
that early treatment can be initiated to reverse diabetic nephropathy (Silverstein 2005).
Annual screening for microalbuminuria, with a random spot urine sample for
microalbumin-to-creatinine ratio, should be started when the child is 10 years of age and
has had diabetes for 5 years.
Exercise within 24 hours of urine collection, infection, fever, congestive heart failure,
marked hyperglycemia, marked hypertension, smoking, and menstruation can affect
albumin excretion; therefore, any abnormal value should be replicated. Two of three
consecutive abnormal values should be obtained on different days to confirm the diagnosis.
Definitions of Albumin Excretion in Children with Diabetes using Spot Urine Collection:
Normal albumin-to-creatine ratio is < 30 mcg/mg
Microalbuminuria is 30 mcg/mg to 299 mcg/mg
Macroalbuminuria is ≥300 mcg/mg

Thyroid-Stimulating Hormone (TSH) Levels

Autoimmune thyroid disorders occur in approximately 17% to 30% of children with type 1
diabetes (Silverstein 2005). Annual screening for thyroid peroxidase and thyroglobulin
antibodies is recommended at the time of diagnosis (American Diabetes Association 2009).
Thyroid-stimulating hormone (TSH) should be measured after metabolic control has been
established. If TSH levels are normal, they should be rechecked every 1 to 2 years or at
the time it's detected that growth rate is abnormal. If TSH levels are abnormal, free T4
should be measured.

Hypertension

Hypertension in adult diabetics is associated with both microvascular and macrovascular
disease. Children with diabetes should have their blood pressure measured at each
visit to prevent the onset of this comorbidity (Silverstein 2005).
Normal blood pressure levels for age, sex and height are presented in The National
Institute of Health's report on the Diagnosis, Evaluation, and Treatment of High Blood
Pressure in Children and Adolescents.
Hypertension in childhood is defined as an average systolic or diastolic blood
pressure in the 95th percentile for age, sex, and height percentile measured on at
least 3 separate days (American Diabetes Association 2009).
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“High-normal” blood pressure is defined as an average systolic or diastolic blood
pressure >90th but <95th percentile for age, sex, and height percentile measured on
at least 3 separate days.
Treatment of high-normal blood pressure should focus on dietary intervention, weight
management, and increased physical activity.
The goal of treatment is a blood pressure <130/80 or below the 90th percentile for
age, sex, and height.


Anthropometric Measurements

Height-, weight-, and body mass index (BMI)-for-age should be plotted on
sex-specific growth charts to determine usual growth patterns and recent weight
changes.
Specialized growth charts for specific populations, including Down syndrome
and Prader-Willi syndrome, are available and should be used for this patient
population in order to make an accurate assesment of growth
BMI-for-age plotting between 5% to 85% is considered within the normal and
healthy range
BMI-for-age plotting greater than 85% but less than 95% is considered as
overweight
BMI-for-age plotting greater than 95% is considered obese
BMI-for-age plotting less than 5% is considered underweight
WHO growth charts are to be used for infants up to 2 years of age; for older children,
Centers for Disease Control and Prevention growth charts include length-for-age and
weight-for-age percentiles as well as head circumference-for-age and
weight-for-length percentiles. All of these charts are available in the Resources
section of this site.

Appropriate Self-Management by Age

Self-management of diabetes changes as children and adolescents grow and develop.
Parental involvement is essential throughout childhood and adolescence to ensure that
blood glucose control is achieved. Following are the self-management stages and goals for
each age group (Silverstein 2005).

Developmental Changes Throughout Childhood and the Effect on Their Diabetes
Management
Infancy (0-12 months of age)
Diabetes Management Goal
Prevent and treat hypoglycemia
Avoid extreme fluctuations in blood glucose levels
Family Issues
Caregivers should share the daily diabetes management to prevent burnout and/or
excessive stress
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Toddler (13-36 months of age)
Diabetes Management Goal
Prevent and treat hypoglycemia
Avoid extreme fluctuations in blood glucose levels due to inconsistent food intake
Family Issues
Establish a schedule and limits to improve cooperation with diabetes management
Offer a variety of foods to prevent food jags and picky eating
Share the burden of care
Preschooler and Early Elementary School-Age (3-7 years of age)
Diabetes Management Goal
Prevent and treat hypoglycemia
Use positive reinforcement to improve cooperation with diabetes management
Adjust insulin regimen to accommodate unpredictable eating and activity
Allow other caregivers to help with diabetes management
Family Issues
Educate school and other caregivers about diabetes management
Reassure child that they did not cause their diabetes
Older Elementary School-Age (8-11 years of age)
Diabetes Management Goal
Insulin regimen should be flexible due to increased participation in school/peer and
sports activities
Educate children regarding the short and long term benefits of optimal glycemic
control
Family Issues
Continue to involve parents in daily diabetes management tasks but encourage
independent self-care during special occasions
Educate school and other caregivers on diabetes management
Early Adolescence (12-15 years of age)
Diabetes Management Goal
Blood glucose control is more difficult during this time
Increase insulin levels during puberty
Weight and body image issues are more apparent and should be assessed
appropriately
Family Issues
Self-management is encouraged with continued parent's guidance
Monitor signs for depression, eating disorders, and risky behavior
Later Adolescence (16-19 years of age)
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Diabetes Management Goal
Significant life changes (social issues, work, education) should be discussed as well
as transition to an adult diabetes team
Modify diabetes management to reflect new lifestyle
Family Issues
Support transition to new diabetes team and independence
Focus on coping skills to gain confidence with diabetes self-care
Monitor for signs of depression, eating disorders and risky behaviors


Hypoglycemia

Hypoglycemia is defined as blood glucose levels lower than 70 mg/dL. Children with
chronic hyperglycemia may experience symptoms of hypoglycemia despite having blood
glucose levels greater than 70 mg/dL (Silverstein 2005). Therefore, it is important to check
blood glucose levels rather than treating based on symptoms alone.

Severe hypoglycemia in children younger than age 5 may be associated with cognitive
deficits; therefore, blood glucose goals are higher. Refer to the Hemoglobin A1c section.
Nocturnal hypoglycemia is common and may be the result of an impaired counterregulatory
reponse to hypoglycemia during sleep. Signs and symptoms include: nightmares; restless
sleep; low fasting blood glucose levels; and headache, confusion, or behavior changes
upon waking.
Mild hypoglycemia is characterized by symptoms including the following:
Sweating
Pallor
Palpitations
Tremors
Difficulty concentrating
Lightheadedness
Lack of coordination
Behavior changes
Mild hypoglycemia can be alleviated by consuming quick-acting carbohydrates. The
guidelines for treatment include the following:
Consume 15 g glucose or other quick-acting carbohydrate to raise blood glucose
levels 40 mg/dL over 30 minutes. If blood glucose levels are less than 50 mg/dL,
20-30 g carbohydrate is necessary to raise blood glucose levels appropriately.
Examples of 15 g quick-acting carbohydrates include the following :
3-4 glucose tablets (which equal approximately 15 g)
4 oz of fruit juice
4 oz of regular soft drink
1 Tbsp honey or syrup (do not give honey or syrup to children younger than 1
year)
Blood glucose levels should increase within 15 minutes and should be retested to
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Blood glucose levels should increase within 15 minutes and should be retested to
ensure levels are within normal ranges.
If blood glucose levels are not within normal ranges, the treatment should be
repeated.
Adding fat may prolong the acute glycemic response; therefore, it is important to
consume quick-acting carbohydrates to treat hypoglycemia.
Severe hypoglycemia is characterized by the following:
Inability to self-treat hypoglycemia because of mental confusion
Lethargy
Unconsciousness
Treatment of severe hypoglycemia includes the following:
Glucagon to stimulate hepatic glucose release should be administered immediately if
the patient is unable to ingest carbohydrates.
A glucagon dose of 30-150 mcg subcutaneously will increase blood glucose levels
within 5 to 15 minutes.
Nausea and vomiting may be associated with glucagon injection.


Acute Illness/Sick Day Management

Acute illness can lead to hyperglycemia and ketoacidosis. During acute illness,
counterregulatory hormones increase; therefore, additional insulin is required to maintain
blood glucose levels (American Diabetes Association 2008).
Ketones are produced by the liver from mobilized free fatty acids when there is a lack of
insulin. Ketones form as a result of increased lipolysis, increased ketogenesis, and
decreased ketone body utilization caused by decreased insulin levels (Brink 2009). Urine
strips or blood strips measure the amount of ketones. The nitroprusside test only detects
the acetoacetate in blood in urine, whereas blood strips measure beta-hydroxybutyrate.
Treatment guidelines are based on the amount of ketones found in the urine or blood.
Blood Ketones (mmol/l) Urine Ketones
<0.6 Negative or trace
0.6-0.9 Trace or small
1.0-1.4 Small or moderate
1.5-2.9 Moderate or large
≥3.0 Large
Ketones

Source: Brink 2009

The physician should be called if signs of ketoacidosis, which include the following, are
present:
Moderate to large ketones with elevated blood glucose levels
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Severe nausea
Vomiting
Diarrhea
Abdominal pain
Rapid breathing
Sick day management goals include the following:
Never stop insulin; the insulin dose may be increased or decreased
Check blood glucose levels and ketones every 2 hours
Give insulin based on elevated blood glucose levels (≥240 mg/dL with moderate to
large ketones or two readings ≥240 mg/dL with or without ketones)
The health care team should be contacted if an illness persists for longer than 24
hours or if the child is unable to eat regular foods for more than 24 hours
Fluid Requirements:
Fluids containing sodium (broth, tomato juice, sports drinks) are recommended
to avoid depletion of intravascular volume (Franz 2002)
1 oz sugar-free fluid per hour per year of age if blood glucose levels are ≥240
mg/dL with ketones
1 oz of sugar-containing fluids every hour per year of age if blood glucose levels
<240 mg/dL with ketones
At least 1 Tbsp sugar-free fluids every 10 minutes if vomiting and blood glucose
levels are ≥240 mg/dL, no ketones
At least 1 Tbsp sugar-containing fluids every 10 minutes if vomiting and blood
glucose levels <240 mg/dL, with or without ketones
Recommended Fluids for Sick-Day
Fruit juice
Sugar-containing beverages: ginger ale, regular 7-Up
Sports drinks
Tea with honey or sugar
Pedialyte
Jell-O (regular)
Popsicles (regular or diet)
Broth-type soups
Recommended Foods for Sick-Day (if patient is able to eat) (Chase 2008)
Saltine crackers
Banana
Applesauce
Bread or toast
Graham crackers
Soup


Alcohol

Alcohol consumption in children and adolescents is illegal in the United States. However, it
is important to discuss the risks associated with drinking alcohol to ensure safe drinking
practices.
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practices.
Notes on Alcohol and Diabetes
Alcohol alters the phase of glucose recovery by interfering with hepatic
gluconeogenesis, inducing hypoglycemia (Franz 2002).
Low blood glucose levels can occur even before a person is aware of being mildly
intoxicated. On an empty stomach, 2 oz alcohol (1 or 2 drinks) is enough to produce
hypoglycemia.
Drinking a moderate amount of alcohol can blunt the awareness of hypoglycemia in
individuals taking insulin.
Drinking alcohol at night increases the risk of nocturnal and fasting hypoglycemia
(Daly, 2007).
Food should be consumed before and during alcohol consumption to avoid
hypoglycemia.
Extra insulin should not be taken when drinking alcohol because of the hypoglycemic
effect.
The frequency of blood sugar testing should be increased when consuming alcohol.

Diabetes Care at School/Day Care

Children and adolescents spend anywhere from 4 to 12 hours at school, day care, or
extended care. School and day care personnel need to be knowledgeable about diabetes
care to maintain adequate blood glucose control (Silverstein 2005). Despite the legal
protections under Section 504 of the Rehabilitation Act of 1973, the Individuals with
Disabilities Education Act, and the Americans with Disabilities Act, children and
adolescents with diabetes remain discriminated against in school and day care
settings (American Diabetes Association, 2009; Living with Diabetes: Discrimination).

The American Diabetes Association recommends the following (2009):
An individualized Diabetes Medical Management Plan should be developed by the
student’s caregiver and health care team.
The school should provide a safe environment to measure blood glucose levels,
recognize and treat hypoglycemia and diabetic ketoacidosis, and administer
glucagon.
Students with diabetes should have access to diabetes supplies (developmentally
appropriate) and should be permitted to self-manage their diabetes in the classroom
or other areas where they will be participating in school activities.


Exercise and Diabetes

The benefits of exercise include weight control, improved physical and cardiovascular
fitness, lower pulse and blood pressure, improved lipid profile, and overall a greater sense
of well-being. It is recommended that all children with diabetes receive a minimum of 30 to
60 minutes of moderate physical activity daily (USDHHS 2005).
Types of Exercise
Anaerobic exercise is characterized by higher intensities of muscular contractions,
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Anaerobic exercise is characterized by higher intensities of muscular contractions,
including sports such as sprinting, power lifting, hockey, and fast motions during basketball.
High-intensity anaerobic exercise can result in post-exercise hyperglycemia (30 to 60
minutes) resulting from increases in catecholamines, free fatty acids, and ketone
bodies, which impair muscle glucose utilization (Riddell 2006).
Aerobic exercise is characterized by lower rates of muscular contractions that have a
prolonged duration including running, cycling, rowing, swimming, soccer, and
ultra-endurance events.
Aerobic exercise can result in lower blood glucose levels during and after the activity.
Guidelines for Exercise and Diabetes
Carbohydrate Supplementation
Carbohydrate supplementation is important to maintain blood glucose levels during
exercise, especially if activity is unplanned and/or of long duration.
If preexercise blood glucose levels are lower than 100 mg/dL (5.6 mmol/L), 15 g
rapidly absorbable carbohydrate should be consumed to prevent hypoglycemia
(Hayes 2008).
It is recommended to consume 15-30 g carbohydrate every 30 to 60 minutes of
exercise, depending on the exercise intensity.
Consume an additional 15 g carbohydrate (1 carbohydrate serving) for 1 hour of
increased moderate-intensity exercise, such as tennis, swimming, or jogging.
Consume 30 g carbohydrate for more strenuous exercise such as 1 or 2 hours
of sport activities (basketball, football, soccer, etc.) or strenuous bicycling.
Moderate exercise of less than 30 minutes generally does not require any
additional carbohydrate or insulin adjustment, unless blood glucose is <100
mg/dL, in which case a small snack may be needed.
It is recommended to consume 1-1.5 g carbohydrate/kg body weight 30 minutes after
intense/competitive exercise and again 1 to 2 hours later to prevent postexercise
hypoglycemia and to replenish glycogen stores (Hayes 2008; Riddell 2006). Late
hypoglycemia occurs as a result of the late effect of increased insulin sensitivity and
delay in replenishing liver and muscle glycogen stores.
Insulin Adjustments for Exercise
Adjusting insulin dosages for a planned activity can increase exercise safety and
performance.
A 30% to 50% reduction in the insulin dose acting during the time of exercise is
recommended to prevent hypoglycemia.
Reductions in insulin dosing of up to 80% may be needed for prolonged or extreme
exercise.
It is recommended to reduce insulin doses to prevent exercise-induced hypoglycemia,
which can extend up to 36 hours after intense or prolonged exercise.
Supplemental insulin may be required to correct preexercise hyperglycemia (blood
glucose levels greater than 240 mg/dL [13.5 mmol/L]) before starting exercise.
Exercise and Insulin Pumps
For planned exercise:
Premeal bolus insulin should be reduced by 50%
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Premeal bolus insulin should be reduced by 50%
Basal rate during activity should be decreased by at least 50% or suspended
Postexercise basal rate should be decreased by 25% for up to 12 hours postexercise
in order to prevent late onset hypoglycemia
For unplanned exercise:
The pump should be suspended
An addtion of a complex carbohydrate preexercise snack of 15 g to 30 g should be
added with bolus for every 60 minutes of exercise
Postexercise basal rate should be decreased by 25% for up to 12 hours postexercise
to prevent late onset hypoglycemia (Rachmiel 2007)
Disconnecting from the Insulin Pump
The type of exercise performed may require disconnecting from the insulin pump to prevent
damage or prevent the pump from being dislodged. The insulin pump uses only
rapid-acting insulin; therefore, disconnecting for longer than 2 hours can increase the risk
of hyperglycemia with ketones.
Guidelines for disconnecting:
Check blood sugar every 1 to 2 hours when disconnected.
Before disconnecting, if blood glucose is in target range, use bolus for 1 to 2 hours of
missed basal rate.
If exercising, replace only a portion of missed basal insulin to prevent hypoglycemia.
Replace missed basal by reconnecting or injecting rapid-acting insulin every 2 hours.

Self-Monitoring of Blood Glucose (SMBG)
Frequent SMBG before, during, and after exercise is recommended to determine
glycemic patterns due to exercise and to appropriately adjust carbohydrate and/or
insulin doses.
SMBG should be conducted every 1 to 2 hours postexercise to assess blood glucose
response to exercise.
Frequent postexercise blood glucose monitoring at night and at 3 am is
recommended to prevent delayed-onset hypoglycemia (Hayes 2008).
Ketones and Exercise
When blood glucose levels are higher than 250 mg/dL to 300 mg/dL and insulin
is deficient, ketosis can result. Insulin is necessary for glucose utilization and
exercise is not a substitute for insulin.
Patients should be advised to not exercise if ketones are present.
Exercise should not begin until ketones are negative.


Celiac Disease

Celiac disease is an immune-mediated disorder that can occur in 1% to 16% of patients
with type 1 diabetes (Silverstein 2005). Symptoms include diarrhea, weight loss or poor
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with type 1 diabetes (Silverstein 2005). Symptoms include diarrhea, weight loss or poor
weight gain, growth failure, abdominal pain, chronic fatigue, malnutrition caused by
malabsorption, and other gastrointestinal problems and unexplained hypoglycemia or
erratic blood glucose concentrations.
Screening for celiac disease should be performed at diagnosis in children with type 1
diabetes, including asymptomatic individuals. Screening includes measuring
circulating IgA autoantibodies to tissue transglutaminase (tTG).
If screening indicates elevated autoantibodies, a small-bowel biopsy should be
performed to confirm the diagnosis of celiac disease.
If the tTG assay is not available, the endomysial autoantibody (EMA) assay may be
used.
Testing should be repeated in children who display growth failure, poor weight gain,
weight loss, diarrhea, flatulence, abdominal pain, or signs of malabsorption. Testing
should also be performed in children with frequent unexplained hypoglycemia or
worsening blood glucose control (American Diabetes Association 2011).
The only treatment for confirmed celiac disease is a gluten-free diet. Since most
gluten-free substitutes are high in carbohydrates, which may alter blood glucose
control, medical nutrition therapy should be performed by a registered dietitian who
has experience with both diabetes and celiac disease (Silverstein 2005).
For more information, see the Celiac Disease section.

Diabetic Ketoacidosis and Hyperosmolar Hyperglycemia State

If clinical signs and symptoms seem indicative of Diabetic Ketoacidosis (DKA) and
Hyperosmolar Hyperglycemia State (HHS), the following criteria can be used to confirm
diagnosis (Kitabchi 2001).
Diagnostic criteria for DKA and HHS:
DKA
Mild
DKA
Moderate
DKA Severe HHS
Plasma
glucose
(mg/dL)
>250 >250 >250 >600
Arterial pH 7.25-7.30 7.00- <7.24 <7.00 >7.30
Serum
bicarbonate
(mEq/L)
15-18 10-<15 <10 >15
Urine
ketones*
Positive Positive Positive Small
Serum
ketones *
Positive Positive Positive Small
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Effective
serum
osmolality
(mOsm/kg)
**
Variable Variable Variable >320
>320 anion
gap+
>10 >12 >12 Variable
Alteration
in sensorial
or mental
obtundation
Alert Alert/drowsy Stupor/coma Stupor/coma
*Nitroprusside reaction method
** calculation: 2[measured NA(mEq/L)] + glucose (mg/dL)/18
+ calculation: (Na+) – (Cl# + HCO3#) (mEq/L)

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Nutrition Care > Diabetes Mellitus > Type 2
Nutrition-Focused Physical Findings

Weight loss in association with glycosuria and possibly ketonuria may be present in
children with type 2 diabetes (Rosenbloom 2008). If insulin is administered, rapid weight
gain and normal linear growth is observed and measured.
Weight gain occurs following insulin therapy as a result of the following (Daly 2007):
Energy retention resulting from improved glycemic control
Excess energy intake
Decreased energy expenditure
Improved hydration
Unphysiologic action of conventional insulin formulations
Skin examination should be performed at each clinic visit to include:
Acanthosis nigricans;
Self-monitoring blood glucose (SMBG) testing sites; and,
Insulin-injection sites/lipohypertropy, if applicable.

Biochemical Data, Medical Tests and Procedures

The fasting plasma glucose (FPG) test is the easiest and least expensive for diagnosing
diabetes (American Diabetes Association 2009). At this time, the hemoglobin A1c test is
not recommended for diagnosis.
The following criteria are used to diagnose diabetes (American Diabetes Association 2009):
FPG ≥126 mg/dL (7.0 mmol/L). "Fasting" is defined as no energy intake for at least 8
hours.
1.
Symptoms of hyperglycemia and a casual (random) plasma glucose ≥200 mg/dL
(11.1 mmol/L). "Casual (random)" is defined as any time of day without regard to time
since last meal. The classic symptoms of hyperglycemia include polyuria, polydipsia,
and unexplained weight loss.
2.
2-hour plasma glucose =200 mg/dL (11.1 mmol/L) during an oral glucose tolerance
test. The test should be performed as described by the World Health Organization
using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in
water or 1.75 g/kg body weight if weight if less than 40 pounds (18 kg) (Rosenbloom
2008).
3.
In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat
testing on a different day. The oral glucose tolerance test is not recommended for routine
clinical use but may be required in the evaluation of patients if diabetes is still suspected
despite a normal fasting plasma glucose (Silverstein 2005).
In type 2 diabetes in youth, the onset is not as clear. Therefore, it is recommended that
children and youth at increased risk of type 2 diabetes should be screened within the health
care setting (American Diabetes Association 2009). The American Diabetes Association's
consensus statement on type 2 diabetes in children and youth is summarized as follows:
Testing for type 2 diabetes in asymptomatic children
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Testing for type 2 diabetes in asymptomatic children
Criteria:
Overweight (body mass index >85th percentile for age and sex, weight for height
>85th percentile, or weight >120% of ideal for height)
Plus any two of the following risk factors:
Family history of type 2 diabetes in first- or second-degree relative
Race/ethnicity (Native American, African American, Latino, Asian American, Pacific
Islander)
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or
small-for-gestational age birthweight)
Maternal history of diabetes or gestational diabetes mellitus
Age of initiation: Age 10 years or at onset of puberty, if puberty occurs at a younger age
Frequency: Every 3 years
Test: FPG (American Diabetes Association 2009)
Laboratory Overview
Laboratory tests for patients with type 2 diabetes mellitus are varied and include tests that
assess for the following:
Diabetic ketoacidosis and hyperosmolar hyperglycemia state
Lipid profile
Microalbuminuria
Recommendations for autoantibody testing, if signs and symptoms are suggestive of type 2
diabetes, include the following:
Diabetes autoantibody testing should be condsidered in all children with type 2
diabetes because of the high frequency of islet cell autoimmunity. Evidence of islet
autoimmunity includes islet cell [ICA] 512, or IA-2, glutamic acid decarboxylase, and
insulin autoantibodies.
Children with type 2 diabetes and postitive antibodies may require insulin earlier than
children without antibodies.
Positive antibodies in children with type 2 diabetes indicate the need to check for
other autoimmune disorders.
If diagnosis is in doubt, evidence of beta-cell secretory capacity should be tested (eg,
C-peptide levels) after 1 year of diagnosis (Rosenbloom 2008).

Laboratory Overview


Client History

Client history should include the following:
Symptoms related to diagnosis of diabetes
Recent or current infections or illnesses
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Recent or current infections or illnesses
Duration of diabetes
Previous diabetes education
Self-monitoring blood glucose patterns/trends
Percentage of A1c hemoglobin (glycated hemoglobin)
Growth, development and pubertal maturation
Family history of diabetes and other endocrine disorders
Current use of medications that will affect blood glucose:
Type of insulin and/or oral hypoglycemic agents
Glucocorticoids
Chemotherapeutic agents
Atypical antipsychotics
History and treatment of other conditions:
Endocrine disorders
Eating disorders
Secondary causes of diabetes: steroid induced, cystic fibrosis
Lifestyle, cultural, psychosocial, educational, and economic factors that will influence
the management of diabetes
Physical activity and exercise patterns
Risk factors for atherosclerosis:
Smoking
Hypertension
Obesity (Body mass index >95th percentile)
Dyslipidemia
Family history (early coronary artery disease or myocardial infarction before age
55)

Food/Nutrition-Related History

When obtaining food history from a client, note the following:

24-hour recall or typical intake on most days of the week
Meal and snack times
Frequency and choice of food when eating out
Travel frequency
Appetite/gastrointestinal issues
Food allergies/intolerances
Use of tobacco, alcohol, and/or recreational drugs
Carbohydrate goals at meals/snacks or daily carbohydrate goal


Comparative Standards

Energy needs
Energy requirements of patients with type 2 diabetes should be based on the child's
usual intake and activity level, which can be obtained through a diet history and/or
actual food intake. Most children with type 2 diabetes are overweight; therefore,
energy requirements should focus on weight loss or preventing further weight gain
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(Smart 2009).
If diet history or food intake information cannot be obtained, energy needs may be
also derived by the following:
Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fatty Acids,
Cholesterol, Protein, and Amino Acids (2002/2005)
Estimated energy requirements (EER) calculator (under the Calculators tab,
above).
Estimated Energy Requirements of Boys and Girls in Each Age
Group at Three Levels of Physical Activity
a
EER (kcal) by
Activity Level
b, c, d
Sex
Age
(years)
Sedentary
b
Moderately
Active
c
Active
d
Male or
Female
2-3 1,000 1,000-1,400 1,000-1,400
Female
4-8
9-13
14-18
1,200
1,600
1,800
1,400-1,600
1,600-2,000
2,000
1,400-1,800
1,800-2,200
2,400
Male
4-8
9-13
14-18
1,400
1,800
2,200
1,400-1,600
1,800-2,200
2,400-2,800
1,600-2,000
2,000-2,600
2,800-3,200
a
These levels are based on EER from the Institutes of Medicine (IOM) Dietary Reference
Intakes macronutrients report, 2002, calculated by sex, age, and activity level for
reference-sized individuals. “Reference size,” as determined by the IOM, is based on
median height and weight for up to 18 years of age.
b
"Sedentary" means a lifestyle that includes the light physical activity associated with
typical day-to-day life.
c
"Moderately active" means a lifestyle that includes physical activity equivalent to walking
approximately 1.5 miles to 3 miles per day at 3 miles to 4 miles per hour, in addition to the
light physical activity associated with typical day-to-day life
d
"Active" means a lifestyle that includes physical activity equivalent to walking more than 3
miles per day at 3 miles to 4 miles per hour, in addition to the light physical activity
associated with typical day-to-day life.
It is important to provide enough energy so that the child maintains consistent growth
within the normal parameters of the Centers for Disease Control and Prevention
(CDC) growth charts and an appropriate BMI for age.
Fluid Needs or Limits
Diabetic ketoacidosis and hyperosmolar hyperglycemic state are not common in children
with type 2 diabetes. However, the presence of ketosis/ketoacidosis can be found
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with type 2 diabetes. However, the presence of ketosis/ketoacidosis can be found
in one-third or more of patients newly diagnosed with type 2 diabetes (Rosenbloom
2008). Refer to type 1 diabetes fluid needs or limits for more information.
Normal Fluid Requirements in Infants, Children and Adolescents
1kg to 10 kg: 100 mL/kg
10 kg to 20 kg: 1,000 mL + 50 mL for each kg over 10 kg
>20 kg: 1,500 mL + 20 mL for each kg over 20 kg

Nutrition Diagnosis

Dietitians working with patients who have type 2 diabetes mellitus should review the signs
and symptoms obtained in the nutrition assessment and diagnose nutrition problems based
on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Altered nutrition-related laboratory values (specify) (NC-2.2)
Unintended weight loss (NC-3.2)
Inappropriate intake of fats (specify) (NI-5.6.3)
Excessive carbohydrate intake (NI-5.8.2)
Inconsistent carbohydrate intake (NI-5.8.4)
Food- and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Limited adherence to nutrition-related recommendations (NB-1.6)
Physical inactivity (NB-2.1)
Inability or lack of desire to manage self-care (NB-2.3)
Impaired ability to prepare foods/meals (NB-2.4)
Sample PES or Nutrition Diagnostic Statements
Excessive carbohydrate intake (NI-5.8.2) related to lack of knowledge of carbohydrate
content of foods as evidenced by elevated hemoglobin A1C with self-report of high
carbohydrate intake.
Inappropriate intake of fats (NI-5.6.3) related to lack of knowledge as evidenced by
high intake of saturated and trans fatty acids.
Altered blood glucose values (NC-2.2) related to inconsistent carbohydrate intake as
evidenced by hyperglycemia.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition Prescription
Implement lifestyle changes to reduce intakes of energy, saturated and trans fatty
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Implement lifestyle changes to reduce intakes of energy, saturated and trans fatty
acids, cholesterol, and sodium, and to increase physical activity in an effort to improve
blood glucose control, dyslipidemia, and blood pressure.
Self blood glucose monitoring can be used to determine if blood glucose control is
managed with medical nutrition therapy (MNT) alone or if medication is required to
achieve glycemic goals.
Nutrition Interventions
According to the American Dietetic Association (JADA 2008), a nutrition intervention is a
planned action to change a nutrition behavior, risk factor, environmental condition, or
aspect of health status. It consists of two components: planning and intervention.
Planning Strategies
Prioritize nutrition diagnoses
Write a nutrition prescription based on patient’s recommended dietary intake
according to current reference standards and dietary guidelines
Collaborate with the patient and the patient’s family to identify goals on the
intervention for each diagnosis
Select specific intervention strategies focused on the etiology of the problem based
on current evidence
Define timing and frequency of care
Implementation Strategies
Collaborate with a patient and his or her family to carry out the plan
Communicate the plan
Modify the plan as needed
Follow-up and verify the plan is implemented.
Revise strategies based on changes in condition or response to intervention
Examples of Nutrition Interventions
General/healthful diet (ND-1.1)
Modify distribution, type, or amount of food and nutrients within meals or at specified
time (ND-1.2)
Specific foods/beverages or groups (ND-1.3)
Initiate/change nutrition-related medication (ND-6.1 and ND-6.2)
Nutrition education content (E-1.1, E-1.2, E-1.3, E-1.4, E-1.5, E-1.6)
Nutrition education application (E-2.1, E-2.2, E-2.3)
Nutrition counseling (C-1.2, C-1.3, C-1.4, C-1.5)
Strategies (C-2.1, C-2.2, C-2.3, C-2.4, C-2.5, C-2.6, C-2.7, C-2.8, C-2.9, C-2.10)
Coordination of other care during nutrition care (RC-1.1, RC-1.2, RC-1.3, RC-1.4)
(IDNT 2010)
The Evidence-Based Nutrition Practice Guidelines for Type 2 Diabetes include the
following nutrition intervention recommendations (EAL, 2008):
The registered dietitian should implement MNT by selecting from a variety of
interventions (reduced energy and fat intake, carbohydrate counting, simplified meal
plans, healthful food choices, individualized meal planning strategies, exchange lists,
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insulin-to-carbohydrate ratios, physical activity, and behavioral strategies)
Nutrition education and counseling should be sensitive to the personal needs,
willingness to change, and ability to make changes of the individual with diabetes
Studies reporting on effectiveness of MNT report a variety in the number and type of
MNT sessions that lead to improved outcomes
Although total carbohydrate content of meals and snacks is the first priority,
macronutrient content and total energy intake cannot be ignored, as excessive energy
intake may lead to weight gain even if glycemic control is maintained
Diets too low in carbohydrate eliminate many foods that are important sources of
vitamins, minerals, fiber, and energy


Nutrition Therapy Efficacy

Children with diabetes should be able to meet the Dietary Reference Intake goals and
normal growth rates if consuming a diet adequate in energy based on age, weight, and
height.
Medical nutrition therapy (MNT) has been documented as effective for diabetes (Franz
2008). MNT is most effective at the initial diagnosis and should be provided at least
annually. MNT should focus on the nutrition needs of the growing child and behavioral
issues that affect adolescent diets, assessing the risk for disordered eating (American
Diabetes Association 2008).
Clinical studies of MNT have reported decreases in HbA1C of approximately 1% to
2% in type 2 diabetes (American Diabetes Association 2008).
MNT reduces low-density lipoprotein cholesterol by 15 mg/dL to 25 mg/dL or up to
16%.
Short-term studies show that moderate weight loss (5% of body weight) in individuals
with type 2 diabetes is associated with decreased insulin resistance, improved
glycemia and lipid levels, and reduced blood pressure.
Low-carbohydrate diets (<130 g/day) are not recommended to manage blood glucose
levels. Diets restricting carbohydrates can eliminate important foods containing
vitamins, minerals, and fiber (EAL, 2008).
Low-fat diets are effective for lowering low-density lipoprotein cholesterol levels and
will not affect normal growth in children aged 2 years and older. Children aged 2
years and younger should not follow a low-fat diet.
To prevent hypoalbuminemia, it is recommended to consume a diet that meets the
Recommended Dietary Allowance for protein.



Goal Setting

The medical nutrition therapy goals for pediatric patients with type 2 diabetes include the
following (American Diabetes Association, 2008):
Maintain optimal blood glucose levels by balancing food, activity, and medication
Achieve normal blood lipid and lipoprotein profile to reduce the risk for vascular
disease
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Prevent and treat acute and chronic complications of diabetes
Maintain blood pressure levels in the normal range or as close to the normal range as
possible
Maintain a normal growth and development pattern and slow the rate of weight gain
or promote weight loss in overweight or obese children
Limit food choices only as indicated by scientific evidence
Meet nutrition needs by taking into account personal and cultural preferences and
willingness to change


Food & Feeding Issues

School-Aged Children (5-11 years)
School-aged children can begin to take on more of the daily tasks involved with diabetes
management; however, they will continue to need their caregiver’s support and
supervision. The fear of hypoglycemia continues if on insulin, from both the parents as well
as the patient. This fear often results in overtreating hypoglycemic symptoms resulting in
keeping blood glucose levels above their target range.
School-aged children will need to set their diet and medication regimen to meet their
school schedule. Reviewing the school lunch menu, recess, and snack schedule with the
child’s teacher or school nurse will help identify appropriate food choices, carbohydrate
goals, and medication doses.
Adolescents (12-19 years)
Adolescents have the fine motor control to manage their diabetes independently of their
parents, but it is important that the parents continue to help with the insulin and/or oral
medication adjustments to continue with better glycemic control. The challenge is finding
the balance of parental involvement with the adolescent’s diabetes management. The
diabetes team can help assist families during this transition period.
Adolescents are encouraged to make healthful dietary changes to promote weight
reduction and increase physical activity to improve insulin resistance (Rosenbloom 2008).
The patient and famiy should be trained to identify proper food portions, quantitiy and
quality of food, and eating behavior. It is recommended that family members
encourage positive reinforcement of small behavior changes rather than using blame to
punish the adolescent for failure.
Although is it illegal for an adolescent to consume alcohol in the United States, it is
important to discuss the effects alcohol has on blood glucose levels as well as safe
consumption.

Nutrition Support

The nutrition support guidelines are the same for patients without diabetes, except that
insulin may be necessary to control blood glucose levels. See the Nutrition Support section
in Resources for more information and guidelines on nutrition support.
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Nutrition Monitoring & Evaluation

The fourth step in the Nutrition Care Process is Nutrition Monitoring and Evaluation.
According to the American Dietetic Association, this step identifies the amount of progress
made and whether the goals were met (ADA 2008).
Nutrition monitoring and evaluation includes three processes:
1. Monitor progress
Check the patient’s understanding of and compliance with the plan
Determine whether the intervention is being implemented
Provide evidence that the plan strategy is or is not changing the patient’s behavior
Identify other positive or negative outcomes
Gather information indicating reasons for lack of progress
Support conclusions with evidence
2. Measure outcomes
Select outcome indicators that are relevant to the nutrition diagnosis or signs and
symptoms, nutrition goals, medical diagnosis, and outcomes and quality management
goals.
3. Evaluate outcomes
Compare current findings with previous status, intervention goals, and/or reference
standards.
The registered dietitian should monitor and evaluate food intake, medication, metabolic
control (glycemia, lipids, and blood pressure), anthropometeric measurements, and
physical activity.
Blood glucose monitoring results are effective for evaluating the achievement of medical
nutrition therapy (MNT) goals. Glucose results can be used to determine whether
adjustments in foods and meals will be sufficient to achieve blood glucose goals or if
medication adjustments need to be combined with MNT.

Nutrition Care FAQs

Question: How many grams of carbohydrates should my child eat each day?
Answer: The amount of carbohydrate depends on your child’s usual intake, activity level,
and growth. The percentage of energy (calories) from carbohydrates can vary from 45% to
65%. For most healthy weight children, approximately 50% to 55% of calories from
carbohydrates are appropriate to promote normal growth and development.
If your child is on a fixed-insulin regimen, he or she will need to eat a set amount of
carbohydrates (grams) at each meal and snacks at around the same time daily to best
control blood glucose levels. However, if your child is on a flexible insulin regimen, he or
she can eat a varied amount of carbohydrate at each meal and snack and at varied times.

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Question: Can my child with diabetes eat “normal” food?
Answer: Having diabetes does not mean that your child cannot eat birthday cake or their
favorite foods. All types of food can be incorporated into his meal plan within moderation.
As with any child, eating healthy foods from the MyPlate is recommended to ensure he is
receiving adequate calories, vitamins and minerals. However, because children with
diabetes are at an increased risk for cardiovascular disease, eating foods low in saturated
and trans fats is recommended.

Question: What types of carbohydrate are best for my child to eat? Should we follow the
glycemic index list?
Answer: Carbohydrates are found in a variety of foods such as fruits, vegetables, breads,
cereals, rice, pasta, juice, crackers, and other sweets and desserts. It is recommended to
eat carbohydrates containing whole-grains (high fiber) because they contain vitamins and
minerals, as well as help your child feel more full, and possibly help reduce blood glucose
and cholesterol levels.
The glycemic index of foods was developed to compare the postprandial responses to
constant amounts of different carbohydrate-containing foods. Foods with low glycemic
indexes include oats, barley, bulgur, beans, lentils, legumes, apples, oranges, milk, and
yogurt. Furthermore, fiber, fructose, lactose, and fat tend to lower the glycemic response. It
appears in several clinical trials that with low-glycemic index diets, blood glucose levels
were reduced; however, other studies have had mixed results and cannot confirm this
effect.

Question: My child has type 2 diabetes. What can she eat to control her blood glucose and
high cholesterol?
Answer: Your child should initially focus on eliminating sugar-containing soft drinks and
juices in large quantities. These drinks can be substituted with water, diet, caffeine-free
soft drinks, and other beverages sweetened with artificial sweeteners.
Your child should also try to increase fiber intake to help control blood glucose levels.
Whole grain breads, cereals, pasta, and brown rice can be substituted for white flour or
refined starches. Fresh fruits and vegetables are also good sources of dietary fiber,
vitamins, and minerals, and they are low in fat.
Reading food labels and identifying foods low in saturated and trans fats will help to select
foods that can lower blood cholesterol levels. Your child should try to substitute unhealthful
fats with more healthful fats found in foods such as nuts; olive and canola oil; peanut butter;
and healthful, light tub spreads. Eating fish (6 oz) twice a week is recommended to
increase omega-3 fats.
In addition to eating more healthful carbohydrates, your child should try to eat
approximately the same amount of carbohydrates at meals and snacks to prevent
hyperglycemia. The Idaho Plate Method is a great start to understanding appropriate
portion sizes to manage weight and blood glucose levels. If your child is taking insulin, she
can learn to count carbohydrates to better manage her diabetes.

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Self-Monitoring of Glucose

Self-monitoring of blood glucose (SMBG) allows patients with diabetes and their families to
measure blood glucose levels quickly and accurately to maintain blood glucose control.
Patients with diabetes who measure their blood glucose levels frequently are able to
determine patterns of glucose variability.
SMBG can be used to adjust insulin doses as follows:
Preprandial blood glucose levels are used to determine the dose of rapid-acting
insulin required to cover the amount of carbohydrate (grams) eaten at the meal or
snack (insulin-to-carbohydrate ratio) as well as the dose of rapid-acting insulin to
correct for a high blood glucose level (correction factor/sensitivity factor).
Testing blood glucose levels 2 hours from the start of the meal can be used to
determine if the premeal insulin dose was appropriate. It is recommended that the
preprandial and postprandial blood glucose level should be within 50 mg/dL of each
other.
Recommendations for SMBG include the following:
SMBG can be performed fasting in the morning, before meals, and/or 2 hours
postprandial. SMBG may vary depending on the type of treatment for type 2 diabetes
(medical nutrition therapy alone versus insulin therapy).
For patients not using insulin or using fewer insulin injections or medical nutrition
therapy, SMBG can be a helpful guide of therapy.
Postprandial target goals can be achieved by using SMBG (2-hour postprandial goal
<140 mg/dL).


Lipid Profile

According to the American Heart Association (AHA), children with diabetes are at high risk
for early cardiovascular disease (Kavey 2007; Gidding 2009). The AHA categorizes
children with type 2 diabetes at moderate risk (tier ll).
The American Diabetes Association suggests the following screening criteria for
hypercholesterolemia:
If there is a family history of hypercholesterolemia (total cholesterol >240 mg/dL) or a
cardiovascular event before age 55 years, or if family history is unknown, then a
fasting lipid profile should be performed on children older than 2 years soon after
diagnosis (after glucose control has been established). If family history is not of
concern, then the first lipid screening should be performed at puberty (approximately
10 years). All children diagnosed with diabetes at or after puberty should have a
fasting lipid profile performed soon after diagnosis (after glucose control has been
established).
If lipids are abnormal, annual monitoring is recommended. If low-density lipoprotein
(LDL) cholesterol values are within the accepted risk levels (<100 mg/dL [2.6
mmol/L]), a lipid profile should be repeated every 5 years (American Diabetes
Assocation 2009).
Lipid Goals for Children with Diabetes:
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Fasting Total Cholesterol: <170 mg/dL (4.42 mmol/L)
Fasting LDL-cholesterol: <100 mg/dL (2.6 mmol/L)
Fasting Triglyceride: <150 mg/dL (1.695 mmol/L)
Fasting high-density lipoprotein cholesterol: >35 mg/dL (0.91 mmol/L)
If LDL cholesterol is elevated higher than 100 mg/dL (2.6 mmol/L), a repeat lipid profile
should be performed in 6 months and dietary intervention to decrease total, saturated fat,
and trans fatty acids initiated (Rosenbloom 2009). See the Disorders of Lipid Metabolism
section for more information.
If LDL cholesterol remains elevated (≥130 mg/dL with positive cardiac family history or
≥160 mg/dL without family cardiac history) after 3 to 6 months of attempting to control
blood glucose levels and diet, pharmacotherapy is warranted.
Statin therapy has been shown to be safe and effective in children and should be the first
pharmacologic intervention. However, long-term safety has not been proven; therefore,
attention should focus on symptoms related to muscle and connective tissues with an
increased risk of rhabdomyolysis (Rosenbloom 2009).

Microalbuminuria

Microalbuminuria is an early sign of diabetic nephropathy. Annual screening allows for
early detection of microalbuminuria so that early treatment can be initiated to reverse
diabetic nephropathy (Silverstein 2005).
Annual screening for microalbuminuria, with a random spot urine sample for
microalbumin-to-creatinine ratio, should be started when the child is 10 years of age and
has had diabetes for 5 years.
Exercise, smoking, and menstruation can affect albumin excretion; therefore, any abnormal
value should be repeated. Two of three consecutive abnormal values should be obtained
on different days to confirm the diagnosis.
Definitions of abnormalities in albumin excretion in children with diabetes are as follows:
Albumin-to-creatinine ratio 30 mg/g to 299 mg/g in a spot urine sample
Timed overnight or 24-hour albumin excretion ratio: 20 mcg/min to 199 mcg/min


Hypertension

Hypertension in adult diabetics is associated with both microvascular and macrovascular
disease. Children with diabetes should have their blood pressure measured at each
visit to prevent the onset of this comorbidity (Silverstein 2005).
Normal blood pressure levels for age, sex, and height are available in the National
Institutes of Health's report on the Diagnosis, Evaluation, and Treatment of High
Blood Pressure in Children and Adolescents.
“High-normal” blood pressure is defined as an average systolic or diastolic blood
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
pressure in the 90th but less than 95th percentile for age, sex, and height
percentile measured on at least 3 separate days.
Treatment of high-normal blood pressure should focus on dietary intervention, weight
management, and increased physical activity.
The goal of treatment is a blood pressure lower than 130/80 or below the 90th
percentile for age, sex, and height.


Hypoglycemia

Hypoglycemia is defined as blood glucose levels lower than 70 mg/dL. Children with type 2
diabetes not taking insulin are less likely to experience hypoglycemia. The following
guidelines are based on children with type 2 diabetes taking insulin.

Children with chronic hyperglycemia may experience symptoms of hypoglycemia despite
normal blood glucose levels (Silverstein 2005). Therefore, it is important to check blood
glucose levels to confirm hypoglycemia rather than basing diagnosis on symptoms alone.

Noctural hypoglycemia is not as common in type 2 diabetes but it can occur in those taking
insulin. Noctural hypoglycemia may be the result of impaired counterregulatory reponse to
hypoglycemia during sleep. Signs and symptoms include nightmares; restless sleep; low
fasting blood glucose levels; and headache, confusion, or behavior changes upon
wakening.
Mild hypoglycemia is characterized by symptoms such as the following:
Sweating
Pallor
Palpitations
Tremors
Difficulty concentrating
Lightheadedness
Lack of coordination
Behavior changes
Treatment of mild hypoglycemia can be alleviated by consuming quick-acting
carbohydrates. The guidelines for treatment include the following:
Consume 15 g glucose or other quick-acting carbohydrate to raise blood glucose
levels 40 mg/dL over 30 minutes. If blood glucose levels are less than 50 mg/dL, 20 g
to 30 g carbohydrate is necessary to raise blood glucose levels appropriately.
Examples of 15 g quick-acting carbohydrates include the following:
15 g carbohydrate glucose tablets or gel
4 oz of fruit juice
6 oz of regular soft drink
1 Tbsp honey or syrup
Blood glucose levels should increase within 15 minutes and should be retested to
ensure levels are within normal ranges.
If blood glucose levels are not within normal ranges, the treatment should be
repeated.
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Adding protein to carbohydrate will not affect blood glucose levels and will not prevent
subsequent hypoglycemia (American Diabetes Association, 2008).
Adding fat may prolong the acute glycemic response; therefore, it is important to
consume quick-acting carbohydrates to treat hypoglycemia.
Severe hypoglycemia is characterized by the following:
Inability to self-treat hypoglycemia because of mental confusion
Lethargy
Unconsciousness
Treatment of severe hypoglycemia includes the following:
Glucagon, which stimulates hepatic glucose release, should be administered
immediately if the patient is unable to ingest carbohydrates.
A glucagon dose of 30 mcg/kg to 1 mg subcutaneously will increase blood glucose
levels within 5 to 15 minutes.
Nausea and vomiting may be associated with glucagon injection.


Anthropometric Measurements

Height-, weight-, and body mass index-for-age (BMI) should be plotted every 3
months on sex-specific growth charts to determine usual growth patterns and recent
weight changes
Specialized growth charts for specific populations are available, such as Down
Syndrome and Prader-Willi syndrome; these charts should be used for such patient
populations in order to make an accurate assesment of growth
BMI-for-age plotting between 5th and 85th percentiles is considered within the normal
and healthy range
BMI-for-age plotting greater than 85th but less than 95th percentile is considered
overweight
BMI-for-age greater than the 95th percentile is considered obese.
BMI-for-age plotting less than the 5th perentile is considered as underweight
WHO growth charts are to be used for infants up to 2 years of age; for older children,
Centers for Disease Control and Prevention (CDC) growth charts include
length-for-age and weight-for-age percentiles as well as head circumference-for-age
and weight-for-length percentiles. All of these charts are available in the Resources
section of this site.


Acute Illness/Sick Day Management

Acute illness can lead to hyperglycemia and ketoacidosis. However, many children with
type 2 diabetes do not take insulin and are not at high risk for developing ketoacidosis.
During acute illness, counterregulatory hormones increase, therefore additional insulin is
required to maintain blood glucose levels (American Diabetes Association, 2008).
The physician should be called if signs of ketoacidosis are present; these signs include the
following:
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Moderate to large ketones with elevated blood glucose levels
Severe nausea
Vomiting
Diarrhea
Abdominal pain
Rapid breathing
Sick day management goals include the following:
Check blood glucose levels and ketones every 2 hours
Give insulin based on blood glucose and ketones
Contact the health care team if an illness persists longer than 24 hours or if the child
is unable to eat regular foods for more than 24 hours
Fluid Requirements:
Fluids containing sodium (broth, tomato juice, sports drinks) are recommended
to avoid depletion of intravascular volume (Franz 2002)
1 oz sugar-free fluid per year of age every hour if blood glucose levels are equal
to 240 mg/dL with ketones
1 oz fluids containing sugar per year of age every hour if blood glucose levels
are less than 240 mg/dL with ketones
At least 1 tablespoon sugar-free fluids every 10 minutes if vomiting and blood
glucose levels are equal to 240 mg/dL without ketones
At least 1 tablespoon fluids containing sugar every 10 minutes if vomiting and
blood glucose levels are less than 240 mg/dL, with or without ketones
Recommended Fluids for Sick Day
Fruit juice
Sugar-containing beverages: ginger ale, regular 7-up
Sports drinks
Tea with honey or sugar
Pedialyte
Jell-O (regular)
Popsicles (regular or diet)
Broth-type soups
Recommended Foods for Sick Day (if patient is able to eat) (Chase 2008)
Saltine crackers
Banana
Applesauce
Bread or toast
Graham crackers
Soup


Alcohol

Alcohol consumption in children and adolescents is illegal in the United States. However, it
is important to discuss the risks associated with drinking alcohol to ensure safe drinking
practices.
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Notes on Alcohol and Diabetes
Alcohol alters the phase of glucose recovery by interfering with hepatic
gluconeogenesis inducing hypoglycemia (Franz 2002).
Low blood glucose levels can occur even before a person is aware of being mildly
intoxicated. On an empty stomach, 2 oz alcohol (1 or 2 drinks) is enough to produce
hypoglycemia.
Drinking a moderate amount of alcohol can blunt the awareness of hypoglycemia in
individuals taking insulin.
Drinking alcohol at night increases the risk of nocturnal and fasting hypoglycemia
(American Diabetes Association, 2007).
Alcohol should be consumed with food to avoid hypoglycemia.


Diabetes Care at School/Day Care

Children and adolescents spend anywhere from 4 to 12 hours at school, day care, or
extended care. School and day care personnel need to be knowledgeable regarding
diabetes care to help students maintain adequate blood glucose control (Silverstein 2005).
Despite the legal protections under Section 504 of the Rehabilitation Act of 1973, the
Individuals with Disabilities Education Act, and the Americans with Disabilities Act, children
and adolescents with diabetes remain discriminated against in school and day care
settings (American Diabetes Association, 2009; Living with Diabetes: Discrimination).
The American Diabetes Association recommends the following (2009):
An individualized Diabetes Medical Management Plan (DMMP) should be developed
by the student’s caregiver and health care team.
The school should provide a safe environment to measure blood glucose levels,
recognize and treat hypoglycemia, diabetic ketoacidosis, and administer glucagon.
Students with diabetes should have access to diabetes supplies (developmentally
appropriate) and should be permitted to self-manage their diabetes in the classroom
or other areas where the student will be participating in school activities.


Exercise and Diabetes

The benefits of exercise include weight control, improved physical and cardiovascular
fitness, lower pulse and blood pressure, improved lipid profile, and an overall greater sense
of well being. It is recommended that all children with diabetes receive a minimum of 30 to
60 minutes of moderate physical activity daily (Dietary Guidelines for Americans, 2005).
Types of Exercise
Anaerobic exercise is characterized by higher intensities of muscular
contractions—includes sports such as sprinting, power lifting, hockey, and basketball.
High-intensity anaerobic exercise can result in post-exercise hyperglycemia (30
to 60 minutes) resulting from increases in catecholamines, free fatty acids, and
ketone bodies, which impair muscle glucose utilization (Riddell 2006)
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Aerobic exercise is characterized by lower rates of muscular contractions that have a
prolonged duration—includes running, cycling, rowing, swimming, soccer, and
ultra-endurance events
Aerobic exercise can result in lower blood glucose levels during and after the
activity
Guidelines for Exercise and Diabetes
Carbohydrate Supplementation
Extra food is not necessary for patients taking oral medication that does not increase
hypoglycemic risk.
For patients taking insulin, an additional 15 g carbohydrate should be consumed if the
blood glucose level is less than 100 mg/dL.
15 g rapid-absorbable carbohydrate should be available for the prevention and
treatment of hypoglycemia and during prolonged activity.
Medication Adjustment for Exercise
Metformin alone does not increase hypoglycemia risk, but patients taking metformin
with insulin, or insulin alone, have an increased risk for hypoglycemia during or after
exercise.
Refer to type 1 diabetes insulin adjustments guidelines for individuals with type 2
diabetes taking insulin.
Self-Monitoring Blood Glucose
Self-monitoring of blood glucose before and after exercise is recommended to
determine glycemic patterns to exercise and to appropriately adjust carbohydrate
and/or insulin doses.


Diabetic Ketoacidosis and HHS

If clinical signs and symptoms seem indicative of Diabetic Ketoacidosis (DKA) and
Hyperosmolar Hyperglycemia State (HHS), the following criteria can be used to confirm
diagnosis (Kitabchi 2001).

Diagnostic criteria for DKA and HHS:

DKA
Mild
DKA
Moderate
DKA Severe HHS
Plasma
glucose
(mg/dL)
>250 >250 >250 >600
Arterial pH 7.25-7.30 7.00-<7.24 <7.00 >7.30
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Serum
bicarbonate
(mEq/L)
15-18 10-<15 <10 >15
Urine
ketones*
Positive Positive Positive Small
Serum
ketones *
Positive Positive Positive Small
Effective
serum
osmolality
(mOsm/kg)
**
Variable Variable Variable >320
>320 anion
gap+
>10 >12 >12 Variable
Alteration
in sensorial
or mental
obtundation
Alert Alert/drowsy Stupor/coma Stupor/coma
*Nitroprusside reation method
** calculation: 2[measured NA(mEq/L0)] + glucose (mg/dL)/18
+ calculation: (Na+) – (Cl# + HCO3#) (mEq/L).

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Nutrition Care > Disorders of Lipid Metabolism
Nutrition Assessment

Key areas of nutrition assessment of a child with dyslipidemia include the following:
Physical assessment
Assess for metabolic syndrome: Evaluate body mass index, waist
circumference, and acanthosis nigricans
Assess for obesity: Body mass index for age >95th percentile
Family history
At least one parent with cardiovascular events before age 55 years
Medical history
Secondary causes of dyslipidemia (as defined by Kwiterovich [2008])
Hypertension (blood pressure by age)
Diabetes
Pancreatitis
Laboratory assessment
Total cholesterol
Low-density lipoprotein cholesterol
High-density lipoprotein (HDL) cholesterol
Non-HDL cholesterol
Triglyceride
Apoprotein-B
Apoprotein-A1
Diet and lifestyle history
Diet and activity patterns
Alcohol intake and smoking (in adolescents)
Drug history
Medications that may alter laboratory values or predispose a child to
dyslipidemia
Side effects of medications if a child has been prescribed cholesterol-lowering
medications

Nutrition-Focused Physical Findings

Overweight or obesity, especially abdominal obesity
Xanthomas (deposits of lipids in the skin)
Xanthelasma (xanthoma of the eyelid)
Corneal arcus (cholesterol deposits in the cornea)
Recurrent abdominal pain
Acanthosis nigricans (related to hyperinsulinemia, part of metabolic syndrome, which
increases cardiovascular risk)

Biochemical Data, Medical Tests and Procedures

Dyslipidemia in childhood is diagnosed and monitored using laboratory values. For children
with coronary artery disease, carotid intima media thickness can be monitored with
ultrasound. It is also to be noted that there are genes that are protective against
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cardiovascular disease, such as the PCSK9, gene which results in reduced low-density
lipoprotein (LDL) cholesterol levels. It reduces the risk of development of congenital heart
disease by the age of 40 to 55 years by 47% to 88%
Classification of Dyslipidemia in Childhood
Lipid Type
Protective
Level
(mg/dL)
Optimal
Level
(mg/dL)
Borderline
Level
(mg/dL)
Elevated
Level
(mg/dL)
Extreme,
Gene-Related
Abnormality
(mg/dL)
LDL-Cholesterol 40-60 <100 100-129 > 130 > 160
HDL-Cholesterol >80 >60 40-59 <40 <30(?)
TG <100 <100 100-200 >200
>400

HDL = high-density lipoprotein; TG = triglyceride
From Zappalla FR, Gidding SS. Lipid management in children. Endocrinol Metab Clin N
Am. 2009;38:171-183. Reprinted with permission from Elsevier. Journal homepage
available at http://www.sciencedirect.com/science/journal/08898529.
Lipid Screening
Unlike lipid screening for adults, there is no consensus on universal lipid screening for
children. Also absent are pediatric markers that predict adult risk for cardiovascular
disease (Daniels, 2008) and a consensus about using single laboratory cutoff values or
having specific cutoffs for age. The National Cholesterol Education Program (NCEP)
provides single cutoff values whereas the Third National Health and Nutrition Examination
Survey (NHANES) provides cutoffs by age. The single NCEP cutoff points for total
cholesterol, LDL cholesterol, and triglycerides have shown to be accurate for identifying
adolescents who develop dyslipidemia in adulthood (Magnussen, 2009). In this same
study, NHANES cutoffs were the best predictors of HDL that tracked into adulthood.
There is controversy as to whether all children should be screened, especially those with
no family history of disease. The American Heart Association statement recommends that
only children with familial history and/or those who present with coronary heart disease
should be screened (McCrindle, 2007). Among children screened, 40% to 55% of those
with elevated lipid levels will still have elevated levels 4 to 15 years later (Hanley, 2007).
The US Preventive Services Task Force states that there is insufficient evidence to
recommend for or against routine screening of lipids for any group of children and
teenagers (Grossman, 2011).
In contrast, the National Lipid Association Expert Panel on Familial Hypercholesterolemia
recommends universal screening at age 9 to 11 years with a fasting lipid profile or
nonfasting non-HDL cholesterol to identify all children with familial
hypercholesterolemias. If nonfasting non-HDL cholesterol is >145 then a fasting lipid
profile is done. A level of LDL >160 or non-HDL cholesterol >190 confirms familial
hypercholesterolemia. If there is a family history of hypercholesterolemia, screening should
occur at >2 years of age. (Daniels, 2011a).
There is agreement that any screening done should occur after 2 years of age, as there is
a gradual increase in total cholesterol before that. Screening should occur no later than 10
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years of age, as lipid levels drop in adolescence and false negative results can be
assessed during puberty and adolescence.
Guidelines for Screening
Child with body mass index = 85% of age- and sex-specific value
Parent with total cholesterol level of >240 mg/dl
Parent, grandparent, or sibling of a parent with cardiovascular disease at younger
than 55 years (for men) or 65 years (for women) with coronary atherosclerosis,
peripheral vascular disease, or cerebrovascular disease; who had a coronary artery
procedure; or who had myocardial infarction or sudden cardiac death
Child who smokes
Child with hypertension
Child with unknown family history
Child with diabetes
Metabolic syndrome adds another risk factor for dyslipidemia. Pediatric Adult Treatment
Panel (ATP) III provides diagnostic criteria for metabolic syndrome in adolescents. Three
of the following five criteria represent a diagnosis:
Blood glucose >100 mg/dL
HDL cholesterol <40 mg/dL
Triglycerides > 110 mg/dL
Waist circumference >90th percentile for age and sex
Blood pressure >90th percentile for age and sex
(Zappalla 2009; McCrindle 2007; Daniels 2008)
See Laboratory for additional information.

Laboratory

Laboratory Tests for Lipid Screening
Initially, total cholesterol is assessed in children with a family history of high cholesterol
levels (>240 mg/dL) (Daniels, 2008; NCEP, 1992). According to The American Heart
Association, if the total cholesterol level is borderline high (170 mg/dL to 200 mg/dL), the
level should be reassessed. If the average is >170 mg/dL, a fasting lipoprotein analysis is
done. The lipoprotein analysis is also done for high total cholesterol (>200 mg/dL). It is
recommended that two lipoprotein panels be done and the low-density lipoprotein (LDL)
averaged, as there is intraindividual variability (Gidding, 2005; McCrindle, 2007).
Lipid panels include the following:
Total cholesterol
Triglyceride
LDL cholesterol
High-density lipoprotein (HDL) cholesterol
Non-HDL cholesterol
Non-HDL cholesterol is determined by total cholesterol minus HDL cholesterol; it is the
amount of cholesterol carried by atherogenic apo B–containing lipoproteins
(very-low-density lipoprotein, intermediate density lipoprotein, and lipoprotein). Non-HDL
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cholesterol is thought to predict adult dyslipidemia as well as LDL cholesterol (Kwiterovich,
2008).
Screening guidelines for dyslipidemia are from a combination of the National Cholesterol
Education Program (NCEP) guidelines and the Third National Health and Nutrition
Examination Survey (NHANES). NHANES provides laboratory guidelines by age and
NCEP gives single cutoffs. Both classifications predict adolescent risk for increased carotid
artery intima-media thickness so the simpler NCEP guidelines are used. The following
table provides the acceptable and abnormal levels.
Category Acceptable Borderline High Low
Total cholesterol <170 170-199 >200
LDL cholestrerol <110 110-129 >130
Non-HDL cholesterol <123 123-143 >144
Apo B <90 90-109 >110
Triglyceride
0-9 years <75 75-99 >100
10-19 years <90 90-129 >130
HDL cholesterol >45 35-45 <35
Apo A-I >120 110-120 <110
(NCEP, 1992, NHANES, 1994)
The Expert Panel on Familial Hypercholesterolemia recommends universal screening for
all children aged 9 to 11 years. It is important to identify familial hypercholesterolemia in
childhood as it is associated with premature coronary heart disease (CHD). The guidelines
for screening are as follows (Daniels, 2011):
Measure non-fasting, non-HDL (subtract HDL from total cholesterol to assess apo
B–containing lipoproteins). A level on non-HDL >145 mg/dL is followed by a fasting
lipid profile.
If there is a family history of hypercholesterolemia or premature CHD, then screening
is done earlier—as early as 2 years of age.
Familial hypercholesterolemia is suspected in patients <20 years if fasting LDL
cholesterol >160 or non-HDL cholesterol is >190 mg/dL.
The goal of treatment is to decrease LDL cholesterol by >50% or <130 mg/dL.

Client History

Age
Sex
Weight
Anthropometric data
Ethnicity
Black children have higher mean total high-density lipoprotein and lower
triglyceride (Hickman, 1998)
Medical history
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Children with monogenic dyslipidemia, familial hypercholesterolemia, familial
defective apolipoprotein-B
Diagnoses associated with coronary artery disease (secondary dyslipidemia):
Diabetes mellitus types 1 and 2
Nephrotic syndrome
Kawasaki disease with aneurysms
Heart transplantation
Metabolic syndrome (insulin resistance syndrome)
Diagnoses where premature coronary artery disease may be present:
Infants born to mothers who are hyperlipidemic (Napoli, 1999)
Kawasaki disease without aneurysms
Human immunodeficiency virus
Post-cancer treatment
Chronic inflammatory diseases
Rheumatoid arthritis
Systemic lupus
Congenital heart diseases (coarctation of the aorta, single coronary anomalies,
transposition corrected by arterial switch procedure) (Zappalla, 2009)
Other risk factors, such as the following:
Hypertension
Smoking or exposure to secondary smoke
Medications that increase cholesterol levels
Progestins
Anabolic steroids
Corticosteroids
Other factors that affect either food intake or limiting physical activity:
Food allergy
Celiac disease
Inflammatory bowel disease
Physical inability to exercise
Physical Activity: More than 60 minutes/day
Family history: Screening should occur if either of the following is present (Daniels, 2008):
Positive family history of dyslipidemia or premature cardiovascular disease (<55 years
of age for men and <65 years of age for women)
If family history is unknown, screening should occur if the following risk factors are
present:
Overweight (body mass index [BMI] = 85th to 95th percentile)
Obesity: (BMI >95th percentile)
Hypertension (BMI) >95th percentile)
Cigarette smoking
Family situation:
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Who does the child live with?
Who prepares the meals?
Where is the food purchased?
What resources are available to purchase food?
What environment does the child live in, with regard to access to physical activity?

Food/Nutrition-Related History

Food history is targeted to assess a child's intake; energy, total fat, saturated fat, trans
fat, and cholesterol intake; and consumption of sugar, sodium, and alcohol.
The positive contribution of fiber, fruit, and vegetables to the diet is also important to
assess.
As children consume much of their energy through beverages, assessment of beverages
consumed is important.
Assessment of where meals are eaten and quantification of fast-food and take-out
frequency should also be performed.
The Dietary Intervention Study in Children showed that snack foods, desserts, and pizza
contribute to one-third of total energy intake at 3 years of age, so special attention must be
given to these foods (Obarzanek, 1997; Van Horn, 2005).
Assess portion sizes and frequency of the following types of food:

Encouraged Discouraged
Dairy
Skim/1% milk
Low-fat cheese
Low-fat yogurt
Low-fat cream cheese
Low-fat cottage cheese
Whole milk
Regular cheese
Whole milk yogurt
Regular cream cheese
Regular cottage cheese
Ice cream
Meat and Other Protein Foods
Fish
Poultry without skin
Very lean meat
Legumes
Soy protein/tofu
Egg whites
Hot dogs
Bologna, ham, luncheon meat
Spareribs
Bacon/sausage
Egg yolk
Bread/Grains
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Whole grains
Whole grain bread
Cold unsweetened cereal
Pasta/rice (whole grain)
Oatmeal and other hot cereals
Croissants
Donuts
Danish pastry
Granola
Toaster pastries
Pizza
Vegetables, Raw or Cooked
All vegetables prepared without added fat
Fried, creamed, buttered vegetables
Vegetables cooked with fatty meat
Vegetables with cheese sauce
Fruits
Any prepared without added fat
Fruit juices (100% juice; 4 to 6 oz daily)
Yogurt-covered fruit
Chocolate-covered fruit
Snacks
Pretzels
Popcorn
Jelly beans
Peanuts
Low-fat crackers/cookies
Almonds
Seeds
Cheese corn and puffs
Chocolate candy
Granola bars
Peanut butter
Desserts
Fudgesicles
Popsicles
Gelatin desserts
Low-fat pudding
Angel food cake
Ice cream
Commercial cakes and pies
Fats and Oils
Low–saturated-fat margarines with no trans fat
Low-fat salad dressings
Corn oil
Canola oil
Olive oil
Low-fat mayonnaise
Margarines containing trans fat
Hard margarines with saturated fat
High-fat salad dressings
Regular-fat mayonnaise
Palm oil
Coconut oil
Butter
Meat drippings/gravy
Lard
Hydrogenated shortenings
Beverages
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Water
Fortified soy milk

Milkshakes
Sports drinks
Juice
Soda
Lattes and other coffee drinks
Fruit smoothies

(Van Horn 2005)
Other factors to assess include the following:
Intake of omega-3 fatty acids
Use of plant stanols and sterols
Amount of soluble fiber in the diet
Herbals/vitamins used
Dietary supplements used
Home environment:
Who the child lives with
Eating patterns in the home
Cooking/meal preparation patterns
Parent eating preferences
Financial support for food (Special Supplemental Nutrition Program for Women,
Infants, and Children; Supplemental Nutrition Assistance Program (SNAP); soup
kitchens; food pantries)
School breakfast participation
School lunch participation
Afterschool snack provisions at an institution or at home
Amount and type of physical activity
Cultural food preferences
Cultural response to weight gain
Number of times/week eating fast food
Number of hours/day screen time


Comparative Standards

Calculate body mass index (BMI) (weight [kg]/height [cm
2
]) and plot on the Centers for
Disease Control and Prevention age for BMI graph (for age 2 years and older).
Blood pressure percentiles can be determined by clicking on the Calculators menu item on
the International Pediatric Hypertension Association Web site.
Calculate energy needs using estimated energy requirements formulas (see Calculators
section).
Protein needs are calculated by multiplying the Dietary Reference Intake for protein for age
by weight in kilograms.
Calculate grams of fat for restriction as follows:
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Multiply energy needs x 30% and divide by 9.
If treatment is for infants and younger children, percentages of energy from fat will be
higher:
1 year: 30% to 40%
2 to 3 years: 30% to 35%
4 to 8 years: 25% to 35%
9 to 13 years: 25% to 35%
14 to 18 years: 25% to 35%
Determine saturated fat needs by multiplying energy needs by 10%; for greater restriction,
multiply by 7%.
Determine trans fat limits, by multiplying total kilocalories by 1%. If the patient's
diet includes meat and dairy, which naturally have trans fat in them, other foods containing
trans fat need to be eliminated.
The remainder of allowed fat (total fat minus the sum of the saturated fat and trans fat)
should be provided as monounsaturated and polyunsaturated fat.
Physical activity is calculated at 60 minutes/day.
Fluid is not restricted with medical nutrition therapy and follows guidelines for age for
children and adolescents. It is important to review fluids consumed, as some beverages
may contribute to fat and energy intake (such as lattes, candy-based milk shakes, juice,
and sports drinks). These drinks can also contribute to weight gain.

Nutrition Diagnosis

Registered dietitians working with patients who have disorders of lipid metabolism should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the following list,
as well as other diagnoses, may be present.
Excessive oral intake (NI-2.2)
Excessive fat intake (NI-5.6.2)
Inappropriate intake of fats (NI-5.6.3)
Excessive carbohydrate intake (NI-5.8.2)
Inadequate fiber intake (NI-5.8.5)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Food–medication interaction (NC-2.3)
Overweight/obesity (NC-3.3)
Food and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Limited adherence to nutrition-related recommendations (NB-1.6)
Undesirable food choices (NB-1.7)
Physical inactivity (NB-2.1)
Sample Problem, Etiology, Signs and Symptoms or Nutrition Diagnostic Statement(s)
Inappropriate intake of saturated and trans fats (NI-5.6.3) related to lack of healthful
food choices as evidenced by low-density lipoprotein cholesterol >160
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mg/dL and non–high-density lipoprotein cholesterol >145 mg/dL.
Not ready for lifestyle change (NB-1.3) related to lack of efficacy to make change or
overcoming barriers to change as evidenced by client history and lack of change in
laboratory data.
Note: Terminology in the examples above is from the third edition of the International
Dietetics and Nutrition Terminology. Code numbers are inserted to assist in finding more
information about the diagnoses, their etiologies, and signs and symptoms. Registered
dietitians should not include these numbers in routine clinical documentation.


Nutrition Intervention

Nutrition Prescription Synonym or Acronym: Healthy lifestyle is preferred for the
population approach
Nutrition Intervention Terminology
Examples include the following:
Meals and Snacks: Modify distribution, type or amount of food and nutrients within meals or
at specified time (ND-1.2)
Bioactive Substance Management: Plant sterol and stanol esters (ND-3.3.1)
Nutrition Education: Nutrition relationship to health/disease (E-1.4); Recommended
modifications (E-1.5)

Both the American Heart Association and the American Academy of Pediatrics have
published nutritional management guidelines for children.
Population Approach
A healthy lifestyle will decrease the number of children who develop abnormal lipid and
lipoprotein concentrations. This approach is for children who are 2 years or older (NCEP,
1992). Recommendations are as follows:
Balanced energy intake
Sufficient physical activity to attain/maintain appropriate weight
A diet that emphasizes fruit, vegetables, whole grains, and low-fat dairy products
A reduction in the intake of fruit juice and sugar-sweetened beverages and foods
A reduction in salt intake
Limit trans fat intake (found in partially hydrogenated fat and in fried and baked
products) ( Gidding, 2005)
Choose low-fat and nonfat dairy products(Gidding, 2006)
Choose beans, fish (especially oily), and lean meat
Use vegetable oils and soft margarines (with no hydrogenated fat) instead of butter
Choose whole grain breads and cereal

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Individual Approach
This individual approach is designed for high-risk children and adolescents. As previously
described, this group includes children with a family history of cardiovascular disease or
children who have risk factors, including children with genetically based dyslipidemias. The
diet changes to implement are as follows:
Total fat limited to 25% to 35% of the total energy, dependent on age (younger
children having more fat)
Saturated fat is restricted to 7% of the total energy
Trans fat limited to 1% of the total energy
Dietary cholesterol is no more than 200 mg
Increase soluble fiber
Increase intake of stanols and sterols
Limit intake of sugar
Counsel on identifying and decreasing saturated and trans fats. Label reading and learning
about choices at fast-food restaurants is also reviewed. Explore reasons for unhealthful fat
choices. Explore portion sizes.
Other considerations include the following:
Soluble fiber is thought to remove cholesterol from bile acids and to reduce
enterohepatic circulation. Adding 5 to a child’s age is commonly used to estimate goal
for fiber intake. For example, the daily fiber intake goal for an adolescent aged
15 years is 20 g/day.
Plant stanols/sterols lower the absorption of cholesterol and can reduce cholesterol by
5% to 10%. Spreads, margarine, orange juice, yogurt drinks, cereal bars, and dietary
supplements have stanols/sterols added. Children in studies were given doses
ranging from 1.6 g to 3 g. Rather than adding additional margarine or other foods to
the diet, an amount of fat is replaced with a comparable amount of the fortified
margarine (Kaitosaari, 2003).
Increase physical activity to 60 minutes/day. Physical activity increases high-density
lipoprotein (HDL) cholesterol and decreases triglyceride. It can have a lowering effect
on low-density lipoprotein (LDL) cholesterol as well.
Decrease all screen time (television, computer, video games) to no more than 1
hour/day
Omega-3 fatty acids: Although there is evidence in the adult population to provide
omega-3 fatty acids, guidelines for children are not currently available. Fish intake 2
to 3 times/week is generally recommended. Docosahexaenoic acid supplementation
of 1.2 g/day (in children 8 to 21 years) has been studied and shown to be effective in
decreasing dense LDL.
Soy protein (Laurin, 1991): 35% of protein energy as soy protein has been shown to
have no effect on plasma cholesterol or total LDL cholesterol. It does increase HDL
cholesterol and the sub-class HDL2 cholesterol, however. Soy protein also reduces
very-low-density lipoprotein (VLDL) and triglycerides.
Overproduction of VLDL results in hypertriglyceridemia.
Lifestyle changes are considered primary therapy for children with disorders of lipid
metabolism, because of the relationship between adiposity and hypertriglyceridemia.
These changes include the following:
Balancing energy intake and expenditure to achieve optimum weight is most
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
important for treating hypertriglyceridemia.
Increasing physical activity and reducing screen time (TV, computer, and video
games).
Reducing intake of sugar-sweetened beverages and food to half of the discretionary
energy allowance
For children needing 1,200 kcal to 1,400 kcal per day, sugar restriction is 16 g or
4 tsp of added sugar
At 1,600 kcal, this is reduced to 12 g or 3 tsp (Johnson, 2009)
Lowest triglyceride levels are noted when added sugar is <10% of the energy.
(Miller, 2011)
Limiting refined carbohydrates
Eating whole grain breads, cereals
Using vegetable oils and soft margarine (Gidding, 2005)
For adolescents, avoiding alcohol
Other therapies include increasing soy protein, which lowers VLDL
There are limited data regarding drug therapy for hypertriglyceridemia in children.
Bile acid–binding resins are not indicated because they increase triglyceride
levels (Manlhiot, 2009)
Fibrates have been suggested for effective treatment of hypertriglyceridemia in
adults
Small studies of efficacy in children have been reported
Studies of fish oil in adults resulted in triglyceride reduction; it is proposed that fish oil
stimulates apo B degradation and therefore VLDL hepatic production is reduced
(Jonkers, 2006)
Levels suggested for adult therapy are 2 g/day to 4 g/day; suggestions have not
been established for children (McKenney, 2007)
Studies on children taking docosahexaenoic acid alone have not shown any
change in triglyceride
Pharmacologic intervention is recommended for children older than 8 years with
homozygous familial hypercholesterolemia or for children in whom LDL cholesterol
continues to increase beyond acceptable levels.
Specific Guidelines by Age for Total Energy
a
, Total Fat, Saturated Fat, Trans Fat,
and Cholesterol
Age
1
year
Age
2-3
years
Age 4-8
years
Age 9-13
years
Age
14-18
years
Approximate
Total Daily
Energy
900
kcal
1,000
kcal
Female:
1,200
kcal;
Male:
1,400
kcal
Female:1,600
kcal;
Males: 1,800
kcal

Females:
1,800 kcal;
Males:
2,200 kcal
Fat, % of
Total Energy
<30%
(<33
g)

<30%
(<40 g)
<30% (<53.3
g Female)
(<60 g Male)
<30%(<60
g Female)
(<73.3
g Male)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Saturated
Fat
<7%
(<7.7
g)

<7%
(<9.3 g)

<7%
(<12.4 g
Female)
(<14 g Male)
<7%
(<14 g
Female)
(<17.1 g
Male)

Trans Fat <1% <1% <1% <1%
Cholesterol <200
mg
<200 mg <200 mg <200 mg
a
Energy estimates are based on a sedentary lifestyle.
(Gidding, 2005; Gidding, 2006)

Daily Portions

Food Group Age
1
Year
Age
2-3
Years
Age 4-8
Years
Age
9-13
Years
Age
14-18
Years
Fats & Oils 3-4 tsp 4-6 tsp Female:
4-6 tsp;
Male: 5-7
tsp
Female:
5-6 tsp;
Male: 5-7
tsp
Lean
Meat/Legumes
1.5
oz
2 oz Female:
3 oz eq;
Males: 4
oz eq
Female:
5 oz eq;
Male: 5
oz eq
Female:
5 oz eq;
Male: 6
oz eq
Milk/Dairy
(Nonfat, Low
Fat)
2
cups
2 cups 2 cups 3 cups 3 cups
Grains 2 oz 3 oz Female:
4 oz eq;
Male: 5
oz eq
Female:
5 oz eq;
Male: 6
oz eq
Female:
6 oz eq;
Male: 7
oz eq
Vegetables ¾
cup
1 cup Female:
1 cup;
Male: 1.5
cup
Female:
2 cups;
Males:
2.5 cups
Female:
2.5 cups;
Males: 3
cups
Fruits 1 cup 1 cup 1.5 cup 1.5 cup Female:
1.5 cup;
Males: 2
cups

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Nutrition Therapy Efficacy

The Dietary Intervention Study in Children (DISC) study (Obarzanek, 1997), the Special
Turku Coronary Risk Factor Intervention Project (Raitakari, 2005), and 5 other studies were
evaluated with the general population of children. These diet studies showed a reduction of
8% in low-density lipoprotein (LDL) cholesterol with a 3-year follow-up. At ages 5 and 7
years, the reduction was not sustained without follow-up (Hanley, 2007).
Several randomized controlled diet studies in children with monogenic dyslipidemias have
been reviewed; results were as follows:
Efficacy of Diet and Drug Therapies for Dyslipidemia

Total
Cholesterol
Reduction
LDL
Reduction
Reduction
in Small,
Dense
LDL
Particles
Triglycerides HDL
Diet Therapies 7.4%-11% 10%-14%
Soluble fiber
increase
7%
Stanol/sterol
increase<
10%
DHA (omega-3
fatty acids)
No change 48% No change
No
change
DHA & EPA
(Omacor)
No change No change
27%
reduction
with 3.4 g

Soy beverage
4%
increase
Drug Therapies
Statins 17%-32% 19%-41% Mixed Mixed
Cholestyramine Yes Yes No change
No
change
Colestipol Yes Yes No change
No
change
Physical
Activity
No change No change No change No change
23%
increase
reported
over
diet and
behavior
and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and
control
groups
HDL = high-density lipoprotein; DHA = docosahexaenoic acid; EPA = eicosapentaenoic
acid
(Hanley, 2007; Ferguson, 1999; Engler, 2005)
Adequacy of Nutrition Therapy
The adequacy of the medical nutrition therapy for reduced fat, reduced saturated fat, and
reduced cholesterol has been studied in children. Breastfeeding would be the gold
standard for infants up to 12 months of age. In general, fat restriction is not recommended
before the child is 2 years of age because of the need for fat in neurological development.
An exception is children who are between the ages of 12 months and 2 years and have a
family history of obesity, dyslipidemia, or cardiovascular disease. For these children,
reduced-fat milk would be recommended before the age of 2 years.
The Special Turku Coronary Risk Factor Intervention Project monitored children from 7
months to 7 years on a fat-reduced diet and did not find nutritional inadequacies but did
find that LDL was reduced in boys at age 7 (Raitakari, 2005).
In children aged 8 to 10 years, at 3 years of follow-up, there were no adverse effects on
growth, development, and sexual maturation when the nutrition prescription for
cardiovascular disease was followed (Daniels, 2008; Obarzanek, 1997). The Dietary
Intervention Study in Children also showed that higher intakes of folate, vitamins C and A,
and iron were ingested when less fat was consumed. Hemoglobin and ferritin were higher
in children consuming less fat. Calcium and zinc were shown to be consumed at lower
intakes but there were no biochemical abnormalities (Van Horn, 2005).
Medications for lowering LDL may affect the adequacy of the diet as follows:
Bile acid sequestrants may result in gastrointestinal symptoms, constipation,
cramping, and bloating, which can affect the appetite. They also decrease absorption
of folate and other fat-soluble vitamins, possibly necessitating supplementation
(Tonstad, 2000).
Cholesterol absorption blockers may also result in gastrointestinal symptoms and may
affect appetite.
Statins (3-hydroxy-3-methyl-glutaryl coenzyme reductase inhibitors) may increase
hepatic transaminase levels and elevate creatine kinase, which, in rare cases, could
result in rhabdomyolysis.


Goal Setting

The overall goals of medical nutrition therapy for children with hypercholesterolemia and for
the caregivers who manage their lifestyle factors are as follows:
Improve serum lipid levels
Identify and manage cardiovascular risk factors
Maintain normal growth and development without promoting obesity
Encourage a physically active lifestyle
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Encourage a physically active lifestyle
The children and their families will accomplish the following:
Identify and limit sources of saturated fat, trans fat, and cholesterol.
Read labels accurately to accomplish this limitation.
Select polyunsaturated sources of fat and sources of linoleic and docosahexaenoic
acids (DHA). Be careful of mercury in any fish-derived oil. Lovaza is the
pharmaceutical grade of fish oil, containing both DHA and eicosapentaenoic acid.
Maintain percentage of energy from total fat at approximately 30% per diet
prescription.
Identify monounsaturated fat as beneficial in reducing low-density lipoprotein and
increasing high-density lipoprotein.
Select appropriate portions of food.
Select food intake that emphasizes fruits, vegetables, whole grains, and low-fat dairy
products and, if meat is preferred, includes lean meats.
Identify other foods that contribute to a healthy heart: fatty fish, soluble fiber, plant
sterols and stanols, and DHA
Limit added sugar to <10% of the energy in the diet and be able to read food
product labels to identify the amount of sugar in processed foods.


Nutrient Exceptions to DRI

A diet low in saturated and trans fats and cholesterol used to manage
hypercholesterolemia is nutritionally adequate. Fat- and cholesterol-restricted diets support
normal growth and development and have been studied in children as young as 7 months
(Tammi, 2002).
When sterols or stanols (which can reduce low-density lipoprotein [LDL] cholesterol by
8%) and/or drug therapy are provided, special attention to fat-soluble vitamins and, in a few
cases, folate and beta carotene is essential. If intake of foods high in carotene
(orange-colored foods such as carrots, apricots, and mango) or foods high in folate (such
as spinach, broccoli, and kale) is low, then a pediatric multivitamin can be provided.
Drug Therapy for Abnormal Lipoproteins and Nutrients Affected
Drug Class
Effect on
LDL
Effect on Other
Laboratory Values
Nutrients
Affected
Bile Acid
Sequestrants*
Decreases
LDL by 13%
to 20%
May increase triglyceride
levels
May increase
homocysteine levels in
some patients
May
interfere with
absorption of
fat-soluble
vitamins

May
increase
folate needs
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
HMG CoA
Reductase
Inhibitors
(statins)
Decreases
LDL with
increasing
doses
- Increases liver
transaminases
- Increases creatine
kinase

Rare instances of
myopathy
Increases cortisol
- Increases
dehydroepiandrosterone
Growth
normal over
time
Niacin or
Nicotinic Acid
Decreases
LDL
Decreases
triglyceride
Increases
high-density
lipoprotein
(HDL)
Decreases
lipoprotein A
Increases liver
transaminases
Glucose intolerance
Hyperuricemia

Fibric Acid
Derivatives
Increases
HDL
Decreases
triglyceride
-Increases liver
transaminases
-Increases creatine
kinase

Cholesterol
Absorption
Inhibitors
Decreases
LDL
cholesterol
by 20%

*Colesevalam (tablet or powder) is indicated for use in the pediatric population aged 10 to
17 years.

Suggested Monitoring Parameters and Recommendations

Repeat laboratory assessments and review and follow up with patient and family to identify
barriers to selecting lower-saturated and trans fats for the child with lipid metabolism
disorder. Lowered levels of low-density lipoprotein (LDL) and triglycerides as well as
non–high-density lipoprotein cholesterol are indicative of an effective intervention.
Monitor weight and body mass index (BMI) and blood pressure.
It is also important to monitor foods that contribute to obesity, including fruit juices,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sweetened drinks, and fast food. It is noted that one-third of the energy in a child’s diet
comes from snacks (Gidding, 2005). Foods most likely to contribute to increased BMI and
LDL in children are snack foods, pizza, dairy foods, and breads and grains. The intake of
these foods should be carefully monitored (Obarzanek, 1997).
Monitor for increased levels of soluble fiber and plant sterols that have been shown to
decrease LDL.
Review intake of docosahexaenoic acid, which is also shown to decrease the density of
LDL, resulting in a less atherogenic lipoprotein.

Nutrition Care FAQs

Q. Should I be concerned about total fat or saturated fat amounts on food labels?
A. Both total fat and saturated fat are important to note on the label. Your registered
dietitian will give you upper limits for both of these types of fat. In general, saturated fat is a
greater concern because it lowers the ability to take up the fat carrier, low-density
lipoprotein (LDL), and therefore more cholesterol will circulate in the blood.
Q. What are trans fats and how much can my child consume in her diet?
A. Trans fat is produced by the food industry to improve the consistency of food. Generally,
a liquid oil is hydrogenated to make it harder, which changes the oil from an unsaturated
fat to a saturated fat or trans fat. Some shortenings and margarines have trans fat. If
commercial or home-baked goods containing this substance are consumed, the human
body identifies and uses it like saturated fat. Therefore, avoidance of trans fat is
recommended.
Q. What are the healthful fats?
A. Healthful fats are polyunsaturated fat and monounsaturated fat. Fish oils are high in
omega-3 fatty acids, which are also heart healthy.
Q. How much total fat should my child consume in a day?
A. Typically, approximately one-third of the calories in a child’s diet (after the age of 2
years) is fat calories. Your registered dietitian will help you to understand how to convert
these calories to grams of fat, which are listed on food labels. The levels and type of fat are
limited related to the degree of cardiovascular risk and the age of your child.
Q. How can my child raise his high-density lipoprotein (HDL) level?
A. Although genetics is important in determining your child’s HDL level, exercise can
increase HDL. A higher HDL is desirable, as it carries away excess cholesterol to the liver,
where it is broken down.
Q. Will a healthful diet lower my child's cholesterol?
A. Typically healthful diet changes will lower cholesterol by 10% to 13%.
Q. What are triglycerides, what causes elevated levels, and how can they be
lowered?
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A. Triglycerides are the fat that circulates in the blood. As the fat content of your child's diet
increases, the amount of fat circulating in the blood increases until the liver or muscles
remove it. When a person consumes high levels of fat or genetically has the inability to
remove it from the blood, the triglycerides will increase. Triglycerides also increase when a
child consumes excessive calories.
Q. Will fish oils lower my child’s cholesterol?
A. There are 2 types of omega-3 fatty acids in fish oils: docosahexaenoic acid (DHA) and
eicosapentaenoic acid. DHA has been shown to decrease the density of LDL. The denser
the LDL, the more atherogenic the LDL becomes, so fish oils are recommended to lower
cholesterol. Over-the-counter fish oils are likely to be contaminated with mercury and lead,
which could have neurological implications for children.
Q. How much fish is safe to eat?
A. Although fish is an important food for children with cardiovascular risk, it has the same
risk of contamination as the fish oils. The US Food and Drug Administration (FDA) and
your local Environmental Protection Agency will provide guidance on safe waterways in
your state. In general, 2 servings of fish or shellfish per week is recommended. For most
children, this would be two 3-ounce servings per week. The fish and
shellfish containing the lowest amount of mercury are shrimp, canned light tuna, salmon,
pollock and catfish. Most fish sticks are made with low-mercury fish. If white albacore tuna
is consumed, then fish consumption for that week should be limited to the one serving of
tuna only. Fish containing high levels of mercury are shark, swordfish, king mackerel, and
tilefish—these should not be consumed by children.
FDA information regarding mercury content in seafood is available here.
Q. How much margarine would my child have to eat to get enough sterols or stanols?
A. Sterols inhibit cholesterol absorption from the gut. They have been shown to decrease
LDL cholesterol by approximately 10% when 1.6 grams/day are consumed. Depending on
the concentration of the sterol in a product, a manufacturer would need to be contacted to
assess what volume should to be consumed to get 1.6 grams.
Products that are fortified with sterols and stanols include margarines, yogurts, granola
bars, and fruit juices including orange juice. It is best to replace some fat in the diet with
sterol-/stanol-containing products rather than adding additional calories.

Anthropometric Measurements

Anthropometric measurements that should be recorded and plotted on the Centers for
Disease Control and Prevention (CDC) growth charts include the following:
Weight for age
Height for age (2 years of age and older)
Body mass index for age (2 years of age and older)
Weight for length
CDC growth charts should be used for children 2 years to 20 years old. Anthropometric
measurements include weight for age, height for age, and BMI for age.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
World Health Organization growth charts should be used for children aged 0 to 24 months.
Anthropometric measurements include weight for age, height for age, weight and height for
age, head circumference.
Skinfolds and bioelectrical impedance can be used to note changes in body fat.
To measure the child's waist:
Use waist circumference tape 1.
Measure at narrowest part of torso above umbilicus and below ribs 2.
Compare with following chart for waist circumference by age (Fernandez, 2004): 3.

Estimated value for percentile regression for all children and adolescents combined,
according to sex
Percentile for boys Percentile for girls
10th 25th 50th 75th 90th 10th 25th 50th 75th 90th
Intercept 39.7 41.3 43.0 44.0 40.7 41.7 43.2 44.7 46.1
Slope 1.7 1.9 2.0 3.4 1.6 1.7 2.0 2.4 3.1
Age (y)
2 43.2 45.0 47.1 48.8 50.8 43.8 45.0 47.1 49.5 52.2
3 44.9 46.9 49.1 51.3 54.2 45.4 46.7 49.1 51.9 55.3
4 46.6 48.7 51.1 53.9 57.6 46.9 48.4 51.1 54.3 58.3
5 48.4 50.6 53.2 56.4 61.0 48.5 50.1 53.0 56.7 61.4
6 50.1 52.4 55.2 59.0 64.4 50.1 51.8 55.0 59.1 64.4
7 51.8 54.3 57.2 61.5 67.8 51.6 53.5 56.9 61.5 67.5
8 53.5 56.1 59.3 64.1 71.2 53.2 55.2 58.9 63.9 70.5
9 55.3 58.0 61.3 66.6 74.6 54.8 56.9 60.8 66.3 73.6
10 57.0 59.8 63.3 69.2 78.0 56.3 58.6 62.8 68.7 76.6
11 58.7 61.7 65.4 71.7 81.4 57.9 60.3 64.8 71.1 79.7
12 60.5 63.5 67.4 74.3 84.8 59.5 62.0 66.7 73.5 82.7
13 62.2 65.4 69.5 76.8 88.2 61.0 63.7 68.7 75.9 85.8
14 63.9 67.2 71.5 79.4 91.6 62.6 65.4 70.6 78.3 88.8
15 65.6 69.1 73.5 81.9 95.0 64.2 67.1 72.6 80.7 91.9
16 67.4 70.9 75.6 84.5 98.4 65.7 68.8 74.6 83.1 94.9
17 69.1 72.8 77.6 87.0 101.8 67.3 70.5 76.5 85.5 98.0
18 70.8 74.6 79.6 89.6 105.2 68.9 72.2 78.5 87.9 101.0
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Reprinted from Fernández JR, Redden DT, Pietrobelli A, Allison DB. J Pediatr.
2004;145:439-444 with permission from Elsevier. All rights reserved. Journal homepage
available at http://www.sciencedirect.com/science/journal/00223476.
Waist circumference greater than the 90th percentile for age correlates with increased
atherogenic lipoprotein profile (Bassali, 2009; Flodmark, 1994).



Oral Intake

Children who have the most difficulty with the nutrition therapy are those with familial
dyslipidemias. Frequently, these children have a low body mass index, so restricting
higher-fat foods makes it difficult to maintain weight. Some of the other therapies, including
soluble fiber and consumption of fish, may not be typical foods in a child’s diet, so these
individuals need to learn and be supported in new food choices. It is essential that children
following these diet restrictions have support from their caregivers; they often need family
to be role models for them.
Snacking and dining out at fast-food restaurants is common with children of all ages and is
the source of much of the saturated and trans fats in their diets. Education needs to focus
on these food groups.
For the younger child with dyslipidemia, picky eating and food refusal can be
evident. Intervention with a feeding team is an option for these children.
There are side effects from medication to control low-density lipoprotein cholesterol that
cause gastrointestinal discomfort, which makes it difficult for children on such prescriptions
to follow the diet plan.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Epilepsy
Epilepsy


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Epilepsy > Pharmacologic Management
Nutrition Assessment

The nutrition assessment should include an evaluation of the child’s food and fluid
intake/tolerance, method of feeding, growth pattern, age, activity level, motor and cognitive
function and development, and the nutritional effects of medical interventions for seizure
control. Vitamin, mineral, and herbal supplements should be also reviewed for complete
nutrition assessment. Nutrition assessment for children with epilepsy on a non-ketogenic
diet is the same as for other children.
Nutrition assessment includes the following:
Client History and Food/Nutrition-Related History
Nutrition-Focused Physical Findings (also refer to Anthropometric Measurements)
Biochemical Data, Medical Tests, and Procedures


Nutrition-Focused Physical Findings

Some children with seizure disorders may exhibit completely normal function, growth, and
development, whereas others may be severely, even catastrophically, incapacitated by
seizures and related developmental disabilities.
Patients taking phenytoin may exhibit gingival hyperplasia. Felbamate can cause aplastic
anemia and phenobarbital can cause aplastic and megaloblastic anemia.
Physical findings may suggest vitamin, mineral, and protein–energy deficiencies. Most of
the physical findings are not specific to an individual nutrient deficiency and must be
assessed along with the historical, anthropometric, and laboratory findings to make a
diagnosis (Morgan, 1999).
The most common nutritional concerns among children with epilepsy are osteopenia and
osteoporosis resulting from the impairment in the renal conversion of vitamin D to active
form caused by many anticonvulsant medications. Children who are immobile have an
additional risk for bone demineralization. The American Academy of Pediatrics
recommends a higher intake of vitamin D for this population.
The new Dietary Reference Intakes (DRIs) for vitamin D are as follows (FNB, 2011):
Infants age 0 to 12 months: 400 IU/day
Children age 1 to 18 years): 600 IU/day
The DRI recommends the following daily calcium intake (FNB, 2011):
0 to 6 months: 200 mg
6 to 12 months: 260 mg
1 to 3 years: 700 mg
4 to 8 years: 1,000 mg
9 to 18 years: 1,300 mg
See Vitamin D, Calcium, Phosphorus, and Bone for more information.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Comparative Standards

Adequate fluid maintains optimal hydration and assists in the prevention and treatment of
constipation. Estimates of fluid requirements based on weight are usually the most
accurate.

Estimated Maintenance Fluid Needs
Patient Weight Daily Maintenance Fluid Requirements
<10 kg 100 mL/kg
10-20 kg 1,000 mL + 50 ml for each kg > 10 kg
>20 kg 1,500 mL + 20 ml for each kg > 20 kg

Energy requirements for children with seizure disorders vary significantly. Energy
requirements depend, in part, on the child’s level of seizure activity, physical activity, and,
possibly, on the degree of spasticity or frequency of muscle contractions related to seizures
(Duncan, 1999). In the child with seizures who has normal growth, function, and activity,
energy requirements should be similar to those of the child without seizures.
When growth is blunted or seizures are coupled with physical impairment, clinicians should
not rely solely on the estimated energy requirements (EER). Disability-specific standards
for estimating energy needs in children (such as calculated by kilocalories per centimeter)
are available; however, they are often of limited use due to small sample size, limited age
ranges studied, and the necessity of an accurate stature measurement (Wittenbrook,
2011). The Dietary Reference Intake equation for calculating energy needs is the most
useful in the acute setting, as it can be adjusted to meet children's needs by adjusting
physical activity/stress coefficients (Wittenbrook, 2011). Children who are severely
debilitated as a result of a seizure disorder may require as little as 50% to 75% of the EER
for energy to maintain weight (Duncan, 1999). When standard prediction equations become
unreliable, a trial-and-error approach may be required to determine an appropriate energy
intake level (Duncan, 1999). Food record and weight history are also essential
tools to assist in assessing children's energy requirements.
Brain activity constitutes a large percentage of the basal metabolic rate in children. The
impact of surgical hemispherectomy, seizure-induced impairment of normal brain function,
or convulsive muscle contractions on energy expenditure is unknown. Comprehensive
nutrition assessment remains the cornerstone of estimating energy requirements in this
population.

Nutrition Diagnosis

Registered dietitians (RDs) working with patients who are on antiepileptic drugs should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the following list
and other diagnoses may be present.
Increased nutrient needs (specify) (NI-5.1)
Inadequate vitamin intake (specify) (NI-5.9.1)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Swallowing difficulty (NC-1.1)
Altered gastrointestinal function (NC-1.4)
Food–medication interaction (NC-2.3)
Unintended weight loss (NC-3.2)
Unintended weight gain (NC-3.4)
Sample PES (Problem, Etiology, Signs and Symptoms) or Nutrition Diagnostic
Statement(s)
Increased nutrient needs (calcium) (NI-5.1) related to carbamazepine
prescribed, causing altered absorption or metabolism of calcium, as evidenced by
decreased serum and ionized calcium levels.
Food–medication interaction (NC-2.3) related to phenytoin dosage as evidenced by
decrease in serum folate levels.
Swallowing difficulty (NC-1.1) related to hemispherectomy as evidenced by
postoperative pharyngeal function and aspiration.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd ed. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.


Nutrition Intervention

Folate
Folate deficiency can be difficult to reverse in children on antiepileptic drugs once it has
occurred, since supplementation alters phenytoin pharmacokinetics, usually leading to
lower serum concentrations and possible seizure breakthrough. However, preventive folate
supplementation of 1 mg/day, beginning with the first dose of phenytoin, prevents
decreased serum folate levels and folate deficiency, normalizes phenytoin metabolism, and
increases serum phenytoin concentration. It should be common practice to start folic acid at
initiation of phenytoin to prevent drug–nutrient interaction complications (Lewis, 1995).
Because folate supplements can mask symptoms of vitamin B-12 deficiency, assessment
of vitamin B-12 status and vitamin B-12 supplementation may also be warranted.
Protein
Protein requirements are individualized to the child according to weight; age; and, when
available, assessment of serum protein levels. Children with reduced energy expenditures
resulting from limited activity or developmental delay may require a greater percentage of
their total energy requirements as protein than children with more typical energy
expenditures. If seizures consistently interfere with adequate intake, a more nutrient-dense
diet may be required.
Energy
Patients’ daily energy intake may need to be adjusted as carbamazepine, gabapentin,
valproate, and ACTH can cause weight gain (Ness-Abramof, 2005; Ben-Menachem, 2007;
Asconapé, 2002, Verrotti, 2011). Felbamate, topiramate, zonisamide, ethosuximide, and
stiripentol may cause weight loss (Ben-Menachem, 2007; Asconapé, 2002; Chiron, 2006).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

For more information on interventions for specific nutrient issues, refer to the following
sections:
Vitamin D, Calcium, Phosphorus, and Bone
Folate and Phenytoin
Carnitine and the Liver

Goal Setting

The goals of nutrition intervention for a child with a seizure disorder are as follows:
To promote optimal growth and development
To prevent or correct nutritional anomalies
To minimize the negative impact of antiepileptic drugs on nutritional status

Behavior

A child with poorly controlled or intractable seizures has a significantly greater risk for
feeding problems; gastrointestinal dysfunction; and malnutrition secondary to delayed,
stagnant, or regressed physical and/or cognitive development (see Developmental
Disabilities) (ADA, 2010). Multidisciplinary assessment by rehabilitation therapists along
with the registered dietitian may be warranted.
Oral-motor dysfunction and prolonged feeding times can significantly decrease energy
intake, but conscientious efforts by caregivers to improve intake are effective in reducing
the risk (Thommessen, 1991). Occupational therapy and adaptive equipment may help
increase nutrient intake if self-feeding is hampered by fine-motor deficits. Speech therapy
and a modified-consistency meal plan may be required if oral motor skills are impaired.
Surgical interventions in children with seizure disorders may temporarily increase energy
expenditure and nutrient requirements to support healing and recovery. Since most surgical
procedures on the brain have the potential to affect chewing and swallowing, oral-motor
and pharyngeal function should be evaluated postoperatively—and the consistency and
texture of foods should be altered, as required—to maximize the child’s oral intake while
minimizing the risk of aspiration.
Small, frequent, nutrient-dense feedings can help maximize intake; proteins, fats, and
sugars may be added to foods to increase energy and protein content. (See various
high-energy, high-protein nutrition therapies under Meal Plans.)

Enteral Nutrition or Tube Feeding

Age-appropriate nutritional supplements or enteral nutrition (see Enteral Nutrition Support)
may be required if the child chronically or increasingly demonstrates the inability to eat
enough to sustain optimal nutritional status.

Nutrition Therapy Efficacy
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Diets for children with seizure disorders must be individualized and planned appropriately
to fully meet 100% of the Dietary Reference Intakes for all vitamins and minerals.
However, special considerations for supplementation should be given to patients taking
medications known to affect certain nutrients in the diet (see Drug–Nutrient
Interactions) (Duncan, 1999).
Children who are severely debilitated as a result of a seizure disorder may require as little
as 50% to 75% of the estimated energy requirement to maintain weight.
When an enterally fed child requires less than 1 L of formula to meet requirements for
macronutrients, supplementation is crucial to prevent micronutrient deficiencies.
Serum trace metal homeostasis might be affected by valproic acid (VPA) therapy, as VPA
may cause copper elevation and zinc depletion (Armutcu, 2004). VPA therapy also can
lower serum free carnitine (Matsui, 1991). Carbamazepine decreases serum biotin and
lower pyruvate carboxylase protein (Rathman, 2003). Complete nutrition assessment and
nutrition supplementation are essential for long-term anticonvulsant treatment in children.

Nutrition Monitoring & Evaluation

During each clinic visit, the patient's height and weight are measured. Triceps skinfold
measurement is an additional tool, if feasible, to assess the patient’s fat storage. Food
records maintained by the patients/parents/caregivers and the biochemical index are also
assessed periodically. The nutrient intake—which includes food or formula, carnitine, and
vitamin and mineral supplements—are continually monitored and adjusted as needed for
optimal growth and nutritional status. Blood work should be reviewed regularly to ensure
adequate supplementation.


Anthropometric Measurements


Careful anthropometric measuring and recording are essential. Children with cerebral
palsy or other developmental disabilities may require modified equipment or methods
for weighing and measuring.
Anthropometrics will include height or length and weight.
Mid-arm circumference and triceps skinfold measurements can be taken if the
registered dietitian believes they will be useful for monitoring and follow-up during the
course of the nutrition therapy.
Indirect calorimetry is usually not indicated unless there is a concern that the patient's
energy needs are very different from what would be predicted for age, condition, and
weight.
Head circumference is one of the last indicators to be affected by undernutrition in
infants and is generally not related to nutrition in children older than 3 years. A
decrease in head circumference percentiles in a child younger than 3, when
accompanied by decreases in weight and height percentiles, could signal a significant
nutritional insult.
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Drug-Nutrient Interactions

Antiepileptic drugs (AEDs) may negatively affect nutritional status and quality of life. The
nutritional impact is often drug- or dose-dependent and may affect the oral cavity,
gastrointestinal tract, hepatic or renal function, bone density, appetite, weight, behavior,
and/or micronutrient metabolism. Supplements may be required with certain AEDs (see the
table on this page); for more information, refer to the discussions of specific nutrients later
in this section: Vitamin D, Calcium, Phosphorus, and Bone; Folate and Phenytoin; and
Carnitine and the Liver.
Impeccable daily oral hygiene and routine professional dental care are paramount to
prevent AED-related tooth and gum diseases, since painful, swollen, and inflamed gums
negatively affect oral intake (Zhou, 1996). Blood chemistries should be routinely monitored,
and registered dietitians should be cognizant of physical signs that suggest nutrient
deficiency.

Nutrition-Related Adverse Effects Associated with Selected AEDs


Potential Adverse Effects
Name
Nutrients
Affected
Oral
a
Weight Gastrointestinal
b
Liver
c
Renal
Calculi
Bone
d
Carbamazepine
Calcium,
vitamin D,
folate,
carnitine
Y Gain Y Y N Y
Ethosuximide
Calcium,
vitamin D
Y Loss Y N N Y
Felbamate – N Loss Y Y N N
Gabapentin – Y Gain N N N N
Phenobarbital
Calcium,
vitamin D,
folate,
carnitine
N – Y Y N Y
Phenytoin
Calcium,
vitamin D,
folate,
carnitine
Y – Y Y N Y
Stiripentol
(Diacomit)
– Y Loss Y Y Y N
Topiramate – N Loss Y N Y N
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Valproate
Calcium,
vitamin D,
carnitine
N Gain Y Y N Y
Zonisamide – N Loss Y N Y N
Lamotrigine – Y Loss Y Y N N
ACTH
Phosphate,
calcium,
sodium,
potassium
N Gain N N N N


a
Dry mouth, hypersalivation, gingival hyperplasia
b
Nausea, vomiting, diarrhea, constipation
c
Elevated liver function tests, hepatotoxicity
d
Impaired osteoid synthesis and calcification, osteoporosis, fractures, rickets
(McAbee, 2000; Pellock, 1999; Zhou, 1996; Baer, 1997; Chung, 1994; Kishi, 1997;
Chapman, 1997; Lewis, 1995; Bazil, 1998; Pronsky, 2000; Bergen, 1995; Holland, 2000;
Demir, 2000; Novak, 1999; Pavlakis, 1998; Akin, 1998; Kubota, 2000; De Vivo, 1998;
Raskind, 2000; Freeman, 2000; Oommen, 1999; Perez, 1999; Chiron, 2000)

Vitamin D, Calcium, Phosphorus, and Bone

Impaired osteoid synthesis and calcification, osteoporosis, fractures, and rickets have been
reported in children on long-term antiepileptic drugs (AEDs) (Pack, 2004; Petty, 2007;
Nakken, 2010; Zhang, 2010). AEDs such as carbamazepine, ethosuximide, phenobarbital,
phenytoin, valproic acid, and topiramate have been associated with inhibited intestinal
calcium transport, increased turnover of skeletal minerals, impaired bone resorption and
formation, inhibition of the cellular response to parathyroid hormone, hyperparathyroidism,
and/or synthesis of inactive forms of vitamin D (Pack, 2004; Zhang 2010). Serum levels of
calcium, phosphate, calcitonin, alkaline phosphatase, and 25-(OH)-vitamin D and
1,25-dihydroxy-vitamin D may be altered, or the deficiencies may be subclinical (Zhang
2010). Increased urinary calcium excretion may precipitate renal calculi in susceptible
children, particularly those on zonisamide (Kubota, 2000).
Bone integrity depends on several factors. Heredity, sex hormones, exposure to sunlight,
physical activity or mobility, weight-bearing status, and calcium and vitamin D intake are
variably controlled in published studies on AEDs and bone density (Nakken, 2010). Of all
these factors, careful follow-up and adequate supplementation of calcium and vitamin D
may be of primary importance (Heller, 2001).
Children with disabling epilepsy and reduced energy requirements are routinely found to
have inadequate intakes of calcium, phosphorus, and vitamin D, even when tube fed
(Shellhaas, 2010a; Menon, 2010; Nakken, 2010). Routine screenings, vitamin D and
calcium supplementation, and bisphosphonates are recommended for the treatment of
AED-associated bone disease (Pack, 2004). The 2011 Dietary Reference Intakes
(DRIs) for calcium and vitamin D are as follows (FNB, 2011):
Vitamin D
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Younger than 1 year: 400 IU/day
Older than 1 year: 600 IU/day
Calcium
0 to 6 months of age: 200 mg
6 to 12 months: 260 mg
1 to 3 years: 700 mg
4 to 8 years: 1,000 mg
9 to 18 years: 1,300 mg


Folate and Phenytoin

Antiepileptic drugs (AED) that induce hepatic microsomal enzymes such as phenobarbital
(Kishi, 1997), phenytoin (Kishi, 1997; Lewis, 1995), and carbamazepine (Kishi, 1997) are
associated with decreased serum folate levels. The nutritional impact of the interdependent
relationship between folate and phenytoin has been the most studied. The decrease in
serum folate seems to be dependent on dosage and duration of therapy but does not
necessarily correlate with serum AED levels (Kishi, 1997).
It was once mistakenly believed that anticonvulsant activity depended on inhibition of folic
acid (Bazil, 1998). Studies now show that preventive folate supplementation initiated
concurrently with AEDs can improve seizure control through enhancement of
pharmacokinetics and pharmacodynamics (Lewis, 1995).
Folic acid is thought to be a cofactor in the metabolism of phenytoin. If concurrent folate
supplements are not given at the beginning of therapy, phenytoin begins to immediately
decrease folate concentration through several mechanisms (Lewis, 1995). Phenytoin may
increase intraluminal pH, causing malabsorption of dietary folate; inhibit intestinal enzymes
responsible for converting dietary folate to its absorbable form; impair folate transport into
tissues; or deplete folate through induction of liver enzymes (Kishi, 1997). Folate deficiency
can lead to microcytosis and megaloblastic anemia and has been implicated in gingival
hyperplasia, a well-known complication of phenytoin. Gingival hyperplasia is characterized
by inflammation, fibroblastic proliferation, and excess collagen deposition in gum tissue.
Researchers suspect that gingival hyperplasia is triggered by induction of cytochrome P450
isoenzyme systems in gingival cells, resulting in folate depletion and oxidative injury to gum
tissues (Zhou, 1996; Arva, 2011).
In the child on AEDs, folate deficiency can be difficult to reverse once it has occurred, since
supplementation alters phenytoin pharmacokinetics, usually leading to lower serum
concentrations and possible seizure breakthrough. However, preventive folate
supplementation of 1 mg/day, beginning with the first dose of phenytoin, prevents
decreased serum folate levels and folate deficiency, normalizes phenytoin metabolism, and
increases serum phenytoin concentration. It should be common practice to start folic acid at
initiation of phenytoin to prevent complications from this drug–nutrient interaction (Lewis,
1995). Since folate supplements can mask symptoms of vitamin B-12 deficiency,
assessment of vitamin B-12 status and vitamin B-12 supplementation may also be
warranted.

Carnitine and the Liver

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Antiepileptic drugs (AEDs)—phenobarbital, phenytoin, carbamazepine, felbamate, and, in
particular, valproic acid (VPA)—have been associated with hepatotoxicity in children. Most
of these AEDs are also associated with decreased serum carnitine levels, and many
researchers believe that there is a link between the two (De Vivo, 1998; Raskind, 2000;
Hamed, 2009; Lheureux, 2009). Some new-generation AEDs, such as vigabatrin,
lamotrigine, and topiramate probably do not cause carnitine deficiency (Zelnik, 2008).
Carnitine is a nonessential amino acid with vitamin-like properties that is involved in
transport of long-chain fatty acids into mitochondria for beta-oxidation (De Vivo, 1998;
Raskind, 2000). Carnitine deficiency is suspected to alter fat metabolism, increase levels of
cytotoxic metabolic byproducts, and impair mitochondrial synthesis and energy production
(Raskind, 2000). Carnitine is primarily obtained from endogenous hepatic biosynthesis
from the essential amino acids methionine and lysine. Dietary sources of carnitine include
red meats, dairy products, fish, and poultry (Raskind, 2000). Total plasma carnitine is
composed of free and esterified (acyl) forms. Only L-carnitine is bioactive; neonates and
infants have less of the enzyme needed for conversion (Raskind, 2000). The AED
valproate requires carnitine for oxidation (Raskind, 2000) and is thought to deplete body
carnitine stores (De Vivo, 1998).
How carnitine deficiency might precipitate hepatotoxicity is unclear. One proposed
mechanism, based on epidemiological surveys and registry data on valproate adverse
reactions, suggests that valproate may exacerbate existing malnutrition syndromes in
fragile children with epilepsy, resulting in tissue carnitine deficiency that ultimately leads to
hepatotoxicity (De Vivo, 1998). Consensus guidelines for carnitine supplementation in
childhood epilepsy, issued in 1996 (De Vivo, 1998), define carnitine deficiency as a
plasma-free concentration of less than or equal to 20 mcmol for children older than 1 week
after term. For repletion, the panel recommends oral L-carnitine equal to 100 mg/kg/day in
divided doses, up to a maximum of 2 g/day; higher doses of intravenous carnitine may be
required for emergency conditions such as VPA-induced hepatotoxicity (De Vivo, 1998).
Supplements are generally well tolerated; nausea, dose-related diarrhea, and a fishy body
odor have been reported (De Vivo, 1998).
However, prophylactic or routine carnitine supplementation for children on AEDs remains
controversial for a number of reasons. Plasma carnitine levels correlate poorly with tissue
stores, which most studies do not measure. This is significant, since 98% of total body
carnitine is stored in concentrations up to 70 times higher than plasma concentrations (De
Vivo, 1998). Since most studies do not measure carnitine levels before initiation of AED
therapy, deficiencies may be related to factors other than the AED (De Vivo, 1998).
Most symptoms of carnitine deficiency are subjective and nonspecific (eg, lethargy,
appetite loss, anemia, gastrointestinal distress, failure to thrive, and hepatic insufficiency)
and may be related to factors other than carnitine deficiency (De Vivo, 1998; Raskind,
2000). Conversely, mechanisms other than carnitine deficiency have been proposed to
explain hepatic insufficiency and hepatotoxicity (De Vivo, 1998; Freeman, 1994; Graf,
1998). Risks associated with carnitine supplementation are low, but related costs are high;
and supplementation may improve symptoms no better than placebo in mildly symptomatic
children (Raskind, 2000).
It is generally agreed that supplementation should be reserved for symptomatic children
with low serum carnitine levels who are at high risk for morbidity and mortality related to
carnitine deficiency—this includes children who are younger than 2 years, are on AED
polytherapy or valproate monotherapy to treat a complex neurological disorder, have renal
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or hepatic impairment, are malnourished, are on long-term total parenteral nutrition, or are
on the ketogenic diet (Kubota, 2000).

Biochemical Data, Medical Tests and Procedures

Blood chemistries should be routinely monitored, and registered dietitians should be
cognizant of physical signs or laboratory results that suggest altered levels of calcium,
phosphorus, vitamin D, folate, and carnitine. For ketogenic diet patients, monitor selenium
and vitamin A to retinol-binding protein molar ratio. Lipid level can be assessed every 6 to
12 months, depending on the patient's history.
For more information, refer to the following sections:
Drug-Nutrient Interactions
Vitamin D, Calcium, Phosphorus, and Bone
Folate and Phenytoin
Carnitine and the Liver

Client History

Client history should include the following:
Family
Parents’ marital status
Educational background
Cultural and religious beliefs
Living arrangement
Number of siblings and their ages and health conditions
Others living in the home such as grandparents, aunts, and uncles
Financial and other socioeconomic status concerns
Social and medical support
Insurance coverage
Government or private financial assistance
Family history
Epilepsy
Hyperlipidemia
Renal stones
Child’s health
Seizure type(s) and frequency
Epilepsy syndrome
Other diagnosed conditions
Medications and methods of administration


Food/Nutrition-Related History

The nutrition history intends to identify underlying mechanisms that put patients at risk due
to nutritional depletion/excess or unsafe swallowing leading to possible complications. A
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition history form or oral interview may be collected by mail or phone call or during the
clinic visit with the patient, parents, and/or caregivers.
Information for the food- and nutrition-related history should include the following:
Patient’s name
Date of birth
Weight, height, head circumference, date of measurement
Weight history, especially with recent weight change
Current medicines, dose and dose time
Current vitamin/mineral supplements, dose and dose time
Activity level
Seizure type and frequency
Previous seizure medicines
Family history
Food allergies and intolerances
Chewing difficulties, swallowing difficulties, feeding route (oral or tube or both)
Religious or cultural dietary restrictions (Zupec-Kania, 2004)
Feeding abilities
Independent or requiring assistance
Food consistency
Regular
Soft/minced
Pureed
Formula through tube
Formula through bottle
Schedule and number of meals/snacks, feeding ability, appetite/portion size of intake,
types of foods patients would eat
Gastrointestinal concerns
Vomiting
Aspiration
Nausea
Diarrhea
Constipation
Results if videofluoroscopy and swallowing studies have been performed and if
feeding difficulties exist


Parenteral Nutrition

Apply the same nutrition standards for parenteral nutrition to patients with epilepsy as to
patients without epilepsy.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Epilepsy > Dietary Management
Dietary Management


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Nutrition Care > Epilepsy > Dietary Management > Classic Ketogenic Diet
Nutrition Intervention

Before Diet Initiation
Patients are instructed to stop consuming all sweets 1 week before initiating the diet (Liu,
2008). Dietitians should also provide information to parents/caregivers regarding topics
such as the following:
Fasting vs. not fasting
How to initiate the diet
Materials needed for initiating the diet
Diet Initiation
Centers often admit patients into hospital to initiate the diet. Fasting may be appropriate
when a quicker time to response is desired, but it is not necessary for long-term efficacy
and may have more immediate side effects. In select situations, the ketogenic diet (KD)
can also be started as an outpatient (Kossoff, 2009).
Whether they are fasted or not, for patients initiated while admitted to the hospital, meals
are typically advanced daily in one-third energy intervals until full-energy meals are
tolerated, while keeping the KD ratio constant (Kossoff, 2009). As outpatients, another
approach to initiating the diet is to begin with full energy but the KD ratio increases daily
from 1:1, 2:1, 3:1, to 4:1 to allow the patient to acclimate to the increasing concentration
(Bergqvist, 2005; Kossoff, 2009).
Vitamin and mineral supplements are adjusted from baseline biochemical indices to meet
the Dietary Reference Intakes in each patient (Liu, 2008). Baseline serum carnitine level is
used to determine supplemental carnitine requirements at 50 mg/kg to 100 mg/kg body
weight. In order to initiate the vitamin and mineral supplements safely, one supplement is
started on a weekly basis, after the diet is initiated, to monitor for possible allergy or
intolerance (Liu, 2008).
If patients admitted to the hospital experience any side effects related to the diet, such as
hypoglycemic or excess ketosis, the KD ratio is immediately lowered (such as lower diet
ratio from 4:1 to 3.5:1 or 3.5:1 to 3:1) to decrease the amount of dietary fat and ensure
patient safety and tolerance. Fine-tuning of the diet to help improve patient’s seizure
control is usually happening after patient discharged from the hospital.
During diet initiation, dietitians continue to provide education to parents/caregivers/patients,
on the following topics:
Identifying foods that are appropriate for the diet
Calculating the diet
Understanding how the diet prescription is created
Weighing foods/formula
Reading labels
Providing adequate vitamin/mineral supplements for the patient
Dealing with complications and potential problems
Knowing what to do if the child becomes sick
Nurses also teach parents/caregivers/patients how to measure blood glucose, urine
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
ketones and urine-specific gravity.
Fine-Tuning and Follow-Up
After patients are discharged from the hospital, they are monitored via phone or e-mail plus
monthly clinic visits for 3 months, then visits every 3 to 6 months (Liu, 2008). If the patients’
seizure control is not efficacious, the KD diet ratio can be gradually increased by either
0.25:1 or 0.5:1 intervals (in other words, increase the diet ratio from 3:1 to 3.25:1 or 3.5:1)
provided the patient’s urine ketone level is low (lower than 80 mg/dL to 160 mg/dL) and
blood glucose is within the normal range (55 mg/dL to 75 mg/dL) (Zupec-Kania, 2008).
During the fine-tuning stage, the dietitian monitors the patient’s progress and modifies the
diet ratio to boost ketosis for better seizure control. Nutrition assessment and nutrient
adjustment are also essential to ensure best growth and nutritional status for each patient.
During the fine-tuning and follow-up, dietitians continue education to parents/caregivers
regarding any questions and problems that may arise, such as when diet and
vitamin/mineral supplements need to be changed and how to wean off the diet.

Ketogenic Ratio

The ketogenic ratio represents the relationship between the grams of fat and the combined
grams of protein and carbohydrate (CHO). In a 4:1 ratio, there are four times as many fat
grams for every 1 g of protein and CHO combined. The ratio is intended to regulate the
degree of ketosis, with a higher ratio theoretically stimulating greater ketosis. The higher
the ratio, the lower the protein and CHO content of the diet (Zupec-Kania, 2004).

Calculating Dietary Units
Dietary unit represents an energy value based on the ratio of fat grams to CHO and
protein. In a 4:1 ratio, a dietary unit has 4 g fat for every gram of protein and CHO
combined. Because fat has 9 kcal/g and the protein and CHO combination has 4 kcal/g,
the dietary unit in the 4:1 ratio has 40 kcal per dietary unit: (9 kcal x 4 g = 36 kcal) + (4 kcal
x 1 g = 4 kcal) = 40 kcal/dietary unit (Zupec-Kania, 2004).
To calculate the number of dietary units for a given diet prescription, divide the energy goal
by the kilocalories per dietary unit for the indicated ratio (see table below).
For example, 1,300 kcal, 4:1 ratio classic ketogenic diet: 1,300 kcal ÷ 40 kcal/dietary unit =
32.5 dietary units (Zupec-Kania, 2004).

Calculating the Fat
The number of fat grams that are required to satisfy the ratio requirement is determined by
multiplying the dietary units by the fat unit in the ratio.
Continuing the example from above for 4:1 ratio, fat equals:
32.5 dietary unit x 4 = 130 g fat daily (Zupec-Kania, 2004).

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Calculating the Protein
The ketogenic diet calculation should allow sufficient protein for normal growth and tissue
turnover (Zupec-Kania, 2004). The Dietary Reference Intakes provide protein goals based
on age and weight in Table 3 in the Comparative Standards section.
For example, a child aged 7 years who weighs 23 kg requires 22 g protein daily:
23 kg x 0.95 g/kg = 22 g protein
It is important to consider that limited energy intake may cause some of the dietary protein
to be used for energy. Careful monitoring of growth and protein status during ketogenic diet
therapy will provide guidance in modifying the diet to preserve endogenous protein
(Zupec-Kania, 2004).

Calculating the Carbohydrate
In order to calculate the grams of carbohydrate, the grams of protein must be calculated
first. The next step is to multiply the dietary units by the unit in the ratio to give a total for
protein and CHO. The last step is to subtract the grams of protein from this number to
determine the grams of carbohydrate allowed daily.
For example: 32.5 dietary units x 1 = 32.5
A child aged 7 years who weighs 23 kg requires 22 g protein, so:
32.5 – 22 = 10.5 g carbohydrate per day (Zupec-Kania, 2004)

Adjusting the Carbohydrate
The carbohydrate value may need to be adjusted to account for nonfood sources of
carbohydrate such as medications and supplements. For example, if the total of the
carbohydrate content from medications and supplements is equal to 500 mg, the excess
amount of carbohydrate should be subtracted from the total dietary carbohydrate allowance
(Zupec-Kania, 2004):
10.5 g carbohydrate (diet) – 0.5 g (nonfood) = 10.0 g carbohydrate

Kilocalories per Dietary Units
Nutrients (kcal)
Fat: Protein +
Carbohydrate
Ratio
Fat
Protein +
Carbohydrate
Value/Dietary
Unit (kcal)
2.0:1
2.0 g
x 9
kcal =
18
1 g x 4 kcal/g =
4
22
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2.5:1
2.5 g x
9 kcal
= 22.5
1 g x 4 kcal/g =
4
26.5
3.0:1
3.0 g x
9 kcal
= 27
1 g x 4 kcal/g =
4
31
3.5:1
3.5 g x
9 kcal
= 31.5
1 g x 4 kcal/g =
4
35.5
4.0:1
4.0 g x
9 kcal
= 36
1 g x 4 kcal/g =
4
40
Source: Zupec-Kania, 2004

Oral Intake

Food groups included in a ketogenic meal plan include the following:
36%, 38% or 40% cream
Meat/egg/poultry/seafood
Vegetable oil/butter/mayonnaise
Vegetables/fruits
All foods can be in regular, soft/minced, or pureed form. Foods have to be measured in
decimal grams.
Calculations are available in the Ketogenic Diet Ratio heading. Computer applications for
calculating ketogenic diets—including “KetoCalculator,” a web-based calculator—can save
time and minimize errors (Zupec-Kania, 2008).

Weaning from the Ketogenic Diet

The timing and actual method for discontinuing the ketogenic diet (KD) are often
individualized based on patient response to the diet (Kossoff, 2009). Most parents are
counseled to continue administering the KD, even if apparently ineffective, for at least 3
months (Freeman, 2006). The International KD Study Group agreed that the KD should be
used for at least a mean of 3.5 months before considering discontinuation (Kossoff, 2009).
In children with more than 50% reduction in seizures, the KD is often discontinued after
approximately 2 years; however, in children in whom seizure control is nearly complete
(more than 90% seizure reduction) and side effects are low, the diet has been reported as
helpful for as long as 6 to 12 years (Groesbeck, 2006). This 2-year period is traditionally
based on a similar time period used for anticonvulsant drugs, which are often discontinued
after that time period in children who become seizure-free (Kossoff, 2009). Children with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
glucose transporter protein 1 deficiency, pyruvate dehydrogenase deficiency, or tuberous
sclerosis complex may require longer KD duration than patients with other conditions
(Kossoff, 2009). Among pediatric patients who have ceased all seizures while on the KD,
80% will remain seizure free after the diet has been discontinued (Martinez, 2007).
Although the diet can be discontinued abruptly in an emergency, typically in an intensive
care unit, it is more often tapered slowly over 2 to 3 months by gradually lowering the
ketogenic ratio from 4:1 to 3:1 to 2:1, then ketogenic foods are discontinued, but energy
and fluids are increased experimentally (Kossoff, 2009).

Once urinary ketosis is resolved, high-carbohydrate foods can be reintroduced. This
recommendation is based on traditional practice pattern and mimics the several weeks of
gradual wean off anticonvulsant drugs (Freeman, 2006). During this time period, nutritional
supplementation needs to be continued. If seizures worsen, the KD can be increased to the
previously effective formulation (Kossoff, 2008). In the majority (58%) of these cases,
seizure control can once again be attained with earlier KD or anticonvulsants (Martinez,
2007).

Nutrition Prescription

The initial energy level can be calculated at 80% to 100% of the Recommended Dietary
Allowance (Zupec-Kania, 2004). The International Ketogenic Diet Study Group advised it is
not necessary to restrict energy intake to 80% to 90% of the daily recommendations for age
as this has never been shown to be beneficial in patients.
An underweight child should be started at energy based on current weight then increased
gradually over time. An overweight child should be allowed to grow to appropriate length for
weight rather than incurring weight loss (Kossoff, 2009). The diet prescription is a ratio of
the weight of fat to the sum of protein and carbohydrate. In a 4:1 ratio, there are 4 grams
of fat for every 1 protein gram and carbohydrate combined (Zupec-Kania, 2008). Therefore,
the classic diet prescription is the number of kilocalories and ratio of fat weight to every 1
protein gram and carbohydrate combined. One example of a classic ketogenic diet
prescription would be a 1,250-kcal, 4:1 ratio classic ketogenic diet.
The classic ketogenic diet is usually divided into three meals and a bedtime snack. The
bedtime snack is made up of 10% of the patient’s daily allowance for carbohydrate, protein,
and fat. The remaining 90% of prescribed carbohydrate, protein, and fat are evenly divided
into breakfast, lunch, and dinner. The advantage of the bedtime snack is to provide ketone
resources overnight, lowering the risk of nighttime or early moring seizures. Meal patterns
can also be varied according to each patient’s habits, daily routine, and seizure control.
Carbohydrate-free or low-carbohydrate multivitamin and mineral supplements are
prescribed according to adjustment from baseline biochemical indices to meet the Dietary
Reference Intake for each patient (Liu, 2008).


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Nutrition Care > Epilepsy > Dietary Management > MCT Oil Ketogenic Diet
Food/Nutrition-Related History

Food and nutrition history can help the medical team and parents/caregivers choose the
ketogenic diet (KD) most suitable for the individual.
Any patient that is on valproate is not a candidate for the medium-chain triglyceride
(MCT) KD due to reports of liver failure when MCT oil and valproate are combined (Liu,
2008). Candidates for the MCT KD do not have chronic diarrhea, are not gastrostomy tube
fed, do not aspirate, and are older than 1 year. Most candidates for the MCT KD are also
picky eaters, are teenagers/adults, and/or have large appetites (Liu, 2008).

Nutrition Intervention

Before Diet Initiation
Patients are instructed to stop consuming all sweets 1 week before initiating the diet (Liu,
2008). Dietitians also provide information to parents/caregivers regarding the following
topics:
Fasting vs. not fasting
How to initiate the diet
Equipment needed for initiating the diet
Diet Initiation
Centers usually admit patients into hospital to initiate the diet. Fasting may be appropriate
when a quicker time to response is desired, but it is not necessary for long-term efficacy
and may have more immediate side effects (Kossoff, 2009).
Whether they are fasted or not, for patients initiated while admitted to the hospital, meals
are typically advanced daily in one-third energy intervals of 6 feeds until full-energy meals
are tolerated; the percentage of the medium-chain triglyceride (MCT) oil is kept constant
(Liu, 2008).
Vitamin and mineral supplements are adjusted for each patient from baseline biochemical
indices to meet recommended intakes (Liu, 2008). Baseline serum carnitine level is used to
determine supplemental carnitine requirements at 50 mg/kg to 100 mg/kg body weight. In
order to initiate the vitamin and mineral supplements safely, one supplement is
administered on a weekly basis after the diet is initiated to monitor for possible allergy or
intolerance (Liu, 2008).
If diarrhea or vomiting occurs, the MCT is lowered by 10% immediately until the patient is
able to tolerate the diet. Vomiting is treated immediately with a diphenhydramine
suppository ordered by the medical staff. If vomiting recurs within 6 hours, oral fluids are
discontinued and hydration proceeds with intravenous normal saline; feedings are
continued at a 10% lower MCT dose. Oral fluids are reintroduced as tolerated. Patients are
discharged when they tolerate the MCT ketogenic diet without vomiting or diarrhea and
caretakers are confident that they can manage the diet (Liu, 2008).
During diet initiation, dietitians provide close continued teaching to
parents/caregivers/patients about the following components:
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Identifying foods that are appropriate for the diet
Calculating the diet
Understanding how the diet prescription is made
Weighing foods/formula
Reading labels
Dosing adequate vitamins/minerals supplements
Dealing with complications and potential problems
Knowing what to do if the child becomes sick
Nurses may also teach parents/caregivers/patients how to measure blood glucose, urine
ketones, and/or specific gravity.
Fine-Tuning and Follow-Up
After patients are discharged from the hospital, they are monitored via phone or e-mail plus
monthly clinic visits for 3 months, then visits for every 3 to 6 months (Liu, 2008). If
a patient’s seizure control is not sufficient, MCT oil can be gradually increased by 0.1 g to
1.0 g per feed every 1 to 3 days according to individual tolerance. Dietitians can also
increase MCT oil during the morning, afternoon, or bedtime feeds to improve seizure
control based on the timing of the seizures and urine ketone level (Liu, 2008).
During the fine-tuning stage, the dietitian monitors the patient’s progress and modifies the
diet to achieve the most effective seizure control. Nutrition assessment and nutrient
adjustment are also essential to ensure optimal growth and nutritional status for each
patient.
Dietitians will continue to provide education to parents/caregivers regarding questions and
problems that arise such as when diet and vitamin and mineral supplements need to be
modified and how to wean off the diet.

Oral Intake

Six food groups form the basis of the MCT oil ketogenic diet:
Starches/grains 1.
Dairy (skim milk/nonfat yogurt) 2.
Meat/egg/poultry/seafood 3.
Vegetables/fruits 4.
Fat 5.
Medium-chain triglyceride (MCT) oil 6.
A food exchange is used to calculate the MCT diet. See the table below for the MCT diet
exchange list, which is from the patients’ teaching handbook in the Hospital for Sick
Children at Toronto (Liu, 2010). Each food portion by gram of weight was calculated
according to Bowes & Church’s Food Values of Portions Commonly Used (Pennington,
1998).
The MCT ketogenic diet is divided into three meals plus three snacks per day. One gram of
MCT oil is equal to 8.3 kcal. MCT oil can be mixed into milk or a salad dressing since it has
no taste or smell; however, MCT oil cannot be used for frying at high temperature. It should
be stored in a dark glass container.
Daily MCT oil needs to be equally divided into 6 feeds in decimal grams during diet
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Daily MCT oil needs to be equally divided into 6 feeds in decimal grams during diet
initiation. If patient’s seizure control is not the most efficacious MCT oil can be gradually
increased by 0.1 g to 1.0 g per feed every 1 to 3 days based on individual tolerance. MCT
oil can also be increased for only the morning. afternoon, or bedtime feed(s) to improve
seizure control based on the timing of the seizures and urine ketone level (Liu, 2008).

MCT Ketogenic Diet Exchange List
1 Exchange Carbohydrate
(g)
Protein (g) Fat (g)
Starch 15 2 0
Fruits and
Vegetables
10 1 0
Milk 6 4 0
Protein
(Lean)
0 7 3
Fat 0 0 5

The following foods—which are used for the purpose of example and are not an exhaustive
list—are equal to 1 starch exchange:
Foods Weight/Exchange
Breads: Whole wheat, cracked-wheat, rye,
enriched white; flour tortilla; bagel; English
muffin; bun or dinner roll; pita; rice cake
30 g
Cereals: Ready-to-eat, unsweetened (shredded
wheat, corn flakes, Rice Krispies, Cheerios,
puffed wheat)
Dry cooked cereal (eg, oatmeal)
20 g
Rice: Brown and white cooked 60 g
Pasta/noodles, cooked 50 g
Potatoes (whole and without skin), yams, and
sweet potatoes
75 g
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Potato chips, corn chips, taco chips (nachos),
cheese puffs
30 g (also 2 fat
exchanges)

The following items—which are used for the purpose of example and are not an exhaustive
list—are equal to 1 fruit and vegetable exchange:
Foods: Weight/Exchange
Applesauce, unsweetened 88 g
Apple, raw 75 g
Watermelon, diced 140 g
Pak choi (Chinese cabbage) 560 g
Spinach, raw 280 g
Asparagus 230 g
Watermelon, diced 140 g

The following are equal to 1 milk exchange:
Foods: Weight/Exchange
Skim milk 125 g
Nonfat buttermilk 125 g
Nonfat evaporated milk50 g
Powdered skim milk 15 g
Plain, nonfat yogurt 80 g

The following items—which are used for the purpose of example and are not an exhaustive
list—are equal to 1 protein exchange:
Foods Weight/Exchange
Lean beef, chicken, goat, ham, pork, turkey, veal, and wild game
(ground or minced, sliced, steak)
30 g
Egg in shell (raw or cooked) 55 g
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Fish fillet or steak, or fish canned in water and drained, herring,
sardines
30 g
*Cottage cheese 55 g

The following are equal to 1 protein exchange and 1 fat exchange:

*Cheese (hard, block) 25 g
*Cheese, dry and finely grated (e.g., parmesan) 15 g
*Bologna 20 g
*Peanut butter (100 % peanuts, unsweetened) 15 g

Foods marked with an asterisk should be eaten with greater caution since they contain
carbohydrate. Use only one serving per day. In larger serving sizes, the quantity of
carbohydrate may be significant, and should be counted as an exchange (eg, 5 g
carbohydrate = 1/2 fruit and vegetable exchange). You can look up the nutritional values of
these foods on labels, or write/ call companies for specific brand information

The following—which are used for the purpose of example and are not an exhaustive
list—are equal to 1 fat exchange:
Vegetable oil 5 g
Butter or margarine 5 g
*Avocado 30 g
*Bacon 5 g
*Cream cheese 15 g
*Nuts: brazil. cashews, hazelnuts, peanuts, pistachios,
sesame seeds, sunflower seeds, walnuts
10 g
*Heavy whipping cream 15 g
*Mayonnaise 7.5 g

Foods marked with an asterisk should be eaten with greater caution since they contain
carbohydrate. Use only one serving per day. In larger serving sizes, the quantity of
carbohydrate may be significant, and should be counted as an exchange (e.g., 5 g
carbohydrate = 1/2 fruit and vegetable exchange). You can look up the nutritional values of
these foods on labels, or write/ call companies for specific brand information.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
these foods on labels, or write/ call companies for specific brand information.
Free foods: Less than 1 kcal per day

Source: Liu YMC. MCT ketogenic diet handbook (Handout). Toronto, ON: The Hospital for
Sick Children; 2010.

Nutrition Prescription

The initial energy level can be calculated at 80% to 100% of the Recommended Dietary
Allowance. The diet prescription is dependent on the percentage of the medium-chain
triglyceride (MCT) oil. The diet is initially calculated at 50% MCT, 19% carbohydrate, 10%
protein, and 21% long-chain fat. Therefore, the MCT ketogenic diet (KD) prescription is the
number of kilocalories and percentage of the MCT oil. For example, the MCT KD
prescription can be 1,680 kcal, 50% MCT.
The MCT KD is divided into three meals plus three snacks plus a carbohydrate-free or
low-carbohydrate multivitamin and mineral prescription, according to the Dietary Reference
Intakes.

Suggested Monitoring Parameters and Recommendations

It is essential to monitor gastrointestinal (GI) side effects—including diarrhea, vomiting,
bloating, and cramps—of patients on the medium-chain triglyceride (MCT) diet. During the
fine-tuning stage, the MCT oil can be increased to 0.1 g to 1.0 g per meal every 1 to 3 days
to improve seizure control, depending on patient’s tolerance. If GI side effects occur,
especially diarrhea or vomiting, MCT oil should immediately be lowered to the previous
dosage.
For information regarding eneral nutrition monitoring parameters and recommendations,
refer to the Dietary Management section.

Weaning from the Ketogenic Diet

The timing and actual method of discontinuing the ketogenic diet (KD) are often
individualized based on patient response to the diet (Kossoff, 2009). Most parents are
counseled to continue the KD, even if apparently ineffective, for at least 3 months
(Freeman, 2006). The International Ketogenic Diet Study Group agreed that the KD should
be used for at least a mean of 3.5 months before considering discontinuation (Kossoff,
2009).
In children with more than 50% seizure response, the KD is often discontinued after
approximately 2 years; however, in children in whom seizure control is nearly complete
(more than 90% seizure reduction) and side effects are low, the diet has been reported to
be helpful for as long as 6 to 12 years (Groesbeck, 2006). This 2-year period is traditionally
based on a similar time period used for anticonvulsant drugs, which are often discontinued
after that time in children who become seizure free (Kossoff, 2009). Children with glucose
transporter protein 1 deficiency, pyruvate dehydrogenase deficiency, or tuberous sclerosis
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
transporter protein 1 deficiency, pyruvate dehydrogenase deficiency, or tuberous sclerosis
complex may require longer KD duration than children with other conditions (Kossoff,
2009). Among patients who ceased seizures while on the diet, 80% will remain seizure free
after the diet has been discontinued (Martinez, 2007).
Although the diet can be discontinued abruptly in an emergency, typically in an intensive
care unit, it is more often tapered slowly (Kossoff, 2009).
The medium-chain triglyceride (MCT) KD is weaned slowly by decreasing the MCT oil by
10% every 1 to 3 months to prevent seizure recurrence. The carbohydrate percentage is
gradually increased while the MCT percentage is gradually decreased. A low-concentrate
carbohydrate diet without MCT oil is then introduced after the 30% MCT diet (Liu, 2008).
Once urinary ketosis is lost, high-carbohydrate foods can be reintroduced. This
recommendation is based on traditional practice pattern and mimics the several weeks of
gradual wean of anticonvulsant drugs (Freeman, 2006). During this time period, nutritional
supplementation must continued (Kossoff, 2008). If seizures worsen, the KD can be
increased to the previously effective formulation (Kossoff, 2008). In the majority (58%) of
these cases, seizure control can once again be attained with earlier KD or anticonvulsants
(Martinez, 2007).

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Nutrition Care > Failure to Thrive
Nutrition Assessment

The interdisciplinary assessment of the child with failure to thrive (FTT) includes a physical
history and examination with laboratory values as indicated, an assessment of feeding
skills or abilities, a behavioral and developmental evaluation, anthropometric measures, a
dietary analysis including dynamics of mealtime behavior (Sharp, 2010), and a
psychosocial evaluation (Logan, 1997). The degree of malnutrition present establishes the
core for an overall medical/nutritional plan. See the Comparative Standards section for
more detail.
The parents or caregivers of the child who is failing to thrive are essential members of the
FTT treatment team (Peterson, 1984). Referral to a dysphagia or feeding disorders clinic,
pediatric occupational therapist, or speech pathologist should be considered for diagnosis
of oral motor problems in infants and children displaying abnormal feeding skills.


Nutrition-Focused Physical Observations

Physical assessment includes a thorough pediatric physical examination and review of
systems by a trained practitioner and should include evaluation of the following
Vital signs
Head, eye, ear, nose, and throat
Cardiovascular function
Gastrointestinal function
Genitourinary function
Neurological function
A nutrition-focused physical examination begins with observation of the general
appearance and any dysmorphic features of the child. The child should be undressed but
appropriately covered. Observe the appearance of the following:
Fat and muscle stores for age appropriateness vs wasting, for example, as might be
visualized in the fat pads of cheeks or temporal wasting. Skinfold thickness can be
obtained as a physical measure of wasting and then compared to the norms for age.
Abdomen for distention or protuberance
Skin for integrity, color, pallor, dryness, rashes, lesions, or other abnormalities
Hair for color, dryness, sparseness
Primary dentition, particularly the maxillary anterior teeth, as rampant dental caries in
early childhood have been associated with pain, disturbed sleeping and eating habits,
and decreased growth velocity
Observation of muscle tone and developmental skills for age may be noted and
reported for further assessment by a physician, occupational therapist, or physical
therapist
(Zenel, 1997; Villee, 1994; Racine, 2001; Christian, 2003; Acs, 1999)

Biochemical Data, Medical Tests and Procedures
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

There are no diagnostic tests for failure to thrive, as it is a symptom rather than a
diagnosis. It is often a diagnosis of exclusion when other causes of poor growth have been
ruled out. Refer to the Nutrition Assessment and Laboratory Assessment sections for
further details.

Laboratory

Laboratory evaluation of failure to thrive (FTT) can be approached as an assessment of
malnutrition. Many laboratory values may help determine the degree of malnutrition present
(see the table on this page), although their use in determining cause of FTT is limited
(Jaffe, 2011).
Most importantly, protein status and immune status can help provide prognostic information
in terms of possible clinical complications. Although early malnutrition cannot be detected
by laboratory tests alone, as they are affected by multiple factors, serum albumin and
prealbumin to assess protein status and transferrin or lymphocyte count to assess immune
status have been used to predict nutritional status of patients about to undergo surgery;
these values have been found to be fairly predictive of good patient outcomes (Banh, 2006;
Buzby, 1988; Mullen, 1981; Rainey-MacDonald, 1983; Lo, 2003).
Laboratory Values
Laboratory Test and
Units
Age of Patient Normal Value
Serum albumin (g/100 ml) 0-1 year >2.5
1-5 years >3.0
6-16 years >3.5
Prealbumin (mg/dL) 0-6 months 7-39
7-36 months 2-36
4-6 years 12-30
7-19 years 19-35
Transferrin saturation (%) 0-2 years >15
2-12 years >20
Total lymphocyte count
(white blood cells x
%lymphocytes) (#/mm
3
)
All ages >1,500

Depending on the underlying cause of malnutrition, other laboratory values may also be
helpful in guiding the treatment of FTT. For example, in a child with FTT secondary to
cystic fibrosis, the clinician needs to assess fat-soluble vitamin levels due to the fat
malabsorption associated with cystic fibrosis.
Other laboratory tests that may be useful include the following:
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Alkaline phosphatase to evaluate for rickets (elevated), zinc deficiency (depressed),
or vitamin B-12 deficiency (depressed)
Hemoglobin/hematocrit to evaluate for anemia, because approximately 50% of
children with FTT present with iron deficiency
Lead levels to evaluate for lead intoxication, which can lead to poor growth (Samour,
2004)
Refer to the Nutrition Support section for more information regarding laboratory monitoring
during refeeding of patients who are severely malnourished.

Client History

The primary caregiver(s) of a child with failure to thrive (FTT) should be interviewed to
evaluate the medical, surgical, social, nutritional, and growth history. Medication and
supplement usage should also be evaluated. Multiple factors may contribute to the
development of nonorganic FTT. The clinician should carefully assess the patient history
for the following:
Prematurity or extended hospitalization around the time of birth that may have
included a delay in oral feeding for an extended period of time
Respiratory status and history
History of uncomfortable oral procedures such as surgery, intubation, or tube feedings
Depression/anxiety and/or history of eating disorder of the caregiver
Gastroesophageal reflux
Abnormal muscle tone
Coordination problems, including coordination of suck and swallow in an infant
Structural problems including cleft lip, cleft palate, and jaw and tongue abnormalities
Oral sensory problems such as oral hypersensitivity or hyposensitivity
Stool patterns
History of vomiting/diarrhea
Use of supplements that may interfere with absorption of nutrients
Social changes in the life of a child, such as parental death or incarceration, divorce,
birth of a sibling, moving to a new home
Nutritional history
(Stevenson, 1991; Tluczek, 1992; Reilly, 1999)

Food/Nutrition-Related History

A thorough diet history or diet records can identify deficiencies or excesses in the diet. As
a basis for nutrition intervention, dietary intake should be compared with expected levels of
energy, fluid, and nutrient intakes.
The diet history or records, usually for a 3-day period, should include all foods, fluids, and
supplements consumed (including water, juice, or soda); the texture or consistency of the
food; the amount consumed; and the time of consumption. If fluctuation of intake is
suspected (a combination of high- and low-kilocalorie intake days), a 5- to 7-day history
may be needed to evaluate the variations. The volume of any emesis may be estimated
and subtracted from the recorded intake. Duration of meals should be assessed along with
current feeding method (bottle or spoon feeding) and feeding environment (such as in a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
high chair, without television on, meals eaten concurrently with other family members, and
so on). A feeding history, including information about the age when solid foods were
introduced and feeding progression, can also reveal clues about the child's current eating
behaviors.
Breastfeeding
The mother of the breastfed infant who is failing to thrive should be interviewed to
determine the usual frequency of nursing, the number of times the infant nurses during the
day and at night, the duration of a usual nursing episode, and the presence of a maternal
let-down reflex. Assessing dietary habits of the breastfeeding mother can be helpful in
determining if the infant is at risk for other nutrient deficiencies, such as vitamin B-12 in the
infant of a vegan mother. Although limited by the accuracy of the scale, a digital scale,
accurate to 1 g, can be used to obtain infant weight before and after breastfeeding within a
30 mL estimate in order to approximate the volume ingested in the nursing session
(Haase, 2009; Savenjie, 2006).
An important component of the dietary evaluation is the observation by a trained team
member or lactation consultant of a nursing session with the infant's before and after
weights and evaluation of positioning, latching on the breast, sucking, swallowing, and
burping.
Formula Feeding
For formula-fed infants, the amount and type of infant formula, mixing instructions, and
dilution must be clarified and not assumed to be standard.
Red flags for diet history or feeding observation—indicating caregiver-child power struggles
that may be behavioral causes of failure to thrive—include the following:
There is an indication of the caregiver "forcing" child to eat
There is a lack of any feeding routine or schedule
The child does not sit at a high chair or table to eat
Mealtime exceeds 30 minutes
Volume of formula intake is excessive (may indicate improper mixing dilution of the
formula)
Parent becomes visually upset or angry about eating behavior during the child's
mealtime


Comparative Standards

The degree of undernutrition with failure to thrive can be determined and classified by using
Waterlow criteria, McLaren criteria, or Gomez classification (TCH, 2008). Calculations and
classification categories are included with the following tables.
Waterlow Criteria: Classification of the Severity of Undernutrition in Infants and
Children
Grade of
Malnutrition
Acute
Malnutrition:
Percent of Median
Chronic
Malnutrition:
Percent of Median
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Weight for Height Height for Age
Normal 90-110 = 95
I. Mild 80-89 90-94
II. Moderate 70-79 85-89
III. Severe < 70 < 85
Where % median weight for height = (actual wt (kg)/expected wt (kg) for ht (cm) at 50th
percentile) x 100
Where % median height for age = (actual ht (cm)/expected ht (cm) for age at 50th
percentile) x 100
Used to classify protein–energy malnutrition for children aged 1 to 3 years based on weight
for length and length/height for age (Waterlow, 1972)

Gomez Classification: Classification of the Severity of Undernutrition in Infants and
Children

Grade of Malnutrition % Median Weight/Height
(using the 50th
percentile of weight for
age)
Normal 91-100
First degree 76-90
Second degree 61-75
Third degree < 61

% median weight/height:
(Actual weight (kg) x 100) /Weight for age at the 50th percentile.
Used to classify malnutrition when height is not available (Bender, 2005; TCH, 2008).

McLaren Criteria: Classification of the Severity of Undernutrition in Infants and
Children
Grade of Malnutrition MAC:FOC Ratio
Normal > 0.31
First degree 0.28 - 0.30
Second degree 0.25 - 0.27
Third degree < 0.25
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Where MAC : FOC ratio = mid-arm circumference (cm)/frontal occipital circumference (cm)
Used as an indicator of malnutrition in children younger than 4 years of age when accurate
height is not available. These criteria cannot be used with hydrocephalus or microcephaly
(TCH, 2008).
Fluid Needs or Limits
Daily fluid requirements should be met with age-appropriate, nutrient-dense liquids, such
as breast milk, infant formula, whole milk, or pediatric formula. Water and 100% fruit juice
should be eliminated or restricted to a maximum of 4 oz per day after the age of 1 year, so
as not to displace more nutrient-dense beverages such as milk or formula (Smith, 1994).
Soda, punch, and other sweetened beverages should be eliminated entirely as they
provide no added nutritional value.
Refer to the table in the Nutrition Therapy Efficacy section for normal daily fluid intakes of
children up to age 6 years. In general, the Holliday-Segar method of maintenance fluid
requirements are more than generous and can be used to provide specific
recommendations as follows:

Weight in
kg
Fluid Needs
1-10 kg 100 ml/kg
11-20 kg
1,000 ml + 50 ml/kg for each kg >
10 kg
> 20 kg
1,500 ml + 20 ml/kg for each kg
> 20 kg
(Holliday, 1957)


Nutrition Diagnosis

Registered dietitians working with patients with failure to thrive should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the following list, as well as
other diagnoses, may be present.
Inadequate energy intake (NI-1.4)
Malnutrition (NI-5.2)
Underweight (NC-3.1)
Sample Problem, Etiology, Signs and Symptoms or Nutrition Diagnostic Statement(s)
Inadequate energy intake (NI-1.4) related to patient refusal to eat meals when
pressured by mother as evidenced by poor growth and suboptimal weight gain.
Note: Terminology in the examples above is from the third edition of the American Dietetic
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Association's International Dietetics and Nutrition Terminology. Code numbers are inserted
to assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. Registered dietitians should not include these numbers in routine clinical
documentation.


Nutrition Intervention

The provision of adequate nutrients and energy for appropriate weight gain and linear
growth in infants, toddlers, and preschoolers who are failing to thrive may require both
dietary alterations and behavioral modifications. Concrete instructions for parents should
include specific techniques for implementing behavioral change in toddlers and preschool
children.
Growth over time is the ultimate outcome measure in the child with failure to thrive (FTT).
Long-term follow-up with the multidisciplinary FTT team at regular intervals provides
opportunities for measurement of growth, reinforcement of nutrition instruction, and
adaptation of goals and expectations to the child's changing nutrition and developmental
needs (Corrales, 2005).
Nutrition intervention is determined by severity and duration of disease, which can be
complicated by comorbid factors. Intervention should begin as soon as possible to reduce
the effects of inadequate intake of nutrients.

Nutrition Therapy Efficacy

The diet for an infant or child who is failing to thrive must be individualized to provide
sufficient energy and nutrients within age- and ability-dependent guidelines. Expected
weight gain and protein, energy, and fluid needs for children from birth to 6 years are listed
in the table on this page. Optimally, nutrition goals are met with typical age-appropriate
foods (see Nutrition for Full-Term Infants, Nutrition for Preschool Children, and Nutrition for
School-Age Children).
Expected Weight Gain and Protein, Energy, and Fluid Needs for Children from Birth
to 6 Years
Age Average
Weight Gain
(g/day)
Average
Protein
(g/kg/day)
Average
Energy
(kcal/kg/day)
Average Fluid
(mL/kg/day)
0-3 mo
3-6 mo
6-12 mo
1-3 yr
4-6 yr
20-35
15-25
10-15
6-8
4.5-6.5
2.2
2.2
1.6
1.2
1.2
108
108
98
102
90
125-160
125-160
130-155
115-135
100-125
(Corrales, 2005; Guo, 1991; Curran, 2000)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Corrales, 2005; Guo, 1991; Curran, 2000)



Goal Setting

Goals for patients with failure to thrive should include the following:
Medical nutrition therapy will meet the requirements based on age for all nutrients
according to the guidelines for the Dietary Reference Intakes and for fluid.
Weight gain and linear growth velocity will equal or exceed expected standards for
age.

Feeding Skills

Observation of a feeding session and subjective data about feedings or meals from parents
and caregivers are important components of an evaluation for failure to thrive (FTT). The
physical act of feeding is a complex physiological process. The reflexive oral-motor feeding
skills of a newborn normally evolve to a voluntary process of eating during the first years of
life, with growth-related anatomic changes, neuromuscular development, and experiential
learning. Early identification and appropriate treatment of problematic feeding or eating
skills will decrease the likelihood of worsening oral aversion and growth failure.
Feeding problems may include failure to imbibe/feeding resistance, which is used to
describe infants with FTT who require longer than normal periods of time to ingest a given
volume of breast milk or formula. These infants consequently experience growth failure
due to inadequate intake (Gremse, 1998; Lichtman, 2000).
Oral-motor difficulties—such as abnormal muscle tone; coordination problems; and
structural problems including cleft lip, cleft palate, and jaw or tongue abnormalities—can
impede a child's ability to suck or swallow adequate nutrients. Oral sensory problems such
as hypersensitivity or hyposensitivity may affect feeding skills. Other sensory issues that
may affect feeding skills include hypersensitivity to smell and tactile experiences.
Specifically, watch for arching during and after feeds, fatigue, seepage around the mouth,
abnormal length of feeding session, and/or instability during feeding. A speech or
occupational therapist can provide a more in-depth assessment if anything abnormal is
observed.

Enteral or Tube Feeding

The infant or child who is failing to thrive and has feeding skill problems may require
nasogastric or gastrostomy feedings to supplement oral intake.
Enteral nutrition support is indicated in the case that a patient with failure to thrive (FTT)
has inadequate intake by mouth due to either physiological impairment or energy needs
increased beyond the patient's ability to consume enough food.
A study at the Cleveland Clinic found that early supplemental enteral nutrition assists
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A study at the Cleveland Clinic found that early supplemental enteral nutrition assists
children with FTT to reach their weight gain goals (DeTallo, 2008). Another study, by
Fortunato and Cuffari (2011), found that percutaneous endoscopic gastrostomy feedings
were minimally invasive and a safe method to treat FTT with low postoperative risk. Enteral
feedings are best used as a supplement to oral intake during FTT and thus can serve their
purpose most effectively as bolus/intermittent feeds at night, so as not to interrupt the
patient's appetite and desire to eat during the day. The choice of enteral formula should be
individualized to the patient's age and other complicating diagnoses ( TCH, 2008).
Refer to the pediatric enteral and parenteral nutrition sections (under the Resources tab)
for more detailed discussion of recommendations and guidelines.

Suggested Monitoring Parameters and Recommendations

Monitoring of nutritional status should be ongoing during the course of failure to thrive until
the condition is completely resolved. The frequency and type of monitoring (eg, laboratory
values) depend on the following:
Which nutrition treatment is utilized
Severity of malnutrition
Duration of nutrition therapy
Age and expected growth rate of the child
Other considerations include the following:
Generally, weight and length measurements should be obtained at least weekly for
infants, and monthly weights and length/height for toddlers and preschool-aged
children.
Adjustments in nutrition regimen should be made accordingly to promote sufficient
catch-up growth or normal growth along a curve.
The goal of nutrition therapy is that the patient will meet the requirements based on
age for all nutrients according to the Dietary Reference Intake guidelines and the
patient will have weight gain and linear growth velocity that will at least equal
expected standards for age.


Nutrition Care FAQs

Q: How much weight should my child gain once nutrition therapy for failure to thrive
begins?
A: A child being treated with a high-kilocalorie diet for failure to thrive should, at minimum,
gain weight at the normal velocity for his or her age. The child may not fall between the 5th
and 95th percentile, but as long as the velocity of weight gain is keeping up with the normal
range, the child is making progress. Some children will have catch-up growth on a
high-kilocalorie diet and ascend growth percentiles on the growth chart, whereas some will
remain below the curve but continue to make gains in growth further into adolescence than
their peers.
Q: If my child refuses to eat at a meal, should I force the child to eat?
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A: You should never force your child to eat. If your child refuses to eat a meal and/or
throws a tantrum, remove him or her from the situation for 10 minutes, and then try
again. If the child still refuses to eat, excuse him or her from the meal and do not offer
anything to eat or drink except plain water until the next scheduled meal or snack time. Try
to retain some emotional perspective and an even tone of voice. Do not make the end of a
meal into a punishment.
Q: What types of food should I give to help my child gain weight?
A: It is important to offer foods that are nutrient dense as well as energy dense. This means
using real food that will contribute energy and other vitamins, protein, and minerals to the
child's diet. Examples include cheese, whole milk, avocado, nuts/nut butters, and ground
beef.

Anthropometric Measurements

The anthropometric evaluation of failure to thrive (FTT) requires the assessment of growth
patterns and comparison with accepted standards using the appropriate growth charts for
sex and age. Consistent measurement technique with accurate, appropriate equipment is
essential for interpretation of serial values.
The age-specific and sex-specific growth charts of the Centers for Disease Control and
Prevention (CDC) are recommended for growth assessment (see Growth Charts) (NCHS,
2000). Growth grids are available for special conditions, including Down syndrome,
myelomeningocele, Prader-Willi syndrome, sickle cell anemia, cerebral palsy,
achondroplasia, and Turner syndrome, but these are based on limited population data and
may underestimate the degree of FTT (Niedbala, 2005). It is advisable when plotting on a
growth grid for special conditions to also plot on a CDC growth curve, paying special
attention to weight-for-height and/or body mass index to assess degree of underweight.
Reference data are available for sex-specific increments of gain in weight and recumbent
length for selected intervals in the first 24 months of life (Guo, 1991). As breastfed infants
gain weight and length at a different velocity than infants who are formula-fed, growth
charts available from the World Health Organization reflect normal growth of children up to
age 5 who are breastfed. The benefit of using these charts for monitoring breastfed infants
is in the slower weight gain and overall leaner build of these infants, thus avoiding
miscategorizing an otherwise healthy breastfed infant as underweight (WHO, 2006).
The evaluation of growth and weight-gain patterns is essential in the differentiation
between acute and chronic malnutrition and symmetrical or asymmetrical growth failure.
Acute malnutrition affects weight initially without slowing linear growth. Chronic malnutrition
persisting over weeks or months is evident with a decline in weight percentiles, followed by
a drop in length or height percentiles. Severe and/or persistent malnutrition will stunt head
circumference.
Symmetrical growth failure—in which weight, linear growth, and head circumference are
equally affected—suggests long-standing malnutrition, possible chromosomal or genetic
abnormalities, or underlying disease processes (Corrales, 2005; Zenel, 1997; Markowitz,
2003; Racine, 2001; Christian, 2003).
Accurate determinations of skinfold thickness are sometimes difficult to obtain for routine
clinical use. However, triceps skinfold thickness, used with mid-arm circumference to
determine arm muscle area, provides a useful estimation of muscle mass (Trowbridge,
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determine arm muscle area, provides a useful estimation of muscle mass (Trowbridge,
1982). Sequential anthropometric measurements throughout nutritional rehabilitation are
valuable indices of fat and muscle repletion over time.

Nutrition Prescription


Provide high-kilocalorie diet, with 3 scheduled meals and 2 to 3 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, including the following recommendations:
Mealtime should last 20 to 30 minutes
Between meals or scheduled snacks, offer only plain water
Discontinue all juice or sugar-sweetened beverages.
Offer milk or other high-kilocalorie/high-protein nutritional beverage with each
meal.
Feed child in a chair at a table with minimal distractions (eg, no television)
Do not discuss eating in front of the child except to ask if he or she wants more
food
Do not pressure or coerce the child to eat
If the child is uncooperative, end the meal/snack in a calm, nonpunitive manner
and try again at the next scheduled meal or snack time
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.
Continue to follow weight and length/height gain every 3 months until child can
demonstrate growth along an acceptable growth curve.
If patient is unable to meet nutrition needs orally and continues to grow at a
suboptimal rate, initiate enteral feeds to provide supplemental nutrition

Oral Intake

Vitamin and mineral requirements should be met with appropriate oral, enteral, or
parenteral feedings.
Oral nutrition should be supplemented with a standard multivitamin/mineral
formulation until oral intake is adequate to meet all nutrition needs.
Enteral nutrition provided in sufficient quantities with polymeric formulas should meet
Dietary Reference Intake requirements unless volume or total energy is restricted.
Additional supplementation may be needed in cases where severe malnutrition is
evident or specific deficiencies can be determined.
Total parenteral nutrition should include standard multivitamin and trace mineral
infusions unless otherwise contraindicated by specific patient factors.
Energy and Protein Needs for Repletion
Individual energy and protein requirements to promote growth will vary. Several methods
exist for making an initial estimation of needs. Initial energy and protein needs may be
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estimated by obtaining ideal body weight for height or kilocalories per kilogram of actual
body weight and adding another 10% to 50%. Total energy requirements for catch-up
growth may be 150% or more than the expected needs based on actual weight (Curran,
2000; Goldbloom, 1987; Spady, 1976).
Incremental increases in the present intake over a period of time may be needed to
accomplish the weight gain and high energy/protein goals. Patient-specific weight and
intake assessments, along with revision of goals, are important components of medical
nutrition therapy for failure to thrive (FTT). Refer to the Meal Plan area for FTT for complete
details regarding implementation of a high-kilocalorie and high-protein diet. Refer to the
Enteral or Tube Feeding section for other important considerations of nutrition repletion.
Fat
Approximately 55% of the total energy intake for an infant should be derived from fat
(Fomon, 1993). Fat should not be restricted to less than 30% of total energy intake in the
diets of children younger than 2 years (AAP, 1992). Incorporating foods that contain more
polyunsaturated and monounsaturated fats, rather than increasing saturated fats, may be a
more acceptable alternative for the caregiver concerned about long-term cardiovascular
health.
Vitamins and Minerals
Supplementation must be individualized on the basis of nutrient analysis of dietary intake
and any evidence of deficiency. Standard Dietary Reference Intake values for vitamins and
minerals serve as the basis for supplementation (FNB, 2004). For children with a high
index of suspicion of zinc deficiency, a therapeutic trial of zinc supplementation at a level of
1 mg/kg/day of elemental zinc is nontoxic and has been suggested (FNB, 2004). In the
zinc-deficient child with adequate zinc supplementation, low alkaline phosphatase levels
normalize, the appetite improves, and growth accelerates.
Management of Breastfed Infants
Breastfeeding is not contraindicated in the infant who is failing to thrive. However, special
attention should be given to the infant's ability to breastfeed and the mother's concerns.
Supplemental bottle feedings and augmentation of the mother's breast milk supply with
pumping and/or medications are frequently used to restore healthy weight gain in the
infant. Hindmilk collection for use as a supplement to breastfeeding is often successful in
boosting energy intake (Lauwers, 2004). Referral to a certified lactation specialist can
provide valuable assistance with breastfeeding problems.
Management of Formula-Fed Infants
Replace low nutrient-dense fluids such as water, juice, soda, and punch with infant formula.
Concentrate formula gradually by increments of approximately 2 kcal/oz/day, as tolerated,
up to 24 kcal/oz, 27 kcal/oz, or 30 kcal/oz (for instructions on the reconstitution of infant
formula-concentrated liquids and powders, see the Pediatric Nutrition Dietetic
Practice Group website [available to PNPG members] or instructions at the facility of
employment).
Caloric additives, such as vegetable oil, microlipids, or carbohydrate modules, are
sometimes added to a total energy density of 30 kcal/oz but will displace the nutrients that
formula alone would provide by simply concentrating. As modulars are added, protein
density must be considered if the modulars are fat or carbohydrate based (Corrales,
2005). The overall nutrient content, including protein and fluids, of the prescribed volume of
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formula and module mixture should be compared with the expected needs of the infant.
Excessive use of caloric additives may result in suboptimal nutrient delivery, and thus
concentrating formula without use of modular additives is preferred when possible.
Highly concentrated formulas (>24 kcal/oz) and/or large amounts of additives are more
likely to cause feeding intolerances due to the increased osmolarity of the formula. This
may include vomiting, diarrhea, or dehydration. An infant who is not tolerating a standard
concentration of formula should not receive a more concentrated formula until tolerance is
established.

Behavior and Development

Coordination of the oral musculature is delayed in premature or hospitalized infants who
cannot be fed orally for extended periods of time. Uncomfortable oral procedures such as
surgery, intubation, or long-term tube feedings are significant risk factors for the
development of feeding problems. Infants who have had such procedures may not suck
and swallow effectively. As the reflexive sucking instinct fades, neuromuscular coordination
problems and oral aversion may become evident if the child is unable to transition to solid
foods. Infants or children fed via an alternate modality for an extended period of time,
making them passive eaters, may be unable to differentiate hunger from satiety (Birch,
1995; Chatoor, 1998).
From birth to 2 months, an infant normally progresses from reflex sucking to a state of
homeostasis, in which volitional oral feedings are controlled by hunger and satiety. Ideally,
an infant should demonstrate a good suck and swallow, give clear signals of hunger and
satiety, and develop a regular feeding pattern. Cues from the infant require careful
interpretation. An infant who is either irritable or lethargic may not give clear signals.
Parents may mistake or ignore the cues given by the infant (Birch, 1995; Chatoor, 1998).
From 2 months to 6 months, the normal infant who has achieved homeostasis begins to
develop attachment, a reciprocal relationship with nurturing caregivers. Feedings should be
pleasurable for both the infant and the caregiver, with frequent verbal, visual, and physical
contact. Maladaptive infant behaviors include disinterest, avoidance of eye contact,
withdrawal, stiffening or arching, and lack of vocalization. A caregiver who appears
detached, depressed, agitated, overwhelmed, or anxious may be unable to respond to the
infant's cues (Pickler, 2009). Gastroesophageal reflux, vomiting, or rumination associated
with feeding may interfere with the normal attachment process (Birch, 1995; Chatoor,
1998).
After the child has learned to regulate food intake and has formed an attachment to
caregivers, the next step in normal development is separation and individuation. Between
the ages of 6 months and 3 years, the child becomes increasingly independent and
separate from caregivers. At this time, specific developmental or psychological problems,
including oromotor or sensory disorder, feeding disorder of infancy, a family relationship
problem, child neglect, or a mental disorder of a parent may emerge as the cause of FTT
among some older infants and toddlers (Gahagan 2006). Most feeding behavior problems
from early childhood resolve over time, but may require intervention. Older preschoolers
and school-age children may remain picky eaters, which may affect their weight in a
negative way (Dubois, 2007a; Dubois, 2007b).
Feeding behaviors develop in a sequential pattern. Maladaptive interaction between the
parent or caregiver and the child can interfere with the progression of healthful eating
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behaviors. Problematic behaviors in the child include disinterest in food, negativity,
aggression, disorganized behavior, and irritability. A caregiver who engages in power
struggles with the child, ignores or misreads the child's cues, controls feedings by force
feeding, or fails to set appropriate limits can inhibit the separation and individuation process
(Birch, 1995; Chatoor, 1998). The ultimate demand of the caregiver for the child to
consume unwanted, forced foods may promote further conflict over time (Sullivan, 1991;
Wright, 2006).

Food Insecurity

Food insecurity, or the limited or uncertain availability of nutritionally adequate and safe
foods, can be a contributing factor in the development of failure to thrive (ADA, 2006). A
family's inadequate financial resources may cause a less than optimal nutrient intake for an
infant or child, such as the substitution of water or other less expensive beverages for
formula or milk.
Eligible families should be educated about food assistance programs, such as the Special
Supplemental Nutrition Program for Women, Infants and Children (WIC) and the
Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamps
Program. In addition, the Expanded Food and Nutrition Education Program (EFNEP)
provides nutrition education to families with limited resources, and programs such as Head
Start provide subsidized meals for needy children. Referrals to appropriate agencies should
be provided as needed.

Food Allergies, Intolerances, and Restrictions

Long-term dietary restriction may occur despite little or no supporting medical evidence.
Strong parental beliefs about sensitivities or allergies to multiple foods may severely limit
the foods offered to the child and may result in growth failure. Foods frequently implicated
include milk, eggs, and wheat, such as in the case of parents using a gluten-free and
casein-free diet to address autism or children on the autism disorder spectrum (Roesler,
1994). Energy and nutrient restriction may occur with the extended use of elimination diets
for the treatment of chronic diarrhea (Lloyd-Still, 1979; Cohen, 1979). Other considerations
include the dietary adequacy of vegan diets; these patients need careful monitoring to
ensure adequate intake of protein and micronutrients.
Parental eating habits and attitudes may also contribute to the development of FTT in an
infant or child. Despite concerns of low weight in a child, parents may restrict foods they
consider to be "fattening" or high in sugar. Parental eating disorders have been associated
with increased restriction of foods in children who are failing to thrive (McCann, 1994).
However, some dietary restrictions may be warranted, such as is the case for children with
multiple food allergies or children with food protein-induced enterocolitis syndrome
(FPIES). FPIES is usually diagnosed during infancy and has been associated with
FTT. The most common dietary proteins implicated are cow's milk and soy, but FPIES can
also occur with cereal grain (rice, oat and barley), fish, poultry, and vegetables. Fortunately,
this condition typically resolves by age 3 years (Nowak-Wegrzyn 2009). Other medical
conditions requiring dietary restrictions may include eosinophilic esophagitis, celiac
disease, and carbohydrate malabsorption, among others.
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Parenteral Nutrition

In severe cases of malnutrition, total parenteral nutrition may be indicated if the patient is
unable to meet nutritional requirements by the enteral route. Parenteral nutrition should be
advanced slowly to avoid refeeding syndrome. See Complications of Nutrition Support for
more information.
When nutrition support is required, enteral nutrition is preferred over parenteral
nutrition because of the associated reduction in cost and decrease in infectious
complications and hospital length of stay (Heyland, 2003).
A glucose infusion rate of 6 mg/kg/min to 15 mg/kg/min is generally well tolerated in
the pediatric population. Generally, older children have a lower tolerance to higher
rates of glucose infusion (TCH, 2008).
Daily protein requirements should be tailored to address the patient’s underlying
metabolic condition. Trophamine and Aminocyn PF have been modified for infants
and children to provide the conditionally essential amino acids taurine, tyrosine, and
histidine, and should be used in the pediatric population (TCH, 2008).
Essential fatty acid deficiency can develop in pediatric patients who receive fat-free
parenteral nutrition for more than a week. This can be prevented by provision of a
minimum 0.5g/kg/day (2.5ml/kg/day) of lipids. Total lipids should not exceed 60% of
energy due to the risk of ketosis (TCH, 2008).
The standard dosing ranges for parenteral electrolytes, multivitamins, and trace
elements assumes normal organ function, without abnormal losses. Adult vitamin
preparations should not be given to neonates or infants younger than 6 months of age.
Phosphorus, calcium, and magnesium supplementation is limited due tfo physical
incompatibility of the parenteral nutrition solution.
Trace minerals may be added using a commercial preparation or as separate
components and should be dosed per kilogram of body weight.
Refer to the sections on pediatric enteral and parenteral nutrition (under the Resources tab)
for detailed recommendations and guidelines.

Complications of Nutrition Support

Complications in Total Parenteral Nutrition (TPN)
Catheter occlusion
Catheter-related infection
Hyperglycemia (from high-dextrose infusion or glucose intolerance)
Hypertriglyceridemia
Intestinal atrophy (usually only from long-term TPN without any oral intake)
Electrolyte disturbances
Refeeding Syndrome
Refeeding syndrome can be a major life-threatening concern for patients with malnutrition
who receive nutrition support.
Following are three metabolic events that characterize refeeding syndrome and that lead to
serious respiratory and/or cardiac compromise, if not detected and treated in a timely
manner:
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manner:
Hypophosphatemia
Hypomagnesemia
Hypokalemia
Any malnourished patient is at potential risk. Therefore, nutrition support should be initiated
at a slow rate, with slow advancements in rate and energy provisions over 5 to 7 days or
until laboratory values have normalized and stabilized.
Patient laboratory analysis should be monitored daily during the initial phase of TPN, with
effective replacement of low electrolytes by separate intravenous infusions, as needed.
Serum calcium will drop precipitously and ionized calcium needs to be monitored to
determine calcium content of TPN solution.
Laboratory values to be monitored daily include the following:
Glucose
Sodium
Potassium
Chloride
Blood urea nitrogen
Creatinine
Carbon dioxide
Magnesium
Phosphorus
Ionized calcium
Triglycerides

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Nutrition Care > Food Allergic Disorders
Food Allergic Disorders


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Nutrition Care > Food Allergic Disorders > Eosinophilic Esophagitis
Nutrition Assessment

Before implementation of any dietary treatment, the nutritional status of the patient should
be evaluated. The initial nutritional status of the patient may affect the choice of dietary
treatment, as some patients with eosinophilic esophagitis may have diminished or deficient
nutritional reserves; further dietary restriction without adequate nutrition support may put
the patient at greater nutritional risk. The dietitian should determine the adequacy of the
prescribed dietary treatment and suggest alternatives if nutrition needs cannot be
met. Once an adequate dietary treatment option is determined, extensive education
regarding avoidance, including how to substitute for the nutrition in eliminated foods, must
be provided.
The diet may need to be supplemented with an elemental formula and/or vitamin and
mineral supplements. Ongoing medical nutrition therapy is needed to monitor nutritional
adequacy, plan for diagnostic food challenges, and implement changes as the patient
progresses through treatment (Feuling, 2010).



Biochemical Data, Medical Tests and Procedures

It is very important to understand that testing for specific food antigens in eosinophilic
esophagitis (EoE) is imperfect. There are presently no tests available to definitively
determine which foods are implicated. Currently, dietary antigen removal, followed by
endoscopic reassessment including biopsies, is the only way to definitively identify specific
causative antigens.
Because EoE typically has non-immunoglobulin E (IgE)–mediated mechanisms,
standardized tests such as skin prick tests (SPT) and measurements of food-specific IgE
levels in the blood are limited and may have poor predictive value in identifying antigens
that provoke an inflammatory response in the esophageal mucosa. However, it is
recommended that all children with EoE undergo a comprehensive allergy evaluation by an
experienced allergist to assess for concurrent IgE-mediated allergies, allergic rhinitis and
eczema. Al though not directly causative, symptoms of other allergic conditions such as
asthma and allergic rhinitis should be as well controlled as possible (Feuling, 2010). To
identify atopic status and potential allergens, SPT for foods and environmental allergens
should be considered in the evaluation of the EoE patient. There are currently no positive
or negative predictive values for food-specific serum IgE testing in EoE, although these
tests may be part of the comprehensive allergy evaluation. A recent report by Erwin et al
(2010) indicated that serum-specific IgE testing may be useful to obtain a full sensitivity
profile of the patient with EoE.
The atopy patch test (APT) has been used to detect antigens in non-IgE–mediated
hypersensitivity reactions. The APT is standardized for atopic dermatitis but not for food
allergens. Spergel et al (2005) used a combination of SPT and APT to detect potential IgE
as well as potential delayed T-cell mediated antigens. The response rate to a diet that
removed foods based on a combination of SPT and APT was approximately 77%, which is
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similar to the response rate seen in empiric elimination of the major allergens without
extensive testing (74%). Positive and negative predictive values of SPT and APT for some
common food allergens in EoE have been determined (Spergel, 2005; Spergel,
2007). Spergel et al (2005) reported that the combination of SPT and APT has a high
success rate in identifying allergens, with the exception of milk. The negative predictive
value for milk was reported at 40.9%, which is unacceptably low. Therefore, negative
testing to milk using both SPT and APT would not rule out milk as a trigger in EoE; milk is
often removed emperically when using directed elimination diets.
SPTs, serum food specific IgE tests and APTs can be used to help identify foods that are
associated with EoE, but these tests alone are not sufficient to make the diagnosis of food
allergy-driven EoE. The clinical utility of these tests in identifying causative foods requires
futher investigation (Liacouras, 2011).


Laboratory

The dietary and medical history, growth pattern, and physical exam will guide the
laboratory evaluation. Children with eosinophilic esophagitis (EoE) and failure to thrive
(FTT) should be evaluated for protein and energy malnutrition. For more details on the
laboratory assessment of malnutrition and FTT, refer to the Failure to Thrive section.
Many children with EoE will be treated with an elimination diet. Overall, children with
prolonged elimination of multiple food allergens are at increased risk for inadequate intake
of calcium, vitamins D and E, iron, zinc, and energy. Serum concentrations of vitamins E
and 25-hydroxy vitamin D can be measured directly.
Laboratory assessment of hemoglobin/hematocrit concentration and red cell indices (mean
corpuscular volume, mean corpuscular hemoglobin), as well as serum transferrin, can help
assess iron status and evaluate for anemias. Erythrocyte alkaline phosphatase serves as
an indirect marker of zinc deficiency.

Anthropometric Measurements

Anthropometric Data
Height
For children older than 2 years, plot on Centers for Disease Control and
Prevention (CDC) chart for age 2-20 years
Length
In children younger than 3 years, plot on CDC chart for birth to age 36 months
Weight
Weight for length
Body mass index (children older than 2 years)
Head circumference (children younger than 36 months)
Assessment of individual growth velocity/growth history
Comparison of growth to the reference population

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Food/Nutrition-Related History

An accurate and detailed diet history is essential with eosinophilic esophagitis
(EoE). During the initial assessment, it is important to know which foods are actually in the
diet at the time that chronic or episodic symptoms were present. Note that with delayed
hypersensitivity reactions, it is often difficult to determine which foods are causing the
symptoms, as they can appear hours to days after ingestion of the offending food.
Consider the following areas in the diet history:
Previous elimination dietary trials
Foods avoided
Effective elimination
Impact on symptoms (and/or histology)
When EoE symptoms first emerged
Any changes to the diet at the time symptoms emerged
Detailed history of foods currently in the diet
Frequency of foods eaten
Feeding and eating skills and behaviors
Current symptoms that may impair nutrient intake
Abdominal pain
Nausea
Vomiting
Feeding dysfunction
Reflux
Dysphagia
Concurrent medical conditions and/or food allergy diagnoses
Medications
Food–medication interaction
Vitamin/mineral/herbal supplements
Complementary and alternative medicine
Estimation of the nutrient intake and comparison to estimation of needs using the
Dietary Reference Intakes (DRI)
When evaluating elimination diets, consider the following:
Type and brand of food consumed, considering ingredients and cross-contact risk
Ingredients in recipes and products
Methods of preparation/cross-contact risk
Ingredients added during preparation
Ingredients added before eating the food
Nutritional quality of substitutions for eliminated foods
Estimation of the nutrient intake and comparison to estimation of needs using the DRI


Nutrition Diagnosis

Dietitians working with patients who have eosinophilic esophagitis should review the signs
and symptoms obtained in the nutrition assessment and diagnose nutrition problems based
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on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Inadequate protein-energy intake (NI-5.3)
Inadequate fat intake (NI-5.6.1)
Inadequate protein intake (NI-5.7.1)
Inadequate carbohydrate intake (NI-5.8.1)
Inadequate vitamin intake (NI-5.9.1)
Inadequate mineral intake (NI-5.10.1)
Altered gastrointestinal function (NC-1.4)
Underweight (NC-3.1)
Food- and nutrition-related knowledge deficit (NB-1.1)
Self-monitoring deficit (NB-1.4)
Limited adherence to nutrition-related recommendations (NB-1.6)
Undesirable food choices (NB-1.7)
Intake of unsafe foods (NB-3.1)
Sample PES or Nutrition Diagnostic Statements
Inadequate oral intake (NI-2.1) related to abdominal pain with losses due to emesis
(secondary eosinophilic esophagitis) as evidenced by intake of less than half of each
meal and 5 to 6 episodes of emesis per week.
Inadequate energy intake (NI-1.4) related to multiple food allergy and
allergen-avoidance diet without adequate dietary substitution or nutrition support to
meet energy needs as evidenced by body mass index below the third percentile for
age and average daily energy intake of 1,100 kcal.
Intake of unsafe foods (NB-3.1) related to poor label-reading skills and consumption
of foods not allowed on the elimination diet as evidenced by food diary.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition intervention aims to achieve the following goals:
Correcting nutritional deficiencies related to the disorder
Providing education to adequately eliminate suspected allergens for diagnostic
dietary trials, food challenges, and therapeutic diets
Ensuring nutrition needs are met within the context of the elimination diet prescription.
It should be noted that meeting nutrition needs may require the addition of a supplemental
amino acid–based formula. A supplemental formula may improve growth in children
with eosinophilic esophagitis (Spergel, 2008).

Nutrition Prescription

As the initial diet prescription is generally a diagnostic dietary trial, follow-up and monitoring
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
As the initial diet prescription is generally a diagnostic dietary trial, follow-up and monitoring
are essential to determine the effectiveness of the treatment and implement changes if
necessary. If one food was eliminated and the dietary trial was effective, the patient may
continue on this diet as therapeutic treatment. If multiple foods were eliminated, however,
then each food should be individually challenged (in other words, added back to the diet) to
determine which foods in the group of eliminated foods are causative. Because of the
potential for delayed allergic response, the food should be introduced and the patient
observed for symptoms over several weeks. If no symptoms occur, biopsies via
esophagogastroduodenoscopy (EGD) may be performed and will confirm continued
absence of esophageal eosinophilia.
Once all foods have been individually challenged (this may take several months or more)
and there is confirmation of the causative foods, then the patient will remain on the
maintenance diet for treatment of the disease. It should be noted that expert opinion varies
as to how to monitor the asymptomatic patient with persistent eosinophilia, as the
long-term consequences of chronic, untreated esophageal eosinophilia is unknown. If the
gastroenterologist chooses endoscopic reassessment in the asymptomatic patient, this
should not be performed within the first 4 weeks following the last intervention (Furuta,
2007).
On the other hand, if the initial diagnostic dietary prescription was ineffective, then further
treatment modalities should be considered. These decisions are generally based on the
degree of symptoms and esophageal abnormalities, patient's nutritional status, patient's
age, and patient and family preferences (Furuta, 2007).
There is no standard dietary treatment for eosinophilic esophagitis, although three main
types of dietary treatments and variations thereof are currently in use, including the
elemental diet, the emperic elimination of food allergens, and the directed elimination diet
(see Oral Intake).
There are many factors that determine the appropriate treatment for a specific patient. The
nutritional status of the patient at the time of diagnosis is a key factor. Other factors
include, but are not limited to, the following:
Age and social needs of the patient
Financial resources of the family
Degree of symptoms and esophageal dysfunction
The number of foods suspected of being causative
Regardless of the type of elimination dietary trial used, the diet must be followed for
approximately 8 weeks before histologic response is seen, although symptomatic response
is typically noted sooner. Generally, follow-up with the gastroenterologist for EGD and
esophageal biopsies is needed to confirm histologic resolution subsequent to the initial
dietary trial and periodically during food reintroductions. Ongoing monitoring by the dietitian
throughout treatment is essential.


Goal Setting

Goals of dietary treatment include the following:
Assess and correct underlying nutritional deficiencies
Identify causative antigens (using diagnostic dietary elimination trials followed by food
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Identify causative antigens (using diagnostic dietary elimination trials followed by food
challenges)
Effectively implement dietary therapy
The goals of effective dietary treatment or, alternatively, pharmacotherapy such as
systemic or topical corticosteroids include the following:
Control symptoms, which may contribute to poor nutritional intake
Normalize esophageal histology
Improve quality of life
Restore expected or predicted growth patterns and nutritional status
Prevent documented potential complications of eosinophilic esophagitis, such as
esophageal food impactions requiring endoscopic removal of the impacted food and
potential esophageal strictures, which may necessitate endoscopic balloon dilations
(Chehade, 2010)
The long-term impact of chronic, untreated esophageal eosinophilia is unknown, but the
treatment goals are to prevent potential progressive esophageal dysfunction.

Oral Intake

Elemental Diet
The elemental diet uses an amino acid–based formula alone. No other foods are included
in the diet although variations of this diet have been tried—namely, including one or two
low-risk foods (fruit or vegetable). Depending on the volume of formula used,
vitamin/mineral supplementation may be required. Supplements should be evaluated for
allergenic ingredients and cross-contact risk. Use of an elemental diet has been shown to
successfully treat symptoms and normalize biopsies in 98% of individuals with eosinophilic
esophagitis (EoE) (Liacouras, 2005).
Once resolution is achieved, foods are systematically added back to the diet, with the most
commonly implicated foods (milk, egg, soy) added last. Periodic evaluation by a
gastroenterologist may be necessary to ensure continued resolution of esophageal
eosinophilia during food introductions. The disadvantage to the elemental diet is the poor
taste and palatability of the amino acid formula. Because of the volume of formula needed
and the poor palatability, nasogastric or gastrostomy tube feeding is often necessary.
Elemental formulas can also be very costly and are not always covered by patient
insurance plans. Pediatric patients and their families are often less inclined to opt for
treatment with an elemental diet.

Empiric Elimination Diet
The empiric elimination diet removes foods most commonly associated with food allergy
without extensive food allergy testing. The diet then continues to allow a large selection of
solid foods, potentially enough to support nutrition needs. In 2006, Kagalwalla and
colleagues (2006) reported the first trial of an empiric elimination diet. The
researchers treated a group of EoE patients with a six food elimination diet that empirically
removed the major allergens—milk, egg, wheat, soy, peanut/tree nut, and
fish/shellfish—and reported 74% had resolution of symptoms and significant improvement
in esophageal eosinophilia (Kagalwalla, 2006). Variations of this diet are used; essentially,
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they remove the foods most often implicated in EoE and commonly remove foods such as
milk, egg, soy, and wheat and potentially others.
Once resolution is confirmed on an empiric elimination diet, foods can be systematically
and individually challenged with periodic reassessment by the gastroenterologist. The
benefit of the empiric elimination diet is that a more palatable diet can be provided. An
additional benefit to the empiric elimination diet, as opposed to the elemental diet, is that if
resolution occurs, the number of foods to be challenged to determine the offending
antigens is greatly reduced. With the removal of multiple foods, however, nutritional
deficiencies may occur.
Extensive education to provide a socially acceptable and nutritionally complete diet is
required. It is important to provide patients and their families with individualized lists of
foods that may be included in the diet. Ongoing dietary monitoring by the dietitian is
necessary to ensure nutritional adequacy. Supplementation with an amino acid–based
formula and/or a hypoallergenic multivitamin/mineral may be necessary.

Directed Elimination Diet
Because EoE typically has non-immunoglobulin E (IgE)–mediated mechanisms,
standardized tests such as skin prick tests (SPT) and measurements of food-specific IgE
levels in the blood are limited and may have poor predictive value in identifying antigens
that provoke an inflammatory response in the esophageal mucosa.
The directed elimination diet uses a combination of SPT and atopy patch testing (APT) to
predict implicated antigens. Spergel et al (2005) used a combination of SPT and APT to
detect potential IgE as well as potential delayed cell-mediated allergens with a success
rate of approximately 77%. Positive and negative predictive values of SPT and APT for
some most common food allergens in EoE have been determined (Spergel, 2005; Spergel,
2007). Spergel reported the combination of SPT and APT had a high success rate of
identifying allergens, with the exception of cow's milk. The negative predictive value for
cow's milk was reported at 40.9%, which is unacceptably low. Cow's milk is also the most
commonly implicated food in EoE. Therefore, cow's milk is generally eliminated
empirically.

Enteral or Tube Feeding

Nutrition support using a hypoallergenic, elemental formula may be necessary in order to
improve the patient’s nutritional status or to support a multiple food elimination diet; it may
also be used exclusively to treat eosinophilic esophagitis (EoE). Other types of
hypoallergenic formulas—namely, extensively hydrolyzed formulas—are not considered
effective treatment for children with EoE. Elemental formulas may be given orally or via
enteral routes, including surgically placed gastrostomy tubes, percutaneous endoscopic
gastrostomy tubes, or a nasogastric tube.
Enteral nutrition can be given to supplement an elimination diet or to provide 100% of the
patient’s nutrition needs.

Complications of Nutrition Support

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As feeding dysfunction is not uncommon in young children with eosinophilic esophagitis,
exclusive enteral feeding may cause further delays in the acquisition of feeding skills. The
inclusion of at least one low-risk food (fruit or vegetable) may be warranted. Inadequate
feeding skills for age may be an indicator for a referral for feeding assessment, and an
individualized oral feeding therapy plan may be necessary.
In addition to amino acid–based formula, an amino acid–based, semi-solid food that can be
used with an elemental diet to continue to offer spoon feeding is now available. This
semi-solid food is considered hypoallergenic but is not nutritionally complete and does not
substitute for a complete amino acid–based formula.

Nutrition Monitoring & Evaluation

Nutrition reassessment of children with EoE should include evaluation of the following:
Nutrition-related behavioral and environmental outcomes
Discuss any accidental ingestion of avoided foods that may have occurred
Determine cause and provide suggestions for prevention
Discuss how the patient and family are managing the diet and their ability to
access recommended substitutes for avoided foods
Review of allergen-avoidance guidelines
Label reading
Avoidance issues in and outside of the home as in school and afterschool
activities, camps, restaurants, while traveling, and so on
Ensure there is access to allergen-free foods in all appropriate environments
Ensure the patient continues to be monitored by his or her allergist and
gastroenterologist
Food and nutrient intake outcomes
Ensure nutritional adequacy of the elimination diet using food diaries to ensure
that micronutrient and macronutrient needs are being met
Ensure adequate elimination
Assess growth
Perform biochemical assessment
Perform physical assessment
Nutrition-related patient- and client-centered outcomes
Assess the impact of the allergen-restricted diet on quality of life
Provide instruction to minimize the impact and allow all age-appropriate activities
Assess the satisfaction of diet for the patient and the impact on shopping and
food preparation for caregiver
Assess symptoms
Recommend support groups, food allergy organizations, and publications to
provide evidence-based information


Nutrition Therapy Efficacy

Nutrition therapy efficacy is determined by adequate intake of all nutrients, expected
growth and development, and adequate allergen elimination. If a child's or family's activities
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are too restricted (based on clinical judgment or family preferences), greater guidance on
how to safely manage the elimination diet while still enjoying typical activities of childhood
may be needed.
Diet therapy is considered effective in the treatment of children with eosinophilic
esophagitis. In addition to dietary treatment, oral and topical steroids have been used to
successfully treat some patients with eosinophilic esophagitis. Once dosage of the
medication is discontinued, however, patients generally have a recurrence of disease
( Furuta, 2007). These medications can be used independently or in combination with
dietary treatment modalities.

Suggested Monitoring Parameters and Recommendations

Suggested monitoring parameters include the following:
Nutritional adequacy of elimination diet (using food diaries)
Effective avoidance (using food diaries, food frequency, and product labels)
Correction of nutritional deficiencies as indicated by laboratory assessment
Anthropometrics
Effective control of symptoms (and potentially histologic response)
Psychosocial impact of treatment
The elimination diet is first prescribed as a diagnostic diet. The initial treatment goal is
aimed at improvement of symptoms and histologic repsonse. Long-term elimination diets
are not advised if the need for dietary restriction has not been clearly established. The only
way to clearly establish if the food is causative is to eliminate it from the diet and establish
symptomatic and histologic response (via esophagogastroduodenoscopy, or EGD, and
biopsies) and then implement a food challenge test. Before any food challenge test, the
patient should be evaluated by the allergist to determine if there is a risk of an immediate,
immunoglobulin E–mediated allergic response.
Often multiple foods are eliminated at one time. If symptoms have resolved and symptoms
have resolved and biopsies have normalized after a multiple-food elimination diet, then
each food must be individually challenged. Because of the potential for delayed allergic
response, the food should be introduced and the patient observed for symptoms over
several weeks. If no symptoms occur, biopsies via EGD may be performed and will confirm
continued absence of esophageal eosinophilia.
It should be noted that expert opinion varies as to how to monitor the asymptomatic patient
with persistent eosinophilia, as the long-term consequences of chronic, untreated
esophageal eosinophilia are unknown (Furuta, 2007). If the gastroenterologist chooses
endoscopic reassessment in the asymptomatic patient, it should not be performed within
the first 4 weeks following the last intervention (Furuta, 2007).
Once a maintenance diet is determined, continued monitoring by the registered dietitian
may be warranted; the frequency of monitoring will be based on the number and type of
foods being eliminated and the age of the patient.
If, after dietary treatment, the patient continues to have persistent symptoms and/or
esophageal eosinophilia, the decision to advance treatment is generally based on the
following factors:
The degree of symptoms
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Age of patient
Presence of esophageal morphologic abnormalities
The patient’s/family’s values and preferences (Furuta, 2007)



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Nutrition Care > Food Allergic Disorders > General Guidance
Nutrition Assessment

A comprehensive nutrition assessment should be performed by a registered dietitian and
should include subjective and objective data from the following sources:
Anthropometric Data
Height (for children >2 years of age: Plot on Centers for Disease Control and
Prevention (CDC) chart for 2 to 20 years of age)
Length (in children <3 years of age: Plot on CDC chart for birth to 36 months of age)
Weight
Weight for length
Body mass index (for children >2 years of age)
Head circumference (in children <36 months)
Assessment of individual growth velocity/growth history
Comparison of growth to the reference population
Medical History
Food allergy diagnosis
Current symptoms that may impair nutrient intake (abdominal pain, nausea, vomiting,
early satiety, reflux) or increase nutrient needs (severe atopic dermatitis)
Reaction history: Accidental ingestions and causes
Concurrent medical conditions
Medications
Vitamin/mineral/herbal supplements
Food–medication interaction
Nutrition History (obtained through patient/caregiver interview and detailed food diary)
Foods avoided
Foods introduced and tolerated
Current diet
Eating/feeding competency
Adequacy of allergen elimination/history of accidental allergen ingestion
Nutritional quality of substitutions for eliminated foods
Feeding and eating skills and behaviors
Estimation of the nutrient intake and comparison to estimation of needs using the
Dietary Reference Intakes
Social History

Person responsible for shopping, cooking, feeding
Individuals providing care for the child (babysitters, day care, schools)
Financial resources
Physical examination
Laboratory tests

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Diagnostic Tests/Allergy Testing


The allergist takes a detailed medical history with a focus on symptom history, performs a
thorough physical examination, and orders diagnostic tests to rule out underlying medical
conditions not related to food allergy (Sicherer, 2006). The medical history alone is typically
not considered diagnostic of food allergy although there are few exceptions (Boyce, 2010)
(see the discussion of food protein-induced enterocolitis syndrome [FPIES] under Serum
Tests on this page).
Allergy Testing
For immunoglobulin E (IgE)–mediated allergies, allergists may use several tests, in
combination with the medical history, physical examination, and dietary history, followed by
an elimination diet and possibly a food challenge to ensure a more accurate diagnosis.
Tests used to assist the allergist in the diagnosis of IgE-mediated food hypersensitivity
include the skin prick test and quantitative measurements of food-specific IgE
antibodies. Be aware that no single test can accurately diagnose the presence of food
hypersensitivity. Furthermore, no test can predict the severity of a potential food allergic
reaction (Sicherer, 2002; ACAAI, 2006). The medical and dietary histories remain important
elements in the diagnostic process and the double-blind, placebo-controlled food challenge
is considered the “gold standard” for food allergy diagnosis.
Skin Prick Test
In a skin prick test, a diluted extract of the suspected food is placed on the skin and the
skin is pricked with a bifurcated needle or a lancet. A skin prick test may also be conducted
using fresh food, which may, in fact, be necessary when testing for hypersensitivity to raw
fruits or vegetables, as the extracts may not adequately represent the raw food protein.
The area is analyzed after 15 minutes. If a wheal (raised area, bump, or hive) is present
and is at least 3 mm larger than the saline control, the test is considered positive
(Sampson, 2001). The wheal is often surrounded by an area of erythema, called the flare.
Although a positive test does not diagnose an allergy, it is indicative of the possibility that
there is clinical reactivity to the tested allergen. The rate of false-positive skin prick tests is
50% (Sampson, 1997). The larger the reaction to the skin test (greater than 8 mm to 10
mm), however, the more likely it is to have clinical significance. On the other hand, a
negative skin prick test virtually confirms the absence of an IgE-mediated food allergy with
a negative predictive accuracy of greater than 95%.
Serum Tests
Quantitative measurement of food-specific IgE was previously measured using the
radioallergosorbent test, which has been replaced with the more sensitive fluorescence
enzyme-labeled assays. Specific threshold levels considered highly predictive of food
allergy for a number of foods have been determined using the Phadia ImmunoCap assay
(Sampson, 2001). For example, IgE antibody level above 7 kUA/L to egg, 15 kUA/L to
milk, and 14 kUA/L to peanut is highly predictive (greater than 95% chance) of clinical
reactivity. For children younger than 2 years, the positive predictive value (greater than
95% chance of reactivity) is associated with significantly lower IgE antibody levels (2 kUA/L
for egg and 5 kUA/L for milk). It should be noted that results from laboratories using
different assays (eg, Turbo-MP or Immunilite) may not be comparable to those using the
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Phadia ImmunoCAP System, and these predictive values cannot be applied when other
assays are used.
As with the skin prick test, the severity of an allergic reaction cannot be predicted by IgE
level alone. Although lower IgE antibody levels do not carry the same positive predictive
value, there is nonetheless a risk of clinical reactivity. There are many nuances involved in
interpreting these tests results, including past reaction history. If the patient has been
advised by the allergist to avoid the food/food group, the registered dietitian (RD) should
not advise the patient to try the food at home. Any questions about the patient's allergy
diagnosis should be directed to the patient's allergist.
Allergy testing is not useful in the diagnosis and treatment of adverse reactions to foods
that are not immunological in nature. RDs should be aware that there are many unproven
methods of allergy testing, which include food-specific immunoglobulin G testing,
provocation/neutralization testing, intradermal testing, kinesiology, cytotoxic tests,
sublingual testing, mediator release assay (LEAP), and electrodermal testing, among
others (Sicherer, 2006; Sicherer, 2002; Beyer, 2005; Boyce, 2010). These tests have no
proven benefit and may endanger patients by leading to unwarranted food-elimination diets
and potentially resulting in undiagnosed dangerous food hypersensitivities or underlying
medical conditions not related to food allergy.
With non-IgE–mediated food allergies, such as those occurring in eosinophilic esophagitis
(EoE) or FPIES, clinicians must rely on other methods to confirm diagnosis. Esophageal
biopsies are needed to confirm a diagnosis of EoE. There is limited value of
diagnostic tests to determine implicated antigenic foods in EoE.
For confirmation of FPIES, the medical history and, in some cases, a diagnostic food
challenge are recommended (Nowak-Wegrzyn, 2003; Sicherer, 2003; Fogg,
2006). However, when the suspected FPIES history is significant for hypotensive episodes
or multiple reactions to the same food, the history alone and resolution of symptoms with
avoidance of the implicated food can be used to diagnose FPIES (Boyce, 2010).
Currently, atopy patch testing is being used as a research tool to determine its utility in
identifying potential allergens in non-IgE–mediated allergic disorders such as EoE. The
2010 Food Allergy Guidelines from the NIAID-Sponsored Expert Panel suggest that atopy
patch testing not be used in the routine evaluation of food allergy due to insufficient
evidence to support its use and lack of consensus on appropriate reagents, methods, or
interpretation of these tests (Boyce, 2010).

Diagnostic Tests/Dietary Manipulation

When chronic symptoms as in atopic dermatitis or delayed symptoms as in eosinophilic
esophagitis or eosinophilic gastroenteritis are present, it may be difficult to determine a
cause-and-effect relationship between the food and the suspected reaction. These allergic
disorders may be immunoglobulin E (IgE) mediated or non-IgE mediated, so testing using
the ImmunoCAP System, fluorescence immunoassay, or skin prick testing may not prove
useful.
In such cases, manipulation of the diet for a patient with suspected food allergy may be
part of the diagnostic process. The food allergy guidelines suggest that elimination of one
or a few specific foods from the diet may be useful in the diagnosis of food allergy,
especially in identifying foods responsible for some non-IgE–mediated, food-induced
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allergic disorders such as food protein-induced enterocolitis syndrome and allergic
proctocolitis, and mixed IgE and non-IgE–mediated food-induced allergic disorders, such
as eosinophilic esophagitis (Boyce, 2010). Suspected food allergens should be eliminated
from the diet, anticipating reduction or clearance of symptoms. Usually 7 to 14 days is
sufficient to show either remission or significant improvement of symptoms in atopic
dermatitis. With eosinophilic esophagitis or eosinophilic gastroenteritis, approximately 6 to
8 weeks of allergen elimination may be necessary to achieve remission.
If symptoms resolve, it is possible that the omitted food is causing the reaction. The use of
an elimination diet, in combination with a convincing history, may be sufficient to diagnose
several food-induced allergic disorders (Boyce, 2010). If multiple foods have been removed
for diagnostic purposes, they should be added back one at a time for a period of 1 week
(possibly longer for eosinophilic esophagitis) while observing for symptoms.
If symptoms do not improve with removal of suspected foods, the diet should be reviewed
to ensure appropriate avoidance. If symptoms do not clear significantly, even with the most
restrictive or elemental diet, it is unlikely that ingested foods are implicated and other
etiologies, such as autoimmune or environmental, must be considered (Sampson, 2004;
Mofidi, 2003).

Oral Food Challenges

Following is a summary of the steps involved in an oral food challenge. For medical
practices preparing to undertake physician-supervised oral food challenges, there are
excellent primary references (Nowak-Wegrzyn, 2009) in addition to an oral food challenge
guidebook (A Health Professional’s Guide to Food Challenges) (FAAN, 2004). Significantly
more detail is available in these reference materials.
Oral food challenges are physician-supervised diagnostic tests during which the suspected
food is administered and gradually increased to a test's full dose. The patient is observed
for symptoms during the procedure and for a period of time after the full dose is
administered. An oral food challenge that results in a clinical reaction is termed a “positive,”
or failed, challenge, whereas an oral food challenge that does not elicit an allergic
response is termed a “negative,” or passed, challenge (Nowak-Wegrzyn, 2009).
Oral food challenges are used to identify, confirm, or rule out suspected food allergies.
Although challenges can be open, single-blind, or double-blind, the double-blind,
placebo-controlled food challenge (DBPCFC) is considered to be the “gold standard” for
food allergy testing (Sicherer, 2006; Nowak-Wegrzyn, 2009). The food allergy guidelines
recommend using oral food challenges for diagnosing food allergy. Although the DBPCFC
is the most specific test, due to the cost and inconvenience of DBPCFC, single-blind and
open-food challenges may be used in the clinical setting (Boyce, 2010). Regardless of the
type of oral food challenge, it should be conducted in a medical facility that has medical
supervision and emergency medications and devices available; furthermore, an emergency
treatment protocol should be in place (Nowak-Wegrzyn, 2009; Sampson, 2001; FAAN,
2004).
An open challenge involves feeding the challenge food in its usual form without disguise.
An open challenge is quick and easy, but it has the disadvantage of being prone to bias by
the clinician, patient, and/or the patient’s family. In a single-blind food challenge, the food is
disguised for the patient but not for the clinician. This type of challenge eliminates the
possibility of patient bias but not clinician bias. The DBPCFC removes any bias in the
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evaluation (Sampson, 1999; Nowak-Wegrzyn, 2009). In the DBPCFC, both the placebo
and the challenge food are disguised, using a challenge vehicle, and neither the patient nor
the clinician administering the test knows which food is the placebo and which is the
challenge food. The challenge vehicle should be chosen to mask the taste, color, texture,
and odor of the challenge food and it should not be too heavy or contain a substantial
amount of fat, as it may interfere with the absorption of the challenge protein (FAAN,
2004). A negative-blinded food challenge should be confirmed by an open challenge
(Nowak-Wegrzyn, 2009).
In preparation for the food challenge, suspected allergens must be eliminated from the diet
for a minimum of 7 to 14 days for immunoglobulin E (IgE)–mediated disorders and 8 to
12 weeks for eosinophilic esophagitis or gastritis (FAAN, 2004). The physician should
review all medications taken by the patient. Medications, such as antihistamines and those
with antihistamine activity, have the ability to interfere with or block a reaction and should
be discontinued long enough before the challenge to allow a normal histamine response
(Bock, 1988; Nowak-Wegrzyn, 2009). The patient should be in good health and chronic
symptoms of allergic disease, such as asthma or atopic dermatitis, should be under
control. It is best to begin the challenge early in the day, after an overnight fast, if possible;
otherwise, food should be avoided for 2 to 4 hours before the challenge (Nowak-Wegrzyn,
2009).
The type of food-allergic disorder will determine how the food challenge is conducted. For
IgE-mediated food allergies, 8 g to 10 g of the dry challenge food such as dry milk powder
or peanut flour, 16 g to 20 g of wet food such as meat or fish, or 100 mL of wet food such
as fruit puree should be prepared. The challenge is administered with increasing doses of
the test food over a 90-minute period. The physician may determine whether the
patient will be challenged in the office setting or in the hospital setting. Regardless of the
setting, the patient must be evaluated for the development of symptoms throughout the
challenge by a board-certified physician and observed for several hours following the
administration of the challenge food (Nowak-Wegrzyn, 2009; FAAN, 2004).
For food protein–induced enterocolitis syndrome, a challenge should only take place in a
hospital setting with a heparin lock in place because of the risk of hypotension in
approximately 15% of these reactions (Sampson, 2004; FAAN, 2004). The patient is given
a test dose of 0.06 g to 0.6 g of test food protein per kilogram of body weight with lower
quantities used for potential severe reactions. The total challenge dose should not exceed
3 g protein or 10 g whole food (Nowak-Wegrzyn, 2009). The challenge is administered in 3
feedings over 45 minutes. The patient should be observed for 4 hours after the test is
administered and, if the patient remains asymptomatic, a second single-serving dose
should be given followed by a 2- to 3-hour observation period (Nowak-Wegrzyn, 2009).
For eosinophilic disorders, if the test food has never caused an immediate reaction and the
patient does not have IgE antibodies to the challenge food, the food may be reintroduced
at home and consumed for approximately 7 to 14 days. It may take several days of
consumption for symptoms to occur. Again, the patient should be observed for symptoms
and periodic evaluation by the gastroenterologist, as endoscopy and esophageal biopsies
may be warranted to monitor the histological response to food reintroduction (FAAN,
2004). If endoscopic evaluation is advised, it should occur no sooner than 4 weeks after the
last dietary intervention (Furuta, 2007).

Laboratory

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Laboratory evaluation of nutritional status in children with food allergy is similar to
laboratory evaluation of nutritional status in the general pediatric population.
The dietary and medical history, growth pattern, and physical exam will guide
the laboratory evaluation. Overall, children with prolonged elimination of cow's milk or
children with multiple food allergies are at increased risk for inadequate intake of calcium,
vitamins D and E, iron, zinc, and energy.
Serum concentrations of vitamins E and 25-hydroxy vitamin D can be measured
directly. Laboratory assessment of hemoglobin concentration and red cell indices (mean
corpuscular volume, mean corpuscular hemoglobin) as well as serum ferritin can be used
to assess iron status. For children at risk of protein and energy malnutrition, laboratory
values of serum prealbumin concentration may be assessed.

Food/Nutrition-Related History

An accurate and detailed dietary history helps in identifying possible relationships between
symptoms and foods consumed. Registered dietitians should consider the following areas
in the individual's diet history:
Type and brand of food consumed
Amount of food consumed
Where food was prepared and eaten
Method of preparation
Who prepared the food
Ingredients added during preparation
Ingredients added before food was eaten
Cross-contact precautions used in food purchasing, storing, preparing, and serving
Whether food had been previously/subsequently eaten
If symptoms occur, the following should also be considered:
Time the food was consumed
Time the symptoms began
Description of symptoms
Order in which symptoms occurred
Time the symptoms subsided
Treatment or medication administered
If food was previously or subsequently eaten, what, if any, symptoms occurred


Nutrition Diagnosis

Registered dietitians (RDs) working with patients who have food-allergic disorders should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the following list,
as well as other diagnoses, may be present.
Inadequate energy intake (NI-1.4)
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Inadequate protein–energy intake (NI-5.3)
Inadequate fat intake (NI-5.6.1)
Inadequate protein intake (NI-5.7.1)
Inadequate carbohydrate intake (NI-5.8.1)
Inadequate vitamin intake (NI-5.9.1)
Inadequate mineral intake (NI-5.10.1)
Underweight (NC-3.1)
Food- and nutrition-related knowledge deficit (NB-1.1)
Self-monitoring deficit (NB-1.4)
Limited adherence to nutrition-related recommendations (NB-1.6)
Undesirable food choices (NB-1.7)
Intake of unsafe foods (NB-3.1)
Sample PES (problem, etiology, signs and symptoms) or Nutrition Diagnostic
Statement(s)
Inadequate energy intake (NI-1.4) related to allergen-avoidance diet as evidenced by
a body mass index <3rd percentile for age and average daily energy intake of 1,100
kcal.
Inadequate mineral intake (calcium) (NI-5.10.1) related to milk and soy avoidance diet
with inadequate substitution or supplementation as evidenced by food diary and food
frequency questionnaire.
Intake of unsafe foods (NB-3.1) related to lack of knowledge about potential
allergen-containing foods as evidenced by three documented adverse food-allergic
reactions in the past 6 months.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition intervention involves a diet prescription that strictly eliminates the identified
allergen but also replaces the nutrients in the eliminated food(s). Nutrition education needs
are extensive and education must address the many skills needed to manage the food
allergy in daily living.
Label reading, shopping, cooking, and finding age- and developmentally appropriate meals
and snacks may be challenging for the family learning how to manage a food allergy. In
addition to knowing how to read labels (already a task with many nuances), families must
be vigilant to prevent accidental exposure through cross-contact with the allergen either in
manufactured products, in the home kitchen, or when eating outside of the
home. Reducing risks while eating outside the home is essential, and families will need to
learn how to ensure a safe restaurant meal and a safe environment in school, camp, or day
care.
Food allergy management also changes as the child matures and gradually takes on more
responsibility for managing his or her food allergy. Adolescents and teenagers, for
example, are at greater risk of anaphylaxis, as they spend more time away from home with
their friends instead of with their parents. Ongoing and comprehensive education is
necessary, and the registered dietitian should work closely with the patient's family,
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caretakers, and allergist (Muñoz-Furlong 2003).
There are numerous resources available to families and health care providers to assist in
food allergy management, such as the following:
Allergy Web sites
Specialty food products
Allergen-free cookbooks
"Chef cards" for eating in restaurants
Sample school and camp forms
Emergency treatment plans
Support groups
For more information, visit the Weblinks page for this topic. The Consortium of Food
Allergy Research Web site has free, downloadable handouts on many food allergy
management topics discussed on this page.

Cow's Milk Protein Allergy

Infants
Cow’s milk protein allergy (CMA) usually begins in infancy and affects approximately 2% to
3% of the infant population. Approximately 80% to 85% of children with cow’s milk protein
allergy will develop clinical tolerance in time ( Sampson, 2004; Skripak, 2007; Sicherer,
2006).
Breastfed infants with CMA may benefit from a maternal dietary restriction of milk protein
from the diet, as recognizable proteins from the maternal diet can be found in breast
milk. Formula-fed infants with CMA cannot consume standard milk-based formulas and a
substitute formula should be recommended. Although soy formula is not hypoallergenic,
many infants (approximately 85%) with immunoglobulin E (IgE)–associated cow’s milk
protein allergy may tolerate soy protein formula (AAPCON, 2000). For infants with
non-IgE–mediated milk protein allergy, such as proctocolitis or enterocolitis, the prevalence
of hypersensitivity to both soy and milk may be greater, with 25% to 60% of infants reacting
to both (AAPCON, 2000). It should be noted that the World Allergy Organization's
Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA) guidelines do
not recommend intact soy protein formula over hypoallergenic formulas (extensively
hydrolyzed milk protein formula and amino acid–based formula) for infants with CMA and
soy formula is specifically not recommended for infants younger than 6 months.
Hypoallergenic formulas: The vast majority of infants with CMA (approximately
90%) tolerate extensively hydrolyzed milk protein infant formulas. For the small percentage
of infants and children who continue to exhibit symptoms on these formulas, a free amino
acid–based formula may be needed. Those with allergic eosinophilic disorders will also
require an amino acid–based formula, as extensively hydrolyzed formulas are not tolerated
with this type of allergy ( Chehade, 2007; Kagalwalla, 2006; Liacouras, 2006; Chehade,
2006). Both extensively hydrolyzed and amino acid–based formulas are considered
hypoallergenic. Partially hydrolyzed cow’s milk formulas are not hypoallergenic and are not
a suitable option for infants with CMA ( AAPCON, 2000).
The World Allergy Organization's Guidelines for the Diagnosis and Rationale against
Cow's Milk Allergy were published in April 2010 (Fiocchi, 2010). These guidelines offer a
basis for decision making for first choice infant formula recommendations based on the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
basis for decision making for first choice infant formula recommendations based on the
type of CMA. Extensively hydrolyzed formula is recommended for those infants with
IgE-mediated allergy with a low risk of anaphylaxis and for non-IgE–mediated CMA such
as food protein-induced enterocolitis or proctocolitis. Amino acid–based formulas are
recommended for infants with IgE-mediated allergy with a high risk of anaphylaxis
(meaning those infants who have experienced symptoms of anaphylaxis in the past and
who are not already on and tolerating extensively hydrolyzed formula), eosinophilic
disorders, or Heiner's syndrome. Soy formula was not specifically recommended as a first
choice formula although the guidelines suggest the recommendations should be based on
individual clinical circumstance, formula availability, and cost. As noted previously,
although not hypoallergenic, soy formula may be tolerated by many infants with
IgE-mediated CMA but for those with non-IgE mediated allergy, soy formula would not be
a good recommendation.
Beyond Infancy
Children with CMA are more likely to consume recommended levels of calcium and vitamin
D if they receive nutrition counseling and continue on their safe infant/toddler formula or
use a fortified soy beverage (Christie, 2002). Nutrients to be replaced on a milk-avoidance
diet include protein; fat (especially in toddlers and young children who require 30% to 40%
of their daily energy intake from fat); vitamins A, D, and B-12; calcium; riboflavin;
pantothenic acid; and phosphorus. DRACMA guidelines suggest a nutritionally adequate
substitute for those with CMA, either breast milk or substitute formula, until 2 years of
age. DRACMA did not specifically grade alternative enriched "milk" beverages such as soy,
rice, oat, almond, hemp, or coconut milks. There are many brands of alternative milks
available, but their nutritional content varies widely. DRACMA suggests these may be used
on an individual basis but it is wise, if using these alternatives prior to the second birthday,
to do so only after nutrition assessment and determination that the young toddler can meet
nutrition needs without substitute formula or breast milk in the diet. Following are points to
consider:
Any chosen alternative milk beverage should be fortified with calcium and vitamin D;
many are also fortified with vitamins B-12 and A. However, be aware that protein,
energy, and fat content can vary as well, so reading the label carefully is advised.
Not all alternative milk products are nutritionally equivalent. Fortified soy milk can be
an adequate substitute for cow's milk, providing a source of protein, calcium, vitamins
D and B-12, and riboflavin. If a concomitant soy allergy occurs, fortified grain, seed, or
nut beverages (if tolerated and approved by the patient's allergist) are an option to
supply a dietary source of calcium and vitamin D. Rice and almond milks, however,
are essentially protein free, so protein needs will need to be met entirely through solid
food intake before switching from a complete formula to some of the alternative milk
substitutes. Oat- and hemp-based milk alternatives may have a higher protein content
(2 g to 4 g per 8 oz) although protein content may vary from one brand to
another. The protein content of the solid food diet should be assessed before
transitioning from breast milk or formula to an alternative milk beverage.
Fat intake will also need to be assessed, as many of these products are lower in fat. In
addition, when milk is eliminated from the diet, not only must whole milk, cheese,
yogurt, and other dairy products be eliminated, but so must many processed and
manufactured foods that contain a milk ingredient—resulting in a diet that comes
primarily from whole foods. Hence, additional sources of dietary fats such as
vegetable oils may need to be added to the diet.
Consider other concomitant nutritional risk factors (poor growth, eating skills,
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self-selective eating, signs or symptoms of nutritional deficiencies) as determined by
the nutrition assessment.
Baked Milk: A certain percentage of those with cow's milk protein allergy are clinically
reactive only to milk that has not been extensively baked (Kim, 2011). Allergists
increasingly are beginning to conduct physician-supervised oral food challenges to baked
milk. Be aware, therefore, that the registered dietitian may have patients who require
guidance on avoiding only unbaked milk. Caution for products that appear baked but may
include unbaked milk protein (for instance, a cookie or cake with an icing that contains
unbaked milk ingredients). Patients should always check with their physician before trying
any new foods and the registered dietitian should not advise patients to try baked milk at
home as there is a risk of a severe, potentially life-threatening allergic reaction.

Wheat Allergy

The prevalence of wheat allergy in the pediatric population is approximately 0.4% to
1% (Sicherer, 2006). Whole grain and enriched wheat products contribute carbohydrates,
iron, niacin, riboflavin, thiamin, folate, and whole wheat products contribute fiber to the diet.
When adequately substituted with alternative enriched grains and whole grain products,
the nutritional quality, variety, and convenience of the wheat-free diet can be vastly
improved.
Teaching caregivers how to substitute alternative grains in recipes will help to make the
diet more palatable as well as offer a source of the nutrients lost to the wheat avoidance
diet. In addition, there is a vast variety of gluten-free products available on the market
today, offering families the options of wheat-free convenience foods. Gluten-free products
are typically wheat free, but the reverse may not be true.
It should be noted that children with one grain allergy are at risk (20% chance) for being
clinically reactive to another grain (Sicherer, 2001; Jones, 1995). Therefore, use of
alternative grains should be individualized based on tolerance as determined by the child’s
allergist or the tolerance history. So while a gluten-free product will be free of wheat, it does
not guarantee tolerance. Tolerance can be determined by the dietary history by reviewing
all products and ingredients eaten and tolerated or by the allergy evaluation. If you are
unsure as to which grains are tolerated, communication with the allergist is recommended.

Egg Allergy

Egg allergy affects 1.3% of children in early childhood (Sicherer, 2006). Nutritionally, egg
contributes protein, vitamins B-12 and D, biotin, riboflavin, pantothenic acid, and selenium
in the diet. Egg white is generally more allergenic than the egg yolk; however, a child with
egg allergy will need to avoid both the egg yolk and the egg white, as it is not possible to
obtain the yolk without contamination from the egg white.
Egg is a common ingredient in the Western diet, and those avoiding egg will need to learn
how to replace egg in a recipe so traditional foods can continue to be enjoyed, if desired.
Egg does not usually account for a large percentage of daily dietary intakes, so the
nutrients lost to egg avoidance should be easily replaced by other dietary sources. A varied
diet that provides milk, meats, fish, poultry, whole grains, fruits, vegetables, legumes, and
vegetable oils can provide adequate nutrition. Educating families on how to avoid egg and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
egg ingredients is necessary.
While those with egg allergy may be allergic to egg in any form, a certain percentage of
patients with egg allergy are clinically reactive only to egg that is not extensively baked into
a product. More and more allergy practices are beginning to conduct physician-supervised
baked egg challenges on appropriate patients with egg allergy. Registered dietitians should
be aware that some patients may need guidance on avoiding egg that is not
extensively baked, rather than egg in any form, as determined by their
allergist (Lemon-Mule, 2008).

Soy Allergy

Soy is a nutrient-dense food that contributes thiamin, riboflavin, pyridoxine, folic acid,
calcium phosphorus, magnesium, iron, and zinc to the diet. Soy is pervasive in our food
supply, although mostly as a minor ingredient. Therefore, soy generally does not contribute
a significant percentage of daily dietary intake so the nutritional impact may be minimal. If
the child has other food allergies or is following other dietary patterns such as a vegetarian
diet, however, the impact will naturally be much greater.
Studies show that most soy-allergic individuals can safely consume soy oil and soy lecithin
(Crevel, 2000; Taylor, 2002). Highly refined soy oil, which is not considered an allergen, is
exempt from labeling requirements under the Food Allergen Labeling and Consumer
Protection Act; but soy lecithin is not exempt (USFDA/CFSAN, 2006).

Peanut Allergy

Recent studies have indicated that the prevalence of peanut allergy has doubled among
children younger than 5 years in the last decade (Sampson, 2004; Waserman, 2011;
Branum, 2009). The prevelance of peanut allergy in the United States is 0.6% (Boyce,
2010)
Peanut avoidance can be challenging, as peanut can show up in surprising and hidden
ways. For instance, peanut butter can be used in recipes to thicken stews or chili, or it may
be used to seal the ends of egg rolls before frying. Asking detailed questions about
ingredients used and food preparation methods is advised when dining out. Other peanut
allergy management tips (such as air travel tips) are available from the Food Allergy &
Anaphylaxis Network.
Highly refined peanut oil is considered safe for those with peanut allergy (Crevel,
2000), and according to the US Food and Drug Administration, highly refined oils are not
considered allergens (FDA website 2011). Registered dietitians should check with the
patient's physician before including highly refined peanut oil in the diet and be aware that
not all peanut oil on the market is highly refined. Oils that are not highly refined—such
as cold pressed, expeller pressed, extruded, and extracted peanut oils—will contain peanut
protein and are not considered safe. It is common practice to maintain elimination of peanut
oil, as there are numerous options for alternative vegetable oils and the degree of
processing a peanut oil may not be easy to determine. For instance, the ingredient list of a
finished food will not inform consumers the nature of the oil or how the oil was
manufactured or refined.
Although any food can cause anaphylaxis, those with peanut allergy are at greater risk for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Although any food can cause anaphylaxis, those with peanut allergy are at greater risk for
a severe, potentially life-threatening allergic reaction. (Waserman, 2011). Adolescents with
peanut allergy and those with asthma are at greater risk. Encouraging peanut-allergic
individuals to carry their emergency medications at all times is important in peanut allergy
management. Adolescents with peanut allergy should also educate their friends about their
allergy, as individuals in this age group may be more likely to spend an increasing amount
of time with friends and without adult supervision.
It was once believed that peanut allergy was always a lifelong allergy, but research
indicates that roughly 20% of young children may eventually develop clinical tolerance
(Skolnick, 2001). Patients should be encouraged to continue to follow up with their allergist.
Although peanut is a legume, cross-reactivity between peanut and legumes is rare, with
only 5% of those with a peanut allergy reacting to another legume (Sicherer, 2001). One
legume, lupine, appears to be an exception, with 44% of those allergic to peanut having a
positive skin prick test response to lupine (Moneret-Vautrin, 1999). Of those with a positive
skin prick test, 7 out of 8 who underwent oral food challenges were clinically reactive to
lupine flour (Moneret-Vautrin, 1999).
Children with peanut allergy, however, are at greater risk for tree nut allergy. Approximately
35% of those allergic to peanut will react to at least one tree nut, although these two foods
are botanically different. Those with peanut allergy may be advised by their physician to
avoid all tree nuts (and potentially some seeds) because of the risk of cross-reactivity
between peanut protein and tree nut proteins in addition to the risk of cross-contact in
manufacturing. Registered dietitians should always check with the peanut-allergic patient's
physician before adding a tree nut to the diet and then do so carefully with guidance on
those without risk of cross-contact with peanut.

Nutrition Therapy Efficacy

Nutrition therapy efficacy is determined by adequate intake of all nutrients, expected
growth and development, and adequate and appropriate allergen elimination. The child
with food allergies should be able to participate in and enjoy all childhood activities. Parents
should feel confident in their knowledge and ability to safeguard their children in all
environments. If the child's or family's activities are too restricted, greater guidance on how
to safely manage the food allergy while still enjoying typical activities of childhood may be
needed.

Goal Setting

Nutrition therapy goals are threefold:
Nutritional adequacy of the elimination diet 1.
Effective avoidance to prevent food-allergic reactions 2.
Food allergy management skills to ensure safety during typical childhood activities 3.
Allergen-elimination diets may affect nutrient intakes and growth. Rickets, vitamin and
mineral deficiencies, shorter stature, and failure to thrive have all been associated with
allergen-elimination diets (Henriksen, 2000; Isolauri, 1998; Jensen, 2004; Christie, 2002).
Christie and colleagues (2002) found that children with two or more food allergies were
shorter, based on height-for-age percentiles, than those with only one food allergy.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
shorter, based on height-for-age percentiles, than those with only one food allergy.
Furthermore, children with cow’s milk allergy or multiple food allergies consumed dietary
calcium less than age- and sex-specific recommendations compared with children without
cow’s milk allergy and/or one food allergy (Christie, 2002). Overall, children with food
allergy are reported to have lower-than-recommended intakes of vitamins D and E, iron,
calcium, and zinc, although, depending on the food avoided, certain nutrients may be at
greater risk of inadequacy. The elimination diet must be carefully planned to ensure
adequate substitution of the macronutrients and micronutrients inherent in the eliminated
food(s).
With appropriate dietary substitutions, the allergen-elimination diet should meet all nutrient
requirements based on height, weight, and age of patient. Nutrition therapy should include
appropriate nutrition support or supplement administration when nutrient needs cannot be
met through dietary means alone. Collaboration with the patient's allergist is
strongly recommended throughout treatment.
Learning how to effectively avoid identified allergens requires extensive education.
Families need to learn how to interpret product information accurately; how to call
manufacturers for more product information when necessary; how to prepare safe foods in
the home or ensure a safe meal in a restaurant (see Restaurant Meals); and how to
communicate with other caretakers, such as other family members, babysitters, and day
care, school, and camp personnel. Eating and/or contact with food in each environment
must be addressed. In addition, families should be encouraged by all health care
professionals to carry emergency medications and their emergency treatment plans with
the allergic child at all times. Families and any additional child care provider should
understand how and when to use these medications.
Because of the nutritional concerns in this population and the many nuances in avoidance
education, extensive education must be provided to ensure adequate management
skills. Ongoing nutrition therapy is advised as nutritional concerns and food
allergy management issues evolve with the maturing child. For example, teenagers with
food allergy are at greater risk for anaphylaxis because they eat more meals
away from home, are less likely to have their emergency medication on hand, and
are more inclined to not recognize or to ignore initial symptoms of a food-allergic reaction.
The Food Allergy & Anaphylaxis Network (FAAN) has developed a variety of resources and
products to help parents, physicians, school personnel (administrators, teachers, school
nurses, foodservice staff), and camp staff work together to keep those with food allergies
safe. Also available are downloadable restaurant cards (also called "chef cards") that can
be personalized to include multiple allergens. FAAN also provides a free e-mail allergy alert
service that notifies members of foods that may be mislabeled or recalled because of
allergen content. The Consortium of Food Allergy Research also has an extensive food
allergy education program that offers free, downloadable handouts on a variety of food
allergy topics.
There are many other helpful Web sites with resources for families and professionals that
registered dietitians should peruse before working with families with food allergies. Visit the
Weblinks section of this heading for more information.
Nutrition counseling should enable individuals with food allergy and their caregivers to do
the following:
Identify foods that typically contain the allergen
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Understand how to read a food label
Recognize the need to read product labels each and every time an item is purchased,
as ingredients may change at any time
Understand the risk of products with an advisory statement for the allergen
Understand the risk of cross-contact with the allergen (in and outside of the home)
Understand the need to teach all caregivers how to manage the food allergy
Know how to prepare allergen-free meals and snacks from whole foods
Know where to find allergen-free products
Identify the nutritional risks of the allergen-elimination nutrition prescription
Know how to safely substitute nutrient-dense alternative food sources for those foods
eliminated because of allergen avoidance
Understand how to obtain a safe restaurant meal by avoiding high-risk eating
establishments, using chef cards, and communicating effectively to appropriate
restaurant personnel (manager and/or chef) Understand how to work together with
school, day care, or camp staff to ensure a safe environment
Recognize the need to have emergency medications and emergency treatment plans
available at all times
Know how to recognize and treat the symptoms of food-allergic reactions

Food and Feeding Issues

Children with food allergies may have anxiety or fear about eating new foods depending on
the food-allergic reaction history. Caregivers may also be fearful of serving a new food and
may be inclined to limit the diet to foods the child has been known to tolerate in the
past. Children or caregivers who limit the diet beyond what is necessary because of
allergen avoidance should be referred back to the allergist for further assessment and to
reassure the family that additional foods may be included in the diet.
Children with multiple food allergies may also have limited experience with a variety of
flavors and textures, which may result in self-selective or “picky” eating or, in some cases,
even a delay in the acquisition of feeding skills. Helping the family to provide a variety of
flavors and textures should be a goal of the registered dietitian. This can be done even with
a limited number of foods or a single food (eg, rice pasta, rice pancake, rice crackers, rice
bread, rice puffs, warm rice cereal) with added tolerated fruits or allergen-free flavors such
as 100% pure maple syrup, salt, refined vegetable oil, milk-free/soy-free margarines, and
so on.
For some children, a referral for a feeding evaluation may be necessary. Feeding teams
can provide the interdisciplinary approach needed when complex feeding issues arise.
Certain food-allergic disorders, such as eosinophilic disorders, may cause a variety of
symptoms such as abdominal pain, poor appetite, and early satiety, all leading to an
impaired ability to meet nutrient needs (Pentiuk, 2007).

Label Reading

The Food Allergen Labeling and Consumer Protection Act, or FALCPA, mandates that food
products must clearly list on the package label all ingredients derived from the "major"
allergenic food sources (defined below). Conventional food products, dietary supplements,
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infant formulas, and medical foods are all subject to the requirements of FALCPA, whereas
raw agricultural commodities are not. Any product manufactured for sale in the United
States must comply with these food labeling laws.
The following 8 foods are identified as the major food allergens in the United States and
are subject to the FALCPA:
Milk
Egg
Soybean
Wheat
Peanut
Tree nut
Fish
Crustacean shellfish
In addition, manufacturers must list the specific tree nut, fish, or crustacean shellfish used
as an ingredient. Mollusks are not considered major food allergens under the FALCPA
(USFDA/CFSAN, 2006).
Major allergens must be listed in one of the following ways (USFDA/CFSAN, 2006):
In the ingredient list
Parenthetically following the food protein derivative—for example, "casein (milk)"
Immediately below the ingredient list in a “contains” statement—for example,
"CONTAINS WHEAT"
Manufacturers are required only use one of these methods on each food label; therefore,
individuals with food allergy should be cautioned to avoid looking only for “contains”
statements. They should also be advised to read product labels each and every time a food
item is purchased because ingredients can change at any time without any notification
other than the ingredient label and/or "contains" statement.
A major food allergen must also be disclosed if it is a component of an incidental ingredient
such as in a spice, flavoring, coloring, or additive, or if it is used merely as a processing aid
in a product (USFDA/CFSAN, 2006). However, an individual with sensitivity to an
ingredient not covered under the FALCPA, such as mustard or sesame, would need to call
the manufacturer to ascertain if these ingredients were included in a vague ingredient term
such as "spice" or "natural flavoring."
Although an ingredient may be derived from an allergenic source, it may contain
insignificant amounts of the allergenic protein. One example is lecithin, which may be
derived from soy but is generally tolerated by most individuals with soy allergy because
of the low levels of allergenic protein and the minute amount of ingredient use in any given
product (Taylor, 2002; Taylor, 2006). Another example is kosher gelatin, derived from fish,
which has a very low relative allergenicity (Taylor, 2002; Taylor, 2006). These ingredients
are not exempt from the FALCPA, however. Currently the only ingredient derived from a
major food allergen that is exempt from the food allergen labeling law is highly refined
vegetable oil, as such oils have almost complete removal of allergenic protein and have not
been shown to pose a risk to human health (Crevel, 2000; Taylor, 2002; USFDA/CFSAN,
2006; Taylor, 2006).
The presence of allergenic ingredients in manufactured foods caused by cross-contact is
not required to be listed on product labels. Cross-contact occurs when an "allergen-safe”
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
food unintentionally comes into contact with an allergen during routine methods of
production such as the use of shared storage, transportation, or production equipment.
Cross-contact may lead to significant levels of hidden allergens in a product without
identification on the product label. Many manufacturers are addressing the issue of
cross-contact with advisory statements such as, “May contain [allergen],” “Manufactured in
a facility that also manufactures [allergen],” or “Manufactured on shared equipment with
[allergen].” Advisory statements are currently voluntary and unregulated; therefore, the
absence of an advisory statement does not necessarily mean there is no risk of
cross-contact. Furthermore, as these statements are not regulated, no one statement
represents a greater or lesser degree of risk than another. The 2010 US Food Allergy
Guidelines suggest avoiding any product that contains an advisory statement or
precautionary label for an allergen.
Food-allergic individuals should also be aware that nonfood items such as lotions,
sunscreens, shampoos and other cosmetic products, art supplies, and pet foods may
contain allergens.

Dietary Interventions for Preventing or Delaying the Onset of Allergic Disease

In January 2008, the American Academy of Pediatrics updated earlier provisional
recommendations aimed at preventing or delaying the onset of allergic response through
dietary intervention in those infants considered at risk (AAPCON, 2000; Greer, 2008).
These guidelines are intended for infants at-risk of developing an allergy and not for the
general pediatric population. Infants are considered at risk if they have one first-degree
relative with an allergic disorder (such as asthma, atopic dermatitis, allergic rhinitis, or food
allergy). The findings of this report (Greer, 2008), published by the joint American Academy
of Pediatrics Committee on Nutrition and Section of Allergy and Immunology, represent
guidance based on evidence from current research and are summarized as follows:
Exclusive breastfeeding for at least 4 months decreases the cumulative incidence of
atopic dermatitis, cow’s milk allergy, and wheezing in early life when compared with
feeding intact cow’s milk protein formula.
Atopic dermatitis may be delayed or prevented by the use of hydrolyzed formulas,
compared with intact cow’s milk formula, in early childhood. Extensively hydrolyzed
formula (EHF) appears to be more protective than partially hydrolyzed formula,
although EHF is more costly.
The use of soy-based infant formula does not appear to play a role in allergy
prevention and is not recommended as a strategy to prevent the development of
allergy in at risk infants.
Complementary foods should not be introduced before 4 to 6 months of age. Delaying
the introduction of complementary foods beyond 4 to 6 months of age does not
appear to provide significant protective effect.
At this time, there is insufficient evidence to recommend further dietary interventions
for those at risk, such as avoidance of specific foods (including those considered
highly allergenic such as foods containing fish, egg, or peanut) during pregnancy,
lactation, or beyond 4 to 6 months of age to protect against the development of
allergic disease.
These recommendations are consistent with recommendations provided in the US Food
Allergy Guidelines (Boyce, 2010) for feeding infants at risk for developing food allergy. As
noted previously, this summary represents feeding guidelines intended for infants who are
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
at risk for developing an allergic disorder (Greer, 2008) and should not be confused with
treatment strategies for infants who already have evidence of allergic disorder or with
general pediatric feeding guidelines for infants. Further research is needed, and it
is possible that there may be changes in guidance as additional evidence emerges.

Restaurant Meals

Planning ahead and good communication are keys to obtaining a safe restaurant
meal. Calling the restaurant ahead of time or avoiding dining out during the restaurant's
busiest hours may improve the amount of attention given to a special request. Patrons
should ask to speak to a manager and not rely on the waitstaff for ingredient information or
to relay important information back to the kitchen. Communicating clearly that there is a
food allergy (not just asking if an item contains the allergen) is also important.
"Chef cards" (available on several Web sites) list ingredients that must be avoided. A
laminated chef card can be given to the chef so he or she has the information available in
writing when preparing the meal. In addition to ingredient information, instructions on how
to prevent cross-contact should be provided. Patrons should ask that their food be
prepared using clean cooking equipment (pans, pots, cutting boards, prep areas, all
utensils) and not shared equipment such as fryers or grills that may be used to prepare a
variety of foods, potentially with allergenic ingredients. Lastly, ordering foods simply
prepared (avoiding casseroles, multiple-ingredient dishes, and complex sauces and
desserts) will help to decrease risk of unintentional exposure to allergens.
Families with food allergies must be vigilant about confirming ingredients used in their
order as well as food preparation methods to prevent exposure through hidden allergens
and cross-contact. In addition, certain eating establishments are considered high risk
depending on the allergy.
More in-depth information on obtaining safe restaurant meals as well as other food allergy
management topics are available on the Consortium of Food Allergy Research Web site.

Nutrition Monitoring & Evaluation

Nutrition reassessment of children with food allergy should include evaluation of the
following:
Nutrition-related behavioral and environmental outcomes
Discuss any reactions that may have occurred, determine cause, and review
how the reactions may have been prevented
Review of allergen-avoidance guidelines: label reading, avoidance issues in the
home and outside of the home in school and afterschool activities, camps,
restaurants, while traveling, and so on
Educate family on age-appropriate self-management skills for the child (for
example, young children can learn to accept foods only from designated adults
whereas responsible teenagers can learn to carry their own medications when
not under adult supervision and to educate their friends about their food allergy)
Ensure there is access to safe foods in all environments
Ensure the patient continues to be monitored by his or her allergist
Ensure patient (or responsible adult) carries emergency treatment plan and
emergency medications (as prescribed by physician) and knows how to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
recognize and treat food allergy reactions
Food and nutrient intake outcomes
Nutritional adequacy of the allergen-free diet
Nutrition-related physical sign and symptom outcomes
Growth assessment
Biochemical assessment
Physical assessment
Control of chronic symptoms such as eczema
Nutrition-related patient- and client-centered outcomes
Assess the impact of the allergen-restricted diet on quality of life and provide
instruction to minimize the impact and allow all age-appropriate activities
Assess the satisfaction of diet for the patient and the impact of the shopping and
food preparation on caregivers
Recommend support groups, food allergy organizations, and publications to
provide evidence-based information


Nutrition Care FAQs

Question: Is calcium lactate safe for patients with milk allergy?
Answer: Calcium lactate, calcium carbonate, cocoa butter, coconut milk, calcium stearoyl
lactylate, oleoresein, cream of tartar, and sodium stearoyl lactylate are all safe ingredients
for those with milk allergy, as they do not contain milk protein. Lactic acid is generally safe
although a lactic acid starter culture may contain milk protein.
Question: If a product does not contain an advisory statement for a specific allergen, does
that mean there is no risk for cross-contact with that allergen?
Answer: Advisory statements are voluntary, and the absence of an advisory statement
does not guarantee that the product is without risk.
Question: Is a product labeled "non-dairy" safe for those with milk allergy?
Answer: "Non-dairy" products are not necessarily safe for individuals with milk allergy.
The US Food and Drug Administration (FDA) allows milk protein derivatives such as
caseinates in products that are labeled "milk-free." The caseinate must be disclosed on the
label as a milk ingredient. The only way to know if the product contains a milk ingredient is
by reading the ingredient list thoroughly.
Question: Is nutmeg safe for patients with tree nut allergy?
Answer: Yes, a person allergic to tree nuts can safely consume nutmeg. Nutmeg is
obtained from the seed of a tropical tree.
Question: Is coconut safe for someone avoiding tree nuts?
Answer: The FDA considers coconut a tree nut and those avoiding tree nuts should not
consume coconut unless otherwise indicated by their allergist.
Question: Are egg substitutes safe for egg-allergic patients?
Answer: Many egg substitutes contain egg proteins and are not considered safe. There
are some egg replacers, such as Egg Replacer by Ener-G foods, that do not contain egg
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and can be used to replace egg in a recipe. The only way to know if a product contains egg
is to read the ingredient label thoroughly.
Question: Are all FDA-regulated products manufactured for sale in the United States
required to comply with the Food Allergen Labeling and Consumer Protection Act
(FALCPA)?
Answer: All products that are regulated by the FDA, including those domestically
manufactured and those imported for sale, must comply with FALCPA.
Question: Are clams considered a major allergen by the FDA?
Answer: FALCPA identifies crustacean shellfish (eg, shrimp, lobster, crab, etc.) as a
major allergen but not mollusks (eg, clam, scallop, oyster, etc.). Therefore, clam is not
considered a major allergen by the FDA.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases
Gastrointestinal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases > Celiac Disease
Nutrition Assessment

Nutrition assessment should include the following (EAL, 2009):
Cient history
Food history
Biochemical data
Nutritional anemia profile
Vitamin profile
Mineral profile
Intestinal biopsy
Anthropometric measurements
Weight, height, or length
Body mass index
Head circumference
Growth pattern
Type, frequency, and volume of bowel pattern
Abdominal pain and bloating
Nausea or vomiting
Reduced gut motility or delayed gastric emptying
Medication and herbal supplement use
Social information
Religious food practices
Family food practices and support (who prepares food)
Day care/school food policies
Factors affecting access to food and food- and nutrition-related supplies (safe food
and meal availability)
Other conditions:
Other food allergies or intolerances
Thyroid conditions
Type 1 diabetes
Other autoimmune diseases

Nutrition-Focused Physical Findings

Patients newly diagnosed with celiac disease or those with celiac disease who are
noncompliant with the gluten-free dietary pattern may show signs of malnutrition including
poor growth, distended abdomen, muscle wasting, and pale skin. However, as the age of
diagnosis increases, physical observations are usually more subtle, such as short
stature or presentation with other autoimmune diseases. One study reports that 11% of the
authors' diagnosed patients (n=143) were overweight (Telega, 2008).
Patients with newly diagnosed dermatitis herpetiformis or those with dermatitis
herpetiformis who are noncompliant with the gluten-free dietary pattern will have grouped
erythematous lesions or blisters that are usually preceded by itching and burning. The
lesions are usually bilateral and the most common site is the elbows, but they may also be
found on the knees, shoulders, buttocks, sacral region, and face. Dermatitis
herpetiformis in children may be associated with abdominal pain, pale skin, and poor
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
growth (Caproni, 2009).
Patients with celiac disease or dermatitis herpetiformis who are following the gluten-free
dietary pattern and are monitored closely by a registered dietitian should have a normal
growth pattern and no signs of malnutrition or skin lesions. If linear growth remains
suboptimal for more than 1 year after the implementation of a gluten-free dietary pattern
and the diet has been evaluated and contains no gluten, then the patient should be
referred for evaluation of growth hormone deficiency (Giovenale, 2006).

Biochemical Data, Medical Tests and Procedures

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
(NASPGHAN) has established guidelines for the diagnosis and treatment of celiac
disease in children and adolescents. These guidelines recommend measuring the IgA
antibody to human recombinant tissue transglutaminase (TTG) as the first step (Hill, 2005).
IgG and IgA anitbodies to deamidated gliaden peptide (DGP) are being used in the
diagnosis of celiac disease but may be more useful in monitoring for compliance (Mozani,
2011).
The IgA antibody to endomysium (EMA) is as accurate as TTG; however, EMA presents
greater risk for interpretation error and is a more expensive test than the TTG. Both of
these tests can give false negative results in IgA deficiency; therefore, a total serum IgA is
also recommended. In patients with IgA deficiency, a TTG IgG is recommended.
The use of antigliadin antibody tests and antireticulin antibody tests is no longer
recommended (Hill, 2005). Even with improvements in the serologic testing, the gold
standard for diagnosis still includes an intestinal biopsy, and diagnosis should still follow
the criteria for the diagnosis of celiac disease established by the European Society for
Pediatric Gastroenterology and Nutrition. These criteria include the following:
Positive clinical presentation
Positive serological test
Single intestinal biopsy with positive histological findings
Clinical response to the gluten-free diet
In order for this testing to be accurate the patient needs to be eating a gluten-containing
diet. Removing gluten before the antibody test or the biopsy can lead to a false negative
result.
Human leukocyte antigen (HLA) testing may be useful in ruling out celiac disease. Almost
90% of patients with celiac disease will have HLA DQ2 and the remaining will have
HLA DQ8. However, 40% of the general population has either HLA DQ2 or HLA DQ8, yet
only 1% of the general population will develop celiac disease (Hill, 2005).

Laboratory

Nutritional deficiencies may occur in the patient newly diagnosed with celiac disease as a
result of malabsorption caused by the damage to the intestinal mucosa. The gluten-free
dietary pattern is the most effective treatment for these deficiencies.
Biochemical data may be helpful at diagnosis and subsequent follow-up to diagnose
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nutrient deficiencies and to evaluate the response to the diet, including the following:
Nutritional anemia profile
Hemoglobin
Hematocrit
Serum ferritin
Total iron-binding capacity
Vitamin B-12
Serum folate
Fat-soluble vitamins, especially if fat malabsorption or decreased bone mineral
density is present
If diarrhea is present:
Serum zinc
Electrolytes to determine hydration status

Anthropometric Measurements

For children with celiac disease, accurate measurements of length or height and weight
should be plotted on sex-specific growth charts to determine the age-appropriate percentile
for height, weight, and body mass index (BMI), usual growth patterns and recent weight
changes.
WHO growth charts should be used for children under the age of 2.
CDC growth charts can be used for children 24 months or older.
These charts can be used to determine height-for-age percentiles, weight-for-age
percentiles, weight-for-length percentiles in children younger than 3, and BMI-for-age
percentiles in children older than 3.
The increase in height per unit of time, or growth velocity, is useful for monitoring
growth rates.
Charts are available for specialized populations, including Down syndrome, and
should be used for this population to make an accurate assessment of growth.
Growth charts are available in the Resources section of this site.

Client History

The client history should include the following (EAL, 2009):
Medical history
Symptoms associated with celiac disease
Growth patterns
Social history
Child care
School and afterschool activities, including lunch, crafts (those involving
gluten-containing grains, such as papier mache or noodle necklaces), snacks,
field trips, sports, and other activities
Multiple caregivers/multiple households
Who does the shopping and cooking, food-preparation skills
How often are meals eaten outside the home and where
Religious activities such as the following:
Christian Communion
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Passover, which involves matzoh, and other foods cooked using matzoh
meal
Assessment of other disease states
Patients with celiac disease may have food allergies and/or endocrine diseases
that may require incorporating other diet prescriptions into the gluten-free dietary
pattern.
Example: A patient with celiac disease and type 1 diabetes will require
incorporation of carbohydrate counting

Food/Nutrition-Related History

Food history/recall should include the following (EAL, 2009):
Food and nutrient intake (such as via diet history) with special attention to calcium,
iron, B-vitamins, vitamin D, and fiber
Diet Order
Diet Experience
Previously prescribed or self-selected diets (including allergies, food
intolerances)
Previous Nutrition Education/Counseling
Eating Environment (Locations such as home, school/daycare;
caregivers/companions, etc.)
Food and Nutrition Knowledge (Resources, websites that have been accessed, etc.)
Beliefs and Attitudes
Readiness to change and adopt a gluten-free lifestyle
Food Preferences
Safe Food/Meal Availability
Availabilty of shopping facilities with gluten-free food choices
Appropriate meal preparation facilities and availability of safe food storage to
prevent cross-contact from gluten containing foods
Physical Activity
Medication and vitamin and herbal supplement use
Factors affecting quality of life
Individuals with celiac disease may have quality-of-life issues because of the
social inconveniences of following the gluten-free dietary pattern

Nutrition Diagnosis

Dietitians working with patients who have celiac disease should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Malnutrition (NI-5.2)
Inadequate fiber intake (NI-5.8.5)
Inadequate vitamin intake (NI-5.9.1)
Inadequate mineral intake (NI-5.10.1)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Altered nutrition-related laboratory values (specify) (NC-2.2)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
Overweight/obesity (NC-3.3)
Food- and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Limited adherence to nutrition-related recommendations (NB-1.6)
Undesirable food choices (NB-1.7)
Impaired ability to prepare meals/foods (NB-2.4)
Poor nutrition quality of life (NB-2.5)
Limited access to food or water (NB-3.2)
Sample PES or Nutrition Diagnostic Statement(s)
Malnutrition related to alteration in gastrointestinal tract structure as evidenced by
failure to thrive with celiac disease
Inadequate fiber intake related to family's lack of awareness of gluten-free, high-fiber
foods as evidenced by food recall and inadequate fecal bulk
Food- and nutrition-related knowledge deficit concerning food and supplement
sources of calcium as evidenced by food recall indicating calcium intake less than
DRI for age
Altered gastrointestinal function related to damage to the intestinal villi as evidenced
by elevated celiac antibody levels and positive intestinal biopsy
Impaired nutrient utilization related to alteration of gastrointestinal tract as evidenced
by elevated celiac antibodies and stunted growth
Altered nutrition-related laboratory values for serum ferritin related to consumption of
gluten-containing foods causing an immune reaction as evidenced by elevated celiac
antibody tests and low serum ferritin
Limited adherence to nutrition-related recommendations related to consumption of
gluten-containing foods as evidenced by elevated celiac antibody tests and report of
eating regular pizza once a week
Limited access to foods related to consumption of gluten-free foods as evidenced by
elevated celiac antibody tests and limited supply of gluten-free foods in the home
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.



Nutrition Intervention

Nutrition intervention should include the following (EAL, 2009):
Nutrition Prescription: A gluten-free meal plan
Adequate nutrient intake for age (macronutrients, micronutrients, and fiber)
Consumption of whole/enriched grains
Inclusion of gluten-free oats in diet of individual who can tolerate them
Multivitamin with minerals
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Iron supplementation for iron-deficiency anemia
Adequate intake of vitamin D and calcium
Education
Label reading
Continous monitoring of labels to identify changes in ingredients
Cross-contamination information
Resources (books, recipes, gluten-free food, support groups)
Lifestyle changes
Discussion of strategies for handling food in a variety of social settings
The following grains are eliminated in a gluten-free dietary pattern:
Wheat
All varieties, including spelt, kamut, einkorn, emmer (faro or farro), durum,
semolina, triticale, and atta
All forms, including wheat bran, couscous, graham flour, matzoh, wheat germ,
cracked wheat, farina, and tabouli
Rye
Barley
All forms, including malt, malt flavoring, malt extract, malt syrup, and malt
vinegar
Untested oats
Tested oats and wheat starch and other forms of the grains listed that have been specially
processed or grown to eliminate the gluten protein may meet the US Food and Drug
Administration's (FDA) proposed rule for "gluten-free" labeling if they contain less than 20
ppm gluten. The FDA's proposed rule on gluten-free labeling can be found here.



Nutrition Therapy Efficacy

The gluten-free meal plan—eliminating the gluten protein from wheat, rye, and barley from
the diet—is currently the only treatment for celiac disease. The following components are
improved in individuals who are compliant with a gluten-free dietary pattern (EAL, 2009):
Villous atrophy
Bone density
Iron-deficiency anemia
Gastrointestinal and neurological symptoms
Quality of life
Studies in children indicate that after starting a gluten-free diet, symptoms may improve
within a few weeks, blood abnormalities improve in 6 months, and bone density returns to
normal after 1 year (Barera, 2000; Patwari, 2003).
For the majority of children with poor growth velocity resulting from celiac disease, a
gluten-free meal plan usually leads to rapid catch-up growth. Children who continue to
have a suboptimal growth pattern after following a gluten-free diet, but whose serological
tests are normal, should be referred for evaluation of growth hormone deficiency (Luciano,
2002; Giovenale, 2006; Cristina, 2009)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Children who do not respond to the diet should be referred back to the gastroenterologist to
be evaluated for other causes of villus atrophy (Hill, 2006).
A gluten-free meal plan can result in a diet that is low in the following nutrients (EAL, 2009):
Fiber
Folate
Niacin
Vitamin B-12
Calcium
Vitamin D
Iron
Thiamin and riboflavin may also be low because many gluten-free grain products are made
from refined flours and/or starches, and most of these products are not enriched with
B-vitamins and iron (Thompson, 1999; Thompson, 2005).
Lactose intolerance is not common in children with celiac disease. However,
lactose-containing foods may be restricted temporarily in children with severe symptoms
until gastrointestinal symptoms subside (Hill, 2005).
Calcium and vitamin D intake has been shown to be less than adequate in adolescents
diagnosed with celiac disease (Blazina, 2010).

Goal Setting

The goal of nutrition intervention is to allow patients with celiac disease to do the following:
Return gastrointestinal function, biochemical/nutrient levels (including celiac
antibodies), and bone density to normal, as well as promote optimal growth and well
being
Identify grains that must be avoided (such as wheat, barley, and rye)
List common foods that contain wheat, barley, and rye (such as bread and bread
products, pasta, and breakfast cereals)
List grains and starches that are allowed in a gluten-free dietary pattern (such as rice,
corn, amaranth, buckwheat, quinoa, millet, and sorghum)
Identify foods that are naturally gluten free such as fruit, vegetables, fresh meat, eggs,
fish, and beans
Identify gluten-free foods that are good sources of fiber, calcium, iron, B-vitamins, and
vitamin D
Acquire coping strategies for eating outside the home, including at restaurants, during
travel, while participating in sports, at school, and at parties
Read a food label and know how to identify sources of gluten (such as wheat, rye,
untested oats, barley, malt and brewers yeast)
Identify sources of gluten-free products (such as mail-order companies, health food
stores, and grocery stores)
Explain cross-contamination and steps to take at home to avoid contaminating
gluten-free foods with wheat, barley, or rye
Identify nonfood items that may be sources of gluten, such as medications
Know where to look for additional reputable information on celiac disease (such as
advocacy groups, books, and online resources)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Food & Feeding Issues

Compliance with the gluten-free dietary pattern is reported to be somewhere between 45%
and 81% and depends on the group that was studied. If the study group consists of
members of a support group, compliance is reported to be higher (Hill, 2005).
Some families may have issues purchasing gluten-free foods because of the increased
expense. All gluten-free grain products are more expensive; gluten-free bread and pasta,
for example, are twice as expensive as their wheat-based counterparts. Gluten-free grain
products are also not as readily available as their gluten-containing counterparts (Lee,
2007).
People with celiac disease frequently report that they are noncompliant when eating away
from home; some report that they choose to avoid activities that involve eating outside the
home (Lee, 2003).
Compliance with the gluten-free diet is improved in the following situations:
Symptoms occur after gluten ingestion
Participation in support groups
Education on the gluten-free diet and celiac disease (including strategies to cope with
eating away from home) is provided
Frequent follow-up
Biopsy-proven diagnosis
Younger age at diagnosis (earlier diagnosis is associated with improved compliance)
Access to palatable, gluten-free food
Compliance with the gluten-free diet will improve quality of life. Adolsecents who are
compliant with the gluten-free diet report a higher quality of life with fewer physical
complaints, fewer problems with their families, and more enjoyment from leisure time
compared to those who are noncompliant (Wagner, 2008; Olsson, 2008).
Many people following the gluten-free diet may not eat enough grain products to meet their
recommended nutrient needs, especially B-vitamins, iron, and fiber (Thompson, 2005).
Adolescents who are non-compliant with the gluten free dietary pattern have lower bone
densities than those who are compliant. Both groups showed less than adeqaute calcium
and vitmain D intake (Blazina, 2010).


Comparative Standards

Energy needs
Energy requirements for patients with celiac disease should be based on the child's
usual intake and level of physical activity, which can be obtained through a diet
history and/or actual food intake.
If this information cannot be obtained, energy needs may be also derived by the
following:
Dietary Reference Intakes (DRI) for Energy, Carbohydrate, Fiber, Fatty Acids,
Cholesterol, Protein, and Amino Acids (2002/2005)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Estimated energy requirements calculator, found under the Calculators tab
(above)
It is important to provide enough energy so that the child maintains consistent growth
within the normal parameters of the Centers for Disease Control and Prevention
growth charts (or WHO growth charts for children under the age of 2) and an
appropriate body mass index for age.

Estimated Energy Requirements (in kilocalories) for Both
Sexes in Each Age Group at Three Levels of Physical
Activity
a
Activity Level
bcd
Age
(years)
Sex
Sedentary
b
Moderately
Active
c
Active
d
2-3
Males and
Females
1,000 1,000-1,400 1,000-1,400
4-8
9-13
14-18
Females
1,200
1,600
1,800
1,400-1,600
1,600-2,000
2,000
1,400-1,800
1,800-2,200
2,400
4-8
9-13
14-18
Males
1,400
1,800
2,200
1,400-1,600
1,800-2,200
2,400-2,800
1,600-2,000
2,000-2,600
2,800-3,200
a
These levels are based on estimated energy requirements from the Institutes of Medicine
(IOM) Dietary Reference Intakes macronutrients report, 2002, calculated by sex, age, and
activity level for reference-sized individuals. “Reference size,” as determined by IOM, is
based on median height and weight for up to 18 years of age.
b
"Sedentary" refers to a lifestyle that includes the light physical activity associated with
typical day-to-day life.
c
Moderately active means a lifestyle that includes physical activity equivalent to walking
approximately 1.5 miles to 3 miles per day at 3-4 miles per hour, in addition to the light
physical activity associated with typical day-to-day life
d
Active means a lifestyle that includes physical activity equivalent to walking more than 3
miles per day at 3-4 miles per hour, in addition to the light physical activity associated with
typical day-to-day life.
Fluid Needs
Normal Fluid Requirements in Infants, Children and Adolescents
1 kg to 10 kg: 100 mL/kg
10 kg to 20 kg: 1,000 mL + 50 mL for each kg over 10 kg
>20 kg: 1,500 mL + 20 mL for each kg over 20 kg
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Nutrition Support

For hospitalized patients with celiac disease who require parenteral or enteral nutrition, the
nutrition assessment, indications for nutrition support, estimates of nutrition needs, and
guidelines for metabolic monitoring are similar to those of their peers without celiac
disease. Enteral/oral formulas are usually gluten free. Some formula additives may contain
gluten. All formula and additive labels should be checked for gluten-containing ingredients.

Nutrition Monitoring & Evaluation

Monitoring and evaluation in patients with celiac disease should include the following:
The gluten-free dietary pattern
Antibody levels
Potential exposure to cross-contamination
Hidden sources of gluten
Factors that will affect quality of life
Growth patterns
Biochemical values


Nutrition Care FAQs

Question: Are products labeled "gluten free" safe?
Answer: The term "gluten free" is not regulated yet. Under its proposed gluten-free
labeling rule, the U.S. Food and Drug Administration (FDA) is suggesting that foods
containing ingredients such as wheat starch that have been processed to remove gluten
qualify for gluten-free labeling as long as the final food product contains less than 20 ppm
gluten. See the FDA's proposed rule on gluten-free labeling here.
Question: Do patients have to adhere to a strict, gluten-free nutrition prescription all
the time or can they have an occasional piece of bread or plate of pasta?
Answer: Persons with celiac disease are strongly advised to follow a gluten-free nutrition
prescription for life, strictly avoiding wheat, barley, and rye. White bread has been reported
to contain 6,200 mg gliadin per 100 g (or, 12,400 mg gluten per 100 g) (Chartrand, 1997).
The FDA's proposed labeling rule suggests that a product labeled "gluten free" will contain
less than 20 ppm (or less than 2 mg/100 g food) (FDA, 2007). It is not known what
minimum amount of gluten may be consumed without damaging the small intestine, but
research indicates that it is somewhere in the range of 10 mg to 50 mg (Catassi, 2007).
Question: What ingredients are made from barley?
Answer: The FDA’s Code of Federal Regulations and Compliance Policy Guide lists the
following foods as made from barley:
Malt
Malt flavoring
Malt syrup
Malt extract
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Malt beverages
Malted milk
Malt vinegar
Beer and ale
Question: If a label says "wheat-free," does that mean it is gluten free?
Answer: No, the product could contain rye, oats, barley, or malt.
Question Is maltodextrin gluten free?
Answer: Yes. Maltodextrin is an ingredient derived from partial hydrolysis of starch (it does
not contain barley despite that "malt" is part of its name). The FDA’s Code of Federal
Regulations and Compliance Policy Guide definition includes the starches corn, potato,
and rice. If wheat is used, it must be labeled as wheat maltodextrin. However, wheat
maltodextrin is not likely to have gluten in it. The European Food Safety Authority
(EFSA) has exempted it from allergen labeling because it meets the EFSA standard
definition (which differs from the FDA definition) of gluten free (maximum of 200 ppm).
Question: Is vinegar gluten free?
Answer: In the United States, vinegar is very rarely made with a gluten-containing grain,
and if it is, it is distilled. When a product is distilled, the gluten protein is prevented from
becoming a part of the final product. However, malt vinegar is made from fermenting barley
and is not gluten free. Flavored or seasoned vinegar may contain gluten in the form of
wheat or barley but if there is any wheat protein, it will be on the label and the barley will
almost always be listed as malt.
Question: Are USDA and FDA food labels different?
Answer: The US Department of Agriculture (USDA) regulates meat, poultry, and egg
products; these foods technically do not have to be declared as allergens under the Food
Allergen Labeling and Consumer Protection Act (FALCPA). USDA encourages
manufacturers to voluntarily declare all allergens (EAL, 2009). It is estimated that 80% to
90% of meat manufacturers currently follow FALCPA.
If a USDA-regulated product (look for the USDA inspection stamp on the package) has a
"contains" statement declaring any allergens, they are following FALCPA. If a product does
not say "gluten free" or does not declare allergens and contains starch, dextrin, or modified
food starch, it might be made with wheat. Processed meats such as hot dogs, poultry such
as canned chicken, or liquid eggs are the products to question. If dextrin, modified food
starch, or starch are found, the manufacturer should be contacted to ask if these
ingredients are wheat based.

Oats

Individuals with celiac disease who can tolerate uncontaminated oats should include them
in their diet.
Moderate amounts of oats—50 g dry or 1 cup cooked—are safe for most adults and
children with celiac disease and can improve diet compliance (EAL, 2009; Koskienen,
2009). The addition of oats can also improve the nutritional quality of the gluten-free dietary
pattern (Pulido, 2009; Lee, 2009).
However, there is some evidence that a few people with celiac disease will have damage
to the small intestine or exacerbation of dermatitis herpetiformis when consuming
uncontaminated oats.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
uncontaminated oats.
Cross-contamination of commercial oat products with wheat or barley is also a concern
(Thompson, 2004; Hernando, 2008). There are several companies now taking precautions
to prevent the cross-contamination of oats.
If a person with celiac disease wants to consume oats, he or she should do so under
medical supervision and be advised to limit intake to 50 g dry or 1 cup cooked oats and to
use the oats that have been tested and meet the U.S. Food and Drug
Administration's proposed rule for gluten-free labeling (contain less than 20 parts per
million gluten) (EAL, 2009).

Supplements and Pharmaceuticals

Supplements and pharmaceuticals may contain wheat or barley (Crowe, 2001; Mangione,
2008). Therefore, it is important to clarify the gluten-free status of all supplements and
medications a patient is taking.
It is not required that allergens be declared on medication labels. Starch (or starch-based
ingredients such as pregelatinized starch) listed on a medication label may be derived from
wheat. Gluten may also be present in dusting powder or used in the coating of a
medication. The pharmacist may need to check with the manufacturer to determine the
gluten-free status of medications.
For more information on pharmaceuticals and gluten, read Medications and Celiac
Disease—Tips from a Pharmacist. More information on the safety of medications can be
found at www.glutenfreedrugs.com (last accessed July 30, 2011).
Labels for supplements (including vitamins), infant formulas, and medical foods are
required to declare allergens by the Food Allergen Labeling and Consumer Protection Act.
This means that if one of these products contains wheat or protein derived from wheat, the
word "wheat" must be clearly stated on the label. This applies to flavoring and coloring
ingredients as well as incidental ingredients.

Label Reading

To determine if a food is gluten free, the ingredient list needs to be examined for the
following 6 words:
Wheat
Rye
Untested oats
Barley
Malt
Brewers yeast
Understanding Food Labels
The Food Allergen Labeling and Consumer Protection Act (FALCPA), effective January
2006, requires the following (CFSAN, 2006):
Any ingredient derived from the top 8 food allergens must be declared on the label of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
foods regulated by the US Food and Drug Administration (FDA)
Wheat is one of the top 8 allergens
Rye, oats, and barley are not included in the top 8 allergens
The allergen must be listed by its common name
The allergen must be declared if used in spices, natural or artificial flavoring,
additives, or colorings
The allergen must be listed next to the ingredient or in a "contains" statement below
or next to the ingredient list
The US Department of Agriculture (USDA) regulates meat, poultry, and egg products
and labels for these foods technically do not have to declare allergens under FALCPA
(USDA-FSIS, 2011). However, the USDA requires proteins to be declared and encourages
manufacturers to voluntarily declare all allergens.
This means starches such as dextrin or modified food starch may contain wheat and not be
declared. The manufacturing company should be called to verify the source of a product's
ingredients.
Rye and oats are not hidden in other ingredients. Barley is almost always declared as
barley, barley malt, or malt.
Advisory Statements
An advisory statement is a declaration, usually under the ingredient list, indicating the
following: “Made on machinery or in a facility that processes wheat” or “May contain
wheat.”
Advisory statements are voluntarily used—a company may choose to use or not use
them.
Good Manufacturing Practices are required to be implemented by all companies.
These practices include the maintenance, monitoring, and cleaning of machinery and
staggering the production time for different types of products .
FDA-regulated foods: The majority of companies, whether they use advisory
statements or not, implement rigid allergen-control programs to eliminate
cross-contact. It is generally safe to use these foods without fear of significant
cross-contamination.
USDA-regulated foods: These statements are only used in situations where the risk
of cross-contamination cannot be avoided. They are infrequently used, but when they
are, the product should be avoided.
"Gluten Free"
The term "gluten free" is currently not regulated; however, regulations are being
developed by the FDA.
The proposed FDA regulations are expected to include the
following distinctions in the definition:
Does not contain wheat, barley, and rye
Does not contain an ingredient derived from a prohibited grain that has not
been processed to remove gluten
Contains less than 20 parts per million gluten
Oats (EAL, 2009)
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Oats that have been tested and meet the FDA proposed rule for gluten-free labeling
are recommended.
Gluten-free oats should be limited to an intake of 50 g dry or 1 cup cooked per day.
Avoid oats that have not been tested.
More Tips
The food ingredient label needs to be checked each time a food is purchased
because food manufacturers may change the ingredients.
Rye, oats, and barley will not be listed in a "contains" statement because they are not
among the top 8 allergens.
Natural and artificial flavoring is gluten free unless wheat, barley, or malt is declared
on the label.
Medication labels are not required to declare allergens.

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Nutrition Care > Gastrointestinal Diseases > Constipation
Client History

Each individual has his or her own normal pattern and frequency of bowel movements. This
varies significantly within the general population (Ternent 2007; Müller-Lissner 2005). This
pattern is an important starting point in determining client history.
Other factors may affect frequency of bowel movements and should be essentially
considered in a client history. These include the following:
Concurrent disease/diagnoses
Diet history including:
Changes in diet
Breastmilk or formula feeding (in infants)
Introduction of solids and transition from breast milk or formula to whole milk (in
infants)
Medication (prescription and over the counter)
Supplement use
Activity level
Diet history
Fluid intake/hydration status
Previous medical conditions or surgeries
Socioeconomic status/food security
Support systems

Biochemical Data, Medical Tests and Procedures

Diagnostic tests begin with a physical exam, including a digital rectal exam and external
examination of the perineum and perianal area. The digital exam is used to assess perianal
sensation, anal tone, and the size of the rectum. It is also helpful in assessing the
consistency of the stool and its location in the rectum.
Other tests might include the following:
Occult stool for blood
Thyroid tests
Celiac disease antibodies
Sweat test
Barium enema x-ray
Rectal manometry and/or biopsy
MRI
Metabolic tests
Abdominal radiograph, measurement of colonic transit time, and measurement of the rectal
diameter on ultrasonography have not been demonstrated to be helpful in diagnosing
childhood constipation. Sensitivity differs significantly between studies but is generally low
(Tabbers, 2011).

Laboratory

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There are no specific laboratory tests for constipation. The underlying factors and/or
diagnoses that might be associated with constipation would have their own specific
laboratory or diagnostic tests (Tabbers 2011). Some of these might include:
Thyroid studies
Occult stool for blood
Celiac antibodies
sweat test

Food/Nutrition-Related History

A complete food history, food frequency, and/or a 24-hour recall should be completed.
Specific areas of concern should include the following:
Number of daily servings from grains, fruits, vegetables, nuts, and legumes
Breastmilk and/or formula intake
Feeding/meal frequency
Caffeine intake
Fluid intake
Dietary supplements
Evaluation of exercise and activity patterns
Past medical history
To quickly estimate fiber intake from a food record, the following calculations can be used
(Marlett 1997):
Multiply number of servings of fruits and vegetables by 1.5 g. 1.
Multiply number of servings of whole grains by 2.5 g. 2.
Multiply number of servings of refined grains by 1.0 g. 3.
Add specific fiber amounts for nuts, legumes, seeds, and high-fiber cereals. 4.
Total = estimated fiber intake 5.

Nutrition Diagnosis

Dietitians working with patients who have constipation should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate fluid intake (NI-3.1)
Inappropriate intake of types of carbohydrate (specify) (NI-5.8.3)
Inadequate fiber intake (NI-5.8.5)
Food- and nutrition-related knowledge deficit (NB-1.1)
Undesirable food choices (NB-1.7)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate fiber intake (NI-5.8.5) related to limited fruits, vegetables, whole grains, or
legumes as evidenced by food record documenting average fiber intake of 5
grams/day.
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Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

The following intervention strategies may be helpful for infants and children with
constipation:
General/healthful diet (ND-1.1); Modify distribution, type, or amount of food and
nutrients within meals or at specified time (ND-1.2):
Provide adequate fiber (NICE, 2010). If fiber intake is inadequate, introduction of fiber
should be gradual, with sufficient fluid. Fiber intake may be related to constipation as
it contributes to fecal bulk and decreases in stool transit time. Types of fiber include
celllulose, psyllium, inulin, and oligosaccharides. These sources of fiber are primarily
found in the skins of fruits, vegetables, wheat and rice bran, and whole wheat.
Although there is no DRI for fiber for infants, complementary foods containing fiber
should be introduced gradually once the infant is developmentally ready. These
include infant cereals and pureed fruits and vegetables.
Children are usually willing to increase their intake of fruit (canned, fresh, or frozen).
Six to eight servings a day of fruits and vegetables are necessary. Serving size
depends on the age of the child. For children who are developmentally ready, nuts
and seeds can also be used to increase caloric intake.
For children 4 years of age and older, a high-fiber diet providing 0.5 g/kg/day of fiber
may be recommended. Alternatively, the child's age plus 5 can be used to calculate
the recommended number of grams of fiber per day (Williams 1995, Tabbers, 2011).
As a general guideline, children should consume enough fluid to meet their
maintenance fluid requirements (Johns Hopkins 2000, Tabbers, 2011).
Institute daily physical activity.
Bioactive Substance Management--Psyllium and ß-glucan (ND-3.3.3);
other (ND-3.3.5):
Consider use of bulk-forming agents such as psyllium, calcium polycarbophil, or
methylcellulose.
Add source of pro/prebiotic to daily nutritional intake.
Nutrition Counseling--Strategies (C-2):
Discourage stool retention behavior and initiate bowel retraining program if required.
Establishing a routine for regular toileting trips is an important part of treatment for
constipation and encopresis (incontinence of feces not due to organic defect or
illness) in the toilet-trained child ( Abi-Hanna 1998, Afzal, 2011).

Nutrition Prescription

It is important to remember that food choices typically include a mixture of fibers so
distinguishing absolute physical effects from individual foods is not as clear as it might
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seem. Types of fiber differ from one another by how they function within the plant structure,
by their own chemical structure, and how they function within the human body. The term
functional fiber is defined as "nondigestible carbohydrates that have been isolated,
extracted, or manufactured and have a demonstrated human benefit" (Gropper,
2009). One method of describing the function of fiber within the body uses the following
characteristics: solubility, binding ability, water holding capacity, and fermentability.
Fibers that are primarily insoluble appear to have the greatest effect on treatment of
constipation. Foods that have the highest proportion of insoluble fiber include whole grains
and vegetables. In general, insoluble fiber adds bulk to the stool, causing it to push
against the intestinal wall to force waste through more rapidly and thus, preventing
constipation. Other types of fiber, including psyllium, inulin, and oligosaccharides, may also
contribute to symptom improvement.
Following are fiber recommendations per day according to the Dietary Reference Intake
standards (DRIs):
Children 1 to 3 years: 19 grams per day
Children 4 to 6 years: 25 grams per day
Boys 9 to 13 years: 31 grams per day
Girls 9 to 13 years: 26 grams per day

Nutrition Therapy Efficacy

It is standard practice to recommend the gradual increase of fiber and fluid intake in order
to treat constipation. Increasing fiber without increasing fluid can lead to more constipation,
abdominal pain, bloating, and gas. Increasing fluid by itself does not appear to have an
effect on treatment of constipation. In some individuals, the increased fiber may actually
make constipation worse (Müller-Lissner 2005).
The North American Society for Pediatric Gastroenterology, Hepatology, and
Nutrition states that the evidence supporting recommendations for a higher-fiber diet in
children for the treatment of constipation is based on Level III evidence: "Opinions of
respected authorities, based on clinical experience, descriptive studies, or reports of expert
committees." This recommendation is also supported by the Standards Practice Task
Force of The American Society of Colon and Rectal Surgeons (Ternent 2007).
Most recently, others have described the use of fiber in treatment of constipation as based
on weak scientific evidence (Lesbros-Pantoflickova 2004, Tan 2007). There is also no clear
evidence in regards to the best type of fiber to treat constipation. Individuals should try
different formulations and see which one works best for them. Patients who routinely take
laxatives may not respond to fiber treatment (Schiller 2008).
Adequacy
Children have a small stomach capacity, and high-fiber diets may have a low-caloric
density. Therefore, it is advisable to make sure that the diet meets the child's caloric needs
for growth.
Dietary fiber may also adversely influence the absorption of certain essential minerals,
such as calcium, iron, copper, magnesium, phosphorus, and zinc (AAP 1998). Chronic use
of laxatives, stool softeners, and mineral oil should be avoided, as these may lead to
malabsorption and create dependency on medications. Mineral oil, in particular, decreases
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absorption of fat-soluble vitamins and impairs calcium and phosphorus absorption. Mineral
oil should be used only with the supervision of a physician ( Johns Hopkins 2000).

Goal Setting

Goals for treatment of constipation should be both short term and long term(Tabbers 2011,
Afzal 2011, NICE guidelines) .
Short-term therapy should aim to treat fecal impaction and/or discomfort by providing stool
evacuation and should include the following:
Physical disimpaction
Use of stool softeners, suppositories, or enemas
Concurrent provision of enough fluids to prevent recurrence
Long-term therapy aims to prevent recurrence of chronic constipation and includes the
following:
Increase intake of high-fiber foods gradually
Increase intake of fluids as fiber intake is increased
Evaluate and treat any underlying medical cause or condition

Comparative Standards

Following are fiber recommendations per day according to the Dietary Reference Intake
standards (DRIs):
Children 1 to 3 years: 19 grams per day
Children 4 to 6 years: 25 grams per day
Boys 9 to 13 years: 31 grams per day
Girls 9 to 13 years: 26 grams per day

Fluid intake should be increased gradually as high-fiber food intake is increased to treat
constipation.
Goal intake amount will vary based on age.
Water is the best fluid but noncarbonated, sugar-free, and decaffeinated fluids are
good substitutes.
Prune juice can be an ideal fluid with natural laxative effects as well.
Estimation of fluid requirements:
Method based on body weight and age:
Age Amount of Fluid
Infants and children
1-10 kg 100-150 mL/kg
11-20 kg Add 50 mL/kg over 10 kg
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>21 kg Add 25 mL/kg over 20 kg
Adolescents 40-60 mL/kg

Nutrition Monitoring & Evaluation

Improve intake and type of foods to resolve/minimize gastrointestinal symptoms.
Outcome measures to include:
increased fiber intake
knowledge of fiber content of foods
stool frequency
ease of stool passage
stool weight and/or consistency improved

Nutrition Assessment

A complete nutrition assessment should include the following (Nahikian-Nelms 2007):
Medical history, including all previous surgeries and medications
Anthropometrics
Biochemical and clinical parameters
Problems chewing and/or sucking/swallowing
Past history of sexual abuse
Nausea/Vomiting
Frequency and consistency of bowel movements
Heartburn
Food allergies, preferences, or intolerances
Previous nutrition education or nutrition therapy
Previous food restrictions
Food preparation or infant's formula preparation technique
Ethnic, cultural, and religious influences
Use of vitamin, mineral, herbal, or other type of supplements
Eating pattern: 24-hour recall, food history, food frequency and any recent dietary
changes
Any other symptoms interfering with ability to ingest normal meal plan

Anthropometric Measurements

Evaluation of growth history should include measurement and plotting of weight for age,
length/height for age, head circumference for age (< 36 months of age), and weight for
length or BMI for age.
Constipation may accompany obesity, especially if the diet contains energy-dense,
low-fiber foods and fluids. Conversely, constipation may contribute to growth failure when a
feeling of fullness or discomfort affects a child's appetite.
See Growth Charts for more information.
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See Growth Charts for more information.

Nutrition Care FAQs

How common is constipation?
Constipation in children is very common. Approximately 3% of all pediatrician visits are
regarding constipation.
How often should a child have bowel movements?
Infants can range from as few as 1-2 times per day up to after every feeding. Children 1-4
years of age typically have bowel movements 1-2 times per day, and more than 90% have
bowel movements at least every other day.
What is "withholding behavior"?
If a child has not had a bowel movement for several days, the stool can begin to fill up the
large intestine. As the large intestine fills up, it can stretch and thus retain more stool. The
larger stool can be more difficult and painful to pass. As a result, some children will avoid
using the bathroom altogether. Other causes of withholding could be fear of strange
restrooms or fear of going to the restroom with others around.
What is encopresis?
Encopresis or soiling occurs when children have bowel movements or leak a small amount
of stool into their underwear. This occurs in about 1.5% of all children and often occurs in
children with constipation.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases > Inflammatory Bowel Disease
Nutrition Assessment

The nutrition assessment is an integral part of the multidisciplinary team approach to taking
care of a patient with inflammatory bowel disease. Waterlow Criteria, McLaren Criteria, or
Gomez Classification systems may be used to determine the degree of malnutrition.

Things to include in the nutritional assessment:
Weight
Height/Length
Body Mass Index (for over 2 years old)
Growth velocity
Head circumference (under 3 years old)
Mid-arm muscle circumference (MAMC)
Stooling history
Emesis history
Output from ostomy
Physical observations
Client history
Food history
Previous laboratory and diagnostic tests

Nutrition-Focused Physical Observations

The following list includes but is not limited to physical findings that may be helpful in
diagnosing nutritional problems in patients with IBD:
Complete physical exam by doctor
Patient’s visceral fat stores
Tricep skinfold thickness
Mouth
Are teeth present and in good condition?
Does the patient have ulcers of the mouth?
Hair
Nails
Skin
Is there bruising? (If so, could potentially be associated with vitamin K
deficiencies.)
Ostomies/Drains
Does the patient have an ileostomy? Colostomy? Any other drains such as
biliary, pancreatic, or fistula drains?
Feeding access points
Central venous access device (CVAD)
Feeding tubes

Biochemical Data, Medical Tests and Procedures

Diagnostic testing can not only be helpful when determining whether the patient has
Crohn's or ulcerative colitis, but may also be useful when helping to determine causes of
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flares, identifying strictures, fistulas, and so on, all which may affect the patient’s ability to
absorb nutrients.
Stool studies
Stool studies can be done including a check for viral particles, cultures, ova and parasites,
Giardia/crypto, and c.diff, all of which can cause flares.
Imaging
Various imaging studies can be helpful depending on the patient’s symptoms. The most
common studies tend to be:
KUB – to look for obstruction
Abdominal ultrasound – for suspected abscess
UGI/small bowel series – best for showing small bowel stricture
CT– sometimes over-reads bowel wall inflammation, may not show stricture
MRI – excellent for fistulas and abscess formations
Endoscopy
Upper endoscopy: A scope is placed through the mouth and worked downward
through the upper portion of the gastrointestinal (GI) tract. Useful for determining if
Crohn’s disease has effected the esophagus, stomach, and duodenum. Biopsies are
usually taken.
Capsule endoscopy: A non-invasive way to see the GI tract. A capsule-sized camera
is swallowed by the patient and takes pictures of the GI tract as peristalsis works it
through. The patient wears a monitor that receives the images produced from the pill
cam. This has been found to be most useful to determine response to
treatment. Note: it is important to make sure there are no strictures in the GI tract as
this can cause risk of obstruction.
Colonoscopy: A scope is placed through the rectum and allows the medical team to
visualize the large intestines. Biopsies are usually taken.

Laboratory

Checking laboratory values on a regular basis is essential in patients with inflammatory
bowel disease. Lab values that may be helpful in monitoring disease state and nutritional
status are as follows (Walker 2008):
Complete blood count, red-cell morphology
Serum albumin
Serum electrolytes
C-reactive protein
Serum iron, total iron-binding capacity, ferritin
Folic acid, vitamin B
12
Serum calcium, magnesium, phosphorous, alkaline phosphatase
Additional tests if growth failure or significant malnutrition:
Zinc
Vitamins A, D, and E
Prothrombin time, partial prothrombin time

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Client History

Truly understanding the patient’s background can be beneficial when deciding what the
best nutritional course of action may be for each patient.
Factors to be considered range from past medical history to religious preferences:
Past medical history (other medical issues)
Age at diagnosis
Portions of the gastrointestinal tract that are affected
Any surgical history
Has there been an ileostomy? Colostomy? A resection? If a resection was done,
which part was resected? If there is a history of multiple resections, how much of
the bowel is left?
Socioeconomic status
Can the patient’s family afford food to eat on a regular basis? Are the
recommended vitamin/mineral supplements affordable?
Physical activity
Is the patient involved in organized or individual sports/physical activities?
For how long do they usually practice/exercise?
Is physical activity outside or inside?
Does the condition affect activity patterns?
Religious preferences
This could become an issue when designing meal plans for a patient whose
religion dictates certain food patterns.

Food/Nutrition-Related History

Obtaining a full diet history of the patient can help to give the health care provider a good
idea of nutrient intake. A 24-hour food recall may help to give some insight into the patient's
regular nutrition regimen; however, some find a 3-day food record more helpful
in determining “normal” eating habits. It is important to figure out the patient’s normal meal
and snack habits, as well as foods that may cause cramping, diarrhea, or distention; these
are called “trigger foods." It is also important to note if the patient is lactose
intolerant. Many patients with inflammatory bowel disease (IBD) are lactose intolerant; this
may affect their dairy and calcium intake.
As with many patients with chronic diseases/conditions, it is important to note any
alternative medications such as herbs and supplements that are being taken and how often
they are consumed. Many herbs and supplements can interact with a medication. The
patient may be unaware of this.
Things to Note
Typical meal patterns
Whether or not snacks are consumed and what foods are usually consumed as
snacks
Foods that are avoided or restricted
Foods that cause cramping, diarrhea, or distention (trigger foods)
Herbs/supplements
Alternative diets – there are many diets circulating in the general population that
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target patients with IBD. It is important to know if they are following any specific “diet”
as some of the diets lack particular nutrients. Diets include:
Specific Carbohydrate Diet – strict grain-free, lactose-free, and sucrose-free diet
The Maker’s Diet – based on Biblical and scientific principles; emphasizing
insulin, infection, and inflammation
Guts & Glory Program – primitive diet including lifestyle therapies

Comparative Standards

For patients who do not fall within normal limits on the Body Mass Index/age growth curve,
catch-up growth will be important. The following calculations may be helpful when
calculating minimum needs required for catch-up growth for both calories and protein:
Kcal: Calculate estimated desired weight (EDW) in kg (50th percentile weight for current
height) x EER kcal/kg/day / actual weight
Protein: Calculate EDW in kg (50th percentile weight for current height) x pro/kg/day
(DRI/age)/actual weight
It is important to note that during a flare, a patient's protein requirements may increase to
150% estimated DRI/age needs.
Maintenance fluid needs
Use the Body Surface Area (BSA) Method; however, note that the patient may have
increased fluid needs based on gastrointestinal output.
Patients with inflammatory bowel disease (IBD) are extremely susceptible to dehydration
due to the gastrointestinal losses that occur. Further problems that can occur from
dehydration are decreased kidney function, kidney stones, and weakness caused by
sodium loss. The Crohn’s and Colitis Foundation of America recommends that patients with
IBD consume one half-ounce of fluid for every pound of body weight each day. Therefore, a
patient who weighs 80 pounds should be consuming a minimum of 40 ounces of fluid per
day (CCFA 2009).
IBD patients who are very physically active or those who live in a warm/hot environment
may need to double the amount of fluids they consume on a daily basis. Water is
appropriate for those who are not in the middle of a flare, but if the patient is experiencing a
flare or has large sweat losses from heat/physical activity, a rehydration solution or
low-sugared beverage with added electrolytes may be appropriate.

Nutrition Diagnosis

Dietitians working with patients who have inflammatory bowel disease should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate oral intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Malnutrition (NI-5.2)
Inadequate mineral intake (specify) (NI-5.10.1)
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Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Underweight (NC-3.1)
Sample PES or Nutrition Diagnostic Statement(s)
Altered gastrointestinal function (NC-1.4) related to inflammatory bowel disease (IBD)
as evidenced by surgical resection and now with significantly increased stools (x10
BM per day)
Impaired nutrient utilization (NC-2.1) related to IBD as evidenced by stool analysis
results indicating fat and carbohydrate malabsorption.
Inadequate oral intake (NI-2.1) related to nausea and vomiting (secondary IBD) as
evidenced by intake of less than 50% of trays per nursing documentation and ___
episodes of emesis in the past 24 hours.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutritional intervention should be individualized. The nutritional plan that works for one
patient with inflammatory bowel disease (IBD) is not necessarily going to work for another
IBD patient. Nutrition support such as total parenteral nutrition or enteral feedings should
be used when deemed medically necessary by the medical team. Otherwise, the following
interventions may help to improve the patient’s quality of life by reducing gastrointestinal
(GI) symptoms and discomforts, as well as prevent further complications from IBD.
General Interventions with Examples of Nutrition Intervention Terminology
Nutrition Counseling: Strategies (NC-2)--Utilize food diary to identify “trigger
foods.” Once trigger foods are identified, avoid these types of foods.
Examples: seeds, simple sugars, acidic foods
General/healthful diet (ND-1.1)--Overall, consume a well-balanced diet
Modify distribution, type, or amount of food and nutrients within meals or at
specified time (ND-1.2); Specific foods/beverages or groups (ND-1.3)
Restrict intake of high fiber foods such as nuts, seeds, corn, and popcorn
Avoid foods that may cause excessive gas such as cruciferous vegetables
Avoid greasy or fried foods as these may cause an increase in diarrhea
If patient is lactose intolerant, limit consumption of milk or milk products.
Alternatives include soy milk or products and/or adding lactase enzyme prior to
consumption to limit GI discomfort
Eat 5 or 6 small meals throughout the day to minimize cramping
Consume plenty of fluids to prevent dehydration
Medical Food Supplements (ND-3.1)--Consider a diet supplement to boost calories
and protein intake, if needed
Meal Plan During a Flare
Low-residue, low-fiber meal plan (canned fruits with no skins, well-cooked vegetables)
Small, frequent meals
High-protein meal plan focusing on lean meats
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High-protein meal plan focusing on lean meats
No caffeine or alcohol
No concentrated sweets
Supplements
Daily multivitamin supplement
1000-1500 mg calcium
Vitamin D 400-800 IU daily
Consider adding omega-3 fatty acids (DHA and AHA) to diet/supplemental
regimen. There is no recommended amount and inconclusive scientific evidence, but
1000 mg overall has been found to be beneficial in the general population. More than
4000 mg can cause loose stools.
Probiotics and prebiotics may be beneficial when not in midst of a flare. Evidence
shows patients with ulcerative colitis may respond better than those with Crohn's, but
use of probiotics or prebiotics should be discussed with a physician first (CCFA, 2009).

Nutrition Therapy Efficacy

Nutritional interventions may help to reduce growth failure and manifestations of
vitamin/mineral deficiencies; however, the meal plan and supplement regimen should be
individually tailored for each patient to better help them meet their specific needs. There is
very limited evidence to determine whether any particular meal plan is effective in
managing inflammatory bowel disease.
Exceptions to DRI
Malabsorption of enterally or orally ingested nutrients may increase the total energy
requirement by as much as 50%. The patient should receive at least 150% of the estimated
energy requirement (EER) for height/age or 100-110% of weight/age for calories and
similar increases above the dietary reference intake (DRI) for protein. Monitoring the
patient’s growth and development will help the health care team decide the exact range for
each individual patient.
Nutrient exceptions to the DRI will vary depending on the site of bowel that is affected (see
list below for complications from bowel segment resections) (Groh-Wargo 2000). Nutrients
to monitor closely as they may need extra supplementation are the fat-soluble vitamins (A,
D, E, K), zinc, B
12
and calcium.
PROXIMAL SMALL BOWEL
Duodenum-jejunum
Decreased fat-soluble vitamin absorption
Decreased fat digestion, absorption
Increased mineral losses: Ca, Fe, Mg, Cu, Cr, Mn
Decreased protein digestion, absorption
Increased loss of water-soluble vitamins
Carbohydrate (deficiency of lactase or other disaccharidase)
DISTAL SMALL BOWEL/COLON
Ileum
Decreased vitamin B-12 absorption
Decreased fat-soluble vitamin absorption
Decreased long-chain fat absorption
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Increased trace element losses
Increased risk of renal oxalate stones
ILEOCECAL VALVE
Decreased vitamin B-12 absorption
Decreased folate absorption
Increased malabsorption
COLON
Decreased electrolytes
Decreased water absorption
Decreased vitamin K (formed by bacterial action)
Medications that the patient is on can cause an additional need for various nutrients. The
general class of medications that can effect nutrient status in patients with inflammatory
bowel disease include: corticosteroids, immunomodulators, 5-ASA, and antibiotics.
5-ASA – causes decreased absorption of folic acid
Corticosteroids – can impair calcium and vitamin D absorption and new bone
formation; can also cause breakdown of existing bone
Immunomodulators – can interfere with folate absorption
Antibiotics – can inhibit vitamin/mineral absorption
The Crohn's and Colitis Foundation of America recommends that patients who are taking
medications such as those above also take the following (CCFA 2009):
Daily multi-vitamin
1 mg folate supplement
Consume minimum 1500 mg calcium per day (ideally no more than 500 mg/dose)
Vitamin D 800 IU/day
Iron supplements if iron deficient, 300 mg ferrous sulfate taken 1-3 times a day
depending on the extent of deficiency
The patient may also need therapeutic doses of magnesium, zinc, vitamin B
12
, and vitamin
K.
The above are general guidelines, and should be adjusted based on the patient’s individual
needs.

Goal Setting

In combination with medical treatment, nutritional goals include:
Improvement in quality of life
Prevention of complications
Control of symptoms
Restoration of nutritional status
Maintainance of electrolyte balance
Prevention of growth retardation and nutrient deficiencies
The overall goal of medical and nutritional treatment is to ultimately allow for remission of
inflammatory bowel disease.

Oral Intake
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There is no specific meal plan for the patient with inflammatory bowel disease (IBD). It is
best to advise the patient to avoid foods that may cause digestive problems, called “trigger
foods."
If unsure of what types of foods exacerbate symptoms, the patient can keep a food and
symptom diary, which may help narrow down the troubling foods. Patients can also try an
elimination diet, which starts with a minimal selection of foods and gradually adds additional
foods one at a time while keeping track of symptoms in a diary. An elimination diet should
take place under the supervision of the medical team to ensure the patient is meeting
calorie, protein, vitamin, and mineral needs throughout the process.
It is important to note that certain foods may aggravate the patient’s symptoms, but there is
no evidence that shows certain foods directly affect the inflammation of the
intestines. However, one hypothesis claims certain foods tend to be “pro-inflammatory”
while other foods (such as omega-3 fatty acids) are “anti-inflammatory.” Ongoing studies
are examining the effects of these types of foods on the IBD population.
Overall, it is important to remember that the patient should receive adequate amounts of
calories, protein, and nutrients on a daily basis. A well-balanced diet should be consumed
including all food groups: Meat/Proteins, Dairy (if tolerated, otherwise substitute),
Grains/Starches, Fruits, Vegetables, and Fats.
Eating a nutritious diet can be difficult for children in general, but especially for those with
IBD whose trigger foods tend to be the healthier foods such as fruits and vegetables. When
dietary restrictions are needed, they should be dictated by the child’s individual tolerance
and state of disease (a flare may require an altered meal plan, such as low residue).
Low-Residue Meal Plan– This meal plan may be helpful with managing ulcerative
colitis or for a Crohn’s patient who has noted significant stricture or narrowing of the
small intestines. This may be helpful during time of flare. It is usually temporary.
Lactose-Restricted Meal Plan– This meal plan may be necessary for a patient with
lactose intolerance. The patient may consider taking lactase supplements to help with
digestion when a product containing lactose is consumed.
Low-Fat Meal Plan– This meal plan may be necessary if the patient has steatorrhea;
however, MCT oil may be used as a replacement and help with increasing caloric
intake.
Although the medical team should limit the patient’s diet to avoid the foods that cause
gastrointestinal (GI) discomfort, it is important to be sure that there are not too many food
restrictions so that the patient gets adequate nutrients to promote age-appropriate growth.
There can be a place for all types of foods so that the patient feels as if they are living a
normal life. Discussing healthier options at fast food establishments and other restaurants
that may be less aggravating of GI symptoms may help the patient to feel a sense of
balance and improve quality of life while coping with IBD.

Enteral or Tube Feeding

Nutrition support may be necessary in order to improve the patient’s nutritional status. This
includes both enteral nutrition and parenteral nutrition.
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Enteral nutrition can be given through a variety of routes including surgically placed
gastrostomy tubes (gtube), percutaneous endoscopic gastrostomy tubes (PEG), or
nasogastric tube (NG). Enteral nutrition can be given as a supplement (e.g., night-time
tube feeding) or be used to provide 100% of the patient’s nutritional needs. Recent studies
have shown that patients with Crohn’s disease tend to respond better to enteral nutrition
therapies than do those with ulcerative colitis (Heuschkel 2008). The practice of providing
100% of nutrient needs via enteral feedings during a flare is common in Europe and
Canada, and is starting to be used more widely at IBD centers across the United
States. Some centers allow the patient to drink what they can during the day (assuming
palatability is tolerable for the patient) and then give the rest via feeding tube. Other centers
will allow the patient to eat 25% of caloric needs (soft, bland foods) and then provide the
rest via formula.
Recent studies have shown that protein composition does not influence the effectiveness
of enteral nutrition in treatment of active disease (Zachos 2001). The elemental formulas
tend to have a bad taste, even with flavor packets, and patient compliance has been poor
with use of strictly elemental formulas (CCFA 2009).
Overall, nutrition support can help prevent further linear growth stunting and help the
patient gain additional weight; however, the combination of enteral nutrition and medicinal
therapy may be most advantageous.

Suggested Monitoring Parameters and Recommendations

Careful monitoring of the patient’s nutritional status and growth should be on an ongoing
basis. Ensuring the patient is meeting growth parameters on a long-term basis can be key
to success in the overall management of the patient with inflammatory bowel disease
(IBD). Monitoring laboratory values, protein, and vitamin/mineral status is also
recommended on an ongoing, long-term basis to ensure that the patient is meeting all of
their needs. Ideally, the patient should see a dietitian at least once a year for a full nutrition
assessment, even if no obvious signs of nutritional issues are present.
As part of the medical team, it is important to monitor for complications that can occur with
IBD that could have further nutritional issues such as:
Primary sclerosing cholangitis: occurs in 5% of ulcerative colitis patients and 1% of
Crohn’s patients; can cause jaundice, nausea, weight loss, itching, and may require a
liver transplant
Gallstones: occurs in 13% to 34% patients with Crohn’s disease of the terminal ileum
Pancreatitis: can cause abdominal pain, nausea, vomiting, fever; could be drug
related or gallstone related

Nutrition Care FAQs

Does poor diet cause inflammatory bowel disease?
To date, there has been no direct evidence that shows a poor diet causes Crohn's disease
or ulcerative colitis.

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What kind of diet should I follow during a flare?
Although there is no specific diet that will help get rid of a flare, a low-residue, low-fiber diet
may be helpful in reducing the cramping and diarrhea one experiences during a flare.

What can I do during periods when I have no appetite, in order to prevent weight
loss?
Oral supplements that provide a balanced source of macronutrients and micronutrients may
be most beneficial. These can be consumed at any time during the day. Some patients find
a hydrolysate formula is easier to tolerate, but others have no problems with polymeric
formulas (or fully intact protein formulas). If needed, enteral nutrition can be given during
the night via a tube feeding to ensure all calories and protein are being provided to promote
optimal growth and weight gain.

Anthropometric Measurements

Anthropometrics that should be measured and plotted at diagnosis and at age-appropriate
intervals include:
Weight for age
Length/Height for age
Weight for length (up to 3 years of age)
Head circumference for age
Body Mass Index for age (in children older than 2 years of age)
Other measurements that could be useful include skinfold caliper measurements and
mid-arm muscle circumference.

Parenteral Nutrition

Total parenteral nutrition (TPN) may be prescribed for patients with inflammatory bowel
disease (IBD) who are experiencing severe growth failure and fit some or all of the
following criteria (CCFA 2009):
cannot tolerate enteral feeds
have the inability to feed
have severe gastrointestinal dysfunction or malabsorption
have increased requirements or excessive losses
Although parenteral nutrition allows the bowel to rest completely, it has complications
associated with its use, such as central line infections. Risks versus benefits should be
assessed and discussed with the patient and family (see Parenteral Nutrition section).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases > Diarrhea
Nutrition Assessment

A complete nutrition assessment should include the following information (Nahikian-Nelms
2007):
Medical history, including all previous surgeries and medications
Anthropometrics
Biochemical and clinical parameters
Problems chewing and/or sucking/swallowing
Nausea/vomiting
Stool pattern, frequency and consistency
Reflux, Heartburn
Any other symptoms interfering with ability to ingest normal meal plan
Food allergies, preferences, or intolerances
Food preparation or infant's formula preparation technique
Previous food restrictions or special diets
Ethnic, cultural, and religious influences
Use of vitamin, mineral, herbal, or other type of supplements
Previous nutrition education or nutrition therapy
Eating pattern: 24-hour recall, food history, food frequency
Feeding environment (home, daycare, school, caregiver's home, etc)
Recent foreign travel or sick exposure

Nutrition-Focused Physical Findings

Physical observation will focus on abdominal physical assessment and assessment of
hydration status, gastrointestinal output, and physical signs of vitamin and mineral
deficiencies.
Abdominal physical assessment may include the following:
Inspection: Color, contour, muscle development, wounds, feeding devices, and
ostomies
Auscultation: Bowel sounds
Percussion: Tympany, dullness, density of abdominal contents
Palpation: Texture, temperature, identification/location of organs
Physical changes caused by dehydration include the following:
Weight change
Dry conjunctiva without tears
Dry, cracked lips
Small, multifurrowed tongue
Decreased skin turgor
Orthostatic blood pressure
Tachycardia
Flattened neck veins
Prolonged filling of hand veins
Decreased diaper changes
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Depressed fontanel in infants
Stool output can be noted for the following:
Volume
Consistency
Color
Signs of malabsorption
Blood
Physical assessment should note any signs of nutrient (vitamin/mineral) deficiencies as
well, although they usually accompany diseases for which diarrhea is a symptom.

Biochemical Data, Medical Tests and Procedures

Stool cultures should be examined for microorganisms, ova and parasites, leukocytes,
lactoferrin, and presence of blood. Additional invasive procedures that may assist in
diagnoses not determined with initial stool cultures include the following:
Upper endoscopy
Flexible sigmoidoscopy or colonoscopy
Stool cultures:
Fecal fat: Qualitative and quantitative to rule out fat malabsorption
Occult blood
Ova and parasites
Bacterial contamination (Clostridium difficile, foodborne illnesses, etc)
Antigen for Rotovirus
Osmolality and electrolyte composition
stool pH
reducing substances
Evaluation of intestinal structure and function:
Sigmoidoscopy
Colonscopy
bowel biopsy to diagnose diseases like Celiac disease
Evaluation of hydration status and electrolyte balance:
Serum electrolytes, serum osmolality
Urinalysis
Physical examination
Current weight, usual weight, percentage of weight change
*Adapted from Nutrition Care Manual: Diarrhea

Laboratory

Laboratory tests include (Nahikian-Nelms 2007):
complete blood count to assess for infection, anemia, and malabsorption
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serum chemistries to assess electrolyte status and acid-base balance
stool cultures
lactose tolerance and hydrogen breath test for assessment of malabsorption
Biochemical Assessment
Protein Profile
Albumin
Prealbumin
Transferrin
Hematological Assessment:
Hemoglobin
Hematocrit
Mean corpuscular volume
Mean corpuscular hematological concentration
Mean corpuscular hemoglobin
Total iron-binding capacity
Hydration Status; Electrolytes and Renal Profile
Blood urea nitrogen
Creatinine
Sodium
Potassium
Phosphate
Cloride
Magnesium
Zinc
Carbon dioxide
Bicarbonate
Osmolality
Urinalysis: note color, appearance, specific gravity; presence of ketones,
protein, or glucose
Celiac tests: Endomysial IgA
Diagnostic tests: as discussed under heading of diagnostic tests.

Anthropometric Measurements

Growth history: weight/age, weight/height, height/age, head circumference.
See Growth Charts for more information.

Client History

Medical/Social History
Diagnoses
Symptoms of condition: frequency, change in pattern, description of stools
Duration of symptoms; presence of symptoms in other family members
Foods believed to be associated with exacerbation of symptoms; 24- to 72-hour
dietary recall can be helpful to determine potential foodborne illnesses or food allergy
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or intolerance
Medications (especially antibiotics, antifungal agents, those containing sorbitol or
xylitol)
Previous medical conditions or surgeries
History of enteral feeding
Recent travel to other countries
Socioeconomic status/food security
Support systems
Caregivers
Primary language
Formula preparation
Formula changes/diet changes/food introductions
Foods containing sorbitol or xylitol (sugar-free candies, gums, medications,etc)
*Adapted from Nutrition Care Manual: Diarrhea

Food/Nutrition-Related History

Diet history should include evaluation of food/formula preparation in addition to evaluation
of those foods and beverages that may be related to diarrhea, including:
Fiber sources
High-fat foods
Lactose
Fructose
Caffeine
Sorbitol
Xylitol
Fruit juice
A detailed history including initiation of symptoms, symptom progression, number of stools
per day, color and consistency of stool, persistence of diarrhea in the absence of eating,
and signs of malabsorption should be obtained. Caregivers should keep a food and
symptom diary to document which foods are tolerable and which seem to exacerbate the
problem.

Nutrition Diagnosis

Dietitians working with patients who have diarrhea should review the signs and symptoms
obtained in the nutrition assessment and diagnose nutrition problems based on these signs
and symptoms. Nutrition diagnoses from the list below as well as other diagnoses may be
present.
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Inappropriate intake of types of carbohydrate (specify) (NI-5.8.3)
Inadequate mineral intake (specify) (NI-5.10.1)
Altered GI function (NC-1.4)
Food medication interaction (NC-2.3)
Food- and nutrition-related knowledge deficit (NB-1.1)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sample PES or Nutrition Diagnostic Statement(s)
Altered gastrointestinal (GI) function (NC-1.4) related to excessive intake of poorly
absorbed carbohydrates as evidenced by cramping and loose stools
Food- and nutrition-related knowledge deficit (NB-1.1) related to frequent intake of
apple juice and products containing sorbitol as evidenced by cramping and loose
stools.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Sample Nutrition Intervention codes based on earlier sample PES statements:
Diagnosis: Altered gastrointestinal (GI) function (NC-1.4) related to excessive intake
of poorly absorbed carbohydrates as evidenced by cramping and loose stools
Intervention: Modify distribution, type, or amount of food and nutrients
within meals or at specified time (ND-1.2); Enteral
formula/solution (ND-2.1.1); Commercial beverage supplement (ND-3.1.1)
Diagnosis: Food- and nutrition-related knowledge deficit (NB-1.1) related to frequent
intake of apple juice and products containing sorbitol as evidenced by cramping and
loose stools.
Interventions: Modify distribution, type, or amount of food and nutrients
within meals or at specified time (ND-1.2); Specific foods/beverages or
groups (ND-1.3); Nutrition education--relationship to health/disease (E-1.4),
recommended modifications (E-1.5)
Treatment of the underlying disorder is the most important component of diarrhea therapy.
If the diarrhea is infectious in nature, antibiotics will be the first line of treatment. Etiology
should be determined prior to recommending antidiarrheals. Restoring normal fluid,
electrolyte, and acid-base balance is crucial (Guerrant 2001). This is accomplished through
intravenous therapy or through use of oral rehydration solutions. The treatment for diarrhea
is designed to achieve the following:
Restore normal fluid, electrolyte, and acid-base balance.
Several oral rehydration solutions are available commercially.
The World Health Organization has a standard recipe for an oral rehydration
solution: 1/3 to 2/3 tsp table salt, 3/4 tsp sodium bicarbonate, 1/3 tsp potassium
chloride (salt substitute), 1
1
/
3
Tbsp sugar or rice powder, 1 L bottled or sterile
water. There is some concern regarding osmolality of standard oral rehydration
solutions but current evidence indicates that standard and lower osmolality oral
rehydration solutions using rice as the carbohydrate source can be equally
successful in managing diarrhea. However the lower osmolality oral rehydration
solutions have shown to decrease fecal volume and duration of diarrhea(Murphy
2004; Khan 2005; Atia 2009; Suh 2010).
Decrease gastrointestinal motility
Avoid clear liquids and other foods high in simple carbohydrates (eg, lactose,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sucrose, or fructose) and sugar alcohols (sorbitol, xylitol, or mannitol).
Avoid caffeine-containing products.
Avoid high-fiber and gas-producing foods such as nuts, beans, corn, broccoli,
cauliflower, or cabbage.
Thicken consistency of the stool
Banana flakes, apple powder, or other pectin sources can be added
to age-appropriate foods for children. If an infant has begun solid foods, use of
strained bananas, applesauce, and rice cereal are the best initial food choices;
historically, the use of the BRAT (bananas, rice, applesauce, and toast) eating
pattern has been used to guide the initial food choices for acute diarrhea but
does not provide a variety of nutrients (Duro 2007).
Stimulate the gastrointestinal tract by slow introduction of solid food without
exacerbation of symptoms
In older children and teenagers low-residue, low-fat, lactose-free nutrition
therapy should guide initial food selections; if there is no evidence of lactose
intolerance, then these foods should be added back to the meal plan (Duro
2007; Steffen 2004).
Infants should continue to breast feed or consume full-strength formula
consistent with standard practice.
Probiotic and prebiotic supplementation may assist with treatment and recovery but current
research does not substantiate dosage recommendations.

Nutrition Therapy Efficacy

The recommendations from the North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition for infants and children with acute diarrhea is to continue to eat a
regular diet. However, if diarrhea persists the limitation of lactose in the diet may be
beneficial with a slow reintroduction once symptoms resolve. When diarrhea is severe,
commercial oral rehydration solutions (ORS) and the World Health Organization's
homemade recipe (see the Nutrition Intervention section) are recommended.
ORS have been very successful in the treatment of diarrhea and their use has resulted in a
decrease in the childhood mortality rate in children less than 5 years of age (Suh 2010; Atia
2009).
Of particular note: The osmolarity of standard ORS, while helping to replete electrolytes
and fluid, has not been shown to decrease fecal volume or duration of diarrhea. Lower
osmolarity ORS have, however, shown some success in decreasing fecal volume and
diarrhea duration (Suh 2010; Atia 2009).
The addition of zinc supplementation orally or to ORS has also shown benefit to decreasing
fecal volume and duration (Bajait 2011; Suh 2010)
This nutrition therapy should be temporary for treatment of acute diarrhea. Depending on
food choices and total volume, this nutrition therapy may be inadequate in all nutrients.
*Adapted from Nutrition Care Manual: Diarrhea

Goal Setting

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Goals for working with patients with diarrhea include the following:
Restore normal fluid, electrolyte, and acid-base balance
Decrease rate at which foods/fluids pass through the gastrointestinal (GI) tract
Thicken consistency of the stool
Repopulate GI tract with normal flora
Stimulate the GI tract by slow introduction of solid food without exacerbation of
symptoms
Improve or maintain nutritional status with food, enteral, or parenteral nutrition as
warranted
*Adapted from Nutrition Care Manual: Diarrhea

Oral Intake

As diarrhea improves and stool becomes more formed, introduce solid food one food at a
time and monitor for tolerance. In older children and teenagers low-residue, low-fat,
lactose-free nutrition therapy should guide initial food selections; if there is no evidence of
lactose intolerance, then these foods should be added back to the meal plan (Duro 2007;
Steffen 2004). If stool output increases, remove the offending food from the meal plan
temporarily. Smaller, more frequent meals may be best tolerated. It may also be helpful to
separate solid food from liquid intake. This can be achieved by drinking liquids between
meals. The use of foods containing prebiotics and probiotics can be helpful although
current research does not substantiate dosage recommendations.
Infants should continue to breast feed or consume full-strength formula consistent with
standard practice. Research demonstrates that resumption of usual milk-based feedings,
including breastmilk and lactose-containing infant formulas, results in better weight gain
and does not prolong diarrhea when compared to extended use of oral rehydration
solutions (Sandhu 1997).
*Adapted from Nutrition Care Manual: Diarrhea

Comparative Standards

When estimating fluid requirements for patients with diarrhea, fluid losses from diarrhea
need to be assessed and replaced in addition to normal fluid requirements.
Estimation of normal fluid requirements
Weight Amount of Fluid
1-10kg 100-150mL/kg
11-20kg 1000mL + 50mL/kg over 10kg
≥ 21 kg 1500mL + 20mL/kg over 20kg
Fluid status should be monitored using the following parameters:
Laboratory parameters (eg, electrolytes)
Clinical observations (edema, dehydration)
Weight fluctuations by obtaining daily weights
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Intake and output records

Enteral or Tube Feeding

Enteral nutrition support is not specifically indicated during diarrhea unless the underlying
condition causing diarrhea requires nutrition support. Diarrhea can be a complication
during enteral feeding and should be aggressively treated to prevent further morbidity and
mortality. Causes for diarrhea during enteral feeding may include atrophy of the intestinal
villi resulting from malnutrition, excessive rate or volume of feeding into the stomach or
small intestine, presence of unabsorbed carbohydrate in large intestine, and diarrhea
secondary to medications (especially those with sugar alcohols) or underlying
gastrointestinal disease (Wiesen 2006; McErlean 2005; Thakkar 2005; Mechanick 2005;
Fuhrman 1999; Russell 2001).
The following interventions may assist in reducing diarrhea in patients receiving enteral
feeding:
Most patients will be able to tolerate a polymeric formula but a chemically defined
formula is an option for those with bowel diease, prolonged bowel rest, or severe
malnutrition, which may affect absorptive capability. Start with a slow, continuous
feeding schedule and increase as tolerated.
Consider the addition of probiotic or prebiotic supplementation though current
research does not substantiate dosage recommendations and further research is
needed (Jonkers 2007; Whelan 2007).
Add soluble fiber such as pectin or insoluble fiber such as psyllium to the medication
regimen.
Consider a formula with added fiber, though long-term results have not been
proven (Yang 2005; Rushdi 2004).
Use an antidiarrheal medication.


Suggested Monitoring Parameters and Recommendations

It is important to monitor patients closely to see if any adjustments need to be made in
nutrition intervention. These measurements can help monitor hydration status.
Intake/Output records
Laboratory values/Electrolytes
Daily weights
As diarrhea improves and diet is advanced it is important to monitor tolerance/intolerance
to foods. Foods that exacerbate diarrhea can be eliminated from the diet temporarily.

Nutrition Care FAQs

Question: Is it normal for breastfed infants to have watery stools?
Answer: Normal stools for breastfeeding babies can range from liquid to solid in nature
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and in frequency from 3-10 per day.
Question: What are the symptoms of dehydration and when should medical attention
be sought?
Symptoms of Minimal Dehydration
Most children who are acutely sick will have minimal or no dehydration. These children are
alert, appear well and have:
normal thirst or may refuse some liquids
a moist mouth and tongue
normal to slightly decreased urine output
less than 3 percent weight loss
normal heart rate, pulses, breathing, and warm extremities
capillary refill less than 2 seconds
instant recoil on skin turgor test
eyes not sunken (and/or fontanel in a baby)
Symptoms of Mild to Moderate Dehydration
As dehydration progresses, children may begin to feel tired, restless, and irritable, which
makes it difficult to get them to drink more fluids. Other signs and symptoms of mild to
moderate dehydration, for which one should contact a pediatrician, include:
a dry mouth and tongue
decreased urine output
3 to 9 percent weight loss
normal to increased heart rate and pulses, normal to fast breathing, and cool
extremities
capillary refill greater than 2 seconds
recoil on skin turgor test in less than 2 seconds
slightly sunken eyes (and/or fontanel in a baby)
Symptoms of Severe Dehydration
Severe dehydration is a medical emergency and requires immediate medical attention.
These children appear lethargic (meaning they are difficult to keep awake) or may be
unconscious. They also may have:
poor drinking or may be unable to drink
a parched mouth and tongue
minimal or no urine output
greater than 9 percent weight loss
increased heart rate, weak pulses, deep breathing, and cool, mottled extremities
capillary refill that is very prolonged or minimal
recoil on skin turgor test in more than 2 seconds
deeply sunken eyes (and/or fontanel in a baby)
Question: Is it ok to give over-the-counter antidiarrheal medication to my child?
Answer: You should never give over-the-counter antidiarrheal medication to your child
without first consulting with his or her pediatrician.

Parenteral Nutrition

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

In acute diarrhea and chronic diarrhea, use of oral and enteral nutrition support is the first
choice because of the importance of gut stimulation. In patients with intractable diarrhea
who are unable to tolerate enteral feedings, however, parenteral nutrition may be
warranted. When the individual situation warrants, parenteral nutrition support
recommendations would follow standard procedures for formula prescription and daily
monitoring.
*Adapted from Nutrition Care Manual: Diarrhea

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases > Gastroesophageal Reflux
Nutrition Diagnosis

Registered dietitians working with patients who have gastroesophageal reflux disease
should review the signs and symptoms obtained in the nutrition assessment and diagnose
nutrition problems based on these signs and symptoms. Nutrition diagnoses from the
following list, as well as other diagnoses, may be present.
Inadequate oral intake (NI-2.1)
Altered gastrointestinal function (NC-1.4)
Unintentional weight loss (NC-3.2)
Food- and nutrition-related knowledge deficit (NB-1.1)
Sample Problem, Etiology, Signs and Symptoms or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to vomiting after feeding as evidenced by
insufficient growth velocity
Note: Terminology in the examples above is from the 3rd edition of the American Dietetic
Association's International Dietetics and Nutrition Terminology. Code numbers are inserted
to assist in finding more information about the diagnoses, their etiologies, and the signs
and symptoms. Registered dietitians should not include these numbers in routine clinical
documentation.

Nutrition Intervention

Recommendations for treatment of gastroesophageal reflux disease (GERD) should be
individualized on the basis of age and developmental stage of the child. A regular diet for
infants and children, with adequate energy and protein for optimal growth, is appropriate.
Parents of most healthy babies can be reassured that GER is common and benign and the
child should outgrow it.
A prone position has been shown to decrease symptoms of GER but should not be
recommended for sleep due to the association between sudden infant death syndrome
(SIDS) and prone positioning (Samour, 2012). Elevation of the head of the bed reduces
GER (Vandenplas, 2009). It has been suggested that transient relaxation of the lower
esophageal sphincter may be increased by larger-volume feedings of formula (Vandenplas,
2009). Decreasing the volume at each feeding and concentrating the formula to meet
energy needs may be beneficial to decrease the frequency of reflux (Vandenplas, 2009).
For children with GER related to milk-protein allergy, a change to hydrolyzed protein or
amino acid–based formula may help to resolve symptoms. If the child is breastfeeding, an
improvement in symptoms may be seen if cow's milk and eggs are eliminated from
mother's diet (Samour, 2012).
A common treatment for GER involves thickening formula feedings with rice cereal.
Studies have shown a decrease in the frequency of regurgitation when formula is
thickened, including thickeners made of rice, corn or potato starch, guar gum, and locust
bean gum (Vandenplas, 2009). Rice cereal is the most widely used thickener in the United
States and has been shown to decrease the volume of regurgitation. However, this method
of thickening may lead to higher energy intake and change in nutrient composition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
of thickening may lead to higher energy intake and change in nutrient composition
(Vandenplas, 2009; Merritt, 2005). Adding 1 tablespoon of rice cereal per 1 oz of formula
increases energy concentration from 20 kcal/oz to ~34 kcal/oz (Vandenplas, 2009). The
addition of 1 tablespoon of rice cereal to 2 oz of formula increases the concentration from
20 kcal/oz to ~27 kcal/oz (Vandenplas, 2009). Accurate calculation of the optimal energy
intake and volume prevents overfeeding (Khoshoo, 2000).
There are now commercially available formulas that contain rice starch that thickens when
exposed to gastric acid (Merritt, 2005). The nutrient composition of these formulas are
comparable to other commercially available formulas, which may make this a more
desirable option than thickening with rice cereal (Vandenplas, 2009). Further studies
related to GER and thickened feeds are needed to make a determination as to the safety
and efficacy of thickening formula with rice cereal. It is still recommended that infant cereal
be introduced with a spoon when the baby is developmentally ready, at approximately 4 to
6 months of age. Use of breast milk vs formula does not appear to affect the incidence of
GER (Groh-Wargo, 2000).
Any known irritants in the child's diet—such as caffeine, chocolate, and spicy
foods—should be avoided if they cause symptoms. Alcohol is also a known irritant that
adults should avoid (Vandenplas, 2009). It is known that alcohol, chocolate, and high-fat
meals decrease lower esophageal sphincter pressure, but it is currently unknown how
much these factors affect reflux symptoms (Vandenplas, 2009).
Intervention based on sample nutrition diagnosis provided in the Nutrition Diagnosis
section:
(NI-2.1) Problem, Etiology, Signs and Symptoms: Inadequate oral intake related to
vomiting after feeding as evidenced by insufficient growth velocity.
Intervention (ND-2.1.1) Formula/solution
Recommendation: Increase energy concentration to 24 kcal/oz and
decrease volume of each feeding
Note: Terminology in the examples above is from the 3rd edition of the American Dietetic
Association's International Dietetics and Nutrition Terminology. Code numbers are inserted
to assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. Registered dietitians should not include these numbers in routine clinical
documentation.

Goal Setting

The goals of nutrition management of gastroesophageal reflux in infants and children are to
decrease symptoms associated with reflux of gastric fluid into the esophagus and to
promote optimal growth and development.

Enteral or Tube Feeding

Continuous tube feedings have been shown to resolve emesis and failure to thrive related
to gastroesophageal reflux (GER) in infants without other medical problems. Standard
infant formulas and breast milk may be provided through the feeding tube, unless there are
indications for a specialty formula. Careful consideration should be given to developmental
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and behavioral issues for all infants who are tube fed (Tsou, 1998; Roy, 1995). A controlled
study of 20 infants, aged 5 to 7 months, with GERD—compared with 20 control
infants—showed infants with GERD have substantial feeding problems, including oral
motor dysfunction and negative feeding experiences for both the infant and mother
(Mathisen, 1999).
Premature infants with apneic events may benefit from a trial of transpyloric continuous
tube feeding to determine if apneic events are related to GER. One study found infants
suspected of having GER-related apnea had a decreased number of apneic episodes once
they were started on continuous, transpyloric tube feeding (Misra, 2007). However, GER
may still occur with transpyloric feeding (Rosen, 2011).

Monitoring & Evaluation

Actual energy and nutrient intake can be difficult to assess because of frequent reflux of
varying volumes. A food diary may be helpful to determine how symptoms are affected by
food so no foods are eliminated unnecessarily from the diet. Monitoring growth patterns
using appropriate pediatric growth curves helps to determine whether dietary intake is
adequate. Excessive dietary intake can also be identified by excessive weight gain.
Following are monitoring and evaluation measures based on the sample diagnosis
provided in the Nutrition Diagnosis section:
(NI-2.1) Problem, Etiology, Signs and Symptoms: Inadequate oral intake related to
vomiting after feeding as evidenced by insufficient growth velocity.
Intervention (ND-2.1.1) Formula/solution
Recommendation: Increase energy concentration to 24 kcal/oz and
decrease volume of each feeding
Monitoring/evaluation (AD-1.1.4) Weight change: weight gain goal of 25 g/day
Note: Terminology in the examples above is from the 3rd edition of the American Dietetic
Association's International Dietetics and Nutrition Terminology. Code numbers are inserted
to assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. Registered dietitians should not include these numbers in routine clinical
documentation.


Nutrition Therapy Efficacy

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and
the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition currently
do not recommend specific dietary changes for the treatment of gastroesophageal reflux
disease because of a lack of evidence (Vandenplas, 2009). However, interventions such as
thickening formula, increasing energy density and decreasing volume of formula, changing
formulas, or eliminating known irritants from the diet may be helpful in reducing symptoms
(Vandenplas, 2009). Until more evidence is available, recommendations should be
individualized based on response to dietary changes.

Medications
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If conservative therapies are not effective in treating gastroesophageal reflux, medication
therapy may be used. Acid suppressant therapy—such as proton pump inhibitors or
histamine-2 receptor antagonists—are the most commonly used medications unless
symptoms are only occasional (Vandenplas, 2009).
Histamine-2 receptor antagonists work by inhibiting the histamine-2 receptors on gastric
parietal cells from producing acid (Vandenplas, 2009). The effect of these medications on
gastric pH is seen within 30 minutes of taking medication and lasts for 6 hours. Tolerance
to histamine-2 receptor antagonists can be seen after 6 weeks of receiving the medication,
decreasing the effectiveness of the medication (Vandenplas, 2009).
Proton pump inhibitors stop acid production,; the proton pump is one of the final steps in
the parietal cell acid production pathway (Vandenplas, 2009). Benefits of proton pump
inhibitors over histamine-2 receptor antagonists include ability to decrease pH for a longer
period of time and there is no loss of effectiveness over time (Vandenplas, 2009).
Prokinetic agents may also be used in treatment, but potential side effects outweigh the
benefits of these medications (Vandenplas, 2009). Examples of side effects related to
prokinetic agents are gynecomastia, galactorrhea, and extrapyramidal reactions
(Vandenplas, 2009).
Buffering agents, sucralfate, and alginate may be used but are not recommended for
long-term use, especially in infants because of the risk of aluminum toxicity (Vandenplas,
2009).

Client History

Medical/Social History
Diagnoses
Symptoms of condition
Duration of condition
Foods associated with exacerbation of symptoms
Medications (especially histamine-2 receptor antagonists and proton pump inhibitors)
Past medical history/surgeries
Family history of gastrointestinal disorders
Socioeconomic status/food security
Caregivers
Primary language
Formula preparation
Formula changes/diet changes/food introductions
Feeding relationship
Parental knowledge of age-appropriate feeding practices

Biochemical Data, Medical Tests and Procedures

Clinical signs and symptoms are often used to diagnose gastroesophageal reflux
disease (GERD) (Vandenplas, 2009). However, these signs and symptoms obtained from a
client/patient history and physical are not reliable in diagnosing infants and children
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
younger than 8 to 12 years, as the signs and symptoms are often nonspecific (Vandenplas,
2009).
The following tests may be used in the diagnosis of GERD (Vandenplas, 2009):
Esophageal pH monitoring
Combined multiple intraluminal impedance and pH monitoring
Endoscopy and biopsy
Barium contrast radiography
Empiric trial of acid suppression
These tests do not specifically diagnose GERD but may be useful in ruling out other
causes of symptoms.

Laboratory

There are no specific laboratory tests for gastroesophageal reflux disease. Electrolyte
monitoring may be needed if the child has had persistent vomiting or if dehydration is a
concern.

Anthropometric Measurements

Evaluation of growth should include the measurement and plotting of weight for age,
height/length for age, head circumference for age (for infants younger than 36 months),
and weight for length or body mass index for age. A comparison of growth percentiles over
time is helpful to determine adequacy of intake. See the Growth Charts, available in the
Resources section, for more information.

Food/Nutrition-Related History

A complete food history, food frequency questionnaire, and/or 24-hour recall should be
completed for a child with gastroesophageal reflux disease (GERD). Specific areas of
concern should include the following (Samour, 2012):
Breast milk or formula intake, including formula preparation
Feeding/meal frequency
Intake of foods that exacerbate GERD symptoms (see Foods Not Recommended
section for details)
Caffeine intake
Fluid intake
Food allergies
Dietary supplements
Evaluation of exercise and activity patterns
Past medical history
Nausea
Vomiting
Diarrhea
Constipation
Problems with chewing, swallowing, or sucking
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Cultural or religious beliefs that affect food intake
Feeding practices, including position of infant/child during and after feeding
Weight history

Comparative Standards

Energy and protein needs: See the Dietary Reference Intakes for age
Fluid needs for children with gastroesophageal reflux disease are the same as for healthy
children of the same age and weight.

Oral Intake

There is currently not enough evidence to support or refute dietary changes to treat
gastroesophageal reflux (GER) in children or adolescents (Vandenplas, 2009). Irritants are
highly individualized, and foods should not be eliminated unnecessarily (Khoshoo, 2000).
Any known dietary irritants—caffeine, chocolate, alcohol, and spicy foods—should be
avoided if they cause symptoms (Vandenplas, 2009). It is known that alcohol, chocolate,
and high-fat meals decrease lower esophageal sphincter pressure, but it is currently
unknown how much these factors affect reflux symptoms (Vandenplas, 2009). In
overweight or obese individuals with GER, weight loss has been shown to be beneficial in
reducing symptoms of GER (Vandenplas, 2009).


Parenteral Nutrition

Parenteral nutrition is not indicated in gastroesophageal reflux disease. Parenteral nutrition
should only be used in children who are unable to tolerate oral or enteral nutrition.

Complications of Nutrition Support

Children with gastroesophageal reflux disease (GERD) may not tolerate bolus tube
feeding, as large volumes of formula may increase transient relaxation of the lower
esophageal sphincter (Vandenplas, 2009). Continuous tube feedings have been shown to
resolve GER-related emesis and failure to thrive in infants without other medical problems.
Standard infant formulas and breast milk may be provided through the feeding tube unless
there other indications for a specialty formula. Careful consideration should be given to
developmental and behavioral issues for all infants who are tube fed. GERD has been
associated with feeding problems, for example, oral motor dysfunction, which is related to
delayed development of feeding skills (Mathisen, 1999).

Suggested Monitoring Parameters and Recommendations

It is important to monitor growth parameters in children with inadequate growth resulting
from gastroesophageal reflux disease (GERD) symptoms. Growth parameters should
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improve as the child undergoes treatment for GERD. It is also important to monitor for
improvement in GERD symptoms while eliminating foods suspected of exacerbating
symptoms. Only the foods found to exacerbate symptoms should be eliminated.

Nutrition Care FAQs

Q: Do all children with reflux require treatment?
A: No. Reflux occurs in all children several times per day. A child only needs treatment if
the reflux leads to complications or symptoms; when reflux leads to complications or
symptoms, it is known as gastroesophageal reflux disease (GERD). Complications of
GERD may include weight loss or poor weight gain, recurrent pneumonia, irritability in
infants, feeding refusal, apneic spells, esophageal stricture, or anemia.
Q: Should all infants with GERD receive thickened formula?
A: No. A Cochrane Review indicates there is not enough evidence at this time to
recommend thickening infant formula when GERD is present. There are potential side
effects of thickening formula, including delayed gastric emptying (Huang, 2002).
Q: Should all children with GERD avoid caffeine, chocolate, and spicy foods?
A: There is currently no evidence that dietary changes should be used to treat reflux in
children. However, it may be beneficial to implement a trial elimination of these foods and
any other foods that cause symptoms of reflux.



© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases > Irritable Bowel Syndrome
Nutrition Assessment

Most children with irritable bowel syndrome (IBS) experience normal growth and
development (Boyle, 2004). However, risk of malnutrition and nutrition-related conditions
may increase due to longevity and severity of symptoms and long-term use of restrictive
dietary practices.
Comprehensive nutrition assessment in individuals with IBS should include the following
(Escott-Stump, 2012):
Food/nutrition-related history
Anthropometric data
Nutrition-focused physical findings
Biochemical data, medical tests and procedures
Medical history
Personal history
Family history of gastrointesintal disorders and conditions
Social history
Participation in social activities
School attendance/absenteeism or home-bound status
If hypersensitivity to certain foods is the suspected cause of IBS, a diet history will be an
important part of the nutrition assessment to gather historical and current information
regarding IBS symptoms.The diet history should include quality and quantity of food
consumed, timing and nature of symptoms, and frequency and consistency of stools.
A trial of food elimination and challenge may be used to diagnose or rule out food
hypersensitivity. Caffeine, legumes, cabbage, sorbitol, milk products, and excess fat have
been associated with gastrointestinal symptoms. Eating smaller, more frequent meals may
also improve symptoms (Browning, 1999; Rothstein, 2000). Because patients with IBS
often experience severe pain, helping patients overcome a fear of eating may be a part of
the registered dietitian's role (Mahan, 1996).

Nutrition Diagnosis

Registered dietitians (RDs) working with patients who have irritable bowel syndrome (IBS)
should develop nutrition diagnoses based on signs and symptoms obtained through
nutrition assessment. Multiple nutrition diagnoses, including the following, may be
applicable when IBS is present.
Inadequate oral intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Altered gastrointestinal function (NC-1.4)
Unintended weight loss (NC-3.2)
Food- and nutrition-related knowledge deficit (NB-1.1)
Limited food acceptance (NI-2.9)
Poor nutritional quality of life (NB-2.5)
Sample PES (problem, etiology, signs and symptoms) or Nutrition Diagnostic
Statement(s)
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Limited food acceptance (NI-2.9) related to anxiety regarding abdominal pain
and diarrhea following ingestion of meals as evidenced by skipping breakfast and
lunch on school days and avoidance of food-related social activities.
Altered gastrointestinal function (NC-1.4) related to changes in gastrointestinal tract
motility as evidenced by abnormal breath hydrogen test and diarrhea following
ingestion of fructose-containing foods and beverages.
Poor nutritional quality of Life (NB-2.5) related to anxiety regarding abdominal pain
and diarrhea following ingestion of meals as evidenced by avoidance of social
activities where food is served.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd ed. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition Prescription
Irritable Bowel Syndrome (IBS) Nutrition Therapy
Lactose-Restricted Diet
Fructose-Restricted Diet
Low FODMAP Diet
Nutrition interventions for management of IBS may include one or more of the
following strategies:
Establish regular eating patterns, regular bowel hygiene, and adequate time for rest
and relaxation (Escott-Stump, 2012).
Avoid constipation by doing the following:
Gradually increase daily fiber intake to meet age-specific requirements*, with an
emphasis on foods that contain predominantly soluble fiber (oat bran, oatmeal,
beans, peas, rice bran, barley, citrus fruits, strawberries, and apple pulp) and/or
fiber supplements containing psyllium (isphagula) husks
Increase fluid intake to meet maintenance fluid requirements
Increase physical activity (Escott-Stump, 2012)
Adhere to a fructose-restricted diet (<25 g/day), if fructose malabsorption is present
(Chiou, 2010)
A 2-3 week trial of a lactose-restricted diet (<12 g/day) may be useful in older children
and adolescents, particularly if abdominal pain, bloating, and diarrhea appear to be
associated with dairy product ingestion (Chiou, 2010)
Individualize nutrition management by maintaining a food/supplement and symptom
diary for 2 to 4 weeks. Eliminate only the foods that cause symptoms on three
separate occasions and only if symptoms occur within 3 days of eating the food
(Heizer, 2009)
Empiric trials eliminating high-fat foods, caffeine, sorbitol, and alcohol/alcoholic
beverages may be helpful in identifying food triggers for symptoms (Heizer, 2009)
Implementation of the FODMAP elimination diet
The low FODMAP (fermentable oligosaccharides, disaccharides,
monosaccharides and polyols) diet restricts short-chain carbohydrates that are
commonly malabsorbed by the small intestine and left for fermentation by
bacteria in the colon for 6 to 8 weeks. After a baseline, symptom-free period has
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
bacteria in the colon for 6 to 8 weeks. After a baseline, symptom-free period has
been established, reintroduction of these carbohydrates occurs in a stepwise
fashion, and patients monitor if and/or when gastrointestinal symptoms
return. Some individuals may tolerate small amounts of these carbohydrates in
the diet; volume of each carbohydrate group is thus increased slowly. The low
FODMAP diet should not be used long-term as it restricts foods that contribute
variety of vitamins and minerals to the diet (Yao, 2011).
*Age-specific recommendations for fiber intake are as follows:
American Academy of Pediatrics (Williams, 1995): (Age in years) + (5 to 10)=
Recommended daily fiber (g)/day
Dietary Reference Intake (NRC, 2005):
1-3 years: 19 g/day
4-8 years: 25 g/day
9-13 years (female): 26 g/day
9-13 years (male): 31 g/day
14-18 years (female): 26 g/day
14-18 years (male): 38 g/day


Goals

Goals for nutrition management of irritable bowel syndrome in children and adolescents
include the following:
Avoidance of known or suspected food intolerances and other diet-related triggers of
symptoms
Adequate intake to support normal growth and development
Adequate intake of a sufficient variety of foods to avoid nutritional deficiencies

Nutrition Therapy Adequacy

The diet prescribed for irritable bowel syndrome (IBS) management is nutritionally
adequate, if a sufficient variety of foods are included on a regular basis to meet the needs
of the individual. If multiple foods or one or more food groups are eliminated due to
association with IBS symptoms (eg, if the individual is following the lactose-restricted
diet) for more than 6 to 8 weeks, alternative foods and/or nutritional supplements should be
recommended to ensure nutritional therapy adequacy.
The elimination phase of the low FODMAP diet should not be used for more than 6 to 8
weeks (Yao, 2011).
Nutritional analysis of intake using food journals and/or validated food frequency
questionnaires facilitates comparison of individual intake with age-specific nutritional
requirements.

Nutrition-Focused Physical Findings

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Muscle wasting, bony prominences, poor muscle tone
Edema
Pallor
(Bessler, 2005)

Client History

The client history may reveal pertinent information related to the etiology of irritable bowel
syndrome (IBS) symptoms and guide treatment selection and outcome goals for children
with IBS.
Age at onset of symptoms
Previous medical conditions/diagnoses
Previous surgeries
Medications
Socioeconomic status/food security
Support systems
Education
Primary language
Social history
Participation in social activities
School attendance/absenteeism or home-bound status
Family history
Gastrointestinal disorders
Psychological or mental health disorders
Change in family dynamics correlating with onset of symptoms


Biochemical Data, Medical Tests and Procedures

Laboratory evaluation
Hemoglobin, hematocrit, mean corpuscular volume, iron panel
Albumin, prealbumin, c-reactive protein (CRP)*
Glucose
Electrolytes (sodium, potassium, carbon dioxide, calcium, magnesium,
phosphorus)
Tissue transglutaminase (tTG)
Medical tests and procedures
X-rays
Colonoscopy or sigmoidoscopy
Breath hydrogen tests
Extensive information may be available from the medical evaluation preceding nutrition
consultation for irritable bowel syndrome.
(Escott-Stump, 2012)
*Note: Albumin and prealbumin continue to be used as markers of nutritional status but are
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
relevant only if inflammatory markers such as CRP are normal (Bessler, 2005).


Anthropometric Measurements

Anthropometric measures are a vital component of nutrition assessment of children and
adolescents with irritable bowel syndrome, especially for individuals who engage in
restrictive dietary practices that increase risk for malnutrition.
Anthropometric measurements to monitor include the following:
Height; height percentile
Weight; weight percentile
Body mass index (BMI); BMI percentile
Desirable weight for height (BMI from 5% to 84% for age)
Growth pattern/weight changes/growth velocity

Food/Nutrition-Related History

Ability to ingest age-appropriate foods in an age-appropriate meal plan
Gastrointestinal symptoms: nausea, abdominal pain, abdominal distention or
bloating, excessive intestinal gas, diarrhea, constipation
Food allergies, intolerances, and preferences with particular attention to the
following:
High-fat foods
Gas-forming foods
High-fiber foods
Lactose
Fructose
Sorbitol
Caffeine
Current or prior food restrictions
Developmental feeding issues (chewing, swallowing, self-feeding skills; air
swallowing)
Ethnic, cultural,and religious influences
Use of vitamin, mineral, or herbal supplements
Use of liquid nutritional supplements
Consumption of energy drinks
Alcohol use (adolescents)
Previous nutrition education or nutrition therapy
Eating pattern (assessed through 24-hour recall or food frequency questionnaire)
(Escott-Stump, 2012; Bessler, 2005)

Comparative Standards

Anthropometric Data
Body composition/growth/weight history (AD-1.1)
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Body composition/growth/weight history (AD-1.1)
Weight for age (% rank)
Stature for age (% rank)
BMI for age (% rank)
Recommended BMI (5% to less than 85% for age)
Desirable weight (based on height and BMI from 5% to 84% for age)
Nutritional Intake
24-hour recall
Food frequency questionnaire
Guidelines for interpretation of Dietary Reference Intakes (DRI) for evaluation of
usual intake:
Recommended Daily Allowance (RDA): estimated intakes at or above RDA
have a high probability of adequacy
Estimated Average Requirement (EAR): estimated usual intake below EAR
denotes a 50% or less probability of adequacy
Average Intake (AI): estimated usual intake at or above AIs are considered
adequate
Tolerable Upper Limit (UL): estimated usual intake below the UL are considered
low risk for toxicity
Estimated energy needs (CS-1.1)
Estimated fiber needs (CS-2.4)
Estimated fluid needs (CS-3.1)
Estimated vitamin needs (CS-4.1)
Estimated mineral/element needs (CS-4.2)
(ADA, 2011)

Oral Intake

Most children with irritable bowel syndrome (IBS) maintain normal growth exclusively
through oral intake (Boyle, 2004). With appropriate guidance and meal planning and use of
nutritional supplements when indicated, a nutritionally adequate intake can be maintained
during treatment of IBS.

Enteral or Tube Feeding

The use of enteral nutrition support in irritable bowel syndrome is indicated only in rare
cases, where efforts to avoid or reduce symptoms lead to self-imposed, extremely
restrictive dietary intake and malnutrition.
A nutritionally complete, standard or hydrolyzed formula containing soluble fiber should be
recommended. Formulas containing fructo-oligosaccharides, sucrose, or fructose may not
be well tolerated in individuals with fructose malabsorption.

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Parenteral Nutrition

The use of parenteral nutrition support for management of irritable bowel syndrome is not
indicated.

Complications of Nutrition Support

Individuals with irritable bowel syndrome who develop malnutrition as a result of severely
restrictive dietary practices or those with recent weight loss of 10% or more should be
monitored for signs/symptoms of refeeding syndrome following implementation of oral
nutrition supplementation or enteral nutritional support.

Suggested Monitoring Parameters and Recommendations

Food/Nutrition-Related History Outcomes (ADA, 2011)
Food and nutrient intake
Medication/supplement use
Knowledge/beliefs
Physical activity
Nutrition quality of life
Anthropometric Outcomes
Height/ %ile
Weight/ %ile
Body mass index/%ile
Growth pattern/weight change/growth velocity
Biochemical Data, Medical Tests and Procedures (Escott-Stump, 2012)
Laboratory evaluation:
Hemoglobin, hematocrit, mean corpuscular volume, iron panel
Albumin, prealbumin, c-reactive protein
Glucose
Electrolytes (sodium, potassium, carbon dioxide, calcium, magnesium,
phosphorus)
Nutrition-Focused Physical Finding Outcomes
Physical appearance
Muscle and fat wasting
Appetite
Affect

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Gastrointestinal Diseases > Short Bowel Syndrome
Nutrition Assessment

The nutrition assessment is an integral part of the multidisciplinary team approach to taking
care of a patient with short bowel syndrome. Waterlow criteria, McLaren criteria, or Gomez
classification systems may be used to determine the degree of malnutrition. For
premature infants, correcting for gestational age may be more realistic for growth aspects
(Carter, 2009).

Other things to include in the nutrition assessment:
Weight
Height/length
Body mass index (for over 2 years old)
Head circumference (under 3 years old)
Mid-arm muscle circumference (MAMC)
Average daily weight gain (especially for infants)
Stooling history
Emesis history
Output from ostomy
"Ins and Outs"
Physical observations
Client history
Food history: for example, current enteral or parenteral prescription (see Food History
section)
Previous laboratory and diagnostic tests
Medications and dosage

Nutrition-Focused Physical Findings

The following list includes but is not limited to physical findings that may be helpful:
Patient's overall appearance
Are there fat stores on the arms and legs?
Are patient's ribs visible?
Mouth
Does the patient have teeth? How many? Where are they located; front or
back?
Are they permanent teeth?
Eyes
Are the sclera yellow?
Are there dark circles under the eyes?
Hair
Nails
Skin
Is it dry and scaly (if so, it may indicate essential fatty acid deficiency)?
Is there bruising (if so, could potentially be associated with Vitamin K
deficiencies)?
Is the skin yellow?
Is there sloughing of skin? Red patches?
Ostomies/drains
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Ostomies/drains
Does the patient have an ileostomy? Colostomy? Any other drains such as
biliary, pancreatic, or fistula drains?
Feeding access points
Central line?
PICC line?
Other central access?
Feeding tubes?

Biochemical Data, Medical Tests and Procedures

Some diagnostic tests can be useful in monitoring the patient with short bowel
syndrome. Overall, some physicians find it helpful to perform an upper gastrointestinal test
with small bowel follow-through, and/or a gastric emptying scan.
If the patient is showing signs of feeding intolerance or increased stooling, the following
diagnostic tests may help:
Stool studies:
Alpha-1-antitripsyn
Guaiac
Reducing substances
Fecal fat
Stool cultures
Viral cultures
If the patient has an ostomy, has had trouble maintaining their electrolyte balance, and/or
output has increased, checking the output for electrolyte content may be useful to help
determine the electrolytes that need to be replaced.

Laboratory

There is very little evidence to guide the health care team regarding how often the
laboratory values should be monitored. The following should be monitored on a regular
basis set by the health care team:
Standard electrolytes (Na, K, Cl, CO
2
)
Blood urea nitrogen (BUN) and creatinine (Crt) levels
Complete blood count (CBC)
Calcium, phosphorous, and magnesium
Triglycerides (TG)
Liver function test (LFT)
Direct/conjugated bilirubin
Albumin and prealbumin
Fat-soluble vitamins (A, D, E, and K)
Vitamin B
12
level, especially if the ileum has been resected
Serum zinc levels

Client History

Truly understanding the patient’s background can be beneficial when deciding what the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Truly understanding the patient’s background can be beneficial when deciding what the
best nutritional course of action may be for each patient.
Things to be considered range from prenatal history to religious preferences:
Prenatal and birth history
Patient’s surgical history: How much bowel is left? Is it in continuity? Is it functional or
is the remaining bowel damaged? Does the patient have their colon or not? Is there
an ileocecal valve? A surgical report may be helpful.
Socioeconomic status: Can the patient's family afford the proper foods and formula
needed? Can they afford or do they have resources for vitamins or supplements that
may be needed?
Religious preferences: This could become an issue when designing diets for a patient
whose religion dictates certain food laws.

Food/Nutrition-Related History

A review of the patient's food history may vary based on whether the patient is an infant,
child, or adolescent. The primary caregiver should be able to provide the information for the
infant or child; however, the adolescent may feel more comfortable answering those
questions themselves.
Infants
Current enteral or parenteral regimen (if applicable)
Mode of feeding: breastfeeding, bottles, feeding tube
Type and concentration of formula used
How the caregiver prepares the formula
How long it takes for patient to feed
Total volume of formula or milk consumed per day
How often patient is feeding
Other formulas previously tried
Food allergies and intolerances
Maternal eating behaviors if breastfeeding
Children/Adolescents
Current enteral or parenteral regimen (if applicable)
Typical meal patterns – is the patient skipping meals? Are snacks being consumed?
Foods patient refuses to eat
Food allergies and intolerance
Types of food usually consumed
Any supplements being taken
A 24-hour recall may be used to get a general idea of what the patient consumes; however,
a 3-day diet record may be needed to evaluate adequacy of specific macro- or
micronutrients.

Comparative Standards

Calorie needs: Estimated Energy Requirement (EER) x 1.2
Minimum estimated protein needs: Dietary Reference Intake for protein (for age or height
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
age) x 1.3

Catch-up growth needs:
EER kcal/kg x ideal body weight (kg)/actual body weight (kg) = minimum catch-up needs

Maintenance fluid needs are calculated using the body surface area (BSA) method;
however, note that the patient may have increased fluid needs based on gastrointestinal
output.
Immediately following extensive bowel surgery, the patient is susceptible to large volume
and electrolyte (Na, K, Cl, Mg) losses for up to 3 weeks post-surgery (Vanderhoof, 2004).
If a patient is having difficulty maintaining electrolytes it may be beneficial to place the
patient on a standard parenteral nutrition solution and replace fluids as needed, sometimes
as often as every 2 hours (Hwang, 2002). There are no current guidelines for fluids for the
patient with short bowel syndrome; however, starting with maintenance fluids and
continuing to monitor the patient would be ideal.

Nutrition Diagnosis

Dietitians working with patients who have short bowel syndrome should review the signs
and symptoms obtained in the nutrition assessment and diagnose nutrition problems based
on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased nutrient needs (NI-5.1)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Sample PES or Nutrition Diagnostic Statement(s)
Altered gastrointestinal function (NC-1.4) related to small bowel syndrome (___cm
remaining), as evidenced by inability to tolerate full enteral feeds and need for
parenteral nutrition support.
Impaired nutrient utilization (NC-2.1) related to small bowel syndrome as evidenced
by decreased pancreatic enzymes.
Increased nutrient needs (NI-5.1) related to small bowel syndrome, as evidenced by
inability to gain weight at estimated Dietary Reference Intake/age needs.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrient Delivery

To maintain fluid, electrolyte, and nutritional status, patients with extensive resection
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
To maintain fluid, electrolyte, and nutritional status, patients with extensive resection
require total parenteral nutrition in the acute phase. Children with lesser resections may
tolerate enteral feedings. The decision of what to feed a patient with short bowel syndrome
(SBS) can be a difficult one. It should be noted that each patient’s feeding regimen should
be individually tailored to their individual specific needs. After surgery, aggressive
introduction of enteral feeds has been found to promote adaptation and reduce duration of
parenteral nutrition (Hwang 2002; Andorskey 2001). For those patients that are likely going
to be using feeding tubes for longer than 3 months and/or have a predicted poor prognosis,
the health care team may want to examine early intervention for a surgically placed
gastrostomy tube (Wessel 2005; Goday 2009).

Intervention based on remaining anatomy
Nutrition interventions for SBS can also differ based on whether or not the patient has a
colon (Matarese 2005). If there is no colon, it may be helpful to decrease calories from
carbohydrate to a total of 40-50% and increase the calories from fat slightly to a total of
30-40% and protein 20-30% (Matarese 2005).
Fiber can be used in older infants and children who have colons. Water-soluble fiber such
as pectin or Benefiber may lengthen the intestinal transit time, enhancing intestinal contact
time with the nutrients and thus decreasing stool ouput (Abad-Siden 2003). However,
consequences of too much fiber can include bloating, gas, abdominal pain, obstruction,
and further malabsorption of magnesium, zinc, and iron (Jeejeebhoy 2002).
Pharmacologic intervention
SBS patients are at risk for small bowel bacteria overgrowth. Under supervision of the
medical team, they may be prescribed oral/enteral antibiotics to help with abdominal
distention or diarrhea, which in turn could help promote nutrient utilization.

Goal Setting

Goals for each patient are determined individually; however, there are a few overall goals
for the pediatric patient with short bowel syndrome (SBS):
Age-appropriate growth
Transition to 100% enteral or oral feedings
Appropriate and timely initiation of parenteral nutrition and enteral nutrition to promote
optimal intestinal adaptation, and to promote continued growth and development
(Abad-Siden, 2003)
Timely initiation of enteral nutrition for stimulation of the gastrointestinal tract
(Abad-Siden, 2003)
Minimize fluid and electrolyte losses (Abad-Siden, 2003)
Supplement appropriately with vitamins and minerals to prevent nutritional
deficiencies (Abad-Siden, 2003)

Oral Intake

Transitioning to solids can be difficult for the patient, caregiver, and health care team.
Continued work with speech and feeding therapy can help promote safe introduction of
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solid foods to the patient (Vanderhoof, 2004). It has been proven that patients with short
bowel syndrome are at risk for osmotic diarrhea caused by simple carbohydrates and
dissacharides such as sucrose, fructose, and lactose (Vanderhoof, 2004; Matarese, 2005);
whereas complex carbohydrates are more easily tolerated. Fats, although easily tolerated
and a good source of energy needs, can increase the osmotic load in the intestines
(Vanderhoof, 2004). Protein is very easily tolerated and does not significantly increase the
osmotic load in the intestines (Vanderhoof, 2004). However, it is important to note which
part of the bowel has been resected because a patient with no terminal ileum is at risk for
fat and fat-soluble vitamin malabsorption.
As the patient grows, it is important to emphasize an overall well-balanced diet, with each
meal consisting of complex carbohydrates, protein, and fat (Matarese, 2005). Patients may
find that eating small, frequent meals throughout the day may be more easily tolerated as
opposed to three large meals (Matarese, 2005). The patient should be monitored for
“dumping,” which can occur if too much fat or carbohydrate is consumed in a short amount
of time (Matarese, 2005).
It is important that while the patient is being transitioned to oral feeds that speech therapy
or occupational therapy help with non-nutritive sucking or small volume of oral feeds (if
appropriate). This will help the patient maintain normal oral motor skills and prevent oral
aversions that can occur in as little as 3 weeks when there is no oral stimulation
(Vanderhoof, 1996; Hwang, 2002; Andorskey, 2001; Axelrod, 2006).

Parenteral Nutrition

The post-surgical patient will likely require total parenteral nutrition (TPN) until the bowel is
ready for nutrients. TPN for infants should provide 90 to 100 kcal/kg/day (Ching,
2007). The TPN solution should be a balance, with dextrose accounting for 40 to 50% of
the solution (Hwang, 2002; Ching, 2007). Ideally, keeping the glucose infusion rate (GIR)
between 8 to 12 mg dextrose/kg/min can help reduce the risk of line infections and hepatic
steatosis (Hwang, 2002). Protein provided at 2.5 gm/kg/day is sufficient enough to promote
age-appropriate growth (Hwang, 2002). Lipids should provide no more than 30 to 40% of
total energy (Hwang, 2002). A common practice of limiting soy-derived lipids to 1
gm/kg/day has been found to be beneficial for reducing the incidence of TPN-associated
cholestasis (Carter, 2009).

There are no specific calorie amounts for the child/adolescent with short bowel
syndrome; thus, for the patient on TPN, ASPEN guidelines should be followed. Starting
with the child's Estimated Energy Requirement (EER), monitor the patient for growth and
weight gain, and adjust the total calories provided up or down based on patient needs.

In addition to the standard vitamins and minerals, additional zinc, carnitine, and selenium
may need to be added to the TPN in order to ensure proper growth and development.

As the patient tolerates advancement of enteral or oral feeds, parenteral nutrition should be
weaned accordingly, ensuring that the total caloric and protein intake remains at optimal
level to promote age-appropriate growth and weight gain.

If the patient is starting oral feeds in addition to enteral and/or parenteral support, it may be
helpful to cycle the enteral/parenteral nutrition in order to allow optimal oral intake. As the
patient’s intake is increased and tolerated, nutrition support (enteral/parenteral) can be
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
weaned gradually.

Nutrition Therapy Efficacy

Malabsorption of enterally or orally ingested nutrients may increase the total energy
requirement by as much as 50%. Based on experience, the infant with short bowel
syndrome requires 110 to 150 kcal/kg/day, but some reports show a need of up to 200 to
250 kcal/kg/day (Rossi, 2007). Monitoring the patient’s growth and development will help
the health care team decide the exact range for each individual patient.
Nutrient exceptions to the Dietary Reference Intakes vary depending on the site of bowel
resection (see list below for complications from bowel segment resections) (Groh-Wargo,
2000). Nutrients to monitor closely, as they may need extra supplementation, are the
fat-soluble vitamins (A, D, E, K), zinc, B
12
, and calcium.
PROXIMAL SMALL BOWEL: Duodenum and jejunum
Decreased fat-soluble vitamin absorption
Decreased fat digestion, absorption
Increased mineral losses: Ca, Fe, Mg, Cu, Cr, Mn
Decreased protein digestion, absorption
Increased loss of water-soluble vitamins
Carbohydrate (deficiency of lactase or other disaccharidase)
DISTAL SMALL BOWEL/COLON: Ileum
Decreased vitamin B
12
absorption
Decreased fat-soluble vitamin absorption
Decreased long-chain fat absorption
Increased trace element losses
Increased risk of renal oxalate stones
ILEOCECAL VALVE
Decreased vitamin B
12
absorption
Decreased folate absorption
Increased malabsorption
COLON
Decreased electrolytes
Decreased water absorption
Decreased vitamin K (formed by bacterial action)

Nutrition Monitoring & Evaluation

Careful monitoring of the patient’s nutritional status and growth should be on an ongoing
basis. Ensuring that the patient is meeting growth parameters on a long-term basis can be
key to success in the overall management of the patient with short bowel
syndrome. Monitoring laboratory values, protein, and vitamin and mineral status is also
recommended on an ongoing, long-term basis to ensure the patient is meeting all of their
needs.

Anthropometric Measurements

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Anthropometric assessment should include:
Weight for age
Length/height for age
Weight for length (plotted on growth curve)
Head circumference for age
Body mass index for age (in children older than 2 years of age)
Other measurements that could be useful include skinfold caliper measurements and
mid-arm muscle circumference.

Enteral or Tube Feeding

Enteral feedings can be administered on either a bolus or continuous feeding schedule,
depending on tolerance. A continuous feeding is advantageous for the patient as it causes
less stress and demand on the intestine’s function, and is the preferred feeding method for
infants and toddlers with short bowel syndrome (SBS) (Parker 1981; Christie 1975;
Vanderhoof 2008). This method promotes constant saturation of the transporters, which
may help promote the adaptation process (Vanderhoof 2008; Parker 1981; Christie
1975). Bolus feeds seem to be used in older children more often and are poorly tolerated in
infants (Ching 2007).

There is inconclusive evidence in the comparison between single amino acid-based
formulas to predigested or hydrolysate formulas (Ksiazyk 2002). However, recent research
has determined that patients with extensive gut surgeries such as an SBS patient are at
increased risk for milk protein allergies (Hwang 2002; Mazon 2008). A recent study also
showed the amino acid-based formulas may be helpful in weaning children off parenteral
nutrition (Bines 1998). For the infant, if breast milk is available, it is recommended for use
as it contains essential growth factors, glutamine, and amino acids that are thought to be
important for intestinal adaptation (Utter 2005). The decision of which type of formula is
used should be done on an individual basis, based on a patient’s medical course.
The advancement of feedings can be just as controversial as choosing which formula to
use. When initially starting feeds, trying Pedialyte or other rehydration solutions briefly may
help to ensure tolerance before transitioning to other forms of enteral feeds (Hwang 2002).
Once rehydration solutions are tolerated, clinicians may want to consider using diluted
formula due to the fact that the SBS patient is at risk of not being able to handle a large
carbohydrate load (Hwang 2002).
If the patient is starting oral feeds in addition to enteral and/or parenteral support, it may be
helpful to cycle the enteral/parenteral nutrition in order to allow optimal oral intake. As the
patient’s intake is increased and tolerated, nutrition support (enteral/parenteral) can be
weaned gradually.
Advancing Feeds
There are two ways to advance enteral nutrition:
Gradual advancement using dilute formula to goal rate, then concentrating the formula 1.
Gradually concentrating the formula to full strength before advancing the rate of
feedings (Hwang 2002; Axelrod 2006)
2.
Whichever method is chosen to advance feeds, advancement should be done in a slow
manner in order to prevent further electrolyte abnormalities (Axelrod 2006). As feeds are
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continuously changed, the patient should be monitored for vomiting, abdominal distention,
and increased stools as a sign of feeding intolerance (Hwang 2002). If the patient starts to
exhibit signs of intolerance, it may be helpful to decrease enteral/po volume given to the
patient to give them time to re-adjust, and then try again in the future to further advance
feeds. Goal enteral or oral feeds should be initiated when the patient can tolerate the
calculated volume, achieve a positive overall nutrition status, and maintain consistent age
appropriate weight gain (Vanderhoof 2008).

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Nutrition Care > Hepatic Diseases
Nutrition Assessment

Nutrition assessment of infants and children with chronic liver disease continues to
be challenging. Anthropometric and biochemical measures commonly used in pediatric
assessment can be altered because of the nature of the disease, including ascites and
hepatomegaly. Triceps skinfold thickness has been accepted as an appropriate tool to
determine degree of malnutrition compared to height and weight (Sokol, 1990).
Assessments should be performed at initial presentation of cholestasis and monitored
(Feranchak, 2007). Routine evaluation of dietary intake, arm anthropometry, growth
velocity, weight fluctuations, level of activity, and liver function are reliable indexes for
assessment of the child with liver disease. Assessment of vitamin and mineral status is
critical and should be done periodically, although levels of these nutrients in the blood may
not accurately reflect body stores (Kleinman, 1994; Shetty, 1999; Kooster, 1986).

Nutrition-Focused Physical Findings

Body weight may not be a reliable indicator of nutritional status, because weight can be
significantly altered by hydration status and the presence of edema or ascites (Taylor,
2005). In addition, length/height for age may not be reliable in assessing nutritional status
due to linear retardation and stunting in liver disease (Kamath, 2010). Physical
assessments are important in chronic liver disease to identify nutrition deficiencies (Taylor,
2005; Ramaccioni, 2000; Nightingale, 2009).
Abdominal distension, edema
Jaundice
Muscle wasting, tone
Presence of fat stores
Legs
Bowed legs
Broken bones
Lower limb tendon reflexes
Skin
Dryness
Bruising
Spider angiomata on face
Dilated superficial veins on chest or abdomen with severe liver
dysfunction/portal hypertension
Head
In alagille syndrome, decreased head circumference, facial dysmorphism
Mouth
Stomatitis
Pallor
Glossitis
Dentition
Gingivitis
Nails
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Hair
Alopecia
Sparseness
Breakability
Feeding route
Non-alcoholic fatty liver disease: Acanthosis

Biochemical Data, Medical Tests and Procedures

Stool tests:
Fecal elastase or 72-hour fecal fat to assess possible pancreatic insufficiency.
Stool Ph to measure possible carbohydrate malabsorption.
Stool alpha-1 antritrypsin to measure protein malabsorption (protein-losing
enteropathy).
Body composition:
Total body potassium has been used as a method to assess body composition
but the cost and availability have led to use in research instead of clinical
practice (Chin, 1992; Nightingale, 2009; Talyor, 2005)
Dual electron x-ray absorptiometry is useful for assessing body composition and
bone density (Ramaccioni, 2000; Talyor, 2005)
Bioimpedance analysis provides information about total body fluid and has been
helpful in adults with liver disease (Schloerb, 1996). Although rarely studied in
pediatrics, it may be a useful tool in pediatric liver disease to estimate fluid
volume when ascites and edema are present (Talyor, 2005).
BodPod is a new tool to measure body fat percentages, but it has not yet been
studied in pediatric liver disease.

Laboratory

Helpful laboratory values include the following:
Liver tests
Bilirubin (conjugated, unconjugated)
Aspartate aminotransferase
Alanine aminotransferase
Gamma-glutamyl transferase
Alkaline phosphatase
Ammonia
Electrolytes and glucose
Blood counts
White blood cells
Platelets
Hemoglobin
Hematocrit
Coagulation panel
International Normalized Ratio
Prothrombin time
Partial prothromboplastin time
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Anemia panel
Serum iron
Percentage iron saturation
Total iron-binding capacity
Ferritin
Transferrin
Protein levels
Albumin, prealbumin, transferrin, and retinol-binding protein are indicators of
worsening liver status compared to nutritional status or protein status (Seres,
2005)
Lipid panel and triglycerides (parenteral-associated cholestasis)
Triene/tetraene ratio to assess essential fatty acid deficiency (Chin, 1992).
Vitamin and mineral levels
Vitamin D: 25-OH D, calcium, phosphorus
Vitamin A: Serum retinol
Vitamin E: plasma tocopherol
Vitamin K: Prothrombin time, International Normalized Ratio
Iron: serum iron, ferritin, transferrin saturation
Zinc: serum zinc
Copper: ceruplasmin, serum copper, urine copper (Wilson’s disease)


Client History

Assess the presence/history of the following in the client:
Medical history, surgical history
Prenatal/birth history
Weight history (birth weight/length in infants)
Ethnic/religious preferences
Gastrointestinal symptoms
Steatorrhea
Bowel movements
Diarrhea
Acholic stools
Vomiting
Anorexia
Medications
Neurodevelopment
Oral motor skills
History of any fractures
Socioeconomic status
Participation in food-assistance programs
Psychosocial history


Food/Nutrition-Related History

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Routine evaluation of dietary intake is appropriate for assessment of the child with liver
disease.
Feeding history
Oral aversion
Dysphagia
Food allergies
Infants: Formulas (type, amount); Breast Fed
Older children: Supplements
Formula/supplements previously tried
Feeding method
Oral
Enteral
Parenteral
Feeding Tolerance
History of total parenteral nutrition: length of time
24-hour food recall
Use of herbal remedies
Vitamin and mineral supplementation

Anthropometric Measurements

Nutritional status should be based on the interpretation of several parameters, especially
growth assessment. The standard anthropometric measurements (height and weight)
should be taken into consideration when evaluating the nutrition needs of a child with liver
disease. Weight is not a good indicator of nutritional status in liver disease patient due to
possible hepatosplenomegaly, ascites, and/or edema (Sokol, 1990).
In children up to 3 years, head circumference (frontaloccipital) can be a helpful
measurement of malnutrition and brain development (Taylor, 2005). Height for age may not
be reliable to assess nutritional status because children with chronic liver disease usually
have some linear growth retardation and stunting, specifically in Alagille syndrome for
which growth failure is a common characteristic (Kamath, 2010). Monitoring linear growth
trends over a period of time provides a more accurate assessment of nutritional status
(Wieman, 2006). Measuring abdominal circumference at level of umbilicus may also be
helpful in differentiate between weight status and fluid fluctuations.
Because weight measurement can be misleading if any level of edema or ascites is
present, an attempt should be made to obtain additional anthropometric measures. Arm
anthropometry has been shown to be valuable in the assessment of children with chronic
liver disease (Kooster, 1986; Sokol, 1990). Triceps skinfold thickness and mid-arm
circumference are most commonly used in a clinical setting, although the validity depends
on the accuracy of measuring techniques and repeat measurements over time (Munoz,
1991). Combining the mid-arm circumference and triceps skinfold measurement enables
indirect determination of the arm muscle area and arm fat area. Arm muscle area is a good
indication of the lean body mass and, thus, skeletal protein reserves (Munoz, 1991). This is
especially valuable when evaluating possible protein–energy malnutrition in pediatric liver
disease.
Triceps Skinfold (TSF)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Triceps Skinfold (TSF)
For standards/references by age refer to the following resource:
Frisancho A. Anthropometric Standards for the Assessment of Growth and Nutritional
Status. Ann Arbor, MI: University of Michigan Press; 1990.
Mid-Arm Circumference (MAC)
Equation for calculation: MAC = 3.14 x [(TSF in mm) / 10]
Arm anthropometry tables can also be found at this link, under the Resources area of this
site.

Comparative Standards

Energy: 125% of Dietary Reference Intakes (DRIs) based on ideal body weight (weight for
height at 50th percentile)
Protein: 2 g/kg/day to 3 g/kg/day in infants

Fat: 50% to 60% of total fat as medium-chain triglycerides (from a pediatric or infant
formula)

Vitamin/Mineral Supplementation (for deficiency in cholestasis):
Vitamin A: 5,000-25,000 international units/day
Vitamin D (25 --OH Vitamin D3): 3-10 DRI/Age
Vitamin E (water soluble fom): 15-25 IU/kg/day as TPGS (d-alpha-tocopherol
polyethylene glycol succinate)
Vitamin K: 2.5 mg twice/week to 5 mg/day
Water-soluble vitamins: 1-2 x DRI/age
Zinc: 1 mg/kg/day
Calcium: 25-100 mg/kg/day up to 800-1000 mg/day
Iron: 5-6 mg/kg/day elemental iron
Adapted from: Guidelines for Nutritional Management in Chronic Cholestasis from Medical
and Nutritional Management of Cholestasis in Infants and Children, by Andrew P.
Feranchak, M.D., and Ronald J. Sokol, M.D. In: Liver Disease in Children, 3rd Edition,
edited by Frederick J. Suchy, Ronald J. Sokol and William F. Balistreri. Copyright © 2007
Cambridge University Press. Reprinted with permission.

Nutrition Diagnosis

Dietitians working with patients who have liver disease should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
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Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein intake (NI-5.7.1)
Inadequate vitamin intake (specify) (NI-5.9.1)
Inadequate mineral intake (specify) (NI-5.10.1)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Sample PES or Nutrition Diagnostic Statement(s)
Impaired nutrient utilization (NC-2.1) related to hepatic failure as evidenced by
hypoglycemia.
Increased nutrient needs (NI-5.1) related to malabsorption as evidenced by bone
demineralization secondary to low calcium and vitamin D absorption.
Altered gastrointestinal function (NC-1.4) related to hepatic dysfunction as evidenced
by patient only able to tolerate/process 68% of protein needs without elevated blood
urea nitrogen/creatinine.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.


Nutrition Intervention

Nutrition therapy in liver disease can reverse malnutrition and improve clinical outcomes.
In a patient at risk for developing malnutrition, increase energy density to goal of
125% of Recommended Dietary Allowance for age at ideal body weight for height.
Energy requirements in older children and adolescents can be initially established
using standards for age and adjusted per progress.
In cholestatic liver disease, medium-chain triglyceride–containing formula or oil should
be used in children to provide additional energy (Baker, 2007).
Nasogastric feeds are useful and should be initiated in the instance of inability to meet
needs.
Parenteral nutrition is indicated in the circumstances when enteral nutrition has failed
(Baker, 2007).
In carbohydrate intolerance, nutrition therapy involves continuous enteral feedings to
avoid periods of fasting and to maintain optimal blood glucose concentration.
In end-stage liver disease, when ascites or edema develops, sodium and fluid
restriction may be warranted.
If fat-soluble vitamin deficiency is detected, appropriate supplementation is needed.
Monitoring at least every 3 months is recommended.
If bone disease or severe cholestasis is present, 25 mg/kg/day to 100 mg/kg/day of
elemental calcium may be indicated as a supplement to dietary intake of calcium.
Vitamin D should be given with calcium supplements to increase absorption (Shetty,
1999; Sokol, 1994).
Genetic metabolic disorders are managed with individualized diets and specialized
metabolic formulas per prescriptions from the metabolic dietitian.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In total parenteral nutrition cholestasis, consider limiting or removing of copper and
manganese from the solutions may slow the progression of disease (Ramaccioni,
2000; Wieman, 2007). Alternative intravenous lipids such as Omegaven has shown to
be beneficial in reversing parenteral nutrition–associated liver disease (Meijer, 2010).
In non-alcoholic fatty liver disease, low glycemic diet (Spieth, 2000) and vitamin E
(Lavine, 2000) have been shown as effective strategies. Overall, combination of a
healthful diet and physical activity should be the first step in nutrition treatment (Alisi,
2009).
In Wilson’s disease, a diet low in copper can be used as an adjunct to limit copper
intake.
Numerous coexisting factors are involved in the development of malnutrition in liver
disease. Major contributors to an inadequate oral intake are anorexia, dysgeusia, early
satiety, and nausea and vomiting associated with liver disease and the medications used in
treatment (Shetty, 1999). These factors should be addressed by the dietitian on an
individual basis. Because chronic liver disease in children can be successfully treated with
liver transplantation, major goals of nutrition therapy are to optimize nutritional status and to
promote normal growth.

Nutrition Therapy Efficacy

Nutrition therapy in hepatic diseases can reverse malnutrition and improve clinical
outcomes. Adequate nutrition support has also been shown to decrease mortality in
chronic liver disease (Ramaccioni, 2000). It is important to stress that each diet should be
individualized to meet the nutrition requirements for each infant and child with liver disease.
Recommendations should be based on the severity and stage of the disease, as well as
additional manifestations such as malabsorption, extraintestinal symptoms, and tolerance
of feeding mechanism.


Goal Setting

The goals of nutrition intervention for pediatric patients with chronic liver disease are as
follows:
To prevent and treat growth failure secondary to protein–energy malnutrition resulting
from malabsorption or poor intake
To prevent and treat nutritional deficiencies associated with this disorder
To enhance quality of life and improve survival
To promote age-appropriate development
To prevent or minimize complications inherent in chronic liver disease

Nutrition Support

Adequate nutrition support has been shown to decrease mortality in chronic liver disease
(Roberts, 2006). Because of the many complications, nutrition support for children with liver
disease should be approached on an individualized basis.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
disease should be approached on an individualized basis.

Oral Intake

The oral route is the preferred modality of feeding with chronic liver disease. In older
children on an oral diet, a high-protein, energy-dense diet is encouraged.
Use of a high-energy supplement may be warranted in the event that the child is unable to
meet energy needs. Because of increased energy needs, a restricted-sodium diet should
not be used often; salt elimination is more effective via diuretics (Kockochis, 2009).
In the instance of poor oral intake, oral supplements should be used. Supplements with
high medium-chain triglyceride content are recommended.

Nutrition Monitoring & Evaluation


Monitoring (approximately monthly) includes ongoing evaluation of the following:
Energy intake
Protein intake
Nutrient adequacy of the diet
Weight/length and alternate measures of nutritional status, such as triceps skinfold
Fluid status
Stool frequency and characteristics
Gastrointestinal symptoms (stools)
Growth and development
Fat-soluble vitamin status
Additional complications with chronic liver disease
Alterations in carbohydrate and protein metabolism
Frequency of assessments will be based on progression /severity of liver disease and
related nutrition symptoms (Kockochis, 2010). Because oversupplementation of vitamins
can result in toxic side effects, monitoring of plasma concentrations every 3 months is
advised (Kleinman, 1994).

Enteral or Tube Feeding

Although the preferred method of feeding is orally, use of nasogastric tube feedings may be
necessary. If nasogastric tube feedings are necessary, they can be used successfully
without increasing the risk of gastrointestinal bleeding (Shepard, 1994; Charlton, 1992). It
is recommended to continue feedings by mouth to promote oral feeding skills in infants and
for psychological issues in older children (Ramaccioni, 2000).
Supplementation of the diet with medium-chain triglyceride (MCT) oil/powder or
MCT-containing formulas is indicated with suspected malabsorption. The addition of
medium-chain fatty acids to the diet of infants and children with cholestasis improves
energy balance and growth (Kleinman, 1994; Shetty, 1999; Pettei, 1991). Enteral formulas
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
energy balance and growth (Kleinman, 1994; Shetty, 1999; Pettei, 1991). Enteral formulas
have been designed for use when fat malabsorption is present and may contain 40% to
85% of energy from fat in the form of medium-chain fatty acids, with the remaining energy
from fat from long-chain fatty acids. Formulas with 50% to 60% of fat from MCT are
generally recommended for infants with cholestasis.
Due to the risk of protein-energy malnutrition, adequate protein should be provided to
prevent catabolism (Wieman, 2007). Although the capacity to use protein may be impaired
in the later stages of chronic liver disease, protein requirements early in the course of the
disease are significantly greater than the Recommended Dietary Allowances (RDA) for
age. Pierro et al (1989) reported that protein intake of 3.2 g/kg/day was required to achieve
a positive nitrogen balance in patients with extrahepatic biliary atresia. Others
recommended 2.5 g protein/kg/day to 4.0 g protein/kg/day protein (Sokol, 1990; Shepard,
1994). Protein intake up to 4 g/kg/day has not been shown to lead to encephalopathy in
children (Charlton, 1992).
Some studies suggest that the use of branch-chain amino acid supplementation in children
with chronic liver disease may be beneficial in facilitating weight gain and linear
growth (Chin, 1990; Chin, 1992a). However, additional studies are needed. Overall, protein
intake (at least equivalent to the RDA) should be encouraged to limit protein malnutrition
and muscle wasting.

Parenteral Nutrition

In the past, treatment and preventive measures for parenteral nutrition–associated liver
disease (PNALD) have been limited. A recent review of the current literature concluded the
use of fish oil–derived parenteral lipids has been shown to reverse PNALD. Studies are
ongoing to examine the possible preventive effect of fish oil–derived lipids (Meijer, 2010).
Although there are few preventative measures available for PNALD, the use of enteral
nutrition along with parenteral nutrition has been shown to promote bile flow (Meijer, 2010).
The use of cyclic parenteral nutrition has been shown to be beneficial in PNALD as well, as
it is similar to normal eating (Jensen, 2009). Limiting parenteral lipids to 1 g/kg/day has
been suggested as a way to prevent PNALD, although it has not been proven and studies
are ongoing (Cober, 2010). Carnitine has been used in several pediatric studies, but the
overall benefit has been inconclusive.
Parenteral nutrition is not contraindicated in chronic liver disease. Parenteral nutrition may
be warranted when enteral nutrition is unsafe in the instance of severe varices,
gastrointestinal bleeding, or ongoing emesis (Wieman, 2007). As liver disease progresses,
intractable diarrhea may develop and parenteral nutrition may be needed (Ramaccioni,
2000). When providing parenteral nutrition, the decrease or removal of copper and
manganese from the solutions may slow the progression of disease (Ramaccioni, 2000;
Wieman, 2007).
All attempts to maintain optimal nutritional status before transplantation are warranted,
because success rates after liver transplantation are significantly improved when
protein–energy malnutrition has been minimized (Chin, 1992b; Kelly, 1997) (see Liver
Transplant: Nutrition Support).

Metabolic Rate Profile (Indirect Calorimetry)
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Metabolic Rate Profile (Indirect Calorimetry)

A metabolic rate profile can be useful when weight gain is suboptimal with appropriate
energy intake (Feranchak, 2007). Studies using indirect calorimetry in adults show an
increase in energy expenditure per unit of lean body mass in stable cirrhotic patients
(Baker, 1991).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > HIV/AIDS
Nutrition-Focused Physical Findings

Physical signs of human immunodeficiency virus (HIV)–associated wasting include the
following:
Severe weight loss
Thinning of face and extremities
Pallor of the skin
Easily pluckable hair
Muscle wasting (signs may include weakness of the extremities, reduced strength,
and a decrease in quality of life)
The Centers for Disease Control and Prevention (CDC) defines wasting in children
younger than age 13 years as: (a) persistent weight loss of more than 10% of baseline; or
(b) downward crossing of at least two of the following percentile lines on the weight-for-age
chart (eg, 95th, 75th, 50th, 25th, 5th) in a child aged 1 year or older; or (c) less than the 5th
percentile on the weight-for-height chart on two consecutive measurements at least 30
days apart, accompanied by chronic diarrhea (ie, at least two loose stools per day for more
than 30 days); or (d) documented fever for at least 30 days, whether intermittent or
constant (CDC, 1994).
In children, anthropometric indicators of nutritional status are the primary way to diagnose
muscle wasting. In addition to the anthropometric parameters used in the CDC definition of
HIV-associated wasting in children, other important parameters can help identify wasting.
Body composition changes, with preferential loss of lean body mass, is commonly found in
HIV infection. Anthropometric measures such as mid-upper arm circumference (discussed
further in the Anthropometric Measurements section) that quantify lean body mass are of
special importance for these patients.
Morphologic changes attributable to lipodystrophy* may result in a combination of any of
the following:
Increased waist size (without rolls of fat)
Increased breast size
Fat gain around the back of the neck and upper back (buffalo hump)
Fat gain around the neck and jaw
Facial wasting, especially of the cheeks
Wasting of extremities and buttocks
Prominent veins in the arms and legs (because of fat loss)

*Signs of HIV lipodystrophy are more difficult to identify in children and adolescents than in
adults because of subtle fat redistribution and physical changes during puberty.

Laboratory

All children and adolescents infected with human immunodeficiency virus (HIV) should be
closely monitored at regular intervals for nutritional, metabolic, and cardiac problems
(Miller, 2008).
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Markers of nutritional status
Serum albumin: useful parameter in chronic, but stable patients
Transthyretin (prealbumin): particularly useful to follow in periods of recovery from
malnutrition
Transferrin saturation: useful to predict nutritional status
Total lymphocyte count: useful to predict nutritional status
CD4 T lymphocyte count/percentage: useful to predict nutritional status.
There is a direct relationship among CD4 T lymphocyte counts and weight,
body mass index, and mid-arm muscle circumference (Weigel, 2010).
C-reactive protein: a measure of the presence of an acute-phase protein response
(indicator of inflammatory response)
Plasma HIV ribonucleic acid (RNA) levels indicate the magnitude of HIV replication,
whereas CD4+ T cell counts indicate the extent of HIV-induced immune damage already
suffered. Regular, periodic measurement of plasma HIV RNA levels and CD4+ T cell
counts is necessary to determine the risk for disease progression in an HIV-infected person
and to determine when to initiate or modify antiretroviral treatment regimens (CDC, 1998).
To assess iron stores and anemia, measure the following:
Iron
Ferritin
Transferrin
Hemoglobin
Hematocrit
Measure the status of the following micronutrients:
Zinc
Selenium
Vitamin D
Measure the following to determine metabolic syndrome and comorbidities
Fasting lipid profile – [lipids ranges]
Fasting glucose and insulin
Hemoglobin A1C
Perform the following biochemical tests for bone density:
Serum calcium levels
Serum phosphorus levels
Serum concentration of 25-hydroxy-vitamin D
Osteocalcin (biochemical marker of bone formation)
Bone-specific alkaline phosphatase (biochemical marker of bone formation)
C-terminal telopeptide of type I collagen (biochemical marker of bone resorption)
Parathyroid hormone
Bone density should be monitored through the use of routine bone density tests such as
dual-energy X-ray absorptiometry (DXA) (ADA, 2010). DXA scans can be performed on the
whole body to assess bone mineral content (BMC), bone mineral density (BMD), lean body
mass, and adiposity (total body, trunk, extremities), and on other specific areas including
the femur and the lumbar spine (L1-L4).
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Changes in bone size over time occur in normal pediatric development; therefore, pediatric
DXA interpretation needs to emphasize considerations unique to pediatrics.
Specifically, the use of DXA in children requires the following considerations (Binkovitz,
2007; Zemel, 2007):
Relevant physiologic patient factors influence BMD results, and those need to be
incorporated into the interpretation of the study. Patient factors include sex, ethnicity,
height, weight, body composition, and physiologic maturity.
An appropriate reference database needs to be selected, and a BMC or BMD
z-score is used as an indicator of bone mineral status. Age, sex, ethnicity, and
physiologic maturity level as factors have been extensively studied and are included
in most current normative datasets provided by the major DXA manufacturers. The
T-score (comparison of the current z-score with peak adult BMD) is used in adult
interpretation of DXA but should not be included in the pediatric DXA report.
The diagnosis of osteoporosis should not be made on DXA results alone but should
take into account other patient factors.

Client History


Comprehensive medical history review should include:
Current human immunodeficiency virus (HIV) status of the child (CD4 T lymphocyte
count, HIV viral load)
Current antiretroviral medicine regimen
Information on any existing nutrition-related issues such as the following:
Hepatitis
Renal disease
Obesity
Diabetes
Cardiovascular diseases
Oral health issues
Bone disorders
Neurological complications such as encephalopathy
Family history of nutrition-related diseases (including cardiovascular disease)
Presence of any opportunistic infections that may affect intake or metabolism
Gastrointestinal symptoms
Potential food and drug interactions, use of complementary therapies, and
nutrition-related side effects from medications


Food/Nutrition-Related History

Comprehensive food/nutrition-related history at each assessment should include the
following:
Food intake records if available: usual food and nutrient intake with attention to
energy, protein, fat, fiber, iron, calcium, and vitamin D content
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With highly active antiretroviral therapy, nutrient intake has changed with
increased intake from carbohydrate-rich foods and persistently
higher-than-recommended macronutrient intake (Sharma, 2008)
Developmental and oral motor feeding skills as delays or regression are associated
with developmental delay or human immunodeficiency virus (HIV) encephalopathy
Use of vitamin/mineral/herb supplements and over-the-counter drugs and the
potential negative interactions between medications and herbal supplements.
Food availability, as many people with HIV and acquired immune deficiency virus face
hunger and multiple barriers to food and nutrition security (JUNP, 2009).
Psychosocial and economic issues, such as the following*:
Living situation
Cooking facilities
Meal locations (eg, school, day care, home)
Family support
Ethnic or religious belief considerations (as related to nutrition)
Parent/caregiver perception of eating habits
Health of other family members
Financial constraints
Participation in food assistance programs
Food and water safety and sanitation practices, food allergies, and food intolerances
Usual level of physical activity
* Dietitians should check if there have been any major changes in the child’s
circumstances from the last visit that might put the care of the child at risk, including access
to food

Comparative Standards

Specific equations for estimating energy needs are provided in the Dietary Reference
Intakes (DRI) (IOM, 2002/2005). However, accurate energy and protein requirements for
children infected with human immunodeficiency virus (HIV) have not yet been established
because individual needs can vary (Sabery, 2009).
The following calculations may be helpful when calculating minimum needs required for
catch-up growth for both energy and protein:
Energy: Calculate ideal body weight (IBW) in kg (50th percentile weight for current
height) x EER* (kcal/kg/day) / actual weight in kg
Protein: Calculate IBW in kg (50th percentile weight for current height) x pro/kg/day
(DRI/age) / actual weight in kg
*EER = Estimated energy requirement (see EER calculators)
The fluid needs of individuals with HIV infection are the same as those of their peers in their
age group, although special clinical circumstances (cardiac disease, renal disease,
gastrointestinal symptoms) may alter fluid requirements.
Fluid requirements according to the Holliday-Segar method are as follows:

Body Weight Fluid Requirements
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0-10 kg 100 mL/kg
10-20 kg 1,000 mL + 50 mL/kg over 10 kg
>20 kg 1,500 mL + 20 mL/kg over 20 kg

Nutrition Diagnosis

Dietitians working with patients who have human immunodeficiency virus should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the following list below as
well as other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Excessive energy intake (NI-1.5)
Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein–energy intake (NI-5.3)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Food–medication interaction (NC-2.3)
Predicted food–medication interaction (NC-2.4)
Unintended weight loss (NC-3.2)
Overweight/obesity (NC-3.3)
Food- and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Self-monitoring deficit (NB-1.4)
Poor nutrition quality of life (NB-2.5)
Limited access to food or water (NB-3.2)
Sample Problem, Etiology, Signs and Symptoms (PES) or Nutrition Diagnostic
Statement(s)
Unintended weight loss (NC-3.2) related to poor appetite due to recent infections with
advanced disease stage as evidenced by a 7.5% weight loss in 3 weeks.
Overweight (NC-3.3) related to excess energy intake as evidenced by physical
inactivity and a body mass index at the 98th percentile.
Note: Terminology in the examples above is from the 3rd edition of the American Dietetic
Association's International Dietetics and Nutrition Terminology. Code numbers are inserted
to assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Knowledge and implementation of effective nutrition interventions is important to improve
medical outcomes and quality of life (Miller, 2003).
Common interventions recommended for children infected with human immunodeficiency
virus (HIV) are presented in the following table:
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Healthy living with
HIV
Combination of antiretroviral drug
therapy, adequate dietary intake,
and frequent exercise
Nutrition education and counseling
Promotion of healthy eating habits
Promotion of normal growth and
development
Self-monitoring of dietary intake
and weight changes
Psychosocial assessment and
appropriate referrals
Unintentional
weight loss and
lean tissue wasting

Careful monitoring of dietary
intake and changes in weight and
body composition
Assessment of food and nutrition
security issues and provide
appropriate counseling and
referrals
Increase in energy and protein
Oral nutritional supplements
Enteral tube feeding to provide
supplemental or total nutritional
support for patients with
inadequate oral intake
Appetite stimulants
Multivitamin/mineral
supplementation at Dietary
Reference Intake (DRI) levels
Micronutrient
deficiency

Multivitamin/mineral
supplementation at DRI levels
Monitoring of intake of key
nutrients
Management of
symptoms that
may affect
nutritional status
Nausea, vomiting: Small, frequent
meals; nutrient-dense beverages
between meals
Anorexia: Increased nutrient
density of foods; small, frequent
meals; appetite stimulants
Taste change: Use of stronger
seasonings, avoidance of
excessively sweet foods; use of
salty foods
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Diarrhea or
malabsorption

Small, frequent feedings
Dietary composition adjusted
according to the degree of
gastrointestinal dysfunction
Identification and management of
lactose intolerance
Semielemental or elemental
formula
Lipodystrophy,
increased
cardiovascular
risk, insulin
resistance
Screening for lipid and metabolic
abnormalities
Heart-healthy diet: Reduced
intake of saturated fat, trans fatty
acids, and dietary cholesterol
Increased fiber intake and limit
simple carbohydrates
Regular exercise
Increased consumption of n-3
fatty acid–rich foods such as fish
(especially fatty fish such as
salmon), plant sources such as
flaxseed and flaxseed oil, canola
oil, soybean oil, and nuts
Loss of bone
mineral density,
osteopenia

Adequate calcium and vitamin D
intake
Lactose-free dairy products for
lactose-intolerant individuals
Supplementation of calcium and
vitamin D intakes to DRI levels for
age if suboptimal intake
Regular weight-bearing exercise
Decreased high-phosphorous,
carbonated beverage intake

(ADA, 2010; ASPEN, 2009; Krauss, 2000)

Goal Setting

Achieving and maintaining optimal nutrition may improve an individual’s immune function,
reduce the incidence of complications associated with human immunodeficiency
virus (HIV) infection, attenuate the progression of HIV infection, improve quality of life, and
ultimately reduce morbidity and mortality associated with HIV.
Goals for nutrition interventions should be individualized according to the problems
identified. Eating pattern and physical activity behaviors should also be identified and goals
set according to the child’s age, cognitive level, and caregiver involvement. Goals for
outcomes should be established during the planning of the nutrition intervention stage of
the Nutrition Care Process. Examples of nutrition interventions are outlined in the Nutrition
Intervention section.
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Intervention section.
In combination with medical treatment, general nutritional goals include the following:
Achieving healthy body weights, body composition, and laboratory values
Minimizing loss of lean body mass
Prevention of nutrient deficiencies
Reduction in nutrition-related side effects and complications
Support of medication treatment goals
Control of symptoms
Prevention of cardiovascular disease—eg, increasing child’s self-confidence and
motivation to make small and persistent lifestyle changes associated with
cardiovascular risk prevention
Enhancement of quality of life and improvement of survival
(ADA, 2006; Mahlungulu, 2007; ADA, 2010)

Enteral or Tube Feeding

Although less common since the introduction of highly active antiretroviral therapy, children
with significant weight loss may be candidates for enteral or parenteral nutrition support.
If oral interventions fail, enteral tube feeding improves weight gain in children with growth
failure (Henderson, 1994; Miller, 1995). With severe malnutrition, nutrition therapy with an
elemental diet may be more effective than higher energy intake from a standard formula for
weight gain (Amadi, 2005).

Nutrition Monitoring & Evaluation

All nutrition and nutrition-related interventions should be routinely monitored for their
efficacy and adjusted accordingly. The following parameters should be evaluated:
Current status of human immunodeficiency virus (HIV) in the child (CD4 T lymphocyte
count, HIV viral load)
Clinical data (see Client History)
Biochemical markers of nutritional status (see Biochemical and Nutrient Issues)
24-hour recall or 3-day food record to determine energy intake and
macronutrient/micronutrient composition of diet
Weight and body composition changes
Pediatric growth points and weight-for-length or body mass index as calculated and
plotted on the growth chart
Food availability and family support
Each follow-up nutrition intervention for patients should include adjusting nutrition goals
and treatment plans according to the individual patient's response to the current treatment.
Each site or program providing nutrition services to children with HIV should identify
appropriate nutrition outcome measures. Programs that recieve government funds to
provide outpatient services for individuals with HIV infection must provide nutrition services.
The registered dietitian uses critical thinking skills to select appropriate indicators and
measures, uses appropriate reference standards for comparison, defines the
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patient's/client's status relative to expected outcomes, explains variance from expected
outcomes, and determines factors that help or hinder progress. In a chronic condition such
as HIV infection, which continues throughout the lifespan, monitoring and evaluation must
adjust to age-specific variables and changes in clinical condition with advances in viral
therapies. As nutrition care is continued, reassessment may result in refinements to the
diagnosis and intervention.
(ADA, 2010; AAP, 2009)

Nutrition Care FAQs

My child used to take an oral supplement, but the doctor and dietitian are no longer
prescribing it. What should I do?
Most likely your child’s growth and development are appropriate, and the child is able to
get adequate nutrition through regular diet. Overall nutritional adequacy should be
achieved by eating a wide variety of foods.
My child is overweight. Should I be concerned?
As children with human immunodeficiency virus (HIV) take medications to fight the virus,
they are becoming healthier. By taking medicine, usually highly active antiretroviral therapy
(HAART), they are growing better, and their eating habits are becoming similar to those of
noninfected children. U.S. children are more sedentary and have been eating more foods
that contain excess calories such as added sugars and fats while consuming fewer fruits,
vegetables, and dairy products.
Overweight is becoming a common problem for HIV-infected children and may increase
their chance to develop heart problems. HAART medications and living with a chronic viral
infection like HIV increase the chances of diabetes and heart problems. Knowing what and
how much your child is eating can help you adjust the diet and avoid excessive weight gain.
Is it safe to use vitamin and mineral supplements?
Because micronutrient deficiencies are common in people living with HIV, when adequate
dietary intakes cannot be guaranteed through a regular diet,
multivitamin/mineral supplementation should be discussed with the health care
provider. Multivitamin/mineral use has been associated with better bone mineral density.
Do herbal medicines interfere with antiretroviral medications or reduce their
effectiveness?
Yes, herbal treatments, supplemental nutrients, or other medications can lead to a
decreased level and efficacy of antiretroviral medications. For example, drug efficacy is
reduced during the concomitant use of supplemental St John’s wort, garlic, and echinacea
with protease inhibitors and/or non-nucleoside reverse transcriptase.

Anthropometric Measurements

Anthropometric assessment of children infected with human immunodeficiency virus (HIV)
should include serial measurements of weight and height. Tracking weight and height
trends over time ensures early identification of nutritional deficits, wasting, or growth failure
(Henderson, 1998; Knox, 2003).
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The Centers for Disease Control and Prevention (CDC) recommends that health
professionals use the World Health Organization growth standards to monitor growth for
infants and children aged 0 to 2 years and the CDC growth charts to monitor growth for
children aged 2 years and older in the United States (CDC, 2000; CDC, 2010). Body mass
index (BMI) should be calculated and plotted on CDC growth charts (CDC, 2000) for
children aged 2 to 20 years. As in noninfected children, indicators of nutritional
status include the following:
Infants, birth to 36 months: weight-for-age, length-for-age, weight-for-length, head
circumference-for-age
Children and adolescents, 2 to 20 years: weight-for-age, stature-for-age, BMI-for-age
Other body measures—including mid-upper arm circumference (MUAC), four site
skinfolds (triceps, biceps, subscapular, and suprailiac skinfolds--see Arm Anthropometry),
and waist and hip circumferences—can better reflect fat and lean body mass and their
regionalization compared with weight and height measurements alone. Quantification of
lean and fat mass is of special importance in these patients because of the increasing
incidence of lipodystrophy.
Further measures of body composition are also needed to identify losses of lean body
mass that are associated with increased mortality in HIV. Measurements of body
compartments (body cell mass and body fat) may be done using a variety of techniques,
such as skinfold thickness (four site), bioelectrical impedance analysis, computed
tomography scans, dual energy x-ray absorptiometry (DXA) scans, or magnetic resonance
imaging. Evaluation of regionalization of body fat may also help define cardiovascular risk
profile.
Lean body mass (LBM) changes measured by anthropometry have been shown to agree
well with LBM changes measured by DXA in different patient populations (Haderslev,
2000), including patients with HIV infection (Paton, 1997) and therefore may be regarded
as a valid tool for prospectively following patients in clinical practice.
Age-adjusted and sex-adjusted percentiles for triceps skinfold, subscapular skin fold,
MUAC, and waist circumference for children aged 3 months to 19 years have been
released by the Third National Health and Nutrition Examination Survey (McDowell, 2009).

Oral Intake

Oral intake should be appropriate for age, incorporating nutrient-dense foods to include
adequate energy, protein, and micronutrients in order to support growth needs. Oral
nutritional supplements may improve weight and growth in HIV-infected children with
growth failure if there is no evidence of gastrointestinal dysfunction and excessive losses
(vomiting and diarrhea). Refer to the Nutrition Intervention section for more detailed
recommendations.

Metabolic Rate Profile (Indirect Calorimetry)

The chronic viral activity of human immunodeficiency virus (HIV) can increase or shunt
effective use of energy substrates from normal, healthy growth patterns to abnormal ones,
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as occurs in many children with chronic illness, including cystic fibrosis, inflammatory bowel
disease, congenital heart disease, and childhood cancer (Grunfeld, 1992; Melchior, 1993;
Alfaro, 1995).
In small studies of energy expenditure, there are generally no differences in resting energy
expenditure (REE) (Alfaro, 1995; Arpadi, 2000) or total energy expenditure (TEE) (Arpadi,
2000; Johann-Liang, 2000) among HIV-infected children with growth failure and those with
normal rates of growth. However, adults with HIV-1 infection show increasing REE with
increasing severity of illness (Melchior, 1993), especially with secondary infection and more
advanced HIV disease (Grunfeld, 1992).
According to the American Dietetic Association Evidence Analysis Library, REE is
increased as much as 5% to 17% in people with HIV infection, compared with healthy
individuals (EAL, 2010). Activity level can be significantly decreased in HIV-infected
individuals, leading to overall TEE similar to that of healthy individuals (Macallan, 1995;
Roubenoff, 2002; Batterham, 2005).
However, energy balance deficits in children with HIV infection result in growth failure.
Factors related to increased energy needs in people with HIV infection include stage of
disease, opportunistic infections and comorbidities, inflammation, and effects of
medications (Johann-Liang, 2000). Maintenance of energy balance is an important feature
of medical nutrition therapy efforts.

Nutrition Prescription

Accurate energy and protein requirements for children infected with
human immunodeficiency virus (HIV) have not yet been established because individual
needs can vary. Energy and protein needs of HIV-infected children depend on their age,
growth patterns, and the long-term effects of HIV disease such as acute/chronic infection or
other complications that chronically increase nutritional requirements (WHO, 2009). These
needs change with time and additional energy may be required to fight infections and
recover lost weight.
During Periods of Well-Being
Energy requirements are relatively normal during periods of well-being. Energy
requirements should be calculated according to the Dietary Reference Intakes for Energy
(IOM, 2002/2005), with allowance made for energy needs resulting from opportunistic
infections or malabsorption. When children have few symptoms, they may need only 10%
more energy intake (WHO, 2009).
During Illness
Energy requirements can increase by up to 20% to 30% during infections and recovery
(WHO, 2009). Factors that affect energy requirements include stage of disease,
opportunistic infections and comorbidities, inflammation, fever, malabsorption, diarrhea,
and vomiting.
Over time, nutrition needs can decrease as underlying infections are treated and there is
immunological improvement. At that point, the nutritional requirements become similar to
those of children who are asymptomatic or who have mild disease (WHO, 2009). Dietary
intake during and following illnesses should be varied to include adequate energy, protein,
and micronutrients in order to protect and repair the body and support nutritional recovery.
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Period of Catch-Up Growth
Equations for estimating catch-up growth requirements for energy and protein are provided
in the Comparative Standards section.
Advanced Disease
Children with advanced disease are often severely malnourished with decreased muscle
mass; little fat reserves; and low levels of vitamins, minerals, and other trace
elements. They often need up to 50% to 100% extra energy to recover and regain weight,
which is best achieved through enteral or parenteral (if enteral has failed) feeding. Severe
malnutrition usually indicates that the child needs antiretroviral therapy (ART) or is resistant
to the current therapy being used (WHO, 2009).
Macronutrient and micronutrient needs may change significantly with one or a combination
of conditions such as changes in nutritional status, energy expenditure, lipid metabolism,
hormonal balances, immune function, constitutional symptoms, and others (ADA, 2010).
During periods of well-being, acceptable macronutrient distribution ranges
(AMDR)—established as percentage of energy intake—can be used to ensure sufficient
intakes of essential nutrients (IOM, 2002/2005). The AMDR for children are as follows:
Age (years) Fat (%) Carbohydrate (%) Protein (%)
1-3 30-40 45-65 10-35
4-18 25-35 45-65 4-18
Source: Dietary Reference Intakes for Energy, Carbohydrate. Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids (2002/2005).
Diet modifications can have a positive effect on HIV-infected children with metabolic
dysfunction. Dietary fat should be monitored and intakes greater than 30% of total energy
should be modified (Miller, 2008). Lifestyle modification interventions with regular physical
activity are also encouraged.
Micronutrient intakes at recommended (DRI) levels must to be ensured in HIV-infected
children through varied diets, fortified foods, and micronutrient supplements when
adequate intakes cannot be guaranteed through regular foods.
HIV-infected children may become anemic because of a variety of non-nutritional
causes. Thus, anemia cannot be assumed to be the result of iron deficiency. Iron
supplements should only be started if iron deficiency is confirmed (WHO, 2009).
In the United States, HIV-infected children may have low intakes of calcium and vitamin D
(Sharma, 2008). It is important to optimize intake of calcium and vitamin D as HIV-infected
children are at increased risk for low bone mineral density. Multivitamin use has been
associated with better bone mineral density (Jacobson, 2005; NIH, 2010).

Parenteral Nutrition

Parenteral nutrition should only be considered in children infected with human
immunodeficiency virus if they have severe malnutrition or are unable to consume
adequate energy enterally, whether as a result of the primary disease process or other
comorbidities.
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Physical Activity

There is growing evidence that exercise contributes to a more competent immune system
while providing therapeutic effects to the patient. The effects of physical activity on
individuals infected with human immunodeficiency virus (HIV) include physical
improvements in body composition with decreased waist circumference and waist-to-hip
ratio and increased lean body mass, as well as cardiometabolic fitness (Miller, 2010;
Lindegaard, 2008; Souza, 2008; Miller, 2007). Thus, health care professionals suggest
exercise as a management strategy to improve lean body mass, cardiovascular fitness, and
decrease metabolic complications of HIV. Regular exercise has been recommended as an
integral part of patients’ care across all ages (Somarriba, 2010).
The 2008 Physical Activity Guidelines for Americans (HHS, 2008) describe physical activity
recommendations for children and adolescents that can be followed by an otherwise
healthy HIV-infected child, including the following:
Children and adolescents should have 60 minutes or more of physical activity daily.
Aerobic: Most of the 60-plus minutes of daily physical activity should be either
moderate-intensity or vigorous-intensity aerobic physical activity and should include
vigorous-intensity physical activity at least 3 days a week.
Muscle-strengthening: As part of their daily physical activity, children and adolescents
should include muscle-strengthening physical activity on at least 3 days of the week.
Bone-strengthening: As part of their daily physical activity, children and adolescents
should include bone-strengthening physical activity on at least 3 days of the week.
These activities—such as running, jumping rope, basketball, tennis, and
hopscotch—produce a force on the bones, leading to bone growth and strength.
It is important to encourage young people to participate in physical activities that are
appropriate for their age, that are enjoyable, and that offer variety.



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Nutrition Care > Inborn Errors of Metabolism
Inborn Errors of Metabolism


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Inborn Errors of Metabolism > General Guidance
Nutrition Assessment

The focus of this section in the Pediatric Nutrition Care Manual is for community providers who have been asked to provide a basic
nutrition assessment for infants and children with a diagnosis of a metabolic disorder. It is not meant as a management tool for
practitioners dealing with advanced cases.
Optimal medical nutrition intervention is required if reasonable physical growth is to be achieved (Acosta, 1993a; Acosta,
1993b; Trahms, 2008). As for all infants and children, appropriate growth reflects the adequacy of energy, protein, vitamin, and
mineral intake. For children with inborn errors of metabolism, growth also reflects the achievement of metabolic balance. Inadequate
weight gain may reflect a limited energy intake, a deficiency of total protein or specific amino acids, or an excessive intake of toxic
substrates, which result in poor metabolic control.
Deficiencies of specific amino acids have significant clinical effects in addition to their impact on growth. For example, clinical signs
may be eczema in the case of leucine or isoleucine deficiency (if inadvertently overrestricted in the treatment of maple syrup urine
disease) or poor growth with phenylalanine deficiency (if overrestricted in the treatment of phenylketonuria). If growth and
development are to proceed appropriately, do the following:
Limit/restrict the “affected” nutrients (the nutrients for which metabolic pathways are affected by the disorder)
Incorporate medical food(s) as a source of macronutrients that contains only limited allowed amounts of restricted nutrients
Supplement compromised components (often the product of the reaction)
Provide energy and all other nutrients in adequate amounts
Ensure related nutrients are adequately provided (eg, essential fatty acids, if fat is restricted; calcium and vitamin D if milk is
eliminated)

Nutrition-Focused Physical Findings

Most inherited metabolic disorders are associated with severe illness that often appears soon after birth. Neurologic impairment and
mental retardation may occur. However, effective newborn screening programs and advanced diagnostic techniques and treatment
modalities have improved the outcome for many of these infants.
Some disorders, when untreated, are associated with characteristic odors (eg, the "maple syrup” odor of untreated maple syrup
urine disease). In addition, specific deficiencies can be associated with characteristic physical findings (eg, skin rashes with
isoleucine deficiency). Health care professionals who work with children should have an understanding of these characteristics and
be able to identify them.

Biochemical Data, Medical Tests and Procedures

Advances in newborn screening technology offer the potential for earlier diagnosis of errors of metabolism, prevention of neurologic
crisis, and improved intellectual and physical outcomes. When tandem mass spectrometry techniques are used in newborn
screening laboratories, a broader range of metabolic disorders can be identified in infants, and identification can be earlier than
ever before. (http://genes-r-us.uthscsa.edu/.) See Some Metabolic Disorders Amenable to Nutrition Therapy for information about
some disorders that are identified by newborn screening.
Positive newborn screening tests are followed by diagnostic testing, usually before treatment is initiated. Confirmatory diagnostic
testing is typically conducted by specialty centers.

Laboratory

Suggested Biochemical Parameters to Monitor for Children with Metabolic Disorders
Disorder Parameter Frequency
Amino acid metabolism
Phenylketonuria Plasma phenylalanine, tyrosine Monthly
a
Tyrosinemia
Plasma tyrosine, phenylalanine,
methionine
Monthly
a
Maple syrup urine disease
Plasma leucine, isoleucine, valine,
alloisoleucine
Monthly
a
Homocystinuria
Plasma methionine, free and total
homocysteine
Monthly
a
Urea cycle disorders
Plasma ammonia, electrolytes,
carnitine, amino acids (especially
glutamine and essential amino
acids)
At each clinic visit
a
Ornithine transcarbamylase
deficiency, carbamyl
phosphate synthetase
deficiency
Plasma citrulline, arginine, ammonia At each clinic visit
a
Argininosuccinic aciduria
Plasma arginine, argininosuccinate,
ammonia
At each clinic visit
a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Organic acidurias
Urine organic acids, plasma
electrolytes, carnitine
At each clinic visit
a
Methylmalonic aciduria Plasma amino acids, carnitine At each clinic visit
a
Propionic aciduria Plasma amino acids, carnitine At each clinic visit
a
Isovaleric acidemia
Plasma amino acids, urinary
isovaleryl glycine
At each clinic visit
a
Ketone utilization disorder Urine organic acids, carnitine At diagnosis
Carbohydrate disorders
Glycogen storage disease,
type Ia
Cholesterol, triglycerides, uric acid
Blood glucose levels
Quarterly, depending
on age and health
status
Daily, or more
frequently if necessary
Galactosemia Galactose-1-phosphate
Quarterly, depending
on age and health
status
All disorders Hematocrit, hemoglobin, ferritin
Twice a year,
depending on age
and health status
All disorders Albumin, prealbumin
Twice a year,
depending on age
and health status
All disorders
Length or height, weight, weight for
height, body mass index, head
circumference
At each clinic visit
a
All disorders
Intake of medical food and foods
as contributors of critical nutrients
Coupled with each
laboratory assessment
All disorders
Protein, energy, fat, nutrients
critical to specific metabolic disorder
Coupled with each
laboratory assessment
All disorders
Provide an “illness protocol” for
families to use at home
Initially provided at
diagnosis and
changed as needed
with age and health
status
All disorders
Provide an “emergency protocol”
for families to use if a hospital
admission is necessary
Initially provided at
diagnosis and
changed as needed
with age and health
status
a
Specialized protocols and more frequent monitoring of the child’s condition are required if there are diet changes, an intake that is
out of the recommended range, or illness.
Reprinted with permission. Trahms C. Overview of assessment of nutritional status for children with metabolic disorders. Nutrition
Focus. 1995;10:1-8. Revised 2009.

Anthropometric Measurements

Length or height, weight, weight for height, body mass index, and head circumference should be measured at each clinic visit and
plotted on the appropriate growth chart of the Centers for Disease Control and Prevention.

Nutrition Diagnosis

Dietitians working with patients who have metabolic disorders should review the signs and symptoms obtained in the nutrition
assessment and diagnose nutrition problems based on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inappropriate intake of fats (specify) (NI-5.6.3)
Excessive protein intake (NI-5.7.1)
Inappropriate intake of protein or amino acids (specify) (NI-5.7.3)
Inappropriate intake of types of carbohydrate (specify) (NI-5.8.3)
Impaired nutrient utilization (NC-2.1)
Altered nutrient-related laboratory values (specify) (NC-2.2)
Food–medication interaction (NC-2.3)
Not ready for diet/lifestyle change (NB-1.3)
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Not ready for diet/lifestyle change (NB-1.3)
Self-monitoring deficit (NB-1.4)
Sample PES or Nutrition Diagnostic Statement(s)
Inappropriate intake of type of carbohydrate (galactose) (NI-5.8.3) related to galactosemia, as evidenced by elevated
galactose-1-phosphate level (5.9 mg/dL) and results of food record analysis.
Note:
Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology,
3rd edition. Code numbers are inserted to assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Most children with inborn errors of metabolism require the restriction and/or supplementation of one or more nutrients or dietary
components. These restrictions and/or supplementations are specific to each disorder and serve to eliminate substances before the
block that cannot be metabolized, or those accumulating beyond the enzymatic block that may have toxic effects. These may
include the supplementation of specific amino acids, carbohydrates, and fats and the restriction of total protein, fatty acids, simple
sugars, or total carbohydrate.
In some disorders, cofactor therapy is sufficient treatment and no dietary restrictions are required (eg, biotin in multiple carboxylase
deficiency). In other disorders, additional dietary components are provided (eg, the treatment of glycogen storage disease requires
the use of raw cornstarch). The slow digestion of cornstarch maintains blood glucose levels and prevents the accumulation of
glycogen in the liver.
The negative impact of the blocked metabolic pathway can be minimized by doing the following:
Restricting the substrate (eg, restricting phenylalanine in the treatment of phenylketonuria [PKU], and restricting leucine,
isoleucine, and valine in the treatment of maple syrup urine disease) and supplementing the product (eg, tyrosine in PKU)
Supplementing cofactors (eg, biotin in biotinidase deficiency)
Enhancing elimination of toxic metabolites (eg, carnitine in propionic acidemia, which enhances the removal of this
accumulating organic acid)
The specific enzyme absence or inactivity for each inborn error of metabolism dictates which components are restricted and which
are supplemented.
The specific nutrient needs of each individual must be carefully considered. Nutrition support recommendations are based on
individual genetic and biochemical requirement for nutrients. If the specific needs of an individual are ignored or misunderstood,
intellectual disability, metabolic acidosis, growth failure, neurological crisis, organ damage, or death may occur. More information on
nutrient needs can be found in Nutrient Exceptions to DRI.
Protocols are available as guides for prescribing, planning, and evaluating medical nutrition support. For examples, see Genetic
Metabolic Dietitians International, Mead Johnson, Abbott, Nutricia, and PKU News.
Medications/Supplementation
Patients with inborn errors of metabolism often require supplemental L-amino acids, which are the product of the diminished or
absent biochemical reaction, to prevent deficiency. L-carnitine is often supplemented if diets are restricted in protein, because
natural protein foods are a primary source of this nutrient. The primary role of carnitine is to transport long-chain fatty acids into the
mitochondria for energy production. In some cases, carnitine also provides an alternative pathway for excretion of metabolites--eg,
carnitine binds to isovaleric acid in isovaleric acidemia. Sodium benzoate, phenylacetate, or other similar medications are often used
to enhance waste nitrogen excretion in treatment of disorders of the urea cycle. Bicitra is often used to buffer against
acidosis. (Some of the compounds listed in this section are not medications that require a prescription. However, they are
administered similar to prescription medications and are often viewed similarly by families and clinicians.)
For more information, see Some Metabolic Disorders Amenable to Nutrition Therapy.

Some Metabolic Disorders Amenable to Nutrition Therapy

The following table lists some metabolic disorders that respond to medical nutrition therapy. The appropriate dietary restrictions and
modifications necessary for treatment are also listed.

Some Metabolic Disorders Amenable to Nutrition Therapy
Disorder
Enzyme: Missing or
Inactive
Biochemical Features
Nutritional
Treatment
Adjunct
Treatment
Analyte Used
for Newborn
Screening
Urea Cycle Disorders
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ornithine
transcarbamylase
deficiency
Ornithine
transcarbamylase
Vomiting, seizures,
sometimes coma leading
to death. Survivors
usually have
ID, increased plasma
ammonia, glutamine
Food: Low-protein
(supplement
essential L-amino
acids), Formula:
without
nonessential
amino acids
L-carnitine,
sodium
phenylbutyrate

,
L-citrulline,
L-arginine
Hemodialysis or
peritoneal
dialysis during
acute episodes

Citrullinemia
Argininosuccinate
synthetase
Increased plasma
arginine,ammonia,
alanine
Neonatal: vomiting,
seizures, coma leading
to death.
Infant: vomiting,
seizures, progressive
developmental delay
Food: Low-protein
(supplement
essential L-amino
acids)
Formula: without
nonessential
amino acids
L-carnitine,
phenylbutyrate

,
L-arginine
Citrulline
Carbamyl
phosphate
synthetase
deficiency
Carbamyl phosphate
synthetase
Vomiting, seizures,
sometimes coma leading
to death.
Survivors usually have
ID, increased plasma
ammonia, glutamine
Food: Low-protein
(supplement
essential L-amino
acids)
Formula: lower
protein, without
nonessential
amino acids
L-carnitine,
phenylbutyrate

,
benzoate,
L-citrulline,
L-arginine
Hemodiaylsis or
peritoneal
dialysis during
acute episodes

Argininosuccinic
aciduria
Argininosuccinate lyase
Increased plasma
argininosuccinic acid,
citrulline, ammonia
Neonatal: hypotonia,
seizures
Subacute: vomiting, FTT,
progressive
developmental delay
Food: Low-protein
(supplement
essential L-amino
acids)
Formula: without
nonessential
amino acids
L-carnitine,
phenylbutyrate

,
L-arginine
Citrulline
Arginase
deficiency
Arginase
Periodic vomiting,
seizures, coma
Progressive spastic
diplesia, developmental
delay
Increased arginine,
ammonia with protein
intake
Food: Low-protein
(supplement
essential L-amino
acids)
Formula: without
nonessential
amino acids
L-carnitine,
phenylbutyrate


Organic Acid Disorders
Methylmalonic
aciduria
Methylmalonyl-CoA
mutase or similar
Metabolic acidosis;
vomiting; seizures,
coma, often death
Increased organic acids,
ammonia levels
Food: Low protein
Formula: without
isoleucine,
methionine,
threonine, valine
L-carnitine,
vitamin B12
Intravenous
(IV) fluids,
bicarbonate
during acute
episodes
C3
Propionic aciduria
Propionyl-CoA
carboxylase or similar
Metabolic acidosis,
increased ammonia,
propionic acid, increased
methylcitric acid in urine
Food: Low protein
without isoleucine,
methionone,
threonine, valine
L-carnitine, biotin
IV fluids,
bicarbonate
during acute
episodes
C3
Fatty Acid Oxidation Disorders
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Long chain
3-hydrox-acyl-CoA
dehydrogenase
(LCHAD)
deficiency
Long-chain
3-hydrox-acyl-CoA
dehydrogenase
Vomiting, lethargy,
hypoglycemia
Low-fat, low–
long-chain fatty
acids, avoid fasting
Possible
medium-chain
triglyceride
(MCT) oil,
L-carnitine
C16-OH +/-
Medium chain
acyl-CoA
dehydrogenase
(MCAD) deficiency

Medium-chain
acyl-CoA
dehydrogenase
Vomiting, lethargy,
hypoglycemia
Low-fat,
low–medium-chain
fatty acids, avoid
fasting
Possible
L-carnitine
C8; C6, C10
Short chain
acyl-CoA
dehydrogenase
(SCAD) deficiency
Short-chain acyl-CoA
dehydrogenase
Vomiting, lethargy,
hypoglycemia
Low-fat,
low–short-chain
fatty acids, avoid
fasting
possible MCT
oil, L-carnitine
C4
Carbohydrate Disorders
Glycogen storage
disease (Type Ia)
Glucose-6-phosphatase
Profound hypoglycemia;
hepatomegaly
Low-lactose,
low-fructose,
low-sucrose,
low-fat,
high-complex
carbohydrates,
avoid fasting
Raw cornstarch,
iron supplements

Hereditary
fructose
intolerance
Fructose-1-phosphate
aldolase
Vomiting, hepatomegaly,
hypoglycemia, FTT,
renal tubular defects
after fructose introduction,
Increased blood/urine
fructose after fructose
feeding

No sucrose
or fructose

Galactosemia
Galactose-1-phosphate
uridyl transferase
Vomiting, hepatomegaly,
FTT; cataracts; ID; often
early sepsis
Increased blood/urine
galactose
Eliminate lactose,
low galactose, use
soy protein isolate
formula
Ensure adequate
calcium, vitamin D
intake

GALT

Elevated
galactose +
deficient GALT
Aromatic Amino Acids
Phenylketonuria
Phenylalanine
hydroxylase
Increased blood phe
Increased phenylketones
in urine
Progressive severe ID
which can be prevented
by early treatment
Food: Low
phenylalanine
Formula: without
phenylalanine,
supplement
tyrosine
Some
individuals
respond to
saptopterin
(Kuvan). Others
Large neutral
amino acids
(LNNA)
Phenylalanine
Tyrosinemia type 1
Fumaryl-acetoacetate
hydrolase
Vomiting, acidosis,
diarrhea, FTT,
hepatomegaly, rickets
Increased blood/urine
tyrosine, methionine;
increased urine
parahydroxy derivatives
of tyrosine
Liver cancer
Food: low protein
Formula: without
tyrosine,
phenylalanine and
methionine
Orfadin*
Tyrosine
Succinylacetone
(in some states)
Branched Chain Disorders
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Maple syrup urine
disease
Branched chain
ketoacid
dehydrogenase
complex
Seizures; acidosis
Plasma leucine,
isoleucine, valine 10x
above normal
Alloisoleucine present
Food: Low protein
Formula: without
leucine,
isoleucine, valine
L-carnitine,
possible thiamin
Leucine
Isovaleric acidemia
Isovaleryl-CoA
dehydrogenase
Poor feeding, lethargy,
seizures,
metabolic ketoacidosis,
hyperammonemia
Food: Low protein
Formula: without
leucine
L-carnitine,
L-glycine
C5
Biotinidase
deficiency
Biotinidase or similar
In infancy, seizures,
hypotonia, rash, stridor,
apnea; in older children
alopecia, ataxia,
developmental delay,
hearing loss

Supplemental
oral biotin
Biotinidase

†Phenylbutyrate is a chemical administered to enhance waste ammonia excretion; other compounds producing the same effect are
also used.
*2-(2-nitro-4-trifluoro-methyl-benzoyl)-1,3-cyclohexanedione, which is an inhibitor of 4-hydroxy-phenylpyruvate dioxygenase
ID, intellectual disability; FTT, failure to thrive.
Source: Reprinted with permission. Trahms C. Overview of assessment of nutritional status for children with metabolic disorders.
Nutrition Focus. 2009; 24.

Protocols are available as guides for prescribing, planning, and evaluating nutrition therapy through various manufacturers such as
GMDI
,
Mead Johnson
,
Abbott
,
Nutricia
, and
National PKU News
.

Goal Setting

The goals of nutrition intervention for infants and children with inborn errors of metabolism are to modify or avoid the affected
metabolic pathways, to prevent neurological damage, and to promote physical growth and development. Outcomes of treatment for
inborn errors of metabolism are variable and depend on early diagnosis and intensive monitoring (Fernandes 2006; Valle, 2009;
Nyhan 2005; GeneClinics).

Nutrition Therapy Efficacy

Efficacy of nutrition interventions for inborn errors of metabolism varies and depends on early diagnosis and intensive monitoring
(Fernandes 2006; Valle, 2009; Nyhan 2005; GeneClinics).
The risk of nutrient deficiencies is always greater for children with inborn errors of metabolism, because of the nutrient restrictions
necessary to modify biochemical parameters. For most children, the DRIs can be used as a starting point to estimate nutrient
needs. The specific disorder, the child’s growth pattern, medications, and other factors may affect nutrient needs, and should be
considered during the nutrition assessment.
Energy
Growth, basal metabolic rate, physical activity, and state of health dictate energy needs. Inadequate energy intake will result in
endogenous breakdown of protein releasing nitrogen and amino acids from muscle which can accumulate due to specific enzyme
deficiencies. Severe energy deficiency depresses anabolism and leads to increased muscle protein catabolism. Monitoring
protein–energy ratio is particularly important for maintaining metabolic balance. To support protein sparing, energy needs may be
greater if only L-amino acids provide protein. Low-protein or nitrogen-free foods, such as low-protein breads and pastas, are often
needed to provide an appropriate energy intake without adding more protein to the food pattern.
Protein
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Protein requirements vary among individuals. Prescribed intake for infants and children with inborn errors of metabolism depends on
the child's specific metabolic disorder, degree of enzyme activity, growth rate, and age. Any prescription that limits protein must be
evaluated to ensure that it provides adequate amounts of all essential amino acids. Growth will be limited by the amino acid in
shortest supply in the diet. Inadequate nitrogen intake may also be a limiting factor for growth. Because L-amino acid mixes are not
metabolized as efficiently as whole protein, recommended total protein intakes may be higher for some disorders whereas
restriction of specific amino acids may be lower than estimated needs if based on the DRIs.
Fat
In inborn errors of amino acid/protein metabolism, energy needs can be met by providing an increased percentage of energy from
carbohydrates or fats. Because of the current questions on essential fatty acid composition of infant formulas, intakes should be
monitored for adequacy. Children with fatty acid oxidation disorders must significantly restrict their intake of specific fatty acids and
thus other sources must be provided to meet energy needs. The table Some Metabolic Disorders Amenable to Nutrition
Therapy describes these disorders and the necessary treatment.
Vitamins and Minerals
Vitamin and mineral needs must be met with medical foods or judicious use of supplements. For certain disorders, some vitamins
are supplemented at levels much higher than DRI levels. Vitamins, which are cofactors for affected metabolic pathways, may have
an enhancing effect if supplied in pharmacological doses. The table Some Metabolic Disorders Amenable to Nutrition Therapy
describes the therapeutic use of some supplemental vitamins and minerals.

Oral Intake

Specialized Formulas and Foods
It is difficult to correct metabolic imbalances caused by many of these disorders and meet nutritional requirements for growth and
activity without the use of a semisynthetic formula or medical food. Formulas and medical foods have been developed for the
treatment of those inborn errors of metabolism that require restriction of specific amino acids. These formulas and medical foods
are intended to provide an adequate total protein intake while supporting the restriction of the specific amino acid substrates.
A variety of formula/medical food products are available for the treatment of inborn errors of metabolism. Some products provide
protein (as L-amino acids), carbohydrate, fat, and vitamins and minerals. Other products provide protein as L-amino acids but do not
contain carbohydrate and fat. Most, but not all, of the products provide essential vitamins and minerals. The choice of product
depends on age, nutrient needs (protein, energy, vitamin/mineral composition of product), preference, cost, and availability of the
product.
Consult with your state metabolic program to determine which of the variety of products meet the nutrition needs of the individual in
question, are available and/or recommended, and are covered by insurance in individual states. (See the NNSGRC Web site for a
listing of state newborn screening programs.)
Amino acid–restricted formulas and medical foods require supplementation of the restricted amino acid, usually with small amounts
of whole natural protein. Natural foods seldom supply more than 25%, and usually much less, of the total protein requirements of
individuals with disorders of protein metabolism (Acosta, 1995). The restricted amino acids are introduced into the diet as
proprietary infant formulas for the very young. For children and adolescents, foods containing a variety of complete proteins, fruits,
vegetables, breads, or cereals assume a larger role in the food pattern.
Feeding Problems
Feeding problems may be associated with some disorders, especially those that affect motor development. Decreased appetite and
food aversion are associated with other disorders. In addition, as with many disorders that require intensive nutrition intervention,
feeding disorders and/or aversions may develop. Tube feeding may be needed for some children. The clinician should include an
assessment of feeding, eating, and the feeding relationship in the nutrition assessment and make appropriate referrals. In many
cases, therapists outside of the core care team (eg, through early intervention centers, school districts, and private therapists) may
be consulted.
Social Issues
Social issues related to food and eating need to be planned for and addressed. The registered dietitian can provide anticipatory
guidance about issues including access to food in child care and school settings, eating with friends, and responding to questions
from peers. When compliance with treatment is an issue, the dietitian can also assist with problem solving.

Fluid Needs or Limits

Fluid needs for children with metabolic disorders are the same as for healthy children without metabolic disorders. Fluid needs
may exceed maintenance requirements during illness when attempting to flush out the accumulation of the toxic metabolite.

Nutrition Support

If a child is unable to achieve adequate energy and nutrient intakes with oral feedings, nasogastric, gastrostomy, or parenteral
routes are used to achieve metabolic balance and an adequate energy intake.
Parenteral therapy is often needed when a child is acutely ill and unable to tolerate enteral nutrition support. Hydration status must
be carefully monitored since dehydration or constipation may be a crisis for these individuals. The usual childhood illnesses may
also pose medical crises for a child with an inborn error of metabolism. Hyperosmolar medical food mixtures may cause significant
gastrointestinal problems. Small, more frequent changes in prescription for medical and supplemental foods lead to more stable
blood levels.
The crucial role of nutrition support cannot be disputed in the treatment of these disorders. Effective treatment requires the
expertise of an experienced team, generally composed of a geneticist, registered dietitian, genetic counselor, psychologist,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
neurologist, and social worker. Frequent monitoring of growth and metabolic and nutritional status—as well as intake of protein,
energy, and other nutrients—is necessary to verify the adequacy of the nutrition support prescription.

Emergency Management

Many infants are acutely ill as newborns, and emergency measures may be needed to stabilize their metabolic condition. For
example, acutely ill infants with urea cycle disorders may require peritoneal dialysis or hemodialysis to remove excess ammonia
and prevent neurological damage. Once ammonia levels are stabilized, medical nutrition therapy can be initiated.
Maintaining metabolic balance requires frequent and intensive monitoring of the biochemical parameters specific to the disorder and
those indicative of normal nutritional status. Frequently monitored levels include plasma amino acids, hematological status, protein
status, electrolytes, blood lipid levels, and ammonia.

Nutrition Monitoring and Evaluation

Monitoring and evaluation of children with metabolic disorders varies depending on the specific disorder and nutrition intervention.
See the Laboratory section for more details.

Nutrition Care FAQs

Q: How does newborn screening affect my clinical practice?
A: It is important to know which disorders are screened in your state, who to contact if an infant is "presumptive" positive for a
disorder, what actions are important immediately, and what actions could be detrimental if implemented. The ACT Sheets provide
guidelines for assessment of these parameters.
Q: A child with a metabolic disorder is admitted to the local hospital with fractured leg; how do I estimate nutrient needs for
bone healing and what type of “diet” should I order to promote bone healing?
A: Contact the specialty clinic and follow the protocol, which will recommend additional calcium and vitamin D among others. Often,
trauma will increase some blood levels and decrease others depending on the disorder. Consult the specialty clinic experts.

Q: How important is a "sick day" letter and what do I do with it?
A: A sick day letter is an essential document and is provided to the family by the specialty clinic. It is a valuable tool that provides
guidelines, assessment, and action needed for illness. Many parents have a sick day letter that is vetted by the specialty and
accepted by the emergency room at the local hospital.
Q: I am treating a child with a metabolic disorder through my early intervention practice. What can I do to support the
family?
A: Develop a relationship with the metabolic clinic. Collaboration between specialty and local providers is essential to good,
comprehensive care. In many instances, local and tertiary providers collaborate to ensure appropriate growth, progression of
feeding skills, and so on. This is achieved with good communication—let the specialty clinic know your concerns and consult with
them for condition-specific recommendations.

Q: When should formula changes be made?
A: The formula prescription is adjusted as a child grows. Each clinic has its own protocol; however, in general, the following factors
are considered:
Is the formula age appropriate in terms of nutrient composition (especially vitamins and minerals)?
Is the formula developmentally appropriate? (Many children with metabolic disorders require a specialized formula/medical
food to provide the majority of their intakes, even through adolescence. Volume, type of formula, and nutrient composition may
be adjusted.)
Is the formula accessible and, if yes, who provides it? Is the cost reimbursable?
Does the patient tolerate the formula?
Be sure to consult with the metabolic clinic before suggesting changes to the formula prescription.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Inborn Errors of Metabolism > Phenylketonuria/PKU
Nutrition Assessment

The focus of this section is for community providers who have been asked to provide a
basic nutrition assessment for infants and children with a diagnosis of a metabolic disorder.
It is not meant as a management tool for practitioners working with advanced cases.
Optimal medical nutrition intervention is required if reasonable physical growth is to be
achieved (Acosta, 1993a; Acosta, 1993b; Trahms, 2008). As for all infants and children,
appropriate growth reflects the adequacy of energy, protein, vitamin, and mineral intake.
For children with inborn errors of metabolism, growth also reflects the achievement of
metabolic balance. Inadequate weight gain may reflect a limited energy intake, a deficiency
of total protein or specific amino acids, or an excessive intake of toxic substrates, which
result in poor metabolic control.
Deficiencies of specific amino acids have significant clinical effects in addition to their
impact on growth. For example, clinical signs may include poor growth with phenylalanine
deficiency (if overrestricted in the treatment of phenylketonuria). If growth and development
are to proceed appropriately, do the following:
Limit/restrict the “affected” nutrients (the nutrients for which metabolic pathways are
affected by the disorder)
Supplement compromised components (often the product of the reaction)
Provide protein supplement that excludes the offending amino acid in order to achieve
total protein needs, which are typically 25 - 30% greater than DRIs for age
Provide energy and all other nutrients in adequate amounts
Ensure related nutrients are adequately provided (eg, essential fatty acids, if fat is
restricted; calcium and vitamin D if milk is eliminated)

Nutrition-Focused Physical Findings

Children with phenylketonuria who were started on treatment as infants and who have
maintained appropriate phenylalanine levels should demonstrate normal body weight for
age and unremarkable physical appearance. Persons who have decreased intelligence
because of high blood levels of phenylalanine may have a changed appearance depending
on level of physical and intellectual capabilities.

*From Nutrition Care Manual

Biochemical Data, Medical Tests and Procedures

In the US, newborn screening for PKU is mandated in all states. In general, blood is
collected from infants between 24 and 48 hours of age for newborn screening. How the
sample is handled, what disorders (in addition to PKU) are identified, and how results are
reported varies from state to state.
Elevated plasma phenylalanine (phe) levels in the presence of normal tyrosine (tyr) levels
are indicative of phenylketonuria. (Other values, including phe:tyr ratios, help
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
in interpretation of these results.) These levels are also the most significant indicators of
adherence to treatment. Plasma phenylalanine and tyrosine levels should be monitored
monthly.
Advances in newborn screening technology offer the potential for earlier diagnosis,
prevention of neurologic crisis, and improved intellectual and physical outcomes. See
Some Metabolic Disorders Amenable to Nutrition Therapy for information about some
disorders that are identified by newborn screening.
Positive newborn screening tests are followed by diagnostic testing, usually before
treatment is initiated. Confirmatory diagnostic testing is typically carried out by specialty
centers.

Laboratory

Some suggested biochemical parameters and general frequency recommendations are
listed in the table that follows. Other parameters may be monitored, as indicated by clinical
status or other concerns (eg, essential fatty acids, trace elements, bone health parameters).
Suggested Biochemical Parameters to Monitor for Children With Phenylketonuria
Parameter Frequency

Plasma phenylalanine, tyrosine Monthly
a
Hematocrit, hemoglobin, ferritin
Twice a year,
depending on age and
health status
Albumin, prealbumin
Twice a year,
depending on age and
health status
Length or height, weight, weight for
height, body mass index, head
circumference
At each clinic visit
a
Intake of medical food and foods as
contributors of critical nutrients
Coupled with each
laboratory assessment
Protein, energy, fat, nutrients critical
to specific metabolic disorder
Coupled with each
laboratory assessment
a
Specialized protocols and more frequent monitoring of the child’s condition are required if
there are diet changes, an intake that is out of the recommended range, or illness.
For more detailed guidelines, consult the Phenylketonuria Consensus Guidelines.
Adapted from Trahms C, Ogata B. Overview of assessment of nutritional status for children
with metabolic disorders. Nutrition Focus. 2009;24
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Food/Nutrition-Related History

Intake of medical food, manufactured low-protein foods, natural foods, and foods as
contributors of critical nutrients such as energy, protein, phenylalanine, tyrosine, and
vitamins and minerals should be assessed along with laboratory values to determine
relationship of those values to metabolic control.
In addition, the clinician should evaluate the developmental appropriateness of the
individual’s food pattern, access to food and formula, other factors that influence intake and
self-management skills.

Comparative Standards

The amount of total protein recommended for the treatment of phenylketonuria (PKU)
during infancy and childhood is greater than the amount suggested for persons without
PKU. Typically the amount recommended is 25% to 30% above the DRI for age.
Calculations necessary to fully assess intake and nourishment are as follows:
Total energy intake and percentage of energy from formula/medical food and other
foods
Total protein intake and percentage of total protein from formula/medical food and
other foods
Phenylalanine intake from foods
Tyrosine intake from medical foods/formula
Vitamin and mineral intakes (including calcium, iron, vitamin D, and others) from
formula/medical foods and other foods
Compare calculated phenylalanine intake with blood phenylalanine levels and adjust
phenylalanine intake to bring phenylalanine levels into the treatment range of <6 mg/dL
(360 mcmol/L) (NIH, 2000). The amount of phenylalanine an individual can safely ingest
depends on individual tolerance (enzyme activity).
Persons with phenylketonuria do not have extraordinary fluid requirements. An adequate
fluid intake is provided to maintain hydration and prevent constipation.

Anthropometric Measurements

Length or height, weight, weight for height, body mass index, and head circumference
should be measured at each clinic visit and plotted on the appropriate growth chart of the
Centers for Disease Control and Prevention.

Nutrition Diagnosis

Dietitians working with patients who have phenylketonuria should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
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Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
Imbalance of nutrients (NI-5.5)
Excessive protein intake (NI-5.7.2)
Inappropriate intake of protein or amino acids (NI-5.7.3)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Unintended weight loss (NC-3.2)
Unintended weight gain (NC-3.4)
Inability or lack of desire to manage self-care (NB-2.3)
Sample PES or Nutrition Diagnostic Statement(s)
Inappropriate intake of amino acids (NI-5.7.3) related to PKU as evidenced by 3-day
food record (intake = 500 mg phenylalanine; estimated needs = 300 mg) and elevated
blood phenylalanine levels (650 mcmol/L).
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition therapy for children with phenylketonuria (PKU) promotes normal cognitive
development by reducing the toxic effects of increased concentrations of phenylalanine and
its metabolites while providing adequate nourishment for growth (Waisbren, 2007; Mitchell,
2007 Anastasoaie, 2008). Without treatment, phenylalanine levels may be higher than
1,200 mcmol/L (> 20 mg/dL).
Meal plans for patients with PKU are modified in sources of protein and energy, restricted
in phenylalanine, and supplemented with tyrosine. Adjustments are required to
accommodate changing needs during growth and changes in the child’s eating habits.
Protocols are available as guides for prescribing, planning, and evaluating nutrition
therapy. For example, see Genetic Metabolic Dietitians International, Mead Johnson,
Abbott, Nutricia, and PKU News.
The Maternal PKU Collaborative Study developed a protocol for treatment of pregnant
women with PKU (Acosta, 1993; Acosta, 2001).
Nutrition Intervention terminology that may be used with patients includes Specific
foods/beverages or groups (ND-1.3); and Supplements: Commercial beverage (ND-3.1.1),
Modified food (ND-3.1.4).
Protein
Foods high in protein (dairy foods, meat, fish, poultry, eggs, legumes, and nuts) are also
high in phenylalanine and are excluded from the diet. Semisynthetic formulas and medical
foods without phenylalanine provide adequate protein and tyrosine. Adequate intake of
formulas and medical foods is critical. Medical foods are the primary source of daily energy,
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protein, vitamins, and minerals.
Various manufacturers provide formula and medical foods to meet the individual nutrient
needs of infants and children. Use of these products must be prescribed and monitored by
an experienced metabolic dietitian and physician.
Phenylalanine
Phenylalanine prescriptions are based on estimated tolerance for ingested phenylalanine,
which is influenced by residual phenylalanine hydroxylase activity (the enzyme deficient in
PKU), age, sex, growth in weight and height, and blood phenylalanine level (Acosta,
1993b). Proprietary infant formula is added to the phenylalanine-free formula or medical
food to provide the small amount of phenylalanine required for growth. Breast milk can be
used as the phenylalanine source in the infant’s prescription for phenylalanine. Formula
and medical foods are supplemented with tyrosine, which is a conditionally essential amino
acid. As infants mature and table food is introduced, medical foods formulated for children
are also introduced.
Lower-protein foods, such as fruits, vegetables, breads, cereals, and pastas (both
low-protein and regular) are used in prescribed amounts to provide the required
phenylalanine for children with PKU.
Energy
Baseline energy requirements are calculated using standard prediction formulas and are
modified based on the growth response of the patient (Acosta, 1995; Trahms, 2008). A
significant percentage of total energy intake is derived from the medical food prescription.
Special low-protein food products, such as low-protein breads and pastas, are used to
meet total energy needs. It is important to provide adequate energy to avoid protein
catabolism, which can elevate blood phenylalanine levels.

Nutrition Therapy Efficacy

Effective treatment for phenylketonuria requires the restriction of phenylalanine to the
tolerance requirement level and supplementation of tyrosine.
Nutrition therapy should reduce blood phenylalanine levels to between 120 mcmol/L and
360 mcmol/L (2 to 6 mg/dL) and maintain tyrosine levels within the normal range, which will
promote normal cognitive development by reducing the toxic effects of increased
concentrations of phenylalanine and its metabolites while providing adequate nourishment
for growth.

Adequacy of Nutrition Therapy

If the specialized formula or medical foods are consumed in sufficient quantities and
supplemental foods are added to meet energy and phenylalanine needs, the restricted
phenylalanine diet meets the Dietary Reference Intakes based on age. Individuals with
phenylketonuria are at risk for nutritional deficiencies if dietary treatment is not carefully
prescribed and monitored, and a multivitamin may need to be prescribed.

Goal Setting
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The goals of nutrition therapy for infants and children with phenylketonuria are to prevent
intellectual disability and neurological deterioration and to support normal growth and
development. The benefits of maintaining blood phenylalanine in the treatment range
include increased attention span, improved executive function, and maintenance of
emotional stability.

Food & Feeding Issues

Formula/medical food is required as an essential component of the
phenylalanine-restricted nutrition prescription to provide adequate protein and energy
intakes. The composition of the prescribed formula/medical food will determine
the percentage of the total energy provided by the formula/medical food as well as the
need for additional vitamin and mineral supplements and/or fat intake.
Social Issues
Social issues related to food/eating need to be planned for and addressed at different life
stages. The registered dietitian can provide anticipatory guidance about issues including
access to food in child care and school settings, eating with friends, and responding to
questions from peers. When compliance to treatment is an issue, the dietitian can also
assist with problem-solving.
*adapted from Nutrition Care Manual: Inborn Errors of Metabolism, 2009.

Nutrition Support

If a child is unable to achieve an adequate energy and nutrient intake with oral feedings,
nasogastric, gastrostomy, or parenteral routes are used to achieve metabolic balance and
an adequate energy intake.
Parenteral therapy is often needed when a child is acutely ill and unable to tolerate enteral
nutrition support. Hydration status must be carefully monitored since dehydration or
constipation may be a crisis for these individuals. The usual childhood illnesses may also
pose medical crises for a child with an inborn error of metabolism. Hyperosmolar medical
food mixtures may cause significant gastrointestinal problems. Small, more frequent
changes in prescription for medical and supplemental foods lead to more stable blood
levels.
The crucial role of nutrition support cannot be disputed in the treatment of these disorders.
Effective treatment requires the expertise of an experienced team, generally composed of a
geneticist, registered dietitian, genetic counselor, psychologist, neurologist, and social
worker. Frequent monitoring of growth and metabolic and nutritional status—as well as
intake of protein, energy, and other nutrients—is necessary to verify the adequacy of the
nutrition support prescription.

Nutrition Monitoring & Evaluation

Frequent monitoring of blood phenylalanine (at least monthly after levels are stabilized) is
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necessary to ensure adequacy of treatment. Overprescription of dietary phenylalanine or
consumption of amounts of dietary phenylalanine greater than required, suboptimal intake
of metabolic foods, or catabolic states during illness also can result in elevated blood
phenylalanine levels. Underprescription of phenylalanine, reduced consumption of
phenylalanine from foods, or increased phenylalanine need, because of accelerated
growth, may cause reduced blood phenylalanine levels.
There is no safe age when dietary phenylalanine restriction can be discontinued. Decline in
intelligence quotient, poor school achievement, behavioral problems, and neurological
deterioration have been documented after discontinuation of treatment (Mitchell,
2007; Waisbren, 2007; Anastasoaie, 2008).
See the Laboratory section for additional information on biochemical monitoring.

Nutrition Prescription

The nutrition prescription for phenylketonuria is for low phenylalanine, which is achieved by
the following measures:
Restricting phenylalanine to the requirement/tolerance level that allows for blood
phenylalanine levels in the treatment range
Providing an adequate energy intake (compare with current guidelines for healthy
children)
Providing an adequate protein intake (compare with Dietary Reference Intakes for
healthy children and in general, increase by about 25% to 30%).
Providing adequate vitamins and minerals (compare with Dietary Reference Intakes
for healthy children).
The prescription for protein, energy, and phenylalanine intake must be tailored to meet the
needs of each individual (see Nutrition Intervention). The individual's tolerance for
phenylalanine must be considered and adjusted to meet treatment goals. General health
status and pregnancy are significant variables. Total protein and energy intakes also affect
blood phenylalanine levels and the tolerance and prescription for dietary phenylalanine.
These nutrition goals cannot be met without the ingestion of a prescribed
phenylalanine-free, tyrosine-supplemented formula/medical food.

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Nutrition Care > Oncology
Oncology


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Nutrition Care > Oncology > General Guidance
Nutrition-Focused Physical Findings

In conjunction with a thorough evaluation of growth, the practitioner should conduct a
nutrition-focused physical assessment. The following table lists the components of a
nutrition-focused physical assessment.
Components of Nutrition-Focused Physical Assessment
Body
Composition
Component
Area Assessed Observation
Subcutaneous
fat
Infraorbital
fat pad
Triceps
skinfold
(pinch test)
Midaxillary
line at the
level of the
lower ribs
Sunken appearance
Excessive or
normal to fingers
touching
Excessive or
normal to fingers
touching
Skeletal Muscle
(Loss of
muscle bulk
and tone by
palpitation)
Temporalis
muscle

Deltoid
muscles


Pectoral
muscles
Latissimus
dorsi muscle
Temporal wasting
Squaring of the
junctions of the
neck and shoulder
and at the shoulder
joint (ie, loss of
normal curvature);
prominent acromial
process; prominent
infraclavicular
fossa along its
lateral aspect;
depression above
scapula when hand
extended against
wall
Prominent
infraclavicular
fossa along its
medial aspect; loss
of chest wall
muscle mass
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Thenar
interosseous
muscles
Depression medial
to scapula or at
axillary border
when hand
extended against
wall
Flattening of the
prominence
between
thumb and index
finger when patient
is asked to press
the pads of these
digits together
(From PEDSGA manual; used with permission of Nancy Sacks, MS, RD)
The following table lists the paradigms of weight loss/body composition changes in illness
that were proposed by Roubenoff et al (1997). Roubenoff proposed three distinctly different
entities for evaluating body composition changes: wasting, cachexia, and sarcopenia.
Paradigms of Weight Loss/Body Composition Changes in
Illness
Cachexia Wasting Sarcopenia
Decreased
body cell
mass
(BCM)
Yes Yes
Yes,
skeletal
muscle cells
Weight loss
None or little
compared with loss
of BCM
Yes
Not
necessarily
Elevated
resting
energy
expenditure
Often
Not
necessarily
Not
necessarily
Decreased
functional
status
Yes Yes Yes
Increased
cytokine
production
Yes No ?
Increased
mortality
Yes Yes ?
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Treatment
? Anticytokine
agents, ? anabolic
hormones
Increased
intake
(adequate to
increase
BCM)
Progressive
resistance
training
Clinical
examples
Critical illness with
adequate nutritional
support, liver
disease, early renal
failure, rheumatoid
arthritis, human
immunodeficiency
virus infection
without opportunistic
infection, kwashiorkor
Critical
illness
without
adequate
nutrition
support,
advanced
acquired
immune
deficiency
syndrome,
end-stage
renal or liver
disease,
marasmus
Aging
Adapted from Roubenoff 1997
An understanding of the weight loss and changes in body composition will help the
practitioner identify the root cause and ultimately the appropriate nutrition intervention. For
example, weight loss that occurs with cancer, infection, or other metabolic stress is
composed of both fat and fat free mass, whereas the losses that occur during prolonged
fasting in the absence of metabolic stress are from body fat at first and then from body
protein stores (Moley, 1987). In addition, the origin of energy imbalance can be
multifactorial.

Biochemical Data, Medical Tests and Procedures

Cancer can be diagnosed or the effectiveness of treatment can be determined by a tissue,
sputum, or fluid sample or via the analysis of tumor markers from blood and body fluids
(NCI 2009). Pathological specimens establish with certainty the diagnosis of cancer.
Specimens are sent to the laboratory to identify histopathology (tumor type, classification,
and grade) of the malignancy. Once a cancer is diagnosed, accurate and specific treatment
can be prescribed and administered, and the individual can be given a prognosis.
Biopsy: A surgical procedure that involves removing all or part of tissue suspected of
being cancerous
Imaging studies: Diagnostic tests that display the structure and function of internal
organs; examples of imaging used for cancer diagnosis include the following:
Computed tomography scans
X-rays
Radioisotope scans
Ultrasonography
Magnetic resonance imaging
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Positron emission tomography scans
Pathologic and cytologic studies: The analysis of tissue samples for the presence of
cancer cells
The cells are obtained via biopsy
squarePap test
Fine-needle aspiration
Surgical incision (removal of a small portion)
Excisional biopsy (removal of the entire lesion)
Laboratory Evaluation
Biochemistries such as a complete metabolic profile and liver function studies will also
be included as part of the workup
Tumor markers may also be included in the workup
Cytologic studies may be completed on fluids such as pleural fluid and ascitic fluid in
some patients
Adapted from Nutrition Care Manual: Oncology

Laboratory

Complete blood count and differential, including the following:
White blood count
Hematocrit
Hemoglobin
Platelets
Neutrophil count
Neutropenia is defined as a decrease in the number of neutrophils (white
blood cells, also known as granulocytes). Neutrophils primarily protect the
body against infection from bacteria and fungi. Neutropenic precautions
and use of a low-bacteria nutrition therapy may be used based on hospital
protocol when the absolute neutrophil count drops below 1,500/mm
3
.
Iron studies to assess iron stores and anemia
Iron
Ferritin (serum iron)
Transferrin
Hemoglobin
Hematocrit
Electrolytes are used to assess hydration status and to evaluate for possible
refeeding syndrome
Sodium
Potassium
Chloride
Magnesium
Phosphorus
Glucose
Calcium
Elevated levels often are indicative of bone metastasis (Note: food calcium
restrictions are not indicated in the presence of elevated calcium levels)
Liver panel is used to assess liver function and possible liver involvement and
metastasis
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Serum-glutamic oxaloacetic transaminase
Serum glutamate pyruvate transaminase
Alkaline phosphate
Phosphate phosphorus
Uric acid
Total bilirubin
Kidney function panel used to assess kidney function
Blood urea nitrogen
Creatinine
Creatinine index
Prognostic nutrition indexes: The following are affected by acute phase response and
are not appropriate measures of nutrition stores in cancer patients:
Albumin
Total protein
Prealbumin
Nitrogen balance
Total lymphocyte count
Glucose:
Often elevated in the presence of steroids and in individuals diagnosed with
pancreatic cancer
C-reactive protein: A measure of the presence of an acute-phase protein response
(indicator of inflammatory response)
Often elevated in the presence of a tumor
Tumor markers
Chromosomal abnormalities
Adapted from Nutrition Care Manual: Oncology

Client History

The appraisal of the extent of the disease, prognosis, cancer treatment modalities, and
treatment-related symptoms is necessary in order to plan appropriate nutrition
interventions. The results of careful evaluation of the patient's medical, social, nutrition, and
medication history are important to consider when performing a thorough nutrition
assessement (Cresci 2006).
The therapies listed after this paragraph are commonly used in combination. Individuals
receiving multimodality therapy often manifest side effects earlier and with greater toxicity.
Chemotherapeutic agents may be administered concurrent with radiation therapy to
produce radiation therapy–enhancing effects. Surgery may be used as the sole method of
cancer treatment or it may be combined with neoadjuvant (preoperative) or adjuvant
(postoperative) chemotherapy with or without radiation therapy. The extent of adverse
effects is generally dependent on type of therapy (or therapies) utilized, dose, route of
administration, and duration of treatment. Nutrition-related side effects should be expected
and aggressively treated in order to maintain nutritional status or to prevent deteriorations
in status as well as to promote the best response to therapy. Inadequate dosing and delays
in treatment schedule can also result from poor nutritional status.
TNM (tumor, node, metastasis) staging: A relatively uniform classification system
used to identify the extent of the tumor, its size, and the degree of growth and spread.
T: Size of the tumor
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N: Degree of spread to the lymph nodes
M: Presence of metastasis
Intent of therapy
Cure, control, or palliative
Treatment modalities
Chemotherapy: Systemic therapy utilized in solid and hematological
malignancies
Severity and impact of treatment are dependent on the specific agent(s)
and duration of treatment
Hormonal therapy: Systemic therapy utilized in hormone-sensitive cancers that
reduces the level of hormones in the body or block the tumor's ability to utilize
endogenous hormones; also called endocrine therapy
It is usually used in combination with other types of cancer treatments
Side effects vary depending on combination with other therapies and
specific agent
Biotherapies: Systemic therapy in which a laboratory-produced molecule can be
targeted to attach to specific substances on cancer cells
May be used to mark cancer cells, block growth signals, deliver radiation to
the tumor, or deliver drugs to the tumor
Side effects are dependent on source of antibody (murine, chimeric,
humanized, or human)
In general, side effects are less severe than with chemotherapy
Radiation therapy: Local therapy utilized in solid and hematological
malignancies
Causes localized effects limited to specific area(s) and surrounding areas
of the body being irradiated
Surgery: Local therapy utilized primarily in solid tumors
Sequelae dependent on organ systems involved in and extent of resection
Stem cell transplant: Utilized in solid and hematologic malignancies, involves a
transfusion of infusion of healthy stem cells from the patient or a donor
Preceded by a conditioning process that may include high doses of
chemotherapy and total body irradiation
Multiple side effects
Parenteral nutrition is often used for nutrition support
Symptom and Activity Scales: Symptom and activity scales assist the health care
professional in assessing for the presence of disease-related/treatment-related symptoms
that may be affecting nutritional intake and status, psychological and functional abilities,
and socioeconomic status. Examples include the following:
National Cancer Institute's Common Toxicity Criteria for Adverse Events, Version 3.0
Outcome measure that compares acute toxicities of different treatment
modalities
Edmonston Symptom Assessment System
Quick, twice-daily assessment of common symptoms associated with advanced
cancer
Karnofsky Performance Scale
Classifies individuals from 100 to 0 based on their functional ability
100 = normal functional ability; 10 = approaching death; 0 = death
Activities of Daily Living
Ability to complete daily activities such as bathing, dressing, eating, etc.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Comorbid Diseases
Hypertension
Cardiovascular disease
Diabetes
Renal insufficiency
Cognitive disorders (eg, depression)
Overweight/Obesity
Other
Adapted from Nutrition Care Manual: Oncology

Food/Nutrition-Related History

Evaluate nutrition history for presence of nutritional impact symptoms including, but not
limited to, the following:
Age-appropriate oral/feeding skills
Difficulty chewing/swallowing
Anorexia
Nausea
Vomiting
Diarrhea/malabsorption
Dysphagia
Mucositis/stomatitis
Dysgeusia
Taste aversions
Constipation
Pain
Infection
Fatigue
Xerostomia
Use of complementary and alternative medicine (CAM) therapies
Use of CAM therapies has increased in the cancer patient population. Whereas
the majority of therapies are harmless, some CAM practices may have serious
contraindications for individuals undergoing cancer therapy and recovery.
Adapted from Nutrition Care Manual: Oncology

Anthropometric Measurements

When conducting a thorough nutrition assessment for any pediatric patient, begin with an
evaluation of growth and continue to evaluate growth throughout the care of the patient. It
may be useful to review growth charts from the child's primary care provider to assess
growth patterns prior to diagnosis and treatment.
Several parameters can be monitored routinely to assess growth. There are growth charts
available for evaluating weight for age, weight for length, length/height for age, frontal
occipital circumference (FOC), body mass index (BMI), triceps skinfold (TSF), and mid-arm
circumference (MAC).
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CDC and WHO growth chart links are available in the Resources area of this site.
The following table highlights expected growth patterns in pediatric patients.
Growth Patterns
Age Expected Growth Notes
Growth
%
Infancy
Birth-1 year
Period of rapid
growth, weight
increase 200%;
length increase 55%;
head circumference
increase 40%
Possible initial
weight regains
of most or all
of body weight
45-50
1-3 years
Stature increase 12
cm, weight increase
3.5 4.5 kg
Growth
velocity
decreases
40-45
Preschool
3-5 years
Stature 6-8 cm/year;
weight 2-4 kg/year
35-40
School-aged
6-10 years
Stature 5-6 cm/year;
weight 2 kg at
7 years and 4 kg at
10 years
Period of
steady growth,
girls faster
than boys
30-35
Adolescence
11-21 years
Maximum velocity of
stature; males
9.5-10.3 cm/year;
Females 8.4-9.0
cm/year
Males develop
more lean
muscle mass;
females, more
adipose tissue
30-40
The Children’s Oncology Group (COG) Nutrition Committee developed categories for
nutritional status based on pediatric growth measurements and recommends that all
practitioners working with pediatric oncology patients use these categories. The following
table lists these categories (Rogers, 2008):
Categories of Nutritional Status for the Pediatric
Oncology Patient
Identify appropriate category
Age >2 years: choose either
Body mass index percentile (BMI) OR
Estimated desired weight (EDW; formerly Ideal Body
Weight, or IBW)
(for height or length percentile)
Age <2 years: choose either
WT/LT (Weight for Length - percentile) OR
EDW (for height or length percentile)
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EDW (for height or length percentile)
Underweight Normal
Risk of
overweight
Overweight
Weight loss/gain may or may not be present
BMI
<5th
percentile
5th-85th
percentile
>85th-95th
percentile
>95th
percentile
WT/LT
<10th
percentile
10th-90th
percentile
>90th percentile
EDW
Severe: <70% >90%-110% >110%-120% >120%
Moderate:
>70-80%

Mild:
>80%-90%



Comparative Standards

Determining Energy Needs
Energy requirements for children are higher in proportion to their weight compared with
adults. In addtion, their total energy needs may be increased by 15% to 50% to
compensate for prediagnosis weight loss and malnutrition or due to increased metabolic
demands. Increased energy requirements may be the result of higher lean muscle mass,
low fat reserves, and high energy demands for normal growth and development (Lucas,
2000). Energy requirements can vary because of disease type, current clinical picture,
duration of disease, and nutritional status as well as activity level (Bechard, 2006).
The World Health Organization (WHO) estimation of basal metabolic rate (BMR) may be
more appropriate in acutely ill patients (AAP, 2004; Hunt, 2009; Sacks, 2004). It is
recommended to reassess energy needs throughout the course of illness (ASPEN, 2009a).
Birth to 12 months of age, use EER; apply catch-up growth calculation if deemed
underweight (Hunt, 2009)
Older than 1 year of age use WHO equation: (W = wt in kg) (Hunt, 2009; Sacks,
2004)
Male:
1-3 years: 60.9W – 54 = (BMR x activity factor = kcal/d)
3-10 years: 22.7W + 495
10-18 years: 17.5W + 651
18-30 years:15.3W + 679
Female:
1-3 years: 61W – 51 = (BMR x activity factor = kcal/d)
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3-10 years: 22.5W + 499
10-18 years: 12.2W + 746
18-30 years: 14.7W + 496
If the child is appropriate weight for height with mild to moderate
stress/activity, use BMR x 1.3 – 1.6
If the child is obese, use BMR x 1.3 (may need to adjust weight)
If the child has had >10% weight loss from usual body weight, or if
current weight <90% of usual body weight/ideal body weight, or
needs to catch up, use BMR x 1.7-2.0
Determining Protein Needs
(AAP, 2004; Hunt, 2009; ASPEN, 2009a)
Birth to 6 months
3 g protein/kg/d
6 months to 12 months
2.5 to 3 g protein/kg/d
1 to 13 years
1.5 to 2 g protein/kg/d
13 to 18 years
1.5 g protein/kg/d
* Note that these are standard recommendations, so they do not reflect consideration for
other conditions, for example, patients with renal impairment.
Recommendations for weight and length increases for healthy children ages birth to
10 years
Age
Weight
(grams/day)
Length
(centimeters/month)
< 3 months 25-35 2.6-3.5
3-6 months 15-21 1.6-2.5
6-12
months
10-13 1.2-1.7
1-3 years 4-10 0.7-1.1
4-6 years 5-8 0.5-0.8
7-10 years 5-12 0.4-0.6
(Nieman Carney, 2010)
Determining Fluid Needs
There are no specific fluid requirements for pediatric cancer patients, however, during
chemotherapy administration additional fluids will likely be given. These additional fluids
are typically part of protocol requirements. ASPEN practice guideline for pediatric fluid
requirements is that needs vary based on age and weight of the child and should be
continuously adjusted as the child grows and develops (ASPEN 2002). Given that fluid
requirements are specific to each patient, the following may be used to estimate
maintenance fluid needs:
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Less than 10 kg
100 mL/kg/24h
11 kg to 20 kg
1,000 mL + 50 mL/kg for each kg over 10 kg
21 kg to 40 kg
1,500 mL + 20 mL/kg for each kg over 20 kg
More than 40 kg
1,500 mL/m
2
/24 hours
(AAP, 2004; ASPEN 2002; ASPEN, 2004; Ringwald-Smith, 2006)
Adjustments are needed for the following conditions:
Fever
For each degree above 38°C, insensible water loss is increased by 5 mL/kg/24
hours
Stress
Diarrhea
Fluid loss should be replaced milliliter for milliliter
Acute weight loss
Weight deficit should be added to maintenance requirements
Loss from ostomies/drains should be replaced daily
(ASPEN 2002)
Fluid needs for parenteral and enteral nutrition are the same as maintenance requirements,
unless the patient is fluid restricted (ASPEN 2002).


Nutrition Diagnosis

Dietitians working with patients who have cancer should review the signs and symptoms
obtained in the nutrition assessment and diagnose nutrition problems based on these signs
and symptoms. Nutrition diagnoses from the list below as well as other diagnoses may be
present.
Inadequate oral intake (NI-2.1)
Malnutrition (NI-5.2)
Inadequate protein-energy intake (NI-5.3)
Predicted suboptimal intake (NI-5.11.1)
Altered gastrointestinal function (NC-1.4)
Underweight (NC-3.1)
Unintentional weight loss (NC-3.2)
Unintentional weight gain (NC-3.4)
Food- and nutrition-related knowledge deficit (NB-1.1)
Undesirable food choices (NB-1.7)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate oral intake (NI-2.1) related to decreased appetite as evidenced by oral
energy intake (FH-1.1.1) meeting 25% of estimated needs.
Altered gastrointestinal function (NC-1.4) related to radiation therapy as evidenced by
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stool output exceeding 2,000 mL per day (FH-8.1).
Inadequate protein–energy intake (NI-5.3) related to increased nausea and
vomiting as evidenced by a 5% decrease in weight in 1 month (AD-1.1).
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition intervention is the third step in the Nutrition Care Process (ADA, 2007) and should
help meet the goals already established in the goals section:
Reverse nutritional deficits
Promote normal growth and development
Minimize morbidity
Maximize quality of life
Nutrition intervention should also achieve the following:
Manage treatment-related side effects
Prevent weight loss
Including in overweight/obese patients
Prevent steroid induced weight gain
Preserve lean body mass
Four Classes of Nutritional Interventions (ADA, 2007)
Food and/or nutrient delivery (ND)
Modify meals and snacks (ND-1.2) to address nutritional deficits and meet
nutrition needs of the patient
Enteral and parenteral nutrition (ND-2.1, ND-2.2) initiated and modified
specifically to each patient's needs
Provide modified beverages (ND-3.1.3), commercial beverage (ND-3.1.1), etc.
Provide individual vitamin/mineral supplementations (ND-3.2) as needed or daily
multivitamin/mineral (ND-3.2.1)
Determine if patient needs assistance in feeding or meal setup (ND-4.3) if
caregivers unavailable
May need to eliminate distractions (ND-5.3) at meal times
Nutrition education (E)
Determine which educational approach will help improve nutritional status
Purpose of nutrition education (E-1.1): ways to improve intakes during
chemotherapy
Priority Modification (E-1.2): ways to increase energy/protein
Purpose of nutrition education (E-1.1): benefits of nutrition support
Example: Provide education on preventing weight gain and conserving bone
health while patient is on steroids.
Nutrition counseling (C)
Setting goals (C-2.2) that are attainable for patients; involving patients and
parents
May be used in older patients to encourage self-monitoring
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Reinforcing behavior modifications, Rewards (C2.10)
Coordination of nutrition care (RC)
Speech therapy involvement to address the following (RC-1.3):
Difficulty swallowing
Textures/texture modifications
Oral aversions
Determination/implementation of feeding plan
Behavioral medicine team/psychosocial team and/or child life (RC-1.3)
Help with strategies to improve eating behavior during and after treatments
Examples of Interventions for the Nutrition Diagnosis PES (problem, etiology, signs
and symptoms) Statements:
Inadequate oral food intakes (NI-2.1) related to decreased appetite as evidenced by oral
energy intake (FH-1.1.1) meeting 25% of estimated needs.
Nutrition intervention could include the following:
Modify distribution, type, or amount of food and nutrients within meals or at
specified time
Initiate enteral or parenteral nutrition
Insert enteral feeding tube
Start commercial beverage
Start modified beverage
Initiate nutrition-related medication management: antinausea or appetite
stimulants (use with caution)
Education: recommend modifications to diet
Altered gastointestinal function (NC-1.4) related to radiation therapy as evidenced by stool
output exceeding 2,000 mL per day (FH-8.1).
Nutrition intervention could include the following:
Initiate parenteral nutrition
Education: recommend modifications to diet
Initiate intravenous fluids or antidiarrheal medication
Inadequate protein–energy intakes (NI-5.3) related to increased nausea and vomiting as
evidenced by a 5% decrease in weight in 1 month (AD-1.1).
Nutrition intervention could include the following:
Initiate antiemetic and/or intravenous fluids
Initiate enteral or parenteral nutrition
Modify distribution, type, or amount of food and nutrients within meals or at
specified time


Nutrition Therapy Efficacy

Efficacy of nutrition support is a complex issue, because it cannot be evaluated simply from
the perspective of clinical parameters. Patients with cancer undergo various stages of
disease, including a maintenance phase and, for some, a terminal phase. Therefore,
nutritional efficacy needs to be evaluated within the context of the stage of disease and the
patient's comorbid conditions and quality of life.
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The interpretation of the research on efficacy of nutrition support in cancer patients is
complicated by the inclusion of heterogeneous populations. One cannot make comparisons
between the impact of nutrition support in different cancer types and stages and treatment
modalities. Some of the factors to consider when evaluating research related to nutrition
support in cancer patients include the following:
Nutritional status at the start of cancer treatment (well nourished vs severely
malnourished)
Comorbid conditions
Differences in severity of disease
Variations in the treatment protocol by cancer type and stage
Metabolic alterations unique to each type of cancer and the exclusion of quality of life
assessment as an efficacy endpoint (Klein, 1994)
Furthermore, the lack of a consistent process in the assessment and reassessment of
nutritional status makes it difficult to compare efficacy at various stages of treatment.
Efficacy of nutrition therapy also needs to consider the various modalities available,
including the following:
Counseling to improve oral intake using nutrient-dense foods and supplements
Enteral and parenteral feeding
Pharmacologic therapies (Cohen, 2000; Daley, 2004; Luthringer, 2002)
In order to evaluate efficacy of nutrition support, it is important to understand some basic
principles related to nutrition support in patients with cancer, including the following
(Fuhrman, 2010; Roberts, 2007; Robinson, 2006; Dechicco, 2006):
Early nutrition evaluation, assessment, and support should be instituted in the
appropriate clinical setting to decrease the likelihood of involuntary weight loss and
protein depletion (Persson, 2002).
Use of specialized nutrition support is not indicated in well-nourished cancer patients
undergoing surgery, chemotherapy, or radiotherapy and in whom adequate oral
intake is anticipated (Fuhrman, 2010).
Severely malnourished patients may benefit from enteral nutrition support
preoperatively (McClave, 2009).
Postoperative nutrition support should be initiated early (within 24 to 48 hours)
following hospital admission in stabilized patients (McClave, 2009).
Management of nutritional impact symptoms that can improve quality of life should be
a consideration for nutrition support in patients with cancer.
Psychosocial well-being of pediatric cancer patients
Which feeding modality is best for the quality of life of the patient
how long should the patient be connected to the feeding modality chosen
Window for enteral nutrition or cycle parenteral nutrition
In 2002, the American Society for Parenteral and Enteral Nutrition published the following
guidelines for the use of nutrition support in cancer patients (ASPEN, 2002):
Specialized nutrition support should not be used routinely in patients undergoing
major cancer operations.
Perioperative specialized nutrition support may be beneficial in moderately or
severely malnourished patients if administered for 7 to 14 days preoperatively, but the
potential benefits of nutrition support must be weighed against the potential risks of
the specialized nutrition support itself and of delaying the operation.
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Specialized nutrition support should not be used routinely as an adjunct to
chemotherapy.
Specialized nutrition support should not be used routinely in patients undergoing
head and neck, abdominal, or pelvic irradiation.
Specialized nutrition support is appropriate in patients receiving active anticancer
treatment who are malnourished and who are anticipated to be unable to ingest and/or
absorb adequate nutrients for a prolonged period of time.
The palliative use of specialized nutrition support in terminally ill cancer patients is
rarely indicated.
Efficacy of nutrition support has been evaluated in the following types of cancer patients:
In high-risk tumor-bearing patients undergoing intensive chemotherapy
In patients with Wilms', stage III and IV neuroblastomas (Andrassy, 1998).
In relapsed leukemia and lymphoma patients undergoing therapy (Andrassy, 1998)
In malnourished cancer patients undergoing surgery (Ashley, 2000)
In patients receiving radiation to the head and neck (enteral nutrition) (Schattner,
2003)

Gastrostomy tube feedings have been found to be effective in improving and/or
maintaining nutritional status of pediatric cancer patients (Mathew, 1996).
Intervention by a multidisciplinary team, including a registered dietitian, can be
beneficial in decreasing weight loss and managing nutritional impact symptoms
(Dawson, 2002; Isenring, 2004)
Enteral feedings can help promote compliance to treatment regimen in head and
neck cancer patients when gastrostomy is placed before the start of treatment
(Margolis, 2003)
Efficacy of neutropenic diet during the treatment of pediatric cancer:
Neutropenic dietary restrictions remain widely used in institutions; however, there is
lack of evidence supporting this practice (ASPEN, 2009b; Gardner, 2008; Moody,
2006a)
The U.S. Food and Drug Administration and Centers for Disease Control and
Prevention have less restrictive guidelines for these patients because of the lack of
evidence. (USDA, 2006; CDC, 2000; Moody, 2006a)
Dietary restrictions common with the neutropenic diet may have a negative impact on
quality of life (Moody, 2006a; Moody, 2006b)


Goal Setting

The goals for nutrition management in the pediatric oncology patient are to prevent or
reverse nutritional deficits, promote normal growth and development, minimize morbidity,
and maximize the quality of life.

Food & Feeding Issues

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Guidelines to Help Manage Feeding Issues in Pediatric Cancer Patients (AAP, 2004;
Bechard, 2007; Charuhas, 2006; Hunt, 2009; Ladas, 2005)

Mucositis
Serve bland soft/pureed foods
Custards, cream soups, mashed potatoes
Moisten foods with butter, gravies or sauces
Avoid spicy/salty foods
Soothe mouth/esophagus with cold, non-irritating foods
Popsicles, ice cream, milkshakes
Dry Mouth (Xerostomia)
Offer moist foods and liquids
Add extra gravies, sauces, and broths to moisten foods
Offer lemon-flavored, sugarless candies to help stimulate saliva
Encourage frequent mouth rinsing
Make available commercial saliva substitutes
Thick Mucus
Encourage adequate fluid intakes
Provide beverages with citric acid
Offer clear liquids
Encourage good oral hygiene
Changes in Taste
Enhance food flavors and taste
Add extra salt, spices, herbs, flavor extracts, marinades
Try tart or spicy foods
Provide aromatic foods
Give fluids with meals to help wash away tastes
Do not give excessively sweet foods
Avoid metallic silverware
Nausea and Vomiting
Do not feed in rooms that are filled with odors of cooking or uncover food trays in front
of patients
Encourage sipping liquids throughout the day
Avoid high-fat foods
Limit acidic juices/foods
Give breads: toast, crackers
Encourage small, frequent feedings
Use antiemetics
Diarrhea
Increase fiber intakes
Ensure adequate fluids
Provide room-temperature foods, which may be better tolerated
Limit lactose until diarrhea resolves
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Limit juice consumption
Limit fat intakes
Constipation
Ensure adequate fluids
Consider hot/warm food to help stimulate the bowel
Promote high-fiber intakes
Use fruit nectars or prunes
Consider stool softeners or laxatives
Loss of Appetite/Early Satiety
Small, frequent meals and snacks
High-energy drinks between meals
Favorite foods between treatments to help prevent aversions
Appetite stimulant, which may be helpful to improve intakes; use after all other
options have failed
Multiple appetite stimulants are available
Review all side effects before suggesting
For example, caution with megestrol acetate, as it can cause adrenal
insufficiency (Gonzalez Villarroel, 2008)

Enteral or Tube Feeding

In the past couple of decades, the use of enteral nutrition (EN) has become the primary
method of nutrition intervention for children diagnosed with cancer who have difficulty
maintaining optimal nutrition orally (Hunt, 2009; Ladas, 2005; Webb, 2009). Once oral
intakes become inadequate to promote growth or improve the nutritional status, then EN
should be considered first before parenteral nutrition (PN) (Ladas, 2005; Mascarenhas,
2007).
EN is a safe and effective intervention shown to reverse malnutrition in children with cancer
(Ladas, 2005; Mascarenhas, 2007; Ringwald-Smith, 2006). It is common that most children
receiving anticancer treatment will require some form of nutrition support throughout their
course of treatment (Ladas, 2006). Initiating EN has been known to reduce anxiety in
patients, parents, and medical staff related to being unable to meet estimated energy,
protein, and fluid needs orally (Hunt, 2009). Therefore, nutrition support is a critical
supportive-care modality in the nutritional management of children with cancer, in that it
has been shown to improve quality of life and tolerance to chemotherapy and decrease the
risk of infection during anticancer treatment (Ladas, 2005; Ladas, 2006).
EN is indicated in the following circumstances (Andrassy, 1998; Hunt, 2009; Webb, 2009):
Patients have a functioning gastrointestinal (GI) tract
A patient is considered malnourished:
Intakes are less than 70% of estimated daily needs for 5 days
Weight loss of more than 5% since diagnosis
Weight for height is 90% or less of ideal body weight for height or weight for
height percentile is below the 10th percentile
Weight decrease crosses two percentile channels in fewer than 3 months
Body mass index falls below the 10th percentile
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EN is contraindicated when the following occurs (AAP, 2004; Ringwald-Smith, 2006;
Sacks, 2004):
GI tract is nonfunctional
Platelet count is considered low by institutional protocol (ie, policies and procedures)
for placing nasoenteric tubes
May request a platelet transfusion if deemed necessary and then tube could be
placed
Uncontrolled vomiting and/or diarrhea
When patient is considered neutropenic, may consider placing tube once counts are
recovering
Follow institutional guidelines for defining neutropenia
Intestinal obstruction that prevents placement of nasoenteric tube
Patient or parent refuses
Advantages of EN over PN include the following (ASPEN, 2002; ASPEN, 2009b; AAP,
2004; Ladas, 2005; Ladas, 2006; Mascarenhas, 2007; Ringwald-Smith, 2006; Sala, 2004):
Reverses malnutrition/protein–energy malnutrition
Using the gut throughout treatment may help stimulate the patient to consume
adequate intakes, once tolerated
Safe and effective method of nutrition support
Promotes growth and development
More physiologic route
Less metabolic, liver abnormalities, and infectious complications
Supports the integrity of the GI tract
Improves immune system function
More cost-effective than PN
Offers alternative route for administering medications
Decreased potential for bacterial translocation
EN can be administered by multiple modalities; nasoenteric is the most common route
because these tubes can be placed into the stomach, duodenum, and jejunum. These
routes are indicated for short-term use, 3 months or less (Ringwald-Smith, 2006; Sacks,
2009). Enterostomies are becoming more commonly used in children diagnosed with
cancer; these should be considered if enteral feeds are expected to last longer than 3
months (Ringwald-Smith, 2006; Sacks, 2009). The current recommendation of the
American Society for Parenteral and Enteral Nutrition (ASPEN) is to consider a long-term
feeding device if enteral feedings are needed for at least 4 weeks (ASPEN, 2009b).
Characteristics of and considerations for gastric vs. intestinal feedings are outlined below.
Gastric feed (AAP, 2004; Mascarenhas, 2007; Sacks, 2004):
Aids in normal digestion and hormonal response to meals
Allows for bolus schedules
Higher osmotic formulas are better tolerated
Maintains or improves weight in pediatric cancer patients
Nasogastric tubes
Preferred method for short-term use
Simplest and lower cost
Used if little or no reflux
Need normal gastric function
Can be used if patient is at minimal/no risk for aspiration
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Can be used if patient is at minimal/no risk for aspiration
Consider replacing tubes about every 3 weeks during treatment
Gastrostomy tube (GT)
Preferred method for long term
Allows for clear nasal passage/airway
More aesthetic
Intestinal feed (ASPEN, 2009b; ASPEN, 2009c; ASPEN, 2009d; Cao, 2008; Mascarenhas,
2007; Muddana, 2009; Sacks, 2004; Spraker, 2009):
Appropriate for patients with:
Known reflux
Aspiration
Gastroparesis
Gastric outlet obstruction
Frequent emesis due to chemotherapy
Limited to continuous feeds only
Nasoduodenal tube
Short-term use to bypass the stomach
Nasojejunal tube
Short-term use to bypass the stomach
May be placed during pancreatitis if gastric feeds are not tolerated
Formula that may be better tolerated for either gastric or intestinal feeds;
small peptides and medium-chain triglycerides or nearly fat-free elemental
formula
Total PN indicated with pseudocyst or necrotizing pancreatitis
Formulas with higher osmolarity are typically less tolerated
Gastrojejunostomy
Long-term possibility for severe reflux
Short term in patient who already has a GT and is currently not tolerating gastric
feeds
Can drain the stomach and feed the intestine at the same time
Jejunostomy
Placed if jejunal feeds are required for 6 months or longer
Not placed unless all other routes have failed
In determining which enteral formula to use, note that most patients may tolerate a
standard or polymeric formula. However, pediatric cancer patients may develop lactose
intolerance as a result of chemotherapy and will better tolerate a lactose-free formula
(AAP, 2004; Ladas, 2005).
Determine formulas based on the following (AAP, 2004; Sacks, 2004):
GI function
Abnormal function may better tolerate:
Reduced-lactose or lactose-free formulas
Protein hydrolysate
Semi-elemental
Elemental
Age
Infant formulas: 20 kcal/oz to 30 kcal/oz may be used for oral or enteral feedings
Pediatric formulas
In some cases, adult formulas may be used
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Formula composition
Unflavored formulas have lower osmolality and are better tolerated than flavored
varieties
Cost/Resources
Insurance coverage
Consider the following if using nutrient-dense formulas (AAP, 2004; Sacks, 2004):
Increase concentration
Slowly with close monitoring
Only if tolerance to feeds has been demonstrated
Increased concentrations can achieve the following:
Increase renal solute load
Cause abdominal distention
Induce vomiting or diarrhea
Allow fluid-restricted to patients receive more kilocalories
Based on ASPEN enteral nutrition practice recommendations, initiating and advancing
enteral feeds in pediatric patients should be done in the hospital over several days
(ASPEN, 2009c).
Considerations for determining the method of administration and feeding advancement
include the following (ASPEN, 2009c; Ladas, 2005; Sacks, 2004):
Continuous
Feeding pump is required
Helps prevent nausea, vomiting, cramping/distention, and diarrhea
More likely to be tolerated than boluses
Start at a rate of 1 mL/kg/hour to 2 mL/kg/hour and advance by 1 mL/kg/hour
per day as tolerated
Day 1 to provide at least 25% of estimated daily needs
If mucositis, diarrhea or gut atrophy:
May start with half-strength formula at 1 mL/kg/hour to 2 mL/kg/hour
After 12 to 24 hours with tolerance, advance to full strength
Advance rate by 1 mL/kg/hour to 2 mL/kg/hour per day
Bolus
Over gravity or pump
Mimics normal feeding
Do not give boluses in a time shorter than it takes your patient to eat a meal
Initiate a bolus volume of 2.5 mL/kg to 5 mL/kg, given 5-8 times/day
Gradually increase volume to give a goal of 5 boluses/day
Combination of bolus and continuous feeds
Can meet nutrition needs while promoting oral-motor development skills
Allows for a more normal lifestyle
Provides half of estimated needs at night continuously and bolus the other half
with 2 to 3 boluses during the day
Monitor tube feedings by:
Checking body weight and input/output balance daily when initiating EN
Once stable, check twice weekly
If refeeding syndrome suspected:
Increase kilocalories slowly
Monitor laboratory values daily, specifically:
Potassium
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Magnesium
Phosphorus


Parenteral Nutrition

Parenteral nutrition (PN) should only be considered once oral and enteral nutrition (EN) can
no longer provide the energy requirements to promote adequate growth and development
(ASPEN, 2002). Given the increased risk for PN-associated infections in children
undergoing cancer treatment, the American College of Physicians recommends that PN
not be used routinely in patients receiving chemotherapy. PN should, however, be
considered an important supportive care modality for malnourished pediatric patients who
are at risk for severe toxicity from intensive treatments (Christensen, 1993).
It is documented that PN can reverse malnutrition and decrease cancer treatment–related
complications in patients who are malnourished at time of diagnosis (ASPEN, 2002;
Andrassy, 1998; Sala, 2004). Using PN to prevent development of malnutrition in
well-nourished patients does not reduce toxicities from chemotherapy and, when used in
conjunction with chemotherapy, it can be deleterious (ASPEN 2009b).
Indications for use of PN include the following (Bechard, 2007; Haney, 2007; Hunt, 2009;
Ladas, 2005; Ringwald-Smith, 2006; Spraker, 2009; Webb, 2009):
Gastrointestinal (GI) tract is not functional or cannot be accessed
Nutritional status cannot be maintained by EN
GI tract is obstructed by tumors
Uncontrolled nausea/vomiting
Ileus
Surgery when patient is malnourished
Intractable diarrhea
Radiation enteritis requiring nil per os (nothing by mouth) status
Severe mucositis
Necrotizing pancreatitis or pancreatic pseudocysts
Patients are unable to digest or absorb adequate nutrients for 7 to 14 days
Patient is deemed malnourished and intakes meet less than 70% of needs for 5 days
or more and EN is refused
Patient is undergoing hematopoetic stem cell transplant and/or has been diagnosed
with gut graft-versus-host disease
Contraindications for the use of PN include the following (Ladas, 2005; Ringwald-Smith,
2006):
If GI tract is functional
If EN can be initiated and maintain nutritional status of the patient
If not needed for more than 7 days (fewer days in infants/neonates)
Complications associated with PN include the following (ASPEN, 2002; Bechard, 2007;
Ladas, 2005; Ringwald-Smith, 2006; Webb, 2009):
Mechanical
Poor access
Malfunctioning equipment
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Catheter obstruction resulting from precipitation of PN
Infectious
Catheter-related infections
Pediatric cancer patients at increased risk for PN-associated infections
Sepsis
GI
Exclusive PN could lead to gut atrophy
Bacterial translocation
Nutritional
Can cause early satiety
Suppress oral intakes
Delay transition back to oral intakes
Hepatotoxicity/cholestasis
Contributing factors:
Concentration of PN
No oral intakes
Age of patient
Long-term use
Cycle PN if long-term use planned
Metabolic
Refeeding syndrome
Can be life threatening if patient is malnourished and aggressive nutrition
support is initiated
Malnourished pediatric cancer patients are susceptible
Monitor the following when starting PN:
Fluid tolerance
Glucose tolerance
Electrolytes:
Potassium
Magnesium
Phosphorus
Cardiac, pulmonary, and neuromuscular functions
PN prescription is as follows (AAP, 2004; Andrassy, 1998; Ladas, 2005; Sacks, 2004;
Trujillo, 2006; Webb, 2009):
Peripheral PN is rarely used in pediatrics
Dextrose concentrations are limited to keep osmolarity below 1,000 mOsm/L
Difficult to meet required nutrition needs
Can be used temporarily if central access is delayed
PN should include dextrose, protein, lipids, electrolytes, multivitamins/minerals, and
trace elements
Based on standard nutrient requirements
Adjust when needed based on clinical situation
Iron should not be given during PN when patient is receiving frequent blood
transfusions
Energy requirements
Provide at least resting energy expenditure (REE) or a minimum of 90% of total
energy needs to prevent lean muscle loss
Goal to prevent weight loss and cancer cachexia
Promote growth and development
Protein requirements
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Start with the Dietary Reference Intakes (DRI), but patient needs may be as
follows:
Infants: 2.2 g/kg/day to 3.5 g/kg/day
Older than 1 year of age: 2 g/kg/day to 3 g/kg/day
Prevent negative nitrogen balance caused by increased protein turnover
Increase protein to promote healing/recovery after chemotherapy, radiation, or
tumor resections
Dextrose requirements
Administration:
Infant (older than 28 days): 5 mg to 6 mg glucose/kg/minute, advance 1
mg/kg/minute to 2 mg/kg/minute every 24 hours, to a maximum of 15
mg/kg/minute
Children and adolescents (weighing more than 20 kg): 8 mg to 14 mg
glucose/kg/min
Maximum dextrose concentration: 25%
Advance dextrose concentration slowly and monitor tolerance
Tumors use anaerobic breakdown of glucose for energy
Increases glucose intolerance secondary to decreased insulin
sensitivity
Steroids are used frequently in cancer treatment
Elevates blood glucose levels
Need tight control
May need insulin
Lipid requirements
Should supply 20% to 60% of energy
Provides dense energy
Essential fatty acid requirements can be met by supplying 0.5 g/kg/day to 1
g/kg/day
3 g/kg/day, maximum per 24 hours
Can become deficient within 20 days, need to start lipids if on PN
for more than 10 days
Cancer increases rate of lipid breakdown
Monitor triglycerides
Some chemotherapy agents can increase levels
Levocarnitine
Added to PN to help fatty acid uptake by mitochondria
Considerations in PN include the following (Webb, 2009):
Tumor lysis syndrome
Mainly seen in leukemia patients
Occurs when tumor cells die and are released into the bloodstream
Causes acute electrolyte imbalances
Closely monitor the following when on PN:
Potassium
Magnesium
Phosphorus
Calcium
Prominent in patients who have high white blood counts or large tumor burdens
at initiation of chemotherapy
If potential for tumor lysis, consider waiting on starting PN until electrolytes are
stable
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Pancreatitis
Steroid or chemotherapy induced
May take 3 to 4 days to resolve
Severe cases complicated by; pseudocyst, hemorrhage, necrosis may require
PN vs EN (Haney, 2007; Spraker, 2009)
EN recommended for acute pancreatitis, nasogastric or nasojejunal tube can
be used (See Nutrition Support: Enteral Guidelines) (ASPEN 2009d; Cao 2008;
Muddana 2009)
IF PN started;
Can use lipids if triglycerides are within normal limits
Provide REE and protein at or above the DRI for age
Monitor blood glucose levels closely
Mucositis
GI lining damage from chemotherapy and/or radiation
Ulcers along the epithelial and mucosal linings
Chemotherapy: along the whole GI tract
Radiation: damage at site
Develops 3 to 4 days after treatment initiated
Resolves in 2 to 3 weeks after completion of therapy
Very painful and limits oral intakes
Monitor weights closely
Encourage oral diet first as tolerated
PN is typically given to these patients; however, recent research finds that EN
may have better response
EN allows the GI tract to be stimulated by contact with nutrients, which can
decrease the inflammatory response and promotes cell regeneration
Transition back to GI feeds (Andrassy, 1998; Bechard, 2007; Ladas, 2005;
Ringwald-Smith, 2006):
When on PN, trophic feeds can be given during times of toxicity from intense therapy
As little as 5 mL/hour can protect the mucosal barrier and decrease bacterial
translocation
Initiation of EN should start as soon as GI tract is functional
Patients should slowly be transitioned back to per os (by mouth)/EN feeds
Once EN or oral intakes tolerated, PN can be discontinued

Nutrient Exceptions to DRI

Recommendations for vitamins and minerals for pediatric cancer patients are to ensure that
the Dietary Reference Intakes (DRI) are being met for age and sex (AAP, 2004). There is
little information regarding specific recommendations for patients receiving therapy, but it is
known that these patients are at increased risk for depleted nutrient stores secondary to
the following effects (AAP, 2004; Hurst, 2006; Ladas, 2005; Ringwald-Smith, 2006):
Decreased oral intakes
Increased losses from the following:
Kidney excretion
Vomiting
Diarrhea
Common side effect to chemotherapy
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Most common vitamins and minerals depleted
Calcium
Vitamin D
Magnesium
Phosphorus
Potassium
Zinc
Cancer may alter metabolism of the following:
Iron
Vitamin C
Vitamin E
Selenium
Zinc
Copper
If oral intakes do not meet DRI recommendations for vitamins and minerals, a
multivitamin/mineral that provides 100% of the DRI should be give daily or provide
intravenous supplementation when appropriate (AAP, 2004). The nutrients mentioned
previously on this page should be monitored closely and supplemented when needed.
Exceptions are as follows (AAP, 2004):
In patients receiving methotrexate, additional folic acid should not be given
Exception: Patients undergoing hematopoietic stem cell transplant or
immediately after may need additional folic acid supplementation (Link, 1986;
Lipkin, 2005; Roberts, 2005; Seattle Cancer Care Alliance, 2002)
In patients receiving frequent blood transfusions and/or going through hematopoietic
stem cell transplant, do not supplement iron (Majhail, 2008; Shander, 2009; Seattle
Cancer Care Alliance, 2002)
Anticipating and understanding each patient's treatment course for diagnosis and its side
effects on nutritional status is essential in planning an effective nutrition intervention
(Ladas, 2005).


Nutrition Monitoring & Evaluation

Nutrition monitoring and evaluation is the final step of the Nutrition Care Process (ADA,
2007).
Example for Monitoring and Evaluating Nutrition Intervention for Enteral Nutrition
Intake (FH-1.3.1):
Determine criteria for evaluation:
Goal: Enteral nutrition to start within 48 hours.
Sample nutrition assessment and monitoring and evaluation
documentation: Patient enteral nutrition has not been started, physician
has ordered enteral nutrition to start within 24 hours at inital rate of 10
mL/hr * 24 hours with advancement schedule of 5 mL/hr increase every 4
hours until goal of 50 mL/hr * 24 hours is reached. Monitor start time and
advancement of enteral nutrition.
Goal: Enteral nutrition is to meet ___% of estimated nutrition needs
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Goal: Enteral nutrition is to meet ___% of estimated nutrition needs
Sample nutrition assessment and monitoring and evaluation
documentation: Patient enteral nutrition intake currently meeting ___% of
estimated needs, to continue advancement by 5 mL/hr every 8 hours until
goal of 65 mL/hr * 18 hours is reached to provide___% of estimated needs.
Monitor enteral nutrition rate and advancement to meet goal.
Goal: Patient to receive a 120 mL bolus five times daily
Sample nutriton assessment and monitoring and evaluation
documentation: Patient enteral nutrition intake of 120 mL bolus five times
daily has been met for the past 3 days, continue to monitor enteral nutrition
intake.

Nutrition Care FAQs

1. Is it safe to use multivitamins/herbal supplements during treatment?
Multivitamins are typically not given during treatment unless there is concern for
deficiency. If there is a concern regarding a specific vitamin or mineral, then that
individual vitamin or mineral may be supplemented once approved by the primary
physician (AAP, 2004). Folic acid/folate is typically not recommended throughout the
course of treatment given its interaction with methotrexate (AAP, 2004). If a
multivitamin is to be administered to a patient, it will need to have no or low folic
acid/folate and, if the patient receives blood transfusions, no iron. This
supplement has to be approved by the primary physician (AAP, 2004).
Herbal supplements are not recommended due to the lack of research to ensure
safety and interactions during the course of treatment (Sencer, 2004). Depending on
the physician, they may be allowed in palliative/hospice patients.
Antioxidant supplements may reduce treatment side effects but should not be
consumed because antioxidants can also decrease the effectiveness of
chemotherapy (Molseed, 2006; Sencer, 2004).

2. What kind of foods should my child be eating?
Encourage variety of foods, ensuring all food groups are being consumed. Patients
may require additional energy and protein, so appropriate foods to meet those
needs should be recommended (Ringwald-Smith, 2006). Recommend that patients
be given favorite foods after the side effects of therapy have subsided; if given before
side effects the patient may be at risk for oral aversions later (Hunt, 2009). In regards
to any form of therapeutic diets promoted on the Internet or in the lay press, the
American Society of Parenteral and Enteral Nutrition recommends that patients not
follow them because their is little or no evidence that they are effective (ASPEN
2009b). Therapeutic diets to avoid, but not limited to: "macrobiotic diets," diets that
encourage pancreatic enzymes for dextoification and the Gerson diet (ASPEN
2009b).
3. Are there any diet restrictions when my child is going through therapy?
Some institutions will require neutropenic patients to follow a neutropenic or
low-bacteria diet. However, studies that show if this is beneficial are limited. In any
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case caution should be taken during handling food to decrease risk of food borne
infections—for instance, proper washing of fruits and vegetables, avoiding
cross-contamination, and cooking meats thoroughly before consumption are
precautions that are recommended (Hunt, 2009; Ringwald-Smith, 2006). For more
information on food safety, refer to the food safety heading under Meal
Plans>Oncology.

Cancer Cachexia

Cancer cachexia is reported to occur in 15% to 49% of newly diagnosed patients, 24%
individuals with advanced cancer, and 80% of patients with terminal disease (Inui, 2002;
Strasser, 2002).
Cancer cachexia is defined as a severe state of malnutrition characterized by anorexia,
weight loss, muscle wasting, and anemia (Bechard, 2006; Trujillo, 2006). The anorexia
associated with cancer cachexia is multifactoral including physiologic (metabolic, physical,
neuroendocrine/immune), psychologic (stress from the illness as well as family and work),
and socioeconomic (changes in income and personal relationships with friends/family)
factors (Marian, 2009).
Cancer cachexia may also include a variety of metabolic phenomena, including the
following (Marian, 2009):
Hypoalbuminemia
Hypoglycemia
Lactic acidosis
Hyperlipidemia
Impaired hepatic function
Glucose intolerance with insulin resistance
Elevated gluconeogenesis
Skeletal muscle atrophy
Visceral organ atrophy
Anergy
Treatment of cancer cachexia often requires pharmacologic and nutrition interventions
since cachexia has not been proven to respond to feeding alone. Pharmacologic
interventions proven to be effective in treating cancer cachexia include the following
(Marian, 2009, St. Jude Guidelines):
Progestational agents
Cannabinoids
Prokinetic agents
Antiserotonergic agents
Anabolic agents


Complementary and Alternative Medicine

The use of complementary and alternative medicine (CAM) has increased dramatically
during the past 20 years. Pediatric patients undergoing treatment for chronic and
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catastrophic diseases may be likely to use CAM because these patients’ parents may be
willing to experiment with any product that could decrease their child’s suffering and “cure”
the disease (Bold, 2001).
A survey conducted by Friedman et al (1997) showed that 65% of pediatric patients with
cancer (n=81) and 51% of the control group (children with routine medical problems, n=80)
used CAM. Fernandez et al (1998) found that in a group of 366 pediatric patients with
cancer, 156 (42%) used CAM during initial medical therapy or after completion of therapy,
and 49 (13.4%) first used CAM after their cancer relapsed. In the Netherlands, Grootenhuis
et al (1998) examined the use of CAM in the families of 84 pediatric patients with
malignancies. They found that 31% of the families had used or were still using alternative
therapies; 46% of the families with a child with relapsed disease used alternative therapies,
and only 16% of the families with a child whose disease was in remission used CAM—a
finding that suggests that CAM use is related to a survival perspective. In Washington
State, Neuhouser et al (2001) conducted telephone interviews with the parents of children
diagnosed with cancer. Their results showed 59 (78.7%) of the parents reported that their
child used at least one form of CAM within the past 12 months. In 2009, a study conducted
by Post-White et al (2009) reported children with chronic and life-threatening illness use
more CAM therapies than children seen in primary care clinics. The top three reported
reasons for using CAM in children with cancer were to manage treatment side effects, to
cope with emotional effects, and to feel more hopeful (Post-White, 2009).
The National Institute of Health (NIH) defines CAM as “those healthcare and medical
practices that are not currently an integral part of conventional medicine” (NCCAM,
2007). The NIH has grouped CAM practices into five domains—these domains and
examples of each are presented in the following table.

Major Types of CAM
Major Types Examples
Whole medical
systems
Western culture
Homeopathic medicine
Naturopathic medicine
Non-Western culture
Traditional Chinese medicine
Ayurveda
Mind–body medicine
Patient support groups
Cognitive behavioral therapy
Meditation
Prayer
Mental healing
Creative therapies: art, music,
dance
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Biologically based
practices
Dietary supplements
Herbal products
Natural products (scientifically
unproven therapies)
Manipulative and
body-based practices
Chiropractic or osteopathic
Massage
Naturopathy
Energy medicine
Biofield therapies
Qi gong
Reiki
Therapeutic touch
Bioelectromagnetic-based therapies
Pulsed fields
Magnetic fields
There are very little scientific data about the consequences of using many of the forms of
CAM during conventional therapy for cancer. However, concerns include toxicities
associated with nonconventional therapies for cancer and/or possible interactions with
chemotherapy (Paltiel, 2001). Investigators have obtained data about the contamination of
CAM products, the production of which is not regulated by the US government, and the
potential interference of CAM products in the reactions of certain chemotherapy agents. In
1994, the National Cancer Institute tested shark cartilage, used for “cancer cures,” in a trial
that was abruptly discontinued after investigators discovered that each batch of cartilage
obtained for the study was contaminated (Ernst, 1998). Contamination can cause serious
health problems in patients who are immunosuppressed. Without federal regulation,
manufacturers may be less stringent in their manufacturing or quality-control practices than
regulated manufacturers; thus, CAM manufacturers may be more likely to produce
products that are contaminated with potentially hazardous material.
Furthermore, Labriola et al (1999) found dietary antioxidants and chemotherapeutic agents
may interact with one another. Limited data to date suggest that concurrent administration
of antioxidants may result in either potentiation or inhibition of radiation therapy and
chemotherapy (Weiger, 2002). Excess antioxidants can decrease the concentration of free
radicals generated by chemotherapy and radiation therapy. Such a reduction can have the
same effect as a reduction in the dose of the chemotherapeutic agent or radiation
itself. Labriola postulated that antioxidants can also interfere with a drug’s ability to destroy
micrometastases; thus, antioxidants may improve the patient’s short-term tolerance of the
chemotherapeutic agent or radiation but worsen the long-term risk of disease recurrence
(Labriola, 1999).
In addition to the risk of contamination and altered drug efficacy, there are several negative
drug–herb interactions that can occur. A review article by Miller reported several
medications commonly utilized during oncology treatment that are known to have negative
interactions with commonly utilized herbs (Miller, 1998). The table below highlights these
interactions.
Several studies looking at the use of CAM in pediatric cancer patients have indicated that
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patients often do not disclose their use of CAM (Post-White, 2009; Myers, 2005). In one
study, the most common reason for not disclosing CAM use was that the patients were
never asked (2009). In light of the increase in CAM use, it has become apparent that
nutritionists must include the use of CAM in their evaluations.
Potential Herb–Drug Interactions




























Medications/Therapeutic
Class
Potential Herbal
Interactions
Possible Adverse
Effects
Antidepressants

Herbs containing
sympathomimetic
amines (eg, agnus
castus alkaloids,
calamus amines, cola
alkaloids, broom
alkaloids, licorice)
Increased risk of
hypertensive crisis
with monoamine
oxidase inhibitors;
may potentate
sedative side effects
Ginkgo biloba
Use with tricyclic
antidepressants or
other medications
known to decrease
the seizure
threshold is not
advised
Antidiabetic drugs


Herbs containing
hypoglycemia or
hyperglycemic agents
(eg, alfalfa, fenugreek,
ginseng)
Possible
antagonism or
potentiation of
action
Herbs containing
diuretic agents (eg,
broom, buchu, corn silk,
juniper)
Antagonistic effects
Chromium, karela
May affect blood
glucose levels,
complicating insulin
and chlorpropamide
requirements,
respectively
Antifungals
Herbs containing
anticholinergic agents
(eg, corkwood tree)
Possible decreased
absorption of
ketoconazole
Herbs containing
diuretic agents (eg,
broom, buchu, corn silk,
juniper)
Possible risk of
increased
potassium loss
Herbs containing
corticosteroid agents or
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Corticosteroids

corticosteroid agents or
action (eg, bayberry)
Herbs, vitamins, and
minerals with
immunostimulating
effects (eg, echinacea,
astragalus, licorice,
alfalfa sprouts, vitamin
E, zinc)
May offset the
immunosuppressive
effects of
corticosteroids
Immune-system affecting
drugs
Herbs containing
immunostimulant agents
(eg, boneset, echinacea,
mistletoe)
Possible
antagonism or
potentiation
Ketaconazole Echinacea
Unpleasant taste,
liver toxicity
Methotrexate



Herbs containing
sufficient levels of
salicylates (eg, willow,
poplar, meadowsweet)
Possible increased
risk of toxicity
Folic acid
Folate depletion,
may affect
chemotherapy, may
affect drug
performance and
toxicity
Vitamin A
Enhances antitumor
activity in animals.
Vitamin B-12
(cobalamin)
May lower B-12/red
blood cell levels
Phenobarbital
Thujone-containing
herbs (eg, wormwood,
sage) and gamolenic
acid-containing herbs
(eg, evening primrose
oil, borage)
May lower seizure
threshold
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Oncology > Medications for GI Problems
Agents to Enhance Upper GI Motility

Metoclopramide and Erythromycin
Common uses for metoclopramide include aiding nasogastric intubations, improving
volume-related feeding intolerance, improving delayed gastric emptying, and reducing
gastroesophageal reflux. It is used as an antiemetic.
Erythromycin has been used for improving feeding tolerance and delayed gastric emptying.
It is an antibiotic.
Mechanisms of Action
Metoclopramide blocks dopamine and serotonin (5-HT3) receptors and probably increases
release of acetylcholine in the gut, which results in increased forward peristalsis in the
stomach and duodenum (Chicella, 2005; Curry, 2001).
Erythromycin has similar effects in the stomach and upper bowel, although the mechanism
is through stimulation of motilin receptors. (Motilin is an endogenous hormone that
stimulates gastric and upper bowel motility.)
Dietary Implications
These drugs are used frequently when patients have delayed gastric emptying with early
satiety. They are commonly used for enteral feeding when the patient has poor tolerance
to feeding because of higher-volume feedings. Published data regarding the benefits of
erythromycin outnumber the data regarding metoclopramide for enhancing tolerance to
feeds in pediatric patients (Chicella, 2005; Curry, 2001). There is a lack of data for either
agent being associated with improved clinical outcomes. For example, most data do not
demonstrate a reduced risk of aspiration pneumonia with the use of prokinetics. (Ridley,
2011) Tachyphylaxis (reduced effects over time) has been reported with prokinetic agents
in the adult critical care setting.(Ridley, 2011) Feeding success was significantly less at 3
or 7 days than after the first day of prokinetic agents. Combination therapy with both
agents has been suggested when a single agent fails, but little data has been published on
this practice.
By changing gut motility, it is possible that the absorption of specific nutrients might be
increased or decreased, as happens with absorption of medications. However, there are
few if any data published on this subject, and presumably normalization of gut motility is
more likely to result in normalized absorption of nutrients than to adversely affect them.
Erythromycin oral products may be absorbed better if they are administered with food, with
the exception of erythromycin stearate and erythromycin base. The latter is absorbed
reasonably well with food as an enteric coated tablet but is not a good product to
reformulate into a liquid for administration.

Concerns for Prescribers
Although erythromycin inhibits the clearance of many drugs that are metabolized by P450
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Although erythromycin inhibits the clearance of many drugs that are metabolized by P450
3A4 or 1A2 enzymes, the low doses used for motility are not likely to be a problem.
Similarly, gastric distress and diarrhea are less likely to occur at the lower doses.
Pediatric patients have a higher risk of extrapyramidal reactions (akathisias or dystonias)
from dopamine blockers like metoclopramide, so many pediatric physicians minimize their
use of dopamine blockers. Diphenhydramine or lorazepam are sometimes used for
prophylaxis or treatment of extrapyramidal reactions. Tardive dyskinesias are extremely
rare but have been reported. They can be permanent and the package insert contains a
boxed warning about this adverse effect. (Taketomo, 2009; Novak, 2009)

Antiemetics

Antiemetics have been studied mostly for use in patients receiving chemotherapy, having
specific types of surgery, or receiving radiation therapy. Serotonin receptor antagonists and
dopamine blockers are commonly used for all three etiologies of nausea and vomiting.
There are many other causes of nausea and vomiting in pediatric oncology patients; for
example, stomach distension from enteral feeding, opioids, ileus, bowel obstruction,
mucositis, and oral infections such as candidiasis. It is important to determine the cause of
the nausea and vomiting, if possible, in order to choose the best possible treatments.
Although antiemetics may be helpful, there is less documentation for efficacy of antiemetics
when used for these other causes of nausea and vomiting.
For chemotherapy-induced nausea and vomiting, several sets of guidelines are available
on the Internet, including guidelines from the American Society of Clinical Oncology (Kris,
2006), the National Comprehensive Cancer Network (NCCN, 2010), and the Multinational
Association of Supportive Care in Cancer (MASCC, 2010). In addition, excellent reviews of
treatment of chemotherapy-induced nausea and vomiting are available (Hesketh, 2008;
Schwartzberg, 2007).

Commonly Used Antiemetics
Serotonin Receptor (5HT3 or 5-hydroxytryptamine-3) Antagonists
Ondansetron, Granisetron, Dolasetron, Palonosetron

Receptors in the gut and chemotherapy receptor trigger zone are blocked by these
agents.
Oral route works as well as intravenous.
They are the most effective class of agents available for chemotherapy-induced
emesis.
They are mostly effective for acute nausea and vomiting (first 24 hours after
chemotherapy), and they are more effective at reducing vomiting than nausea.
Palonosetron is longer acting than the others, but is currently much more expensive.
Most common adverse effects are headaches with higher doses and constipation with
multiple-day therapy.
They cause some prolongation of cardiac QTc interval but this is thought to usually be
clinically insignificant.

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Neurokinin-1 Receptor Antagonists
Aprepitant and Fosaprepitant
Substance P is the ligand for this receptor.
The major effect is reducing delayed nausea and vomiting after chemotherapy.
The typical indication is for highly emetic chemotherapy, and in a combination with a
glucocorticoid and serotonin receptor antagonist.
These have generally been administered in the first 3 days of the chemotherapy
regimen, even for reducing delayed emesis.
Aprepitant is administered orally. Fosaprepitant is a more water-soluble form that can
be administered intravenously at a slightly lower dose, or recently it has been shown
to be non-inferior to the oral dosage regimen when given in a higher intravenous dose
(150mg for adults) only on day one of the regimen. (Grundberg, 2011)
Dosing regimens for pediatrics are not well established and are not approved by the
US Food and Drug Administration.
Glucocorticoids
Dexamethasone, Methylprednisolone Sodium Succinate
Mechanism of action is not established.
These are generally used in combination with serotonin receptor antagonists or
metoclopramide.
They may be useful as single agents for mild to moderately emetic chemotherapy.
They are useful for delayed and acute nausea and vomiting.
The most common short-term adverse effects are hyperglycemia, gastritis, mental or
behavioral changes, increased appetite, and occasionally elevations of blood
pressure.

Phenothiazines (prochlorperazine, chlorpromazine, promethazine), Butyrophenones (haloperidol, droperidol),
and Atypical Antipsychotics (olanzapine)
These agents block dopamine receptors but also may block cholinergic and alpha
adrenergic pathways.
They are generally not as effective as serotonin receptor antagonists but are usually
effective for moderately emetic chemotherapy. They have also been used for
breakthrough or delayed nausea and vomiting. Olanzapine has only been used for
breakthrough or difficult-to-treat cases.
Side effects include sedation, anticholinergic effects such as urinary retention and
constipation, and alpha-adrenergic blockade causing hypotension.
A major adverse effect is extrapyramidal effects such as akathisias (restlessness) and
dystonias (muscle contractions—torticollis, oculogyric crisis, trismus). Many pediatric
practitioners limit the use of these agents because of the higher risk of extrapyramidal
side effects in pediatrics. Diphenhydramine may prevent or treat both types of effects,
and lorazepam is helpful for akathisias.
Droperidol can lengthen the cardiac QTc interval.

Cannabinoids
Dronabinol, Nabilone
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Dronabinol, Nabilone
The mechanism is not clear although there are cannabinoid receptors in the brain.
These agents are synthetic tetrahydrocannabinol, the active ingredient of marijuana.
They are generally used as second or third line agents when more common drugs are
not controlling vomiting.
There are many side effects, including euphoria or dysphoria, hypotension,
tachycardia, increased appetite, dry mouth, and hallucinations.
There are not a lot of published data on pediatric use.

Antihistamines
Diphenhydramine and Benzodiazepines (Lorazepam)
Neither of these agents has good antiemetic activity for chemotherapy-induced
nausea and vomiting. However, sedation can help a patient sleep through nausea
and vomiting.
Lorazepam is effective in reducing akathisias caused by dopamine-blocking
antiemetics.
Diphenhydramine is effective in reducing akathisias and dystonias caused by
dopamine-blocking antiemetics.
Both of these agents normally cause sedation, but there is a risk that paradoxical
reactions might occur in pediatric patients, resulting in agitation.
Lorazepam in higher doses can cause weepiness or hallucinations.
Lorazepam can cause anterograde amnesia, which can be useful in reducing
anticipatory nausea and vomiting.
(Taketomo, 2009; Novak, 2009)
Dietary Implications
Since nausea and vomiting can reduce oral intake, antiemetics can help increase intake of
food and oral liquids. It is important to maintain good hydration in the patient to reduce
nausea and vomiting as well as toxicities such as electrolyte changes or nephrotoxicity.
Acute change in the patient's weight, especially with intake and output, can be a good
indicator of changes in hydration status.
Glucocorticoids can increase appetite and are sometimes used for that purpose. Increases
in weight can result from increased energy intake, although acute weight increases also
could result from fluid retention. Glucocorticoids increase blood glucose in many patients by
blocking the effects of insulin and by increasing liver gluconeogenesis. The negative
anabolic effects of glucocorticoids reduce muscle mass and increase blood urea nitrogen.
Chronic use of glucocorticoids reduces synthesis of collagen causing easy bruising and
skin tears, and reduced absorption of calcium causes osteomalacia and osteoporosis.
Osteonecrosis (avascular necrosis) can also occur. Mineralocorticoid effects of
glucocorticoids occasionally cause hypertension and potassium loss with hypokalemia.
Cannabinoids, which can increase appetite, are discussed in the Appetite Stimulants
section.
When used chronically as an antipsychotic, olanzapine can cause weight gain and increase
the risk of metabolic syndrome. It should not be used chronically as an antiemetic.
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Droperidol, serotonin receptor antagonists, and olanzapine can potentially cause prolonged
QTc syndrome with arrhythmias. Electrolyte disturbances (specifically low potassium or
magnesium) increase the risk of arrhythmias with these agents.
(Hesketh, 2008; Schwartzberg, 2007)

Appetite Stimulants

A number of factors can cause weight loss in cancer patients. (Del Fabbro, 2011;
Donohoe, 2011) Common issues include nausea and vomiting from medications or
disease, loss of taste from chemotherapy agents, and cachexia that is most likely the result
of release of cytokines and metabolic dysfunction (Fearon, 2011; Lee, 2011). Weight gain
may not occur even if nutritional intake is increased. Intervention prior to weight loss in high
risk patients may be of benefit (Donohoe, 2011). Studies of medications that might prevent
or reverse weight loss have yielded mixed results (Donohoe, 2011). Progestins and
glucocorticoids have shown a benefit in some studies of cancer-induced weight loss
(Yavuzsen, 2005); however, weight gain from megestrol (progestin) may consist more of fat
and water than lean body mass (Loprinzi, 1993). Glucocorticoids cause loss of lean body
mass over time because of their negative anabolic effects, leading to muscle weakness
with chronic use.
Medications Used As Appetite Stimulants
Glucocorticoids
Prednisone, methylprednisolone, and dexamethasone have resulted in increased
appetite and weight gain in cancer patients.
In addition to the short-term adverse effects discussed in the Antiemetics section,
chronic side effects—such as osteoporosis, osteonecrosis, cataracts, easy tearing of
the skin, and loss of muscle strength—complicate therapy.
These agents are often reserved for shorter-term, hospice-based treatment of weight
loss.

Progestins
Megestrol, Medroxyprogesterone
Numerous studies have shown increased appetite and weight gain, including 7
patients in one pediatric study (Couluris, 2008).
Weight gain may consist more of fat and fluid than lean body mass (Loprinzi, 1993).
There are a number of uncommon but serious adverse effects: thrombophlebitis,
impotence in men, photosensitivity, and Cushing’s syndrome or Addisonian crisis.
The authors of one study suggested that all children treated with megestrol should
receive hydrocortisone replacement therapy due to the frequency and potential
severity of the adrenal suppression (Orme, 2003).

Cannabinoids
Dronabinol
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Cannabinoids are approved by the US Food and Drug Administration to treat anorexia
in patients with acquired immune deficiency syndrome. Very few data regarding
cancer or pediatric patients have been published. Studies in cancer patients have not
clearly shown beneficial effects on weight in spite of increased appetite (Jatoi, 2002;
Strasser, 2006).
Doses used for appetite stimulation (2.5 mg twice daily in adults) are lower than those
used in nausea and vomiting, so there are fewer problems with the adverse effects
listed in the antiemetic section.

Serotonin Antagonist/Antihistamine
Cyproheptadine
A study of adult patients showed increased appetite without reducing weight loss
(Kardinal, 1990).
A study of pediatric patients showed weight gain in cancer patients (Couluris, 2008).
Additional pediatric studies are ongoing.
(Yavuzsen, 2005)
Dietary Implications
Although many of these drugs have been shown to increase appetite, in general, the value
of these agents in gaining or maintaining weight and improving nutritional status in cancer
patients is unclear.

Medications that Block Stomach Acid Secretion

Ulcers and gastroesophageal reflux disease are the main indications for using gastric acid
blocking medications approved by the US Food and Drug Administration. In oncology
patients, these agents are also commonly used for gastritis or mucositis that can occur
from chemotherapy. The most important agents that block acid secretion are proton pump
inhibitors and H-2 receptor antagonists.
Antacids or sucralfate are reasonable alternatives for short-term use in pediatrics, but
absorption of aluminum from these products contraindicates chronic use.

H-2 Receptor Antagonists
Famotidine, Ranitidine, Nizatidine, Cimetidine
These receptors block histamine-induced acid secretion.
Higher doses block acid secretion better than lower doses; neither raises gastric pH
as much a proton pump inhibitors.
Tolerance to the acid neutralization has been reported after several days (Whitworth,
2004).
Cimetidine can inhibit the metabolism of some drugs, but the other drugs in this class
do not affect metabolism of other drugs significantly.
Raising gastric pH by administering these drugs may alter the absorption of some
pH-sensitive drugs.
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Side effects are uncommon, but headaches, sedation, and gastrointestinal symptoms
are occasionally reported. Lower blood counts have been reported on rare occasions;
many transplanters avoid the use of these agents in hematopoietic stem cell
recipients.
All four medications are available in nonprescription products.
(Taketomo, 2009; Novak, 2009)
Proton Pump Inhibitors
Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Rabeprazole)
These medications block the “proton pump” (hydrogen-potassium ATPase), blocking
acid secretion from all stimuli.
There is some evidence for efficacy in pediatric patients with gastroesophageal reflux
disease (Whitworth, 2004), but efficacy is debatable, especially for infants (van der
Pol, 2011). Parenteral esomeprazole was FDA approved in 2011 for short term use
in pediatric patients one-month to 17 years old that have gastroesophageal reflux
disease with erosive gastritis.
Acid suppression is optimal when these drugs are given approximately 30-60 minutes
before a meal (especially early in the day) (Hatlebakk, 2000).
Omeprazole can inhibit the activity of some hepatic P450 metabolizing enzymes;
other agents in the class have not been shown to alter enzyme activity to a significant
degree.
Adverse effects are uncommon but can include headaches or gastrointestinal
symptoms. Possible associations with anemia secondary to deficiency of folate,
vitamin B-12, or iron, and associations with increased risk of Clostridium difficile
infections, osteoporosis, fractures, pneumonia, hypomagnesemia have been
reported. (Tanzi, 2010; Roux, 2009; Sharma, 2004; Urquhart, 2010; Thomson, 2010;
Eom, 2011a; Eom, 2011b; Gill, 2011; Cundy, 2011)
Administration techniques for these medications with enteral nutrition depend on the
size and location of the tube and the product being used. Recommendations have
been summarized elsewhere (Wohlt, 2009).
Omeprazole and lansoprazole are available in nonprescription formulations.
(Taketomo, 2009; Novak, 2009)
Dietary Implications
The increased gastric pH resulting from these medications may reduce the absorption of
folate and vitamin B-12 from food and of iron from food or iron supplements. Case reports
of clinical deficiencies have been reported but have not been shown to be common.

Medications for Mucositis

Radiation or chemotherapy (especially conditioning regimens for hematopoietic stem cell
transplant) can cause ulcerations in the mouth and gut that are referred to as mucositis or
stomatitis. After chemotherapy, mucositis follows roughly the same time course as
neutropenia, peaking at 7 to 14 days and resolving with or without treatment by 21 days.
Medications used for mucositis either treat the symptoms (pain) or attempt to prevent
mucositis (Keefe, 2007; Rosenthal, 2009).
Palifermin is used for prevention or reducing the severity of mucositis in patients with
hematologic malignancies receiving hematopoietic stem cell transplants. Traumeel S is a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
hematologic malignancies receiving hematopoietic stem cell transplants. Traumeel S is a
combination of herbals and supplements that may reduce the frequency of mucositis.
Glutamine, Caphosol, and chlorhexidine are also used in attempts to reduce mucositis or
heal it more rapidly. Local anesthetic combinations, opioids, Gelclair, and sucralfate are
medications that have commonly been used to reduce the pain of mucositis.

Medications for Prevention or Reduction of Duration and Severity of Mucositis
Palifermin
It is a recombinant human keratinocyte growth factor.
Only approved by the US Food and Drug Administration (FDA) for use in patients with
hematologic malignancies who are receiving hematopoietic stem cell transplants.
There is theoretical concern that it could stimulate solid tumor growth. Studies in solid
tumor patients are few and have mixed results, however there is some evidence for
efficacy after chemotherapy or chemoradiotherapy (Rosen, 2006; Henke, 2011; Le,
2011).
Data suggest that it may reduce the duration and severity of mucositis and reduce
opioid use.
Most of the data are based on patients receiving autologous transplants, but
most hematologic malignancies are treated with allogeneic transplants.
It is very expensive and can cause “thick tongue,” altered taste, and rashes.
Traumeel S
It is a homeopathic remedy containing a dozen herbals and supplements
It does not have many side effects.
There is one favorable study in pediatric patients (Oberbaum, 2001), but a larger
Children's Oncology Group study with 190 hematopoietic stem cell transplant patients
had negative results (Sencer, 2009).
It is purchased at health food stores, not available by prescription.
Chlorhexidine
It has antiseptic/antifungal properties. Mouth infections may cause or worsen
mucositis.
There is minimal evidence for benefits; not recommended for prophylaxis or
treatment by the Multinational Association of Supportive Care in Cancer (MASCC)
guidelines.
Most products contain ethanol, which can elicit pain in a patient that has mucositis.
Caphosol
It is a neutral pH super-saturated solution of calcium and phosphate used as a mouth
rinse to reduce the risk and severity of mucositis
One double-blinded study in hematopoietic stem cell transplant patients of
unspecified age (n=95) compared Caphosol plus fluoride rinses to fluoride rinses
alone and showed a very significant benefit to the Caphosol. No adverse effects were
reported (Papas, 2003).
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Glutamine
It is an amino acid that is thought to help maintain the integrity of the gut during times
of stress, such as mucositis or during total parenteral nutrition.
Some data have suggested efficacy in preventing or treating mucositis; however, the
MASCC guidelines do not recommend the use of glutamine.
A recent pediatric study of glutamine-enriched total parenteral nutrition in well
nourished allogeneic stem cell transplant patients showed no apparent benefit of the
glutamine (Uderzo, 2011).
Studies using special formulations of glutamine continue.
(Keefe, 2007; Rosenthal, 2009)
Medications Used to Treat the Symptoms (Pain) of Mucositis
Local Anesthetic Combinations
Viscous lidocaine is often combined with diphenhydramine and an antacid or nystatin
and called “magic mouthwash” or various other institution-specific names. The local
anesthetic is probably the main active ingredient in these combinations. Some
patients do attain symptom relief with these combinations, although published efficacy
data are difficult to find.
With small patients and high or frequent doses, there is some risk of lidocaine toxicity
if the medication is swallowed instead of swished and spit out.
Gelclair
It is a combination of polyvinylpyrrolidone, hyaluronic acid, and glycyrrhetinic acid that
forms a gel, coating the mouth and protecting ulcerations from exposure to air (which
increases pain).
The patient should not eat or drink for at least an hour after using Gelclair.
Some patients find that this product helps reduce pain. Published studies are small
and inconclusive. (Barber, 2007)
Opioids
Morphine, Oxycodone
Opioids are used when other treatments have failed and pain is affecting oral intake.
They may allow the patient to continue oral intake of food and fluids.
Side effects include constipation; urinary retention; nausea and vomiting; itching; and,
with higher doses, respiratory depression.
Sucralfate
Sucralfate is thought to work by coating ulcerations and protecting them from painful
stimuli. The drug is FDA-approved for peptic ulcers.
Data for efficacy in mucositis are conflicting.
It is not recommended in the MASCC guidelines.
(Keefe, 2007; Rosenthal, 2009)
Dietary Implications
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Mucositis can be very painful, reducing the patient’s oral intake and impairing nutritional
status. For patients with significant mucositis, dietitians should assess the patient's need
for nutrition support. To the extent that they reduce mucositis or relieve its symptoms, the
agents discussed in this section can help patients maintain their eating, drinking, and
nutritional status. Gelclair should not be used within an hour before eating and Caphosol
within 15 minutes; however, other medications that relieve pain should be used prior to
eating and timed so that their maximal effects occur at the time the patient eats.

Overview of Medications

Pediatric oncology patients have medication- or disease-related gastrointestinal (GI)
problems that can affect their nutritional status. Frequent problems include reduced gut
motility, nausea and vomiting, loss of appetite, hyperacidity, and mucositis. Maintaining a
patient’s gastrointestinal tract and minimizing GI symptoms can help patients maintain their
nutritional status (Corkins, 2010).
This section discusses some of the medications that have been commonly used to prevent
or treat GI complications in pediatric patients with cancer. Although many of the
medications can be very helpful, others have very little data to confirm their benefits and
may not be worth the effort, cost, and potential for side effects.

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Nutrition Care > Oncology > Survivorship
Long-Term Follow-Up Guidelines

The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of
Childhood, Adolescent, and Young Adult Cancers (COG-LTFU Guidelines) (COG, 2008)
are clinical practice guidelines used in screening and management of late effects that can
result from treatment for pediatric malignancies. The guidelines are evidence-based
(utilizing established associations between therapeutic exposures and late effects to
identify high-risk categories) and grounded in the collective clinical experience of experts
(matching the magnitude of the risk with the intensity of the screening recommendations).
These guidelines are appropriate for survivors of childhood, adolescent, or young adult
cancers two or more years after the completion of cancer therapy. Given the wide age
range for application of these guidelines, some individual recommendations may not be
applicable (for example, limiting alcohol intake in a 10-year-old is not a likely concern);
therefore, clinicians must use their judgment based on the age of the patient and the
relevance of the guidelines. References related to each late effect and patient education
materials on a variety of topics are also included in the guidelines (COG, 2008).
When determining which guidelines apply to individual cancer survivors, it is important to
use traditional assessment/recommendations, taking into account the age of the survivor
and his or her pertinent clinical history. Suggestions are geared toward leading a healthful
lifestyle and include nutrition and activity guidelines. The recommendations for cancer
survivors is that they adopt the prevention guidelines.
Because the COG-LTFU Guidelines are too detailed to be listed in their entirety here, the
other headings in this topic cover recommendations for some of the most common
nutrition-related issues in survivors. The entire set of guidelines can be accessed here;
they are updated periodically. More nutritional guidelines can be found under the Health
Links area of the COG website, which are also updated on a periodic basis.

Gastrointestinal Problems

Treatment for childhood cancer can result in chronic problems of the intestine or other
parts of the gastrointestinal (GI) system, including bowel obstruction, gallstones,
esophageal stricture, hepatic fibrosis, colorectal cancer, and chronic enterocolitis
(Castellino, 2008).
Cancer and related treatments may also result in dysphagia or anorexia. Some survivors
who were on tube feeding and/or parenteral nutrition for an extended time would benefit
from an evaluation and treatment to manage swallowing dysfunction, sensitivity to certain
foods, and reintroduction of foods.
Treatments that increase risk for GI problems include the following:
Radiation—doses of 30 Gy (3000 cGy/rads) or higher to the chest, neck, pelvis, or
abdomen
Surgery in the pelvis or abdomen
Other risk factors include a family history of gallstones, colorectal or esophageal cancer,
patient history of bowel adhesions (scarring) or bowel obstruction (blockage), use of
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tobacco, or chronic graft-versus-host disease.
Possible symptoms of GI problems can include chronic nausea, vomiting, acid reflux,
constipation or diarrhea, pain (swallowing, abdominal), change in appetite, weight loss,
black tarry stools or blood in stool, abdominal distention, and jaundice.
Suggestions for managing GI problems may include the following (AICR, 2007):
Eat 5 or more servings of fruits and vegetables daily
Choose a variety of foods from all food groups
Include high-fiber foods in the diet (whole grain breads, cereal)
Avoid foods high in sugar (candy, soda)
Choose low-fat milk and dairy products
When eating meats, choose leaner cuts and broil or boil when preparing
Decrease high-fat foods (potato chips, french fries)
Limit the use of alcohol
Do not smoke or use tobacco; avoid second-hand smoke

Bone Health

Bone is a living growing tissue; the 206 bones in the body are composed of calcium,
phosphorus, magnesium, vitamin D, and fluoride. All of these nutrients are important in the
development and maintenance of bone and other calcified tissues. As a consequence of
treatment for childhood cancer, survivors may not be able to obtain normal peak bone
mass and may experience an increased loss of calcium from the bones.
Survivors are at increased risk for osteoporosis, a result of too little bone formation or too
much bone loss; therefore, fractures may occur as bones become weaker. Osteoporosis is
diagnosed by dual energy x-ray absorptiometry (DXA), which measures bone density or
bone mass and take less than 20 minutes to complete (Blatt, 2008).
General risk factors for osteoporosis include the following:
Female
Family history of osteoporosis
White or Asian
Older age
Small/thin frame
Smoking
Diet low in calcium
Increased amounts of alcohol, caffeine, or soda
Lack of weight-bearing exercise
Diet that is high in salt
Risk factors in survivors of childhood cancer include the following:
Anticancer treatment utilizing methotrexate or corticosteroids as well as radiation to
weight-bearing bones
Other medical treatments such as anticonvulsants (barbiturates and phenytoin) and
medication used to treat early puberty and endometriosis (Lupron)
Drugs including aluminum containing antacids (Maalox), cholesterol-lowering
medication (cholestyramine), and high-dose heparin for prolonged periods
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Suggestions for decreasing risk of osteoporosis include activity with weight-bearing (such
as walking or dancing) and resistance (such as light weightlifting) exercises.
Calcium
General guidelines for calcium intake requirements are 1,000 mg to 1,500 mg a day
(elemental calcium), but this may vary based on age, clinical history, and results of DXA
scan. Food sources include dairy products—such as milk, cheese, and yogurt—and
nondairy food sources including salmon, collards, broccoli, white beans, and fortified foods
such as orange juice and some cereals.
Calcium is found in supplements as a salt and is bound to carbonate, gluconate, citrate, or
lactate. The recommendations are based on elemental calcium: the amount of actual
calcium, excluding the salt, in a supplement that is available for the body to absorb.
Calcium carbonate is the most prevalent form of calcium supplement on the market and
should be taken after meals, as it requires stomach acid for better absorption. It provides
more elemental calcium (40% elemental) than calcium citrate; therefore, not as many
tablets are required. Calcium citrate is the best-absorbed supplemental form of calcium. It
does not require extra stomach acid for absorption, so it may be taken anytime during the
day, even on an empty stomach.
Some brands of supplements list total weight of calcium salt, not the amount of elemental
calcium. Generic brands are less expensive, but they may not meet US Pharmacopeia
standards for quality and purity. It is best to avoid oyster shell, bone meal, and dolomite, as
they may contain lead, mercury, and arsenic. Products' Nutrition Facts labels should state
the percentage of the Daily Value based on 1,000 mg of elemental calcium. It is necessary
to individualize calcium requirements based on age and clinical history.
(Blatt, 2008)
Vitamin D
Vitamin D is needed to absorb calcium and is generally found in fortified dairy products. It is
recommended that supplements not exceed 800 IU per day; rather, dosing should be
based on age and clinical history, as children with documented vitamin D deficiency may
require more than this amount. Vitamin D levels can be checked using the 25-OH vitamin
D test every 3 to 6 months to determine whether to supplement and whether dosing should
be individualized.
Although the body can obtain vitamin D via sun exposure, most people do not absorb
enough as a result of increased use of sun screen.
The Dietary Reference Intakes for vitamin D can be found here.

Heart Health

Cancer treatments that can cause heart problems include chemotherapy (anthracyclines)
and radiation to the heart or surrounding tissues (Friedman, 2008). Types of heart
problems that can occur after treatment include left ventricular dysfunction,
cardiomyopathy, arrhythmias, valvular stenosis or insufficiency, pericardial fibrosis, and
coronary artery disease.
Risk factors for developing heart problems can be related to other medical conditions,
including obesity, high blood pressure, diabetes, and elevated cholesterol or triglycerides.
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including obesity, high blood pressure, diabetes, and elevated cholesterol or triglycerides.
Aerobic exercise is generally safe and healthy for the heart, but some forms of exercise,
such as wrestling and heavy weightlifting, can be stressful to the heart. Survivors who
might be at risk for heart problems should check with their health care provider before
starting an exercise program.
Tests performed to monitor heart function include electrocardiogram, echocardiogram, or
multigated acquisition scan and should be recommended by a health care provider if
appropriate. To prevent problems with the heart, it is best to maintain a healthy body
weight, limit fat intake to no more than 30% of energy, exercise moderately for at least 30
minutes on most days, and avoid smoking (Friedman, 2008).

Diet and Physical Activity

The special recommendations for cancer survivors published by the American Institute for
Cancer Research (2007) state that “once treatment has ended, cancer survivors should
adopt the panel’s recommendations for cancer prevention”; these recommendations
include the following:
Be as lean as possible (not underweight).
Be physically active (30 minutes on most days).
Avoid sugary drinks. Limit intake of processed foods high in fat, added sugar or low in
fiber
Eat variety of vegetables, fruits, whole grains and legumes (beans).
Limit consumption of red meat (beef, pork, lamb). Avoid processed meats.
If consumed, limit alcoholic drinks to 2 for men and 1 for women per day.
Limit consumption of salty foods and foods processed with salt.
Do not use supplements to protect against cancer.
Do not smoke or chew tobacco.
Handle food safely (immune system may be affected in survivors).
Rethink the pattern of eating so that two-thirds of a meal is composed of vegetables,
fruits, whole grains and beans, and one-third comes from cheese or animal foods.
Maximize the variety of vegetables and fruits eaten, as they contain phytochemicals,
which are plant compounds that have been shown to have effects such as antioxidant
boosting the immune system; anti-inflammatory; antiviral; antibacterial; and cellular
repair.
Nutrients should be provided in the diet from a variety of sources.
Protein is needed for growth and repair of body tissue and helps with maintenance of
immune function.
Carbohydrates and fats are the body’s major energy sources.
Vitamins and minerals are essential for proper growth and development and are
needed to utilize the energy in food.
Water is important to prevent dehydration, which may cause a person to feel listless
or dizzy.
Benefits of regular exercise and good nutrition for childhood cancer survivors include
promoting healing of tissues/organs damaged by cancer and treatment, building strength
and endurance, reducing risk of certain types of adult cancers and diseases (diabetes,
heart disease), decreasing stress, and providing a feeling of well being (Frierdich, 2008).
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Although late effects occur in survivors of pediatric cancer, a healthful lifestyle—including a
proper diet and adequate exercise—is important to decrease the risk of certain types of
diseases. Children should be eating enough to have adequate growth but not excessively
so that they are overweight (body mass index = 85th to 95th percentile) or obese (above
the 95th percentile).

Overview

The 5-year survival rate for pediatric cancer has improved and is approximately 80% for
some diagnoses; however, many patients experience late effects or long-term
health-related outcomes, which can result in organ dysfunction, second malignant
neoplasms, and adverse psychological sequelae (National Cancer Institute). The term
"survivor" usually refers to patients who are 5 years post-diagnosis and 2 to 3 years
posttreatment.
Risk factors for late effects can be related to tumor, direct tissue effects, tumor-induced
organ dysfunction, and mechanical effects. The multimodal approach used during
treatment can also be responsible for many late effects. The Long-Term Follow-Up
Guidelines for Survivors of Childhood Cancer (Children's Oncology Group, 2008)
extensively review late effects of treatments used. Genetic predisposition, capacity for
normal tissue repair, organ function not affected by treatment, developmental status, and
premorbid state can influence development of late effects (National Cancer Institute;
Schwartz, 1995; Sacks, 2010).

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Nutrition Care > Oncology > Treatment Modalities
Chemotherapy

Chemotherapy is defined as the use of chemicals to treat cancer. There are three main
categories of chemotherapeutic agents: cytotoxic therapies, hormonal therapies, and
biotherapies (see Immunotherapy). These agents work by several actions, including
interfering with cell division, leading to cell death by cytocidal effects, or by interfering with
replication, termed "cytostatic effects" (Bender, 1998).
These medications are unable to distinguish between cancerous cells and normal cells, so
normal tissue, as well as malignant tissue, suffers injury. Therefore, tissue that has a high
turnover rate as a normal process (bone marrow and gastrointestinal system) is susceptible
to the effects of chemotherapy. Short-term side effects are usually reversible; however,
chemotherapy can also produce long-term side effects that may be delayed and
irreversible. Chemotherapy may be used as follows:
Primary treatment
Adjuvant treatment: After surgery to treat possible systemic disease
Neoadjuvant treatment: Before surgery to decrease tumor bulk and spare healthy
tissue
Combination treatment: In conjunction with other methods of treating cancer such as
with biologic therapies and radiation therapy to sensitize the cancer cells so that they
are more easily killed by radiation therapy (radiosensitizing chemotherapy)
Following are multiple factors involved in determining the optimal chemotherapy regimen:
Histologic tumor type
Stage of disease
Comorbid conditions
Sequelae of treatment
Patient risk factors for sequelae of treatment
Chemotherapy medications act at various stages of the cell cycle with differing
mechanisms of action. Cell cycle–specific drugs exert their action only when cells are in a
specific phase of the cell cycle whereas cell cycle–nonspecific drugs affect dividing and
resting cells at all phases of the cell cycle. The main categories of chemotherapeutic
agents include the following:
Cytotoxic agents: Specifically target cells with high replication rates
Alkylating agents: Act directly by attacking deoxyribonucleic acid (DNA), causing
breaks in and cross-linking of DNA strands
Antimetabolites: Block cell development by interfering with metabolic processes
and affect the cell during the "s" phase. All drugs in this category are cell
cycle–specific.
Nitrosureas: Act similarly to alkylating agents and inhibit enzymatic changes
necessary for DNA repair
Antitumor antibiotics: Act by binding with DNA and preventing ribonucleic
acid synthesis
Plant alkaloids: Naturally occurring substances that block cell division by
inhibiting spindle formation during mitosis
Topoisomerase inhibitors: Inhibit topoisomerase enzyme, which prevents repair
of DNA strands
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Hormonal agents: Systemic therapy utilized in hormone-sensitive cancers, which
reduces the level of hormones in the body or block the tumor's ability to utilize
endogenous hormones
Also called endocrine therapy, it is usually used in combination with other types
of cancer treatments
Side effects vary depending on combination with other therapies and specific
agent
Many chemotherapy protocols include combinations of chemotherapy agents to minimize
drug resistance and to provide a regimen that acts at multiple sites of the cell cycle to
improve likelihood of cure.
Chemotherapy Administration
Chemotherapy medications are given in cycles, which may include taking the drugs daily,
in weekly or monthly rotations. Routes of administration include oral, intravenous,
intramuscular, and intrathecal (infused directly into the central nervous system).
Chemotherapy Toxicity
Chemotherapy medications are toxic agents and have the potential to cause many adverse
side effects because of toxicity to normal as well as neoplastic cells. Chemotherapy can
cause short-term and long-term toxicities in multiple body systems. The National Cancer
Institute has developed a standardized system for evaluating various toxicities to
chemotherapy and is called the Common Terminology Criteria for Adverse Events (CTCAE
[version 4.0]). It is organized as a rating system from 1 to 5 and has specific clinical
descriptions of severity for each adverse event related to chemotherapy. Toxicity criteria
include multiple nutritional side effects.
Chemotherapy medications are sometimes given in conjunction with a protocol that is
prescribed as a component of a clinical trial. Clinical trials may require evaluation using the
CTCAE criteria and may require additional evaluation of the patient using various host
performance scales such as the Karnofsky Scale; criteria of performance status; or the
Eastern Cooperative Oncology Group Scale performance status, which is an important
component in determining the toxicity patients will experience from chemotherapy. (See
factors affecting toxicity to chemotherapy, below.)
Bone marrow toxicity is common with many chemotherapy medications. Toxicity can
present as either leukopenia (decreased white blood cells), neutropenia (decreased
neutrophils), anemia (decreased red blood cells), thrombocytopenia (decreased platelets),
or panctyopenia (decrease of all blood cells). Each chemotherapy drug has a predicted
time frame for the maximum effect (called the "nadir") on the bone marrow. The nadir is
when the blood counts will be at their lowest point after administration of chemotherapy.
In order to decrease the toxicity of chemotherapy, chemoprotective agents are sometimes
used to protect against specific toxic effects of chemotherapy. These agents include the
following:
Dexrazoxane: Cardioprotective against doxorubicin for a cumulative dose higher
than 300 mg/m
2
Amifostine: Cytoprotective for toxic effects of radiation therapy and selected
chemotherapy medications
Mesna: Cytoprotective to the bladder against ifosfamide
Hematopoietic growth factors (eg, erythropoietin, interleukin-3, and colony-stimulating
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
factors) are routinely administered to decrease bone marrow toxicity and decrease the
likelihood of infection and anemia. Other side effects are managed with supportive
interventions, including pharmacologic and nutrition interventions. See individual
nutrition-related side effects.
Factors Affecting Toxicity to Chemotherapy
Performance status
Nutritional status
Chemotherapy agents
Dose
Route of administration
Frequency of administration
Comorbid conditions
Nutrition-Related Side Effects
Anemia
Neutropenia
Electrolyte imbalance
Constipation
Diarrhea
Malabsorption
Dysphagia
Stomatitis/mucositis
Dehydration
Nausea/vomiting
Anorexia
Dysgeusia
Fatigue
Weight loss
Pain
Chemotherapy Effects by Body System (Bender, 1998)
Constitutional fatigue
Hematopoietic anemia:
Leukopenia
Neutropenia
Thrombocytopenia
Cardiopulmonary toxicity:
Venous thrombosis
Pulmonary fibrosis
Neurological peripheral neuropathy:
Ototoxicity
Cognitive effects
Gastrointestinal anorexia:
Nausea
Mucositis
Constipation
Diarrhea
Hepatic toxicity
Integumentary dermatitis:
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Hyperpigmentation
Alopecia
Hand-foot syndrome
Reproductive and infertility or urologic:
Changes in libido
Erectile dysfunction
Cystitis
Renal toxicity
Metabolic aberrations hypoglycemia/hyperglycemia:
Hypokalemia
Hypomagnesemia
Hyperuricemia
Latent effects
Secondary malignancy
Emetogenic Potential of Chemotherapeutic Agents (Wilkes, 2003)
Level Frequency of Emesis Agents
Level 5 Very high, >90% Cisplatin
a
, Dacarbazine
Level 4 High, 60% to 90% Etoposide
a
, Methotrexate
a
Level 3 Moderate, 30% to 60% Doxorubicin
a
, 5-Fluorouracil
a
Level 2 Low, 10% to 30% Docetaxel, Gemcitabine
Level 1 Very low, <10% Paclitaxel, Vincristine
a
Dose-related, potential increases with higher doses.
Source: Clinical Guide to Oncology Nutrition, Table 6.2: Emetogenic Potential of
Chemotherapeutic Agents (Level 1-5).

Adapted from Nutrition Care Manual.

Immunotherapy

Biologic and Targeted Therapies (Appel, 2001)
Biotherapy is defined as treatment with agents derived from biologic sources and affecting
biologic responses. Biologic therapies include the following:
Interferons
Interleukins
Hematopoietic growth factors
Many of these agents are cytokines, which are naturally occurring proteins of the immune
system. The mechanism of action of these drugs can be classified as affecting the body's
immunlogic mechanisms in any of the following ways:
Augmenting
Modulating
Restoring
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Restoring
The fact that tumor cells are infiltrated with lymphocytes, macrophages, and plasma cells
supports the use of immunologic therapies to treat cancer. Side effects are determined by
the dose given, infusion method, and the length of time the patient continues to receive
them.
Side Effects of Selected Biologic Agents
Interferons:
Flu-like symptoms
Fever
Headache
Myalgia
General malaise
Nausea
Vomiting
Diarrhea
Altered taste
Increasing fatigue and anorexia over time
Weight loss
Depression
Memory difficulties
Neuropathy
Interleukins:
Chills
Fever
Headache
Myalgia
Arthralgia
General malaise
Capillary leak syndrome
Renal toxicity
Nausea and vomiting
Dysosmia
Diarrhea
Central nervous system toxicity
Integumentary changes:
Erythema
Rash
Pruritis
Dryness
Neutropenia
Thrombocytopenia
Anemia
Increased liver enzymes and bilirubin
Hematopoietic growth factors:
Bone pain
Fluid retention
Targeted Therapies
The biology of the cell cycle has been increasingly understood as a complex, finely
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
regulated process in malignant disease, which has recently become the focus of emerging
targeted therapies to treat cancer. Over the last few decades, knowledge of molecular
biology has continued to evolve and has led to development of therapies targeting tumor
cells while sparing normal tissue. Growth factor receptors are important in regulating
various cellular process that are necessary for continued replication of the cell and its
survival. The epidermal growth factor receptor is normally expressed on cells of epithelial
origin and is overexpressed in several cancers. This has led to several therapies directed
at interfering with its expression with the use of tyrosine kinase inhibitors and
antiangiogenesis agents.
Targeted therapies refer to drugs that interfere with cancer cell growth and division.
Examples of targeted therapies include the following (National Cancer Institute):
Monoclonal antibodies
Signal-transduction inhibitors
Proteasome inhibitors
Monoclonal Antibodies
Monoclonal antibodies target a single specific antigen of the tumor cell and act by directly
killing the cell, inhibiting proliferation of tumor cells, or sensitizing the cells to
chemotherapy. These are laboratory-produced molecules that can be targeted to attach to
specific substances on cancer cells. They may be used to mark cancer cells, block growth
signals, deliver radiation to the tumor, or deliver drugs to the tumor. If identified as
unconjugated, they do not have anything attached to them (eg, rituximab); if
conjugated, they have a piggyback anticancer therapy such as a radioisotope (eg,
tositumomab) attachment, thereby acting as a delivery agent for the radioactive agent.
Side Effects
Side effects of monoclonal antibodies are dependent on source of antibody (murine,
chimeric, humanized, or human); however, in general, side effects are less severe than
those for chemotherapy. An advantage to monoclonal antibodies and targeted therapies is
that normal, healthy cells are generally not significantly affected, minimizing toxicity to the
patient. Allergic reactions are a concern with monoclonal antibodies if they are chimeric
(part mouse deoxyribonucleic acid). The main side effects of targeted molecular therapies
include acne-like skin rash and diarrhea. Although side effects from these agents are
generally not as severe as chemotherapy, the clinician must remember that many patients
will be receiving targeted therapies in addition to standard chemotherapy.
Signal Transduction Inhibitors
Signal transduction inhibitors are small-molecule drugs that block specific enzymes and
growth factor receptors involved in cancer cell growth. Examples of these drugs are
mesylate and gefitinib.
Proteasome Inhibitors
Proteasome inhibitors are apoptosis-inducing drugs whose primary mechanism is blocking
proteasomes enzymes, which help to regulate cell function and growth. Examples of these
drugs are bortezomib and oblimersen.

*Adapted from Nutrition Care Manual.
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Radiation Therapy

Radiation therapy exerts its effects through the use of ionizing radiation to lyse cells
directly or indirectly by penetrating the cell's nucleus and causing the formation of hydroxyl
(free) radicals in the area being treated. By damaging the cell structure, including the
genetic material in the cell, further growth is inhibited. Radiosensitivity of cancer cells
depends on the following:
Type of cell
Phase of the cell cycle
More actively dividing cells are more sensitive
Degree of differentiation of the cell
Poorly differentiated cells are more sensitive
Oxygenation of the cell
More oxygenated cells are more sensitive
Radiation is a local therapy typically provided in conjunction with other therapies, including
surgery, chemotherapy, and immunotherapy, and treats multiple solid tumor types.
Radiation may be provided as follows:
Neoadjuvant (presurgery) therapy to shrink the tumor margins such as in rectal cancer
Adjuvant (postsurgery) treatment
Background Information
Goals of radiation therapy:
Curative: To prevent local recurrence in the area being treated
Palliative: To relieve distressing symptoms such as bone pain
Prophylactic: To prevent metastasis such as brain irradiation for patients with
small-cell lung cancer
Types of radiation (Smith, 2004):
External beam: Radiation directed at the tumor from outside of the body:
Most common form of radiation treatment
Daily treatment for 3 to 6 weeks depending on the goal (curative vs palliative)
Some protocols require twice-daily treatment
Side effects determined by area treated, dose received, and patient-related
factors
Brachytherapy: Radiation source placed directly into the body:
Radiation source is placed within a catheter or receptacle in the malignant
lesion
Example: intracavitary insertion of radiation material into the vaginal vault
for treatment of endometrial cancer
Interstitial implants describe placement of a radioactive source with needles,
wires, seeds, or catheters directly in the tissues
Head and neck cancers may have temporary interstitial implants
In general, there are no nutritional side effects
Stereotactic radiosurgery: High-dose radiation and steep-dose gradients to small
volumes are delivered to a precise area via a gamma knife
Commonly used to treat brain tumors
No nutrition-related side effects
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No nutrition-related side effects
Intraoperative radiation therapy
High radiation dose delivered to tumor bed during surgery
Radiation delivered to a sensitive area such as the pancreas and spares patient
side effects that would be experienced if given same dose with external beam
radiation
Intensity-modulated radiation therapy: Uses digital technology and
computer-generated images to aim powerful radiation beams at tumors and avoid
damaging healthy organs and tissue nearby. Nutrition-related side effects are
determined by the area being treated.
Nonsealed radioactive therapy:
Intravenous injection or oral administration of radioactive source iodine-131
taken orally for thyroid cancer
Patient's secretions must be isolated for period of high radioactivity to prevent
leakage of radioactive material into environment
In general, no nutritional side effects
Radioimmunotherapy delivers radiation directly to the cancer site by being
attached to an antibody
Photodynamic therapy: Use of light-sensitive molecules or photosensitizers,
which—when activated by light—form oxygen radicals, resulting in damage to
deoxyribonucleic acid and cell death:
Porfimer sodium most widely used photosensitizer
Photosensitivity continues for another 30 to 90 days
No nutrition-related side effects
Nutritional Impact Symptoms (See Table: Nutrition Sequelae of Radiation Therapy,
below)
Nutritional side effects are related to the following:
Area being treated
Surrounding areas
Total dose received
If radiation is given in conjunction with another form of treatment such as
chemotherapy
The gastrointestinal tract is especially sensitive to the effects of radiation. Acute side
effects begin 2 to 3 weeks after starting the treatment for most patients. Side effects
typically diminish gradually 3 or more weeks after completion of treatment; however, some
patients may have chronic side effects. Patients with poor nutritional status in general have
more pronounced nutritional side effects. Some degree of anorexia and fatigue is almost
universal in patients receiving radiation therapy.
Nutrition Assessment/Intervention (See Oncology: Nutrition Assessment headings)
Perform baseline nutrition assessment. Clinician should anticipate nutritional side effects
patient will have and provide proactive nutrition intervention to achieve the following:
Correct nutritional deficiencies
Provide supportive nutrition therapy to manage side effects
Monitor nutritional status throughout treatment to adjust nutrition prescription based
on the needs of the patient
Educate patient and/or caregivers on modifications in meal plan to meet nutrition
needs at start of treatment and as side effects develop
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
needs at start of treatment and as side effects develop
Supplements and alteration in meal frequency should be considered to help patients meet
their nutrition needs. Knowledge of pharmaceutical interventions may be helpful to patients.
Acute Side Effects
Glutamine in radiation therapy patients:
Possible use to minimize mucositis in patients receiving radiation therapy to
head and neck region
Possible use for patients receiving radiation therapy to pelvis to minimize
diarrhea
Studies inconclusive, but actively being researched (Decker, 2002): The
oncology workgroup of the American Dietetic Association Evidence Analysis
Library found no evidence that directly supports or refutes that the use of oral
glutamine can improve and support recovery from radiation therapy or can
reduce mucositis associated with radiation therapy.
Zinc sulfate may help mediate taste changes associated with radiation therapy to the
head and neck (Ripamonti, 1998).
High-dose vitamin supplementation, especially of antioxidant vitamins, is not
recommended at present because of potential interference with radiation treatment
(Thomson, 2000).
Nutrition Sequelae of Radiation Therapy and Suggested Nutrition Intervention (by
site)
Acute Side
Effects
Chronic Side
Effects
Intervention
Tongue, soft and hard palate, tonsils, pharynx, nasopharynx,
mandible
Mucositis
Oropharyngeal
ulceration
Oral anesthetics, good oral
care; avoid temperature
extremes, irritants
Xerostomia Xerostomia
Moist foods, artificial saliva,
extra fluids with meals
Dysgeusia Dysgeusia
Determine specific
aberrations; emphasize use
of acceptable seasonings
and flavorings
Dental caries Dental caries
Good oral care, topical
fluoride; avoid sticky,
sugary foods
Viscous saliva
Pureed or liquid nutrition
therapy; limit milk products;
avoid oily, greasy, or dry
foods
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Osteoradionecrosis
Pureed or liquid nutrition
therapy if able to tolerate,
enteral nutrition if surgical
intervention is planned
Fistula
Depending on location, may
need tube feeding or
parenteral nutrition until
healed from surgery
Trismus
Depending on severity, may
be able to take oral liquids,
may need tube feeding
Esophagus, thorax, thoracic, cervical spine
Esophagitis,
dysphagia
Esophagitis,
esophageal stricture,
fibrosis
Adjust texture; avoid
irritants; adjust liquids as
needed for dysphagia;
dilatation for stricture, tube
feeding for dysphagia
Stomach, liver, pancreas, bile duct, small intestine
Nausea,
vomiting,
diarrhea
Gastrointestinal
ulceration, perforation
Antiemetic medications
before meals; small
feedings; avoid foods with
strong odor; liquids
between meals; low fat;
limit lactose if small bowel
in treatment field and
diarrhea is present
Enteritis,
malabsorption
Intestinal fistula,
fibrosis, necrosis,
obstruction
Pancreatic enzymes,
low-fat, low-residue,
low-lactose, tube feeding
with elemental formula;
total parenteral nutrition
(TPN) if high-output fistula
Bladder, prostate, colon, rectum, male and female sexual organs
Colitis,
cystitis,
diarrhea
Chronic colitis,
proctitis
Low residue, avoid irritants;
lactose restriction if small
bowel in treatment field
Radiation enteritis
Low residue, lactose
reduced, low fat; may need
bowel rest with elemental
formula or TPN
Adapted from Nutrition Care Manual

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Nutrition Care > Pulmonary Diseases
Pulmonary Diseases


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Nutrition Care > Pulmonary Diseases > Asthma
Nutrition Assessment

Items to check during the nutrition assessment may include the following (terminology and
codes from IDNT, 2011):
Food/Nutrition-Related History
Total energy intake (FH-1.1.1.1)
Total fat intake (FH-1.5.1.1)
Calcium intake (FH-1.6.2.1)
Medications, specify prescription or over-the-counter (FH-3.1.1)
Herbal/complementary products (specify) (FH-3.1.2)
Diagnosis-specific or global nutrition-related knowledge score (FH-4.1.2)
Eligibility for government programs (FH-6.1.1)
Participation in government programs (FH-6.1.2)
Physical activity history (FH-7.3.1)
Television/screen time (FH-7.3.8)
Anthropometric Measurements
Height/length (AD-1.1.1)
Weight (AD-1.1.2)
Weight change (AD-1.1.4)
Body mass index (BMI) (AD-1.1.5)
Growth percentiles indices/percentile ranks (AD-1.1.6)
Nutrition-Focused Physical Findings
Overall appearance (specify) (PD-1.1.1)
Client History
Personal data (CH-1.1.1–10)
Patient/client or family nutrition-oriented medical/health history (CH-2.1)
Medical treatment/therapy (specify) (CH-2.2.1)
Complementary/alternative medicine (specify) (CH-2.2.3)
Comparative Standards
Total estimated energy needs (CS-1.1.1)
Estimated calcium needs (CS-4.2.1)
Recommended BMI (CS-5.1.2)


Nutrition-Focused Physical Findings

A child with asthma generally has a normal appearance. A child with an acute asthma
exacerbation may have shortness of breath, cough, and wheeze.

Biochemical Data, Medical Tests and Procedures
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Diagnostic testing for asthma includes pulmonary function testing and chest radiographs
(x-ray). Pulse oximetry may be done to assess oxygenation. Bone densitometry may also
be tested (using dual-energy x-ray absorptiometry) if there is concern about bone health.

Laboratory

There are no particular laboratory tests to assess nutritional status of patients with asthma.
Serum vitamin D may be measured to determine if levels are adequate, particularly for
calcium absorption in steroid-dependent asthmatic patients. Usual laboratory parameters
can be used.

Client History

Important client history elements for the child with asthma include the following:
Growth and weight history
Administration route (oral vs inhaled) of corticosteroids and the length of time the child
was on corticosteroids
Exercise patterns
History of food allergies
Caregiver's understanding of the relationship between nutrition and asthma
Family history of osteoporosis

Food/Nutrition-Related History

Information to collect for a food history includes the following:
24-hour recall or 3-day diet history, as appropriate
Food groups that are excluded
Allergy to any food or food additive
Use of any alternative therapies or supplements

Comparative Standards

Energy and protein requirements for healthy children are based on age and sex.
Calculations should include an assessment of calcium and vitamin D intake. Dietary
Reference Intakes should be used for comparison of macronutrients and micronutrients.
Other age-appropriate nutrients that may be at risk for insufficiency should also be
monitored. Fluid needs correspond to levels appropriate for age and body weight.

Nutrition Diagnosis

Registered dietitians (RDs) working with patients who have asthma should review the signs
and symptoms obtained in the nutrition assessment and diagnose nutrition problems based
on these signs and symptoms. Nutrition diagnoses from the following list, as well as
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other diagnoses, may be present.
Excessive energy intake (NI-1.5)
Inadequate mineral intake (specify) (NI-5.10.1)
Food–medication interaction (NC-2.3)
Overweight/obesity (NC-3.3)
Food- and nutrition-related knowledge deficit (NB-1.1)
Physical inactivity (NB-2.1)
Sample PES (problem, etiology, signs and symptoms) or Nutrition Diagnostic
Statement(s)
Overweight/obesity (NC-3.3) related to excessive energy intake as evidenced by body
mass index (BMI) >95th percentile.
Inadequate mineral intake (calcium) (NI-5.10.1) related to the belief that milk causes
increased mucus production, as evidenced by reported exclusion of dairy products
from the child's diet.
Underweight (NC-3.1) related to inadequate oral food/beverage intake as evidenced
by BMI <10th percentile and weight <10th percentile.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.

Nutrition Intervention

Actions to consider during a nutrition intervention include the following:
Modify distribution, type, or amount of food and nutrients within meals or at specified
time (ND-1.2) to meet Dietary Reference Intake (DRI) level for age
Supplement calcium and vitamin D intakes to DRI levels for age (ND-3.2.3[3];
ND-3.2.4[1])
Assist families with resources for supplementation to ensure adherence (RC-1.4)
Provide nutrition education regarding the importance of adequate calcium and vitamin
D for children with asthma (E-1.1, E-1.4, E-1.5)
Estimate energy needs based on age, activity level, and need for weight loss (E-2.1,
E-2.2)
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.

Nutrition Therapy Efficacy

A recent, systematic review of the effect of weight loss on asthma showed there was
improvement in at least one case of asthma in overweight adults and children with asthma
of those studied (Eneli, 2008). Adequate calcium and vitamin D intakes are necessary for
proper bone mineralization in children. Children with asthma who have been on frequent
courses of oral steroids may require calcium and vitamin D intakes above the Dietary
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Reference Intake levels to foster bone mineralization. Frequent use of oral steroids may
lead to increased appetite and deposition of body fat.

Goal Setting

Goals of nutrition interventions should include the following:
Body mass index appropriate for age
For children younger than 2 years, appropriate weight for length
Calcium intake at Dietary Reference Intake (DRI) levels
Vitamin D intake at DRI levels
Physical activity for 60 minutes daily (start with 30 minutes and work up to 60 minutes
as tolerated)

Food & Feeding Issues

Children experiencing a flare may have repeated or prolonged vomiting for up to 12 hours.
If this occurs, there may be a risk for dehydration. Coughing and wheezing may interfere
with eating and result in emesis.
Families may need guidelines for hydration and when to escalate care with their provider.

Nutrition Support

Children with asthma rarely require nutrition support. A child experiencing a life-threatening
asthmatic episode ("status asthmaticus") may require intubation and mechanical
ventilation. Parenteral nutrition would be necessary if the child remained intubated for a
period of several days or was tachypneic.


Suggested Monitoring Parameters and Recommendations

The following factors need to be monitored in children with asthma:
Total energy intake
Weight
Weight change
Growth pattern indices/percentile ranks
Consistency of physical activity
Calcium intake
Vitamin D intake
Total fat intake
Sodium intake

Nutrition Care FAQs

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
What is the relationship between body weight and asthma?
Children with asthma who are overweight have more asthma symptoms than those who are
at a healthy weight. Infants who weigh more than 3 kg at birth and middle school–age
children who are overweight have an increased risk of being diagnosed with asthma later in
life (Flaherman, 2006).
Should children with asthma avoid milk products?
There is a misconception that children with asthma who drink fluid milk will have an
increase in mucus production. A 2005 review has disputed this myth (Wuthrich, 2005).
Children without a milk or milk protein allergy should consume adequate amounts of dairy
products to meet the Dietary Reference Intake levels for calcium and vitamin D.

Anthropometric Measurements

Weight, height, and body mass index percentile should be monitored frequently. In younger
children, weight for length or height should be measured.

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Nutrition Care > Pulmonary Diseases > Bronchopulmonary Dysplasia
Nutrition Assessment

Nutrition assessment of the infant/child with bronchopulmonary dysplasia may include:
Total energy intake
Fluid/beverage intake
Breast milk/formula intake
Total protein intake
Calcium intake
Multivitamin intake
Prescription medication use
Mealtime behavior
Food/nutrition program participation
Height
Weight
Weight change
Growth pattern indices/percentile ranks
Electrolyte and renal profile
Alkaline phosphatase
Respiratory quotient
Hemoglobin/hematocrit
Overall appearance
Personal history
Patient/family medical history
Total energy estimated needs
Total protein estimated needs
Total fluid estimated needs
Estimated calcium needs
Desired growth pattern

Nutrition-Focused Physical Findings

The infant or child with bronchopulmonary dysplasia often has an increased respiratory
rate and requires supplemental oxygen. Physical observations also include hyperinflation,
appearance of wasting, smallness for gestational age, and developmental delay.

Biochemical Data, Medical Tests and Procedures

The National Institutes of Health Consensus definition of bronchopulmonary dysplasia
(BPD) states that a minimum of 28 days of supplemental oxygen is necessary for a BPD
diagnosis (Ehrenkranz, 2005). Once the infant is taking some oral feeds, a
videofluoroscopic test for swallowing function may be indicated.

Laboratory

Laboratory tests for monitoring the infant or child with bronchopulmonary dysplasia (BPD)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Laboratory tests for monitoring the infant or child with bronchopulmonary dysplasia (BPD)
who is prescribed furosemide diuretics include serum calcium and phosphorus. Infants who
are fluid restricted and receiving diuretics may require monitoring of urine specific gravity
and/or urine osmolality to determine hydration status. Serum alkaline phosphatase can be
followed to monitor infants with metabolic bone disease. An assessment of vitamin D status
(23-OH) levels may also be helpful for infants with metabolic bone disease. Laboratory
tests should be evaluated periodically.

Client History

Relevant client history information includes:
Birth weight
Gestational age
Average daily weight gain since birth
Feeding history
Oral motor skills
Coexisting medical conditions
Developmental assessment
Information about child's care givers
Eligibility for supplemental nutrition programs such as Women, Infants, and Children
(WIC)
Date of last laboratory values
Elimination patterns

Food/Nutrition-Related History

Relevant food history information includes:
Breast feeding or infant formula (what is being added?)
Exact recipe of formula or formula & breast milk
Amount of human milk or formula consumed at each feeding
Number of feedings per 24 hours
The length of time it takes for the infant to consume a feeding
Choking, gagging, or spitting up during feedings
Who feeds the infant or child
Solid foods ingested and how (spoon, self-feeding skills?)
Where the feedings take place
The caregiver's perspective on the feeding process
How the formula is being prepared

Comparative Standards

Caloric requirements have been stated to be 120-150 kcal/kg body weight/day for infants
with bronchopulmonary dysplasia (Biniwale, 2006).
Infants and children with bronchopulmonary dysplasia (BPD) are often fluid restricted and
given diuretics to improve lung function and prevent pulmonary edema. The infant or child
should be monitored closely to determine the best balance between requirements and
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tolerance.
Maintenance fluids for an infant or child with BPD are 100 ml/kg/day for the first 10 kg of
body weight, 50 ml/kg for the next 10 kg body weight, and an additional 20 ml/kg for the
remaining body weight.
The energy content of expressed breastmilk and formulas can be enhanced to increase
energy intake while minimizing fluid intake.

Nutrition Diagnosis

Dietitians working with patients who have bronchopulmonary dysplasia should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased nutrient needs (NI-5.1)
Inadequate protein intake (NI-5.7.1)
Sample PES or Nutrition Diagnostic Statement(s)
Increased nutrient needs (NI-5.1) related to lung disease and supplemental oxygen as
evidenced by increased energy requirements and inadequate weight gain.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Infants and children with bronchopulmonary dysplasia (BPD) have increased energy needs
due to increased effort in breathing and the need for “catch-up” growth. The energy content
of expressed breast milk and formulas can be enhanced to increase energy intake while
minimizing fluid intake. This can be provided by the use of human milk fortifiers or the
addition of concentrated infant formula to increase the caloric density to 24-30 kcal/oz.
Caution should be used when concentrating calories in an infant or child with BPD. Note
that powdered fortifiers or powdered infant formula are not sterile products. Pathogenic
bacteria (enterobacter sakazakii, or cronobacter) have been found in some powdered
infant formula products.
It is important to recognize that as formula is concentrated with additives of fat or
carbohydrate, dilution of concentrations of protein, vitamins, and minerals will occur. If
infant formula is given, formulas designed for the premature or other infants of low birth
weight are recommended. These formulas are higher in calorie and nutrient density. The
American Academy of Pediatrics Committee on Nutrition recommends these formulas for
pre-term infants up to 9 months post-natal age (AAP, 2004). Recommendations have been
made to continue using these formulas for up to 12 months post-natal age in an infant with
BPD. Infants may require 120-150 kcal/kg/day to gain weight (Biniwale, 2006).
If the infant or child with BPD is unable to take adequate feedings orally, tube feedings may
be necessary. Nasogastric, gastrostomy tube, nasoduodenal, or nasojejunal feedings may
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be used as either primary or supplemental feedings (see Nutrition Support section).
Laboratory values should be part of the ongoing care.

Nutrition Therapy Efficacy

The expected outcome for the child who receives optimum nutrition therapy is adequate
growth with eventual resolution of lung disease. Infants and children with
bronchopulmonary dysplasia may require additional calcium, phosphorus, and iron once
they are stabilized on enteral nutrition due to inadequate storage during the third trimester
of pregnancy. These nutrients may also be provided at less than Dietary Reference Intake
(DRI) levels during the initial days of nutritional support in the neonatal intensive care unit.
Vitamin D is also needed in most cases to meet the DRI of 400 IU. Iron should be provided
in breastfed babies at 2-4 mg/kg/day (Neiman, 2006). Medications such as furosemide
diuretics and prednisone may interfere with electrolytes and minerals such as calcium and
phosphorus.

Goal Setting

Goals of therapy for the infant or child with bronchopulmonary dysplasia (BPD) are to
normalize growth and pulmonary functions. Weight gain and length velocity goals for
infants with BPD should be the same as a term infant at the same corrected age (Neiman,
2006).

Food & Feeding Issues

Feeding issues for the infant or child with BPD may include the following:
uncoordinated suck, swallow and breathe
oral-motor dysfunction
adverse feeding behaviors
A feeding evaluation should be done by a speech language or occupational therapist to
determine if there are feeding issues that are preventing adequate feeding skills. A
swallowing study may be required to determine the safety of oral feedings. Ongoing therapy
may be required to allow the child with BPD to achieve adequate oral intake for growth. The
introduction of complementary foods should follow the infant’s developmental skills related
to head control and trunk stability rather than chronological age.


Nutrition Support

If an infant or child with bronchopulmonary dysplasia is unable to maintain adequate oral
intake, nutritional support is necessary.
Enteral feedings (supplemental or exclusive) may be required to attain adequate intake.
Parenteral nutrition may be required if enteral nutrition support is not feasible. Maintaining
oral intake is critical to resuming full feedings when the child is older and to avoid feeding
resistance. Nonnutritive oral motor stimulation should be provided to maintain normal oral
motor development.
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A combination of enteral and parenteral nutrition may also be appropriate.

Suggested Monitoring Parameters and Recommendations

Monitor for the following:
Oral fluid amounts
Amount of food
Breast milk/infant formula intake
Total energy intake
Height/length
Weight
Weight change
Growth pattern indices/percentile ranks
Alkaline phosphatase
Serum sodium
Urine specific gravity
Urine osmolality
Serum ferritin
Serum prealbumin levels
Serum electrolytes

Nutrition Care FAQs

When can the infant with bronchopulmonary dysplasia (BPD) start solid foods?
Start feeding solid foods when the infant displays the following:
4-6 months corrected age (at least)
Shows interest in solid food
Good head control
Sit up with support
Extrusion reflex is diminished and infant can transfer solid food from front of the
tongue to back
What is the general energy expenditure for the infant with BPD?

Energy expenditure has been reported to be up to 25% above basal needs in infants with
BPD (Zerzan, 2006).

Anthropometric Measurements

Infants and children with bronchopulmonary dysplasia (BPD) are often small for their
gestational age. Correction for prematurity is generally done for up to 2 years of
weight-for-age and 3 years of length-for-age. Weight-for-length is important to follow to
prevent over- or under-nutrition. Weight for age, length or height for age, weight-for-length
or Body Mass Index for age, and head circumference for age should be monitored
routinely. The frequency of monitoring growth parameters will be dependent on the infant or
child’s age and severity of their BPD. Appropriate growth charts should be used for infants
who are less than term. Correction for gestational age should be done once the infant has
reached 40 weeks post-gestation.
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reached 40 weeks post-gestation.

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Nutrition Care > Pulmonary Diseases > Cystic Fibrosis
Nutrition Assessment

All aspects of the nutrition assessment are completed at diagnosis for all persons who
have cystic fibrosis (CF), with the exception of infants (Borowitz, 2002). For infants, the
assessment is completed at diagnosis with laboratory studies completed 2 to 3 months
following the initiation of therapy (enzymes, if applicable, and vitamins), which may
begin sooner based on genotype and/or clinical symptoms (Borowitz, 2009).
Nutrition assessment is done annually for all persons who have CF (Borowitz,
2002). Nutrition assessment for the person who has CF includes anthropometry,
biochemistry, and clinical and diet evaluation (Mueller, 2000).

Anthropometry includes measures of length or height, weight, and head circumference,
taken for infants from birth to 3 years of age. The measures are plotted on the age- and
sex-specific growth curves and compared to reference data from the Centers for Disease
Control and Prevention–National Center for Health Statistics. The patient's height is
compared to genetic potential based on the parents' height (Zhang, 2010).

Biochemical measurements can be used to assess blood levels of fat-soluble vitamins;
hemoglobin; hematocrit; protein; and, when indicated, zinc, essential fatty acids, calcium,
phosphorus, and parathyroid hormone.

Clinical measures include looking at the patient’s hair, skin, lips, fingernails, and fat and
muscle distribution.

Diet evaluation should assess what the patient is eating and if there are any concerns
about feeding or eating behaviors. Is the patient consuming a balanced diet including
sufficient salt and fluid? Are vitamin and/or energy supplements being taken as directed? Is
the patient using complementary or alternative medicine including supplements or herbal
medications?
Other areas to evaluate include the "E's," as shown below (Mueller, 2000):
Enzymes: Is the patient taking the appropriate dose of enzymes and as directed?
Education: What does the nutrition education need to be and what is the patient's
education level in terms of understanding materials?
Economics: Are there financial challenges with which the patient will require help?
Environment: Is the patient’s home environment conducive to meeting nutrition goals?
Emotions: Are there psychosocial issues that may interfere with patient’s ability to
meet goals?

Nutrition-Focused Physical Findings

In addition to anthropometric measurements (length, weight, head circumference, and
weight-for-length in patients younger than 3 years and height, weight, and body mass
index percentile for older patients), physical observations should include assessment of
patient’s hair, skin, body habitus for fat and muscle, edema, moon facies, and ascites.
Each of these physical symptoms can indicate the presence of nutrient deficiency and/or
medical complication.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In infants, excoriation of the perianal area could be the result of enzyme initiation. If it does
not resolve within a week or two of starting enzymes, confirm that the infant is not receiving
excessive enzyme supplementation. Barrier cream can help reduce the occurrence of the
complication. Acrodermatitis enteropathica-like rash, prior to or after diagnosis, may
indicate zinc deficiency. Excessive spitting up can be a symptom of gastroesophageal
reflux.
Excessive gas, rectal prolapse, and/or loose, strong smelling, light-colored, bulky, and/or
oily-appearing stools may all be symptoms of uncontrolled malabsorption. Excessive gas
can also indicate small-bowel bacterial overgrowth, which is more common in individuals
with cystic fibrosis due to frequent antibiotic use.

Respiratory symptoms that occur with infections—including increased cough, sputum
production, and shortness of breath—can lead to eating difficulty. Excessive sweating from
exercise, fever, or infection increases the risk of hyponatremic dehydration.


Biochemical Data, Medical Tests and Procedures

A diagnosis of cystic fibrosis (CF) is confirmed with genetic testing and measurement of
sweat chloride levels. Two copies of cystic fibrosis transmembrane conductance regulator
mutations and an elevated sweat chloride level confirm the diagnosis of CF (see the Cystic
Fibrosis Foundation's definitions of elevated levels). Currently more than 1,500 mutations
have been identified; all such mutations result in a diagnosis of CF. When genetic analysis
reveals rarer mutations, diagnosis can be a challenge (Farrell, 2008). Genotype most often
determines pancreatic status—either pancreatic sufficient or pancreatic insufficient. See
Borowitz (2009) for more information on these genotypes.
Fecal elastase measurement is a qualitative measurement of pancreatic function. Levels
below 200 indicate pancreatic insufficiency (Daftary, 2006; Borowitz, 2004, Borowitz, 2007).
A 72-hour fecal fat study is a quantitative measurement of absorption. Levels of
coefficient of fat absorption below 93% indicate fat malabsorption; however, normal levels
are usually difficult to achieve in individuals with CF despite enzyme therapy.
Annual measurements of vitamin A, E, D25OH, and protein-in vitamin K absence or
prothrombin time (indirect measurement of vitamin K status) are recommended. With the
exception of infants, the same laboratory studies are obtained at diagnosis to monitor
fat-soluble vitamin levels (Borowitz, 2002). In infants, obtain levels 2 to 3 months after
initiating therapy (Borowitz, 2009).
For additional details regarding diagnostic testing in children and in infants, refer to
Borowitz (2009), and Table 5 in Borowitz (2002).
Anthropometric measures (weight, length or height, and head circumference for children
younger than 3 years of age) are obtained at diagnosis and compared to age- and
sex-specific norms.
A 2-hour oral glucose tolerance test (OGTT) is the most sensitive method to screen for
impaired glucose tolerance and cystic fibrosis–related diabetes (CFRD). The OGTT is
performed annually on patients 10 years of age and older and on individuals who have
symptoms of diabetes or elevated random glucose level (Moran, 1999). Illness, steroids, or
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
pregnancy can trigger CFRD, which often resolves when the stressor is eliminated (Moran,
1999; CF 101).
The Behavioral Pediatric Feeding Assessment Scale (BPFAS) can be used for toddlers
and school-age children to screen for problematic eating behaviors (Crist, 1994). The
BPFAS scale detects the frequency of problematic eating behaviors as well as caregivers'
feelings about the problematic eating behaviors (Crist, 1994; Stark, 2000). Adolescent
patients may benefit from assessment of eating behaviors and risk for disturbed eating
behavior (Abbott, 2007; Bryon, 2008).

Laboratory

The Cystic Fibrosis (CF) Foundation recommends assessment of vitamins A, D, E, and
K at diagnosis (for patients not diagnosed through neonatal screening) and monitoring
annually thereafter. Iron and protein stores should be checked at diagnosis and annually.
Note the following parameters for monitoring other nutrients (Borowitz, 2002; Borowitz,
2009):
Beta carotene: Check at physician's discretion
Essential fatty acids: Consider checking in infants or those with failure to thrive
Sodium: Check if patients are exposed to heat stress and become dehydrated
For more information on tests for monitoring, see Table 5 in Borowitz, 2002.
In addition, examine complete blood count, liver function tests, random glucose,
electrolytes, and urinalysis. Abnormal values should be addressed and repeated to assess
response to change in therapy. Monitoring for diabetes with an oral glucose tolerance test
should occur in individuals 10 years of age and older (Moran, 2010). Fingerstick glucose
monitoring and hemoglobin A1C testing is recommended for individuals who have
CF-related diabetes.

Client History

Client history includes the following:
Comprehensive family medical history, including cystic fibrosis (CF); diabetes;
pulmonary, heart, and gastrointestinal diseases; allergies; and cancer
Patient medical history including surgeries, CF complications, allergies including food
allergies, and gastrointestinal complications and/or symptoms
Usual exercise; use of enzymes, vitamins, and energy supplements; use of tube
feeding; and religious, social, and cultural beliefs that may influence care
Parental heights (in order to calculate midparental height); assessment of patient and
family coping skills; referral to social worker as indicated.
Since relationships between health professionals and CF patients are long term, it is
usually helpful to have interest in the patients' outside activities and social life to maintain
rapport and build trust. Knowledge of an individual's support system will also help when
developing a care plan.

Food/Nutrition-Related History

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Food history can be obtained using food frequency, diet recall, or diet records. In a
fast-paced clinic environment, 24-hour diet recall or usual food intake are often the most
practical way to assess intake, but these records will not provide detailed information about
nutrient intake. Still, a diet recall can help the registered dietitian (RD) assess meal/snack
patterns and content, high-kilocalorie foods and/or supplement use, and enzyme
management.
The food recall or usual food intake can provide a baseline estimate of energy consumed
and be used to set goals for increasing energy intake with specific suggestions based on
the client's food preferences and habits. Concerns regarding the use of salt and enzymes
can be addressed.
A quantitative 3- to 5-day diet record is necessary for fecal fat studies. The information
provided can be helpful when completing a full assessment on clients who are at nutritional
risk. Enzyme use can be included with the diet record to help the RD assess enzyme
adherence and dose based on fat consumed. Using the information from the diet record,
the RD can provide suggestions for increasing energy, set energy goals for meals and/or
snacks, and adjust enzyme dose and/or administration.

Comparative Standards

Energy
Defining energy needs of patients who have cystic fibrosis (CF) is a challenge. Individual
variables include differences in maldigestion and resultant malabsorption, pulmonary
exacerbation, pulmonary function, fat-free mass, sex, pubertal status, genetic mutation,
age, and medical complications including liver disease or CF-related diabetes (Michel,
2009a). Daily energy recommendations from various CF societies range from 110% to
200% of recommended levels for people without CF (Stallings, 2008; Australasian
Guidelines, 2006).
A formula incorporating age, sex, activity, pulmonary function, and fat malabsorption was
included in the 1992 United States CF Foundation nutrition consensus report (see table on
this page) (Ramsey, 1992). Formulas for calculating the energy needs of children with mild
to moderate pulmonary disease were evaluated; the estimated energy requirement of the
Dietary Reference Intake at the active level best estimated the energy needs of this
particular group (Trabulsi, 2007).
It is suggested that formulas be used as a starting point for calculating energy needs, but
assessing the gain in weight and height, the velocity of weight and height gain, and fat
stores may provide a more objective measure of energy balance (Trabulsi, 2007). Energy
intake is adjusted based on these objective measures. To achieve energy goals, persons
who have CF often require a greater fat intake (35% to 40% of energy) compared to those
without CF (Borowitz, 2002).
Determination of Energy Requirements According to the US Cystic Fibrosis Foundation
Step 1. Calculate basal metabolic rate (BMR) in kcal from body weight in kg using World
Health Organization equations.
Age Range (y) Females Males
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Age Range (y) Females Males
0-3 61.0 wt -51 60.9 wt - 54
3-10 22.5 wt + 499 22.7 wt + 495
10-18 12.2 wt + 746 17.5 wt + 651
18-30 14.7 wt + 496 15.3 wt +679

Step 2. Calculate the daily energy expenditure (DEE) by multiplying the BMR by activity
plus disease coefficients.

Activity
Coefficients (AC)
Disease Coefficients DEE
Confined to bed:
BMR x 1.3
FEV1> 80% predicted: 0
BMR x (AC
+ 0)
Sedentary: BMR x
1.5
FEV1 40-79% predicted:
0.2
BMR x (AC
+ 0.2)
Active: BMR x 1.7
FEV1 <40% predicted:
0.3 to 0.5*
BMR x (AC
+ 0.3*)
* May range up to 0.5 with very severe lung disease

Step 3. Calculate total daily energy requirements (DERs) from DEE and degree of
steatorrhea.
If a stool collection is not available to determine the fraction of fat intake, an approximate
value of 0.85 may be used in the calculation. For pancreatic sufficient patients and
pancreatic insufficient patients with a coefficient of fat absorption (COA) > 93% of intake,
DER = DEE. For example: for a patient with a COA of 0.78, the factor is 0.93/0.78, or 1.2. If
the COA is not known the factor is 1.1.
Example:
This is an assessment of a 10-year old boy with the following measurements:
Weight= 32 kg; AC = active; FEV1% predicted = 85%; COA = not available.
12.2 (32) + 746 = 1136
1136 x (1.7 + 0) = 1931
1931 x 1.1= 2124 kcal per day

Adapted from: Ramsey BW, Farrell PM, Pencharz P. Nutritional assessment and
management in cystic fibrosis: a consensus report. Am J Clin Nutr. 1992;55:115-116.

Height
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To assess adequacy of linear growth, the child’s height is compared to midparental height.
For a boy:
Add mother’s height (cm) + 13 (cm) to father’s height (cm) and divide by 2. This is the
midparental height. Adjust ±10 cm for target height range.

For a girl:
Add mother’s height (cm) to father’s height (cm) – 13 (cm) and divide by 2. This is the
midparental height.
Adjust ±9 cm for target height range.

Pancreatic Enzyme Replacement Therapy (Borowitz, 2002)
Dosing by weight is the most commonly used method.
Infants and children younger than 4 years old:
2,000 lipase units to 4,000 lipase units (LU) per 120 mL of formula or per breastfeeding.
Not to exceed 2,500 LU/kg/feeding or 10,000 LU/kg/day. This provides approximately 450
LU/g to 900 LU/g of fat ingested.
Children 4 years and older:
Initiate at 1,000 LU/kg/meal for children younger than 4 years of age and 500 LU/kg/meal
for those older than 4 years.
Dose should not exceed 2,500 LU/kg/meal or 10,000 LU/kg/day.
Dosing by gram of fat:
500 LU/g to 4,000 LU/g of fat ingested per day (mean = 1,800 LU/g of fat per day). Not to
exceed 4,000 LU/g/day.

Fluids
Fluid requirements are determined by age and weight as for any other infant, child, or
adolescent. There are no extraordinary requirements or limitations due to cystic fibrosis
(CF). Adequate hydration is important for patients with CF, as dehydration can quickly lead
to distal intestinal obstruction syndrome (Houwen, 2010). Patients and their families should
be advised to call their CF center if insufficient fluid intake is observed or if vomiting and/or
diarrhea persists.
Special attention should be given to situations involving physical exertion in hot conditions.
Adolescent athletes in particular should be provided with anticipatory guidance on fluid and
salt requirements. Salt tablets are available in pharmacies and from the CF Services
pharmacy.

Nutrition Diagnosis
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Registered dietitians (RDs) working with patients who have cystic fibrosis should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the following list, as well as
other diagnoses, may be present.
Increased energy expenditure (NI-1.2)
Inadequate oral intake (NI-2.1)
Malnutrition (NI-5.2)
Inadequate fat intake (NI-5.6.1)
Excessive fluid intake (NI-3.1)
Inadequate mineral intake (NI-5.10.1)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Sample PES (problem, etiology, signs and symptoms) or Nutrition Diagnostic
Statement(s)
Increased nutrient needs (NI-5.1) related to malabsorption and lung disease as
evidenced by poor weight gain and growth.
Impaired nutrient utilization (NC-2.1) related to malabsorption as evidenced by
increased steatorrhea.
Inadequate energy intake (NI-1.4) related to anorexia and increased work of
breathing as evidenced by 24-hour dietary recall.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition interventions for patients with cystic fibrosis (CF) include the following:
1. Recommendation of a modified diet:
110% to 200% Dietary Reference Intake for energy and protein based on growth, lung
disease, malabsorption, and other coexisting complications of CF (Stallings, 2008).
Fat intake of 30% to 40% of energy as tolerated.
Increased vitamin intake per Cystic Fibrosis Foundation (CFF) guidelines or greater
(Borowitz, 2002; Michel, 2009a; Leonard, 1996)
Use of CF-specific multivitamins or additional supplementation to meet needs of
the child with CF (Michel 2009a).
Increased salt intake per CFF guidelines (Borowitz, 2002; Borowitz, 2009).
Optimal calcium and vitamin D intake (Aris, 2005).
2. Modification of diet to include 3 meals and 3 snacks/day
3. Pancreatic enzyme supplementation, if prescribed, to be taken no more than 30 minutes
prior to all meals and snacks (Borowitz, 2002; Leonard, 1996)
Enzyme Cheat Sheet (provided courtesy of Brigid Mordeson, MA, RD, LMNT; last
updated 11/16/11)
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updated 11/16/11)
4. Nutrition education on the relationship between nutrition and lung function in CF
5. Collaboration with other members of the health care team

Nutrition Therapy Efficacy

The diet for patients with cystic fibrosis (CF) should be adequate in all nutrients
and dependent on daily food and beverage intake. Careful planning is necessary to ensure
intake of energy-dense and nutrient-dense foods.
There is an inaccurate belief that nutrient content of foods and beverages is unimportant as
long as energy is sufficient. Nutrition therapy efficacy is determined by evaluation of growth
parameters and biochemical measurements. Optimal nutrition, including weight, may
influence lung function (Stallings, 2008).
Body mass includes fat mass and fat-free mass; the latter reflects muscle and protein
stores, and body weight in the absence of fluid retention indirectly reflects fat-free mass. A
few small studies have demonstrated improvements in respiratory muscle function with
provision of adequate nutrition support. This can lead to maintenance of improved
pulmonary function and fewer pulmonary exacerbations (Matel, 2009).
Nutrient exceptions to the Dietary Reference Intakes (DRI) for CF patients include the
following:
110% to 200% of DRI for energy and protein
Fat intake of 30% to 40% (40% to 50% for children younger than 2) of energy
Increased vitamin intake per CF Foundation guidelines (Borowitz, 2009)
Increased salt intake per CF Foundation guidelines (Borowitz, 2009)
Increased calcium intake
Increased zinc intake

Goal Setting

Goals are dependent on age, developmental status, and clinical status.
Goals for a young child are parent-based, such as the following:
Milk will be offered instead of apple juice
Enzymes will be kept at grandmother's house
Other potential goals for patients and caregivers:
The patient will increase energy intake by 300 kcal/day.
The patient will gain 1 kg of weight per month over the next 3 months.
The patient will drink whole milk at all meals.
The caregiver will supervise enzyme administration at all meals and snacks.
The patient will take vitamins simultaneously with meals and pancreatic enzyme
replacement therapy.

Oral Intake
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The keys to an adequate diet for a patient with cystic fibrosis (CF) include the following:
Energy-dense and nutrient-dense variety of foods
Energy-dense and nutrient-dense beverages (eg, milk, flavored milk, yogurt
smoothies, commercial supplements)
Development and maintenance of good mealtime and snacking habits
Goals of oral intake are to promote weight at or above the 50th percentile for
weight-for-length by age 2 years and maintenance of weight at or above the 50th percentile
for body mass index after age 2 years (Stallings, 2008). Oral nutritional supplements are
widely used and are intended to add to energy consumed during meals and snacks, not as
meal replacements.
Potential barriers:
Energy: Inadequate intake, malabsorption, increased energy expenditure,
undiagnosed CF-related diabetes
Protein: Inadequate intake, catabolism, nonadherence to enzymes
Vitamin and mineral deficiencies: Insufficient intake, malabsorption, nonadherence to
vitamin and mineral therapy
Fluid and salt needs: Risk of dehydration given increased sweat production/salt loss
Enzymes: Refusal or nonadherence to prescribed enzyme administration
Parenting: Inadequate skills related to feeding and meal/snack structure
Child behaviors: Maladaptive feeding behaviors due to illness early in life or other
interruption of acquisition of age-appropriate feeding behaviors
Constipation: Often underdiagnosed and undertreated; can negatively affect appetite
(van der Doef, 2010; Chao, 2008)

Enteral or Tube Feedings

When sufficient energy and nutrients cannot be consumed orally and after cystic fibrosis
(CF)–related diabetes has been ruled out, the option of enteral nutrition should be
introduced to the family. In younger children, bolus feedings after meals are often advised
to help promote the feeling of hunger and satiety. These feedings may be accompanied by
overnight feedings for provision of sufficient energy.
For school-age children and adolescents, nocturnal feedings are used to supplement the
oral diet. The choice of enteral formula should be individualized. Generally, school -age
children can receive adequate nutrition support from a 1.0 kcal/cc or 1.5 kcal/cc polymeric
formula. Adolescents typically are able to tolerate a 1.5 kcal/mL or 2.0 kcal/mL polymeric
formula. Pancreatic enzyme replacement therapy administration is essential with a
polymeric formula. The mealtime enzyme dose is given just prior to nocturnal tube feedings
and at the end of feeding. This approach is not optimal but it remains the best option at this
time.
Semi-elemental formulas may require a lower dosage of pancreatic enzyme
supplementation (Erskine, 2007). Total parenteral nutrition (TPN) is seldom used for
nutrition support with CF. A notable exception is in infancy after intestinal resection
with resultant short bowel syndrome. PN also may be used in premature infants with CF or
those born with meconium illeus requiring medical intervention. Every effort should be
made to limit time on intravenous nutrition support due to the potential for TPN-related
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made to limit time on intravenous nutrition support due to the potential for TPN-related
cholestasis (Michel, 2009a; Borowitz, 2002; Cantin, 2007; Aris 2005; Australasian
Guidelines, 2006; Borowitz, 2009).

Suggested Monitoring Parameters and Recommendations

The following should be evaluated at every visit with the exception of "sick" visits:
Clinical data
24-hour recall or 3-day food record to determine energy intake and
macronutrient/micronutrient composition of diet
Weight changes
Pediatric growth points and weight for length or body mass index as calculated and
plotted on the growth chart
Each follow-up nutrition intervention for patients should include adjusting nutrition
goals and treatment plans according to a patient's response to the current treatment
Laboratory data, including complete blood count, fat-soluble vitamin levels (or markers for
vitamin K), prealbumin, and essential fatty acid levels should be obtained yearly (see
the Biochemical Data, Medical Tests and Procedures; Nutrition Assessment; and
Laboratory sections).
The registered dietitian uses critical thinking skills to select appropriate indicators and
measures, uses appropriate reference standards for comparison, defines the
patient's/client's progress relative to expected outcomes, explains variance from expected
outcomes, and determines factors that help or hinder progress. In a chronic condition such
as cystic fibrosis, which continues throughout the lifespan, monitoring and evaluation must
adjust to age-specific variables. As nutrition care is continued, reassessment may result in
refinements to the diagnosis and intervention.

Nutrition Care FAQs

Do children with cystic fibrosis (CF) need extra salt after infancy?
After infancy, when children no longer consume unseasoned infant foods, the need for salt
is usually met by intake of normal foods from the typical diet in the amount that will meet
energy requirements. However, those who live in a very hot climate might need salt added
to food, and those who engage in vigorous physical activity may need salt supplements.
In addition, children whose sole source of nutrition support is by tube feeding might
require salt supplementation because most enteral formulas provide only a modest amount
of sodium. There are reports of emergency room visits and even hospitalization of children
with CF for serum electrolyte depletion (Legris, 1998). The registered dietitian (RD) should
provide anticipatory guidance for salt supplementation. Salt supplements are available from
the CF Services pharmacy.
Plasma zinc is a poor measure of sufficiency. When should extra supplementation
be given in addition to the CF-specific vitamins?
Serum zinc isn’t suppressed until zinc stores are very low and deficiency is quite profound.
Those with mild to moderate zinc deficiency may fail to be identified. Signs of zinc
deficiency (changes in appetite and growth) and more subtle symptoms (decreased
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immunity) can occur while plasma levels are within normal reference ranges (Christian,
1998).
The CF Foundation Consensus Report on Nutrition for Pediatric Patients recommended
the following (Borowitz, 2002):
Zinc levels should not be measured
A trial of zinc supplementation (1 mg elemental zinc/kg/day in divided doses for 6
months) may be given to patients who are not adequately growing despite adequate
energy intake and pancreatic enzyme replacement therapy.
A complete diet review might reveal few dietary zinc sources, particularly if children
are consuming few animal products.
How does CF-related diabetes (CFRD) affect anabolism?
Insulin is an anabolic hormone. Insulin insufficiency in CF leads to protein and fat
breakdown. Studies show improved weight and lean body mass with insulin therapy,
particularly with supervised use of an insulin pump (Hardin, 2009). Glucosuria is present
with blood glucose levels greater than 180 mg/day.
What does the term "DIOS" mean and how does it differ from constipation?
Constipation in cystic fibrosis has been defined as follows:
Abdominal pain and/or distension
Reduced frequency of bowel movements in the last few weeks or months
Increased consistency of stools in the last few weeks or months
First 2 symptoms are relieved by the use of laxatives/stool softener
Newer research indicates that constipation in CF is underrecognized and undertreated (van
der Doef, 2010).
Distal intestinal obstruction syndrome (DIOS) is unique to CF patients, and DIOS replaces
the term "meconium ileus equivalent" because the bowel obstruction can occur within the
right colon as well as the ileum. It is a recurring form of either partial or complete intestinal
obstruction (Houwen, 2010).
Symptoms of DIOS include the following:
Progressive, colicky abdominal pain and bloating
Nausea and anorexia
The possibility, but not necessity, of fewer bowel movements
Precipitating factors:
Pancreatic insufficient and abnormal mucus: dehydration of luminal contents
Poor adherence to pancreatic enzyme replacement therapy
Major surgery, eg, post-transplant
Dysmotility, which can be exacerbated by low-fiber diet and drugs (analgesics)
Management of DIOS includes the following:
Ensure adequate fluid intake
Ensure adequate enzyme usage
Initiate treatment early to avoid the need for surgical intervention
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Initiate treatment early to avoid the need for surgical intervention
It is appropriate for the RD to ask a patient with CF about constipation; RDs are qualified to
educate about steps to take to prevent DIOS.
How is blood sugar controlled in CFRD when a high-kilocalorie diet is needed?
An endocrinologist who is experienced in CF care should collaborate with the patient to
develop an insulin regimen that allows for a flexible eating schedule and a high-kilocalorie
and liberal carbohydrate intake. The staff RD at the CF center should be knowledgeable
with regard to carbohydrate counting and insulin therapies including the insulin pump.
Foods that are not nutritious such as candy, soda, apple juice, and other sweet liquids
should be limited to the same degree they are limited for any patient with CF. The RD
should encourage open discussion of individual preferences to foster long-term adherence.
If a blood test reveals low serum vitamin A, and vitamins and enzymes are being
taken as advised, should additional vitamin A supplementation be recommended?
Vitamin A and carotenoids are necessary in cell differentiation and immune function, as
well as pulmonary and bone health (Maqbool, 2008). Serum levels of vitamin A are affected
by inflammation, nutritional status, hepatic function, and zinc status. Vitamin A or
retinol circulates in blood bound to retinol-binding protein (RBP). When serum levels of
vitamin A are low, a retinol-binding protein level should be obtained. RBP is one of the
visceral proteins that is decreased in malnutrition, inflammation, and hepatic disease. Extra
vitamin A should not be given when RBP is depressed. Vitamin A cannot leave the liver if
RBP is low and the addition of extra vitamin A could result in toxicity. Zinc deficiency also
depresses synthesis of RBP in the liver (Tinley, 2008).
Prior to supplementing with vitamin A, inflammation should be controlled and malnutrition
should be corrected. Individual diets should be assessed for zinc content, and diarrhea,
which can lead to loss of zinc, should be considered. Zinc supplementation should be
considered along with vitamin A supplementation (Tinley, 2008). Some CF-specific
vitamins contain a higher percentage of beta-carotene, which is thought less likely to be
toxic in high amounts than retinol (Maqbool, 2008).

Anthropometric Measurements

Anthropometrics
Measurement, plotting, and interpretation of head circumference, weight, and length are
essential to the care of children with cystic fibrosis (CF). Mid-arm circumference and triceps
skinfold thickness measurements provide clinical information about lean body mass
development and subcutaneous fat stores but are no longer recommended for all patients.
Clinic Visits and Hospital Admission
Younger than 2 years of age
In 2009, the Cystic Fibrosis Foundation published evidence-based guidelines for
management of infants with CF (Borowitz, 2009). Monthly clinic visits are recommended
during the first year of life, during which weight, length, and head circumference are
measured and plotted on growth charts. Weight-for-length is calculated and plotted.
The Foundation continues to use CDC growth charts for these measurements. During
hospitalization, weight should be measured daily. A calibrated length board, rather than a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
hospitalization, weight should be measured daily. A calibrated length board, rather than a
tape measure, is recommended for accuracy and consistency.
Older than 2 years of age
As children age, weight and height are monitored every 3 months. Weight and height are
measured and plotted on growth charts. A stadiometer should be used to measure
height. Body mass index should be calculated and plotted. Biological parents' height should
be obtained and mid-parental height should be calculated and compared to the
child's height (Zhang, 2010). Specifying days of the week for measuring weight during
hospitalization (such as Monday, Wednesday, or Friday) may make follow-through more
likely.
For most patients with CF, calculation of energy needs based on recommended
mathematical formulas is sufficiently accurate. Indirect calorimetry might be useful in
patients in the intensive care unit who are critically ill.

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Nutrition Care > Pulmonary Diseases > Ventilator Issues
Nutrition Assessment

Nutritional assessment should be done routinely for a child on mechanical ventilation. This
assessment should be conducted more frequently on the critically ill child in an intensive
care setting and less often on the child who is stable and on mechanical ventilation at
home. Nutrition assessment may include:
Food/Nutrition Related History
Total energy intake
Enteral nutrition intake
Total protein intake
Vitamin intake
Mineral/element intake
Women, Infants, and Children (WIC) eligibility
Caregiver, companion
Physical activity history
Fluid needs
Fiber needs
Mealtime behavior
Sequential weight gain or loss

Nutrition-Focused Physical Findings

Assess the following for a child on mechanical ventilation:
Overall appearance
Presence/appearance of feeding tube
Skin condition
Extremities

Biochemical Data, Medical Tests and Procedures

An evaluation to rule out swallowing dysfunction and aspiration should be conducted prior
to orally feeding a child on mechanical ventilation (Ambrosino, 2004).
Respiratory quotient (RQ) may be assessed in the intensive care unit to determine
adequacy of feedings. However, there is controversy about the effectiveness of RQ in
predicting the accuracy of overfeeding (Akrabawi, 1996). RQ is affected by varying levels
of oxygen.

Laboratory

The following should be evaluated for a child on mechanical ventilation:
Serum albumin, total protein, prealbumin
Hemoglobin, hematocrit
Vitamin levels (A,D)
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Urine profile to evaluate hydration status
Electrolytes

Client History

Assess the following for a child on mechanical ventilation:
Personal data
Client medical/health history
Treatments/therapy/alternative medicine
Social history
Birth history

Food/Nutrition-Related History

Assess the following for a child on mechanical ventilation:
Length of time on the ventilator
Length of time on tube feedings
Type of feeding tube (GJ, ND, G-tube, etc)
Formulas used
Additives to the formula
Rate and timing of tube feedings
Ability to feed orally
Presence of oral aversion
Results of swallowing study

Comparative Standards

Calculations for assessment should begin with estimated energy requirement or total
energy expenditure needs for age and gender. Adjustments for activity level should be
done. For a child who is very inactive, the energy requirements may be decreased. In some
cases, using kcal/cm length may more adequately assess needs (Cloud, 2005).
Fluid needs will depend on the underlying diagnosis of the ventilator-dependent child.
Baseline needs are 100 ml/kg/day for the first 10 kg in weight, 50 ml/kg for the next 10 kg,
and 20 ml/kg for each kg above 20.

Nutrition Diagnosis

Dietitians working with patients who are on ventilators should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Inadequate energy intake (NI-1.4)
Excessive energy intake (NI-1.5)
Predicted suboptimal energy intake (NI-1.7)
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Less than optimal enteral nutrition (NI-2.5)
Swallowing difficulty (NC-1.1)
Underweight (NC-3.1)
Self-feeding difficulty (NB-2.6)
Sample PES or Nutrition Diagnostic Statement(s)
Underweight (NC-3.1) related to inadequate energy intake as evidenced by weight <
5th percentile for age and Body Mass Index < 5th percentile.
Excessive energy intake (NI-1.5) related to decreased energy expenditure secondary
to inactivity and mechanical ventilation as evidenced by excessive gain for age and
gender.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.


Nutrition Intervention

The following are examples of nutrition interventions that may be helpful for
ventilator-dependent children:
Modification of rate, concentration, composition or schedule of enteral nutrition
(ND-1.2, ND-2.1.1)
Supplementation with multivitamin/mineral/trace elements (ND-3.2.1, ND-3.2.2)
Feeding assistance (ND-4.1, ND-4.2, ND-4.3, ND-4.4)
Collaboration with/referral to OT/PT or speech therapist (RC-1.3)
Site care (Enteral, ND-2.1.3; Parenteral, ND-2.2.2)
Bioactive substance management (ND-3.3.4)

Nutrition Therapy Efficacy

Expected outcomes of nutrition therapy would be that the child on mechanical ventilation
exhibits normalization of growth and development. Normalization is indicated by an
appropriate weight-for-length or height.
Children who are medically stable and require long-term mechanical ventilation may have
lower energy requirements. Adjustments should be made to ensure adequate protein,
vitamin, and mineral intake while preventing excessive weight gain. Tube feedings alone
may not provide adequate fluids if the volume of formula is reduced to avoid excessive
weight gain.

Goal Setting

Goals of nutrition therapy are:
Adequate nutrient intakes
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Adequate nutrient intakes
Weight for height or length between the 10th and 90th percentiles


Food & Feeding Issues

Most children who are ventilator dependent require tube feedings. They may have
oral-motor aversion, difficulty swallowing, and/or aspiration problems. Oral feedings should
be utilized only if a swallowing study has documented the safety of oral feedings. A speech
language pathologist or occupational therapist should work with the child to provide
oral-motor stimulation if the child is exclusively tube fed.

Nutrition Support

Ventilator-dependent children usually require tube feedings due to concerns about
swallowing and/or aspiration. Gastrostomy feedings are commonly utilized to meet
nutritional requirements. Formulas should be appropriate for age. Adequate fluids and fiber
should be provided due to inactivity and risk for constipation. A critically ill child who is
unable to be fed enterally may require parenteral nutrition.

Suggested Monitoring Parameters and Recommendations

Monitor and evaluate the following for the ventilator-dependent infant or child:
Total energy intake
Enteral nutrition intake
Total protein intake
Vitamin intake
Mineral/element intake
Women, Infants, and Children (WIC) eligibility
Physical activity history
Respiratory quotient (RQ)
Digestive system – bowel function

Nutrition Care FAQs

What are the energy requirements for a child on a long-term mechanical ventilator?
Adjustments to the calculated estimated energy requirement (EER) based on age and
gender may be necessary to ensure adequate but not excessive weight gain. Activity level
must be considered. Calculation of kcal/cm of length may more appropriately estimate
energy requirements (Cloud, 2005). A complete nutrition assessment should be conducted
to help determine if the patient's needs are being met appropriately. If the intake does not
measure up to the child's weight and height, more investigation may be warranted.

Anthropometric Measurements

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Anthropometric assessment should include:
weight for age
length or height for age
weight for length or BMI for age
head circumference for age (up to 36 months of age)
arm span, for patients unable to stand or who have contractures that prevent an
accurate recumbent length


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Renal Diseases
Renal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Renal Diseases > Chronic Kidney Disease
Nutrition Assessment

It is important for a child to receive regular nutrition assessments starting with initial diagnosis, so
that subtle changes in appetite and weight gain or linear growth and biochemical abnormalities can
be addressed before the child is failing to thrive.
For children with stage 2 through stage 5 and 5D chronic kidney disease (CKD), monitoring of
nutrition and growth parameters should be based on age and stage of CKD. A good rule of thumb
is that monitoring should be done twice as often as for a healthy child of the same age. If nutritional
concerns are identified, monitoring will need to be more frequent (NKF, 2009).
Whenever a child has abnormal laboratory results or problems with weight gain (high or low) or
other medical problems, nutrition assessment will be needed more frequently. The renal registered
dietitian should be monitoring the child with the medical team and advising on any altered nutrition
needs associated with laboratory or weight gain abnormalities or medical problems.
A complete nutrition assessment evaluates feeding behavior/concerns, nutritional intake (see table
below), growth, and laboratory values (see Laboratory). All of this information is used to create an
individualized nutrition plan for a child.
Minimum Interval (months)
Age 0-1 yr Age 1-3 yr Age >3 yr
Measure (Stage)
CKD
2-3
CKD
4-5
CKD
5D
CKD
2-3
CKD
4-5
CKD
5D
CKD
2
CKD
3
CKD
4-5
CKD
5D
Dietary intake 0.5-3 0.5-3 0.5-2 1-3 1-3 1-3 6-12 6 3-4 3-4
Height or length-for-age,
percentile or SD
0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3
Height or
length-velocity-for-age,
percentile or SD
0.5-2 0.5-2 0.5-1 1-6 1-3 1-2 6 6 6 6
Estimated dry weight and
weight for age, percentile
or SD
0.5-1.5 0.5-1.5 0.25-1 1-3 1-2 0.5-1 3-6 3-6 1-3 1-3
Body mass index for height
for age, weight for length
(younger than 24 months),
percentile or SD
0.5-1 0.5-1 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3
Head circumference-for-
height age, percentile or
SDS
0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 N/A N/A N/A N/A
Normalized protein
catabolic rate, dialysis only
N/A N/A N/A N/A N/A N/A N/A N/A N/A 1
a
Recommended Parameters and Frequency of Nutritional Assessment for Children with
CKD Stages 2 through 5
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Abbreviations: SD = Standard deviation; N/A = not applicable
a
Only applies to adolescents receiving hemodialysis
From KDOQI Work Group. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD:
2008 update. Executive summary. Am J Kidney Dis. 2009;53(3 Suppl 2):S16. Table reprinted with
permission from Elsevier. Journal available at:
http://www.sciencedirect.com/science/journal/02726386.

Anthropometric Measurements

Measure length (up to 24 to 36 months of age) or height (older than 2 years of age), weight, and
head circumference (up to 3 years of age) and compare to World Health Organization
(WHO) Growth Charts of children aged 0 to 24 months; go to the Growth Charts area of
Resources to download WHO growth charts and the 2001 Centers for Disease Control and
Prevention (CDC) growth charts for children older than 2 years.
The WHO charts were derived from an international sample of healthy breastfed infants and young
children raised in environments that do not constrain growth (WHO, 2006). These charts are
considered the best standards for optimal growth, as there is very little difference in growth related
to country of origin or ethnicity. The Kidney Disease Outcomes Quality Initiative guidelines
recommend using the WHO charts rather than the 2001 CDC growth charts for children aged 0 to
24 months (NKF, 2009). Because the differences between the WHO and CDC charts for children
older than 2 years are minimal, it is recommended that CDC charts are used for older children.
Plot weight-for-length ratio (until 24 to 36 months of age) or calculate and plot body mass index
(BMI) (older than 2 years) on growth chart. It is important to measure weight when the child is
euvolemic, to determine "real" or "dry" weight.
Because of growth and/or maturational delay in children with chronic kidney disease (CKD), it is
often best to assess BMI using height age rather than chronological age (height age is age at
which current height is at the 50th percentile).
Evaluate growth history to determine if growth rate is normal. Weight gain, linear growth velocity,
and head circumference growth velocity for children younger than 2 years can be calculated using
the WHO growth standards. Weight gain and linear growth velocity for children from 2 to 18 years
of age can be determined by calculating standard deviation change over time (see CDC growth
charts) or by using data from the Fels Longitudinal Study (Baumgartner, 1986).
Standard deviation (SD or Z-score), rather than percentile, is often used for children with CKD as it
is a fairly precise way to look at change in growth over time—for example, a child's height may
increase from –3 to –2.5 SD, which is a significant improvement; however, both would be
considered below the 3rd percentile for age and improvement not appreciated if percentiles were
being used.
When evaluating a child's height, it is helpful to look at genetic potential; this can be done by
calculating mid-parental height:
Girls: 5 inches (13 cm) subtracted from the father's height and averaged with the mother's
height.
Boys: 5 inches (13 cm) added to the mother's height and averaged with the father's height.
The midparental height is plotted on the growth chart (based on child's sex) at 20 years of age. For
both girls and boys, 3.5 inches (8.5 cm) on either side of this calculated value (target height)
represents the 3rd to 97th percentiles for anticipated adult height (the 5 inches or 13 cm represents
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
represents the 3rd to 97th percentiles for anticipated adult height (the 5 inches or 13 cm represents
the average difference in height of men and women; the average child grows to the midparental
height percentile (NKF, 2009).

Biochemical Data, Medical Tests and Procedures

Laboratory tests are used to help diagnose the degree of kidney insufficiency as well as metabolic
abnormalities associated with chronic kidney disease (CKD).
Other tests that might be done include the following:
Kidney ultrasound, which shows the size of the kidneys and general physiology. Ultrasound
shows whether the kidneys are developing normally for age and if both kidneys are present
and gives information about the vasculature and anatomy of the kidneys. This can be helpful
in determining the potential for kidney function over time (eg, if a child is admitted for
decreased kidney function, an ultrasound may help determine whether the child has a
reversible or a permanent kidney disorder).
Kidney biopsy, which can help determine the etiology of kidney disease in a child. Some
types of kidney diseases can be reversed with medical or surgical intervention, whereas
others are progressive and/or irreversible.
Hemodialysis access function. If dialysis is not going well, evaluation of the hemodialysis
central line, fistula, or graft is done. If the access is not working well, removal of fluid and
toxins will be suboptimal. It may be necessary for the registered dietitian (RD) to revise the
nutrition prescription to further limit fluid, sodium, potassium, and phosphorus until dialysis
access is improved or a new access is obtained.
The knowledge obtained from ultrasound and/or biopsy helps the RD know how to approach
nutrition education for families. For example, a high phosphorus level may not be a significant
problem when kidney failure is acute and temporary, so a strict low-phosphorus diet and
phosphate binders might not be appropriate. However, if it is known that a child has irreversible
CKD, it will be very important for the RD to teach a family how to keep phosphorus levels within
normal limits.
A child on peritoneal dialysis may be tested to evaluate peritoneal membrane function. This helps
to determine efficiency of fluid and toxin removal as well as dextrose absorption and protein loss.
The RD will use this information in developing the nutrition prescription for an individual child.
Any test that evaluates kidney function or dialysis function is very useful to the RD in developing
the nutrition prescription and providing accurate nutrition education to the family as well as to the
medical team.

Laboratory

Laboratory Tests and Interpretation of Results for Children with Chronic Kidney Disease
(CKD)
Laboratory
Tests
Reason for
Testing
Conditions That
Alter Results
Nutritional
Significance
of High Values
Nutritional
Significance of
Low Values
Creatinine
(varies with
muscle mass)
Measure of
kidney function
Fluid status
If dehydrated,
creatinine is high
Indicates
decreasing
kidney function
Indicates low
muscle mass
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Blood Urea
Nitrogen
(BUN)
Waste products
of protein
If creatinine is
high, expect
BUN to be 10-20
X creatine
Fluid status
If dehydrated, BUN
is high
Excessive
protein intake
Dehydration
If lower than
expected,
could signal
overhydration
and/or low
protein intake
Sodium Helpful in
assessing fluid
status and
adequacy of
sodium intake
(low sodium
levels affect
growth and
development)
Fluid status
If fluid overload,
sodium is low
If dehydrated,
sodium may be high
If polyuric and a
“salt waster,”
sodium may be low,
even with
dehydration
Dehydration Overhydration
or sodium
deficiency
and/or
inadequate intake
Potassium Extremely
important in
cardiac function
Metabolic acidosis
(if carbon dioxide is
low, potassium is
likely to be high).
Renal tubular
acidosis results in
high potassium
Potassium wasting
diseases such as
cystinosis, Barter
syndrome
Peritoneal dialysis
may result in
excess potassium
removal
Medications like
Enalapril cause
increase in
potassium; Lasix
(furosemide) causes
decrease in
potassium
Excess intake
Need for more
dialysis or
decrease in food
sources of
potassium
Inadequate intake
May need
supplement
Carbon
Dioxide
Indicator of
acid/base status
Important for
bone
development and
growth
Metabolic acidosis
is caused by chronic
kidney disease
(CKD) and renal
tubular acidosis
Metabolic alkalosis Metabolic
acidosis
Causes poor
growth and poor
bone
development
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Calcium Important for
bone
mineraliz-ation
and muscle
function
Low serum albumin
(calcium is bound to
albumin)
If albumin is low,
need to check
ionized calcium to
get true assessment
of calcium status
If extremely high,
patient may have
seizures or go
into tetany
Chronically high
levels, especially
with high
phosphorus levels,
result in
calcification of
soft tissues—
especially arteries
(arteriosclerosis),
increasing risk for
coronary artery
disease
Indicator of low
vitamin D status;
may need more
activated
vitamin D to
enhance
absorption of
calcium
Phosphorus Important for
bone
mineraliz-ation
Decreased kidney
function causes
phosphorus
retention
Results in
increased
parathyroid
hormone and
decreased bone
mineralization
Indicator of low
intake of
phosphorus; if
low when there
is renal failure,
suggests poor
protein intake or
oversuppression
of phosphorus
with phosphate
binders
Parathyroid
Hormone
(PTH)
Plays a role in
calcium and
phosphorus
regulation and
bone
mineraliz-ation
CKD results in
elevated PTH
High levels are
indicative of high
bone turnover,
which can result in
metabolic bone
disease
Low levels are
indicative of low
bone turnover,
which can
result in
osteomalacia
Albumin Protein in the
blood
Carrier of
calcium and
other minerals
Systemic
inflammation,
volume overload,
urinary or dialysate
protein losses all
decrease serum
albumin;
protein–energy
malnutrition may
cause decreased
serum albumin
High levels are
indicative of
dehydration
Low levels do
not necessarily
indicate
malnutrition;
associated more
with fluid
overload and
systemic
inflammation or
protein losses;
low albumin with
inflammation is
associated with
increased
mortality in
children and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
adults with CKD
25-OH
Vitamin D
Inactive form of
vitamin D is
important for
many
physiologic
functions that
supplement-ation
of activated
vitamin D
(calcitriol) will not
meet
Low sunlight
exposure, low intake
of vitamin
D–containing foods
(eg, fluid milk and
seafood)
High values can
result in
hyper-calcemia,
hyperphos-phatemia
Low values
increase risk for
autoimmune
diseases,
cardiovascular
disease, and
several cancers;
the child with
CKD needs to
have normal
levels of 25-OH
vitamin D, even
though he or
she does not
activate it via the
kidneys
Hemoglobin/
Hematocrit
(Hgb/Hct)
Evaluate for
anemia
Determine need
for
erythro-poiesis-
stimulating agent
(ESA)
CKD results in low
erythropoietin,
which lowers
production of red
blood cells
High values can
mean dehydration
or that ESA needs
to be decreased
If Hgb/Hct are
excessive, a child
is at high risk for
hypertension and
cerbrovascular
accident (stroke)
Low values
indicate
overhydration or
anemia
If a child with
CKD is anemic,
more iron and/or
more ESA may
be necessary
Iron studies:
Serum
Ferritin and
Transferrin
Saturation
Evaluate iron
stores, which
help determine
whether anemia
is the result
of poor
erythropoiesis or
low iron
Determine if iron
stores are
adequate before
initiating ESA
Iron stores may be
low due to poor
appetite associated
with CKD or
exhausted due to
ESA therapy to
increase red blood
cell production
ESA therapy will not
be effective without
adequate iron stores
Very high values
can cause iron
toxicity and need
for iron removal
(even if anemia is
a concern)
High values
suggest that iron
supplementation
is temporarily
unnecessary
Low values
suggest need for
increased iron in
diet and/or
supplementation;
most
children with
CKD on ESA will
need regular iron
supplementation
If levels are very
low, intravenous
iron will be
necessary
Normalized
Protein
Catabolic
Rate
(Adolescents
who are
hemodialyzed
Estimate dietary
protein intake in
hemodialysis
patients (not
accurate in
growing children)
Dietary intake of
protein and energy
High values
suggest excess
protein intake
and will result in
higher-than-
desired BUN levels
Low values
suggest poor
dietary protein
intake
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
with CKD
stage 5D)
References: NKF, 2009; NKF, 2006

Client History

Development of Chronic Kidney Disease
Age at which chronic kidney disease (CKD) was diagnosed
Rate of progression of CKD
If CKD is at stage 5D, age at which dialysis was started
Dialysis history, including mode of dialysis, change in mode, complications (eg, peritonitis,
hemodialysis line infections)
Comorbid Conditions
Conditions associated with CKD (eg, failure to thrive, metabolic bone disease, anemia,
hypertension)
Coexisting conditions that are not associated with CKD (eg, asthma, food allergy, short bowel
syndrome, isolated heart defect)
Coexisting conditions that are a part of a syndrome that includes CKD
Developmental History
Cognitive or neurologic development and any issues that interfere with
feeding/eating/adherence to prescribed diet
Physical development (gross and fine motor skills) and any issues that interfere with
feeding/eating
Growth History, Starting with Birth
Birth weight, length, and head occipitofrontal circumference (OFC) and percentiles for
gestational age at birth
Rate of weight gain from birth to present; age at which any abnormal weight gain began
Linear growth rate from birth to present
OFC growth rate from birth to present
Weight-for-length ratio from birth to present; age at which any abnormalities were detected


Food/Nutrition-Related History

Obtain a feeding history from the child and family.
For preschool-aged children, start with infancy
For older children and adolescents, determine when/if appetite or food intake changed
relative to diagnosis of chronic kidney disease
Obtain the following information regarding current food intake:
Typical intake on weekdays and weekends (perform a detailed food intake interview and/or
ask family to complete a 3- to 7-day food record)
Food frequency, focusing especially on food sources of protein, sodium, potassium, calcium
and phosphorus
Fluid intake: if fluid intake (high or low) is a problem, ask the family to measure fluids before
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fluid intake: if fluid intake (high or low) is a problem, ask the family to measure fluids before
the child drinks and, if possible, to keep a written log for recording fluid intake.
If food records are available, quantify intake of protein, sodium, potassium, calcium,
phosphorus, fluid, and energy

Comparative Standards: Glomerular Filtration Rate

For information on body mass index and estimation of energy needs for age, height, and weight,
see Calculators.
Glomerular Filtration Rate
The Schwartz formula has traditionally been used to estimate glomerular filtration rate (GFR) in
children. In an effort to standardize creatinine measurements globally, measurements are being
calibrated to be traceable to isotope dilution mass spectroscopy (IDMS). The creatinine values
obtained are lower than with previous methods of measurement; if the original Schwartz formula is
used with creatinine measurement methods that are calibrated to be traceable to IDMS, GFR will
be overestimated. The calculation that follows is an "interim IDMS-traceable Schwartz calculator
for children." See the National Kidney Diseases Education Program (NKDEP) Web site (an
initiative of the National Institutes of Health) for more information on calculation of GFR in children.

Interim IDMS-traceable Schwartz formula for estimating GFR in children:
GFR (mL/min/1.73 m²) = (0.41 x Height [cm]) / Serum creatinine (mg/dL)


Nutrition Diagnosis

Registered dietitians (RDs) working with patients who have chronic kidney disease (CKD) should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the following list, as well
as other diagnoses, may be present.
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Excessive oral intake (NI-2.2)
Inadequate fluid intake (NI-3.1)
Excessive fluid intake (NI-3.2)
Malnutrition (NI-5.2)
Inadequate protein intake (NI-5.7.1)
Excessive protein intake (NI-5.7.2)
Inadequate vitamin intake (specify) (NI-5.9.1)
Excessive mineral intake (specify) (NI-5.10.2)
Inadequate mineral intake (specify) (NI-5.10.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Underweight (NC-3.1)
Overweight/obesity (NC-3.3)
Unintended weight gain (NC-3.4)
Sample PES (problem, etiology, signs and symptoms) or Nutrition Diagnostic Statement(s)
Inadequate energy intake (NI-1.4) related to poor appetite as evidenced by low body weight
compared to established reference standards or recommendations with weight for length
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
ratio below 5th percentile for age.
Unintended weight gain (NC-3.4) related to increased appetite secondary to prednisone as
evidenced by increased percentage of body mass index.
Altered nutrition-related laboratory values (NC-2.2) related to kidney dysfunction as
evidenced by abnormal laboratory values.
Excessive fluid intake (NI-3.2) related to high sodium intake and increased thirst as evidenced
by excessive weight gain with edema.
Inadequate fluid intake (NI-3.1) related to vomiting, diarrhea, and inability to drink enough to
meet fluid needs as evidenced by acute weight loss, increased blood urea nitrogen (BUN),
dry skin and mucous membranes, and reports of estimated intake of fluid less than
requirements.
Inadequate vitamin intake (vitamin D) (NI-5.9.1) related to low sunlight exposure and low
intake of vitamin D-containing foods as evidenced by low 25-OH vitamin D level.
Excessive vitamin intake (vitamin A) (NI-5.9.2) related to decreased vitamin A excretion
resulting from CKD and decreased retinol binding protein excretion as evidenced by high
serum retinol concentration and high molar ratio of retinol to retinol-binding protein.
Inadequate protein intake (NI-5.7.1) related to protein losses with dialysis as evidenced by
low BUN relative to creatinine, poor growth, low normalized protein catabolic rate, and low
reported protein intake.
Excessive protein intake (NI-5.7.2) related to CKD stages 4-5 resulting in decreased protein
needs as evidenced by high BUN, nausea, and vomiting.
Note: Terminology in the examples above is from the American Dietetic Association's International
Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to assist in finding
more information about the diagnoses, their etiologies and signs and symptoms. RDs should not
include these numbers in routine clinical documentation.

Nutrition Intervention

Nutrition intervention is individualized based on the specific nutrition diagnoses for a child with
chronic kidney disease (CKD):
Inadequate Oral Intake; Underweight; Unintended Weight Loss:
Increase energy intake with oral foods and supplements or with supplemental tube feeding. It
is very common for a child or adolescent with CKD to require tube feeding in order to meet
100% of needs.
Excessive Oral Intake, Overweight/Obesity, Unintended Weight Gain:
Decrease energy intake and/or increase physical activity.
If a child is tube fed, decrease formula.
If a child eats by mouth, work with the child and family to find ways to decrease energy
density of foods (decrease fats and sugars and increase foods of low energy density). For
children on prednisone, this can be extremely difficult, due to increased appetite. (See Weight
Management section.)
An older child or adolescent on peritoneal dialysis may absorb several hundred
kilocalories/day from dextrose in dialysate. Although energy intake needs to be decreased,
protein intake needs are slightly increased because of protein losses with dialysis. It is
important to provide lean protein sources or protein supplements that can meet needs without
excessive energy intake.
Inadequate or Excessive Electrolyte or Mineral Intakes (Sodium, Potassium, Calcium, and/or
Phosphorus), Imbalance of Nutrients, Less Than Optimal Enteral Nutrition:
Careful evaluation of diet and medications to determine intake of specific electrolytes and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
minerals is essential.
If a child is tube fed, formula can be altered to meet but not exceed electrolyte and mineral
needs.
The registered dietitian must work with the child and family to alter food intake to ensure
adequate, but not excessive, intake of electrolytes and minerals.
If sodium intake is high, as evidenced by hypertension or edema, find ways to decrease or
avoid processed foods as well as salt added to foods.
If potassium intake is high, evaluate fruit and vegetable intake, eliminate fruit juices, limit
high-potassium fruits and vegetables to no servings or only 1 serving/day. Help the child and
family to identify low-potassium fruits and vegetables. Evaluate dialysis dose; the child may
need more dialysis in order to maintain an appropriate potassium level and meet nutrition
needs.
If phosphorus intake is high, evaluate phosphate binder use as well as phosphorus intake.
Make sure the child is taking his or her binders with meals and snacks. If it is determined that
the child is adherent to current binder prescription, consider increasing it. Decreasing or
eliminating dairy products as well as other moderately high-phosphorus foods (eg, whole
grains/bran products, cola drinks, and other sodas that contain phosphoric acid), along with
ensuring adequate phosphate binder intake, typically results in improved phosphorus levels.
If calcium intake is high, evaluate active vitamin D supplementation and calcium-containing
phosphate binder use. It may be necessary to decrease active vitamin D or change to a
vitamin D analogue that has a lower calcemic effect, as well as to switch from calcium
carbonate or calcium acetate to a noncalcium phosphate binder, such as sevelamer.
If any of these electrolytes or minerals are low, evaluate diet and supplement nutrients that
are low. Low levels of phosphorus or potassium may indicate an overall low nutritional intake;
before supplementing specific nutrients, make sure energy and protein needs are met. If
necessary, begin oral or enteral formula supplements to meet energy, protein, and electrolyte
and mineral needs.
Excessive Fluid Intake
Evaluate total fluid intake; assess liquids as well as fluid-containing foods.
Evaluate sodium intake.
Evaluate dialysis prescription.
If the child is formula fed by mouth or tube, concentration of formula can be increased to
decrease total fluid intake.
If the child is eating totally by mouth, first work on decreasing sodium intake ("water follows
salt"). If the child is taking in too much sodium, he or she will require more fluid to keep
sodium level in blood within normal limits. This is a huge challenge for many families. Limited
time for cooking often results in high use of processed or fast foods. Children with CKD are
very picky eaters, and processed and fast foods may be more appealing than low-salt foods
for many children. Families on a limited food budget and/or who rely on food banks often end
up eating more canned or processed food that is inexpensive or available from food banks.
Once a child is following his or her sodium prescription, it is much easier to decrease fluid
intake.
In many cases, a child needs more dialysis. It is often not possible to remove enough fluid in
a reasonable amount of time with peritoneal dialysis for older or larger children. Children on
hemodialysis may need more sessions each week to remove adequate fluid.
Inadequate Fluid Intake, Increased Nutrient Needs
Many young children with CKD are polyuric. It is very difficult for them to keep up with fluid
needs and take in adequate nutrients.
If a child is tube fed, water can be given by feeding tube in between formula boluses or
mixed with formula if continuous drip feedings are given.
Children who eat and drink by mouth need to be given a prescription for a specific amount of
fluid every 2 to 4 hours through out the day (eg, 300 mL between waking and 10:00 am, 300
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
mL between 10:00 am and 12:00 noon, etc.) to ensure adequate intake. If the child cannot
meet fluid needs by mouth, consider a feeding tube (a gastrostomy tube is preferable to a
nasogastric tube, as a g-tube is hidden and does not interfere with breathing or eating.
However, for the child on peritoneal dialysis, the risk of infection in placing a gastrostomy
must be weighed against the convenience of a g-tube).
Inadequate Vitamin Intake
Children with CKD may be deficient in 25-OH vitamin D because of low sunlight exposure
and/or low intake of vitamin D–containing foods. If blood level is low, it will be important to
provide a supplement of at least the Recommended Dietary Allowance/Dietary Reference
Intake (DRI) for age (600 IU/day is the most recent recommendation for children of all ages)
(IOM, 2011); many children will need a higher amount of vitamin D to get blood levels up to
within normal limits.
Children with CKD on dialysis may be deficient in folic acid and possibly other water-soluble
vitamins. Diet must be evaluated and supplements provided to bring intake up to at least
100% of DRI for age for children with CKD stages 2 through 5. Children with CKD stage 5D
should receive a water-soluble vitamin supplement to address losses with dialysis (NKF,
2005; NKF, 2009).
Excessive Vitamin A Intake
Vitamin A and retinol-binding protein accumulate when glomerular filtration rate is decreased.
It is very common for plasma levels of vitamin A to be high in children with CKD and on
dialysis, even without supplementation.
Do not give vitamin A supplements, and limit vitamin A intake to the DRI for age.
Inadequate or Excessive Protein Intake
Ensure that protein intake meets, but does not exceed, 100% to 140% of DRI for age for
children with CKD stage 3, and 100% to 120% for children with CKD stage 4-5. Higher levels
will result in increased blood urea nitrogen.
Recommendations for children and adolescents on hemodialysis are DRI plus 0.1 g/kg/day.
Recommendations for children and adolescents on peritoneal dialysis are DRI plus 0.15
g/kg/day to 0.3 g/kg/day. (These recommendations are much lower than those previously
given because there is a lack of evidence that high protein intake on dialysis is beneficial and,
in fact, may be detrimental.)
(NKF, 2005; NKF, 2009)


Nutrition Therapy Efficacy

The child with chronic kidney disease (CKD) who has received effective nutrition therapy is more
likely to do well developmentally and cognitively and be able to function well at home and school
and in the community.
Many of the common guidelines for healthful eating must be altered for nutrition with CKD. When a
patient requires restrictions of fluid, potassium, and phosphorus intake, he or she cannot eat and
drink many of the foods and fluids considered healthful for typical children. Milk and dairy products
are often the first foods that are restricted because of phosphorus content. Once a potassium
restriction becomes necessary, many fruits and vegetables must also be limited.
Restrictions in food groups result in decreased calcium and protein intake (dairy products) and
vitamin C and folic acid intake (fruits and vegetables). Once on dialysis, folic acid and possibly
other water-soluble vitamin needs are increased to above normal limits, and a special “renal
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
vitamin” that contains just water-soluble vitamins is generally given. Studies have not been done to
determine how much of these vitamins are needed by children on dialysis, so dosing is typically
done empirically based on research on adults (Heinz, 2008). It is known that zinc and copper levels
are often low in children on dialysis; if serum levels are low for either of these minerals,
supplementation is recommended (Charney, 2002; NKF, 2008).
The following headings list specific nutrient exceptions for children with CKD:
Energy
Protein
Potassium
Sodium
Calcium
Phosphorus
Vitamin A
Vitamin D
Water-Soluble Vitamins, Zinc, and Copper



Goal Setting

The ultimate goal is for a child with chronic kidney disease to achieve normal growth and
development and to grow up to become a healthy, productive adult. This will not happen if the
following goals are not achieved:
Optimal weight gain for age
Following weight percentile on growth chart; catching up to previous weight percentile if
weight gain has slowed or decreased
Optimal linear growth (even with excellent nutrition and metabolic control, a young child with
chronic kidney disease is likely to need exogenous growth hormone therapy to achieve
genetic potential for height; however, without optimized nutrition, bone development and
metabolic control, growth hormone therapy will be unsuccessful)
Following height percentile on growth chart; achieving genetic potential for adult height
(using mid-parental height)
Optimal bone development, including appropriate calcium, phosphorus, and parathyroid
hormone levels.
Laboratory values within normal limits for age
Metabolic control
Normal electrolyte and mineral levels as indicated by laboratory where blood is tested

Food and Feeding Issues

Individuals with chronic kidney disease (CKD) have decreased appetite because of a combination
of factors such as high blood urea nitrogen, anemia, hormone abnormalities, and
gastroesophageal reflux (especially in infants).
High blood urea nitrogen tends to cause nausea and to alter taste sensations, resulting in
decreased appetite.
Untreated anemia is a known cause of poor appetite; however, treatment of anemia in CKD
patients does not necessarily correct poor appetite.
The hormone leptin plays a role in appetite; leptin levels fall as blood sugar drops and is a
factor in stimulating hunger in healthy people; levels rise as a person becomes satiated.
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factor in stimulating hunger in healthy people; levels rise as a person becomes satiated.
Leptin is cleared via the kidneys; when kidney function is decreased, blood leptin levels
remain high—this may contribute to poor appetite in individuals with CKD (Daschner, 1998).
Gastroesophageal reflux is a limiting factor in meeting nutrition needs. Because of frequent
vomiting, it is often necessary to go to continuous drip tube feeding, intermittent drip feeding,
or a combination of small daytime bolus feeds with nighttime drip feeding to meet a child's
needs. This can be a major issue for children with very high fluid needs.
Infants and young children commonly need nutrition support (supplemental gastrostomy or
nasogastric tube feeding) to meet 100% of needs. It is important to consistently work on and
encourage oral feeding in infants and young children to avoid feeding aversions. Referral to a
speech or occupational therapist specializing in feeding therapy is an important part of the
patient's medical therapy. Most pediatric patients eat well after receiving a successful kidney
transplant; however, if they did not have oral feeding and stimulation starting in infancy, they
are likely to have aversions to many tastes and textures.
In many cases, older children and adolescents benefit from supplemental enteral feeding to
maintain optimal energy and protein intake.

Enteral or Tube Feeding

Many infants and children with chronic kidney disease (CKD) cannot meet their nutrient needs with
oral intake alone. In these cases, nutrition support in the form of tube feeding may be necessary.
Gastrostomy tubes are often better tolerated than nasogastric tubes, as they do not interfere with
breathing or eating and are not easily pulled out. However, placement of a gastrostomy tube in a
child who has already started peritoneal dialysis puts the child at risk for peritonitis (in some
centers, a child is switched to hemodialysis until a new gastrostomy is well healed).
It is always important to encourage oral intake and use tube feeding as a supplement to ensure
that 100% of nutrition needs are met. In most cases, children will eat well by mouth once they have
a successful kidney transplant, but if oral intake is not actively encouraged during infancy and early
childhood, oral feeding aversions are likely to develop.
Nutrition Support in CKD Stages 2-5 and 5D
Infants
Typically infants are fed breast milk if it is available. Breast milk is low in protein and phosphorus,
relative to standard formulas. It may need to be fortified in energy and protein with the addition of
formula powder or modular products. Infants on peritoneal dialysis need protein-fortified breast
milk to meet their goals; infants on hemodialysis may also need protein-fortified breast milk to meet
their goals. A reduced-phosphorus and reduced-potassium formula may also be used. Formula
often needs to be increased to greater than 20 kcal/oz to meet energy needs for children who are
oliguric or anuric. Once a child is on dialysis, it may be necessary to fortify formula with protein
because of protein losses.
Children and Adolescents
Young children may need nutrition support as early as CKD stage 2; it is not uncommon for older
children to need support as they approach stage 5. Several renal formulas are available. These
formulas can be mixed and matched with each other and/or standard enteral formulas or modulars
to obtain the desired energy and protein density and optimal electrolyte and mineral content.
See the Formulary Database for protein, potassium, calcium, phosphorus, and sodium contents of
formulas and to compare multiple formulas.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Comparative Standards: Estimated Energy Needs

Energy needs for children with chronic kidney disease (CKD) stages 1 through 5 are similar to
those of healthy children of the same age, adjusted for height, weight, and activity level. However,
many pediatric patients with CKD have low intake because of poor appetite associated with CKD
(see Food and Feeding Issues).
Energy needs remain the same on hemodialysis. The patient on peritoneal dialysis has lower
dietary energy needs as a result of absorption of dextrose from dialysate; the amount varies
depending on dialysate solution and peritoneal membrane permeability. This is especially
important when prescribing tube-feeding formula for an infant on peritoneal dialysis, as energy
needs may be decreased by up to 200 kcal/day. If formula is not adjusted, weight gain and fat
deposition will be excessive. For the older pediatric patient on peritoneal dialysis, the dextrose
absorbed from dialysate may serve as an energy supplement or may result in decreased appetite.
It is essential that each patient's energy needs are determined individually; energy needs may vary
because of a variety of issues beyond CKD and/or dialysis. Use the recommendations presented
in this section as a starting point and adjust energy intake as needed based on weight gain and
growth (NKF, 2008).

Comparative Standards: Estimated Protein Needs

Healthy children typically eat more than 200% of the Dietary Reference Intake (DRI) for protein. As
appetite decreases in the child with chronic kidney disease (CKD), energy intake tends to
significantly decrease whereas protein intake remains high (150% to 200% of the DRI).
Protein is not typically restricted for children with CKD stages 1 and 2, as protein restriction tends
to result in decreased energy and nutrient restriction. Current recommendations are for children
with stage 3 CKD to limit protein to 100% to 140% of the DRI for age and for children with stage 4
and stage 5 CKD to limit to 100% to 120% of the DRI. In most cases, when protein is limited, it is
important to increase energy intake with low-protein, high-energy foods or supplements.
Protein can be easily manipulated for children on tube feedings; this often requires mixing one or
more formulas and/or modular products to get the desired energy and protein concentration.
Once a child is on dialysis, protein needs increase to make up for proteins and amino acids lost
with dialysis. For hemodialysis, protein needs are calculated as follows to compensate for dialytic
losses:
DRI + 0.1 g/kg/day
For peritoneal dialysis, protein needs are calculated as follows, depending on patient age, to
compensate for peritoneal losses (NKF, 2009)
DRI + (0.15 – 0.3 g/kg/day)
The decrease in energy needs with concomitant increase in protein needs with peritoneal dialysis
plus restrictions in phosphorus can make it difficult to meet protein needs in children receiving
peritoneal dialysis (Brem, 2002).
Evaluation of Protein Status
Normalized protein catabolic rate (nPCR) can be calculated in children on hemodialysis to get a
good idea of protein intake. The calculation is more accurate in older children/adolescents than in
infants and toddlers. It has been found to be more predictive of nutritional status than serum
albumin. Calculation of nPCR is based on the increase in blood urea nitrogen (BUN) level from the
end of one hemodialysis treatment to the beginning of the next treatment to calculate the urea
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generation rate (G; mg/min):
G (mg/min) = [(C2 x V2) – (C1 x V1)]/t
where C1 is postdialysis BUN (mg/dL); C2 is predialysis BUN (mg/dL); V1 is postdialysis total body
water (dL; V1 = 5.8 dL/kg x postdialysis weight in kg); V2 is predialysis total body water (dL; V2 =
5.8 dL/kg x predialysis weight in kg); and t is time (minutes) from the end of the dialysis treatment
to the beginning of the following treatment.
nPCR is calculated using the modified Borah equation as follows:
nPCR = 5.43 x estG/V1 + 0.17
where V1 is total body water postdialysis (in liters [L]; 0.58 x weight in kg)
(NKF, 2009)


Vitamin A

Vitamin A is typically bound by retinol-binding protein (RBP), which is excreted via the kidneys. In
chronic kidney disease (CKD), RBP is not excreted, so RBP and retinol (vitamin A) accumulate in
the blood. Supplementation is rarely needed in children or adults with CKD. Risk of vitamin A
toxicity is high in CKD, so intake should not exceed the Dietary Reference Intake (NKF, 2009).

Potassium

Potassium is excreted via the kidneys; when kidney function is significantly decreased (glomerular
filtration rate <10 mL/min/1.73 m
2
to 15 mL/min/1.73 m
2
), potassium excretion is decreased and
dietary potassium restriction is usually necessary. In earlier stages of chronic kidney disease,
some conditions (eg, urinary obstruction or acidosis) and medications (eg, potassium-sparing
diuretics, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers) result in
accumulation of high levels of potassium, requiring dietary restriction. Fruits and vegetables, as
well as milk and yogurt, are all high in potassium (see Recommended Foods). Some patients,
such as those with polyuria, may also waste potassium and need potassium increased in their diet
via food or supplementation.

Sodium

Adequate but not excessive sodium is essential for normal growth and development.
Increased Sodium Needs
For the many infants with chronic kidney disease (CKD) who are polyuric and waste sodium,
sodium must be supplemented. Use of a pharmacologic preparation is recommended. Infants on
peritoneal dialysis lose high amounts of sodium chloride, even when anuric; thus, supplements are
almost always necessary. Sodium chloride supplementation must be individualized based on
serum sodium and chloride levels and hypotension/hypertension. Optimal growth has
been reported in young children with intakes of 2 mEq sodium supplement/100 mL fluid intake to 4
mEq sodium supplement/100 mL fluid intake. Sodium balance can be determined from dietary and
medication intake and dialysate effluent losses; this should be done every 6 months, when dialysis
adequacy is assessed or when there is a change in dialysis prescription (Parekh, 2001).
Decreased Sodium Needs
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Decreased Sodium Needs
When a child has hypertension, sodium should be restricted. Hypertension is often present in the
very early stages of CKD; if not controlled, CKD will progress more quickly and the child is at risk
for hypertensive encephalopathy, seizures, cerebrovascular events, and congestive heart failure.
For children requiring fluid restriction, sodium restriction is imperative. High sodium intake leads to
thirst, fluid retention, and edema as well as exacerbation of hypertension.
Recommendations are to limit sodium to 1 mmol/kg/day to 2 mmol/kg/day (23 mg/kg/day to 46
mg/kg/day). Approximately 75% of salt intake comes from salt added to foods during commercial
processing. It is important to teach families to read labels and choose lower-sodium processed
foods, to replace processed and canned foods with fresh foods or "no salt added" versions of
canned foods, and to use salt-free seasonings (garlic, onion, peppers, herbs, spices) in place of
salt in cooking.


Calcium

Calcium needs are 100% of the Dietary Reference Intakes (DRI) for age in children with chronic
kidney disease (CKD). If a review of the patient's diet shows inadequate calcium intake,
high-calcium and calcium-fortified foods should be encouraged. The foods that are highest in
bioavailable calcium are dairy products, but these are also the foods highest in phosphorus, which
must be restricted as CKD progresses. Calcium carbonate or calcium acetate are often used as
phosphate binders (medication taken with meals to decrease phosphorus absorption); when used
in this capacity, they also serve as a calcium supplement.
It is important to avoid giving more than 200% of the DRI for age; give a maximum of 2,500
mg calcium from all sources (food, supplements, and phosphate binders) (NKF, 2009; NKF, 2006).

Phosphorus

Excess phosphorus is excreted in the urine of healthy individuals. With advancing chronic kidney
disease (CKD), phosphorus excretion is impaired and intake usually needs to be restricted.
The 2008 Kidney Disease Outcomes Quality Initiative guidelines recommend lowering phosphorus
intake to 100% of the Dietary Reference Intake (DRI) when parathyroid hormone level is increased,
but phosphorus levels are still within normal limits. Once phosphorus levels become high, intake
should be further decreased to 80% DRI (NKF, 2009).
Phosphate restriction is most easily accomplished by strictly limiting intake of dairy products, the
foods highest in phosphorus. It is generally recommended that the CKD patient with increasing
blood phosphorus levels limit dairy products to 1 to 2 servings per day. If phosphorus levels remain
high after dairy products are decreased, and phosphate binders are started, then other
phosphorus-containing foods may need to be restricted.
It is important to avoid meats that are injected with sodium phosphate or potassium phosphate.
Some meats, especially pork and poultry, are injected with sodium or potassium phosphate to
enhance flavor and tenderness; these additives result in doubling the phosphate level of the meat
compared with the same type of meat when unprocessed.
Whole grains, legumes, meats, poultry, and fish are all relatively high in phosphorus. When dairy
restriction is not enough, whole grains and legumes can be restricted (this is counterintuitive for
families that try to eat a very healthy, high-fiber diet—one of those “rules of good nutrition” that has
an exception with CKD).
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Colas and some other sugar-sweetened drinks, such as some powdered and frozen fruit-flavored
drinks, contain significant amounts of phosphorus and should be avoided.
By stages 4 and 5, it is frequently impossible for individuals with CKD to meet energy and protein
needs with foods while keeping serum phosphorus within normal levels. The addition of phosphate
binders with each meal and continued dietary phosphorus restriction makes it possible to keep
phosphorus levels normal and meet energy and protein needs (NKF, 2009; NKF, 2005).
Phosphate Binders
Calcium carbonate and calcium acetate are both excellent phosphate binders. For infants and
young children, calcium carbonate is easy to use since it is available in liquid and chewable and
nonchewable tablet forms. If serum calcium levels are high or calcium intake is maximized,
noncalcium binders are available. Sevelamer is a resin that is available in powder or film-coated
tablets.
Breast milk, formula, or cow’s milk can be pretreated with sevelamer to decrease phosphorus
content: dissolve sevelamer in the liquid, wait for precipitation, decant the fluid, and feed the
supernatant of the processed fluid. This process can decrease phosphorus content by 80% to 90%.
Lanthanum carbonate is another calcium-free phosphate binder, but studies on its safety have not
been done in children.
All phosphate binders work best if given right before, with, or right after food or formula is
consumed; the binder must mix with the food in the stomach to bind phosphorus. Phosphate
binders place a major “pill burden” on the patient, who often needs to swallow 4 to 6 large pills or
capsules with each meal and snack to maintain good phosphorus control. It is important to
prescribe the smallest number of binders necessary to keep phosphorus in control. When
phosphorus is out of control, it may be necessary to increase the dialysis prescription rather than
expect a patient to take more and more pills with each meal. Large numbers of pills or capsules
often make a child feel full and make food unappealing.


Vitamin D

Inactive Vitamin D
Serum 25-hydroxyvitamin D levels should be measured yearly. If the level is less than 30 ng/mL
(75 mmol/L), supplements of vitamin D2 or D3 are necessary. During the time of repletion, calcium
and phosphorus levels should be checked at 1 month following initiation or change in vitamin D
dose and at least every 3 months thereafter. Once normal 25-hydroxyvitamin D levels are attained,
supplementation to maintain normal levels should be continued (NKF, 2009). 25-hydroxyvitamin D
is mainly activated by 1-a-hydroxylase in the kidney, although some activation is by extra renal
1-a-hydroxylase activity. 25-hydroxyvitamin D has effects on cell metabolism separate from that of
1,25- hydroxyvitamin D. Vitamin D intake is often low in patients with chronic kidney disease (CKD)
due to sedentary lifestyle with reduced sunlight exposure, as well as low intake of vitamin D–rich
foods (NKF, 2009).
Additional guidelines for treating vitamin D deficiency were published in the KDOQI Clinical
Practice Guidelies for Nutrition in Children with CKD: 2008 Update.
Active Vitamin D
As CKD progresses, renal production of 1, 25-dihydroxyvitamin D
3
(active vitamin D) decreases,
resulting in decreased calcium absorption and thus low serum calcium levels. At the same time,
renal phosphorus excretion decreases, and phosphorus levels rise. Decreased calcium levels and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
renal phosphorus excretion decreases, and phosphorus levels rise. Decreased calcium levels and
increased phosphorus levels stimulate parathyroid hormone production, which stimulates bone
turnover to release calcium into the blood stream. If this cycle is not interrupted, severe metabolic
bone disease will develop, which, in turn, causes bone malformation and impairs growth. When
parathyroid hormone (PTH) levels are above the target range (see table at this link for PTH target
ranges by stage of CKD), an active vitamin D sterol (calcitriol) should be started. Doses are
adjusted depending on calcium, phosphorus, and PTH levels. These are typically mangaged by the
nephrologist, but the renal registered dietitian needs to have a thorough understanding of the
rationale behind use of vitamin D sterols and their dosing (NKF, 2005).
In addition to managing PTH and calcium/phosphorus balance, it is essential to avoid a
high-sodium and high-phosphorus product. Active vitamin D enhances absorption of both calcium
and phosphorus; thus, it is important that these levels be monitored regularly. For the child with
stage 2 through stage 4 CKD, measurements should be taken monthly for the first 3 months after
vitamin D therapy is initiated and at least every 3 months after that. For children with stage 5 or 5D
CKD, measurements should be taken every 2 weeks for the first month after active vitamin D
therapy is initiated and then monthly after that. Elevation of either sodium or phosphorus or both
can result in a high product, which causes vascular calcifications leading to cardiovascular
disease. If sodium and/or phosphorus are high, active vitamin D therapy should be delayed until
levels are within normal limits. It may be useful to use an active vitamin D metabolite such as oral
or intravenous doxercalciferol or intravenous paricalcitol, as these have less of an effect on
absorption of calcium and phosphorus than oral or intravenous calcitriol (NKF, 2005).
Active vitamin D therapy can overcorrect PTH, leading to low PTH levels and low turnover bone
disease. Measurement of PTH every 3 months is important to make sure that PTH is not too low.
Guidelines for assessing serum PTH, serum calcium, serum phosphorus, and dosing for oral
calcitriol for children with varying degrees of CKD can be found in the KDOQI Clinical Practice
Guidelines for Bone Metabolism and Disease in Children with Chronic Kidney Disease on the
National Kidney Foundation Web site.

Water-Soluble Vitamins, Zinc, and Copper

Research in adult dialysis patients suggests that water-soluble vitamins, especially folic acid, are
lost in dialysate. It has also been postulated that intake of these vitamins is significantly decreased
due to dietary restrictions and decreased appetite. Adults on dialysis have long been given a “renal
vitamin” with extra amounts of folic acid.
Research on pediatric patients has shown decreased intake of most water-soluble vitamins, as
well as zinc and copper, with diet alone. It is recommended that children on dialysis receive a
water-soluble vitamin supplement. Most of the “renal vitamins” available are formulated for adults;
infants and young children need to be given partial doses (eg, ¼- to ½-tab per day) or dosing every
2 to 3 days if a liquid product or tablet easily breakable into smaller portions is not available. Avoid
giving more than the Tolerable Upper Intake Levels. Because of vitamin A retention with CKD,
supplements that contain vitamin A are discouraged, so a “renal vitamin” is necessary. Renal
vitamins that contain zinc and copper are available. Supplementation above the DRI is only
recommended if levels are low or there are signs of deficiency.
Information on the Dietary Reference Intakes and how they relate to kidney disease, as well as a
comparison of multivitamins commonly prescribed, can be found at the Vitamin and Trace Element
Requirements and Therapy page, which is available through the National Kidney Foundation Web
site.
See the Dietary Reference Intakes for Vitamins for general information.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Nutrition Monitoring & Evaluation

For children with stage 2 through stage 5 and 5D chronic kidney disease (CKD), monitoring of
nutrition and growth parameters should be based on age and stage of CKD. Weight gain, linear
growth, occipital frontal circumference growth (younger than 3 years), nutritional intake, and
biochemical indices should be evaluated at each visit with the registered dietitian.
Once a child is on dialysis, biochemical indices will be evaluated monthly; nutritional intake and
growth should be evaluated at least every month in infants and every 3 months in children and
adolescents, though it should be assessed more often if problems are identified.
It may be helpful to give parents and older children on dialysis a “report card” with laboratory
values and growth at each nutrition evaluation.
Nutrition monitoring is necessary to detect both poor and excessive weight gain. Although appetite
is depressed and many children with CKD do not gain weight well, some children are overweight.
Long-term corticosteroid therapy results in increased appetite and increased weight gain and fat
deposition. Children on peritoneal dialysis absorb dextrose from the peritoneal dialysate; this
contributes to total energy intake and can result in excessive weight gain. At the same time, protein
is lost with peritoneal dialysis; thus, a child on peritoneal dialysis may need a protein supplement
but an overall decreased energy intake (NKF, 2005; NKF, 2009).

Nutrition Care FAQs

Frequent Questions from Parents:
Should the family follow the diet same diet as my child with CKD?
Your family can benefit from a lower sodium intake, but other restrictions, such as on potassium
and phosphorus, would unduly limit intake of foods that you and your other children need to meet
nutrition needs. Chronic kidney disease (CKD) is a very "unnatural" condition; the very strict diet of
a child who has low or no urine output and is on dialysis does not meet recommendations for the
general population. Your goal is to allow your child with CKD to enjoy as many of the same foods
as the family as possible but to maintain normal laboratory values by following the prescribed diet.
Will my child be on the same diet forever?
Your child's diet will change as CKD progresses and again when he starts dialysis and if he
switches from hemodialysis to peritoneal dialysis or vice versa. Diet needs will change again when
he receives a kidney transplant.
If my child begins tube feeding, will that cause her to "outgrow" her kidney and need
dialysis sooner?
It is true that a small, dysplastic, or a damaged kidney may support an infant but not have enough
function for a larger child, but optimal growth and development are the goals of nutrition support. If
a child is malnourished, she will not grow and develop normally; the risk of developmental delay
and failure to thrive far outweighs the possibility that improved growth might result in sooner need
for dialysis.
Questions Frequently Asked by Registered Dietitians (RDs):
Should a child with CKD stage 2 or 3 be put on a low-sodium, low-potassium,
low-phosphorus diet in order to be accustomed to it by the time he progresses to stage 4 or
5 and has abnormal laboratory values?
No. You want the diet to be as liberal as possible and still maintain optimal metabolic control. If
you overrestrict the diet, total nutritional intake suffers. Children with mild CKD (stage 2) may
already have some anorexia, so restricting more than is necessary may result in low energy and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrient intake. Promoting optimal nutrition outweighs the need for a child to be accustomed a
restricted diet.
Is there a maximum energy density for formula for infants with CKD?
Energy density needs and tolerance are very individualized. Most infants with CKD will need their
formula concentrated to some degree in order to meet nutrition needs (unless they are polyuric).
The infant who is anuric or oliguric and on hemodialysis benefits from a much more concentrated
formula because of fluid limits (even if dialyzed 7 days/week, most infants will need some fluid
limit).
The trick is to increase gradually (eg, 2 kcal/oz or 0.1 kcal/mL to 0.2 kcal/mL every few days); if
formula concentration is increased too quickly, an infant will likely have problems tolerating the
increased osmolarity. If the infant tolerates it, energy density can be gradually increased to 30
kcal/oz or to as high as 60 kcal/oz (1 kcal/mL to 2 kcal/mL)
Many infants have issues with vomiting and diarrhea once formula is concentrated above 30
kcal/oz (1 kcal/mL). The RD must carefully monitor tolerance to formula as concentration is
increased; it may not be possible to increase the density to a level that meets needs with current
fluid limits. If the infant is not yet on dialysis, The RD must work with the medical team to
discuss the initiation of dialysis. If the child is on dialysis, the RD may need to recommend
an increase in hours of peritoneal dialysis or increase in number of hemodialysis sessions each
week in order to meet nutrition needs given concentration tolerance and fluid limits.
If a child is meeting needs by gastrostomy tube and parents are too stressed to work on
oral feeding, what can the RD do?
Work on oral stimulation is extremely important for long-term development.
In a case like this, the RD needs to work with the social worker and feeding therapist to determine
how to help the parents do some daily oral feeding. It may be possible for a therapist to work with
the child in his home rather than requiring parents to take him to another medical appointment.
Very small oral feedings that teach the infant/child to accept different textures and develop chewing
and swallowing skills can make a big difference in the child's ability to wean off tube feedings after
successful transplant.
How would one go about convincing a teenager that she needs a g-tube to optimize her
nutritional intake?
The RD must develop a good rapport with the teenager before making such a major
recommendation. Families of a child or adolescent with CKD tend to view a feeding tube as failure
on their part to nourish their child, so it is an extremely emotional experience to be told that
supplemental feeding is necessary.
First, the RD must explore ways for the teen to meet needs by mouth using foods and oral
supplements. Because of the anorexia that goes along with CKD, it is often just not possible to
meet needs by mouth; oral supplements often just replace the food that was previously consumed
and energy intake does not increase.
It helps to explain the hormonal and metabolic abnormalities that result in decreased appetite—for
example, leptin, a hormone that helps us know when we are full and drops when we would
normally be hungry, is cleared by the kidneys. With CKD, leptin is always high, so it decreases
appetite. Blood urea nitrogen is always higher in people with CKD than in healthy individuals. It
can result in decreased appetite.
Having a gastrostomy button can make getting enough energy fairly easy; it can alleviate the
pressure on the patient and family.
Optimal nutrition can help keep a teen healthy and ready for a kidney transplant when one is
available. The gastrostomy can be removed once successful transplant is achieved.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Comparative Standards: Estimated Fluid Needs

Fluid and electrolyte management are major issues in treatment of anyone with chronic kidney
disease (CKD), especially when it is advanced. Children with CKD may be polyuric; in those
cases, supplementation with water to maintain hydration is essential—some children need a
feeding tube just for extra water. These children often waste sodium, which must be
supplemented. Polyuria may persist even when kidney function is low enough to require
replacement therapy.

On the other hand, a child with CKD may have decreasing urine output as kidney function
decreases; kidney replacement therapy is often started by the time significant fluid restriction is
necessary. If a child is on dialysis, fluid limits are typically as follows:
Insensible losses + Daily urine output + Amount to replace additional losses (eg,
vomiting, diarrhea, enterostomy output) + Dialysis fluid removal ÷ Days between
dialysis sessions
For an anuric child on hemodialysis, it is expected and desirable for interdialytic weight gain to be
less than 5% of dry weight.
Severe fluid restriction to decrease number of hemodialysis sessions is discouraged, as it fosters
malnutrition. A child on peritoneal dialysis typically receives nightly cyclic peritoneal dialysis or
continuous ambulatory peritoneal dialysis and may not need as strict a fluid limit as that of a child
on hemodialysis. Fluid removal with dialysis varies with type of dialysis, frequency and length of
dialysis sessions, and efficacy of dialysis—if there are problems with the hemodialysis line or with
peritoneal membrane, fluid removal may not be optimal, resulting in a need for decreased fluid
intake until problems with dialysis are resolved.
In any case where fluid restriction is necessary, sodium must also be restricted. When high
amounts of sodium are ingested, thirst is stimulated and fluid intake increased.
Insensible Fluid Losses
Age Group Fluid Loss
Preterm infants 40 mL/kg/d
Neonates 20-30 mL/kg/d
Children and adolescents 20 mL/kg/d or 400 mL/m
2

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Nutrition Care > Renal Diseases > Nephrotic Syndrome
Nutrition Assessment

Assessment of the following should be done when a child is first diagnosed with nephrotic
syndrome (NS):
Growth and weight gain
Blood pressure
Edema
Serum lipids
Blood glucose
Nutritional intake
Periodic monitoring is important for the child who relapses after treatment, has several
courses of prednisone, or is started on a second-line medication because of frequently
relapsing steroid-responsive NS or steroid-resistant NS.

Laboratory

Serum albumin: Low with nephrotic syndrome (NS); rising levels suggest that the
child is responding to treatment.
Ionized calcium or corrected serum calcium: Serum calcium will be low because of
low albumin level; may be low as a result of calcium excretion in the urine.
25(OH) vitamin D: A low vitamin D level puts a child at further risk for
prednisone-induced calcium losses and poor bone mineralization (low vitamin D
levels are relatively common, especially in children living at high latitudes, for
example, higher than the 42nd parallel).
Fasting cholesterol (total, low-density lipoprotein, and high-density lipoprotein),
triglycerides: Hyperlipidemia is associated with both NS and prednisone therapy as
well as with many of the noncorticosteroids used as second-line treatment for NS.
Blood glucose: High blood glucose levels are associated with prednisone therapy; the
child who is overweight or obese before diagnosis or who becomes overweight or
obese while treated with prednisone is at increased risk for hyperglycemia.
Serum sodium: Children with edema may have low serum sodium levels.

Nutrition Diagnosis

Registered dietitians (RDs) working with patients who have nephrotic syndrome should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the following list,
as well as other diagnoses, may be present.
Increased nutrient needs (specify) (NI-5.1)
Excessive fat intake (NI-5.6.2)
Inappropriate intake of fats (NI-5.6.3)
Inadequate protein intake (NI-5.7.1)
Excessive protein intake (NI-5.7.2)
Inadequate mineral intake (specify) (NI-5.10.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
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Altered nutrition-related laboratory values (specify) (NC-2.2)
Food–medication interaction (NC-2.3)
Unintended weight gain (NC-3.4)
Sample PES (problem, etiology, signs and symptoms) or Nutrition Diagnostic
Statement(s)
Unintended weight gain (NC-3.4) related to large urinary protein losses as evidenced
by edema, increased weight, and shortness of breath.
Food–medication interaction (NC-2.3) related to prednisone therapy as evidenced by
increased appetite and excessive increase in weight.
Food–medication interaction (NC-2.3) related to prednisone therapy as evidenced by
increased calcium in urine and decreased bone mineral content on dual-energy x-ray
absorptiometry scan.
Food-medication interaction (NC-2.3) related to prednisone therapy as evidenced by
high blood glucose levels.
Excessive mineral intake (sodium) (NI-5.10.2) related to overconsumption of
high-sodium foods as evidenced by increased weight from edema.
Altered nutrition-related laboratory values (cholesterol and triglycerides) (NC-2.2)
related to kidney dysfunction causing NS, resulting in hyperlipidemia, as evidenced by
high total and low-density lipoprotein cholesterol and high triglycerides.
Increased nutrient needs (vitamin D) (NI-5.1) related to prednisone therapy and
resulting vitamin D deficiency as evidenced by low serum vitamin D levels.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies, and signs and
symptoms. RDs should not include these numbers in routine clinical documentation.


Nutrition Intervention

A low-sodium diet and medications to stop protein loss, possibly including diuretics to treat
edema, are generally quite adequate.
Nutrition intervention comprises a low-sodium diet of 1 mEq/kg/day to 2 mEq/kg/day,
depending on degree of edema; the more edematous a child is, the more sodium will need
to be restricted. It is very important to give families lists of high-sodium and low-sodium
foods, including information on restaurant foods and recipes and sample menus to help
them adhere to the diet.
Teaching parents and children to read labels on processed foods is very helpful—it
typically shows them that there are few processed foods that are appropriate for a
low-sodium diet. If a family is used to using prepared/processed foods, having to follow a
low-sodium diet—combined with the overall stress of nephrotic syndrome (NS)—can be a
daunting task.
High Calcium and Vitamin D Intakes
If a child drinks 3 to 4 cups of vitamin D–fortified milk per day, he or she will meet calcium
recommendations and get 300 IU to 400 IU vitamin D/day; an additional 400 IU vitamin D
in a children’s multivitamin should meet vitamin D needs. If a child does not or cannot drink
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
milk, a calcium with vitamin D supplement is indicated. If ionized calcium and/or 25-OH
vitamin D are low, additional vitamin D supplementation will be needed. Whenever high
levels of vitamin D are given with NS, serum calcium needs to be monitored (ionized
calcium while albumin is low) to make sure hypercalcemia does not occur.
If hypercalcemia occurs, vitamin D dose needs to be decreased. It is possible to calculate
corrected calcium when albumin is low; the following calculation can be used when the
ionized calcium level is unavailable (NKF, 2003):
Corrected Calcium = Total Calcium (mg/dL) + 0.8 X (4 – Serum Albumin [g/dL])

Modify Distribution, Type, or Amount of Food and Nutrients within Meals or at
Specified Time
It an be very difficult for a child who has an increased appetite caused by prednisone to
follow the low-fat, low–simple sugar diet that is recommended for this population. Families
should be given lots of ideas for foods of low energy density that can be used in meals and
snacks.
Nutrition Counseling for the Feeding Environment: Strategies
The following additional information on feeding behavior may also be very helpful:
Always eat at the table, without television, toys, or other distractions
Serve 3 meals and 2 to 3 snacks with 2 to 3 hours between each meal and snack
Eat together as a family as often as possible
Increasing physical activity as much as possible is also important for preventing excess
weight gain. Swimming or water play can be a great way to keep a child active and help
reduce edema.

Goal Setting

Decreased edema
Acceptable weight gain and linear growth for age
Normal bone development
Normal blood pressure for age
Decreased or normal lipid levels (total cholesterol, low-density lipoprotein cholesterol,
triglycerides)

Nutrition Monitoring and Evaluation

Periodic monitoring is important for the child who relapses after treatment for nephrotic
syndrome (NS), has several courses of prednisone, or is started on a second-line
medication because of frequently relapsing steroid-responsive NS or steroid-resistant NS.
Typically a patient and the patient's family are seen by a registered dietitian (RD) for initial
nutrition education soon after diagnosis. Follow-up nutrition monitoring depends on the
child's symptoms; if the child responds to treatment and does not relapse, follow-up may
not be needed.
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Each time the patient relapses, the RD should reassess nutritional status and diet. If the
family is doing very well in following the low-sodium diet (evidenced by very little or no
edema), keeping sugars and fats low (evidenced by little excessive weight gain), and
meeting calcium and vitamin D needs (determine by nutrition interview), the family may not
need further nutrition education. If the family or nephrology team has concerns about
adherence to the diet, then the RD will need to do a more in-depth nutrition assessment
and provide additional education.
Professional expertise will guide the RD as to how often the child with NS must be
monitored; because the incidence of relapse and severity of nutritional symptoms widely
vary, a specific frequency for nutrition monitoring cannot be recommended.

Anthropometric Measurements

When a child is first diagnosed with nephrotic syndrome, measure weight—and
determine dry weight if edema is present—as well as length (if younger than 24 to 36
months) or height (if older than 2 years).
Reevaluate anthropometrics with each nutrition-related visit (number of visits varies
depending on whether and how often a child relapses)
See Anthropometric Measurements for Chronic Kidney Disease for more information


Food/Nutrition-Related History

Obtain a diet history and information about typical intake. Inquire about the following:
Food preparation at home, including use of natural ingredients vs packaged or
processed foods
Meals at school (child may be on free or reduced-fee school breakfast and lunch
program and eating those meals at school 5 days/week)
Eating out at restaurants

Nutrition Therapy Efficacy

A low-sodium diet helps prevent or decrease the edema and associated hypertension that
occur with nephrotic syndrome.
A diet low in fat and low in refined carbohydrates and sugars is recommended to help
prevent weight gain associated with prednisone therapy.
Calcium and vitamin D needs are increased to greater amounts than the Dietary Reference
Intakes (DRI) for age because of prednisone therapy. High calcium and vitamin D intakes
help counteract the calcium excretion and bone loss that are associated with prednisone
therapy.
Other nutrient needs are within the DRIs for age.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Nutrition Care FAQs

Q: What would happen if my child did not follow a low-sodium diet?
A: When your child is spilling protein into his urine, and the protein in his blood is very low,
a high-sodium diet will result in water and sodium going from his blood stream into the cells
in his body. When this happens, he becomes very swollen or "puffy"; this is edema.
Q: If my child already has edema, how will she get rid of it?
A: If her edema is very bad, her physician may give her a medication (diuretic) to help her
produce more urine and get rid of the extra water in her body.
A low-sodium diet will make it easier for water to be pulled from the cells into the blood
stream; then the diuretic medication will work to increase urine output to get rid of the extra
fluid in your child's body.
Q: Prednisone has many bad side effects (decreased bone building, increased
appetite and weight gain, muscle loss, eye problems, etc.). Is it truly helpful to give
prednisone to my child?
A: Prednisone is a very powerful medication that can help stop your child from spilling
protein into his urine. If nephrotic syndrome (NS) is not treated, it is life threatening—risk of
infection in the abdomen (peritonitis), problems breathing, heart problems from high
edema, and blood clots are some of the problems associated with NS. All of these
conditions can cause critical illness and even death.
Q: Does NS go away?
A: In most cases, children "outgrow" NS by their late teens or in early adulthood. There is a
small percentage of cases where children develop a more severe form of NS, however,
which results in chronic kidney disease.
Q: Is it OK for my whole family to go on a low-sodium diet?
A: Yes, the child with NS needs enough sodium to meet basic needs, so other members of
your family can eat a similar diet and still meet their sodium needs.

Client History

Interview the family to obtain a history of weight gain and growth, development, and
nutrition-related concerns (eg, feeding problems, food allergies) after diagnosis of nephrotic
syndrome.
Review the chart and talk with family members and the health care team to get a history of
the patient's nephrotic syndrome and diet since diagnosis.
Interview the family to determine food preparation skills; ability to procure food; and ability
to follow the low-sodium diet, which is the most important dietary prescription for nephrotic
syndrome.

Comparative Standards

Calculations needed for assessment of patients with nephrotic syndrome are as follows:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Body mass index (BMI) for age
Energy needs based on age, height, and estimated "dry weight"—it can be very
difficult to determine "dry weight" because of edema, as well as "real weight gain" that
occurs with prednisone therapy; the registered dietitian will need to confer with the
nephrology team to determine what weight to use when calculating energy needs and
BMI)
Protein needs based on Dietary Reference Intake for age
The child with nephrotic syndrome loses excessive amounts of protein from the blood,
which spills into the urine; this results in edema, especially in the face, stomach, and legs.
The child does not typically need fluid restriction unless edema is severe and is
compromising pulmonary or cardiac function (in this case, the child would likely be
hospitalized and possibly in the intensive care unit; the registered dietitian would work with
the hospital team to determine appropriate fluid needs).

Food and Feeding Issues

A child with nephrotic syndrome (NS) who is on prednisone may have a significantly
increased appetite and increased irritability, as these effects are commonly associated with
this medication. The patients' parents/family will need guidance in finding ways to satisfy
the child's appetite and in understanding possible feeding behaviors associated with food
without providing excessive energy intake.
Some of the other medications used to get NS into remission when a child relapses
frequently (cyclophosphamide, chlorambucil, cyclosporin) may cause nausea and poor
appetite.
It is important that the registered dietitian is regularly monitoring the patient with NS when
he or she is first diagnosed, as long as the patient is on medication, and whenever the
patient has a relapse.

Biochemical Data, Medical Tests and Procedures

The main diagnostic test for nephrotic syndrome (NS) is a urine test to determine whether
a child is spilling protein; the child is considered to be in remission once there is zero or
trace protein in the urine.
If NS does not resolve with prednisone therapy, it is common for a kidney biopsy to be
done to determine what kind of NS the child has. This approach will guide the physicians in
determining what type of medication/therapy to pursue.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Transplantation
Transplantation


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Transplantation > Organ Transplant
Immunosuppressive Medications

Immunosuppresive medications and associated side effects
Drug Adverse Reactions Diet
Corticosteroids
(prednisone)
Edema/Hypertension
Avoid high sodium
foods, weight
management for the
overweight
Calciuria/ growth
suppression
Ensure adequate
protein, calcium,
phosphorus, and
vitamin D intake
Impaired wound
healing
Ensure adequate
calorie, protein, intake
Muscle weakness
Regular weight-bearing
exercise
Hyperglycemia
Reduced simple sugars
or carbohydrate
counting if on insulin
Hypokalemia
Encourage high
potassium foods
Nausea/vomiting Consider antiemetic
Increased appetite
Calorie-controlled diet if
necessary, exercise
Food reduces rate of
absorption by about
27%. Do not
consume grapefruit
or grapefruit juice
(Chan, 2001;
Pediatric Lexi
Drugs).
Water-soluble
Vitamin E
supplementation
may increase serum
levels of drug if
taking this
medication (Pan,
1996).
St John’s Wort
affects the

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tacrolimus

pharmacokinetics of
Tacrolimus (Ernst,
2002)
Hypertension/edema
Avoid high sodium
foods, weight
management for the
overweight
Hyperkalemia
Avoid high potassium
foods
Hypomagnesium
Magnesium
supplementation
Hypophosphatemia
Phosphorus
supplementation
Hyperglycemia
Reduced simple sugars
or carbohydrate
counting if on insulin
Diarrhea/constipation Adequate intake of fluid
Nausea/vomiting Consider antiemetic
Anemia
Increase vitamin or
minerals as appropriate
Mycophenolate
(Cellcept)
Food decreases
peak concentration
by 40% (Pediatric
Lexi Drugs Online)

Hypertension
Avoid high sodium
foods, weight
management for the
overweight
Hypercholesterolemia AHA Step 1 Diet
Hypophosphatemia
Phosphorus
supplementation
Hyper/hypokalemia
Adjust potassium as
needed
Hyperglycemia
Reduced simple sugars
or carbohydrate
counting if on insulin
Esophagitis Acid suppression
Gastritis Acid suppression
Anemia
Increase vitamin or
minerals as appropriate
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diarrhea
Nausea, loss of
appetite
Ensure adequate fluid
intake
Consider antiemetic
Cyclosporine
(Neoral,Sandimmune,Gengraf)
Do not consume
grapefruit or
grapefruit juice if
taking this
medication (Chan,
2001; Pediatric
dosing 28)
St John’s Wart
decreases serum
Cyclosporine levels
Water soluble
Vitamin E
supplementation
may increase serum
levels of the drug
(Pan, 1996; Ernst,
2002)

Hypertension/edema
Avoid high sodium
foods, weight
management for the
overweight
Hyperkalemia
Avoid high potassium
foods
Hypomagnesemia
Magnesium
supplementation
Hyperchloremia
Hyperlipidemia
AHA Step 1 diet ,
exercise
Diarrhea Adequate fluid intake
Nausea/vomiting Try antiemetic
Anorexia
Offer nutrient dense
foods
Hyperglycemia
Reduced simple sugars
or
carbohydrate-controlled
diet
Do not consume
grapefruit or
grapefruit juice if
taking this
medication (Chan,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sirolimus
(Rapamycin)
2001; Pediatric Lexi
Drugs Online).
Consumption with a
high-fat meal will
increase serum
levels of the
medication. Should
be taken consistently
with or without food.
Water soluble
Vitamin E
supplementation
may increase serum
levels of drug (Pan,
1996)

Hypertension/edema
Avoid high sodium
foods, weight
management for the
overweight
Hypokalemia
Encourage high
potassium foods
Hypophosphatemia
Phosphorus
supplementation
Hyperlipidemia
AHA Step 1 diet,
exercise
Anemia
Adjust vitamin and
mineral intake as
needed
Diarrhea Adequate fluid intake
Azathioprine
Nausea/Vomiting
Take with food to
decrease stomach
upset
Anorexia
Offer nutrient dense
foods
Anemia
Adjust vitamin and
mineral intake as
needed
Diarrhea Adequate fluid intake
Mouth ulcers
Hypotension (rare)
Adequate fluid/sodium
intake
Muromonab-CD3
Hyper/hypotension
Adjust fluid, sodium
intake and weight
management
accordingly
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diarrhea Adequate fluid intake
Nausea/vomiting Try antiemetic
Antithymocyte Globulin
Hypo-/hypertension
and edema
Adjust fluid, sodium
intake, and weight
management
accordingly
Diarrhea Adequate fluid intake
Nausea Try antiemetic
Mouth ulcers
Basiliximab
Constipation High-fiber/fluid diet
Nausea/vomiting Try antiemetic
Diarrhea Adequate fluid intake
Abdominal pain Take with food
Dyspepsia
Assess adequacy of
intake
Hyper-/Hypokalemia
Adjust potassium
accordingly
Hyperglycemia Reduce simple sugars
Hypercalcemia Adjust calcium intake
Hypophosphatemia
Phosphorus
supplementation
Hypercholesterolemia
AHA Step 1 Diet,
exercise
Acidosis
Treat with bicarb as
needed
Daclizumab
Constipation High-fiber/fluid diet
Nausea/vomiting Try antiemetic
Diarrhea Adequate fluid intake
Abdominal pain
Assess adequacy of
intake
Adapted from Nutrition Care Manual: Transplant, and compiled from Chan, 2001; Pan,
1996; Ernst, 2002; Fernandez, 1999; Pediatric Lexi Drugs Online

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Transplantation > Organ Transplant > Cardiac Transplant
Nutrition Assessment

A comprehensive nutrition assessment of a transplant candidate should include several
assessment parameters, such as physical examination, history, anthropometric
measurements, and laboratory values (Hasse, 2001). Nutrition assessment should be done
during pretransplant and posttransplant evaluations.
Nutrition Assessment (Hasse, 2001; Garson, 1998)
History
Medical
Psychosocial
Dietary: Is the patient following a restricted (low-sodium,
low-potassium, or fluid-restricted) diet?
Gastrointestinal symptoms (eg, nausea, diarrhea, vomiting, early
satiety)
Physical Examination
Height
Appropriate weight for stature
History of weight loss/gain
Head circumference
Tanner stage
Muscle wasting
Ascites or fluid retention
Use of oxygen, wheelchair, or other assistive device(s)
Alertness
Anthropometry
Skinfold measurements
Midarm circumference
Upper arm circumference (fluid retention may have least effect on
this measurement)
Biochemical Studies
Albumin
Prealbumin
Retinol-binding protein
Cholesterol
Triglycerides
Hemoglobin
C-reactive protein
Hematocrit
Vitamin levels
Mineral levels (eg, zinc, iron, magnesium, calcium)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Nutrition-Focused Physical Findings

Weight may not be an accurate indicator of nutritional status for heart transplant candidates
due to the edema that results from heart failure. For this reason, it is important to use other
anthropometric parameters such as height/length and head circumference.
Other physical findings to assess include the following:
Fluid status (Is fluid positive or negative?)
Weight trend over a 4-week to 8-week period, if available (helps to determine dry
weight pretransplant and posttransplant)
Nutrient intake (calorie count from TPN or enteral feeds)
Bruising (indicates vitamin K deficiency or use of anticoagulants like heparin
or coumadin)
Wound healing (poor healing may indicate inadequate intake of protein-energy,
ascorbic acid, vitamin A, and/or zinc)
Long-term use of diuretics (could lead to vitamin D deficiency, especially in babies)


Client History

Client history should include evaluation of the following factors that may lead to decreased
nutrition intake and inadequate care after transplant:
Home location (medical center visits may require extensive travel)
Inappropriate medical behaviors that could jeopardize the child's overall nutritional
and clinical status
Missed follow-up appointments
Noncompliance with medical or dietary interventions
Other social factors associated with poor growth
Dysfunctional family dynamics or unstable marital status of caregivers
Teenaged parents
Low socioeconomic status
Positive history of mental illness in caregivers
Positive history of caregiver substance abuse
Feeding support
Eligibility for food stamps or Special Supplemental Nutrition Program for
Women, Infants, and Children

Biochemical Data, Medical Tests and Procedures

Pretransplant tests and procedures may include the following:
Blood work, including human immunodeficiency virus and hepatitis tests
Chest x-ray
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Electrocardiogram
Coronary angiogram
Echocardiogram
Cardiopulmonary test (using a bicycle or treadmill and a metabolic cart to measure
oxygen use)
Ultrasound of abdomen and blood vessels
Breathing test/pulmonary function tests
Stool sample to detect blood
Measurements of pressure in heart chambers (cardiac catheterization)
Other blood, urine, and x-ray tests
Right heart catheterization
(Jurt, 2002)

Laboratory

Laboratory Value Normal Range
Hematocrit
6–24 months: 33%–36%
2–6 years: 34%–37%
6–12 years: 35%–40%
Male, 12–18 years: 36%–43%
Female, 12–18 years: 37%–41%
Hemoglobin
6–24 months: 10.5–12 g/dL
2–6 years: 11.5–12.5 g/dL
6–12 years: 11.5–13.5 g/dL
Male, 12–18 years: 13–14.5 g/dL
Female, 12-18 years: 12–14 g/dL
Electrolytes: Transplant recipients are at increased risk for
acute and chronic changes because of medical complications
and immunosuppressive drugs
Sodium 133–146 mEq/L
Potassium
Infant: 4.1–5.3 mEq/L
Child: 3.4–4.7 mEq/L
Chloride 98–107 mEq/L
Calcium
Infant: 9–11 mg/dL
Child: 8.8–10.8 mg/dL
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Phosphorus
Infant: 4.5–6.7 mg/dL
Child: 4.5–5.5 mg/dL
Magnesium 1.3–2.0 mEq/L
Glucose: Transplant recipients are at increased risk for
hyperglycemia
Fasting glucose <110 mg/dL
Random glucose 70–125 mg/dL
Hemoglobin A1C <7%
Lipids: Transplant recipients are at increased long-term risk
for hyperlipidemia
Cholesterol <200 mg/dL
High-density
lipoprotein
cholesterol
>45 mg/dL
Low-density
lipoprotein
cholesterol
<130 mg/dL
Triglycerides <200 mg/dL
Renal function: Transplant recipients are at increased risk for
renal insufficiency because of immunosuppressive drugs
Blood urea nitrogen 5–18 mg/dL
Creatinine
Infant: 0.2–0.4 mg/dL
Child: 0.3–0.7 mg/dL
Micronutrients: Liver transplant recipients are at increased
risk for zinc and copper deficiency if biliary drain is present
Zinc 70–120 mg/dL
Copper
Infant: 20–70 mcg/dL
Child: 80–160 mcg/dL
(Hasse, 2009; Robertson, 2005; Fischbach, 2009;Ng, 2008; Varo, 2002; Perez, 2009;
Fernandez, 1999; Scolapio, 2001; Stratta, 2005; Araki, 2006)

Metabolic Rate Profile (Indirect Calorimetry)

Assessment of energy needs in critically ill children can be challenging, as their disease
may alter metabolic function and put them at high risk for malnutrition. Thus, children who
are cardiac transplant recipients are at higher risk for overfeeding and underfeeding.
Overfeeding is associated with increased risk of infection and impaired liver
function; underfeeding is associated with the loss of lean body mass, decreased respiratory
drive, and impaired immune function. Either can lead to prolonged need for mechanical
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
ventilation (Mehta, 2009; Burritt, 2010).
Nutrition therapy is an important aspect of the care of critically ill patients. For those with
underlying malnutrition or those who require long-term support in the intensive care unit,
adequate energy intake with appropriate macronutrient composition is essential to
recovery. Several equations are used to predict energy needs in critically ill patients: the
DRI-RDA, Basal Metabolic Rate, and WHO equations add stress factors adjusted for
ventilation or sedation; other equations have been derived specifically for critically ill
patients. Indirect calorimetry is a dependable, noninvasive measurement that can
determine true energy expenditure and is therefore a valuable tool for directing calorie
goals in nutrition therapy for all patients undergoing heart transplantation (Porter, 1996).
For more information, see Critical Care: Indirect Calorimetry.


Anthropometric Measurements

Pretransplant pediatric patients may present with poor growth, which could be a
consequence of inadequate intake or the underlying condition itself. Linear growth may
improve after the transplant especially if the patient is on a steroid-sparing
immunosuppressant (Bannister, 2010; Cohen, 2004).
Obesity has been documented in adult heart transplant recipients, but there are limited
data on the development of obesity in children post–heart transplant (Peterson, 2008).
Monitoring linear growth and body mass index (BMI) should be part of routine evaluation
for pediatric patients after heart transplant (Kaufman, 2008).
Some general guidelines for anthropometric measurements based on clinical practice
include the following:
Weight
Daily weight measurements in the immediate posttransplant phase may not be accurate
because of patient hydration status. Patients should be euvolemic in order to have an
accurate dry weight recorded. After the patient is extubated and stable and feeds have
begun, daily weight recordings must be implemented to assess nutritional status. After
hospital discharge, obtain growth measurements at each follow-up clinic visit.
Height or Length
Measure recumbent length (up to age 36 months) and standing height (age 2 to 20 years)
weekly while in the hospital and then at each follow-up clinic visit.
Head Circumference
Measure head circumference in patients up to 3 years of age weekly while in the hospital
and then at each follow-up clinic visit. Head measurement is important to assess brain
growth.
BMI
BMI in posttransplant patients encompasses height and weight and linear growth.
Growth Charts
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Anthropometric measurements are plotted on the 2000 Growth Charts published by the
Centers for Disease Control and Prevention.

Food/Nutrition-Related History

Food and nutrition-related history should include:
Home feeding or diet history (24-hour food questionnaire)
Formula preparation method (for infants)
Frequency and volume of feeds
Food allergies
Use of home tube feeding or total parenteral nutrition
If home feeding: are supplements used?
Eligibility for WIC or other food assistance
Use of multivitamins or herbal supplements
Special religious/ethnic practices that may affect oral intake

Comparative Standards

Note: DRI tables can be found in the Resources section by clicking here.
Energy and protein needs should be assessed individually based on the patient's
situation posttransplant (intubated, extracorporeal membrane oxygenation [ECMO],
continuous veno-venous hemofiltration [CVVH]).
Energy
For patients at a healthy weight: Energy levels should be based on the Estimated
Energy Requirements (EER) and activity levels from the Dietary Reference Intakes
(DRI), Macronutrients Report, 2002.
To estimate catch-up growth in failure to thrive (FTT): Determine ideal body weight
(IBW) for height and use indirect calorimetry or energy levels based on EER for that
weight. Children in heart failure often require 10% to 50% more energy intake due to
increased metabolic rates. See Anthropometrics and Indirect Calorimetry for more
information.
Protein
Protein requirements are based on an increase in needs of 50% to 100% above DRIs.
Protein requirements in FTT = [DRI protein for age x IBW for height (kg)]/actual
weight.
Carbohydrates
Should make up 55% to 60% of total energy.
Added sugars should comprise no more than 25% of total energy intake.
Fats
The higher end of the DRI range is recommended only when hyperglycemia is severe
and not under control with insulin.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fluids
Total average fluid requirements are estimated based on the weight of the child:
1-10 kg: 100 ml/kg
10-20 kg: 1000 ml + 50 ml/kg for each kg above 10 kg
> 20 kg: 1500 ml + 20 ml/kg for each kg above 20 kg

During the acute posttransplant phase, fluid retention is common. Fluid needs are
individualized depending on hydration status, renal function, and amount of fluid loss.
Consider fluid losses from drains, nasogastric tube, stool output, and urine, and adjust fluid
intake based on these factors. Most heart transplant patients are receiving
medication intravenously, and this should be factored in the total fluids.

Nutrition Diagnosis

Dietitians working with patients who are pre- or post-organ transplant should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Inadequate parenteral nutrition infusion (NI-2.6)
Less than optimal parenteral nutrition (NI-2.8)
Inadequate fluid intake (NI-3.1)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein–energy intake (NI-5.3)
Inappropriate intake of protein or amino acids (specify) (NI-5.7.3)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Food-medication interaction (NC-2.3)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
Overweight/obesity (NC-3.3)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate energy intake (NI-1.4) related to pathophysiological needs secondary to
surgery and recovery period as evidenced by intake of less than <50% of estimated
energy needs for more than 3 days.
Inadequate oral intake (NI-2.1) related to psychological depression with worsening
heart function as evidenced by reported change in appetite and disposition.
Inappropriate intake of amino acids (NI-5.7.3) related to inability to tolerate required
protein as evidenced by increased BUN/Creatinine.
Less than optimal parenteral nutrition (NI-2.8) related to decrease in TPN to treat
undesirable medication interaction as evidenced by glucose levels of more than 345
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mg/dL with usual prescription of IV dextrose.
Impaired nutrient utilization (NC-2.1) related to compromised function of the liver as
evidenced by direct bilirubinemia (>18 and rising) and elevated alkaline phosphatase
(liver faction).
Underweight (NC-3.1) related to increased energy needs due to worsening heart
function causing wasting as evidenced by <15th percentile BMI for age.
Unintended weight loss (NC-3.2) related to increased nutrient needs from long-term
congestive heart failure as evidenced by weight loss of 8% of admission weight by
day 10 of hospital stay.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

The acute posttransplant phase is characterized by the patient's recovery from surgery.
During this time, rejection, infection, and surgical complications are prevalent.
Medical and nutritional care is provided by a team approach and is individualized based on
each patient's situation. The focus is on meeting nutritional needs after the transplant.
Based on clinical practice, nutrition interventions should include the following:
Providing adequate nutrients (increasing nutrient density as needed) to treat
catabolism and promote healing.
Monitoring and treating electrolytes and related abnormalities.
Achieving optimal blood glucose control:
Treat hyperglycemia with insulin; add other hypoglycemic agents as needed.
The higher end of the DRI range of lipids is recommended only when
hyperglycemia is severe and not under control with insulin.
Replenishing lost nutrient stores and mediating the immune response.
Correcting potassium, magnesium, and phosphorus. The degree of supplementation
required depends on the type and amount of diuretics used and serum electrolyte
values.
Implementing an aggressive nutrition support plan including gastrostomy or
intravenous feeding if a nutritional problem becomes chronic and the patient presents
with severe growth failure (BMI <5%ile or wt/ht <5%ile), or when oral supplementation
becomes inadequate (Miller, 2007).
Monitoring fluids: In the early postoperative period, infants are at significant risk for
fluid overload due to high fluid volumes given intraoperatively, fluids administered with
cardiac medications, and reduced cardiac and renal function.
Fluids may be liberalized to the maximum value tolerated without medical
compromise (Carlson, 2000).
Fluid restriction to 30–50 mL/kg is common. In addition, to control edema, most
infants will receive diuretics such as thiazides, furosemide, spironolactone, or a
combination of these medications.
Infants sensitive to fluid intake and placed on strict fluid restrictions may have
difficulty achieving nutritional goals. During the postoperative period, fluid
conservation strategies include the following:
Concentrating IV medications to limit excess fluid administration.
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Compounding IV medications in high dextrose concentrations (D25W) can
improve energy intake.
Other recommendations include the following:
For mild to moderate undernutrition, ad libitum oral feeding is appropriate, and energy
density of foods and liquids should be increased (Miller, 2007).
Energy-dense feedings may be made from concentrated formulas or breast milk
mixed with concentrated formulas or protein powder to meet protein needs in infants
(Hummell, 2003).
Immunosuppression drugs (from Liver Transplant)
Immunosuppression drugs are used to prevent rejection of the transplanted organ.
Immunosuppressive therapy usually consists of a combination of medicines. These drugs
are the cause of many of the nutritional issues in both the acute and chronic
posttransplantation phases (Ng, 2008; McPartland, 2007; Chan, 2001). Some of the side
effects include hypertension; renal insufficiency; hyperlipidemia; glucose intolerance;
osteoporosis; and alteration in calcium, potassium, and magnesium (Ng, 2008; Varo, 2002;
Perez, 2009; Fernandez, 1999; Scolapio, 2001; Everhardt, 1998; Helenius, 2006; Giannini,
2000; Stratta, 2005; Araki, 2006; Chan, 2001). See Immunosuppressive Medications for
nutrition-related side effects of immunosuppressants.
In addition, these drugs have significant drug–nutrient interactions. The coadministration of
grapefruit, grapefruit juice, or water-soluble vitamin E enhance the absorption of
cyclosporine (Chan, 2001; Pan, 1996). The mechanism by which this occurs is unclear. It is
recommended that patients be instructed to avoid grapefruit and grapefruit juice entirely
while taking cyclosporine, tacrolimus, or sirolimus. Pending additional studies, cyclosporine
levels should be closely monitored in patients taking vitamin E (Pan, 1996).


Nutrition Prescription

Nutrient
Acute Phase
(up to 3 months or
until stable)
Chronic/Stable Phase
(more than 3 months)
Energy
Healthy weight: energy
levels based on the
estimated energy
requirements (EER) and
activity levels from the
Institute of Medicine
Dietary References
Intakes (DRI),
Macronutrients Report,
2002
Estimate catch-up
growth in failure by
DRI for age; adjust as
needed for growth
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determining ideal body
weight for height and
using by indirect
calorimetry or using
energy levels based on
EER for that weight

Protein
Infants: 3–3.5 g/kg dry
weight
1–2 years: 2.5–3.5 g/kg
dry weight
3–13 years: 2–2.5 g/kg
dry weight
Adolescents: 1.5–2 g/kg
dry weight
15% to 17% of total
energy; adjust as
needed with renal
insufficiency (Sutton,
2002)
Carbohydrate
Reduce intake of simple
sugars to prevent
hyperglycemia while
corticosteroid doses are
high
Carbohydrate-controlled
diet as needed for
control of
hyperglycemia
Carbohydrate-controlled
diet as needed for
control of
hyperglycemia
Fat and
cholesterol
No restriction
Limit saturated/trans fat
to 10% or less;
low-cholesterol diet for
children older than 2
years
Sodium
2 mEq/kg/day, restrict
as needed for
hypertension and
edema
Same as for acute
phase
Potassium
Restrict only with renal
insuffiency
Same as for acute
phase
Calcium
DRI plus 130% to 150%
of DRI for bone
repletion if
malnourished
pretransplant
Minimum to meet DRI
Phosphorus
DRI plus supplement as
needed
DRI
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Magnesium
DRI plus supplement as
needed (McPartland,
2007)
DRI
Iron
6 months to 3 years: 1
mg/kg dry weight
(Sutton, 2002)
DRI, supplement as
needed
Zinc
Infants and children:
1–3 mg/kg
Adolescents: 10–15
mg/kg dry weight
(Sutton, 2002)
DRI, supplement as
needed
Vitamins
1–4 years: 1 mL
multivitamin, twice daily
4–11 years: 1 chewable
multivitamin, twice daily
11 years and older: 1
pediatric multivitamin
daily to provide 400 IU
vitamin D (Sutton, 2002)
Multivitamin with
minerals if diet is not
adequate; individual
nutrients as needed

DRI = Dietary Reference Intake

Goal Setting

Pretransplant nutrition support goals are as follows (Hasse, 2001):
Maintain or improve nutritional status, if possible
Increase energy intake to promote anabolism, if possible
Increase protein intake to promote wound healing
Promote adequate intake of vitamins and minerals
Manage fluid restriction (high-energy beverages or formulas may be needed)
Acute posttransplant nutrition support goals are as follows:
Provide adequate nutrients to treat catabolism
Promote healing
Monitor and treat electrolyte abnormalities
Achieve optimal blood glucose control
Replenish lost nutrient stores


Oral Intake

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Patients with end-stage heart failure usually are not able to eat by mouth and meet their
energy and protein needs. Factors contributing to low energy intake include feeding
difficulties associated with tachypnea, fatigue, excessive emesis, and respiratory infections.
Restriction of fluid intake as treatment for congestive heart failure may have the unintended
effect of excessive energy restriction. In addition, standard diuretic therapy may produce
anorexia from metabolic alkalosis and hypokalemia and may inhibit effective protein
anabolism by interfering with the maintenance of adequate sodium balance. Intestinal
malabsorption may also be present, as a consequence of edema of the intestinal wall and
mucosal surfaces, which leads to impaired nutrient absorption and lymphatic drainage.
A daily total intake analysis is imperative for these patients in order to assess their oral
intake. Kilocalorie counting must be initiated and the dietitian and dietetic technician must
work together to help patients and family with food preferences and food choices.
Enteral nutrition support may be used in combination with oral intake.
If intestinal malabsorption is present, total parenteral nutrition should be implemented.
Following are important considerations regarding nutrient needs:
Energy needs may be increased because of treatment. If possible, obtain a
metabolic cart to assess needs.
Protein needs are increased due to catabolism. Monitor renal function in order to
assess protein needs. For some patients with end-stage heart failure, renal
dysfunction may be a substantial barrier to meeting protein needs.
Lipid clearance may be decreased in patients with hepatic dysfunction. Check
triglycerides.
Carbohydrate needs may be decreased if hyperglycemia occurs.


Enteral or Tube Feeding

Poor nutritional status has been associated with the development of infections
and longer intensive care unit and hospital stays (Figueiredo, 2000). Thus,
postoperative nutrition support should be provided if the patient is unable to eat
adequately within 3 days posttransplant.
Ideally, nutrition support should be provided enterally unless there are contraindications to
enteral feeding. Enteral nutrition has been shown to improve nutritional status in various
pediatric populations with growth failure. Nasojejunal feeding has shown to be well
tolerated in prospective, randomized studies of adult liver transplant patients (Hasse, 1995;
Wicks, 1994). Infection occurred significantly less often in patients who received early tube
feeding as compared to patients who received intravenous fluid before a diet was initiated
(Hasse, 1995). Cumulative energy intake of the tube-fed group was also significantly
more than that of patients who stayed on intravenous fluid until the diet was advanced
(Hasse, 1995).
Enteral feeding support is often initiated pretransplant with a goal to maintain nutritional
stores or prevent further losses. The following recommendations are based on clinical
practice:
A semi-elemental or elemental formula may be better tolerated for those patients with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A semi-elemental or elemental formula may be better tolerated for those patients with
end-stage heart failure who have developed edema in the intestinal wall.
High-calorie, high-protein formula (45 kcal/oz) is necessary to meet the nutritional
needs in patients who are very fluid restricted. It may be beneficial to start with a
concentration of 30 kcal/oz and advance to the full-strength concentration as the
patient tolerates.
Enteral feeds may be done overnight to allow oral intake in daytime.
Bolus feeds is an option when patient is not able to meet his calorie needs by mouth.
Studies have demonstrated that tube feedings have improved growth in infants with CHD
(Schwarz, 1990). Rates of increase in weight and height z-scores posttransplant were
higher for children who were exposed to enteral feeding support in comparison with those
who were not (Bannister, 2010).
Delivery of nutrients through the enteral route is dependent on patient tolerance and
amount of oral intake, and may be suboptimal if the only feeding option used in neonatal
patients (Schwalbe-Terilli, 2009). If the pediatric cardiac patient has gastrointestinal
problems such as reflux, a continuous infusion may be better tolerated than a bolus feeding
(Cox, 1997). A bolus schedule can provide a physiologic feeding regimen. Nocturnal or
cyclic feedings allow for oral intake during the day, with supplementation during the night
while the child is asleep.


Parenteral Nutrition

Pediatric patients may require parenteral nutrition support (PN) when not able to start
enteral feeds after the transplant.
The goals of PN are to promote growth and development as well as tissue repair until oral
or enteral nutrition is tolerated. PN should be initiated immediately for conditions in which
enteral feedings are contraindicated until the medical situation allows for safe initiation of
enteral feedings.
In clinical practice, for cardiac patients, PN orders are driven by the total fluid limit (TFL).
Maintenance fluids are usually provided preoperatively and postoperatively, but further
restrictions may be necessary depending on the medical condition. Providing adequate
energy and protein is often difficult secondary to the multiple medication infusions and line
carriers that are included in the TFL. This limits the amount of fluid that can be used for PN.
Infusions and carriers should be concentrated and run at the lowest rate possible to
maximize the fluid available for PN. These parameters must be monitored daily so
adjustments to the total PN (TPN) can be made to maximize energy and protein.
Monitoring Parenteral Nutrition
Body weight
Fluid intake and output
Laboratory values
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
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Blood urea nitrogen
Creatinine
Calcium
Phosphorus
Magnesium
Glucose
Oral or enteral intake to aid in transition


Complications of Nutrition Support

Refeeding syndrome is a complication that often occurs with the initiation of aggressive
nutrition support. Onset is most commonly associated with use of parenteral nutrition, but
this metabolic abnormality also has been found to occur with both enteral and oral feeding.
Treatment for this syndrome in transplant patients is the same as for any other patient
population who is experiencing this problem.

Nutrition Monitoring & Evaluation

Growth parameters should be assessed at each doctor visit after the transplant (once a
month) and should be plotted in the patient's growth chart.
The following conditions in heart transplant recipients should trigger an evaluation and
intervention:
Substantial weight change (loss or gain)
Feeding intolerance (formula concentration)
Impaired wound healing
Prolonged reduction in appetite
Prolonged nausea, vomiting, or diarrhea
Development of diabetes, hyperlipidemia, food allergies, or any other metabolic
condition that could be treated with nutrition therapy
Renal impairment

Nutrition Therapy Efficacy

Poor nutritional status has been associated with the development of infections
and longer intensive care unit and hospital stay (Figueiredo, 2000). Thus,
postoperative nutrition support should be provided if the patient is unable to eat
adequately within 3 days posttransplant.
Nasojejunal feeding has shown to be well tolerated in prospective, randomized studies of
adult liver transplant patients (Hasse, 1995; Wicks, 1994). Infection occurred significantly
less often in patients who received early tube feeding as compared to patients who
received intravenous fluid before a diet was initiated (Hasse, 1995). Cumulative energy
intake of the tube-fed group was also significantly more than that of patients who stayed on
intravenous fluid until the diet was advanced (Hasse, 1995).
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Adequacy
Depending on individual food choices and tolerance, the posttransplant diet can be
adequate in all nutrients per the Dietary Reference Intakes (DRIs). Special attention must
be given to the patient’s feeding skills, developmental level, and food preferences.
However, drug-nutrient interactions may affect absorption and metabolism of nutrients. In
addition, if a patient has food restrictions, the eating plan may be deficient in certain
nutrients: For example, if a patient must restrict potassium intake because of hyperkalemia
from tacrolimus, that patient is at higher risk for vitamin C deficiency.
Energy-dense and protein-dense supplements and snacks may be used to meet increased
needs immediately posttransplantation, to achieve weight gain and catch-up growth, and to
correct nutrient deficiencies. Supplements may be discontinued once oral intake is
adequate to sustain continued growth and optimal nutritional status.
Exceptions to DRI
Calcium, phosphorus, magnesium, and vitamin D requirements may exceed the DRI during
the acute posttransplant phase in those who were malnourished pretransplant and those
who require frequent or long-term, high-dose steroids.
Osteopenic bone disease is a common problem in transplant patients (Helenius, 2006;
Guichelaar, 2002). Exercise is an important factor in bone mineralization and should be
encouraged.
Zinc requirements may exceed the DRI if the patient is experiencing complications with
wound healing and/or has bile drainage.

*Adapted from Liver Transplant

Nutrition Care FAQs

Question: Do children who receive a heart transplant grow normally posttransplant?
Answer: Bannister and colleagues (Bannister, 2010) and Peterson and colleagues
(Peterson, 2008) noted that patients demonstrated an increase in weight z-score that was
significantly faster 6 to 12 months after transplantation; however, no significant increase in
height z-score was seen, and increases in weight and body mass index z-scores plateaued
in the late posttransplant period. Transplant recipients with comorbid conditions, more
rejection episodes, or longer exposure to cyclosporine and steroids tend to experience
slower growth, and those with coronary heart disease and severe growth delay
pretransplant did not experience catch-up weight gain.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Transplantation > Organ Transplant > Kidney Transplant
Nutrition Assessment

Nutrition assessment should be done frequently in the early posttransplant phase (every 1
to 2 weeks) to evaluate for all of the issues listed under Biochemical and Nutrient Issues.
Over the long term, a transplant patient should visit a registered dietitian on a regular basis
(every 3 to 12 months, depending on age, nutritional concerns, and stage of chronic kidney
disease [CKD]) to evaluate weight gain and growth as well as dietary-related
cardiovascular risks and CKD nutritional risks.
(NKF, 2009)

Anthropometric Measurements

Measure length (up to 24 to 36 months of age) or height (older than 2 years), weight, and
head circumference (up to 3 years of age) and compare with growth charts of the Centers
for Disease Control and Prevention (2001) for appropriate age.
Plot weight-for-length ratio (up to 24 to 36 months of age) or calculate and plot body mass
index (BMI) (older than 2 years) on growth chart. It is important to measure weight when
the child is euvolemic to determine "real," or "dry," weight.
Because of growth and/or maturational delay in children with chronic kidney disease, it is
often best to assess BMI using height age rather than chronological age (height age is age
at which current height is at the 50th percentile).
Evaluate growth history to determine if growth rate is normal. Weight gain, linear growth
velocity, and head circumference growth velocity for children younger than 2 years can be
calculated using the 2006 World Health Organization's Child Growth Standards. Weight
gain and linear growth velocity for children from 2 to 18 years of age can be determined by
calculating standard deviation change over time or by using data from the Fels Longitudinal
Study (Baumgartner, 1986).

Laboratory


Laboratory
Tests
Reason for
Testing
Conditions that
Alter Results
Nutritional
Significance of
High Values
Nutritional
Significance of
Low Values
Creatinine/varies
with muscle
mass
Measure of
kidney
function
Fluid status; if
dehydrated,
creatinine is high
Indicates
decreasing kidney
function
Indicates low
muscle mass
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Blood urea
nitogen (BUN)
Waste
products of
protein; if
creatinine is
high, expect
BUN to be
10-20 X
creatinine
Fluid status; if
dehydrated, BUN
is high
Excessive protein
intake; dehydration
If lower than
expected, low
protein intake
Sodium
Helpful in
assessing
fluid status
and
adequacy of
sodium intake
(low sodium
levels affect
growth and
development)
Fluid status; if fluid
overload, sodium
is low; if
dehydrated,
sodium may be
high; if polyuric
and a “salt waster,”
sodium may be
low, even with
dehydration
Dehydration
Sodium
deficiency and/or
inadequate
intake
Potassium
Extremely
important in
cardiac
function
Metabolic acidosis
(if CO
2
is
low, potassium is
likely to be high)
Potassium-wasting
diseases such as
cystinosis, Barter
syndrome
Medications such
as enalapril cause
increase in
potassium
whereas Lasix
causes decrease
in potassium
Excess intake;
need for more
dialysis or
decrease in food
sources of
potassium
Inadequate
intake; may
need supplement
Carbon dioxide
(CO
2
)
Indicator of
acid/base
status
Important for
bone
development
and growth
Metabolic alkalosis
Metabolic
acidosis; causes
poor growth and
poor bone
development
Low serum
albumin (calcium is
If extremely high,
patient may have
seizures or go into
“tetany”
Chronically high
Indicator of low
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Calcium
Important for
bone
mineralization
and muscle
function
bound to albumin);
if albumin is low,
need to check
ionized calcium to
get true
assessment of
calcium status
levels, especially
with high
phosphorus levels,
result in
calcification of soft
tissues—especially
calcification of
arteries
(arteriosclerosis),
increasing risk for
heart attack
vitamin D status;
may need more
activated vitamin
D to enhance
absorption of
calcium
Phosphorus
Important for
bone
mineralization
Decreased kidney
function causes
phosphorus
retention
Results in
increased
parathyroid
hormone and
decreased bone
mineralization
Indicator of low
intake of
phosphorus
If low in face of
renal failure,
suggests poor
protein intake or
oversuppression
of phosphorus
with phosphate
binders
Parahyroid
hormone (PTH)
Plays a role
in calcium
and
phosphorus
regulation
and bone
mineralization
Chronic kidney
disease results in
elevated PTH
High levels are
indicative of high
bone turnover,
which can result in
renal
osteodystrophy
Low levels are
indicative of low
bone turnover,
which can result
in osteomalacia
Albumin
Protein in the
blood
Carrier of
calcium and
other minerals
Systemic
inflammation,
volume overload,
urinary or dialysate
protein losses all
decrease serum
albumin
Protein–energy
malnutrition may
cause decreased
serum albumin
High levels are
indicative of
dehydration
Low levels do
not necessarily
indicate
malnutrition;
they are more
commonly
associated with
fluid overload
and systemic
inflammation or
protein losses
Low albumin
with
inflammation is
associated with
increased
mortality in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
children and
adults with
chronic kidney
disease

Client History

Development of chronic kidney disease (CKD)
When was the child first diagnosed and how fast has kidney disease
progressed?
Comorbid conditions
Are these conditions directly associated with his CKD, or are they isolated
conditions (eg, a child with a syndrome that includes CKD as opposed to a child
with severe milk allergy who also has CKD)?
Growth history, starting with birth
If a child is currently small for age or genetic potential, size at birth
Weight gain, linear and head circumference growth in infancy
Weight gain, linear and head circumference growth in toddler/childhood years
Growth and weight gain since transplant
Current medications
Current and past laboratory values (look at trends in laboratory values)
Current and past complications associated with transplant
Transplant rejections
Opportunistic infections
Electrolyte and mineral abnormalities
Hyperlipidemia

Food/Nutrition-Related History

Obtain food records or history of usual intake.
Pay special attention to energy and fat intake as correlated to weight gain/loss and
lipid levels.
Pay special attention to sodium intake if hypertension is present and to any nutrient
for which laboratory values are abnormal (potassium, magnesium, phosphorus,
glucose).

Comparative Standards

Body mass index and estimation of energy needs for age, height, and weight—see
Calculators.
Fluid needs are increased with successful kidney transplant. It is imperative that fluid needs
are met, because dehydration can result in loss of function of the transplanted kidney.
Fluid prescription will be determined by the nephrologist.
The dietitian gives guidance regarding how to meet needs, including the following:
How much water should be consumed between waking and 10:00 am, 10:00 am
and noon, noon and 2:00 pm, and so on.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
For the tube-fed child, if a prescribed amount of water has not been consumed
by mouth over a specified time period, it can be given as a tube-feeding bolus.



Nutrition Diagnosis

Dietitians working with patients who are pre- or post-organ transplant should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Inadequate parenteral nutrition infusion (NI-2.6)
Less than optimal parenteral nutrition (NI-2.8)
Inadequate fluid intake (NI-3.1)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein–energy intake (NI-5.3)
Inappropriate intake of protein or amino acids (specify) (NI-5.7.3)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Food-medication interaction (NC-2.3)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
Overweight/obesity (NC-3.3)
Sample PES or Nutrition Diagnostic Statement(s)
Inadequate energy intake (NI-1.4) related to pathophysiological needs secondary to
surgery and recovery period as evidenced by intake of less than <50% of estimated
energy needs for more than 3 days.
Inadequate oral intake (NI-2.1) related to psychological depression with worsening
heart function as evidenced by reported change in appetite and disposition.
Inappropriate intake of amino acids (NI-5.7.3) related to inability to tolerate required
protein as evidenced by increased BUN/Creatinine.
Less than optimal parenteral nutrition (NI-2.8) related to decrease in TPN to treat
undesirable medication interaction as evidenced by glucose levels of more than 345
mg/dL with usual prescription of IV dextrose.
Impaired nutrient utilization (NC-2.1) related to compromised function of the liver as
evidenced by direct bilirubinemia (>18 and rising) and elevated alkaline phosphatase
(liver faction).
Underweight (NC-3.1) related to increased energy needs due to worsening heart
function causing wasting as evidenced by <15th percentile BMI for age.
Unintended weight loss (NC-3.2) related to increased nutrient needs from long-term
congestive heart failure as evidenced by weight loss of 8% of admission weight by
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
congestive heart failure as evidenced by weight loss of 8% of admission weight by
day 10 of hospital stay.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

Provide nutrition recommendations to the nephrology team and to patient families as
indicated by results of laboratory tests, weight gain and growth, and level of chronic kidney
disease (CKD). Early and frequent nutrition education has been shown to make a
difference in nutritional outcomes in transplant patients (Patel, 1998; Lopes, 1999).
Providing hands-on, experiential education, such as classes on selecting and preparing
foods, may be more effective than traditional instruction in a clinic situation (Gray, 2006).
When dealing with adolescents, it is imperative that they are considered part of their
treatment team and that they buy in to any necessary dietary modifications. If a
teenage patient does not believe that the registered dietitian's (RD) recommendations will
do anything to improve his or her life, that patient is not going to adhere to them. Any RD
who is working with adolescents and/or young adults needs to have an understanding of
the complex factors that help adolescents desire to and be able to care for themselves and
therefore to adhere to recommendations. There has been quite a bit of research in the
area of adolescent and young adult adherence to medical regimens (Kyngas, 2000;
Staples, 2002; Olsson, 2003; Hopman, 2006; Rosina, 2003; Sawyer, 2003; Stewart, 2001);
the pediatric RD who works with children with chronic diseases should read some of this
body of research and talk with colleagues in the social work and psychology fields to learn
how to best relate to the teenagers with whom he or she works. Much of the research in the
area of adolescent adherence to medical recommendations comes from the asthma,
diabetes, and celiac disease literature.
In the early posttransplant phase, if the graft is not yet functioning, follow the dietary
guidelines for CKD stage 5 or 5D. If on dialysis, follow guidelines for CKD stage 5D; if not
on dialysis, follow guidelines for CKD stage 5.

Once the graft is functioning, provide supportive therapy depending on nutrition diagnoses:
Hypertension
Teach low-sodium meal plan
Hypophosphatemia and/or hypomagnesemia
Provide phosphorus or magnesium supplements to bring serum levels up to
normal.
Be aware that both phosphorus and magnesium supplements can work as
cathartics. If supplements doses are very high, resulting diarrhea may further
decrease mineral in serum.
Divide doses 2 to 3 times/day as it may prevent diarrhea.
Hyperglycemia
See guidelines for type 2 diabetes. Encourage complex carbohydrates with high
fiber content in lieu of simple sugars and refined carbohydrates, a balanced diet
throughout day, and increased physical activity. Avoid sugared drinks and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
excess weight gain (NKF, 2009)
See guidelines for weight management.
Decreased bone density
Ensure adequate calcium and vitamin D intake.
The American College of Rhuematology Ad Hoc Committe on
Glucocorticoid-Induced Osteoporosis recommends approximately 150% of
the Dietary Reference Intake (DRI) for age for calcium in children taking
prednisone (ACR, 1996).
Recent research suggests that current DRIs for vitamin D may not be
adequate for many children. It is important to ensure at least 100% of DRI
for vitamin D and to check serum levels of 25-OH vitamin D; if low, vitamin
D should be supplemented at rates higher than the DRI (up to 2,000 IU/day
is safe and tolerable for children older than 1 year (DRI, 2006). If serum
levels are below normal, pharmacologic levels of vitamin D may be
prescribed (Roth, 2005).

Nutrition Therapy Efficacy

Research shows that transplant patients who follow a heart-healthy diet and are physically
fit have improved health and quality of life. Early, intensive and long term nutrition
intervention and education can enable patients to make the dietary and exercise changes
necessary to lower lipid levels and decrease level of obesity/overweight (Painter, 1997;
Patel, 1998; Lopes, 1999; Barbagallo, 1999; Hines, 2000).

Goal Setting

Goals of nutrition intervention are to promote the following:
Optimal growth
Healthy weight gain
Optimal bone development
Optimal biochemical balance
Decreased risk for cardiovascular diseases associated with
hypertension, hyperlipidemia, and obesity

Oral Intake

Children with chronic kidney disease (CKD) often have food aversions and poor
appetite and require tube feeding to meet needs (see Chronic Kidney Disease).
Continued tube feeding is often required for several weeks or months after successful
kidney transplant.
Nutrient and fluid needs will change (see Biochemical and Nutrient Issues), requiring
a change in tube-feeding formula.
Over time, with feeding therapy, dependence on tube feeding may decrease. It is
important to leave tube in place until a child is meeting not only nutrient needs but
fluid needs by mouth as well.

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Nutrition Support

Kidney transplant patients are generally able to begin oral or enteral feeding within 24 hours
of surgery. In rare cases, parenteral nutrition is needed. (See Oral Intake for information
on tube feeding.)

Nutrition Monitoring and Evaluation

Nutrition monitoring should begin within 24 hours of transplant.
If the transplant is functioning well, concerns will focus on blood glucose, phosphorus
and magnesium levels, and fluid balance.
If the transplant is not functioning well or at all, many of the same nutrition needs of
the patient with chronic kidney disease (CKD) on dialysis will remain.
As kidney function improves, nutrient needs will change.
Daily monitoring is necessary until the patient is stable and the kidney is functioning
well; frequent monitoring throughout the hospital stay is necessary as needs for blood
glucose control, fluid, sodium and potassium intake, and phosphorus and magnesium
supplements will change over the first few weeks after transplant.
Following hospital discharge, weekly nutrition monitoring will be important until the
patient is very stable.
Long-term, standard nutrition monitoring is necessary to monitor weight gain and
growth, kidney function, and nutrient needs associated with level of CKD,
cardiovascular risk factors, and intake.

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Nutrition Care > Transplantation > Organ Transplant > Liver Transplant
Nutrition Assessment

Malnutrition and growth failure in pediatric patients with liver disease is multifactorial and
contributes to morbidity and mortality (Ramaccioni, 2000). A thorough pretransplant
evaluation of the metabolic and nutritional effects of the underlying disease on the child is
imperative. For optimal care, children with liver disease should be monitored by a
registered dietitian and receive appropriate intervention upon initial diagnosis of disease.

Improvement in nutritional status during the pretransplant period maximizes success of the
liver transplant and growth posttransplant (Ramaccioni, 2000; Pikul, 1994; Figueiredo,
2000). In the acute period after transplantation, diet modifications are designed to provide
adequate energy and protein to counteract the catabolic effects of surgery and high-dose
corticosteroid (prednisone) use and to treat early drug–nutrient interaction associated with
other immunosuppressive drugs.

Long-term nutrition management is designed to provide optimal nutrition for growth and
development and to control the chronic nutritional side effects of immunosuppressive drugs.
Assessment and recommendation for transplantation can be divided into two phases: acute
(1 to 3 months posttransplantation) and chronic (more than 3 months posttransplantation).
Nutrition Assessment Parameters
Physical Observations
Wasting of extremities
Presence of edema or ascites
History of excessive weight gain
Anthropometrics
Weight, length or height, weight/length below the 5th percentile
Weight/length above the 95th percentile
Body mass index above the 85th percentile
History of excessive weight loss/gain not induced by fluid retention or diuresis of 1% to
2% in past week, 5% in past month, 7.5% in past 3 months, or 10% in past 6 months
Decrease in length or height by 2 or more percentile curves in 6 months
Food/Fluid Intake
Poor appetite for 1 week or longer
Restricted diets (eg, low potassium for hyperkalemia related to calcineurin inhibitor
administration)
Gastrointestinal Symptoms
Vomiting for 3 days or longer
Diarrhea for 3 days or longer
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Laboratory Values
Hemoglobin below 10.7 g/dL for infants and below 10.3 g/dL for a child; hematocrit
below 35% for an infant, below 32% for a child
Serum albumin level below 3.8 g/dL (if liver and kidney function are normal and fluid
retention is absent)
Serum prealbumin level below 17 mg/dL (if liver and kidney function are normal and
fluid retention is absent)
Fasting serum glucose level greater than 126 mg/dL or random serum glucose level
200 mg/dL or higher or glycosylated hemoglobin above 7%
Fasting serum cholesterol level greater than 200 mg/dL
Fasting serum low-density lipoprotein cholesterol level above 130 mg/dL
Fasting serum triglyceride above 200 mg/dL
(Fischblach, 2009; Robertson, 2005)

Nutrition-Focused Physical Findings

During the acute posttransplant phase, fluid retention can mask muscle and subcutaneous
fat wasting that frequently occurs with end-stage liver disease. During the chronic
posttransplant phase, however, the physical exam is reliable.
Check for the following:
Wasting
Excess fat deposition
Bruising (vitamin K deficiency)
Dry skin (vitamin A and essential fatty acid deficiency)
Sparse or brittle hair (malnutrition, zinc deficiency)
Enlargement of epiphyses, bowed legs, beading of ribs (rickets)
Delayed eruption of teeth (calcium and vitamin D deficiencies)
Frontal bossing and persistent open anterior fontanelle (rickets)
Delayed wound healing (inadequate energy or protein intake, zinc deficiency)

Laboratory

Laboratory Value Normal Range
Hematocrit
6-24 months: 36% to 33 %
2-6 years: 37% to 34%
6-12 years: 40% to 35%
12-18 years, male: 43% to 36%
12-18 years, female: 41% to 37%
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Hemoglobin
6-24 months: 12-10.5 g/dL
2-6 years: 12.5-11.5 g/dL
6-12 years: 13.5-11.5 g/dL
12-18 years, male: 14.5-13 g/dL
12-18 years, female: 14-12 g/dL
Electrolytes: Transplant recipients are at increased risk for acute and
chronic changes because of medical complications and
immunosuppressive drugs
Sodium 133-146 mEq/L
Potassium
Infant: 4.1-5.3 mEq/L
Child: 3.4-4.7 mEq/L
Chloride 98-107 mEq/L
Calcium
Infant 9-11 mg/dL
Child 8.8-10.8 mg/dL
Phosphorus
Infant: 4.5-6.7 mg/dL
Child: 4.5-5.5mg/dL
Magnesium 1.3-2.0 mEq/L
Glucose: Transplant recipients are at increased risk for hyperglycemia
Fasting glucose <110 mg/dL
Random glucose 70-125 mg/dL
Hemoglobin A1C <7%
Lipids: Transplant recipients are at increased long-term risk for
hyperlipidemia
Cholesterol <200 mg/dL
High-density lipoprotein
cholesterol
>45 mg/dL
Low-density lipoprotein
cholesterol
<130 mg/dL
Triglycerides <200 mg/dL
Renal function: Transplant recipients are at increased risk for renal
insufficiency because of immunosuppressive drugs
Blood urea nitrogen 5-18 mg/dL
Creatinine
Infant: 0.2-0.4
Child: 0.3-0.7 mg/dL
Micronutrients: Liver transplant recipients are at increased risk for
Zinc, and Copper deficiency if biliary drain.
Zinc 70-120 mg/dL
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Copper
Infants: 20-70 mcg/dL
Child: 80-160 mcg/dL
(Hasse, 2009; Robertson, 2005; Fischbach, 2009;Ng, 2008; Varo, 2002; Perez, 2009;
Fernandez, 1999; Scolapio, 2001; Stratta, 2005; Araki, 2006)

Anthropometric Measurements

Weight
Measurement of daily weight during the immediate posttransplant period and at each
follow-up clinic visit is essential to assess hydration and adequacy or overnutrition. A
report from the Studies in Pediatric Liver Transplant registry compiled from transplant
centers in Canada and the United States between 1996-2001 indicates that the weight
distribution of 5-year survivors was similar to that of the normal population; 12% were
overweight, exceeding 95th percentile (Ng, 2008). Lifestyle changes to increase physical
activity, decrease inactivity, and decrease dietary intake of fat and energy are necessary to
treat overweight or obesity.
Height or length
Growth failure is one of the primary features of childhood cholestatic liver
disease. Improved nutrient absorption, appetite, and hepatic synthetic function all
contribute to the catch-up weight gain and subsequent linear growth seen after liver
transplant. Note that since the liver is the main organ that synthesizes insulin-like growth
factor (IGF-1), its binding proteins, and a family of high-affinity binding proteins,
pretransplant growth failure cannot be repaired with optimal nutrition support because
growth hormone with decreased levels of IGF-1 and binding proteins leads to growth
hormone resistance (Pawlowska, 2010).
A 2009 study showed accelerated growth up to 24 months posttransplant (Alonso, 2009);
conversely, earlier studies observed delayed growth during the initial 6 to 24 months
posttransplantation (Bartosh, 1999; Urbach, 1999). Slowing of catch-up growth after the
third to fourth transplant years has also been shown (Bartosh, 1999; Urbach, 1999). This
plateau of catch-up growth results in height of children with liver transplant below the
mean of the normal population even after 5 years posttransplant. Children who were less
stunted at the time of transplant grew slowly initially but achieved normal growth velocity,
whereas older children who were more stunted grew more quickly initially posttransplant
but did not achieve normal height (Bartosh, 1999).
Catch-up linear growth occurs but is incomplete and does not result in complete restoration
of normal height (Alonso, 2009; Scheenstra, 2008). The North American multicenter
registry database report on 5-year survivors of pediatric liver transplantation indicated that
among study participants, 73% had height below the 50th percentile, 47% were below
the 25th percentile, and 29% were below the 10th percentile (Ng, 2008). Strong
association between incomplete catch-up linear growth and advanced growth failure before
transplant and prolonged steroid exposure has been described (Bartosh, 1999; Urbach,
1999; Alonso, 2009). Children who received transplant when younger than 2 years
old displayed better catch-up growth ( Evans, 2005).
Patients with biliary atresia have been shown to have the greatest catch-up growth
posttransplant (Alonso, 2004). There have been conflicting findings regarding growth of
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posttransplant (Alonso, 2004). There have been conflicting findings regarding growth of
Alagille Syndrome patients, as catch-up growth was reported in one study (Quiros-Tejeira,
2000), but other researchers did not observe catch-up growth with Alagille Syndrome and
familial cirrhosis patients (Viner, 1999).
Body Mass Index
Body mass index is used posttransplant as an assessment tool of body fatness with
children between the ages of 2 to 20 years.
Head Circumference
In children up to age 3 years, accurate measurement of occipital-frontal circumference is
essential for assessing brain growth.
Growth Charts
Anthropometrics for posttransplant patients are plotted on the growth charts of the Centers
for Disease Control and Prevention (Kuczmarski, 2002). In addition, progression of growth
can more easily be monitored when measurements are converted to Z-scores. Z-score can
be calculated by subtracting the mean standard value for age and sex from the child’s
weight, height, or weight-for-height and dividing it by the standard deviation of the
reference mean.

Client History

Client history should include, but is not limited to, the following:
Medical history/comorbidities
Ethnic/religious background and family’s economic status to help modify nutrition care
delivery appropriately given family's cultural and economic background
Feeding support
Special Supplemental Nutrition Program for Women, Infants, and Children
Supplemental Nutrition Assistance Program (SNAP, formerly called Food
Stamps)
Food banks
Family stressors
Financial
Marital
Employment
Substance abuse or other psychopathology

Food/Nutrition-Related History

Dietary intake history can include the following:
24-hour diet recall and/or food diary or food frequency questionnaire as indicated
Method of formula preparation (when diet is infant formula)
Home tube feeding/total parenteral nutrition
History of alternative dietary pattern (vegetarian/fad diets)
Use of herbal/vitamin-mineral supplement
Extremes of food faddism
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Eating disorder
Observation of feeding interaction/behavior


Comparative Standards

Nutrient needs for children after transplant have not been well defined. During the acute
posttransplantation phase, adult studies have shown that patients do not tend to be
hypermetabolic after organ transplant unless secondary conditions such as sepsis occur
(Shanbhogue,1987).
To accurately determine energy needs, indirect calorimetry should be used. During the
acute phase, energy requirements are estimated at 120% to 130% of the Recommended
Dietary Allowance (RDA) (Sutton, 2002). Protein needs during the acute posttransplant
phase tend to be higher because steroid doses are higher. Protein requirement is also
related to losses from drains, stomas, and need for wound healing. Protein provision
recommendations have been at 15% to 17% of total energy (Sutton, 2002).
After the initial postoperative period, nutrient needs usually normalize. During the stable,
chronic phase, RDA for energy, or 130% to 150% of the RDA for severe growth
retardation, can be given (Sutton, 2002). Protein requirements are based on the RDA for
age and adjusted based on nutrition assessment.
During the acute posttransplant phase, fluid retention is common. Fluid needs are
individualized depending on hydration status, renal function, and amount of fluid loss.
Consider fluid losses from drains, nasogastric tube, stool output, and urine, and adjust fluid
intake based on these factors. During the chronic phase, normal fluid therapy with
adequate fluid intake is encouraged.

Nutrition Intervention

Nutrition guidelines and interventions posttransplantation can be divided into acute phase
(the first 3 months) and chronic phase. For nutrition prescription in the acute and chronic
stable posttransplantation phases, see Nutrition Prescription.
Immunosuppression drugs are used to prevent rejection of the transplanted organ.
Immunosuppressive therapy usually consists of a combination of medicines. These drugs
are the cause of many of the nutritional issues in both the acute and chronic
posttransplantation phases (Ng, 2008; McPartland, 2007; Chan, 2001). Some of the side
effects include hypertension; renal insufficiency; hyperlipidemia; glucose intolerance;
osteoporosis; and alteration in calcium, potassium, and magnesium (Ng, 2008; Varo, 2002;
Perez, 2009; Fernandez,1999; Scolapio, 2001; Everhardt, 1998; Helenius, 2006; Giannini,
2000; Stratta, 2005; Araki, 2006; Chan, 2001). See Immunosuppressive Medications for
nutrition-related side effects of immunosuppressants.
In addition, these drugs have significant drug–nutrient interactions. The coadministration of
grapefruit/grapefruit juice or water-soluble vitamin E has been reported to significantly
affect the absorption of cyclosporine, as they both enhance it (Chan, 2001; Pan, 1996). The
mechanism by which this occurs is unclear. It is recommended that patients be instructed
to avoid grapefruit and grapefruit juice entirely while taking cyclosporine, tacrolimus, or
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sirolimus. Pending additional studies, cyclosporine level should be closely monitored
in patients taking vitamin E (Pan, 1996).

Nutrition Prescription

Nutrient
Acute Phase
(Up to 3 Months or Until
Stable)
Chronic/Stable
Phase
(More Than 3
Months)
Energy
130% to 180% of Dietary
Reference Intake (DRI) for
age for postoperative
recovery; adjust as needed
for weight gain
DRI for age;
adjust as needed
for growth
Protein
Infants: 3-3.5 g/kg dry weight
1-2 years: 2.5-3.5 g/kg dry
weight
3-13 years: 2-2.5 g/kg dry
weight
Adolescents: 1.5-2 g/kg dry
weight
15% to 17% of
total energy;
adjust as needed
with renal
insufficiency
a
Carbohydrate
Reduced intake of simple
sugars to prevent
hyperglycemia while
corticosteroid doses are
high.
Carbohydrate-controlled diet
as needed for control of
hyperglycemia
Carbohydrate
controlled, as
needed for control
of hyperglycemia
Fat and
cholesterol
No restriction
Limit
saturated/trans
fat to 10% or less
and low
cholesterol diet for
children older
than 2 years
Sodium
2 mEq/kg/day; restrict as
needed for hypertension and
edema
Same as for acute
phase
Potassium
Restrict only with renal
insufficiency
Same as for acute
phase
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Calcium
130% to 150% of DRI for
age for bone repletion if
malnourished pretransplant
At the minimum to
meet DRI
Phosphorus
DRI plus supplement as
needed
DRI
Magnesium
DRI plus supplement as
needed
b
DRI
Iron
6 months to 3 years 1 mg/kg
dry weight
a
DRI, supplement
as needed
Zinc
Infants and children: 1-3
mg/kg
Adolescents: 10-15 mg/kg
dry weight
a
DRI, supplement
as needed
Vitamins
1-4 years: 1 mL multivitamin,
twice daily
4-11 years: 1 chewable
multivitamin, twice daily
11 years and older: 1
pediatric multivitamin daily
to provide 400 IU vitamin D
a
Multivitamin with
minerals if diet is
not adequate;
individual nutrients
as needed
a
Source: Sutton, 2002
b
Source: McPartland, 2007
(Partially adapted from Nutrition Care Manual: Transplant section)

Nutrition Therapy Efficacy

Malnutrition is a common complication of chronic liver disease in children (Ramaccioni,
2000). Poor nutritional status has been associated with the development of infections
and longer intensive care unit and hospital stay (Figueiredo, 2000). Thus,
postoperative nutrition support should be provided if the patient is unable to eat
adequately within 3 days posttransplant.
Nasojejunal feeding has shown to be well tolerated in prospective, randomized studies of
adult liver transplant patients (Hasse, 1995; Wicks, 1994). Infection occurred significantly
less often in patients who received early tube feeding as compared with patients who
received intravenous fluid before a diet was initiated (Hasse, 1995). Cumulative energy
intake of the tube-fed group was also significantly higher than that of patients who stayed
on intravenous fluid until the diet was advanced (Hasse, 1995).
Adequacy
Depending on individual food choices and tolerance, the diet after organ transplantation
can be adequate in all nutrients based on the Dietary Reference Intakes (DRI). Special
attention must be given to the patient’s feeding skills, developmental level, and food
preferences. However, food–drug interactions may affect absorption and metabolism of
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nutrients. In addition, if a patient has food restrictions, the eating plan may be deficient in
certain nutrients. For example, if a patient must restrict potassium intake because of
hyperkalemia from tacrolimus, that patient is at higher risk for vitamin C deficiency.
Energy- and protein-dense supplements and snacks may be used to meet increased needs
immediately posttransplantation, to achieve weight gain and catch-up growth, and to correct
nutrient deficiencies. Supplements may be discontinued once oral intake is adequate to
sustain continued growth and optimal nutritional status.
Exceptions to DRI
Calcium, phosphorus, and vitamin D requirements may exceed the DRIs during the acute
posttransplant phase in patients who were malnourished pretransplant and patients who
require frequent or long-term, high-dose steroids.
Osteopenic bone disease is a common problem in transplant patients (Helenius, 2006;
Guichelaar, 2006). Exercise is an important factor in bone mineralization and should be
encouraged.
Zinc requirements may exceed the DRI if the patient is experiencing complications with
wound healing and/or has bile drainage.

Goal Setting

During the acute posttransplant phase, nutrition goals include the following:
Establish adequate intake
Maintain adequate hydration and electrolyte balance
Promote surgical wound healing
Promote anabolism
Maintain adequate intake to fight infection
Minimize side effects of medications
During the chronic posttransplant phase, goals are as follows:
Optimize linear growth
Maintain healthy body weight
Maintain adequate hydration
Minimize electrolyte and mineral abnormalities
In a posttransplant patient with diabetes, maintain glucose levels at 100 mg/dL to 180
mg/dL for toddlers/preschoolers, 90 mg/dL to 180 mg/dL for school-aged children,
and 90 mg/dL to 130 mg/dL for adolescents; maintain glycosylated hemoglobin (A1c)
at 7.5% to 8.5% for toddlers/preschoolers, less than 8% for school-aged children, and
less than 7.5% for adolescents (American Diabetes Association, 2009)
Maintain bone density at levels normal for age
Maintain serum cholesterol level below 200 mg/dL and triglyceride level below 200
mg/dL
Maintain normal blood pressure for age


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Complications of Nutrition Support

Often during the acute posttransplant phase of critical illness, intubation and
enteral/parenteral feeding interrupt the normal eating process, which could result in oral
aversion and lack of hunger–satiety cycle. Thus, oral stimulation is essential to facilitate
transition to oral diet. Overemphasis on feeding by the medical team could also cause
parent/child anxiety related to feeding.

A multidisciplinary approach with an intense feeding behavioral regimen is indicated to
effectively treat aversion. For many of these children, supplemental tube feeding is needed
to adequately meet growth needs while undergoing feeding behavioral therapy.

Enteral or Tube Feeding

Many pediatric transplant patients have a pretransplant history of feeding problems.
Aversions to tastes and textures of foods and oral defensiveness may interfere with
adequate nutrient intake. Most can tolerate enteral feeding in the first few days
posttransplantation (Hasse, 2006). Transplant patients who were tube fed before
transplantation will likely require tube feeding for at least a few weeks posttransplantation.
A standard, age-appropriate formula should be used. In the early posttransplant phase,
infants and small children commonly have vomiting caused by the donor organ pushing on
the stomach. Gradually advanced continuous drip feedings and prokinetic agents may
improve feeding tolerance.
Roux-en-Y anastomoses during surgery can delay initiation of enteral feeding as it causes
manipulation of the small bowel, which can shorten small bowel length in the smallest
children. Testing for fat and carbohydrate malabsorption is essential once feeding is
initiated.
For a summary of nutrition issues and appropriate interventions in the acute and chronic
stable posttransplantation phases, see Nutrition Prescription.
Monitoring Tube Feeding Tolerance
Body weight
Fluid intake and output
Laboratory values
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Creatinine
Calcium
Phosphorus
Magnesium
Glucose
Bowel movements
Number, volume, and consistency
Stool pH
Clinitest
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Qualitative fecal fat
Vomiting
Oral nutrient intake: To help wean to an oral meal plan

Complications of Nutrition Support/Refeeding Syndrome

Transplant recipients are at the same risk for nutrition support complications as any group
of patients receiving enteral or parenteral feedings.
Refeeding Syndrome
Malnourished transplant recipients are at risk for refeeding syndrome. Initiate nutrition
support slowly in these patients and monitor serum potassium, magnesium, and
phosphorus levels daily until the nutrition goal is achieved and levels are normal.
Supplement electrolytes to normal levels before advancing nutrition support.


Nutrition Monitoring & Evaluation

During the posttransplant hospitalization period, patients should be reassessed at regular
intervals based on their risk level. If transplant patients are readmitted to the hospital, a
screening process should identify those who need nutrition intervention and follow-up.
Suggested Monitoring Parameters and Recommendations
The same nutrition assessment parameters that are discussed in Nutrition
Assessment may be used. In addition, if liver function and fluid status have normalized,
hepatic protein markers become a valid marker of nutrition.
The following conditions should trigger an evaluation and/or intervention in transplant
recipients:
Substantial weight change (loss or gain)
Impaired wound healing
Prolonged reduction in appetite
Prolonged nausea, vomiting, or diarrhea
Development of diabetes, hyperlipidemia, food allergies, or any other metabolic
condition treated with nutrition therapy
Osteopenic bone disease
Graft dysfunction
Renal impairment


Nutrition Care FAQs

Question: Do children with liver transplant grow normally after transplant?
Answer: Catch-up linear growth begins after the initial 6 months posttransplant. Based on
a recently published 5-year multicenter database report, however, at 5 years
posttransplant, close to 73% of children with liver transplant had below-average height
whereas weight distribution was similar to the normal population with no weight deficit, and
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12% of 5-year survivors were overweight (Ng, 2008). Posttransplant factors that may affect
growth include primary diagnosis, chronic rejection, steroid dose, infection (eg,
cytomegalovirus), occurrence of posttransplant lymphoproliferative disease, and
retransplantation (Pawlowska, 2010).
Question: What must a child who has received a liver transplant do to prevent
excessive weight gain in the long term?
Answer: If weight gain is not related to fluid retention, the objectives for weight loss and
maintenance are the same for transplant patients as they are for other children of similar
age. Promote division of responsibility between the child and his or her adult caregivers.
The responsibility of adults is to provide positive structure, age-appropriate support, and
healthful food and beverage choices. Children are responsible for whether and how much
to eat (Satter, 2007).
Physical activity goes hand in hand with healthful eating to prevent obesity and to decrease
hyperlipidemia and hypertension. Exercise as early as possible posttransplantation could
help decrease muscle and bone loss associated with high-dose corticosteroid (prednisone)
treatment. Regular physical activity helps to prevent excessive weight gain and to improve
hypertension, hyperlipidemia, diabetes mellitus, arthritis, and osteoporosis (Painter, 2005).
Many patients can begin doing simple exercises during their posttransplant hospitalization.
It is important that patients are monitored carefully as they begin an exercise program to
make sure that exercise is not so strenuous as to cause hypertension or cardiac
problems.

Nutrition Diagnosis

Dietitians working with patients who are pre- or post-organ transplant should review the
signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems
based on these signs and symptoms. Nutrition diagnoses from the list below as well as
other diagnoses may be present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Inadequate parenteral nutrition infusion (NI-2.6)
Less than optimal parenteral nutrition (NI-2.8)
Inadequate fluid intake (NI-3.1)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein–energy intake (NI-5.3)
Inappropriate intake of protein or amino acids (specify) (NI-5.7.3)
Altered gastrointestinal function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Food-medication interaction (NC-2.3)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
Overweight/obesity (NC-3.3)
Sample PES or Nutrition Diagnostic Statement(s)
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Inadequate energy intake (NI-1.4) related to pathophysiological needs secondary to
surgery and recovery period as evidenced by intake of less than <50% of estimated
energy needs for more than 3 days.
Inadequate oral intake (NI-2.1) related to psychological depression with worsening
heart function as evidenced by reported change in appetite and disposition.
Inappropriate intake of amino acids (NI-5.7.3) related to inability to tolerate required
protein as evidenced by increased BUN/Creatinine.
Less than optimal parenteral nutrition (NI-2.8) related to decrease in TPN to treat
undesirable medication interaction as evidenced by glucose levels of more than 345
mg/dL with usual prescription of IV dextrose.
Impaired nutrient utilization (NC-2.1) related to compromised function of the liver as
evidenced by direct bilirubinemia (>18 and rising) and elevated alkaline phosphatase
(liver faction).
Underweight (NC-3.1) related to increased energy needs due to worsening heart
function causing wasting as evidenced by <15th percentile BMI for age.
Unintended weight loss (NC-3.2) related to increased nutrient needs from long-term
congestive heart failure as evidenced by weight loss of 8% of admission weight by
day 10 of hospital stay.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Oral Intake

A clear liquid diet can be initiated as soon as bowel function returns, generally 24 to 72
hours after surgery. Once the child is extubated, an oral diet is advanced as quickly as
possible, based on tolerance. The diet should be individualized according to the clinical
status and developmental level of the child and the function of the transplanted graft. If it is
not possible to start feeding orally or by tube by the third postoperative day, parenteral
nutrition should be initiated.

Parenteral Nutrition

Monitoring Parenteral Nutrition
Body weight
Fluid intake and output
Laboratory values
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Creatinine
Calcium
Phosphorus
Magnesium
Glucose
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Glucose
Oral or enteral intake to aid in transition


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Nutrition Care > Transplantation > Hematopoietic Stem Cell Transplant
Nutrition Assessment

Step 1, nutrition assessment, of the Nutrition Care Process forms the foundation for
progressing through the other three steps in the process. It is a systematic method for
obtaining, verifying, and interpreting data needed to identify nutrition-related problems,
their causes, and significance. Nutrition assessment is an ongoing, nonlinear, dynamic
process that involves initial data collection as well as also continual reassessment and
analysis of the patient/client’s status compared to specified criteria (IDNT, 2010).
Objective and subjective data should be used to complete the nutrition assessment.
In-depth nutrition assessment should be provided any time patients are at risk for
malnutrition.
Patients can be identified as at risk by medical personnel, other caregivers, or by
periodic screening.
Nutrition assessment should only be done by trained personnel experienced in
assessing patients at nutritional risk.
Data collection should include medical history, physical examination, biochemical and
hematological data, anthropometric measurements, food/nutrition history, and
medical tests and procedures.
The medical history portion of the assessment includes current and past information about
the patient's acute and chronic illnesses, surgical and diagnostic procedures, any
medications or dietary supplements, and social history.

For more information on specific components of the assessment, please see the following
headings:
Biochemical and Nutrient Issues
Physical Observations
Diagnostic Tests
Food History
Anthropometrics or Indirect Calorimetry



Nutrition-Focused Physical Findings

The physical examination of a child with cancer is an integral part of nutrition assessment
and should never be omitted. It should include the general appearance and activity level of
the patient.
The clinician should focus on the presence of edema, ascites, cachexia, obesity, skin
changes, dry mucous membranes, petechiae or ecchymoses, healing of wounds,
glossitis, stomatitis, and cheilosis (ASPEN, 2002).
The physical examination should include an evaluation of body composition, including
fat and muscle stores. Sites to assess fat stores are overlying the lower ribs, orbital
fat pads, triceps skinfold, groin, and armpits. Sites to assess muscle stores are
temples, clavicles, calves, and quadriceps (thighs) (Norman, 2005; Pham, 2007).
Other physical signs of malnutrition are liver enlargement and changes in skin, hair,
eyes, face, lymph glands, mouth, and teeth; however, psychological status should
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eyes, face, lymph glands, mouth, and teeth; however, psychological status should
also be monitored (Alvarez, 1995; Balint, 1998; Psoter, 2008).
Nutritional skin disorders are common of vitamin or mineral deficiencies (Oumeish,
2003).
Patients with allogeneic hematopoietic stem cell transplantation may have
graft-versus-host disease of the skin.


Biochemical Data, Medical Tests and Procedures

The medical tests and procedures included in the assessment are a nitrogen balance, a
delayed cutaneous hypersensitivity (DCH) test, prognostic nutritional index (PNI), an
indirect calorimetry, and a dual energy x-ray absorptiometry (DXA) scan.
Nitrogen balance will assess protein metabolism in the patient's body.
DCH will determine if the body reacts to foreign substances like antigens or allergens
that are injected into the skin. This test measures cell-mediated immunity.
A PNI will assess nutritional status and the risk of complications during the hospital
stay. A score of greater than 40 indicates that the patient is well nourished upon
hospital admission and a score of less than 40 indicates that the patient is
malnourished.
Indirect calorimetry measures the energy expenditure and determines the energy
needs of the patient by measuring the oxygen consumed, the amount of carbon
dioxide produced, and the respiratory quotient. The DXA scan measures bone
mineral content and bone mineral density. This is important because pediatric
oncology patients often have deficits in bone mineralization (Wasilewski-Masker,
2008).
Following the screening assessment, the choice of tests and the timing of their
performance will be dictated by the particular clinical circumstances.

Maldigestion and Malabsorption Tests
An important issue is whether a child with cancer has maldigestion or malabsorption, for
which the gold standard is a 3-day fecal fat test and calculation of the percentage of dietary
fat absorbed (3-day stool collection combined with 3-day dietary record). Coefficient of fat
absorption values are < 85% for infants and < 93% for older subjects and can be used to
define steatorrhea (Ramsey, 1992). An easier and more effective method for determining
maldigestion and malabsorption resulting from pancreatic insufficiency is a fecal elastase
test. This test is a much more sensitive method of determining pancreatic insufficiency and
the need for pancreatic enzyme replacement therapy than a fecal fat test. Maldigestion can
be caused by loss of regulated gastric emptying, insufficient pancreatic exocrine function,
bile salt deficiency, or mucosal disease. Malabsorption can be caused by loss of intestinal
surface area, impaired circulation or lymphatic damage in the gut, mucosal infiltration with
abnormal cells, genetic mutations of transport proteins, or impaired motility.

Indirect Calorimetry
Indirect calorimetry is discussed elsewhere.
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DXA
DXA is a noninvasive technique for measuring bone mineral content and bone mineral
density with minimal exposure to ionizing radiation (Gordon, 2008). It can also be used to
measure body composition and therefore changes in lean and nonlean tissue. Deficits in
bone mineralization are common sequelae of the treatment of cancer in childhood
(Wasilewski-Masker, 2008).

Laboratory

Visceral Proteins
Visceral proteins such as albumin, prealbumin, transferrin, and retinol-binding protein are
often used as indicators of nutritional status. All four parameters have their limitations,
however, and none can be regarded as a “gold standard.” These changes in values may
not be useful nutritional indicators, particularly in hematopoietic stem cell transplant
(HSCT) patients because they may be confounded by inflammation, drugs, and hydration
status. Albumin concentrations can be increased by the use of corticosteroids, insulin, or
thyroid hormone and by dehydration (as can the other markers). Albumin concentrations
decrease in acutely or chronically ill patients as a result of the effects of inflammatory
mediators on hepatic protein synthesis, severe liver and renal disease, malabsorption,
intravascular volume overload, and zinc deficiency (Ingenbleek, 1994; Mendez, 2005).
It is important to note that hemoglobin, hematocrit, and total lymphocyte counts are not
good tools to assess nutritional status in the HSCT population, as so many factors like
engraftment, conditioning regimens, medications, and infection can affect results; see
below for additional information on the limitations of using hemoglobin and
hematocrit. Though they may be appropriate indicators with other patients, they are not
appropriate within the HSCT population.
A study done to determine the usefulness of visceral proteins in assessing patients after
hematopoietic stem cell transplants found that prealbumin, retinol-binding protein, and
transferrin all were sensitive markers (Rzepecki, 2007). However, prealbumin is influenced
by some of the same factors that affect albumin (Raguso, 2003).
Blood Glucose and Lipid Profile
In cancer patients who are malnourished, increased glucose production occurs in the
fasting state, and there are abnormalities with insulin secretion and action (Raguso, 2003).
Insulin resistance may be caused by medication used during treatment, including
glucocorticoids and L-asparaginase (Robertson, 2009). When hyperglycemia occurs,
synthesis of very low-density lipoprotein (VLDL) is increased, and both triglycerides and
cholesterol rise.
In one study involving children with cancer, results showed that bone marrow transplant
and solid tumor patients had significantly higher triacylglycerol levels than healthy children
because of increased VLDL and low-density lipoprotein particles in the blood and
significantly lower high-density lipoprotein (Taskinen, 2000). L-asparaginase induces
prominent changes in the lipid profile, especially hypertriglyceridemia (Halton, 1998).
During anticancer treatment, the focus of nutrition is to maintain healthy weight. If total
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cholesterol levels remain elevated after treatment, the patient should be educated to follow
a diet aimed at lowering cholesterol levels (plant based, low fat, high fiber).
Hemoglobin/Hematocrit
Hemoglobin and hematocrit can be decreased in pediatric cancer patients because of
chemotherapy, penetration of malignant cells into bone marrow, radiotherapy,
inflammation, and blood loss (Michon, 2002). However, the hemoglobin and hematocrit can
be falsely high if the person is dehydrated. Iron status needs to be considered when
evaluating hemoglobin and hematocrit, and the best single marker is serum ferritin. Many
children with cancer experience iatrogenic myelosuppression and anemia of sufficient
severity that repeated red blood cell transfusion is required, resulting in some degree of iron
overload rather than iron deficiency.
Lymphocyte Count
Malnutrition can also be indicated by a trend of low total lymphocyte counts, but this may
be the result of chemotherapy or the impact of the disease (Brugler, 2005).

Client History

The medical history should include current and past information about acute and chronic
illnesses, surgical and diagnostic procedures, medications and use of dietary
supplements, social history, family history, and psychosocial history.
When collecting information related to psychosocial history, it is important to consider the
child's living situation, including determining if the family receives assistance from the
Special Supplemental Nutrition Program for Women, Infants, and Children, if the family has
financial difficulties, and what is the current housing arrangement; whether the child
participates in activities outside the home such as at day care; and any possible safety
issues in or away from the home. Inquire about the composition of the family as well as the
occupation of the parents. Find out the child's current developmental level and the ages
that certain developmental milestones were achieved, such as smiling, rolling, sitting
without assistance, crawling, walking, running, toilet training, and riding a bike, as well as
the child's first word. Also collect information about sleep patterns and behavior to find out
if actions like enuresis, temper tantrums, thumb sucking, pica, or nightmares are present. It
would be beneficial to consider the child's current grade in school and any specific
problems or concerning interactions he or she has with peers.
A family history should inform the dietetics professional of any illnesses like heart disease,
hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy and asthma, and
epilepsy, any family history of intellectual disability, congenital anomalies, chromosomal
problems, growth problems, and/or consanguinity. It should also include current or past
surgical procedures, relevant therapies, and medications or use of supplements.
When gathering food/nutrition history of the client, the dietetics professional should make
sure to collect information about the following:
Home diet (regular, low-bacterial diet, no concentrated sweets, etc.)
Feeding ability (uses cup, feeds self, requires some assistance or total assistance,
etc.)
Current home feeding regimen
Food consumption patterns (meal times, snacks)
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Quality and quantity of food
Food preferences (textures, types, food avoidance)
Feeding environment (at table, in front of TV, etc.)
Food allergies or intolerances
History of appetite stimulants, dietary supplements, and nutrition support



Food/Nutrition-Related History

Food history consists of information about the following factors:
Current dietary orders
Diet history
Current home feeding regimen
Food consumption patterns
Quality and quantity of food
Food preferences
Feeding environment
Food allergies and intolerances
Social history
Socioeconomic status
Caregivers’ perception of the patient’s nutritional status
Religious or cultural factors that affect food intake
Clinical factors
Vitamin and supplement use
Stool habits and characteristics
Activity level
Developmental level
Sleep patterns
Oral intake can be estimated by 24-hour dietary recall (ask about all oral intake from the
previous day), a 3-day food record, or a food frequency questionnaire (Fraser, 2006).
In multiple studies, cancer treatment has been found to cause decreased food intake,
decreased nutrient absorption, increased metabolic demand, and change in taste
perception (Lai, 2005; Chiodi, 2000).

Comparative Standards: REE

Resting Energy Expenditure (REE)
World Health Organization method for calculation for REE is located under the Calculators
tab.
The thermic effect of food:
0% = Full total parenteral nutrition
5% = Continuous tube feeding and eating a little
10% = Bolus tube feeding and eating normally
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Activity:
5% = Bed rest
10% = Light activity (inpatient, but out of bed/playing)
20% = Moderate activity/exercise at least 3 times per week
25% = Heavy activity/daily

Anthropometric Measurements

Anthropometric measurements include weight, height, mid-upper-arm circumference, and
triceps skinfold thickness. These anthropometric measures can be used to assess a
patient's nutrition status by using BMI, estimated desired weight (EDW), waist-to-height
ratio, and percentage of weight loss.
Arm Anthropometry
Arm anthropometry is effective for kids with a tumor mass (Brennan, 1997; Brennan,
1999; Oguz, 1999). Triceps and subscapular skinfold thickness is used to determine body
fat index, and mid-upper-arm muscle circumference is used to measure muscle
mass. These measurements can be affected by fluid retention, dehydration, or steroid
therapy (Hall, 1992; Manning, 1995).
The mid-arm circumference measures muscle, fat, and bone in the arm and is an
indicator of lean body mass. The measured values will be compared with reference
values from the Anthropometric Standards for the Assessment of Growth and
Nutritional Status (Frisancho, 1990).
The triceps skinfold is used to monitor any changes in body fat. These measured
values also will be compared to Anthropometric Standards for the Assessment of
Growth and Nutritional Status (Frisancho, 1990).
Weight and Height Measurements for Nutritional Assessment (Mosby, 2009)
Weight as a percentage of EDW:
Express actual weight as percentage of EDW (50th %ile weight for height):
Option 1: (actual weight divided by EDW) x 100
Option 2: (actual weight divided by EDW calculated using BMI) x 100
Calculating the percentage of weight loss:
Weight loss expressed as a percentage of actual weight:
- (Weight loss [kg]/actual weight [kg]) x 100
Adjusted Body Weight:
An adjusted body weight (ABW) should be calculated for patients at or older than 36
months of age and at 120% or more of EDW. No ABW recommendation is made for
chemotherapy unless directed by attending physician.
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ABW = (Actual wt – EDW) x 0.25 + EDW
Assessing EDW using the CDC growth charts (St Jude, 2006)
Birth to 36 months of age:
First identify the age for which the measured height is on the 50th percentile, and
then determine the corresponding 50th percentile weight for that height. Use
WHO growth charts for children under 2 years of age.
2 to 20 years of age:
plot BMI at the 50th percentile for age; then divide by (10,000 x height
2
)
After 20 years of age:
Identify BMI and document; CDC growth charts may no longer be used.


Nutrition Diagnosis

Dietitians working with patients undergoing hematopoietic stem cell transplant should
review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition
problems based on these signs and symptoms. Nutrition diagnoses from the list below as
well as other diagnoses may be present.
Inadequate oral intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Swallowing difficulty (NC-1.1)
Altered GI function (NC-1.4)
Unintentional weight loss (NC-3.2)
Sample PES or Nutrition Diagnostic Statement(s)
Swallowing difficulty (NI-1.1) related to pain from mucositis as evidenced by reported
refusal to eat solid foods.
Unintentional weight loss (NC-3.2) related to inability to consume adequate energy as
evidenced by 6 pound weight loss in 2 weeks while "trying" to eat.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.
(IDNT, 2010)

Nutrition Intervention

Sample Nutrition Intervention codes related to the interventions listed below are as follows:
Modify distribution, type, or amount of food and nutrients within meals or at specified
time (ND-1.2)
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Feeding position (ND-4.2)
Meal set-up (ND-4.3)
Mouth care (ND-4.4)
Odors (ND-5.2)
Room temperature (ND-5.6)
Medications (ND-6.1)
(IDNT, 2010)
Management of Treatment-Related Side Effects
Alterations in Taste and Smell
Decreased taste sensation
Select appealing foods; consider smell, texture and appearance. Bright colors
attract interest.
Red meat may taste different; substitute poultry, fish, eggs, or other protein
foods.
Avoid foods that do not look and/or smell good.
Try tart or spicy foods are not indicated with sore mouth or throat.
Try cold foods: cold sandwiches, cheese, shakes.
Try foods at room temperature.
Dental problems
Rule out dental problems as the source of strange tastes.
Ask dentist about good mouth care.
Mouth and Throat Problems
Sore mouth or throat
Difficulty swallowing
Jaw pain
Try soft and/or pureed foods that are easy to chew and swallow.
Cook foods until they are tender.
Cut foods into small pieces.
Use a blender to puree food and add gravies or sauces to moisten.
Use a straw to drink liquids.
Try foods at room temperature.
Adjust swallowing technique by tilting head back or moving it forward.
Rinse mouth with water after eating to remove residual food and bacteria.
Ask doctor about anesthetic lozenges and sprays for the mouth and throat.
Ask dentist/doctor to recommend a product to coat/protect mouth and throat.
Avoid foods that are irritating, such as rough, coarse foods; spicy or salty foods;
and acidic foods like chili pepper; replace citric fruits and juices with nectars.
Tooth decay
Dental problems
Maintain regular dentist visits.
Use a soft toothbrush and/or toothpaste for sensitive teeth/gums.
Avoid candies or gum that contain sugar; try sugar-free gum or candy instead.
Avoid sticky foods like caramel or chewy candy bars.
Ask dentist/doctor to recommend a product to coat/protect mouth and throat.
Rinse mouth with water after eating to remove residual food and bacteria.
Ask dentist to recommend a special cleaning product if gums and mouth are
sore.
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Dry mouth
Use a blender to puree food and add gravies to moisten.
Use lip salves to keep lips moist.
Sip on water or ice chips every few minutes.
Sweet/tart foods produce more saliva—this is not indicated with sore mouth or
throat.
Suck on sugar-free hard candy, popsicles, or sugar-free gum—produces more
saliva (if mouth and throat are not sore).
Rinse mouth with water after eating to remove residual food and bacteria.
Ask doctor about anesthetic lozenges and sprays for the mouth and throat.
Ask dentist/doctor to suggest product to coat/protect the mouth and throat.
Ask dentist/doctor to suggest artificial saliva.
Gastrointestinal Complications
Cramps
Bloating and gas
Heartburn
Get full quickly, easily
For heartburn, sit up or stand for about an hour after eating.
Rest after meals (sitting up); do not participate in rigorous activity.
Wear loose-fitting clothing.
Avoid eating 1 to 2 hours before cancer treatment.
Avoid gas-producing foods such as broccoli, cabbage, cauliflower, beans, lentils,
and onions.
Eat small amounts often and slowly.
Ask doctor about medications.
Diarrhea
Drink plenty of liquids to prevent dehydration.
Small amounts of food throughout the day vs. three large meals.
Replenish sodium and potassium.
Eat a low-fiber diet.
Avoid grease, fat, raw foods, spices.
Drink liquids at room temperature.
Limit caffeine, strong teas, soda, and chocolate.
Rule out lactose intolerance.
Constipation
Drink plenty of liquids.
Drink something hot 30 minutes before expected bowel movement.
Eat a high-fiber diet.
Ask doctor about stool softener/laxative.
Anorexia/Cachexia
Nausea
Vomiting
Keep track of when nausea and/or vomiting occurs and the potential cause in a
food diary.
Avoid hot foods—these add to nausea.
Avoid favorite foods during periods of nausea and vomiting.
Avoid greasy, fried, or heavily spiced foods.
Eat crackers or Melba toast before getting out of bed.
Ask doctor about antiemetics.
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Ask doctor about antiemetics.
Eat small amounts often and slowly.
Avoid eating in rooms with strong odors.
Drink fewer liquids with meals—these can cause bloated feeling.
Drink/sip liquids throughout day.
Drink cool/cold beverages.
With vomiting, avoid trying to drink or eat until it is resolved.
Drink small amounts of clear liquids until vomiting is controlled; then
advance to full liquids and eventually a soft and/or regular diet.
Loss of appetite
Ask doctor about appetite stimulant.
Keep snacks handy and munch throughout the day.
Ask dietitian/doctor about adding nutrients to diet with supplements.
Serve small food portions on small plate.
Stay calm at mealtimes; don’t rush to finish meals.
Question depression; consult psychiatrist.
Encourage eating with others, such as family or friends.
Eat whenever hungry; don’t restrict intake to mealtimes only.
Take advantage of good days to increase your food intake.
Weight Gain
Delay dieting/losing weight until the cause of weight gain is identified.
Follow no concentrated sweets/no added salt diet if weight gain attributed to steroids.
Use glycemic load method to plan meals if insulin resistance is suspected.
Use hunger scale.
Exercise regularly unless it is contraindicated.
Try to identify emotional and environmental reasons for overeating and snacking.
Appetite Stimulants
The use of appetite stimulants in this patient population is recommended only when all
other attempts to increase oral intake (such as oral supplements) have failed. A variety of
appetite stimulants exists (see table below). Consult a pharmacist and doctor before
recommending any medication.

Appetite Stimulants
Agent Trade NameAdverse Reactions
Dronabinol Marinol
Drowsiness, dizziness,
depression, detachment,
anxiety, difficulty concentration,
mood change, xerostomia,
orthostatic hypotension,
tachycardia, ataxia, headache

Megestrol acetateMegace
Edema, insomnia, fever,
headache, depression,
breakthrough bleeding and
amenorrhea, changes in
menstrual flow, nausea,
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vomiting, stomach cramps,
cholestatic jaundice,
hepatotoxicity, thrombophlebitis,
hyperpnea

Cyproheptadine Periactin
Drowsiness, headache, fatigue,
thickening of bronchial
secretions, pharyngitis, nausea,
diarrhea, abdominal pain,
xerostomia, arthralgia

Nutrition Therapy Efficacy

Nutrition-Related Side Effects of Specific Chemotherapy Medications (pdf)
Enteral feedings using gastric or postpyloric tubes have been considered a viable option
for some subgroups of hematopoietic stem cell transplant (HSCT) patients. Nasojejunal
tubes have been used successfully in one small pilot study of adult allogeneic transplant
recipients (Sefcick, 2001). Mixed success has been achieved in other studies using
nasogastric tubes in adults and children (Szeluga, 1987; Papadopoulou, 1997; Langdana,
2001). Difficulties with successful enteral feeding are primarily related to feeding intolerance
with nausea, vomiting, and diarrhea. There has also been reluctance among care providers
to insert tubes into neutropenic and/or pancytopenic patients, although the risk of infection
has not proven to be greater than the risk of feeding parenterally through transplant.
The amino acid glutamine has been highlighted as a fuel source for rapidly turning over
cells. Several studies have attempted to evaluate the clinical efficacy of
glutamine-supplemented nutrition in HSCT patients (Bechard, 2000). Although one
randomized, controlled study of glutamine-supplemented parenteral nutrition showed
improved nitrogen balance, fewer clinical infections, and shorter length of hospital stay
(Ziegler, 1992), subsequent studies have demonstrated some similar but less dramatic
results in allogeneic (Schloerb, 1993) and autologous (Piccirillo, 2003) HSCT
recipients. One study using parenteral glutamine supplementation during auto HSCT was
associated with more relapses and death (Pytlik, 2002). Parenteral nutrition has also been
shown to delay resumption of oral intake in HSCT patients (Charuhas, 1997). Studies using
oral glutamine supplementation have found no significant effects on clinical outcomes
during HSCT (Schloerb, 1999; Coghlin Dickson, 2000); thus, the routine use of glutamine is
not yet justified.
A specific study looking at oral glutamine supplementation and the prevention of mucositis
in children undergoing HSCT concluded that glutamine is safe and effective in reducing the
severity of mucositis in this pediatric population. A glutamine supplement should be given
great consideration in the routine care of SCT patients (Aquino, 2005). Patients
supplemented with glutamine have shown a significant reduction in the number of days
they require morphine and total parenteral nutrition (TPN), both which are objective
indicators of a decrease in mucositis severity (Anderson, 1998).
Research has found that TPN is not always superior to individualized enteral feeding. It is
recommended that TPN be reserved for bone marrow transplant (BMT) patients who
experience an intolerance to enteral feeds. Studies have found that although TPN is shown
to preserve body mass in critically ill patients recovering from BMTs, it is also linked to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
specific complications and high costs (Weisdorf, 1984). Although enteral nutrition (EN) has
been found in some cases to be less effective in maintaining body cell mass, it did not
change the outcome of hematopoietic rate, length of hospitalization, and survival. With EN,
most common toxicities and the high costs associated with TPN were avoided (Szeluga,
1987)
Studies have also found that an aggressive enteral feeding program along with the help of
a supportive team can maintain nutritional status in the pediatric BMT population. Patients
have shown to be very compliant to and able to tolerate nasogastric feeds very well. EN
also provides an easy way to administer oral medications, with the exception of
cyclosporine, given via a nasogastric tube. A lower incidence of diarrhea was also found in
patients on EN in comparison to those on TPN (Langdana, 2001). One study found that
continuous nasogastric feeding during a time of extreme gut toxicity could accelerate the
healing process (Heubi, 1999). Other studies on EN and TPN found that EN maintained
mucosal integrity by supporting the barrier function of the gut and therefore lowering the
risk of bacterial translocation (Moore, 1989; Moore, 1992).
A study by Hastings, White, and Young (2006) found that EN via a nasogastric tube was
effective in providing nutrition during bone marrow transplantation. Their findings were
supported by a study that found that EN, when tolerated, was effective in limiting nutritional
decline during BMT (Papadopolou, 1997).
A study by Stratton and colleagues (1999) looked specifically at enteral and parenteral tube
feeds in correlation to appetite sensations and food intake. This study found that EN
improves anorexia and voluntary food consumption typically in malnourished patients
during recovery and that “small amounts of food taken orally during PN may relieve
appetite sensations more effectively than PN alone.” The study concluded that total energy
intake is increased when PN is combined with oral food intake.
A study by Papadopoulou and colleagues (1997) looked at EN specifically after bone
marrow transplantation. This research found that those patients receiving EN had fewer
episodes of fever as well as fewer positive blood cultures. The study found that EN is also
more effective in preventing deterioration of nutritional status after BMT than those not
receiving EN. A significant positive correlation between duration of feeds and improvement
in nutritional status also was found.

Goal Setting

The goals of nutrition therapy for patients undergoing hematopoietic stem cell transplant
are to maintain weight during treatment and to achieve age-appropriate growth and weight
gain after treatment. Special attention must be paid to food safety so patients do not
acquire foodborne illness during treatment.
These goals can be achieved by dietary modifications, use of dietary supplements,
appetite stimulants, or by starting nutrition support. Enteral nutrition is always preferred
because it has many benefits to patients. When enteral nutrition is not feasible, parenteral
nutrition has to be administered to maintain appropriate nutritional status of the patient. The
appropriate time to begin nutrition support will depend on the patient's age, nutritional
status, and pending therapy. The younger the patient and the poorer his or her nutrition
status, the sooner nutrition support should be initiated.

Food & Feeding Issues
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Food poisoning can occur if a person eats or drinks something that contains harmful
germs. Food consumed by hematopoietic stem cell transplant patients should be prepared
in a manner to minimize bacterial growth. Prepackaged, individual serving items are
frequently used to limit food handling by kitchen personnel.
Dietary Practices for Immunocompromised Patients (Bechard, 2000; Charuhas, 1997;
CDC, 2000):
Practice good hand washing before, during, and after preparing and eating meals.
Do not share food with others.
Avoid foods from street vendors, salad bars, and shared bins of foods in grocery
stores.
Wash raw foods well before eating; inspect for bruises, cuts, and mold. Do not eat
food that smells bad.
Cook meats, fish, poultry, and eggs until well done.
Do not eat hot dogs, luncheon meats, or deli meats, unless they are reheated until
steaming hot.
Do not eat pates or meat spreads unless canned or shelf stable.
Avoid unpasteurized selections of dairy products, fruit juices, vegetable juice, honey,
and beer.
Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or
Mexican-style cheeses such as queso blanco, queso fresco, and Panela, unless they
have been cooked. Pasteurized cheeses are still considered high risk.
Avoid raw eggs and smoked or pickled fish.
Keep foods at lower than 40°F or greater than 140°F to minimize growth of bacteria.
Clean all preparation items thoroughly before and after use to avoid
cross-contamination.
Keep refrigerated leftovers for no more than 3 days.
Well water should come from a well that is tested yearly and it should be boiled 15 to
20 minutes before use.
Use clean utensils and food-preparation areas.
Divide leftovers into small units and store in shallow containers for quick cooking.
Refrigerate leftovers within 2 hours of cooking.
Discard leftovers that were kept at room temperature for more than 2 hours.
Reheat leftovers or heat partially cooked foods to more than 165°F throughout before
serving.
Bring leftover soups, sauces, and gravies to a rolling boil before serving.
Although there has been little convincing evidence that a low-microbial meal plan leads to
a better outcome in the transplant setting, it is clear that food pathogens exist and,
intuitively, fewer pathogens should reduce risk. A reasonable approach to keep
recommendations current and appropriate is to consider questionable items individually
with systematic analysis of food culture data. Because food culturing may be impractical
for many institutions, another way to obtain food safety information is from reputable
sources.
Sources of Food Safety Information:
American Council on Science and Health
Food Safety FAQs from Iowa State University
Food Safety from Centers for Disease Control and Prevention
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Gateway to Government Food Safety Information
Food Safety and Inspection Service
Food Safety Research Information Office
Food Safety Educational Materials Database
The Bad Bug Book
Food Safety – State and Federal Standards and Regulations
Food Safety – World Health Organization
Food Safety Guidelines from the Seattle Cancer Care Alliance

Nutrition Support

Delivery of nutrients into the gut is the preferred method of feeding when use of the
gastrointestinal (GI) tract is feasible. Utilization of the GI tract may not be feasible for the
following reasons: persistent vomiting, intractable diarrhea, graft-versus-host disease of the
gut (nasogastric placement: symptomatic thrombocytopenia or platelet count <50,000),
ileus, status postsurgery requiring nil per os status for prolonged period, and inadequate
gag reflex.
Parenteral nutrition should only be utilized when the GI tract is not usable for at least 7 to
10 days. Exceptions to the “7- to 10-day rule” are children younger than 4 years of age or
those who are already malnourished before diagnosis. These patients usually require
long-term nutrition support or have less reserve to lose and thus nutrition support is
required to sustain nutritional status.

Nutrition Monitoring & Evaluation

Nutrition monitoring and frequency of reassessment will depend on the risk level and
condition of the patient (Ringwald-Smith, 2000).
Patients at high risk will be assessed within 24 hours of admission and reassessed a
minimum of 2 times per week. The following factors, among others, may be true of
these high-risk patients:
On nutrition support
Bone marrow transplantation (initial)
Weight loss of 3% to 5% in the last month
Nil per os status greater than 3 days
Patients at moderate risk will be assessed within 72 hours of admission and reassessed, at
minimum, one time per week. These patients may present the following factors, among
others:
Nonchemotherapy induced nausea, vomiting, diarrhea
Mucositis/oral problems
Modified diet
Patients at low risk will be assessed within 72 hours of admission and reassessed as
indicated. It is possible that these patients may be newly diagnosed and on protocols.

Suggested Schedule for Monitoring Blood Biochemical and Other Indices During
Early Stages of HSCT (Sacks, 2010)
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Lab Frequency
Sodium, potassium,
chloride, carbonate, BUN,
creatine, calcium,
magnesium
Every day until stable on total
parenteral nutrition (TPN), then 3
times per week while on long-term
TPN
Phosphorous
3 times per week until stable on
TPN, then weekly
Ionized calcium With consistent low-serum calcium
LFTs, albumin, total
bilirubin
3 times per week until Day +30,
then weekly while on TPN
Prothrombin time Weekly while on multiple antibiotics
Vitamin D (25 OH D2+D3)
Pre-transplant; then every 3
months until 1 year
Zinc
1
When increased losses suspected
Manganese, copper,
selenium
Monthly when on long-term TPN
(4-6 weeks)
Triglycerides
Weekly while on intravenous lipid
emulsion
Weights
Daily while inpatient, then with
every outpatient visit
Input/Output Daily while inpatient
1Clinical discretion should be used when evaluating zinc levels, keeping in mind that zinc levels in
blood do not reflect tissue stores
Categories of Nutritional Status for the Pediatric Oncology
Patient
Identify appropriate category
Age >2 years
Body mass index (BMI) percentile
Ideal body weight (IBW) for height or length percentile
Age <2 years
WT/LT (Weight-for-length percentile)
Ideal body weight (IBW for height or length percentile)

Underweight Normal
Risk of Overweight/
Overweight
Weight loss/gain may or may not be present
BMI
< 5th percentile
5th - 85th
percentile
>85th – 95th percentile
>95th percentile
WT/LT
< 10th percentile
10th - 90th
percentile
> 90th percentile
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EDW
<70% severe
>70% to 80%
moderate
>80% to 90% mild
>90% to 110%
>110% to 120%
>120%
(Rogers, 2008)


Discharge planning for allogeneic hematopoietic stem cell transplant (HSCT) patients may
include any or all of the following:

Education on high-energy/high-protein meal plan
Education on the following meal plans:
Low bacteria
Lactose free
Graft-versus-host disease bland
Mucositis
Provision of oral supplement of choice and instruction on how to use
Provision of appetite stimulant and education on daily dosage
Education on how to keep kilocalorie count records
Education on parenteral nutrition or enteral nutrition (EN)
Follow-up with outpatient dietitian as needed
Discharge planning for autologous HSCT patients may include any or all of the following:

Education on high-energy/high-protein meal plan
Education on the following meal plans
Lactose free
Bland
Mucositis
Education on food safety/low-bacteria meal plans and how to follow first 3 months
post-HSCT
Provision of oral supplement of choice and instruction on how to use
Provision of appetite stimulant and education on daily dosage
Education on how to keep kilocalorie count records
Education on total parenteral nutrition or EN
Follow-up with outpatient dietitian as needed


Nutrition Care FAQs

Frequently Asked Questions:
Q: What is a hematopoietic stem cell transplant (HSCT)?
A: An HSCT, or bone marrow transplant (BMT), is a transplant of cells given to those with
life-threatening blood, immune system, or genetic disorders. In this transplant, the patient's
unhealthy blood-forming cells are replaced with healthy ones.
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Q: What are the types of HSCTs?
A: There are several types of transplants: autologous, allogeneic, and syngeneic. An
autologous transplant is one where a patient receives his or her own cells. In an
allogeneic transplant, a patient receives stem cells from a family member or unrelated
donor. In a syngeneic transplant, a patient receives cells from his or her identical twin.
Q: How are bone marrow and stem cells collected and transported for transplant?
A: There are two common ways stem cells may be collected and transported: bone
marrow harvesting and stem cell harvesting. In bone marrow harvesting, the bone marrow
is taken, most often from the pelvis bone by a large needle or syringe. Blood and bone
fragments are then removed from the collected marrow. This can be performed as an
inpatient or outpatient procedure.
The process of stem cell harvesting requires a catheter to be inserted into a large
vein. Blood is drawn from the vein and into a machine that removes stem cells. The
remaining blood is then returned to the patient.
Q: What should I expect after HSCT?
A: Patients undergoing HSCT may have episodes of nausea and vomiting while receiving
the transplant as well as chills and a fever during the first 24 hours after the transplant. Be
aware that your child will be much more susceptible to infection and bleeding as a result of
their cancer treatments. Complete recovery of immune function may take up to several
months for autologous transplant patients, and 1 to 2 years for allogeneic or
syngeneic transplant patients. These intense cancer treatments may cause short-term side
effects like nausea, vomiting, fatigue, loss of appetite, mouth sores, hair loss, and skin
reactions. Patients with allogeneic HSCT may develop graft-versus-host disease (GVHD).
(See next question for information on GVHD.)
Q: What is GVHD?
A: GVHD only occurs in those receiving an allogeneic transplant. It occurs when white
blood cells from the donor marrow identify the patient's cells as foreign and start attacking
it. GVHD is normally treated with the use of steroids or another immunosuppressive agent.
Q: Can I give my child food from home after the transplant?
A: You should not bring food from home to the hospital after your child's transplant.
During this time, your child will be on a low-bacteria diet, which means that everything he
or she eats must be cooked or provided in individual servings. Raw fruits and vegetables
are not allowed because they may carry bacteria. At this time, it is best for your child to eat
only at the hospital to ensure the food's proper preparation. If your child has any specific
requests, you may speak with the dietitian. Usually various beverages, ice cream, pudding,
jell-o, popsicles, and cookies are available from the hospital's kitchen or cafeteria and can
be kept in a refrigerator in your room.
Q: Is there a special diet to follow after transplant?
A: Every hospital has different criteria to be followed. In general, strict food safety is
recommended for all posttransplant patients until their immune system completely
recovers. Some hospitals recommend to follow a neutropenic diet after an allogeneic
HSCT. Other recommended diets are symptom specific (for example, mucositis or GVHD
diet).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Q: What can I do if my child refuses to eat after the transplant?
A: Many children experience poor appetite after HSCT, the result of side effects of
treatment. Initiation of nutrition support often is necessary in the form of enteral or
parenteral nutrition. Dietary supplements may be used to improve daily energy intake. One
way to improve appetite is the use of appetite stimulants. If nausea or vomiting is the
reason your child refuses to eat, antiemetics may be used.
Q: What can I do to maintain my child's pretransplant weight?
A: Possible tactics to help your child maintain his or her pretransplant weight include the
following:
Try to reach/maintain optimal weight before transplant
Consume high-energy foods
Use days that your child feels good to maximize food/energy intake
Keep snacks handy for the child to snack throughout the day
Eat whenever hungry; don't restrict intake to mealtimes only
Substitute poultry, fish, eggs, or other protein foods for red meat, which may have a
funny taste
If your child presents with diarrhea, have him or her drink plenty of liquids at room
temperature to prevent dehydration; avoid grease, fat, raw foods, and spices; and
limit caffeine, strong teas, soda, and chocolate
To manage constipation, have your child eat a high-fiber diet and drink plenty of
liquids
Avoid your child's favorite foods during periods of nausea and vomiting
Avoid having your child eat in rooms with strong odors to prevent nausea/vomiting
Consider asking your child's doctor about appetite stimulants
Ask the dietitian/doctor about adding nutrients to diet with supplements
Serve small food portions on a small plate
Stay calm at mealtimes; don't rush your child to finish meals
Encourage eating with others, such as family or friends
Cook foods until tender and cut into small pieces if your child is experiencing mouth or
throat soreness
To relieve gastrointestinal complications, have your child rest after meals (sitting up)
and do not let him or her participate in rigorous activity


Refeeding Syndrome

Refeeding syndrome is a complication that often occurs with the initiation of aggressive
nutrition support. Parenteral nutrition support is most commonly associated with the onset
of refeeding syndrome, but this metabolic abnormality has been found to occur with both
enteral and oral feeding.
The syndrome is characterized by the individual becoming metabolically unstable with the
development of hyperglycemia, hyperlipidemia, and hypophosphotemia. Individuals at
highest risk for developing refeeding syndrome include chronically semi-starved, marasmic
patients whose bodies have adapted largely to use of free fatty acids and ketone bodies as
energy sources. Patients undergoing hematopoietic stem cell transplant (HSCT) may fit
into this category because of treatment-induced weight loss and anorexia. Because
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
into this category because of treatment-induced weight loss and anorexia. Because
nutrition support is commonly utilized in the HSCT population, a clear understanding of the
causes of and the ways to prevent refeeding syndrome is crucial. To avoid the
development of refeeding syndrome, nutrition support in patients at risk should be
increased slowly (Hearing, 2004; NCM, 2009).

Metabolic Rate Profile (Indirect Calorimetry)

The basal energy needs of a patient can be estimated by using the WHO predictive
equation (Food and Nutrition Technical Report Series, 2001) or other predictive
equations. Basal energy needs can be directly measured by respiratory gas exchange
using an indirect calorimeter. When basal energy needs are predicted by WHO or other
predictive equations, stress, growth, and other activity factors are usually added to the
basal estimated needs. Indirect calorimetry will precisely measure resting energy
expenditure and then activity factors may be added.
Indirect calorimetry is used to estimate the energy needs of a patient by directly measuring
the respiratory gas exchange. A metabolic cart test or MedGem is used for this procedure.
An indirect calorimetry specifically measures oxygen consumption, carbon dioxide
production, and the respiratory quotient. Once an indirect calorimetry is taken, it
is beneficial to relate the measured resting metabolic rate (RMR) with the calculated RMR
(AARC, 2004).


Oral Intake

An evaluation of dietary intake and adequacy during hematopoietic stem cell
transplantation (HSCT) is paramount. Understanding how well the patient is eating before
and during HSCT will provide invaluable information that will aid in assessing the
individual’s nutritional status and developing a nutrition plan.
Detailed food records can be used to determine food preferences and aversions and assist
in managing the individual’s nutrition care. A complete dietary history should include an
evaluation of oral and gastrointestinal symptoms, to include but not be limited to chewing or
swallowing, dental health, taste alterations, heartburn or gastric reflux, mucosal lining, and
bowel habits.
Other issues that should be addressed in the dietary history evaluation include current
dietary practices, modifications or use of supplements; food allergies or intolerances; in
children, an evaluation of feeding stage of development; in infants, identification of those
being breastfed and recommendations for those diagnosed with severe combined
immunodeficiency and/or Immunodysregulation polyendocrinopathy enteropathy X-linked
syndrome to wean off breast milk. Generally, HSCT patients who are unable to meet their
requirements orally for 5 to 7 days should receive nutrition support (NCM, 2009).
Energy needs:
May be increased because of treatment, fever, infections, graft-versus-host disease
(GVHD), metabolic complications, and growth demands of children
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Protein needs:
Increased for tissue repair and to decrease breakdown of lean body mass
May be increased during high-dose corticosteroid therapy and during active GVHD
May be modified if hepatic, renal, or neurological function is altered

Fat needs:
Lipid clearance may be decreased in patients with hepatic dysfunction

Carbohydrate needs:
May be decreased if hyperglycemia occurs

Comparative Standards: Energy Needs

Energy needs of children undergoing HSCT are not well described. Energy requirements
may be higher due to mucositis, nausea and vomiting and diarrhea; furthermore, GVDH
may also increase energy requirements, post transplantation. However, the standard
estimation equations for energy expenditure significantly overestimate the energy needs of
pediatric patients undergoing HSCT (Ringwald-Smith, 2002). Similarly, a study on children
undergoing allogeneic stem cell transplantation showed significant reductions in REE after
transplantation (Duggan, 2003). Until more research is available for estimating energy
needs, indirect calorimetry is the best method currently available.
Energy requirements (kcal) of pediatric HSCT patients (Sacks et al. 2010)
Age Calories (kcal)
1-12 months BMR
1
x 1.6-1.8
1-6 years BMR x 1.6-1.8
7-10 years BMR x 1.4-1.6
11-14 years BMR x 1.4-1.6
15-18 years BMR x 1.5-1.6
>19 years BEE
2
x 1.5
1
BMR equations: WHO Method (WHO 1985), located under the Calculators tab.

2
BEE equations: Harris-Benedict Equation (Harris, 1919)

Growth
Age Expected Growth Notes Growth
(%)
Infancy–
1 year
Period of rapid growth:
weight increase 200%;
length increase
55%; head
circumference increase
40%
Possible initial
wt regains most
or all of
birthweight
45-50
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1-3 years Stature increase of 12
cm, weight increase
3.5-4.5 kg
Growth velocity
decreases
40-45
Preschool
3-5 years
Stature 6-8 cm/year;
weight 2-4 kg/yr
35-40
Elementary
School
6-10 years
Stature 5-6 cm/year;
weight 2 kg at 7 years
and 4 kg at 10 years
Period of steady
growth:
Girls faster than
boys.
30-35
Adolescence

Maximum velocity of
stature;
Males 9.5-10.3 cm/year
Females 8.4-9.0
cm/year
Males develop
more lean
muscle mass;
Females more
adipose tissue
30-40
Intense treatment may slow growth. However, this delay in growth may be regained when
off treatment. Total parenteral nutrition should be assessed for maintenance energy for
only 2 weeks in infants and pediatrics. Then growth will need to be considered.
Obese Oncology Patients:
For obese oncology patients, use ABW to calculate energy needs.
Failure to Thrive (FTT):
Weight for height/length below 5th percentile
Less than 80% of IBW based on height
FTT (kcal/kg) = (RDA kcal for wt age) x (50th %ile wt/ht)
Actual weight

OR add on 10% energy factor, using the BMR.

Comparative Standards: Macronutrients

Protein Requirements
Children undergoing allogeneic stem cell transplantation have been shown to have
decreased lean body mass (Duggan, 2003). Therefore, protein requirements are increased
to minimize this loss.
Protein requirements (g/kg/d) of pediatric HSCT patients (Sacks, 2010)
Age Protein (g/kg/d)
1-12 months 3
1-6 years 2.5-3
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7-10 years 2.4
11-14 years 2
15-18 years 1.8
>19 years 1.5
Protein is often calculated for 1 g nitrogen
Posttransplant patients usually have higher protein needs
In patients receiving parenteral nutrition, the usual nonprotein calories to nitrogen (NPC:
N
2
) ratio is 150 NPC to 250 NPC for every gram of nitrogen provided. When monitoring for
response, assess the prealbumin levels weekly. Prealbumin is influenced by fluid
disturbances as well as in renal and hepatic failure; therefore, prealbumin concentrations
should not be used as a measure of response in those patients who are hemodynamically
unstable. A baseline prealbumin should be obtained at the beginning of enteral or
parenteral therapy. Albumin has a long half-life and therefore should not be used to assess
response to nutrition support over a short period of time.
To determine the grams of protein/kg of body weight of a patient:
(Total energy / NPC) x 6.25
Body weight

NPC = nonprotein calories
NPC for low-stress patients: 1 g nitrogen/250 kcal
NPC for medium-stress patients: 1 g nitrogen/200 kcal
NPC for catabolic child: 1 g nitrogen/150 kcal
1 g nitrogen = 6.25 g protein
Protein restriction may be required in patients with renal failure and liver failure. For
patients with a pre-renal elevation of blood urea nitrogen (BUN) not related to renal failure
(eg, gastrointestinal bleed, aggressive therapy with loop diuretics), protein restriction
should be considered as the BUN rises above 60. Also take into consideration if the patient
is maintained on catabolic steroid therapy.
For FTT, protein should be increased to 1.5 to 2.0 times the DRI for age. Avoid exceeding
4 g/kg.
In a patient receiving total parenteral nutrition, use the total energy:nitrogen ratio of 150 TC
to 250 TC for every gram of nitrogen provided.
The equation to determine protein requirements for those with FTT is:
FTT protein = Protein required for weight age (g/kg/d) x EDW (kg)
3.5
EDW: Estimated Desired Weight
Protein tolerance can be monitored with a BUN, serum creatinine, nitrogen balance,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
visceral proteins, and ammonia level in patients with liver failure.

Fat Requirements
For infants and toddlers, fat intake equivalent to 30% to 55% of total energy is
appropriate. Those older than 2 years may go less than 30% without compromising
growth. More than 50% is not recommended.
In total parenteral nutrition, fat should be 20% to 60% of energy. Upper limit in infants is 4
g/kg/d.
Medium-chain triglyceride (MCT) oil does not provide essential fatty acids (EFA) or
facilitate absorption of fat soluble vitamins. Monitor the patient receiving more than 86% of
total fat as MCT oil, which contains 8.3 kcal/g. Microlipid is a source of EFA, containing 4.5
kcal/mL.

Comparative Standards: Fluid Needs

Method 1
Maintenance Body Weight (kg) Amount Per Day
1-3 120-150 mL/kg
3-10 100 mL/kg
11-20 1,000 mL + 50 mL/kg for each kg
above 10
>20 - 40 1,500 mL + 25 mL/kg for each kg
above 20
>40 1,500 mL/m
2
body surface area

Method 2
Maintenance: > 11 kg = 1,500-1,800 mL/m
2
/day
Fluid needs may be increased in patients with significant losses like those with
gastrointestinal (GI) suctioning, GI fistulas, persistent vomiting, diarrhea, and high fever.
Fluid needs may be decreased in patients with renal failure or pulmonary edema; patients
at risk for veno-occlusive disease; or patients at risk for capillary leak syndrome, which
includes those undergoing high-dose chemotherapy, total body irradiation, and interleukin
therapy.
Fluid tolerance and response can be monitored by assessing weight changes, 24-hour
urine input and output, blood urea nitrogen, skin turgor, PE, and urine output.

Comparative Standards: Micronutrients

Vitamin and Mineral Needs
Vitamin and minerals are essential for normal growth and development in children. There
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
are no specific requirements for pediatric HSCT patients. The nutrition plan should meet
100% of the dietary reference intake (DRI) of vitamin and minerals. Risk of vitamin
deficiency is higher in patients with diarrhea, vomiting and malabsoprtion. If vitamin and
mineral supplementations is required, iron-free supplements are generally recommended
as many HSCT patients experience repeated red blood cell transfusion, resulting in some
degree of iron overload rather than iron deficiency.
Of particular interest among children post-HSCT are the nutrients important for bone
development and maintenance. A recent study showed that vitamin D insufficiency and
deficiency are common in children following HSCT (Duncan, 2011). Risk of vitamin D
deficiency is due to multiple reasons including limited sun exposure and
malabsorption. Furthermore, long-term survivors of HSCT are at risk for loss of bone
mineral density (BMD) and subsequent osteoporosis (McClune, 2011). Therefore, vitamin
D and calcium should be monitored. The latest recommendations for vitamin D intake are
10 µg/d (IOM, 2011).

Follow-up Guidelines for Survivors of Childhood Cancer

Survival rates are increasing for most childhood cancers. The 5-year survival rates for all
childhood cancers combined has increased from 58.1% in 1975–77 to 83% for ages 0-4
years; 81.2% for ages 5-9 years; 82.7% for ages 10-14 years; and 82.8% for ages 15-19
years in 2001-2007 (Howlader, 2011).
Cancer survivors are people who are living with a diagnosis of cancer, including those who
have recovered from the disease. The progress in survival rates is largely attributable to
improvements in treatment and advances in research. The Children’s Oncology Group has
developed Long-Term Follow-up Guidelines for Survivors of Childhood Adolescent and
Young Adult Cancers (COG-LTFU Guidelines, 2008). These guidelines represent a
statement of consensus from a panel of experts in the late effects of pediatric cancer
treatment. The current version of the COG-LTFU Guidelines (Version 3.0) is available
online (www.childrensoncologygroup.org).
Diet and Physical Activity for Survivors
The American Institute for Cancer Research (AICR) also has guidelines for cancer
survivors (American Institute for Cancer Research, 2003). The three key areas to reduce
cancer risk are weight, diet, and physical activity. The most recent recommendations from
the World Cancer Research Fund (WCRF) / AICR second expert report (WCRF/AICR,
2007) are applicable for prevention against a secondary tumor or a recurrence. The table
below lists the ten recommendations for cancer prevention.
Recommendations for Cancer Prevention (WCRF/AICR, 2007):
Be as lean as possible without becoming underweight. 1.
Be physically active for at least 30 minutes every day. 2.
Avoid sugary drinks. Limit consumption of energy-dense foods. 3.
Eat more of a variety of vegetables, fruits, whole grains and legumes such as beans. 4.
Limit consumption of red meats (such as beef, pork and lamb) and avoid processed
meats.
5.
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If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day. 6.
Limit consumption of salty foods and foods processed with salt (sodium). 7.
Don't use supplements to protect against cancer. 8.
*It is best for mothers to breastfeed exclusively for up to 6 months and then add other
liquids and foods.
9.
*After treatment, cancer survivors should follow the recommendations for cancer
prevention.
10.
And always remember – do not smoke or chew tobacco
*Special Population Recommendations. Anyone who has received a diagnosis of cancer
should receive specialized nutritional advice from an appropriately trained professional.
Additional recommendations covered in the Nutrition and the Cancer Survivor guidelines
(American Institute for Cancer Research, 2003) include:
Rethink the ratio of plant foods to animal foods (aim for two thirds or more
plant-based foods)
11.
Cook with care (marinate meats; don’t cook meats directly over the flame; avoid
charred or burnt meat)
12.
Handle food safely (keep hands, counters, dishes, cutting boards and utensils clean;
was fruits and vegetables thoroughly; use separate dishes/chopping boards/utensils
for preparing raw meat, fish or poultry; thaw frozen food in microwave or refrigerator).
13.



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Nutrition Care > Weight Management
Weight Management


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Care > Weight Management > Overweight/Obesity
Nutrition-Focused Physical Findings

The following are physical examination findings associated with overweight/obesity and their common causes:

Physical Findings and Common Causes Associated with Pediatric Overweight/Obesity
Physical Finding Common Causes
High body mass index percentile
Overweight or obesity or increased percentage
of muscle mass as in athletes
Short stature Underlying endocrine or genetic condition
Elevated blood pressure
Hypertension if systolic or diastolic blood
pressure in the 95th percentile for age, sex,
and height on 3 occasions
Acanthosis nigricans Increased risk of insulin resistance
Excessive acne and hirsutism
Amenorrhea
Polycystic ovary syndrome
Skin irritation and/or
inflammation
Severe obesity
Violaceous striae Cushing's syndrome
Papilledema, cranial nerve VI
paralysis, recurring headaches
Pseudotumor cerebri
Tonsillar hypertrophy, snoring,
apnea, daytime sleepiness
Nocturnal enuresis
Obstructive sleep apnea
Neck goiter Hypothyroidism
Chest wheezing
Asthma (may explain or contribute to exercise
intolerance)
Polyuria, polydipsia Type 2 diabetes mellitus
Abdominal tenderness
Gastroesophageal reflux disorder, gall
bladderdisease, non-alcoholic fatty liver
disease (NAFLD)
Hepatomegaly NAFLD
Advanced Tanner stage Premature puberty
Apparent micropenis May be normal penis that is buried in fat
Undescended testes Prader-Willi syndrome
Abnormal gait, limited hip range
of motion, hip pain, knee pain,
walking pain
Slipped capital femoral epiphysis
Bowing of tibia Blount's disease
Small hands and feet,
polydactyly
Genetic syndromes
Anxiety, school avoidance,
social isolation
Depression
(Barlow, 2007)

Biochemical Data, Medical Tests and Procedures
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Depending on physical findings, additional diagnostic tests may be ordered by the physician, nurse practitioner, or
physician’s assistant to confirm a medical diagnosis.
These tests and procedures may include endoscopy, liver biopsies, polysomnography, and oral glucose tolerance tests.


Laboratory

Medical assessment of the overweight or obese pediatric patient requires a detailed family medical history, a thorough
physical examination (including blood pressure and pulse measurements), assessment for signs of comorbidities
associated with overweight and obesity, and laboratory assessments based on body mass index (BMI) criteria for age
and sex (Barlow, 2007). Additional diagnostic testing may be warranted based on review of systems, physical
examination findings, and family medical history.
Laboratory Assessments for Overweight and Obese Pediatric Patients
Pediatric patients without health risks
a
with a BMI between the 85th and 94th percentiles are recommended to have a
fasting lipid profile.
Pediatric patients with a BMI between the 85th and 94th percentiles with health risks
a
are recommended to have a
fasting lipid profile, AST, ALT, and a fasting glucose.
Pediatric patients regardless of presence health risks
a
with a BMI >95
th
% with health risks are recommended to have
a fasting lipid profile, AST, ALT, BUN and a fasting glucose.
Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; BUN = blood urea nitrogen
a
Risk factors include obesity-related medical conditions (such as hyperlipidemia, high blood pressure,
hyperinsulinemia) and/or positive family history for type 2 diabetes mellitus, insulin resistance, and cardiovascular
disease and cardiovascular disease risk factors.
(Barlow, 2007)

National Cholesterol Education Program Classifications of Total and Low Density Lipoprotein
(LDL) Cholesterol Levels in Children and Adolescents
Category
Total Cholesterol
(mg/dL)
LDL Cholesterol
(mg/dL)
Acceptable < 170 < 110
Borderline 170-199 110-129
High > 200 > 130
(NCEP, 1991; Kavey, 2003)
Triglycerides are considered acceptable if they are under 75 mg/dL in children younger than 10 years of age; for those
10-19 years old, levels under 90 mg/dL are acceptable. HDL cholesterol in children is considered acceptable if it is over
45. A table with more details on new acceptable levels for plasma lipids, lipoproteins, and apolipoprotein concentrations
is available at this link (Expert Panel, 2011).

Anthropometric Measurements

Registered dietitians and other health care providers should classify the weight status of a child or adolescent by
calculating the person’s body mass index (BMI), plotting the BMI on the sex-specific and age-appropriate growth charts
of the Centers for Disease Control and Prevention, and then comparing the person’s BMI percentile to the weight
classifications from the expert panel recommendations provided below (Barlow, 2007). Frequency of monitoring
anthropometrics should be determined using individualized weight management goals based on the expert panel
recommendations, which are specific to age, BMI percentile, and risk factor (see Weight Goals section). Skinfolds and
waist-to-hip ratios are not recommended for use in the assessment of adiposity in children and adolescents (Barlow,
2007).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Weight Classifications from the Expert Panel Recommendations
Classification BMI Percentile
Underweight <5th
Healthy weight 5th to 84th
Overweight 85th to <95th
Obesity >95th

If possible, resting metabolic rate (RMR) should be measured using indirect calorimetry. See Comparative Standards
for these measurements.

Client History

Client history should include the following:
Social History
Family socioeconomic status
Social and medical support
Housing situation and social isolation/connection
Child and adolescent peer relationships
Involvement in school/afterschool activities
Personal history for child or adolescent
Age
Academic performance
Jobs
Role in family (eg, food preparer, purchaser, child care giver)
Medical/health history
Present/past illnesses and surgeries
History of genetic disorders
Hypertension
Dyslipidemia
Insulin resistance
Hyperinsulinemia
Non-alcoholic fatty liver disease
Type 2 diabetes mellitus
Blount’s disease
Gall bladder disease
Sleep apnea and respiratory problems
Eating disorders
Screen for existing or potential eating disorders
Polycystic ovary syndrome
Mental and emotional health and cognitive abilities
Smoking history
Frequency and amount of alcohol intake
Medication and Supplement History
Prescription psychotrophic, anti-inflamatory, lipid-lowering, antihypertensive, diabetes, and thyroid
medications
Over-the-counter drugs
Herbal and dietary supplements (such as diet pills, those with potential for food or drug interaction)
Illegal drugs
Personal history for parent/guardian includes the following:
Education level
Occupation
Role in family
Religious beliefs

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Client/Family Behaviors and Association with Pediatric Overweight/Obesity

Child and family diet behavior factors that may be associated with an increase in the risk of pediatric obesity and
should be included in the nutrition assessment are as follows (EAL 2007):
Parental restriction of highly palatable foods
Consumption of food away from home
Increased portion size of meals
Breakfast skipping
The following child and family diet behaviors may not be related to pediatric overweight or obesity, or the research is
still unclear as to their relationship to overweight and obesity, but dietitians should be aware of these factors when
performing a nutrition assessment:
Parental encouragement or pressure to eat
Parental control over child’s dietary intake
Meal frequency
Snacking frequency or snack food intake
Use of food as a reward
Family climate factors that may be associated with an increase in the risk of pediatric obesity are as follows:
Parental dietary disinhibition and restraint
Negative aspects of family functioning (such as lack of parental support or overpossessiveness)
Parental concern about child’s weight status
Family climate factors that may be associated with a decrease in the risk of pediatric obesity are positive aspects of
family functioning, such as the following:
Family cohesion
Expressiveness
Democratic style
Parental support
Cognitive stimulation at home
Household food insecurity may not be related to pediatric overweight or obesity—the research is still unclear as to the
relationship—but practicioners should be aware of this factor in their nutrition assessment.
The following sedentary behaviors may be associated with an increase in the risk of pediatric overweight and pediatric
obesity:
Excessive television viewing
Excessive use of video games
Regular physical activity and sports participation may be associated with a decrease in the risk of pediatric overweight
and pediatric obesity.


Food/Nutrition-Related History

Food intake must establish a baseline for the following factors:
Energy intake
Percentage of estimated energy needs
Percentage of energy from fat and carbohydrate
Other nutrient analysis
Patient/client behaviors to consider include the following:
Physical activity
Video game use
Television viewing
Fruit and vegetable intake
Consumption of sweetened beverages
Parental restriction of highly palatable foods
Meals consumed outside the home
Increased portion sizes
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Skipping breakfast


Nutrition Diagnosis

Dietitians working with patients who are overweight or obese should review the signs and symptoms obtained in the
nutrition assessment and diagnose nutrition problems based on these signs and symptoms. Nutrition diagnoses from
the list below as well as other diagnoses may be present.
Excessive energy intake (NI-1.5)
Excessive oral intake (NI-2.2)
Excessive enteral nutrition infusion (NI-2.4)
Excessive parenteral nutrition infusion (NI-2.7)
Decreased nutrient needs (specify) (NI-5.4)
Overweight/obesity (NC-3.3)
Unintended weight gain (NC-3.4)
Food- and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Self-monitoring deficit (NB-1.4)
Limited adherence to nutrition-related recommendations (NB-1.6)
Undesirable food choices (NB-1.7)
Sample PES or Nutrition Diagnostic Statement(s)
Overweight/obesity (NC-3.3) related to high frequency of restaurant-prepared meals brought into the home and
menu selections as evidenced by self-report of large portions, high-fat foods, rich desserts, sweetened
beverages, and a body mass index above the 95th percentile.
Note: Terminology in the examples above is from the American Dietetic Association's International Dietetics and
Nutrition Terminology, 3rd edition. Code numbers are inserted to assist in finding more information about the
diagnoses, their etiologies and signs and symptoms. Dietitians should not include these numbers in routine clinical
documentation.

Nutrition Intervention

The Expert Committee Recommendations on Child and Adolescent Overweight and Obesity (Barlow, 2007) propose a
staged treatment approach to the treatment of pediatric overweight and obesity based on body mass index (BMI)
percentile and health risk. There are 4 stages of increasing intensity.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Figure reproducted with permission from Pediatrics. 2007;120;S164-S192 by the AAP.
Stage 1: Prevention Plus
Prevention Plus is a family approach focusing on healthful eating and activity behaviors aimed at improving BMI status
with frequent monitoring by the health care provider. The targeted behaviors include decreased television viewing,
decreased sweetened beverage and juice consumption, increased fruit and vegetable consumption, increased daily
activity, more home-prepared meals and family meals, and daily breakfast consumption. The American Dietetic
Association's (ADA) Evidence Analysis Library Evidence-Based Pediatric Weight Management Nutrition Practice
Guideline strongly recommends that a parent/caregiver should be included in multicomponent pediatric weight
management programs as an agent of change when treating children aged 6 to 12 years (EAL, 2007).
Stage 2: Structured Weight Management
Structured Weight Management differs from Stage 1 in that the level of structure and support, with the addition of a
registered dietitian (RD), is increased. A dietary prescription, including a mild energy deficit, a meal and snack
schedule, 1 hour of daily supervised and planned daily physical activity, and self-monitoring are implemented by the
family with staff support using motivational interviewing techniques to help set goals and identify barriers. A nutrition
prescription should be formulated as part of the dietary intervention in a multicomponent pediatric weight management
program. Research shows that when individualized nutrition prescription is included, improvements in weight status in
children and adolescents are consistent. When an individualized nutrition prescription is not included, results are less
consistent (EAL, 2007).
Stage 3: Comprehensive Multidisciplinary Intervention
Comprehensive Multidisciplinary Intervention increases the intensity of behavior changes, frequency of visits (weekly
for a minimum of 8 to 12 weeks with monthly follow-up visits), and involvement of an interdisciplinary team of specialists
with experience in pediatric obesity. The ADA’s Evidence-Based Pediatric Weight Management Nutrition Practice
Guideline recommends that, during the intensive treatment phase, medical nutrition therapy for pediatric overweight
should last at least 3 months or until initial weight management goals are achieved. Because overweight is a chronic,
often lifelong condition, it is critical that a weight management plan be implemented after the intensive phase of
treatment. A greater frequency of contacts between the patient and practitioner may lead to more successful weight
loss and maintenance (EAL, 2007).
Stage 4: Tertiary Care Interventions
Tertiary Care Interventions are appropriate for some severely obese youth who have attempted the Stage 3 intervention
and who have the maturity to understand the ramifications of the interventions as well as the willingness to comply with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and who have the maturity to understand the ramifications of the interventions as well as the willingness to comply with
diet and exercise recommendations. Lack of success in Stage 3 is not by itself a criterion to advance to Stage 4.
Interventions include medications, very-low-energy diets, and weight control surgery with standard clinical protocols.
Because the intensity of the interventions, they should be delivered at pediatric weight management centers staffed
with a team consisting of a physician/nurse practitioner, RD, behavioral counselor, and exercise specialist.

Expert Panel Intervention Stages according to Age and BMI % (Barlow, 2007)
Counseling Stage: Prevention Counseling
<18 yrs with a BMI % <94% without health risks
Counseling Stage: Lowest-Prevention Plus; Highest-Structured Weight Management
2-5 yrs, with a BMI % 85-94 % with health risks
6-18 yrs with a BMI % 85-94 %
Counseling Stage: Lowest- Prevention Plus; Highest-Comprehensive Weight Management
2-5 yrs, with a BMI % >95 % with health risks
6-18 yrs with a BMI % >95-99 % with health risks
Counseling Stage: Lowest- Prevention Plus; Highest-Tertiary Care Intervention
6-18 yrs with a BMI % >99 % with health risks

Goal Setting

The Expert Committee Recommendations on Child and Adolescent Overweight and Obesity have set weight goals for
age, body mass index (BMI) category, and health risk (Barlow 2007).
Weight Goals and Intervention Strategies for Children and Adolescents, 2 to 18 Years
2- to 5-Year-Olds
Overweight, BMI in the 85th to 94th percentiles: Goal is weight maintenance until BMI is below the 85th percentile or a
slower rate of weight gain (ie, downward shift in curve on BMI growth chart). Prevention counseling is the
recommended intervention if the child has no health risks. If patient has health risks, recommended interventions are
Stage 1: Prevention Plus and Stage 2: Structured Weight Management.
Obese, BMI at 95th percentile or higher: Goal is weight maintenance until BMI is below the 85th percentile. Any weight
loss should be limited to no more than 1 lb/month.* Recommended interventions are Stage 1: Prevention Plus through
Stage 3: Comprehensive Multidisciplinary Intervention.
Obese, BMI ≥ 21: Goal is gradual weight loss. Weight loss should be limited to no more than 1 lb/month.
Recommended interventions are Stage 1: Prevention Plus through Stage 3: Comprehensive Multidisciplinary
Intervention.

6- to 11-Year-Olds
Overweight, BMI in 85th to 94th percentiles: Goal is weight maintenance until BMI is below the 85th percentile or a
slower rate of weight gain (ie, downward shift in curve on BMI growth chart). Prevention counseling is the
recommended intervention if the child has no health risks. If patient has health risks, recommended interventions are
Stage 1: Prevention Plus and Stage 2: Structured Weight Management.
Obese, BMI in 95th to 98th percentiles: Goal is either weight maintenance until BMI is below the 85th percentile or
gradual weight loss (approximately 1 lb/month). Recommended interventions are Stage 1: Prevention Plus and Stage
2: Structured Weight Management.
Obese, BMI in the 99th percentile or higher: Goal is weight loss averaging 2 lb/week. Recommended interventions are
Stage 1: Prevention Plus through Stage 3: Comprehensive Multidisciplinary Intervention. Intervention can begin at
Stage 2 or 3, if family is motivated.

Adolescents (12- to 18-Year-Olds)
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Overweight, BMI in 85th to 94th percentiles: Goal is weight maintenance until BMI is below the 85th percentile or a
slower rate of weight gain (ie, downward shift in curve on BMI growth chart). Prevention counseling is the
recommended intervention if the child has no health risks. If patient has health risks, recommended interventions are
Stage 1: Prevention Plus and Stage 2: Structured Weight Management.
Obese, BMI in 95th to 98th percentiles: Weight loss (no more than 2 lb/week) until BMI is below the 85th percentile.
Recommended interventions are Stage 1: Prevention Plus through Stage 4: Tertiary Care Interventions (if appropriate).
Intervention can begin at Stage 2 or 3, if family is motivated.
Obese, BMI in the 99th percentile or higher: Goal is weight loss averaging 2 lb/week. Recommended interventions are
Stage 1: Prevention Plus through Stage 4: Tertiary Care Interventions (if appropriate). Intervention can begin at Stage 2
or 3, if family is motivated.
For patients in all age ranges, weight loss greater than the goal recommendation should be monitored and causes
determined.

Nutrition Prescription

According to the American Dietetic Association's Evidence-Based Pediatric Weight Management Nutrition Practice
Guideline (EAL, 2007), a nutrition prescription should be formulated as part of the dietary intervention in a
multicomponent pediatric weight-management program. The exact specification of nutrients and energy is often
translated into a specific eating plan. Nutrition interventions are selected based on the nutrition prescription. Research
shows that when an individualized nutrition prescription is included, improvements in weight status in children and
adolescents are consistent. When an individualized nutrition prescription is not included, results are less consistent.
An example of a nutrition prescription is as follows:
A balanced hypocaloric diet of 1,200 kcal/day with 45% to 65% carbohydrate,10% to 35% protein, and 20% to 35% fat.

Alternative Dietary Alterations

Balanced Macronutrient Hypocaloric Diets
According to the American Dietetic Association's (ADA) Evidence-Based Pediatric Weight Management Nutrition
Practice Guideline (EAL, 2007), use of a balanced macronutrient diet that contains no fewer than 900 kcal/day for
children aged 6 to 12 years and 1,200 kcal/day for adolescents aged 13 to 18 years is recommended to improve weight
status within a multicomponent pediatric weight management program in which patients are medically monitored.
Research indicates that balanced macronutrient diets at 900 kcal to 1,200 kcal per day are associated with short-term
and longer-term (longer than 1 year) improved weight status and body composition in the pediatric population. A
balanced macronutrient diet for children is defined by the Dietary Reference Intakes (DRI) in terms of the following
percentages of daily energy intake:
Carbohydrates: 45% to 65%
Protein: 10% to 35%
Fat: 20% to 35%

Traffic Light Diet
ADA’s Pediatric Weight Management Evidence Analysis Project has concluded that the Traffic Light Diet is an effective
component of a clinically supervised, multicomponent childhood weight management intervention program (EAL, 2007).

Very-Low-Fat Diet
ADA’s Pediatric Weight Management Evidence Analysis Project did not identify any research in which a diet with less
than 20% of total daily energy intake from fat was used to treat childhood overweight. There is insufficient evidence to
make a judgment on the effectiveness of using a low-fat diet (less than 20% of total daily energy intake from fat) as a
means to treat childhood overweight (EAL, 2007).

Ad Libitum, Low-Carbohydrate Diets
An ad libitum, low-carbohydrate diet is defined as a diet with less than 45% to 65% of total energy from carbohydrates.
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ADA’s Pediatric Weight Management Evidence Analysis Project did not identify any studies that used a
low-carbohydrate diet in the treatment of overweight among children aged 6 to 12 years. If a low carbohydrate diet is
selected for use in adolescents, then it is recommended for short-term use (up to 12 weeks). The use of an ad libitum,
very-low-carbohydrate diet (a diet containing 20 g to 60 g carbohydrate) to treat overweight adolescents has shown
short-term improvement in weight status. However, because of the lack of evidence, it is not recommended for
long-term treatment of pediatric overweight (EAL, 2007).
Nutritional considerations for implementing this diet are as follows:
Electrolyte imbalance, especially hypokalemia, can be an adverse effect of the diet, especially when an
adolescent is in a state of ketoacidosis. When this diet is implemented, electrolytes should be monitored and
potassium should be increased through dietary supplements.
Constipation may occur secondary to inadequate fiber and fluid intakes.
A daily multivitamin supplement containing 100% of the DRI should be prescribed with the diet to ensure
adequate vitamin and mineral intake, especially because fruit, vegetable, and dairy consumption may be limited.

Ad Libitum, Low Glycemic Load Diet
According to ADA’s Evidence-Based Pediatric Weight Management Nutrition Practice Guideline, the use of an ad
libitum, low glycemic load diet that contains approximately 45% to 50% of energy from carbohydrates and 30% to 35%
of energy from fat may be effective for modest, short-term weight loss in children between the ages of 6 and 12 years,
and may be effective for longer-term weight loss in adolescents (EAL, 2007).

Protein-Sparing Modified Fast
ADA’s Evidence-Based Pediatric Weight Management Nutrition Practice Guideline gives a weak and conditional
recommendation for the use of the protein-sparing modified fast (PSMF) in overweight (more than 120% ideal body
weight) children and adolescents with serious medical complications who would benefit from rapid weight loss in a
short-term intervention (typically 10 weeks) under the supervision of a multidisciplinary team of health care providers
who specialize in pediatric overweight. Research shows that short-term use of a PSMF brings about short-term and
longer-term improvement in weight status and body composition when part of a medically supervised, multicomponent
program. There are few well-designed studies to support the use of this intervention for longer than 10 weeks
(EAL, 2007).

Pharmacotherapy

Research on the use of weight loss medication in the pediatric population has been limited to adolescents in
conjunction with a structured multicomponent weight management program delivered by an interdisciplinary staff
specializing in pediatric weight management.
The gastrointestinal lipase inhibitor orlistat has been approved by the US Food and Drug Administration (FDA) for use
in adolescents aged 12 years or older. The diet regimen includes a hypocaloric, low-fat (30% energy from fat) diet
supplemented with a multivitamin at bedtime. Potential adverse effects of the medication and poor compliance with the
diet/multivitamin requirements can include malabsorption of fat-soluble vitamins; increased defecation; oily spotting on
clothing; soft, fatty, or oily stools; increased flatulence; and fecal incontinence. The American Dietetic Association's
Evidence-Based Pediatric Weight Management Nutrition Practice Guideline gives a fair and conditional
recommendation for the use of a gastric lipase inhibitor for weight loss in adolescents (EAL, 2007).



Bariatric Surgery

Another treatment option for morbidly obese adolescents for whom other comprehensive dietary and behavioral
approaches to weight loss have been unsuccessful is gastric bypass. Gastric bypass surgery should be performed only
by a surgeon with extensive experience in bariatric surgery and at a center that has a multidisciplinary support staff for
the patient and family for preoperative and postoperative care. Adolescents should receive psychological and nutritional
screening and intervention before the surgery and require long-term medical and nutritional surveillance. A recent
review of 10 adolescents aged 15 to 17 years who underwent gastric bypass surgery found complications including
iron-deficiency anemia, folate deficiency, vitamin D deficiency, cholelithiasis, and protein-energy malnutrition (Strauss,
2001; Inge, 2004).
Recommended criteria for adolescents being considered for weight loss surgery are as follows (EAL, 2007; Barlow,
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2007):
Experienced failure of at least 6 months of organized weight-loss attempts, as determined by their primary care
provider
Have met certain anthropometric and medical criteria:
Be severely obese (BMI 40 or greater) with serious obesity-related medical complications or have a BMI of
50 or more with less severe co-morbidities
Have co-morbidities related to obesity that might be resolved with durable weight loss
Have attained a majority of skeletal maturity (generally at least 13 years of age for girls and at least 15
years of age for boys).
Demonstrate commitment to comprehensive medical and psychological evaluations both before and after
weight-loss surgery
Be capable and willing to adhere to nutritional guidelines post-operatively
Possesses decisional capacity and participates in the decision process to undergo weight-loss surgery. In other
words, the adolescent must want the intervention and understand what is involved.
Have a supportive family environment
Is being evaluated by a multi-disciplinary team that is involved in the patient selection, preparation and surgery as
well as immediate and long-term post-operative follow-up care.
More information on MNT for adolescent bariatric surgery patients can be found in the ADA Pocket Guide to Bariatric
Surgery.

Nutrition Therapy Efficacy

Except for the protein-sparing modified fast and gastric bypass surgery meal plans, all of the dietary interventions
discussed earlier (when planned appropriately) will meet the nutrient requirements based on the Dietary Reference
Intakes for children older than 2 years and for adolescents.

Nutrition Counseling

The American Dietetic Association's Evidence-Based Pediatric Weight Management Nutrition Practice Guideline
consensus recommendation states that nutrition counseling—which includes goal setting, self-monitoring, stimulus
control, problem solving, contingency management, cognitive restructuring, use of incentives and rewards, and social
supports—that is delivered by a registered dietitian (RD) should be a part of the behavior therapy component of a
multicomponent pediatric weight management program. The Guideline strongly recommends that behavior therapy
strategies should be included as part of a multicomponent pediatric weight management program. Research shows that
weight status and body composition improve when behavior therapy strategies are included within the context of a
multidisciplinary team. Family-based counseling that includes parent training or modeling also should be included as
part of a multicomponent weight management program that targets children aged 6 to 12 years.
During the development of a multicomponent treatment program for children aged 12 years and younger, the RD
should advise the health care team on the advantages of incorporating parent training or modeling as part of the
treatment program. Studies that included parent training or modeling as part of a multicomponent weight management
program for children 12 years and younger showed positive changes in a child’s weight status and adiposity
(EAL, 2007).
If parent or caregiver participation is included in child and adolescent weight management programs, health
professionals should tailor the format (eg, group vs. individual format, parent or caregiver with child vs. parent or
caregiver and child separate, etc.) to meet individual, family, and program needs. Research does not show a clear
superiority of one format over another for parent or caregiver participation (EAL, 2007).
Either group or individual nutrition intervention may be used as part of a multicomponent pediatric weight management
program. Limited research that compares individual format with group format does not indicate differences in overall
pediatric weight status. However, two studies suggest that some dietary outcome measures may be improved with an
individual counseling format (EAL, 2007).


Nutrition Education

In a multicomponent program, if there is a nutrition diagnosis for food and nutrition-related knowledge deficit,
the American Dietetic Association's Evidence-Based Pediatric Weight Management Nutrition Practice Guideline
recommends that nutrition education be tailored to the nutrition prescription. Research shows that if nutrition education
is not tailored to nutrition prescription, improvement in weight status is not consistent.
For children under the age of 13 years, parental involvement in education and counseling is recommended. For
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
adolescents, counseling/education can be directed solely to the teen with or with family/caregiver involvement (EAL,
2007; see PWM: Family Participation in Treating Pediatric Obesity in Children and Adolescents)


Physical Activity and Reduction of Sedentary Behaviors

The American Dietetic Association's Evidence-Based Pediatric Weight Management Nutrition Practice Guideline
(EAL, 2007) concludes that using a program to increase physical activity as part of a clinical intervention treatment
program results in significant reductions in weight status/adiposity in children and adolescents. It is unclear whether
lifestyle or structured approaches are more effective. Current physical activity recommendations from the Expert
Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent
Overweight and Obesity (Barlow, 2007) are in agreement with the recommendations from the Centers for Disease
Control, the American Academy of Pediatrics, and the Institute of Medicine. These physical activity recommendations
state that children should engage in 60 minutes of physical activity daily.
Children and adolescents should be counseled to reduce or limit sedentary activities (eg, TV, video games, or other
forms of “screen time”). The American Academy of Pediatrics recommends limiting television viewing to less than 2
hours per day. Intervention research indicates that reducing sedentary activities may have both short-term and
longer-term benefits for pediatric overweight, and limited intervention research indicates that reducing sedentary
activities may have short-term benefits for adolescent overweight. Observational research indicates that TV time may
also be associated with increased consumption of energy-dense foods (EAL, 2007).


Coordination of Nutrition Care

The dietitian should collaborate with members of the health care team whenever possible in planning and implementing
behavior, physical activity, and adjunct therapy strategies. Effective multicomponent interventions for pediatric weight
management benefit from the diverse expertise of different health care professionals (EAL, 2007).

Nutrition Monitoring & Evaluation

A registered dietitian should follow up frequently with patients during the intensive treatment phase. Medical nutrition
therapy (MNT) for pediatric overweight should last at least 3 months or until initial weight management goals are
achieved. Because overweight can be a chronic, often lifelong condition, it is critical that a weight management plan be
implemented after the intensive phase of treatment. A greater frequency of contacts between the patient and
practitioner may lead to more successful weight loss and weight maintenance (EAL, 2007).

Listed below are outcomes that can be used to monitor MNT progress:

Nutrition-Related Behavioral Environmental Outcomes
Physical activity (min/day)
Video game use (hr/day)
Television viewing (hr/day)
Fruit and vegetable intake (servings/day)
Consumption of calorically sweetened beverages (ounces/day)
Parental restriction of highly palatable foods
Meals outside of home (meals/week)
Increased portion sizes
Increased portion sizes
Skipping breakfast (meals/week)

Food and Nutrient Intake Outcomes
Calorie/energy intake
Total fat (g/day)
Saturated fat (g/day)
Trans fat (g/day)
% kcal from fat
% kcal from saturated fat
Dietary cholesterol (mg/day)
% kcal from mono fat
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% kcal from poly fat
% kcal from carbohydrate
Total fiber (g/day)
Calcium (mg/day)
% kcal from protein

Nutrition-Related Physical Sign/Symptom Outcomes
Weight (lbs)
Height (in)
BMI
BMI %
Total cholesterol (mg/dL)
LDL cholesterol (mg/dL)
HDL cholesterol (mg/dL)
Triglycerides (mg/dL)
FBG (mg/dl)
Blood pressure: systolic (mm Hg)
Blood pressure: systolic (mm Hg)
ALT
AST

Nutrition-Related Patient/Client-Centered Outcomes
Self-monitoring

Nutrition Care FAQs

How should a practitioner integrate the Expert Panel Recommendations and the Evidence Analysis Library's
(EAL) Pediatric Weight Management Guidelines in the treatment of the overweight and obese child and
adolescent?
The EAL Pediatric Weight Management Guidelines were developed as a result of an evidence analysis process
involving a workgroup of pediatric obesity experts supported by data analysts. The recommendations are
evidence-based guidelines that include recommendation strengths (strong, fair, weak, etc.) as well as conditions
(conditional or imperative) that enable the practitioner to formulate a nutrition care plan with the child/adolescent and
family.
The Expert Panel Recommendations is a consensus document based on evidence that supports recommendations for
prevention, assessment, and treatment of pediatric overweight and obesity. It offers medical, nutrition, physical activity,
and behavioral guidelines for interdisciplinary practitioners to assess and treat pediatric patients and their family. The
two guidelines are complementary.

Why is there a difference between the EAL Pediatric Weight Management Guidelines and the Expert Panel
Recommendations in the minimum energy recommendations for hypocaloric balanced macronutrient diets for
the school-aged child?
This difference is a result of how the weight management studies involving this population were classified. In the Expert
Panel Recommendations, the studies conducted by Epstein et al with this age group were treated separately from other
studies involving the school-aged child, resulting in a difference in the lower limit of energy recommendations from the
EAL Pediatric Weight Management guidelines, which did not separate this group of studies in its analysis (Epstein
,1984a; Epstein, 1984b; Epstein, 1986; Epstein, 1990; Epstein, 1994; Epstein, 2001; EAL, 2007).

Why do some recommendations for interventions and treatment format differ according to age group?
The recommendations are based on three age groups: age 2 to 5 years, age 6 to 12 years, and and age 13 to 18
years to take into consideration nutrient requirements and growth and development patterns as well as data available
for age groups from the supporting evidence.

Comparative Standards

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If resting metabolic rate (RMR) cannot be measured, then the Institute of Medicine’s total energy expenditure equations
for overweight boys, girls, and adolescents can be used (EAL, 2007). The Institute of Medicine’s report on
macronutrient Dietary Reference Intakes provided formulas to estimate amount of energy needed to maintain energy
balance for sex-specific and age-specific groups at three different physical activity levels for overweight pediatric
patients aged 3 to 18 years (IOM, 2005). These equations are as follows:

Overweight Boys and Adolescent Boys (Aged 3 to 18 years)
114 – (50.9 x Age) + [Physical activity x (19.5 x Weight + 1161.4 x Height)]
Age is measured in years, weight in kilograms, and height in meters.
Physical activity:
Sedentary: 1, Low active: 1.12
Active: 1.24, Very active: 1.45
Weight loss: Deduct 108 kcal/day = 1 lb wt

Overweight Girls and Adolescent Girls (Aged 3 to 18 years)
389 – (41.2 x age) + [Physical activity x (15 x weight + 701.6 x ht)]
Age is measured in years, weight in kilograms, and height in meters.
Physical activity:
Sedentary: 1, Low active: 1.18
Active: 1.35, Very active: 1.60
Weight loss: Deduct 108 kcal/day =1 lb wt loss/month

Physical Activity Definitions (IOM, 2005)
Sedentary
Reflects basal metabolism, thermic effect of food, and physical
activities required for independent living
Low
active
Same as sedentary but includes daily physical activity equivalent to
walking approximately 2 miles per day at 15 to 20 minutes per mile or
an equal amount of other moderate-intensity activities (such as raking
leaves, hand washing or waxing a car, vigorous housework,
low-impact aerobics class) each day
Active
Same as sedentary but includes daily physical activity equivalent to
walking approximately 7 miles per day at 15 to 20 minutes per
mile—approximately 1 hour and 45 minutes to 2 hours and 40
minutes—or 70 minutes of vigorous-intensity activities (bicycle riding,
tennis, jogging)
Very
active
Same as sedentary but includes daily physical activity equivalent to
(on average) walking 7 miles/day at the rate of 3 to 4 mph


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Nutrition Care > Weight Management > Underweight
Biochemical Data, Medical Tests and Procedures

Testing in the underweight child should be targeted only to suspected etiologies or
complications.
Nutrient analysis to evaluate whether the nutrients consumed meet, exceed, or fall
short of expected needs for age and gender
Swallowing and feeding evaluations for choking, chewing, swallowing problems
Medical evaluation related to suspected underlying medical issues, such as:
Gastroenterology - parasite tests, malabsorption studies, fecal volume studies,
reducing substance studies, intestinal imaging
Sweat test to rule out cystic fibrosis
Endocrine work-up for hormonal influences
Developmental Pediatrics for developmental delays
Dual-energy x-ray absortiometry (DEXA) scans to measure bone density
X-ray testing for bone age


Laboratory

Laboratory values offer insight into the source or consequence of underweight. The
following list addresses typical nutrient concerns and their associated lab work-up:
Iron and B
12
or folate status via complete blood count, ferritin, total iron binding
capacity, transferrin
Water imbalance via sodium, potassium, urine specific gravity
Specific vitamin or mineral levels via blood levels
Hypermetabolism via thyroid function tests
General or specific nutrient malabsorption via tissue transglutaminase
Allergies via radioallergosorbent test (RAST)
Excess lead via blood levels
Fat absorption can be revealed through a fecal fat study. Children receiving nutrition
therapy should be assessed for risk of refeeding syndrome and monitored carefully during
the process of renourishment (Baker, 2007).


Client History

Increasing caloric intake and/or absorption cures the underweight, but determining and
addressing the etiology of the inadequate weight is necessary to cure the
problem. Reasons for food rejection might include:
Lack of reminder
Easily distracted
Appetite reduction when excited
“Too busy” to remember
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“Too busy” to remember
“No time” to eat
Lack of cues from smell, sight, or ingestion (Gomez-Pinilla, 2008)
Child’s need for touch and company may exceed parent’s (Feldman, 2004)
Early satiety
Slow or quiet response to hunger cues
Parent of a different temperament may overlook hunger cues
Child may take longer to finish eating than others
Refusal of food
Child may refuse to eat to rebel against parent
Parent may withhold food for disciplinary reasons
“Pickiness” (unwillingness to eat many familiar foods)
Neophobia (unwillingness to eat new foods)
Food aversions (learned behavior)
Anxiety or anger overriding desire to eat (Worobey, 2002)
Taste preferences (Mennella, 2005)
Mood changes caused by malnutrition (Stanga, 2007; Reinblatt, 2008;
Gomez-Pinilla, 2008)
Influence of family and peer eating practices (Batada, 2008)
Lack of previous exposure (Cooke, 2002)
While the central regulations to signal satiety and satiation are many and redundant, the
signals to begin eating are limited and singular (Woods, 2008). In some cases, the need for
help naturally lessens with time, as children who reduce eating when emotionally excited,
feel full easily or early, eat slowly, or who respond less enthusiastically to food reduce
these negative behaviors as they age (Ashcroft, 2008). In the meantime, parents can easily
become frustrated and discouraged, and feeding problems that occur during infancy could
result in parent/child discordances (McDermott, 2008) that last for years.
Since adequate nourishment improves academic performance, mood stability, and social
interactions (Weinreb, 2002), and a child has more success in school having started the
day with breakfast (Kleinman, 2002; Grantham-McGregor, 2005), client history should
include an evaluation of not only number and timing of meals but also daily social
interactions and academic performance. Consider assessing the following:
Who eats with the child and what is the social “climate” during those times?
Where does the child eat and what else is going on during mealtime?
What types of food and beverages are available:
during meals and snacks?
in between meals and snacks?
What are the child’s previous exposures and responses to food?
What are the caregivers' previous responses to child’s acceptance or refusal of the
food?
What times are meals, snacks, and sleeping? Is the schedule structured or varied?
Does the child need more or less structure?
Are the caregivers present throughout the day and night?
How long does the child take to eat?
What happens if the child refuses a food or meal?
How does the child indicate the end of a feeding time?
Who initiates mealtimes (caregiver or child)?
Who determines when the feeding time ends, and how?
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A historical perspective on a patient's developmental and academic progress, in addition to
possible temperament changes, may give insight as to the longevity and impact of the
patient’s underweight status. Evaluate the status of these parameters against a growth
timeline to find clues about behaviors and attitudes that exacerbate poor oral intake.

Food/Nutrition-Related History

When obtaining historical information about dietary intake, in addition to questions
regarding types of food and beverages consumed, registered dietitians should also inquire
about eating behaviors and dynamics between those present during eating opportunities.
Consider questions such as the following:
Who determines when it is time to start eating? How is that determination made?
Consider degree of parental controls – are they encouraging but not restrictive?
Can the child eat when hungry or must the child wait until it is the “right” time?
Who determines when it is time to end eating? How is that determination made?
Can the child stop eating when feeling full?
Is the food sufficient to satisfy the child?
Does the child undereat unless an adult intercedes with reminders?
How does the child participate in food purchasing and preparation?
Does an analytical child who needs to exert control on their environment get an
opportunity to voice opinions before being presented with a meal?
Is the child who needs to plan in advance included in meal preparation as a way
to transition the child from one activity to eating?
Do the desires of a “picky” eater determine the family meals or does the adult
work with the picky eater to incorporate some familiar foods?
Does the child eat at a table?
Can the child move around, appropriate to the child’s age?
Is there a recognized eating place in the home?
Are the table and chairs size-appropriate and safe?
Is time at table limited to 20-30 minutes?
What other activities occur during eating times?
Is the child expected and able to focus on eating as a primary activity or is
another activity distracting?
Is a highly distracted child concentrating on sound or visual diversions rather
than the food?
Who eats with the child?
Consider food consumption modeling by other adults and children: Do they
model feeling and responding to normal hunger and satiety cues? Do they
exhibit food inhibitions or restrictions?
Consider the tone of emotions of all participants at eating times: Does the child
feel emotionally safe while eating? Are adults arguing at the table or elsewhere
but within earshot of the child? Was the child disciplined just before eating?
How often is the child offered a new food to try?
Is the child offered a variety of foods regularly?
Has the child been offered a new food in an emotionally neutral way at least
eight times?
What is the child’s acceptance of a new food and the adult’s reaction to the
child's acceptance?
Are table interactions age-appropriate?
Does the child have access to appropriate-sized utensils?
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Is the adult allowing independence and age-appropriate experiences?
Does an adult still serve an adolescent child food?
Does the adult urge the child to eat too often or too much?
Does the child appropriately experience food through touch (fingers, hands,
face, and so on)?
Have any of the below feeding strategies already been attempted to increase the
child's nutrient intake?
Structured meals and snacks without grazing or sipping
High calorie, nutrient-dense options
Fortifying foods and drinks
Supplements
Are there any problems preparing food for the child?
Consider economics: Does the caregiver have resources such as a stove or
refrigerator?
What are the physical and mental abilities of the caregiver?
The above list is geared towards younger patients. For adolescents, use similar lines of
questioning but also obtain historical information to understand the overall feeding
relationship experienced by the patient.

Calculations for Assessment

See the calculators area for more information.

Nutrition Diagnosis

Dietitians working with patients who are underweight should review the signs and
symptoms obtained in the nutrition assessment and diagnose nutrition problems based on
these signs and symptoms. The below list of potential nutrition diagnoses substantiates the
numerous and confounding etiologies of poor weight gain. Other diagnoses may be
present.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Inadequate enteral nutrition infusion (NI-2.3)
Increased nutrient needs (specify) (NI-5.1)
Malnutrition (NI-5.2)
Inadequate protein-energy intake (NI-5.3)
Inadequate fat intake (NI-5.6.1)
Inadequate protein intake (NI-5.7.1)
Inappropriate intake of protein or amino acids (specify) (NI-5.7.3)
Inadequate carbohydrate intake (NI-5.8.1)
Swallowing difficulty (NC-1.1)
Biting/Chewing (Masticatory) difficulty (NC-1.2)
Breastfeeding difficulty (NC-1.3)
Altered GI function (NC-1.4)
Impaired nutrient utilization (NC-2.1)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
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Unintended weight loss (NC-3.2)
Food- and nutrition-knowledge related deficit (NB-1.1)
Disordered eating pattern (NB-1.5)
Harmful beliefs/attitudes about food- or nutrition-related topics (NB-1.2)
Inability or lack of desire to manage self-care (NB-2.3)
Impaired ability to prepare foods/meals (NB-2.4)
Self-feeding difficulty (NB-2.6)
Intake of unsafe food (NB-3.1)
Limited access to food or water (NB-3.2)
Sample PES or Nutrition Diagnostic Statement(s)
Breastfeeding difficulty (NC-1.3) related to poor latch-on as evidenced by drop of 1
standard deviation in weight per WHO growth chart.
Inappropriate intake of protein (NI-5.7.3) related to corn allergy as evidenced by
diarrhea with corn intake per diet history and inadequate weight gain despite
adequate oral food and beverage intake.
Food- and nutrition-related knowledge deficit (NB-1.1) related to parent restricting
child’s access to age-appropriate snacks as evidenced by poor growth.
Impaired ability to prepare meals (NB-2.4) related to mother’s physical restrictions
(back injury) as evidenced by dinners no longer prepared at home.
Note: Terminology in the examples above is from the American Dietetic Association's
International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to
assist in finding more information about the diagnoses, their etiologies and signs and
symptoms. Dietitians should not include these numbers in routine clinical documentation.

Nutrition Intervention

The long list of potential nutrition intervention terminology substantiates the numerous and
complementary opportunities for interventions in poor weight gain.
Sample Nutrition Interventions
Based on the sample PES statements provided earlier, related interventions may be as
follows:
Diagnosis
Breastfeeding difficulty (NC-1.3) related to poor latch-on as evidenced by drop of 1
standard deviation in weight per WHO growth chart.
Intervention(s)
Collaboration/Referral to another provider (RC-1.3): Recommend urgent referral to
lactation consultant.
Nutrition Education (E-1.5): Recommended modifications in current latch on
sequence (lightly tap baby’s mouth with nipple, baby's chin to nipple first, aim nipple
to top of baby’s mouth).
Diagnosis
Inappropriate intake of protein (NI-5.7.3) related to corn allergy as evidenced by
diarrhea with corn intake per diet history and inadequate weight gain despite
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adequate oral food and beverage intake.
Intervention(s)
Nutrition Education: Nutrition relationship to health/disease (E-1.4)
Nutrition Education: Recommended modifications (corn-allergen-free diet) (E-1.5)
Meal and Snacks: Modify distribution, type, or amount of food and nutrients within
meals (provide protein and energy to meet estimated needs for recovery) (ND-1.2)
Diagnosis
Food- and nutrition-related knowledge deficit (NB-1.1) related to parent restricting
child’s access to age-appropriate snacks as evidenced by poor growth.
Intervention(s)
Nutrition Education: Priority modifications (patient requires x kcals from snacks)
(E-1.2) and nutrition relationship to health/disease (E-1.4)
Strategies: Goal setting (C-2.2): Prepare age-appropriate snacks according to written
guidelines provided today; provide twice daily
Diagnosis
Impaired ability to prepare meals (NB-2.4) related to mother’s physical restrictions
(back injury) as evidenced by dinners no longer prepared at home.
Intervention(s):
Strategies: Goal setting (C-2.2): Mom to coordinate meal preparation support with
extended family for the next 5 weeks; dad to feed patient whenever mom cannot.


Nutrition Therapy Efficacy

Effective nutrition therapy targets the underlying reason for underweight as well as methods
to reverse underweight. Therefore, successful outcomes include patient and family
understanding of issues, adherence to effective interventions, and an achievement of a
healthy weight. In situations with other nutrient deficiencies, interventions reverse the
deficiencies as well.

Goal Setting

The long list of possible nutrition diagnoses reflects the multiple reasons a child may be
underweight. Potential goals to address these etiologies vary from one patient to another,
and possibly even one visit to another for an individual child. Sample goals could include
the following:
Offer bitter-tasting vegetables twice a week. Allow patient to add up to 1/8 teaspoon
of sugar with each serving.
Substitute two breastfeedings each day with expressed breast milk plus formula to
equal 22 cal/oz feedings.
Caregivers to avoid all foods containing corn or corn-related ingredients for three
weeks. Caregivers and patient to record all episodes of diarrhea during these same
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weeks. Patient to follow up for weight check at the end of this time period.
Caregiver to provide daily snacks at 10:00 am and 3:00 pm. Snacks will include one
serving milk or protein and one serving fruit or grain.
Caregiver to cook dinner once a week and make sufficient quantities to freeze
leftovers for another meal.
Caregiver to add 2 teaspoon of dietary fat to each meal for an extra 100 calories a
day.
For adolescent, caregiver to provide only one reminder to eat at meal/snack time.
Review response of patient at 4-week follow-up appointment.

Food & Feeding Issues

Family dining reduces stress within a family and improves the feeding relationship for the
involved children (Franko, 2008; Neumark-Sztainer, 2008). However, dynamics within a
family also impact the feeding relationship for children and adolescents (Ackard, 2001),
with stressful communication during mealtime resulting in negative feeding experiences
(Worobey, 2002). In other words, eating together as a family reduces feeding disorders but
the quality of communication during those shared times may negate or reverse the benefit.
Taste preferences between child and caregiver can vary tremendously. Misguided or
uninformed adults can label children as easy or difficult to feed, based on
misunderstandings of taste preferences. Forcing a child to eat a bitter-tasting food reduces
the likelihood of the child eventually accepting that food (Bell, 2006), causing further
tensions between child and caregiver. The preference for salt and sweet is likely
biologically based and enhanced by repeated exposure (Liem, 2004a). Bitter-taste
sensitivity is determined genetically and children with low tast sensitivity tend to eat more
vegetables than children with higher taste sensitivity (Bell, 2006). Bitter vegetables and
fruits include turnip greens, raw spinach, black olives, broccoli, cucumber, and grapefruit
juice. Salt blocks bitterness (Duffy, 2000), making it an advantageous addition to a
bitter-sensitive child’s food. The preference for sour tastes is likely developed through
positive exposures and a temperament that enjoys new and different experiences (Liem,
2004b). Toddlers who respond favorably to sour tastes eat fruit more often (Glossfeld,
2007), as do older boys (Liem, 2006). An interesting divergence to this trend is older girls
whose fruit intake is more regulated by health-related messages, parental influences, and
availability.
A child learns to accept or reject a food beginning in utero and continuing with infant
feeding experiences (Skinner, 2002; Mennella, 2005). Breastfeeding exposes an infant to
greater taste variations than formula feeding (Cooke, 2002). Those taste variations develop
into earlier acceptance of new foods (Maier, 2008). However, even under these favorable
conditions a child's acceptance of a new food requires repeated exposure, and it can take
up to 10 exposures before the child accepts the food (Sullivan, 1994; Forestell, 2007).
Additionally, parental (particularly maternal) acceptance of foods also trains a child to
accept or reject a food (Galloway, 2003).
In general, children self-regulate energy intake when left alone (Nicklas, 2008), although
those with special health care needs may require more guidance and interventions (Cloud,
2004). Food considered appetizing, as compared to bland, triggers an interest in food and
eating, although the strength of the trigger varies with individuals (Passamonti, 2009).
Practical advice on how to best nurture a healthy relationship with food in a child can be
found in the work of Ellyn Satter (Satter, 1999; Satter, 2000). In short, Satter recommends:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Adults provide the right amount and mix of food and beverages and demonstrate
positive role modeling and encouragement.
Children decide whether and how much to eat of what the adult provided.
Additionally, advertisements aimed at children influence their food preferences (Committee
on Food Marketing and the Diets of Children and Youth, 2006) and promote foods high in
calories but low in nutrients (Batada, 2008). Older children typically respond by overeating
total calories but younger children may respond by underselecting nutrients in favor of
normalizing total calories (McConahy, 2004; Rolls, 2000).

Comparative Standards

Fluid needs for the underweight child are best based on weight or body surface area rather
than age. For children with underlying medical issues, monitoring fluid balance during
renourishment will reduce the risk for electrolyte imbalance or water-loading.
For more information on standards and how to calculate energy and other needs, see
Dietary Reference Intakes and Calculators.

Nutrition Support

Nutrition support is indicated when the child refuses or is unable to consume adequate
calories and protein for renourishment. Examples of these situations:
Mental illness or disability
Underlying medical conditions effecting oral or gastrointestinal tolerance
Caloric demands exceeding the patient's abilities, such as with cystic fibrosis or burns
Enteral nutrition is the preferred route when the gastrointestinal tract is functional.
However, formula choices are based on the medical needs of the patient, keeping in mind
that severely underweight patients may transiently require elemental feedings due to loss of
intestinal villi.
In situations where underweight is consistent with severe malnutrition, the child remains at
high risk for refeeding syndrome during initial feeding progressions, and requires close
monitoring and appropriate supplementation until safely past this stage.

Nutrition Care FAQs

Q: How can I get my child to gain weight?
A: Reduced growth in length or stature may indicate inadequate protein intake, or
inadequate calories to support normal use (tissue growth and repair) of protein intake.
Reduced growth in weight typically indicates inadequate total calories. Weight gain
requires more calorie intake than current levels obtained by the child. However, avoiding a
relapse and achieving a higher caloric or protein intake requires a thorough understanding
of how the weight became too low.
Q: What are the main reasons for underweight?
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A: Typically more than one risk occurs before the child’s weight is impacted. The following
is a quick list of potential risks:
Low family income
Maternal depression
Low maternal education level
Child characteristics perceived as difficult by the caregiver
Insufficient parental supervision
Controlling behavior on the part of parent or child
Taste perceptions
Medical problems interfering with digestion or absorption, increasing metabolism, or
making oral intake difficult
Developmental delays impacting the feeding process


Nutrient Exceptions to DRI

Depending on the severity of the underweight, a child may require protein and/or calories in
excess of the acceptable macronutrient distribution range (AMDR), estimated energy
requirement (EER), or other standardized calculations. See the Catch-Up Growth
Calculator for more information.
Vitamin and mineral deficiencies require

Nutrition Monitoring & Evaluation

Interventions define the need for monitoring and evaluation. Examples of monitoring and
evaluation based on earlier examples include the following:
Diagnosis
Breastfeeding difficulty (NC-1.3) related to poor latch-on as evidenced by drop of 1
standard deviation in weight per WHO growth chart.
Intervention(s)
Collaboration/Referral to another provider (RC-1.3): Recommend urgent referral to
lactation consultant.
Nutrition Education (E-1.5): Recommended modifications in current latch on
sequence (lightly tap baby’s mouth with nipple, baby's chin to nipple first, aim nipple
to top of baby’s mouth).
Monitoring & Evaluation
Weight and Growth Recommendations: Desired growth pattern CS-5.1.3 Weight
check in 2 weeks
Breastfeeding problems: Assess mom’s comfort with process FH-7.1.4

Diagnosis
Inappropriate intake of protein (NI-5.7.3) related to corn allergy as evidenced by
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
diarrhea with corn intake per diet history and inadequate weight gain despite
adequate oral food and beverage intake.
Intervention(s)
Nutrition Education: Nutrition relationship to health/disease (E-1.4)
Nutrition Education: Recommended modifications (corn-allergen-free diet) (E-1.5)
Meal and Snacks: Modify distribution, type, or amount of food and nutrients within
meals (provide protein and energy to meet estimated needs for recovery) (ND-1.2)
Monitoring & Evaluation
Level of knowledge regarding sources of corn allergen FH-4.1
Food intake: Diet quality index FH 1.2.2.4
Weight and Growth Recommendations: Desired growth pattern CS-5.1.3
Nutrition-focused physical findings: Digestive system (cessation of diarrhea) PD-1.1.5

Diagnosis
Food- and nutrition-related knowledge deficit (NB-1.1) related to parent restricting
child’s access to age-appropriate snacks as evidenced by poor growth.
Intervention(s)
Nutrition Education: Priority modifications (patient requires x kcals from snacks)
(E-1.2) and nutrition relationship to health/disease (E-1.4)
Strategies: Goal setting (C-2.2): Prepare age-appropriate snacks according to written
guidelines provided today; provide twice daily
Monitoring & Evaluation
Weight and Growth Recommendations: Desired growth pattern CS-5.1.3
Beliefs and attitudes: Conflict with mom/family value system FH-4.2.1

Diagnosis
Impaired ability to prepare meals (NB-2.4) related to mother’s physical restrictions
(back injury) as evidenced by dinners no longer prepared at home.
Intervention(s):
Strategies: Goal setting (C-2.2): Mom to coordinate meal preparation support with
extended family for the next 5 weeks; dad to feed patient whenever mom cannot.
Monitoring & Evaluation
Mealtime behavior; caregiver fatigue during feeding process resulting in inadequate
intake FH-5.4.7
Social network: Ability to build and utilize social network FH-5.5.1

Nutrition-Focused Physical Findings

Good health is synonymous with normal growth for the pediatric and adolescent
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Good health is synonymous with normal growth for the pediatric and adolescent
populations. Measuring subcutaneous fat through triceps skinfold and mid-arm muscle
circumference provides an additional measurement of body weight distribution .
In a situation where a specific nutrient deficiency is suspected, a thorough examination
might reveal physical findings to substantiate the concern.

Anthropometric Measurements

A thorough nutrition assessment is indicated in children who are deemed underweight or
with poor weight gain because normal growth is a necessity for good health (Baker, 2007).
Weight evaluations include comparisons on the following:
Against national (CDC Growth Charts, 2000), world (World Health Organization,
2006), or syndrome-specific averages (Note the limitations of the syndrome-specific
charts)
Weight-for-age
Weight-for-length/stature
Body Mass Index (BMI)
On a growth chart for individual variation over time
The average rate of weight gain against expected averages per age
A child is classified as underweight if his or her weight-for-length or BMI-for-age is less than
the 5th percentile (Polhamus, 2003). Also concerning is a child whose weight-for-age is
less than the 5th percentile (Leonberg, 2008).
The American Academy of Pediatrics recommends pediatricians and family physicians
screen all children’s weight and growth patterns at least annually (American Academy of
Pediatrics, 2009). Primary care physicians typically refer even mildly underweight children
more readily than overweight children (Miller, 2002). Slowing or sudden changes in weight
gain velocity warrant a nutrition assessment (Baker, 2007). For this reason, dietitians and
dietetic technicians should be well versed in interpreting growth patterns. A thorough
evaluation of a child’s growth includes an evaluation of the biological parents’ height and
weight. For instance, thinner children tend to grow into thinner adults (Ashcroft, 2008) and
will likely be patterned after at least one parent.
Growth is measured in weight, stature, and in young children, head circumference
(Leonberg, 2008). Of these anthropometric measurements, weight is the most sensitive to
the onset of health or nutritional intake disturbances. Weight measurements are also easier
to obtain than length measurements. At least for the newborn, length measurements
provide more accurate information about current and long-term growth (Moyer-Mileur,
2007). So if in doubt, both measurements should be obtained and evaluated against
normalized growth standards. Evaluate weight-for-age and length-for-age, in addition to
weight for length. Use growth charts from the Centers for Disease Control and Prevention
or others designed for specific populations, such as Down Syndrome (CDC, 2000;
Leonberg, 2008).
In the context of comparing growth chart information, weight-for-length (vs weight-for-age)
provides insight as to whether the child’s poor growth may be chronic or acute. Chronic
under-nutrition generally stunts overall growth whereas acute malnutrition results in
wasting. Underweight can also be due to a combination of stunting and wasting (Garza,
2007). Comparing weight-for-height growth velocities also provides an opportunity to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
classify the degree of malnutrition observed (Hendricks, 2007). Using the Center for
Disease Control definition of underweight, BMI-for-age is less than the 5th percentile
(CDC, 2000), or, using the Waterlow classifications of underweight (Waterlow, 1972),
percent ideal body weight (50th percentile weight for current length/height) of:
90% or greater = Normal weight
80-90% = Mild wasting
70-80% = Moderate wasting
<70% = Severe wasting

Metabolic Rate Profile (Indirect Calorimetry)

Indirect calorimetry provides an opportunity to evaluate a patient’s resting energy
expenditure against predicted norms. For an underweight child, this information can aid in
the determination of the presence and impact of a hypo- or hyper-metabolic state.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References home page
Welcome to the References home page.
Here you can find full alphabetical lists of references for every section of this website,
complete with links to article abstracts or full texts (if available). Please select your topic of
interest in the left-hand navigation for more information.
References > Modified Consistency Meal Plans
References: Modified Consistency Meal Plans

American Academy of Pediatrics. Section on Breastfeeding. Breastfeeding and the use of
human milk. Pediatrics. 2012 Mar;129(3):e827-41. Epub 2012 Feb 27. Related
links: Abstract
American Diabetes Association, Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark
NG, Franz MJ, Hoogwerf BJ, Lichtenstein AH, Mayer-Davis E, Mooradian AD, Wheeler
ML. Nutrition Recommendations and Interventions for Diabetes: A position statement of the
American Diabetes Association. Diabetes Care. 2008 Jan;31 Suppl 1:S61-78. Related
links: Full Text
Arvedson J. Assessment of pediatric dysphasia and feeding disorders: Clinical and
instrumental approaches. Dev Disabil Res Rev. 2008;14:118-127. Related links: Abstract
Chima C, Dietz-Seher C, Kushner-Benson S. Nutrition risk screening in acute care: A
survey of practice. Nutr Clin Pract. 2008;23(4):417-423. Related links: Abstract
Cook-Sather S, Litman R. Modern fasting guidelines in children. Best Pract Res Clin
Anaesthesiol. 2006;20(3):471-481. Related links: Abstract
De Aguilar-Nascimento J, Dock-Nascimento D. Reducing preoperative fasting time: A trend
based on evidence. World J Gastrointest Surg. 2010;2(3):57-60. Related links: Abstract;
Full Text
El-Baba M, Padilla M, Houston C, Madani S, Lin C, Thomas R, Tolia V. A prospective
study comparing oral sodium phosphate solution to a bowel cleansing preparation with
nutrition food package in children. J Pediatr Gastroenterol Nutr. 2006;42(2):174-177.
Related links: Abstract
Franklin G, McClave S, Hurt R, Lowen C, Stout A, Stogner L, Priest N, Haffner M, Deibel K,
Bose D. Physician-delivered malnutrition: why do patients receive nothing by mouth or a
clear liquid diet in a university hospital setting? JPEN J Parenter Enteral Nutr.
2011;3:337-342. Related links: Abstract
Hancock S, Cresci G, Martindale R. The clear liquid diet: when is it appropriate? Curr
Gastroenterol Rep. 2002;4:324-31.Related links: Abstract
Hurlock-Chorostecki C. Initial refeeding with a soft diet was better than a clear liquid diet
for length of stay in mild acute pancreatitis. Evid Based Nurs. 2009;12(1):22.
Jacobson B, Vander Vliet M, Hughes M, Maurer R, McManus K, Banks P. A prospective,
randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute
pancreatitis. Clin Gastroenterol Hepatol. 2007;5(8):946-951. Related links: Abstract; Full
Text
James DC, Lessen R. Position of the American Dietetic Association: promoting and
supporting breastfeeding. J Am Diet Assoc. 2009;109:1926-1942. Related links: Abstract
Jeffery K, Harkins B, Cresci G, Martindale R. The clear liquid diet is no longer a necessity
in the routine postoperative management of surgical patients, Am Surg.
1996;62(3):167-170. Related links: Abstract
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Mahan LK, Escott-Stump S. Krause’s Food, Nutrition & Diet Therapy. 11th ed.
Philadelphia, PA: Saunders; 2004.
Martindale R. Clear liquid diets: Tradition or intuition? Nutr Clin Pract. 1998;13:186-187.
Miller K. Updates on pediatric feeding and swallowing problems. Curr Opin Otolaryngol
Head Neck Surg. 2009;17(3):194-199. Related links: Abstract
Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to
Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing
Elective Procedures: An Updated Report by the American Society of Anesthesiologists
Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511.
Related links: Full Text
Prasse J, Kikano G. An overview of pediatric dysphagia. Clin Pediatr. 2009;(3)48:247-251.
Related links: Abstract
Sathiearaj E, Murthy S, Mansard M, Rao G, Mahukar S, Reddy D. Clinical trial: Oral
feeding with a soft diet compared with clear liquid diet as an initial meal in mild acute
pancreatitis. Aliment Pharmacol Ther. 2008;28(6):777-781. Related links: Abstract
Smith I, Kranke P, Murat I, Smith A, O’Sullivan G, Sreide E, Spies C, In’t Veld B.
Perioperative fasting in adults and children: guidelines from the European Society of
Anesthesiology. Eur J Anaesthesiol. 2011;28(8):556-569. Related links: Abstract; Full Text
Soweid A, Kobeissy A, Jamaili F, El-Tarchichi M, Skoury A, Abdul-Baki H, El-Zahabi L,
El-Sayyed A, Barada K, Sharara A, Mourad F, Arabi A. A randomized single-blind trial of
standard diet versus fiber-free diet with polyethylene glycol electrolyte solution for
colonoscopy preparation. Endoscopy. 2010;42(8):663-638. Related links: Abstract
Warren J, Bhalla V, Cresci G. Postoperative diet advancement: Surgical dogma vs
evidence-based medicine. Nutr Clin Pract. 2011;26(2):115-125. Related links: Abstract
Yurtcu M, Gunel E, Sahin T, Sivrikaya A. Effects of fasting and preoperative feeding in
children. World J Gastroenterol. 2009;15(39):4919-4922. Related links: Abstract; Full Text

Weblinks: Modified Consistency Meal Plans

American Speech-Language-Hearing Association: Pediatric Dysphagia and Dysphagia
Diets. Accessed March 26, 2012.
Medscape: Dysphagia. Accessed March 26, 2012.

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References > Nutrition Care > Nutrition Assessment > Comparative Standards
Comparative Standards

See Parenteral Nutrition Nutrient Requirements and Enteral Nutrition Nutrient Requirements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Nutrition Care > Nutrition Assessment > Intake Assessment
Intake Assessment

Data Collection
To assess dietary intake, review the medical record or nursing flow sheets to determine
nutrient sources—parenteral nutrition (PN); intravenous solutions; human milk; human milk
fortifier; infant formula; and vitamin, mineral, or other modular supplements.
Data Analysis
The dietary intake assessment should include both qualitative and quantitative analyses.
In the qualitative analysis, consider whether current nutrient solutions are appropriate
for the patient’s gestational age, size, tolerance issues (if any), and diagnoses.
In the quantitative analysis, calculate nutrient intakes (at least mL/kg/day, kcal/kg/day,
and grams of protein/kg/day).
PN calculations (including dextrose, crystalline amino acids, and intravenous fat
grams per kilogram per day) are done in the same way for infants as they are for
other populations.
Dextrose and/or electrolytes in intravenous drip medications often contribute
substantially to an infant’s intake and are calculated.
Occasionally, even medication flushes influence the small infant’s glucose or
electrolyte status.
A more detailed, targeted nutrient intake analysis may be done on intakes of
infants with certain diagnoses or conditions (eg, assessing calcium, phosphorus,
and vitamin D intake for infants with osteopenia).
Calculating Nutrient Intakes
Calculations of nutrient intakes are compared with recommended intakes (see Parenteral
Nutrition and Enteral Nutrition for recommendations) and interpreted in light of the baby’s
medical condition and growth. Following is an example of how to calculate nutrient intake.
Sample Nutrient Intake Calculation for 1,500-g Preterm Infant
Intake
Maternal milk fortified to 24 kcal/fl oz with human milk fortifier, taking 28 mL every 3 hours
Calculations
28 mL × 8 feedings/day = 224 mL/d ÷ 1.5 kg = 149 mL/kg/d
149 mL/kg/d × 0.8 kcal/mL
a
= 119 kcal/kg/d
149 mL/kg/d × 0.024 g protein/mL
a
= 3.6 g protein/kg/d
a
For most precise calculations, consult the specific manufacturer’s literature.

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References > Nutrition Care > Nutrition Assessment > Nutrition > Focused Physical Findings
Nutrition-Focused Physical Findings

Observe the infant’s general condition, bedside nursing documentation, feeding tolerance,
and medical status. Additional information on physical observations is included under the
following headings.


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References > Nutrition Care > Nutrition Monitoring & Evaluation
Nutrition Monitoring & Evaluation

The purpose of nutrition monitoring and evaluation in neonatal intensive care units,
intermediate neonatal care units, normal newborn nurseries, newborn follow-up clinics, or
pediatricians’ offices is to assess progress toward nutrition goals and expected
outcomes. Goals and expected outcomes are defined by reference standards or an
improvement in nutrition care indicators and may be categorized using the nutrition
assessment terminology categories as follows:
Food/Nutrition-Related History Outcomes (FH)
Food and Nutrient Intake (1)
Food and Nutrient Administration (2)
Breastfeeding (7.1)
Anthropometric Measurement Outcomes (AD)
Length
Weight
Weight change
Growth pattern indices/percentile ranks for corrected age for prematurity
Head circumference
Weight-for-age
Length-for-age
Head circumference-for-age
Weight-for-length
Bone density and bone age
Biochemical Data, Medical Tests and Procedure Outcomes (BD)
Laboratory data
Electrolyte
Essential fatty acid
Gastrointestinal measures
Glucose
Mineral
Nutritional anemia
Protein
Vitamin profiles
Nutrition-Focused Physical Finding Outcomes (PD)
Overall appearance
Extremities, muscles, bones
Digestive system
Skin
Vital signs
Critical thinking is necessary when completing the following step of the nutrition care
process*:
Select the appropriate indicators or measures to monitor and evaluate the impact of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition intervention on the patient’s/client’s progress toward defined goals.
Examples include the following:
Grams per day weight gain
Grams per kilogram per day protein intake
Serum alkaline phosphatase level
Use current and age-specific/disease-specific reference standards for comparison.
Examples include the following:
120 kcal/kg/d and 4 g protein/kg/day for infants 0.9 kg to 1.2 kg (Ziegler, 2007)
400 mcg zinc/kg/day parenteral zinc requirement for preterm infants (Tsang,
2005)
Define progress toward goals in terms of expected outcomes. Examples include the
following:
Increase in head circumference of 0.6 cm/week compared with standard 0.9
cm/week (Moyer-Mileur, 2007).
Compared to a norm of less than 550 IU/L, and a previous level of 850 IU/L,
alkaline phosphatase is now 750 IU/L after mineral intake was increased.
Explain any variance from expected outcomes. Examples include the following:
Increase in head circumference is less than expected, which may be related to
use of steroid medication
Less than expected weight gain, which may be related to temperature instability
during weaning from isolette to open crib
Identify factors that enhance or impede progress and ways to address these factors.
Examples include the following:
Frequent episodes of vomiting are impeding progress toward full enteral
feedings; giving gavage feedings over longer duration(eg, over 60 minutes
instead of 10 minutes) may prevent vomiting and allow continued progression to
full enteral feedings
Interrupting parenteral nutrition for antibiotic administration is preventing
adequate parenteral nutrition intake; increase parenteral nutrition hourly rate
during the 20 hours of parenteral nutrition administration to accommodate 4
hours of antibiotic infusion
Identify when follow-up will occur, or if nutrition care can be discontinued. Examples
include the following:
Follow-up in 5 days
Nutrition goals are met; no nutrition care follow-up is necessary at this time
*Adapted from Pocket Guide for International Dietetics & Nutrition Terminology Reference
Manual. 3rd edition. Chicago, IL: American Dietetic Association; 2011: 314.

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References > Normal Nutrition
Normal Nutrition


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References > Normal Nutrition > Breastfeeding & Lactation Support
References: Breastfeeding & Lactation Support

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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powdered infant formula. Available at: Website. Accessed January 28, 2010.
WHO Working Group on the Growth Reference Protocol and the WHO Task Force on
Methods for the Natural Regulation of Fertility. Growth of healthy infants and the timing,
type, and ferquency of complementary foods. Am J Clin Nutr. 2002;76:620-627.
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Neonatol. 2009;50:135-142.
Yliharsila H, Kajantie E, Osmond C, Forsen T, Barker DJP, Eriksson JG. Body mass index
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Yliharsila H, Kajantie E, Osmond C, Forsen T, Barker DJP, Eriksson JG. Body mass index
during childhood and adult body composition in men and women aged 56-70 y. Am J Clin
Nutr. 2008;87;1769-1775. Related links: Abstract; Full Text
Yu ZB, Han SP, Zhu GZ, Zhu C, Wang XJ, Cao XG, Guo XR. Birth weight and subsequent
risk of obesity: A systematic review and meta-analysis. Obes Rev. 2011;12:525-542.
Zeiger RS. Food allergen avoidance in the prevention of food allergy in infants and
children. Pediatrics. 2003;111:1662-1671. Related links: Abstract; Full Text
Ziegler EE, Nelson SE, Jeter JM. Iron supplementation of breastfed infants from an early
age. Am J Clin Nutr. 2009;89:525-532. Related links: Abstract; Full Text
Ziegler E, Vnaderhoof JA, Petschow B, Mitmesser SH, Stolz SI, Harris CL, Berseth CL.
Term infants fed formula supplemented with selected blends of prebiotics grow normally
and have soft stools similar to those reported for breast-fed infants. J Pediatr Gastroenterol
Nutr. 2007;44:359-364. Related links: Abstract
Ziegler EE, Jiang T, Romero E, Vinco A, Frantz JA, Nelson SE. Cow’s milk and intestinal
blood loss in late infancy. J Pediatr. 1999;135:720-726. Related links: Abstract
Zutavern A, Brockow I, Schaaf B, Bolte G, von Berg A, Diez U, Borte M, Herbarth O,
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atopic dermatitis and atopic sensitization: Results from a prospective birth cohort study.
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2008;121:e44-e52. Related links: Abstract; Full Text

Web Links

American Academy of Pediatrics presents information on a variety of health topics for
parents and professionals and a listing of publications and books.
Feeding Your Newborn: What You Need to Know is an article by the Mayo Clinic that
provides information on feeding infants; links to infant health information are available at
the end of the page.
Food and Nutrition Information Center is a collection of resources on infant nutrition and
feeding, including books, pamphlets, and audiovisuals published since 2000.
HealthyChildren.org, from the American Academy of Pediatrics provides child health
information, including nutrition from birth through adolescence, for parents.
Healthy Meals Resource System provides information on infant feeding for child care
providers from the US Department of Agriculture (USDA).
Infant and Toddler Nutrition, managed by the National Library of Medicine, provides
information for parents and professionals regarding infant nutrition along with links to other
resources.
Infant Nutrition from The World Health Organization (WHO) provides information on WHO
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Infant Nutrition from The World Health Organization (WHO) provides information on WHO
initiatives and publications related to infant feeding.
Maternal & Infant Nutrition Briefs is a research-based newsletter for professionals
interested in maternal and infant nutrition, published by the University of California–Davis
Department of Nutrition
North American Society of Pediatric Gastroenterology Hepatology, and
Nutrition provides family resources, clinical guidelines, and position statements
Pediatric Nutrition Practice Group of the American Dietetic Association aims to promote
optimal nutrition as part of a healthy lifestyle for all infants, children, and adolescents
through education, research, and service by qualified dietetics professionals.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) of the
USDA provides online professional training resources and materials for WIC audiences via
its WIC Works Resource System.
Wellstart International is a nonprofit organization in San Diego, CA, dedicated to optimal
mother and infant nutrition worldwide.
WIC Works Infant Nutrition and Health has an infant feeding guide for professionals;
information on breastfeeding, bottle feeding, complementary foods, and oral health; and
links to reports and statistics and general education materials.
(Websites last accessed January 31, 2012)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Normal Nutrition > Toddlers
References: Normal Nutrition for Toddlers

American Dietetic Association. Position of The American Dietetic Association: Dietary
guidelines for healthy children aged 2 to 11 years. J Am Diet Assoc. 2008;108:1038-1047.
Related Links: Abstract; Full text
Center for Nutrition Policy and Promotion. USDA Food Guidance System. Health and
Nutrition Information for Preschoolers; Daily Food Plan. Available at: Website. Last
accessed May 3, 2012.
Daniels SR, Greer FR, Committee on Nutrition. Lipid screening and cardiovascular health
in childhood. Pediatrics. 2008;122(1):198-208. Related Links: Abstract; Full Text
Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans. Washington,
DC: USDA, HHS; 2010. Related Links: Website
Food and Nutrition Board, Institute of Medicine, Standing Committee on the Scientific
Evaluation of Dietary Reference Intakes. Dietary Reference Intakes: The Essential Guide
to Nutrient Requirements. Washington, DC; National Academy Press; 1997-2006. Related
Links: Website
Hornick B, Krester A, Nicklas T. Menu modeling with MyPyramid food patterns:
Incremental dietary changes lead to dramatic improvements in diet quality of menus. J Am
Diet Assoc. 2008;108:2077-2083. Related Links: Abstract
Maber AK, ed; Iowa Dietetic Association. Nutrition Guidelines for Children. In: Simplified
Diet Manual. 10th ed. Ames, IA: Blackwell Publishing Professional; 2007. Related
Links: Website
NCMHD Center of Excellence for Nutritional Genomics. Lactose Intolerance: Molecular
Explanation. Related Links: Website. Accessed February 15, 2010.
National Center for Health Statistics, National Center for Chronic Disease Prevention and
Health Promotion. Growth Charts; 2000. Related Links: Website
Nunn MD, Braunstein NS, Krall Kaye EA, Dietrich T, Barcia RI, Henshaw MM. Healthy
eating index is a predictor of early childhood caries. J Dent Res. 2009;88(4):361-366. Related
Links: Abstract Full Text
Patrick H, Nicklas TA. A review of family and social determinants of children’s eating
patterns and diet quality. J Am Coll Nutr. 2005;24(2):83-92. Related Links: Abstract; Full
text
Samour P, Helm K. Handbook of Pediatric Nutrition. 3rd ed. Sudbury, MA: Jones & Bartlett
Publishing; 2005.
Satter E. Secrets of Feeding a Healthy Family: Orchestrating and Enjoying the Family
Meal. 2nd ed. Madison, WI: Kelcy Press; 2008.
Shelov SP, Altmann TR, eds. Caring for Your Baby and Young Child, 5th ed. Elk Grove, IL:
American Academy of Pediatrics, 2009. Available at: Website.
Trahms CM, Pipes PL. Nutrition in Infancy and Childhood. New York: McGraw-Hill Science;
1997.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Normal Nutrition > Preschool Children
References: Normal Nutrition for Preschool Children

American Dietetic Association. Position of The American Dietetic Association: Dietary
guidelines for healthy children aged 2 to 11 years. J Am Diet Assoc. 2008;108:1038-1047.
Center for Nutrition Policy and Promotion. USDA Food Guidance System. Health and
Nutrition Information for Preschoolers; Daily Food Plan. Available at: Website. Last
accessed May 3, 2012.
Daniels SR, Greer FR; Committee on Nutrition. Lipid screening and cardiovascular health
in childhood. Pediatrics. 2008;122(1):198-208. Related Links: Abstract; Full text
Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans. Washington,
DC: USDA, HHS; 2010. Available at: Website.
Food and Nutrition Board, Institute of Medicine, Standing Committee on the Scientific
Evaluation of Dietary Reference Intakes. Dietary Reference Intakes: The Essential Guide
to Nutrient Requirements. Washington, DC; National Academy Press, 1997-2006. Related
Links: Website
Hornick B, Krester A, Nicklas T. Menu modeling with MyPyramid food patterns:
Incremental dietary changes lead to dramatic improvements in diet quality of menus. J Am
Diet Assoc. 2008;108:2077-2083. Related Links: Abstract
Kranz S. Meeting the Dietary Reference Intakes for fiber: Sociodemographic
characteristics of preschoolers with high fiber intakes. Am J Public Health.
2006;96:1538-1541. Related Links: Abstract
Maber AK, ed; Iowa Dietetic Association. Nutrition Guidelines for Children. In: Simplified
Diet Manual. 10th ed. Ames, IA: Blackwell Publishing Professional; 2007. Related
Links: Website
NCMHD Center of Excellence for Nutritional Genomics, Lactose Intolerance: Molecular
Explanation. Related Links: Website Accessed February 15, 2010.
National Center for Health Statistics, National Center for Chronic Disease Prevention and
Health Promotion. Growth Charts; 2000. Related Links: Website
Nunn MD, Braunstein NS, Krall Kaye EA, Dietrich T, Barcia RI, Henshaw MM. Healthy
eating index is a predictor of early childhood caries. J Dent Res. 2009;88(4):361-366.
Related Links: Abstract; Full text
Patrick H, Nicklas TA. A review of family and social determinants of children’s eating
patterns and diet quality. J Am Coll Nutr. 2005;24(2):83-92. Related Links: Abstract; Full
text
Samour P, Helm K. Handbook of Pediatric Nutrition. 3rd ed. Sudbury, MA: Jones & Bartlett
Publishing; 2005.
Satter E. Secrets of Feeding a Healthy Family: Orchestrating and Enjoying the Family
Meal. 2nd ed. Madison, WI: Kelcy Press; 2008.
Shelov SP, Altmann TR, eds. Caring for Your Baby and Young Child, 5th ed. Elk Grove, IL:
American Academy of Pediatrics, 2009. Available at: Website.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Trahms CM, Pipes PL. Nutrition in Infancy and Childhood. New York: McGraw-Hill Science;
1997.
United States Department of Agriculture (USDA), Food and Nutrition Information Services,
2005. MyPyramid for preschoolers. Related Links: Website Accessed February 10, 2010.
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Medicaid-eligible children aged 1-5 years: An updated approach to targeting a group at
high risk. MMWR Recomm Rep. 2009;58(RR-9):1-11. Related Links: Abstract; Full text

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Normal Nutrition > School > Age Children
References: Normal Nutrition for School-Age Children

American Academy of Pediatrics. Clinical Practice Guideline: diagnosis and evaluation of the child with attention
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American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics. 2000;105:671-680. Related
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American Dietetic Association. Position of the American Dietetic Association: Dietary guidance for healthy children
aged 2-11 years. J Am Diet Assoc. 2008;108:1038-1047. Related Links: Abstract
American Dietetic Association. Position of the American Dietetic Association: Local support for nutrition integrity in
schools. J Am Diet Assoc. 2006;106:122-133. Related Links: Abstract
Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M. Relationship of physical activity and television watching with
body weight and level of fatness among children. JAMA. 1998;279:938-942. Related Links: Abstract
Anzman SL, Birch LL. Low inhibitory control and restrictive feeding practices predict weight outcomes. J Pediatr.
2009;155:651-656. Related Links: Abstract
Baranowki T, Smith M, Baranowki J, Wang DT, Doyle C, Lin LS, Hearn MD, Resnicow K. Low validity of a seven-item
fruit and vegetable food frequency questionnaire among third-grade students. J Am Diet Assoc. 1997;97:66-68.
Baker SS, Cochran WJ, Flores CA, Georgieff MK, Jacobsen, MS, Jaksic T, Krebs MS. American Academy of
Pediatrics Committee on Nutrition. Calcium requirements of infants, children and adolescents. Pediatrics.
1999;104:1152-1157. Related Links: Abstract; Full Text
Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics. 1998;101:539-549.
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Birch LL, Fisher JO. Mothers’ child-feeding practices influence daughters’ eating and weight. Am J Clin Nutr.
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Centers for Disease Control and Prevention. Competitive foods and beverages available for purchase in secondary
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Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122:198-208. Related
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Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics.
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Eisenberg ME, Olson RE, Neumark-Sztainer D, Story M, Bearinger LH. Correlations between family meals and
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Full Text
Fisher EA, Van Horn L, McGill HC. Nutrition and children: A statement for healthcare professionals from the nutrition
committee. American Heart Association. Circulation. 1997;95:2332-2333.
Fisher JO, Birch LL. Parent’s restrictive feeding practices are associated with young girls’ negative self-evaluation of
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The Food Allergy & Anaphylaxis Network. New Laws Passed in 2009! Available at: Website. Accessed October 19,
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Greer FR. Issues in establishing vitamin D recommendations for infants and children. Am J Clin Nutr.
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Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: nutritional consequences. J
Am Diet Assoc. 1999;99:436-441. Related Links: Abstract
Healthy People 2010. Washington, DC: US Dept of Health and Human Services; 2000.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Healthy People 2010. Washington, DC: US Dept of Health and Human Services; 2000.
Infante D, Tormo R. Risk of inadequate bond mineralization in diseases involving long-term suppression of dairy
products. J Pediatr Gastroenterol Nutr. 2000;30:310-313. Related Links: Abstract
Institute of Medicine. Nutrition standards and meal requirements for national school lunch and breakfast programs:
Phase 1. Proposed approach for recommending revisions. Washington DC: National Academy of Sciences; 2008.
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Abstract
Nutrition services: an essential component of comprehensive school health programs—Joint position of American
Dietetic Association, Society for Nutrition Education and American School Food Service Association. J Am Diet Assoc.
2003;103:505-514. Related links: Abstract
Obarzanek E, Kimm S, Barton B, Van Horn L, Kwiterovich P, Simons-Morton D, Hunsberger S, Lasser N, Robson A,
Franklin F, Lauer R, Stevens V, Friedman L, Dorgan J, Greenlick M. Long-term safety and efficacy of a
cholesterol-lowering diet in children with elevated low-density lipoprotein cholesterol: seven-year results of the dietary
intervention study in children (DISC). Pediatrics. 2001;107:256-264. Related Links: Abstract
Reynolds KD, Franklin FA, Binkley D, Raczynski JM, Harrington KF. Increasing the fruit and vegetable consumption of
fourth-graders: Results from the high 5 project. Prev Med. 2000;30:309-319. Related Links: Abstract
Rhee KE, Appugliese DP, Kaciroti N, Bradley RH. Parenting styles and overweight status in first grade. Pediatrics.
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Robinson TN. Reducing children’s television viewing to prevent obesity: A randomized controlled trial. JAMA.
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Story M, Holt K, Sofka D, eds. Bright Futures in Practice: Nutrition. 2nd ed. Arlington, VA: National Center for
Education in Maternal and Child Health; 2002.
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for Leadership, Education, and Training in Maternal and Child Nutrition, University of Minnesota; 2000.
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US Department of Agriculture, Food and Nutrition Services. National School Lunch Program, State Competitive Foods
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U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC:
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Centers for Disease Control and Prevention. Clinical Growth Charts. Available at:
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The Food Allergy & Anaphylaxis Network. New Laws Passed in 2009! Available at:
http://www.foodallergy.org/page/legislation. Accessed October 19, 2009.
MyPyramid for kids:
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Normal Nutrition > Adolescents
References: Normal Nutrition for Adolescents

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American Academy of Pediatrics Committee on Nutrition. Calcium requirements of infants,
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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References > Normal Nutrition > Child Athletes
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Normal Nutrition > Vegetarian Children
References: Normal Nutrition for Vegetarian Children

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Drake R, Reddy S, Davies J. Nutrient intake during pregnancy and pregnancy outcome of
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Hebbelinck M, Clarys P. Physical growth and development of vegetarian children and adolescents.
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Lea EJ, Crawford D, Worsley A. Public views of the benefits and barriers to the consumption of a
plant-based diet. Eur J Clin Nutr. 2006a;60:828-837. Related Links: Abstract
Lea EJ, Crawford D, Worsley A. Consumers' readiness to eat a plant-based diet. Eur J Clin Nutr.
2006b;60:342-351. Related Links: Abstract
Mangels AR, Messina V. Considerations in planning vegan diets: Infants. J Am Diet Assoc.
2001;101:670-677. Related Links: Abstract
Mangels R, Messina V, Messina M. The Dietitian's Guide to Vegetarian Diets: Issues and
Applications. 3rd ed. Sudbury, MA: Jones and Bartlett Learning; 2011.
Martins Y, Pliner P, O’Connor R. Restrained eating among vegetarians: Does a vegetarian eating
style mask concerns about weight? Appetite. 1999;32:145-154. Related Links: Abstract
Messina V, Mangels AR. Considerations in planning vegan diets: Children. J Am Diet Assoc.
2001;101:661-669. Related Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Messina V, Melina V, Mangels AR. A new food guide for North American vegetarians. J Am Diet
Assoc. 2003;103:771-775. Related Links: Abstract
Nathan I, Hackett AF, Kirby S. A longitudinal study of the growth of matched pairs of vegetarian
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Full Text
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Perry CL, McGuire MT, Neumark-Sztainer D, Story M. Adolescent vegetarians. How well do their
dietary patterns meet the Healthy People 2010 objectives? Arch Pediatr Adolesc Med.
2002;156:431-437. Related Links: Abstract; Full Text
Perry CL, McGuire MT, Newmark-Sztainer D, Story M. Characteristics of vegetarian adolescents in
a multiethnic urban population. J Adolesc Health. 2001;29:406-416. Related Links: Abstract
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2003;27:728-734. Related Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Thane CW, Bates CJ. Dietary intakes and nutrient status of vegetarian preschool children from a
British national survey. J Hum Nutr Diet. 2000;13:149-162. Related Links: Abstract
Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of
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Links: Abstract; Full Text
Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American
Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in
infants, children, and adolescents. Pediatrics. 2008;122:1142-1152. Related Links: Abstract
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2006;65:42-50. Related Links: Abstract

Web Links: Normal Nutrition for Vegetarian Children

Resources for Professionals
Craig WJ, Mangels AR. Position of the American Dietetic Association: Vegetarian diets. J Am Diet
Assoc. 2009;109:1266-1282. Available
at: http://www.adajournal.org/article/S0002-8223(09)00700-7/fulltext. Comprehensive review of
vegetarian diets.
Messina V, Melina V, Mangels AR. A new food guide for North American vegetarians. J Am Diet
Assoc. 2003;103:771-775. Available
at: http://www.adajournal.org/article/S0002-8223(03)00293-1/fulltext. Food guide useful for
lacto-ovo, lacto, and vegan vegetarians. Article includes modifications for children, adolescents,
and pregnant and lactating women. Available free to ADA members.
Messina V, Mangels AR. Considerations in planning vegan diets: Children. J Am Diet Assoc.
2001;101:661-669. Available
at: http://www.adajournal.org/article/S0002-8223(01)00167-5/fulltext. Article provides guidelines on
counseling parents of vegan children as well as food guides for vegan children. Available free to
ADA members.
Mangels AR, Messina V. Considerations in planning vegan diets: Infants. J Am Diet Assoc.
2001;101:670-677. Available at: http://www.adajournal.org/article/S0002-8223(01)00169-9/fulltext.
Article provides guidelines for parents of vegan infants including breast feeding, breastmilk
substitutes, use of supplements, and weaning. Available free to ADA members.
Martinez-Pedersen S, Meerscheart CM. Vegan children. Vegetarian Nutrition Dietetic Practice
Group. http://www.vndpg.org/articles/Vegan-Diets-For-Children.php. Review of nutritional needs of
vegan children.

Norris J. Vitamin B-12: Are You Getting It? Available at:
http://www.veganhealth.org/articles/vitaminb12. Thorough review of what is known about vitamin
B-12.
Resources for Clients
Feeding Vegan Kids. The Vegetarian Resource Group. http://www.vrg.org/nutshell/kids.htm.
Practical information for parents of children from infancy through adolescence.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Healthy Eating for Vegetarians. USDA. Available at:
http://www.choosemyplate.gov/downloads/TenTips/DGTipsheet8HealthyEatingForVegetarians.pdf
One-page fact sheet from the USDA with selected tips for vegetarians.
Vegetarian Diets. USDA. Available at:
http://www.choosemyplate.gov/tipsresources/vegetarian_diets.html Key nutrients for vegetarians.
Also includes suggestions for easy meals.
Vegetarian Nutrition for Teenagers. The Vegetarian Resource Group. Available at:
http://www.vrg.org/nutshell/teen_veg.pdf. Brochure designed for teen vegetarians. Covers key
nutrients, body weight issues, and simple snacks.
Raising Vegetarian Children. Vegetarian Nutrition Dietetic Practice Group. Available at:
http://vegetariannutrition.net/vegetarian-kids/ Blog written by registered dietitians with suggestions
for vegetarian families.
Teen FAQs. Vegetarian Resource Group. Available at: http://www.vrg.org/teen/. Questions and
answers about nutrition, social situations, family issues, foods and cooking for vegetarian teens.
Vegetarian Teens. Vegetarian Nutrition Dietetic Practice Group. Available at:
http://vegetariannutrition.net/vegetarian-teens/ Blog written by registered dietitians with a focus on
vegetarian teens.
Vegan Lunch Box Blog. Available at: http://veganlunchbox.blogspot.com/. Blog includes many
ideas for healthy packed lunches for vegetarian and vegan children.
Vegetarian Diet: How to Get the Best Nutrition. Mayo Clinic. Available
at: http://mayoclinic.com/health/vegetarian-diet/HQ01596. Includes information on substitutes for
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interested in becoming vegetarian.

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Stettler N, Zemel B, Kawchak D, Ohene-Frempong K, Stalings V. Iron status of children
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Weblinks: Anemia

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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001554/. (accessed 9/13/11)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Behavioral Health
Behavioral Health


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Behavioral Health > Eating Disorders
Weblinks

Comprehensive overview of treatment for AN, BN and BED with evidence, links to studies.
http://www.guideline.gov/Compare/comparison.aspx?file=EATING_DISORDERS2.inc#t4comprehensive
Link to FBT training provided by Dr. James Lock and Dr. Daniel Le Grange: www.train2treat4ed.com
Eating Disorders Coalition-EDC: www.eatingdisorderscoalition.org
American Academy of Pediatrics: www.aap.org
Academy of Eating Disorders: www.aedweb.org
American Psychological Association: www.apa.org
American Dietetic Association: www.eatright.org
Binge Eating Disorders Association (BEDA): www.bedaonline.com
Family-based treatment for eating disorders: maudsleyparents.org
ICD-10 Classification of Mental and Behavioural
DIsorders: http://www.who.int/classifications/icd/en/GRNBOOK.pdf
http://www.kartiniclinic.com/AV
Living with the 'anorexic voice': A thematic analysis. Jan 28
2010: http://www.ncbi.nlm.nih.gov/pubmed/20109280?
Children with some form of BED are frequently overweight. While there have been many programs aimed at
helping overweight children, one has to be cautious in the use of programs designed to help overweight
children. The Academy for Eating Disorders has a set of guidelines concerning childhood obesity programs
at http://www.aedweb.org/media/Guidelines.cfm
Cape Town Metropole Paedeatric Group guidelines for pediatric refeeding syndrome
For an excellent summary of various definitions on eating disorders go to the Summerset and Wessex Eating
Disorder Assn page on ICD-10:http://www.swedauk.org/disorders/definitions.htm
Kings College London has developed a screen for whether a person could possibly have an eating disorder.
http://www.iop.kcl.ac.uk/sites/edu/downloads/HP/COULD_THIS_BE_AN_EATING_DISORDER.pdf
The nonprofit group FEAST (Families Empowered and Seeking Treatment for Eating Disorders, maintains a
list of treatment centers and providers. It also promotes evidenced based treatment and has a wealth of
information about eating disorders for families as well as professionals. www.FEAST-ED.org
National Eating Disorders Association-NEDA www.nationaleatingdisorders.org
A blog by Dr S. Ravin, for more information regarding ideas about FBT
treatment. http://www.blog.drsarahravin.com/eating-disorders/maudsley-is-as-maudsley-does/

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Behavioral Health > Mood Disorders
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Weblinks: Behavioral Disorders

American Academy of Pediatrics
American Academy of Child and Adolescent Psychiatry
American Psychological Association
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
American Dietetic Association
Behavioral Health Nutrition Dietetic Practice Group of the American Dietetic Association
National Alliance on Mental Illness
National Institutes of Health Fact Sheet: Mood Disorders (last accessed 8/3/2011)
Pediatric Nutrition Practice Group of the American Dietetic Association

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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References > Cardiology
Weblinks: Cardiology


Cincinnati Children’s Hospital: Heart Institute Encyclopedia (Last accessed 2/7/2012)
American Heart Association: Congenital Cardiovascular Defects (Last accessed 3/18/12)
Texas Heart Institute: Congenital Heart Disease (Last accessed 2/7/2012)
What are Congenital Heart Defects? (Last accessed 2/7/2012)

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References > Cleft Lip and Palate
Weblinks

Cleft Palate Foundation (CPF): This site has good information for parents on feeding, the
clinic team members, and support. (Last accessed 7/15/11)
Smile Train: An organization to repair cleft lip and palate for children all over the world.
(Last accessed 7/15/11)
Smiles: An organization for support of parents. (Last accessed 7/15/11)
Breastfeeding.com: An excellent website for breastfeeding support. (Last accessed 7/15/11)
International Lactation Consultant Association: This site can direct parents to lactation
consultants outside of hospital-based lactation support, and provides education and
support for both health professionals and parents. (Last accessed 7/15/11)
The Academy of Breastfeeding Medicine: This website is a well-referenced guide to issues
surrounding challenges to breastfeeding and includes cleft lip and palate
recommendations. (Last accessed 7/15/11)
Special Feeders:
Medela SpecialNeeds® Feeder (Last accessed 7/15/11)
Pigeon Specialty Feeding Products (Last accessed 7/15/11)
Note: the SpecialNeeds Feeder does have a flow variability that the Pigeon does not have,
but most parents don't find this too necessary. The Pigeon Feeder is much less expensive,
and looks more normal, yet it has the one-way valve in the nipple, and the soft nipple so
that the baby gets the milk mostly by compression.

References: Cleft Lip and Palate

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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Related links: Abstract

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Critical Care
Critical Care References

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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References > Developmental Disabilities
Links: Developmental Disabilities

Autism Spectrum Disorders Knowledge Path
is an electronic guide to resources about screening for autism spectrum disorders,
diagnosis, treatment and intervention, communication, education, vocational challenges,
and impact on family life. The knowledge path, produced by the Maternal and Child Health
Library, contains information on Web sites, publications, distance learning resources,
databases, and social media. It is intended for use by health professionals, educators,
researchers, policymakers, and families and will be updated periodically.
http://mchlibrary.info/KnowledgePaths/kp_autism.html (last accessed July 6, 2011)
Medline Plus: Autism is a website that includes a description of autism and links to
up-to-date information about treatment, research, and other information.
http://www.nlm.nih.gov/medlineplus/autism.html (last accessed July 6, 2011)
MCHB (Maternal and Child Health Bureau) Growth Charts Training – Self-study
material, including modules about equipment, measurement technique, and using the CDC
Growth Charts with children with special health care needs.
http://depts.washington.edu/growth/index.htm (last accessed July 6, 2011)
Nutrition for Children with Special Health Care Needs, Module 1 – A self-study module
about growth (measurement and interpretation) for children with special health care needs.
http://depts.washington.edu/pwdlearn/web (last accessed July 6, 2011)
Nutrition Interventions for Children with Special Health Care Needs – A publication by
the Washington State Department of Health, includes a chapter on anthropometry and
growth assessment; more information and download at
http://here.doh.wa.gov/materials/nutrition-interventions (last accessed July 6, 2011)
Knowledge Path: Children and Adolescents with Special Health Care Needs. This
knowledge path was compiled by the Maternal and Child Health Library at Georgetown
University. It points to recent, high-quality resources for health professionals and families
about caring for children and adolescents with special health care needs. Online:
http://www.mchlibrary.info/KnowledgePaths/kp_CSHCN.html (last accessed July 6, 2011)
United Cerebral Palsy (UCP) website is a wealth of information about cerebral palsy. The
organization supports program development, education, research, and advocacy for
individuals with cerebral palsy and their families. http://www.ucp.org/ (last accessed July 6,
2011)
Medlen J. The Down Syndrome Nutrition Handbook, 2nd ed. Lake Oswego, OR:
Phronesis Publishing, LLC. 2006 http://downsyndromenutrition.com (last accessed July 6,
2011)
National Down Syndrome Society (NDSS) http://www.ndss.org. This organization is a
comprehensive resource for information about Down syndrome for individuals of all ages.
The website is extensive and includes questions and answers, resources, events and
conferences, as well as links to other groups, organizations and resources. (last accessed
July 6, 2011)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
July 6, 2011)
Medline Plus: Spina Bifida is a website that includes a description of spina bifida and
links to up-to-date information about treatment, research, and other information.
http://www.nlm.nih.gov/medlineplus/spinabifida.html (last accessed July 6, 2011)
Spina Bifida Association http://www.spinabifidaassociation.org (last accessed July 6,
2011)
Prader-Willi Syndrome Association USA http://www.pwsausa.org (last accessed July 6,
2011)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Developmental Disabilities > Autism Spectrum Disorders
References: Autism Spectrum Disorders

American Dietetic Association. Position of the American Dietetic Association: providing
nutrition services for infants, children and adults with developmental disabilities and special
health care needs. J Am Diet Assoc. 2010;110:296-301. Related links: Abstract
Augustyn M. Diagnosis of autism spectrum disorders. UpToDate. 2009 (last updated
08/10/2010). Related links: Website. Accessed March 17, 2011.
Baer MT, Harris AB. Pediatric nutrition assessment: identifying children at risk. J Am Diet
Assoc. 1997; 97(10 Suppl 2):S107-S115. Related links: Abstract
Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. Prevalence of overweight in children
with developmental disorders in the continuous National Health and Nutrition Examination
Survey (NHANES) 1999-2002. J Pediatr. 2005;146:738-743. Related links: Abstract
Boyd LD, Palmer C, Dwyer JT. Managing oral health related nutrition issues of high risk
infants and children. Journal of Clinical Pediatric Dentistry. 1998; 23(1): 31-36. Related
links: Abstract
Brizee LS. Medication-nutrient interactions revisited. Nutrition Focus. 2006;21(5). (Note:
This article reviews the potential effects that medications can have on nutrient intake,
absorption, metabolism, and/or excretion).
Campbell MK, Kelsey KS. The PEACH survey: a nutrition screening tool for use in early
intervention programs. J Am Diet Assoc. 1994;94:1156-1158. Related links: Abstract
Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion (CDC, NCCDPHP). Use and Interpretation of the CDC
Growth Charts: An Instructional Guide. Related links: Web site. Accessed 30 April 2009.
Charney P, Ogata B, Nevin-Folino N, Holt K, Brewer H, Sharrett MK, Carney LN.
American Dietetic Association: Standards of Practice and Standards of Professional
Performance (Generalist, Specialty, and Advanced) for Registered Dietitians in Pediatric
Nutrition. J Am Diet Assoc. 2009;109(8):1468-1478.
Cloud HH. Feeding problems for children with developmental disorders. In: Ekvall S and
Ekvall V. Pediatric Nutrition in Chronic Diseases and Developmental Disorders, ed 2.
Oxford Press, 2005.
Craig GM, Scrambler G, Spitz L. Why parents of children with neurodevelopmental
disabilities requiring gastrostomy need more support. Dev Med Child Neurol.
2003;45:183-188. Related links: Abstract
Cricco K, Holland M. Nutrition assessment guidelines for children with special health care
needs. Nutrition Focus. 2007; 22(3).
Depasquale, G, Geraghty, M, Taylor, C, Peel, L. A Comparative Study of Bone Health
Nutrient Levels in Children With and Without Autism (Masters thesis). The Ohio State
University, May, 2009.
Elder JH. The gluten-free, casein-free diet in autism: an overview with clinical implications.
Nutr Clin Pract. 2008;23(6):583-588. Related links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Emerson M, Kerr P, Soler MC, Girard TA, Hoffinger R, Pritchett E, Otto M. American
Dietetic Association: standards of practice and standards of professional performance for
registered dietitians (generalist, specialty, and advanced) in behavioral health care. J Am
Diet Assoc. 2006;106(4):608-613. Related links: Abstract
Faine MP. The role of dietetics professionals in preventing early childhood caries. Building
Block for Life. 2001; 25(1).
Feucht S, Ogata B, Lucas B. Nutrition concerns of children with autism spectrum disorders.
Nutrition Focus. 2010;24(4).
Gilliam J, Laney SO, Yang Y. Community based nutrition services for children with special
health care needs in Spokane County, Washington. Olympia, WA: Children with Special
Health Care Needs Program, Washington State Department of Health. 2006. Related links:
Full Text
Herman DR, Baer MT. Demonstrating cost-effectiveness of nutrition services for children
with special health care needs: A national network. Arlington, VA: National Center for
Education in Maternal and Child Health; Los Angeles, CA: Center for Child Development
and Developmental Disabilities, University of Southern California. 1999.
Levy, S, Hyman, S. Complementary and alternative medicine treatments for children with
autism spectrum disorders. Child Adoles Psychiatric Clin N Am 2008; 17:803-820. Related
links: Abstract
Lucas BL, Feucht SA, Grieger LE, eds. Children with Special Health Care Needs: nutrition
care handbook. Pediatric Nutrition Practice Group and Dietetics in Developmental and
Psychiatric Disorders, American Dietetic Association. 2004.
Lucas B, Feucht S, Nardella M, eds. Medicaid reimbursement for medical nutrition products
and nutrition services for children with special health care needs: A Washington state case
studies report. Olympia, WA: Children with Special Health Care Needs Program,
Washington State Department of Health. 2004. Related links: Full Text
Millward C, Ferriter M, Calver SJ, Connell-Jones GG. Gluten- and casein-free diets for
autistic spectrum disorder. Cochrane Database of Systematic Reviews 2008, Issue 2. Art.
No.: CD003498. DOI: 10.1002/14651858.CD003498.pub3. Related links: Abstract
Nardella MT, Owens-Kuehner A. Feeding and eating. In: Lucas BL, Feucht SA, Grieger LE,
eds. Children with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition
Practice Group and Dietetics in Developmental and Psychiatric Disorders, American
Dietetic Association. 2004.
Nye C, Brice A. Combined vitamin B6-magnesium treatment in autism spectrum disorder.
Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003497. DOI:
10.1002/14651858.CD003497.pub2. Related links: Abstract
Obara M, Willis JH. Nutrition issues facing CSHCN in early intervention programs and at
school. Nutr Focus. 2011;26(1).
Ospina MB, Seida JK, Clark B, Karkhaneh M, Hartling L, Tjosvold L, Vandermeer B, Smith
V. Behavioural and developmental interventions for autism spectrum disorder: a clinical
systematic review. PLoS ONE. 2008;3(11):e3755. Related links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Peregrin T. Registered dietitians’ insights in treating autistic children. J Am Dietetic Assoc.
2007; 107(5):727-730.
Petersen MC, Kedia S, Davis P, Newman L, Temple C. Eating and feeding are not the
same: caregivers’ perceptions of gastrostomy feeding for children with cerebral palsy. Dev
Med Child Neurol. 2006;48:713-717. Related links: Abstract
Rapin I, Tuchman RF. Autism: definition, neurobiology, screening, diagnosis. Pediatr Clin N
Am. 2008; 55:1129-1146. Related links: Abstract
Rice C. Prevalence of autism spectrum disorders - Autism and Developmental Disabilities
Monitoring Network, United States 2006. MMWR 2009;55(SS10):1-20. Related
links: Abstract
Willis JH. Community Services and Programs. In: Lucas BL, Feucht SA, Grieger LE, eds.
Children with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition
Practice Group and Dietetics in Developmental and Psychiatric Disorders, American
Dietetic Association. 2004.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Developmental Disabilities > Cerebral Palsy
References: Cerebral Palsy

American Dietetic Association. Position of the American Dietetic Association: Providing
nutrition services for infants, children and adults with developmental disabilities and special
health care needs. J Am Diet Assoc. 2010;110:296-301. Related Links: Abstract
Arrowsmith FE, Allen JR, Gaskin KJ, Gruca MA, Clarke SL, Briody JN, Howman-Giles RB,
Somerville H, O’Loughlin EV. Reduced body protein in children with spastic quadriplegic
cerebral palsy. Am J Clin Nutr. 2006;83:613-618. Related Links: Abstract
Arvedson JS. Assessment of pediatric dysphagia and feeding disorders: Clinical and
instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-127. Related
Links: Abstract
Baer MT, Harris AB. Pediatric nutrition assessment: Identifying children at risk. J Am Diet
Assoc. 1997;97(10 Suppl 2):S107-S115. Related Links: Abstract
Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. Prevalence of overweight in children
with developmental disorders in the continuous National Health and Nutrition Examination
Survey (NHANES) 1999-2002. J Pediatr. 2005;146:738-743. Related Links: Abstract
Bandini L, Ekvall SW, Stallings V. Cerebral palsy. In: Ekvall SW, Ekvall VK. Pediatric
Nutrition in Chronic Diseases and Developmental Disorders. 2nd ed. New York: Oxford
University Press; 2005.
Bell KL, Boyd RN, Tweedy SM, Weir KA, Stevenson RD, Davies PSW. A prospective,
longitudinal study of growth, nutrition and sedentary behaviour in young children with
cerebral palsy. BMC Public Health. 2010;10:179. Related Links: Abstract; Full Text
Bell KL, Davies PSW. Energy expenditure and physical activity of ambulatory children with
cerebral palsy and of typically developing children. Am J Clin Nutr. 2010;92:313-319.
Related Links: Abstract
Boyd LD, Palmer C, Dwyer JT. Managing oral health related nutrition issues of high risk
infants and children. J Clin Pediatr Dent. 1998;23(1):31-36. Related Links: Abstract
Brizee LS. Medication-nutrient interactions revisited. Nutr Focus. 2006;21(5). Related
Links: Website
Campbell MK, Kelsey KS. The PEACH survey: A nutrition screening tool for use in early
intervention programs. J Am Diet Assoc. 1994;94:1156-1158. Related Links: Abstract
Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion. Use and Interpretation of the CDC Growth Charts: An
Instructional Guide. 2007. Related Links: Website Accessed 30 April 2009.
Charney P, Ogata B, Nevin-Folino N, Holt K, Brewer H, Sharrett MK, Carney LN.
American Dietetic Association: Standards of Practice and Standards of Professional
Performance (Generalist, Specialty, and Advanced) for Registered Dietitians in Pediatric
Nutrition. J Am Diet Assoc. 2009;109(8):1468-1478. Related Links: Abstract
Chumlea WC, Guo SS, Steinbaugh ML. Prediction of stature from knee height for black
and white adults and children with applications to mobility-impaired of handicapped
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
persons. J Am Diet Assoc. 1994;94(12):1385-1388. Related Links: Abstract
Cloud HH. Feeding problems for children with developmental disorders. In: Ekvall SW,
Ekvall VK. Pediatric Nutrition in Chronic Diseases and Developmental Disorders. 2nd ed.
New York: Oxford Press; 2005.
Craig GM, Scrambler G, Spitz L. Why parents of children with neurodevelopmental
disabilities requiring gastrostomy need more support. Dev Med Child Neurol.
2003;45:183-188. Related Links: Abstract
Cricco K, Holland M. Nutrition assessment guidelines for children with special health care
needs. Nutr Focus. 2007;22(3).
Day SM, Strauss DJ, Vachon PJ, Rosenbloom L, Shavelle RM, Wu YU. Growth patterns in
a population of children and adolescents with cerebral palsy. Dev Med Child Neurol.
2007;49: 167-171. Related Links: Abstract
Dickerson RN, Brown RO, Gervasio JG, Hak EB, Hak LJ, Williams JE. Measured energy
expenditure of tube-fed patients with severe neurodevelopmental disabilities. J Am Coll
Nutr. 1999;18(1):61-68. Related Links: Abstract
Dodge NN. Cerebral palsy: Medical aspects. Pediatr Clin N Am. 2008;55(5):1189-1207.
Related Links: Abstract
Emerson M, Kerr P, Soler MC, Girard TA, Hoffinger R, Pritchett E, Otto M. American
Dietetic Association: Standards of practice and standards of professional performance for
registered dietitians (generalist, specialty, and advanced) in behavioral health care. J Am
Diet Assoc. 2006;106(4):608-613. Related Links: Abstract
Faine MP. The role of dietetics professionals in preventing early childhood caries. Building
Block for Life. 2001;25(1).
Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional
status. Am J Clin Nutr. 1981;34:2540-2545. Related Links: Abstract
Gilliam J, Laney SO, Yang Y. Community Based Nutrition Services for Children with
Special Health Care Needs in Spokane County, Washington. Olympia, WA: Children with
Special Health Care Needs Program, Washington State Department of Health; 2006.
Related Links: Website
Hamill PV, et al. Body weight, stature and sitting height. US Vital and Health Statistics.
Washington DC: US Government Printing Office; 1973. Series 11, No. 126; Publication No.
HSM 73-1606. Related Links: Abstract
Herman DR, Baer MT. Cost-Effectiveness of Nutrition Services for Children with Special
Health Care Needs: A National Network. Los Angeles, CA: University Affiliated Center for
Child Development and Developmental Disabilities, University of Southern California. 1999
Holland M, Murray M. Diet and nutrition. In: Lucas BL, Feucht SA, Grieger LE, eds.
Children with Special Health Care Needs: Nutrition Care Handbook. Chicago, IL: Pediatric
Nutrition Dietetic Practice Group, Dietetics in Developmental and Psychiatric Disorders
Dietetic Practice Group, American Dietetic Association; 2004.
Isaacs JS. Fluid and bowel problems. In: Lucas BL, Feucht SA, Grieger LE, eds. Children
with Special Health Care Needs: Nutrition Care Handbook. Chicago, IL: Pediatric Nutrition
Dietetic Practice Group, Dietetics in Developmental and Psychiatric Disorders Dietetic
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Practice Group, American Dietetic Association; 2004.
Krick J, Miller P. Nutritional implications in children with cerebral palsy. Nutr Focus.
2003;18(3).
Krick J, Murphy PE, Markham JFB, Shapiro BK. A proposed formula for calculating energy
needs of children with cerebral palsy. Dev Med Child Neurol. 1992;34:481-487. Related
Links: Abstract
Krick J, Murphy-Miller P, Zeger S, Wright E. Pattern of growth in children with cerebral
palsy. J Am Diet Assoc. 1996;96(7):680-685. Related Links: Abstract
Kuperminc MN, Gurka MJ, Bennis JA, Busby MG, Grossberg RI, Henderson RC,
Stevenson RD. Anthropometric measures: Poor predictors of body fat in children with
moderate to severe cerebral palsy. Dev Med Child Neurol. 2010;52(9):824-830. Related
Links: Abstract
Kuperminc MN, Stevenson RD. Growth and nutrition disorders in children with cerebral
palsy. Dev Disabil Res Rev. 2008;14:137-146. Related Links: Abstract
Lanier C. Passing the baton: Nutrition and transition to adulthood for youth with special
health care needs using enteral nutrition. Nutr Focus. 2005;20(3). Related Links: Website
Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference
Manual. Champaign, IL: Human Kinetics Books; 1988. ISBN 0-87322-331-4.
Lucas BL, Feucht SA, Grieger LE, eds. Children with Special Health Care Needs: Nutrition
Care Handbook. Chicago, IL: Pediatric Nutrition Dietetic Practice Group, Dietetics in
Developmental and Psychiatric Disorders Dietetic Practice Group, American Dietetic
Association; 2004.
Lucas B, Feucht S, Nardella M, eds. Medicaid Reimbursement for Medical Nutrition
Products and Nutrition Services for Children with Special Health Care Needs: A
Washington State Case Studies Report. Olympia, WA: Children with Special Health Care
Needs Program, Washington State Department of Health; 2004. Related Links: Full text
Mahant S, Friedman JN, Connolly B, Goia C, Macarthur C. Tube feeding and quality of life
in children with severe neurological impairment. Arch Dis Child. 2009;94:668-673. Related
Links: Abstract
McCary JM. Improving access to school-based nutrition services for children with special
health care needs. J Am Diet Assoc. 2006;106(9):1333-1334. Related Links: Abstract
Mehta NM, Compher C, ASPEN Board of Directors. A.S.P.E.N. clinical guidelines: Nutrition
support for the critically ill child. JPEN J Parenter Enteral Nutr. 2009;33:260-277. Related
Links: Abstract
Najar MF, Rowland M. Anthropometric Reference Data and Prevalence of Overweight,
United States 1976-80. Vital Health Statistics Series 11, No. 238. Washington, DC: US
Dept of Health and Human Services; 1987. DHHS (PHS) publication 87-1688. Related
Links: Abstract
Nardella MT, Owens-Kuehner A. Feeding and eating. In: Lucas BL, Feucht SA, Grieger LE,
eds. Children with Special Health Care Needs: Nutrition Care Handbook. Chicago,
IL: Pediatric Nutrition Dietetic Practice Group, Dietetics in Developmental and Psychiatric
Disorders Dietetic Practice Group, American Dietetic Association; 2004.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Disorders Dietetic Practice Group, American Dietetic Association; 2004.
Nowak-Cooperman K, Cumbie E. Nutrition considerations for children with seizure
disorders. Nutr Focus. 2007;22(2).
Obara M, Willis JH. Nutrition issues facing children with special health care needs in early
intervention programs and at school. Nutr Focus. 2011;26(1).
Ogata BN, Trahms CM. Nutrition and oral health for children. Nutr Focus. 2003;18(6).
Petersen MC, Kedia S, Davis P, Newman L, Temple C. Eating and feeding are not the
same: caregivers’ perceptions of gastrostomy feeding for children with cerebral palsy. Dev
Med Child Neurol. 2006;48:713-717. Related Links: Abstract
Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson
B. A report: The definition and classification of cerebral palsy April 2006. Dev Med Child
Neurol Suppl. 2007;190:8-14. Related Links: Abstract
Stevenson RD, Conaway M, Chumlea WC, Rosenbaum P, Fung EB, Henderson RC,
Worley G, Liptak G, O’Donnell M, Samson-Fang L, Stallings VA. Growth and health in
children with moderate-to-severe cerebral palsy. Pediatrics. 2006;118(3):1010-1018.
Related Links: Abstract; Full Text
Sullivan PB, Juszczak E, Lambert BR, Rose M, Ford-Adams ME, Johnson A. Impact of
feeding problems on nutritional intake and growth: Oxford Feeding Study II. Dev Med Child
Neurol. 2002;44:461-467. Related Links: Abstract
Van Ripper C. Practical strategies to enhance nutrient and energy intake for oral feeding.
Nutr Focus. 2010;25(2).
Willis JH. Community Services and Programs. In: Lucas BL, Feucht SA, Grieger LE, eds.
Children with Special Health Care Needs: Nutrition Care Handbook. Chicago, IL: Pediatric
Nutrition Dietetic Practice Group, Dietetics in Developmental and Psychiatric Disorders
Dietetic Practice Group, American Dietetic Association; 2004.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Developmental Disabilities > Down Syndrome
References: Down Syndrome

Position of the American Dietetic Association: providing nutrition services for infants,
children and adults with developmental disabilities and special health care needs. J Am
Diet Assoc. 2010; 110:296-301. Related links: Abstract
Baer MT, Harris AB. Pediatric nutrition assessment: identifying children at risk. J Am Diet
Assoc. 1997; 97(10 Suppl 2):S107-S115. Related links: Abstract
Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. Prevalence of overweight in children
with developmental disorders in the continuous National Health and Nutrition Examination
Survey (NHANES) 1999-2002. J Pediatr. 2005; 146:738-743. Related links: Abstract
Boyd LD, Palmer C, Dwyer JT. Managing oral health related nutrition issues of high risk
infants and children. J Clin Pediatr Dent. 1998; 23(1): 31-36. Related links: Abstract
Brizee LS. Medication-nutrient interactions revisited. Nutrition Focus. 2006; 21(5).
Campbell MK, Kelsey KS. The PEACH survey: a nutrition screening tool for use in early
intervention programs. J Am Diet Assoc. 1994;94:1156-1158.
Capone G, Muller D, Ekvall S. Down syndrome. In: Ekvall S and Ekvall V. Pediatric
Nutrition in Chronic Diseases and Developmental Disorders, 2ed. Oxford Press, 2005.
Cassidy SB. Prader-Willi syndrome. J Med Genet. 1997;34:917-923. Related links: Abstract
Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion (CDC, NCCDPHP). Use and Interpretation of the CDC
Growth Charts: An Instructional Guide. Related links: Website. Accessed 30 April 2009.
Charney P, Ogata B, Nevin-Folino N, Holt K, Brewer H, Sharrett MK, Carney LN.
American Dietetic Association: Standards of Practice and Standards of Professional
Performance (Generalist, Specialty, and Advanced) for Registered Dietitians in Pediatric
Nutrition. J Am Diet Assoc. 2009;109(8):1468-1478.
Chumlea WC, Guo SS, Steinbaugh ML. Prediction of stature from knee height for black
and white adults and children with applications to mobility-impaired of handicapped
persons. J Am Diet Assoc. 1994; 94(12): 1385-1388. Related links: Abstract
Cialone JA. Growth. In: Lucas BL, Feucht SA, Grieger LE, eds. Children with Special
Health Care Needs: nutrition care handbook. Pediatric Nutrition Practice Group and
Dietetics in Developmental and Psychiatric Disorders, American Dietetic Association. 2004.
Cloud HH. Feeding problems for children with developmental disorders. In: Ekvall S and
Ekvall V. Pediatric Nutrition in Chronic Diseases and Developmental Disorders, 2nd ed.
Oxford Press, 2005.
Craig GM, Scrambler G, Spitz L. Why parents of children with neurodevelopmental
disabilities requiring gastrostomy need more support. Dev Med Child Neurol. 2003;
45:183-188. Related links: Abstract
Cricco K, Holland M. Nutrition assessment guidelines for children with special health care
needs. Nutrition Focus. 2007; 22(3).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cully WJ et al. Calorie intake of children with Down’s syndrome. J Pediatr. 1965;
66:772-775.
Davidson MA. Primary care for children and adolescents with Down syndrome. Pediatr Clin
North Am. 2008; 55:1099-1111. Related links: Abstract
Department of Health and Human Services (DHHS), Centers for Disease Control and
Prevention. Developmental Disabilities. Related links: Website. Accessed April 13, 2009.
Emerson M, Kerr P, Soler MC, Girard TA, Hoffinger R, Pritchett E, Otto M. American
Dietetic Association: standards of practice and standards of professional performance for
registered dietitians (generalist, specialty, and advanced) in behavioral health care. J Am
Diet Assoc. 2006; 106(4):608-613. Related links: Abstract
Faine MP. The role of dietetics professionals in preventing early childhood caries. Building
Blocks for Life. 2001; 25(1).
Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional
status. Am J Clin Nutr. 34: 2540-2545, 1981. Related links: Abstract; Full text
Gilliam J, Laney SO, Yang Y. Community based nutrition services for children with special
health care needs in Spokane County, Washington. Olympia, WA: Children with Special
Health Care Needs Program, Washington State Department of Health. 2006. Related
links: Website
Hamill PV, et al. Body weight, stature and sitting height. US Vital and Health Statistics,
Series 11, #126; Publication No. HSM 73-1606. Washington DC: US Government Printing
Office, 1973.
Herman DR, Baer MT. Demonstrating cost-effectiveness of nutrition services for children
with special health care needs: A national network. Arlington, VA: National Center for
Education in Maternal and Child Health; Los Angeles, CA: Center for Child Development
and Developmental Disabilities, University of Southern California. 1999.
Hill ID, Dirks MH, Liptak GS, Colletti RB, Fasano A, Guandalini S, Hoffenberg EJ, Horvath
K, Murray JA, Pivor M, Seidman EG, North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition. Guideline for the diagnosis and treatment of
celiac disease in children: recommendations of the North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;
40(1):1-19. Related links: Abstract
Isaacs JS. Fluid and bowel problems. In: Lucas BL, Feucht SA, Grieger LE, eds. Children
with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition Practice
Group and Dietetics in Developmental and Psychiatric Disorders, American Dietetic
Association. 2004.
Krick J, Miller P. Nutritional implications in children with cerebral palsy. Nutrition Focus.
2003; 18(3).
Lanier C. Passing the baton: nutrition and transition to adulthood for youth with special
health care needs using enteral nutrition. Nutrition Focus. 2005; 20(3).
Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference
Manual. Champaign, Ill: Human Kinetics Books, 1988. ISBN 0-87322-331-4.
Lucas B, Feucht S. Nutrition issues for children with Down syndrome. Nutrition Focus.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2008;23(3).
Lucas BL, Feucht SA, Grieger LE, eds. Children with Special Health Care Needs: nutrition
care handbook. Pediatric Nutrition Practice Group and Dietetics in Developmental and
Psychiatric Disorders, American Dietetic Association. 2004.
Lucas B, Feucht S, Nardella M, eds. Medicaid reimbursement for medical nutrition products
and nutrition services for children with special health care needs: A Washington state case
studies report. Olympia, WA: Children with Special Health Care Needs Program,
Washington State Department of Health. 2004. Related links: Full Text
McCary JM. Improving access to school-based nutrition services for children with special
health care needs. J Am Diet Assoc. 2006; 106(9):1333-1334. Related links: Abstract
Mehta NM, Compher C, ASPEN Board of Directors. A.S.P.E.N. clinical guidelines: nutrition
support for the critically ill child. J Parenter Enteral Nutr. 2009; 33:260-277. Related links:
Abstract
Najar MF, Rowland M. Anthropometric Reference Data and Prevalence of Overweight,
United States 1976-80. Vital Health Statistics, Series 11. No. 238. Washington, DC: US
Dept of Health and Human Services; 1987. DHHS (PHS) publication 87-1688.
Nardella MT, Owens-Kuehner A. Feeding and eating. In: Lucas BL, Feucht SA, Grieger LE,
eds. Children with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition
Practice Group and Dietetics in Developmental and Psychiatric Disorders, American
Dietetic Association. 2004.
National Down Syndrome Society website (NDSS Website). Available at
http://www.ndss.org. Accessed 30 April 2009.
Obara M, Willis JH. Nutrition issues facing CSHCN in early intervention programs and at
school. Nutr Focus. 2011;26(1).
Ogata BN, Trahms CM. Nutrition and oral health for children. Nutrition Focus. 2003;18(6).
Petersen MC, Kedia S, Davis P, Newman L, Temple C. Eating and feeding are not the
same: caregivers’ perceptions of gastrostomy feeding for children with cerebral palsy. Dev
Med Child Neuro. 2006; 48:713-717. Related links: Abstract
Sullivan PB, Juszczak E, Lambert BR, Rose M, Ford-Adams ME, Johnson A. Impact of
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Van Ripper C. Practical strategies to enhance nutrient and energy intake for oral feeding.
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Willis JH. Community Services and Programs. In: Lucas BL, Feucht SA, Grieger LE, eds.
Children with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition
Practice Group and Dietetics in Developmental and Psychiatric Disorders, American
Dietetic Association. 2004.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Developmental Disabilities > Spina Bifida
References: Spina Bifida

American Dietetic Association. Position of the American Dietetic Association: providing
nutrition services for infants, children and adults with developmental disabilities and special
health care needs. J Am Diet Assoc. 2010; 110:296-301. Related links: Abstract
Baer MT, Harris AB. Pediatric nutrition assessment: identifying children at risk. J Am Diet
Assoc. 1997; 97(10 Suppl 2):S107-S115. Related links: Abstract
Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. Prevalence of overweight in children
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Campbell MK, Kelsey KS. The PEACH survey: a nutrition screening tool for use in early
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Centers for Disease Control and Prevention, National Center for Chronic Disease
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Charney P, Ogata B, Nevin-Folino N, Holt K, Brewer H, Sharrett MK, Carney LN.
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Developmental Disabilities > Prader > Willi Syndrome
References: Prader-Willi Syndrome

American Dietetic Association. Position of the American Dietetic Association: providing
nutrition services for infants, children and adults with developmental disabilities and special
health care needs. J Am Diet Assoc. 2010; 110:296-301. Related links: Abstract
Baer MT, Harris AB. Pediatric nutrition assessment: identifying children at risk. J Am Diet
Assoc. 1997; 97(10 Suppl 2):S107-S115. Related links: Abstract
Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. Prevalence of overweight in children
with developmental disorders in the continuous National Health and Nutrition Examination
Survey (NHANES) 1999-2002. J Pediatr. 2005; 146:738-743. Related links: Abstract
Brizee LS. Medication-nutrient interactions revisited. Nutrition Focus. 2006; 21(5).
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American Dietetic Association: Standards of Practice and Standards of Professional
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Nutrition. J Am Diet Assoc. 2009;109(8):1468-1478.
Craig GM, Scrambler G, Spitz L. Why parents of children with neurodevelopmental
disabilities requiring gastrostomy need more support. Dev Med Child Neurol. 2003;
45:183-188. Related links: Abstract
Cricco K, Holland M. Nutrition assessment guidelines for children with special health care
needs. Nutrition Focus. 2007; 22(3).
Emerson M, Kerr P, Soler MC, Girard TA, Hoffinger R, Pritchett E, Otto M. American
Dietetic Association: standards of practice and standards of professional performance for
registered dietitians (generalist, specialty, and advanced) in behavioral health care. J Am
Diet Assoc. 2006; 106(4):608-613. Related links: Abstract
Gilliam J, Laney SO, Yang Y. Community based nutrition services for children with special
health care needs in Spokane County, Washington. Olympia, WA: Children with Special
Health Care Needs Program, Washington State Department of Health. 2006. Related links:
Full Text
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Herman DR, Baer MT. Demonstrating cost-effectiveness of nutrition services for children
with special health care needs: A national network. Arlington, VA: National Center for
Education in Maternal and Child Health; Los Angeles, CA: Center for Child Development
and Developmental Disabilities, University of Southern California. 1999.
Holland M, Murray M. Diet and nutrition. In: Lucas BL, Feucht SA, Grieger LE, eds.
Children with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition
Practice Group and Dietetics in Developmental and Psychiatric Disorders, American
Dietetic Association. 2004.
Lanier C. Passing the baton: nutrition and transition to adulthood for youth with special
health care needs using enteral nutrition. Nutrition Focus. 2005;20(3).
Lucas BL, Feucht SA, Grieger LE, eds. Children with Special Health Care Needs: nutrition
care handbook. Pediatric Nutrition Practice Group and Dietetics in Developmental and
Psychiatric Disorders, American Dietetic Association. 2004.
Lucas B, Feucht S, Nardella M, eds. Medicaid reimbursement for medical nutrition products
and nutrition services for children with special health care needs: A Washington state case
studies report. Olympia, WA: Children with Special Health Care Needs Program,
Washington State Department of Health. 2004. Related links: Website
McCary JM. Improving access to school-based nutrition services for children with special
health care needs. J Am Diet Assoc. 2006; 106(9):1333-1334. Related links: Abstract
Najar MF, Rowland M. Anthropometric Reference Data and Prevalence of Overweight,
United States 1976-80. Vital Health Statistics Series 11, No. 238. Washington, DC: US
Dept of Health and Human Services; 1987. DHHS (PHS) publication 87-1688.
Nativio DG. The genetics, diagnosis, and management of Prader-Willi syndrome. J Pediatr
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Obara M, Willis JH. Nutrition issues facing CSHCN in early intervention programs and at
school. Nutr Focus. 2011;26(1).
Pereira R, Schalk A, Geraghty ME. Prader-Willi syndrome. A review for pediatric nutrition
professionals. Infant, Child, and Adolescent Nutrition. 2009; 1(5):282-287.
Petersen MC, Kedia S, Davis P, Newman L, Temple C. Eating and feeding are not the
same: caregivers’ perceptions of gastrostomy feeding for children with cerebral palsy. Dev
Med Child Neurol. 2006; 48:713-717. Related links: Abstract
Willis JH. Community Services and Programs. In: Lucas BL, Feucht SA, Grieger LE, eds.
Children with Special Health Care Needs: nutrition care handbook. Pediatric Nutrition
Practice Group and Dietetics in Developmental and Psychiatric Disorders, American
Dietetic Association. 2004.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Diabetes Mellitus
Diabetes Mellitus References

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Weblinks: Diabetes Mellitus

NutritionData provides a complete nutrient analysis for any food or recipe and helps you
select foods that best match your dietary needs.
CalorieKing provides nutritional information and carbohydrate amounts for a wide variety of
foods and restaurant menu items.
The American Dietetic Association Web site provides general nutrition information for all
age groups and lists of nutrition resources.
BD provides a fast food guide available for download.
The Family Support Network's Children with Diabetes community provides a wide variety of
educational materials and diabetes support for families. Kid-friendly recipes with nutrition
information are also provided.
The Diabetes Network presents diet and nutrition information regarding the glycemic index,
type and amount of carbohydrates you should eat, and carbohydrate-counting tips.
The US Department of Agriculture's www.choosemyplate.gov web site explains the
different food groups and amount of food you should eat based on your age and sex. It also
offers individualized meal plans and diet analysis to help balance your diet.
The American Diabetes Association Web site provides nutrition information on healthful
recipes and a food advisor. The food advisor allows you to develop a healthful meal plan,
including a detailed nutrient analysis.
Nutrition in the Kitchen, published by The Children's Hospital of Philadelphia (CHOP),
provides a list of healthy recipes developed by the Healthy Weight Program at
CHOP. Each recipe is kid friendly and provides a complete nutrient analysis.
The US Department of Agriculture's Nutrient Data Laboratory lists a detailed nutrient
analysis for any food.
Foodpicker provides information on carbohydrate counting and helpful nutrition tips for
people with diabetes.
Spark Recipes (www.sparkrecipes.com) allows you to calcuate the carbohydrate grams of
your favorite recipes. This site also provides the nutrient analysis of various healthy
recipes.
Sugar Stats (www.sugarstats.com) is a simple online tool to track your blood glucose level,
food and activity to help manage your diabetes.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The 2010 Dietary Guidelines for
Americans(http://www.cnpp.usda.gov/DietaryGuidelines.htm provides nutrition and physical
activity recommendations from the USDA.

All sites last accessed 7/21/2011.

Additional Resources: Diabetes Mellitus

Books
America’s Best Cookbook for Kids with Diabetes (2005), by Colleen Bartley;
published by Robert Rose.

1,001 Delicious Recipes for People with Diabetes (2008), edited by Sue Spitler
and Linda Eugene, RD, CDE; with Linda Yoakam, RD, MS; published by Surrey
Books.

The Art of Cooking for the Diabetic (1995), by Mary Abbot Hess and Katherine
Middleton (1995); published by Contemporary Books.

The Carbohydrate Counting Cookbook (1998), by Tami Ross, RD, CDE and Patti
Geil, RD, CDE; published by John Wiley & Sons, Inc.

Complete Guide to Carb Counting (2004), 2nd ed, by Hope Warshaw, MMSc, RD,
CDE, and Karmeen Kikarni, MS, RD, CDE; published by the American Diabetes
Association.

Convenience Food Facts (1997), 4th ed, by Arlene Monk, RD, LD, CDE, and Nancy
Cooper, RD, LD, CDE; published by IDC Publishing, .

Cooking Up Fun for Kids with Diabetes (2003), by Patti Geil and Tami Ross;
published by the ADA.

The Diabetes Carbohydrate & Fat Gram Guide (2005), 3rd ed, by Lea Ann
Holzmeister, RD, CDE; published by the American Diabetes Association and the
American Dietetic Association.

Diabetes Meal Planning Made Easy (2006), 3rd ed, by Hope Warshaw, MMSc, RD,
CDE; published by the American Diabetes Association.

The Ultimate Guide to Accurate Carb Counting (2006), by Gary Sheiner, MS, CDE;
published by Marlowe & Company.

The Carbohydrate Gram Counter (1994), by Corinne T. Netzer. Dell, New York.

The Calorie King Calorie, Fat, and Carbohydrate Counter (2011), by Allan Borushek,
MD.
Software
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
www.childrenwithdiabetes.com Balance PC Diabetes Software by Proactive Metabolics
www.calorieking.com/software/: search products under computerized meal planning
www.diabetespilot.com For Palm, pocket PC and/or desktop nutrient analysis

Smart Phone Apps




Apple iPhone
· Glucose Buddy - This application lets you track blood glucose, medications,
activity, and food. It also features an A1c calculator, graphs, and will send
reminders.
· Diabetes Log Free- Simple application that lets you log your glucose
readings, food intake, and medicine records. You can send your blood
glucose readings to your personal computer or even health care professional.
· Glucose Mate Free- This app allows simple glucose logs and saves your
glucose levels, relationship of blood sugars to meals, and times blood glucose
was checked. It also does statistical analysis and allows you to email glucose
readings to your health care professional.

Blackberry
· iRecordit Diabetes Sugar Glucose & Health Tracker - This app lets you
record blood glucose levels, blood pressure readings, weight, cholesterol
levels, food intake, exercise, medications, and lab results. It also features a
database with over 7,000 foods with nutrition information.
· Handy Logs Sugar, Glucose, Insulin, & A1c Tracker for Diabetes - This app
allows you to track your blood glucose, A1cs, and medications. It also
features a summary through graphs.

Verizon Droid X or Droid 2
· Food Street Diabetes Free- This is a great app for those who love to cook.
This application is a guide to help you make healthy meals.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
This application is a guide to help you make healthy meals.
· OnTrack Diabetes Free- Easy to use interface that allows you to keep track
of blood glucose levels, food intake, medications, blood pressure readings,
pulse, and weight. It features graphs and reports.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Disorders of Lipid Metabolism
References: Disorders of Lipid Metabolism

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
hypocholesterolemic effect of the step I diet in childhood. J Am Coll
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Weblinks: Disorders of Lipid Metabolism

American Academy of Pediatrics Policy on Lipid Screening and Heart Health in Children
(2008)
Academy of Nutrition and Dietetics Evidence Analysis Library, Hypercholesterolemia
(accessible to Academy members)
American Heart Association: Children and Cholesterol
American Heart Association: Healthier Kids
Cholesterol and Your Child
Cholesterol Diet—Children
Diagnosis of Hyperlipidemia
Healthy Children website (includes information on low-fat, low-cholesterol foods)
Medscape Reference: Pediatric Lipid Disorders in Clinical Practice
Patient Information from the Foundation of the National Lipid Association
Websites last accessed February 2, 2012.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Epilepsy
Weblinks: Pediatric Epilepsy

Ketogenic Diet Meal Planner (Accessed November 5, 2010): page contains downloadable Excel file
National Institutes of Health Clinical Trials (Accessed January 20, 2011)
The Charlie Foundation to Help Cure Pediatric Epilepsy (Accessed January 20, 2011)
Epilepsy Foundation (Accessed January 20, 2011)
Keto Calculator (Accessed November 5, 2010)
Nutricia: Cooking with KetoCal (Accessed January 20, 2011)

References: Epilepsy

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Berry-Kravis E, Booth G, Sanchez AC, Woodbury-Kolb J. Carnitine levels and the ketogenic diet. Epilepsia.
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Abstract; Full text
Chapman DP, Giles WH. Pharmacologic and dietary therapies in epilepsy: Conventional treatment and recent
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Related Links: Abstract
De Vivo DC, Garcia-Alvarez M, Ronen G, Trifiletti R. Glucose transport protein deficiency: An emerging syndrome with
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Erbayat-Altay E, Yamada KA, Wong M, Thio LL. Increased severity of pentylenetetrazol induced seizures in leptin
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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and calcium currents in CA1 neurons. Proc Natl Acad Sci U S A. 1996; 93:12559-12563. Related Links: Abstract; Full
text
Wexler ID, Hemalatha SG, McConnell J, Buist NR, Dahl HH, Berry SA, Cederbaum SD, Patel MS, Kerr DS. Outcome
of pyruvate dehydrogenase deficiency treated with ketogenic diets. Neurology. 1997;49:1655-1661. Related
Links: Abstract
Wheless JW, Ashwal S. The ketogenic diet. In: Swaiman KF, Ashwal S, eds. Pediatric Neurology: Principles and
Practice. Vol. 1. 3rd ed. St. Louis, MO: Mosby-Year Book; 1999:719-728.
Wheless JW, Baumgartner J, Ghanbari C. Vagus nerve stimulation and the ketogenic diet. Neurol Clin.
2001a;19:371-407. Related Links: Abstract
Wheless JW. The ketogenic diet: An effective medical therapy with side effects. J Clin Neurol. 2001b;16:633-635.
Related Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Wilder RM. The effect of ketonemia on the course of epilepsy. Mayo Clin Bull. 1921;2:307-308.
Williams S, Basualdo-Hammond C, Curtis R, Schuller R. Growth retardation in children with epilepsy on the ketogenic
diet: A retrospective chart review. J Am Diet Assoc. 2002;102:405-407. Related Links: Abstract
Wittenbrook W. Nutritional assessment and intervention in cerebral palsy. Nutrition Issues in Gastroenterology, Series
#92. Pract Gastroenterol Nutr. 2011:21-32. Related links: Full text (pdf)
Wyllie E. Surgical treatment of epilepsy in children. Pediatr Neurol. 1998;19:179-188. Related Links: Abstract
Xiao YF, Gomez AM, Morgan JP, Lederer WJ, Leaf A. Suppression of voltage-gated L-type Ca++ current by
polyunsaturated fatty acids in adult and neonatal rat ventricular myocytes. Proc Natl Acad Sci U S A.
1997;94:4182-4187. Related Links: Abstract; Full text
Xiao YF, Wright SN, Wang GK, Morgan JP, Leaf A. Fatty acids suppress voltage-gated Na+ current in HEK293t cells
transfected with the alpha-subunit of the human cardiac Na+ channel. Proc Natl Acad Sci U S A. 1998;95:2680-2685.
Related Links: Abstract; Full text
Yudkoff M, Daikhin Y, Melø TM, Nissim I, Sonnewald U. The ketogenic diet and brain metabolism of amino acids:
Relationship to the anticonvulsant effect. Annu Rev Nutr. 2007;27:415-430. Related Links: Abstract
Zelnik N, Isler N, Goez H, Shiffer M, David M, Shahar E. Vigabatrin, lamotrigine, topiramate and serum carnitine levels.
Pediatr Neurol. 2008;39(1):18-21. Related links: Abstract
Zhang J, Wang KX, Wei Y, Xu MH, Su JM, Bao YG, Zhao SY. [Effect of topiramate and carbamazepine on bone
metabolism in children with epilepsy.] Zhongguo Dang Dai Er Ke Za Zhi. 2010;12(2):96-98. Chinese. Related
links: Abstract; Full Text
Zhou LX, Pihlstrom B, Hardwick JP, Park SS, Wrighton SA, Holtzman JL. Metabolism of phenytoin by the gingiva of
normal humans: The possible role of reactive metabolites of phenytoin in the initiation of gingival hyperplasia. Clin
Pharmacol Ther. 1996;60:191-198. Related Links: Abstract
Ziegler DR, Ribeiro LC, Hagenn M, Siquerira IR, Araújo E, Torres IL, Gottfried C, Netto CA, Gonçalves CA. Ketogenic
diet increase glutathione peroxidase activity in rat hippocampus. Neurochem Res. 2003;28:1793-1797. Related
Links: Abstract; Full text
Zupec-Kania B. KetoCalculator: A web-based calculator for the ketogenic diet. Epilepsia. 2008;49(suppl 8):14-16.
Related Links: Abstract; Full text
Zupec-Kania B, Spellman E. An overview of the ketogenic diet for pediatric epilepsy. Nutr Clin Pract.
2008b;23:589-596. Related Links: Abstract
Zupec-Kania B, Werner R, Zupanc ML. Clinical use of the ketogenic diet: The dietitian’s role. In: Stafstrom CE, Rho JM,
eds. Epilepsy and the Ketogenic Diet. Totowa, NJ: Humana Press; 2004:63-81.

Additional Resources: Ketogenic Diet

Exchange List for MCT Oil Ketogenic Diet

Epilepsy Information

Epilepsy Foundation of America
4351 Garden City Drive
Landover, MD 20785-7223
800/EFA-1000
http://www.efa.org

Ketogenic Diet Centers
The Pediatric Epilepsy Center at Johns Hopkins University
600 North Wolfe Street, Meyer 2-147
Baltimore, MD 21287-8247
410/955-9100
http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/epilepsy/about_us/ketogenic_diet.html

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ketogenic Diet Program at Stanford University Medical Center
Department of Neurology, H3160
300 Pasteur Drive
Stanford, CA 94305-5235
650/723-6841
http://www.stanford.edu/group/ketodiet/

Ketogenic Diet Program for Pediatric Epilepsy
Texas Comprehensive Epilepsy Program
University of Texas Medical School–Houston
6431 Fannin Street
Houston, TX 77030
713/500-7052

Montefiore Medical Center Ketogenic Diet Team
Comprehensive Epilepsy Management Center
111 East 210 Street
Bronx, NY 10467-2490
718/920-4378

Computer Software
Ketogenic Diet Meal Planner (Microsoft Excel spreadsheet)
http://www.stanford.edu/group/ketodiet/
Ketocalculator
http:www.ketocalculator.com/ketocalc/

Books
Brake D, Brake C. The Ketogenic Cookook. Gilman, CT: Pennycorner Press; 1997.
Stafstrom CE, Rho JM. Epilepsy and the ketogenic diet. Totawa, NJ: Humana Press; 2004.
Freeman JM, Kossoff EH, Freeman JB, Kelly MT. The Ketogenic Diet: A Treatment for Children and Others with
Epilepsy. 4th ed. New York, NY: Demos Publications; 2007.
Snyder D. Keto Kid: Helping Your Child Succeed on the Ketogenic Diet. New York, NY: Demos Publications; 2007.


Videotapes
The Charlie Foundation to Help Cure Pediatric Epilepsy
501 10th Street
Santa Monica, CA 90402
800/FOR-KETO

Family Support
Keto Klub Newsletter (quarterly newsletter for parents)
61557 Miami Meadows Court
South Bend, IN 46614
FAX 219/299-8602
Abilities Network
8503 LaSalle Rd
Towson, MD 21286
800/492-2523
http://www.abilitiesnetwork.org/services/epilepsy/

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Failure to Thrive
References: Failure to Thrive

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Monsen ALB, Ueland PM. Homocysteine and methylmalonic acid in diagnosis and risk
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
newborn infants. Arch Dis Child Fetal Neonatal Ed. 2006;91(5):F330-F332. Related
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1997;18(11):371-378. Related Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Weblinks: Failure to Thrive

Department of Health and Human Services. NIH. National Library of Medicine. Infant and
Newborn Nutrition: http://www.nlm.nih.gov/medlineplus/infantandtoddlernutrition.html
Nemours. Breastfeeding versus Formula Feeding:
http://kidshealth.org/parent/food/infants/breast_bottle_feeding.html
Ontario Society of Nutrition Professionals, Pediatric Nutrition Guidelines for for Primary
Health Providers: http://www.osnpph.on.ca/pdfs/ImprovingOddsJune-08.pdf
University of Kentucky Cooperative Extension Service, Family and Consumer Sciences:
http://www.ca.uky.edu/hes/
US Department of Agriculture. MyPlate: http://www.choosemyplate.gov/
US Department of Agriculture, National Agricultural Library. Food and Nutrition Information
Center. Infant Nutrition and Health Resource List:
http://www.nal.usda.gov/fnic/pubs/bibs/gen/infnut.pdf
Gaining and Growing: Assuring Nutritional Care of Preterm Infants (site funded by grant
from Maternal and Child Health Bureau): http://depts.washington.edu/growing/
Medline: Failure to Thrive: http://www.nlm.nih.gov/medlineplus/ency/article/000991.htm
Johns Hopkins Children's
Center: http://www.hopkinschildrens.org/tpl_rlinks_nav1up.aspx?id=5112
Children’s Hospital Boston
http://www.childrenshospital.org/az/Site870/mainpageS870P0.html

Feeding Programs
Children's Hospital of Orange County Feeding Program, Orange,
CA: www.choc.org/feedingprogram/index.cfm
Children's Hospital Colorado, Aurora, CO:
http://www.childrenscolorado.org/conditions/clinical-nutrition/growth-and-nutrition-clinic.aspx
Mealtime Notions, LLC, Tucson, AZ: www.mealtimenotions.com
Transitions Pediatric Feeding Program, Good Shepherd Hospital, Bethlehem, PA:
www.goodshepherdrehab.org
The Feeding, Swallowing and Nutrition Center of the Children's Hospital of Wisconsin,
Milwaukee, WI: www.cwh.org

Growth Charts
Centers for Disease Control and Prevention Growth Charts (2000):
http://www.cdc.gov/GrowthCharts/
World Health Organization Child Growth Standards:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
World Health Organization Child Growth Standards:
http://www.who.int/childgrowth/standards/en/

Other Resources
American Academy of Pediatrics http://www.aap.org/
La Leche League International http://www.llli.org/


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Food Allergic Disorders
Food Allergic Disorders


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Food Allergic Disorders > Eosinophilic Esophagitis
References: Eosinophilic Esophagitis

Chehade M, Aceves SS. Food allergy and eosinophilic esophagitis. Curr Opin Allergy Clin
Immunol. 2010;10:231-237. Related Links: Abstract
Chehade M, Magid MS, Mofidi S, Nowak-Wegrzyn A, Sampson HA, Sicherer SH. Allergic
eosinophilic gastroenteritis with protein-losing enteropathy: Intestinal pathology, clinical
course, and long-term follow-up. J Pediatr Gastroenterol Nutr. 2006;42:516-521. Related
Links: Abstract
Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake
and growth. J Am Diet Assoc. 2002;102:1648-1651. Related Links: Abstract
Erwin E, James HR, Gutekunst HM, Russo JM, Kelleher KJ, Platts-Mills TA. Serum IgE
measurement and detection of food allergy in pediatric patients with eosinophilic
esophagitis. Ann Allergy Asthma Immunol. 2010;104(6):496-502. Related Links: Abstract
Feuling MB, Noel RJ. Medical and nutrition management of eosinophilic esophagitis in
children. Nutr Clin Pract. 2010;25:166-174. Related Links: Abstract
Fogg MI, Ruchelli E, Spergel JM. Pollen and eosinophilic esophagitis. J Allergy Clin
Immunol. 2003;112:796-797. Related Links: Abstract
Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE, Bonis P, Hassall
E, Straumann A, Rothenberg ME; First International Gastrointestinal Eosinophil Research
Symposium (FIGERS) Subcommittees. Eosinophilic esophagitis in children and adults: A
systematic review and consensus recommendations for diagnosis and treatment.
Gastroenterology. 2007;133:1342-1363. Related Links: Abstract; Full text
Henriksen C, Eggesbo M, Halvorsen R, Botten G. Nutrient intake among two-year-old
children on cows' milk-restricted diets. Acta Paediatr. 2000;89:272-278. Related Links:
Abstract
Isolauri E, Sutas Y, Salo MK, Isosomppi R, Kaila M. Elimination diet in cow's milk allergy:
Risk for impaired growth in young children. J Pediatr. 1998;132:1004-1009. Related Links:
Abstract
Jensen VB, Jorgensen IM, Rasmussen KB, Molgaard C, Prahl P. Bone mineral status in
children with cow milk allergy. Pediatr Allergy Immunol. 2004;15:562-565. Related Links:
Abstract
Kagalwalla AF, Sentongo TA, Ritz S, Hess T, Nelson SP, Emerick KM, Melin-Aldana H, Li
BU. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic
esophagitis. Clin Gastroenterol Hepatol. 2006;4:1097-1102. Related Links: Abstract
Kelly KJ, Lazenby AJ, Rowe PC, Yardley JH, Perman JA, Sampson HA. Eosinophilic
esophagitis attributed to gastroesophageal reflux: Improvement with an amino acid-based
formula. Gastroenterology. 1995;109:1503-1512. Related Links: Abstract
Liacouras CA, Markowitz JE. Eosinophilic esophagitis: A subset of eosinophilic
gastroenteritis. Curr Gastroenterol Rep. 1999;1:253-258. Related Links: Abstract
Liacouras CA, Spergel JM, Ruchelli E, Verma R, Mascarenhas M, Semeao E, Flick J, Kelly
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
J, Brown-Whitehorn T, Mamula P, Markowitz JE. Eosinophilic esophagitis: A 10-year
experience in 381 children. Clin Gastroenterol Hepatol. 2005;3:1198-1206. Related Links:
Abstract
Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: Updated consensus
recommendations for children and adults. JACI. 2011 (in press as of 5/2011).
Markowitz JE, Spergel JM, Ruchelli E, Liacouras CA. Elemental diet is an effective
treatment for eosinophilic esophagitis in children and adolescents. Am J Gastroenterol.
2003;98:777-782. Related Links: Abstract
Noel RJ, Putnam PE, Rothenberg ME. Eosinophilic esophagitis. N Engl J Med.
2004;351:940-941. Related Links: Abstract; Full text
Onbasi K, Sin AZ, Doganavsargil B, Onder GF, Bor S, Sebik F. Eosinophil infiltration of the
oesophageal mucosa in patients with pollen allergy during the season. Clin Exp Allergy.
2005;35:1423-1431. Related Links: Abstract
Scurlock AM, Lee LA, Burks AW. Food allergy in children. Immunol Allergy Clin North Am.
2005;25:369-388. Related Links: Abstract
Sicherer SH, Sampson HA. 9. Food allergy. J Allergy Clin Immunol. 2006 Feb;117(2 Suppl
Mini-Primer):S470-S475. Related Links: Abstract; Full text
Spergel JM, Andrews T, Brown-Whitehorn TF, Beausoleil JL, Liacouras CA. Treatment of
eosinophilic esophagitis with specific food elimination diet directed by a combination of skin
prick and patch tests. Ann Allergy Asthma Immunol. 2005;95:336-343. Related Links:
Abstract
Spergel JM, Brown-Whitehorn T, Beausoleil JL, Shuker M, Liacouras CA. Predictive values
for skin prick test and atopy patch test for eosinophilic esophagitis. J Allergy Clin Immunol.
2007;119:509-511. Related Links: Abstract
Straumann A. The natural history and complications of eosinophilic esophagitis.
Gastrointest Endosc Clin N Am. 2008;18:99-118. Related Links: Abstract

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Food Allergic Disorders > General Guidance
Weblinks

Sources of Formulas, Supplements, Substitute Foods, Ingredient Lists, and Recipes
AllerEnergy
www.allerenergy.com
Amanda's Own Confections
www.amandasown.com
Arrowhead Mills, Inc.
www.arrowheadmills.com
Barbara’s Bakery
www.barbarasbakery.com
Bob’s Red Mill
www.bobsredmill.com
Cherry Brook Kitchen
www.cherrybrookkitchen.com
Chocolate Decadence
www.chocolatedecadence.com
Cream Hill Estates
www.creamhillestates.com
Divvies
www.divvies.com
Eden Foods
www.edenfoods.com
Ener-G-Foods
www.ener-g.com
Enjoy Life
www.enjoylifefoods.com
The Gluten-Free Pantry
www.glutenfree.com
Home Free Treats
www.homefreetreats.com
I.M. Healthy—The SoyNut Butter Company
http://www.soynutbutter.com/
King Arthur Gluten Free
www.kingarthurflour.com/glutenfree
Meraby's
www.meraby.com
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Namaste Foods
www.namastefoods.com
Nonuttin Foods, Inc.
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Orgran Foods
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Pamela's Products
http://pamelasproducts.com/
Peanut Free Planet
www.peanutfreeplanet.com
Schär
www.schar.com
SunButter—Sunflower seed spread
www.sunbutter.com
Vermont Nut Free Chocolate
www.vermontnutfree.com

Formulas
Abbott Nutrition
www.abbottnutrition.com
Extensively Hydrolyzed Formulas:
Similac Alimentum
Amino Acid–Based Formulas:
EleCare
EleCare Vanilla
Bright Beginnings
www.brightbeginnings.com
Soy toddler formula
Mead Johnson Nutritionals
www.meadjohnson.com
Extensively Hydrolyzed Formulas:
Nutramigen
Nutramigen with Enflora LGG
Pregestimil
Amino Acid–Based Formula:
Nutramigen AA
Nutricia North America
www.nutricia.com
Amino Acid–Based Formulas:
Neocate Infant
Neocate Infant with DHA and ARA
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Neocate Junior with Prebiotic
Neocate Junior (unflavored, chocolate, tropical)
EO28 Splash
Amino Acid–Based Semisolid Medical Food: Nutra Neocate

Organizations
Asthma and Allergy Foundation of America
www.aafa.org
The American Academy of Allergy, Asthma, and Immunology
www.aaaai.org
The American College of Allergy, Asthma, and Immunology
http://www.acaai.org
The Food Allergy & Anaphylaxis Network
www.foodallergy.org
Food Allergy Initiative
www.faiusa.org
The American Partnership for Eosinophilic Disorders
www.apfed.org
Food Allergy Research and Resource Program
http://www.farrp.org/
Kids with Food Allergies Foundation
http://www.kidswithfoodallergies.org
National Institute of Allergy and Infectious Disease
http://www3.niaid.nih.gov/topics/foodAllergy
Consortium of Food Allergy Research (click on the Food Allergy Education Program)
https://web.emmes.com/study/cofar/
Websites last accessed February 12, 2012.

References: Food Allergic Disorders

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, Plaut M, Cooper SF,
Fenton MJ, Arshad SH, Bahna SL, Beck LA, Byrd-Bredbenner C, Camargo CA Jr,
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Chehade M. IgE and non-IgE-mediated food allergy: Treatment in 2007. Curr Opin Allergy
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fleischer DM, Conover-Walker MK, Christie L, Burks AW, Wood RA. The natural
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Furuta GT, Liacouras CA, Collins MH, Gupta AK, Justinich C, Putnam PE, Bonis P, Hassall
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Children and Adults: A Systematic Review and Consensus Recommendations for
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links: Abstract; Full text
Hays T. Special considerations for managing food allergies. JPEN J Parenter Enteral Nutr.
2012 Jan;36(1 Suppl):56S-59S. Related links: Abstract
Henriksen C, Eggesbo M, Halvorsen R, Botten G. Nutrient intake among two-year-old
children on cows' milk-restricted diets. Acta Paediatr. 2000;89(3):272-278. Related links:
Abstract
Hofmann A, Burks AW. Pollen food syndrome: Update on the allergens. Curr Allergy
Asthma Rep. 2008;8(5):413-417. Related links: Abstract
Isolauri E, Sutas Y, Salo MK, Isosomppi R, Kaila M. Elimination diet in cow's milk allergy:
Risk for impaired growth in young children. J Pediatr. 1998;132(6):1004-1009. Related links:
Abstract
Jensen VB, Jorgensen IM, Rasmussen KB, Molgaard C, Prahl P. Bone mineral status in
children with cow milk allergy. Pediatr Allergy Immunol. 2004;15(6):562-565. Related
links: Abstract
Jones SM, Pons L, Roberts JL, Scurlock AM, Perry TT, Kulis M, Shreffler WG, Steele P,
Henry KA, Adair M, Francis JM, Durham S, Vickery BP, Zhong X, Burks AW. Clinical
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Jones SM, Magnolfi CF, Cooke SK, Sampson HA. Immunologic cross-reactivity among
cereal grains and grasses in children with food hypersensitivity. J Allergy Clin Immunol.
1995;96(3):341-351. Related links: Abstract
Kagalwalla AF, Sentongo TA, Ritz S, Hess T, Nelson SP, Emerick KM, Melin-Aldana H, Li
BU. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic
esophagitis. Clin Gastroenterol Hepatol. 2006;4(9):1097-1102. Related links: Abstract
Kelly KJ, Lazenby AJ, Rowe PC, Yardley JH, Perman JA, Sampson HA. Eosinophilic
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
esophagitis attributed to gastroesophageal reflux: Improvement with an amino acid-based
formula. Gastroenterology. 1995;109:1503-1512. Related links: Abstract
Kim JS, Nowak-Wegrzyn A, Sicherer SH, Noone S, Moshier EL, Sampson HA. Dietary
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Kirby M, Danner E. Nutritional deficiencies in children on restricted diets. Pediatr Clin North
Am. 2009;56:1085-1103. Related links: Abstract
Lemon-Mule H, Sampson HA, Sicherer SH, Shreffler WG, Noone S, Nowak-Wegrzyn A.
Immunologic changes in children with egg allergy ingesting extensively heated egg. J
Allergy Clin Immunol. 2008;122(5):977-983. Related links: Abstract
Liacouras CA. Eosinophilic esophagitis: Treatment in 2005. Curr Opin Gastroenterol.
2006;22(2):147-152. Related links: Abstract
Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, Burks AW, Chehade
M, Collins MH, Dellon ES, Dohil R, Falk GW, Gonsalves N, Gupta SK, Katzka DA, Lucendo
AJ, Markowitz JE, Noel RJ, Odze RD, Putnam PE, Richter JE, Romero Y, Ruchelli E,
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Mofidi S. Nutritional management of pediatric food hypersensitivity. Pediatrics. 2003;111(6
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HA. Tolerance to extensively heated milk in children with cow's milk allergy. J Allergy Clin
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Nowak-Wegrzyn A, Sampson HA. Future therapies for food allergies. J Allergy Clin
Immunol 2011 Mar;127(3):558-573. Related links: Abstract; Full text
Nowak-Wegrzyn A, Sampson HA, Wood RA, Sicherer SH. Food protein-induced
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nowak-Wegrzyn A, Sampson HA, Wood RA, Sicherer SH. Food protein-induced
enterocolitis syndrome caused by solid food proteins. Pediatrics. 2003;111(4 Pt
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Sampson HA. Food allergy. JAMA. 1997;278:1888-1894. Related links: Abstract
Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A,
Brown SG, Camargo CA Jr, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD Jr,
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Sampson HA. Use of food-challenge tests in children. Lancet. 2001;358(9296):1832-1833.
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2005;25(2):369-388. Related links: Abstract
Sicherer SH, Sampson HA. Food allergy. J Allergy Clin Immunol. 2006;117(2 Suppl
Mini-Primer):S470-S475. Related links: Abstract
Sicherer SH. Clinical aspects of gastrointestinal food allergy in childhood. Pediatrics.
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
links: Abstract
Skripak JM, Matsui EC, Mudd K, Wood RA. The natural history of IgE-mediated cow's milk
allergy. J Allergy Clin Immunol. 2007;120(5):1172-1177. Related links: Abstract
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2008;19(4):368-373. Related links: Abstract
Spergel JM, Andrews T, Brown-Whitehorn TF, Beausoleil JL, Liacouras CA. Treatment of
esosinophilic esophagitis with specific food elimination diet directed by a combination of
skin prick and patch tests. Ann Allergy Asthma Immunol. 2005;95(4):336. Related
links: Abstract
Srivastava KD, Qu C, Zhang T, Goldfarb J, Sampson HA, Li XM. Food Allergy Herbal
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IFN-gamma-producing CD8+ T cells. J Allergy Clin Immunol. 2009;123(2):443-451.
Related links: Abstract
Straumann A. The natural history and complications of eosinophilic esophagitis.
Gastrointest Endosc Clin N Am. 2008;18(1):99-118. Related links: Abstract
Taylor SL, Hefle SL, Bindslev-Jensen C, Bock SA, Burks AW Jr, Christie L, Hill DJ, Host A,
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Taylor SL, Hefle SL. Food allergen labeling in the USA and Europe. Curr Opin Allergy Clin
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Challenges. Fairfax, VA: FAAN, 2004. Available at: Website.
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Waserman S, Watson W. Food allergy. Allergy Asthma Clin Immunol. 2011;7 Suppl 1:S7.
Related links: Abstract; Full text

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Gastrointestinal Diseases
Gastrointestinal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Gastrointestinal Diseases > Celiac Disease
References: Celiac Disease

American Dietetic Association Evidence-Based Practice Guidelines: Celiac Disease 2009.
Available at: Website.
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Giovenale D, Meazza C, Cardinale GM, Sposito M, Mastrangelo C, Messini B, Citro G,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Delvecchio M, Di Maio S, Bozzola M. The prevalence of growth hormone deficiency and
celiac disease in short children. Clin Med Res. 2006;4(3):180-183. Related links: Abstract
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Hernando A, Mujico JR, Mena MC, Lombardía M, Méndez E. Measurement of wheat gluten
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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11(25):3935-3938. Related Links: Abstract; Full Text


Weblinks: Diarrhea

American Academy of Pediatrics: Diarrhea Accessed 12/20/2011
American Gastroenterological Association Accessed 12/20/2011
Food Safety Partnership for Food Safety Education Accessed 12/20/2011
International Foundation for Functional Gastrointestinal Disorders: Kids and
Teens Accessed 12/20/2011
National Digestive Diseases Information Clearinghouse (NDDIC): Diarrhea Accessed
12/20/2011

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References > Gastrointestinal Diseases > Gastroesophageal Reflux
References: Gastroesophageal Reflux

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References > Gastrointestinal Diseases > Irritable Bowel Syndrome
References: Irritable Bowel Syndrome

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Williams CL, Bollella M, Wynder EL. A new recommendation for dietary fiber in childhood.
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Weblinks: Irritable Bowel Syndrome

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition:
www.naspghan.org
American Gastroenterological Association: www.gastro.org
National Institute of Diabetes and Digestive and Kidney Diseases: www.niddk.nih.gov
International Foundation for Functional Gastrointestinal Disorders Inc.: www.iffgd.org
Irritable Bowel Syndrome Self-Help and Support Group: www.ibsgroup.org


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References > Gastrointestinal Diseases > Short Bowel Syndrome
References: Short Bowel Syndrome

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References > Hepatic Diseases
Weblinks: Hepatic Diseases

American Liver Foundation: http://www.liverfoundation.org
Children’s Liver Alliance for Families (Yahoo! group):
http://health.groups.yahoo.com/group/LIVER-CHILDREN/
Children’s Liver Association for Support Services (CLASS): http://www.classkids.org
Children’s Liver Disease Foundation: http://www.childliverdisease.org
Family Village: A Global Community of Disability Resources: Liver Disease:
http://www.familyvillage.wisc.edu/lib_liver.htm
Liver Families: http://www.liverfamilies.net/
Children's Hospital St. Louis: Liver Transplantation:
http://www.stlouischildrens.org/content/greystone_1414.htm
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References > HIV/AIDS
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Jacobson DL, Spiegelman D, Duggan C, Weinberg GA, Bechard L, Furuta L, Nicchitta J,
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2002;283:E138-E145. Related Links: Abstract; Full text
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Press; 2007:115-125.

Weblinks for HIV/AIDS

American Academy of Pediatrics, Committee on Pediatric AIDS
http://www.aap.org/committees/pediatricaids/default.htm
Dietary Guidelines for Americans 2010
http://www.cnpp.usda.gov/DGAs2010-PolicyDocument.htm
Centers for Disease Control and Prevention: HIV/AIDS
http://www.cdc.gov/hiv/
Centers for Disease Control and Prevention growth charts: United States
http://www.cdc.gov/growthcharts/
National Center for Health Statistics: Anthropometric Reference Data for Children and
Adults, 1988-1994
http://www.cdc.gov/nchs/data/series/sr_11/sr11_249.pdf
2008 Physical Activity Guidelines for Americans
http://www.health.gov/paguidelines/
The Complete HIV/AIDS Resource
http://www.thebody.com/
UNAIDS Joint United Nations Programme on HIV/AIDS
http://www.unaids.org/globalreport
Women, Children and HIV: Resources for Prevention and Treatment
http://www.womenchildrenhiv.org/

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Inborn Errors of Metabolism
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References > Oncology
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Weblinks: Oncology

American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer
Prevention accessed 7/18/2011
American Institute for Cancer Research accessed 7/18/2011
Cure4Kids at St. Jude Children's Research Hospital accessed 7/18/2011
Dana-Farber Cancer Institute Nutrition Services accessed 7/18/2011
Long-Term Follow-up Guidelines from Children's Oncology Group accessed 7/18/2011
National Cancer Institute accessed 7/18/2011
Oncology Nutrition Dietetic Practice Group (a dietetic practice group of the American
Dietetic Association) accessed 7/18/2011
St. Jude Children's Research Hospital Department of Clinical Nutrition accessed
7/18/2011

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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Rugby Laboratories, a subsidiary of Watson
Sanofi-Aventis
Solace Nutrition
SourceCF, Inc
Yasoo Health Inc

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References > Pulmonary Diseases
Pulmonary Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Pulmonary Diseases > Asthma
References: Asthma

Belamarich PF, Luder E, Kattan M, Mitchell H, Islam S, Lynn H, Crain EF. Do obese
inner-city children with asthma have more symptoms than nonobese children with asthma?
Pediatrics. 2000;106(6):1436-1441. Related links: Abstract
Dawson KP, Ford RP, Mogridge N. Childhood asthma: What do parents add or avoid in
their children's diets? N Z Med J. 1990;103(890):239-240. Related links: Abstract
Eneli IU, Skybo T, Carmargo CA. Weight loss and asthma: A systematic review. Thorax.
2008;63(8):671-676. Related links: Abstract
Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. Full
Report. National Heart, Lung, and Blood Institute, National Institutes of Health, US
Department of Health and Human Services, August 28, 2007. Available at: Website
Flaherman V, Rutherford GW. A meta-analysis of the effect of high weight on asthma. Arch
Dis Child. 2006;91:334-339. Related links: Abstract; Full Text
Ozol D, Mete E. Asthma and food allergy. Curr Opin Pulm Med. 2008;14(1):9-12. Related
links: Abstract
Wuthrich B, Schmid A, Walther B, Seiber, R. Milk consumption does not lead to mucus
production or occurrence of asthma. J Am Coll Nutr. 2005;24:547s-555s. Related
links: Abstract; Full Text

Weblinks: Asthma

Asthma and Allergy Foundation: http://www.aafa.org
National Heart, Lung, and Blood Institute Asthma Management Guidelines:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
Medline Plus: "Asthma in
Children": http://www.nlm.nih.gov/medlineplus/asthmainchildren.html




© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Pulmonary Diseases > Bronchopulmonary Dysplasia
References: Bronchopulmonary Dysplasia

Ambalavanan N, Soltau TD. Bronchopulmonary dysplasia. Medscape Reference. Available at
http://emedicine.medscape.com/article/973717-overview. Last updated Aug 26, 2011.
Bancalari E, Claure N. Definitions and diagnostic criteria for bronchopulmonary dysplasia. Semin Perinatol.
2006;(30):164-170. Related links: Abstract
Bhandari A, Bhandari V. Pitfalls, problems, and progress in bronchopulmonary dysplasia. Pediatrics. 2009
Jun;123(6):1562-73. Related links: Abstract

Biniwale MA, Ehrenkranz RA. The role of nutrition in the prevention and management of bronchopulmonary
dysplasia. Semin Perinatol. 2006;(30):200-208. Related links: Abstract
Ehrenkranz RA, Walsh MC, Vohr BR, Jobe AH, Wright LL, Fanaroff AA, Wrage LA, Poole K; National
Institutes of Child Health and Human Development Neonatal Research Network. Validation of the National
Institutes of Health consensus definition of bronchopulmonary dysplasia. Pediatrics. 2005
Dec;116(6):1353-60. Related links: Abstract; Full Text
Koo WW, Hockman EM. Posthospital discharge feeding for preterm infants: effects of standard compared
with enriched milk formula on growth, bone mass, and body composition. Am J Clin Nutr. 2006
Dec;84(6):1357-64. Related links: Abstract; Full Text
Neiman L. Follow-up nutrition after discharge from the neonatal ICU. Building Block for Life. The Pediatric
Nutrition Practice Group. 2006;(29)1.
Reynolds RM, Thureen PJ. Special circumstances: trophic feeds, necrotizing enterocolitis and
bronchopulmonary dysplasia. Semin Fetal Neonatal Med. 2007 Feb;12(1):64-70. Epub 2006 Dec 26.
Related links: Abstract
Zerzan J. Case Report – Infant with BPD. Building Block for Life. The Pediatric Nutrition Practice Group.
2006;(29)1.

Weblinks: Bronchopulmonary Dysplasia

Gaining & Growing website: http://depts.washington.edu/growing/Assess/BPD.htm
CHEO website: http://www.cheo.on.ca/
Wellsphere: Bronchopulmonary
Dysplasia: http://stanford.wellsphere.com/general-medicine-article/bronchopulmonary-dysplasia/730622
WebMD: Bronchopulmonary Dysplasia: http://www.webmd.com/lung/bronchopulmonary-dysplasia-bpd

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Pulmonary Diseases > Cystic Fibrosis
References: Cystic Fibrosis

Abbott J, Morton AM, Musson H, Conway SP, Etherington C, Gee L, Fitzjohn J, Webb
AK. Nutritional status, perceived body image and eating behaviors in adults with cystic
fibrosis. Clin Nutr. 2007;26:91-99. Related links: Abstract
Aris RM, Merkel PA, Bachrach LK, Borowitz DS, Boyle MP, Elkin SL, Guise TA, Hardin DS,
Haworth CS, Holick MF, Joseph PM, O'Brien K, Tullis E, Watts NB, White TB. Guide to
bone health and disease in cystic fibrosis. J Clin Endocrinol Metab. 2005;90:1888-1896.
Related links: Abstract; Full Text
Australasian Clinical Practice Guidelines for Nutrition in Cystic Fibrosis. 2006. Available at:
Website. Accessed February 21, 2012.
Borowitz D, Baker RD, Stallings V. Consensus report on nutrition for pediatric patients with
cystic fibrosis. J Pediatr Gastroenterol Nutr. 2002;35(3):246-259. Related links: Full Text
Borowitz D, Baker SS, Duffy L, Baker RD, Fitzpatrick L, Gyamfi J, et al. Use of fecal
elastase-1 to classify pancreatic status in patients with cystic fibrosis. J Pediatr.
2004;145:322-326. Related links: Abstract
Borowitz D, Lin R, Baker SS. Comparison of monoclonal and polyclonal ELISAs for fecal
elastase in patients with cystic fibrosis and pancreatic insufficiency. J Pediatr Gastroenterol
Nutr. 2007;44(2):219-223. Related links: Abstract
Bryon M, Shearer J, Davies H. Eating disorders and disturbance in children and
adolescents with cystic fibrosis. Child Health Care. 2008;37:67-77. Related links: Abstract
Cantin AM, White TB, Cross CE, Forman HJ, Sokol RJ, Borowitz D. Antioxidants in cystic
fibrosis. Conclusions from the CF antioxidant workshop, Bethesda, Maryland, November
11-12, 2003. Free Radic Biol Med. 2007;42(1):15-31. Epub 2006 Sep 29. Related
links: Abstract; Full Text
Cystic Fibrosis Foundation. Patient Registry 2006 Annual Report. Bethesda, MD: Cystic
Fibrosis Foundation; 2008. Related links: Full Text
Cystic Fibrosis Foundation, Borowitz D, Robinson KA, Rosenfeld M, Davis SD, Sabadosa
KA, Spear SL, Michel SH, Parad RB, White TB, Farrell PM, Marshall BC, Accurso FJ.
Cystic Fibrosis Foundation evidence-based guidelines for management of infants with
cystic fibrosis. J Pediatr. 2009; 155:S73-S93. Related links: Abstract
Chao HC, Chen SY, Chen CC, Chang KW, Kong MS, Lai MW, Chiu CH. The impact of
constipation on growth in children. Pediatr Res. 2008;64(3):308-311. Related links: Abstract
Christian P, West KP Jr. Interactions between zinc and vitamin A: An update. Am J Clin
Nutr. 1998;68(suppl):435S–441S. Related links: Abstract; Full Text
Crist W, McDonnel P, Beck M, Gillespie CT, Barrett P, Mathews J. Behavior at mealtimes
and the young child with cystic fibrosis. J Dev Behav Pediatr. 1994;15:157-161. Related
links: Abstract
Daftary A, Acton J, Heubi J, Amin R. Fecal elastase-1: Utility in pancreatic function in
cystic fibrosis. J Cyst Fibros. 2006;5:71-76. Related links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Erskine JM, Lingard C, Sontag M. Update on enteral nutrition for cystic fibrosis. Nutr Clin
Pract. 2007;22:223-232. Related link: Abstract
Farrell PM, Rosenstein BJ, White TB, Accurso FJ, et al. Guidelines for diagnosis of cystic
fibrosis in newborns through older adults: Cystic Fibrosis Foundation Consensus Report. J
Pediatr. 2008;153:S4-S14. Related links: Abstract; Full Text
Grande L. Pancreatic enzyme products: what's new? Updates for pancreatic enzymes for
patients with cystic fibrosis. ICAN: Infant Child Adolesc Nutr. 2011;3(2):87-91. Related
links: Abstract
Hardin D, Rice J, Rice M, Rosenblatt R. Use of the insulin pump in treatment of cystic
fibrosis related diabetes. J Cystic Fibros. 2009;8(3):174-178. Related links: Abstract
Haycock GB. The influence of sodium on growth in infancy. Pediatr Nephrol.
1993;7:871-875. Related links: Abstract
Houwen RH, van der Doef HP, Sermet I, Munck A, Hauser B, Walkowiak J, Robberecht E,
Colombo C, Sinaasappel M, Wilschanski M; ESPGHAN Cystic Fibrosis Working Group.
Defining DIOS and constipation in cystic fibrosis with a multicentre study on the incidence,
characteristics, and treatment of DIOS. J Pediatr Gastroenterol Nutr. 2010;50:1:38-42.
Related links: Abstract
Kriemler S, Wilk B, Schurer W, Wilson WM, Bar-Or O. Preventing dehydration in children
with cystic fibrosis who exercise in the heat. Med Sci Sports Exerc. 1993;31;774-779.
Related links: Abstract
Laughlin JJ, Brady MS, Elgen H. Changing feeding trends as a cause of electrolyte
depletion in infants with cystic fibrosis. Pediatrics. 1981;68:203-207. Related links: Abstract
Legris G, Dearborn D, Stern R, Geiss C, Hopfer U, Douglas J, Doershuk C. Sodium space
and intravascular volume: Dietary sodium effects in cystic fibrosis and healthy adolescent
subjects. Pediatrics. 1998;101:48-56. Related links: Abstract
Leonard A, Schindler T. CF Nutrition 101: A module for CF health care
providers. Bethesda, MD: Cystic Fibrosis Foundation; 1996-2002.
Maqbool A, Stallings V. Update on fat-soluble vitamins in cystic fibrosis. Curr Opin Pulm
Med. 2008;14:574-581. Related links: Abstract
Matel J, Milla C. Nutrition in cystic fibrosis. Semin Respir Crit Care Med.
2009;30:5:579-586. Related links: Abstract
Michel SH, Maqbool A, Hanna MD, Mascarenhas M. Nutrition management of pediatric
patients who have cystic fibrosis. Pediatr Clin N Am. 2009a;56:5. Related links: Abstract
Michel SH. Fatty acids and cystic fibrosis. CF Supplement. 2006;4(1):1-3.
Michel SH. Pancreatitis and cystic fibrosis. CF Supplement. 2009b;7(4):1-4.
Michel SH. The liver and cystic fibrosis. CF Supplement. 2009c;7(3):1-4.
Michel SH. Are eating disorders present in cystic fibrosis? CF Supplement. 2010; 8(1):1-4.
Moran A, Brunzell C, Cohen RC, Katz M, Marshall BC, Onady G, Robinson KA, Sabadosa
KA, Stecenko A, Slovis B; CFRD Guidelines Committee. Clinical care guidelines for cystic
fibrosis-related diabetes: A position statement of the American Diabetes Association and a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric
Endocrine Society. Diabetes Care. 2010;33(12):2697-2708. Related Link: Full Text
Moran A, Hardin D, Rodman D, Allen HF, Beall RJ, Borowitz D, Brunzell C, Campbell PW
3rd, Chesrown SE, Duchow C, Fink RJ, Fitzsimmons SC, Hamilton N, Hirsch I,
Howenstine MS, Klein DJ, Madhun Z, Pencharz PB, Quittner AL, Robbins MK, Schindler
T, Schissel K, Schwarzenberg SJ, Stallings VA, Zipf WB, et al. Diagnosis, screening and
management of cystic fibrosis related diabetes mellitus: A consensus conference report.
Diabetes Res Clin Pract. 1999;45:61-73.
Mueller DH. Associate Professor, Nutrition Sciences Department, Drexel University,
Philadelphia, PA. Personal communication, 2000.
Powers SW, Byars KC, Mitchell MJ, Patton SR, Schindler T, Zeller MH. A randomized pilot
study of behavioral treatment to increase calorie intake in toddlers with cystic fibrosis. Child
Health Care. 2003;32(4):297-311. Related links: Abstract
Ramsey BW, Farrell PM, Pencharz P. Nutritional assessment and management in cystic
fibrosis: A consensus report. Am J Clin Nutr. 1992;55;108-16. Related links: Abstract Full
text
Sokol RJ, Durie PR. Recommendations for management of liver and biliary tract disease in
cystic fibrosis. Cystic Fibrosis Foundation Hepatobiliary Disease Consensus Group. J
Pediatr Gastroenterol Nutr. 1999;28(Suppl 1):S1-S13.
Stallings VA, Stark LJ, Robinson KA, Feranchak AP, Quinton H. Evidence-based practice
recommendations for nutrition-related management of children and adults with cystic
fibrosis and pancreatic insufficiency: Results of a systematic review. J Am Diet Assoc.
2008;108:832-839. Related links: Abstract
Stark LJ, Jelalian E, Powers SW, Mulvihill MM, Opipari LC, Bowen A, Harwood I, Passero
MA, Lapey A, Light M, Hovell MF. Parent and child mealtime behavior in families of
children with cystic fibrosis. J Pediatr. 2000;136:195-200. Related links: Abstract
Tinley C, Withers W, Sheldon C, Quinn A, Jackson A. Zinc therapy for night blindness in
cystic fibrosis. J Cystic Fibros. 2008;7:333-335. Related links: Abstract
Trabulsi J, Ittenbach RF, Schall JI, Olsen IE, Yudkoff M, Daikhin Y, Zemel BS, Stallings
VA. Evaluation of formulas for calculating total energy requirements of preadolescent
children with cystic fibrosis. Am J Clin Nutr. 2007;85:144-151. Related links: Abstract;
Full Text
van der Doef H, Kokke F, Beek F, Woestenenk J, Froeling S, Houwen R. Constipation in
pediatric cystic fibrosis patients: An underestimated medical condition. J Cyst
Fibros. 2010;9:59-63. Related links: Abstract
Zhang Z, Lai H. Comparison of the use of body mass index percentiles and percentage of
ideal body weight to screen for malnutrition in children with cystic fibrosis. Am J Clin
Nutr. 2004;80:982-991. Related links: Abstract; Full Text
Zhang Z, Shoff S, and Hui Chuan J. Incorporating genetic potential when evaluating stature
in children with cystic fibrosis. J Cyst Fibros. 2010;9:2:135-142. Related links: Abstract

Weblinks: Cystic Fibrosis

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Children's Memorial
Hospital: https://secure.childrensmemorial.org/depts/pmcc/cysticfibrosis/tubefeeding.aspx
Cystic Fibrosis Foundation www.cff.org
Cystic Fibrosis resource: http://www.cysticfibrosis.com
Cystic Fibrosis Services, Inc. http://www.cfservicespharmacy.com
Johns Hopkins Cystic Fibrosis Center: http://www.hopkinscf.org/
Mayo Clinic: http://www.mayoclinic.com/health/cystic-fibrosis/DS00287
National Heart, Lung, and Blood
Institute: http://www.nhlbi.nih.gov/health/dci/Diseases/cf/cf_what.html
Source CF educational materials: http://www.sourcecf.com/education.htm
TeensHealth: http://kidshealth.org/teen/diseases_conditions/respiratory/cystic_fibrosis.html
All sites last accessed February 18, 2012.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Pulmonary Diseases > Ventilator Issues
References: Ventilator Issues

Akrabawi SS, Mobarhan S, Stoltz RR, Ferguson PW. Gastric emptying, pulmonary
function, gas exchange, and respiratory quotient after feeding a moderate versus high fat
enteral formula meal in chronic obstructive pulmonary disease patients. Nutrition. 1996
Apr;12(4):260-5. Related links: Abstract
Ambrosino N, Clini E. Long-term mechanical ventilation and nutrition. Respir Med. 2004;
98:413-420. Related links: Abstract
Cloud HH. Developmental Disabilities. In: Samour PQ and King K, eds. Handbook of
Pediatric Nutrition, 3rd Edition. Sudbury MA: Jones and Bartlett Publishers, 2005.
Graham AS, Kirby AL. Ventilator management protocols in pediatrics. Respir Care Clin N
Am. 2006 Sep; 12(3):389-402. Related links: Abstract
Joosten KF, Jacobs FI, van Klaarwater E, Baartmans MG, Hop WC, Meriläinen PT,
Hazelzet JA. Accuracy of an indirect calorimeter for mechanically ventilated infants and
children: the influence of low rates of gas exchange and varying FIO2. Crit Care Med. 2000
Aug; 28(8):3014-8. Related links: Abstract
Kendirli T, Kavaz A, Yalaki Z, Ozturk Hismi B ,Derelli E, Ince E. Mechanical ventilation in
children. Turk J Pediatrics 2006; 48(4)323-7. Related links: Abstract

Weblinks: Ventilator Issues

Pennsylvania Department of Health VACHP: http://www.kidshome-vent.org/
C.S. Mott Children's Hospital: http://www.med.umich.edu/mott/pedhomevent/team.html

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Renal Diseases
References: Renal Diseases

Baumgartner R, Roche A, Himes J. Incremental growth tables supplementary to previously published
charts. Am J Clin Nutr. 1986;43:711-722. Related links: Abstract; Full Text
Brem A, Lambert C, Hill, C, Kitsen J, Shemin D. Prevalence of protein malnutrition in children maintained on
peritoneal dialysis. Paediatr Nephrol. 2002;17:527-530. Related links: Abstract
Cano F, Azocar M, Delucchi M, Rodriguez E, Marin V, Diaz E, Mazuela N. Nitrogen balance studies and
Kt/V urea in children undergoing chronic peritoneal dialysis. Adv Perit Dial. 2004;20:245-250. Related
links: Abstract
Centers for Disease Control and Prevention, National Center for Health Statistics. Z-Scores Data Files.
Available at: Website. Accessed February 14, 2012.
Charney C, Charney D. Nutrition support in renal failure. Nutr Clin Pract. 2002;17:226-236.
Daschner M, Tohshoff B, Blum W. Englaro P, Wingen A, Schaefer F, Wij E, Rascher W, Mehls O.
Inappropriate elevation of serum leptin levels in children with chronic renal failure. European Study Group
for Nutritional Treatment of Chronic Renal Failure in Childhood. J Am Soc Nephrol. 1998;9:1074-1079.
Related links: Abstract; Full Text
Heinz J, Domrose U, Westphal S, Luley C, Neumann KH, Dierkes J. Washout of water-soluble vitamins and
of homocysteine during haemodialysis: Effect of high-flux and low-flux dialyser. Nephrology.
2008;13(5):384-389. Related links: Abstract
Hodson E, Willis N, Craig J. Non-corticosteroid treatment for nephrotic syndrome in children (Review).
Cochrane Database Syst Rev. 2008;(1):CD002290. Related links: Abstract
Holick M. Medical progress: Vitamin D deficiency [review article]. N Engl J Med. 2007;357:266-281. Related
links: Abstract
Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National
Academy of Sciences; 2011.
Leonard M, Feldman H, Shults J, Zemel B, Foster B, Stallings V. Long-term, high-dose glucocorticoids and
bone mineral content in childhood glucocorticoid-sensitive nephrotic syndrome. N Engl J Med.
2004;351:868-875. Related links: Abstract; Full Text
McDonough AK, Curtis JR, Saag KG. The epidemiology of glucocorticoid-associated adverse events. Curr
Opin Rheumatol. 2008;20(2):131-7. Related links: Abstract
National Kidney Foundation. A to Z Health Guide. Available at: Website. Accessed February 14, 2012.
National Kidney Foundation KDOQI Guidelines: KDOQI Clinical practice guidelines for bone metabolism
and disease in children with chronic kidney disease. Available at: Website. Accessed February 14, 2012.
National Kidney Foundation KDOQI (Kidney Dialysis Outcomes Quality Initiative) Clinical practice guideline
for nutrition in children with CKD: 2008 Update. Am J Kid Dis. 2009;52(Suppl 2):S1-S124.
National Kidney Foundation; KDOQI Work Group. KDOQI Clinical Practice Guideline for Nutrition in
Children with CKD: 2008 update. Executive summary. Am J Kidney Dis. 2009b Mar;53(3 Suppl 2):S11-104.
Related links: Full text (pdf)

National Kidney Foundation KDOQI Guidelines: KDOQI Clinical practice guideline and clinical practice
recommendations for anemia in chronic kidney disease. III: Clinical practice recommendations for anemia in
chronic kidney disease in children. 2006 National Kidney Foundation. Available at: Website. Accessed
February 14, 2012.
National Kidney Foundation. Glomerular Filtration Rate. Stages of CKD. Available at: Website. Accessed
February 14, 2012.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Norman L, Coleman E, Macdonald I, Tomsett A, Watson A. Nutrition and growth in relation to severity of
renal disease in children. Pediatr Nephrol. 2000;15:259-265. Related links: Abstract
Norman L, Macdonald I, Watson A. Optimising nutrition in chronic renal insufficiency—growth. Pediatr
Nephrol. 2004;19:1245-1252. Related links: Abstract
Parekh R, Flynn J, Smoyer J, Milne D, Kershaw T, Bunchman T, Sedman A. Improved growth in young
children with severe chronic renal insufficiency who use specified nutritional therapy. J Am Soc Nephrol.
2001;12(11):2418-2426.
Rees L, Shaw V. Nutrition in children with CRF and on dialysis. Pediatr Nephrol. 2007;22:1689-1702.
Related links: Abstract; Full Text
Roth D, Martz P, Yeo R, Prosser C, Bell M, Jones A. Are national vitamin D guidelines sufficient to maintain
adequate blood levels in children? Can J Public Health. 2005;96:443-449. Related links: Abstract
Solan P. Nutrition assessment and management of children with chronic kidney disease. Building Block for
Life [ADA Pediatric Nutrition Practice Group]. 2008;31(2):1-6.
Wingen AM, Mehls O. Nutrition in children with preterminal chronic renal failure. Myth or important
therapeutic aid? Pediatr Nephrol. 2002;17:111-120. Related links: Abstract
Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American Academy of
Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and
adolescents. Pediatrics. 2008;122(5):1142-1152. Related links: Abstract; Full Text
2006 World Health Organization Growth Standards. Available at: Website. Accessed February 14, 2012.

Weblinks: Renal Diseases

Resources for healthcare providers:
Council on Renal Nutrition of the National Kidney Foundation:
http://www.kidney.org/professionals/CRN/ (accessed 8/1/11)
Full text of KDOQI (Kidney Dialysis Outcome Quality Initiative) Clinical Practice Guideline for Nutrition in
Children with CKD; 2008 update, published in American Journal of Kidney Diseases. 2009;52(Suppl
2):S1-S124:
http://www.kidney.org/professionals/KDOQI/guidelines_updates/pdf/CPGPedNutr2008.pdf (accessed 8/1/11)

KDOQI Guidelines on Pediatric Renal Bone Disease:
http://www.kidney.org/professionals/Kdoqi/guidelines_pedbone/guide17.htm (accessed 8/1/11)
Information on glomerular filtration rate, how to determine it and stages of chronic kidney disease:
http://www.kidney.org/kidneydisease/ckd/knowGFR.cfm (accessed 8/1/11)
World Health Organization Growth Data—used for evaluating growth from birth to 2 years of age (shows
optimal growth): http://www.who.int/childgrowth/en/ (accessed 8/1/11
Centers for Disease Control and Prevention growth charts—use for children older than 2 years:
http://www.cdc.gov/growthcharts/ (accessed 8/1/11)
National Kidney Disease Education Program: Information on estimation of glomerular filtration rate:
http://nkdep.nih.gov/professionals/gfr_calculators/idms_schwartz.htm (accessed 8/1/11)
National Kidney Foundation: Information on Nephrotic Syndrome. Available at:
http://www.kidney.org/Atoz/atozItem.cfm?id=53 (accessed 8/1/11)

Renal Formulas (accessed 8/5/11)
Similac PM 60/40
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Suplena
Nepro
Novasource Renal:
Renalcal
Renastart

Patient Infomation and Education
Kidney Times, a program of Renal Support Network: http://ikidney.com/index.php (accessed 8/1/11)
Overview of Kidney Diseases in Children on the National Kidney and Urologic Diseases Information
Clearinghouse Web site; a service of the National Institute of Diabetes, and Digestive and Kidney Diseases
(NIDDKD) of the National Institutes of Health:
http://kidney.niddk.nih.gov/kudiseases/pubs/childkidneydiseases/overview/ (accessed 8/1/11)


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Renal Diseases > Nephrotic Syndrome
Nephrotic Syndrome

This section is blank.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Transplantation
Transplantation


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Transplantation > Organ Transplant
Weblinks: Organ Transplant

Transplant Living
How the Liver Works (accessed 2/15/10)
During the Transplant (accessed 2/15/10)
Medications: Protecting your Transplant (accessed 2/15/10)
Liver Transplant
Medscape: History of Pediatric Liver Transplantation (accessed 2/15/10)
Resources for healthcare providers on the National Kidney Foundation Web site
Council on Renal Nutrition of the National Kidney Foundation:
http://www.kidney.org/professionals/CRN/ (accessed 1/1/10)
Full text of KDOQI (Kidney Dialysis Outcome Quality Initiative) Clinical Practice Guideline for Nutrition in
Children with CKD; 2008 update, published in American Journal of Kidney Diseases. 2009;52(Suppl
2):S1-S124:
http://www.kidney.org/professionals/KDOQI/guidelines_updates/pdf/CPGPedNutr2008.pdf (accessed 1/1/10)

KDOQI Guidelines on Pediatric Renal Bone Disease: (accessed 1/1/10)
Information on glomerular filtration rate, how to determine it and stages of chronic kidney disease:
http://www.kidney.org/kidneydisease/ckd/knowGFR.cfm (accessed 1/1/10)
World Health Organization Growth Data—used for evaluating growth from birth to 2 years of age (shows
optimal growth): http://www.who.int/childgrowth/en/ (accessed 1/1/10)
Centers for Disease Control and Prevention growth charts—use for children older than 2 years:
http://www.cdc.gov/growthcharts/ (accessed 1/1/10)
National Kidney Disease Education Program: Information on estimation of glomerular filtration rate:
http://nkdep.nih.gov/professionals/gfr_calculators/idms_schwartz.htm (accessed 1/2/10)

Web Sites for Formula Companies
Nestle Web site: http://www.nestle-nutrition.com/Products/Default.aspx
Ross Labs Web site: http://abbottnutrition.com/
Mead Johnson Web
site: https://www.mjn.com/app/iwp/HCP/guestHome.do?dm=mj&ls=1&csred=1&r=3419615686
Nutricia Web site: http://www.shsna.com/pages/products.htm
Good Start Formulas Web site: http://www.gerber.com/Products/Default.aspx
Sites for Kidney Transplant Patient Infomation and Education
Kidney Times, a program of Renal Support Network: http://ikidney.com/index.php (accessed 1/1/10)
Overview of Kidney Diseases in Children on the National Kidney and Urologic Diseases Information
Clearinghouse Web site; a service of the National Institute of Diabetes, and Digestive and Kidney Diseases
(NIDDKD) of the National Institutes of Health:
http://kidney.niddk.nih.gov/kudiseases/pubs/childkidneydiseases/overview/ (accessed 1/1/10)

LifeAlysis: A resource for people with kidney disease and their families:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
http://www.lifealysis.com/Pediatric.html (accessed 1/1/10)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Transplantation > Organ Transplant > Cardiac Transplant
References: Cardiac Transplant

Bailey L. The evolution of infant heart transplantation. J Heart Lung Transplant.
2009;28(12):1241-1245. Related Links: Abstract
Bannister L, Manlhiot C, Pollock-BarZiv S, Stone T, McCrindle B, Dipchand A.
Anthropometric growth and utilization of enteral feeding support in pediatric heart
transplant recipients. Pediatr Transplant. 2010;14:879-886. Related Links: Abstract
Baum D, Bernstein D, Starnes VA, Oyer P, Pitlick P, Stinson E, Shumway N. Pediatric
heart transplantation at Stanford: results of a 15-year experience. Pediatrics.
1991;88(2):203-214. Related Links: Abstract
Burritt E. Use of indirect calorimetry in the pediatric intensive care unit.
ICAN. 2010;2(4):246-250. Related Links: Abstract
Carlson S, Ryan J. Congenital heart disease. In: Groh-Wargo S, Thompson M, Cox J, eds.
Nutritional Care for High-Risk Newborns. 3rd ed. Chicago, IL: Precept Press, Inc;
2000:397-408.
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Heart Association Council on Cardiovascular Disease in the Young; American Heart
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Indications for heart transplantation in pediatric heart disease: a scientific statement from
the American Heart Association Council on Cardiovascular Disease in the Young, the
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Chinnock RE, Freier MC, Ashwal S, Pivonka-Jones J, Shankel T, Cutler D, Bailey L.
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Abstract
Kaine SF, Reid BS. Nutrition and growth in congenital heart disease. In: Garson A Jr,
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Parenter Enteral Nutr. 2001;25(3):120-131. Related Links: Abstract
Hummell A. Nutrition for cardiac transplant patients. Support Line. 2003;25(1):10-17.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Jurt U, Delgado D, Malhotra K, Bishop H, Ross, H. Cardiology Patient Pages. Heart
transplant: what to expect. Circulation. 2002;106(14):1750-1752. Related Links: Abstract;
Full text
Kaufman BD, Nagle ML, Levine SR, Vijaynathan N, Hanna BD, Paridon S, Ravishankar C,
Chrisant MK. Too fat or too thin? Body habitus assessment in children listed for heart
transplant and impact on outcome. J Heart Lung Transplant. 2008;27(5):508-513. Related
Links: Abstract
Miller TL, Neri D, Extein J, Somarriba G, Strickman-Stein N. Nutrition in pediatric
cardiomyopathy. Progr Pediatr Cardiol. 2007;24(1):59-71. Related Links: Abstract; Full text
Nydegger A, Bines JE. Energy metabolism in infants with congenital heart disease.
Nutrition. 2006;22(7-8):697-704. Related Links: Abstract
Peterson RE, Perens GS, Alejos JC, Wetzel GT, Chang RK. Growth and weight gain of
prepubertal children after cardiac transplantation. Pediatr Transplant. 2008;12(4):436-441.
Related Links: Abstract
Porter C, Cohen NH. Indirect calorimetry in critically ill patients: Role of the clinical dietitian
in interpreting results. J Am Diet Assoc. 1996;96(1):49-57. Related Links: Abstract
Schwalbe-Terilli CR, Hartman D, Nagle M, Gallagher P, Ittenbach RF, Burnham NB,
Gaynor JW, Ravishankar C. Enteral feeding and caloric intake in neonates after cardiac
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Vogt KN, Manlhiot C, Van Arsdell G, Russell JL, Mital S, McCrindle BW. Somatic growth in
children with single ventricle physiology impact of physiologic state. J Am Coll Cardiol.
2007;50(19):1876-1883. Related Links: Abstract ; Full text

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Transplantation > Organ Transplant > Kidney Transplant
References: Kidney Transplant

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Links: Abstract
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Links: Abstract
Feber J, Dupuis J, Chapuis F, Braillon P, Jocteur-Monrozier D, Daudet G, So S, Levrey H,
Hadj-Aissa A, Martin X, Bellon G, Cochat P. Body composition and physical performance
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Gray K. Effects of Experiential Nutrition Education in Pediatric Renal Transplant Patients
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Links: Abstract
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Painter P, Luetkemeier M, Moore G, Dibble, Green G, Myll J, Carlson L. Health-related
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Transplantation > Organ Transplant > Liver Transplant
References: Liver Transplant

Alonso EM, Shepherd R, Martz KL, Yin W, Anand R; the SPLIT Research Group. Linear
growth patterns in prepubertal children following liver transplantation. Am J
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Alonso G, Duca P, Pasqualini T, D'Agostino D. Evaluation of catch-up growth after liver
transplantation in children with biliary atresia. Pediatr Transplant. 2004;8:255-259. Related
Links: Abstract
American Diabetes Association. Standards of Medical Care in Diabetes—2009. Diabetes
Care. 2009;32(Suppl 1):S13-61. Related Links: Abstact; Full text
Araki M, Flechener SM, Ismail HR, Flechner LM, Zhou L, Derweesh IH, Goldfrab D, Modlin
C, Novick AC, Faiman C. Posttransplant diabetes mellitus in kidney transplant recipients
receiving calcineurin or mTOR inhibitor drugs. Transplantation. 2006;81(3):335-341.
Related Links: Abstract
Bartosh S, Thomas S, Sutton M, Brady L, Whitington P. Linear growth after pediatric liver
transplantation. J Pediatr. 1999;135:624-631. Related Links: Abstract
Chan LN. Drug-nutrient interactions in transplant recipients. JPEN J Parenter Enteral Nutr.
2001;25(3):132-141. Related Links: Abstract
Ernst E. St John’s Wort supplements endanger the success of organ transplantation. Arch
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Evans IV, Belle SH, Wei Y, Penovich C, Ruppert K, Detre KM; National Institute of
Diabetes and Digestive and Kidney Diseases Liver Transplantation Database Team.
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Gidding SS, Dennison BA, Birch LL, Daniels SR, Gilman MW, Lichtenstein AH, Rattay KT,
Steinberger J, Stettler N, van Horn L; American Heart Association; American Academy of
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Related Links: Abstract
Hasse JM. Examining the role of tube feeding after liver transplantation. Nutr Clin Pract.
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Hasse JM. Organ Transplant. In: Nutrition Care Manual, 2009 Update. Chicago,
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oral cyclosporine absorption with water-soluble vitamin E early after liver transplantation.
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Pawlowska J, Socha P, Jankowska I. Factors affecting catch-up growth after liver
transplantation in children with cholestatic liver diseases. Ann Transplant.
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predictive of postoperative morbidity and mortality in liver transplant
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Quiros-Tejeira RE, Ament ME, Heyman MB, Martin MG, Rosenthal P, Gornbein JA,
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lexi-Comp Inc; 2008.
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Transplantation > Hematopoietic Stem Cell Transplant
Additional readings: HSCT


Arfons LM, Lazarus HM. Total parenteral nutrition and hematopoietic stem cell
transplantation: An expensive placebo? Bone Marrow Transplant.
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Auletta JJ, Cooke KR. Bone marrow transplantation: New approaches to
immunosuppression and management of acute graft-versus-host disease. Curr Opin
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Baird K, Pavletic S. Chronic graft versus host disease. Curr Opin Hematol.
2006;13:426-435. Related links: Abstract
Barfield RC, Kasow KA, Hale GA. Advances in pediatric hematopoietic stem cell
transplantation. Cancer Biol Ther. 2008;7:1533-1539. Related links: Abstract; Full Text
(downloadable)
Barker J, Wagner J. Umbilical cord blood transplantation: Current practice and futrue
innovations. Crit Rev Oncol Hematol. 2003;48:35-43. Related links: Abstract
Candusso M, Faraguna D, Landini P. Artificial nutrition and bone marrow transplantation.
Haematologica. 2000;85:58-61. Related links: Abstract
Centers for Disease Control and Prevention. Guidelines for preventing opportunistic
infections among hematopoietic stem cell transplant recipients. Recommendations and
reports. MMWR. 2000;49(RR10):1-128. Available at: Website. Accessed March 23, 2010.
Chybicka A. Quality of life and ethical and legal dilemmas in children during and after
hematopoietic SCT procedure. Bone Marrow Transplant. 2008;42(Suppl 2):S87-S89.
Related links: Abstract; Full Text
Cohen A, Bekassy A, Gaiero A, Faraci M, Zecca S, Tichelli A, Dini G; EBMT Paediatric and
Late Effects Working Parties. Endocrinological late complications after hematopoietic SCT
in children. Bone Marrow Transplant. 2008;41(Suppl 2):S43-S48. Related links: Abstract;
Full Text
Dahllof G, Hingorani S, Sanders J. Late effects following hematopoietic cell transplantation
for children. Biol Blood Marrow Transplant. 2008;14:88-93. Related links: Abstract
DeSwarte-Wallace J, Firouzbakhsh S, Finklestein J. Using research to change practice:
Enteral feedings for pediatric oncology patients. J Pediatr Oncol Nurs. 2001;18:217-223.
Related links: Abstract
Elia M, Van Bokhorst-de van der Schueren MA, Garvey J, Goedhart A, Lundholm K,
Nitenberg G, Stratton R. Enteral (oral or tube administration) nutritional support and
eicosapentaenoic acid in patients with cancer; a systematic review. Int J Oncol.
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Hastings Y, White M, Young J. Enteral nutrition and bone marrow transplantation. J Pediatr
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Henry L. Immunocompromised patients and nutrition. Prof Nurse. 1997;12:655-659.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Related links: Abstract
Hopman GD, Pena EG, le Cessie S, van Weel MH, Vossen JMJJ, Mearin ML. Tube
feeding and bone marrow transplantation. Med Pediatr Oncol. 2003;40:375-379. Related
links: Abstract; Full Text
Imataki O, Nakatani S, Hasegawa T, Kondo M, Ichihashi K, Araki M, Ishida T, Kim S, Mori
S, Fukuda T, Tobinai K, Tanosaki R, Makimoto A, Takaue Y. Nutritional support for
patients suffering from intestinal graft-versus-host disease after allogeneic hematopoietic
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Full Text
Johns Hopkins Bayview Medical Center, Clinical Nutrition Department. Neutropenic diet.
Available at: Website. Accessed February 26, 2010.
Keenan A. Nutritional support of the bone marrow transplant patient. Nurs Clin North Am.
1989;24:383-393. Related links: Abstract
Larson E, et al. Evidence-based nursing practice to prevent infection in hospitalized
neutropenic patients with cancer. Oncol Nurs Forum. 2004;31:717. Related links: Abstract;
Full Text (downloadable)
Lee JH, Lim GY, Im SA, Chung NG, Hahn ST. Gastrointestinal complications following
hematopoietic stem cell transplantation in children. Korean J Radiol. 2008;9:449-457.
Related links: Abstract; Full Text
Lesko L. Bone marrow transplantation: Support of the patient and his/her family. Support
Care Cancer. 1994;2:35-49. Related links: Abstract
Mahan KL, Escott-Stump S. Krause's Food, Nutrition and Diet Therapy. 11th
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Moody K, Charlson ME, Finlay J. The neutropenic diet: What’s the evidence? J Pediatr
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Mosby TT, Barr RD, Pencharz PB. Nutritional assessment of children with cancer. J
Pediatr Oncol Nurs. 2009 Jul-Aug;26(4):186-97. Related links: Abstract
Muscaritoli M, Grieco G, Capria S, Lori A, Rossi Fanelli F. Nutritional and metabolic support
in patients undergoing bone marrow transplantation. Am J Clin Nutr. 2002;75:183-190.
Related links: Abstract; Full Text
National Institute of Health, National Cancer Institute. Eating Hints for Cancer Patients. NIH
publication No.03-2079. 2003. Related links: Website. Accessed March 23, 2010.
Papadopoulou A, MacDonald A, Williams M, Darbyshire P, Booth I. Enteral nutrition after
bone marrow transplantation. Arch Dis Child. 1997;77:131-136. Related
links: Abstract; Full Text
Pietsch J; Ford C; Whitlock J. Nasogastric tube feedings in children with high-risk cancer:
A pilot study. J Pediatr Hematol Oncol. 1999;21:111-114. Related links: Abstract
Rice L, et al. Fresh fruit for neutropenics: a diet with “a peel.” Proceedings of the 26th
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Rodgers C, Walsh T. Nutritional issues in adolescents after bone marrow transplant: A
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
literature review. J Pediatr Oncol Nurs. 2008;25:254-264. Related links: Abstract
Rogers P, Melnick S, Ladas E, Halton J, Baillargeon J, Sacks N; Children's Oncology
Group (COG) Nutrition Committee. Children's oncology group (COG) nutrition committee.
Pediatr Blood Cancer. 2008;50:447-450. Related links: Abstract
Sanders J. Chronic graft-versus-host disease and late effects after hematopoietic stem cell
transplantation. Int J Hematol. 2002;76(Suppl 2):15-28. Related links: Abstract
Sefcick A, Anderton D, Byrne JL, Teahon K, Russell NH. Naso-jejunal feeding in allogeneic
bone marrow transplant recipients: Results of a pilot study. Bone Marrow Transplant.
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Smith LH, Besser SG. Dietary restrictions for patients with neutropenia: A survey of
institutional practices. Oncol Nurs Forum. 2000;27:515. Related links: Abstract
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Stonybrook State University of New York, University Hospital. Diet manual: C. Neutropenic
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Stratton RJ, Elia M. The effects of enteral tube feeding and parenteral nutrition on appetite
sensations and food intake in health and disease. Clin Nutr. 1999;18:63-70. Related
links: Abstract
Szeluga D, Stuart R, Brookmeyer R, Utermohlen V, Santos G. Nutritional support of bone
marrow transplant recipients: A prospective, randomized clinical trial comparing total
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References > Weight Management
Weight Management


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References > Weight Management > Overweight/Obesity
EAL Recommendation Summaries

Pediatric Weight Management (PWM) Major Recommendations Available for ADA
Members in the Evidence Analysis Library

Overview
PWM: Comprehensive Multicomponent Weight Management Program for Treating
Childhood Obesity
PWM: Obesity in Children Ages 2-5
Assessment
PWM: Assessing Foods and Pediatric Overweight
PWM: Assessing Child and Family Diet Behaviors in Pediatric Obesity
PWM: Assessing Physical Activity and Sedentary Behaviors
PWM: Determination of Total Energy Expenditure
PWM: Assessing Family Climate Factors
Intervention:
Nutrition Prescription
PWM: Nutrition Prescription in the Treatment of Pediatric Obesity
Energy Restriction
PWM: Energy Restricted Diets
Altered Macronutrient Diets
PWM: Reduced Glycemic Load Diet
PWM: Very Low Carbohydrate Diet
PWM: Using Protein Sparing Modified Fast Diets for Pediatric Weight Loss
PWM: Very Low Fat Diet (<20% Daily Energy Intake from Fat)
Nutrition Education
PWM: Nutrition Education in the Treatment of Pediatric Obesity
Nutrition Counseling
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
PWM: Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Obesity in
Children and Adolescents
PWM: Family Participation in Treating Pediatric Obesity in Children and Adolescents
PWM: Nutrition Counseling: Setting Weight Goals with Patient and Family
Coordination of Nutrition Care
PWM: Coordination of Care in Pediatric Weight Management
Physical Activity and Inactivity
PWM: Decreasing Sedentary Behaviors in Children and Adolescents
PWM: Physical Activity in the Treatment of Childhood and Adolescent Obesity
Adjunct Therapies
PWM: Adjunct Therapies: Use of Weight Loss Medications in Treating Obesity in
Adolescents
PWM: Adjunct Therapies: Weight Loss Surgery and Adolescent Obesity
Treatment Format Options
PWM: Treatment Format Options: Group vs. Individual Intervention
Monitoring and Evaluation
PWM: Optimal Length of Weight Management Therapy in Children and Adolescents

Major EAL Recommendation Summaries for non-ADA Members
Explanation of Ratings
Energy-Restricted Diets
PWM: Energy-Restricted Diets: Children Aged 6 to 12 Years
If energy restriction is appropriate based on the registered dietitian's professional judgment,
a balanced macronutrient diet that contains no fewer than 900 kcal per day is
recommended to improve weight status within a multicomponent pediatric weight
management program in children aged 6 to 12, who are medically monitored. Research
indicates that balanced macronutrient diets at 900 kcal to 1,200 kcal per day are associated
with short-term and longer-term (more than 1 year) improved weight status and body
composition among children aged 6 to 12 years.
Strong, Conditional
PWM: Energy-Restricted Diets: Adolescents
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
If energy-restriction is appropriate, based on the registered dietitian's professional
judgment, a balanced macronutrient diet that contains no fewer than 1, 200 kcal per day is
recommended to improve weight status within a multicomponent pediatric weight
management program for adolescents (aged 13 to 18) who are medically monitored.
Research indicates that energy-restricted balanced macronutrient diets no lower than 1,
200 kcal per day are associated with short-term and longer-term (more than 1 year)
improved weight status and body composition among adolescents aged 13 to 18 years.
Strong, Conditional

Altered Macronutrient Diets
Reduced Glycemic Load Diet
PWM: Reduced Glycemic Load Diet: Children Aged 6 to 12 Years
If an ad libitum, reduced glycemic load diet is selected for use in children (aged 6 to 12
years), this diet could be used to produce modest, short-term improvement in weight
status. Limited research shows that an ad libitum, reduced glycemic load diet results in
short-term improvement in weight status in this age group.
Weak, Conditional
PWM: Reduced Glycemic Load Diet: Adolescents
If an ad libitum, reduced glycemic load diet is selected for use in adolescents (aged 13 to
18 years), this diet could be used to produce modest, short-term and longer-term
improvement in weight status and body composition. Limited research shows that an ad
libitum, reduced glycemic load diet results in short-term improvement in weight status and
body composition in this age group. One study shows weight status improvement at 1 year.
Fair, Conditional
Very-Low-Carbohydrate Diet
PWM: Very-Low-Carbohydrate Diet: Adolescents
If a low-carbohydrate diet is selected for use in adolescents, it is recommended for
short-term (up to 12 weeks) use. The use of an ad libitum, very-low-carbohydrate diet,
which is defined as a diet containing 20 g to 60 g carbohydrates to treat obese adolescents
has shown short-term improvement in weight status. However, because of the lack of
evidence, it is not recommended for long-term treatment of pediatric obesity.
Weak, Conditional
Using Protein-Sparing Modified Fast Diets for Pediatric Weight Loss
PWM: Protein-Sparing Modified Fast Diets: Short-term Treatment
If children and adolescents are more than 120% of ideal body weight, have serious medical
complications, and would benefit from rapid weight loss, a protein-sparing modified fast
diet (PSMF) could be used in a short-term intervention (typically 10 weeks) under the
supervision of a multidisciplinary team of health care providers who specialize in pediatric
obesity. Research shows that short term use of a PSMF diet brings about short-term and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
longer-term improvement in weight status and body composition when part of a medically
supervised, multicomponent program.
Weak, Conditional
PWM: Protein-Sparing Modified Fast Diets: Long-term Treatment
The PSMF diet is not recommended for long-term weight management for obesity in
children or adolescents. There are few well-designed studies to support the use of this
intervention for longer than 10 weeks.
Weak, Imperative
Very-Low-Fat Diet (Less than 20% Daily Energy Intake from Fat)
PWM: Very-Low-Fat Diet
Use of a very-low-fat diet is not recommended for use in pediatric weight management.
The efficacy of a very-low-fat diet, defined as less than 20% of total daily energy intake
from fat, has not been studied in the treatment of pediatric obesity.
Insufficient Evidence, Imperative
PWM: Weight Loss Medication
If a weight-loss medication is selected as an adjunct therapy, then an over-the-counter or
prescription gastrointestinal lipase inhibitor (eg, orlistat), approved by the US Food and
Drug Administration (FDA) for use in adolescents, may be recommended to treat obese
adolescents participating in a multicomponent pediatric weight management program.
Research indicates that a gastrointestinal lipase inhibitor further improves weight status
and body composition in some individuals within a multicomponent adolescent
weight-management program. However, the FDA has not studied or approved the use of
this class of medication for children younger than 12 years.
Fair, Conditional
Weight Loss Surgery and Adolescent Obesity
PWM: Weight Loss Surgery
Dietitians should collaborate with other members of the health care team regarding the
appropriateness of weight loss surgery for severely obese adolescents who have not
achieved weight loss goals with less-invasive weight loss methods and who meet specified
criteria (see Conditions of Application below). Research indicates that for a subset of
adolescents who meet the recommended criteria, weight loss surgery may be effective in
bringing about significant short-term and long-term weight loss. Obese children (younger
than 13 years) are generally not considered to be appropriate candidates for weight loss
surgery.
Consensus, Imperative


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Weblinks: Underweight

Medication Information: http://www.nlm.nih.gov/medlineplus/druginformation.html
Feeding Relationships: http://www.ellynsatter.com ; http://www.bulimia.com
Metabolic Disorders: http://www.nlm.nih.gov/medlineplus/metabolicdisorders.html
Celiac Disease: http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ ; http://www.celiac.org/
Attention Deficit/Hyperactivity Disorder: http://www.cdc.gov/ncbddd/ADHD/ ;
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml



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References > Nutrition Support
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Mirtallo J, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, Seres D, Guenter P;
Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for
parenteral nutrition. JPEN J Parenter Enteral Nutr. 2004;28:S55-S70.
Mitton SG. Amino acid and lipid in total parenteral nutrition for the newborn. J Pediatr
Gastroenterol Nutr. 1993;18:25-31.
Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB,
Kellum JM Jr, Welling RE, Moore EE. Early enteral feeding, compared with parenteral,
reduces postoperative septic complications. The results of a meta-analysis. Ann Surg.
1992;216:172-183. Related Links: Abstract
Moukarzel AA, Haddad I, Ament ME, Buchanan AL, Reyen L, Maggioni A, Baron HI,
Vargas J. 230 patient years of experience with home long-term parenteral nutrition in
childhood: Natural history and life of central venous catheters. J Pediatr Surg.
1994;29:1323-1327. Related Links: Abstract
Moukarzel AA, Dahlstrom KA, Bouchman AL, Ament ME. Carnitine status of children
receiving long-term total parenteral nutrition: A longitudinal prospective study. J Pediatr.
1992;120:759-762. Related Links: Abstract
Mouser JF, Wu AH, Herson VC. Aluminum contamination of neonatal parenteral nutrient
solutions and additives. Am J Health Syst Pharm. 1998;55:1071-1072.
Myron Johnson A, Merlini G, Sheldon J, Ichihara K; Scientific Division Committee on
Plasma Proteins (C-PP), International Federation of Clinical Chemistry and Laboratory
Medicine (IFCC). Clinical indications for plasma protein asssays: Transthyretin
(prealbumin) in inflammation and malnutrition. Clin Chem Lab Med. 2007;45:419-426.
Related Links: Abstract
Neuzil J, Darlow BA, Inder, TE, Sluis KB, Winterbourn CC, Stocker R. Oxidation of
parenteral lipid emulsion by ambient and phototherapy lights: Potential toxicity of routine
parenteral feeding. J Pediatr 1995;126:785-790. Related Links: Abstract
Nicol JJ, Hoagland RL, Heitlinger LA. The prevalence of nausea and vomiting in pediatric
patients receiving home parenteral nutrition. Nutr Clin Pract. 1995;10:189-192. Related
Links: Abstract
Niemiec PW, Vanderveen TW. Compatibility considerations in parenteral solutions. Am J
Pharm. 1984;41:893-911. Related Links: Abstract
Nose O, Tipton JR, Ament W, Yabuuchi H. Effect of energy source on changes in energy
expenditure, respiratory quotient and nitrogen balance during parenteral nutrition in
children. Pediatr Res. 1987;21:538-541. Related Links: Abstract
Nousia-Arvanitakis S, Angelpoulou-Sakadami N, Matrolion K. Complications associated
with total parenteral nutrition in infants with short bowel syndrome.
Hepatogastroenterology. 1992;39:169-172. Related Links: Abstract
Picaud JC, Steghens JP, Auxenfans C, Barbieux A, Laborie S, Claris O. Lipid peroxidation
assessment by malondialdehyde measurement in parenteral nutrition solutions for newborn
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
infants: A pilot study. Acta Paediatr. 2004;93:241-145. Related Links: Abstract
Pineault M, Chessex P, Piedboeuf B, Bisaillon S. Beneficial effect of coinfusing a lipid
emulsion on venous patency. JPEN J Parenter Enteral Nutr. 1989;13:637-640. Related
Links: Abstract
Poole RL, Hintz SR, Mackenzie NI, Kerner JA. Aluminum exposure from pediatric
parenteral nutrition: Meeting the new FDA regulation. JPEN J Parenter Enteral Nutr.
2008;32:242-246. Related Links: Abstract
Puntis JW, Wilkins KM, Boll PA, Rushton DT, Booth IW. Hazards of parenteral treatment:
Do particles count? Arch Dis Child. 1992;67:1475-1477. Related Links: Abstract
Reynolds AP, Kiely E, Meadows N. Manganese in long-term paediatric parenteral nutrition.
Arch Dis Child. 1994;71:527-528. Related Links: Abstract
Rintala R, Lindahl H, Pahjavuori M, Saxon H, Sarriola H. Surgical treatment of intractable
cholestasis associated with total parenteral nutrition in premature infants. J Pediatr Surg.
1993;28:716-719. Related Links: Abstract
Rollins CJ, Elsberry VA, Pollack KA. Three-in-one parenteral nutrition: A safe and
economical method of nutritional support for infants. JPEN J Parenter Enteral Nutr.
1990;14:290-294. Related Links: Abstract
Sax HC, Bower RH. Hepatic complications of total parenteral nutrition. JPEN J Parenter
Enteral Nutr. 1988;12:615-618. Related Links: Abstract
Schanler RJ, Shulman RJ, Prestidge LL. Parenteral nutrient needs of very low birth weight
infants. J Pediatr. 1994;125:961-968. Related Links: Abstract
Schneider PJ. Nutrition support teams: An evidence-based practice. Nutr Clin
Pract. 2006;21:62-67. Related Links: Abstract
Shatsky F, Borum PR. Should carnitine be added to parenteral nutrition solutions? Nutr
Clin Pract. 2000;15:152-154.
Shulman RJ, Phillips S. Parenteral nutrition indications, administration, and monitoring. In:
Baker S, Baker R, Davis A, eds. Pediatric Nutrition Support. 1st ed. Sudbury, MA: Jones
and Bartlett Publishers; 2007:273-286.
Slicker J, Vermilyea S. Pediatric parenteral nutrition putting the microscope on
macronutrients and micronutrients. Nutr Clin Pract. 2009;24:481-486. Related Links:
Abstract
Stahl GE, Spear MC, Hamosch M. Intravenous administration of lipid emulsions to
premature infants. Clin Perinatol. 1986;13:133-162. Related Links: Abstract
Stokes MA, Hill GL. Peripheral parenteral nutrition: A preliminary report on its efficacy and
safety. JPEN J Parenter Enteral Nutr. 1992;17:145-147. Related Links: Abstract
Szeszycki E, Cruse W, Strup M. Evaluation and monitoring of pediatric patients receiving
specialized nutrition support. In: Corkins MR, ed. The ASPEN Pediatric Nutrition Support
Core Curriculum. Silver Spring, MD: ASPEN Publishers; 2010:460-475.
Trissel LA. Trissel’s Calcium and Phosphorus Compatibility in Parenteral Nutrition.
Houston, TX: Tri. Pharma; 2001.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Wessel J, Balint J, Crill C, Klotz K; American Society for Parenteral and Enteral Nutrition;
Task Force on Standards for Specialized Nutrition Support for Hospitalized Pediatric
Patients. Standards for specialized nutrition Support: Hospitalized pediatric patients. Nutr
Clin Pract. 2005;20:103-116.
Wesley JR, Coran AG. Intravenous nutrition for the pediatric patient. Semin Pediatr Surg.
1992;1:212-230. Related Links: Abstract
Wolfe RR. Carbohydrate metabolism and requirements. In: Rombeau JL, Caldwell MD,
eds. Clinical Nutrition: Parenteral Nutrition. Philadelphia, PA. WB Saunders Co;
1993:113-131.
Ziegler EE, Thureen PJ, Carlson SJ. Aggressive nutrition of the very low birth weight
infant. Clin Perinatol. 2002;29:255-244. Related Links: Abstract

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans/Client Education home page
Welcome to the Meal Plans/Client Education home page.
If you are looking for Spanish translations of handouts, you can find a complete list
here.
Here you can locate information on foods that should be recommended or avoided for a
specific disease, condition, or life stage. The crosswalk table below is roughly organized by
PNCM section, and includes links to printable pdfs of the following:
Nutrition Therapy handouts for disease/condition topics
Nutrition handouts for pediatric life stages
Food lists for these life stages and conditions
Sample 1-day menus for these life stages and conditions
The first column in the table includes diet names that may correspond to these handouts,
and with which you may be more familiar. You can look up the appropriate handout by
locating a client's condition in the table, or by finding the diet name as it is referred to in
your facility.
PDFs are geared towards clients unless otherwise specified. Each handout includes a
Notes area where you can type additional instructions to individualize the information for
your clients' food preferences or age. Changing the information on the handout itself is
prohibited by copyright restrictions.
To view Tips handouts and information on-screen that may contain more detailed
notes for RDs and Food Services, please select a topic from the left-hand navigation.

Diet Names Nutrition Therapy Foods and
Sample Menu
Complementary Foods Nutrition for Full-Term Infants Menu for 9- to
12-month olds
Foods for 9- to
12-month olds
Nutrition for Preterm Infants: 4-6
Months Corrected Age (CA)
Nutrition for Preterm Infants: 6-8
Months CA
Nutrition for Preterm Infants: 8-12
Months CA
Normal Diet Nutrition for Toddlers Foods; Menu
Nutrition for Preschool Children Foods; Menu
Nutrition for School-Age Children Foods; Menu
Nutrition for Adolescent Boys Menu
Nutrition for Adolescent Girls Menu
Nutrition for Teen Athletes 2200-kcal Menu
3300-kcal Menu
Normal Diet (with weight
management as needed)
Asthma Nutrition Therapy Foods; Menu
Autism Nutrition Therapy Foods; Menu
Down Syndrome Nutrition Therapy Foods; Menu
Nutrition During and After Cancer
Treatment

Spina Bifida Nutrition Therapy Foods; Menu
Diet for Breastfeeding
Mothers
Lactation Nutrition Therapy Foods; Menu
Vegetarian/Vegan Diet Vegetarian
Menu:
9-12 Months
Vegetarian Nutrition for Young
Children
Vegetarian Menu
Vegan Menu
Foods
Vegetarian Nutrition for
School-Age Children
Vegetarian Menu
Vegan Menu
Foods
Vegetarian Nutrition: Teen
Pregnancy
Vegetarian Menu
Vegan Menu
Foods
Vegetarian Nutrition: Teen Athletes Vegetarian Menu
Vegan Menu
Foods
Iron-Rich Diet Iron Deficiency Anemia Nutrition
Therapy
Foods; Menu
High-Calorie/High-Protein
Diet
Sickle Cell Disease Nutrition
Therapy
Foods; Menu
Burns Nutrition Therapy Foods; Menu
Failure to Thrive Nutrition Therapy Foods; Menu
Tips for Increasing Calories and
Protein
Bronchopulmonary Dysplasia
Nutrition Therapy
Foods; Menu
Cystic Fibrosis Nutrition Therapy Foods; Menu
Underweight Nutrition Therapy Foods; Menu
Low-Sodium Diet Low Sodium/Consistent-Vitamin K
Nutrition Therapy
Menu
Low-Sodium Nutrition Therapy for
CKD
Foods; Menu
Nephrotic Syndrome Nutrition
Therapy
Foods; Menu
Carbohydrate Counting for
Diabetes

Carbohydrate Counting and
Diabetes
Diabetes Mellitus Nutrition Therapy Foods; Menu
Dyslipidemia Diet/
Heart Healthy Eating

High Cholesterol Nutrition Therapy Foods; Menu
High Triglycerides Nutrition
Therapy
DHA Nutrition Therapy
Food Hypersensitive Diets Major Food Allergens Nutrition
Therapy
Foods; Menu
Egg Avoidance Nutrition Therapy Foods; Menu
Fish Avoidance Nutrition Therapy Foods; Menu
Milk Avoidance Nutrition Therapy Foods; Menu
Peanut Avoidance Nutrition
Therapy
Foods; Menu
Shellfish Avoidance Nutrition
Therapy
Foods; Menu
Soy Avoidance Nutrition Therapy Foods; Menu
Tree Nut Avoidance Nutrition
Therapy
Foods; Menu
Wheat Avoidance Nutrition
Therapy
Foods; Menu
Fiber-Restricted Diet Diarrhea Nutrition Therapy Foods; Menu
High-Fiber Diet High-Fiber Nutrition Therapy Foods; Menu
Lactose-Restricted Diet Low-Lactose Nutrition Therapy Foods; Menu
Gluten-Free Diet Gluten-Free Nutrition Therapy Foods; Menu
Ketogenic Diet Ketogenic Exchange List Foods; Menu
MCT Oil Foods;
MCT Oil Menu
PKU Diet PKU Nutrition Therapy Menu
Low-Microbial/
Low-Bacteria Diet
Oncology Nutrition Therapy Foods; Menu
Neutropenic Nutrition Therapy Foods; Menu
Organ Transplant Nutrition
Therapy
Foods; Menu
Diet for Home – Preterm
Infants
Nutrition for Preterm Infants at
Home: 1 to 4 Months Corrected
Age
Nutrition for Preterm Infants at
Home: 4 to 6 Months Corrected
Age
Nutrition for Preterm Infants at
Home: 6 to 8 Months Corrected
Age
Nutrition for Preterm Infants at
Home: 8 to 12 Months Corrected
Age
Low-Potassium/ Renal Diet Low-Potassium Nutrition Therapy
for CKD
Foods; Menu
Low-Phosphorus Diet Low-Phosphorus Nutrition
Therapy for CKD
Menu
Weight loss/ Weight
management Diet
Weight Management Nutrition
Therapy: 7- to 10-year olds
Foods; Menu
Weight Management Nutrition
Therapy: 11- to 14-year olds
Foods; Menu
Prader-Willi Syndrome Nutrition
Therapy
Foods; Menu
Others Gastroesophageal Reflux Disease
Nutrition Therapy
Foods; Menu
Graft-versus-Host Disease
Nutrition Therapy
Foods; Menu
Hepatic Disease Nutrition Therapy Foods; Menu
Mucositis Nutrition Therapy Foods; Menu
Nausea and Vomiting Nutrition
Therapy
Foods; Menu
Short Bowel Syndrome Nutrition
Therapy
Foods; Menu
Modified Consistency Diets Pureed Nutrition Therapy
Mechanical Soft Nutrition Therapy
Clear Liquid Diet
Full Liquid Diet
High-Calcium Diet Calcium-Rich Nutrition Therapy
Kosher food practices
For additional information on cultural food practices, see the section within Resources.

Meal Plans > Modified Consistency Meal Plans
Modified Consistency Meal Plans


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Modified Consistency Meal Plans > General Guidance
General Guidance

Modified consistency diets are derived from regular foods and modified for consumption
based on the ability to chew, swallow, or eat. Medical conditions, procedures, or illness
may require adjustments for type of food tolerated or provided.
Typically there has been a diet progression from clear liquids to full liquid to mechanically
altered foods (blenderized, pureed, chopped, or soft textures). The clear and full liquid diets
should be monitored closely for nutritional adequacy. These diets are intended for
short-term use and additional protein-rich and energy-rich supplements should be
considered.
Pediatric patients may also require more frequent feedings and a review of food
preferences to meet the nutrition needs appropriate for age.
There are also recommended guidelines for use of clear liquid regime for preoperative
fasting and for specific medical conditions and age.
Refer to specific section guidelines for tips to properly blend, puree, or chop to the
appropriate food consistency.
Pediatric patients with dysphagia and feeding difficulties can benefit from a
multidisciplinary approach. Include a speech therapist, registered dietitian, and key
specialists such as a pediatric gastroenterologist and child psychologist to evaluate
nutritional strategies.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Modified Consistency Meal Plans > Liquid Diet
Overview

The clear liquid diet will supply fluids, energy, and electrolytes. This diet provides little
residue and is easily absorbed. It requires minimal digestion and stimulation of the
gastrointestinal tract. The clear liquid diet is also used to prevent dehydration.
The clear liquid diet includes clear or transparent foods that are liquid at body
temperature. These foods consist primarily of sugar, water and some may include sodium
(clear broth). Some health care facilities may allow hard candy that dissolves to sugar and
water at body temperature.
Consider fortified juices, fortified broths, or other commercial clear liquid supplements for
additional nutrition support. These items can provide energy, protein, vitamins, and
minerals for those at nutritional risk or have poor nutritional status.

Indications and Contraindications

The clear liquid diet maintains oral hydration while minimizing colonic residue in the
following circumstances:
When gastrointestinal illness, including abdominal distention, nausea, vomiting, and
diarrhea, is present
In preparation of bowels to eliminate residue in the colon for surgery
In preparation for a gastrointestinal procedure
To reintroduce foods following a period with no oral intake when poor tolerance,
aspiration, or anastomotic leak is anticipated
The clear liquid diet, once widely used in hospitals, has been a mainstay based on
tradition without scientific evidence to document specific indications or benefits. Use when
only absolutely necessary. It has been used as the first step in oral alimentation and is
intended as the initial start in restoring gut activity. This diet is recommended as a
short-term or transitional diet and can be considered as an adjunct to other therapies.
This diet is nutritionally inadequate for patients of all ages, as it does not provide adequate
energy intake and significantly lacks protein and fat. Long-term use of clear liquids without
additional nutrition support may contribute to hospital malnutrition (Franklin, 2011;
Hancock, 2002; Martindale, 1998). Energy and protein supplements may be ordered when
patients receive a clear liquid for more than 3 days, but these are not widely accepted by
patients.
Use of the clear liquid diet has declined as a result of the following:
Widespread use of polyethylene glycol and sodium phosphate to prepare the bowel
for surgical or gastrointestinal procedures has decreased the time required for bowel
preparation to less than 1 day. Bowel preparation is typically completed within 48
hours and patients consume clear liquids for less than 24 hours (Soweid, 2010;
Warren, 2011). Children older than 4 years may be managed more effectively using a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
prepackaged diet kit in combination with magnesium citrate/bisacodyl laxative for
improved bowel cleansing (Hurlock-Chorostecki, 2009).
There is now a more precise understanding of the actual time required for gastric
emptying. Recommendations for oral intake before surgery have been revised and
only one clear liquid meal may be needed preoperatively (El-Baba, 2006).
Postoperatively, the amount of time regular foods can be consumed has been
shortened because of improved anesthesia, the knowledge that return of bowel
sounds is not a prerequisite for feeding, reduced use of postoperative nasogastric
suction, and a push toward early feedings to facilitate early discharge (Hancock,
2002; Jeffery, 1996; Warren, 2011).
The clear liquid diet may decrease gastric emptying due to high osmolality. It may be
more difficult to swallow than regular foods and may increase risk for aspiration with
more rapid movement and greater displacement of these liquids through the
oropharynx (Jeffery, 1996).
Patients reintroduced to soft foods rather than clear liquid not only have more satiety,
but the length of stay may also be reduced with better feeding tolerance. This
outcome was particularly noted in patients with acute pancreatitis
(Hurlock-Chorostecki, 2009; Jacobson, 2007; Sathiearaj, 2008; Soweid, 2010).
If there is difficulty swallowing, thickened liquids may be needed. Thickened liquids
may be purchased as already mixed or made by adding commercial thickeners into
the liquid. Consult with speech and language pathologists or occupational therapists
to evaluate swallowing problems. See the Pureed Diet section for more information
on thickening liquids.

Foods Recommended

Food Group Foods Recommended
Milk None
Beverages
Ice water, ice chips, coffee, tea, decaffeinated
coffee, carbonated beverages, artificially
flavored fruit drinks, fortified beverages (such
as sports drinks or commercial pediatric
supplements) for additional electrolytes, breast
milk, or infant formula
Meat and
Other
Protein
Products
None, except clear fat-free meat broth,
bouillon, fortified broths.
Grains None
Vegetables
Strained juice without pulp or seeds; clear,
fat-free vegetable broth, bouillon.
Fruits Clear juice; strained juice without pulp or seeds.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fats and Oils None
Other
Plain gelatin, fruit-flavored ice, popsicles,
sugar, plain hard candy, honey (age
appropriate), salt, fortified gelatin, or Pedialtye
pops.


Sample 1-Day Menu

Portions in this clear liquid menu are appropriate for a child 5 to 10 years old.
Breakfast
4 ounces apple juice
½ cup strawberry-flavored gelatin
1 water ice or popsicle
8 ounces plain tea
Snack
8 ounces ginger ale
1/2 cup lime gelatin
8 ounces chicken broth
Lunch
1/2 cup cranberry juice
8 ounces vegetable broth
1/2 cup orange-flavored gelatin
8 ounces ginger ale
8 ounces plain tea
Snack
4 ounces grape juice
1 water ice or popsicle
Evening Meal
4 ounces apple juice
8 ounces beef broth
8 ounces ginger ale
8 ounces tea
Snack
4 ounces apple juice
1 water ice or popsicle
4 ounces cherry-flavored gelatin

*Diet is not adequate for long-term intake. Add fortified juices and electrolyte drinks for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
*Diet is not adequate for long-term intake. Add fortified juices and electrolyte drinks for
additional nutritional content.
Approximate Nutrient Analysis
Energy (kcal) 1,043
Total protein (g) 11 (4% of kcal)
Total carbohydrate (g)
249 (95% of
kcal)
Total fat (g) 1.9 (1% of kcal)
Saturated fatty acids (g)
0.44 (0.37% of
kcal)
Monounsaturated fatty
acids (g)
0.26 (0.22% of
kcal)
Polyunsaturated fatty
acids (g)
0.29 (0.36% of
kcal)
Cholesterol (mg) 0
Calcium (mg) 113
Iron (mg) 3.6
Magnesium (mg) 70
Phosphorus (mg) 231
Potassium (mg) 1,068
Sodium (mg) 3,202
Zinc (mg) 1
Vitamin A (mcg RAE) 0
Vitamin C (mg) 218.2
Thiamin (mg) 0.9
Riboflavin (mg) 0.3
Niacin (mg) 3.5
Total folate (mcg) 45
Vitamin B-6 (mg) 0.1
Vitamin B-12 (mcg) 0.3
Total dietary fiber (g) 0.9
Vitamin D (mcg) 0

Guidelines

To improve a palatable clear liquid regimen with a nutritionally complete diet, consider
protein-rich and energy-dense supplements (Hancock, 2002).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Joint Commission–accredited acute care hospitals are required to screen patients for
nutritional risk. Criteria commonly used include patients receiving nothing by mouth (NPO,
or nil per os) or clear liquid diet orders for longer than 3 days (Chima, 2008).
Guidelines for Preoperative Fasting
The American Society of Anesthesiologists Task Force's updated report from 2011 states
that the preoperative fasting recommendations are that healthy infants (younger than 2
years), children (aged 2 to 16 years), and adults may fast from clear liquids at least 2 or
more hours before procedures requiring general anesthesia (ASACSPP, 2011). The
task force also notes it is appropriate to fast from intake of any light meal (such as toast and
clear liquids) at least 6 hours before elective surgery requiring general anesthesia. Infants
can be breastfed up to 4 hours prior to surgery or formula fed up to 6 hours prior to surgery
(Cook-Sather, 2006; Jeffery, 2006; Warren, 2011). This recommendation is consistent with
other published studies (De Aguilar-Nascimento, 2001; Smith, 2011; Yurtcu, 2009).
Guidelines for Patients with Diabetes
Physicians or healthcare supervisors may request diabetes-appropriate or “sugar-free”
liquids for patients with diabetes. The American Diabetes Association guidelines do not
recommend this, noting that patients with diabetes can be given clear liquid diets that
consist of approximately 200 g carbohydrate spread equally throughout the day (ADA,
2008).
Guidelines for Age and Condition
The amount of clear liquids may be increased or decreased depending on the age and
weight of the child. Certain diagnostic procedures may require caffeine restriction, and
individualized tolerance may necessitate alterations.
The modified consistency diet can be hyperosmolar. Consideration of osmolality may be
important for children who have had prolonged NPO status and disorders for which
gastrointestinal tolerance is likely to be limited. Foods high in concentration of simple
sugars, electrolytes, and amino acids have the greatest effect on osmolality. It may be
necessary in certain patients to initiate clear liquids that are either isotonic or made so by
dilution. The osmolality of normal body fluids is approximately 300 mOsm/kg of body
weight.
Consider additional modifications for sodium and volume of liquid if restrictions are required
for children with severe kidney diseases or with sodium imbalances.
For infant feeding, human milk is preferred exclusively for the first 6 months of
life. Additional fluids including clear liquids may not be appropriate. These are established
guidelines noted by the Academy of Nutrition and Dietetics and the American Academy of
Pediatrics (James, 2009; AAP, 2012).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Modified Consistency Meal Plans > Blenderized Diet
Overview

The blenderized diet consists of fluids and foods that are modified to a smooth consistency.
The goal is to provide foods that can be mechanically altered by blenderizing the
consistency. These foods should be easy to pass through a straw, syringe, or feeding tube.
Examples of nutrition diagnoses that may relate to the blenderized diet include the
following (IDNT, 2011):
Swallowing difficulty (NC-1.1)
Biting/Chewing (masticatory) difficulty (NC-1.2)
Self-Feeding difficulty (NB-2.6)

Indications and Contraindications

The modified consistency diet is designed for patients that are unable to chew or swallow
foods. The blenderized diet is used after surgical procedures for craniofacial
reconstruction, including fixation of fractures of the mandible or the maxilla secondary to
trauma; after repair of developmental malocclusions; and after dental surgeries. It is also
used for patients with oral, esophageal, or gastric disorders who are unable to tolerate
solids or semisolids and may be volume sensitive because of stricture or anatomic
abnormalities.
Intermaxillary fixation is a procedure in which the jaws are tightly wired together with the
aid of arch bars or with braces attached to the teeth. The amount of space between upper
and lower teeth is minimal, unless teeth have been removed or are missing secondary to
trauma. Duration of fixation of the jaws is variable and may last for 4 to 8 weeks. For rigid
fixation, a procedure in which screws and metal plates are placed permanently, the jaw
may be wired for the initial 1 to 2 weeks. A blenderized liquid diet may be needed for the
first 2 to 4 weeks, with progression to a mechanical soft diet for an additional 2 to 4 weeks.
Vestibuloplasty, a procedure that alters the vestibule of the mouth in preparation of
dentures, requires approximately 10 days of a blenderized liquid diet, 4 weeks of pureed
foods, and 1 to 2 months (until dentures) of mechanically soft foods.
Temporomandibular joint procedures, including arthroscopy and/or implantation of artificial
meniscus, frequently involve pain and headaches, especially when eating. The blenderized
diet can be used for the first 3 days to minimize discomfort; after that, the patient should be
advanced to a mechanical soft diet for up to 3 months. Hard foods and those that are
difficult to chew should be generally avoided.
For esophageal strictures or anatomic abnormalities, the diet should be individualized to
the medical condition, tolerance, and acceptance if dysphagia is suspected; a swallowing
evaluation should be performed.
If a feeding tube is indicated and more information about types of tubing and associated
concerns is needed, refer to the Blenderized Formulas heading under Enteral Nutrition
Support.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Foods Recommended


Printable Version
Food Group Foods
Milk
All milk products
Pudding, custard, ice cream, sherbet,
sorbets, malts, frozen yogurt, and cottage
cheese
Meat and Other
Protein Products
Tender, well-cooked meat, poultry, or fish
prepared without bones, skin, or added fat
Baby food meats—Stage 1, 2, or 3
Well-cooked eggs prepared without added
fat
Soft soy foods like tofu
Smooth nut butters
Grains
Rice
Pasta
Couscous without seeds and nuts
Cooked cereals such as oatmeal and
cream of wheat
Cookies softened with milk, coffee, or
other liquid
Vegetables
Any cooked or canned vegetables without
seeds and skins
Baby food vegetables—Stage 1, 2, or 3
Fruits
Any cooked or canned fruits without seeds
and skins
Fresh, peeled soft fruits (like peaches and
bananas) that can be blended until smooth
Baby food fruits—Stage 1, 2, or 3
Fats and Oils
Any oils
Melted butter or margarine
Heavy cream
Beverages
Any
Look for pediatric liquid supplements that
provide energy and protein
Other
Finely ground spices, seeds, nuts
Smooth condiments such as mustard and
ketchup

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Foods Not Recommended

Avoid all foods that contain whole nuts or seeds, pieces of nuts or seeds, skins, peels, or
bones. All foods must be easily blended.

Sample 1-Day Menu

Note: Portions are appropriate for a child 5 to 10 years old
Printable version

Breakfast
Mix in blender: 1/2 cup oatmeal made with 1/2
cup whole milk, 1/2 teaspoon lump-free brown
sugar, and ½ teaspoon cinnamon
Snack
Eggnog—Mix in blender: 1/2 cup liquid
pasteurized eggs, 1 very ripe banana, 1/2 cup
whole milk, 1/2 teaspoon vanilla, and 1/2
teaspoon nutmeg
Lunch
Mix well in blender: 1 cup of cream of chicken
soup, 1/4 cup cooked chicken, 1/4 cup mashed
potatoes, 1/4 cup cooked carrots, and 1/2 cup
orange juice
Snack 8-12 ounces pediatric liquid supplement
Evening
Meal
Mix well in blender: 2 ounces tender, cooked
ground beef; 1/2 cup tomato spaghetti sauce; 1/2
cup cooked pasta; and enough vegetable juice to
make the blended food drinkable
Snack
1 cup vanilla ice cream blended with 1/2 cup
mango juice

Approximate Nutrient Analysis
Energy (kcal) 1,874
Total protein (g) 84 (18% of kcal)
Total carbohydrate (g)
220 (46% of
kcal)
Total fat (g) 75 (36% of kcal)
Saturated fatty acids (g)
29.4 (13.8% of
kcal)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Monounsaturated fatty
acids (g)
24.7 (1.2% of
kcal)
Polyunsaturated fatty
acids (g)
10.8 (0.08% of
kcal)
Cholesterol (mg) 699
Calcium (mg) 102.7
Iron (mg) 13.3
Magnesium (mg) 300
Phosphorus (mg) 1,333
Potassium (mg) 3,069
Sodium (mg) 2,586
Zinc (mg) 27.6
Vitamin A (mcg RAE) 1,181
Vitamin C (mg) 106.5
Thiamin (mg) 1.13
Riboflavin (mg) 2.42
Niacin (mg) 19
Total folate (mcg) 333
Vitamin B-6 (mg) 9
Vitamin B-12 (mcg) 6.3
Total dietary fiber (g) 13.2
Vitamin D (mcg) 9.6


Guidelines

For oral feeding, consider a straw with a larger diameter to decrease the amount of time it
takes to eat. Some children may fatigue quickly if the feeding time is extended without this
type of modification. Review for any swallowing considerations.
General guidelines to blenderize food are as follows:
A food processor or blender is required.
Use a wire mesh strainer to remove any large particles remaining after processing.
Cut food into small pieces before blending; then strain to remove chunks.
Use liquids that provide energy (eg, sour cream, milk, half and half, cream, fruit juice,
broth, gravy, cheese sauce, or tomato sauce) instead of water. These will also
enhance flavor.
Add liquid to blenderized mixtures gradually, because too much will change or dilute
flavors of foods.
Adding warm liquids such as broth, cream soups, or spaghetti sauce helps blend the
mixture to a smooth consistency and adds kilocalories too.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Increase energy and protein by adding whole milk, grated cheese, powdered milk,
creamy peanut butter, pasteurized eggs, concentrated fruit juice, butter, oil and/or
margarine to the blenderized mixture.
Refrigerate immediately after preparation, because the mixture is an excellent
medium for bacterial growth. Blenderized foods can be kept refrigerated up to 48
hours.
To decrease meal preparation time, freeze blenderized foods in meal-sized portions
or in covered ice cube trays.
Disassemble and clean blender equipment thoroughly after each use. Clean with hot,
soapy water or clean parts in a dishwasher.
Remember that salty or sweet flavors in food are enhanced by blending.
Look for variety of flavors in blenderized foods. Try blending favorite foods, such as
hamburgers, spaghetti, pizza, and peanut butter and jelly sandwiches. This provides
more appeal and variety and maintains adequate intake.
For quick meals, blenderize commercially prepared products, such as cooked frozen
entrees, soups, puddings, instant mashed potatoes, cereals, strained baby foods and
liquid nutritional supplements.
Blended food viscosity ranges from the thickness of fruit juice to that of cream soup.
Thin milkshakes, custards, and puddings with a nutrient-dense liquid for appropriate
consistency.
Use syringes, spoons, or straws to move liquids through openings in the teeth.
If use of a straw is allowed, shorten the straw to decrease suction requirements.
Place blended food in a cup with a lid and straw if the appearance detracts from its
palatability.
Avoid caramel or other excessively sticky foods.
Avoid extremes in food temperature, either very hot or cold.
Add bran to blended foods, if needed, to treat or prevent constipation.
If proper selection of food is maintained, the blenderized diet is adequate in all nutrients,
according to the Recommended Dietary Allowances and Dietary Reference Intakes (add
weblink to site in NCM). Six to eight small meals are usually required to achieve adequate
energy intake.
Decreased food intake is common due to eating fatigue; taste of liquids become boring and
large volume of liquid causes satiety. Monitor closely for adequate energy, fluid, and
protein intake for growth, healing, and hydration. If appropriate goals are not met, enteral
nutrition should be considered.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Modified Consistency Meal Plans > Pureed Diet
Overview

The pureed diet includes foods that can be chewed with little or no effort and that can be
safely and easily swallowed. Foods may be easier to swallow than a liquid diet because of
decreased viscosity, allowing more time for oral management and greater likelihood of a
safer swallow.
Foods that are coarsely textured, like raw fruits and vegetables or grains with hulls and
nuts, should be avoided.
The anatomy of the oral, pharyngeal, and esophageal areas affects the ability to chew and
swallow foods. During swallowing, the muscles of the oropharynx, upper esophageal
sphincter, body of the esophagus, and lower esophageal sphincter must be well
coordinated and timed.
The registered dietitian should work closely with the speech therapist to evaluate
suspected swallowing problems. An interdisciplinary team approach with the physician,
registered dietitian, speech therapist and other caregivers will better serve the patient and
family for optimal nutrition therapy in pediatric dysphagia and feeding disorders (Mahan,
2004).
Swallowing therapy for infants and children involve not only modifying the texture of the
diet, but may also include repositioning to achieve optimal safety during meals.
A bedside swallowing evaluation, videofluoroscopic swallow study, or barium esophogram
swallow may be necessary (Prasse, 2009; Arvedson, 2008). Swallowing disorders have a
direct impact on nutrition, and adequate nutrition is required for growth and development of
all body systems in infants and children. Identifying pediatric patients at risk is critical, as
infants and children with dysphagia may not have the same symptoms and signs as do
adults with dysphagia (Miller, 2009).
Examples of nutrition diagnoses that may relate to the blenderized diet include the
following (IDNT, 2011):
Swallowing difficulty (NC-1.1)
Biting/Chewing (masticatory) difficulty (NC-1.2)
Self-Feeding difficulty (NB-2.6)

Indications and Contraindications

Pureeed consistency meal plans are used for patients with difficulty chewing and/or
swallowing resulting from a variety of medical conditions.
Infants and children experience swallowing problems (dysphagia) due to behavioral,
developmental, or neurological conditions; respiratory problems and/or gastroesophageal
reflux; or structural deficits (eg, cleft lip or palate) (Prasse, 2009). The throat/mouth may be
affected because of inflammation, neurological damage, neuromotor disorders, severe
mental retardation, severely delayed feeding skills, primary esophageal muscle disease,
and/or anatomic alterations of the mouth or esophagus. These swallowing difficulties have
a direct impact on hydration as well as the nutritional status of the child.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Foods Recommended

Printable version
Food Group Foods Recommended
Milk
Milk used to moisten foods; smooth puddings,
custards, or yogurt
Meat and
Other Protein
Products
Pureed cooked meats or fish, casseroles;
blended canned or potted meats;
Braunschweiger sausage; soufflés and other
soft egg dishes.
Grains
Smooth cooked cereals (such as farina and
cream of wheat) with small amounts of milk

Breads, rolls, crackers, pancakes, sweet rolls,
pastries, french toast, muffins, well-cooked
pasta, noodles, bread dressing, and rice that
have been pureed to a pudding consistency
Vegetables
Pureed vegetables, tomato sauce or tomato
paste without seeds and seasoned as desired
with butter, margarine or oil

Mashed or pureed potatoes without skins
seasoned with gravy, butter, margarine, or
sour cream

If thin liquids are allowed: Strained juice
without pulp or seeds
Fruits
Pureed fruits, well-mashed fresh bananas or
avocados

If thin liquids are allowed: strained juice
without pulp or seeds
Fats and Oils
Butter; margarine; strained gravy; sour cream;
mayonnaise; cream cheese; whipped topping;
smooth sauces such as white sauce, cheese
sauce, or hollandaise sauce.

Foods Not Recommended

Printable version
Food Group Foods Not Recommended
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk Yogurt with pieces of fruits or nuts
Meat and
Other Protein
Foods
Whole or ground meats, fish, or poultry
Dried or cooked lentils or legumes that have
been cooked, but not mashed or pureed
Cheese, cottage cheese, or peanut butter
unless incorporated into foods and pureed
Fried, scrambled, or hard-cooked eggs
unless pureed
Grains
Breads, rolls, crackers, biscuits, pancakes,
waffles, French toast, muffins, and bread
dressing, pasta, noodles and rice that have
not been pureed to pudding consistency.
Dry cereals,
Oatmeal or cooked cereals with lumps,
seeds, or chunks.
Vegetables
Fresh, frozen, canned or dried vegetables
that have not been pureed Tomatoes or
tomato sauce with seeds
Fruits
Whole fresh, frozen, canned or dried fruits
that have not been pureed
Watermelon with seeds
Fats and Oils All fats with coarse or chunky additives

Sample 1-Day Menu

Note: portions are appropriate for ages 5 to 10 years
Printable version
Breakfast
6 ounces cream of wheat made with milk added,
sprinkled with lump-free brown sugar
1 pureed scrambled egg
1 cup low-fat 2% milk, at the prescribed liquid
consistency
Snack
1/2 cup orange juice at the prescribed liquid
consistency
1 blended or pureed muffin with 1 pat butter or
margarine
Lunch
2 ounces pureed turkey
1/2 cup mashed potatoes with gravy at
prescribed consistency
1/2 cup pureed carrots
1/2 cup pureed peaches
1 cup water at prescribed liquid consistency
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
6 ounces smooth, whipped fruit-flavored or
custard-style yogurt
1/2 cup pureed pears
Evening
Meal
1/2 cup pureed spaghetti and
1/4 cup tomato sauce
2 ounces pureed meatball
1/2 cup pureed green beans
1/2 pureed applesauce
1/2 cup low-fat milk at the prescribed consistency
Snack
1/2 cup low-fat milk at the prescribed consistency
2 squares graham crackers pureed with low-fat
milk
1 small mashed banana

Approximate Nutrient Analysis
Energy (kcal) 1,783
Total protein (g)
77.4 (17% of
kcal)
Total carbohydrate (g)
257 (57.7% of
kcal)
Total fat (g)
52.1 (25.3% of
kcal)
Saturated fatty acids (g)
21.4 (10.6% of
kcal)
Monounsaturated fatty
acids (g)
16.6 (8.2% of
kcal)
Polyunsaturated fatty
acids (g)
7.9 (5.8% of
kcal)
Cholesterol (mg) 344
Calcium (mg) 1,463
Iron (mg) 17.2
Magnesium (mg) 291
Phosphorus (mg) 1,429
Potassium (mg) 3,485
Sodium (mg) 2,469
Zinc (mg) 11.57
Vitamin A (mcg RAE) 2367
Vitamin C (mg) 102.9
Thiamin (mg) 1.1
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Riboflavin (mg) 2.4
Niacin (mg) 16.5
Total folate (mcg) 285
Vitamin B-6 (mg) 1.9
Vitamin B-12 (mcg) 5
Total dietary fiber (g) 19.8
Vitamin D (mcg) 4.1

Guidelines

The pureed diet is prepared by pureeing or straining foods, unless already in a smooth
form (e.g. applesauce or mashed potatoes). It consists of foods that are blended, whipped
or mashed until they are a “pudding-like” texture. Pureed foods should be smooth and free
of lumps.
Guidelines for preparing a pureed diet include the following:
Add small amounts of liquids (eg, broth, milk, gravy, sauce) during processing to
obtain the desired consistency.
Liquids should not mask the flavor of the food.
To increase energy density, add milk, gravy, butter, margarine, honey, or sugar to the
foods and liquid. Heavy cream is a great way to add additional kilocalories.
Puree each item separately and top with a sauce or gravy. This presentation may be
more appealing than having all items mixed together.
When adding sauce or gravy, check for appropriate thinness or thickness of the food
to ensure a safe swallow of the mixture.
Proper preparation and care must be taken during preparation using a blender. The
texture can be adjusted by the amount of liquid added when pureeing the food item.
Liquids can be thickened with other foods including applesauce, bread crumbs,
instant potato flakes, and infant cereal. Consider other thickening foods such as
pudding, yogurt, mashed potatoes.
Directions should be carefully followed for commercial pureed foods or reheating
pureed foods so that a tough outer crust doesn’t form and affect ability to swallow.
Consider taste and temperature of the puree when serving the food to the child.
Based on age and food preferences of the child, use fresh or prepared foods for
blending into pureed consistency. Commercial baby foods are convenient and food
safe but may be costly for long-term use. These are intended for infants younger than
the age of 1 year and may not be as well received by older children.
The pureed menu can be nutritionally adequate. An oral supplement may be needed if
energy needs cannot be met by pureed foods alone.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Modified Consistency Meal Plans > Mechanical Soft Diet
Overview

This meal plan provides foods that are chopped, ground, mashed, or pureed.
The patient’s acceptance and tolerance of the meal plan can indicate the extent of texture
modification required. If dysphagia is suspected, a swallowing evaluation should be
performed and the meal plan should be individualized as a result.
The mechanical soft diet can be adequate in all nutrients according to the Recommended
Dietary Allowances and Dietary Reference Intakes. This meal plan may be low in dietary
fiber.
Examples of nutrition diagnoses that may relate to the blenderized diet include the
following (IDNT, 2011):
Swallowing difficulty (NC-1.1)
Biting/Chewing (masticatory) difficulty (NC-1.2)
Self-Feeding difficulty (NB-2.6)

Indications and Contraindications

The mechanical soft diet provides foods for children who have difficulty chewing and
swallowing. These foods can be safely and easily swallowed.
This diet is indicated for patients who do not require a diet for dysphagia and do no not
require blenderized or pureed textures. Patients who have undergone head, neck, and/or
oral surgery; patients with dentition problems; and patients with anatomic esophageal
stricture are likely to benefit from the mechanical soft diet. It is also appropriate as a
transition to foods of regular consistency.

Foods Recommended

Printable version
Food Group Foods
Milk and Dairy
Pudding, custard, ice cream, sherbet,
malts, frozen yogurt, and cottage cheese
Moistened ground or tender-cooked meat
less than ¼ inch size, poultry, or fish with
gravy or sauce
Casseroles without rice
Moist macaroni and cheese, well-cooked
pasta with meat sauce, tuna-noodle
casserole, soft and moist lasagna
Moist meatballs, meatloaf, or fish loaf
Tuna, egg, or meat salad without large
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meat and Other
Protein Products
chunks or hard-to-chew vegetables
Smooth quiche without large chunks
Poached, scrambled, or soft-cooked eggs
mashed with butter, margarine, sauce, or
gravy
Soufflés with small chunks of meat, fruit,
or vegetables
Tofu
Well-cooked, moistened, and mashed
dried and cooked beans, peas, baked
beans and other legumes
Grains
Soft pancakes, breads, sweet rolls,
Danish pastries, french toast well
moistened with syrup or sauce to form a
slurry
Well-cooked pasta, noodles, and bread
dressing
Well-cooked noodles in sauce
Spaetzle or soft dumplings that have been
moistened with butter or gravy
Purchased pureed bread products
Cooked cereals with little texture,
including oatmeal or cream of wheat
Slightly moistened dry cereals with little
texture such as corn flakes, wheat flakes,
and puffed rice
Unprocessed wheat bran stirred into
cereals to provide fiber
Soft, moist cakes with icing; cake
dissolved in milk or juice to form a slurry
Cookies softened with milk, coffee, or
other liquid
Vegetables
Moist, well-cooked, soft-boiled, baked, or
mashed potatoes without skin
All soft, well-cooked vegetables in pieces
less than ½ inch in size
Fruits
Drained canned or cooked soft fruits
without seeds or skin
Fresh, ripe banana
Plain gelatin or gelatin with canned fruit,
except pineapple
Soft fruit pies with bottom crust only
Crisps and cobblers without seeds or nuts
and with soft crust or crumb topping
Fruit ices
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fats and Oils
Butter, margarine
Gravy, cream sauces
Mayonnaise, salad dressings
Cream cheese, cream cheese spreads
with soft fruits or vegetables added
Sour cream, sour cream dips with soft
fruits or vegetables
Whipped toppings

Foods Not Recommended

Printable version
Food Group Foods
Milk and Dairy
Breakfast yogurt with granola, dried fruit, or
nuts
Meat and Other
Protein Foods
Nuts; foods made with nuts
Dry meats, tough meats (such as bacon,
sausage, hot dogs, bratwurst)
Dry casseroles or casseroles with rice or
large chunks
Cheese slices and cubes
Peanut butter
Hard-cooked or crisp, fried egg
Sandwiches
Pizza
Grains
All breads not in the recommended list
Very coarse cooked cereals that contain
flax or other seeds or nuts
Whole-grain, dry or coarse cereals
Cereals with nuts, seeds, dried fruit, and/or
coconut
Dry, coarse cakes and cookies
Rice
Rice or bread pudding
Vegetables
Potato skins
Potato and other vegetable chips
Fried or french-fried potatoes
Cooked corn and peas
Broccoli, cabbage, brussels sprouts,
asparagus, celery, and other fibrous, tough,
or stringy or undercooked vegetables
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruits
Pineapple
Fruit with seeds
Coconut
Dried fruit
Fats and Oils All fats with coarse or chunky additives

Sample 1-Day Menu

Note: Portion sizes are appropriate for children 5 to 10 years old.
printable version
Breakfast
6 ounces oatmeal made with low-fat milk added,
sprinkled with lump-free brown sugar
1 scrambled egg
1 cup low-fat milk, at the prescribed liquid
consistency
Snack
1/2 cup orange juice, at the prescribed liquid
consistency
1 muffin with butter or margarine
Lunch
2 ounces chopped tender turkey
1/2 cup mashed potatoes with gravy
1/2 cup well-cooked, soft, diced carrots
1/2 cup soft, canned, bite-size peaches
1/2 cup water at the prescribed liquid consistency
Snack
6 ounces smooth, whipped fruit-flavored or
custard-style yogurt
Evening
Meal
1/2 cup well-cooked spaghetti and tomato sauce
2 ounces chopped meatball
1/2 cup chopped cooked green beans without
strings
1/2 cup applesauce
1/2 cup low-fat milk, at the prescribed
consistency
Snack
1/2 cup low-fat milk, at the prescribed
consistency
2 graham crackers dissolved in whole milk
1 small soft, ripe banana

Approximate Nutrient Analysis
Energy (kcal) 1,751
Total protein (g)
78.7 (18% of
kcal)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Total carbohydrate (g)
242 (55% of
kcal)
Total fat (g)
54.3 (27% of
kcal)
Saturated fatty acids (g)
21.9 (11% of
kcal)
Monounsaturated fatty
acids (g)
17.3 (8.7% of
kcal)
Polyunsaturated fatty acids
(g)
8.7 (6.5% of
kcal)
Cholesterol (mg) 344
Calcium (mg) 1,300
Iron (mg) 10.9
Magnesium (mg) 320
Phosphorus (mg) 1,519
Potassium (mg) 3,456
Sodium (mg) 2,228
Zinc (mg) 13
Vitamin A (mcg RAE) 2367
Vitamin C (mg) 100.9
Thiamin (mg) 1.1
Riboflavin (mg) 2.3
Niacin (mg) 15.6
Total folate (mcg) 262
Vitamin B-6 (mg) 1.8
Vitamin B-12 (mcg) 5
Total dietary fiber (g) 19.9
Vitamin D (mcg) 4.1


Guidelines

The mechanical soft diet includes foods on a regular diet for age appropriateness but has
been modified in texture to be easily chewed and swallowed. Any diet can be made a
mechanical soft consistency by modifying the texture of the food by chopping, grinding,
and/or blending the food.
General guidelines for mechanically altering the food include the following:
Regular meats can be replaced with meats that are chopped, ground, blended, or
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Regular meats can be replaced with meats that are chopped, ground, blended, or
pureed
Use foods that are moist and require minimal chewing
Add sauces, natural juices, and gravies to add moisture
Cook vegetables (eg, broccoli and carrots) until they are soft
Foods that are coarse textured like raw fruits and vegetables and grains with hulls and nuts
should be avoided.
Liquids may be difficult to swallow and may require thickening. The diet may be adjusted to
allow thickened or thin liquids. When preparing or storing thickened liquids, pay special
attention to safety and sterility guidelines (Robbins, 2011).
Thickened liquids may be purchased as already mixed or made by adding commercial
thickeners. They can be pureed in a blender and thickened with infant cereal, flour,
cornstarch, or potato flakes for a pudding-like texture.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Nutrition Care > Nutrition Assessment > Comparative Standards
Comparative Standards

See Parenteral Nutrition Nutrient Requirements and Enteral Nutrition Nutrient Requirements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Nutrition Care > Nutrition Assessment > Intake Assessment
Intake Assessment

Data Collection
To assess dietary intake, review the medical record or nursing flow sheets to determine
nutrient sources—parenteral nutrition (PN); intravenous solutions; human milk; human milk
fortifier; infant formula; and vitamin, mineral, or other modular supplements.
Data Analysis
The dietary intake assessment should include both qualitative and quantitative analyses.
In the qualitative analysis, consider whether current nutrient solutions are appropriate
for the patient’s gestational age, size, tolerance issues (if any), and diagnoses.
In the quantitative analysis, calculate nutrient intakes (at least mL/kg/day, kcal/kg/day,
and grams of protein/kg/day).
PN calculations (including dextrose, crystalline amino acids, and intravenous fat
grams per kilogram per day) are done in the same way for infants as they are for
other populations.
Dextrose and/or electrolytes in intravenous drip medications often contribute
substantially to an infant’s intake and are calculated.
Occasionally, even medication flushes influence the small infant’s glucose or
electrolyte status.
A more detailed, targeted nutrient intake analysis may be done on intakes of
infants with certain diagnoses or conditions (eg, assessing calcium, phosphorus,
and vitamin D intake for infants with osteopenia).
Calculating Nutrient Intakes
Calculations of nutrient intakes are compared with recommended intakes (see Parenteral
Nutrition and Enteral Nutrition for recommendations) and interpreted in light of the baby’s
medical condition and growth. Following is an example of how to calculate nutrient intake.
Sample Nutrient Intake Calculation for 1,500-g Preterm Infant
Intake
Maternal milk fortified to 24 kcal/fl oz with human milk fortifier, taking 28 mL every 3 hours
Calculations
28 mL × 8 feedings/day = 224 mL/d ÷ 1.5 kg = 149 mL/kg/d
149 mL/kg/d × 0.8 kcal/mL
a
= 119 kcal/kg/d
149 mL/kg/d × 0.024 g protein/mL
a
= 3.6 g protein/kg/d
a
For most precise calculations, consult the specific manufacturer’s literature.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Nutrition Care > Nutrition Assessment > Nutrition > Focused Physical Findings
Nutrition-Focused Physical Findings

Observe the infant’s general condition, bedside nursing documentation, feeding tolerance,
and medical status. Additional information on physical observations is included under the
following headings.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Nutrition Care > Nutrition Monitoring & Evaluation
Nutrition Monitoring & Evaluation

The purpose of nutrition monitoring and evaluation in neonatal intensive care units,
intermediate neonatal care units, normal newborn nurseries, newborn follow-up clinics, or
pediatricians’ offices is to assess progress toward nutrition goals and expected
outcomes. Goals and expected outcomes are defined by reference standards or an
improvement in nutrition care indicators and may be categorized using the nutrition
assessment terminology categories as follows:
Food/Nutrition-Related History Outcomes (FH)
Food and Nutrient Intake (1)
Food and Nutrient Administration (2)
Breastfeeding (7.1)
Anthropometric Measurement Outcomes (AD)
Length
Weight
Weight change
Growth pattern indices/percentile ranks for corrected age for prematurity
Head circumference
Weight-for-age
Length-for-age
Head circumference-for-age
Weight-for-length
Bone density and bone age
Biochemical Data, Medical Tests and Procedure Outcomes (BD)
Laboratory data
Electrolyte
Essential fatty acid
Gastrointestinal measures
Glucose
Mineral
Nutritional anemia
Protein
Vitamin profiles
Nutrition-Focused Physical Finding Outcomes (PD)
Overall appearance
Extremities, muscles, bones
Digestive system
Skin
Vital signs
Critical thinking is necessary when completing the following step of the nutrition care
process*:
Select the appropriate indicators or measures to monitor and evaluate the impact of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition intervention on the patient’s/client’s progress toward defined goals.
Examples include the following:
Grams per day weight gain
Grams per kilogram per day protein intake
Serum alkaline phosphatase level
Use current and age-specific/disease-specific reference standards for comparison.
Examples include the following:
120 kcal/kg/d and 4 g protein/kg/day for infants 0.9 kg to 1.2 kg (Ziegler, 2007)
400 mcg zinc/kg/day parenteral zinc requirement for preterm infants (Tsang,
2005)
Define progress toward goals in terms of expected outcomes. Examples include the
following:
Increase in head circumference of 0.6 cm/week compared with standard 0.9
cm/week (Moyer-Mileur, 2007).
Compared to a norm of less than 550 IU/L, and a previous level of 850 IU/L,
alkaline phosphatase is now 750 IU/L after mineral intake was increased.
Explain any variance from expected outcomes. Examples include the following:
Increase in head circumference is less than expected, which may be related to
use of steroid medication
Less than expected weight gain, which may be related to temperature instability
during weaning from isolette to open crib
Identify factors that enhance or impede progress and ways to address these factors.
Examples include the following:
Frequent episodes of vomiting are impeding progress toward full enteral
feedings; giving gavage feedings over longer duration(eg, over 60 minutes
instead of 10 minutes) may prevent vomiting and allow continued progression to
full enteral feedings
Interrupting parenteral nutrition for antibiotic administration is preventing
adequate parenteral nutrition intake; increase parenteral nutrition hourly rate
during the 20 hours of parenteral nutrition administration to accommodate 4
hours of antibiotic infusion
Identify when follow-up will occur, or if nutrition care can be discontinued. Examples
include the following:
Follow-up in 5 days
Nutrition goals are met; no nutrition care follow-up is necessary at this time
*Adapted from Pocket Guide for International Dietetics & Nutrition Terminology Reference
Manual. 3rd edition. Chicago, IL: American Dietetic Association; 2011: 314.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition
Normal Nutrition


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Breastfeeding & Lactation Support
Client Education Handouts

The following guidelines should be provided to mothers who are breastfeeding:
(printable version)
Breastfeed per infant feeding cues at least 8 times per day.
Feed on one breast until the infant releases the nipple and/or falls asleep, and the
breast feels less full.
Massage and compress the breast throughout the feeding whenever infant sucking
decreases.
Encourage complete emptying of the breast.
Offer second breast after waking baby. Baby may or may not feed from second breast.
Alternate starting breast at each feeding.
Baby should have at least 6 wet diapers and 3 or more yellow, soft, seedy stools after
day 5.
Sore nipples, plugged ducts or persistent engorgement may indicate problems with
latching or positioning and may benefit from evaluation by an IBCLC who is trained to
help mothers and babies with lactation.
Breastfeeding support groups and/or peer counseling are invaluable for providing
emotional support, networking and non-medical guidance for mothers.
Babies need only breast milk for the first six months. Supplementing with formula
increases the risk of ear and respiratory infections, hospitalizations in the first year,
SIDS, childhood cancers, obesity, allergies, and diabetes.
When mothers and babies are separated, milk can be expressed and fed to the infant
by bottle.
(ABM 2007, AAP 2009, ADA 2009, Lawrence 2011)
Nutrition Therapy for Women who are Breastfeeding



Foods Recommended

Printable version
Daily Food Group Guidelines During Lactation (amounts will vary based on milk
production, maternal weight and activity)
Food
Group
Best Sources
Daily
Amount
Grains
Whole grains, fortified ready-to-eat
cereals, fortified cooked cereals like
oatmeal or farina, wheat germ
8 oz
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vegetables
Carrots, sweet potatoes, pumpkin,
spinach, cooked greens, winter
squash, tomatoes, red sweet pepper
3 cups
Fruit
Melon, mango, prunes, bananas,
apricot, orange, red grapefruit,
avocado, 100% fruit juice
2 cups
Dairy
Fat-free or low-fat yogurt or milk,
low-fat cheese or cottage cheese, soy
milk
3 cups
Meat and
Proteins
Cooked dry beans or peas; nuts and
seeds; lean lamb, poultry, beef, or
pork; shellfish and fish. Avoid shark,
swordfish, king mackerel, or tilefish
(high levels of mercury).
6-7 oz
Fluids Drink to satisfy thirst varies
Oils
Use vegetable oil. Avoid extra calories
by limiting foods high in fat (regular
cheese, ice cream, butter, shortening,
margarine) and sugar.
6-8 tsp

Foods Not Recommended

printable version
Alcohol:
After having 1 alcoholic drink, wait at least 2 hours before breastfeeding. One serving
of alcohol is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor.
Wait an extra 2 hours for every additional serving of alcohol consumed.
Caffeine:
Limit drinks with caffeine (coffee, tea, and soft drinks) to no more than 2 to 5 cups per
day.
Other sources of caffeine include some medications and weight-loss aids. Discuss the
use of these with a doctor or dietitian.
Herbal teas:
Avoid consumption of herbal teas if possible, or use with caution.
Fish and shellfish:
Avoid fish with high mercury levels, such as shark, swordfish, king mackerel, and tile
fish.
Eat no more than 12 oz per week of fish and shellfish that have lower concentrations
of
mercury. Types to limit include shrimp, canned light tuna, salmon, pollock, and
catfish.
Albacore (white) tuna has more mercury than canned light tuna. Limit it to 6 ounces
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
per
week
If no advice is available about locally caught fish, do not eat more than 6 ounces per
week.
Other items to avoid:
Tobacco
Herbal remedies or supplements
Vitamin or mineral supplements other than those recommended or prescribed by a
doctor, nurse practitioner, or midwife


Sample 1-Day Menu

Sample Menu for a Lactating Mother (First 6 Months)
Printable menu
Breakfast
Orange juice, ½ cup
Whole grain cereal, ¾ cup
Banana (½)
Whole wheat toast (2 slices)
Margarine, 2 tsp
Jelly or jam, 1 Tbsp
Reduced-fat milk, 1 cup
Mid-Morning Snack
Canned peach halves in water (2)
Whole-wheat bagel (½)
Peanut butter, 1 Tbsp
Water
Lunch
Vegetable soup, 1 cup
Saltine crackers (4)

Lean beef patty, 3 oz
Hamburger bun (1)
Mustard, 1 Tbsp
Ketchup, 1 Tbsp
Sliced tomato (2 oz)
Lettuce (1 leaf)

Fresh fruit salad, ½ cup
Graham crackers (4)
Reduced-fat milk, 1 cup
Decaffeinated tea
Mid-Afternoon Snack
Whole grain crackers (4)
American cheese, 1 oz
Fruit juice, ½ cup
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dinner
Green salad, 3½ oz
Vinegar and oil dressing, 1 Tbsp
Broiled, skinless chicken breast, 3 oz
Herbed brown rice, ½ cup
Broccoli (steamed), ½ cup
Whole grain roll (1)
Margarine, 2 tsp
Low-fat frozen yogurt, ½ cup
Reduced-fat milk, 1 cup
Decaffeinated tea
Evening Snack
Water, ½ cup
Apple, medium


Approximate Nutrient Analysis
Energy (kcal) 2,800
Protein (g) 127
Carbohydrate (g) 386
Total fat (g) 94
Saturated fatty acids (g) 33
Monounsaturated fatty acids (g) 38
Polyunsaturated fatty acids (g) 15
Cholesterol (mg) 237
Calcium (mg) 1,774
Iron (mg) 22
Magnesium (mg) 542
Phosphorus (mg) 2,269
Potassium (mg) 4,947
Sodium (mg) 4,037
Zinc (mg) 16
Total vitamin A activity (retinol activity equivalents) (mcg) 2,032
Vitamin C (ascorbic acid) (mg) 212
Thiamin (vitamin B-1) (mg) 2.37
Riboflavin (vitamin B-2) (mg) 3.39
Niacin (vitamin B-3) (mg) 37.33
Folate (mcg) 535
Vitamin B-6 (pyridoxine, pyridoxyl, and pyridoxamine) (mg) 3.18
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin B-12 (cobalamin) (mcg) 5.83
Total dietary fiber (g) 32
Insoluble dietary fiber (g) 22
Vitamin D (calciferol) (mcg) 10

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Full > Term Infants
Client Education Materials

Nutrition for Full-Term Infants
WIC Works Resources
Exclusive Breastfeeding Nutrition Therapy
Breastfeeding and Supplementing Nutrition Therapy
Tips for the Breastfeeding Mother
Preventing Dehydration in Your Baby
Tips to Prevent Choking
Texture Progression

Handouts in Spanish
Nutrition for Full-Term Infants
Exclusive Breastfeeding Nutrition Therapy
Breastfeeding and Supplementing Nutrition Therapy
Vegetarian Sample Menu for Infants
Preventing Dehydration in Your Baby
Tips to Prevent Choking

Foods Recommended

Printable Version
Breast milk
Iron-fortified infant formula
Complementary foods, including the following, should be introduced between 4 to 6
months of age, when the infant shows developmental signs of readiness
Iron-fortified infant cereals
Pureed meats, beans, and legumes
Vegetables and fruits, once meats and cereals are accepted
Single-ingredient commercial baby foods
Typical Portion Sizes and Daily Intake for Infants
Age
(Months)

Food (Portion Size)
Feedings
Per Day
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
0-4
Breast milk or infant formula (2-4
oz)
8-12
4-6
Breast milk or infant formula (6-8
oz)
Infant cereal (1-2 Tbsp)
4-6
1-2
6-8
Breast milk or infant formula (6-8
oz)
Infant cereal (2-4 Tbsp)
Crackers (2), bread (½ slice)
Juice (0-3 oz)
Fruit or vegetable (2-3 Tbsp)
Meat (1-2 Tbsp) or beans (1-2
Tbsp)
3-5
2
1
1
1-2
1-2
8-12
Breast milk or infant formula (6-8
oz)
Cheese (½ oz) or yogurt (½ cup)
Infant cereal (2-4 Tbsp), bread (½
slice), crackers (2), or pasta (3-4
Tbsp)
Juice (3 oz)
Fruit or vegetable (3-4 Tbsp)
Meat (3-4 Tbsp) or beans (¼ cup)
3-4
1
2

1
2-3
2

See the Feeding Recommendations heading for more details.

Foods Not Recommended

Printable Version
The following foods are not recommended for infants because of the risk of choking
(Isaacs, 2005):
Popcorn
Peanuts
Raisins, whole grapes
Uncut, stringy meats
Hot dog pieces
Hard, raw fruits or vegetables such as apples, green beans
Pieces of food that the infant cannot completely masticate because of decreased
chewing skills and can block the airway since voluntary coughing and the ability to
clear the throat is not developed (Isaacs, 2005)
Sticky foods such as peanut butter, which can get stuck in the back of mouth (Isaacs,
2005)
Honey should not be given because of the risk of botulism spores. Milks other than those
specifically designed for infants—such as cow's, goat, rice, or soy milk—are not
appropriate before 1 year of age.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
appropriate before 1 year of age.
Juice should not be introduced before 6 months of age (AAP, 2009d). When introduced,
juice (100% only) should be given in a cup, not a bottle, and limited to 4 oz per day.
Sugar-containing foods and beverages and the addition of salt to food are not
recommended for infants (Story, 2002; Glinnsmann, 1996; ESPGHAN, 2008).
In commercial baby foods, avoid fillers such as modified food starch or tapioca. Baby food
desserts are not recommended because of the added sugar.

Sample 1-Day Menu

Sample Menu for a 9- to 12-month-old Infant
Printable Version
Breakfast Banana, 2 Tbsp
Iron-fortified infant rice
cereal, 4 Tbsp
Breast milk or formula, 4-6 oz
Mid-Morning Snack Whole wheat crackers, ½ oz
Yogurt, 2-3 Tbsp
Water, 2 oz
Lunch Cooked green beans, 2-3
Tbsp
Pasta (chopped), 2-3 Tbsp
Chicken (finely chopped), 1 oz
Pears (soft, chopped), 2 Tbsp
Breast milk or formula, 4-6 oz
Mid-Afternoon Snack Dry toast, ½ slice
Cottage cheese, 2 Tbsp
Breast milk or formula, 4-6 oz
Dinner Beef (finely chopped), 1 oz
Mashed sweet potato, 2-3
Tbsp
Peas, 2-3 Tbsp
Breast milk or formula, 4-6 oz
Evening Snack Peaches (soft, chopped), 2
Tbsp
Breast milk or formula, 4-6 oz

Approximate Nutrient Analysis

Energy (kcal) 991
Protein (g) (12% of kcal) 29.75
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Carbohydrate (g)
(47.6% of kcal)
118
Total fat (g) (38% of
kcal)
41.9
Calcium (mg) 456.9
Iron (mg) 8.7
Magnesium (mg) 131.2
Total dietary fiber (g) 8
Vitamin B-12 (mcg) 1.66
Phosphorus (mg) 534.7
Potassium (mg) 1,165
Sodium (mg) 903
Zinc (mg) 3.62
Vitamin C (mg) 50.7
Thiamin (mg) 0.76
Riboflavin (mg) 0.86
Niacin (mg) 12.6
Folate (mcg) 119.8
Vitamin B-6 0.853
Vitamin A (mcg) (retinol
activity equivalents)
869.2


Sample Menu for a Vegetarian 9-Month-Old Infant
printable version
Breakfast Banana, 2 Tbsp
Iron-fortified infant rice cereal,
4 Tbsp
Breast milk or soy formula, 4-6
oz
Mid-Morning Snack Whole wheat cracker, ½ oz
Hummus, 2-3 Tbsp
Water, 2 oz
Lunch Green beans (cooked), 2-3
Tbsp
Pasta (chopped), 2-3 Tbsp
Split peas (cooked), 2-3 Tbsp
Peaches (soft, chopped), 2
Tbsp
Breast milk or soy formula, 4-6
oz
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mid-Afternoon Snack Dry toast, ½ slice
Mashed avocado, 2 Tbsp
Breast milk or soy formula, 4-6
oz
Dinner Mashed black beans, 2-3 Tbsp
Mashed sweet potato, 2-3
Tbsp
Peas, 2-3 Tbsp
Breast milk or soy formula, 4-6
oz
Evening Snack Pears (soft, chopped), 2 Tbsp
Breast milk or soy formula, 4-6
oz
Approximate Nutrient Analysis
Energy (kcal) 1,010
Protein (g) (8.9% of kcal) 22.5
Carbohydrate (g)
(54.2% of kcal)
137
Total fat (g) (38% of
kcal)
42.7
Calcium (mg) 394.2
Iron (mg) 9.3
Magnesium (mg) 153.5
Total dietary fiber (g) 15
Vitamin B-12 (mcg) 0.36
Phosphorus (mg) 444.2
Potassium (mg) 1,319
Sodium (mg) 770
Zinc (mg) 3.62
Vitamin C (mg) 50.7
Thiamin (mg) 0.858
Riboflavin (mg) 0.76
Niacin (mg) 8.628
Folate (mcg) 188.1
Vitamin B-6 0.753
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin A (mcg) (retinol
activity equivalents)
869.2
The analysis is based on average intake of the age ranges, allowing for extra kilocalories
in the food that remains on the infant’s face and bib.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Toddlers
Client Education Materials

Nutrition for Toddlers
Feeding Tips for Toddlers
Tips to Prevent Choking
Vegetarian Nutrition for Young Children

Handouts in Spanish
Nutrition for Toddlers
Vegetarian Nutrition for Young Children
Tips to Prevent Choking

Foods Recommended

Printable version
Types of Food
Provide foods with a variety of colors, textures, and interesting shapes and arrange food
attractively on the plate.
Food Group Recommended Foods
Milk and Milk
Products
Breast milk
Whole or low-fat cow’s milk,
buttermilk, calcium-fortified soy milk,
reconstituted powdered milk
Whole-fat or low-fat yogurt
Regular-fat or low-fat cheeses
Meat and Other
Protein Foods
Tender, well-cooked lean beef, pork,
poultry
High omega-3 fish
Eggs
Nuts (chopped) or nut butter
Soy beans, lentils, dried peas and
beans, mashed or well cooked,
especially with complementary grains
Grains Choose whole grain for at least half
of daily grain servings
Vegetables All types; eat a variety of colors,
especially dark green and orange
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruits All types; eat a variety of colors and
shapes
Dried fruits that have been cooked
Fats and Oils Limit to less than 4 teaspoons daily
Choose heart-healthy vegetable oils
such as olive oil or canola oil
Fats and oils with omega-3 fatty
acids
Beverages Offer plenty of water between meals
Limit soft drinks as a rare treat only
Sweets/Desserts Low-nutrient foods such as candy,
cookies, cake, or snack food should
only be given as a rare treat and not
in place of more nutritious foods



Foods Not Recommended

Tips to Prevent Choking (AAP, 2009)
Printable version
A child who is choking may not be able to make noise or attract attention. Always
supervise mealtimes.
Be aware if the child is eating in the car.
Discourage eating while walking or playing.
Avoid hard-to-chew foods or foods that increase the risk of choking. Some childhood
favorites can be given simply by changing the form in which it's served.
Cut hotdogs and link sausage lengthwise and grapes into quarters.
Cook or steam carrots and chop corn.
Serve peanut butter spread thinly with jelly or fruit sauce and not by the spoonful.
Coughing is a sign a child is removing an object naturally.
Food That May Cause Choking
Whole corn
Whole grapes
Hot dogs
Meat chunks, unless finely chopped and combined
Sausage links
Nuts, unless chopped fine
Peanut butter
Popcorn, unless served with water to cleanse the palate
Raisins, unless cooked
Raw apples
Raw vegetables
Gum drops
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Gum drops
Hard candy
Jelly beans
Foods Not Recommended
Printable version
Food Group Foods Not Recommended
Milk and Milk
Products
Skim milk before second birthday (need
cholesterol)
Sweetened flavored milk drinks, such as
chocolate or strawberry
Meat and Other
Protein Foods
Undercooked meat served as chunks larger
than ¼" pieces (difficult to chew, bolus texture
difficult to swallow)
Whole nuts
Grains
Fried snack foods
Chips
Pastries
Cereal mixes
Vegetables
Difficult-to-chew fresh vegetables, especially
with peelings
Fruits
Difficult-to-chew whole fresh or dried fruit,
especially with peelings
Fats and Oils
Limit added fats and oils to less than 4
teaspoons daily.
Limit fried and breaded foods (very high calorie,
low nutrients).
Beverages
All sweetened beverages such as fruit drinks
(none to low percentage of fruit juice), soda pop,
sports drinks, and soft drinks (no nutrients)
Sweets and
Desserts
Sweet or sticky foods and candy that can
remain in the mouth for a long time (can cause
dental caries)

Sample 1-Day Menu

Sample Menu for a 1- to 3-year old child
Printable version
Breakfast
Whole milk, ½ cup
Oatmeal, ½ cup
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cooked raisins, 2 Tbsp
Mid-Morning
Snack
Peanut butter and jelly sandwich (½)
Orange juice, ½ cup
Lunch
Whole milk, ½ cup
Ham and cheese, ½ oz each, on whole
grain bread, 1 slice
Carrots, 2 Tbsp cooked
Banana, ½
Mid-Afternoon
Snack
Fruit yogurt, ½ cup
Granola, ¼ cup
Water, ½ cup
Dinner
Whole milk, ½ cup
Chicken, 1½ oz
Green beans, 2 Tbsp
Mashed potatoes, 2 Tbsp
Gravy, 2 Tbsp
Small whole-grain dinner roll (1)
Margarine, ½ tsp
Evening Snack
Applesauce, ¼ cup
Graham crackers (2)
Whole milk, ½ cup
Approximate Nutrient Analysis
Energy (kcal) 1396
Protein (g) 60
Carbohydrates (g) 190
Dietary Fiber (g) 17.5
Fat (g) 48.8
Saturated Fat (g) 18.12
Monounsaturated Fat (g) 9.27
Polyunsaturated Fat (g) 6.23
Trans Fatty Acid (g) 1.00
Cholesterol (mg) 94.41
Vitamin A (RAE) 229.08
Vitamin B1 -Thiamin (mg) 0.93
Vitamin B2 -Riboflavin (mg) 1.52
Vitamin B3 -Niacin (mg) 7.97
Niacin Equivalents (mg) 16.78
Vitamin B6 (mg) 0.78
Vitamin B12 (mcg) 2.88
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Biotin (mcg) 18.30
Vitamin C (mg) 66.87
Vitamin D (mcg) 4.92
Vitamin E -α-Tocopherol (mg) 2.47
Folate, DFE (mcg) 168.12
Vitamin K (mcg) 16.82
Pantothenic Acid (mg) 3.73
Calcium (mg) 1081.96
Chromium (mcg) 2.75
Copper (mg) 0.66
Fluoride (mg) 0.13
Iodine (mcg) 161.58
Iron (mg) 7.29
Magnesium (mg) 276.89
Manganese (mg) 3.65
Molybdenum (mcg) 15.40
Phosphorus (mg) 1041.36
Potassium (mg) 1969.56
Selenium (mcg) 63.77
Sodium (mg) 1713.11
Zinc (mg) 6.24

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Preschool Children
Client Education Materials

Nutrition for Preschool Children
Feeding Tips for Preschoolers
Tips to Prevent Choking
Vegetarian Nutrition for Young Children

Handouts in Spanish
Nutrition for Preschool Children
Tips to Prevent Choking
Vegetarian Nutrition for Young Children

Foods Recommended

Printable version
Food Group Recommended Foods
Milk and Milk
Products
Low-fat cow’s milk, buttermilk,
calcium-fortified soy milk, reconstituted
powdered milk
Low-fat yogurt
Regular-fat or low-fat cheeses
Meat and Other
Protein Foods
Tender, well-cooked lean beef, pork,
poultry
High omega-3 fish
Eggs
Nuts or nut butter
Soybeans, lentils, dried peas and
beans (well-cooked), especially with
complementary grains
Grains Choose whole grain for at least half of
daily grain servings
Vegetables All types, especially dark green and
orange
Fruits Eat a variety of colors and shapes
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fats and oils Limit added fats and oils to less than 3
teaspoons daily
Choose heart-healthy vegetable oils
such as olive oil or canola oil,
especially brain-healthy high omega-3
fats and oils
Beverages Offer plenty of water between meals
Sweets,
desserts, and
snack foods
Low-nutrient, high-sugar, or
high-sodium foods such as candy,
cookies, cake, or chips should only be
given as a rare treat and not in place
of more nutritious foods


Foods Not Recommended

Foods That May Cause Choking
Printable version
Corn
Whole grapes
Gum drops
Hard candy
Hot dogs
Jelly beans
Meat chunks
Nuts, unless chopped
Peanut butter
Popcorn
Raisins
Raw apples
Raw vegetables
Sausage links
Tips to Prevent Choking
Choking is not as serious a concern with the preschooler as it is with infants or toddlers,
but precautions are warranted.
Discourage eating while walking or playing or viewing television
Encourage the child to eat and carry on a conversation to slow down the
eating. Children can't overstuff their mouths if they need to answer a question.
Be aware if the child is eating in the car. A child who is choking may not be able to
make noise or attract attention.
Coughing is a sign a child is removing an object naturally.
Foods Not Recommended
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Printable version
Food Group Foods Not Recommended
Milk and Milk
Products
Sweetened flavored milk, such as
chocolate or strawberry
Skim milk is allowed after the age of 2
years
Meat and Other
Protein Foods
Meat that is undercooked or served in
chunks or larger than bite-sized pieces
Grains
Fried snack foods
Chips
Pastries
Cereal mixes
Vegetables Raw carrots or corn
Fruits Dried fruit that is not well chopped
Fats and Oils Fried foods should be limited
Beverages
More than 6 oz daily of any sweet
beverages such as juice, fruit drinks,
soda pop, or sports drinks
Sweets and
Desserts
Sweet or sticky foods that remain in
the mouth for a long time

Sample 1-Day Menu

Sample Menu for a 4- to 5-year old child
Printable version
Breakfast Reduced-fat milk, ½ cup
Oatmeal, ¾ cup with dash of cinnamon
Raisins, ¼ cup cooked with oatmeal
Mid-Morning
Snack
Peanut butter and jelly sandwich (½)
Orange juice, ½ cup
Lunch Reduced-fat milk, ½ cup
Ham and cheese, ¾ oz each, on whole
grain bread, 2 slices
Carrot sticks, 1/3 cup steamed
Banana, 1 small
Mid-Afternoon
Snack
Yogurt, ¾ cup
Sliced fruit, ¼ cup
Granola, ¼ cup
Water, ½ cup
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dinner Reduced-fat milk, ¾ cup
Chicken, 2 oz
Green beans, 2 Tbsp
Mashed potatoes, ¼ cup
Gravy, 3 Tbsp
Small whole-grain dinner roll (1)
Margarine, ½ tsp
Evening Snack Applesauce, ½ cup
Whole grain crackers (5)
Water, ½ cup
Approximate Nutrient Analysis
Energy (kcal) 1694
Protein (g) 72
Carbohydrates (g) 242.86
Dietary Fiber (g) 24.56
Fat (g) 55.90
Saturated Fat (g) 21.22
Monounsaturated Fat (g) 9.57
Polyunsaturated Fat (g) 7.08
Trans Fatty Acid (g) 1.12
Cholesterol (mg) 115.22
Vitamin A (RAE) 282.67
Vitamin B1 - Thiamin (mg) 1.00
Vitamin B2 - Riboflavin (mg) 1.62
Vitamin B3 - Niacin (mg) 10.05
Niacin Equivalents (mg) 19.82
Vitamin B6 (mg) 1.17
Vitamin B12 (mcg) 2.97
Biotin (mcg) 22.86
Vitamin C (mg) 76.27
Vitamin D (mcg) 4.35
Vitamin E - Alpha-Toco (mg) 2.91
Folate (mcg) DFE 196.48
Vitamin K (mcg) 28.07
Pantothenic Acid (mg) 4.22
Calcium (mg) 1351.30
Chromium (mcg) 4.02
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Copper (mg) 0.95
Fluoride (mg) 0.31
Iodine (mcg) 172.60
Iron (mg) 8.14
Magnesium (mg) 303.26
Manganese (mg) 4.16
Molybdenum (mcg) 16.99
Phosphorus (mg) 1166.42
Potassium (mg) 2628.88
Selenium (mcg) 73.37
Sodium (mg) 2390.28
Zinc (mg) 7.13


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > School > Age Children
Client Education Materials

Nutrition for the School-Age Child
Vegetarian Nutrition for School-Age Children

Handouts in Spanish:
Nutrition for the School-Age Child
Vegetarian Nutrition for School-Age Children

Foods Recommended

Printable recommendations for clients
It is recommended for school-age children to consume a well-balanced diet while staying
within energy needs, which may include the following (ADA, 2008):
Whole-grain products (frequently): at least half (approximately 3 oz) of the grain
should be whole grains daily. In the list of ingredients on product packaging, grains
like wheat, rice, or oats are referred to as "whole" grain.
Calcium-rich foods: 2-3 cups of nonfat or low-fat milk or equivalent amount of low-fat
yogurt and/or cheese every day.
1½ to 2 cups of fruits daily: choose fruits that are fresh, frozen, canned, or dried; 4 oz
of 100% fruit juice is equivalent to one cup of fruit.
At least 1½ cups of a variety of vegetables, including dark green vegetables (spinach,
broccoli, kale) and orange vegetables (carrots, sweet potatoes, pumpkin).
Lean meats and poultry: opt for cooking methods that don't require additional fat/oil,
such as baking, broiling, or grilling.
Please refer to MyPyramid for further details.
Choose foods that contain less than 3 g fat per serving or less than 30% of total calories
from fat. Read the Nutrition Facts label to help find foods low in saturated fats and trans
fats (<10% total daily caloric intake from saturated fat and <1% total caloric intake from
trans fat).

Foods Not Recommended

Printable recommendations for clients
Foods that contain more than 30% of calories from fat are not recommended. Read the
Nutrition Facts label on foods to determine the percentage of calories from fat.
Limit intakes of foods of minimal nutrient value (FMNV), which are defined as foods
providing less than 5% of recommended intakes for 8 key nutrients. These foods include
carbonated soda, gum, hard candies, and jelly beans.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sugar-sweetened beverages can displace the intakes of calcium-rich, nutrient-dense foods.
Noncalorie sweeteners—though they are tested by the US Food and Drug
Administration and have shown to be safe for adults and children—can displace the intakes
of more healthful options.
There are no current guidelines for caffeine in children; however, there are health-related
effects with drinking caffeinated beverages such as increased caloric intakes. This is
because caffeinated beverages frequently contain a lot of sugar, which can also lead to
decreased intakes of more nutritive beverages. In addition, caffeine acts as a diuretic,
which can increase the likelihood of dehydration.

Sample 1-Day Menu

Sample Menu for Children Aged 4 to 8 years Who Are Not Physically Active
Printable version
Breakfast Cheerios (¾ cup)
1% low-fat milk (½ cup)
Whole wheat toast (1 slice)
Peanut butter (1 Tbsp)
100% orange juice (½ cup)
Lunch Whole wheat bread (2 slices)
Turkey slice (1 oz)
Mozzarella cheese (1 slice)
Reduced-calorie
mayonnaise (1 Tbsp)
Banana (1, medium)
Baby carrots (6)
Water (1 cup)
Afternoon Snack Graham cracker squares (4)
Pear (1, medium)
String cheese (1 oz)
Dinner Mixed leafy green
vegetables (½ cup)
Low-fat Italian dressing (2
Tbsp)
Roasted, skinless chicken (1
oz)
Steamed rice (½ cup)
Broccoli (½ cup)
Frozen low-fat yogurt (½
cup)
Water (1 cup)
Evening Snack (optional, for
active children)
Apple (1, medium)
Low-fat cheese (1 oz)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Approximate Nutrient Analysis
DRI
abc
Energy (kcal) 1,383.00
Protein (g)
69.12
(19.99%
of kcal)
19
Carbohydrate (g)
211.4
(61.14%
of kcal)
130
Total fat (g)
33.36
(21.7% of
kcal)
ND
Saturated fatty acids
(SFA) (g)
11.35
(7.38% of
kcal)

Monounsaturated fatty
acids (g)
11.41
(7.42% of
kcal)

Polyunsaturated fatty
acids (g)
7.03
(4.57% of
kcal)

Cholesterol (mg) 115
Calcium (mg) 1,103.00 800
Iron (mg) 14.76 10
Magnesium (mg) 291 130
Phosphorus (mg) 1,274.00 500
Potassium (mg) 2,586.00 1300
Sodium (mg) 2,167.00 1200
Zinc (mg) 11.71 5
Total vitamin A activity
(retinol activity
equivalents) (mcg)
1,078.00 400
Vitamin C (ascorbic
acid) (mg)
141.8 25
Thiamin (vitamin B-1)
(mg)
1.29 0.6
Riboflavin (vitamin B-2)
(mg)
1.71 0.6
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Niacin (vitamin B-3)
(mg)
18.46 8
Folate (mcg) 530 200
Vitamin B-6
(pyridoxine,
pyridoxyl, and
pyridoxamine) (mg)
1.81
Vitamin B-12
(cobalamin) (mcg)
3.54 1.2
Vitamin D (calciferol)
(mcg)
5.7 5
Total dietary fiber (g) 24.28 25
a
DRI = Dietary Reference Intakes
b
Values presented in boldface type represent Recommended Dietary Allowances (RDA)
c
ND = not determined

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Adolescents
Client Education Materials

Nutrition for Adolescent Boys
Nutrition for Adolescent Girls
Vegetarian Nutrition for Teen Athletes
Vegetarian Nutrition for Pregnant Teens
Vegetarian Tips for Pregnant Teens

Handouts in Spanish:
Nutrition for Adolescent Boys
Nutrition for Adolescent Girls
Vegetarian Nutrition for Teen Athletes
Vegetarian Nutrition for Pregnant Teens

Sample 1-Day Menus

Sample 1-Day Menu for an Adolescent Boy
Printable version
Breakfast 100% whole grain toast (2 slices)
Peanut butter (2 Tbsp)
Banana (1)
Skim milk (8 oz)
Lunch Turkey sandwich:
Whole grain bread (2 slices)
Turkey (3 oz)
Lettuce (1 leaf)
Tomato (2 slices)
Cucumber (2 slices)
Low-fat mayonnaise (1 Tbsp)
Low-fat yogurt (8 oz)
Blueberries (½ cup)
Potato chips (1 oz)
Peanut butter granola bar (1)
Skim milk (8 oz)
Afternoon Snack Wheat thins (1½ cup)
Carrot sticks (1 cup)
Low-fat ranch dressing (2 Tbsp)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dinner Spaghetti (1 cup)
Chicken (3 oz)
Broccoli (¾ cup)
Tomato sauce (½ cup)
Garlic breadsticks (2)
Skim milk (10 oz)
Evening Snack Apple

Approximate Nutrient Analysis
Energy (kcal) 2823
% energy from carbohydrates 53
% energy from protein 17
% energy from fat 30
Fiber (g) 37
Calcium (mg) 1600
Iron (mg) 18.6
Zinc (mg) 17
Folate (mcg) 650
Vitamin A (mcg retinol activity
equivalents (RAE)
1500
Vitamin C (mg) 145
Vitamin B-12 (mcg) 6
Vitamin B-6 (mg) 3.3


Sample 1-Day Menu for an Adolescent Girl
Printable version
Breakfast Frosted shredded wheat (1 cup)
Skim milk (½ cup)
Strawberries (1 cup)
Water
Lunch Chicken salad wrap:
Whole wheat tortilla (1)
½ cup chicken salad made with celery
and low-fat mayonnaise
Tomato (2 slices)
Lettuce (1 leaf)
Green pepper strips (1 cup)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Hummus (1 Tbsp)
Baked chips (1 oz)
Chocolate chip cookies (2)
Skim milk (8 oz)
Afternoon
Snack
Apple (1)
Fruit-flavored, low-fat yogurt (6 oz)
Dinner Pizza with sausage, onion, and green pepper
(2 slices)
Mixed greens salad with carrots, cucumbers,
peppers (2 cups)
Low-fat dressing (2 Tbsp)
Skim milk (8 oz)
Evening
Snack
Graham crackers (6 squares)
Peanut butter (1 Tbsp)
Skim milk (8 oz)
Approximate Nutrient Analysis

Energy (kcal) 2242
% energy from carbohydrates 59
% energy from protein 16
% energy from fat 25
Fiber (g) 30
Calcium (mg) 1871
Iron (mg) 15
Zinc (mg) 12.7
Folate (mcg) 469
Vitamin A (mcg retinol activity
equivalents (RAE)
1385
Vitamin C (mg) 263
Vitamin B-12 (mcg) 6.6
Vitamin B-6 (mg) 2.7


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Child Athletes
Client Education Materials

Sports Nutrition Tips for Teen Athletes—a handout for parents and children
Sports Nutrition Tips for Athletes—a handout for coaches
Vegetarian Nutrition for Teen Athletes

Consumer resources from the US Food and Drug Administration:
A Key to Choosing Healthful Foods: Using the Nutrition Facts on the Food Label (link)
Dietary Supplements: What You Need to Know (link)

Handout in Spanish
Vegetarian Nutrition for Teen Athletes

Sample 1-Day Menu

In addition to the menu provided on this page, a Sample 1-Day Menu at the 2200 kcal
Level is also available to print out for your clients. Menus and food choices may be
individualized as necessary, depending on the athlete's size and sport.
Sample 1-Day Menu (3,300 kcal) for a 15-Year-Old Male on the Freshman Football
Team
Printable version
Height: 67 in (170 cm)
Weight: 132 lbs (60 kg)
Body mass index: 21 (55th percentile)
Energy needs based on estimated energy requirements (3,000 kcal to 3,500
kcal: Active–Very Active)
Carbohydrate: 7 g/kg (5 g/kg to 8 g/kg normal range) = 420 g
Protein: 1 g/kg (0.8 g/kg to 1.2 g/kg) = 60 g
Breakfast Orange juice (8 oz)
Pancakes (2)
Syrup (1/4 cup)
Margarine (2 tsp)
2% milk (8 oz)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lunch Hand-tossed cheese pizza (2
slices)
Garlic toast (1 piece)
Watermelon (2 cups)
Juice (8 oz)
Snack Peanut butter crackers (4)
Sports drink (8 oz)
Afterschool Practice Sports drink (16 oz)
Dinner Chicken breast (5 oz, grilled)
Pasta with stir-fried
vegetables (1 cup)
Dinner roll
Margarine (1 tsp)
2% milk (8 oz)
Frozen yogurt (1 cup)
Snack Honey nut cheerios (1½ cup)
2% milk (1/2 cup)


Approximate Nutrient Analysis
Energy (kcal) 3,300
Protein (g) 134
Carbohydrate (g) 437
Fat (g) 100
Saturated fat (g) 31
Monounsaturated
fat (g)
22
Cholesterol (mg) 270
Vitamin A mcg RAE
(retinol activity
equivalents)
951
Thiamin (mg) 2.7
Riboflavin (mg) 3.5
Niacin (mg) 58
Vitamin B-6 (mg) 2.9
Vitamin B-12 (mcg) 3.8
Vitamin C (mg) 226
Vitamin D (mg) 900
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Folate (mcg) 440
Calcium (mg) 1,757
Iron (mg) 22
Magnesium (mg) 486
Phosphorus (mg) 1,908
Potassium (mg) 4,399
Selenium (mcg) 97
Sodium (mg) 3,485
Zinc (mg) 21.8

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Normal Nutrition > Vegetarian Children
Client Education Materials for Vegetarian Children

A variety of handouts are available for clients and caregivers from various populations:
Vegetarian Nutrition for Young Children
Vegetarian Nutrition for School-Age Children
Vegetarian Nutrition for Teen Athletes
Vegetarian Nutrition for Pregnant Teens
Tips for a Healthy Vegetarian Pregnancy

Links to Vegetarian handouts for RDs and consumers from the Vegetarian Nutrition Dietetic
Practice Group (VNDPG):
http://www.vndpg.org/resources/docs/School-Aged-Children-RD.pdf
http://www.vndpg.org/resources/docs/School-Aged-Children-Consumer.pdf
http://www.vndpg.org/resources/docs/Toddlers-Preschoolers-RD.pdf
http://www.vndpg.org/resources/docs/Toddlers-Preschoolers-Consumer.pdf
http://www.vndpg.org/resources/docs/Vegetarian-Teens-RD.pdf
http://www.vndpg.org/resources/docs/Vegetarian-Teens-Consumer.pdf

Handouts in Spanish
Vegetarian Nutrition for Young Children
Vegetarian Nutrition for School-Age Children
Vegetarian Nutrition for Teen Athletes
Vegetarian Nutrition for Pregnant Teens
Sample 1-Day Menu for Infants
For printable versions of separate food lists and sample menus for lacto-ovo or vegan
populations, please see Meal Plans.

Foods Recommended

The chart below shows general recommendations for healthy eating.
Food Group Recommended Foods
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk and Milk
Products
Buttermilk
a
Evaporated skim milk
a
Skim or 1% low-fat milk
a
Fortified soy milk
Nonfat or low-fat yogurt
a
Powdered milk
a
Nonfat or low-fat cheeses
a
Low-fat ice cream
a
Protein Foods
Dried beans
Soy products
Nuts and nut butters
Eggs
a
Grains
Any; choose whole grains for at least half of
your child’s grain servings
Vegetables
Any; eat a variety of vegetables, including
green and orange ones
Fruits Any; eat a variety of fruits
Fat and oils
Limit to 3-4 tsp per day; choose heart-healthy
vegetable oils, such as olive or canola oil, and
low-fat salad dressings and mayonnaise
*Note: A vegan diet for children will not include asterisked foods. A diet
for lacto-vegetarian or vegan children will not include eggs.
Printable versions:
Vegetarian Foods for Young Children
Vegetarian Foods for School-Age Children
Vegetarian Foods for Teen Athletes
Vegetarian Foods for Pregnant Teens

Foods Not Recommended

This chart provides general recommendations for foods not included in a vegetarian diet.
Type of
Vegetarian
Foods Not Included
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lacto-ovo
vegetarian
Meat, poultry, seafood, or products made from
meat, poultry or seafood such as gelatin,
broths, gravy, and lard
Lacto
vegetarian
Meat, poultry, seafood, or products made from
meat, poultry or seafood such as gelatin,
broths, gravy, and lard
Eggs, products containing eggs such as
baked goods
Vegan
Meat, poultry, seafood, or products made from
meat, poultry, or seafood such as gelatin,
broths, gravy, and lard
Eggs, products containing eggs such as
baked goods
Dairy products including milk, cheese, yogurt,
and ice cream and products containing dairy
products including whey and casein
Honey

Sample 1-Day Menus

Included on this screen:
Sample menu for a 2-year old lacto-ovo vegetarian
Sample menu for a 2-year old vegan
Sample menu for a 7-year old lacto-ovo vegetarian
Sample menu for a 7-year old vegan

Printable versions of sample menus for other populations:
Sample menu for a vegetarian infant
Sample menu for a lacto-ovo vegetarian athletic teen
Sample menu for a vegan athletic teen
Sample menu for a lacto-ovo vegetarian pregnant teen
Sample menu for a vegan pregnant teen

Sample 1-Day Menu for a 2-Year-Old Lacto-Ovo Vegetarian
printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast
¾ cup 1% low-fat milk
¾ oz fortified, ready-to-eat breakfast cereal
½ small banana
Midmorning
snack
½ toasted English muffin
1 tsp soft margarine
Lunch
¾ cup 1% low-fat milk
Meatless hot dog, sliced into small pieces
½ slice whole-wheat bread
¼ cup steamed green beans
½ cup sliced strawberries
Afternoon snack
½ cup 1% low-fat milk
4 whole wheat crackers
Evening meal
¾ cup 1% low-fat milk
½ cup spaghetti with ¼ cup kidney beans
and ¼ cup meatless marinara sauce
¼ cup steamed broccoli with 1 tsp olive oil
Complete nutrient analysisa
1,039 kcal
53 g protein
132 g carbohydrate
18 g total fiber
36.2 g total fat
9.6 g saturated fat
14 g monounsaturated fat
11 g polyunsaturated fat
8.2 g linoleic acid
1 g alphalinolenic acid
37 mg cholesterol
625.8 mcg retinol activity equivalents (RAE) vitamin A
95.7 mg vitamin C
5.5 mg alpha-tocopherol equivalents (alpha-TE) vitamin E
1.1 mg thiamin
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2.4 mg riboflavin
11.1 mg niacin
438.3 mcg dietary folate equivalents (DFE)
1.2 mg vitamin B-6
5.7 mcg vitamin B-12
1,034.9 mg calcium
1,233 mg phosphorus
222.8 mg magnesium
11.7 mg iron
8.3 mg zinc
a
Results from MyPyramid Tracker

Sample 1-Day Menu for a 2-Year-Old Vegan
printable version
Breakfast
¾ cup fortified soy milk
¾ oz fortified, ready-to-eat breakfast cereal
½ cup calcium-fortified orange juice
Mid-Morning
Snack
½ toasted English muffin
1 tsp soft margarine
Lunch
¾ cup fortified soy milk
¼ cup hummus
½ small apple
¼ cup steamed carrots
Afternoon
Snack
Smoothie made with ½ cup fortified soy
milk, 2 oz soft tofu, ¼ cup strawberries
Evening Meal
¾ cup fortified soy milk
¼ cup spaghetti with ¼ cup kidney beans
and ¼ cup meatless marinara sauce
¼ cup steamed broccoli with 1 tsp olive oil

Complete nutrient analysis
a
1,010 kcal
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
46 g protein
128 g carbohydrate
24 g total fiber
39.4 g total fat
6 g saturated fat
14 g monounsaturated fat
12 g polyunsaturated fat
11.3 g linoleic acid
1.3 g alphalinolenic acid
0 mg cholesterol
566.6 mcg RAE vitamin A
121.4 mg vitamin C
4.9 mg alpha-TE vitamin E
1.9 mg thiamin
1.1 mg riboflavin
8.7 mg niacin
456.3 mcg DFE
1.3 mg vitamin B-6
9.4 mcg vitamin B-12
1272.2 mg calcium
747.7 mg phosphorus
268.2 mg magnesium
15 mg iron
6.7 mg zinc
a
Results from MyPyramid Tracker and product information for fortified soy milk

Sample 1-Day Menu for a 7-Year-Old Lacto-Ovo Vegetarian
printable version
Breakfast ¾ cup 1% low-fat milk
1 slice whole wheat toast
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


1 tsp soft margarine
½ medium banana
¾ oz fortified, ready-to-eat breakfast cereal
Mid-Morning
Snack
3 Tbsp shelled peanuts
¼ cup raisins
Lunch
½ cup low-fat fruit yogurt
Meatless hot dog
Hot dog bun
½ cup steamed green beans
Afternoon Snack
½ whole wheat bagel
1 Tbsp hummus
Evening Meal
¾ cup 1% low-fat milk
½ cup spaghetti with ½ cup kidney beans
and 1/3 cup meatless marinara sauce
½ cup steamed broccoli with 1 tsp olive oil
¾ cup sliced strawberries
Complete nutrient analysis
a
1,866 kcal
75 g protein
282 g carbohydrate
36 g total fiber
57.2 g total fat
13.3 g saturated fat
24 g monounsaturated fat
17 g polyunsaturated fat
14 g linoleic acid
1.4 g alpha linolenic acid
29 mg cholesterol
538.6 mcg RAE vitamin A
164.5 mg vitamin C
9.4 mg alpha-TE vitamin E
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1.8 mg thiamin
2.7 mg riboflavin
21.2 mg niacin
736.3 mcg DFE
2 mg vitamin B-6
5.1 mcg vitamin B-12
1,055 mg calcium
1,503.1 mg phosphorus
383.1 mg magnesium
19.2 mg iron
11.2 mg zinc

a
Results from MyPyramid Tracker

Sample 1-Day Menu for a 7-Year-Old Vegan
printable version
Breakfast
1 cup fortified soy milk
¾ oz fortified, ready-to-eat breakfast cereal
1 slice whole wheat toast
1 tsp soft margarine
¾ cup sliced strawberries
Mid-Morning
Snack
½ cup fortified soy milk
3 Tbsp shelled peanuts
¼ cup raisins
Lunch
1 cup fortified soy milk
Sandwich:
½ cup hummus
1 slice whole wheat bread
1 medium apple
8 carrot sticks
Afternoon
Snack
½ whole wheat bagel
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
1 tsp soft margaine
Evening Meal
½ cup fortified soy milk
½ cup spaghetti with 1/3 cup tofu
cubes and ½ cup meatless marinara sauce
½ cup steamed broccoli with 1 tsp olive oil
Dinner roll
1 tsp soft margarine

Complete nutrient analysis
a
1,842 kcal
71 g protein
257 g carbohydrate
41 g total fiber
70.2 g total fat
10.2 g saturated fat
29 g monounsaturated fat
22 g polyunsaturated fat
20.5 g linoleic acid
1.7 g alpha linolenic acid
0 mg cholesterol
576.3 mcg RAE vitamin A
162.9 mg vitamin C
8.8 mg alpha-TE vitamin E
2.5 mg thiamin
1.6 mg riboflavin
18.7 mg niacin
595.3 mcg DFE
2.1 mg vitamin B-6
10.1 mcg vitamin B-12
1,358.4 mg calcium
1,238.4 mg phosphorus
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
450.6 mg magnesium
21.3 mg iron
10.5 mg zinc

a
Results from MyPyramid Tracker and product information for fortified soy milk

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Anemia
Anemia


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Anemia > Iron Deficiency Anemia
Foods Recommended

Printable version
Infants
Preterm infants (less than 37 weeks' gestation at birth) fed human milk should receive
2 mg/kg/day elemental iron by 1 month of age through 12 months of age.
Term infants who are exclusively breastfed or who receive more than half of their daily
feedings from human milk should receive an iron supplement of 1 mg/kg/day
beginning at 4 months of age and extending until iron-rich complementary foods are
introduced.
When formula is used, it should be iron fortified.
Children/Adolescents
Iron from meat, fish, and poultry is better absorbed than iron from plants. Advice on
iron intake for children and adolescents who follow vegetarian or vegan diets may be
found under the Vegetarian section.
Include foods high in vitamin C such as citrus juice and fruits; melons; dark green,
leafy vegetables; and potatoes with meals. This may help the body absorb more iron.
Eat enriched or fortified grain products.
Limit coffee and tea at meal times, since they decrease iron absorption.
Some cereals contain 18 mg iron per serving (eg, Total, 100% Bran Flakes,
Grapenuts, and Product 19). Having ¾ cup of preferred cereal among high-iron
options will ensure daily iron intake.
Recommended Foods
Foods with at least 2 mg iron per serving

Food Serving Size
Beef, veal 3 oz
Clams, oysters, shrimp, sardines 3 oz
Bran flakes ¾ cup
Cream of wheat ½ cup
Oatmeal (fortified) ¾ cup
Baked potato, with skin 1
Dried beans, cooked (kidney,
lentils, lima, navy)
½ cup
Soybeans ½ cup
Tofu ½ cup
Spinach 1 cup
Dried prunes 4 pieces
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Reconstituted instant breakfast
powder
1 cup


Foods with 1 mg to 2 mg iron per serving
Food Serving Size
Poultry 3 oz
Corned beef 3 oz
Cooked kale 1 cup
Dried apricots 7 halves
Raisins 5 Tbsp
Whole wheat bread 1 slice
Nuts: Cashews, brazil nuts,
walnuts
1 oz


Foods Not Recommended

Printable version

Some foods may reduce iron absorption. To maximize absorption, avoid the following:
Consuming too much dietary fiber
Drinking large amounts of tea or coffee with meals
Relying on nonheme (plant) sources for iron
Instead, eat heme iron sources (such as meat) with a nonheme source (such as
dried beans) to improve absorption
For children aged 1 to 5 years, consuming more than 24 oz of milk each day



Sample 1-Day Menu

Sample 1-Day Menu for a Child Aged 7 to 10 Years with Iron-Deficiency Anemia
printable version
Breakfast
Iron-enriched cereal (such as Total raisin
bran), ½ cup
nonfat milk, ½ cup
Orange juice, 8 oz
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mid-Morning
Snack
Celery sticks (1 medium stalk) with 2T
peanut butter
Water
Lunch
Roast beef sandwich
Whole wheat bread, 2 slices
Roast beef, 1 oz
Cheddar cheese, 1 oz
Ketchup, 1 Tbsp
Nonfat milk, 8 oz
Molasses cookie
Afternoon Snack
Fresh fruit smoothie
Frozen strawberries, ½ cup
Orange, ½ fresh
Popcorn, no fat or salt, 1 cup
Dinner
BBQ chicken drumstick (without skin), 1
piece
Broccoli, ½ cup
Rice, ½ cup
BBQ sauce, 1 Tbsp
Corn, ½ cup
Nonfat milk, 8 oz


Approximate Nutrient Analysis
Food Energy/Total Calories (kcal) 1365
Protein (g) (% energy from protein:
21%)
70
Carbohydrate (g) (% energy from
carbohydrate: 57%)
193
Total Fiber (g) 19
Total Fat (g) (% energy from fat:
27%)
41.3
Saturated Fat (g) 13.9
Monounsaturated Fat (g) 16
Polyunsaturated Fat (g) 8
Linoleic (omega 6) (g) 7.5
Alpha Linolenic (omega 3) (g) 0.5
Cholesterol (mg) 101
Vitamin A (mcg RAE) 572
Vitamin C (mg) 237
Vitamin E (mg-TE) 11.7
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Thiamin (mg) 1.9
Riboflavin (mg) 2.5
Niacin (mg) 25.4
Folate (mcg, DFE) 624
Vitamin B6 (mg) 2.2
Vitamin B12 (mcg) 6.5
Calcium (mg) 1479
Phosphorus (mg) 1344
Magnesium (mg) 323.8
Iron (mg) 17
Zinc (mg) 16.8
Selenium (mcg) 69.9
Potassium (mg) 2859
Sodium (mg) 1990

Client Education Materials

Iron Deficiency Anemia Nutrition Therapy

Handout in Spanish:
Iron Deficiency Anemia Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Anemia > Sickle Cell Disease
Foods Recommended

Foods Recommended for Sickle Cell Disease
Printable version
Food Group Recommended Foods
Beverages
Whole milk with instant breakfast, liquid
supplements, fruit nectars
Soups Creamed meat, bean, or pea soups
Meat and Other
Protein Foods
Fried or smothered meats (chicken, fish, beef,
pork), fried or smothered eggs, baked beans,
refried beans, peanut butter, nuts; add dry milk
powder to milk, soups, sauces, and casseroles
Vegetables
All vegetables made with added fat (margarine,
butter, or cheese); vegetables fried in oil; dark
green and yellow vegetables like acorn squash,
greens, sweet potatoes (sweet potato pie),
carrots, pumpkin, broccoli, or spinach
Fruits
Canned fruit in heavy syrup; fresh fruits, such as
blackberries, oranges, strawberries, or kiwi; dark
yellow fruit such as apricots, cantaloupe, or
peaches
Bread, Cereals,
Starches
Hot cereals made with milk, butter or margarine,
and sugar; breads, pasta, rice, or potatoes made
with butter, oils, margarine, or cheese; granola
and other cereals with dried fruit
Milk
Whole milk and milk products (yogurt, ice cream,
cheese; whipped cream, half & half, heavy
cream; low-lactose milk if milk not tolerated; add
dry milk powder to cream soups, cream sauces,
and casseroles
Fats
All oils, butter, margarine, mayonnaise, olives,
salad dressings, gravy


Foods Not Recommended

Food Group Not Recommended
Beverages
Drinks with caffeine such as tea, coffee,
and some soft drinks
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Soups Low-calorie broths
Meat and Other
Protein Foods
Meats cooked in water, broth; baked meats
should include gravy
Vegetables
Plain vegetables cooked in water and
served without added fat
Fruits More than 2 servings of fresh fruit per day
Bread, Cereals, and
Starches
Nonfat and/or low-calorie breads and
cereals; plain bread, cereals, rice, or pasta
Milk and Dairy
Products
Fat-free and reduced-fat dairy products
Fats Fat-free and reduced-fat foods
Printable version



Sample 1-Day Menu

Sample High-Calorie Menus
Printable version
Day 1
Breakfast
2 scrambled eggs with ½ ounce cheese
2 sausage links
1 medium blueberry muffin with 1 teaspoon
butter and 2 teaspoons jam
6 ounces custard yogurt
8 ounces orange juice
Snack
Fruit smoothie: ½ cup fruit (mango, strawberry,
banana, etc), 6 ounces yogurt or ice cream
blended with 2 ice cubes, 2 tablespoons peanut
butter, 4 ounces whole milk
Lunch
Grilled cheese with 2 slices of cheese and thin
slices of avocado
½ cup fruit canned in heavy syrup
½ cup sweet potato french fries
8 ounces whole milk
Snack
6 ounces pudding with 2 tablespoons whipped
cream
½ cup sliced strawberries
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Evening
Meal
Fried chicken drumstick and thigh
¾ cup mashed potatoes with 2
tablespoons sour cream
½ cup broccoli with ¼ cup cheese sauce
3-inch square piece of cornbread with 1
tablespoon butter and 1 tablespoon honey
8 ounces whole chocolate milk
3,655 kcal; 126 g protein; 392 g carbohydrate; 176 g fat.

Day 2
Breakfast
3 waffles with 2 tablespoons butter and 3
tablespoons syrup
½cup strawberries or bananas topped with
sweetened sour cream
2 sausage links
8 ounces hot chocolate
Snack
2 tablespoons peanut butter on graham crackers
1 medium banana or apple
Lunch
Tuna salad sandwich on whole wheat bread
2 ounces corn chips
½ cup carrot sticks with 2 tablespoons ranch dip
½ cup trail mix
8 ounces whole milk
Snack
8 ounce whole milk yogurt
¼ cup honey-roasted nuts
Evening
Meal
2 slices pizza topped with chicken and extra
cheese
1 cup salad with sliced salad vegetables (carrots,
cucumbers, tomato) and 1 ounce finely chopped,
ripe avocado topped with 2 tablespoons salad
dressing and ¼ cup croutons
½ cup fresh pineapple
8 ounces whole milk
3,858 kcal; 108 g protein; 392 g carbohydrate; 206 g fat.

Client Education Materials

Sickle Cell Disease Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Behavioral Health
Behavioral Health


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Behavioral Health > Eating Disorders
Foods Recommended or Not Recommended

In general, all foods are recommended. Meal plans are individualized to take into account
the rate of weight gain as determined by the child’s doctor, food tolerances, and family
eating styles.
Exclude diet, light, or low fat foods unless medically necessary. Snacks can be manipulated
as necessary to achieve a set rate of weight gain.

Sample 1-Day Menu

Meal Plans are individualized to take into account the rate of weight gain as determined by
the child’s doctor, food tolerances, and family eating styles. Meal and food
information should be given to the family, not the adolescent or child. Older adolescents at
a later stage of illness might benefit from food information as determined by the therapeutic
team.
Please note that the following information is for the registered dietitian only, to be
used as a reference when formulating client needs. This is NOT a prescriptive meal
plan, but is just an example of a basic weight gain-type of diet for an adolescent.

Breakfast
Minimum of 2 servings of bread, cereal, or
other grain (1 serving =1 piece bread, 1
bagel, ½ cup cereal)
Minimum of 1 serving (8 oz) milk, yogurt
(whole milk and whole milk yogurt) cheese (1
oz) or 1 protein shake
Minimum of 2 eggs OR 4 oz meat OR add
another milk OR bean serving
Minimum of 1 fruit OR vegetable serving
Minimum of 2 servings oil, butter, cream
cheese (1 tbsp oil/butter or 3 tbsp cream
cheese)
NOTE: you can combine many of the above and
create pancakes or omelets, for example, with fruit
and yogurt.
Snack
1 fruit or vegetable serving
1 serving of bread, grain, or crackers
1 serving minimum of nuts (3 oz), nut butters,
oils (2 tbsp), OR 1 serving of cheese (1 oz),
milk (8 oz)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lunch
Minimum of 3 oz meat, 2/3 cup beans, 6 oz
tofu, 2 eggs, 3 oz nuts
Minimum of 2 servings grain
Minimum of 1 fruit or vegetable serving or 1
cup salad (greens, mixed vegetable)
Minimum of 1 “free” condiment, snack food,
½ cup juice, crackers
Snack
As above OR
Minimum of 6 oz nuts
bread or crackers (1 serving) with cheese (2
oz) or cream cheese (4 Tbsp)
1 bowl (8 oz) “hearty soup” chili, 1 8-oz
yogurt plus 1 fruit serving
Late Day
meal
Minimum of 4 oz meat or 8 oz tofu or 2/3 Cup
beans
Minimum of 1 serving bread/carbohydrate (1
slice hearty bread, 1 tortilla, 1 bagel), 1 6-oz
potato, 1 cup rice or noodles
Minimum of 1 tbsp oil or butter
Minimum 2 servings vegetables (1/2 cup
each or 1 medium vegetable or 1 cup salad)
Minimum 8 oz milk, or 1 protein shake
Exclude diet, light, or low-fat foods unless medically necessary. Snacks can be
manipulated as necessary to achieve set rate of weight gain.
This meal plan was analyzed by FoodWorks 9 for a 15 yr. old female, for a weight of 130
pounds/height 5'5" and the "minimum" portions were chosen. Total Kcal = 3016, total
fat=150 grams, total protein =125 grams, total carbs=310 grams. All vitamins/minerals at or
above DRI. This is a weight gain diet.. Dependent on the foods selected it can be
manipulated to have more calories and accomodate needs for adolescents of varying ages
as well as males.



© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Behavioral Health > Mood Disorders
Client Education: Behavioral Disorders

Generally, information regarding a healthful, age-appropriate diet (relative to any coexisting
medical conditions) is the typical education provided to these patients. Refer to the specific
age group under the Normal Nutrition section for handouts on healthful eating.
The Resources tab has information about drug–nutrient interactions.

Foods Recommended

A typical, age-appropriate, healthful diet is recommended in most patients.

Foods Not Recommended

A typical, age-appropriate, healthful diet is recommended; if coexisting medical conditions
require restrictions of certain foods, these restrictions should be advised.
If a patient is on medications or supplements, there may be specific foods that should be
limited or eliminated, such as grapefruit juice or beverages containing grapefruit juice.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Burns
Foods Recommended

Printable version
Protein and Calorie Boosters
Add dried milk powder or protein powder to milk, hot or cold cereals, scrambled eggs,
soups, gravies, casseroles, and desserts.
Use milk to replace water in recipes.
Add meat to soups, casseroles, canned spaghetti sauce, pasta dishes, or vegetables.
Mix cheese in sauces, soups, or vegetables.
Mix hard-cooked eggs with meat, tuna, salads, sauces, or casseroles.
Add raisins, dates, or chopped nuts to hot cereals and desserts.
High-Protein Snacks
Celery sticks with cream cheese or peanut butter
Greek yogurt with nuts and berries
Apples with almond butter
String cheese
Homemade trail mix (combine nuts, dried fruit, and cereal)
Carrots dipped in hummus
Yogurt drinks
Animal crackers with cream cheese
Protein bars
High-Protein Milkshake
Ingredients:
1 cup milk
1 package instant breakfast
1 cup ice cream
¼ cup whipped cream
2 Tbsp butterscotch, chocolate syrup, or peanut butter

Directions:
Blend all ingredients at low speed until smooth.


Foods Not Recommended

Printable version
Foods to which the child is allergic
Too many high-fat, high-sugar foods such as desserts
Beverages that do not contain protein (water, soda, juice, sports drinks)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sample 1-Day Menu

Printable version
Breakfast
1 well-cooked egg (prepared any way)
½ cup fruit (berries, melon wedge, or banana)
1 slice of white or wheat toast with butter
½ cup milk (any type)
Snack
Milkshake, yogurt, or peanut butter and
crackers
Lunch
3/4 cup macaroni and cheese
½ cup vegetables
½ cup fruit
1 cup milk (any type)
Snack 1 piece of fruit
Evening
Meal

3 oz chicken, fish, or beef (prepared any way)
½ cup potatoes (prepared any way), rice, or
pasta
½ cup vegetables
1 cup milk (any type)
Approximate Nutrient Analysis*:
Calories: 1,600 kcal
Protein: 84 g (20% of calories)
Carbohydrate: 203 g (51% of calories)
Fat: 51 g (29% of calories)
*Analysis will vary widely based on food choices

Client Education Materials

Nutrition Therapy for Children with Burn Injuries
Tips to Increase Calories and Protein

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Cardiology
Foods Recommended and Not Recommended

General recommendations that should be applied to cardiac patient care include the
following:
A wide variety of foods should be eaten.
Energy intake should be adjusted to avoid overweight.
Encourage consumption of fruit, vegetables, whole grain cereals and bread, fish
(especially oily), lean meat, and low-fat dairy products.
Replace saturated fats with the foods listed above and with monounsaturated and
polyunsaturated fats from vegetables and fish sources to reduce total fat to less than
30% of energy, of which less than one-third comprises saturated fat. A diet with less
than 30% of total energy from fat is not recommended for children younger than 2
years, as fat is an important source of energy for growth and development.
Reduce salt intake if blood pressure is elevated by avoiding table salt and salt in
cooking and by choosing fresh or frozen, unsalted food. Many processed and
prepared foods, including bread, are high in salt (Graham, 2007).
Enabling the patient to implement lifelong dietary changes is an important role of the home
health care provider. "Family" efforts to comply with a healthy heart regimen have
increased the overall acceptance of dietary changes. Facilitating changes in dietary
behaviors, even with family involvement, can be challenging. Dietary change may be met
with resistance for reasons such as incomplete nutrition education, lack of motivation and
resources, taste preferences, cultural and family traditions, and feelings of being
overwhelmed and depressed. Facilitating changes in nutritional behaviors should begin by
making small modifications and substitutions pertinent to the family or individual. Modifying
these foods to make significant changes in fat and sodium content is an easier transition
than introducing new foods.
Following are suggestions to modify a recipe and how to choose low-fat foods when dining
out.
Printable version
Simple Ways to Modify a Recipe

To Reduce Fat and Cholesterol
Instead of:
Butter, lard, bacon
grease
Sour cream
Mayonnaise, salad
dressing
Whole milk
Cheddar, Swiss,
American cheese
Whole egg
Use:
Margarine or oil
Yogurt, blended cottage
cheese with lemon juice
Fat-free salad dressing
Skim milk
Part-skim cheese
2 egg whites
Evaporated skim milk
White sauce made with 1
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cream
Condensed cream
soup
White sauce made with 1
cup skim milk, 1 Tbsp
margarine, 2 Tbsp flour
To Reduce Sodium:
Instead of:
Salt*
Garlic salt, onion salt
Regular canned
products
Canned vegetables
Luncheon meats,
ham, bacon, hot
dogs, and sausage
Use:
Herbs and spices
Garlic powder, onion powder
Low-sodium canned
products
Reduced-sodium canned
soup or homemade soup
Fresh meats, poultry, and
fish and low-sodium
luncheon meats.

*Salt can be omitted from most recipes except those that contain yeast. Do not add salt to
boiling water for pasta, cereal, or vegetables.
(Murray, 1991)
Low-Fat Choices When Dining Out
In place of:
Deluxe hamburger
Fried chicken
Pepperoni pizza
Sweet and sour
shrimp
French fries
Danish pastry
Bacon
Cream soup
Cake, pies,
pastries
Suggest:
Small hamburger
Grilled chicken
Vegetarian pizza
Shrimp and vegetables
Baked potato (no butter or
sour cream)
Bagel or cereal
Canadian bacon
Consomme or vegetable soup
Fruit cup or angel food cake
(Graham, 2007)

Sample 1-Day Menus

Available on this page:
Sample 1-day menu for a liberalized diet
Sample menu for a low-sodium, consistent vitamin K diet
Note: Menus for children with cardiac conditions are usually created on an individual basis,
with emphasis on getting the patient to eat enough to meet basic needs, even if nutrient
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
intake is not ideal. If patients experience fluid retention due to higher sodium levels, it is
advised to increase the diuretics.
If the patient and caregivers are willing to try a meal plan with restricted sodium that meets
the child's energy needs, this can be developed. The following sample menus are an
example of a liberalized diet suitable for a 7- to 10-year-old child.
Printable version
Day 1
Breakfast
Wheat English muffin
1/4 cup egg beaters
2 ounces low-fat ham
1 slice low-fat cheese
1 cup citrus fruit salad
Lunch
Turkey sloppy joe on wheat bun or hoagie (use
1/2 cup turkey joe mix)
6 sweet potato fries
1 cup strawberries
Evening
Meal
1 green pepper stuffed with ground beef
½ cup mashed potatoes
(use red sauce instead of gravy)
1 cup side salad with 1 ounce fat-free dressing

Approximate Nutrient Analysis
Energy (kcal) 1,275
Protein (g) 66
Carbohydrate (g) 177
Dietary fiber (g) 20
Fat (g) 38.5
Saturated fat (g) 13.5
Cholesterol (mg) 115
Vitamin A (RE) 821
Vitamin C (mg) 203
Vitamin D (mcg) 1.98
Vitamin E (mg) 0.83
Thiamin (mg) 1.29
Riboflavin (mg) 1.64
Niacin (mg) 10
Vitamin B-6 (mg) 0.94
Folate (mcg) 195
Vitamin B-12 (mcg) 2.79
Pantothenic acid (mg) 2.71
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin K (mcg) 36.8
Potassium (mg) 1758
Iron (mg) 9.06
Phosphorus (mg) 701
Magnesium (mg) 154
Zinc (mg) 7.74
Copper (mg) 0.61
Manganese (mg) 1.8
Selenium (mcg) 54
Chromium (mg) 0.019
Calcium (mg) 598
Sodium (mg) 2,981

Day 2

Breakfast
1/2 peanut butter and honey sandwich on wheat
bread
4 ounces yogurt
4 ounces canned fruit in light syrup
Lunch
Turkey roll-up:
3 ounces of deli turkey
1 flour tortilla
¼ cup shredded mozzarella cheese
¼ cup shredded lettuce
½ cup tomato salad with balsamic dressing
Apple slices
1 Tablespoon caramel for dipping
Evening
Meal
Chicken kabobs:
4 ounces chicken
½ cup onions, pepper, mushrooms
1/2 cup wild rice
1 cup pineapple
Approximate Nutrient Analysis
Energy (kcal) 1,374
Protein (g) 75
Carbohydrate (g) 194
Dietary fiber (g) 21.7
Fat (g) 38
Saturated fat (g) 12
Cholesterol (mg) 132
Vitamin A (RE) 700
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin C (mg) 203
Vitamin D (µg) 2.22
Vitamin E (mg) 0.89
Thiamin (mg) 1.09
Riboflavin (mg) 1.46
Niacin (mg) 18
Vitamin B-6 (mg) 1.215
Folate (mcg) 186
Vitamin B-12 (mcg) 1.94
Pantothenic acid (mg) 3.38
Vitamin K (mcg) 59.3
Potassium (mg) 1985
Iron (mg) 9.17
Phosphorus (mg) 828
Magnesium (mg) 159
Zinc (mg) 6.85
Copper (mg) 0.77
Manganese (mg) 2.079
Selenium (mcg) 56.9
Chromium (mg) 0.053
Calcium (mg) 526
Sodium (mg) 2642
The following menu is low in sodium and intended to be part of an eating plan that provides
a consistent amount of vitamin K from day to day for a child who is 7 to 10 years of age.
Printable version
Breakfast
1 cup plain oatmeal with brown sugar
1 scrambled egg
4 ounces sliced canned peaches in juice
4 ounces 100% apple juice
Lunch
3 ounces roasted turkey (dark meat, no skin)
1 cup unsalted french fries
½ cup steamed broccoli
1½ cups sliced, peeled apples
8 ounces diet orange carrot drink with vitamin C
Evening Meal
9 ounces lasagna with meat and sauce
½ cup steamed carrots
1 cup caesar salad without dressing
½ cup canned mandarin oranges in juice
½ cup strawberry ice cream
Approximate Nutrient Analysis
Energy (kcal) 1,725
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Protein (g) 80.2
Carbohydrate (g) 197.99
Dietary fiber (g) 20.59
Soluble fiber (g) 4.48
Fat (g) 69.18
Saturated fat (g) 26
Cholesterol (mg) 643.56
Vitamin A (mcg RAE) 1,306.26
Thiamin (mg) 0.57
Riboflavin (mg) 1.07
Niacin (mg) 5.48
Vitamin B-6 (mg) 0.86
Vitamin B-12 (mcg) 1.41
Vitamin D (mcg) 0
Vitamin E (mg) 3.84
Folate (mcg) 193.28
Vitamin K (mcg) 114.74
Pantothenic acid (mg) 3.84
Calcium (mg) 640.21
Chromium (mcg) 9.6
Copper (mg) 0.56
Iron (mg) 10.79
Magnesium (mg) 142.3
Phosphorus (mg) 728.61
Potassium (mg) 2,177.52
Selenium (mcg) 49.22
Sodium (mg) 1,549.26
Zinc (mg) 8.78



Client Education Materials

Vitamin K-Controlled Nutrition Therapy
Shopping, Cooking, and Eating Out Tips for Caregivers
Heart-Healthy Tips

Handouts in Spanish:
Heart-Healthy Tips
Controlled Vitamin K Nutrition Therapy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Controlled Vitamin K Nutrition Therapy
Shopping, Cooking, and Eating Out Tips
Sample Regular 1-Day Menu for Cardiac Patients

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Cleft Lip and Palate
Foods Recommended

0 to 12 months
Breastmilk is highly recommended for infants with cleft lip and palate since they are very
susceptible to ear infections due to their anatomical structure. Additionally, surgery for the
cleft palate does not usually take place before 8-12 months, and even then there are often
multiple surgeries before correction is completed. Studies show that incidence of otitis
media is greatly reduced if a child is breastfed (Froom, 2001). Breastmilk aspirated into
nasal structures does not promote the growth of bacteria (Oddy, 2003; Stepans, 2006).
Infant formula can be used for those infants who are not using breastmilk.
12 to 36 months
Depending on the timing of the surgery, and state of repair of the palate, the diet can be
normal for a toddler. Breastmilk or whole milk should be continued as an important part of
the diet but should not constitute more than 30 to 35% of the total calories. The diet may
need to be mostly soft foods, with hard, raw items avoided until surgeries are complete.
Post surgery
Infants still on breastmilk or bottle formula will be limited to cup drinking for a few days, and
use of pureed or very soft foods will be necessary. Therefore, it should be stressed to
parents from age 6 months on to use a cup for some liquids so that the child will be skilled
and comfortable with cup use. This means an open cup or a cup which flows freely when
tipped, not a sippy cup with spout. Such a cup requires sucking, which is why the bottle
and breast are limited at this time.

Foods Not Recommended

When solid foods are started, purees are not limited in any way. Depending on the size of
the cleft lip or palate, and the infant's feeding ability, there may be some limit to foods with
lumpy textures.
Hard, crunchy foods should not be given until the child's cleft is repaired due to the danger
of bacteria growth on foods left in the mouth.
The best recommendation is to have the cleft lip and palate clinic discuss with the
caregiver what is best for their child.

Sample 1-Day Menu

Meal Foods
Breakfast

1/2 cup oatmeal with milk, 1/4 cup fruit, 3-4
oz milk in cup
Suggested 1-day menus for 12-24 month old with cleft lip
Day 1
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack 1/2 cup applesauce
Lunch
3/4 cup vegetable soup with crackers, 4-5
oz milk in cup
Snack
1/2 cup whole milk yogurt with 2-3 teaspoons
applesauce
Dinner
Slices of meat (soft), 1/4 cup mashed potato
with milk/cheese, 1/4 cup green beans, 1/3
cup pears

Meal Foods
Breakfast

Scrambled egg, 1/4 cup cooked cereal with
raisins, 4 oz milk in cup
Snack 1/2 banana
Lunch
1/3-1/2 cup pasta with cheese and 2
teaspoons milk
1/4 cup creamed spinach, 3-4 oz milk
Snack 1/2 apple (sliced), softened in microwave
Dinner
Baked beans, rice with peas or grated
carrots, blueberries with milk, 2-3 oz of milk
Day 2


Client Education Materials

The Cleft Palate Foundation offers numerous patient education materials in html and pdf
format that can be printed out and shared with families of children in all age groups.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Developmental Disabilities
Developmental Disabilities


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Developmental Disabilities > Autism Spectrum Disorders
Client Education Materials

Nutrition Therapy for Children with Autism Spectrum Disorders


Foods Recommended

Note: The chart shows general recommendations for children without growth problems,
major medical concerns, or special dietary limitations. This list may need to be tailored to
individuals' needs.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
Low-fat or nonfat milk
Soy milk
Nonfat or low-fat yogurt
Nonfat or low-fat cheeses
Meat and Other
Protein Foods
Tender, well-cooked lean meat, poultry,
fish, eggs, or soy foods
Nuts and nut butter (these are higher in
fat)
Grains
Any
Choose whole grains for at least half of
each day’s grain servings
Vegetables
Any
Include a variety of different-colored
vegetables
Fruits Any
Fat and Oils
Heart-healthy vegetable oils, such as
olive or canola oil

Sample 1-Day Menu

Printable version
Breakfast
Buckwheat pancake with 1 teaspoon strawberry
preserves and ½ teaspoon margarine
½ pear
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
½ cup low-fat milk
Snack
3 ounces low-fat fruit yogurt
2 tablespoons fresh blueberries
Lunch
Turkey sandwich: 1 slice whole wheat bread,
1 ounce turkey, 1 teaspoon mayonnaise, 1 slice
tomato
Raw carrot sticks with 1 tablespoon dressing
½ cup applesauce
½ cup low-fat milk
Snack
5 crackers, butter type
Water
Evening
Meal
½ cup sweet potato
½ cup broccoli
2 ounces stir-fried beef
½ cup low-fat milk

Approximate Nutrient Analysis
Energy (kcal) 1330
Total protein (g)
58
17.1% of kcal
Total carbohydrate (g)
145
43% of kcal
Total fat (g)
60
40% of kcal
Saturated fatty acids (g)
20
13% of kcal
Monounsaturated fatty acids (g)
17
12% of kcal
Polyunsaturated fatty acids (g)
9
6% of kcal
Cholesterol (mg) 172
Calcium (mg) 750
Iron (mg) 8
Magnesium (mg) 185
Phosphorus (mg) 1040
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Potassium (mg) 2200
Sodium (mg) 1550
Zinc (mg) 12
Vitamin A (mcg RAE) 1485
Vitamin C (mg) 72
Thiamin(mg) 0.6
Riboflavin (mg) 1.5
Niacin (mg) 8
Total folate (mcg) 100
Vitamin B-6 (mg) 1.2
Vitamin B-12 (mcg) 4.2
Total dietary fiber (g) 14
Insoluble dietary fiber (g) 0.7
Vitamin D (mcg) 4.1


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Developmental Disabilities > Down Syndrome
Client Education Materials

Nutrition Therapy for Children with Down Syndrome

Handout in Spanish:
Nutrition Therapy for Children with Down Syndrome

Foods Recommended

Note: The chart shows general recommendations for children without growth problems,
major medical concerns, or special dietary limitations. This list may need to be tailored to
individuals' needs.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
Low-fat or nonfat milk
Soy milk
Nonfat or low-fat yogurt
Nonfat or low-fat cheeses
Meat and Other
Protein Foods
Tender, well-cooked lean meat, poultry,
fish, eggs, or soy foods
Nuts and nut butter (these are higher in
fat)
Grains
Any
Choose whole grains for at least half of
each day’s grain servings.
Vegetables
Any
Include a variety of different colored
vegetables.
Fruits Any
Fat and Oils
Heart-healthy vegetable oils, such as
olive or canola oil

Sample 1-Day Menu

Printable version
Breakfast
Buckwheat pancake with 1 teaspoon strawberry
preserves and ½ teaspoon margarine
½ pear
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
½ cup low-fat milk
Snack
3 ounces low-fat fruit yogurt
2 tablespoons fresh blueberries
Lunch
Turkey sandwich: 1 slice whole-wheat bread,
1 ounce turkey, 1 teaspoon mayonnaise, 1 slice
tomato
Raw carrot sticks with 1 tablespoon reduced-fat
dressing
½ cup applesauce
½ cup low-fat milk
Snack
5 crackers, butter type
Water
Evening
Meal
½ cup sweet potato
½ cup broccoli
2 ounces stir-fried beef
½ cup low-fat milk

Approximate Nutrient Analysis
Energy (kcal) 1330
Total protein (g)
58
17.1% of kcal
Total carbohydrate (g)
145
43% of kcal
Total fat (g)
60
40% of kcal
Saturated fatty acids (g)
20
13% of kcal
Monounsaturated fatty acids (g)
17
12% of kcal
Polyunsaturated fatty acids (g)
9
6% f kcal
Cholesterol (mg) 172
Calcium (mg) 750
Iron (mg) 8
Magnesium (mg) 185
Phosphorus (mg) 1040
Potassium (mg) 2200
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sodium (mg) 1550
Zinc (mg) 12
Vitamin A (mcg RAE) 1485
Vitamin C (mg) 72
Thiamin (mg) 0.6
Riboflavin (mg) 1.5
Niacin (mg) 8
Total folate (mcg) 100
Vitamin B-6 (mg) 1.2
Vitamin B-12 (mcg) 4.2
Total dietary fiber (g) 14
Insoluble dietary fiber (g) 0.7
Vitamin D (mcg) 4.1





© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Developmental Disabilities > Spina Bifida
Client Education Materials

Nutrition Therapy for Children with Spina Bifida

Handout in Spanish
Nutrition Therapy for Children with Spina Bifida

Foods Recommended

Note: The chart below shows general recommendations for children without growth
problems, major medical concerns, or special dietary limitations. This list may need to be
tailored to individuals' needs.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
Low-fat or nonfat milk
Soy milk
Nonfat or low-fat yogurt
Nonfat or low-fat cheeses
Meat and Other
Protein Foods
Tender, well-cooked lean meat, poultry,
fish, eggs, or soy foods
Nuts and nut butter (these are higher in
fat)
Grains
Any
Choose whole grains for at least half of
each day’s grain servings.
Vegetables
Any
Include a variety of different colored
vegetables.
Fruits Any
Fat and Oils
Heart-healthy vegetable oils, such as
olive or canola oil


Sample 1-Day Menu

Note: This menu provides general information only. Nutritional needs may be different,
especially if there are concerns about a client's weight. This menu may need to be tailored
to meet individuals' needs.

Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast
Buckwheat pancake with 1 teaspoon strawberry
preserves and ½ teaspoon margarine
½ pear
½ cup low-fat milk
Snack
3 ounces low-fat fruit yogurt
2 tablespoons fresh blueberries
Lunch
Turkey sandwich: 1 slice whole-wheat bread,
1 ounce turkey, 1 teaspoon mayonnaise, and 1
slice tomato
Raw carrot sticks with 1 tablespoon reduced-fat
dressing
½ cup applesauce
½ cup low-fat milk
Snack
5 crackers, butter type
Water
Evening
meal
½ cup sweet potato
½ cup broccoli
2 ounces stir-fried beef
½ cup low-fat milk
Approximate Nutrient Analysis
Energy (kcal) 1330
Total protein (g)
58
17.1% of kcal
Total carbohydrate (g)
145
43% of kcal
Total fat (g)
60
40% of kcal
Saturated fatty acids (g)
20
13% of kcal
Monounsaturated fatty acids (g)
17
12% of kcal
Polyunsaturated fatty acids (g)
9
6% of kcal
Cholesterol (mg) 172
Calcium (mg) 750
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Iron (mg) 8
Magnesium (mg) 185
Phosphorus (mg) 1040
Potassium (mg) 2200
Sodium (mg) 1550
Zinc (mg) 12
Vitamin A (mcg RAE) 1485
Vitamin C (mg) 72
Thiamin (mg) 0.6
Riboflavin (mg) 1.5
Niacin (mg) 8
Total folate (mcg) 100
Vitamin B-6 (mg) 1.2
Vitamin B-12 (mcg) 4.2
Total dietary fiber (g) 14
Insoluble dietary fiber (g) 0.7
Vitamin D (mcg) 4.1


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Developmental Disabilities > Prader > Willi Syndrome
Client Education Materials

Nutrition Therapy for Children with Prader-Willi Syndrome

Foods Recommended

Note: The chart shows general recommendations for children without major medical
concerns, or special dietary limitations. This list may need to be tailored to individuals'
needs.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
Nonfat milk or soy milk
Nonfat or low-fat yogurt
Nonfat or low-fat cheeses
Meat and Other
Protein Foods
Tender, well-cooked lean meat, poultry,
fish, eggs, or soy foods
Grains
Any
Choose whole grains for at least half of
each day’s grain servings.
Vegetables
Any
Include a variety of different colored
vegetables.
Fruits Any
Fat and Oils
Small amounts of heart-healthy
vegetable oils, such as olive or canola oil

Sample 1-Day Menu

Printable version
Breakfast
Buckwheat pancake with 1 teaspoon strawberry
preserves
½ pear
½ cup nonfat milk
Snack
3 ounces nonfat fruit yogurt
2 tablespoons fresh blueberries
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lunch
Turkey breast sandwich: 1 slice whole-wheat
bread,
1 ounce turkey, 1 teaspoon mayonnaise, and 1
slice tomato
Raw carrot sticks with 1 tablespoon reduced-fat
dressing
½ cup applesauce
½ cup nonfat milk
Snack
5 crackers, butter type
Water
Evening
Meal
½ cup sweet potato
½ cup broccoli
2 ounces stir-fried beef
½ cup nonfat milk

Approximate Nutrient Analysis
Energy (kcal) 1150
Total protein (g)
58
20% of kcal
Total carbohydrate (g)
146
50% of kcal
Total fat (g)
39
30% of kcal
Saturated fatty acids (g)
12
9% of kcal
Monounsaturated fatty acids (g)
13
10% of kcal
Polyunsaturated fatty acids (g)
5
3% of kcal
Cholesterol (mg) 142
Calcium (mg) 800
Iron (mg) 8
Magnesium (mg) 185
Phosphorus (mg) 1090
Potassium (mg) 2200
Sodium (mg) 1460
Zinc (mg) 12
Vitamin A (mcg RAE) 1476
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin C (mg) 70
Thiamin (mg) 0.6
Riboflavin (mg) 1.5
Niacin (mg) 8
Total folate (mcg) 100
Vitamin B-6 (mg) 1.1
Vitamin B-12 (mcg) 4.5
Total dietary fiber (g) 14
Insoluble dietary fiber (g) 0.7
Vitamin D (mcg) 3.8

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Diabetes Mellitus
Diabetes Mellitus

Since 1994, the American Diabetes Association (ADA) has not endorsed specific meal
plans; therefore, use of the term “ADA diet” is no longer appropriate (American Diabetes
Association, 2009). The registered dietitian should serve as an inpatient team member to
gather information regarding the patient’s eating and lifestyle habits to establish an
appropriate insulin regimen and nutrition therapy plan.
Energy Intake Recommendations
Total daily energy intake should be distributed as follows:
Percentages of total carbohyrate and fat are based on nutrition assessment and
treatment goals
Less than 10% of energy comes from saturated fat
Protein should comprise 10% to 20% of the total energy needs


Foods Recommended

Following is a list of recommended foods from each food group to keep blood glucose in
control and promote heart health.
Printable version
Food Group Recommended Foods
Milk and
Milk
Products
Nonfat or 1% milk (except in children younger
than 2 years); soy milk; low-fat yogurt; light
yogurt; light or low-fat cheese; light or low-fat
ice cream
Meat and
Other
Protein
Foods
Lean (90% lean or higher) ground beef; sirloin;
tenderloin; pork loin, center pork chop; chicken
or turkey breast without skin; ground turkey
breast; ground chicken breast without skin;
peanut butter; soy-based sausage/meats; light
or low-fat hot dogs; dried, cooked beans,
legumes, and lentils; nuts; eggs or egg whites.
Grains
Whole grain breads, cereals, pasta; brown rice;
potatoes; whole grain crackers, pretzels; whole
grain couscous; whole grain waffles and
pancakes (choose whole grains for at least half
of your grain servings)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vegetables
All fresh or frozen vegetables steamed,
roasted, stir-fried, or grilled without added fat
Fruits
All fresh or frozen fruits; canned fruit in natural
juices.
Fat and Oils
Canola, olive, or peanut oil; light, tub spread;
light or low-fat salad dressing
Beverages
Water, diet- and caffeine-free soft drinks or
sugar-free beverages sweetened with artificial
sweeteners; nonfat or 1% milk
Other
All condiments, herbs, and spices; sugar-free
or light syrup; all-fruit spread or sugar-free
jelly; artificial sweeteners approved by the
US Food and Drug Administration


Foods Not Recommended

Following are foods that are not recommended to eat every day. These foods are higher in
unhealthful fats and low in fiber, which may affect blood sugar and cholesterol
levels. These foods should be eaten only occasionally and in small amounts.
Printable version
Food Group Foods Not Recommended
Milk and Milk
Products
2% milk or whole milk (except in children
younger than 2 years); whole milk yogurt;
regular cheese; whole-milk ice cream
Meat and
Other Protein
Foods
Regular ground beef (80% to 85% lean);
chuck ground beef; chicken or turkey
legs/thighs with skin; ground turkey; ground
chicken; sausage; hot dogs; salami, bologna
Vegetables Fried or tempura vegetables
Fruits Canned fruit in syrup
Fat and Oils
Palm or coconut oils; stick butter and
margarine; regular creamy salad dressings;
lard; hydrogenated oil
Beverages
Sugar-containing beverages except natural
sugars found in white milk and 100% fruit juice

Sample 1-Day Menu

Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Carbohydrate Counting for Children Aged 6 to 8 years
45-60 g carbohydrate each meal
15-20 g carbohydrate each snack
Breakfast
1 cup whole grain cereal
8 oz 1% milk
½ large banana
Snack 1 whole grain granola bar
Lunch
½ sandwich:
1 slice whole grain bread
1 oz turkey
1 oz light cheese
Light mayonnaise
1 small apple
1 oz baked chips
8 oz 1% milk
Snack
6 whole grain crackers
1 Tbsp peanut butter
Evening Meal
¾-1 cup whole wheat pasta
¼ cup tomato sauce with two 1-oz meatballs
½ cup steamed green beans
1 cup tossed salad with 2 tablespoons light
dressing
2 tsp light, tub spread
8 oz 1% milk
Evening
Snack
½ cup light ice cream

Approximate Nutrient Analysis
Energy (kcal) 1,516
Total protein (g) 69
% kilocalories from
protein
18
Total carbohydrate (g) 195
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
% kilocalories from
carbohydrate
51
Total fat (g) 55.8
% kilocalories from fat 33
Total saturated fat (g) 19.1
% kilocalories from
saturated fat
11
Total monounsaturated
fat (g)
19
% kilocalories from
monounsaturated fat
11
Total polyunsaturated
fat (g)
13
% kilocalories from
polyunsaturated fat
7.7
Trans fatty acids (g) 0
Cholesterol (mg) 111
Calcium (mg) 1,338.1
Dietary fiber (g) 16
Vitamin A (mcg retinol
activity equivalents)
874.6
Vitamin C (mg) 33.5
Vitamin E (mg
alphatocopherol
equivalents)
5
Thiamin (mg) 0.9
Riboflavin (mg) 2.2
Niacin (mg) 13.6
Folate (mcg, dietary
folate equivalents)
338.7
Vitamin B-6 (mg) 1.7
Vitamin B-12 (mcg) 5.6
Phosphorus (mg) 1,516.2
Magnesium (mg) 297.8
Iron (mg) 11.9
Zinc (mg) 12.2
Selenium (mcg) 65.3
Potassium (mg) 2,762
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sodium (mg) 2,646

Client Education Materials

Diabetes Mellitus Nutrition Therapy
Carbohydrate Counting
Fiber Tips
Label Reading Tips
Portion Size Tips

Handouts in Spanish:
Diabetes Mellitus Nutrition Therapy
Carbohydrate Counting
Fiber Tips
Label Reading Tips
Portion Size Tips


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Disorders of Lipid Metabolism
Foods Recommended or Not Recommended

Food Lists for High Cholesterol
Printable version
Food Group
Foods
Recommendedab
Foods Not
Recommended
Milk and Milk
Products
Skim or 1% milk
Nonfat or low-fat (1%)
yogurt
Low-fat cheese
Low-fat cottage cheese
Nonfat cream cheese
Whole or 2% milk
Regular cheese
Whole or 2% milk
yogurt
Regular cream
cheese
Ice cream
Cream or
half-and-half
Meat
and Protein
Foods
Fish, especially pink
salmon, herring,
mackerel, white
albacore tuna, rainbow
trout
Poultry without skin
Very lean meat
Legumes
Soy protein/tofu
Egg whites
Low-fat peanut butter
Hot dogs
Bologna, salami,
pepperoni
Spareribs
Egg yolk
Bacon, sausage
Breads/Grains
Whole grains prepared
without fat
Bread
Cold cereal
Pasta, rice
Oatmeal and other hot
cereals
Pizza with low-fat
Croissants
Donuts
Danish pastry
Granola/granola
bars containing
trans fat
Toaster pastries
Pizza prepared with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cheese and vegetables
Nonfat bagel
high-fat meats or
cheeses
Bakery bagels
Vegetables
All vegetables, raw or
cooked, prepared
without fat
Fried, creamed,
buttered vegetables
Vegetables cooked
with fatty meat>
Vegetables with
cheese sauce
Onion rings
Fruits
All fruits prepared
without fat
100% fruit juice to a
maximum of 4 oz/day to
6 oz/day
Dried fruit
Yogurt-covered fruit
Chocolate-covered
fruit
Snacks
Pretzels
Popcorn, plain (no
added fat)
Jelly beans
Peanuts
Low-fat crackers/cookies
Almonds
Seeds
Cheese, chips, and
puffs
Chocolate candy
Regular granola bars
Regular peanut
butter
Desserts
Fudgesicles/Popsicles
Gelatin desserts
Low-fat pudding
Angel food cake
Regular ice cream
Commercially baked
cakes, pies,
cookies, bars
Fats and Oils
Low-saturated-fat
margarines
Low fat salad dressings
Corn oil
Hard stick
margarines with
saturated fat
High-fat salad
dressings
Regular-fat
mayonnaise
Palm oil
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Canola oil
Low-fat mayonnaise
Olive oil
Coconut oil
Butter
Meat drippings/gravy
Lard
Hydrogenated
shortenings
Beverages
Water
Fortified soy milk
YooHoo chocolate drink
(Dr Pepper Snapple
Group, Carlstadt, NJ)
Milk shakes
Sports drinks and
juices (limit based
on calorie content)
Soda
Lattes and other
coffee drinks
Fruit smoothies,
commercially
prepared
a
If child is overweight, foods lower in energy should be emphasized.
b
Take extra care to avoid trans fats. Peanut butter, cookies, margarines, and other food
products should not contain hydrogenated oils.
Food Lists for High Triglycerides
Printable version
Food Group
Foods
Recommended
Foods
Not Recommended
Milk and Milk
Products
Skim or 1% low-fat
milk
Nonfat or low-fat
yogurt
Nonfat or low-fat
cheeses
Low-fat ice cream
Whole or 2% milk
Whole or 2% dairy
products, high-fat
cheeses, whole milk
cream cheese and sour
cream, cream, whole
milk yogurt
Meat
and Other
Protein
Soy protein (use to
replace meat in chili
or pasta sauce)
Tofu
Soy yogurt
Very lean meats
Poultry with skin
removed
High-fat meats including
cold cuts, bacon,
sausages, hot dogs,
Spam, beef jerky,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Foods
Fish
Legumes/Beans
Nuts/Seeds
Peanut butter
Egg whites
Spam, beef jerky,
marbled beef
Grains
Any prepared
without added fat or
sugar; choose
100% whole grains
for at least half of
your grain servings
Muffins, coffee cakes,
donuts, croissants,
Danishes, toaster
pastries
Vegetables
Any prepared
without added fat or
sugar
Those with added
sugars or sweetened
sauces
Fruits
Any prepared
without added fat or
sugar
Those in syrups or
sweetened sauces
Fat and oils
Heart-healthy
vegetable oils such
as olive or canola
Low-calorie salad
dressings and
mayonnaise
Fats and oils that are
saturated or
hydrogenated
Beverages
Fortified soy milk
Water
Soda
Sweetened drinks,
coffee drinks, yogurt
drinks, cocoas
Alcoholic beverages
Other
Candy, cookies, cake,
and other sweetened
desserts
Added sugars should be
less than 5% of total
calories


Sample 1-Day Menus

Available on This Page:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Available on This Page:
Sample Menu for a 2- to 3-Year-Old with a Disorder of Lipid Metabolism
Sample Menu for a 4- to 8-Year-Old with a Disorder of Lipid Metabolism (printable version
available)
Sample Menu for a 9- to 13-Year-Old with a Disorder of Lipid Metabolism
Sample Menu for a 14- to 18-Year-Old with a Disorder of Lipid Metabolism
Sample Menus:
Child Aged 2 to 3 Years with a Disorder of Lipid Metabolism
Breakfast
Low-fat yogurt, 1/4 cup
Sliced strawberries, 1/4 cup
Whole wheat toast, 1/2 slice
Natural peanut butter, 1 tsp (no trans fat)
Lunch
English muffin pizza:
1/2 whole wheat English muffin
Tomato sauce, 2 Tbsp
Mixed veggies, 2 Tbsp
Shredded low-fat cheese, 1½ Tbsp
Nonfat milk, ½ cup
Dinner
Spaghetti & meatballs:
Cooked whole wheat pasta, ¼ cup
Tomato sauce, 2 Tbsp
1 meatball (1 oz extra-lean ground beef)
1/4 cup broccoli florets
Nonfat milk, ½ cup
Snack 1
Toasted oat cereal, ½ cup
Pineapple, ½ cup diced
Snack 2
Orange juice, ¼ cup
1 low-fat string cheese
3 whole wheat crackers
Natural peanut butter, 1 Tbsp
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Approximate Nutrient Analysis for a 2- to 3-Year-Old Child
Nutrient Value
%
Recommended
Energy (kcal) 893 89
Energy from Fat
(kcal) <30%
200 67
Energy from
Saturated Fat
(kcal) <7%
56 80
Protein (g) 47 341
Carbohydrates(g) 133 94
Dietary Fiber (g) 13 88
Soluble Fiber (g) 1.8
Total Sugars (g) 57
Monosaccharides
(g)
9
Disaccharides (g) 11
Other
Carbohydrates (g)
61
Fat (g) 22 66
Saturated Fat (g) 6 75
Monounsaturated
Fat (g)
2 15
Polyunsaturated
Fat (g)
1 11
Trans Fatty Acid (g) 0.79 56
Cholesterol (mg) 41 21
Water (g) 687 53
Vitamin A (IU) 2,318 155
Vitamin A (RE) 440
Vitamin A (RAE) 202 68
Vitamin A
Carotenoid (RE)
78
Vitamin A Retinol
(RE)
164
Beta Carotene mcg 930
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin B-1
Thiamin (mg)
0.58 116
Vitamin B-2
Riboflavin (mg)
0.91 181
Vitamin B-3 Niacin
(mg)
11 185
Niacin Equivalents
(mg)
14 237
Vitamin B-6 (mg) 0.64 128
Vitamin B-12 (mcg) 1.68 186
Biotin (mcg) 9.13 114
Vitamin C (mg) 93 618
Vitamin D (IU) 149 75
Vitamin D (mcg) 3.73 75
Vitamin E
Alphatocopherol
Equivalents (mg)
1.44
Vitamin E
Alphatocopherol
(mg)
1.44 24
Folate (mcg) 320 213
Folate DFE (mcg) 469 312
Vitamin K (mcg) 7 23
Pantothenic acid
(mg)
1.4 71
Calcium (mg) 830 166
Chromium (mcg) 2.3 21
Copper (mg) 0.6 177
Fluoride (mg) 0.03 5
Iodine (mcg) 36 40
Iron (mg) 9 133
Magnesium (mg) 145 181
Manganese (mg) 3.5 290
Molybdenum (mcg) 2.5 14
Phosphorus (mg) 565 123
Potassium (mg) 1,308 44
Selenium (mcg) 41.5 207
Sodium (mg) 1578 158
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Xylitol (g) 0
Zinc (mg) 6.3 210
Omega-3 Fatty
Acid (Linolenic
Acid) (g)
0.1 14
Omega-6 Fatty
Acid (g)
0.68 9.7
Alcohol (g) 0
Caffeine (mg) 0
Choline (mg) 51 26

Child Aged 4 to 8 Years with a Disorder of Lipid Metabolism (printable version)

Breakfast
Oatmeal, ½ cup
Banana, ½
Low-fat yogurt, ½ cup
Lunch
Peanut butter & jelly sandwich:
Natural peanut butter, 1 Tbsp
Jelly, 1 tsp
2 slices whole wheat bread
Carrot sticks, ½ cup, with 1 Tbsp light dressing
Apple slices, ½ cup
Nonfat milk, 1 cup
Dinner
Baked chicken, 2 oz
Whole wheat pasta, ½ cup with 1 Tbsp tomato
sauce
Green beans with almonds, ¾ cup
Soft margarine, 1 tsp
Nonfat milk, 1 cup
Snack 1
Mixed fruit cup in natural juices, ½ cup
1 low-fat string cheese
Snack 2
Low-fat pudding, ½ cup
2 cinnamon graham crackers


Approximate Nutrient Analysis for a 4- to 8-Year-Old Child
Nutrient Value
%
Recommended
Energy (kcal) 1,324 102
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Energy from Fat
(kcal)
286 73
Energy from
Saturated Fat
(kcal)
65 71
Protein (g) 68 342
Carbohydrates (g) 200 88
Dietary Fiber (g) 19 82
Soluble Fiber (g) 3.3 –
Total Sugars (g) 107.8 –
Monosaccharides
(g)
10.4 –
Disaccharides (g) 27.5 –
Other
Carbohydrates (g)
70.1 –
Fat (g) 31.8 74
Saturated Fat (g) 7.2 72
Monounsaturated
Fat (g)
5.4 29
Polyunsaturated
Fat (g)
2.9 17
Trans Fatty Acid
(g)
1.2 67
Cholesterol (mg) 66 33
Water (g) 1,165 69
Vitamin A (IU) 11,138 557
Vitamin A (RE) 1,420 –
Vitamin A (RAE) 752 188
Carotenoid (RE) 907
Vitamin A Retinol
(RE)
299
Beta Carotene
(mcg)
4,435
Vitamin B-1
Thiamin (mg)
0.7 116
Vitamin B-2
Riboflavin (mg)
1.45 242
Vitamin B-3
Niacin (mg)
7.96 99.5
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Niacin
Equivalents (mg)
14 176
Vitamin B-6 (mg) 0.74 124
Vitamin B-12
(mcg)
Biotin (mcg)
2.84
23.1
236
193
Vitamin C (mg) 20.7 83
Vitamin D (IU) 254 127
Vitamin D (mcg) 6.35 127
Vitamin E
Alphatocopherol
Equivalents (mg)
4.31
Vitamin E
Alphatocopherol
(mg)
4.31 61.5
Folate (mcg) 101 50
Folate DFE (mcg) 90.6 45
Vitamin K mcg 10 18
Pantothenic Acid
(mg)
3.2 107
Calcium (mg) 1,243 155
Chromium (mcg) 3.75 25
Copper (mg) 0.84 191.5
Fluoride (mg) 0.11 11
Iodine (mcg) 117 130.6
Iron (mg) 6.8 68
Magnesium (mg) 243 187
Manganese (mg) 3.5 236
Molybdenum
(mcg)
13 60
Phosphorus (mg) 1069 214
Potassium (mg) 1,958 52
Selenium (mcg) 64 215
Sodium (mg) 2,113 176
Xylitol (g) 0.01
Zinc (mg) 6.28 126
Omega-3 Fatty
Acid (g)
0.09
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Omega-6 Fatty
Acid (g)
2.8
Alcohol (g) 0
Caffeine (mg) 0
Choline (mg) 129 51

Child Aged 9 to 13 Years with a Disorder of Lipid Metabolism
Breakfast
Cereal, 1 cup
Nonfat milk, 4 oz
Strawberries, ½ cup
Lunch
Turkey sandwich:
Turkey, 2 oz
Low-fat cheese, 1 oz
2 slices whole wheat bread
Fat-free mayonnaise, 2 tsp
Sliced cucumbers, ½ cup
Light ranch dressing, 1 Tbsp
Orange, medium size
Nonfat milk, 1 cup
Dinner
Baked cod fish, 3 oz
Brown rice, ½ cup
Steamed broccoli, 1 cup
Soft margarine, 1 tsp
Unsweetened applesauce, ½ cup
Nonfat milk, 1 cup
Snack 1
Low-fat yogurt, 1 cup
Whole grain crackers, 2 oz
Reduced fat peanut butter, 1 Tbsp
Snack 2
Mixed nuts, ½ oz
1 low-fat string cheese
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Approximate Nutrient Analysis for a 9- to 13-Year-Old Child
Nutrient Value
%
Recommended
Energy (kcal) 1,668 98
Energy from Fat
(kcal)
368 72
Energy from
Saturated Fat (kcal)
76 64
Protein (g) 100 282
Carbohydrates(g) 238 74
Dietary Fiber (g)
Soluble Fiber (g)
26
3.7
78
Total Sugars (g) 101
Monosaccharides
(g)
18.6
Disaccharides (g) 34
Other
Carbohydrates (g)
109
Fat (g) 41 72
Saturated Fat (g) 8 62
Monounsaturated
Fat (g)
8.9 35
Polyunsaturated
fat (g)
3.7 16
Trans Fatty Acid (g)
Cholesterol (mg)
0.48
123
27
62
Water (g) 1,385 58
Vitamin A (IU) 5,279 176
Vitamin A (RE) 971
Vitamin A (RAE) 615 102
Vitamin A
Carotenoid (RE)
247
Vitamin A Retinol
(RE)
491
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Beta Carotene
(mcg)
1,434
Vitamin B-1
Thiamin (mg)
1.42 157
Vitamin B-2
Riboflavin (mg)
2.6 288
Vitamin B-3 Niacin
(mg)
16.1 134
Niacin Equivalents
(mg)
23 193
Vitamin B-6 (mg) 1.8 180
Vitamin B-12 (mcg) 6.3 348
Biotin (mg) 30 149
Vitamin C (mg) 237 527
Vitamin D (IU) 370 185
Vitamin D (mcg) 9.3 185
Vitamin E
Alphatocopherol
Equivalents (mg)
2.8
Vitamin E
Alphatocopherol
(mg)
2.8 25
Folate (mcg) 337 112
Folate DFE (mcg) 412 137
Vitamin K (mcg) 32.5 54.1
Pantothenic acid
(mg)
4 100
Calcium (mg) 1,553 127
Chromium (mcg) 2.89 11.6
Copper (mg) 0.96 138
Fluoride (mg) 0.03 1.4
Iodine (mcg) 147.8 123
Iron (mg) 16 202
Magnesium (mg) 291 121
Manganese (mg) 3.1 166
Molybdenum (mcg) 18.8 55
Phosphorus (mg) 1,321 106
Potassium (mg) 2,954 66
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Selenium (mcg) 57 143
Sodium (mg) 2,686 117
Xylitol (g) 0
Zinc (mg) 7.2 90
Omega-3 Fatty
Acid (g)
0.34
Omega-6 Fatty
Acid (g)
2.65
Alcohol (g) 0
Caffeine (mg) 0
Choline (mg) 129.5 35

Child Aged 14 to 18 Years with a Disorder of Lipid Metabolism
Breakfast
Whole wheat bagel, 3 oz
Low-fat cream cheese, 1 Tbsp
Orange juice, 6 oz
Lunch
Pita sandwich:
1 large whole grain pita
Turkey breast or lean ham, 3 oz
Shredded romaine lettuce, ¼ cup
Pickle
Raw mixed vegetables, 1 cup
Fat-free mayonnaise, 1 Tbsp
1 small banana
Nonfat milk, 1 cup
Dinner
Soft taco (meat or veggie)
2 small tortillas
Salad greens, ½ cup
Chopped tomatoes, ¼ cup
Low-fat shredded cheese, 3 Tbsp
Cooked 90% lean ground beef, 3 oz, or
refried beans (fat free), ½ cup
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sliced fresh avocado, 2 oz
Nonfat milk, 1 cup
Snack 1
Low-fat cottage cheese, ½ cup
1 medium peach
2 pieces melba toast
Natural peanut butter, 1 Tbsp
Snack 2 Soy nuts, ½ cup

Approximate Nutrient Analysis for a 14- to 18-Year-Old Child

Nutrient Value
%
Recommended
Energy (kcal) 1,909 95
Energy from Fat
(kcal)
400 66
Energy from
Saturated Fat
(kcal)
96 69
Protein (g) 120 228
Carbohydrates (g) 267 70
Dietary Fiber (g)
Soluble Fiber
33
3.1
85
Total Sugars (g) 94.8
Monosaccharides
(g)
14.2
Disaccharides (g) 16.9
Other
Carbohydrates (g)
138.6
Fat (g) 44.5 66
Saturated Fat (g) 10.6 66
Monounsaturated
Fat (g)
11.5 37
Polyunsaturated
Fat (g)
4 15
Trans Fatty Acid
(g)
Cholesterol (mg)
.38

105
17

53
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Water (g) 1467 45
Vitamin A (IU) 12,365 275
Vitamin A (RE) 1412
Vitamin A (RAE) 747 83
Vitamin A
Carotenoid (RE)
1,123
Vitamin A Retinol
(RE)
186
Beta Carotene
(mcg)
11,099
Vitamin B-1
Thiamin (mg)
1.2 100
Vitamin B-2
Riboflavin (mg)
1.1 87
Vitamin B-3
Niacin (mg)
17.5 109
Niacin
Equivalents (mg)
23.8 149
Vitamin B-6 (mg) 1.1 85
Vitamin B-12
(mcg)
Biotin (mcg)
3.6
18.4
151
74
Vitamin C (mg) 145 193
Vitamin D (IU) 200 100
Vitamin D (mcg) 5 100
Vitamin E
Alphatocopherol
Equivalents (mg)
2.97
Vitamin E
Alphatocopherol
(mg)
2.97 20
Folate (mcg) 424 106
Folate DFE (mcg) 476 119
Vitamin K (mcg) 131 175
Pantothenic Acid
(mg)
3.2 63
Calcium (mg) 1,332 102
Chromium (mcg) 2.5 7
Copper (mg) 0.88 98.7
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fluoride (mg) 0.04 1.4
Iodine (mcg) 69.7 46.5
Iron (mg) 14.5 132
Magnesium (mg) 215 52
Manganese (mg) 2.3 103
Molybdenum
(mcg)
12.2 28
Phosphorus (mg) 900 72
Potassium (mg) 2,743 58
Selenium (mcg) 58 105
Sodium (mg) 3,429 149
Xylitol (g) 0.01
Zinc (mg) 8.57 78
Omega-3 Fatty
Acid (g)
0.37
Omega-6 Fatty
Acid (g)
3.29
Alcohol (g) 0
Caffeine (mg) 0
Choline (mg) 98 18


Client Education Materials

High Cholesterol Nutrition Therapy
High Triglycerides Nutrition Therapy
DHA and Heart Health
Triglycerides and Added Sugars
Heart-Healthy Eating: Cooking Tips
Heart-Healthy Eating: Fiber Tips
Heart-Healthy Tips for Children
Heart-Healthy Eating: Shopping Tips
Heart-Healthy Eating: Soy Protein

Handouts in Spanish
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
DHA and Heart Health
High Cholesterol Nutrition Therapy
High Triglycerides Nutrition Therapy
Heart-Healthy Tips for Children

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Epilepsy
Epilepsy


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Epilepsy > Dietary Management
Dietary Management


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Epilepsy > Dietary Management > Classic Ketogenic Diet
Sample Menu: Classic Ketogenic Diet

Printable version
The following sample menu is calculated for a 6-year-old girl who weighs 23.1 kg and
has the following diet prescription:
Daily diet prescription: 1,320 kcal
4:1 classic ketogenic diet with 3 meals plus 1 bedtime snack
4:1 ratio means 4 parts of fat by weight compared with 1 part of total
carbohydrate plus protein by weight
Each meal has 396 kcal and bedtime snack has 132 kcal (see detailed
instructions in Nutrition Care: Nutrition Intervention)
Daily intake:
Carbohydrate: 5.05 g
Protein: 26.84 g
Fat: 132.0 g
Ratio: 4.14:1 due to 1.11 g carbohydrate from patient’s medications plus
supplements
For breakfast, lunch, and dinner (amounts are for each meal):
Carbohydrate: 1.51 g
Protein: 8.06 g
Fat: 39.60 g
For bedtime snack:
Carbohydrate: 0.51 g
Protein: 2.68 g
Fat: 13.20 g

Daily Cream Shakes
For sick day or to substitute for one solid meal:
For breakfast, lunch, or dinner
36% heavy cream: 56 g
Egg substitute: 52 g
Canola oil: 13 g
For bedtime snack

36% heavy cream: 19 g
Egg substitute: 20 g
Canola oil: 4 g

Daily Solid Food
Breakfast
36% heavy cream: 23 g
Fresh strawberries: 13 g
Egg substitute (scrambled with oil): 66 g
Olive oil: 24 g
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lunch
36% heavy cream: 14 g
Sliced cucumber (raw): 6 g
Sweet corn (canned, drained): 4 g
Grilled chicken breast: 25 g
Olive oil: 35 g (use for salad dressing for
cucumber, cook with corn and chicken, mix the
rest with cream for beverage)
Dinner

Green beans (cooked): 14 g
Baked, lean, ground beef patties: 15 g
Butter: 35 g
KetoCal powder: 14 g
Sugar-free, low-kilocalorie gelatin dessert
powder (any flavor): 1.3 g (use to make KetoCal
pudding
a
)
Bedtime
snack

36% heavy cream: 18 g
Blueberries (fresh): 8 g
Egg white: 14 g
Olive oil: 8 g
a
KetoCal pudding recipe (Adapted from Nutricia: Cooking with KetoCal, available at
http://www.shsna.com/pdf/KetoCalRecipes_5-08.pdf):
1. Weigh sugar-free Jell-O pudding powder in a small bowl.
2. Heat ½ cup water to a boil, then weigh out 60 g and stir into sugar-free Jell-O
pudding. Allow to cool for about 3 minutes.
3. Stir KetoCal powder into Jell-O mixture with a small spatula.
4. Refrigerate for at least 2 hours.


Foods Recommended

Printable version
Food Group Recommended
Dairy Products 35% to 40% heavy
whipping cream
Fat Butter
Any vegetable oil low
in saturated fat
Margarine
(carbohydrate free, low
in saturated fat and
trans fat free)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mayonnaise
(carbohydrate free, low
in saturated fat and
trans fat free)
Nuts (calculate
carbohydrate content
in the diet)
Fruits and
Vegetables
All fruits and vegetables
Protein foods Lean meats
Eggs
Poultry
Seafood
Beverages Plain water
Sugar-free,
caffeine-free
beverages (less than 1
kcal/day)
Mineral water or club
soda
Caffeine-free,
carbohydrate-free
herbal tea


Foods Not Recommended

Printable version
Food rich in carbohydrate including sugar (Zupec-Kania, 2008) and all sugar-containing
foods are not allowed.
Food Group Food Not Recommended
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Bread and Cereal
Products
All, unless it can be
calculated into
individual’s meal plan
Protein Foods None
Dairy Products Sweetened yogurt
Plain yogurt
a
Milk
a

Cheese
a
Fruits and
Vegetables
Fruits packed in syrups
Dried candied fruits
Fats Dressings containing
sugar or sugar products
Gravies with
carbohydrate
ingredients
Beverages Fruit juices
b
Fruit punch
Regular soft drinks
Diet,
caffeine-containing soft
drinks
Regular tea or coffee
Any other sugar- or
caffeine-containing
drinks
Desserts, Candies,
or Snacks
All, unless homemade
using ketogenic diet
recipes
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

a
Unless it can be calculated into the individual's meal plan
b
These should be used only for treatment of hypoglycemia or hyperketosis

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Epilepsy > Dietary Management > MCT Oil Ketogenic Diet
Foods Recommended

Printable version
Food Group Food Recommended
Breads, Grains, and
Cereal Products
Bread: Whole wheat,
cracked wheat, rye,
enriched white, flour
tortilla, bagel, English
muffin, bun or dinner roll,
pita, rice cake
Dry cereals: Ready-to-eat,
unsweetened
No-sugar-added, cooked
cereal
Pasta
Potatoes, yams, and sweet
potatoes
Corn, dry beans, peas
Vegetables/Fruits Fresh vegetables
Canned, water-packed
vegetables
Frozen, plain vegetables
Fresh fruits
Canned, water-packed
fruits
Frozen, plain,
no-sugar-added fruits
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Protein Unprocessed fresh, frozen
meats
Unprocessed fresh, frozen
poultry
Unprocessed fresh, frozen
seafood
Eggs, egg substitute
Milk Skim milk
Nonfat buttermilk
Nonfat evaporated milk
Nonfat powdered milk
Nonfat plain yogurt
Fats Vegetable oil
Margarine
Mayonnaise
Nuts

Medium-chain
triglyceride (MCT) oil
100% MCT oil
Beverages Plain water
Sugar-free, caffeine-free
beverage (less than 1
kcal/serving)
Mineral water or club soda
Caffeine-free,
carbohydrate-free herbal
tea
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(Liu, 2008)


Foods Not Recommended

Printable version
Foods rich in carbohydrate, including sugar and all sugar-containing foods, are not
recommended beyond what is calculated as carbohydrate to add to ketogenic milkshakes.
(Liu, 2008)
Food Group Food Not Recommended
Breads, Grains,
and Cereals
All sugar-added bread, dry
cereals, and cooked
cereals
Fried starchy foods, unless
the fat is calculated into
the diet
Fruits and Vegetables Fruits packed in syrups
Dried or candied fruits
Protein Carbohydrate- or
sugar-added processed
meat
Cheese
a
Peanut butter
a
Sugar-added peanut butter
Dairy Products Sweetened yogurt
Whole, 2%, and 1% milk
b
Fats Dressings containing
sugar or sugar products
Gravies with carbohydrate
ingredients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Beverages Fruits juices
c
Fruit punches
Regular soft drinks
Diet caffeinated soft drinks
Regular tea or coffee
Any other sugar- or
caffeine-containing drinks
Desserts, Candies, or
Snacks
All, unless homemade
using ketogenic diet
recipes

a
Unless used cautiously
b
Unless it can be calculated into the individual’s meal plan
c
These should be used only for treatment of hypoglycemia or hyperketosis


Sample 1-Day Menu

Sample 1-day menu for a girl aged 15 years with the following details:
Weight: 40 kg
Height: 147 cm
Daily diet prescription:
1,482 kcal
60% medium-chain triglyceride (MCT) ketogenic diet:
60% MCT oil: 107.2 g
11% fat: 18.2 g
19% carbohydrate: 70.3 g
10% protein: 37.1 g
Printable version
Printable version of MCT Oil Ketogenic Diet Exchange List

Daily milkshake recipe for sick day (whole day recipe):
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1,082 g skim milk
17 g sugar
19 g canola oil
17 g sugar = 17 g of carbohydrate
carbohydrate in the milk = 53.3 g
53.3 g + 17 g = 70.3 g as prescribed
Mix all ingredients and divide into 6 feeds per day. Mix into 17.9 g MCT oil before each
feeding.

Daily Meals
*Food serving/exchange size: please see table under Oral Intake
Breakfast
Starch: (½ serving/exchange) 10 g cooked
oatmeal
Fruit/vegetable: (½ serving/exchange) 65 g
diced cantaloupe
Protein: (½ serving/exchange) 28 g
scrambled egg
Skim milk: (1 serving/exchange) 125 g skim
milk
Fat: (1 serving/exchange) 5 g canola oil
MCT oil: 17.9 g (mix with milk)
Snack
Skim milk: (1 serving/exchange) 125 g skim
milk
MCT oil: 17.9 g (mix with milk)
Lunch
Starch: (1/3 serving/exchange) 20 g brown
rice
Fruit/vegetable: (½ serving/exchange) 75 g
strawberries
Protein: (5/8 serving/exchange) 19 g sliced,
grilled chicken breast
Skim milk: (1 serving/exchange) 125 g skim
milk
Fat: (½ serving/exchange) 3 g canola oil
MCT oil: 17.9 g (mix with milk)
Snack
Fruit/vegetable: (½ serving/exchange)
include the following:
23 g sliced raw carrots (¼ serving/exchange)
31 g sliced raw celery (1/8 serving/exchange)
46 g sliced raw cucumber (1/8
serving/exchange)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Skim milk: (½ serving/exchange) 63 g skim
milk
MCT oil: 17.9 g (add salt, pinch of garlic
powder, black pepper as vegetable dip)
Dinner
Starch: (1/3 serving/exchange) 16 g whole
grain spaghetti
Fruit/vegetable: (½ serving/exchange)
include the following:
35 g tomato sauce (¼ serving/exchange)
63 g lettuce (1/8 serving/exchange)
26 g raw tomato slices (1/8 serving/exchange)
Protein: (5/8 serving/exchange) 19 g cooked
ground lean beef (cooked with olive oil and
tomato sauce as spaghetti sauce)
Skim milk: (1 serving/exchange) 125 g skim
milk
Fat: (1 serving/exchange) 5 g olive oil
MCT oil: 17.9 g (add pinch of salt, garlic
powder, black pepper and sugar-free vinegar
as salad dressing)
Snack
Fruit/vegetable: (½ serving/exchange) 50 g
diced papaya
Skim milk: (1 serving/exchange) 125 g skim
milk
Fat: (1 serving/exchange) 5 g canola oil (mix
with milk)
MCT oil: 17.9 g (mix with milk)



© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Failure to Thrive
Foods Recommended

Printable version
Food Group Recommended Foods
Milk and
Milk
Products
Whole milk, cream, half and half, whole milk
yogurt, puddings, powdered nonfat dry milk,
whipping cream, sweetened condensed milk,
cheese, sour cream, ice cream, butter
Meat and
Other
Protein
Foods
High-fat meats, including beef, pork, chicken,
turkey, and fish; eggs, nuts, nut and
seed-butters (such as peanut, almond, cashew,
and sunflower), and legumes
Cook with oil or butter to add kilocalories
Grains
Bread, rolls, English muffins, bagels with
spread (butter, cream cheese, peanut butter);
muffins; pancakes/waffles/french toast with
butter and syrup; crackers with fat, such as
fish-shaped and club; breakfast cereals with
whole milk or cream; hot cereal prepared with
whole milk or cream
Vegetables
All vegetables should be prepared with oil or
butter and served with butter, margarine, or
cheese on top
Fruits
All fruits can be served with sugar or cream on
top or with yogurt for dipping
Fat and oils
Butter, margarine, oil, mayonnaise, salad
dressing— use generous amounts
Beverages
Whole milk and flavored milks such as
chocolate or strawberry; Pediasure, Kindercal,
or other liquid supplements designed for
children
Other
Chocolate syrup; sauces such as caramel,
barbecue, ketchup, tartar, and sweet and sour;
maple syrup.; cheese spread; honey (for
children older than 1 year); hummus; nutella

Foods Not Recommended

Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Food Group Foods Not Recommended
Milk and Milk
Products
Skim, 1% or 2% milk, nonfat or low-fat
yogurt, low-fat ice cream, sherbet, low-fat
cheese, or other low-fat or nonfat dairy
products.
Meat and
Other Protein
Foods
None
Grains Any prepared without added fat
Vegetables None
Fruits None
Fat and Oils None
Beverages
Excessive juice, fruit-flavored beverages,
water – limit to 4 ounces per day
Other
Diet products or products prepared with
artificial sweeteners; products marked low
fat or reduced fat

Sample 1-Day Menu

The following menu is a sample of an appropriate 1-day menu for a 7- to 8-year-old child
with failure to thrive. Please note that recommendations may vary depending on the child's
age and specific conditions.
Printable version
Breakfast
½ cup oatmeal, cooked in whole milk, with 1
Tablespoon brown sugar
½ fresh banana, sliced, with 1 tablespoon
peanut butter spread on top
4 ounces whole milk
Snack
2 high-fat crackers
1 ounce cheddar or American cheese
4 ounces water or juice
Lunch
½ cup macaroni and cheese, prepared with
butter and whole milk
¼ cup carrot sticks with 1 teaspoon ranch
dressing dip
½ cup sliced strawberries with 1 teaspoon
sugar on top
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
4 ounces whole milk
Snack
4 ounces whole milk yogurt
1 Tablespoon raisins
Evening
meal
2 breaded chicken tenders
1 teaspoon barbecue sauce
¼ cup tater tots
½ cup steamed broccoli with 1 Tablespoon
shredded cheese
4 ounces whole milk
Evening
Snack
4 ounces strawberry shake supplement

Approximate Nutrient Analysis
Energy (kcal) 1,700
Total protein (g) (% kcal)
67
(15)
Total carbohydrate (g) (% kcal)
206
(47)
Total fat (g) (% kcal)
74
(38)
Total saturated fatty acids (g) (%
kcal)
27
(14)
Total monounsaturated fatty acids
(g) (% kcal)
2.5
(1.3)
Total polyunsaturated fatty acids (g)
(% kcal)
1.3
(1.0)
Cholesterol (mg) 149
Calcium (mg) 1,380
Iron (mg) 20
Magnesium (mg) 117
Phosphorus (mg) 577
Potassium (mg) 1,472
Sodium (mg) 2,788
Zinc (mg) 3.6
Total vitamin A (retinol activity
equivalents) (mcg)
356
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin C (ascorbic acid) (mg) 86
Thiamin (vitamin B-1) (mg) 1
Riboflavin (vitamin B-2) (mg) 1.4
Niacin (vitamin B-3) (mg) 12
Total folate (mcg) 104
Vitamin B-6 (pyridoxine, pyridoxyl,
and pyridoxamine) (mg)
0.8
Vitamin B-12
(cyanocobalamin)(mcg)
1.4
Total Dietary Fiber (g) 12
Vitamin D (calciferol) (mcg) 210

Client Education Materials

Failure to Thrive Nutrition Therapy

Handout in Spanish:
Failure to Thrive Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Food Allergic Disorders
Food Allergic Disorders


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Food Allergic Disorders > Eosinophilic Esophagitis
Foods Recommended

Empiric Elimination Diet
Eliminates milk, egg, wheat, soy, peanut, tree nut, fish, shellfish.
Check all labels and verify food-preparation techniques to determine safety. Any foods
prepared with allergenic ingredients are not recommended.
Nutrition Therapy for Children with Multiple Food Allergies
Nutrition Therapy for Children with Multiple Food Allergies (Spanish)
Tips for Managing Multiple Food Allergies
Food Group Recommended Foods
Milk and Milk
Products
None
Meat and
Other Protein
Foods
All fresh, frozen or canned meats (beef, veal,
pork, lamb) or poultry without indicated
allergenic ingredients

All dried beans and peas—except peanut and
soy

Processed meats and luncheon meats without
indicated allergenic ingredients
Grains
All alternative grains products, such as
breads, other baked goods, cereals, crackers,
noodles, pancakes, pasta, pretzels, rice, and
tortillas made without wheat or other indicated
allergenic ingredients

The following wheat-free grains, legumes,
vegetables, or seeds are available as flours for
home baking or cooking and in many
wheat-free commercial foods:
Arrowroot
Barley
Buckwheat
Chickpea flour
Corn
Fava bean flour
Flaxseed meal
Millet
Oat
Potato starch
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Potato starch
Quinoa
Rice
Rye
Sorghum
Tapioca
Teff
Vegetables
All fresh, frozen, or canned vegetables
prepared without indicated allergenic
ingredients

100% vegetable juices
Fruits
All fresh, frozen or canned fruits prepared
without indicated allergenic ingredients

100% fruit juices
Fat and Oils
Margarine without milk, soy, or other allergenic
ingredients

Highly processed vegetables oils (including
soy oil)

Soy lecithin

Vegetable oil spray, gravies, sauces, and
salad dressings, if made without indicated
allergenic ingredients
Beverages
Alternative enriched “milk” beverages (for
example, beverages made from rice, oat,
hemp, or potato)

Commercial hypoallergenic amino acid–based
formulas (check Formulary for choices)
Other
Cocoa butter
Calcium lactate
Oleoresin
Cream of tartar
Lactic acid (note: lactic acid starter culture
may contain milk)
Pepper and salt
Herbs and spices
Mustard
Ketchup
Relish
Soups and casseroles made without indicated
allergenic ingredients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Gelatin
Honey
Jam, jelly, marmalade, preserves
Sugar
Maple syrup

Foods Not Recommended

Check all labels and verify food-preparation techniques to determine safety. Any foods
prepared with allergenic ingredients are not recommended.
Multiple Food Allergies Food Lists
Food Group Foods Not Recommended
Milk and Milk
Products
All types of milk (including whole, reduced-fat,
low-fat, fat-free, powdered, condensed,
evaporated)
Butter, butter fat, butter solids
Buttermilk
Cheese (all forms) and cheese flavor
Cream (heavy, light, sour, whipping, whipped)
Half-and-half
Custards
Ghee
Ice cream
Pudding
Yogurt

Milk ingredients:
Casein
Caseinates (all forms)
Curds
Hydrolysates (casein, milk protein,
protein, whey, whey protein)
Lactalbumin, lactalbumin phosphate,
lactoglobulin, lactoferrin
Milk derivative, milk powder, milk
protein, milk solids, nonfat milk solids,
nonfat dry milk
Rennet casein
Whey (all forms, including cured whey,
lactose-free whey, demineralized whey,
sweet dairy whey, whey protein
concentrate, whey powder, whey solids)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meat and
Other Protein
Foods
All fresh or frozen meats (beef, veal, pork,
lamb) or poultry prepared with an indicated
allergenic ingredient

Processed meats and luncheon meats with
allergenic ingredients

Fresh, frozen, or canned fish or shellfish

Eggs

Egg substitutes that contain egg protein
ingredients, egg powder, egg white, or egg
yolk

Egg ingredients:
Albumin
Apovitellin
Avidin
Globulin
Livetin
Lysozyme
Ovalbumin
Ovoglobulin
Ovomucin
Ovomucoid
Ovovitellin
Vitellin
Soy-based foods:
Vegetarian and vegan products that may
contain soy ingredients:
Edamame
Miso
Natto
Shoyu sauce or soy sauce
Soy foods (including soy cheese, fiber,
flour, grits, ice cream, milk, nuts,
sprouts, and yogurt)
Soy protein (concentrate, hydrolyzed,
isolate)
Tempeh
Textured vegetable protein
Tofu
Peanuts

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tree nuts:
Almond
Beech nut
Brazil nut
Butter nut
Cashew
Chestnut
Chinquapin
Coconut
Filbert/hazelnut
Ginkgo
Hickory
Lychee nut
Macadamia nut
Pecan
Pili nut
Pine nut/pignolia nut
Pistachio
Shea nut
Walnut
Grains
Any of the following, if made with wheat or
other allergenic ingredients:
Breads and rolls (white, whole wheat,
multi-grain, potato, rye, etc.)
Other baked goods (brownies, cakes,
cookies, muffins, etc.)
Bread crumbs
Cereals
Couscous
Pancakes and waffles
Pasta
Flour tortillas

Wheat ingredients:
Bulgur
Cereal extract
Durum flour, durum wheat
Emmer
Einkorn
Farina
Farro
Flour (all-purpose, bread, cake,
enriched, graham, high-gluten,
high-protein, pastry, and wheat)
Kamut
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Semolina
Spelt
Sprouted wheat
Triticale
Vital gluten, wheat (bran, germ, gluten,
malt, starch)
Wheat berries
Vegetables
All fresh, frozen, or canned vegetables
prepared with indicated allergenic ingredients
Fruits
All fresh, frozen, or canned fruits prepared
with indicated allergenic ingredients
Fat and Oils
Butter

Margarines with milk, soy, or other indicated
allergenic ingredients

Gravies, sauces or salad dressings made with
indicated allergenic ingredients

Fish oils

Nut oils (such as hazelnut, walnut, or almond
oil)

Cold-pressed, expressed, or expeller pressed
soy oil

Arachis oil

Cold-pressed, expressed, expelled, or
extruded peanut oils

Béarnaise sauce

Hollandaise sauce

Mayonnaise
Beverages
All forms of cow’s milk

Alternative milk beverages made from soy

Almond, hazelnut, or other nut-based milks

Nut-flavored coffees (made with natural nut
extracts)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nut-flavored alcoholic beverages

Clam juice

Beverages with added fish oils
Other
Goat’s milk

Sheep’s milk

Other mammalian milks and their products

Recaldent (an ingredient in whitening chewing
gum)

Simplesse (a fat substitute)

Natural extracts such as almond or hazelnut
extract

Custard

Meringue

Marzipan

Nougat

Artificial nuts

Pesto

Nut meal

Gianduja

Marinades and condiments with indicated
allergenic ingredients

Worcestershire sauce

Soy sauce

Tamari sauce

Caesar salad and caesar salad dressings

Surimi; “sea legs,” or artificial crab
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sample 1-Day Menu

Printable sample menu
Breakfast
½ cup cooked rice cereal
½ cup enriched rice milk
¼ cup fresh blueberries
1 turkey sausage link
½ cup orange juice
Lunch
½ cup corn pasta salad with 2 ounces grilled
chicken, carrots, and grape tomatoes served with
homemade vinaigrette
½ cup enriched rice milk
1 homemade oatmeal–chocolate chip cookie
Snack
5 tortilla chips with 2 tablespoons white bean dip
Water
Dinner
2 ounces pork tenderloin pan roasted with onions
and apples
½ cup brown rice with 1 teaspoon margarine (if
allowed)
½ cup green beans
½ cup fresh strawberries
½ cup enriched rice milk
Snack
Smoothie: ½ cup enriched rice milk, ½ banana, 1
teaspoon milk-free cocoa powder

Approximate Nutrient Analysis
Energy (kcal) 1,482
Protein (g) 52.8
Carbohydrates (g) 204.25
Fat (g) 50.46
Saturated fat (g) 12
Total dietary fiber (g) 16
Water (g) 1,262
Vitamin A (IU) 406
Thiamin (mg) 1.8
Riboflavin (mg) 1.1
Niacin (mg) 23
Pantothenic acid (mg) 2.8
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin B-6 (mg) 1.4
Total folate (mcg) 257.0
Vitamin B-12 (mcg) 2.0
Vitamin C (mg) 90.75
Vitamin D (IU) 200
Vitamin E alphatocopherol
equivalents (mg)
2.11
Calcium (mg) 656.0
Iron (mg) 6.31
Magnesium (mg) 337.59
Manganese (mg) 4.52
Phosphorus (mg) 1,026.31
Sodium (mg) 1,369.73
Zinc (mg) 2.94

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Food Allergic Disorders > General Guidance
Foods Recommended: Egg Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
All milk products allowed, such as whole,
reduced-fat, low-fat, and skim milk; condensed,
evaporated, and dry milk; cheese, cream
cheese, pudding, sour cream, yogurt, and ice
creams if made without egg ingredients
Meat and
Other
Protein
Foods
Prepared without added egg ingredients:
All fresh or frozen meats (beef, veal, lamb,
pork, poultry)
Fresh, frozen, or canned fish or shellfish
Legumes, nuts, and seeds
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles, if
prepared without added egg ingredients
Vegetables
All fresh, frozen, and canned vegetables
prepared without egg ingredients
100% vegetable juice
Fruits
All fresh, frozen, and canned fruits prepared
without egg ingredients
100% fruit juice
Fat and oils
Butter, margarine, liquid oils and solid fat,
egg-free mayonnaise (vegan varieties),
vegetable oil spray, gravies, sauces, and salad
dressings without egg ingredients
Beverages
Milk, juice, coffee, tea: all beverages without
egg ingredients
Pepper and salt, herbs and spices, mustard,
ketchup, relish, soups, and casseroles made
without egg-containing ingredients, flavoring
extracts; gelatin; honey; jams, jellies,
marmalades, preserves; sugar; maple syrup
Egg replacers: Brands such as Ener-G, Bob's
Red Mill, and Orgran make potato-based egg
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Other
replacers that can be used in recipes to
substitute for egg. The following ingredients
can be used to substitute for each egg in a
recipe:
1 tsp. baking powder, 1 Tablespoon water, 1
Tablespoon vinegar
1 teaspoon yeast dissolved in ¼ cup warm
water
1-2 Tablespoons fruit puree
1½ Tablespoons water, 1½ Tablespoons oil, 1
teaspoon baking powder
1 packet gelatin, 2 Tablespoons warm water
(do not mix until ready to use)

Foods Not Recommended: Egg Allergy

Printable version

Food Group Foods Not Recommended
Milk and Milk
Products
Eggnog or any milk product prepared with egg
ingredients
Meat and
Other Protein
Foods
Egg (hen, duck, turkey, goose, quail), many
egg substitutes that contain an egg ingredient,
egg powder, egg white or yolk
Any meats (beef, veal, lamb, pork), fish and
shellfish, poultry, and legumes prepared with
egg or egg ingredients
Egg ingredients:
Albumin
Apovitellin
Avidin
Globulin
Livetin
Lysozyme
Ovalbumin
Ovoglobulin
Ovomucin
Ovomucoid
Ovovitellin
Vitellin
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitellin

Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles made
with added egg or egg ingredients
Vegetables
Vegetables made with egg or egg ingredients
such as those with a batter, sauce, or topping
containing egg ingredients
Fruits
All fresh, frozen, and canned fruits prepared
with egg ingredients
Fat and oils
Béarnaise sauce, Hollandaise sauce,
mayonnaise
Beverages Eggnog
Other Custard, meringue, nougat, marzipan

Sample 1-Day Menu: Egg Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Egg Allergy
Printable version
Breakfast 2 pancakes made without egg*
Fresh raspberries, 1/3 cup
Maple syrup, 2 Tablespoon

1% milk, 1 cup
Mid-Morning Snack Mandarin oranges (2, small)

Water
Lunch Chicken sandwich:
Chicken breast, 2 ounces
Egg-free vegan mayonnaise, 1
teaspoon
Egg-free whole wheat bread, 2
slices

Homemade vegetable soup, 1 cup

1% milk, 1 cup

Store-bought egg-free chocolate
chip cookie (1)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mid-Afternoon Snack Carrots and red pepper strips
Homemade, egg-free ranch dip, 1
Tablespoon

Water
Dinner Hamburger, 2 ounces
Egg-free hamburger bun
Cheddar cheese, 1 ounce
Ketchup, 1 Tablespoon

Broccoli, ½ cup

Watermelon, ½ cup

Water
* May use Ener-G brand egg replacer or one of the following to substitute for 1 egg:
1 teaspoon baking powder, 1 Tablespoon water, 1 Tablespoon vinegar
1 teaspoon yeast dissolved in ¼ cup warm water
1 to 2 Tablespoons fruit puree
1½ Tablespoons water, 1½ Tablespoons oil, 1 teaspoon baking powder
1 packet gelatin, 2 Tablespoon warm water (do not mix until ready to use)

Approximate Nutrient Analysis
Energy (kcal) 1,614.55
Protein (g) 60.94
Carbohydrates (g) 223.34
Fat (g) 54.73
Saturated fat (g) 11.36
Cholesterol (mg) 88.64
Total dietary fiber
(g)
19.37
Vitamin A (IU) 7,543.35
Thiamin (mg) 0.76
Riboflavin (mg) 1.35
Niacin (mg) 8.87
Pantothenic acid
(mg)
2.74
Vitamin B-6 (mg) 0.68
Total folate (mcg) 175.92
Vitamin B-12 (mcg) 1.96
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin C (mg) 180.49
Vitamin D (IU) 195.20
Vitamin E
alphatocopherol
equivalents (mg)
12.05
Calcium (mg) 1,096.34
Iron (mg) 9.61
Magnesium (mg) 138.58
Manganese (mg) 1.90
Phosphorus (mg) 814.57
Selenium (mcg) 24.01
Sodium (mg) 1,795.92
Zinc (mg) 4.44


Foods Recommended: Milk Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and
Milk
Products
None
Meat and
Other
Protein
Foods
All fresh or frozen meats (beef, veal, pork,
lamb) or poultry
Fresh, frozen, or canned fish or shellfish without
milk ingredients
Eggs prepared without milk ingredients
Legumes, nuts, and seeds
Processed meats and luncheon meats without
milk ingredients
Grains
All grains, such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles made
without milk ingredients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vegetables
All fresh, frozen, or canned vegetables prepared
without milk ingredients
100% vegetable juices
Fruits
All fresh, frozen, or canned fruits prepared
without milk ingredients
100% fruit juices
Fat and oils
Milk-free margarine, vegetables oils, milk-free
vegetable oil spray, gravies, sauces, salad
dressings, and mayonnaise made without milk
or milk ingredients
Beverages
Alternative enriched “milk” beverages (made
from soy, rice, oat, hemp, etc.)—for older
children
These alternative milks should be enriched to
include calcium, vitamin D, and other
nutrients. The protein and fat contents of these
alternative milks vary greatly and may not be
equivalent to cow's milk.
Hypoallergenic commercial infant and toddler
formulas
Other
Cocoa butter, coconut milk, calcium lactate,
oleoresin, cream of tartar, lactic acid (although
lactic acid starter culture may contain milk),
pepper and salt, herbs and spices, mustard,
ketchup, relish, soups, and casseroles made
without milk ingredients, flavoring extracts;
gelatin; honey; jams, jellies, marmalades,
preserves; sugar; maple syrup

Foods Not Recommended: Milk Allergy

Printable version

Food Group Foods Not Recommended
Milk (whole, reduced fat, low fat, fat-free,
powdered, condensed, evaporated)
Butter, butter fat, butter milk, butter solids
Cheese (all forms) and cheese flavor
Cream (heavy, light, sour, whipping, whipped),
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk and Milk
Products
half and half
Custards
Ghee
Ice cream
Pudding
Yogurt

Milk ingredients:
Casein
Caseinates (all forms)
Curds
Hydrolysates (casein, milk protein, protein,
whey, whey protein)
Lactalbumin, lactalbumin phosphate,
lactoglobulin, lactoferrin
Milk derivative, milk powder, milk protein, milk
solids, nonfat milk solids, nonfat dry milk
Rennet casein
Whey (all forms such as cured whey,
lactose-free whey, demineralized whey, sweet
dairy whey, whey protein concentrate, whey
powder, whey solids)
Meat and
Other Protein
Foods
All fresh or frozen meats (beef, veal, pork
lamb) or poultry prepared with a milk ingredient
Fish, shellfish, and canned fish with a milk
ingredient
Eggs prepared with milk ingredients
Legumes, nuts, seeds with added milk
ingredients; processed meats and luncheon
meats with added milk ingredients
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles made
with milk ingredients
Vegetables
All fresh, frozen, or canned vegetables
prepared with milk ingredients
Fruits
All fresh, frozen, or canned fruits prepared
with milk ingredients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fat and Oils
Butter, margarines, gravies, sauces, or salad
dressings made with milk ingredients
Beverages
All forms of cow’s milk and cow's milk
proteins—with the exception of hypoallergenic
formulas made from extensively hydrolyzed
cow's milk proteins and labeled
"hypoallergenic"
Other
Goat’s milk, sheep’s milk, other mammalian
milks and their products
Recaldent—an ingredient in whitening
chewing gum
Simplesse—a fat substitute
Many dessert items (cake, cookies, puddings,
etc) may contain milk—check ingredients
carefully

Sample 1-Day Menu: Milk Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Milk Allergy
Printable version
Breakfast
Oatmeal (½ cup)
Enriched soy “milk” beverage (½ cup)
Fresh blueberries
Orange juice (½ cup)
Mid-Morning
Snack
Apple
Water
Lunch
Turkey sandwich:
2 ounces turkey breast
1 teaspoon mayonnaise
1 slice tomato/lettuce
2 slices milk-free, whole wheat bread
3 baby carrots with 2 Tablespoons
hummus dip
1 cup enriched soy “milk” beverage
1 homemade milk-free oatmeal cookie
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mid-Afternoon
Snack
Tortilla chips (5) with avocado dip
Water
Dinner
Grilled chicken breast, 3 ounces
Corn on cob with 1 Tablespoon milk-free
margarine
Grilled asparagus (olive oil and garlic), 5
spears
Brown rice, ½ cup
Fresh strawberries (1/2 cup) with 1
Tablespoon powdered sugar
Enriched soy “milk” beverage (1/2 cup)
Bedtime Snack
Soy smoothie:
4 ounces soy “milk” beverage
1 banana
1 Tablespoon milk-free cocoa powder
Approximate Nutrient Analysis
Energy (kcal) 1,610
Protein (g) 79
Carbohydrates (g) 215
Fat (g) 54
Saturated Fat (g) 12
Cholesterol (mg) 80
Total dietary fiber (g) 31
Water (g) 1,262
Vitamin A (IU) 3,006
Thiamin (mg) 1.8
Riboflavin (mg) 1.1
Niacin (mg) 23
Pantothenic acid (mg) 2.8
Vitamin B-6 (mg) 1.4
Total folate (mcg) 257.0
Vitamin B-12 (mcg) 0.98
Vitamin C (mg) 65.61
Vitamin D (IU) 300.00
Vitamin E alphatocopherol
equivalents (mg)
5.5
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Calcium (mg) 800.0
Iron (mg) 12.11
Magnesium (mg) 337.59
Manganese (mg) 4.52
Phosphorus (mg) 1,026.31
Selenium (mcg) 98.11
Sodium (mg) 1,369.73
Zinc (mg) 5.94

Foods Recommended: Fish Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
All milk products allowed, such as whole,
reduced-fat, low-fat, and skim milk; cheese;
cream cheese; pudding; sour cream; yogurt;
and ice cream
Be aware that products including milk
products advertised as high in Omega 3 may
have added fish oil. Please check labels
carefully.
Meat and
Other Protein
Foods
All fresh or frozen meats (beef, veal, pork,
lamb), poultry, eggs, legumes, nuts, and seeds
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles
Vegetables
All fresh, frozen, or canned vegetables
prepared without fish ingredients
100% vegetable juice without added fish oil
ingredients
Fruits
All fresh, frozen, or canned fruits
100% fruit juice without added fish or fish oil
ingredients
Fat and oils
Butter, margarine, vegetables oils, vegetable
oil spray, gravies, sauces, salad
dressings, and mayonnaise made without fish
or fish oil ingredients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Beverages
Milk, juice, coffee, tea without added fish or
fish oil ingredients
Other
Carrageen is a marine algae, not a fish, and is
safe for those with fish allergy

Foods Not Recommended: Fish Allergy

Printable version

Food Group Foods Not Recommended
Milk and
Milk Products
Milk products with added fish ingredients (such
as yogurt or milk with added fish oil for
omega-3 supplementation)
Meat and
Other
Protein
Foods
All finned fish species; ask your doctor if you
should avoid all fish or just certain species
Grains All allowed
Vegetables All allowed
Fruits All allowed
Fat and oils
Fish oil, caesar salad dressing, margarines,
and oils with added fish oils
Beverages Beverages (juice, milk) with added fish oils
Other
Worcestershire sauce; caesar salad usually
contains fish ingredients (anchovies); fish stock
or seafood flavoring; surimi or artificial crab or
“sea legs” are made from fish; Asian fish
sauces; caponata may contain anchovies;
shellfish chowder may contain fish or fish stock
Note: For very sensitive individuals, there is a risk of reacting to cooking vapors of fish or
from handling fish.

Sample 1-Day Menu: Fish Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Fish Allergy
Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast
2 pancakes
Fresh raspberries, 1/3 cup
Maple syrup, 2 Tablespoons

1% milk, 1 cup
Mid-Morning Snack
Peach
Water
Lunch
Egg salad sandwich:
2 eggs
1 Tablespoon mayonnaise
2 slices whole wheat bread

1 cup homemade vegetable soup

1% milk, 1 cup
Mid-Afternoon Snack
1 store-bought oatmeal cookie

1% milk, 4 ounces
Dinner
Hamburger, 2 ounces
Hamburger bun
Cheddar cheese, 1 ounce
Ketchup, 1 Tablespoon
Tomato and cucumber slices

Broccoli, ½ cup

Cantaloupe melon, ½ cup

Water

Approximate Nutrient Analysis
Energy (kcal) 1,439
Protein (g) 70
Carbohydrate (g) 176
Total fiber (g) 18
Total fat (g) 53.8
Saturated fat (g) 19.5
Monounsaturated fat (g) 18
Polyunsaturated fat (g) 11
Linoleic acid (omega-6) (g) 9.5
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Alphalinolenic acid (omega-3) (g) 1.3
Cholesterol (mg) 333
Vitamin A (mcg RAE) 889.6
Vitamin C (mg) 100.2
Vitamin E (mg a-TE) 4.4
Thiamin (mg) 1
Riboflavin (mg) 2.3
Niacin (mg) 12.8
Folate (mcg, DFE) 283.9
Vitamin B-6 (mg) 1.3
Vitamin B-12 (mcg) 5.1
Calcium (mg) 1,204.3
Phosphorus (mg) 1,523.7
Magnesium (mg) 271.7
Iron (mg) 11
Zinc (mg) 13.6
Selenium (mcg) 110.1
Potassium (mg) 2,539
Sodium (mg) 3,018

Foods Recommended: Peanut Allergy

Check all labels and verify safe food preparation techniques to determine safety. Check
products purchased for cross-contact risk.
Printable version
Food Group Recommended Foods
Milk and
Milk
Products
All milk products allowed, such as whole,
reduced-fat, low-fat, fat-free, condensed,
evaporated, and dry milk; cheese, cream
cheese, pudding, sour cream, yogurt and ice
creams if made without peanut ingredients and
without potential for cross-contact with peanut
Meat and
All fresh and frozen meats (beef, veal, lamb,
pork) and poultry; fresh, frozen, and canned fish
and shellfish; eggs; legumes (other than peanut
and lupine) and legume butter (such as soynut
butter); and seeds (and seed butter such as
sunflower seed butter) without added peanut
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meat and
Other
Protein
Foods
ingredients and without potential for
cross-contact with peanut
Although peanut is a legume and not a tree nut,
allergy to tree nuts is a risk for those with
peanut allergy. Ask your doctor if you can
include tree nuts in your child's diet. Also be
aware that peanuts and tree nuts often come in
contact during manufacturing. Avoid those
products with precautionary labeling for peanut.
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles without
added peanut ingredients and without potential
for cross-contact with peanut
Vegetables
All fresh, frozen, and canned vegetables
prepared without peanuts
100% vegetable juice
Fruits
All fresh, frozen, and canned fruits prepared
without peanuts
100% fruit juice
Fat and oils
Butter, margarine, vegetable oils (except
expeller-pressed, expelled, extruded, and
cold-pressed peanut oils), vegetable oil spray,
gravies, mayonnaise, sauces, and salad
dressings made without peanut ingredients and
without potential for cross-contact with peanut
Note: The FDA has exempted refined peanut
oil from mandatory labeling because studies
show that refined peanut oil can be safely
consumed by individuals with peanut allergy.
Beverages
All beverages without peanut ingredients and
without potential for cross-contact with peanut
Other
Pepper and salt, herbs and spices, mustard,
ketchup, relish, gelatin, honey; jam, jelly,
marmalade, preserves; sugar; maple syrup

Foods Not Recommended: Peanut Allergy

Printable version
Food Group Foods Not Recommended
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk and
Milk
Products
Any with added peanut ingredients
Meat and
Other
Protein
Foods
All fresh and frozen meats (beef, veal, lamb,
port), fish and shellfish, poultry, and eggs with
added peanut ingredients
Peanuts and peanut ingredients:
Peanut
Peanut butter
Peanut flour
Mixed nuts
Ground nuts
Beer nuts
Nut pieces
Nutmeat

Nu-Nuts and other artificial nuts (such as
mandelonas, which are peanuts that have been
soaked in almond flavoring)
Goobers
Note: Ask the child's doctor if the child should
avoid lupine and tree nuts as well as peanuts
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles with
added peanut ingredients or potential for
cross-contact with peanut
Vegetables
Fresh, frozen, and canned vegetables prepared
with peanuts
Fruits
Fresh, frozen, and canned fruits prepared with
peanuts
Fat and oils
Peanut protein may be found in arachis oil
and cold-pressed, expressed, expelled, or
extruded peanut oils—these should be avoided
Beverages Peanut-containing beverages
Other
Peanut-containing candies and chocolates;
certain ethnic foods such as Thai, Chinese,
Indonesian, Vietnamese, and African use
peanut ingredients frequently; peanut may be
used as a thickener in soups, stews, chili and
pasta sauces; peanut may also be used to seal
egg rolls before frying
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sample 1-Day Menu: Peanut Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Peanut Allergy
Printable version

Breakfast
Scrambled egg (1)
Whole grain bagel, ½
Cream cheese, 2 teaspoons
Strawberry jam, 2 teaspoons
1/2 cup grapes
Orange juice, 4 ounces
Lunch
Turkey sandwich:
Turkey, 3 ounces
Whole wheat bread
Lettuce
Mayonnaise, 1 teaspoon
Lettuce and tomato
Homemade cookie
1/2 cup cherries
1 cup 1% milk
Snack
Mixed berry smoothie:
1% milk, 4 ounces
Mixed berries, ½ cup
Dinner
Barbecued chicken, 2 ounces
a
Mashed potatoes, 1/2 cup
Broccoli, 1/2 cup, with olive oil, 1 teaspoon
Spinach salad with vinaigrette
1% milk, 1 cup
a
Read labels carefully, as bottled barbecue sauces or marinades may contain peanut (or
tree nut) ingredients.
Approximate Nutrient Analysis

Energy (kcal) 1,384
Protein (g) 76
Carbohydrate (g) 168
Total fiber (g) 19
Total fat (g) 50.2
Saturated fat (g) 13.6
Monounsaturated fat (g) 24
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Polyunsaturated fat (g) 10
Linoleic acid (omega-6) (g) 8.4
Alphalinolenic acid (omega-3) (g) 1
Cholesterol (mg) 299
Vitamin A (mcg retinol activity
equivalents)
872.9
Vitamin C (mg) 154.3
Vitamin E (mg alphatocopherol
equivalents)
7.4
Thiamin (mg) 0.9
Riboflavin (mg) 2
Niacin (mg) 15.7
Folate (mcg, dietary folate
equivalents)
365.6
Vitamin B-6 (mg) 1.5
Vitamin B-12 (mcg) 3.6
Calcium (mg) 1,002.5
Phosphorus (mg) 1,476.1
Magnesium (mg) 309
Iron (mg) 9.3
Zinc (mg) 7.9
Selenium (mcg) 96
Potassium (mg) 3,045
Sodium (mg) 3,206


Foods Recommended: Shellfish Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
All milk products allowed such as whole,
reduced-fat, low-fat, fat-free, condensed,
evaporated, and dry milk; cheese, cream
cheese, pudding, sour cream, yogurt, and ice
creams
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meat and
Other Protein
Foods
All fresh or frozen meats (beef, veal, pork,
lamb), poultry, fresh, frozen or canned fish,
eggs, legumes, nuts, and seeds
Grains
All grains, such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles
Vegetables
All fresh, frozen, or canned vegetables
prepared without shellfish ingredients
Fruits All fresh, frozen, or canned fruits
Fat and oils
Butter, margarine, vegetable oils, vegetable
oil spray, gravies, sauces, salad
dressings, and mayonnaise made without
shellfish ingredients
Beverages Milk, juice, coffee, tea
Other
Carrageenan is a marine algae, not a
shellfish, and is safe for those with shellfish
allergy

Foods Not Recommended: Shellfish Allergy

Printable version

Food Group Foods Not Recommended
Milk and Milk
Products
All allowed
Meat and
Other Protein
Foods
All shellfish species. If the child is allergic to
one type of shellfish, he or she is at greater
risk of having other shellfish allergies. Ask the
child's doctor if the child needs to avoid all
shellfish or just specific types of shellfish.
Crustacean
Shrimp (prawns, crevette)
Lobster (langouste, langoustine, scampo,
coral, tomalley)
Crab
Crawfish (crayfish, ecrevisse)

Mollusks
Abalone
Clam
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cockle
Mussel
Octopus
Oyster
Scallop
Snail (escargot)
Squid (calamari)
Grains All allowed
Vegetables All allowed
Fruits All allowed
Fat and oils All allowed
Beverages Clam juice
Other
Fish stock, seafood flavoring, and seafood
chowder may contain shellfish
Note: For very sensitive individuals, there is a risk of reacting to cooking vapors of shellfish
or from handling shellfish.

Sample 1-Day Menu: Shellfish Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Shellfish Allergy
Printable version
Breakfast Whole grain waffle (1)
Fresh blueberries, ½ cup
Maple syrup, 1 Tablespoon
Orange juice, 4 ounces
Lunch Grilled cheese sandwich:
Muenster cheese, 2 ounces
Olive oil, 1 Tablespoon
Whole wheat bread, 2 slices
Spinach salad, 1 cup
Vinaigrette, 2 Tablespoons
Cherries (10)
Water
Mid-Afternoon Snack Graham crackers, 2 squares
1/2 cup grapes
1% milk, 4 ounces
Dinner Grilled steak, 3 ounces
Mashed potatoes, 1/2 cup
Peas, 1/2 cup
Peach
1% milk, 4 ounces

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Approximate Nutrient Analysis
Energy (kcal) 1,377
Protein (g) 67
Carbohydrate (g) 155
Total fiber (g) 16
Total fat (g) 58.1
Saturated fat (g) 20.9
Monounsaturated fat (g) 26
Polyunsaturated fat (g) 7
Linoleic acid (omega-6) (g) 6.3
Alphalinolenic
acid (omega- 3) (g)
0.8
Cholesterol (mg) 173
Vitamin A (mcg retinol
activity equivalents)
636.9
Vitamin C (mg) 95.4
Vitamin E (mg
alphatocopherol
equivalents)
5.6
Thiamin (mg) 1
Riboflavin (mg) 1.5
Niacin (mg) 12.6
Folate (mcg, dietary folate
equivalents)
259.6
Vitamin B-6 (mg) 1.3
Vitamin B-12 (mcg) 4.4
Calcium (mg) 994.6
Phosphorus (mg) 1,172.4
Magnesium (mg) 248.2
Iron (mg) 9.6
Zinc (mg) 12
Selenium (mcg) 75.7
Potassium (mg) 2,379
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sodium (mg) 2,043

Foods Recommended: Soy Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and
Milk Products
All milk products allowed, such as whole,
reduced-fat, low-fat, and skim milk; condensed,
evaporated, and dry milk; cheese, cream
cheese, pudding, sour cream, yogurt, and ice
creams if made without soy ingredients
Meat and
Other
Protein
Foods
All fresh or frozen meats (beef, veal, pork
lamb), fish, shellfish, and canned fish (without
added soy), poultry, eggs, legumes (other than
soy), nuts, seeds if without added soy
ingredients; processed meats and luncheon
meats without soy ingredients
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles without
added soy ingredients
Vegetables
All fresh, frozen, or canned vegetables
prepared without soy ingredients
100% vegetable juices
Fruits
All fresh, frozen, or canned fruits prepared
without soy ingredients
100% fruit juices
Fat and Oils
Butter, margarine, vegetable oils (including
refined soy oil*, which is considered safe for
those with soy allergy), vegetable oil spray,
gravies, sauces, salad dressing, and
mayonnaise made without soy ingredients
Beverages
Milk, juice, coffee, tea; all beverages without
soy ingredients
Other
Refined soy oil is considered safe*
Soy lecithin is considered safe for the vast
majority of individuals who are allergic to soy
Pepper and salt, herbs and spices, mustard,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
ketchup, relish, soups, and casseroles made
without soy ingredients; flavoring extracts;
gelatin; honey; jams, jellies, marmalades,
preserves; sugar; maple syrup
* A refined vegetable oil is processed to minimize the quantity of undesirable compounds
such as free fatty acids, carbohydrates, metals, and proteins by using caustic agents,
washing, deodorization, and winterization. Because the protein component is removed in
the processing, refined vegetable oils are not considered allergenic. However, vegetable
oils that are not highly refined—such as cold pressed, expressed, expeller pressed, or
extruded—may contain protein components and may cause an allergic reaction in those
individuals allergic to the oil source.

Foods Not Recommended: Soy Allergy

Printable version

Food Group Foods Not Recommended
Milk and Milk
Products
Any with added soy protein ingredients
Meat and
Other Protein
Foods
Soy-based foods and ingredients:

Soy, soya, soybean
Edamame
Miso
Natto
Shoyu sauce
Soy (cheese, fiber, flour, grits, ice cream, milk,
nuts, sprouts, yogurt)
Soy protein (concentrate, hydrolyzed, isolate)
Soy sauce
Tamari
Tempeh
Textured vegetable protein
Tofu
All fresh or frozen meats (beef, veal, pork,
lamb) or poultry prepared, marinated, or
prebasted with a soy ingredient;
Canned fish with a soy ingredient
Processed meats and luncheon meats with
added soy ingredients (such as reduced-fat
frankfurters)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Reduced-fat peanut butters
Vegetarian and vegan products may contain
soy ingredients
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
breakfast cereals, crackers, noodles,
pancakes, pasta, pretzels, rice, tortillas, and
waffles made with soy ingredients
Vegetables
All fresh, frozen, or canned vegetables
prepared with soy ingredients
Fruits
All fresh, frozen, or canned fruits prepared with
soy ingredients
Fat and oils
Margarines, gravies, sauces, or salad
dressings made with soy protein ingredients
“Expeller-pressed” soy oil is not highly refined
and should be avoided*
Beverages
Soy milk, soy protein shakes, and other
soy-containing beverages
Other
Soy-containing broths and bouillons,
marinades, many nondairy and vegan
products, nutrition supplements and bars (high
protein, high energy, breakfast, etc.), vegan
mayonnaise, soy protein powder, soy sauce
*Vegetable oils that are not highly refined—such as cold pressed, expressed, expeller
pressed, or extruded—may contain protein components and may cause an allergic reaction
in individuals allergic to the oil source.

Sample 1-Day Menu: Soy Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Soy Allergy
Printable version
Breakfast Blueberry pancakes (2)
Butter, 1 teaspoon
Maple syrup
1% milk, 1 cup
Mid-Morning Snack Orange juice, ½ cup
Soy-free crackers (4)
Cheese, 1 oz
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lunch Chicken salad sandwich:
Chicken, 2 ounces
Mayonnaise, 1 Tablespoon
Chopped celery
Tomato, 1 slice
Soy-free, whole wheat bread, 2
slices
Avocado, cucumber, and tomato
salad
Soy-free vinaigrette
1% milk, 1 cup
Homemade oatmeal cookie (1)
Mid-Afternoon Snack Carrots
Hummus dip
Water
Dinner Barbecued pork tenderloin, 3 ounces
1/2 cup skillet potatoes
Steamed broccoli
Olive oil, 1 teaspoon
Fresh peach
1% milk, ½ cup

Approximate Nutrient Analysis
Energy (kcal) 1,374
Protein (g) 73
Carbohydrate (g) 163
Total fiber (g) 20
Total fat (g) 51.3
Saturated fat (g) 15.9
Monounsaturated fat (g) 20
Polyunsaturated fat (g) 12
Linoleic acid (omega-6) (g) 10.1
Alphalinolenic
acid (omega-3) (gm)
1.3
Cholesterol (mg) 153
Vitamin A (mcg retinol
activity equivalents)
1,194.5
Vitamin C (mg) 150.5
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin E (mg
alphatocopherol
equivalents)
7.3
Thiamin (mg) 1.4
Riboflavin (mg) 1.9
Niacin (mg) 19.5
Folate (mcg, dietary folate
equivalents)
337.2
Vitamin B-6 (mg) 1.9
Vitamin B-12 (mcg) 3
Calcium (mg) 1,019.5
Phosphorus (mg) 1416
Magnesium (mg) 247.2
Iron (mg) 8.4
Zinc (mg) 8.8
Selenium (mcg) 86.6
Potassium (mg) 3,315
Sodium (mg) 1,772

Foods Recommended: Tree Nut Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and
Milk Products
All milk products allowed, such as whole,
reduced-fat, low-fat, and skim milk; cheese;
cream cheese; pudding; sour cream; yogurt;
and ice creams, if made without tree nut
ingredients or potential for cross-contact with
tree nuts
Meat and
Other
Protein
Foods
All fresh and frozen meats (beef, veal, lamb,
port), fish and shellfish, poultry, eggs, legumes,
and seeds without added tree nut ingredients
and without potential for cross-contact with tree
nuts
Peanut is not a tree nut although there is a risk
of peanut allergy in those with tree nut allergy.
Ask your child's doctor if your child can have
peanut or peanut products such as peanut
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
butter. If allowed, choose those without
potential for cross-contact with tree nuts.
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles without
added tree nut ingredients and without
potential for cross-contact with tree nuts
Vegetables
All fresh, frozen, and canned vegetables
prepared without tree nuts
Fruits
All fresh, frozen, and canned fruits prepared
without tree nuts
Fat and oils
Butter, margarine, vegetables oils (except tree
nut oils), vegetable oil spray, gravies,
mayonnaise, sauces, and salad dressings
made without tree nut ingredients or potential
for cross-contact with tree nuts
Beverages
Milk, juice, coffee, tea; all beverages without
tree nut ingredients or potential for
cross-contact with tree nuts
Other
Pepper and salt, herbs and spices (such as
nutmeg, which is not a tree nut), mustard,
ketchup, relish, flavoring extracts (except
natural tree nut flavorings); gelatin; honey;
jams, jellies, marmalades, preserves; sugar;
maple syrup

Foods Not Recommended: Tree Nut Allergy

Printable version
Food Group Foods Not Recommended
Milk and
Milk
Products
Any with added tree nut ingredients
Meat and
Other
Protein
Almond, beech nut, Brazil nut, butter nut,
cashew, chestnut, chinquapin, coconut,
filbert/hazelnut, ginkgo, hickory, lychee nut,
macadamia nut, pecan, pili nut, pine nut
(pignolia nut), pistachio, shea nut, walnut
Ask your child's doctor if the child should avoid
all tree nuts or just specific tree nuts. Be aware
there is a risk of cross-contact during
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Foods
processing of various tree nuts (and peanuts). If
allowed, choose those without potential for
cross-contact.
Peanut is not a tree nut, although those with
tree nut allergy may be at risk for a peanut
allergy. Ask your child's doctor if peanuts should
be avoided.
Grains
All grains such as breads, other baked goods
(brownies, cakes, cookies, muffins, etc.),
cereals, crackers, noodles, pancakes, pasta,
pretzels, rice, rolls, tortillas, and waffles with
added tree nut ingredients or potential for
cross-contact with tree nuts
Vegetables
Fresh, frozen, and canned vegetables made
with tree nuts
Fruits
Fresh, frozen, and canned fruits prepared with
tree nuts
Fat and oils Tree nut oils (hazelnut, walnut, almond, etc.)
Beverages
Nut-flavored coffees (made with natural nut
extracts), nut-flavored alcoholic beverages,
almond milk, hazelnut milk, and other beverages
with tree nut ingredients
Other
Natural extracts such as almond or hazelnut
extract; barbecue sauces and other marinades
with tree nut ingredients, marzipan, nougat,
artificial nuts, pesto, and nut meal; gianduja;
mortadella (luncheon meat)—contains pistachio
nut; mandalona—peanut meal that is molded,
shaped, and reflavored with a tree nut flavoring
(typically almond or pecan)

Sample 1-Day Menu: Tree Nut Allergy

Sample 1-Day Menu for a 6- to 8-Year Old Child with Tree Nut Allergy
Printable version
Breakfast
Cheese omelet:
Egg (1)
Cheddar cheese, 1 slice
Whole grain toast, 1 slice
Margarine, 1 teaspoon
Strawberry jam, 1 teaspoon
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Strawberry jam, 1 teaspoon
Honeydew melon, ½ cup
Orange juice, 4 ounces
Lunc
Ham sandwich:
Ham, 2 ounces
Whole wheat wrap
Lettuce
Pasta and tomato salad
Italian dressing, 2 Tablespoons
Homemade brownie
1% milk, 1 cup
Snack
Mixed berry smoothie:
1% milk, 4 ounces
Mixed berries, 1/2 cup
Dinner
2 ounces grilled chicken
Baked sweet potato, 1/2 cup
Zucchini, 1/2 cup
Corn on the cob
Margarine, 2 teaspoons
1% milk, 1 cup
Approximate Nutrient Analysis
Energy (kcal) 1,474
Protein (gm) 74
Carbohydrate (g) 183
Total fiber (g) 19
Total fat (g) 53.4
Saturated fat (g) 14.2
Monounsaturated fat (g) 19
Polyunsaturated fat (g) 15
Linoleic acid (omega-6) (g) 13.4
Alphalinolenic acid (omega-3) (g) 1.6
Cholesterol (mg) 324
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vitamin A (mcg retinol activity
equivalents)
1,305.5
Vitamin C (mg) 115
Vitamin E (mg alphatocopherol
equivalents)
5.6
Thiamin (mg) 1.5
Riboflavin (mg) 1.9
Niacin (mg) 20.2
Folate (mcg, dietary folate
equivalents)
311.3
Vitamin B-6 (mg) 1.7
Vitamin B-12 (mcg) 3.3
Calcium (mg) 781.4
Phosphorus (mg) 1,265.2
Magnesium (mg) 286.4
Iron (mg) 9.7
Zinc (mg) 8.1
Selenium (mcg) 114.9
Potassium (mg) 3,000
Sodium (mg) 2,323


Foods Recommended: Wheat Allergy

Check all labels and verify safe food preparation techniques to determine safety.
Printable version
Food Group Recommended Foods
Milk and Milk
Products
All milk products allowed such as whole,
reduced-fat, low-fat, fat-free, condensed,
evaporated, and dry milk; cheese, cream
cheese, pudding, sour cream, yogurt, and ice
creams if made without wheat ingredients
Meat and
Other Protein
Foods
All fresh or frozen meats (beef, veal, lamb,
pork); fresh, frozen, or canned fish and
shellfish; egg, poultry; legumes; nuts; and
seeds without added wheat ingredients
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Grains
The following wheat-free grains, nuts, and
seeds are available as flours for home baking
or cooking and in many wheat-free commercial
products (such as wheat-free breads, pastas,
cookies, cereals, etc.):
Almond meal
Amaranth
Arrowroot
Barley
Buckwheat
Chickpea flour
Corn
Fava bean flour
Flax seed meal
Millet
Oat
Potato starch
Quinoa
Rice
Rye
Sorghum
Soy flour
Tapioca
Teff
*Ask the child’s doctor which of these wheat
alternatives may be safe
Vegetables
All fresh, frozen, and canned vegetables
prepared without wheat ingredients
100% vegetable juice
Fruits
All fresh, frozen, and canned fruits prepared
without wheat ingredients
100% fruit juice
Fat and oils
Butter, margarine, liquid oils and solid fat,
mayonnaise, vegetable oil spray, and salad
dressings without wheat ingredients
Beverages
Milk, juice, coffee, tea; all beverages without
wheat ingredients
Other
Pepper and salt, herbs and spices, mustard,
ketchup, relish, flavoring extracts; gelatin;
honey; jams, jellies, marmalades, preserves;
sugar; maple syrup

Foods Not Recommended: Wheat Allergy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Printable version

Food Group Foods Not Recommended
Milk and Milk
Products
Any with added wheat ingredients
Meat and
Other
Protein
Foods
Any meats (beef, veal, lamb, pork), fish and
shellfish, egg, poultry, legumes, nuts, or seeds
prepared with wheat ingredients
Grains
Most of the following contain wheat: Breads
and rolls (white, whole wheat, multigrain,
potato, rye, etc.), other baked goods
(brownies, cakes, cookies, muffins, etc.), bread
crumbs, bulgur, cereals, couscous, pancakes,
pasta, and waffles.

Wheat ingredients:
Cereal extract
Durum flour, durum wheat
Emmer
Einkorn
Farina
Flour (all-purpose, cake, enriched, graham,
high gluten, high protein, pastry, and wheat)
Kamut
Semolina
Spelt
Sprouted wheat
Triticale
Vital gluten, wheat (bran, germ, gluten, malt,
starch)
Whole wheat berries
Vegetables
All fresh, frozen, and canned vegetables
prepared with wheat ingredients
Fruits
All fresh, frozen, and canned fruits prepared
with wheat ingredients
Fat and oils
Gravies, sauces, and salad dressings prepared
with wheat ingredients
Beverages Some ready-made “instant breakfast” products
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Other
Condiments that contain wheat (such as soy
sauce); licorice (such as Twizzlers)

Sample 1-Day Menu: Wheat Allergy

Sample 1-Day Menu for a 6- to 8-Year-Old Child with Wheat Allergy

Printable version

Breakfast 1 oat-blueberry pancakes
Maple syrup, 2 Tablespoons
1% milk, 8 oz
Cantaloupe melon
2 slices turkey bacon
Mid-Morning Snack Fresh orange
Lunch Corn quinoa pasta, 1 cup
Tomato sauce, ¼ cup
2 meatballs made with
wheat-free breadcrumbs

Mixed green salad
Vinaigrette, 2 teaspoons
Water
Mid-Afternoon Snack 1 store-bought wheat-free
cookie bar
1% milk, 4 ounces
Dinner Baked chicken, 3 ounces
Brown rice, ½ cup
Glazed carrots, ½ cup
Wheat-free bread
Cherry tomatoes (6)
Margarine, 1 teaspoon
1% milk, 8 ounces

Approximate Nutrient Analysis
Energy (kcal) 1,620.19
Protein (g) 67.35
Carbohydrates (g) 220.42
Fat (g) 52.27
Saturated fat (g) 13.12
Cholesterol (mg) 140.84
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Total dietary fiber (g) 21.60
Vitamin A (mcg) 433.56
Thiamin (mg) 0.75
Riboflavin (mg) 1.40
Niacin (mg) 6.44
Pantothenic acid
(mg)
3.03
Vitamin B-6 (mg) 0.84
Total folate (mcg) 181.72
Vitamin B-12 (mcg) 2.17
Vitamin C (mg) 76.80
Vitamin D (IU) 226.80
Vitamin E
alphatocopherol
equivalents (mg)
1.93
Calcium (mg) 887.59
Iron (mg) 9.79
Magnesium (mg) 232.74
Manganese (mg) 3.26
Phosphorus (mg) 972.34
Selenium (mcg) 32.54
Sodium (mg) 2,549.91
Zinc (mg) 6.15





Client Education Materials

Nutrition Therapy Handouts
Nutrition Therapy for Children with Multiple Food Allergies
Nutrition Therapy for Children with Egg Allergies
Nutrition Therapy for Children with Fish Allergies
Nutrition Therapy for Children with Milk Allergies
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Therapy for Children with Peanut Allergies
Nutrition Therapy for Children with Shellfish Allergies
Nutrition Therapy for Children with Soy Allergies
Nutrition Therapy for Children with Tree Nut Allergies
Nutrition Therapy for Children with Wheat Allergies

Tip Sheets
Tips for Managing Multiple Food Allergies
Tips for Managing Egg Allergy
Tips for Managing Fish Allergy
Tips for Managing Milk Allergy
Tips for Managing Peanut Allergy
Tips for Managing Shellfish Allergy
Tips for Managing Soy Allergy
Tips for Managing Tree Nut Allergy
Tips for Managing Wheat Allergy

Handouts in Spanish:
Nutrition Therapy for Children with Multiple Food Allergies
Nutrition Therapy for Children with Egg Allergies
Nutrition Therapy for Children with Fish Allergies
Nutrition Therapy for Children with Milk Allergies
Nutrition Therapy for Children with Peanut Allergies
Nutrition Therapy for Children with Soy Allergies
Nutrition Therapy for Children with Wheat Allergies
Tips for Managing Multiple Food Allergies

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases
Gastrointestinal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Celiac Disease
Foods Recommended

Printable version
The following grains and starches are acceptable for the gluten-free dietary pattern:
Amaranth
Arrowroot
Bean flours
Buckwheat
Corn (corn bran, corn grits, hominy, masa harina, cornmeal, corn flour)
Chia seeds/flour
Flax
Indian rice grass (montina)
Job's tears
Mesquite
Millet
Nut flours
Oats specially grown and processed to be gluten-free
Potato (potato starch and potato flour)
Quinoa
Ragi
Rice (all forms)
Salba
Sorghum
Soy
Tapioca
Tef
Wild rice
It is recommended that these naturally gluten-free grains and starches be labeled "gluten
free" to ensure that they are processed to prevent cross-contact with gluten-containing
grains (Thompson, 2010).
Other Naturally Gluten-Free Foods
Fresh, plain frozen, and canned fruits and vegetables
Milk
Fresh meat, fish, poultry, and eggs
Aged cheese
Vegetable oils
Butter
Unprocessed nuts and seeds
Dried legumes, lentils

Foods Not Recommended

Printable version
Grains to Avoid
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The following grains are eliminated in a gluten-free dietary pattern:
Wheat
All varieties, including spelt, kamut, einkorn, emmer (faro or farro), durum,
semolina, triticale, and atta
All forms, including wheat bran, couscous, graham flour, matzoh, wheat germ,
cracked wheat, farina, and tabouli
Rye
Barley
All forms, including malt, malt flavoring, malt extract, malt syrup, and malt
vinegar
Untested oats
Tested oats and wheat starch and other forms of these listed grains that have been
specially processed or grown to eliminate the gluten protein may meet the US Food and
Drug Administration's proposed rule for "gluten-free" labeling if they contain less than 20
ppm gluten. The FDA's proposed rule on gluten-free labeling can be found here.

Other Ingredients to Avoid
Any ingredient derived from wheat, rye, oats, or barley, including malt
Read labels to ensure that the words wheat, rye, oats, barley, and malt are not
included in the ingredients
The following ingredients, which are often overlooked, should be avoided or
questioned:
Soy sauce (may be made with wheat)
Malt vinegar (made with fermented barley)
Seasoning (may use wheat)
Marinades (may have wheat or barley)
Broth (may be made with wheat)
Notes:
Wheat has to be declared under the Food Allergy Labeling and Consumer Protection
Act.
Barley is almost always listed as barley or malt
Cross-Contamination
Cross-contamination may occur any time gluten-free and gluten-containing grain or food is
grown, harvested, transported, processed, or prepared in the same area, including
manufacturing plants, restaurants, and home kitchens.
Good manufacturing practices will eliminate issues with cross-contamination for most
manufactured foods.
When gluten-containing foods are prepared in the same kitchen as gluten-free foods,
cooking equipment and utensils should be thoroughly cleaned. Cooking oils or water that
can be reused should not be used to prepare gluten-free foods if they have been
previously used to cook gluten-containing foods.

Sample 1-Day Menu
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sample Gluten-Restricted, Gliadin-Free Menus
These sample menus are designed for a 7- to 10-year-old and may need to be adjusted to
meet the needs of children in other age groups.

Printable version

Menu 1
A gluten-free meal plan does not have to be all that different from a wheat-based meal
plan. There are gluten-free versions of almost all foods that are usually made from wheat.

Breakfast


1 whole-grain, gluten-free waffle
2 tablespoons maple syrup, 2 teaspoons
margarine, and ½ cup strawberries
8 ounces low-fat milk
Lunch

1 slice gluten-free cheese frozen pizza topped
with 2 tablespoons green pepper and 6 slices
pepperoni
½ cup baby carrots
1 apple (sliced)
8 ounces low-fat milk
Snack
Parfait: ½ cup low-fat yogurt mixed with 2
tablespoons whole grain gluten-free granola and
½ cup blueberries
Evening
Meal
1 cup whole grain or enriched gluten-free pasta
topped with ½ cup spaghetti sauce and ¼ cup
ground turkey
½ cup peas
8 ounces lemonade
Snack 2 gluten-free snickerdoodle cookies

Approximate Nutrient Analysis
Energy (kcal) 1,800
Protein (g) 58 (15% of kcal)
Fat (g) 58 (30% of kcal)
Carbohydrate (g) 245 (55% of kcal)
Fiber (g) 21
Calcium (mg) 1,200
Iron (mg) 8
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sodium (mg) 2,265
Potassium(mg) 2,473

Menu 2
This sample menu uses foods commonly available in grocery stores. The meals do not
require the use of any specially made gluten-free foods.
Breakfast
2 cups Rice or Corn Chex cereal
8 ounces low-fat milk
4 ounces orange juice
Lunch
2 ounces taco meat seasoned with chili powder,
2 corn taco shells, 1 ½ cups lettuce/tomato, 2
tablespoons shredded cheese
1 apple
8 ounces low-fat milk
Snack
1 ounce string cheese
3 cups plain microwave popcorn
Evening
meal
2 ounces chicken and 1 cup fresh vegetables
stir-fried in 1 teaspoon oil and spices
½ cup plain brown rice or plain enriched white rice
½ cup mandarin oranges
8 ounces water
Snack
½ cup vanilla ice cream with 2 tablespoons plain
peanuts

Approximate Nutrient Analysis
Energy (kcal) 1,800
Protein (g) 78 (15% of kcal)
Fat (g) 70 (35% of kcal)
Carbohydrate (g) 220 (50% of kcal)
Fiber (g) 16
Calcium (mg) 1,344
Iron (mg) 8
Sodium (mg) 3,100
Potassium(mg) 2.728

Client Education Materials

Gluten-Free Nutrition Therapy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Gluten-Free Label Reading Tips
Gluten-Free Resources
Gluten-Free Multivitamins

Handout in Spanish:
Gluten-Free Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Constipation
Foods Recommended

Printable version
Food
Group
Foods to Include to Increase Fiber Intake
Fruits
apple, avocado, banana, cantaloupe, cherries,
grapefruit, mango, nectarine, orange, papaya,
peach, pear, pineapple, watermelon,
blackberries, blueberries, kiwi, raspberries,
strawberries, dried fruits (raisins, apricots, dates,
figs, prunes, peaches, cranberries, etc)
Vegetables
raw or cooked vegetables: asparagus, broccoli,
potato with peel, brussels sprouts, cabbage,
carrots, cauliflower, celery, corn, green beans,
peas, peppers, spinach, squash, sweet potato,
tomato, legumes (eg, kidney beans, garbanzo
beans, black beans, pinto beans, baked beans
etc), nuts (eg, peanuts, almonds, cashews,
pistachios, walnuts etc)
Grains
whole grain breads, pastas, cereals, and
crackers, wild rice and brown rice
Dairy fruited yogurt


Foods Not Recommended

Unprocessed bran is not recommended, as it may cause bloating and flatulence and
reduce the absorption of micronutrients (NICE, 2010). In addition, low-fiber foods are not
recommended as they could exacerbate constipation.
Printable food lists

Sample 1-Day Menu

Sample Menu for a High-Fiber Diet
Printable version
This sample menu is designed to meet the requirements of a 7- to 10-year old child.
Oatmeal (1/2 cup)
Raisins (1 tbsp)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast
Raisins (1 tbsp)
Whole wheat toast (1/2 slice)
Margarine (1 tsp)
Seeded jam (2 tsp)
Reduced fat milk (1 cup)
Pear nectar (4 oz)
Morning Snack
Orange (1/2)
Crackers (2)
Water (8 oz)
Lunch
Whole wheat bread (1 slice)
Peanut butter, crunchy (1 tbsp)
Seeded jam (2 tsp)
Carrot stick (1 medium)
Ranch dressing, low fat (1 tbsp)
Grapes (1/2 cup)
Reduced fat milk (8 oz)
Afternoon Snack
Popcorn (1 cup)
Apple juice (1 cup)
Dinner
Hamburger bun (1)
Beef patty (3 oz)
Lettuce (1 leaf)
Tomato (1 slice)
Ketchup (1 tsp)
Homemade french fries with skin (1/2 cup)
Corn-on-the-cob (1/2 cob)
Margarine (2 tsp)
Fig cookies (2)
Reduced fat milk (8 oz)
Evening Snack
Oatmeal raisin cookie (1)
Water (4 oz)

Approximate Nutrient Analysis
Energy (kcal) 2341
Protein (g) 91
Carbohydrate (g) 335
Total fat (g) 81
Saturated fat (g) 27
Monounsaturated fat (g) 32
Polyunsaturated fat (g) 15
Cholesterol (mg) 136
Calcium (mg) 1676
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Iron (mg) 21
Magnesium (mg)

444
Dietary Fiber (g)

18.5
Phosphorus (mg) 1967
Potassium (mg) 4288
Sodium (mg) 2047
Zinc (mg) 21
Vitamin A (µg RE) 2142
Vitamin C (mg) 125
Thiamin (mg) 2.5
Riboflavin (mg) 3.5
Niacin (mg) 29
Folate (µg) 432
Vitamin B
6
(mg) 2.9
Vitamin B
12
(µg) 8.6

Client Education Materials

High-Fiber Nutrition Therapy
Meal Planning Tips for Children with Constipation
Tips for Increasing Fiber Intake in Children

Handouts in Spanish:
High-Fiber Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Inflammatory Bowel Disease
Foods Recommended

Printable version
If a client is lactose intolerant, the following foods are recommended:

Food Group Recommended
Grains and Starches Whole-grain or enriched breads
and cereals, potatoes, enriched
rice, barley; noodles, spaghetti,
macaroni, and other pastas
Meat and Other
Protein Foods
All meats, poultry, fish, and
shellfish; eggs, dried peas and
beans, nuts, peanut butter,
aged cheese (if tolerated),
yogurt (if tolerated)
Vegetables All
Fruits All fruits and fruit juices
Soups Broth, bouillon; soups made
with allowed ingredients
Beverages All beverages with allowed
ingredients, soy-based
infant formulas, soy-based milk
products (yogurt, cheese, sour
cream, etc), and other
lactose-free supplements;
almond or rice milk;
lactase-hydrolyzed milk*
Sweets/Desserts Sugar, corn syrup, honey,
jellies, jams, pure sugar
candies, marshmallows, cakes,
cookies, pies; flavored gelatin
desserts; water ices made with
allowed foods
Fats and Oils Milk-free margarine; salad
dressing; non-dairy creamer; all
oils
Other All spices, seasonings,
flavorings
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Foods Not Recommended

Printable version
If a client is lactose intolerant, the following foods may cause gastrointestinal distress:
Food Group Foods Not Recommended
Grains and Starches Depending on tolerance, some
breads and cereals prepared with
milk or milk products may need to
be avoided; potatoes or
substitutes prepared with milk or
milk products; mixes prepared
with lactose-containing
ingredients
Vegetables Vegetables prepared with milk or
milk products
Fruits None
Meat and
Other Protein Foods
Cold cuts and frankfurters that
contain lactose filler; cottage
cheese
Soups Soups made with milk or milk
products
Beverages Milk, milk products, or
acidophilus milk as tolerance
dictates
Sweets/Desserts Chocolate, caramels, any
candies made with
lactose-containing ingredients
Any desserts prepared with milk
or milk products (eg, sherbet, ice
cream, ice milk, custard, pudding,
commercial desserts, and mixes)
Fats and Oils Any prepared with
lactose-containing ingredients
Other Any prepared with milk or milk
products

Sample 1-Day Menu: Low Lactose

Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast

Orange juice (½ cup)
Ready-to-eat cereal (1 cup)
Whole-wheat toast (1 slice)
Margarine (1 teaspoon)
Jelly or jam (2 teaspoons)
100% lactose-hydrolyzed, low-fat milk
(1 cup)
Lunch Ham sandwich:
Ham (3 ounces)
Whole-wheat bread (2 slices)
Mayonnaise (2 teaspoons)
Pretzels (¾ ounces)
Carrot sticks (1/2 cup)
Fruit yogurt (½ cup)
Apple juice (1/2 cup)
Afternoon Snack Graham crackers (2 squares)
Orange (1 medium)
Dinner Hamburger patty (3 ounces)
Hamburger bun (1)
French fries, baked (½ cup)
Broccoli (½ cup)
Tossed salad (1 cup)
Salad dressing (2 tablespoons)
Applesauce (½ cup)
100 % lactose-hydrolyzed, low-fat milk
(1 cup)
Evening Snack

Fruit ice (½ cup)
Vanilla wafers (4)
This sample menu meets requirements for an 8-year-old child.

Approximate Nutrient Analysis
Energy (kcal) 2,167.87
Protein (g) (16.09% of kcal) 87.18
Carbohydrate (g) (56.07% of kcal) 303.87
Total fat (g) (30.24% of kcal) 72.85
Saturated fatty acids (SFA) (g) (9.35%
of kcal) 22.52
Monounsaturated fatty acids (MUFA)
(g)
(12.8% of kcal) 30.83
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Polyunsaturated fatty acids (PUFA) (g)
(5.47% of kcal) 13.18
Cholesterol (mg) 176.58
Calcium (mg) 1,186.25
Iron (mg) 20.73
Magnesium (mg) 329.51
Phosphorus (mg) 1,497.55
Potassium (mg) 3,298.72
Sodium (mg) 3,392.21
Zinc (mg) 16.67
Total vitamin A activity (retinol
equivalents) (mcg) 2,004.02
Vitamin C (ascorbic acid) (mg) 210.62
Thiamin (vitamin B1) (mg) 2.41
Riboflavin (vitamin B2) (mg) 2.6
Niacin (vitamin B3) (mg) 23.73
Folate (mcg) 541.63
Vitamin B-6 (pyridoxine, pyridoxyl, &
pyridoxamine) (mg) 2.16
Vitamin B-12 (cobalamin) (mcg) 6.82
Total dietary fiber (g) 23.29
Insoluble dietary fiber (g) 15.02
Vitamin D (calciferol) (mcg) 7.12

Sample 1-Day Menu: Low Residue

NOTE: This meal plan is rarely used; the information below is for RD or food service use
only in case a low-residue diet order is still used in a facility.
Conditions that may require a low-residue diet
Preparation for or recovery from abdominal or intestinal surgery
Bowel inflammation
Crohn’s disease
Diverticulitis
Ulcerative colitis
Radiation therapy to the pelvis and lower bowel
Chemotherapy
Preparation for a colonoscopy

Tips
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tips
Instruct the client to limit milk and milk products, caffeine, and prune juice.
Clients who are lactose intolerant may need to avoid dairy foods completely.
Fruits and vegetables should be limited on this meal plan.
Recommend supplements if necessary.
Sample Menu for Fiber- and Residue-Restricted Diet
This sample menu is designed to meet the requirements of a 7-10 year old child.

Breakfast
Cranberry juice (1/2 cup)
Puffed rice cereal (3/4 cup)
Canned peaches (1/2 cup)
Reduced fat milk (1/2 cup)
White bread toast (2 slices)
Margarine (2 tsp)
Jelly (1 tbsp)
Lunch
Lean beef patty (3 oz)
Hamburger bun without seeds (1)
Mustard (1 tbsp)
Ketchup (1 tbsp)
Canned fruit cocktail (1/2 cup)
Vanilla wafer cookies (2)
Reduced-fat milk (1 cup)
Afternoon Snack
Applesauce (1/2 cup)
Graham crackers (2 squares)
Dinner
Strained tomato juice (1/2 cup)
Breaded baked chicken strips (3 oz)
White rice (1/2 cup)
Cooked carrots (1/2 cup)
White bread dinner roll (1)
Margarine (2 tsp)
Sherbet (1/2 cup)
Reduced-fat milk (1 cup)
Evening Snack Fruit ice (1/2 cup)

Approximate Nutrient Analysis
Energy (kcal) 2,025
Protein (g) 71
Carbohydrate (g) 288
Total fat (g) 68
Saturated fat (g) 22
Monounsaturated fat (g) 29
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Polyunsaturated fat (g) 11
Cholesterol (mg) 152
Calcium (mg) 754
Iron (mg) 11.7
Magnesium (mg) 198
Dietary Fiber (g) 13.1
Phosphorus (mg) 970
Potassium (mg) 2,282
Sodium (mg) 2,763
Zinc (mg) 10
Vitamin A (ug RE) 2,254
Vitamin C (mg) 93
Thiamin (mg) 1.4
Riboflavin (mg) 1.7
Niacin (mg) 133
Folate (mcg) 133
Vitamin B
6
(mg) 1.4
Vitamin B
12
(mcg) 3.3


Client Education Materials

Low-Lactose Nutrition Therapy
Low-Residue Nutrition Therapy: See Meal Plans


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Diarrhea
Foods Recommended

These suggestions are suitable for most children. However, if the patient's symptoms get
worse after eating specific foods on this list, they should stop eating them until after they
recover.
Printable version
Food
Group
Recommended Foods Notes
Milk and
Milk
Products
Breastmilk and infant
formula
Buttermilk
Evaporated, skim, and
low-fat milk
Soy milk
Yogurt with live active
cultures added
probiotics/prebiotics
Powdered milk
Cheese
Low-fat ice cream
Sherbet
If the child has lactose
intolerance, drinking
milk products may
aggravate diarrhea. Try
lactose-free products.
Avoid yogurts with nuts
or dried fruit.
Meat and
Other
Protein
Foods
Tender, well-cooked
meat, poultry, fish,
eggs, or soy foods
made without added
fat
Smooth nut butters

Grains
White flour
Bread, bagels, rolls,
crackers, and pasta
made from white or
refined flour
Cold or hot cereals
made from white or
refined flour
Choose grain foods
with less than 2g
dietary fiber per
serving. (To find out
how much fiber is in a
serving of a packaged
food, look on its
Nutrition Facts label.)
Vegetables
Most well-cooked
vegetables without
seeds or skins
Potatoes without skin
Strained vegetable
juice
See the Foods Not
Recommended chart
for vegetables to avoid.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruits
Fruit juice without
pulp, except prune
juice
Ripe bananas
Melons
Canned soft fruits
See the Foods Not
Recommended chart
for fruits to avoid.
Fats and
oils
Oil
Butter
Cream cheese
Margarine
Mayonnaise

Beverages
Decaffeinated coffee
Caffeine-free teas
Soft drinks without
caffeine
Rehydration
beverages
Fluid requirements will
vary depending on the
age/size of the
child. Fluid needs may
be increased in order
to replace fluids lost to
diarrhea.

*adapted from Nutrition Care Manual: Diarrhea

Foods Not Recommended


Printable version
Food Group Foods Not Recommended
Milk and Milk
Products
Whole milk
Half-and-half
Cream
Sour cream
Regular (whole milk) ice cream
Yogurt with berries, dried fruit, or nuts
Meat and Other
Protein Foods
Fried meat, poultry, or fish
Luncheon meats, such as bologna or salami
Sausage and bacon
Hot dogs
Fatty meats
Nuts
Chunky nut butters
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Grains
Whole wheat or whole grain breads, rolls,
crackers, or pasta
Brown or wild rice
Barley, oats, and other whole grains
Cereals made from whole grain or bran
Breads or cereals made with seeds or nuts
Popcorn
Vegetables
Raw vegetables
Fried vegetables
Beets
Broccoli
Brussels sprouts
Cabbage
Cauliflower
Collard, mustard, and turnip greens
Corn
Potato skins
Fruits
All raw fruits except banana and melons
Dried fruits, including prunes and raisins
Fruit juice with pulp
Canned fruit in heavy syrup
Any fruits sweetened with sorbitol
Prune juice

Fats and Oils All fats should be limited
Beverages
Beverages containing caffeine, including
regular coffee, regular tea, colas, and energy
drinks
Limit beverages containing high fructose corn
syrup; avoid beverages sweetened with
sorbitol.

Other foods to
avoid
Sugar alcohols such as xylitol and sorbitol;
honey

*Adapted from Nutrition Care Manual: Diarrhea

Sample 1-Day Menu

Sample Menu for a 7- to 10-Year Old Child with Diarrhea
Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast
1 cup Rice Krispies
1 cup vanilla soy milk
½ ripe banana
Snack
1 cup water or other decaffeinated beverage
6 ounces yogurt or 2 graham cracker rectangles
Lunch
2 cups chicken rice soup with 2 ounces of added
chicken
¼ cup cooked carrots
1 slice white toast with thin spread of jelly
½ cup applesauce
Snack
2 or 3 saltine crackers
1 cup fruit juice without pulp
Dinner
4 to 6 ounces baked fish topped with
breadcrumbs, a squeeze of lemon, and 1
teaspoon butter or margarine
½ cup mashed potato without skins
½ cup green beans, cooked well
1½ cups water or other caffeine-free beverages
Snack
½ cup sorbet
1 cup hot chocolate made with water or soy milk

Approximate Nutrient Analysis
Energy (kcal) 1620
Total protein (g)
70 (17% of
kcal)
Total carbohydrate (g)
251 (61% of
kcal)
Total fat (g)
42.9 (23% of
kcal)
Saturated fatty acids (g)
13.1 (7% of
kcal)
Monounsaturated fatty
acids (g)
15 (8% of kcal)
Polyunsaturated fatty acids
(g)
10 (5% of kcal)
Cholesterol (mg) 164
Calcium (mg) 765.6
Iron (mg) 10.6
Magnesium (mg) 301.7
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Phosphorus (mg) 1258.8
Potassium (mg) 3213
Sodium (mg) 3679
Zinc (mg) 6.1
Vitamin A (mcg RAE) 894.5
Vitamin C (mg) 126.7
Thiamin (mg) 1.6
Riboflavin (mg) 1.9
Niacin (mg) 15.3
Total folate (mcg) 291.8
Vitamin B-6 (mg) 1.7
Vitamin B-12 (mcg) 6.2
Total dietary fiber (g) 17

Client Education Materials

Nutrition Therapy for Children with Diarrhea

Handout in Spanish:
Nutrition Therapy for Children with Diarrhea

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Gastroesophageal Reflux
Foods Recommended

Printable version
Food Group Recommended Foods
Milk and Milk
Products
Breast milk and infant formula
Buttermilk
Evaporated skim milk
Skim or 1% low-fat milk
Soy, rice, nut, and hemp milks
Nonfat or low-fat yogurt
Powdered milk
Nonfat or low-fat cheeses
Low-fat ice cream
Sherbet
Meat and Other
Protein Foods
Tender, well-cooked lean meat,
poultry, fish, eggs, or soy prepared
without added fat
Dried beans and peas
Nuts and nut butters (limit amount
eaten)
Grains
Any prepared without added fat
Choose whole grains for at least half
of grain servings
Vegetables
Any prepared without added fat
Eat a variety of vegetables, especially
green and orange ones
Fruits
Any prepared without added fat
Eat a variety of fruits
Fats
Addition of fats to foods should be
limited
Beverages
Caffeine-free beverages such as juice
and water
Other All condiments except pepper
For recommended foods, age should be considered to ensure the child is receiving
age-appropriate foods.
Low-fat products are not appropriate for children younger than 2 years because of the role
of fat in neurologic development and brain function.

Foods Not Recommended

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Printable version
A trial of limiting or eliminating the following foods may reduce the symptoms of
gastroesophageal reflux disease. Elimination of large meals or overeating may also reduce
symptoms.
Peppermint and spearmint
Chocolate
Caffeinated beverages
Regular tea
Colas
Coffee
Energy drinks
Other caffeinated soft drinks
Pepper
Spicy foods
High-fat foods in children older than 2 years of age, including the following:
2% milk, whole milk, cream, high-fat cheeses, high-fat yogurt, chocolate milk,
cocoa
Fried meats, bacon, sausage, pepperoni, salami, bologna, frankfurters/hot dogs
Other fried foods (doughnuts, french toast, french fries, deep-fried vegetables)
Pastries, cakes, cookies, regular ice cream, cheesecake
Nuts and nut butters
Oil, butter, margarine, mayonnaise
Any fruit or vegetable that causes symptoms, such as citrus fruits or tomatoes


Sample 1-Day Menu

Printable version
Sample Menu for a Child Aged 7 to 8 Years with Gastroesophageal Reflux Disease
Breakfast
1 cup corn flakes
1 cup 1% milk
1/2 medium banana
1 slice toast with 1 teaspoon margarine and 1
Tablespoon jam
Snack
1 cup water or other decaffeinated beverage
2 graham cracker squares
1/2 medium apple
Lunch
1 slice whole wheat bread
2 ounces turkey
1 teaspoon mustard
8 baby carrots
1 Tablespoon ranch dressing
1/2 cup grapes
1 cup 1% milk
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
1 cup air-popped popcorn
6 ounces low-fat fruit yogurt
6 ounces water
Dinner
3 ounces broiled chicken breast without skin
1/2 cup mashed potatoes
1/2 cup green beans
1 dinner roll
8 ounces water or other decaffeinated beverage
Snack 1 oatmeal raisin cookie
Approximate Nutrient Analysis
Energy (kcal) 1648 Phosphorus
(mg)
1,132
Protein (g) 82.8 Potassium
(mg)
2972
Carbohydrate (g) 251 Sodium (mg) 2249
Total fat (g) 39 Zinc (mg) 8.2
Saturated fat (g) 11 Vitamin A
(mcg RE)
1075
Monounsaturated
fat (g)
13.5 Vitamin C 45
Polyunsaturated
fat (g)
11 Thiamin
(mg)
1.3
Cholesterol (mg) 143 Riboflavin
(mg)
2.3
Calcium (mg) 1073 Niacin (mg) 27
Iron (mg) 15 Folate
(mcg)
291
Magnesium (mg) 263 Vitamin B-6
(mg)
2.4
Dietary fiber (g) 18 Vitamin
B-12 (mcg)
4.9


Client Education Handouts

Gastroesophageal Reflux Disease Nutrition Therapy

Handout in Spanish
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Gastroesophageal Reflux Disease Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Irritable Bowel Syndrome
Foods Recommended

Increasing Fiber Intake in Children
Printable version
Foods to Include (~2 g
Fiber/Serving)
Suggestions for Increasing
Intake
Fruit
Fresh Fruit
Apple with skin (2/3)
Avocado (1/4)
Banana (1 medium)
Cantaloupe (1½ cups)
Cherries (20)
Grapefruit (1 medium)
Mango (2/3 medium)
Nectarine (1 medium)
Orange (2/3)
Papaya (2/3)
Peach (1 medium)
Pear (1/2 medium)
Pineapple (1 cup)
Plums (2 medium)
Watermelon (3 cups)
Fruit preserves (5
tablespoons)
Fruit with edible seeds
Blackberries (1/4 cup)
Blueberries (1/3 cup)
Kiwi (3/4 medium)
Raspberries (1/4 cup)
Strawberries (2/3 cup
sliced)
Dried fruit
Apricots (8 halves)
Raisins (1/3 cup)
Dates (4)
Figs (1)
Peach (2 halves)
Prunes (3)
Fruit-filled cereal bars
(1)
Try scoring an apple so it
is striped
Spread crunchy peanut
butter on apple and
banana slices
Dip fruit in yogurt or
chocolate then nuts or
favorite whole grain cereal
Add dried fruit to cereals,
baked goods, pancake
batter, fruit salad, etc.
Make fresh fruit kabobs
on popsicle sticks
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(1)
Fruit nectar
Apricot nectar (10 oz)
Pear nectar (10 oz)
Prune juice (8 oz)
Vegetables
Raw/cooked vegetables
Asparagus (1 cup)
Broccoli (1/2 cup)
Potato with peel (1/2
medium)
Brussel sprouts (2½
sprouts)
Cabbage, raw (1½-2
cups)
Carrots (1 medium or 2
baby carrots)
Cauliflower (3/4 cup)
Celery (½-3/4 cup)
Eggplant (1 cup)
Green beans (1/2-1
cup)
Peas (1/3 cup)
Pepper, sweet (1 cup)
Spinach (½ cup)
Squash (½-1 cup)
Sweet potato (½ cup)
Tomato (1¼ medium)
Potato skins (2)
Corn on the cob (5½-in
pieces)
Carrot juice (8 ounces)
Try raw veggies and dip
Leave the peel on
Add chopped celery,
carrots, green peppers,
etc, to tuna, chicken, and
other salads
Use unpeeled potatoes to
make potato salad, french
fries, hash browns, etc.
Spread crunchy peanut
butter on celery slices and
top with raisins
Make vegetable kabobs
on popsicle sticks
Add shredded vegetables
to coleslaw
Add chopped or pureed
vegetables to soups,
casseroles, pasta dishes,
and sauces
Legumes and Nuts
Bean soup (1/4 cup)
Kidney beans (2½
tablespoons)
Garbanzo beans (1/4
cup)
Black beans (2½
tablespoons)
Refried beans (2½
tablespoons)
Baked beans (2½
tablespoons)
Add beans to salads and
soups.
Make a bean dip for
nachos or raw vegetables.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chili with beans (3
tablespoons)
Crunchy peanut butter
(2 tablespoons)
Sunflower kernels (2/3
ounce)
Tahini (sesame butter)
(2 tablespoons)
Peanuts (1 ounce)
Almonds (15 nuts)
Cashews (2 ounces)
Pistachios (32 nuts)
Walnuts (22 halves)
Hazelnuts (1 ounce)
nachos or raw vegetables.
Puree beans and add to
soups, casseroles, and
ground meat dishes.
Add chopped nuts to
baked goods, fruit salads,
etc.
Grains
Cereals
Corn bran (1/4 cup)
Frosted Mini Wheats
(1/3 cup)
Cracklin' Oat Bran (1/4
cup)
Cheerios (2/3 cup)
Multigrain Cheerios
(2/3 cup)
Raisin bran (1/3 cup)
Bran Chex (1/4 cup)
Shredded wheat and
bran (1/3 cup)
Bran flakes (1/2 cup)
Grape Nuts (1/4 cup)
Granola (1/2 cup)
Oatmeal (1/2 cup)
Wheat germ (2
tablespoons)
100% bran (4
teaspoons)
Whole-grain/seeded bagels
(1)
Whole-grain bread (1-3
slices)
Whole-grain muffins
(banana, blueberry, bran)
(1-2)
Cornbread (2 pieces, or 3
ounces)
Mix low- and high-fiber
cereals such as Rice
Chex and Bran Chex or
Apple Jacks and Cheerios
Add wheat germ or a
high-fiber cereal to a
favorite low-fiber cereal
Substitute whole-grain
flour for portion of white
flour when baking
Use one slice wheat, one
slice white bread for a
sandwich
Make quesadillas with
cheese and beans on
whole wheat/corn tortillas
Top pancakes, waffles, or
french toast with berries
and nuts
Mix white and brown rice
Try tabbouleh, wild rice, or
pasta salad with fresh
vegetables
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Whole-wheat noodles (½
cup)
Whole-wheat tortilla (1/4 of
one)
Corn tortilla (2 5-in)
Whole-grain frozen waffle (1)
Buckwheat pancakes (½
serving or 2½ ounce
pancake)
French toast made with
whole-grain bread (1 slice)
Polenta (10 oz)
Wild rice (2/3 cup)
Brown rice (2/3 cup cooked)
Whole-grain crackers (1-4)
Bulgur (1/4 cup)
Desserts

Top graham crackers or
cookies with seeded jam
Make peanut butter
desserts with crunchy
peanut butter
Make Rice Krispie treats
with peanuts, wheat germ,
and other high-fiber
cereals
Top frozen yogurt or ice
cream with dried fruit,
granola, nuts, or favorite
high-fiber cereal
Make a frozen yogurt/ice
cream sandwich between
two oatmeal cookies or
graham crackers
Snack Foods
Popcorn (2 cups)
Yellow, blue, red corn tortilla
chips (15) (fiber varies from
1-3 g/5 chips)
Whole-wheat pretzels (1 oz)
Mini popcorn cakes (8)
Make trail mix with cereal,
dried fruit, nuts, etc.
Make popcorn balls with
dried fruit and nuts
Make Chex mix with Bran
Chex
Note: Nuts, seeds, raisins, popcorn, small candies, raw vegetables, olives, and granola
may cause choking in small children. These foods should not be given to children younger
than 4 years of age.
Data are from the US Department of Agriculture Nutrient Database for Standard
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Reference. Available at:
http://www.ars.usda.gov/main/site_main.htm?modecode=12-35-45-00. Accessed February
20, 2012; and Pennington JAT. Bowes & Church’s Food Values of Portions Commonly
Used. 17th ed. Philadelphia, PA: JB Lippincott Co; 1998.

Sample 1-Day Menu

Sample Menu for a High-Fiber Diet
Printable version
This sample menu is designed to meet the requirements of a 7- to 10-year-old child.
Breakfast
Oatmeal (1/2 cup)
Raisins (1 tablespoon)
Whole wheat toast (1/2 slice)
Margarine (1 teaspoon)
Seeded jam (2 teaspoon)
Reduced-fat milk (1 cup)
Pear nectar (4 ounces)
Morning Snack
Orange (1/2)
Crackers (2)
Water (8 oz)
Lunch
Whole wheat bread (1 slice)
Peanut butter, crunchy (1 tablespoon)
Seeded jam (2 teaspoons)
Carrot stick (1 medium)
Ranch dressing, low fat (1 tablespoon)
Grapes (1/2 cup)
Reduced-fat milk (8 oz)
Afternoon Snack
Popcorn (1 cup)
Apple juice (1 cup)
Dinner
Hamburger bun (1)
Beef patty (3 oz)
Lettuce (1 leaf)
Tomato (1 slice)
Ketchup (1 teaspoon)
Homemade french fries with skin (1/2 cup)
Corn-on-the-cob (1/2 cob)
Margarine (2 teaspoon)
Fig cookies (2)
Reduced-fat milk (8 oz)
Evening Snack
Oatmeal raisin cookie (1)
Water (4 oz)

Approximate Nutrient Analysis
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Energy (kcal) 2,341
Protein (g) 91
Carbohydrate (g) 335
Total fat (g) 81
Saturated fat (g) 27
Monounsaturated fat (g) 32
Polyunsaturated fat (g) 15
Cholesterol (mg) 136
Calcium (mg) 1,676
Iron (mg) 21
Magnesium (mg) 444
Dietary Fiber (g) 18.5
Phosphorus (mg) 1,967
Potassium (mg) 4,288
Sodium (mg) 2,047
Zinc (mg) 21
Vitamin A (mcg RE) 2,142
Vitamin C (mg) 125
Thiamin (mg) 2.5
Riboflavin (mg) 3.5
Niacin (mg) 29
Folate (mcg) 432
Vitamin B-6 (mg) 2.9
Vitamin B-12 (mcg) 8.6

Foods Not Recommended


Gas-Forming Foods
Beans, brussel sprouts, onions,
celery, carrots, raisins, bananas,
prune juice, apricots, wheat germ,
bagels (Dapoigny, 2003).
High
Fructose-Containing
Foods
Soft drinks, sweetened breakfast
cereals, baked goods, candies, jams
(Heizer, 2009), apples, cherries,
mango, pears, watermelon, large
quantities of fruit juice or dried fruit
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sorbitol-Containing
Foods
Sugar-free gum, sugar-free candy,
other sugar-free foods
Caffeine-Containing
Foods
Coffee, dark sodas, chocolate,
caffeine/energy drinks
Lactose-Containing
Foods*
Milk, cheese, ice cream, pudding,
yogurt
*Foods to avoid when initiating the low FODMAP diet.
General Recommendations
Eat small, frequent meals
Consume a low-fat diet
Consider a lactose-free diet
Avoid caffeine, chocolate, and alcohol
Reduce fructose and sorbitol
Avoid gas-forming foods
Increase soluble-fiber in diet

Client Education Materials


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Gastrointestinal Diseases > Short Bowel Syndrome
Foods Recommended

Printable version
Food Group Recommended Foods
Milk and
Milk
Products
Low fat milk, low fat cheese, low fat cottage
cheese (lactose free if needed)
Yogurt (lactose is already broken down, so
patient should be able to tolerate it)

Meat and
Other
Protein
Foods
White meat chicken, lean pork chops/loin, lean
ground beef (minimum 90% lean), tuna fish,
baked/broiled/grilled fish, lean cold cuts (roast
beef, turkey, or ham), low-fat hot dogs, baked
chicken nuggets/tenders, beans, legumes,
peanut butter, eggs, tofu
Grains Wheat bread, rolls, pita bread, English muffins,
bagels, crescent rolls, biscuits, oatmeal, cream
of wheat cereal, grits, pasta, rice, couscous,
pretzels, crackers, baked potato chips,
potatoes, sweet potatoes, low-sugar cereals
(Cheerios, Rice Krispies, Life)
Vegetables Fresh, frozen, or canned vegetables. Well
cooked vegetables tend to be best tolerated:
carrots, green beans, squash, zucchini, peas,
spinach, broccoli stems, asparagus tips, etc.
Fruits Canned fruits in own juice or light syrup; fresh
or frozen fruits such as unsweetened
applesauce, strawberries, bananas, apples,
pears, peaches, oranges, melon, plums,
nectarines, etc.
Fat and Oils Regular or light mayonnaise, oil-based salad
dressings, butter or margarine, safflower oil,
vegetable oil, canola oil, olive oil
Beverages Water, rehydration solutions like
Pedialyte, Crystal Light, sugar-free
Kool-Aid, decaffeinated beverages such as
decaf tea, coffee, diet soda.
Other Low-sugar cookies such as graham crackers,
animal crackers, vanilla wafers, ginger snaps,
sugar-free Jell-o, sugar-free pudding,
lactose-free no sugar added ice cream and
frozen yogurt; flavored rice cakes
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Foods Not Recommended

Printable version
Food Group Foods Not Recommended
Milk and
Milk
Products
Regular milk, cheese, ice cream/frozen yogurt
Meat and
Other
Protein
Foods
Fried meats; high-fat meats like hamburgers or
regular hot dogs; bacon, sausage, pepperoni
Grains Foods made with table sugar such as: cake,
candy, brownies, doughnuts, pastries, etc;
regular potato chips; French fries; high-sugar
cereals (Trix, Fruit Loops, Cinnamon Toast
Crunch)
Vegetables Any vegetable with large, hard seeds; broccoli
stems; corn; onions; cabbage; peppers;
cucumbers
Fruits Fruits with tough skins and large seeds; fruit
juice
Fats and
Oils
Limit intake of saturated fats (which is fat found
in animal products such as meat or whole
dairy products)
Beverages Caffeinated beverages such as tea, coffee,
and regular soda; fruit juice; sugar-sweetened
beverages such as Kool-Aid, Sunny Delight,
fruit punch
Other Regular cookies, cake, pie, candy, regular
syrup, honey, jelly, popcorn, spicy foods

Sample 1-Day Menu

Printable version
Breakfast
1 cup oatmeal
½ cup strawberries
1 egg
1 piece of toast with 2 teaspoons margarine
4 ounces lactose-free milk
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
6 saltine crackers
1 ounce cheese
½ banana
4-8 ounces water/oral rehydration solution
Lunch
3 ounces of lean deli meat
2 pieces of wheat bread
2 tsp mayonnaise
1 ounce of pretzels
1 cup lettuce with 2 tablespoons salad dressing
At least 4 ounces fluid (water, sugar-free drink,
rehydration solution)
Snack
6-8 ounces yogurt
1 english muffin with 1-2 tablespoons creamy
peanut butter and sugar-free jelly
At least 4 ounces fluid (water, sugar-free drink,
rehydration solution)
Dinner
4 ounces lean pork loin
½-¾ cup mashed potatoes
1 dinner roll w/2 teaspoons margarine
½ cup cooked carrots
At least 4 ounces fluid (water, rehydration solution,
sugar-free drink)

Approximate Nutrient Analysis
Energy (kcal) 2,225
Protein (g) 105
Carbohydrate (g) 245
Total Fiber (g) 22
Total Fat (g) 95.9
Cholesterol (mg) 399
Vitamin A (mcg RAE) 1529.6
Vitamin C (mg) 75.3
Vitamin E (mg a-TE) 8.4
Thiamin (mg) 3.4
Riboflavin (mg) 2.7
Niacin (mg) 31
Folate (mcg, DFE) 435.5
Vitamin B6 (mg) 2.9
Vitamin B12 (mcg) 3.8
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Calcium (mg) 1104.4
Phosphorus (mg) 1613.2
Magnesium (mg) 365.4
Iron (mg) 19
Zinc (mg) 12.8
Selenium (mcg) 150.1
Potassium (mg) 3116


Client Education Materials

Short Bowel Syndrome Nutrition Therapy
Short Bowel Syndrome Tips

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Hepatic Diseases
Client Education Materials

Nutrition Therapy for Children with Liver Disease

Foods Recommended

Printable version
If the patient is on a high-protein diet:
From non-animal sources:
Food Serving Protein (g)
Peanuts ½ cup 19
Black bean burger 1 patty 11
Soybeans, cooked ½ cup 11-14
Soymilk 8 ounces 10
Tofu ½ cup 10
Mixed nuts and seeds ½ cup 10-15
Lentils, cooked ½ cup 9
Chick peas, split peas, cooked ½ cup 8
Peanut butter, crunchy 2 Tbsp 8
Pasta, cooked 1 cup 7
Oatmeal, cooked 1 cup 6
Beans, cooked ½ cup 5-8
Hummus ¼ cup 5
Rice, brown 1 cup 5
From animal sources:
Food Serving Protein (g)
Chicken, boneless, cooked 3 ounces 27
Turkey, roasted 3 ounces 25
Pork, roast, trimmed 3 ounces 25
Roast beef, lean, cooked 3 ounces 24
Ground beef, lean, cooked 3 ounces 24
Ground turkey, cooked 3 ounces 23
Tuna 3 ounces 23–26
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Salmon, cooked 3 ounces 22
Ham, cooked 3 ounces 21
Shrimp, boiled 3 ounces 21
Cottage cheese ½ cup 14
Milk 8 ounces 8
Cheese 1 ounce 7
Egg 1 medium 6
Egg substitute ¼ cup 6
Yogurt 6 ounces 5
Egg white 1 items 4

Foods Not Recommended

Printable version
If the patient has a sodium restriction:
Instead of (Avoid) Use (Choose)
Salt
Herbs and spices or salt-free
seasoning
Garlic salt / Onion salt Garlic powder / Onion powder
Soy sauce
Frozen meals Fresh meats and vegetables
Regular canned foods
Salt-free or low-sodium canned
foods
Canned soups
Reduced-sodium canned soup
or homemade soup
Luncheon meats, ham,
bacon, hot dogs, and
sausage
Fresh meats, poultry, and fish
Low-sodium luncheon meats
Canned vegetables Fresh or frozen vegetables
Pretzels; chips Unsalted popcorn; rice cakes

Sample 1-Day Meal Plan

High-Protein/Low-Sodium Sample Menu for 10-year old

Printable version
Breakfast
1 egg, scrambled (with 2 tsp regular butter, no milk)
1 English muffin (with 1 tsp butter and 1 tsp jam)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
½ banana
1 cup whole milk
Snack
1 Tbsp peanut butter
Graham crackers, 4 squares
Lunch
Turkey sandwich made with
2 1-oz slices white bread
2 oz turkey (roasted without salt)
2 tsp mayonnaise
1 slice low sodium cheese
8 baby carrots
1 small (4 oz) apple
1 sugar cookie
8 ounces water
Snack
6-8 ounces of yogurt
3/4 cup raw strawberries
Dinner
3 ounces baked chicken
½ cup rice
1 cup green beans (with 1 tsp butter)
½ cup applesauce
1 cup whole milk
NOTE: All foods are prepared without added salt.

Approximate Nutrient Analysis
Energy (kcal) 2,190
Total protein (g)
105 gm
(19% of
kcal)
Total carbohydrate (g)
268 gm
(49% of
kcal)
Total fat (g)
81 gm
(32% of
kcal)
Saturated fatty acids (g) 33 gm
Monounsaturated fatty acids
(g)
23 gm
Polyunsaturated fatty acids (g) 15 gm
Cholesterol (mg) 439 mg
Calcium (mg) 1345 mg
Iron (mg) 12 mg
Magnesium (mg) 307
Phosphorus (mg) 1656 mg
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Potassium (mg) 3105
Sodium (mg) 1,971 mg
Zinc (mg) 9
Vitamin A (mcg RAE) 971
Vitamin C (mg) 104
Thiamin (mg) 1.3
Riboflavin (mg) 2.5
Niacin (mg) 30
Total folate (mcg) 367
Vitamin B-6 (mg) 2.2
Vitamin B-12 (mcg) 4.4
Total dietary fiber (g) 21 g
Vitamin D (mcg) 6.1

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > HIV/AIDS
Foods Recommended

There is no specific list of recommended foods that is appropriate for all children living with
human immunodeficiency virus. The dietitian should work closely with each patient to
monitor dietary intake, symptom management, metabolic complications, and disease
progression and recommend foods that help patients meet their individual needs.
The following list is based on a healthful eating pattern and includes foods within and
among the basic food groups with emphasis on fat moderation for cardiovascular risk
prevention. Lower-fat diets (less than 30% of energy from fat) should not be recommended
for children younger than 2 years.
Printable version
Food Group Foods Recommended
Milk and Milk
Products

Plain, fat-free yogurt with fresh fruit
Low-fat or fat-free milk
Low-fat or reduced-fat cheese
Meat and Other
Protein Foods

Fish, canned fish packed in water
Beef (loin, round) with fat trimmed off
Poultry without skin
Egg whites
Low-fat lunch meats (95% to 97% fat
free)
Low-fat hot dogs
Soy products (tofu)
Canadian bacon or lean ham
Cooked or canned kidney or pinto
beans, fat-free refried beans
Grains

Low-fat granola
Unsweetened cereals with cut-up fruit
Barley
Grits
Pasta with vegetables or tomato-based
sauce
Whole grain breads
Fruits

Fresh fruits
Unsweetened applesauce
Canned fruit packed in juice or light
syrup
Vegetables
Any fresh or frozen
Baked potato with salsa
Steamed or roasted vegetables
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fats

Light or fat-free cream cheese
Foods cooked without added fat
(baked, broiled, roasted, boiled)
Other Beverages
Water
100% fruit juice (limited to 8 oz/day)
Unsweetened coffee or tea
Sugar-free soft drinks

Foods Not Recommended

Printable version
Milk and Milk Products
Whole milk
Cream
Regular cheese
Ice cream
Meat and Other Protein
Foods
Beef (chuck, rib, brisket)
Chicken with skin
Lunch meats (such as bologna)
Regular hot dogs
Bacon or sausage
Refried beans
Grains
Sweetened cereal
Fried rice
Pasta with cheese or white sauce
(alfredo)
Pastries
Fruits
Candy, cake, or pie that includes
fruit
Sweetened applesauce
Canned fruit packed in syrup
Vegetables
Deep-fried french fries
Baked potato with cheese sauce
Fried vegetables
Fats

Cream cheese
Sour cream
Regular margarine or butter
Added Sugars

Sugar-sweetened soft drinks
Sweetened tea
Syrup on pancakes or french toast
Candy
Cookies, cake, pastry
Sugar added in recipes

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sample 1-Day Menus

The following printable sample menus may be applicable to clients with human
immunodeficiency virus or acquired immune deficiency syndrome:
Sample 1-Day Menu for Failure to Thrive
Sample 1-Day Menu for Heart-Healthy Diet
Sample 1-Day Menu for Weight Loss for Children Aged 7 to 10 Years
Sample 1-Day Menu for Weight Loss for Children Aged 11 to 14 Years
Sample 1-Day Menu for a Healthy Adolescent Boy
Sample 1-Day Menu for a Healthy Adolescent Girl

Client Education Materials

Calcium-Rich Nutrition Therapy
Nutrition Therapy for Diarrhea
Food Safety Tips
Tips for Increasing Calories and Protein
Heart-Healthy Eating Tips for Children

Handouts in Spanish:
Calcium-Rich Nutrition Therapy
Nutrition Therapy for Diarrhea
Food Safety Tips
Heart-Healthy Eating Tips for Children


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Inborn Errors of Metabolism
Foods Recommended

Foods recommended for individuals with phenylketonuria (PKU) include the following:
Phenylalanine-free formula/medical food
Fruits and vegetables
Low-protein bread/cereal products
Limited, carefully measured amounts of some starch and grain products, depending
on individual phe prescription
A detailed list of the phenylalanine content of foods is provided in the Low Protein Foods
List for PKU by Virginia Schuett. Amino acid content of many foods is also available from
the USDA Nutrient Data Laboratory.


Foods Not Recommended

All foods high in high biological value protein are excluded or greatly restricted in meal
plans for children with phenylketonuria. This includes meat, fish, chicken, dairy foods, eggs,
soy, and dried beans.

Sample 1-Day Menu

Individuals require a meal plan based on age, activity and tolerance for phenylalanine. The
following menu is an example of a menu created for a 7-year-old boy with PKU. Changes
may need to be made depending on the client's prescription, age, and other factors.
Printable version
Prescription for phenylalanine = 350 mg/day
Prescription for formula/medical food: 180 g Phenex 2 with water to 32 oz.

Meal/Food Amount Phenylalanine Protein Energy
Breakfast
Formula/medical
food
8 oz 0 13.5 185
Orange juice 4 oz 10 0.8 51
Rice Krispies cereal ½ c 49 1.0 54
Non-dairy creamer ¼ c 8 0.2 40
Lunch
Formula/medical
food
8 oz 0 13.5 185
Tomato soup
made with water
1 cup 68 1.9 73
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Saltine crackers 4 54 1.1 50
Cookies,
butterscotch, low
protein
1 4 0.1 150
Snack
Formula/medical
food
4 oz 0 6.9 93
Banana 1 small 50 1.1 90
Dinner
Formula/medical
food
8 oz 0 13.5 185
Romaine greens
salad
1 c 31 0.6 8
Green olives 3 3 0.1 9
French dressing 2 Tbsp 5 0.3 146
Pasta, low protein ½ c 4 0.1 105
Tomato sauce,
Ragu
¼ c 23 0.9 32
Garlic bread, low
protein
1 slice 5 0.1 114
Raspberry sorbet ½ c 0 0 113
Snack
Formula/medical
food
4 oz 0 6.8 93
Total
367
62.5 1,776

Approximate Nutrient Analysis
Energy (kcal) 1780
Total protein (g)
63
(14% of kcal)
Total carbohydrate (g)
300
(67% of kcal)
Total fat (g)
67
(34% of kcal)
Cholesterol (mg) 11
Calcium (mg) 1840
Iron (mg) 33
Magnesium (mg) 508
Phosphorus (mg) 1612
Potassium (mg) 4070
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sodium (mg) 2970
Zinc (mg) 25
Vitamin A (mcg RAE) 1695
Vitamin C (mg) 249
Thiamin (mg) 6.6
Riboflavin (mg) 3.9
Niacin (mg) 36
Total folate (mcg) 1050
Vitamin B-6 (mg) 3.5
Vitamin B-12 (mcg) 10
Total dietary fiber (g) 11
Vitamin D (mcg) 14

Client Education Materials

Nutrition Therapy for Children with Phenylketonuria (PKU)
Tips for Caregivers of Children with PKU

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Oncology
Foods Recommended

Cancer patients and survivors generally require a healthy eating plan appropriate for their
age, examples of which can be found under the Normal Nutrition section of the Meal Plans
tab. Children who are immunosuppressed require a low-bacteria meal plan. The foods
listed below are recommended for safety.
Printable version
Beverages
Freshly drawn tap water from a safe
source
Bottled water that has been processed
by reverse osmosis, distillation or 1-μm
particulate absolute filtration
Well water that has been boiled for
15-20 minutes; must be stored in a
refrigerator and used within 48 hours.
Water should be tested for harmful
bacteria.
Shelf-stable bottled or canned drinks
(e.g. juices, flavored waters, sports
drinks)
Freshly made ice from acceptable water
source
Hot beverages heated to at least 175ºF
Any tea allowed should be made with
boiled water
For safe handling and storage of breast
milk or infant formula, please see
Expression, Handling, and Storage of
Human Milk or Infant Formula
Preparation and Storage, or refer to
Robbins 2011.
Bread and
Cereal
Products
All
Freshly prepared rice or pasta
Eggs
All eggs must be cooked well done
Fresh egg products must be
pasteurized
Meat, Fish,
Poultry, Meat
Substitutes,
Soups, Nuts
Prepackaged, heat-treated deli meat
Any well-cooked, canned, or
prepackaged meat, fish, or poultry
Roasted or cooked nuts
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dairy
Products
Cheeses made from pasteurized milk
Pasteurized milk or yogurt
Prepackaged or freshly homemade
pasteurized ice cream, frozen yogurt, or
sherbet
Commercially made nutritional
products, supplements, and baby
formulas
Fruit
All well-washed fresh fruits
Pasteurized juice
All canned or cooked fruits
Vegetables
All well-washed fresh vegetables
All cooked or canned vegetables
Fats and
Spices
Cooked spices prepared/cooked in
foods
Oils, crisp bacon, butter, cream cheese,
margarine, mayonnaise
Salt


Foods Not Recommended

Cancer patients and survivors generally require a healthy eating plan appropriate for their
age, examples of which can be found under the Normal Nutrition section of the Meal Plans
tab.
Foodborne illnesses can occur if a person eats or drinks something that contains harmful
germs. These germs include certain kinds of bacteria, molds, and fungi. Signs of food
poisoning include fever, chills, headache, stomach aches, stomach cramps, nausea,
vomiting, and diarrhea that sometimes contains blood. A person who has food poisoning
may show none, some, or all of these signs. These signs most often develop 6 to 48 hours
after the person eats the food that contains the harmful germ.
In healthy people, foodborne illness is usually not too serious. The ill person should drink
plenty of fluids until he or she can eat solid foods again. If a person is very sick, he or she
may need to be treated in the hospital. Some types of food poisoning can be dangerous or
life threatening, especially in a person with a weak immune system. Some germs that
cause foodborne illness can lead to infections of the blood (bacteremia), the brain
(encephalitis), or the covering of the spinal cord and brain (meningitis).

Most germs that cause foodborne illness have no taste, color, or odor. Because you cannot
tell when harmful germs are present, you should take steps to keep them away from the
foods that you and your family eat. The following foods have germs that cause foodborne
illness more often than other foods:

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

• Raw or undercooked chicken or turkey, meat such as hamburger and steak, fish, and
eggs
• Unpasteurized milk and cheese
• Unclean water

Printable version

Beverages
Water from a well that has not been
tested
Unpasteurized juice, milk
Ice from ice machines in public places
Icee frozen drinks or other drinks
from bulk machines
Tea not made with boiling water
Open drinks left at room temperature
for 1 hour or more
Bread and
Cereal Products
Reheated, refried, or leftover rice or
pasta that has not been heated to at
least 165 degrees
Uncooked brewer’s yeast
Eggs
Any raw, undercooked or
soft-cooked eggs
Salad dressing with raw egg (i.e.
Ceaser)
Meat, Fish,
Poultry, Meat
Substitutes,
Soups, Nuts
Meats that are not well done
Fresh deli meat
Cold smoked salmon, lox, shellfish,
sushi, pickled fish
Uncooked nuts
Milk
Raw/unpasteurized milk or yogurt
Cheeses with molds (bleu cheese,
Gorgonzola, or Roquefort)
Cheeses made from unpasteurized
milk
Soft-serve ice cream, frozen yogurt,
or sherbets from bulk machines
Fruit
Berries
All other well-washed fruits or any
that are cooked/canned are OK
Vegetables
Raw sprouts, including alfalfa, mung
beans
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fats and Spices
Dressings containing cheeses with
mold (bleu cheese) or raw eggs
(Caesar), unpasteurized whipped
cream, homemade mayonnaise, or
other products that may contain raw
eggs
Spices added after cooking


Sample 1-Day Menu

Sample 1-Day Menu for Oncology Patients Aged 7-10 Years
Printable version
Based on ~ 1,800 kcal/day
Breakfast
1 cup cereal of choice
1 cup reduced-fat milk
1 small banana
1 slice whole wheat toast
1 tsp soft margarine
1 cup orange juice
Lunch
2 slices whole wheat bread
2 slices tomato
2 oz sliced smoked turkey breast
1 slice Swiss cheese
1 tbsp mayonnaise-type salad dressing
1 tsp yellow mustard
1/2 cup apple slices
1 oz potato chips
Dinner
3 oz boneless, skinless chicken breast
1 medium baked potato/sweet potato
1/2 cup peas and onions
2 oz whole wheat dinner roll
2 tsp soft margarine
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack 1 cup (6 oz) low-fat fruited yogurt
Approximate Nutrient Analysis
Energy (kcal) 1741
Total protein (g) 72
Total carbohydrate (g) 263
Total fat (g) 50
Saturated fatty acids (g) 14
Monounsaturated fatty acids (g) 16
Polyunsaturated fatty acids (g) 12
Cholesterol (mg) 132
Calcium (mg) 1163
Iron (mg) 12
Magnesium (mg) 204
Phosphorus (mg) 871
Potassium (mg) 2904
Sodium (mg) 2534
Zinc (mg) 5
Vitamin A (mcg RAE) 450
Vitamin C (mg) 127
Thiamin (mg) 1
Riboflavin (mg) 1
Niacin (mg) 23
Total folate (mcg) 258
Vitamin B-6 (mg) 2
Vitamin B-12 (mcg) 3
Total dietary fiber (g) 23
Vitamin D (mcg) 6
Alter portion sizes according to overall nutrient needs:
Kcal
Required/Day
Grains Vegetables Fruits Fats/Oils Milk
Meats and
Beans
1,400 kcal 5 oz 1½ cups

cups
4 tsp
2
cups
4 oz
1,600 kcal 5 oz 2 cups

cups
5 tsp
3
cups
5 oz
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1,800 kcal 6 oz 2½ cups

cups
5 tsp
3
cups
5 oz
2,000 kcal 6 oz 2½ cups
2
cups
6 tsp
3
cups
5½ oz

Client Education Materials

Oncology Nutrition Therapy
Nutrition During and After Cancer Treatment
Feeding Options for Children in Cancer Treatment (nutrition support handout)
Complementary and Alternative Medicine
Oncology Cooking Tips
Oncology Well-Being Tips
Food Safety Tips
Tips to Increase Calories and Protein
Nutrition for Cancer Survivors

Handouts dealing with side effects
Managing Side Effects
Constipation Nutrition Therapy
Constipation Meal Planning Tips
Diarrhea Nutrition Therapy
Lactose Intolerance Nutrition Therapy
Mucositis Nutrition Therapy
Nausea and Vomiting Nutrition Therapy
Nausea and Vomiting Tips
Oral Care Tips

Forms for the RD
Nutrition Instructions
Food and Activity Form

Handouts in Spanish
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Constipation Nutrition Therapy
Diarrhea Nutrition Therapy
Nausea and Vomiting Nutrition Therapy
Nausea and Vomiting Tips

Food Safety

The guidelines on this page for buying, storing, and preparing foods will help clients and
their families eat safely.
Printable version (does not include Eating Out or Eating in Foreign Countries)
Spanish version
Shopping for Food
Be careful about where you shop. Choose stores where floors, shelves, storage areas, and
the store’s workers follow sanitary practices. Packages should not be torn, opened, or
damaged. Food displays should be safe. (For example, raw shrimp should be stored on ice
that is separate from the ice on which other seafood is stored.)
Use a “safe shopping pattern.” First, collect canned items or dry, packaged items such as
pasta, bread, and rice. Then, pick up fresh fruits and vegetables. Finally, select frozen and
refrigerated items such as meat, eggs, and milk products.
Inspect the products you want to buy. Choose products for which the “sell by” or “best used
by” date has not passed. Do not buy cans that have dents, holes, rust, bulges, or leaks. Do
not buy any package that has been damaged or opened. Put packaged meat, fish,
chicken, or turkey in a plastic bag before placing in the shopping cart. This prevents germs
on the wrapping of the meat from spreading to other items.
Buy only the number of eggs that you will need for 1 to 2 weeks. Look for the word
“pasteurized” on the labels of milk, cheese, and other milk products. "Pasteurized" means
that the product has gone through a process that helps kill germs.

Storing Food
As soon as you get home, follow a safe food-storage pattern. (This pattern is the opposite
of the safe shopping pattern.) First, put frozen items in the freezer and cold foods in the
refrigerator. Then, put away fresh fruits and vegetables. Finally, put away canned items
and dry, packaged items.
Know how long foods will keep in the refrigerator.
Eggs: 7 to 14 days
Raw fish and seafood: 1 to 2 days
Raw fruits and vegetables: 7 days
Leftovers: 3 to 4 days
Raw meat: 2 to 3 days
Luncheon meat: 4 to 7 days
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk: 5 days
Raw chicken and turkey (poultry): 2 to 3 days

Other Food Storage Tips
Store raw foods in a separate bin or shelf from cooked foods. Use cellophane and
lidded containers to keep food airtight.
Store seafood, meat, chicken, and turkey in the coldest part of the refrigerator. The
coldest part is usually at the back of the bottom shelf or the bottom bin.
Put the whole carton of eggs directly into the refrigerator. Do not remove them from
the carton to put them in the “eggs” area of the refrigerator. Eggs will last longer if
they are stored in the original container. Also, do not wash eggs before storing them.
Wash fresh fruits and vegetables with water. Then, put them in the refrigerator.
Washing the vegetables helps keep them fresh.
Keep canned goods in a cool, dry place. Do not store food in cabinets that are under
the sink or that have water, drain, or heating pipes passing through them. Storing
foods here can attract bugs, mice, and rats, which can get through openings around
the pipes.
Throw away food that has mold on it. Cutting off the mold will not remove all of the
harmful germs.
After you finish eating, put cooked food in the refrigerator as soon as you can. Foods
cool more quickly if you use covered, shallow pans rather than deep pots. If the food
will not be eaten within a few days, wrap the food, write the date on the outside of
wrapper, and freeze it.
Be careful not to overfill your refrigerator and freezer. It will decrease the unit’s overall
ability to keep food cool.

Preparing Food
Clean all kitchen tools and work surfaces before you start to prepare food.
Wash your hands with soap and warm water for at least 20 seconds at these times:
Before you start preparing food
Before you start working with a different food or a different kitchen tool
After you finish preparing food
Before you serve food
If one of your hands has a cut, scrape, or some other injury, wear rubber or plastic
gloves while you prepare foods. Wash your gloved hands just as often as you would
wash your bare hands.
Thaw meat, chicken, turkey, or seafood in the refrigerator, in the microwave oven, or
in a water-tight plastic bag set in cold water. If you thaw the item in cold water,
change the water every 30 minutes. Never thaw meat, chicken, turkey, or seafood on
the kitchen counter because germs can grow rapidly at room temperature.
Cut up raw meat, fish, or raw chicken or turkey on an acrylic or plastic cutting board.
Scrub fresh fruits and vegetables well and rinse them with water.
Do not leave raw eggs at room temperature for more than 2 hours.
Wash the lids of cans with soap and water before you open them. Use a clean can
opener to open the cans.
Do not interrupt cooking time. Stopping and then restarting cooking may allow harmful
germs to grow in the food.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cook meat thoroughly. You should cook beef, pork, chicken, turkey, and other meat
so that the temperature at the center of the meat reaches at least 165°F. Use a meat
thermometer to measure the temperature of the meat. If meat is too thin to test, follow
the recipe and cook the meat until the juices are clear.
Cook eggs until the yolk and white are firm, not runny.
Never serve or eat raw eggs or foods that contain them. Use cooked eggs or egg
substitutes when you make foods such as homemade ice cream, eggnog, and
mayonnaise.
Serve cooked meat, chicken, or turkey on clean plates. Never place cooked foods on
a plate that has raw meat juices on it. Germs from the raw juices might be transferred
to the cooked food or to other items served at the same meal.
Use leftovers within 2-3 days. Reheat leftovers to 165°F either in the microwave or
conventional oven. Only use leftovers that were stored in a refrigerator within 1 hour
after they are prepared. When heating in the microwave make sure to stop and stir
every 30 seconds to prevent cold spots where bacteria could live.
Boil gravies, marinades, and soups for at least 1 minute before they are served.
Never taste foods you think are unsafe. When in doubt, throw it out!

Eating in Foreign Countries
Many countries lack the high standards for food cleanliness and safety that the United
States has. For that reason, take extra care when you are eating and drinking in other
countries. A good rule of thumb is “boil it, cook it, peel it, or forget it.”
Before you drink any tap water, boil it for 15 minutes.
Drink canned drinks, carbonated, bottled drinks, or drinks that have been made from
boiled water.
Only use ice made from boiled water. Eat cooked foods while they are still hot.
Do not eat uncooked vegetables and salads. If you must eat raw fruits and
vegetables, wash and peel them.

More Guidelines for a Safe Kitchen
Use a covered, lined trash can. Empty the trash can often.
Clean up spills quickly.
Frequently clean things that come in contact with food or that are in the kitchen.
Some of these things include shelves, counters, floors, table tops, refrigerators,
freezers, utensils, can openers, sponges, and towels. This is one of the best ways to
keep harmful germs out of your food at home. Before or after you have prepared
food, wipe down counter tops and cutting boards with a sanitizing solution made from
1 teaspoon (5 milliliters) of bleach in 1 quart (1 liter) of water. Then rinse the counter
tops and cutting boards well with water.
Every 6 months, clean your kitchen sink drain, garbage disposal, and the connecting
pipes by pouring the bleach solution (see above) or a store-bought kitchen cleaning
agent (follow the company’s instructions) down the sink. This step is needed because
food particles trapped in the damp drain and disposal create good conditions for the
growth of germs.
Do not let dirty dishes sit in water for a long time before you wash them. The food left
on the plates and in the dishwater create a place where germs can grow rapidly.
When you wash dishes by hand, wash them in hot, soapy water within 2 hours of use
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
When you wash dishes by hand, wash them in hot, soapy water within 2 hours of use
and let them air dry.
If you use a dishwasher, be sure that the heater is set properly. You can learn how to
set the heater to the proper temperature by reading the owner’s manual and following
its instructions.
Check the temperature of your refrigerator and freezer about every 6 months. The
temperature of the refrigerator should be 20°F to 40°F. The temperature of the freezer
should be 0°F or lower.
If your tap water comes from a private well and not from a city supply, test your well
water every year to be sure that it is safe to use. Check with your doctor before
drinking well water. Call your local water company or health department to find out
how to test your water.

Eating Out Safely
Eating out at restaurants can be a fun family outing, but it also can present a risk for food
poisoning. It is possible to eat out safely, but it takes practice to know what and how to
order. Just keep a few rules in mind.
Look for the Health Inspector Score. Most restaurants post their scores where you
can see them. Try to stick with restaurants with scores better than 90.
Look around. Pay attention to the restaurant’s bathrooms, floors, and tables. If they
are dirty, the kitchen probably is as well. If possible, go to restaurants that have open
kitchens. Do not be afraid to leave. It is more important to stay healthy.
Order carefully.
Be careful of foods like chicken, ham, or potato salad that must be chopped or
mixed a lot when being made. The more people and utensils that touch the food,
the more chance for germs to spread.
Buffets can have increased risks with more people handling the foods.
Avoid dishes with fried rice because it is sometimes made with leftover rice. This
practice has been connected to a certain form of food poisoning.
If ordering food with raw eggs, such as salad dressings, make sure the
restaurant uses pasteurized eggs. Ask your server. Or, avoid foods with raw
eggs altogether.
Order chicken, pork, red meat, and eggs cooked well done.
At fast food restaurants, special order your food to make sure it has not been
sitting under a heat lamp for a long time.
Inspect before eating.
Check for spills, clean plates, and cold temperatures on the salad bar or buffet
before ordering it. If the foods are messy and food temperatures are not right, do
not order. If you do decide on the salad bar, avoid raw sprouts. They have been
connected with outbreaks of food poisoning.
Cut into meat before the server leaves. Make sure the poultry or pork is white
with clear juices. If it looks at all pink, send it back. Make sure there is no pink in
your hamburger or red meat. If there is, send it back.
Remember, cooked shellfish such as clams or mussels should be open. If any
shell is closed or the dish smells bad send it back.
Check the temperature. Hot foods should be steaming, and cold foods very cold. If
they are not, send the dish back.
Handle leftovers and take-out food properly.
Go straight home and put leftovers in the refrigerator right away. Make sure they
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Go straight home and put leftovers in the refrigerator right away. Make sure they
are kept at 40°F or lower.
Finish leftovers within 3 to 4 days.
When reheating leftovers, heat to 165°F. Then, eat right away. Do not let
leftovers sit at room temperature.
When in doubt, throw it out! If the food looks or smells funny or you cannot
remember how long it has been in the refrigerator, throw it away instead of
eating it.

Copyright © 2004 St. Jude Children's Research Hospital www.stjude.org Revised 7/05

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Preterm Infants
Client Education Materials

Nutrition for Preterm Infants at Home: 1-4 Months Corrected Age
Nutrition for Preterm Infants at Home: 4-6 Months Corrected Age
Nutrition for Preterm Infants at Home: 6-8 Months Corrected Age
Nutrition for Preterm Infants at Home: 8-12 Months Corrected Age
Preventing Dehydration in Infants

Handouts in Spanish
Nutrition for Preterm Infants at Home: 1-4 Months Corrected Age
Nutrition for Preterm Infants at Home: 4-6 Months Corrected Age
Nutrition for Preterm Infants at Home: 6-8 Months Corrected Age
Nutrition for Preterm Infants at Home: 8-12 Months Corrected Age
Preventing Dehydration in Infants

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Pulmonary Diseases
Pulmonary Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Pulmonary Diseases > Asthma
Foods Recommended or Not Recommended

Generally, foods found in a regular diet for age are recommended. The registered dietitian
may want to decrease fat, sodium, and kilocalories in the meal plan if the client is
overweight. Foods high in calcium, phosphorus, and vitamin D should be encouraged.
Printable version

Sample 1-Day Menu

Sample 1-Day Menu for a Child with Asthma
Printable version
Breakfast
1 large egg, scrambled
1 slice whole wheat toast with 1 teaspoon butter or
reduced-calorie margarine
½ grapefruit
1 cup low-fat or nonfat milk
Lunch
Chicken salad sandwich made with 3 ounces
cooked chicken breast, celery, lettuce, 1 teaspoon
mayonnaise, and pita bread
1 apple (or other whole fruit)
1 cup fresh miniature carrots or large carrot cut
into slices
2 teaspoons nonfat dip
1 cup 100% fruit juice
Dinner
3 ounces lean roast beef, broiled
½ cup mushrooms, fresh or canned (served over
beef)
2 cups tossed salad with 2 tablespoons
reduced-calorie salad dressing
1 cup steamed broccoli
1 cup low-fat or nonfat milk
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
2 cups light popped popcorn
1 cup chocolate milk
*This menu is for an 8-year-old child, approximately 45 inches tall and weighing 60 lbs.

Approximate Nutrient Analysis
Energy (kcal) 1,429
Protein (g) 79
Carbohydrate (g) 172
Fiber (g) 23
Total fat (g) 50.7
Saturated fat (g) 15
Monounsaturated fat (g) 17
Polyunsaturated fat (g) 13
Linoleic acid (omega-6) (g) 11
Alphalinolenic acid (omega-3) (g) 1.6
Cholesterol (mg) 358
Vitamin A (mcg RAE) 1,748
Vitamin C (mg) 253.4
Vitamin E (mg a-TE) 8.1
Thiamin (mg) 1
Riboflavin (mg) 2.2
Niacin (mg) 15.3
Folate (mcg, DFE) 500
Vitamin B-6 (mg) 1.7
Vitamin B-12 (mcg) 4.9
Calcium (mg) 927.2
Phosphorus (mg) 1,281. 7
Magnesium (mg) 278.9
Iron (mg) 11.6
Zinc (mg) 12.7
Selenium (mcg) 93.6
Potassium (mg) 3,319
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sodium (mg) 2,602

Client Education Materials

Nutrition Therapy for Children with Asthma

Handout in Spanish:
Nutrition Therapy for Children with Asthma

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Pulmonary Diseases > Bronchopulmonary Dysplasia
Foods Recommended or Not Recommended

All foods can be included in the meal plan, depending on the infant or child’s
developmental status and ability to chew and swallow appropriately.
Human milk fortifiers or concentrated infant formula should be used until the infant is
2.0-2.5 kg; they can be added to increase the caloric density of the meal plan.
Printable food lists

Sample 1-Day Menu

Sample 1-day menu for a 6-month old (corrected age) infant with bronchopulmonary
dysplasia, prescribed formula with concentration of 22 kcal/oz
Printable version
8 am
4 oz fortified breast milk/post-discharge formula
2 tablespoons rice cereal mixed with formula
11 am 4 oz fortified breast milk/post-discharge formula
2 pm 4 oz fortified breast milk/post-discharge formula
5 pm
4 oz fortified breast milk/post-discharge formula
2 tablespoons rice cereal mixed with formula
8 pm 4 oz fortified breast milk/post-discharge formula
10:30 pm4–6 oz fortified breast milk/post-discharge formula

Sample menu provides:

528 kcal, 16.2 grams protein, 648 mL free water, 720 mL fluid

Client Education Materials

Nutrition Therapy for Infants or Children with BPD

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Pulmonary Diseases > Cystic Fibrosis
Foods Recommended

Printable food lists
The meal plan for cystic fibrosis should be based on nutritious, high-calorie foods.
For infants, breast milk is preferred. If breast milk is not available, then standard
cow's milk formula is appropriate. Close monitoring of weight and growth status is
essential and breast milk fortification or calorie-dense infant formula may be needed
to meet the energy needs of the infant with cystic fibrosis.
Following a regular schedule for meal and snack times helps promote a feeling of
hunger and fullness and provides a pattern in which meal and snack times are
expected.
Modeling healthful eating in younger children and family dining with teenagers are
associated with better-quality food intake.
Parents and caregivers can reinforce eating behavior with positive, pleasant
interactions and targeted praise. Arguments and punishment for non-eating behaviors
should be avoided. Attention received for refusing food and not eating often promotes
poor eating behaviors.
Symptoms such as coughing and tiredness might make eating difficult. Consuming
high-calorie foods can promote weight gain without larger portions. Snacks should be
nutritious, high-calorie foods.
High-calorie, nutritious beverages such as whole milk, flavored milk, commercial
supplements, or fruit smoothies made with whole milk, yogurt, ice cream, or pudding
are recommended.
Although sports drinks are not recommended for general fluid intake, they may be
appropriate with added salt for athletes or children who are active in hot weather to
replenish sodium lost through sweat. One study has shown that persons with CF
need to add extra salt to sports drinks to drive fluid intake (Kriemler, 1993).

Tips to increase calories:
Provide at least 5 small meals or large snacks each day.
Provide healthful beverages that add calories.
Serve vegetables with cream, butter or margarine, cheese sauce, olive oil, or salad
dressing.
Serve high-protein foods, such as milk, eggs, cheese, meats, nuts, and beans.
Add fortified milk made with 1 cup whole milk and 2 tablespoons to 4 tablespoons
nonfat dry milk; mix the ingredients a few hours in advance to blend flavors.
Add 2 tablespoons to 4 tablespoons of nonfat dry milk powder per cup of flour when
baking cookies and cakes or making pancakes.
Add foods that are very high in both calories and nutrients, such as peanut or almond
butter, sweet potatoes, avocado, baked beans, refried beans.
High-calorie foods, such as those listed below, can be added to increase calories and
nutrients without significantly increasing volume of food.
POWDERED SKIM MILK: 25 calories/tablespoon
Stir powdered skim milk into potatoes, soups, ground meats, cooked
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cereals, pudding, yogurt, milkshakes, canned soups, and other foods containing milk.
CHEESE: 100 calories/ounce
Add prepared cheese sauce or melted cheese to vegetables, casseroles, fish, meats,
eggs, pasta, and rice.
SOUR CREAM: 50 calories/tablespoon
Add sour cream to potatoes, beans, and squash. Mix in gravies and casseroles or
with salad dressing to use as a dip.
HEAVY CREAM: 60 calories/tablespoon
Add to hot chocolate, cooked cereals, mashed potatoes, desserts, scrambled eggs,
canned cream-based soup, and milkshakes.
BUTTER, MARGARINE, OR OLIVE OIL: 45 calories/teaspoon
Add butter, margarine, or corn oil to soups, gravies, mashed potatoes, cooked
cereal, rice, and pasta. Add butter or margarine to crackers, breads, and muffins. Add
vegetable oil to spaghetti sauce and noodles.
CREAM CHEESE: 50 calories/tablespoon
Spread cream cheese on toast, crackers, muffins, bagels, bread, and fruits. Use it
on a sandwich with jelly.
MAYONNAISE: 100 calories/tablespoon
Use mayonnaise instead of salad dressing because it has almost twice as
many calories. Use on salads or in sandwiches.
PEANUT BUTTER: 100 calories/tablespoon
Spread peanut butter on toast, bread, crackers, cookies, or fruits such as apples and
bananas.
EGGS: 75 calories per large egg
Add to meatballs, meatloaf, casseroles, broth-based soups. Add hardboiled eggs to
salads or pasta salads. Serve pickled eggs or deviled eggs as snacks/side dishes.
WHEAT GERM: 25 calories/tablespoon
Add wheat germ to cereals, salads, yogurt, and meat dishes. Mix into cookie
batter, casseroles, and so on.
COOKED MEATS: 50-75 calories/ounce
Add cooked and diced meats, shrimp, and tuna to soups, casseroles,
cooked noodles, casseroles, and sauces.
CARNATION INSTANT BREAKFAST: 130 calories/packet
Add to whole milk, potatoes, cooked cereals, puddings, yogurts, milkshakes, and
other foods containing milk.
COOKED SWEET POTATO OR AVOCADO: 60 calories in ¼ cup
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Slice thin and add to grilled cheese, salads, or other sandwiches. Puree and add to
soups and tomato sauce.


Foods Not Recommended

Printable food lists
Everyone needs specific nutrients from foods in addition to energy (calories). Some
important nutrients for children and teens with cystic fibrosis (CF) are protein, calcium,
fat-soluble vitamins, iron, and zinc. Fiber is necessary too.
Foods that provide few calories and/or nutrients are not recommended.
Food such as juices, fruit drinks, punches, ades, sodas, iced tea, lemonade, broth
soups, gelatin, popsicles, and so on are often satisfying and limit desire for other
foods. These foods may provide only modest calories, no protein, and a limited variety
of vitamins and minerals and are not recommended except in minimal
amounts. Foods that satisfy but don't nourish can be considered "competitive" foods,
as they crowd more nutritious foods out of the diet.
Although sports drinks are not recommended for general fluid intake, they may be
appropriate with added salt for athletes or children who are active in hot weather to
replenish sodium lost through sweat. One study has shown that persons with CF
need to add extra salt to sports drinks to drive fluid intake (Kriemler, 1993).
Each food should be considered in the context of the overall diet. An excess of
refined carbohydrate foods such as crackers, breads, and pasta can take the place of
more nutritious foods such as whole grains and foods containing protein. However,
crackers and other foods used to supply calories with the addition of cheese, cream
cheese, or peanut butter may be appropriate.
Diet or zero-calorie beverages and low-carbohydrate or sugar-free items should be
avoided.
Particular attention should be given to beverages and snacks. Choosing these
wisely will contribute significantly to the overall diet.

Sample 1-Day Menus

The following menus are generally appropriate for children older than 10 years. Adjust
portion sizes and food choices accordingly to meet requirements for younger children or
those with different needs.

Printable version
DAY 1
Breakfast
2 scrambled eggs with ½-ounce cheese
2 sausage links
1 medium blueberry muffin with 1 teaspoon butter
and 2 teaspoons jam
6 ounces custard yogurt
8 ounces orange juice
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
Fruit smoothie:
½ cup fruit (mango, strawberry, banana, etc)
6 ounces yogurt or ice cream blended with 2
ice cubes
2 tablespoons peanut butter
4 ounces whole milk
Lunch
Grilled cheese sandwich with 2 slices of cheese
and thin slices of avocado
½ cup fruit canned with heavy syrup
½ cup sweet potato fries
8 ounces whole milk
Snack
6 ounces pudding with 2 tablespoons whipped
cream
½ cup strawberries, sliced
Dinner
Fried chicken drumstick and leg
¾ cup mashed potatoes with 2 tablespoons sour
cream
½ cup broccoli with ¼ cup cheese sauce
3" x 3" square cornbread with 1 tablespoon butter
and 1 tablespoon honey
8 ounces whole chocolate milk

DAY 2
Breakfast
3 waffles with 2 tablespoons butter and 3
tablespoons syrup
½ cup strawberries or bananas and sweetened
sour cream
2 sausage links
8 ounces hot chocolate
Snack
2 tablespoons peanut butter on graham crackers
1 medium banana or apple
Lunch
Tuna salad sandwich on whole wheat bread
1 bag or 2 ounces corn chips
½ cup carrot sticks with 2 tablespoons ranch dip
½ cup trail mix
8 ounces whole milk
Snack
8 ounce whole milk yogurt
¼ cup honey-roasted nuts
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dinner
2 slices pizza topped with chicken and extra
cheese
1 cup salad with sliced salad vegetables (carrots,
cucumbers, tomato) and 1 ounce finely chopped,
ripe avocado, 2 tablespoons dressing and ¼ cup
croutons
½ cup fresh pineapple
8 ounces whole milk


Client Education Materials

Nutrition Therapy for Children with Cystic Fibrosis
Handout in Spanish:
Nutrition Therapy for Children with Cystic Fibrosis
Links to handouts (PDFs) from the Cystic Fibrosis Foundation:
Grab 'N Go! Meal and Snack Ideas for People with CF on the Run
Color Your Calories: Adding Antioxidants to Your High-Calorie CF Diet
Nutrition: Cystic Fibrosis: Changes Through Life


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Pulmonary Diseases > Ventilator Issues
Foods Recommended or Not Recommended

All foods can be included in the meal plan, depending on the infant or child’s
developmental status and ability to chew and swallow appropriately.

Client Education Materials

Nutrition Therapy for the Ventilator-Dependent Child

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Renal Diseases
Renal Diseases


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Renal Diseases > Chronic Kidney Disease
Foods Recommended or Not Recommended: Sodium

The specific foods recommended for a child with chronic kidney disease (CKD) vary,
depending on stage and cause of CKD.
When a patient is first diagnosed with CKD, he or she is generally able to eat anything;
getting adequate energy intake may require an increase in energy-dense foods. As the
patient's CKD progresses, sodium, phosphorus, and protein may need to be restricted; as
the patient approaches CKD stage 5, potassium may also need to be restricted.
Once this same patient starts peritoneal dialysis, he or she will need to increase protein
and possibly potassium but continue a low-sodium to moderate-sodium, low-phosphorus
diet. Energy needs would actually decrease from what they were before dialysis because
of absorption of dextrose from dialysate.
If this patient starts hemodialysis 3 to 4 days per week rather than peritoneal dialysis, he or
she will need a smaller increase in protein but will need to continue potassium and
phosphorus restriction and may need a more restricted sodium intake. Energy needs will
be similar to what they were before dialysis. If the patient were to follow one of the newer,
daily hemodialysis regimens, he or she may not need any dietary restrictions at all, as long
as dialysis is going well.
It is not possible to give a single list of recommended foods that meets the needs of all
pediatric patients with CKD. It is extremely important to allow as liberal a diet as possible to
help the patient meet energy and nutrient needs. Many patients will need supplemental
tube feeding for optimal nutritional intake.

Low-Sodium Eating
Printable version

Recommended Not Recommended
Herbs and Seasonings

Herbs
Mrs. Dash
Garlic
Onion
Garlic powder
Onion powder

Salt
Soy sauce
Garlic salt
Onion salt
Celery salt
Seasoning mixes
(taco seasoning,
spaghetti sauce
seasoning)
Dairy Products
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk
Natural cheese (Swiss,
cheddar, jack)
Yogurt
Processed cheese
(American, Velveeta,
etc.)
Bread and Cereals
Shredded wheat
Puffed cereals
Tortillas
Pita bread
Rice
Quinoa
Pasta
Salt-free or regular bread
with <140 mg
sodium/serving
Bran cereal
Noodle mixes
(macaroni and
cheese, Top Ramen)
Rice mixes
(Rice-a-Roni)
Instant oatmeal
Ready-to-eat cereals
with more than 140
mg sodium/serving
Meats and Protein
Fresh fish, poultry, beef,
and pork
Water-packed tuna (rinse
well with cold water in a
strainer)
Eggs
Canned or dried beans
with no added salt (canned
beans should be rinsed
thoroughly with water)
Canned meats
Smoked meats
Bacon
Hot dogs
Corned beef
Deli meats
Sausage
Canned baked beans
Vegetables
Fresh vegetables
Frozen vegetables
Canned vegetables with no
added salt
Canned vegetables
Frozen vegetables
with sauces
Fruits
All fruits are OK
Fresh
Frozen
Canned
Snacks
Fruit
Fresh vegetables
Unsalted nuts
Rice cakes
Low-salt crackers
Unsalted popcorn
Salted chips
Salted pretzels
Salted crackers
Salted nuts
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Main Dishes
Homemade casseroles,
made without added salt
Low-salt soups
Homemade soups using
low-salt broth and no
added salt
Homemade stews/chili
without added salt
TV dinners with more
than 500 mg
sodium/serving
Frozen entrees with
more than 500 mg
sodium/serving
Lunchables
Canned soups
Canned stews
Canned chili


Sample 1-Day Menu

Sample 1-Day Limited Phosphorus Menu for a 10-Year-Old Child with Chronic
Kidney Disease
Printable version
Breakfast
1 serving hot chocolate made with 1
packet cocoa mix and hot water
2 eggs, scrambled (made with 2 teaspoon
regular butter, no milk)
1 slice white toast with 1 teaspoon butter
and 1 teaspoon jam
3/4 cup raw strawberries
Mid-Morning
Snack
½ cup applesauce
Lunch
Turkey sandwich made with two 1-ounce
slices white french bread, 2 ounces turkey
(roasted without salt), 2 teaspoons
mayonnaise
1 carrot cut into sticks
1 small (4-ounce) apple
1 sugar cookie
8 ounces water
Mid-Afternoon
Snack
4 graham cracker squares
½ cup cranberry juice cocktail
Dinner
1 chicken thigh, baked
½ cup rice
½ cup green beans
1 small slice lemon meringue pie
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Note: All foods are prepared without added salt.

Approximate Nutrient Analysis
Energy (kcal) 1,850
Protein (g) 65
Carbohydrates (g) 237
Fat (g) 70
Calcium (mg) 296
Phosphorus (mg) 696
Potassium (mg) 1,308
Sodium (mg) 1,626

Low-Potassium Sample Menu
Low-Sodium Sample Menu

Client Education Materials

Low-Sodium Nutrition Therapy
Low-Phosphorus Nutrition Therapy
Low-Potassium Nutrition Therapy
Low-Sodium Cooking Tips
Phosphate Binders

Foods Recommended or Not Recommended: Phosphorus

Low-Phosphorus Eating
Almost all foods contain contain some phosphorus; protein foods contain more than others.
Because getting enough protein while limiting phosphorus is important for children on
dialysis, the phosphorus-to-protein ratio is listed in the "Dairy" and "Protein" foods sections.
Printable version
Recommended Not Recommended
Herbs and Spices
All None
Dairy Products (typically contain 26 mg to 33 mg
phosphorus per 1 g protein)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Cream cheese
Whipped cream
Butter
Nondairy substitutes
Typically limit to 0 to 2
servings/day; 1 serving is
1/2 cup to 1 cup milk or 1
ounce to 1.5 ounces cheese
(the larger servings are
appropriate only for
adolescents)
Milk
Buttermilk
Fruit-flavored yogurt
Nonfat, plain yogurt
Pudding
Cheeses, natural
Cheeses, processed
Breads and Cereals

French bread
Sourdough bread
White bread (that does
not contain milk)
Corn

Bran (wheat or oat)
Oatmeal
Whole grain breads and
cereals (only if
phosphorus is not
controlled with low dairy
intake)
Breads made with milk
or cheese
Protein Foods

Egg white (1.14 mg
phosphorus/g protein
Beef (7-8 mg
phosphorus/g protein)
Pork (8-10 mg
phosphorus/g protein)
Chicken (6.5-7.5 mg
phosphorus/g protein)
Turkey (6.5-7.5 mg
phosphorus/g protein)
Fish (10-14 mg
phosphorus/g protein)
Split peas (12 mg
phosphorous/g protein)

Egg, whole (14 mg
phosphorus/g protein)
Egg, yolk (30 mg
phosphorus/g protein)
Lunch meats or
sausages containing milk
solids or cheese
Ham (13-16 mg
phosphorus/g protein)
Salami (7-18 mg
phosphorus/g protein)
Egg (14 mg
phosphorus/g protein)
Tofu (12-15 mg
phosphorus/g protein)
Beans: Kidney, black,
garbanzo, navy, pinto
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved



(16-20 mg phosphorus/g
protein)
Lentils (20 mg
phosphorus/g protein)
Nuts and seeds (20-30
mg phosphorus/g protein)
Soy nuts (22
mg phosphorus/g protein)
Fruits
All None
Vegetables (see Proteins section for legumes)
All
None (with exception of
legumes)
Snack Foods

Popcorn
Pretzels
Tortilla chips
Granola bars

Chips, popcorn, and
crackers made with
cheese
Candy bars made with
nuts or chocolate
Milk chocolate candies
Cola drinks

Main Dishes

Soups, casseroles,
pasta dishes, and
other mixed foods made
without cheese and/or
milk

Pizza, lasagna, and
other casseroles made
with cheese
Cream- or milk-based
soups



Foods Recommended or Not Recommended: Potassium

Low-Potassium Eating
The greatest food sources of potassium are fruits and vegetables. If potassium must be
restricted, choose mostly low-potassium fruits and vegetables and use those high in
potassium in very small amounts. Limit milk and dairy products like yogurt and ice cream to
1 cup per day. Some vegetables can be soaked to decrease their total potassium content
(see description below the table). If potassium needs to be increased (eg, for a child on
peritoneal dialysis), use the high-potassium fruits and vegetables.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Printable version

Low-Potassium Fruits and Vegetables Potassium mg
Fruits
Applesauce (½ cup) 90
Apple (1 medium/1 cup) 160
Blackberries (½ cup) 140
Blueberries (1 cup) 130
Cherries (10/2 oz) 150
Cranberries raw, whole (1 cup/3 oz) 67
Fruit cocktail (½ cup) 115
Grapes, seedless (10) 90
Grapefruit (½ med/4 oz) 170
Kiwi (½ med/1.3 oz) 126
Mango (½ med/3.5 oz) 160
Pears, canned (½ cup) 90
Peach (1 med/3 oz) 198
Pineapple (½ cup) 90
Plums (canned in syrup) (½ cup) 115
Raspberries (½ cup) 95
Rhubarb, cooked (½ cup) 115
Tangerine (1 med/3 oz) 130
Watermelon (1 cup) 175
Vegetables
Alfalfa sprouts (½ cup) 15
Asparagus (4 spears/2 oz) 130
Bamboo shoot , canned (1/2 cup) 53
Bean sprouts
Mung, raw (1 cup) 155
Soybeans, raw (½ cup) 170
Bell pepper (½ med/2 oz) 106
Broccoli, cooked (½ cup/3.2 oz) 166
Cabbage, raw, red/green (1 cup) 172
Cauliflower, raw (½ cup) 150
Carrots raw (½ cup) 180
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Celery, raw (7.5” stalk) 115
Chinese broccoli, boiled (½ cup) 115
Collards, boiled (1 cup) 170
Corn, frozen, boiled (½ cup) 121
Cucumber:
(¼ or 2” w/peel) 108
(¼ or 2” w/o peel) 75
Eggplant, cooked (½ cup) 125
Garlic (4 cloves) 50
Ginger root, raw (¼ cup) 100
Green beans
Fresh, boiled (½ cup) 187
Frozen, boiled (½ cup) 85
Lemon grass, raw (2 Tablespoons) 70
Lettuce:
Romaine (1 cup) 162
Iceberg, chopped (1 cup) 87
Looseleaf (1 cup) 148
Butterhead (1 cup) 141
Mixed vegetables, frozen (½ cup) 155
Okra, boiled (1/2 cup) 135
Onion, raw, chopped (¼ cup) 63
Pepper, chili, green, hot, raw (1 pepper) 153
Radishes (10/1.5 oz) 105
Rutabagas, raw (1 cup) 150
Spaghetti squash, baked (1 cup) 181
Summer squash: Raw, sliced (½ cup) 110
Turnip, cooked (½ cup) 105
Water chestnuts, canned (½ cup) 83
Zucchini squash: Raw, sliced (½ cup) 140



High-Potassium Fruits and
Vegetables
Potassium mg
Fruits
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Apricots (3 med/3.5 oz) 315
Avocado (¼ med/1.5 oz) 275
Banana (1 med/4 oz) 450
Cantaloupe (½ cup) 245
Cassava ((½ cup) 279
Dates, dried (5 med/1.4 oz) 350
Guava, medium (90 grams) 256
Honeydew (½ cup) 230
Orange (1 med/4.4 oz) 235
Papaya (½ med/5 oz) 390
Pear, fresh (1 med/5.5 oz) 210
Plums (2 med/4.4 oz) 220
Prunes (5 med/1.4 oz) 315
Raisins (¼ cup/1.3 oz) 310
Tamarind (½ cup) 377
100% fruit juices (1c) 300-500
Vegetables
Artichoke (¼ med/2.5 oz) 265
Beans:
Kidney, canned (½ cup) 330
Lima, canned (½ cup) 265
Mung, boiled (½ cup) 269
Navy, canned (½ cup) 380
Pinto, canned (½ cup) 290
Beets, boiled (½ cup) 260
Brussel sprouts (½ cup) 247
Chard, swiss, boiled (½ cup) 430
Corn, fresh boiled (½ cup) 204
Mushrooms, raw (½ cup) 259
Peas, dried, cooked (½ cup):
Black-eyed peas 240
Chickpeas/garbanzo 240
Lentils 365
Split peas 355
Potato, all types (1 sm/4.9 oz):
Baked with skin 759
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Boiled without skin 457
Sweet potatoes:
Baked with skin (1 med/4 oz) 397
Boiled/mashed (½ cup) 302
Tomato, raw, chopped (1 cup) 273
Tomato puree, canned (¼ cup) 266
Winter squash, baked (½ cup) 450
Yam, baked/boiled (½ cup) 456
Source: Pennington and Douglas Bowes & Church's Food Values of Portions Commonly
Used. 18th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
Try soaking vegetables, such as potatoes, to decrease the potassium content:
Peel and cut into pieces that are approximately 1/8 inch thick 1.
Rinse and soak them in warm water for at least 2 hours (use 10 cups water for every
1 cup vegetables)
2.
Drain and rinse under warm water. 3.
Boil vegetables for 5 minutes (use 5 cups water for every 1 cup vegetables) 4.
Soaked vegetables can be used in soups and stews or can be scalloped, mashed, or
fried
5.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Renal Diseases > Nephrotic Syndrome
Foods Recommended

Low-sodium foods, including the following, are the mainstay of the diet for a child with
nephrotic syndrome:
All fruits
Vegetables that are fresh or frozen, without salt
Whole grains
Brown rice, whole grain pasta, corn, quinoa, oatmeal
Low-sodium, ready-to-eat cereals (look for <140 mg sodium per serving);
shredded wheat and puffed cereals typically have 0 mg sodium
Hot cereals (avoid "instant" hot cereals, as they have added salt)
Low-sodium breads (regular breads may be used in limited amounts, but check
the sodium amount)
Milk, yogurt, low-sodium cheeses (regular, natural cheeses may be used in small
amounts)
Meat, poultry, fish, legumes, eggs (cooked from fresh without added salt; be sure
meat has not been "flavor enhanced" or preseasoned)
Printable version

Foods Not Recommended

Printable version
Avoid all processed and packaged foods with more than 500 mg sodium/serving
Avoid foods at restaurants, including fast-food restaurants, that have more than 500
mg/serving.
Foods to avoid by food group:
Fruits: Asian salted plums—otherwise, all fresh, frozen, canned, or dried fruits are
acceptable
Vegetables: Canned vegetables with salt, frozen with sauces or added salt (if canned
vegetables must be used, rinse in a strainer under cold water to remove a substantial
portion of the salt); salted french fries; packaged, flavored vegetable mixtures, such as au
gratin or scalloped potatoes
Grains: Packaged grain dishes such as flavored rice or noodle dishes; crackers, breads, or
cereals with more than 140 mg sodium per serving
Dairy products: All processed cheeses; more than 1 oz to 2 oz per day of regular, natural
cheeses (exception: natural Swiss cheese is very low in sodium)
Meat, poultry, fish, eggs: Processed meats: deli meat or poultry, ham, sausages, hot dogs,
bologna; preseasoned fresh meats, canned meats, fish, or poultry (exception: tuna canned
in water can be rinsed in a strainer under cold water to remove the majority of salt)
Salty snack foods: Chips, crackers, cheese puffs that have more than 140 mg sodium per
serving; read labels to determine which brands of tortilla chips and popcorn are low in salt
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
serving; read labels to determine which brands of tortilla chips and popcorn are low in salt
and thus acceptable for persons with nephrotic syndrome

Sample 1-Day Menu

Sample Low-Sodium Menu
Printable version
Serving sizes for a typical 10-year-old male
Breakfast
1 cup spoon-size shredded wheat
1 cup (½ with cereal, ½ to drink) 1% low-fat
milk
Medium banana
Morning
Snack
½ medium orange
2 graham cracker squares
Lunch
Turkey sandwich:
2 oz turkey (low-fat, low-sodium deli
meat)
1 slice low-salt bread
1 Tablespoon reduced-fat mayonnaise
1 medium carrot, cut into sticks
1 small apple
Afternoon
Snack

1 slice low-salt bread, toasted
1 Tablespoon peanut butter
Dinner
1½ cups macaroni and cheese (see recipe
below)
1 cup green salad (romaine, green leaf, and
butter lettuce)
1 Tablespoon balsamic vinaigrette
½ cup steamed broccoli
Evening Snack ½ cup applesauce
Approximate Nutrient Analysis

Nutrient Value
%
Recommended
Energy (kcal) 1732
Protein (g) (%
Calories from
protein)
74.5
(17)
149%
Carbohydrates (g) 266 89%
Sugars (g) 97
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fiber (g) (%
Calories from
carbohydrates)
27
(60)
109%
Fat (g) 47 72%
Saturated fat (g) 18.9 94%
Monounsaturated
fat (g)
2.2
Polyunsaturated
fat (% Calories
from fat)
1.9
(24)

Cholesterol (mg) 100.5 33%
Vitamin A (mcg
retinol activity
equivalents)
679.5
Vitamin A (IU) 17400 348%
Vitamin B-1 (mg) 1 70%
Vitamin B-2 (mg) 0.76 45%
Vitamin B-3 (mg) 11.8 59%
Vitamin B-6 (mg) 1.2 58%
Folic Acid (mcg) 302 75%
Vitamin C (mg) 139 231%
Vitamin D (IU) 175 44%
Vitamin E (IU) 1.8 6%
Vitamin K (mcg) 142 177%
Calcium (mg) 1193 119%
Magnesium (mg) 227 57%
Phosphorus (mg) 535 54%
Potassium (mg) 1637
Sodium (mg) 1542
Iron (mg) 9.23 51%
Manganese (mg) 2.71 135%
Zinc (mg) 4.03 27%
Macaroni and Cheese
Servings: 4
Serving Size: ~1½ cups

Ingredients:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Whole-wheat macaroni, dry: 2 cups
Water for cooking macaroni: 8 cups
Nonfat milk: 2 cups
Cornstarch: 2 Tablespoons
Optional: 3-4 drops tabasco sauce; ¼ teaspoon dry mustard; 1/8 teaspoons ground black
pepper
Shredded low-sodium medium or sharp cheddar or swiss cheese: 2 cups (a sharper-tasting
cheese gives more cheese flavor with less cheese)

Directions:
Start water heating for cooking macaroni; once boiling, add macaroni and cook for 8 to 10
minutes and then drain. Shred cheese. Mix cold milk with cornstarch and optional
seasonings in a heavy saucepan until cornstarch is dissolved. Heat milk mixture over
medium to high heat, stirring constantly until mixture comes to a boil and thickens. Add
shredded cheese and stir until melted. Mix with cooked macaroni and serve.
Optional ideas: add chopped, cooked, or frozen vegetables, or chopped, cooked chicken,
shrimp, or firm fish.

Client Education Materials

Nephrotic Syndrome Nutrition Therapy
Low-Sodium Cooking Tips

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Transplantation
Foods Recommended or Not Recommended: Low Bacteria

Neutropenic Food Lists
Printable version
Food Group
Foods
Recommended
Foods Not
Recommended
Beverages
Bottled water
that has been
processed by
reverse
osmosis,
distillation
or 1-mcm
particulate
absolute
filtration
Freshly drawn
tap water from
a safe source
Well water that
has been
boiled for 15 to
20 minutes
and stored in
a refrigerator
no longer than
48 hours
Shelf-stable
bottled or
canned drinks
(eg, juices,
flavored
waters, sports
drinks)
Freshly made
ice from
acceptable
water source
Steaming hot
beverages (at
least 175ºF)
Tea made with
boiling water
Water from a well
that has not been
tested
Unpasteurized juice
or milk
Ice from ice
machines in public
places
Icee frozen drinks
or other drinks from
bulk machines
Open drinks left at
room temperature
for 1 hour or more

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Bread and
Cereal
Products

All breads and
cereals are OK
Freshly
prepared rice
and pasta
Reheated, refried,
or leftover rice or
pasta (unless
heated to at least
165 degrees)
Uncooked grain
products
Breads, rolls, and
pastries in
self-service bins

Eggs
All eggs must be
cooked well done
Any undercooked or
soft-cooked eggs

Meat, Fish,
Poultry,
Meat
Substitutes,
Soups, Nuts
Any
well-cooked,
canned, or
prepackaged
meat, fish, or
poultry
Roasted or
cooked nuts
Prepackaged
heat-treated
deli meat
Meats that are not
well done
Fresh deli meat
Cold smoked
salmon, lox,
shellfish, sushi,
pickled fish
Uncooked nuts
Milk
Pasteurized
milk or yogurt
Cheeses
made from
pasteurized
milk
Prepackaged
or freshly
homemade
pasteurized
ice cream,
sherbet, or
frozen yogurt
Commercially
made
nutritional
products,
supplements,
and baby
formulas
Raw/unpasteurized
milk or yogurt
Cheeses with molds
(blue cheese,
gorgonzola, or
Roquefort)
Cheeses made
from unpasteurized
milk
Soft-serve ice
cream, frozen
yogurt, or sherbets
from bulk machines
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Fruit
All
well-washed
fresh fruits
except berries
Canned or
cooked fruits
Pasteurized
juice
Berries
Unpasteurized juice
Vegetables
All
well-washed
fresh
vegetables
All cooked or
canned
vegetables
Raw sprouts (e.g.,
alfalfa, mung bean)
Salads from
delicatessens
Commercial salsas
stored in
refrigerated case
Fats
Oil and
shortening
Refrigerated
lard,
margarine,
butter
Commercial,
shelf-stable
mayonnaise
and salad
dressings
(including
cheese-based
salad
dressings,
refrigerated
after opening)
Cooked gravy
and sauces
Fresh salad
dressings
containing aged
cheese (eg, blue
cheese, Roquefort)
or raw eggs, stored
in refrigerated cases
Salt,
granulated
sugar, brown
sugar
Jam, jelly,
syrups;
refrigerated
after opening
Commercial
(heat-treated)
honey
Raw or
non–heat-treated
honey; honey in the
comb
Herbal and nutrient
supplement
preparations
Brewer’s yeast, if
uncooked
Unrefrigerated,
cream-filled pastry
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Other Catsup,
mustard, BBQ
sauce, soy
sauce, other
condiments
(refrigerated
after opening)
Pickles, pickle
relish, olives
(refrigerated
after opening)
Candy, gum
products


(Smith, 2000; CDC, 2000; Rice, 2001; Moody, 2002; Wilson, 2002; Larson, 2004)


Foods to Avoid for Food Safety

Food Safety Tips handout
Raw or undercooked eggs
Monte Cristo sandwich
French toast
Caesar salad dressing
Hollandaise sauce
Some custards
Chocolate mousse
Tiramisu
Cookie dough/cake batter
Raw or rare meat or undercooked poultry
Raw or rare hamburger
Carpaccio (thin shavings of raw beef fillet)
Beef or steak
Raw or undercooked shellfish
Sushi
Clams
Oysters
Mussels
Scallops
Raw dairy products
Raw or unpasteurized milk or cheese
Fresh soft cheeses
Brie
Camembert
Blue-veined varieties
Mexican-style queso fresco
Ready-to-eat foods
Uncooked hot dogs
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Uncooked luncheon meats
Uncooked sausage
Other deli-style foods
Do not eat or drink:
Tea, unless commercially bottled or prepared with boiled water
Black pepper (used after meal was prepared)
Leftovers, unless heated to at least 165°F

Sample 1-Day Menus: HSCT

On this screen:
Graft-vs-host disease sample menu
Mucositis sample menu
Low-bacteria sample menu
Sample menus for nausea and vomiting, and diarrhea

Graft-vs-Host Disease Sample Menus Printable version
Menu Limited to Group 1 Foods (see Food Lists handout)
Breakfast
½ toasted bagel
1 teaspoon grape jelly
Snack ½ cup fruit-flavored gelatin
Lunch
¼ cup plain noodles
½ cup chicken broth
Snack ½ cup applesauce
Evening Meal
¼ cup steamed rice
½ cup beef broth
Snack
2 vanilla wafers
1 frozen fruit-flavored pop
Approximate Nutrient Analysis
Energy (kcal) 456
Total protein (g)
12 (10% of
kcal)
Total carbohydrate (g)
97 (85% of
kcal)
Total fat (g)
3.5 (5% of
kcal)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Saturated fatty acids (g)
0.9 (1.8% of
kcal)
Monounsaturated fatty
acids (g)
1 (2% of kcal)
Polyunsaturated fatty acids
(g)
1 (2% of kcal)
Cholesterol (mg) 17
Calcium (mg) 54.7
Iron (mg) 3.1
Magnesium (mg) 38.6
Phosphorus (mg) 165.9
Potassium (mg) 446
Sodium (mg) 1116
Zinc (mg) 0.9
Vitamin A (mcg RAE) 5.5
Vitamin C (mg) 5.7
Thiamin (mg) 0.3
Riboflavin (mg) 0.3
Niacin (mg) 5.6
Total folate (mcg) 90
Vitamin B-6 (mg) 0.2
Vitamin B-12 (mcg) 0.3
Total dietary fiber (g) 4

Menu Including Group 2 Foods (see Food Lists handout)
Breakfast
1 cup half-strength apple juice
Toasted English muffin
1 teaspoon butter
Snack 2 graham crackers
Lunch ½ low-fat turkey sandwich on white bread
Snack ½ banana
Evening Meal
1 cup chicken and rice soup
1 white dinner roll
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Snack
½ cup Rice Krispies
1 cup lactose-free milk
Approximate Nutrient Analysis
Energy (kcal) 913
Total protein (g)
37 (16% of
kcal)
Total carbohydrate (g)
145 (63% of
kcal)
Total fat (g)
21.1 (21% of
kcal)
Saturated fatty acids (g)
8.2 (8% of
kcal)
Monounsaturated fatty
acids (g)
6 (6% of kcal)
Polyunsaturated fatty acids
(g)
5 (5% of kcal)
Cholesterol (mg) 70
Calcium (mg) 542
Iron (mg) 7.8
Magnesium (mg) 98.3
Phosphorus (mg) 536.2
Potassium (mg) 1280
Sodium (mg) 1924
Zinc (mg) 4
Vitamin A (mcg RAE) 255.2
Vitamin C (mg) 10.5
Thiamin (mg) 0.9
Riboflavin (mg) 1.2
Niacin (mg) 12.1
Total folate (mcg) 208.1
Vitamin B-6 (mg) 0.9
Vitamin B-12 (mcg) 2.2
Total dietary fiber (g) 6


Mucositis Sample Menu Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mucositis Sample Menu Printable version
Breakfast
1 scrambled egg
1 banana
1 cup whole milk
Lunch
1 creamy peanut butter and jelly
sandwich on soft white bread
½ cup chocolate pudding
1 small canned peach half
Snack 1 blueberry muffin
Evening Meal
3 ounces soft turkey breast with gravy
½ cup mashed potato with butter
½ cup cooked carrots
Snack 1 small piece of cake without nuts

Approximate Nutrient Analysis
Energy (kcal) 1439
Total protein (g)
55 (15% of
kcal)
Total carbohydrate (g)
209 (58% of
kcal)
Total fat (g)
45.7 (28% of
kcal)
Saturated fatty acids (g)
14.1 (8% of
kcal)
Monounsaturated fatty
acids (g)
17 (10% of
kcal)
Polyunsaturated fatty acids
(g)
11 (6% of kcal)
Cholesterol (mg) 279
Calcium (mg) 695.2
Iron (mg) 7.4
Magnesium (mg) 211.6
Phosphorus (mg) 1053
Potassium (mg) 2319
Sodium (mg) 2451
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Zinc (mg) 6.3
Vitamin A (mcg RAE) 1271.4
Vitamin C (mg) 26.2
Thiamin (mg) 0.8
Riboflavin (mg) 1.6
Niacin (mg) 13.5
Total folate (mcg) 236.5
Vitamin B-6 (mg) 1.5
Vitamin B-12 (mcg) 2.7
Total dietary fiber (g) 15


Low-Bacteria Sample Menu Printable version
Breakfast
1 medium whole wheat bagel
2 Tbsp cream cheese
1 egg, scrambled
1 cup whole milk
1 small banana
Snack
1 sheet (4 small rectangles) graham crackers
1 Tbsp peanut butter
1 cup whole milk
Lunch
Turkey sandwich:
2 slices whole wheat bread
1 tsp mayonnaise
1 slice pasteurized cheese
2 oz packaged turkey

4 oz applesauce
½ cup cooked carrots
1 cup 100% fruit juice
Snack
5 whole wheat crackers
1 cup whole milk
1 medium apple, peeled
Dinner
3 oz chicken breast, broiled
½ cup mashed potatoes
1 Tbsp sour cream
1 tsp butter
1 cup green beans, steamed or cooked
1 cup 100% fruit juice
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dessert 8 oz chocolate milkshake

Note: Portions may vary depending on age of the child
Approximate Nutrient Analysis
Energy (kcal) 2396
Total protein (g)
101 (16% of
kcal)
Total carbohydrate (g)
305 (50% of
kcal)
Total fat (g)
94.2 (35% of
kcal)
Saturated fatty acids (g)
39.8 (6% of
kcal)
Monounsaturated fatty
acids (g)
31 (11% of
kcal)
Polyunsaturated fatty acids
(g)
15 (5% of kcal)
Cholesterol (mg) 435
Calcium (mg) 1420.1
Iron (mg) 12.1
Magnesium (mg) 443.1
Phosphorus (mg) 1967.7
Potassium (mg) 4417
Sodium (mg) 3603
Zinc (mg) 10.6
Vitamin A (mcg RAE) 1353.1
Vitamin C (mg) 185.9
Thiamin (mg) 1.5
Riboflavin (mg) 3
Niacin (mg) 25.2
Total folate (mcg) 321.3
Vitamin B-6 (mg) 2.6
Vitamin B-12 (mcg) 4.9
Total dietary fiber (g) 32

Sample Menu for Nausea and Vomiting Printable version
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breakfast
1 banana
1 cup apple juice
1 piece toast
Snack
½ cup applesauce
8 ounces flat lemon-lime soda
Lunch
1 cup chicken and rice soup
5 saltine crackers
½ cup cooked green beans
8 ounces flat lemon-lime soda
Snack
1 cup dry Cheerios
1 popsicle
Evening Meal
3 ounces soft, baked turkey
½ cup mashed potatoes
½ cup apple juice
8 ounces flat lemon-lime soda
Snack
½ cup fruit gelatin
1 piece toast
Approximate Nutrient Analysis
Energy (kcal) 1341
Total protein (g)
43 (12% of
kcal)
Total carbohydrate (g)
255 (76% of
kcal)
Total fat (g)
20 (13% of
kcal)
Saturated fatty acids (g)
4.7 (3% of
kcal)
Monounsaturated fatty
acids (g)
7 (4% of kcal)
Polyunsaturated fatty acids
(g)
5 (3% of kcal)
Cholesterol (mg) 74
Calcium (mg) 307.9
Iron (mg) 14.9
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Magnesium (mg) 158.3
Phosphorus (mg) 510.4
Potassium (mg) 1858
Sodium (mg) 2238
Zinc (mg) 7.2
Vitamin A (mcg RAE) 252.8
Vitamin C (mg) 34.6
Thiamin (mg) 1
Riboflavin (mg) 1.1
Niacin (mg) 16.7
Total folate (mcg) 317.2
Vitamin B-6 (mg) 1.8
Vitamin B-12 (mcg) 2
Total dietary fiber (g) 13

Sample Menu for Diarrhea Printable version
Breakfast
1 cup Rice Krispies
1 cup vanilla soy milk
½ ripe banana
Snack
1 cup decaffeinated tea
6 ounces yogurt or 2 graham cracker rectangles
Lunch
2 cups chicken rice soup with 2 ounces of added
chicken
¼ cup cooked carrots
1 slice white toast with thin spread of jelly
½ cup applesauce
Snack
2 or 3 saltine crackers
1 cup fruit juice without pulp
Evening
Meal
4 to 6 ounces baked fish topped with
breadcrumbs, a squeeze of lemon, and 1
teaspoon butter or margarine
½ cup mashed potato without skins
½ cup green beans, cooked well
1½ cups water or other caffeine-free beverages
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1½ cups water or other caffeine-free beverages
Snack
½ cup sorbet
1 cup sugar-free hot chocolate made with water
or soy milk

Approximate Nutrient Analysis
Energy (kcal) 1620
Total protein (g)
70 (17% of
kcal)
Total carbohydrate (g)
251 (61% of
kcal)
Total fat (g)
42.9 (23% of
kcal)
Saturated fatty acids (g)
13.1 (7% of
kcal)
Monounsaturated fatty
acids (g)
15 (8% of kcal)
Polyunsaturated fatty acids
(g)
10 (5% of kcal)
Cholesterol (mg) 164
Calcium (mg) 765.6
Iron (mg) 10.6
Magnesium (mg) 301.7
Phosphorus (mg) 1258.8
Potassium (mg) 3213
Sodium (mg) 3679
Zinc (mg) 6.1
Vitamin A (mcg RAE) 894.5
Vitamin C (mg) 126.7
Thiamin (mg) 1.6
Riboflavin (mg) 1.9
Niacin (mg) 15.3
Total folate (mcg) 291.8
Vitamin B-6 (mg) 1.7
Vitamin B-12 (mcg) 6.2
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Total dietary fiber (g) 17

Foods Recommended or Not Recommended: GVHD

Printable version
GVHD may cause nausea, vomiting, and diarrhea. Eating bland foods helps the gut heal
and lessens the irritation the child is feeling.
At first, children should only eat from Group 1 in the table below. When they are eating
foods from Group 1 without problems, determine whether they are ready to move on to
Group 2 foods. To avoid making nausea, vomiting, or diarrhea worse, introduce Group 2
foods slowly.
Food Types
Foods Recommended
(Group 1)
Foods Not
Recommended
Beverages
Noncarbonated drinks:
Gatorade
Fruit punch
Bottled water
Resource (Orange,
Wildberry)
All other beverages
Soups
Chicken broth
Vegetable broth
Beef broth
All other soups
Vegetables
(1/2 cup
serving)
Well-cooked green
beans
Well-cooked carrots
Sweet potato
All other vegetables
Fruit
Banana (half)
Applesauce
Canned peaches
All other fruits
Snacks
Frozen, fruit-flavored
ice pop
Jell-O (regular or
sugar-free)
All other snacks
Starchy foods
(1/2 cup
serving)
Plain mashed potatoes
Steamed or baked
potatoes
Steamed rice
Plain noodles
Cream of Wheat
Cream of Rice
Corn flakes
Rice Krispies
All other starchy
foods
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Breads
Toasted white bread (1
slice)
Toasted bagel (½)
Toasted English muffin
(½)
Saltines (2 crackers)
Graham crackers (2
crackers)
White dinner roll
Plain pretzels (1 oz)
Vanilla wafers (2 wafers)
All other breads
Condiments
Salt
Sugar (1 packet)
Grape jelly (1 portion)
Jelly, sugar-free (1
portion)
All other
condiments

Foods Allowed
(Group 2, in addition
to Group 1)
Foods Excluded
Nutritional
supplements
Boost: Chocolate,
Strawberry, Vanilla
Pediasure: Chocolate,
Strawberry, Vanilla,
Banana
All other nutritional
supplements
Soups
Chicken rice soup
Chicken noodle soup
Ramen noodles with ½
pkg seasoning
All other soups
Dairy foods
and substitutes
(1 cup serving)
Lactose-free 2% milk
Rice milk
Soy milk
All others
Meat and
protein foods
(3 oz serving)
Baked chicken breast
(skinless)
Roast turkey
Hard-boiled egg
Tuna, water packed
Lean ham
Baked mild fish (catfish
or cod)
You can request baby
food
All other protein
Juices
(1/2 strength, 1
cup serving)
Apple juice
Cranberry juice
Grape juice
All other juices
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sandwiches
(1/2)
Low-fat plain tuna salad
sandwich on white
bread
Low-fat ham sandwich
on white bread
Plain egg salad on
white bread
Low-fat turkey
sandwich on white
bread
All other
sandwiches
Condiments
Butter (1 pat)
Low-fat mayonnaise (1
tsp)
Sour cream (1 tbsp)
All other
condiments


Foods Recommended or Not Recommended: Mucositis

Printable version
Food
Groups
Foods Recommended
Foods Not
Recommended
Beverages
Cocoa, chocolate drinks,
tea, egg nog, fruit
punch, milk, milk
beverages, buttermilk,
fruit juices except citrus.
Very hot or cold
beverages,
vegetable juices
Citrus juices,
carbonated drinks
Bread and
cereal
products
Soft bread and toast as
tolerated, crackers, rolls,
muffins, farina, cream of
wheat, cream, oatmeal,
cream of rice, grits; dry
cereals if tolerated.
Breads made with
nuts or seeds
Hard, crunchy
breads, crackers, or
cereals
Desserts
Soft desserts such as
gelatin, ice cream, ices,
sherbet, custard,
pudding, tapioca, and
rice pudding, fruit whips,
honey, syrup, molasses,
jelly, cookies as
tolerated
All containing nuts
or seeds
Hard-to-chew or
crunchy desserts
Fats
Butter, margarine,
cream, oils, mayonnaise
Nuts
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruit
All fruit juices; cooked or
canned fruits
Soft, fresh fruits as
tolerated
Fruit with seeds
Hard fresh fruits
Citrus fruits
Meat and
other protein
sources
Baked, broiled, fried or
boiled beef, lamb, veal,
chicken, pork, turkey,
liver, fish, cottage
cheese, creamy peanut
butter, eggs
Highly seasoned
meat, crunchy
peanut butter
Tough meat,
hard-to-chew meats
Milk All milk and milk drinks None
Soups
All except tomato
Soups with allowed
foods
Tomato soup
Soups with foods
not allowed
Vegetables
Tender vegetables, soft
raw vegetables, as
tolerated, such as
mashed or baked
potatoes, green beans,
cooked spinach,
squash, asparagus,
beans, mushrooms,
sweet potatoes
Coarse, raw
vegetables, such as
cauliflower, and
broccoli
Hard, cooked
vegetables, such as
broccoli stalks
Tomato-based
sauces
Seasonings/
condiments
Cinnamon, ginger,
nutmeg, paprika,
rosemary, mace,
vinegar, cocoa, catsup,
vanilla, mildly seasoned
or cream gravy as
tolerated
Salty foods
Strong, hot spices
such as red pepper,
garlic, curry, chili
powder,
horseradish,
relishes, pickles,
pepper

(Mahan, 2004; NIH NCI, 2003)


Client Education Materials

Nutrition Therapy for Diarrhea
Nutrition Therapy for Graft-Versus-Host Disease
Nutrition Therapy for Mucositis
Nutrition Therapy for Nausea and Vomiting
Neutropenic Nutrition Therapy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Food Safety Tips
Nausea and Vomiting Tips

Handouts in Spanish
Nutrition Therapy for Diarrhea
Nutrition Therapy for Nausea and Vomiting
Food Safety Tips
Nausea and Vomiting Tips

Foods Recommended: Organ Transplant

Once the transplanted organ is working well and a child is out of the early posttransplant
phase, an unrestricted healthful, well-balanced diet is recommended. During the chronic
posttransplant phase, the goal of nutrion therapy is growth and optimization of intake to
counteract the long-term side effects of immunosuppressive drugs, including hypertension,
diabetes, obesity, hyperlipidemia, and bone disease. This can be acheived by promoting
the 2005 Dietary Guidelines for healthy children after the age of 2 years.
Macronutrient distribution should be within the acceptable range:
Carbohydrate: 45% to 65% of total energy. Half of all grains should be whole grain.
Encourage a variety of vegetables and friuts within energy needs but discourage
juices.
Protein: 5% to 20% for young children and 10% to 30% for older children. Children
aged 2 to 8 years should consume 2 servings/day of fat-free or low-fat dairy products
and children aged 9 years and older should consume 3 servings/day. Protein in the
form of low-mercury fish, skinless poultry, lean meats, eggs, nuts, beans, peas, and
other meat alternatives such as low-fat tofu and tempeh should be included
Fat: 30% to 40% for children aged 1 to 3 years and 25% to 35% for children aged 4 to
18 years. Limit saturated fats to less than 10% of total energy; polyunsaturated fats,
10% of energy; and monounsaturated fat, the remaining energy from fat.
Recommended Foods
Printable version
Food Group Recommended Foods
Dairy

Skim milk
Fat-free yogurt
Low-fat or fat-free cheese
Low-fat ice cream
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meat and other
foods with protein
(baked, grilled,
broiled, boiled,
poached)
Skinless chicken and turkey
Fish
Lean, fresh beef and pork
Dry beans and peas
Unsalted nuts
Tofu
Egg
Fruits Fresh fruits (except grapefruit)
Unsweetened canned and
frozen fruit (except grapefruit)
Unsweetened juice (in small
amounts) (except grapefruit
juice)
Unsweetened dried fruits
Vegetables

Fresh vegetables
Unsalted canned or frozen
vegetables
Unsalted vegetable juices
Grains Whole grain breads
Whole grain pastas, rice,
brown wild rice
Whole grain, unsweetened
cereals
Fats and Oils Olive oil
Canola oil
Trans-fat-free margarine
Nonfat or low-fat salad
dressing
Seasonings Fresh or dried cooking herbs
Onion or onion powder (not
onion salt)
Garlic or garlic powder (not
garlic salt)
Salt-free and sodium-free
seasonings
See Nutrition Diagnosis and Nutrition Intervention for specific foods or nutrients to
limit or increase during early posttransplant phase.

Foods Not Recommended: Organ Transplant

Printable version
In the early posttransplant phase, foods high in salt, sugar, and fat will likely need to be
limited or avoided. Once the transplant is functioning well, there are very few foods that a
patient must absolutely avoid. Because of immunosuppression, the transplant patient must
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
be very careful to avoid the possibility of food poisoning or foodborne infection. Foods to be
totally avoided include the following:
Raw, rare, or undercooked meats, fish, shellfish, poultry, or eggs
Raw/unpasteurized dairy products
Raw/unpasteurized honey
Unwashed raw fruits and vegetables, fresh sprouts (such as bean or alfalfa sprouts)
Grapefruit or grapefruit juice (if the patient is taking Cyclosporine or Prograf, because
grapefruit interferes with the metabolism of these drugs)
Well water, unless tested
Food that is spoiled or moldy; food that is past its "use by" date
Any food that has a high possibility of contamination with a pathogen
Fruits or vegetables prepared on a counter or cutting board that has had raw
meat, fish, poultry, or eggs on it
Food containing animal protein that has been between 40°F and 140°F degrees
for more than 2 hours
Foods purchased from a street vendor that has not been certified by the health
department
Foods purchased from a street vendor in a third world country
Food Safety Tips Handout
As with all children, transplant patients would benefit from avoiding highly processed,
high-sodium, high-sugar and high-fat foods.

Sample 1-Day Menu: Organ Transplant

Sample 1-Day Menu for an 8-Year-Old Child with Organ Transplant
Printable version
Breakfast
Egg, 1 large, scrambled with 1 tsp oil
Whole wheat toast, 1 slice
Smart Balance, 1 tsp
Jelly, 1 tsp
Strawberry and banana, ¾ cup sliced
2% milk, 8 oz
Water, 4 oz
Lunch
Peanut butter (2 Tbsp) and jelly (1 Tbsp) sandwich
Baby carrots, 6-8 sticks
Peach, 1 large
Water, 8 oz
Snack
Graham cracker squares, 4
Apple, 1 large
Water, 8 oz
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dinner
Skinless chicken breast, 3 oz grilled
Broccoli, 1 cup steamed with Smart Balance, 1 tsp
Tangerine, 1 large
2% milk, 8 oz
Water, 8 oz
Snack
Unbuttered popcorn, 1 cup
Grape juice, 8 oz

Approximate Nutrient Analysis
Energy (kcal) 1,805
Protein (g) 82
Carbohydrate (g) 281.6
Fiber (g) 29
Total fat (g) 61
Saturated fat (g) 16.7
Trans fat (g) 1.2
Cholesterol (mg) 248
Calcium (mg) 988
Iron (mg) 10
Sodium (mg) 2,148

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Weight Management
Weight Management


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Weight Management > Overweight/Obesity
Sample 1-Day Menus

Sample Menu for a Weight-Reduction Diet for a 7-Year-Old to 10-Year-Old Child
Printable version
Breakfast
2 oz part-skim string cheese
1 oz whole wheat crackers
¼ mango, medium
1 cup nonfat milk
Lunch
Ham and cheese sandwich:
1½ oz lean ham
2/3 oz nonfat American cheese
3½" whole wheat roll

Tossed salad:
1¼ cup romaine lettuce
1/3 cup sliced cucumber
1/3 cup cubed tomato
5 strips red pepper
3 slices radish
2 Tbsp fat-free 1,000 island dressing

1 apple, medium
1 cup nonfat milk with ¼ packet sugar-free chocolate flavoring
Dinner
4 1½" meatballs (15% lean round or sirloin beef in tomato sauce)
2/3 cup brown rice
1 cup sautéed eggplant (use olive oil)
12 oz flavored seltzer
Snack 1
3 cups light low-fat popcorn
12 oz water or flavored seltzer
Snack 2 1 cup strawberries

Approximate Nutrient Analysis
Energy (kcal) 1,463.13
Protein (g) (23.56% of kcal) 86.17
Carbohydrate (g) (52.4% of kcal) 191.68
Total fat (g) (26.64% of kcal) 43.31
Saturated fatty acids (g) (9.91% of kcal) 16.11
Monounsaturated fatty acids (g) (11.25% of kcal) 18.29
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Polyunsaturated fatty acids (g) (2.76% of kcal) 4.48
Cholesterol (mg) 178.09
Calcium (mg) 1,370.68
Iron (mg) 10.98
Magnesium (mg) 331.84
Phosphorus (mg) 1,722.05
Potassium (mg) 3,437.83
Sodium (mg) 2,545.69
Zinc (mg) 12.28
Total vitamin A (retinol activity equivalents) (mcg) 890.75
Vitamin C (ascorbic acid) (mg) 170.1
Thiamin (vitamin B-1) (mg) 1.58
Riboflavin (vitamin B-2) (mg) 1.95
Niacin (vitamin B-3) (mg) 14.31
Folate (mcg) 293.94
Vitamin B-6 (pyridoxine, pyridoxyl, pyridoxamine) (mg) 1.61
Vitamin B-12 (cobalamin) (mcg) 5.07
Total dietary fiber (g) 23.79
Insoluble dietary fiber (g) 18.28
Vitamin D (calciferol) (mcg) 6.1

Sample Menu for a Weight-Reduction Diet for an 11-Year-Old to 14-Year-Old
Adolescent
Printable version
Breakfast
1 cup nonfat milk
½ cup cantaloupe
1 packet instant oatmeal cereal
Lunch
1 baked chicken leg and drumstick (skin removed
prior to cooking), medium with 1 Tbsp barbecue
sauce
1 2" whole wheat roll
½ cup corn kernels
1 tsp lite tub margarine (no trans fatty acids)
1 plum, medium
½ cup nonfat milk
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dinner
6 oz baked flounder with
1 Tbsp olive oil
2 wedges fresh lemon
½ cup steamed green peas
½ cup whole-wheat noodles
1½ cup tossed salad (romaine lettuce)
1 Tbsp olive oil
2 Tbsp balsamic vinegar
½ cup fruit cocktail packed in water
12 oz homemade decaffeinated iced tea, no sugar
added
Snack 1
6 oz low-fat vanilla yogurt
½ cup carrot sticks
½ cup sliced cucumbers
2 Tbsp reduced-calorie French dressing
12 oz flavored seltzer
Snack 2
1 cup nonfat milk
4 reduced-fat chocolate-vanilla wafers

Approximate Nutrient Analysis
Energy (kcal) 1,683.77
Protein (g) (28.21% of kcal) 118.73
Carbohydrate (g) (47.27% of kcal) 199
Total fat (g) (27.24% of kcal) 50.96
Saturated fatty acids (g) (5.15% of kcal) 9.63
Monounsaturated fatty acids (g) (14.01% of kcal) 26.22
Polyunsaturated fatty acids (g) (6% of kcal) 11.23
Cholesterol (mg) 210.85
Calcium (mg) 1,298.61
Iron (mg) 18.67
Magnesium (mg) 419.78
Phosphorus (mg) 2,010.51
Potassium (mg) 3,977.33
Sodium (mg) 1,688.64
Zinc (mg) 12.5
Total vitamin A (retinol activity equivalents) (mcg) 2,594.3
Vitamin C (ascorbic acid) (mg) 98.93
Thiamin (vitamin B-1) (mg) 1.64
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Riboflavin (vitamin B-2) (mg) 2.51
Niacin (vitamin B-3) (mg) 20.11
Folate (mcg) 396.44
Vitamin B-6 (pyridoxine, pyridoxyl, pyridoxamine) (mg) 2.18
Vitamin B-12 (cobalamin) (mcg) 7.63
Total dietary fiber (g) 21.65
Insoluble dietary (g) 14.62
Vitamin D (calciferol) (mcg) 8.98


Foods Recommended

Printable version
Food Group Foods Lower in Calories
Beverages
Water, unsweetened coffee or tea, diet carbonated
beverages, sugar-free soft drinks
Dairy
Skim or low-fat milk; reduced-fat cheese;
reduced-fat or fat-free sour cream; yogurt
Fats
Foods cooked without added fat (bake, broil, roast,
boil)
Condiments Vinegar; reduced-calorie or fat-free salad dressing
Meat Lean meat, fish, poultry without skin
Vegetables
Any fresh or frozen, served raw or cooked without
added fat (steamed, roasted)
Starches
Smaller portions (1/2 cup serving) of pasta, rice,
potatoes, corn, or nonstarchy vegetables
Fruits &
Desserts
Fresh, frozen or canned fruit without added sugar
A large portion = 1/2 of a dinner plate
A small portion = 1/3 of a dinner plate
Snacks should contain less than 10 g sugar, at least 2 g fiber, and less than 2 g saturated
fat.


Foods Not Recommended

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Printable version
Food Group Foods Higher in Calories
Beverages
Regular carbonated beverages; alcoholic
beverages; limit portions of juice and fruit drinks
Dairy
High-fat dairy products (whole milk, cream, regular
cheese, ice cream)
Fats
Fried foods or those otherwise prepared with
butter, oil, cream, or lard
Condiments Regular salad dressing (large portions)
Meat High-fat meats or those prepared with fats
Vegetables Those prepared with fats (butter, sauces, oils)
Starches Large portions of pasta, rice, potatoes, corn
Fruits &
Desserts
Candy, cake, pie, cookies, sweet rolls, etc.
A large portion = 1/2 of a dinner plate
A small portion = 1/3 of a dinner plate
Snacks should contain less than 10 g sugar, at least 2 g fiber, and less than 2 g saturated
fat.


Client Education Materials

Weight Management Nutrition Therapy for Children Ages 7-10
Weight Management Nutrition Therapy for Children Ages 11-14
Weight Management Self-Monitoring Goals Sheet
Weight Management Self-Monitoring Contract
Portion Size Tips Sheet

Handouts in Spanish
Weight Management Nutrition Therapy for Children Ages 7-10
Weight Management Nutrition Therapy for Children Ages 11-14
Weight Management Self-Monitoring Goals Sheet
Weight Management Self-Monitoring Contract
Portion Size Tips Sheet

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Meal Plans > Weight Management > Underweight
Foods Recommended

Underweight children may benefit from additions to their normal diet of high-calorie foods
and supplements. Food selections should concentrate on replacement of identified nutrient
deficiencies. For instance:
Caloric deficiency: Provide foods with high fat calorie concentration.
Fat (butter, margarine, oil, cream, whip cream, cream cheese, bacon)
Full-fat cheese
Protein deficiency: Provide foods rich in protein and adequate calorie intake.
Peanut butter
Nuts (ground, chopped, whole)
Supplemental drinks
Milkshakes
Protein bars
Vitamin or mineral deficiency: Provide foods concentrated in the deficient nutrient
and foods containing complementary nutrients to aid in absorption or utilization of the
deficient nutrient.
Printable version of high-calorie food list

Foods Not Recommended

Low-calorie, low-nutrient-dense foods are not recommended. These include foods such as:
Sugar-free beverages
Reduced fat desserts
Sugar-free candies
Diet margarine
In certain medical conditions, specific foods exacerbate symptoms. These foods should be
avoided. For instance:
Celiac disease
Wheat, oats (controversial), barley, rye, or malt
Food allergy
Foods containing any source of the allergen
Malabsorption
Situation-specific but may require gastrointenstinal rest or temporary food
modifications
Printable version of high-calorie food list

Sample 1-Day Menu

Sample High-Calorie Menu for a 7- or 8-year old child
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Printable version
Breakfast
Yogurt shake:
2% milk (1/4 cup)
Low fat yogurt (1/2 cup)
Banana (1/2)
Strawberries (1/4 cup)
Honey (1 tbsp)
Vanilla (1/2 tsp)
Oat bran muffin (1/2)
Butter (1 tsp)
Lunch
Egg salad sandwich (1/2)
Chocolate whole milk (1/2 cup)
Apple (1 small)
Celery (1/2 stalk) with cream cheese (1 tbsp)
Snack
Tortilla chips (2 oz)
Cheddar cheese melted on top (1/4 cup)
Evening Meal
Meatloaf (2 oz)
Mashed potato (1/2 cup)
Butter (2 tsp)
Whole wheat bread (1/2 slice)
Carrot sticks and broccoli florets (1/4 cup)
Ranch salad dressing for dipping (2 tbsp)
2% milk (1 cup)
Evening Snack
Peanut butter (1 tbsp)
Graham cracker (2 squares)

Approximate Nutrient Analysis
Energy (kcal) 2900
Total protein (g) 74
% kilocalories from protein 10
Total carbohydrate (g) 350
% kilocalories from carbohydrate 48
Total fat (g) 137
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
% kilocalories from fat 42
Total saturated fatty acids (SFA) (g) 44
% kilocalories from SFA 14
Total monounsaturated fatty acids
(MUFA) (g)
39
% kilocalories from MUFA 12
Total polyunsaturated fatty acids
(PUFA) (g)
31
% kilocalories from PUFA 10
Cholesterol (mg) 278
Calcium (mg) 1245
Iron (mg) 10
Potassium (mg) 5438
Sodium (mg) 5270
Vitamin A (IU) 6380
Vitamin C (mg) 157
Thiamin (mg) 1.6
Riboflavin (mg) 2
Niacin (mg) 21
Total folate (mcg) 270
Total dietary fiber (g) 30

Client Education Materials

High-Calorie Nutrition Therapy
Tips for Underweight Children
Tips for Picky Eaters

Handouts in Spanish
Tips for Underweight Children

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources
Pediatric Nutrition Care Manual
®
Pediatric Nutrition Practice Group
Academy of Nutrition and Dietetics
The Nutrition Care Manual
®
(NCM
®
) is a publication of the Academy of Nutrition and Dietetics.
Our goal is yours - Professional Excellence
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Publisher
Beth Leonberg, MS, RD, CSP, FADA, LDN
Editor-in-Chief
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Senior Content Reviewer
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Developmental Editor
Nutrition Care Manual
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®
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Copyright © 2012 Academy of Nutrition and Dietetics. All rights reserved. With the
exception of the client education handouts, no part of this publication may be reproduced,
stored in a retrieval system or transmitted in any form or by any means without prior
written consent of the publisher.
The client education handouts in the Pediatric Nutrition Care Manual
®
are not intended to
substitute for nutrition counseling with a registered dietitian. The information is meant to
serve as a general guideline, and may not meet the unique nutritional needs of individual
patients. All medical professionals should consult with a registered dietitian before
providing handouts to clients or patients.
The views expressed in this publication are those of the authors and do not necessarily
reflect policies and/or official positions of the Academy of Nutrition and Dietetics. Mention of
product names in this publication does not constitute endorsement by the authors or the
Academy of Nutrition and Dietetics. The Academy of Nutrition and Dietetics disclaims
responsibility for the application of the information contained herein.
Resources > Contributors
Contributors


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Contributors > Authors
2011 Update Contributors

Normal Nutrition Topics
Normal Nutrition for Full-Term Infants:
Dena Goldberg, PhD, RD, CSP

Normal Nutrition for Toddlers and Preschoolers:
Diana M. Miller, MPH, RD, CLC, LDN

Normal Nutrition for Adolescents:
Beth Lulinski, MS, RD, LDN

Normal Nutrition for Vegetarian Children:
Reed Mangels, PhD, RD, LD, FADA
Disease/Condition Topics
Anemia: Iron-Deficiency Anemia:
Carissa Cheng, PhD(c), RD

Burns:
Kathy Prelack, PhD, RD
Maggie L. Dylewski, PhD, RD

Developmental Disabilities:
Beth Ogata, MS, RD, CSP

Epilepsy:
Yeou-mei Christiana Liu, MS, RD, CHES

Failure to Thrive:
Betsy Hjelmgren, MS, RD, LDN, CSP

Food Allergic Disorders/Eosinophilic Esophagitis:
Marion Groetch, MS, RD

GI Diseases: Gastroesophageal Reflux Disease
Jill Rockwell, RD, CSP, LD, CNSD

Hepatic Diseases:
Stacey M. Silver, MPH, RD, LD

HIV/AIDS:
Daniela Neri-Almeida, MS, RD, LD
Tracie L. Miller, MD

Inborn Errors of Metabolism:
Cristine M. Trahms, MS, RD, FADA

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Oncology: Survivorship:
Nancy Sacks, MS, RD, LDN

Oncology: Medications:
David W. Henry, MS Pharmacy, BCOP, FASHP

Behavioral Health/Eating Disorders:
Therese S. Waterhous, PhD, RD, LD

Behavioral Health/Mood Disorders:
Lee Shelly Wallace, MS, RD, LDN, FADA

Cardiac Transplant:
Claudia Sassano-Miguel, MS, CD, RD

Liver Transplant:
Meheret Asfaw, MMSc, RD, LD, CNSD, CSP

Weight Management: Underweight:
Rachel Riddiford, MS, RD, LD
Resources Topics
Growth Charts: Olsen Intrauterine Growth Chart
Nancy Nevin-Folino, MEd, RD, CSP, LD, FADA

Nutrition Support: Enteral Nutrition:
Ana Abad-Jorge, MS, RD, CNSC
Brandis Roman, RD, CNSD

2010 and earlier Contributors

Normal Nutrition Topics
Normal Nutrition for Full-Term Infants:
Dena Goldberg, PhD, RD, CSP
Clinical Dietitian II
Neonatal Intensive Care Unit
Carilion Clinic Children's Hospital
Roanoke, Virginia

Normal Nutrition for Toddlers and Preschoolers:
Diana M. Miller, MPH, RD, CLC, LDN
Pediatric Nutritionist III
Sandhills Children’s Developmental Services Agency
Pinehurst, North Carolina

Normal Nutrition for School-Age Children:
Coleen Liscano, MS, RD, CNSD
Clinical Dietitian II
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Childrens Hospital Los Angeles
Los Angeles, California

Normal Nutrition for Adolescents:
Shira Feldman, MPH, RD, LD
Public Health Interventionist—New Moves
University of Minnesota School of Public Health
Minneapolis, Minnesota

Normal Nutrition for Child Athletes:
Bonnie Spear, PhD, RD, LD
Professor of Pediatrics
University of Alabama at Birmingham
Birmingham, Alabama

Normal Nutrition for Vegetarian Children:
Reed Mangels, PhD, RD, LD, FADA
Nutrition Advisor, The Vegetarian Resource Group
Amherst, Massachusetts

Disease/Condition Topics
Anemia: Iron-Deficiency Anemia:
Carissa Cheng, PhD(c), RD
Doctoral Candidate in Nutritional Sciences, University of Washington
Seattle, Washington

Anemia: Sickle Cell Disease:
Jean Ann Olds, MS, RD
Director, Clinical Nutrition
The Children’s Hospital
Anschutz Medical Campus
Aurora, Colorado

Cardiac Conditions:
Melanie Savoca, MS, RD, LDN
Clinical Dietitian for the Cardiac Intensive Care Unit
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Claudia Sassano-Miguel, MS, CD, RD
Clinical Pediatric Dietitian, Clinical Nutrition Department
Cardiac Intensive Care Unit (CICU), Pediatric Intensive Care Unit (PICU)
Seattle Children’s Hospital, Seattle, Washington

Cleft Lip/Palate:
Michelle I. Scott, MA, RD/LD, IBCLC
Nutrition Consultant for NH State Special Medical Services
Lactation Consultant for Nashua Pediatrics
Cleft Lip and Palate Outreach worker for Special Medical Services
Mason, New Hampshire
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Critical Care:
Christine M. Framson, PhD, RD, CNSD, LDN
Director, Pediatric Nutrition Support
Pediatric Gastroenterology, Nutrition & Liver Diseases
Rhode Island Hospital
Providence, Rhode Island

Developmental Disabilities:
Beth Ogata, MS, RD, CD
Nutritionist, CHDD-University of Washington
Seattle, Washington

Diabetes Mellitus:
Megan T. Robinson, MS, RD, CDE, LDN
Clinical Outpatient Dietitian, Certified Diabetes Educator at The Children’s Hospital of
Philadelphia
Philadelphia, Pennsylvania

Disorders of Lipid Metabolism:
Claire Dalidowitz MS, MA, RD, CD-N
Connecticut Children's Medical Center
Hartford, Connecticut

Epilepsy:
Previous contributor: Beth Zupac-Kania, RD

Failure to Thrive:
Betsy Hjelmgren, MS, RD, LDN, CSP
Owner/Manager, Feed to Succeed, LLC
Chicago, Illinois

Food Allergies:
Marion Groetch, MS, RD
Dietitian, Jaffe Food Allergy Institute
Mount Sinai School of Medicine
New York, New York

GI Diseases: Constipation and Diarrhea:
Amy C. Lynch, MS, RD, CSP, CNSC, LDN
Dietitian, Nutrition Support at Vanderbilt Center for Human Nutrition
Nashville, Tennessee

GI Diseases: Gastroesophageal Reflux Disease and Irritable Bowel Syndrome:
Previous contributor: Erin Horowitz, RD
Cedars Sinai Medical Center, Los Angeles, California
Previous contributor: Jessica Shenson, RD
Cedars Sinai Medical Center, Los Angeles, California

GI Diseases: Inflammatory Bowel Disease and Short Bowel Syndrome:
Kristi L. King, MPH, RD, LD
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Support/Intestinal Rehabilitation Dietitian
Texas Children’s Hospital, Houston, Texas

GI Diseases: Celiac Disease:
Mary K. Sharrett, MS, RD, LD, CNSD
Nutrition Support Dietitian
Nationwide Children’s Hospital
Columbus, Ohio

Hepatic Diseases:
Previous contributor: Jessica L. Arvay, RD
The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Inborn Errors of Metabolism:
Cristine M. Trahms, MS, RD
Cristine M. Trahms Phenylketonuria Program
LEND Training Program
Center on Human Development and Disability
University of Washington, Seattle, Washington

Oncology:
Nancy Sacks, MS, RD, LDN
Research Coordinator, Registered Dietitian
Division of Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Karen Ringwald-Smith, MS, RD, LDN
Clinical Coordinator, Research and Education Coordinator
St. Jude Children’s Research Hospital, Clinical Nutrition
Memphis, Tennessee

Amiee R. Trauth, MS, RD, LD
Clinical Oncology/BMT Dietitian
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio

Preterm Infants:
Janice L. Hovasi Cox, MS, RD, CSP
Neonatal Dietitian
Michigan

Sharon Groh-Wargo, PhD, RD
Senior Nutritionist and Associate Professor
Case Western Reserve University School of Medicine at MetroHealth Medical Center
Cleveland, Ohio

Melody Thompson, MS, RD
Pediatric Clinical Nutrition Specialist
Abbott Nutrition, Nationwide Children’s Hospital, and The Ohio State University
Columbus, Ohio
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Psychiatric Disorders/Eating Disorders:
Therese S. Waterhous, PhD, RD, LD
Nutrition Consultant, Private Practice
Corvallis, Oregon

Mary M. Tholking, MEd, RD, LD
Research Dietitian, The Research Institute
Harold C. Schott Foundation Eating Disorders Program
Mason, Ohio

Pulmonary Diseases: Asthma, Bronchopulmonary Dysplasia, Ventilator Issues:
Ellen K. Bowser, MS,RD,LD/N
Faculty Nutritionist
University of Florida Pediatric Pulmonary Division
Gainesville, Florida

Pulmonary Diseases: Cystic Fibrosis:
Terri Schindler, MS, RD, LD
Nutritionist, Pediatric Pulmonology
Rainbow Babies and Children’s Hospital
Cleveland, Ohio

Barbara Robinson,
Suzanne Michel

Renal Diseases and Kidney Transplant:
Lori S. Brizee, MS, RD, LD
Central Oregon Nutrition Consultants
Bend, Oregon

Liver Transplant:
Meheret Asfaw, MMSc, RD, LD, CNSD, CSP
Clinical Nutritionist
Children’s Health Care of Atlanta
Atlanta, Georgia

Hematopoietic Stem Cell Transplant:
Terezie Tolar Mosby, MS, RD, CSP, IBCLC, LD/N
Clinical Nutritionist
St. Jude Children’s Research Hospital
Memphis, Tennessee

Weight Management: Overweight:
Nancy Copperman, MS, RD, CDN
Director of Public Health Initiatives
Office of Community Health
North Shore Long Island Jewish Health System
Great Neck, New York

Weight Management: Underweight:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Rachel Riddiford, MS, RD, LD
Manager, Clinical Dietetics
Department of Dietetics and Nutrition
Dayton Children’s Medical Center
Dayton, Ohio

Resources Topics
Nutrition Care Process: Common NICU Diagnoses and PES Statements:
Nancy Nevin-Folino

Nutrition Support: Enteral Nutrition:
Robin Aufdenkampe, MS, RD, LD
Manager, Nutrition Services
University of Michigan Hospital,
Mott Children's Hospital
Ann Arbor, Michigan

Previous contributor: Bridget M. Klawitter, PhD, RD, FADA
All Saints Healthcare, Inc., Racine, Wisconsin

Nutrition Support: Parenteral Nutrition:
Karen Weaver, MS, RD, LD, CNSC
Cardinal Glennon Children's Medical Center
St. Louis, Missouri

Support for the Lactating Mother:
Laura J. Benson Szekely, MS, RD/LD
Metabolic/Neonatal Nutrition
Department of Nutrition
Akron Children’s Hospital
Akron, Ohio

2012 Update Contributors

Note: If you are looking for contributor information for a topic that is not listed here, please
refer to the Contributor lists from previous years.
Normal Nutrition
Breastfeeding and Lactation Support
Rachelle Lessen, MS, RD, IBCLC, LDN
Full-Term Infants
Dena Goldberg, PhD, RD, CSP
Toddlers and Preschool-Age Children
Diana M. Miller, MPH, RD, CLC, LDN
School-Age Children
Coleen Liscano, MS, RD, CNSD, CSP, CLE
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Vegetarian Children
Reed Mangels, PhD, RD, LD, FADA
Preterm Infants
Janice L. Hovasi Cox, MS, RD, CSP
Sharon Groh-Wargo, PhD, LD
Melody Thompson, MS, RD
Diseases/Conditions
Anemia: Iron Deficiency Anemia
Carissa Cheng, PhD, RD
Anemia: Sickle Cell Disease
Jean Ann Olds, MS, RD
Behavioral Health: Eating Disorders
Therese S. Waterhous, PhD, LD
Cardiology
Christina DeTallo, MS, RD, CSP, LD
Critical Care
Heather E. Skillman, MS, RD, CSP, CNSC
Developmental Disabilities
Beth Ogata, MS, RD, CSP
Diabetes Mellitus
Megan Robinson, MS, RD, CDE, LDN
Disorders of Lipid Metabolism
Claire Dalidowitz, MS, MA, RD, CD-N
Epilepsy: Pharmacologic Management
Yeou-mei Christiana Liu, MSc, RD, CHES
Failure to Thrive
Betsy Hjelmgren, MS, RD, LDN, CSP
Food Allergies: General Guidance
Marion Groetch, MS, RD
Gastrointestinal: Celiac Disease
Mary K. Sharrett, MS, RD, LD, CNSD
Gastrointestinal: Constipation; Diarrhea
Amy C. Lynch, MS, RD, CSP, CNSC, LDN
Gastrointestinal: Gastroesophageal Reflux
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Jill Rockwell, RD, CSP, LD, CNSD
Gastrointestinal: Irritable Bowel Syndrome
Martha P. Ballew, MEd, RD, CNSC, LDN
Ellen Strickler, RD, LDN, CSP
Hepatic Diseases
Stacey M. Silver, MPH, RD, LD
Inborn Errors of Metabolism
Beth Ogata, MS, RD, CSP
Modified Consistency Meal Plans
Susan K. Kinzler, RD, LDN
Oncology
Dave Henry, MS, BCOP, FASHP
Karen Ringwald-Smith, RD, MS, LDN
Nancy Sacks, MS, RD, LDN
Amiee Trauth, MS, RD, LD
Pulmonary Diseases: Cystic Fibrosis
Susan C. Casey, RD, CD
Renal Diseases
Lori Brizee
Peggy Solan, RD, CD
Transplantation: Hematopoietic Stem Cell Transplant
Terezie Tolar Mosby, MS, RD, CSP, IBCLC, LD/N
Weight Management: Overweight
Nancy Copperman, MS, RD, CDN
Weight Management: Underweight
Rachel Riddiford, MS, RD, LD
Resources
Nutrition Support: Parenteral Nutrition Support
Karen Weaver, MS, RD, LD, CNSC



© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Contributors > Reviewers
2011 Reviewers

2010 Pre-revision Reviewers
Paula Charuhas Macris, MS, RD, CSO, FADA, CD
Kerry Regnier, MPH, RD, LD
Normal Nutrition Topics
Normal Nutrition for Adolescents:
Jill Lindeman Castle, MS, RD, LDN
Bonnie A. Spear, PhD, RD
Disease/Condition Topics
Burns:
Marjorie Bennett, MS, RD, RN
Heather E. Skillman, MS, RD, CSP, CNSC

Epilepsy:
Marta Mazzanti
Aaron Owens, MS, RD, CSP, CD
Beth Zupec-Kania, RD

Food Allergic Disorders/Eosinophilic Esophagitis:
Ellen Karlin, MMSc, RD, LDN, FADA
Karen Weaver, MS, RD, LD, CNSC

GI Diseases: GERD and IBS
Kristi King
Samantha Maloney, MS, RD, CSP, CNSC, LD

Hepatic Diseases:
Emily Barr, MS, RD, CNSC
Angela Somogyi, RD, LD

HIV/AIDS:
Sue Cowen, MS, RD, LDN, CSP
Pamela Rothpletz-Puglia, EdD, RD

Oncology: Survivorship and Medications:
Paula Charuhas Macris, MS, RD, CSO, FADA, CD
Susan R. Rheingold, MD
Lynda Rosini, MA, RD, CNSD, CSO, CDE

Behavioral Health/Mood Disorders:
Jennifer M. Hogansen, PhD
Linda L. Venning, MS, RD

Cardiac Transplant:
Christina M. DeTallo, MS, RD, LD, CSP
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Christina M. DeTallo, MS, RD, LD, CSP
Letitia B. Warren, RD, CSP
Resources Topics
Nutrition Support: Enteral Nutrition:
Michelle Harrington, MS, RD, LDN
Amy Hood, MPH, RD, CNSC

2010 Reviewers

Normal Nutrition Topics
Normal Nutrition for Full-Term Infants
Kimberly Mack, MS, RD, LDN
Caroline Steele, MS, RD, CSP, IBCLC
Kelly R. Walsh, PhD, RD, CD

Normal Nutrition for Toddlers and Preschoolers
Jill Castle, MS, RD, LDN
Anne M. Emenheiser, MS, RD, CSP
Letitia B. Warren, RD, CSP

Normal Nutrition for School-Age Children
Jill Castle, MS, RD, LDN
Sherry M. Coleman, MS, RD, LD, SND
Blair Giles, MS, RD, LD
Katrina Holt, MPH, MS, RD

Normal Nutrition for Adolescents
April Callahan, MS, RD, CDE
Beverly W. Henry, PhD, RD, LDN
Jamie Stang

Normal Nutrition for Child Athletes
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Jennifer M. Kuck, MS, RD, LD, ACSM
Martha V. Shaffer, MA, RD, CDE
Mary Sowa, MS, RD, CSP, CNSD

Normal Nutrition for Vegetarian Children
Jill Castle, MS, RD, LDN
Carolyn A. Silzle, MS, MBA, RD, LD
Cristine M. Trahms, MS, RD

Disease/Condition Topics
Anemia: Iron Deficiency
Jean Ann Olds, MS, RD
Joan C. Zerzan, MS, RD, CD

Anemia: Sickle Cell Disease
Carissa Cheng, PhD(c), RD
Joan C. Zerzan, MS, RD, CD

Cardiac Conditions
Christina DeTallo, MS, RD, CSP, LD
Susan C. Teske, MS, RD, LD, CNSD

Cleft Lip/Palate
Zoe Carbo, RD, MEd
Camille L. Lanier, RD, CD

Critical Care
Amy Hood, MPH, RD, CNSD
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mary Ellen Sherry, MMSc, RD, LDN
Rachel E. Teneralli, MS, RD, CSP

Developmental Disabilities
Susan D. Boyden, MS, RD, CSP, LDN
Lucinda Lynn Earle, MPH, RD
Sharon Feucht, MA, RD, CD
Maureen Geraghty, PhD, RD, LD
Diabetes Mellitus
April Callahan, MS, RD, CDE
Blair Giles, MS, RD, LD
Joanne Giannantonio, RD, CSP, CDE, LDN
Jenny Kinne, MS, RD, LDN, CLC

Disorders of Lipid Metabolism
Jill Castle, MS, RD, LDN
Kerry Regnier, MPH, RD, LDN

Epilepsy
Karen Amorde-Spalding, MS, RD, CSP
Yeou-mei Christiana Liu, MS, RD, CHES

Failure to Thrive
Susan D. Boyden, MS, RD, CSP, LDN
Patricia Miller, MS, RD, CSP, LDN
Shelley Bolt Wilkins, MS, MPH, RD, LDN

Food Allergies
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ellen Karlin, MMSc, RD, LDN, FADA
Lori P. Enriquez, MPH, RD, CSP, CHES, LDN
Barbara Robinson, MPH, RD, CNSD

Gastrointestinal Diseases
Emily Barr, MS, RD, CNSC
Nancy Patin Falini, MA, RD, LDN
Kristi L. King, MPH, RD, LD
Amy C. Lynch, MS, RD, CSP, CNSC, LDN
Samantha Maloney, MS, RD, CNSC, CSP, LD

Hepatic Diseases
Emily Barr, MS, RD, CNSC
Georgiana Gross

Inborn Errors of Metabolism
Elaina Jurecki, MS, RD
Mary M. Niewinski, MS, RD, LDN
Mary Sowa, MS, RD, CSP, CNSD
Bridget Wardley, MS, RD

Oncology
Paula Charuhas Macris, MS, RD, CSO, CD, FADA
Lynda Rosini, MS, RD, CNSD, CSO, CDE

Premature Infants
Diane Anderson, PhD, RD, LD
Susan J. Carlson, MMSc, RD, CSP, CNSD
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Laurie J. Moyer-Mileur, PhD, RD
Nancy L. Nevin-Folino, MEd, RD, CSP, FADA
Amy Sapsford, RD, CSP

Psychiatric Disorders/Eating Disorders
Leila T. Beker, PhD, RD
James Lock, MD, PhD
Leslie P. Schilling, MA, RD, CSSD, LDN, CSCS

Pulmonary Diseases
Leila T. Beker, PhD, RD
Susan Casey, RD, CD
Melody Persinger-Yeargin, MS, RD, CSP

Renal Diseases
Emily Abercrombie, MS, RD, LD
Bethany Beckerdite, MS, RD, CNSD, LDN

Transplant: HSCT
Lori J. Bechard, MEd, RD, LDN
Paula Charuhas Macris, MS, RD, CSO, CD, FADA

Transplant: Organ Transplant
Emily Abercrombie, MS, RD, LD
Bethany Beckerdite, MS, RD, CNSD, LDN

Weight Management
Keith-Thomas Ayoob, EdD, RD, FADA
Michelle DeMeule-Hayes, MS, RD, LDN
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Michelle DeMeule-Hayes, MS, RD, LDN
Alicia Dixon Docter, MS, RD, CD
Jenny Kinne, MS, RD, LDN, CLC

Nutrition Support
Amy Hood, MPH, RD, CNSD
Rachel E. Teneralli, MS, RD, CSP




2012 Reviewers

Breastfeeding/Lactation
Kimberly A. Mack, MS, RD, LDN, CNSC
Caroline Steele, MS, RD, CSP, IBCLC

Full-Term Infants
Amy Kovar Resnik, MS, RD, CSP, LDN, IBCLC
Caroline Steele, MS, RD, CSP, IBCLC

Cardiology
Susan C. Teske, MS, RD, CNSD

Disorders of Lipid Metabolism
Blair Giles, MS, RD, LD
Elizabeth L. Wright, MS, RD, CSP, LDN

Epilepsy: Pharmacologic Management
Chaya Lidor, MS, RN, RD
Aaron Owens, MS, RD, CSP, CD
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Failure to Thrive
Shelley Bolt Wilkins, MS, MPH, RD, CSP, LDN
Hope Wills

Food Allergies
Ellen Karlin, MMSc, RD, LDN, FADA
Barbara B. Robinson, MPH, RD

Gastrointestinal Diseases
Patricia Miller, MS, RD, CSP, LDN
Jill Castle, MS, RD, LDN
Nancy Patin Falini, MA, RD, LDN
Mirta Rios, RD, CSP, LD, CLC
Samantha Maloney, MS, RD, CSP, CNSC, LD

Modified Consistency Meal Plans
Therese O’Flaherty, MS, RD, CSP, LD
Kathy B. Santoro, MEd, RD, LD, CSP
Elizabeth M. S. Cater, MPH, OTR/L, CPST

Pulmonary Diseases: Cystic Fibrosis
Erin Corrigan, MS, RD, LD/N
Heather Harden, MS, RD, CSP, LD
Kimberly Bilger, MPH, RD, CSP, LD

Renal Diseases
Mirta Rios, RD, SCP, LD, CLC

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Nutrition Care Process (NCP)
Nutrition Assessment

Nutrition Assessment is the first step of the Nutrition Care Process. It is defined as a
systematic method for obtaining, verifying, and interpreting data needed to identify
nutrition-related problems and their causes and significance (JADA 2008). It is an ongoing,
nonlinear, dynamic process that involves initial data collection as well as continual
reassessment and analysis of the patient's/client’s status compared with specified criteria.
Nutrition assessment data are obtained from a variety of sources, including the following:
Screening or referral form
Patient/client interview
Medical or health records
Consultation with other caregivers, including family members
Community-based surveys and focus groups
Statistical reports, administrative data, and epidemiological studies
Nutrition assessment data include the food and nutrition-related history, anthropometric
data, biochemical data, medical tests and procedures, nutrition-related physical
examination findings, and the patient/client’s history. Standardized language has been
developed for use in nutrition assessment. The International Dietetics and Nutrition
Terminology (Nutrition Assessment and Monitoring and Evaluation Terminology) contains
dozens of terms that may be used to document nutrition assessment findings (IDNT 2009).
The registered dietitian may delegate aspects of data collection for nutrition assessment to
appropriately trained and supervised support personnel including dietetic technicians,
registered but is responsible for reviewing data collected for factors that affect nutrition and
health status, clustering individual data elements to identify a nutrition diagnosis as
described in the diagnosis reference sheets, and identifying standards by which data will
be compared (SOP/SOPP 2008). In performing a nutrition assessment, the registered
dietitian uses critical thinking to:
Determine the need for additional information
Select assessment tools and procedures that match the situation
Apply assessment tools in valid and reliable ways
Distinguish relevant from irrelevant data
Distinguish important from unimportant data
Validate the data
At the end of nutrition assessment, if the registered dietitian determines that the problem
cannot be modified by further nutrition care, discharge or discontinuation from this episode
of nutrition care may be appropriate.

Nutrition Diagnosis

Nutrition Diagnosis is the second step of the Nutrition Care Process. In this step, the
registered dietitian (RD) identifies and labels an existing nutrition problem that the RD is
responsible for treating independently (JADA 2008). In diagnosing a nutrition problem, the
RD organizes the assessment data, clusters nutrition signs and symptoms, and compares
them with the defining characteristics of suspected diagnoses as listed in the nutrition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
diagnosis reference sheets. Reference sheets that define each nutrition diagnosis are
found in the International Dietetics and Nutrition Terminology (IDNT 2009). The nutrition
diagnosis is expressed using nutrition diagnostic terms and the etiologies, signs, and
symptoms that have been identified in the reference sheets describing each diagnosis.
There are three distinct parts to a nutrition diagnostic statement:
The nutrition diagnosis describes alterations in the patient/client status. A diagnostic
label may be accompanied by a descriptor such as “altered,” “excessive,” or
“inadequate.”
1.
Etiology is a factor gathered during the nutrition assessment that contributes to the
existence or the maintenance of pathophysiological, psychosocial, situational,
developmental, cultural, and/or environmental problems.
The etiology is preceded by the words “related to”
Identifying the etiology will lead to the selection of a nutrition intervention aimed
at resolving the underlying cause of the nutrition problem whenever possible
Major and minor etiologies may result from medical, genetic, or environmental
factors
2.
Signs/Symptoms (defining characteristics): The defining characteristics are a typical
cluster of signs and symptoms that provide evidence that a nutrition diagnosis exists.
The signs and symptoms are preceded by the words “as evidenced by”
Signs are the observations of a trained clinician
Symptoms are changes reported by the patient/client
A well-written Nutrition Diagnostic Statement should have the following
characteristics:
Clear and concise
Specific to a patient/client
Limited to a single client problem
Accurately related to one etiology
Based on signs and symptoms from the assessment data
3.
In formulating the nutrition diagnosis, the RD uses critical thinking to find patterns and
relationships among the data and possible causes. Critical thinking is also used to make
inferences, clearly and singularly state the nutrition problem, make interdisciplinary
connections, and rule in or out specific diagnoses. Since the nutrition diagnosis step
involves identifying and describing the problem, the determination for continuation of care
follows the nutrition diagnosis step. If the RD does not find a nutrition diagnosis, the
patient/client may be referred back to the primary provider. If the potential exists for a
nutrition diagnosis to develop, the RD establishes an appropriate method and interval for
follow-up. It is the responsibility of the RD to diagnose nutrition problems (SOP/SOPP
2008). While appropriately trained and supervised support personnel—including dietetic
technicians, registered—may contribute information to the nutrition diagnosis, they may not
independently perform this step of the Nutrition Care Process (SOP/SOPP 2008).


Nutrition Intervention

The third step of the Nutrition Care Process is Nutrition Intervention, which is defined as
purposefully planned action(s) designed with the intent of changing a nutrition-related
behavior, risk factor, environmental condition, or aspect of health status (JADA 2008).
Nutrition intervention consists of two interrelated components: planning and intervention.
The nutrition intervention is typically directed toward resolving the nutrition diagnosis or the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
nutrition etiology. Less often, it is directed at relieving signs and symptoms. Sources of data
and tools for nutrition intervention include the following:
The American Dietetic Association’s (ADA) Evidence-Based Nutrition Practice Guides
or other guidelines from professional organizations
ADA’s Evidence Analysis Library and other secondary evidence sources such as the
Cochrane Library
Current research literature
Results of outcome-management studies or quality-improvement projects
The nutrition intervention is composed of two parts: planning and implementation. Planning
includes prioritizing diagnoses based on urgency, impact, and available resources. In this
step, the registered dietitian (RD) may identify nutrition diagnoses for immediate treatment
and nutrition diagnoses for which treatment should be delayed until a more favorable
environment is available or more resources exist. The RD then writes a nutrition
prescription that is based on the patient's/client’s individualized recommended dietary
intake of energy and/or selected foods or nutrients based on current reference standards
and dietary guidelines and the patient’s/client’s health condition and nutrition diagnosis. As
part of the planning step, the RD collaborates with the patient/client to identify goals of the
intervention for each diagnosis then selects specific intervention strategies that are focused
on the etiology of the problem and that are known to be effective based on the best current
knowledge and evidence. The planning portion of the nutrition intervention includes the
timing and frequency of nutrition care, including the intensity, duration, and follow-up.
Collaborate with the patient/client and other caregivers to carry out the plan of care as
follows:
Communicate the plan of nutrition care
Modify the plan of care as needed
Follow up and verify that the plan is being implemented
Revise strategies based on changes in condition or response to intervention
During the nutrition intervention step, the RD uses critical thinking skills to set goals and
prioritize them, to define the nutrition prescription or basic plan, to make interdisciplinary
connections, to match intervention strategies with patient/client needs, nutrition diagnoses
and values. Critical thinking is also used to choose from among alternatives to determine a
course of action and specify the time and frequency of care. If the patient/client has met
intervention goals or at this time is not able/ready to make needed changes, the
patient/client may be discharged from this episode of care. The RD supervises the nutrition
intervention but may delegate aspects of the nutrition intervention to appropriately trained
support personnel, including dietetic technicians, registered (SOP/SOPP 2008).



Nutrition Monitoring & Evaluation

The fourth step of the Nutrition Care Process is Nutrition Monitoring and Evaluation. In
this step, the registered dietitian (RD) identifies the amount of progress made if goals or
expected outcomes are being met (JADA 2008). Nutrition monitoring and evaluation
identifies outcomes relevant to the nutrition diagnosis and intervention plans and goals.
Data sources and tools for Nutrition Monitoring and Evaluation include the following:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Self-monitoring data or data from other records including forms, spreadsheets, and
computer programs
Anthropometric measurements, biochemical data, medical tests, and procedures
Patient/client surveys, pretests, posttests and/or questionnaires
Mail or telephone follow-up
The RD or appropriately trained and supervised support personnel including the dietetic
technician, registered, may monitor outcomes associated with the following nutrition-related
behavior and environmental outcomes:
Food and nutrient intake outcomes
Nutrition-related physical sign and symptom outcomes
Nutrition-related patient/client-centered outcomes (IDNT 2009)
Nutrition monitoring and evaluation includes three distinct and interrelated processes.
The first, monitoring progress, includes checking patient/client understanding and
compliance with the plan, determining if the intervention is being implemented as
prescribed, providing evidence that the plan/intervention strategy is or is not changing
patient/client behavior or status, identifying other positive or negative outcomes, gathering
information, indicating reasons for lack of progress, gathering information that indicate
reasons for lack of progress and supporting conclusions with evidence.
The second process in nutrition monitoring and evaluation is measuring outcomes. In this
step, the RD selects outcome indicators that are relevant to the nutrition diagnosis or signs
and symptoms, nutrition goals, medical diagnosis and outcomes, and quality-management
goals.
The third process is to evaluate outcomes by comparing current findings with previous
status, intervention goals, and/or reference standards.
In nutrition intervention, the RD uses critical thinking skills to select appropriate
indicators/measures and appropriate reference standards for comparison, define the status
of the patient/client relative to expected outcomes, explain variance from expected
outcomes, and determine factors that help or hinder progress. The RD may actively
continue care, or, if nutrition care is complete or no further change is expected, the
patient/client may be discharged. If nutrition care is to be continued, reassessment may
result in refinements to the diagnosis and intervention. If care does not continue, the
patient/client may still be monitored for a change in status and reentry to nutrition care at a
later date.



NICU: Common Nutrition Diagnoses

Below are some nutrition diagnoses commonly used in the NICU. These may apply to
some or all of the specific conditions covered in this section. Additional information on
corresponding medical diagnoses and how to construct a PES statement is included. For
more information on the Nutrition Care Process, please see previous headings.
Nutrition Diagnosis Etiology/Signs or
Symptoms
NICU Condition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A problem that the
dietitian will address.
This is NOT the
Medical Diagnosis.
This is the nutrition
condition that only
the dietitian can treat
and be credited with
the treatment,
remedy and or cure.
Etiology: The cause of
the nutrition problem
and may well be
connected to the
medical diagnosis.
S/S: What you will be
attempting to elevate
or treat a condition
associated with a
diagnosis.
Included here is
typical verbiage that
is used with the
medical team, very
similar or exactly like
the medical
diagnosis. This is to
help make the
connection between
Nutrition Diagnosis
and medical
diagnosis.
NI 1.2 Increased
Energy Expenditure
Etiology: Increased
work of breathing
causing increased
energy demand.
S/S: Experiencing
uneven weight
gain/loss cycles. OR
Failure to gain
appropriate weight
Chronic lung disease,
150 % of energy
requirements
NI 1.4 Inadequate
Energy Intake
E: Pathologic or
physiological causes
that result in
increased energy
requirements OR
decreased ability to
consume sufficient
energy
S/S: Consuming less
than required to gain
weight consistently
Prematurity or IUGR
NI 1.5 Excessive
Energy Intake
E: Overfeeding of
PN/EN
S/S: Gaining > twice
the expected weekly
gain
Neurologic deficit
with continuous tube
feeding on a
high-calorie formula
NI 2.1 Inadequate
Oral Intake
E: Factors that
contribute to
existence or
maintenance of
developmental
problems
S/S: < 50 % oral
intake
34 weeks GA, starting
oral feeds
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
NI 2.2 Excessive
Oral Intake
E: Decreased needs
related to low activity
levels with
defect/repair
S/S: Intake
consistently
exceeding 140
kcal/kg on ad lib
feeds OR
Weight gain of >40
g/d/average
Baby with
myelomeningocele
NI 2.6 Inadequate
Parenteral Nutrition
Infusion
E: Lack of,
compromised or
incorrect access for
delivering PN
S/S: Parenteral
nutrients 70% of
predicted
requirements
Line occlusion, or line
interruption
for delivery
NI 3.1 Inadequate
Fluid Intake
E: Lower intake
compared to
established reference
standards or
recommendations
based on
physiological needs
S/S: 100 mL/kg order
giving less than
predicted
energy/nutrient needs
Patent ductus
arteriosus
NI 5.3 Inadequate
Protein-Energy Intake
E: Inadequate intake
of protein and/or
energy compared to
established reference
standards or
recommendations
based on
physiological needs of
short or recent
duration
S/S: 12 g/gain/day
with breastmilk
feeds, OR
protein intake 34% of
predicted needs
Preterm birth, or
needs greater than
breastmilk or
commercial formula
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
NI 5.1 Increased
Nutrient Needs
E: Renal/liver
dysfunction, heart
failure
S/S: Intake 120% of
predicted preterm
needs with slow
growth
Ventricular Septal
Defect (VSD)
NI 5.5 Imbalance of
Nutrients
E: An undesirable
combination of
nutrients such that the
amount of one
nutrient interferes
with or alters
absorption and/or
utilization of another
nutrient OR
Ca:P ratio of 1:1 in
TPN order
S/S: Consistently low
serum phosphorus
and elevated alkaline
phosphatase
Calcium: phosphorus
ratio
NI 5.10.1 Inadequate
mineral intake
specify: Iron (3)
E: Lower intake of
iron compared to
reference standards
of recommendation
based on
physiological needs
S/S: Iron labs
indicative of iron
deficiency anemia
Long-term TPN with
no dietary iron delivery
NC 1.1 Swallowing
Difficulty
E: Neurological
disorder of prematurity
S/S: Abnormality in
gag reflex, swallow
and tongue range of
motion per
radiological study
Hypoxic ischemic
encephalopathy (HIE)
from birth trauma
NC 1.2
Biting/Chewing
(Masticatory)
Difficulty
E: Craniofacial
malformations
S/S: Intake PO/AL
70% of estimated
needs OR
Lack of lip
seal/closure with
bottle feeding
Cleft lip/palate
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
NC 1.3
Breastfeeding
Difficulty
E: Infant: Difficulty
latching, e.g. tight
frenulum
S/S: Early cessation
of breastfeeding OR
Lack of satiety after
feeding
Baby with shortened
frenulum
NC 1.4 Altered
Gastrointestinal (GI)
Function
E: Alteration in
gastrointestinal tract
structure and or
function OR
16 cm of small bowel
noted by surgeons
S/S: Intolerance to
volume of feeds OR
30% of estimated
needs by oral feeds
Congenital short gut
NC 2.2 Altered
Nutrition-Related
Laboratory Values
E: Prematurity Hemoglobin: 9.2 g/dL
NC 2.3
Food–Medication
Interaction
E: Undesirable
interaction between
nutrients and
prescribed
medications that
diminishes, enhances
or alters effect of
nutrients and/or
medications
S/S: Glucose of
144mg/dL with GIR of
4.1
Dexamethasone
therapy
NC 3.1 Underweight E: Low body weight
compared to
established reference
standards or
recommendations
S/S: < 3 %ile on
intrauterine growth
chart
32 weeks gestational
age SGA/IUGR
NC 3.2 Unintentional
Weight Loss
E: Physiological
causes increasing
nutrient needs due to
prolonged
malabsorption
S/S: Enteral feeds
with weight loss and
Short Gut Infant
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
growth failure
NC 3.4 Unintentional
Weight Gain


E: Any increase in
weight more than
planned or desired,
such as grams/day
S/S: Paralysis and
immobility OR
> 45
g/gain/day/average
Grade IV bilateral
intraventicular
hemorrhages

NICU: Excerpts from the Neonatal Nutrition Toolkit

The Neonatal Toolkit is not a stand-alone document, and it is recommended that
examination of the reference sheets that are in the International Dietetics and Nutrition
Terminology Reference Manual, Second Edition and the Pocket Guide for the International
Dietetics and Nutrition Terminology Reference Manual, Second Edition, is essential in
completing the Nutrition Care Process. Many of the NICU conditions now appear and are
made clear in the etiologies/definitions section of the Nutrition Diagnosis reference sheets.
The pdfs included below are excerpts from the Toolkit and can be used for reference by
NICU professionals who are looking for additional information on creating PES statements
and following the Nutrition Care Process for high-risk infants. For further explanation on
terminology and usage, and for case studies using NCP, please refer to the full Toolkit,
which is available at https://www.adaevidencelibrary.com/store.cfm?category=8.
Terms and Definitions tables include NICU Notes in bold to facilitate the relationship
between NICU terminology and NCP terminology.
Nutrition Care Process Implementation Strategies (resource for RDs at facilities where
NCP has not been implemented)
Nutrition Assessment and Nutrition Monitoring & Evaluation Terms and Definitions
Nutrition Diagnosis Terms and Definitions
Nutrition Intervention Terms and Definitions
Common NICU Diagnoses and PES Statements

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Nutrition Support
Nutrition Support


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Nutrition Support > Pediatric Enteral Nutrition Support
References: Enteral Nutrition

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neonates with short bowel syndrome correlates with clinical outcomes. J Pediatr.
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Allergy Asthma Immunol. 2008;101:453-459. Related Links: Abstract
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2007.
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GG improves recovery in infants with blood in the stools and presumptive allergic colitis
compared with extensively hydrolyzed formula alone. J Pediatr. 2010;156:397-401. Related
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standard intact protein formula versus a partially hydrolyzed formula in healthy, term
infants. Nutr J. 2008;8:27. Related Links: Abstract; Full text
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feeding. Pediatrics. 2008;121(5):1062-1068. Related Links: Abstract; Full text
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diabetes. Am J Clin Nutr. 2002:76(6):1991-1201. Related Links: Abstract; Full text
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syndrome: Impact of an amino acid-based complete infant formula. J Pediatr Gastroenterol
Nutr. 1998;26:123-128. Related Links: Abstract
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of docosahexaenoic acid and arachidonic acid in the diet of term infant. Pediatr Res. 1998;
44: 2091-209. Related Links: Abstract
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of age in a double-blind, randomized trial of long-chain polyunsaturated fatty
acid-supplemented infant formula. Early Human Dev. 2007;83:279-284. Related Links:
Abstract
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intensive care unit. Adv Neonatal Care. 2009;9:180-184. Related Links: Abstract
Bongaerts, GPA, Severijnen, RSVM. Arguments for a lower carbohydrate-high fat diet in
patients with short bowel syndrome. Med Hypotheses. 2006;67:280-282. Related
Links: Abstract
Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral
nutrition: A meta-analysis. Am J Clin Nutr. 2001;74:534-542. Related Links: Abstract; Full
text
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immunization and type of feeding in babies of atopic families. Pediatr Allergy Immunol.
1990;1:60-63. Related Links: Abstract
Callenbach JC, Sheehan MB, Abramson SJ, Hall RT. Etiologic factors in rickets of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Callenbach JC, Sheehan MB, Abramson SJ, Hall RT. Etiologic factors in rickets of
very-low-birth-weight infants. J Pediatr. 1981;98(5):800-805. Related Links: Abstract
Center for Disease Control. Enterobacter sakazakii Infections Associated with Use of
Powdered Infant Formula—Tennessee, 2001. MMWR. 2002:51(14);298-300.
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Chan EH, Russell JL, Williams WG, Van Arsdell GS, Coles JG, McCrindle BW.
Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg.
2005;80:1864-1870. Related Links: Abstract
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patient? Nutr Clin Pract. 2009;24(3):344-355. Related Links: Abstract
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and infant formula, including proposed standards for formulas. Pediatrics.
1976;57:278. Related Links: Abstract; Full text

Cormack BE, Wilson NJ, Finucane K, West TM. Use of Monogen for pediatric
postoperative chylothorax. Ann Thorac Surg. 2004;77:301-305. Related Links: Abstract
Cox JH, ed. Nutrition Manual for At-Risk Infants and Toddlers. Chicago, IL: Precept Press;
1997.
Crosby J, Duerksen DR. A prospective study of tube- and feeding-related complications in
patients receiving long-term home enteral nutrition. JPEN J Parenter Enteral Nutr.
2007;31:274-277. Related Links: Abstract
Cross HS, Kallay E, Lechner D, Gerdenitsch W, Adlercreutz H, Armbrecht HJ.
Phytoestrogens and vitamin D metabolism: a new concept for the prevention and therapy
of colorectal, prostate and mammary carcinomas. J Nutr. 2004;134(5):1207S-1212S.
Related Links: Abstract; Full text
De Lucas C, Moreno M, Lopez-Herece J, Ruiz F, Perez-Palencia M, Carrillo A.
Transpyloric enteral nutrition reduces the complication rate and cost in the critically ill child.
J Pediatr Gastroenterol Nutr. 1994;59:659-662. Related Links: Abstract
DeMichele SJ, Karlstad MD, Bistrian BR, Istfan N, Babayan VK, Blackburn GL. Enteral
nutrition with structured lipids: Effect on protein metabolism in thermal injury. Am J Clin
Nutr. 1989; 50:1295-1302. Related Links: Abstract; Full text
Dent D, Heyland D, Levy H. Immunonutrition may increase mortality in critically ill patients
with pneumonia: Results of a randomized trial. Crit Care Med. 2003;30:A17.
Emery EA, Ahmad S, Koethe JD, Skipper A, Perlmutter S, Paskin DL. Banana flakes
control diarrhea in enterally fed patients. Nutr Clin Pract. 1997;12:72-75. Related Links:
Abstract
Enrione EB, Thomlison B, Rubin A. Medical and psychosocial experiences of family
caregivers with children fed enterally at home. JPEN J Parenter Enteral Nutr.
2005;29:413-419. Related Links: Abstract
Evans S, MacDonald A, Daly A, Hopkins V, Holden C. Home enteral tube feeding in
patients with inherited metabolic disorders: Safety issues. J Hum Nutr Diet.
2007;20:440-445. Related Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
FAO/WHO Joint Expert Consultation. Lipids in Early Development: FAO Food and Nutrition
Paper. 1994;57:49-55.
Faustino EV, Apkon M. Persistent hyperglycemia in critically ill children. J Pediatr.
2005;146:30-34. Related Links: Abstract
Fomon SJ. Nutrition of Normal Infants. 3rd ed. St. Louis, MO: Mosby-Year Book; 1993.

Fuchs GJ. Enteral support of the hospitalized child. In: Suskind RM, Lewinter-Suskind L,
eds. Textbook of Pediatric Nutrition. New York, NY: Raven Press Ltd; 1993:239-246.

Gibbons K, Cyr N, Christensen ML, Helms RA. Techniques for pediatric enteral and
parenteral nutrition. In: Christensen ML, Merritt RJ, eds. The ASPEN Nutrition Support
Practice Manual. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition;
1998:21-1.
Glass RP, Lucas B. Making the transition from tube feeding to oral feeding. Nutr Focus.
1990;5:1-4.
Groh-Wargo S. Recommended Enteral Nutrition Intakes. In: Groh-Wargo S, Thompson M,
Cox J, eds. Nutritional Care for High-Risk Newborns. 3rd ed. Chicago, IL: Precept Press
Inc.; 2000:232.

Hay WW. Nutritional needs of the extremely low-birthweight infant. Semin Perinatol.
1991;15:482. Related Links: Abstract
Heiss CJ, Goldberg L, Dzarnoski M. Registered dietitians and speech language
pathologists: An important partnership in dysphagia management. J Am Diet Assoc.
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Henderson G, Fahey T, McGuire W. Nutrient-enriched formula versus standard term
formula for preterm infants following hospital discharge. Cochrane Database Syst Rev.
2007;(4):CD004696. Related Links: Abstract
Hendricks KM, Walker WA. Manual of Pediatric Nutrition. 2nd ed. Philadelphia, PA; BC
Decker Inc; 1990.
Heubi J, Karasov R, Reisinger K, Blatter M, Rosenberg L, Vanderhoof J, Darden PM,
Safier J, Martin T, Euler AR. Randomized multicenter trial documenting the efficacy and
safety or a lactose-free and a lactose-containing formula for term infants. J Am Diet Assoc.
2000;100:212-217. Related Links: Abstract
Heyland, DK, MacDonald, S, Keefe, L, Drover, JW. Total parenteral nutrition in the critically
ill patient: A meta-analysis. JAMA. 1998; 280:2010-2019. Related Links: Abstract; Full text
Heyland DK, Novak F, Drover JW, Minot J, Wiangyao S, Suchner U. Should
immunonutrition become routine in critically ill patients? A systematic review of the
evidence. JAMA. 2001;286:944-953. Related Links: Abstract; Full
Heyland DK, Samis A. Does immunonutrition in patients with sepsis do more harm than
good? Intensive Care Med. 2003;29:669-671. Related Links: Abstract
Hoffman DR, Birch EE, Castaneda YS, et al. Dietary docosahexanoic acid (DHA) and
visual maturation in the post-weaning term infant. Invest Opthamol Vis Sci.
2001;42:S122-S128.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Hoffman DR, Wheaton DK, James KJ, Tuazon M, Diersen-Schade DA, Harris CL, Stolz S,
Berseth CL. Docosahexaenoic acid in red blood cells of term infants receiving two levels of
long-chain polyunsaturated fatty acids on later visual development. J Pediatr Gastroenterol
Nutr. 2006;42(3):287-292. Related Links: Abstract

Holliday MA. Requirements of sodium chloride and potassium and their interrelation with
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2009;24(3):356-362. Related Links: Abstract
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Infect Control. 2001;29(2):109-114. Related links: Abstract
Kenler AS, Swails WS, Driscoll DF, DeMichele SJ, Daley B, Babineau TJ, Peterson MB,
Bistrian BR. Early enteral feeding in postsurgical cancer patients. Fish oil structured
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Leichty, EA. Water requirements. In: Polin RA, Fox WW, eds. Fetal and Neonatal
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lucas A, Fewtrell MS, Morley R, Singhal A, Abbott RA, Isaacs E, Stephenson T,
MacFadyen UM, Clements H. Randomized trial of nutrient-enriched formula versus
standard formula for postdischarge preterm infants. Pediatrics. 2001;108:703-711. Related
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administration, interactions, and complications. JPEN J Parenter Enteral Nutr.
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brain, retina, and erythrocytes in breast- and formula-fed infants. Am J Clin Nutr.
1994;60:189-194. Related Links: Abstract; Full text

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P, Malone A, eds. ADA Pocket Guide to Enteral Nutrition. Chicago, IL: American Dietetic
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analysis of the literature. Intensive Care Med. 2008;34:1980-1990. Related Links: Abstract
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J Pediatr. 1992;120:S129-S138. Related Links: Abstract
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text
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Mehta NM. Approach to enteral feeding in the PICU. Nutr Clin Pract. 2009;24(3):377-387.
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Mehta NM, Compher C. A.S.P.E.N. clinical guidelines: Nutrition support of the critically ill
child. J Parenter Enteral Nutr. 2009;33:260-276. Related Links: Abstract; Full text
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Merritt RJ, Jenks BH. Safety of soy-based infant formulas containing isoflavones: The
clinical evidence. J Nutr. 2004;134(5):1220S-1224S. Related Links: Abstract; Full text
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Head Neck Surg. 2009;17:194-199. Related Links: Abstract
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Moller A, Kalhoff H, Reuter T, Friedrichs N, Wagner N. Congenital intestinal
lymphangiectasia: A rare differential diagnosis in hypoproteinemia in infants. Klin Padiatr.
2006;218:224-225. Related Links: Abstract
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reduces postoperative septic complications: The results of a meta-analysis. Ann Surg.
1992;216:172-183. Related Links: Abstract; Full text
Moukarzel AA, Abdelnour H, Akatcherian C. Effects of a pre-thickened formula on
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2007;41:823-829. Related Links: Abstract
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prolonged feeding with a premature formula. Pediatrics. 1993;92:862-864. Related
Links: Abstract
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soy product for premature infants. S Afr Med J. 1979;55(24):982-986. Related Links:
Abstract
Nevin-Folino N, Loughead JL, Loughead MK. Enhanced-caloric formulas: Considerations
and options. J Neonatal Nurs. 2001;20:7. Related Links: Abstract

Nevin-Folino N, Miller M. Enteral Nutrition. In: Samour PQ, King K, eds. Handbook of
Pediatric Nutrition. Sudbury, MA: Jones and Bartlett Publishers; 2005:499-524. (was 1999)
Nestle HealthCare Nutrition, Inc. Nestle Nutrition HealthCare Products Guide. Vevey,
Switzerland; 2010.
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Guidelines: Nutrition Support of the Critically Ill Child. JPEN J Parenter Enteral Nutr.
2009;33(4):260-276. Related Links: Abstract; Full text
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10th ed. Washington DC: National Academy of Sciences; 1989. Related Links: Abstract;
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Orenstein SR, Shalby TM, Putnam PE. Thickened feedings as a cause of increased
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
coughing when used as therapy for gastroesophageal reflux in infants. J Pediatr.
1992;121:913-915. Related Links: Abstract
Parrish CR, McClave S. Checking Gastric Residual Volumes: A Practice in Search of
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Penna FJ, Norton RC, Carvolho AS, Pompeu BC, Penna GC, Ferreira MF, Duque CG,
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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
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Resources > Nutrition Support > Pediatric Enteral Nutrition Support > Adult and Specialized
Formulas for Use in Pediatrics
Standard Formulas with Fiber

Nutrition support of children older than 10 years may be effectively managed with standard
adult formulas with fiber. These products are generally of low to moderate osmolality and
gluten and lactose free, typically containing carbohydrate in the form of maltodextrins or
corn syrup solids. The protein content of these formulas is typically 40 g to 45 g protein per
liter and composed of intact polymeric protein, usually sodium or calcium caseinates,
though some contain mixtures of caseinates and soy protein isolates (Abbott, 2010; Nestle,
2010).
Given the increase in protein content of approximately 50% more than the amount in
pediatric standard formulas of the same energy density, standard adult enteral
formulas often more effectively meet the protein requirements of children older than 10
years. This is particularly true for chronically ill children who are nonambulatory and have
decreased energy needs. Often, the decreased volume needed to prevent overfeeding in
these special needs children may result in inadequate protein intake when on standard
pediatric formulas alone. The percentage of energy from fat in standard adult enteral
formulas typically ranges from 29% to 35%; the fat blend is usually composed of a blend of
soy, safflower, canola, or corn oil, as well as medium-chain triglyceride oil, to easily meet
essential fatty acid requirements while also providing a blend of omega-6 and omega-3 fatty
acids. These formulas may meet the Recommended Dietary Allowances within a volume of
1,800 mL to 2,000 mL for most children older than age 10, but chronically ill,
nonambulatory children with decreased energy requirements who are volume restricted to
less than 1,500 mL may require additional vitamin and mineral supplementation—most
notably, calcium, phosphorus, and vitamin D (Nevin-Folino, 2005).
Although standard adult enteral formulas are available with and without fiber, in
general, formulas with fiber would be recommended for use with most children older than
10 years. Fiber-containing enteral products promote improved gastrointestinal function
and bowel regularity and may help in the management of constipation (as long as sufficient
free water is provided) and diarrhea.
The fiber levels in adult enteral formulas commonly range from 10 g to 14 g per liter, and
typical fiber sources include oat and soy fiber, partially hydrolyzed guar gum, cellulose gel,
and gum arabic. As with the pediatric standard and energy-dense formulas, adult enteral
formulas are also now available with added prebiotics, most notably short
chain fructo-oligosaccharide for promotion of improved gut flora and gastrointestinal
function ( Abbott, 2010; Nestle, 2010).


Calorically Dense Formulas

Energy-dense adult enteral formulas may be effectively used in pediatric patients older
than 10 years who have high energy and protein needs or for those children who
require volume restriction. Typical clinical pediatric cases where an energy-dense adult
formula may be indicated include, but are not limited to, the following:
Critically ill children older than 10 years
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Critically ill children older than 10 years
Children older than 10 years with cardiorespiratory disease (cystic fibrosis or
congenital heart disease)
Children older than 10 years with cancer and extremely high energy and protein needs
Critically ill older children in the intensive care unit setting who have experienced trauma,
sepsis, or acute respiratory distress and infection may be edematous, require volume
restriction, and may be on multiple intravenous medications. Children older than 10 in
this type of clinical scenario may benefit from energy-dense adult formulas.
Given the limited volume allocated for the provision of enteral nutrition, a high-energy
formula of 1.5 kcal/mL to 2.0 kcal/mL can often help to meet the energy, protein, and most
of the micronutrient requirements of critically ill children within the restrictions.
Older children with underlying cardiorespiratory disease and resultant growth failure, such
as those with cystic fibrosis, may also benefit from enteral feeds with high-energy adult
formulas provided either over 24 hours or in a nocturnal schedule over 8 to 12 hours within
the home setting. Finally, children with cancer, who are experiencing anorexia, cachexia,
malnutrition, and growth failure may also be good candidates for enteral nutrition with
energy-dense adult enteral formulas.
These formulas are typically lactose free and contain intact, polymeric protein. To provide
the extra energy and nutrient density, the amount of protein per liter generally ranges from
55 g to 70 g. The percentage of energy from fat generally ranges from 35% to 40%, given
the need for higher energy concentration and to balance out the formula's
osmolality. However, the fat source is the same as that found in the standard adult
formulas—namely, a blend of soy, safflower, canola, and MCT oil—providing both omega-6
and omega-3 fatty acids while meeting essential fatty acid needs and promoting
gastrointestinal tolerance. Given the higher energy and protein concentrations per liter,
energy-dense formulas usually have high renal solute loads and osmolality and are
generally not recommended for transpyloric feedings.

High-Protein Formulas

Older pediatric patients—particularly adolescents—who have experienced trauma, burn, or
acute illness with sepsis and infection may benefit from a high-protein adult enteral
formula. Adolescents who have high-protein requirements due to trauma such as head
injury, burns and spinal cord injury, but who are not volume restricted, can effectively meet
their energy, protein, and micronutrient requirements with adult high-protein formulas.
Pediatric patients with low energy needs may also benefit from high-protein adult
formulas in order to better meet protein and micronutrient needs without additional
supplementation. These formulas are typically available with and without fiber and have
high levels of intact, polymeric protein in the range of 60 g to 75 g protein per liter.
However, most of these high-protein formulations are of normal energy density between
1.0 kcal to 1.2 kcal per mL and, as such, have a fairly low to moderate osmolality.
The protein source of these high-protein adult formulas include sodium and calcium
caseinates; the fat content generally provides 20% to 30% of energy from fat, composed of
a blend of vegetable oils such as soy oil and medium-chain triglyceride oil, as is used in
adult standard formulas. Adult high-protein formulas are also lactose free and usually
contain maltodextrins and corn syrup solids as the predominant carbohydrate sources. The
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
fiber content, as with the standard and energy-dense adult formulas, is composed of
varying blends and amounts of oat fiber, soy fiber, cellulose gel, and guar gum. Some of
these high-protein adult formulas are now also available with prebiotics, usually in the form
of short-chain fructo-oligosaccharide (Abbott, 2010; Nestle, 2010).

Specialized Formulas

Specialized formulas are designed to be disease specific and vary in energy density and
macronutrient and electrolyte composition. Manufacturers provide a full line of specialty
formulas for the treatment of a number of clinical disease states and metabolic
disorders. Numerous adult enteral products are available in each of the major adult
specialized categories, which include the following ( Chen, 2009):
Diabetes formulas
Renal formulas
Hepatic formulas
Pulmonary formulas
Immune-enhancing formulas
Elemental and semi-elemental formulas
The manufacturers of the formulas that fall into these categories make numerous
claims about the benefits of their particular product, making it challenging for the
clinician—and, even more so, for the pediatric clinician trying to select an appropriate
formula for an older pediatric patient. The data to support the claims for use of many of
these specialized formulas, however, are not particularly strong. These products may have
altered concentrations of macronutrients, addition of "conditionally" essential amino acids
such as arginine or glutamine, use of altered fat blends using marine oils, and increased
levels of micronutrients such as vitamin A or zinc for conditionally increased needs. Given
the variety of claims, specialized formulas designed for adults must be even more carefully
evaluated for appropriate use in the pediatric population.
Specific information, protocols for use, and supplementation guidelines are available from
manufacturers. However, the pediatric clinician should evaluate the literature and the
strength of the clinical evidence in support of using specialized formulas for pediatric
patients. A brief review of the available evidence related to use of adult immune formulas
and renal formulas follows.
Immune-Enhancing Formulas in Pediatric Patients
Numerous immune-enhancing products are available on the market (Abbott, 2010; Nestle,
2010) with suggested benefits including support of the immune system, promotion of the
anti-inflammatory process, and preservation of the gastrointestinal mucosa. These
specialized immune-enhancing formulas contain one or more combinations of nutrients
such as omega-3 fatty acids, arginine, glutamine, nucleotides, and added level of
antioxidants ( Chen, 2009). Numerous adult clinical studies over the past 15 years and
more recent systematic reviews and meta-analyses within the literature regarding adult
patients have indicated that enteral immunonutrition decreases infection rates, length of
hospital stay, and days on the ventilator; however, other clinical trials have led to
inconsistent findings, suggesting increased mortality rates in septic patients (Dent, 2003;
Marik, 2008; Heyland, 2003; Sakurai, 2007). The inconsistent results in immune-enhancing
studies is related to poor methodology; small sample size; and inconsistency in the
formulas used, with different and varying amounts of immune-enhancing nutrients (Chen,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2009).
Within the pediatric population, however, very few studies have been conducted to support
the use of immune-enhancing enteral products. Briassoulis and
colleagues (2005) conducted a small study in 50 pediatric patients, with a mean age of
10.3 years, that demonstrated an increasing trend in nitrogen balance and nutritional
indices, and a decreasing trend in nosocomial infections, colonization with Candida
species, and positive gastric aspirate cultures; however, no differences were noted in
length of stay or mortality. Additional studies regarding critically ill pediatric patients using
single nutrient effects in multicenter prospective randomized trials are needed; current
clinical guidelines of the American Society for Parenteral and Enteral Nutrition do not
support the routine use of immune-enhancing products in critically ill pediatric
patients (Mehta & Compher, 2009).
Adult Renal Formulas in Pediatric Patients
Adult renal formulas are designed for use with patients with acute and chronic renal
failure. These products typically have reduced levels of protein and electrolyte levels per
liter as compared with standard adult enteral formulas (Abbott, 2010; Nestle, 2010). Which
renal formula is selected is typically based on the degree of kidney function, use of dialysis,
underlying nutritional status, and the specific energy and protein requirements of the
patient.
Commercially available adult renal formulas range in protein concentration from 7% to 18%
of energy, with the lower-protein products used in the management of patients for whom
the goal is to prevent or delay the initiation of dialysis (Chen, 2009). The higher protein
and electrolyte renal formulas are designed for patients with chronic renal disease who are
managed with dialysis and experience increased nutrient losses, including electrolytes and
protein.
Specific guidelines for the nutritional management of pediatric patients with chronic renal
disease have been established by the Kidney Disease Outcomes Quality Initiative (KDOQI)
(NKF, 2008). Adult renal formulas may be used for pediatric patients provided that KDOQI
guidelines for energy and protein recommendations are followed based on the child's renal
function and type of dialysis management.
Adult renal formulas provide energy in the range of 1.8 kcal/mL to 2.0 kcal/mL and protein
at levels of 45 g to 82 g protein per liter, from a milk protein concentrate source (Abbott,
2010; Nestle, 2010). Renal formulas are typically lower in phosphorus, sodium, and
potassium but contain higher levels of water-soluble vitamins such as B-6 and folic
acid. Furthermore, some products contain added arginine to reduce the potential for
hyperammonemia ( Nestle, 2010). The fat source for these products is a blend of canola oil
and medium-chain triglyceride oil and fat generally comprises 35% to 48% of total energy.
Maltodextrin and corn syrup solids are the primary sources of carbohydrates. Renal
products are also now available with added prebiotics in the form of short-chain
fructo-oligosaccharides to promote normal gut flora and gastrointestinal function.
Given the high energy concentrations and osmolality in the range of 580 mOsm/kg to 600
mOsm/kg, these products may need to be diluted for use in pediatric patients. Moreover,
careful attention should also be given to changes in the child's electrolyte and serum
creatinine levels and gastrointestinal tolerance as enteral nutrition is advanced to meet
energy goals.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Nutrition Support > Pediatric Enteral Nutrition Support > Infant Formulas
Cow's Milk-Based Infant Formulas

Defining Feature
Cow's milk–based infant formulas are designed to be the sole source of infant nutrition for
the healthy, term, non-breastfed infant for the first 6 months of life. After 6 months of age,
complementary foods may provide additional nutrients as the volume of formula decreases
(Joeckel, 2009).
Indications
Term, healthy infant feeding
Contraindications
Cow's milk protein allergy or sensitivity
Primary lactose intolerance
There are cow's milk based infant formulas that are lactose free—see
Lactose-Free Infant Formulas
Galactosemia
Composition
Protein: These formulas contain between 1.45 g/dL and 1.6 g/dL protein—significantly
more protein than human milk. The source is generally a blend of whey and casein,
with specific ratios of casein to whey varying by product manufacturer. Although
breast milk and infant formulas both contain whey protein, the primary source in
cow's milk is beta-lactoglobulin, whereas the whey in human milk is alpha-lactalbumin
(Joeckel, 2009; AAP, 2009).
Fat: Vegetable oils are the primary fat source and provide 40% to 50% of energy.
Carbohydrate: The carbohydrate source in standard cow’s milk–based formulas is
lactose, which mimics human milk (Joeckel, 2009). Many infant formulas now also
contain prebiotics, which are nondigestible oligosaccharides including
galacto-oligosaccharides and polydextrose. Human milk also contains
oligosaccharides, but there are up to 200 types available to infants fed human milk.
Prebiotics are known to modify gut flora and function in infants because they prevent
pathogenic bacteria from binding to the gut epithelium and serve as nutritional
substrates for beneficial bacteria (Marcobal, 2010). In many studies, the addition of
prebiotics to infant formula has resulted in stool bacterial counts and stool
frequency/consistency more similar to those of breastfed infants (Rao, 2009).
Micronutrients: Levels in standard infant formulas are generally comparable across
product manufacturers; however, recent trends in formula development have yielded
newborn formulas with higher levels of vitamin D to provide at least 400 IU in volumes
typically consumed by neonates younger than 3 months.


Soy Infant Formulas

Defining Feature
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Replacement of cow's milk protein with soy protein isolate; lactose free.
Indications
Term infants with galactosemia or hereditary primary lactase deficiency (rare) (Bhatia,
2008).
Preference for a vegetarian or vegan diet (Bhatia, 2008).
Short-term use when there is secondary lactose intolerance after a bout of acute
gastroenteritis (although many infants may do well on breast milk or cow's milk–based
formulas in this situation) (Bhatia, 2008).
Contraindications
Preterm infants, particularly those with low birth weight, because of the potentially
negative effects on bone health and mineralization (Bhatia, 2008; Joeckel,
2009). Serum phosphorus concentrations are lower and alkaline phosphatase
concentrations are higher in preterm infants fed soy formula than they are in preterm
infants fed cow's milk–based formula (Naude, 1979; Shenai, 1981). Observational
findings have also concluded that the degree of osteopenia increases in
low-birth-weight infants receiving soy formulas (Kulkarni, 1980; Callenbach, 1981).
Intact cow's milk or soy protein allergy/enteropathy, particularly a non-immunoglobulin
E (IgE)–mediated reaction. Infants with documented or suspected cow's milk protein
intolerance should not be fed soy formula, as 10% to 14% will also have a soy protein
allergy (Bhatia, 2008; Committee on Nutrition, 2009). More significantly, 30% to 64%
of infants with non-IgE-mediated allergy symptoms (eg, bloody diarrhea) will have a
concomitant soy protein allergy (Bhatia, 2008).
Composition
Protein: The protein source is soy isolate with additional L-carnitine, L-taurine, and
L-methionine (Bhatia, 2008).
Fat: The fat source is typically a blend of vegetable oil; most manufacturers
also add docosahexaenoic acid and arachidonic acid (Bhatia, 2008).
Carbohydrate: The carbohydrate source is generally a blend of corn maltodextrin,
corn syrup solids, and/or sucrose (Bhatia, 2008).
Micronutrients: Soy formulas typically contain 20% more calcium and phosphorus
than cow's milk–based formulas because soy formulas also contain phytates, which
bind calcium and phosphorus, making them unavailable for absorption (Bhatia, 2008).
Other Information
Concerns related to phytoestrogens/isoflavones include their potential negative effects on
sexual development and reproduction, neurobehavioral development, immune function,
and thyroid function. Although studied by numerous investigators in various species, there
is no conclusive evidence from animal, adult human, or infant populations that dietary soy
isoflavones may adversely affect human development, reproduction, or endocrine function
(Bhatia, 2008). Literature reviews and clinical studies of infants fed soy protein–based
infant formulas raise no clinical concerns with respect to nutritional adequacy, sexual
development, thyroid disease, immune function, or neurodevelopment (Merritt,
2004). Evidenced-based studies also confirm that soy protein–based formulas do not
interfere with normal immune responses to oral immunization or poliovirus vaccine (Zoppo,
1983; Businco, 1990). Epidemiologic studies have suggested a protective effect of
isoflavones against a number of adult chronic diseases, including coronary heart disease
and breast, endometrial, and prostate cancers (Bhathena, 2002; Cross, 2004).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
There is no evidence to support the routine use of soy formula to prevent or manage
infantile colic or fussiness, nor is there clear value in using soy formula to prevent atopic
disease in infants (Bhatia, 2008).


Lactose-free Infant Formulas

Defining Feature
Cow's milk based, but lactose free.
Indications
Congenital or primary lactase deficiency (rare) (Joeckel, 2009; Heubi, 2000)
Secondary lactase deficiency (eg, after a bout of gastroenteritis) (Heubi, 2000;
Jia-Hua, 2009)
Contraindications
Galactosemia (Joeckel, 2009)
Intact cow's milk protein allergy (Joeckel, 2009)
Composition
Protein: The protein in these formulas is cow's milk (Joeckel, 2009).
Fat: The fat source for these formulas is a blend of vegetable oils, with added
docosahexaenoic acid and arachidonic acid (Joeckel, 2009).
Carbohydrate: The lactose is replaced with corn syrup solids as the carbohydrate
source (Joeckel, 2009).
Other Information
Although the mainstream use of lactose-free formulas for occasional infantile fussiness or
gas is not supported by the current literature, lactose-free formulas—along with
conventional medical and oral rehydration therapy—may have a place in the management
of acute diarrhea. In one study of 120 infants, the use lactose-free formula resulted in a
shorter duration of diarrhea and a higher cure rate when compared with standard infant
formula (Jia-Hua, 2009).

Added Rice Infant Formulas

Defining Feature
Added rice formulas are also known as prethickened formulas, as they are made with
added rice starch during the manufacturing process. When the rice starch comes into
contact with stomach acid, the formula's viscosity increases (Vanderhoof, 2003).
Indications
Symptomatic gastroesophageal reflux. In two separate studies, infants fed a
prethickened, added-rice formula showed reduced episodes of regurgitation and
vomiting and reduced regurgitation volume when compared with infants fed a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
standard infant formula (Moukarzel, 2007; Vanderhoof, 2003). The prethickened
formula did not negatively affect gastric emptying times (Moukarzel, 2007). A joint
panel of the North American and European Societies for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN/ESPGHAN) issued recommendations in 2009
in support of trials of prethickened formulas as a way to reduce episodes of observed
regurgitation and to improve the quality of life or infants with reflux (Vandenplas,
2009).
Contraindications
There are no overt contraindications to these formulas.
Composition
Protein: The protein source for these formulas is typically cow's milk protein, with a
blend of casein and whey (Abad-Jorge, 2010).
Fat: Vegetable oils make up the fat blend for these formulas, and they typically
contain docosahexaenoic acid and arachidonic acid (Abad-Jorge, 2010).
Carbohydrate: The carbohydrate source may be a blend of lactose, corn syrup solids,
sucrose, and/or maltodextrin. Up to 30% of carbohydrate is replaced with rice starch
for the thickening effect (Vanderhoof, 2003).
Other Information
The use of prethickened formulas may be preferred over standard infant formula thickened
with rice cereal or other thickener for the following two reasons:
Formula thickened with rice cereal may be too viscous and difficult for the infant to
extract from the nipple, prompting the caregivers to enlarge the nipple's hole, which
can lead to increased air ingestion and further reflux. Prethickened formulas, although
more viscous than standard infant formulas or breast milk, are 3 times less viscous
than standard formula thickened with rice cereal. Infants feeding with
prethickened formulas can still use a standard nipple (Moukarzel, 2007).
Rice cereal or other thickeners may significantly alter the energy content and/or
macronutrient distribution of the infant formula, which could affect nutritional status
and growth. Prethickened formulas are formulated to be 20 kcal/oz with an
appropriate macronutrient distribution (Moukarzel, 2007).
However, one study did find that prethickened formulas may be no more effective at
reducing reflux symptoms than standard formulas thickened with corn starch or rice cereal
(Penna, 2003).
Prethickened formulas concentrated to more than 24 kcal/oz may be too thick for effective
infant feeding. If an increased energy density is required for medical reasons, it may be
reasonable to mix the prethickened/added rice formula to 20 kcal/oz and then add standard
infant formula powder or liquid concentrate to yield the desired energy density.
Prethickened formulas require gastric acid in order to achieve the desired increase in
formula viscosity. This will need to be considered in infants who are on acid suppression
therapy, as is common in the case of gastroesophageal reflux.

Partially Hydrolyzed Infant Formulas

Defining Feature
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Defining Feature
Partially hydrolyzed formulas (PHFs) contain milk protein that has been partially broken
down. They are not hypoallergenic, compared to extensively hydrolyzed formulas, because
of peptide size.
Indications
Healthy, term infant feeding. PHFs have been found to produce similar growth and
weight gain patterns in infants and children when compared with infants fed standard
cow's milk formula or breast milk (Rzehak, 2009).
Reduction in risk of atopic disease, particularly in infants who are at high risk (with a
family history of allergy). A meta-analysis of 18 studies and 12 infant populations
found a 44% to 55% reduction in risk of atopic disease when infants were fed a 100%
whey PHF vs. intact cow's milk protein (Alexander, 2010).
Contraindications
Intact cow's milk protein allergy. PHFs contain peptide chains that are large enough to
be considered allergenic (Committee on Nutrition, 2009).
Composition
Protein: The most well-studied form of PHF contains 100% hydrolyzed whey protein
and no casein, although PHFs containing a blend of hydrolyzed whey and casein are
currently on the market. Intact proteins are chemically and enzymatically hydrolyzed
to reduce the cow's milk protein peptide size, theoretically reducing the allergenicity of
the protein (Alexander, 2010).
Fat: The fat source in these formulas includes vegetable oil blends similar to standard
infant formulas (Committee on Nutrition, 2009).
Carbohydrate: The carbohydrate source is typically corn syrup solids but may also
include lactose (Committee on Nutrition, 2009).
Other Information
PHFs are often marketed to consumers as solutions for infantile fussiness and gas. In a
60-day study of 335 healthy, term infants, there was no significant difference in parent- or
physician-rated formula intolerance in the PHF group compared with the standard intact
formula group (Berseth, 2008). However, in a separate study using a subset of healthy,
term infants whose parents rated them as very fussy or extremely fussy, there was a
significant reduction in fussiness, crying, spit-up, and gas as quickly as one day after
formula switch from standard intact protein to PHF (Berseth, 2009) For many healthy, term
infants, standard infant formula is probably the best choice, but for select subgroups, there
may be benefits to using a PHF.

Extensively Hydrolyzed Infant Formulas

Defining Feature
Extensively hydrolyzed formulas (EHFs) contain a milk protein source that has been
treated to yield small peptides and free amino acids, reducing the allergenicity of the
formula. EHFs are considered to be hypoallergenic.
Indications
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Allergy to intact cow's milk protein and soy protein formulas. Approximately 90% of
infants with allergy to intact protein can tolerate EHFs (Bahna, 2008; AAP, 2000).
Gastrointestinal impairment—such as liver disease, cystic fibrosis, or short gut—that
may benefit from an EHF with medium-chain triglycerides (MCT) (Joeckel, 2009).
Prevention of atopic disease in infants with a significant family history. A longitudinal
study of more than 2,000 newborns revealed a 10% to 20% risk reduction in allergic
manifestation and an 8% to 29% risk reduction in atopic eczema at age 6 years when
compared with intact cow's milk protein formula (von Berg, 2008).
Contraindications
Severe protein allergy requiring 100% free amino acids. Approximately 10% of infants
with allergic disease will require a completely elemental formula (Joeckel, 2009; AAP,
2000).
Composition
Protein: These formulas contain whey and/or casein that has been chemically or
enzymatically treated to yield peptides and some free amino acids (Joeckel, 2009).
Fat: The fat is typically a blend of vegetable oils, and some specific brands contain
substantial portions (up to 55%) of the fat as MCT (Abad-Jorge, 2010). Formulas with
significant amounts of MCT may be beneficial for infants with the potential for fat
malabsorption, such as in the case of liver disease or cystic fibrosis, as
MCT bypasses the lymphatic system and goes straight to the liver via the portal vein.
MCT requires less pancreatic lipase and bile for digestion and absorption (Joeckel,
2009)
Carbohydrate: The carbohydrate source is generally a blend of modified tapioca
starch, sucrose, corn syrup solids, modified cornstarch, and/or dextrose (Abad-Jorge,
2010). All are lactose free.
Other Information
Protein hydrolysate formulas are more expensive than standard formulas and may be less
palatable (Joeckel, 2009), so they should be used judiciously.
A recent finding related to EHFs has yielded the addition of probiotics, specifically
lactobacillus GG, to one particular brand of formula. In a study of 26 infants with bloody
stools attributed to cow's milk protein sensitivity, the addition of probiotics to the EHF
resulted in fewer markers of intestinal inflammation and a complete resolution of bloody
stools in all infants with the probiotic formula as compared to those on the nonprobiotic
EHF (Baldassarre, 2010).




Elemental Infant Formulas

Defining Feature
Amino acid–based formulas contain 100% free amino acids and are considered to be
hypoallergenic and nutritionally complete (Joeckel, 2009).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Indications
Severe protein allergy and intolerance to extensively hydrolyzed formulas (EHF)
(Joeckel, 2009).
Severe short bowel syndrome with persistent intolerance of EHF (Bines, 1998;
Abad-Sinden, 2003). In a small case series, 4 pediatric patients were switched from
EHF to amino acid–based formula and were able to transition off parenteral nutrition
within 15 months. These patients had fewer hospitalizations, few episodes of proven
and suspected sepsis, and improved intestinal permeability (Bines, 1998). In a larger
retrospective review of 30 infants with short bowel syndrome, number of days fed with
an amino acid–based formula was significantly, negatively correlated with duration of
parenteral nutrition; however, in this study, breast milk also had a similar negative
correlation with parenteral nutrition duration (Andorsky, 2001).
Contraindications
None
Composition
Protein: These formulas contain 100% free amino acids.
Fat: The fat in these products include a blend of vegetable oils (Joeckel, 2009). Levels
of medium-chain triglycerides vary among product manufacturers, from 5% to 33% of
fat as MCT. Many now contain docosahexaenoic acid and arachidonic
acid (Abad-Jorge, 2010).
Carbohydrate: The carbohydrate source of these formulas includes corn syrup solids
and/or modified tapioca starch (Joeckel, 2009).
Other Information
Elemental formulas are composed of macronutrients of low molecular weights. Since the
nutrients are provided in elemental forms, they tend to have minimal residue. However, the
lower the molecular weight, the higher the formula's osmolality. Excess osmolality,
particularly in infants with short bowel syndrome, can cause osmotic diarrhea and dumping
(Pereira-da-Silva, 2008).
Elemental formulas are usually more expensive and commonly considered unpalatable.

Preterm Infant Formulas

Defining Feature
Preterm infant formulas are generally cow's milk–based formulas designed for the
premature infant. They are available in 20 kcal/oz, 24 kcal/oz, and 30 kcal/oz ready-to-feed
forms (Abad-Jorge, 2010). Ready-to-feed formulas are highly preferable to powdered
formulas because of the risk of infection with nonsterile forms of infant formula (Committee
on Nutrition, 2009).
Indications
Premature, hospitalized infants
Contraindications
Intolerance or allergy to intact protein
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Intolerance or allergy to intact protein
Composition
Protein: The protein source is primarily whey, and these formulas have higher protein
contents than standard infant formulas. Most contain 3 g of protein/100 kcal
(Committee on Nutrition, 2009), although a new addition to the formula market now
contains 3.3 g of protein/100 kcal (Abbott Laboratories, Columbus, OH; Mead
Johnson Nutrition, Evansville, IN).
Fat: The fat source is a blend of vegetable oils, but these typically contain a higher
percentage (ie, 40% to 50%) of fat from medium–chain triglycerides (MCT) than
standard infant formulas. This is because premature infants are thought to have lower
levels of lipase and bile to digest and absorb long–chain fats; higher MCT contents
may result in improved fat absorption (Joeckel, 2009). All premature formulas now
contain docosahexaenoic acid and arachidonic acid, very–long-chain polyunsaturated
fatty acids.
Carbohydrate: The carbohydrate in premature formulas comes from glucose polymers
instead of lactose because of the lower lactase activity in the premature gut (Joeckel,
2009).
Micronutrients: These formulas contain higher levels of micronutrients, including
calcium, phosphorus, and vitamin D to maximize bone health (Committee on
Nutrition, 2009).
Other Information
It is not advisable to discharge infants to home on premature infant formulas. Although
rare, hypervitaminosis D and resultant hypercalcemia are possible because of the
increased micronutrient content of premature formulas (Nako, 1993). A more appropriate
discharge formula would be a transitional infant formula (typically 22 kcal/oz, but
modifiable).

Preterm Discharge Formulas

Defining Feature
Preterm discharge formulas are designed to transition premature infants from a preterm
hospital formula to a standard formula. In general, the nutrient levels are in between that of
standard term formulas and premature infant formulas. When mixed according to
manufacturer instructions, these formulas are 22 kcal/oz.
Indications
The premature infant whose weight is approaching 2 kg and who is preparing for
hospital discharge (Committee on Nutrition, 2009).
Contraindications
Allergy or intolerance to intact cow's milk protein.
Composition
Protein: The protein source is cow's milk protein, and the content is 2.8 g protein per
100 kcal (Committee on Nutrition, 2009; Joeckel, 2009).
Fat: The fat is a blend of vegetable oils, with 20% to 25% of fat coming from
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
medium-chain triglycerides. These formulas do contain docosahexaenoic acid and
arachidonic acid (Abad-Jorge, 2010).
Carbohydrate: The carbohydrate source is a blend of lactose and corn syrup solids or
maltodextrin (Abad-Jorge, 2010).
Micronutrients: Preterm discharge formulas contain higher levels of phosphorus,
vitamins A and D, and calcium than standard infant formulas, but the levels of these
nutrients are lower than those in preterm infant formulas (Joeckel, 2009).
Other Information
Some evidence supports the use of preterm discharge formulas in the premature infant
approaching hospital discharge, including a study of 284 premature infants that found that
infants fed a preterm discharge formula had higher weights and lengths at 9 months of
age than those fed a standard infant formula (Lucas, 2001). However, a more recent
meta-analysis involving data from 631 infants found no strong, conclusive evidence that
preterm discharge formulas result in improved growth rates in premature infants
(Henderson, 2007).


Fat-Modified Infant Formulas

Defining Feature
Fat-modified infant formulas contain significant amounts of medium-chain triglycerides
(MCT) as a fat source (ie, more than 80% of fat from MCT) for infants who cannot absorb
or tolerate large amounts of long-chain fats. Medium-chain triglycerides can be taken up by
enteric cells without being hydrolyzed by lipase in the intestinal lumen. If they are
hydrolyzed by lipase, the medium-chain fatty acids can be absorbed by the intestinal cells
without being incorporated into micelles by bile salts (Committee on Nutrition,
2009). Furthermore, medium-chain fats do not enter lymphatic circulation as chylomicrons;
rather, they are transported directly to the liver via portal circulation.
Indications
Chylothorax (Cormack, 2004). Fat-modified formulas with a high MCT content are
often recommended for patients with chylothorax despite a lack of randomized,
controlled clinical trials documenting efficacy (Chan, 2005). Recommendations for
use are based on knowledge of how medium-chain fats are absorbed and routed to
the liver.
Long-chain fatty acid oxidation disorders, including long-chain 3-hydroxyacyl-coA
dehydrogenase deficiency (Committee on Nutrition, 2009).
Intestinal lymphangiectasia (Koo, 2005; Moller, 2006).
Contraindications
Allergy or intolerance to intact cow's milk protein.
Composition
Protein: The protein sources are either intact whey or casein (Mead Johnson
Nutrition, Evansville, IN ; Nutricia North America, Gaithersburg, MD). The protein
content is generally higher than in standard infant formulas, which is particularly
beneficial for infants with chylothorax and protein-losing diseases.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
beneficial for infants with chylothorax and protein-losing diseases.
Fat: The percentage of energy from fat can vary from 25% to 45% depending on
product manufacturer; however, all products contain at least 84% of fat from MCT
(Mead Johnson Nutrition, Evansville, IN ; Nutricia North America, Gaithersburg, MD).
Carbohydrate: The carbohydrate source in these products is corn syrup solids (Mead
Johnson Nutrition, Evansville, IN ; Nutricia North America, Gaithersburg, MD).
Other Information
These products may come as either a ready-to-feed 30 kcal/oz liquid that can be diluted
with sterile water or as a powdered product that can be mixed to a desired energy density.
Care should be taken to monitor for signs of essential fatty acid deficiency, given the
relatively low amounts of long chain fats provided by these formulas.

Electrolyte-Modified Infant Formulas

Defining Feature
Electrolyte-modified formulas contain lower levels of minerals than standard formulas.
Indications
Serum calcium disorders
Impaired renal function
Composition
Macronutrient sources and amounts are very similar to those in standard formulas
(Abad-Jorge, 2010).
This type of formula contains lower amounts of calcium, phosphorus, magnesium,
potassium, and sodium than standard infant formulas (Abad-Jorge, 2010).
This type of formula is considered to be low in iron, so iron supplementation is
required for infants on this formula.


Other Infant Formulas

A variety of other specialty infant formulas that address various disorders and family
preferences are available. Some examples include the following:
Carbohydrate-free formulas used for infants with carbohydrate malabsorption
For these formulas to be nutritionally complete, a monosaccharide additive is
needed; usually this is added in gradually increasing amounts in order to assess
tolerance to increasing amounts of carbohydrate. (Joeckel, 2009)
Metabolic formulas for infants and children with inborn errors of metabolism
Organic infant formulas
Formulas containing probiotics, which may be useful in the prevention of diarrhea or
food allergy (Wallace, 2009)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Nutrition Support > Pediatric Enteral Nutrition Support > Pediatric Formulas
Pediatric Follow-up Formulas

Over the past 20 years, the pediatric formula market has expanded significantly,
particularly in the development of products to better meet the nutrition needs of children
aged 1 to 10 years. Pediatric follow-up formulas and pediatric enteral formulas began
entering the market in 1988, resulting in an increased availability of transitional, standard,
and specialty pediatric products during the 1990s (Abbott, 2010; Mead Johnson,
2010). Although the follow-up formulas are primarily targeted for oral intake in children
from 10 to 36 months of age, they may also be used in some cases for providing enteral
nutrition support to young children with chronic illness who are unable to achieve sufficient
oral intake to meet their nutritional requirements.
Follow-up formulas are available from all of the major formula manufacturers, including
Abbott Labs (Columbus, OH), Mead Johnson (Evansville, IN), and Nestle Nutrition (Vevey,
Switzerland). However, it is important to note that the American Academy of Pediatrics has
stated that follow-up formulas are nutritionally adequate but provide no clear advantage
over standard infant formula in the first year of life (AAP, 2009).
Follow-up formulas are designed to better meet toddler requirements for protein, fatty
acids, vitamins and minerals, including iron. Data from the Third National Health and
Nutrition Examination Survey ( AAP, 2004) indicated that the diets of toddlers in the second
year of life fell below recommended dietary allowances for a variety of nutrients, including
iron and vitamins A, D and E. Furthermore, because of their limited variety of food intake
and tendency to fall into food jags, toddlers who are no longer drinking breast milk or infant
formula are getting suboptimal intakes of docosahexaenoic acid (DHA), which is important
to optimize neurodevelopment during infancy and early childhood.
Follow-up formulas are available both in both cow's milk protein and soy protein isolate
forms. The soy follow-up formulas are designed for toddlers who are milk intolerant or
following a vegan diet. When mixed per manufacturer's specifications, follow-up formulas
provide 20 kcal per oz and contain higher protein intake than standard infant formulas while
providing appropriate levels of iron and vitamins, C, D, and E. These formulas also contain
DHA and arachidonic acid, which are absent in cow's milk. Fat in these formulas is a blend
of high-oleic sunflower oil and marine oil as the source of DHA, and carbohydrate is a blend
of maltodextrins, modified corn starch, and lactose.
Although pediatric enteral products are the preferred formula for tube-feeding children
unable to meet their nutrition needs via the oral route, follow-up formulas may also be used
for enteral feedings, particularly if used as a base for mixing home made blenderized
formulas. Manufacturers clearly state, however, that follow-up formulas are not intended to
be used as a meal replacement or the sole source of nutrition. Follow-up formulas are
slightly less expensive than infant formula, although they are more expensive than cow's
milk. However, depending on the family's financial situation and the availability
of funding through the Special Supplemental Nutrition Program for Women, Infants, and
Children, use of a follow-up formula and blenderized foods may be more cost effective than
paying for pediatric enteral formulas out of pocket.
With careful guidance from a pediatric dietitian, an effective blenderized formula can be
designed using powdered follow-up formula and a variety of fruits, vegetables, meats and
added fats, and free water.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Standard and High-Calorie Formulas

Nutrition support of children older than 1 year is typically managed with pediatric standard
or pediatric high-energy formulas, available both with and without fiber. The selection of a
standard 1.0 kcal/mL vs. a 1.5 kcal/mL formula depends on the child's clinical status,
energy requirements, and need for volume restriction.
Standard pediatric enteral formulas in 900 mL to 1,300 mL generally meet 100% of the
Recommended Dietary Allowances (RDAs) for children aged 1 to 10 years. These formulas
are typically milk protein concentrates, containing intact protein, usually in the form of both
casein and whey, with approximately 30 g to 35 g protein per liter. Products containing
soy protein isolate as the protein source are also now available.
The fat blend of standard pediatric formulas is typically a mixture of high-oleic safflower oil,
soy oil, and other vegetable oils to meet essential fatty acid needs within a blend of
omega-6 and omega-3 fatty acids. Moreover, these products may also contain a small
amount of medium-chain triglycerides (MCT) to optimize fat
absorption. Recent reformulations of the pediatric enteral formula products include the
addition of long-chain fatty acids in the form of docosahexaenoic acid (DHA) to meet
continued neurological development needs beyond the first year of life. Pediatric standard
formulas are isotonic and lactose free, using corn maltodextrin and sucrose as the primary
carbohydrate sources.
Pediatric standard formulas are available with and without fiber. Fiber-containing pediatric
formulas can promote improved gastrointestinal function and gut health through the
promotion of lactic acid bacteria growth, such as lactobacilli and bifidobacteria (Joeckel,
2009). Fiber-enriched pediatric formulas contain both dietary fiber and prebiotic fiber in the
range of 6 g to 8 g fiber per liter, with a blend of oat and soy fiber usually as the dietary
fiber source, although at times cellulose gel and guar gum are also used. Prebiotics in the
form of short-chain fructo-oligosaccharide (scFOS) are also now being added to pediatric
standard formulas to promote improved gastrointestinal flora and gut function ( Abbott,
2010; Nestle, 2010).
Pediatric high-energy formulas with an energy density of 1.5 kcal/mL are currently available
from two manufacturers. High-energy formulas contain more protein, carbohydrate, fat, and
micronutrients to provide 100% of the RDAs in approximately 700 mL to 900 mL for
children 1 to 10 years of age. These products are also lactose free and contain intact milk
protein concentrates, a blend of vegetable oils such as high-oleic safflower oil and soy oil,
MCT oil, and more recently DHA, to better meet both energy and essential fatty acid
requirements, while promoting optimal long-chain fatty acid intake for neurological
development.
The protein content of these formulas ranges from 42 g to 59 g protein per liter to better
meet increased protein needs within a reduced volume in critically and chronically ill
children. The osmolality of these products range from 370 mOsm/L through 410 mOsm/L,
depending on the flavor, but are generally well tolerated by most pediatric patients with
normal gastrointestinal function. Although these higher-energy formulas can be used for
tube feedings, they are also flavored—one product line offers a choice of vanilla, chocolate,
and strawberry and thus is appropriate for use as an oral supplement.
The energy-dense pediatric products are also available with and without
fiber; fiber-containing products have both dietary fiber and prebiotics in the range of 9 g
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
to 13 g fiber per liter. Dietary fiber includes different blends of oat and soy fiber, cellulose
gel, or guar gum, as with the standard 1.0 kcal/mL pediatric formulas. These products are
also available with the prebiotic scFOS to promote improved gut function. High-energy
pediatric formulas may be typically used in children with cardiorespiratory disease such as
those with cystic fibrosis and congenital heart disease, as well as in critically ill children in
the context of significant fluid restriction.

Partially Hydrolyzed Formulas

Partially hydrolyzed, semi-elemental, or peptide-based pediatric formulas are typically
indicated for children older than 1 year who have severe gastrointestinal (GI) impairment
and persistent intolerance of intact protein, polymeric formulas.
A variety of semi-elemental pediatric formulas have entered the market over the past 10 to
15 years. These products contain a blend of hydrolyzed protein from a variety of sources
ranging from low molecular weight peptides from pork and soy hydrolysates in addition to
amino acids (Abad-Jorge, 2007). Other peptide-based pediatric products contain 100%
whey-based peptides, which may promote improved GI tolerance in some children.
Which product is best tolerated by a given patient is highly individualized and should be
evaluated through close monitoring of the patient's tolerance of the initiation and
advancement of the selected formula. These products range in osmolality from 260
mOsm/kg in an unflavored variety to as high as 440 mOsm/kg in the flavored form (Abbott,
2010; Nestle, 2010; Nutricia, 2009).
Partially hydrolyzed, peptide-based pediatric formulas provide 33% to 46% of energy from
fat, using a blend of long-chain triglycerides (LCTs) and medium-chain triglycerides
(MCTs). The sources of the LCTs are vegetable oil blends such as high oleic safflower oil,
soy oil, and canola oil, and the ratio of LCT to MCT can range from 65:35 to 40:60.
One partially hydrolyzed pediatric product uses structured lipids, consisting of interesterified
canola and MCT oil ( Abbott, 2010). Structured lipids may result in better absorption and
tolerance as well as enhanced absorption of fat-soluble vitamins (Kenler, 1996; Tso,
2001). All of the currently available partially hydrolyzed formulas are lactose free, but only
some—usually the unflavored variety—are also sucrose free.
Formulas with a higher relative fat content may be better tolerated by some children as the
relatively lower carbohydrate content may reduce lactic acid and carbon dioxide production,
which may, in turn, reduce flatulence and pain ( Bongaerts, 2006). The primary
carbohydrate sources in these products are maltodextrin and corn syrup solids (Abbott,
2010; Nestle, 2010; Nutricia, 2009).

Elemental Formulas

Elemental pediatric formulas are indicated for infants and children up to age 10 with severe
gastrointestinal impairment, in cases of severe malabsorption as seen with short bowel
syndrome, for eosinophilic esophagitis, and for children with severe protein allergies who
are unable to tolerate hydrolysate formulas (Abad-Jorge, 2007).
Although indications for use of completely elemental pediatric formulas may be rare, these
formulas can be extremely useful and well tolerated by children who demonstrate persistent
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
malabsorption, malnutrition, and growth failure. Elemental formulas, available in powdered
and ready-to-feed forms, can be used for tube feeding or for oral supplementation and
contain 100% free amino acids (Abbott, 2010; Nutricia, 2009). The protein level is usually
30 g per liter, with 10% to 15% of energy from protein. At an energy density of 1.0 kcal/mL
or 30 kcal/oz, the osmolality ranges from 596 mOsm/kg to 610 mOsm/kg. However,
elemental formulas may be mixed to different energy concentrations—if necessary,
by using varying amounts of free water.
Subtle variations exist in the nutrient composition and source among the currently available
elemental pediatric formulas. The percentage of energy from fat ranges from 25% to 46%
and consists of a blend of long-chain triglycerides (LCT) and medium-chain triglycerides
(MCT). The LCT and MCT ratio typically ranges from 67:33 to 95:5, and the selection of
one formula over another depends on the degree of fat malabsorption.
The fat composition is generally a blend of safflower and coconut oil, from which the
MCT fraction is obtained, and soy or canola oil (Abbott, 2010; Nutricia, 2009). In addition,
some products contain structured lipids, where fatty acids of varying length, ranging from
MCTs to LCTs, are located on the same glycerol backbone. Potential benefits or
advantages of using structured lipids over traditional physical lipid mixtures include
improved fat absorption and tolerance and reduction of muscle catabolism (DeMichele,
1989; Kenler, 1996; Tso, 2001). The typical carbohydrate source in pediatric elemental
formulas is corn syrup solids or maltodextrins.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Nutrition Support > Pediatric Enteral Nutrition Support > General Guidance
Overview

Enteral nutrition (EN) support is the optimal method for providing the nutritional
requirements to an infant or child with a functioning gastrointestinal (GI) tract but unable to
orally meet his or her nutrition needs for optimal growth and development. EN provides a
number of benefits and is generally considered to be the preferred mode of nutritional
support for a variety of reasons, including the following ( Mehta, 2009):
It is more physiologic than parenteral nutrition (PN)
It is associated with decreased infectious complications (Heyland, 1998)
It is associated with decreased length of hospital stay (Simpson, 2005)
It promotes trophic stimulation of the GI tract, which maintains microvillus structure
and function, stimulates intestinal secretions including digestive enzymes and
immunoglobulin A, increases intestinal motility, and maintains immune function of the
GI tract through preservation of the epithelial tight cell junctions (Sondheimer, 2004;
McClure, 2000; McClure, 2002).
It is associated with reduction of the systemic inflammatory response
(Sanderson, 2005).
It may reduce the incidence of pathogen entry through bacterial translocation
(MacFie, 2006).
It is more cost effective without the added risk of nosocomial infection inherent with
PN (Kawagoe, 2001)
The establishment of EN as the optimal route of nutrient delivery in pediatric patients has
not been systematically studied in children through randomized controlled trials comparing
the effects of EN vs PN. However, current EN practice guidelines have been well
established and promoted by consensus-based guidelines in both adult and pediatric
patients ( ASPEN, 2002; Mehta, 2009).
Current practice in many centers includes the initiation of early enteral feedings (within
approximately 48 to 72 hours after admission). PN is used to supplement or replace EN in
patients for whom EN alone is unable to meet optimal nutrition goals for recovery and for
growth and development when indicated (Mehta, 2009; Petrillo-Albarano, 2006).
This section presents guidelines for safe and appropriate pediatric EN support, including
the following:
Indications and criteria
Selection of appropriate infant, pediatric, and adult formulas
Administration and monitoring in pediatric patients
Prevention and management complications
Use of EN in the home setting

Indications and Criteria

Indications and Criteria
Enteral nutrition (EN) may be used as an exclusive source of nutrition or in combination
with either oral or parenteral nutrition (ASPEN, 2002). EN can provide partial or complete
nutrition in cases such as malnutrition and malabsorption, prematurity, failure to thrive,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
chronic illness, and gastrointestinal (GI) disorders, to name a few.
In general, EN is considered safer, more physiologic, and less expensive than parenteral
nutrition (PN) and is considered the preferred method of nutrition support in chronically and
critically children and adults (ASPEN, 2002). A meta-analysis found fewer infections with
EN compared with PN (Braunschweig, 2001). EN can safely be used when there are
functional and/or structural problems. Functional problems include neurologic and
neuromuscular disorders, prematurity, inability to take adequate nutrition, and genetic or
metabolic disorders. Structural problems include congenital anomalies (such as
tracheoesophageal fistula, esophageal atresia, cleft palate, and Pierre Robin’s syndrome),
obstruction (cancer of head/neck, intubation), injury (caustic ingestion, trauma, sepsis), and
surgery (Nevin-Folino, 2005). If an infant or child is unable to consume an adequate
nutrient intake to promote appropriate growth and development, an enteral feeding route is
indicated.
Common Indications for Enteral Nutrition
Insufficient oral intake
Anorexia
GI disease
Biliary atresia
Cystic fibrosis
Short bowel syndrome
Pancreatic insufficiency or pancreatitis
Severe gastroesophageal reflux
Cardiorespiratory disease increasing energy needs
Bronchopulmonary dysplasia
Congenital heart disease
Cystic fibrosis
Chronic disease resulting in growth failure
Cholestatic liver disease
Chronic renal disease
Growth failure
Genetic or chromosomal anomalies resulting in metabolic disease
Trisomy 13 or trisomy 18
Cri-du-chat syndrome
Glycogen storage diseases
Urea cycle disorders
Oral motor dysfunction
Prematurity (usually infants below 32 to 34 weeks' gestational age)
Neuromuscular disorder
Neurological disease
Neurological impairment (cerebral palsy)
Intubation or long-term coma
Structural or functional abnormality of the GI tract
Congenital malformation
Esophageal stenosis
Gastroschisis (following surgical repair and initial PN)
Intestinal pseudo-obstruction
Hypermetabolic state
Injury/critical illness
Burns
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cancer
Sepsis
Trauma
Figure 1 illustrates the decision process for initiation of enteral feeding (Marchand, 2007).
Even if an infant or child is unable to tolerate adequate volumes to meet nutrient needs by
enteral route, enteral stimulation may help to maintain mucosal integrity, limit bacterial
translocation, blunt the hypermetabolic response, and decrease septic morbidity and/or
multisystem organ failure (Mehta, 2009; Moore, 2002; ASPEN, 2002).
Criteria for Consideration of Enteral Nutrition Support in Pediatrics (Nevin-Folino,
2005)
Unable to meet 80% of energy needs by mouth
Minimal or no weight gain for 3 months
Documented weight loss over 3-month period
Weight/height ratio decreased to below the 5th percentile
Triceps skinfold below the 5th percentile
Total oral feeding time greater than 4 to 6 hours per day
Impaired assimilation or delivery of nutrients
Oral aversion
Mechanical problems with chewing, swallowing, or peristalsis
EN is contraindicated when the gastrointestinal tract is anatomically or functionally
impaired. Often, EN can be initiated shortly after surgery. Typically small bowel motility
returns within 6 to 8 hours, stomach motility returns after 24 to 48 hours, and the colon
regains normal motility after 48 to 72 hours. EN can be started almost immediately after
surgery when the stomach can be decompressed while feeding the patient directly into the
small bowel (Marchand, 2007).
Potential Contraindications for the Initiation or Use of EN (Nevin-Folino, 2005;
Marchand, 2007)
Gastrointestinal obstruction
Prolonged ileus
Necrotizing enterocolitis (initial 7-10 days)
High-output fistulae
Severe acute pancreatitis (in rare cases)
Intestinal ischemia
Intestinal atresias
Severe flare of inflammatory bowel disease
Severe malabsorption
Diarrhea exacerbated by enteral feeding
Severe GI side effects of cancer therapy

Formula Selection

Enteral feedings may consist of human milk, standard infant formulas, specialty and
metabolic infant formulas, pediatric enteral formulas, blenderized feedings, modular
formulas, or adult supplements adapted to the child’s needs (Hendricks, 1990). When
available, mother’s milk should be given priority over infant formulas. Human milk has
many beneficial effects on the health of infants, especially premature and low-birth-weight
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
many beneficial effects on the health of infants, especially premature and low-birth-weight
infants and young children. It is the position of the American Dietetic Association that the
exclusive provision of human milk ensures optimal nutrition and health protection for the
first 6 months of life, and human milk in combination with complementary foods from age 6
months until at least 12 months is the ideal feeding pattern for infants (ADA, 2009).
Although human milk provides optimal nutrition to infants, some mothers cannot or choose
not to provide their milk, and some infants and children require specialized formulas. The
American Academy of Pediatrics Committee on Nutrition provided specific guidelines for
minimum and maximum nutrient content in infant formulas based on the composition of
human breast milk (AAP, 1976).
Selecting the appropriate feeding for the infant or pediatric patient requires a clear
understanding of how the development and physiology of the gastrointestinal tract of
infants and children differ from that of adults, as well as familiarity with the variety of enteral
formulas and modulars that are prepared specifically or are readily adaptable for infants
and children (Fuchs, 1993). The choice of feeding product is dependent on the infant's or
child’s absorptive capacity, underlying disease state, fluid allowance, and nutrition needs.
Figure: Clinical Algorithm for Formula Selection

Nutrient Composition: Energy

The Recommended Dietary Allowances (RDAs) and Dietary Reference Intakes (DRIs)
provide initial guidelines in determining the macronutrient and micronutrient needs of
infants and children. The American Academy of Pediatrics (AAP) Committee on Nutrition
provides specific guidelines for minimum and maximum nutrient content in infant formulas
based on the composition of human milk (AAP, 2009).
Breast milk and standard infant formulas are considered nutritionally complete for the
healthy term infant, meeting all macronutrient and micronutrient needs. Most pediatric
formulas will meet the complete nutrition needs of children either entirely or in combination
with a balanced diet. However, the nutrient needs of the chronically or critically ill infant or
pediatric patient may be altered. The AAP provides suggested modifications to energy
requirements for infants and pediatric patients who need them (AAP, 2009). General
recommendations for acceptable macronutrient distribution ranges for infants and children
are similar to adults in that they should receive 45% to 65% of energy intake from
carbohydrate, 10% to 35% of energy from fat, and 10% to 35% of energy from
protein. However, infants and younger children need a higher percentage of energy from
fat, generally 25% to 40%.
Pediatric nutrition support guidelines issued by the American Society for Parenteral and
Enteral Nutrition recommend that energy expenditure be assessed throughout the course
of illness to determine the energy needs of critically ill pediatric patients (Mehta, 2009). A
number of disease conditions—including both acute illness and chronic illness, such as
cystic fibrosis, congenital heart disease, gastrointestinal disease and dysfunction, and
neuromuscular disease—affect energy requirements and interfere with nutrient availability,
absorption, utilization, and metabolism. Critical illness in pediatric patients alters energy
requirements and leads to catabolism, affected by the extent and duration of the of the
injury or trauma.
Although some conditions such as burn injury can lead to significant increases in energy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and protein requirements, the use of sedation, analgesia, and neuromuscular paralysis, in
addition to ventilation within the pediatric intensive unit setting, can result in a significant
reduction in energy requirements. Within the critical care setting and in pediatric patients
with suspected metabolic alterations or malnutrition, the use of indirect calorimetry (IC) for
accurately measuring energy expenditure is recommended. If IC is not feasible or
available, initial energy provisions may be based on published formulas or
nomograms. However, the use of standard equations and stress or activity correction
factors can lead to an underestimation or an overestimation of energy
requirements. Overfeeding of pediatric patients in the intensive care unit and chronic
setting can lead to deterioration in respiratory function, hepatic function and overall
survival. Attention to imbalance between energy intake and expenditure will help to prevent
overfeeding and underfeeding in the pediatric population ( Mehta, 2009).
When medical nutrition therapies requiring modification to standard infant and pediatric
formulas are indicated, consultation with a registered dietitian (RD) experienced in
pediatric health care is recommended. This RD will help to assess the patient's individual
nutritional requirements and provide guidance in developing a nutrition regimen
with appropriate levels of energy, macronutrients, micronutrients, and fluid ( Nevin-Folino,
2005).
When providing breast milk and/or infant formula or pediatric formula of increased energy
density, careful monitoring of the infant’s or child’s fluid status (intake and output), weight,
serum electrolytes, and urine-specific gravity is essential. These formulas have less
free water than standard breast milk or formula. Therefore, when an infant or child shows
signs of dehydration, additional free water may need to be given. Conversely, when
formula mixtures are too dilute (less than 20 kcal/oz) or when free water is given alternately
with feedings, the infant or child may be at risk for inadequate energy for growth, fluid
overload (as evidenced by puffiness, rapid breathing, and rapid weight gain), and/or
hyponatremic seizures.
A number of factors affect energy requirements in enterally fed pediatric
patients. Depending on the extent or type of injury or chronic illness, the medications being
used to manage the patient, or the presence or degree of preexisting malnutrition, energy
requirements may be elevated. The following table reviews factors that may increase or
decrease energy requirements.
Factors that Increase
Energy Requirements
Factors that Decrease
Energy Requirements
Trauma, closed head
injury
Surgery, sepsis, and
fever
Hypermetabolism:
tumors/burns
Seizures, storming
Athetoid cerebral palsy,
hypertonia
Spinal cord injury
Lack of activity/bed rest
Mechanical ventilation
Extracorporeal
membrane oxygenation
Medical sedation:
fentanyl or morphine
Medical paralysis:
vecuronium, or
pancuronium
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved


Fluid Needs or Limits

The availability of free water is an essential consideration in choosing infant and pediatric
enteral products. Fluid management is especially important in infants because of the
following:
Large body surface area
High percentage of body water and its high rate of turnover
Limited renal capacity for handling solute load
Susceptibility to dehydration due to inability to express thirst (Groh-Wargo, 2000)
Fluid requirements vary with age and disease states (Heyland, 2001). The following three
methods, each with its own limitations, have been proposed to calculate maintenance
fluids (Thomas, 2007):
Body surface area (1,500 mL/m
2
to 1,700 mL/m
2
) 1.
Body weight:
1-10 kg = 100 mL/kg
11-20 kg = 1,000 mL + 50 mL/kg for each kg >10 kg
>20 kg = 1,500 mL + 20 mL/kg for each kg >20 kg
2.
Energy expended (100 mL/100 kcal) 3.
The intake of water should promote or produce the following (Hay, 1991; Leichty, 1998;
Holliday, 1988):
Serum sodium within the normal range
Urine with a specific gravity of 1.010 g/mL to 1.016 g/mL
Flow of 2 mL/kg/hr to 6 mL/kg/hr and maintain urine osmolality around 200 mOsm/kg
to 400 mOsm/kg water.
Infants and children receiving enteral nutrition usually tolerate fluid intakes of more than
maintenance needs (AAP, 2009; Nevin-Folino, 2005). Most infants who weigh 10 kg or
less will require more than basic maintenance fluid requirements from their daily enteral
formula volume in order to meet their energy, macronutrient, and micronutrient needs. For
pediatric patients receiving enteral nutrition, several factors may alter fluid maintenance
requirements.
Insensible water losses increase in the following conditions:
Rise in body temperature (+13% per degree centigrade)
Elevated environmental temperatures (50% to 100%)
Visible sweating (5 mL/100 kcal/day to 25 mL/100 kcal/day)
Increased activity
Respiratory distress
Metabolic acidosis
Cardiorespiratory disease
Skin breakdown
Phototherapy
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Insensible water losses decrease in the following conditions:
Humidified air
Ventilator or tracheostomy collar
Topical agents
Humidified incubator
Daily water loss in urine and stool, and insensible loss as a function of age are shown in
the table.
Maintenance Water Loss Components Based on Age (mL/kg/d)
Component 0-6 m 6 m - 5 y 5 - 10 y >10 y
Insensible 40 30 20 10
Urinary 60 60 50 40
Fecal 20 10 – –
Total 120 100 70 50

(Thomas, 2007)
In general, enteral formulas contain approximately 70% to 90% free water. Fluid
restrictions may be required for some cardiac, renal, liver, or respiratory conditions. In
addition, children with neuromuscular disease and other neurological disorders, such as
cerebral palsy, may be at risk for not receiving sufficient free water and they may not be
able to let their caregivers know they are thirsty ( AAP, 2009). In an attempt to minimize the
risk of aspiration or better manage their tube-feeding schedules with both nocturnal feeds
and daytime bolus feedings, these children are often on concentrated formulas with
inadequate free water intake to meet their fluid needs. As a result, dehydration and
subsequent problems such as constipation or metabolic complications can occur.
The fluid balance of children on high-energy, high-protein formulas should be carefully
monitored; moreover, conditions such as emesis, diarrhea and fever can further increase
the risk for dehydration in chronically ill children ( AAP, 2009).

Osmolality

Osmolality is the measurement of the osmotic concentration of a solution and is expressed
as milliosmoles per kilogram of water (mOsm/kg H
2
O). Formula osmolality is determined
by the number and size of particles in a kilogram of solution: the smaller the particle, the
greater its effect on osmolality. Osmolality of the final diet is important, as it can affect
feeding tolerance. Hyperosmolar feedings and formulas can cause nausea, vomiting,
diarrhea, dumping syndrome, and delayed gastric emptying (Valentine, 2007).
Carbohydrate, electrolytes, and amino acids are the major factors that determine the
osmotic load of a formula. Formulas containing hydrolyzed protein and monosaccharides
tend to have a higher osmolality than formulas with intact protein and glucose polymers. As
energy density increases, the osmolality of the formula also increases. The ideal osmolality
of enteral formulas for infants and children is that of either human milk (277 mOsm to 303
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
mOsm per kilogram of water) or normal serum (275 mOsm to 325 mOsm per kilogram of
water) (Rombeau, 1990). Formulas higher or lower than 300 mOsm/kg H
2
O are
hyperosmolar or hypo-osmolar, respectively.
The American Academy of Pediatrics recommends that infant formulas have
concentrations of no greater than 450 mOsm/kg water (AAP, 1976). The osmolality of
formula given to infants and children younger than 4 years should not exceed 400
mOsm/kg; for older children, it should not exceed 600 mOsm/kg for older children (Cox,
1997). Possible intolerance issues associated with hypertonic formulas include delayed
gastric emptying with nausea and vomiting, osmotic diarrhea, and dehydration (Hendricks,
1990; Nevin-Folino, 1999). When given with formula, medications—including vitamin and
mineral supplements—often alter the osmolality to a greater extent than the formula
composition itself.

Mixing

To mix standard infant formula of 20 kcal/oz, caregivers should follow the manufacturer’s
directions on the product package. When a higher energy density is medically indicated,
the infant’s primary caretaker must be provided with specific and understandable mixing
directions (Baker, 1994). Although standard formulas of 22 kcal/oz and 24 kcal/oz are
available in ready-to-feed form for hospital use, they are not easily accessible in the retail
market. They can be purchased online through product manufacturers or obtained through
durable medical equipment providers and the Special Supplemental Nutrition Program for
Women, Infants, and Children.
To prepare a more nutrient-dense formula, liquid concentrate or powder is typically used.
Formulas that require mixing during a patient’s hospital stay should meet the American
Dietetic Association's guidelines for hospital preparation (ADA, 2003). It is generally
recommended that the formula first be concentrated to 24 kcal/oz to improve overall
nutrient density. When concentrating formulas in the hospital setting, liquid concentrate
formulas are the first choice; if powdered formula must be used, manufacturer instructions
must be followed (see the Pediatric Nutrition Dietetic Practice Group Web site for formula
recipes).
When providing a formula of higher nutrient density from either concentration or
supplementation, the following clinical parameters should be monitored:
Gastrointestinal tolerance
Stool frequency and volume output
Urine-specific gravity
Body weight and rate of weight gain
Serum electrolytes, blood urea nitrogen, and osmolality
Clinical monitoring parameters for inpatients (Klotz, 1998) and outpatients (Nordella, 2001;
Theriot, 2000) should be completed.
If an infant is not taking an adequate volume to meet protein, vitamin, and mineral needs,
the energy density may need to be increased to 27 kcal/oz and, as a next step, 30 kcal/oz.
In order to avoid excessive potential renal solute loads, fat and carbohydrate modulars may
be added to the 24 kcal/oz formula to increase energy density via supplementation rather
than concentration (ie, adding less water). However, these modulars can be difficult to
obtain outside of the hospital setting and mixing at home can be confusing to caregivers.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The patient's individual condition, gastrointestinal tolerance, and needs will dictate the
method of increasing energy density (supplementation with modules vs. concentration with
less water).
The choice of modulars depends on disease state, product availability, current formula
macronutrient proportions, and cost. To make formula of 30 kcal/oz, both fat and
carbohydrate may be added, in an attempt to “balance” the substrate composition of the
formula. Once the formula is at 30 kcal/oz through the use of modulars, the protein content
may drop to 7% of total energy, which is marginal intake for linear growth. If protein intake
appears insufficient, the feeding schedule should be reevaluated and a protein modular or
further formula concentration may be considered. If protein intake seem to be insufficient,
the feeding schedule should be reevaluated and a protein module may be considered.
When using modulars to concentrate the energy of a formula, the percentage of total
energy from fat should not exceed 55% (Klotz, 1998).
When products designed for adults are used in children and when the patient is receiving
less than the volume required to meet the Recommended Dietary Allowances (RDA),
vitamin and mineral supplements are often required—especially calcium, phosphorus,
vitamin D, and iron (AAP, 2009; Nevin-Folino, 2005). Vitamin and mineral supplements can
be used to bring these levels up to the RDA/Dietary Reference Intake values or to meet the
increased requirements secondary to the disease process. Some supplements,
however, may alter formula viscosity, resulting in an increased chance of clogging the
tube. As such, attention should be given to formula delivery, flow, and tube patency when a
new formula additive is introduced. In addition, if given separately from the formula,
supplement absorption may be enhanced.

Delivery

Feeding Location
Enteral feedings can be administered into multiple sites in the gastrointestinal tract,
depending on the functional status of the gastrointestinal tract and the risk of aspiration
(Gibbons, 1998; Wessel, 2000). Specific conditions usually make one of the following the
preferred route of nutrient administration: oral, gastric (nasogastric or gastrostomy), or
enteric (nasoduodenal, nasojejunal, gastrojejunal, or jejunal). Neonates are obligate nose
breathers; as such, orogastric tubes are often used in this patient population, particularly
for those on continuous positive airway pressure. However, many neonatal intensive care
units use nasogastric tube placement to avoid interference with oral feeding trials and to
reduce the risk for tube displacement (Birnbaum, 2009).
Gastric Feeding
Feeding into the stomach is the desired route, for it more closely stimulates physiological
digestive and hormonal responses and allows for easier tube insertion and tolerance of
large osmotic loads. Nasogastric and gastrostomy feedings may be given either as bolus or
continuous. Feeding into the stomach may be contraindicated in patients with vomiting,
delayed gastric emptying, increased risk of aspiration with neuromotor disorders, some
types of severe pulmonary disease, or severe gastroesophageal reflux (Gibbons, 1998;
Wessel, 2000).
Gastrostomy placement is recommended when it is expected the patient will require
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
enteral feeding for at least 4 to 6 weeks (Gibbons, 1998). These tubes have a greater
inside diameter and can accommodate thicker or blenderized formulas. Gastrostomy
buttons, which are flush with the skin, are often placed after adaptation to the gastrostomy
tube is ensured. Benefits of the skin-level devices include the following:
Less bulk
Reduced likelihood of being pulled out by the infant or child
Better aesthetic acceptance by a child
Percutaneous endoscopic placement of gastrostomy tubes is now commonly used in
pediatric patients.
Small Bowel Feeding
Feeding into the small intestine is useful for patients with delayed gastric emptying,
gastrointestinal dysmotility, increased risk of aspiration related to poor gag reflex,
gastroesophageal reflux, and emesis, as well as in the immediate postoperative period
(Gibbons, 1998; Wessel, 2000). In a study of 62 critically ill pediatric patients, those fed
into the small bowel received significantly more of their daily energy goals than those fed
into the stomach. However, the small bowel–fed patients did not have a lower incidence of
tracheal aspiration (Meert, 2004). Jejunal feeds (as opposed to parenteral nutrition) may be
appropriate for patients with pancreatitis (Samaraee, 2010), although this has not been
well-studied in pediatric patients.
Because the small intestine is more sensitive to concentration changes, the use of bolus
feedings is not recommended because the small bowel has no reservoir capacity and there
is a consequential risk of dumping syndrome. It is recommended that feedings be given by
continuous infusion and advanced gradually (Gibbons, 1998; Wessel, 2000). Isotonic
feedings are usually more easily tolerated. Tube placement can be difficult and may require
fluoroscopy as well as an intravenous bolus of erythromycin to stimulate peristalsis. Placing
the child on his or her right side and using metoclopramide (Reglan [Robins Company,
Richmond, VA]) may promote independent passage into the small intestine (Kerner, 1983).
Small-bore 5, 6, or 8 French feeding tubes can be directed into the small intestine through
an in-place gastrostomy tube.
Complications from this method include perforations of the intestine and renal pelvis,
diarrhea, malabsorption due to poor mixing of nutrients with enzymes and bile, and
dumping syndrome. Frequent tube repositioning/replacement because of displacement or
clogging may be a disadvantage.

Feeding Method or Schedule
Enteral feedings can be administered continuously or intermittently. Choice of feeding
schedule is dependent on route of administration, adequacy/presence of oral intake,
tolerance, and cost (Nevin-Folino, 1999; Wessel, 2000).
Bolus Tube Feeding After Oral Feeding
In this method, the desired volume of formula is offered by mouth, and any volume not
taken orally is given via tube.
Indications: Appropriate for patients who can and will take formula orally but tire quickly,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
feed very slowly, or take inadequate amounts.
Advantages: Provides psychological and physiological benefits of oral intake while ensuring
adequate volume delivery.

Continuous Feeding
Feedings are administered at a constant rate over a period of time via a feeding pump.
Occasionally, a combination of bolus administration and continuous administration may be
used (eg, daytime bolus feeding and nocturnal continuous feeding). Diluted formulas are
usually not required. Full-strength feedings can be started at a lower volume and gradually
advanced, as tolerated, to the goal rate. Because of the limited tolerance of the small
intestine for bolus feedings, nasoenteric and jejunostomy feedings must be given by
continuous feeding (Gibbons, 1998).
Indications: Recommended for patients who have not been fed enterally for an extended
period of time (for slow initiation of enteral feeds) and for those fed transpylorically or
whose intestinal mucosa is damaged by disease or surgery.
Advantages: These feedings may be delivered into the stomach or small bowel; improved
absorption and tolerance in children with decreased absorptive or digestive capabilities;
may reduce risk of aspiration, diarrhea, and/or gastric distension; ease of administration;
presence of formula in stomach may increase gastric pH.
Disadvantages: There is potential for bacterial contamination of formula; clogged feeding
tubes; generally more expensive for home enteral support, because of the cost of the pump
and related supplies; mobility limited (portable pumps are available for home use);
buffering of stomach contents by enteral feedings may be undesirable, since the
bacteriostatic benefit of a low gastric pH will be lost (Hendricks, 1990; Fomon, 1993; AAP,
1998; Young, 1989).

Nocturnal Feeding
Feedings are delivered continuously via a feeding pump during only the overnight hours.
Advantages: Oral intake during the day is not diminished, owing to satiety associated with
tube feedings; the patient can eat during the day while receiving supplemental feedings
overnight to meet nutrition needs.
Disadvantages: The patient may find it difficult to sleep while connected to the feeding
pump and may experience nausea and/or vomiting in the morning.

Intermittent Feeding
The total quantity of formula needed for the 24-hour period is divided into 5 to 8 feedings
per day and delivered intermittently either by gravity drip, syringe, or feeding pump for 15 to
20 minutes (Nevin-Folino, 1999). When transitioning a fragile patient from continuous to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
intermittent feedings, feedings may be better tolerated if given at first every 2 hours, then
every 3 hours, then progressing step-wise to the goal feeding schedule.
Advantages: Most clearly simulates normal eating patterns; allows for a great deal of
patient freedom; most desirable method for home use because of a reduced cost and
minimal need for equipment; increased delivery of fat from breast milk (Hendricks, 1990;
Fomon, 1993; AAP, 1998; Young, 1989).
Disadvantages: May be poorly tolerated in critically ill individuals; may increase the risk of
reflux, distension, emesis, and diarrhea. Intermittent feeds into the small bowel
are contraindicated due to the risk of dumping syndrome.

Equipment

Feeding Tubes
Nasogastric tubes should be soft, small-bore (5 to 8 French), and made of a material that
remains flexible throughout use (Fuchs, 1993; Baker, 2007). Silicone tubes are pliable and
can be used for 1 to 3 days without removal. Polyurethane tubes are very soft and can be
kept in place for extended periods. Their inner diameter is larger than equivalent sizes of
silicone tubes, which makes them more practical, particularly when medications are given.
For long-term enteral access, a percutaneously or surgically placed gastrostomy tube
should be considered for esthetic, logistical, and safety reasons (Vanderhoof, 2003).
Feeding Pumps
The pump selected for use with infants and children must deliver accurate, controlled
amounts from 0.5 mL to 1.0 mL per hour. Care must be taken to ensure that the pump is
approved for powdered formulas, if applicable. Formula containers and infusion sets are
usually manufactured to be pump specific.

Initiation and Advancement

Guidelines for the initiation and advancement of enteral nutrition in pediatric patients have
been published and are often based on appropriate modifications of adult advancement
protocols, with the goal of establishing gastrointestinal (GI) tolerance while meeting fluid
and electrolyte requirements in the process ( Nevin-Folino, 2005).
During enteral formula advancement, fluid requirements are typically met by
either intravenous solutions or through parenteral nutrition (PN), which supported the
patient prior to enteral feeding initiation. Although enteral feedings generally should be
started at full strength, if the formula is started at a lesser strength and the child is not on
either intravenous fluids or PN, the formula volume should be increased first, as tolerated,
until nutrient requirements are met, before the strength is advanced. As enteral feeding is
advanced, only one change—whether it be concentration, rate, or formula—should be
made at a time. In general, changes can be made every 4 to 24 hours, as indicated by the
child's previous GI status and as tolerated.
Although clinical guidelines and protocols have been established by professional
organizations and individual health care facilities for the initiation and advancement of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
enteral feedings, the rate of advancement should be adjusted or individualized to each
patient by the clinician based on the infant or child's GI structure and function. For example,
patients with a history of severe GI impairment, such as those with short bowel syndrome,
may require a slower feeding advancement every 2 to 4 days. Typically, institutional
guidelines for formula initiation and advancement are presented for both continuous
infusion and intermittent feedings.
Continuous Tube Feeding Infusions
Continuous feeding infusions—typically used in critically ill children or patients who have
not been enterally fed for more than 1 week—are generally begun with continuous
pump-controlled feedings using an isotonic formula at a rate of 0.5 mL/kg/hour to 1
mL/kg/hour, with advancements from 0.5 mL/kg/hr to 1.0 mL/kg/hr of formula every 4 to 24
hours, depending on the child's GI status (Abad-Jorge, 2010).
Preterm, smaller, or critically ill infants and young children who have not been enterally fed
for an extended period of time may require starting with a lower initial volume of 0.5
mL/kg/hr to promote GI tolerance. Generally speaking, continuous feeding administration is
better tolerated in infants and children who are critically ill, have limited absorptive surface
area, have significant respiratory instability, or have persistent feeding
intolerance. Continuous feeding administration is also the method of choice for feeding
directly into the small bowel.
The following table presents a typical institutional protocol for initiation and advancement of
continuous enteral feedings in pediatric patients (Abad-Jorge, 2010).
Weight Initial Infusion Rate Daily Increases Goal Rate
2.0-15 kg
1-15 mL/hr
(0.5-1 mL/kg/hr)
1-15 mL/hr every 4-8 hours
(0.5-1 mL/kg/hr)
15-55 mL/hr
16-30 kg
8-30 mL/hr
(0.5-1 mL/kg/hr)
8-15 mL/hr every 4-8 hours
(0.5-1 mL/kg/hr)
45-90 mL/hr
30-50 kg
15-25 mL/hr
(0.5 ml/kg/hr)
15-25 mL/hr every 4-8 hours
(0.5 mL/kg/hr)
70-130 mL/hr
> 50 kg 25 mL/hr
10-25 mL/hr q 4-8 hours
per GI tolerance
90-125 mL/hr
Intermittent Tube Feeding Progression
Intermittent or bolus feedings may generally begin with 5 mL/kg every 2 to 4 hours,
depending on the child's age and weight. Intermittent feedings may be advanced by a
volume similar to the start rate every 4 to 24 hours, again depending on GI status and
tolerance. The selection of appropriate start volumes for intermittent feedings is based on
factors such as stomach capacity, GI function, and previously established absorptive
capacity. Intermittent feedings should achieve a maximum rate of no more than 30 mL per
hour in very small infants weighing less than 5.0 kg. Intermittent feedings should generally
be delivered by gravity for 15 to 20 minutes or longer; however, in infants with small gastric
capacity and persistent feeding intolerance, the feedings may need to be delivered more
slowly over 45 minutes to 1 hours.
Intermittent feeds are more physiological and practical for long-term gastrostomy feedings
within the home setting. Transition from continuous to intermittent feedings are generally
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
indicated in children who are more medically stable and have achieved full feeding
tolerance of continuous feeds. Intermittent feeding schedules also allow for greater patient
mobility and are thus more appropriate in the rehabilitation or home setting.
The following table presents a typical institutional protocol for initiation and advancement
of intermittent enteral feedings in pediatric patients (Abad-Jorge, 2010).

Weight Initial Volumes Daily Increases Goals Volume
2.0-15
kg
5-75 mL every 3 or
4 hours
5-30 mL every 3 to 12
hours
50-200 mL every 3 - 4
hours
16-30 kg
15-60 mL every 4
hours
15-60 mL every 3 to 12
hours
150-350 mL every 4
hours
> 30 kg
30-60 mL every 4
hours
30-60 mL every 3 to 12
hours
240-360 mL every 4
hours


Medication Administration

Knowledge of a pediatric patient's medication profile is important for optimizing nutrition
support intake and delivery. The pediatric registered dietitian (RD) should review each
patient's profile and determine how these drugs affect nutrition (Abad-Jorge, 2010).
General Guidelines for Administering Medications with Tube Feedings
When administering medications with tube feedings, special care should be taken to
minimize the risk of tube occlusion and to ensure optimal absorption of the drug. In many
cases, administering drugs to patients receiving enteral nutrition products is similar to drug
administration to patients who are eating. In many health care facilities, the RD works with
the team—including physicians and nursing and pharmacy staff—by following general
guidelines for medication administration (Magnuson, 2005):
Consult a pharmacist before administering medications through a feeding tube.
Use a liquid form of medications when available. The composition of lipid and protein
varies in feedings and may affect liver and gut drug metabolism. Syrups—especially
those that are acidic, such as metoproterenol (Alupent) or metoclopromide
(Reglan)—may cause clumping of the enteral feeding if given concurrently.
Crush tablets only when other alternatives are not feasible (rectal, intravenous, or
liquid). Tablets need to be crushed into a fine powder and mixed with water to prevent
clogging of the tube.
Sustained-release and enteric-coated tablets should never be crushed. Consult the
pharmacy for alternatives.
Administer each medication separately and flush tube with 5 mL to 10 mL of water
between doses.
Flush the tube with water before and after giving the medication.
Drugs that are normally given on an empty stomach—for example, bisacodyl,
captopril, isoniazid, mercaptopurine, methotrexate, penicillin G, and
tetracycline—should not be administered with tube feedings. Consult the pharmacist
for additional medications that should not be given on an empty stomach.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Critical Care Medications and Nutritional Delivery
Critically ill infants and children are often fluid restricted and require multiple intravenous
medications and infusions that are counted as part of overall fluid delivery. The pediatric
RD should work closely with the pediatric or newborn intensive care unit (ICU) teams to
optimize delivery delivery of nutritional support in the face of fluid restriction and multiple
intravenous medications. Common intravenous infusions used in pediatric and newborn
ICU settings are presented in the following table (Abad-Jorge, 2010).
Medication Classification
Chlorothiazide
(Diuril)
Diuretic
Cisatracurium
Neuromuscular
blocker
Dobutamine Inotrope
Dopamine Inotrope
Epinephrine Intotrope
Fentanyl Analgesic
Furosemide (Lasix) Diuretic
Midazolam (Versed) Sedative
Milrinone Inotrope
Morphine Analgesic
Pentobarbitol Sedative
Vasopressin Inotrope
Vecuronium
Neuromuscular
blocker
The pediatric RD should work with the pharmacist, nurse, and medical team to determine
how best to concentrate the intravenous medication, given the child's dosage and plans for
weaning of the medication, in order to allow for increased delivery of nutritional support
fluids, including parenteral and enteral nutrition.
Common Enteral Electrolyte Supplementation
Enterally fed pediatric patients who are on diuretics or other medications that lead to
electrolyte wasting, as well as previously malnourished infants and children at risk for
refeeding syndrome, should have serum electrolytes monitored frequently. Electrolyte
replacement to provide sodium, potassium, chloride, magnesium, calcium, and phosphorus
is often indicated. Common electrolyte supplements used in the pediatric setting include
the list that follows. (The pharmacist should be consulted to determine the precise
electrolyte content of the enteral supplements.)
Neutra-Phos (PhosNaK): available in packets
Neutra-PhosK: available in packets
Calcium carbonate
Calcium glubionate (Neo-Calglucon)
Tums, Regular: 10 mEq (200 mg) elemental calcium per 500 mg tablet
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tums, E-X Extra Strength: 15 mEq (300 mg) elemental calcium per 750 mg tablet
Tums, Ultra (Maximum) Strength: 20 mEq (400 mg) elemental calcium per 1,000 mg
tablet
Magnesium gluconate
Potassium chloride
Table salt: Contains 101 mEq (2,325 mg) sodium and 101 mEq (2,325 mg) chloride
per teaspoon


Transition to Oral Feeding

Psychomotor development may be impaired in children who have been maintained on tube
feedings for long periods. As a result, feeding skills and oral motor development may be
delayed. Nonnutritive sucking on a pacifier or taking very small amounts of food from a
spoon or liquid from a cup is important in preventing serious delays in psychomotor
development, developing an association between oral activity and satiety, and learning
eating and feeding skills (Hendricks, 1990; Robbins, 1982; Miller, 2009). To reduce the
potential for feeding aversions, an initial feeding evaluation and ongoing feeding therapy
should be ordered when enteral feedings are begun.
Before weaning from tube feeding, it is important to optimize the infant's or child's
nutritional status. Once this has occurred, certain criteria need to be considered to
determine the patient's readiness to make the transition from tube to oral feeds. These
criteria may include the following (Glass, 1990):
Resolution of the initial problem precipitating the use of the tube
Quality of oral motor skills
Documentation of adequate/safe swallowing skills
Documentation of the social situation and caretaker readiness
Once a decision has been made to start oral feeding, the enteral feeding schedule needs
to be adjusted (Nevin-Folino, 2005). Feedings can be changed from continuous to bolus,
from 24-hour-continuous to continuous only at night, or a combination of these types of
schedules. It is important to change the schedule to promote a sense of hunger in the
infant or child. If possible, the energy intake from the enteral feeding should be decreased
gradually to stimulate appetite (Wright, 2010). A decrease of 25% may be an appropriate
first step.
A feeding plan should be initiated and the following should be monitored:
Total intake (tube vs. oral)
Rate of growth
General tone of the feeding experience for the child and the caretaker
If the plan of care is progressing satisfactorily, tube-feeding energy could be reduced by
another 25%. Once the child or infant is consistently receiving approximately 75% of total
energy from the oral diet and is able to meet his or her daily fluid needs, the tube feeding
can be discontinued. Close monitoring should continue until the infant or child is safely able
to orally consume 100% of nutrient needs. For children with inconsistent oral intake,
supplemental enteral feedings to meet growth and developmental needs may be
necessary.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
A multidisciplinary approach is critical to maximize the success of feeding therapy and tube
weaning. Collaboration among dietitians, nurses, physicians, psychologists, occupational
therapists, and speech language pathologists is key. Each member of a multidisciplinary
feeding team can contribute skills and strengths to make the patient's transition from tube
to oral feeds much smoother (Wright, 2010; Miller, 2009; Heiss, 2010).

Monitoring and Complications

Tolerance of enteral feedings should be monitored closely during the initiation and
advancement process to prevent complications. Potential enteral feeding complications
can be categorized into mechanical (tube related), gastrointestinal, metabolic, or
psychologic (Nevin-Folino, 2005; Abad-Jorge, 2010). Although these categories may be
seen with enteral feedings, in many cases, the complications may be unrelated to the
enteral formula itself, but may be related to the method of delivery, administration, use of
medications, or physiological or anatomical problems related to the patient's condition. Key
components for avoiding complications include the following ( Nevin-Folino, 2005;
Abad-Jorge, 2010):
Mechanical
Tube placement should be checked or verified before every feeding for intermittent
feeds and every 3 hours for continuous feeds.
The tube should be flushed before and after checking residual volumes, after
intermittent feedings, and every 4 to 8 hours during continuous feeds.
Liquid elixirs, rather than crushed tablets, should be used whenever possible.
A pharmacist should be consulted regarding the administration of any crushed
medications. Typically crushed tablets should be dissolved in warm water before
administration via tube.
Powdered enteral formulas should be mixed thoroughly, especially when energy or
nutrient modulars are added.
Depending on tube size, consideration should be given to switching to a
lower-viscosity formula if indicated and/or using an appropriate-sized tube for the
formula viscosity used.
Gastrointestinal
The head of the patent's bed should be elevated to a 30-degree angle during
feedings and for 30 to 45 minutes after gastric feedings to minimize the risk of
aspiration.
The value and importance of checking gastric residuals remains a controversial
practice in the literature regarding adult patients (Parrish, 2008). The pediatric
literature is limited with regard to the evidence behind this practice, and it may be
difficult to obtain residuals from soft, small-bore feeding tubes. However, checking
gastric residuals before every feeding for intermittent feedings and every 3 to 4 hours
for continuous gastric feedings may be warranted for preterm infants as well as
pediatric patients with a history of severe gastrointestinal impairment or intolerance.
Abdominal girths should be monitored for distension. Stools should be monitored for
frequency, color, and consistency, as well as for occult blood or reducing sugars and
pH (6 or more is desirable). Together, these tests give indications for malabsorption
and gastrointestinal irritation and can be invaluable when malabsorption may be
suspected. Every stool should be checked initially for frequency, color, and
consistency, and these observations should be repeated as needed until negative for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
consistency, and these observations should be repeated as needed until negative for
at least 48 hours.
If the patient is not tolerating the feeding advancement, consider advancing feedings
more slowly or using small bowel feedings rather than gastric feedings.
Metabolic
Routinely check blood and urine glucose, urine-specific gravity, serum electrolytes,
and blood urea nitrogen while advancing formula volume. It may also be appropriate
to monitor other laboratory indexes weekly or monthly to assess nutritional adequacy.
These may include hemoglobin, hematocrit, calcium, phosphorus, alkaline
phosphatase, prealbumin, albumin, and magnesium. It may be
necessary to monitor trace element and vitamin level status, depending on
underlying diagnoses and potential for nutritional risk to further assess nutritional
adequacy.
Monitor for medications that can cause electrolyte wasting such as diuretics, and
supplement enteral feeding formulas accordingly with sodium, potassium, phosphorus
or magnesium, as needed.
Initiate and advance enteral feedings especially slowly in severely malnourished
pediatric patients at risk for refeeding syndrome. Cautious advancement is needed to
decrease the risk of hyperglycemia, hypokalemia, hypophosphatemia,
hypomagnesemia, and tachycardia, commonly seen in refeeding syndrome. Monitor
serum potassium, phosphorus, and magnesium in these patients and replace as
needed.
Routinely monitor patient's daily intake and output to assess hydration status and to
help prevent dehydration and serum electrolyte concentration. Evaluate the
electrolyte adequacy and renal solute load of the infant formula or enteral formula.
Psychologic (Nevin-Folino, 2005)
Use of relaxation techniques and comfort measures for the child during tube insertion
can prove beneficial. Involvement of the parents and caretakers in the process to
reassure and comfort the child is usually encouraged.
Consider the use of medical sedation before replacement of gastrostomy tube.
The use of medical play to help the child handle and understand the purpose of the
tube feedings is often an effective strategy.
Consider should be given to alternative feeding schedules such as nocturnal tube
feedings and removal of the nasogastric feeding tube during the day.
Consideration should be given to the use of low-profile gastrostomy device.
Oral feedings should be introduced as soon as medically feasible to promote earlier
transition from enteral to oral nutrition
It is important to work with speech therapists and nursing staff to provide positive oral
experiences during tube feedings.



Tube Feeding at Home

Some pediatric patients may require home enteral nutrition to improve and/or maintain their
nutritional status. Before discharge from a hospital, all primary caretakers need to be
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
identified and instructed about tube-feeding procedures, including formula preparation
using sanitary equipment and technique (Balley, 1987). Ideally, the teaching should involve
a multidisciplinary team, and the plan should be developed to meet the needs of the patient
and family/caretaker. For example, the timing of the feedings may have to be adjusted
around the parent’s work schedule. Weekday feeding schedules may also vary from
weekend schedules.
Special equipment to maximize quality of life in the home setting for a pediatric patient
dependent on enteral nutrition is available. For instance, backpack pumps allow children to
remain ambulatory and active while a feeding is being infused (Vanderhoof, 2003b).
The multidisciplinary care team needs to be aware of potential problems, both medical and
psychosocial, that the patient and/or caregiver/family may encounter while using home
enteral nutrition. For instance, commonly reported medical problems include tube
dysfunction or leakage, difficulty tolerating enteral feeds, or granulation tissue development
at the stoma site. Health care professionals should also be aware of the psychological
burden placed on families. Caregivers report the following effects (Enrione, 2005; Crosby,
2007; Evans, 2007):
Feeling overwhelmed by the amount of care required in the home setting
Feeling anxious about leaving their child with a secondary caregiver or frustrated
about finding a competent secondary caregiver
Feeling sadness that their child is deprived of many normal age-appropriate activities
or eating by mouth
Concern that other members in the household are resentful of the time that the tube
fed child requires
Sleep disturbance
Caregivers should be given resources that will help them troubleshoot common problems
at home and should always have access to a medical professional competent in assisting
them with home enteral nutrition issues. Furthermore, patients and caregivers should be
provided with psychosocial resources that may help with coping with stress. Examples of
these resources include support groups and forums through organizations such as Inspire
and the Oley Foundation.
Consistent follow-up is essential to ensure the child is still tolerating the tube feedings, his
or her nutrient needs are being met, and the medical condition and social situation are
stable. During follow-up, medical and psychosocial complications should be addressed so
that parents and other caregivers can learn strategies to deal with medical issues and
discuss coping mechanisms for psychosocial problems. Home enteral nutrition plans may
need to be adjusted frequently to achieve optimal provision of nutrients, growth and
development, and quality of life for both the patient and caregivers.

Follow-Up Formulas

Defining Feature
Follow-up formulas are designed for older infants and toddlers in the age range of 9
months to 36 months. These formulas contain 20 kcal/oz.
Indications
There are no clear indications for these products in the literature, although they are
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
frequently marketed for use in older infants and toddlers who may have a
discrepancy between their nutrition needs and intake.
Contraindications
There are no clear contraindications for the use of these formulas, other than
intolerances to the intact protein sources used in these products.
Composition
Protein: The protein source varies according to product manufacturer and follow-up
formula type. For instance, some are made of 100% whey, whereas others are soy
protein based. Protein amounts vary from 9% to 12% of energy (Mead Johnson
Nutrition, Evansville, IN ; Nutricia North America, Gaithersburg, MD).
Fat: The fat source is a blend of vegetable oils, and these products do typically
contain docosahexaenoic acid and arachidonic acid (Mead Johnson Nutrition,
Evansville, IN ; Nutricia North America, Gaithersburg, MD).
Carbohydrate: The carbohydrate source can be a blend of maltodextrin, lactose, and
corn syrup solids. Some products contain galacto-oligosaccharides as a prebiotic
(Mead Johnson Nutrition, Evansville, IN ; Nutricia North America, Gaithersburg, MD).
Micronutrients: These formulas contain more calcium and phosphorus than their
standard infant formula counterparts (Mead Johnson Nutrition, Evansville, IN ;
Nutricia North America, Gaithersburg, MD).


Blenderized Formulas

Blenderized pediatric standard formulas are also commercially available. These formulas
consist of a mixture of blenderized foods including chicken, vegetables, fruit, and juices and
provide several benefits for some children who have gastrointestinal (GI) issues
and intolerance of milk protein–based enteral products. These "real food" enteral formulas
also have added medium-chain triglyceride oil and guar gum, however. These products are
lactose and gluten free with a low osmolality of 380 mOsm/kg. From the perspective of
some families, blenderized pediatric enteral products may also provide the added
advantage of being made from real blenderized food, closer to the typical diet a child would
receive at home ( Nestle, 2010).
Homemade, blenderized feedings are prepared from a mixture of various table foods,
including meats, fruits, vegetables, milk or formula (both liquid and powdered), powdered
or granulated cereals, additional fats, water, vitamins, and minerals. Blenderized formulas
can be prepared from already pureed infant food or from whole foods or family meals,
pureed using a home blender or food processor. These feedings may thus vary in
appearance, macronutrient composition, digestibility, and tolerance. Pediatric dietitians can
work with families to develop blenderized feeding recipes for use at home for the
intermittent enteral feeding of children. Although blenderized recipes may be prepared in
the institutional setting, this practice is not recommended as it increases the risk of
bacterial contamination of the formula.
Generally speaking, blenderized formulas can be of moderate to high osmolality and
viscosity, depending on the specific recipe, ingredients used, and amount of added water
( Nevin-Folino, 2005). Blenderized formulas of high viscosity can lead to clogging of
small-bore feeding tubes; consequently, these formulas are more commonly recommended
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
small-bore feeding tubes; consequently, these formulas are more commonly recommended
for use in children with adequately sized gastrostomy tubes. Blenderized formulas are also
often more difficult to give by continuous feeding because of the viscosity of the formula
and often provide inconsistent nutrient intake. Consequently, intermittent or bolus feeding
daytime schedules should be used for formula administration.
Blenderized feedings offer an economical alternative to commercial formulas, especially for
families whose commercially available formula is not appropriately covered through
third-party reimbursement or Medicaid, or if the child is older than 5 years and thus no
longer covered by the Special Supplemental Nutrition Program for Women, Infants, and
Children.
Blenderized feedings may also offer taste and physiological benefits for chronically
ill children with normal digestive capabilities requiring long-term enteral nutrition. Potential
advantages include increased fiber intake and the provision of variable nutrient content due
to the use of a variety of foods. However, nutrition guidance for the home caregivers is
important to ensure proper sanitation during preparation, as well as nutrient and free-water
adequacy.
While the use of blenderized formulas potentially provide a number of advantages, the
following limitations must also be considered (Nevin-Folino, 2005):
Blenderized formulas are not emulsified and thus may separate during delivery,
causing formula intolerance or clogging of the feeding tube.
These formulas must be used only when providing enteral nutrition into the stomach
Given the potential for variability in the nutrient content, blenderizing may result in
nutrient deficiencies if the family is not effectively instructed on recipe formulation.
Inappropriate homemade blenderized formula recipes without adequate free water
can lead to hypernatremic dehydration and other electrolyte abnormalities.
There is an increased risk for bacterial contamination of formula and subsequent
gastrointestinal infection.
Given the potential for incorrect preparation technique and inadequate nutrient formulation
of blenderized feedings, pediatric dietitians should work with physicians and nursing staff,
as well as caregivers, to periodically review the formula recipe, preparation technique, and
amount of free water added; they should also perform an assessment of the child's nutrition
status with particular attention to serum electrolytes and hydration ( Nevin-Folino, 2005).

Nutrient Composition: Protein

The recommended percentages of total energy contributed by protein are 7% to 16% for
infants from birth to 12 months and 10% to 20% for children older than 1 year. For critically
ill children, guidelines established by the American Society for Parenteral and Enteral
Nutrition recently concluded there are insufficient data to make evidence-based
recommendations for macronutrient intakes. After determination of energy needs of the
critically ill child, the rational partitioning of the major substrates should be based on basic
understanding of protein metabolism and carbohydrate and lipid handling during critical
illness (Nilesh, 2009).
The amount of protein required to optimally enhance protein accretion is higher in critically
ill children than in healthy children. The provision of protein sufficient to optimize protein
synthesis, facilitate wound healing and the inflammatory response, and preserve skeletal
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
muscle protein mass is the most important nutrition intervention in critically ill
children. Excessive protein administration should be avoided, as toxicity has been
documented, particularly in children with marginal renal and hepatic function. Studies using
high protein allotments of 4 g/kg/day to 6 g/kg/day have been associated with adverse
effects such as azotemia, metabolic acidosis, and neurodevelopmental abnormalities
(Premji, 2006). A similar evaluation of the effects of high protein administration using newer
formulas is desirable.
Estimated protein requirements for critically ill children of various age groups are as follows
(Nilesh, 2009):
0 to 2 years: 2 g/kg/day to 3 g/kg/day
2 to 13 years: 1.5 g/kg/day to 2 g/kg/day
13 to 18 years: 1.5 g/kg/day
For catch-up growth, 3 g to 4 g protein per kilogram and at least 7% to 8% of the catch-up
growth energy are recommended. Protein needs can be estimated for catch-up growth with
the following equation (Hendricks 1990, AAP 1998):
g protein/kg for weight age (DRI
a
) x IBW
b
for age (kg)
Actual weight (kg)
a
DRI = Dietary Reference Intake
b
IBW=ideal body weight

Protein Composition of Pediatric Formulas
Protein compositions greater than 18% of total energy exceed the maximum established
for infant formulas. Children younger than 4 years should be closely monitored when such
products are used as the sole nutrition source. The use of protein-concentrated formulas
should be carefully evaluated for supplemented vitamins, minerals, and/or fluids that may
be indicated. With careful monitoring for azotemia and hydration status, protein intakes can
be increased for replacement from gastrointestinal, fistula, and wound losses.
Protein can be supplied in infant and pediatric formulas as intact protein, which requires
complete digestion, or in three alternative forms:
Hydrolyzed protein, which yields free amino acids plus dipeptides and tripeptides and
may be absorbed directly (considered hypoallergenic)
Larger peptides, which require partial hydrolysis
Crystalline amino acids, which are absorbed by active transport (considered
hypoallergenic)
The molecular weight of the protein hydrolysate is an index of antigenicity. Those with a
molecular weight of less than 1,000 cannot elicit an antigen-specific response. Hydrolyzed
casein-based formulas consist primarily of free amino acids and peptides with less than
1,500 molecular weight and are considered hypoallergenic. Beta-lactoglobulin is the most
prevalent allergenic protein in cow’s milk and is the major protein found in whey. As a
result, hydrolyzed whey-based formulas, though useful under some circumstances, may
produce symptoms in those with cow’s milk protein allergy (AAP, 2000).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrient Composition: Fat

Breast milk contains approximately 55% of energy as fat, with most of the fat as saturated
or monounsaturated fatty acids. It contains linolenic acid, eicosapentaenoic acid, and
docosahexaenoic acid (DHA). Infant formulas contain a mixture of vegetable oils, mostly
soybean, safflower, sunflower, coconut, and palm and contain arachadonic acid (ARA) and
DHA. Enteral feeding products mostly contain vegetable oils such as palm, olein,
sunflower, safflower, corn, canola, and soy; medium-chain triglycerides (MCT);
monoglycerides and diglycerides; and coconut and lecithin in various concentrations to
meet energy and fatty acid requirements (Marchand, 2007). Pediatric enteral feeding
products are also now being supplemented with DHA.
The recommended percentages of total energy contributed by fat are as follows:
approximately 40% to 50% for infants, based on the composition of human milk (range
30% to 55%); 35% for 1 to 2 years of age; and 30% for children older than 2 years
(Valentine, 2007). The American Academy of Pediatrics recommends a minimum intake of
linolenic acid from 2.7% o 8% of total fat and a maximum intake of 21% to 35% of total fatty
acids. The minimum recommended intake of alpha-linolenic acid in term infant formulas are
1.75% and 4% of total fatty acids. A balanced intake of the two fatty acids is recommended
at a ratio of 5 to 6 and 15 to 16 (AAP, 2009).
Fat intakes greater than 60% of total energy may induce ketosis. Oils with high
concentrations (85% or higher) of MCT are used as fat and energy sources. MCTs provide
8.3 kcal/g and long-chain triglycerides (LCT) provide 9.0 kcal/g. MCT modulars are useful
when fat malabsorption or maldigestion exists. MCTs are not re-esterfied by the
enterocyte, but are transported bound to albumin as free fatty acid through the portal
circulation. MCTs are oxidized to acetic acid; thus, the efficiency of MCT absorption is
estimated to be 4 times that of LCTs ( Bennett, 1964).
The most important disadvantage for infants and children, however, is that MCT oil does
not contain essential fatty acids (EFA). When MCTs are used, the fat composition of the
final diet must be reviewed to be sure adequate amounts of EFAs are available. It is vital to
evaluate EFA status when these products are used for more than 2- to 4-week periods, as
with chylothorax or chylous ascites (Marchand, 2007). To decrease the risk for EFA
deficiency, the most commonly used MCT oil–based infant formula has been recently
renamed and reformulated to provide 84% of the fat as MCT oil, rather than 88%, while the
remaining fat content contains higher levels of linoleic and linolenic acid (Nestle, 2010).
Long-chain polyunsaturated fatty acids with chain lengths of more than 18 carbons and 2
or more double bonds, particularly DHA and ARA, play a key role in the neurodevelopment
of infants and children. DHA, a 22 carbon long-chain fatty acid found in human milk, plays
a key role in the structure and function of phospholipid membranes of neural tissues. DHA
serves as a key structural component of cell membranes and is found in high levels in the
cells of the retina and the brain, comprising approximately 30% to 65% of the cell
membrane fatty acids of the retinal photoreceptors (Martinez, 1992).
Although DHA can be synthesized from alphalinolenic acid, this synthetic pathway is only a
backup to direct dietary intake and the conversion process is low, estimated at only 0.2%
to 4%. Intake of preformed DHA via either the placenta or from the diet is the preferred
mode of DHA accumulation during infancy (Makrides, 1994). Higher levels of DHA
concentrations in plasma and red blood cell phospholipid membranes in breastfed infants
and infants fed formula supplemented with DHA suggest that endogenous production of
DHA is less than the amount provided in breast milk or supplemented formula.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
DHA is less than the amount provided in breast milk or supplemented formula.
A number of studies have demonstrated a dose-response relationship between infant
dietary intake of DHA from breast milk or formula and the level of DHA found in the red
blood cells. Infants taking in unsupplemented formula only had approximately 4% DHA in
the red blood cells, whereas infants taking in breast milk or formula with higher levels of
DHA (0.29% to 0.36%) had the highest level of red blood cell DHA (10% to 12% fatty acids)
( Birch, 1998; Hoffman, 2001; Hoffman, 2006). Furthermore, these studies have also found
a strong correlation between the DHA levels in red blood cells and visual acuity outcomes,
as measured by visual evoked potentials.
The important role of DHA and ARA in cognitive development has also been established
through various studies during infancy and through preschool using the Bayley Scales of
Infant Development, considered the “gold standard” for assessing infant mental and
psychomotor developmental outcomes. In the original study by Birch et al (1998), term
infants who were fed the DHA- and ARA-supplemented formulas at levels of 0.36% DHA
and 0.72% ARA had significantly higher mental development index scores on the Bayley
Scales at 18 months of age than the unsupplemented group. Furthermore, in a
continuation of this study in preschoolers (Birch, 2007), DHA supplementation at
appropriate levels in formula resulted in improved developmental scores at four years of
age using the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R),
which uses two separate subscales—the Performance and Verbal IQ—to develop a full IQ
scale. As a result of more than 10 years of research on neurodevelopmental
outcomes resulting from DHA and ARA supplementation of infant formulas, a number of
international regulatory and advisory organizations—including the Food and Agricultural
Organization of the World Health Organization ( 1994) and the American Dietetic
Association (2007)—have recommended that infant formulas, particularly those intended
for preterm infants be supplemented with DHA and ARA.
Currently, approximately 75% of term infant formulas and 100% of preterm formulas are
supplemented with DHA and ARA ( AAP, 2009). Furthermore, both toddler formulas for
children through the age of 36 months, as well as standard and energy-dense pediatric
enteral formulas, are also supplemented with DHA ( Mead Johnson, 2010; Abbott, 2010).

Nutrient Composition: Carbohydrate

The recommended percentages of total energy contributed by carbohydrate are 35% to
65% for infants from birth to 12 months and 40% to 60% for children older than 1 year
(Rombeau, 1990; AAP, 1998). Because the body can synthesize glucose from both protein
and fat, there is no absolute requirement for carbohydrate. However, dietary carbohydrate
is essential for infants and children, because glucose is the primary energy used by the
brain, erythrocyte, and renal medulla and is useful in the repair of injured tissue.
Synthesis of glucose from amino acids and glycerol is a backup mechanism to supply
glucose or ketones when carbohydrate intake is inadequate. For infants and children, a
carbohydrate intake of less than 4 mg/kg/minute leads to gluconeogenesis and diets that
provide less than 10% of total energy as carbohydrate may lead to ketosis ( Tsang,
1997). Hyperglycemia is prevalent in critically ill children and has been associated with
poor outcomes in retrospective studies (Alaedeen, 2006; Faustino, 2005; Srinivasan, 2004).
Dietary Reference Intakes: Recommendations for Carbohydrates and Fiber by Age
and Sex
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Age Range/Sex Carbohydrates (g/day) Fiber (g/day)
Infants
0-6 months 60
a
ND
7-12 months 95
a
ND
Children
1-3 years 130
b
19
a
4-8 years 130
b
25
a
Males
9-13 years 130
b
31
a
14-18 years 130
b
38
a
Females
9-13 years 130
b
26
a
14-18 years 130
b
26
a
a
AI = Adequate Intake
b
RDA = Recommendary Dietary Allowance
ND = Not determined (there are no recommendations for fiber for infants, since the gold
standard for infant feeding during the first year of life is breast milk, which does not contain
fiber)
Source: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrates, Fiber,
Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington DC: National
Academies Press; 2002/2005.
Carbohydrate Sources in Pediatric Formulas
Enteral formulas and products contain a variety of carbohydrates including simple sugars,
glucose, fructose, disaccharides, sucrose, lactose, and more complex carbohydrates such
as corn syrup solids and maltodextrins. The sources of maltodextrins can be corn or other
vegetables such as soy or tapioca. Some formulas contain nondigestible carbohydrates
such as fructo-oligosaccharides, galacto-oligosaccharides, or soy fibers. Most infant
formulas contain lactose as the major carbohydrate to mimic human milk. Enteral foods
designed for children older than 1 year are generally lactose free (Marchand, 2007).
Formulas with added fiber have been developed, but care must be taken because
high-fiber intake may interfere with adequate energy intake and inhibit the absorption of
some minerals (Williams, 1995). The potential benefits of fiber are the control of diarrhea,
prevention of constipation, and production of short-chain fatty acids in the large intenstine.
Carbohydrate Intolerance
Deficiencies of carbohydrate-digesting enzymes can produce significant malabsorption and
formula intolerance. Such deficiencies may be congenital or secondary to acute infections
causing diarrhea. Gastrointestinal diseases, such as gluten-sensitive enteropathy or
Crohn’s disease, and loss of absorptive area, as in bowel resections, also limit
carbohydrate absorption capabilities. Primary lactose intolerance occurs rarely. Secondary
lactose intolerance occurs more commonly after intestinal mucosal damage with acute
diarrhea and gastroenteritis ( Ulshen, 1997). Tolerance of infant formula and enteral
feedings may be improved by using a lactose-free and/or sucrose-free formula for at least
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
7 to 14 days to allow for at least one 5-day cycle of reproliferation of gastrointestinal
enterocytes.
In extreme circumstances, it may be necessary to restrict dietary carbohydrate temporarily
and to use a monosaccharide-free and disaccharide-free formula or a carbohydrate-free
formula. These formulas provide the protein and fat components and allow for the gradual
addition of modular carbohydrate, as tolerated by the patient. Until the carbohydrate
content of the formula can be advanced to provide at least 4 g/kg/minute and/or prevent
hypoglycemia, intravenous carbohydrate should be provided (Marchand, 2007).

Goals

It is important to evaluate each infant or child individually. Goals for pediatric enteral
nutrition support include the following (Klotz, 1998; Lyman, 2010):
Provision of appropriate nutrition for growth and development
Maintenance of normal fluid and electrolyte balance
Preservation of existing tissue stores
Provision for catch-up growth, as indicated
Preservation of oral motor skills appropriate for age
Resolution of disease progression, wound healing, and/or rehabilitation of nutritionally
depleted patients
Simplification of the enteral feeding regimen as much as possible to maximize quality
of life

Modular Products

Modular products, also frequently referred to as energy or nutrient additives, may be used
in enterally feeding infants and children to increase energy, protein, fat, or fiber intake. The
Mixing section contains guidelines for mixing infant formulas to varying levels of energy and
nutrient density.
Modular products are available as carbohydrate, fat, and protein modules in both powder
and liquid forms and can be used to increase the energy and nutrient density of both infant
and pediatric enteral formulas. However, the use of modular products to augment infant
and pediatric formula nutrient density has decreased over the past 10 years since the
reporting of the adverse event of an infant death due to infection with Enterobacter
sakazaki following the consumption of a powdered infant formula. The use of powdered
formulas and modular products is discouraged, particularly for institutional use, unless no
other viable alternative is available. As such, formula energy and nutrient density is more
often manipulated via altered formula mixing procedures by using less water in the
preparation process.
Despite the change in clinical practice with regard to the use of formula concentration
versus formula supplementation for increasing energy and nutrient density, the use of
modular products sometimes may be the best clinical approach. Pediatric renal patients,
for example, often need additional energy without a corresponding increase in protein or
electrolyte content of the formula. Increasing formula energy density through the use of
energy additives is an appropriate approach for this pediatric population. The most
common commercially available modular products used for the supplementation of infant
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and pediatric formulas are carbohydrate modulars composed of glucose polymers or corn
syrup solids, protein modulars, composed of whey protein isolate, and fat modulars
composed of an emulsified safflower oil blend ( Abbott, 2010; Nestle, 2010). Also
commercially available is an energy modular that contains both carbohydrate and fat and
that provides 42 kcal per Tbsp and provides additional energy for nutrient
supplementation for use with renal patients, thus preventing an increase in the protein
content or renal solute load of the formula (Nutricia, 2009). Alternatively, another energy
additive product that can be added to both enteral products and foods contains both fat and
protein, providing 330 kcal and 7 g protein per serving (Nestle, 2010).
Within the home setting, light corn syrup or vegetable oils, such as canola oil, may be
added to infant or pediatric formula to increase energy density. However, when vegetable
oils are used for energy supplementation, the formula needs to be shaken before
administration through a nasogastric or gastrostomy tube and provided via a bolus or
intermittent feeding to prevent separation of the oil from the solution, which may lead to
feeding intolerance and steatorrhea.
When adding modulars to infant and pediatric formulas, attention should be given to
formula viscosity to prevent the clogging of feeding tubes, as the additives may separate
out of the solution (Joeckel, 2009). The use of emulsified fat modular products and
whey-based protein additives usually prevents problems with formula separation and failure
of the protein additive to go into solution. In addition, enteral formulas prepared with energy
and nutrient additives may be best administered via the intermittent or bolus delivery
method to minimize the potential for mechanical problems.
A number of fiber additives are also available for use with infants and children with
gastrointestinal problems such as diarrhea and constipation. These fiber products
include fruit pectin, which has been used in both infants and children (Finkel, 1990);
banana flakes (Emery, 1997); and fiber additives made of partially hydrolyzed guar gum
(Nestle, 2010). Use of fiber modular products may improve gut function, regularity, and
overall feeding tolerance.


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Resources > Nutrition Support > Pediatric Parenteral Nutrition Support
Overview

Parenteral nutrition (PN) can be provided to adequately support the child with insufficient
enteral intake (AAP, 1983). PN is used when alimentation via the gastrointestinal (GI) tract
is limited because of the inability to feed or if there is GI dysfunction and malabsorption or
increased requirements and excessive nutrient losses. An interdisciplinary approach to
nutrition care should include optimizing the safety and effectiveness of the nutrition
therapy, ensuring quality of care, providing evidence-based practice, and controlling costs
(Schneider, 2006; ASPEN, 2007).

Indications and Criteria

Medical conditions and nutrition assessment indicators for parenteral nutrition (PN) use are
listed in the table on this page (Cox, 2005; Collier, 2005; Szeszycki, 2010). Considerations
for the use of PN should include the child’s nutritional status, gastrointestinal (GI) function,
and the extent and severity of the underlying disease. In some conditions, enteral therapies
may be attempted first, with documented medical and nutritional deterioration used as a
rationale for PN. Infants and children are at increased nutritional risk during catabolic
states, because of limited somatic reserves, high metabolic demands, physiological
immaturity, and growth and developmental needs (Schneider, 2006; Cunningham, 1995).
Depletion of nutrient stores; metabolic derangements in fluid, glucose, and electrolytes;
decreased immune response and wound healing; progressive weakness; apathy; irritability;
and anorexia can negatively affect physiological capabilities and delay treatment and
recovery (Schneider, 2006; Marian, 1993).
If possible, enteral feedings should supplement PN to decrease the risk of complications
associated with an extended period of bowel inactivity. Enteral stimulation may decrease
cholestasis, sepsis, GI atrophy, and oral-motor delay (Cox, 2005; Minard, 1994). The
degree and duration of nutrient deficit (primarily energy and nitrogen) are considerations for
use of early PN to minimize the effects of acute protein depletion on recovery (Marian,
1993).
The suggested guidelines for nutrition care of pediatric patients are based on the American
Society of Parenteral and Enteral Nutrition (ASPEN) and Joint Commission standards for
screening, nutrition support, preparation for discharge, and outcome monitors (ASPEN,
2002; ASPEN, 2005; ASPEN, 2007; Joint Commission, 2009).
Anorexia nervosa < 65% ideal body weight and history of
treatment failures
Chylothorax/chylous ascites bowel Bowel rest > 1 week
Chronic, intractable diarrhea or vomiting Feeding intolerance with fluid and
electrolyte imbalances
GI dysfunction Crohn's disease, inflammatory bowel
disease, necrotizing enterocolitis, short
bowel syndrome, villous atrophy
Hypermetabolic states Cardiac cachexia, cancer and radiation
enteritis, sepsis, trauma, thermal injury
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Low birth weight < 1,500-g infants, lesser stores and high
metabolic demand
Neurological disorder Absent gag reflex, drug-induced paralysis
Renal failure Unable to feed enterally
Respiratory failure Bronchopulmonary dysplasia, respiratory
distress syndrome
Surgical GI disorder Atresia, diaphragmatic hernia, enteric
fistulas, gastroschisis, Hirschsprung’s
disease, intestinal pseudo-obstruction
syndrome, intussusception, malrotation,
omphalocele, resection especially with
removal of ileocecal valve,
tracheoesophageal fistula, and volvulus
Weight loss > 10% of usual body weight without the
ability to enterally replete

When to start if unable to feed enterally:
Preterm infants Within 1 to 3 days of life
Term infants Within 3 to 5 days
Children with GI dysfunction due to
disease or injury
= 3 days
Children with suboptimal nutritional status =3 days

When to start if enteral intake suboptimal:
Normally nourished children After 5 to 7 days
Malnourished children = 3 days

Data are from references Cox, 2005; Collier, 2005


Goals

The goal of parenteral nutrition (PN) is the provision of nutrients to promote weight
maintenance, catch-up growth or optimal growth, and development for patients unable to
tolerate full enteral nutrition. PN should minimize the effects of illness or injury on nutritional
status and prevent nutrition-related complications. PN should be provided in a timely and
safe manner to avoid metabolic, infectious, and mechanical complications.

Glucose Infusion Rate

Carbohydrate
The most common source of parenteral nutrition (PN) carbohydrate is glucose as dextrose
monohydrate (hydrated glucose), with an energy yield of 3.4 kcal/g. Glucose infusion rate
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(GIR) suggestions are based on age- and size-dependent glucose needs to limit
glycogenolysis, especially in preterm or undernourished infants with high obligate glucose
requirements and limited glycogen stores. A customary GIR for pediatrics at initiation is 4
mg to 6 mg glucose per kilogram per minute, with stepwise advancement during 3 to 4
days, to a recommended maximum of 14 mg per kilogram per minute or until 50% to 60%
of total energy needs are met ( Cox, 2005; Kerner, 1983). For GIR guidelines, see the
table that follows (ASPEN, 2005).
GIR Guidelines (mg/kg/min)
Term Infant Child Adolescent
Initiation 6-8 4-6 2-3
Advancement 2-3 1-2 1-2
Goal 10-14 8-10 5-6

GIR = g/kg/day glucose x 1,000
1,440 min/day

Gradual progression allows for appropriate insulin response, thus avoiding hyperglycemia
(blood glucose higher than 200 mg/dL), which can result in high serum osmolality and
glucosuria (> 2+) with osmotic diuresis. Even if tolerated, a higher GIR will most likely
exceed oxidation rates and increase the risks of lipogenesis, overfeeding, and cholestasis
(see Contraindications and Complications). Supplemental dosing with insulin to maintain
appropriate blood glucose levels is generally not necessary in pediatric patients, so long as
advancement and GIR are appropriate for the child's age, needs, and clinical status
(Kerner, 1983).
In the critically ill or injured child (eg, the child with trauma, sepsis, or respiratory distress),
glucose intolerance at levels consistent with hepatic glucose production may be due to high
levels of counterregulatory hormones and may respond to a decrease in the GIR. Consider
the administration of insulin if hyperglycemia persists and if minimum dextrose infusion rate
for age is not tolerated. Insulin must be used cautiously to avoid the risk associated with
hypoglycemia.
Most pharmacies have a protocol for providing insulin. In premature infants, it can be
piggybacked into the PN solution at a starting rate of 0.05 units per kg per hour and titrated
to keep glucose below 250 mg/dL. In the older infant and child, an insulin infusion of 0.01
unit per kg to 0.1 unit per kg per hour is considered safe. Glucose should be monitored at
least every 2 hours ( ASPEN, 2002). Concentration of the dextrose infusion is dependent
on the site of the venous access. Periperhal access limits are set at 10% to 12.5%,
depending on the amino acid and electrolyte content, for a total below 900 mOsm/L.

This is to avoid complications to the blood vessel, such as thrombosis, extravasation, and
suppurative thrombophlebitis. With central access, concentrations lower than 30% are
preferred; if the osmolality of the solutions is higher, this increases the risk of thrombosis. If
the infusion is abruptly discontinued, substantial hypoglycemia may occur (Kerner, 1983;
Hill, 1986).

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Protein

A crystalline amino acid source is the preferred choice of protein for parenteral nutrition
(PN) solutions. Commercial solutions vary in the composition of individual amino acids and
nitrogen content, with an approximate energy yield of 4 kcal/g and 0.16 g nitrogen per gram
of protein. Pediatric protein requirements for PN range from 1.5 g/kg/day to 4 g/kg/day for
maintenance of expected growth rates. This is based on a greater than 75% conversion
rate of amino acid intake to body protein and needs for catch-up growth and/or repletion.
The younger child with rapid growth needs and lower muscle mass has higher levels of
protein requirements. Stress factors—such as infection, sepsis, thermal injury, surgery, and
trauma—can increase obligatory nitrogen losses twofold or threefold and can increase
needs for synthesis of acute-phase proteins (Heird, 1995; ASPEN, 2009; Diamond, 1997).
Preterm Infants 3-4
Infants 2-3
Children 1.5-2
Adolescents 0.8-2
Daily Protein
Requirement (g/kg)
Azotemia, hyperammonemia, and acidosis are potential consequences of excess amino
acid infusion. These consequences should resolve by decreasing the protein intake and/or
L-cysteine hydrochloride supplement. Intolerance may also occur with reasonable protein
intakes when insufficient energy is provided. Nonprotein energy to nitrogen (NPE/N) ratios
of 150:1 to 250:1 are suggested in pediatric PN (Wesley, 1992). In the metabolic phase for
a stressed or injured child, protein intakes may be higher with lower NPE/N ratios
( ASPEN, 2002; Diamond, 1997). Younger children and sick preterm infants with high
metabolic demands are at the higher end of the NPE/N range (Marian 1993). Along with
energy and protein intake, intake of adequate levels of sodium, potassium, and phosphorus
are required for nitrogen metabolism.
Protein needs also may increase with urinary excretion of nitrogen and minerals, owing to
diuretic and steroid therapies (Heird, 1995; Schanler, 1994). Nitrogen balance studies and
short half-life proteins—transthyretin (prealbumin), transferrin, or retinol-binding
protein—can be useful. Whereas low concentrations of these markers are usually
associated with acute phase responses and not malnutrition, rising levels can be used as
an indicator that the child has moved to the post-stress recovery stage, allowing for
nutrition support to advance from the acute metabolic stress phase to normal values for
age. The child's response to nutrition therapy and actual protein status can be evaluated by
following the trend of short half-life protein levels ( ASPEN, 2002; Myron, 2007).

Requirements of specific amino acids may vary based on physiological immaturity and
disease states. Mixtures for pediatric patients—TrophAmine (Kendall McGaw, Irvine, CA)
and Aminosyn PF (Abbott Laboratories, Abbott Park, IL)—have been modified to result in
plasma amino acid profiles similar to those of breastfed term infants (Heird, 1991; Mitton,
1993). The metabolic immaturity of neonates may make cysteine, taurine, tyrosine, and
histidine conditionally essential. The potential buildup of precursors and the deficiency of
these amino acids for protein synthesis with standard amino acid solutions are a concern.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

The total need for sulfur-containing amino acids (methionine and cysteine) is 40 mg/g
protein and is provided with methionine in standard solutions or with added cysteine when
mixing specialized products (Cox, 2005). The more soluble derivative N-acetyl-L-tyrosine
and some taurine are provided in pediatric solutions (Heird, 1995). The proposed benefits
of modified pediatric solutions are nitrogen retention, weight gain, growth, decreased
cholestasis, and improved mineralization when more calcium and phosphorus are provided
in the more acidotic solutions, but clinical significance has not been clearly demonstrated.
These solutions may be most cost effective when used in young infants and individuals on
long-term pediatric PN (Heird, 1988; Cox, 2005).

Amino acid intake may require modification with renal disease, hepatic failure, and inborn
errors of metabolism. In hepatic and renal failure, restriction of protein should be balanced
with minimal needs required for growth. Protein restriction in liver failure is only indicated in
the presence of intractable encephalopathy or emergent fulminate hepatic failure or
coma. In chronic liver disease, protein requirements are increased with a requirement of
(2-3 g/kg/day) (Sultan, 2011). Acute renal failure with anuria may necessitate protein
restriction until function returns, whereas chronic renal failure with dialysis may require
increased protein intake because of losses during dialysis. In inborn errors of metabolism,
the primary substrate is temporarily limited to correct the imbalance and energy is
increased to limit catabolism of body protein (Acosta, 1999). For renal disease, the typical
solution may limit amino acids and calcium intake while eliminating magnesium,
phosphorus, and potassium ( Collier, 2005). For amino acidopathies, specific PN solutions
from compounded powders are available from Coram (Denver, CO).

Fat

Currently in the United States, lipid mixtures contain an emulsion of soybean oil and
safflower oil. Provision of at least 0.5 g/kg/day of lipids will prevent essential fatty acid
deficiency and there are no known contraindications to providing minimum requirements to
pediatric patients. Clinical deficiency of essential fatty acids has been observed within the
first week of life in preterm infants without lipid intake (Friedman, 1976). Lipid intake may be
limited to 0.5 g/kg/day to 1.0 g/kg/day in children at risk for adverse effects on pulmonary
gas exchange, hyperbilirubinemia (>10 mg/dL or more than half the exchange rate), and
thrombocytopenia. Ongoing studies regarding lipids in sepsis and systemic inflammatory
response syndrome seem to indicate infants and children can oxidize intravenous lipid
(Heird, 1991; Mitton, 1993; Caresta, 2007).
Lipids can function as an isotonic, concentrated energy source. In the pediatric patient,
20% emulsions (with an energy yield of 2.0 kcal/mL) are preferred over 10% emulsions for
improved lipid clearance. Energy provided as fat along with dextrose may promote nitrogen
retention and lower carbon dioxide production and use less energy cost to fat synthesis
(Nose, 1987; Bresson, 1991; Heird, 1995). General pediatric recommendations limit
parenteral fat intake to 3 g/kg/day to 4 g/kg/day or 30% to 40% of total energy
intake; tolerance of lipids are dose related (Diamond, 1997; AAP, 2009). For infants or
children at risk for respiratory problems or hypertriglyceridemia, the daily infusion may be
slowly advanced up to 0.12 g/kg/hr (Kao, 1984; Brans, 1988). In general, lipids should be
infused as slowly as possible. Advancement by 0.5 g/kg/day and up to 0.15 g/kg/hr may be
tolerated in older children.
Lipid clearance is monitored with serum triglyceride (TG) levels (for example, less than 150
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mg/dL 2 hours after the infusion is completed, or less than 200 mg/dL with 24-hour
infusions) (Stahl, 1986; Mitton, 1993). Lipoprotein lipase (LPL), the key enzyme in TG
clearance and lipoprotein formation, is bound to the luminal surface of the capillary
endothelium. Factors that increase clearance activity are maturity, glucose intake, insulin
levels, and heparin. Immaturity, decreased adipose mass, growth hormone (increased in
malnutrition), stress, steroids, theophylline, hypercholesterolemia, and phospholipidemia
may decrease LPL activity (Heird, 1995). Low-dose heparin therapy (eg, IU/mL parenteral
nutrition [PN]) has been used to stimulate LPL activity but has not been routinely beneficial
in improving clearance of triglycerides in the long term (Adamkin, 1997; Cox, 2005). High
blood glucose levels may also result from excessive lipid intakes because of glycerol
release from triglycerides and palmitate turnover (Baugeneres, 1982).
Egg yolk phospholipid (PL) is the emulsifying agent for lipid solutions. Phospholipidemia
may occur with fat overload and further decrease LPL activity. Intake of PL is consistent
with the volume of lipids provided (20% solutions contain half as much PL per gram of TG
as 10% solutions). In preterm infants, infusion of 20% lipids improves tolerance. Even at
high-fat intakes, use of a 20% lipid infusion results in decreased accumulation of TG,
cholesterol, and phospholipid (Haumont, 1992; Giovanni, 1995).
Sick or preterm infants receiving PN and lipids may have high levels
of hydroperoxides. The formation of hydroperoxides is caused by light (eg, ambient and
especially phototherapy) exposure of the solutions, which can cause damage at the
cellular level (Neuzil, 1995; Basu, 1999; Baird, 2001). Hydroperoxides have been linked
with many conditions associated with prematurity, such as intraventricular hemorrhage,
chronic lung disease, retinopathy of prematurity, and necrotizing enterocolitis. Protective
effects against this damage occur from the antioxidant systems within the body. However,
studies of antioxidants (eg, vitamins C and E) added directly to the lipid emulsion have had
mixed results, whereas protection from light exposure has consistently demonstrated lower
hydroperoxide formation (Neuzil, 1995; Baird, 2001; Picaud, 2004; Bayerle-Eder, 2004).
When lipid intake surpasses LPL function, the reticuloendothelial system may become
lipid-laden and the immune response may become suppressed. Decreased resistance to
infection may occur with depressed macrophage function (Mitton, 1993). High-fat loads will
also stress oxidation of long-chain fatty acids (LCFA) and inundate available carnitine. Low
levels of carnitine, synthesized by the liver from methionine and lysine, have been identified
in parenterally fed infants and children. Carnitine supplementation has been proposed to
benefit ketogenesis and to improve LCFA metabolism in children (Helms, 1990; Bonner,
1995). Clinical signs of carnitine deficiency have not been observed and low carnitine
status appears to plateau even with extended carnitine-free PN (Moukarzel, 1992). If
supplementation is desired, with long-term PN or questionable liver function, an initial dose
can be estimated from standard dietary intake. Parenteral dosing of 8 mg/kg/day to 16
mg/kg/day of pure L-carnitine is suggested, with ongoing monitoring of serum levels
(Shatsky, 2000). For identified deficiencies, the dose would need to be individually
considered, with dosing as high as 50 mg/kg/day.
A common complication of long-term PN therapy is PN–associated liver disease
(PNALD). The standard soybean oil emulsions that are available in the United States may
be contributing significantly to PNALD because of the high content of omega-6 fatty
acids. Omega-6 fatty acids impair immune function, alter biliary excretion, and stimulate
proimflammatory response (Slicker, 2009). Studies have shown reversal of PNALD with
fish oil lipid emulsions (Gura, 2006). These emulsions are currently only available in the
United States for compassionate use since they are not approved by the US Food and
Drug Administration. In addition to fish oil lipid emulsions, some medical centers are
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Drug Administration. In addition to fish oil lipid emulsions, some medical centers are
currently studying the effects of enteral fish oil in infants with PNALD and short gut who
have enteral access. A recently published study showed that PN-dependent children who
were switched from soy based lipid to fish oil based lipid had an improvement in serum
triglyceride and VLDL levels, a significant increase inserumomega-3 fatty adids and a
decrease in serum omega-6 fatty acids (Le, 2011). Until alternatives of soybean-based lipid
are readily available in the United States, minimizing PNALD by limiting lipid to 1 g per kg,
avoiding overfeeding, and cycling PN is recommended.

Fluid Needs or Limits

Fluid requirements are consistent with general fluid guidelines. Hydration status, size,
environmental factors, and disease state affect fluid needs (Cox, 2005; ASPEN, 2002;
Cochran, 1988). Insensible water losses through the skin contribute significantly to
maintenance fluid intake goals. In the smaller child, fluid needs per kilogram are increased
as body surface area per kilogram is increased. Radiant warmers and ultraviolet light
exposure can increase needs by 20% to 25%.
Fluids may be restricted in patients with cardiac disease, bronchopulmonary dysplasia,
head trauma, and renal failure. For these children, the PN composition is often carefully
concentrated to optimize nutrient intake with limited fluids. Fever increases fluid needs by
12% per degree Centigrade of temperature increase (Cox, 2005). High urinary output or
ostomy losses, diarrhea, and vomiting also increase needs and may require management
via a separate intravenous infusion. Fluid status should be monitored with daily weight,
daily intake and output, and laboratory parameters (electrolytes, blood urea
nitrogen/creatinine, carbon dioxide, and urine-specific gravity).
Basic maintenance fluid needs can be calculated as follows:

Weight in
kg
Fluid Needs
1-10 kg 100 mL/kg
11-20 kg
1000 mL + 50 mL/kg for each kg
> 10 kg
> 20 kg
1500 mL + 20 mL/kg for each kg
> 20 kg
(Holliday, 1957)

Vitamins

Recommendations for parenteral nutrition (PN) typically include administration of vitamins.
The standard components of the pediatric product for PN vitamins are listed in the table on
this page. Intravenous requirements for children are provided by reconstitution of the 5-mL
vial of powdered MVI-Pediatric (Hospira) or Infuvite Pediatric (Baxter). Dosing suggestions
are as follows:
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30% (1.5 mL) to infants who weigh less than 1 kg
65% (3.25 mL) to infants 1 to 3 kg
100% (5 mL) to infants and children up to 11 years of age who weigh more than 3 kg
For children older than 11 years, use 10 mL per day of Hospira MVI Adult or
Baxter MVI Adult. (
Intravenous Vitamins*
Vitamin Dosage
A 700/2,300 mcg/IU
D 10/400 mcg/IU
E 7 mg
K 200 mcg
Ascorbic acid 80 mg
Thiamin 1.2 mg
Riboflavin 1.4 mg
Pyridoxine Cl 1.0 mg
Niacin 17 mg
Pantothenate 5 mg
Biotin 20 mcg
Folate 140 mcg
B-12 1.0 mcg
*5 mL MVI-Pediatric (Hospira)
Disease status can affect vitamin requirements. For example, children with cystic fibrosis
typically have higher requirements for fat-soluble vitamins, whereas renal disease, with
diminished excretion capabilities, may cause decreased needs for some water-soluble
vitamins and vitamin A (Cochran, 1988; Greene, 1988). Measurements of serum levels
could be warranted in these situations to assess sufficiency or excess. .

Minerals

General guidelines for mineral intake are listed in the first table on this page (Cox, 2005;
Collier 2005; Kerner, 1983; Heird, 1991; Bayerle-Eder, 2004; Greene, 1988). Requirements
can vary significantly among pediatric patients, depending on age, size, and clinical
condition. To balance excretion rates, adjustments during treatment may be necessary.
Typically, excretion occurs via the gastrointestinal (GI) tract, urine, and/or biliary tract.
Parenteral nutrition (PN) intakes of calcium and phosphorus ratios at approximately 2 mEq
calcium: intakes of 1 mmol phosphorus have resulted in improved mineral retention
consistent with intrauterine accretion rates (Koo, 1991). For the older child and teen (body
weight greater than 30 kg), micronutrient requirements may be provided in daily doses vs
intake per kilogram per day. Monitoring of electrolytes and mineral status should occur
during the treatment course at frequencies consistent with clinical status, prescription
changes, and duration of therapy.
Intravenous Mineral Requirements for Infants and Children

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Electrolyte Amount/kg/day Factors That May
Increase or
Decrease Needs
Sodium 2-4 mEq Increased with
diuretic use, GI
losses, nasogastric
(NG) suction;
decreased with
cardiac, hepatic,
renal conditions
Potassium 2-4 mEq Increased
with potassium-
wasting medications,
GI losses, NG
suction, refeeding;
decreased with renal
failure
Chloride 2-3 mEq Increased with NG
suction, metabolic
alkalosis; decreased
with metabolic
acidosis
Calcium 0.5-3.0 mEq Increased with rapid
bone mineralization,
pancreatitis
Phosphorus 0.5-2 mcmol Increased with rapid
bone growth,
anabolism, refeeding;
decreased with renal
failure
Magnesium
a
0.25-0.5 mEq Increased with loop
and thiazide diuretics,
aminoglycosides,
cisplatin, GI
losses
b
; decreased
with renal failure
Acetate balance PN Increased with
metabolic acidosis, GI
and renal losses,
excessive protein
load; decreased with
lower protein load
decreased with renal
failure

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a
Sulfate is provided with magnesium.
b
Refractory hypokalemia and hypocalcemia may be due to hypomagnesemia.

Intravenous Mineral and Trace Element Requirements for Infants and Children

Trace Amount/kg/day Factors That May
Increase or
Decrease Needs
Zinc 100-300 mcg Increased with
growth, catabolism,
GI losses, wound
healing; decreased
with renal disease
Copper 20 mcg Increased with
growth, GI losses,
exterior biliary
drainage;
decreased with
cholestatic liver
disease
Chromium 0.14-0.2 mcg Decreased with
renal failure
Manganese 2-10 mcg Increased with
exterior biliary
drainage;
decreased with
cholestatic liver
disease, biliary
obstruction
Iron 0.1 mg Increased with
growth; needs may
have increased
with exclusive
PN for longer
than 2 months
Selenium 3 mcg; max 40
mcg/day
Decreased with
renal failure;
decrease occurred
if selenium was a
contaminant in PN
dextrose solutions;
needs may have
increased with
exclusive PN for
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longer than 2
months
Iodide 1.0 mcg Decreased if it was
absorbed from
cleansing solutions;
needs may have
increased with
exclusive PN for
longer than 2
months
Molybdenum 0.25 mcg Decreased with
renal failure; needs
may have
increased with
exclusive PN for
longer than 2
months

Data are from references Cox, 2005; Collier, 2005; Kerner, 1983; Myron, 2007; Baird, 2001.

The high requirements of calcium and phosphorus for skeletal growth in infants and young
children can exceed compatibility limits of PN. The risks for precipitation are increased with
solution temperature, time in solution, pH, carbohydrate and lipid concentrations, lower
amino acid content, and the addition of calcium and phosphorus in close sequence. The
addition of cysteine to PN can allow for added calcium and phosphorus to meet the
increased needs of the preterm infant. Compatibility curves are useful to predict solubility of
minerals in the PN formulation (Eggert, 1982). A simplified solubility guideline for PN with
amino acids is to use the “rule of 45.” The following example shows the calculation for
using this rule when dosing calcium gluconate and phosphorus to predict acceptable
solubility of the protein-containing PN solution (Trissel, 2001). The sum of calcium (mEq/kg)
and phosphorus (mmol/kg) provided is multiplied by 1,000 and by the child's weight in
kilograms and then divided by the total volume of the solution.

Example: PN with 2.5% protein content with 2 mEq/kg of calcium and 1 mmol/kg of
phosphorus for a 3-kg infant at a volume of 110 mL/kg for a total volume of 330 mL.

(2 mEq/kg Ca + 1 mmol/kg Phos) × 1,000 mL/L × 3 kg =
330 mL

9,000 = 27
330 mL
In this example, because the result is less than 45, the calcium and phosphorus provided
are acceptable by general solubility guidelines. Differences in the pH of the various brands
of amino acid solutions will also affect the final solubility. In addition, the use of 3:1
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solutions will make the rule of 45 invalid. It is always best to check with the compounding
pharmacist for the final compatibility doses.

Infusion of concentrated calcium solutions into a central vein may avoid tissue damage.
Guidelines for potassium concentrations are based on line access and infusion rates.
Limits suggested are less than 40 mEq/L for peripheral access to decrease the risk of
damage to the veins, phlebitis, skin sloughing, and tissue necrosis, and less than 0.5
mEq/kg/hr to prevent cardiac complications (Cochran, 1988).

Standard trace mineral packages include four, five, or six elements. Zinc, copper,
chromium, and manganese are the basic four; selenium and iodine are also available. Zinc
and copper are recommended with initiation of PN. To meet requirements for trace
elements, supplementation with individual minerals may be needed; there may also be an
increased need for zinc to replace losses through ostomy output or diarrhea. Also,
decreased dosing of copper and manganese may be necessary with cholestasis. Pediatric
patients are at high risk for developing copper deficiency when copper is removed from PN
solutions. It is recommended that serum copper and whole blood manganese levels be
checked on infants and children who develop cholestasis (conjugated serum bilirubin
levels of 2 mg/dL or greater). It may be prudent to decrease the copper in the PN solution
to half the normal dose and monitor levels monthly (Cox, 2005; Greene, 1988; Reynolds,
1994; Hurwitz, 2004; McMillan, 2008). Manganese overload, identified on brain magnetic
resonance imaging, has also been reported in long-term PN use (Iinuma, 2003). Periodic
monitoring of trace elements (status or function) and dose adjustments are recommended.

Multitrace solutions are typically used. Examples include Multitrace-4 Neonatal and
Multitrace-4 Pediatric (American Regent Laboratories, Shirley, NY).

Selenium supplementation is recommended for long-term PN (longer than 2 months
duration), but incidental provision of iodine with cleansing of the catheter site limits the
need for this additive (Adamkin, 1997). Trace-metal monitoring includes levels of
nonstandard supplements and possible contaminants such as aluminum or added
chromium and iodine (Leung, 1995). Identification of deficiencies and toxicities is
recommended, especially with infants.

Because of concerns about the role of aluminum toxicity in impaired bone mineraliztion,
renal insufficiency, and neurotoxicity, the US Food and Drug Administration (FDA)
mandated the manufacturers of small-volume parenteral products (eg, calcium gluconate,
potassium phosphate) to identify the amount of aluminum in their products, effective July
2004 (Mouser, 1998; Poole, 2008). The ultimate goal is to provide less than 5 mcg
aluminum per kilogram per day, an amount the FDA deems safe. Meeting these
regulations is not possible with current parenteral products that are available on the market.

Daily provision of iron needs with PN may result in iron overload (Cox, 2005; Ben Hariz,
1993). Enteral supplementation is the first choice, whenever possible, to lessen risks of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
1993). Enteral supplementation is the first choice, whenever possible, to lessen risks of
localized or systemic reactions to intravenous iron. Supplementation with iron dextran is
recommended only with documented iron deficiency of serum ferritin levels below 12 mcg/L
in growing children (Kumpf, 1996). Intramuscular injections should be avoided in patients
with limited muscle mass. The repletion dosing calculation for intravenous iron in children
older than 2 months is as follows:


Body weight (pounds) × (100 – % Hgb) × 0.3 = mg iron

Percent hemoglobin (Hgb) is obtained by multiplying the observed Hgb by 100 and dividing
this product by the expected Hgb (eg, 14.8 g/dL for greater than 15 kg weight or 12 g/dL
for lower than 15 kg weight). The daily dose should not exceed 25 mg and the dose may
be divided over successive days on a monthly schedule (Brans, 1988; McMillan, 2008).
Iron doses from 0.1 mg/kg/day to 1 mg/kg/day have been suggested to meet ongoing
needs with long-term PN once the child’s iron stores are replete (Greene, 1988; Kumpf,
1996).

Initiation and Advancement

Energy needs are estimated at 10% to 15% less than enteral requirements, because
digestive and absorptive losses do not occur. In addition, energy requirements are
decreased when a hospitalized child is inactive or less active (Cox, 2005; Wesley,
1992). General pediatric guidelines for positive nitrogen balance are nonprotein energy to
nitrogen ratios of 150:1 to 250:1 (Wesley, 1992). In a stable child, feedings may be initiated
at two-thirds of the goal for maintenance. A sample initiation for an infant is 30
kcal/kg/day to 50 kcal/kg/day, with 5 mg/kg/min to 7 mg/kg/min of glucose, 2 g/kg to 3 g/kg
of protein, and 1 g/kg/day of lipids. A sample calculation of parenteral nutrition (PN)
initiation and advancement is described here.
Suggested energy distribution is 45% to 60% carbohydrate, 8% to 15% protein, and 25% to
40% fat (Cox, 2005). Provision of balanced solutions within the range of energy
expenditure decrease risks for metabolic intolerance of individual substrates, overfeeding,
and long-term complications associated with PN. Aggressive PN goals to limit nutrition
deficits are balanced against the need for other therapies and potential complications with
feeding during the acute phase.
The target for a critically ill child should consider the effects of physiological
stress. Overfeeding and underfeeding of the critically ill child will result in energy
imbalances. Infants and children in the intensive care unit and who are at high risk for
metabolic stress should have energy needs measured by indirect calorimetry.
Protein needs should be met by providing 2 g/kg/day to 3 g/kg/day to individuals aged 0 to
2 years; 1.5 g/kg/day to 2 g/kg/day to individuals aged 2 to 13 years; and 1.5 g/kg/day to
individuals aged 13 to 18 years (Mehta, 2009).
Initial carbohydrate is given at 8.5 g/kg to 10 g/kg per day for individuals aged 0 to 2 years
and 5 g/kg per day for children older than 2 years.
Fat is initiated at 1 g/kg (0.5 g per kg for patients older than 12 years) (ASPEN, 2004;
Diamond, 1997)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diamond, 1997)
Weight gain goals are 15 g/day to 30 g/day, which is approximately 1% of weight per day in
infants and less than 0.5% weight per day in older children (Schneider, 2006; Leung, 1995;
Mouser, 1998).
Evaluation of intake and output with weight gain is needed to assess true somatic gains vs
fluid retention.

Vascular Access
Intravenous access needs are determined by the extent to which endogenous stores will
be depleted with decreased or eliminated feedings. Peripheral venous access may benefit
well-nourished children with anticipated fluid needs greater than maintenance when
expected duration of PN is less than 5 days or when enteral goals are not achieved within
2 weeks (ASPEN, 2007; ASPEN, 2002). Concentration of amino acids, as well as dextrose
and electrolytes, needs to be considered with the PN prescription (eg, 2% amino acids add
200 mOsm/L to the solution). Lipids are isotonic, and the infusion of lipids with peripheral
PN may protect against phlebitis and loss of IV access (Pineault, 1989). Complication rates
have been comparable between peripheral and central routes (Cox, 2005; Groh-Wargo,
2000; Stokes, 1992).

Access into a central vein is preferred when expected duration of the PN is more than 5
days and is used typically with PN for greater than 2 weeks (Cox, 2005; ASPEN, 2002).
Concentrated nutrient solutions (higher than 1,000 mOsm/L) are acceptable. A PN solution
delivered into a central vein can provide for maintenance needs or achieve repletion and
growth goals. Central venous access requires a lumen, dedicated for exclusive use with
PN, to avoid (a) interruptions in delivery, (b) a higher risk of infection, (c) drug
incompatibility, (d) variable glucose infiltration rate, and (e) suboptimal provision of
nutrients. A peripherally inserted central catheter has been used successfully in pediatrics
with fewer insertion complications and provides access to a central vein (Cox, 2005).
Temporary percutaneous central venous may be placed for anticipated short-term use in
the hospital setting (Aiello, 1999).

Vitamin Administration
Vitamin levels in PN mixtures may decrease because of light degradation, decomposition
with disulfite (antioxidant) additive, or adherence to plastic or glass (Cox, 2005, Gillis,
1983). Vitamins are typically added to the PN solution just before administration, and
recommended hang time is no more than 24 hours (Cochran, 1988). Also, vinyl, opaque
PN bag covers are used with solutions containing protein and vitamins to protect from
degradation caused by IV light (Kishi, 1981).

Total Nutrient Admixture
Total nutrient admixture is the delivery of all three macronutrients—dextrose, amino acids,
and fat—in one solution (3-in-1). Use of this system varies from institution to institution, and
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preparation guidelines are simpler, because only a single container needs to be hung (Cox,
2005; Groh-Wargo, 2000; Rollins, 1990). Newer PN delivery containers use separate
storage compartments for the lipids. Lipids are released to mix with the dextrose and amino
acid–containing solution shortly before delivery.
Concerns with 3-in-1 solutions are that there is an inability to separately titrate the lipid
dosing once the PN formula is mixed and an inability to measure lipid clearance levels with
continuous PN rates. Using 3-in-1 solutions does match lipid rates with the PN infusion,
which may be of benefit with large lipid intakes in continuous PN infusions. Lipids
contained in PN solution may not stay in emulsion with high electrolyte contents, resulting
in a lower pH of the solutions; if cracking is observed (it will look like salad oil on top of
milk), the solution is not usable.
With lipids added into the PN solution, detection of precipitation is limited, and the pH of
the solution is increased. This raises the risk of precipitation of minerals. Use of 3-in-1
solutions may limit the dosing of minerals to less than needed. The different levels of
minerals should be carefully checked with 3-in-1 mixtures (Shulman 2007). There is special
concern regarding the poor solubility of calcium and phosphorus. For some pediatric PN,
keeping the administration of lipids separate may be advisable; this would be the case with
high calcium and phosphorus dosing, as is used in premature infants, or with low fluid
volumes, as is used in postsurgical cardiac patients.
Emulsions and particle size have been measured within acceptable rates with limited
refrigerator storage (24 hours) and hang time (24 hours) in pediatric 3-in-1 solutions.
Visible creaming was reversible with agitation. Effective in-line end filtration can prevent
adverse effects from particle contaminant (Shulman 2007; Bullock, 1992; Puntis, 1992).
Triple-mix solutions can be filtered if the pore size is greater than 1.2 mcm vs the 0.22
mcm size used with 2-in-1 solutions. With regard to overall infection rates with simplified
administration but a larger filter pore size, more data are needed.

Cycling

Cycling should be used to deliver parenteral nutrition (PN) solutions in less than a 24-hour
period for longer-term PN support. Proposed benefits are as follows:
The cessation of the glucose infusion with a consequent decrease in stimulating
insulin production, which may help minimize the risk of developing a fatty liver
Promotion of a semifasted state as a more normal physiological feeding process
Functional outcomes, such as quality of life and development, may also be enhanced by
allowing playtime and activities during the time off the PN infusion pump. The older child on
a stable PN schedule is a candidate for cycling the infusion rate down to 10 to 18 hours
each day, depending on the child’s age, medications, and ability to eat/absorb enteral
nutrients (Cox, 2005; Groh-Wargo, 2000). Weaning to the goal PN infusion rate and
volume can take 3 days, if the time off the infusion is increased in 2- to 4-hour increments,
depending on the glucose infusion rate, blood glucose levels, and age. Graduated
increases and decreases on and off PN solutions can be easily set with current infusion
pumps.
High-obligate glucose requirements make cycling PN in children more difficult, with
increased risks of hypoglycemia and hyperglycemia and a lack of potential benefit. Cycling
PN is not generally recommended when body weight is less than 3 kg. The need for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
tapering the PN infusion at half-rate for the last hour in children may be monitored by
assessing serum glucose levels after 30 to 60 minutes off the infusion (Eisberg, 1995;
Bendorf, 1996). If glucose levels lower than 60 mg/dL occur, tapering down by giving half
the infusion rate for one-half to 1 hour before the end of the cycle may improve tolerance.

Monitoring

Standard parenteral nutrition (PN) monitoring for potential metabolic and catheter-related
complications are ongoing, with frequencies related to changes in therapy and clinical
status ( Cox, 2005; Groh-Wargo, 2000; Shulman, 2007). Monitoring protocols vary by
institution. Components to be evaluated usually include laboratory, physical examination,
and anthropometric measurements. Laboratory parameters include glucose, electrolytes,
minerals, blood counts, protein status, acid-base status, and liver function ( Szeszycki,
2010).
Children with critical illness, malnutrition, or significant gastrointestinal dysfunction may
present with vitamin and mineral deficiencies. Long-term PN may result in trace mineral
and fat-soluble vitamin excessess or deficiencies, and blood levels may need to be
monitored. Also, the need for testing must be related to goals and improved outcomes,
either with periodic assurances of metabolic tolerance or adequacy of nutrition support to
the individual child.
Infection should be considered as a possible cause of intolerance when stable patients
become intolerant of their therapy. The costs of testing, as well as the benefits of PN
therapy itself, are weighed against the risk of potential complications. With early
identification and treatment of such complications, there is added value to the patient.
Testing for the presence of glucose in the urine with output and weight measures are
cost-effective ways to monitor for carbohydrate intolerance to avoid osmotic diuresis.
Frequency in measurement is based on the response time for the indicators that are
valuable to identify a problem—for example, daily intake and output with weight and urine
glucose checks each shift until advancement of the PN is completed, and then daily urine
glucose checks. The physical examination should include measurement of vital signs, and
evaluation of the infusion site, dressing, and wound healing.
With documentation of therapeutic objectives, an evaluation of the child's response to PN
should also include monitoring growth and developmental progress. Growth changes
should be compared with expected velocities for age and should consider overall body
composition. Careful measurement of mid-arm anthropometry can be useful in the pediatric
population to assess lean mass and adipose stores. Short-term body composition and
growth assessments for the young child are valuable references for periodic nutrition
evaluation (ASPEN, 2000; Fomon, 1993). Expected intrauterine gains of 10 g/kg/day to 15
g/kg/day, or 1.0% to 1.5% body weight per day, in the last trimester (Heird, 1995) are the
basis for goals in premature infants for weekly averages of at least 7% per week after
regaining birth weight. Length increases will lag behind weight changes until weight for
length is above the 50th percentile. As an indicator of growth, head circumference may be
measured weekly in preterm infants, biweekly in the first year of life, and then monthly for
the next 2 years (Ziegler, 2002).

The child's care plan should include the education of all caregivers about the treatment
process. The older child's ability to provide self-care and to be compliant with
recommendations is a necessary component for PN support. The developmental needs of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
recommendations is a necessary component for PN support. The developmental needs of
the child, such as nonnutritive sucking for the infant who is unable to eat, should be
included in the care plan. Transitioning to enteral support is often the ultimate objective of
any PN therapy. In most patients, PN may be safely discontinued when enteral feedings
(by tube and/or mouth) provide at least 75% of estimated needs. When the endpoint for PN
therapy is very distant, special care must be taken to optimize any opportunities to develop
feeding skills and tolerance (Cox, 2005; Szeszycki, 2010).


Contraindications and Complications

Related Physiology
To avoid deficiencies and optimize tolerance and growth, parenteral nutrition (PN) requires
the balanced provision of micronutrients and macronutrients for acute and long-term
therapies. The nutrition history, clinical status, age, and development of the child must be
considered, with initial and successive care plans. Multidisciplinary expertise is essential for
the effective management of PN.
Expected benefits of PN with measurable indexes in children include the following:
Growth and somatic reserves: rate of weight gain, head circumference, length/height,
normal weight/height, lean mass, fat stores
Protein metabolism: hepatic synthesis of plasma proteins, immunocompetence,
and wound healing
Morbidity and survival: response to treatment, infection, recurrence or relapse rate,
complications, emergency visits, and hospitalizations
Recovery rate and quality of life: length of stay, return to school/work (including
parents), patient satisfaction, and family impact (Schneider, 2006)
Cost information is useful to evaluate all therapies and should be included for both the
morbidity and recovery concerns. Ethical decisions regarding treatment must be developed
carefully with the medical team and the family.
Contraindications and Complications
PN therapy may not benefit all patients (Levi, 2003). Some contraindications to PN support
are listed below (Cox, 2005; Collier, 2005). Indications for discontinuation of PN other than
initiation or advancement of enteral feeding are usually related to various complications,
which can include infections, mechanical malfunctioning, and metabolic occurrences.
Contraindications for Parenteral Nutrition
Unstable fluid and electrolyte status
Limited fluid availability (eg, when more than 50% of restricted fluids needed for
medical therapies)
Lack of available access sites
Functional gastrointestinal tract
Organ failure without transplant options
Nutrition objectives cannot be met (eg, with cessation of treatment for terminal
conditions)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Complications
Catheter-related. The most frequent complication of long-term PN in children is
catheter-related septicemia. It is estimated that 250,000 to 500,000 central venous access
device (CVAD)–associated bloodstream infections (BSIs) occur annually. In the pediatric
population the CVAD the infection rate ranges from 1 to 4 per 1,000 catheter days.
Children with intestinal failure are at increased risk for infections. The use of Ethanol-lock
therapy for the prevention of CVAD infections has significantly decreased BSI rates in this
pioulation (Cober, 2011). Catheter occlusion is the most common non infectious
complication. These can be of thrombotic or non-thrombotic etiology and treatment is
dependent on the cause. Most instutitions have specific protocols for line placement and
infusion to prevent or minimize complications. The Centers for Disease Control and
Prevention have published guidelines for catheter maintenenace (O'Grady, 2002). Careful
monitoring, patient education, and regular follow-up may improve longevity of the central
venous catheter.
Liver Disease. Liver disease is the primary metabolic complication associated with
long-term PN in children (Btiache, 2002; Briones, 1995). The consequences of cholestatic
jaundice are more severe in children than in adults, and development of cirrhosis with liver
failure has a poor prognosis (Sax, 1988). Laboratory parameters are used to monitor for
cholestasis (Nousia-Arvanitakis, 1992). Serum gamma-glutamyl-transpeptidase (GGT) is
an early but nonspecific marker. Additional measures of serum bile salts or bile acids (eg,
choleglycine) with GGT are also used. Alkaline phosphatase levels are influenced by
nutritional status and bone turnover in the young child. Elevations of other transaminases
and serum bilirubin (more than 2 mg/dL of direct bilirubin) are late markers of cholestasis.
Enteral administration of Ursodiol (Actigall, Axcon Pharma US Inc, Minneapolis, MN) in the
child receiving PN has shown better effects in the treatment of hepatobiliary disease and
cholestasis than previous trials with phenobarbital (Luminal sodium, Abbott Laboratories,
Abbott Park, IL) (De Marco, 2006). The occurrence of gallstones and biliary sludge may be
reversed with surgical interventions (De Marco, 2006).
Etiologies of cholestasis associated with PN include immature hepatic and biliary function;
perinatal insults (eg, sepsis, hypoxia, hypoperfusion, surgery, medications, and viruses); no
enteral feedings; toxicities (eg, amino acids, trace elements, and photo-oxidation products);
excessive dextrose, energy, and protein loads; and specific nutrient deficiencies (eg,
taurine, fatty acids, and trace elements) (Rintala, 1993). High glucose infusion, at or close
to the maximal rate of glucose oxidation, is correlated with fatty liver (Kumpf, 2006).
Researchers in the United States and Europe have noted that soy-predominant (high
omega-6 fatty acid content) intravenous fat emulsion may be a contributing factor in
cholestasis. Use of omega-3 fatty acid intravenous fat emulsion to prevent PN-associated
cholestasis is being studied (Gura, 2006; Lee, 2006). A recent study showed the
PN-dependent children with cholestasis and dyslipidemia who switched from soy-based
lipid to fish oil–based lipid had an improvement in serum triglyceride and VLDL
concentrations, a significant increase in serum omega-3 fatty acids, and a decrease in
serum omega-6 fatty acids (Le, 2011).
Avoidance of overfeeding with PN by provision of accurately estimated needs decreases
the risk of metabolic complications (Rintala, 1993; Chwals, 1994). Current practice
guidelines include avoiding nutrient toxicities from amino acids and photo-oxidation
products. Amino acid formulations for pediatrics have been modified to improve tolerances.
The addition of taurine may compensate for immature biosynthesis in premature infants,
because it has a role in conjugation of bile salts and bile secretion (De Marco, 2006). Since
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
because it has a role in conjugation of bile salts and bile secretion (De Marco, 2006). Since
cholestasis is still associated with PN in older children even when taurine-containing
products are provided, a general recommendation is to limit PN duration to the shortest
time of benefit. Other concerns regarding overfeeding of energy and/or glucose are
increased synthesis of fat; increased respiratory quotient as more carbon dioxide is
produced relative to the oxygen consumed; and, as more water is produced, there is
an increased water load for the lungs. Metabolic bone disease, as a potential metabolic
complication of PN in pediatric patients, is of greatest concern at peak growth periods
( Cox, 2005; Cunningham, 1995; Kerner, 1991).
Nausea and Vomiting. Up to two-thirds of children receiving PN have been reported to
experience nausea and/or vomiting associated with PN infusion (Nicol, 1995). Children with
cancer and cystic fibrosis often experience more problems than those with gastrointestinal
disorders. Nausea and vomiting may decrease with extended weaning rates, oral
carbohydrate intake, adjusted macronutrient distribution, antiemetics, and discontinuation
of PN.
Hyperglycemia and Immune Function. Typically, an increased glucose level on a stable
infusion is considered an early indicator of infection. It is proposed that serum glucose
levels of > 11 mcmol/dL (200 mg/dL) may increase susceptibility to infection with
decreased immune response (Hostetter, 1990). The reduced rate of septic complications in
enterally fed vs parenterally fed patients may partly be the result of the decreased
incidence of hyperglycemia in the tube-fed patients (Moore, 1992).
Mineral Precipitation. Metabolic bone disease, as a potential metabolic complication of
PN in pediatric patients, is of greatest concern at peak growth periods The risk of mineral
precipitation with phosphorus limits calcium provision to less than the recommended intake
for premature infants. The use of calcium gluconate and moderate magnesium doses, with
careful handling of the solution, limits disassociation at reasonable calcium and
phosphorus doses (Niemiec, 1984). When appropriate, the use of modified amino acid
solutions with a lower pH can allow increased dosing of minerals in the PN solution as well
as the addition of cysteine ( Cox, 2005; Cunningham, 1995; Groh-Wargo 2000).
Refeeding Syndrome. Rapid provision of energy and electrolytes to the malnourished
child is possible with PN. However, hypophosphatemia, hypokalemia, hypomagnesemia,
hyperglycemia, and fluid shifts may result if repletion feedings are too aggressive (Kraft,
2005). To ensure optimum nutrition rehabilitation, gradual advancement and careful
laboratory and clinical monitoring are needed.

FAQs

Is Omegaven available in the United States?
Omegaven has been effective in treating parenteral nutrition–associated liver disease
(PNALD), though it is not approved by the US Food and Drug Administration
(FDA). Omegaven is expensive and generally not reimbursed by insurance. It is available
for compassionate use in centers that have received permission from the FDA. Contact
[email protected]. (Gura, 2006)

Are there other options for fish oil–based lipids other than Omegaven?

Enteral fish oil is being used in some health centers. It has been shown to be an effective
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
treatment for PNALD and is usually well tolerated. There is an FDA-approved product that
has the mercury removed. One potential risk is increased bleeding (Le Bonheur Children’s
Medical Center).

Is it acceptable to use an adjusted body weight to calculate energy needs for the
obese pediatric patient?

The American Society of Parenteral and Enteral Nutrition (ASPEN) recently published
clinical guidelines for supporting obese, hospitalized pediatric patients. The
recommendation is that because there is not sufficient evidence to determine the clinical
outcomes of hypocaloric feeding during hospitalization of obese children, indirect
calorimetry is preferred over predictive equations. Estimating ideal body weight is not
possible because no valid tool exists for this. Therefore, predicting needs based on
adjusted body weight is not recommended. The goals for meeting energy needs in the
obese pediatric patient should be similar to goals for the nonobese patient (Szeszycki,
2010, www.nutritioncare.org).

What should I do if there is a shortage of pediatric intravenous multivitamin?

ASPEN has published recommendations for intravenous multivitamin shortages, which are
posted on the organization's website at www.nutritioncare.org.

Weblinks

Academy of Nutrition and Dietetics
www.eatright.org
American Academy of Pediatrics
www.aap.org

American Society of Parenteral and Enteral Nutrition
www.nutritioncare.org
The Joint Commission
www.jointcommission.org
How physicians can obtain Omegaven
[email protected]
Oley Foundation
www.oley.org
University of Virginia Pediatric Nutrition
http://www.healthsystem.virginia.edu/pub/peds-nutrition
Intravenous Vitamins:
Hospira Inc.
www.hospira.com
Baxter Healthcare
www.baxter.com
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Trace Elements:
American Regent Inc.
www.americanregent.com

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Cochran EB, Phelps SJ, Helms RA. Parenteral nutrition in pediatric patients. Clin Pharm.
1988;7:351-366. Related Links: Abstract
Collier SB. Parenteral nutrition. In: Hendricks KM, Dudgeon JA, Walker WA, eds. Manual
of Pediatric Nutrition. 4th ed. Toronto, ON: BC Decker Inc; 2005:317-375.
Colomb V, Goulet O, De Potter S, Ricour C. Liver diseases associated with long-term
parenteral nutrition in children. Transplant Proc. 1994;26:1467.
Cox JH, Melbardis JM. Parenteral nutrition. In: Samour R, King K, eds. Handbook of
Pediatric Nutrition. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2005:317-375.
Cunningham JJ. Body composition and nutrition support in pediatrics: What to defend and
how soon to begin. Nutr Clin Pract. 1995;10:177-182. Related Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
how soon to begin. Nutr Clin Pract. 1995;10:177-182. Related Links: Abstract
De Marco G, Sordino D, Burssese E, Di Caro S, Mambretti D, Tramontanon A, Colombo
C, Simoni P, Guarion A. Early treatment with ursodeoxycholic acid for cholestasis in
children on parenteral nutrition because of primary intestinal failure. Aliment Pharmacol
Ther. 2006;24:387-394. Related Links: Abstract
Diamond RJ. Parenteral nutrition in the critically ill infant and child. In: Baker RD, Baker
SS, Davis A, eds. Pediatric Parenteral Nutrition. New York, NY: Chapman & Hill;
1997:273-300.
Eggert LD, Rusho WJ, MacKay MW, Chan GM. Calcium and phosphorus comparability in
parenteral nutrition solutions for neonates. Am J Hosp Pharm. 1982;39:49-53. Related
Links: Abstract
Eisberg PG, Gianimo S, Clutter WE, Fleshman JW. Abrupt discontinuation of cycled
parenteral nutrition is safe. Dis Colon Rectum. 1995;38:933-939. Related Links: Abstract
Fomon SJ, ed. Nutrition of Normal Infants. St. Louis, MO: Mosby-Year Book; 1993.
Fomon SJ, Haschke F, Ziegler EE, Nelson SE. Body composition of reference children
from birth to age 10 years. Am J Clin Nutr. 1982;35:1169-1175. Related links: Full text
Friedman A, Daron A, Stahlman MT, Oates JA. Rapid onset of essential fatty acid
deficiency in the newborn. Pediatrics. 1976;58:640-649. Related Links: Abstract
Gillis J, Jones G, Pencharz PB. Delivery of vitamins A, D and E in TPN solutions. JPEN J
Parenter Enteral Nutr. 1983;7:11-14.
Giovanni M, Riva E, Agostoni C. Fatty acids in pediatric nutrition. Pediatr Clin North Am.
1995;42:861-877.
Greene BL, Harnbridge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins,
trace elements, calcium, magnesium, and phosphorus in infants and children receiving
total parenteral nutrition: Report of the Subcommittee of Pediatric Parenteral Nutrient
Requirements from the Committee on Clinical Practice Issues of the American Society for
Clinical Nutrition. Am J Clin Nutr. 1988;48:1324-1342. Related Links: Full text
Groh-Wargo S, Thompson M, Cox JH, eds. Nutritional Care for High-Risk Newborns.
Chicago, IL: Precept Press Inc; 2000.
Gura KM, Duggan CP, Collier SB, Jennings RW, Folkman J, Bistrian BR, Puder M.
Reversal of parenteral nutrition-associated liver disease in two infants with short bowel
syndrome using parenteral fish oil: Implications for future management. Pediatrics.
2006;118:197-201. Related Links: Abstract; Full text
Haumont D, Richelle M, Deckelbaum RJ, Coussaert E, Carpentier YA. Effect of liposomal
content of lipid emulsions on plasma lipid concentrations in low birth weight infants
receiving parenteral nutrition. J Pediatr. 1992;121:759-763. Related Links: Abstract
Heird WC. Amino acids and energy needs of pediatric patients receiving parenteral
nutrition. Pediatr Clin North Am. 1995;42:765-789. Related Links: Abstract
Heird WC, Kashyap S, Gomez MR. Parenteral alimentation of the neonate. Semin
Perinatol. 1991;15:493-502.
Heird WC, Hay W, Helms RA, Storm MC, Kashyap S, Dell RB. Pediatric parenteral amino
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
acid mixture in low birth weight infants. Pediatrics. 1988;81:41-50. Related Links: Abstract
Helms RA, Whitington PF, Mauer EC, Catarau EM, Christiansen MC, Borum PR. Enhanced
lipid utilization in infants receiving oral L-carnitine during long-term parenteral nutrition. J
Pediatr. 1990;109:984-988. Related Links: Abstract
Hill ID, Madrrazo-de la Garza JA, Lebenthal E. Parenteral nutrition in pediatric patients. In:
Rombeau JR, Caldwell MD, eds. Parenteral Nutrition. 2nd ed. Philadelphia, PA: WB
Saunders Co; 1986:770-790.
Hostetter MK. Handicaps to host defense: Effects of hyperglycemia on C3 and Candida
albicans. Diabetes. 1990;39:271-275. Related Links: Abstract
Hurwitz M, Garcia MG, Poole RL, Kerner JA. Copper deficiency during parenteral
nutrition: A report of four pediatric cases. Nutr Clin Pract. 2004;19:305-308. Related Links:
Abstract
Iinuma Y, Kubota M, Uchiyama M, Kanada S, Yamezaki S, Murata H. Okamoto K, Suzuki
M, Nitta K. Whole blood manganese levels and brain manganese accumulation in children
receiving long-term home parenteral nutrition. Pediatr Surg Int. 2003;19:268-292. Related
Links: Abstract
Joint Commission. 2009 Hospital Accreditation Standards PC.01.02.01, PC.01.02.03, EP
7. Oakbrook Terrace, IL: Joint Commission; 2009.
Kao LC, Cheng MH, Warburton D. Triglycerides, free fatty acids/albumin molar ratio, and
cholesterol levels in serum of neonates receiving long-term lipid infusions: Controlled trial
of continuous and intermittent regimens. J Pediatr. 1984;104:429-435. Related Links:
Abstract
Kerner JA, ed. Manual of Pediatric Parenteral Nutrition. New York, NY: John Wiley and
Sons; 1983.
Kerner JJ. Parenteral nutrition. In: Walker WA, Durie PR, Hamilton JR, Walker-Smith JA,
Watkins JB, eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis,
Management. Philadelphia, PA: BC Decker Inc; 1991:1645-1675.
Kimura S, Nose O, Seino Y. Effects of alternate and simultaneous administrations of
calcium and phosphorus on calcium metabolism in children receiving total parenteral
nutrition. JPEN J Parenter Enteral Nutr. 1986;10:513-516. Related Links: Abstract
Kishi H, Yamaji A, Kazusaburo K, Fujii Y, Nishikawa K, Ottnishi N, Hiraoka E, Okada A,
Kim C-N. Vitamin A and E requirements during total parenteral nutrition. JPEN J Parenter
Enteral Nutr. 1981;5:420-423. Related Links: Abstract
Koo WW, Tsang RC. Mineral requirements of low-birth-weight infants. J Am Coll Nutr.
1991;10:474-486. Related Links: Abstract
Kraft MD, Btaiche IF, Sacks GS. Review of the refeeding syndrome. Nutr Clin Pract.
2005;20:625-633. Related Links: Abstract
Kumpf VJ. Parenteral nutrition-associated liver disease in adult and pediatric patients. Nutr
Clin Pract. 2006;21:279-290. Related Links: Abstract
Kumpf VJ. Parenteral iron supplementation. Nutr Clin Pract. 1996;11:139-146. Related
Links: Abstract
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lee S, Gura KM, Kim S, Arsenault DA, Bistrian BR, Puder M. Current clinical applications
of omega-6 and omega-3 fatty acids. Nutr Clin Pract. 2006;21:323-341. Related Links:
Abstract
Le HD, de Meijer VE, Robinson EM, Zurakowski D, Petemkin AK, Aresenault DA, Fallon
EM, Malkan A, Bristrian BR, Gura JM, Puder M. Parenteral fish-oil-based lipid emulsion
improves fatty acid profiles and lipids in parenteral nutrition-dependent children. Am J Clin
Nutr. 2011 July 20 [Epub ahead of print]. Related Links: Abstract
Leung FY. Trace elements in parenteral micronutrition. Clin Biochem. 1995;28:561-566.
Related Links: Abstract
Levi BH. Withdrawing nutrition and hydration from children: Legal, ethical and professional
issues. Clin Pediatr. 2003;42:137-148.
Marian M. Pediatric nutrition support. Nutr Clin Pract. 1993;8:199-209.
McMillan NB, Mulroy C, Mackay MW, McDonald CM, Jackson WD. Correlation of
cholestasis with serum copper and whole-blood manganese levels in pediatric
patients. Nutr Clin Pract. 2008;23:161-165. Related Links: Abstract
Mehta NM, Compher C, ASPEN Board of Dirctors. ASPEN. Clinical guidelines: Nutrition
support of the critically ill child. JPEN J Parenter Enteral Nutr. 2009;33:260-276. Related
links: Full text
Minard G, Kudsk KA. Effect of route of feeding on the incidence of septic complications in
critically ill patients. Semin Respir Infect. 1994;9:228-231. Related Links: Abstract
Mirtallo J, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, Seres D, Guenter P;
Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for
parenteral nutrition. JPEN J Parenter Enteral Nutr. 2004;28:S55-S70.
Mitton SG. Amino acid and lipid in total parenteral nutrition for the newborn. J Pediatr
Gastroenterol Nutr. 1993;18:25-31.
Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB,
Kellum JM Jr, Welling RE, Moore EE. Early enteral feeding, compared with parenteral,
reduces postoperative septic complications. The results of a meta-analysis. Ann Surg.
1992;216:172-183. Related Links: Abstract
Moukarzel AA, Dahlstrom KA, Bouchman AL, Ament ME. Carnitine status of children
receiving long-term total parenteral nutrition: A longitudinal prospective study. J Pediatr.
1992;120:759-762. Related Links: Abstract
Mouser JF, Wu AH, Herson VC. Aluminum contamination of neonatal parenteral nutrient
solutions and additives. Am J Health Syst Pharm. 1998;55:1071-1072.
Myron Johnson A, Merlini G, Sheldon J, Ichihara K; Scientific Division Committee on
Plasma Proteins (C-PP), International Federation of Clinical Chemistry and Laboratory
Medicine (IFCC). Clinical indications for plasma protein asssays: Transthyretin
(prealbumin) in inflammation and malnutrition. Clin Chem Lab Med. 2007;45:419-426.
Related Links: Abstract
Neuzil J, Darlow BA, Inder, TE, Sluis KB, Winterbourn CC, Stocker R. Oxidation of
parenteral lipid emulsion by ambient and phototherapy lights: Potential toxicity of routine
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
parenteral feeding. J Pediatr 1995;126:785-790. Related Links: Abstract
Nicol JJ, Hoagland RL, Heitlinger LA. The prevalence of nausea and vomiting in pediatric
patients receiving home parenteral nutrition. Nutr Clin Pract. 1995;10:189-192. Related
Links: Abstract
Niemiec PW, Vanderveen TW. Compatibility considerations in parenteral solutions. Am J
Pharm. 1984;41:893-911. Related Links: Abstract
Nose O, Tipton JR, Ament W, Yabuuchi H. Effect of energy source on changes in energy
expenditure, respiratory quotient and nitrogen balance during parenteral nutrition in
children. Pediatr Res. 1987;21:538-541. Related Links: Abstract
Nousia-Arvanitakis S, Angelpoulou-Sakadami N, Matrolion K. Complications associated
with total parenteral nutrition in infants with short bowel syndrome.
Hepatogastroenterology. 1992;39:169-172. Related Links: Abstract
O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H,
McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines
for the prevention of intravascular catheter-related infections. Centers for Disease Control
and Prevention. MMWR Recomm Rep. 2002 Aug 9;51(RR-10):1-29. Related
links: Abstract; Full text
Picaud JC, Steghens JP, Auxenfans C, Barbieux A, Laborie S, Claris O. Lipid peroxidation
assessment by malondialdehyde measurement in parenteral nutrition solutions for newborn
infants: A pilot study. Acta Paediatr. 2004;93:241-145. Related Links: Abstract
Pineault M, Chessex P, Piedboeuf B, Bisaillon S. Beneficial effect of coinfusing a lipid
emulsion on venous patency. JPEN J Parenter Enteral Nutr. 1989;13:637-640. Related
Links: Abstract
Poole RL, Hintz SR, Mackenzie NI, Kerner JA. Aluminum exposure from pediatric
parenteral nutrition: Meeting the new FDA regulation. JPEN J Parenter Enteral Nutr.
2008;32:242-246. Related Links: Abstract
Puntis JW, Wilkins KM, Boll PA, Rushton DT, Booth IW. Hazards of parenteral treatment:
Do particles count? Arch Dis Child. 1992;67:1475-1477. Related Links: Abstract
Reynolds AP, Kiely E, Meadows N. Manganese in long-term paediatric parenteral nutrition.
Arch Dis Child. 1994;71:527-528. Related Links: Abstract
Rintala R, Lindahl H, Pahjavuori M, Saxon H, Sarriola H. Surgical treatment of intractable
cholestasis associated with total parenteral nutrition in premature infants. J Pediatr Surg.
1993;28:716-719. Related Links: Abstract
Rollins CJ, Elsberry VA, Pollack KA. Three-in-one parenteral nutrition: A safe and
economical method of nutritional support for infants. JPEN J Parenter Enteral Nutr.
1990;14:290-294. Related Links: Abstract
Sax HC, Bower RH. Hepatic complications of total parenteral nutrition. JPEN J Parenter
Enteral Nutr. 1988;12:615-618. Related Links: Abstract
Schanler RJ, Shulman RJ, Prestidge LL. Parenteral nutrient needs of very low birth weight
infants. J Pediatr. 1994;125:961-968. Related Links: Abstract
Schneider PJ. Nutrition support teams: An evidence-based practice. Nutr Clin
Pract. 2006;21:62-67. Related Links: Abstract
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Pract. 2006;21:62-67. Related Links: Abstract
Shatsky F, Borum PR. Should carnitine be added to parenteral nutrition solutions? Nutr
Clin Pract. 2000;15:152-154.
Shulman RJ, Phillips S. Parenteral nutrition indications, administration, and monitoring. In:
Baker S, Baker R, Davis A, eds. Pediatric Nutrition Support. 1st ed. Sudbury, MA: Jones
and Bartlett Publishers; 2007:273-286.
Slicker J, Vermilyea S. Pediatric parenteral nutrition putting the microscope on
macronutrients and micronutrients. Nutr Clin Pract. 2009;24:481-486. Related Links:
Abstract
Stahl GE, Spear MC, Hamosch M. Intravenous administration of lipid emulsions to
premature infants. Clin Perinatol. 1986;13:133-162. Related Links: Abstract
Stokes MA, Hill GL. Peripheral parenteral nutrition: A preliminary report on its efficacy and
safety. JPEN J Parenter Enteral Nutr. 1992;17:145-147. Related Links: Abstract
Sultan MI, Leon CD, Biank VF. Role of nutrition in pediatric chronic liver disease Nutr Clin
Prac. 2011 Aug;26(4):401-408. Related Links: Abstract
Szeszycki E, Cruse W, Strup M. Evaluation and monitoring of pediatric patients receiving
specialized nutrition support. In: Corkins MR, ed. The ASPEN Pediatric Nutrition Support
Core Curriculum. Silver Spring, MD: ASPEN Publishers; 2010:460-475.
Trissel LA. Trissel’s Calcium and Phosphorus Compatibility in Parenteral Nutrition.
Houston, TX: Tri. Pharma; 2001.
Wesley JR, Coran AG. Intravenous nutrition for the pediatric patient. Semin Pediatr Surg.
1992;1:212-230. Related Links: Abstract
Wessel J, Balint J, Crill C, Klotz K; American Society for Parenteral and Enteral Nutrition;
Task Force on Standards for Specialized Nutrition Support for Hospitalized Pediatric
Patients. Standards for specialized nutrition Support: Hospitalized pediatric patients. Nutr
Clin Pract. 2005;20:103-116.
Wolfe RR. Carbohydrate metabolism and requirements. In: Rombeau JL, Caldwell MD,
eds. Clinical Nutrition: Parenteral Nutrition. Philadelphia, PA. WB Saunders Co;
1993:113-131.
Ziegler EE, Thureen PJ, Carlson SJ. Aggressive nutrition of the very low birth weight
infant. Clin Perinatol. 2002;29:255-244. Related Links: Abstract

Sample PN Initiation and Advancement

The following example demonstrates one possible use of parenteral nutrition (PN) to meet
estimated needs in a pediatric patient. Timing for advancement will vary for individuals and
by different institutions and approaches. Specific guidelines for nutrition assessment and
disease-related requirements can be found in the related sections.
An 8-year-old, prepubescent boy is admitted to the hospital with newly diagnosed Crohn's
disease and a peripherally inserted central catheter line is in place. PN has been
prescribed for at least 7 to 10 days with bowel rest and intravenous (IV) medications
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
(including steroids), to promote remission of the disease and repletion of nutritional status.
Albumin is 2.8 g/dL and iron status is fair.

Growth and diet history:

Oral intake has been decreasing during the past 2 to 3 months, with a 3 kg weight loss and
increasing fatigue. Height is lower than the 5th percentile and parental midpoint is at the
50th percentile; weight is 85% of ideal body weight (IBW). Expected growth velocity is +6
cm/year for height and +2.5 kg/year for weight.

Current measurements:

Weight: 17 kg; IBW: 20 kg; height: 115 cm; mid-arm circumference: 17 cm; triceps
skinfold: 7 mm; arm muscle circumference: 14.8 cm (10th to 25th percentiles).

Estimated needs:

Fluid available for PN = 1,290 mL/day (75% maintenance); electrolytes are stable.

Initial energy goal is 64 kcal/kg [basal metabolic rate (BMR) × IBW × 1.5 (light activity) ×
the 85% factor for IV nutrient utilization]. Protein goal is 1.5 g/kg/day to 2.0 g/kg/day and
approximately 30% of energy from fat.

Initial PN vitamins, minerals, and trace elements:

Sodium: 2 mEq/kg; Potassium: 2 mEq/kg; Chlorine: 2 mEq/kg; Magnesium: 0.25 mEq/kg;
Calcium: 0.3 mEq/kg; Phosphorus: 1 mmol/kg.

Additives:
5 mL Peds MVI (multivitamin), 0.1 mL/kg PTE-4 (trace elements, zinc, copper, manganese,
chromium)

Hours for
Infusion
Day PN Regimen Volume
(mL/kg/day)
GIR
(mg/kg/min)
Energy
(kcal/kg/day)
Protein
(g/kg/day)
24 1 11%
carbohydrate
(CHO), 1.5%
amino
acid(AA)
85 mL, 20%
lipids
75 5.4
Glucose
infusion rate
(GIR)
42 1
24 2 13% CHO,
2.2% AA
130 mL 20%
lipids
75 6.1 50 1.5
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
24 3 16% CHO,
3% AA
170 mL 20%
lipids
75 7.2 64 2.0
20 4 16% CHO,
3% AA
170 mL 20%
lipids
75 8.6 64 2.0
16 5 Same as
days 3 and 4
75 10.7 64 2.0

Continue full volume and assess patient response at 1.5 × BMR and nonprotein energy
to nitrogen ratio of 175:1.




© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Spanish Language Resources
Spanish Language Resources

Client Education Handouts in Spanish
Each of the following pdf handouts is geared towards clients and includes a Notes area
where you can type additional instructions to accommodate individuals' food preferences or
age. Changing the information on the handout itself is prohibited by copyright
restrictions.
Anemia
Iron Deficiency Anemia Nutrition Therapy

Cardiology
Cardiac Conditions: Consistent Vitamin K Sample 1-Day Menu
Cardiac Conditions: Cooking, Shopping, and Eating Out Tips
Congenital Heart Disease Sample 1-Day Menu

Developmental Disabilities
Down Syndrome Nutrition Therapy
Spina Bifida Nutrition Therapy

Diabetes Mellitus
Diabetes: Carbohydrate Counting
Diabetes: Fiber Tips
Diabetes: Label Reading Tips
Diabetes Nutrition Therapy
Diabetes: Portion Tips

Disorders of Lipid Metabolism
DHA and Heart Health
Heart-Healthy Tips
High Cholesterol Nutrition Therapy
High Triglycerides Nutrition Therapy

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Failure to Thrive
Failure to Thrive Nutrition Therapy

Food Allergic Disorders
Egg Allergy Nutrition Therapy
Fish Allergy Nutrition Therapy
Major Food Allergens Nutrition Therapy
Milk Allergy Nutrition Therapy
Multiple Food Allergies Tips
Peanut Allergy Nutrition Therapy
Soy Allergy Nutrition Therapy
Wheat Allergy Nutrition Therapy

GI Conditions
Celiac Disease/Gluten-Free Nutrition Therapy
Constipation Nutrition Therapy
Diarrhea Nutrition Therapy
Gastroesophageal Reflux Disease Nutrition Therapy
Nausea/Vomiting Nutrition Therapy
Nausea/Vomiting Tips

Normal Nutrition
Lactation Nutrition Therapy
Nutrition for Full-Term Infants
Nutrition for Toddlers
Nutrition for Preschool-Age Children
Nutrition for School-Age Children
Nutrition for Adolescent Boys
Nutrition for Adolescent Girls
Nutrition for Vegetarian Athletes
Nutrition for Vegetarian Pregnant Adolescents
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition for Vegetarian School-Age Children
Nutrition for Vegetarian Toddlers
Preventing Dehydration in Infants
Sample Vegetarian Menu for Infants
Tips to Prevent Choking

Preterm Infants
Nutrition for 1-4 Months Corrected Age
Nutrition for 4-6 Months Corrected Age
Nutrition for 6-8 Months Corrected Age
Nutrition for 8-12 Months Corrected Age

Pulmonary Diseases
Asthma Nutrition Therapy
Cystic Fibrosis Nutrition Therapy

Weight Management
Weight Management Nutrition Therapy for Children Ages 7-10
Weight Management Nutrition Therapy for Children Ages 11-14
Weight Management: Sample Menu for Children Ages 11-14
Weight Management Contract
Weight Management: Self-Monitoring Goals
Weight Management: Portion Size Tips
Nutrition Therapy for Underweight Children

Other Handouts
Calcium-Rich Nutrition Therapy
Food Safety Tips

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Arm Anthropometry
Arm Anthropometry

The following pdf charts have been adapted with permission from Frisancho AR. New
norms of upper limb fat and muscle areas for assessment of nutritional status. Am J
Clin Nutr. 1981;34:2540-2545. © Am. J. Clin. Nutr. American Society for Clinical Nutrition.
The full text of the original article, including complete tables, is available in pdf format here.
Triceps Skinfold Percentiles
Arm Circumference Percentiles
Arm Muscle Circumference Percentiles
Arm Muscle Area Percentiles
Arm Fat Area Percentiles

Please see the following links for tables and charts from the World Health Organization
website that relate to arm anthropometry for children up to age 60 months:
Arm circumference for age
Simplified field tables

Triceps skinfold for age
Simplified field tables

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions
Common Nutrient-Drug Interactions

Medication
Nutrients
Affected
Overall Effect
Prevention of
Interaction
Antibiotics
Minerals
Fat
Protein
Temporary decrease
in absorption
(resulting from
dirrhea, nausea,
and/or vomiting);
destroys "good"
intestinal bacterial
flora.
Acidophilus and
probiotics may
counteract loss of
intestinal flora.
Anticonvulsants
Vitamin D
Vitamin K
Vitamin B-6
Vitamin
B-12
Folate
Calcium
Decrease nutrient
absorption or stores.
Recommend diet high
in these nutrients.
Vitamin and mineral
supplements may be
appropriate; seek
physician approval.
Cardiac medications
(diuretics)
Potassium
Magnesium
Calcium
Folate
Loss or depletion of
nutrient stores; some
diuretics can produce
these effects; may
also cause nausea,
diarrhea, and
vomiting that lead to
reduced food intake.
Recommend foods and
fluids high in
potassium and
magnesium. Suggest
strategies to help with
decreased appetite.
Corticosteroids (used
with asthma, arthritis,
gastrointestinal
disease, cardiac
disease, cancer, etc)
Calcium
Phosphorus
Glucose
Long-term use can
cause stunting of
growth; can deplete
calcium and
phosphorus that can
result in bone loss;
can affect glucose
levels. May also
increase appetite,
leading to weight gain.
Monitor weight and
laboratory values.
Supplement with
calcium and vitamin D.
Laxatives
Fat-soluble
vitamins
Some are bulking
agents and others are
laxatives. Some
laxatives may deplete
fat-soluble vitamins
when used long-term.
Encourage a meal plan
high in fiber and fluid to
wean child off
medication. Check with
physician for
alternative medication
that will not deplete
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
stores.
Stimulants (used for
attention
deficit/hyperactivity
disorder)

Can decrease
appetite, cause
weight loss; may
affect overall growth.
Have child eat before
each medication
dosage if possible.
Monitor growth and
discuss with physician
if affected.
Sulfonamides (used in
spina bifida)
Vitamin C
Protein
Folate
Iron
Promotes
crystallization of large
doses of vitamin C in
the bladder; inhibits
protein synthesis;
decreases serum
folate and iron.
Avoid supplementation
of vitamin C in large
doses (>1000 mg).
Increase intake of
high-folate foods.
Tranquilizers
Increases appetite;
results in excessive
weight gain.
Recommend a low-fat
meal plan, if
appropriate. Monitor
weight.
Data from Nardella M, Campo L, Ogata B, eds. Nutrition Interventions for Children With
Special Health Care Needs. Olympia, Wash: Washington State Department of Health;
2002; and previous Pediatric Manual of Clinical Dietetics.
Table adapted from Pediatric Nutrition Practice Group and Dietetics in Developmental and
Psychiatric Disorders. Children with Special Health Care Needs. Chicago, Ill: American
Dietetic Association; 2004.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > Anti > inflammatory
Anti-inflammatory

Anti-inflammatory drugs and food/nutrient interactions
Drug Trade Name

Drug Class
Methylprednisolone Medrol® Anti-inflammatory

Prednisone Prednisone
Intensol® Sterapred®
Major Nutrient or Food Interaction
Patients who take steroids such as prednisone, prednisolone or methylprednisone may
experience hyperglycemia, fluid retention, or ulcers. These side effects usually resolve
when the medication is discontinued.
Recommendations
Patients taking steroids may eat normally unless they develop hyperglycemia (high blood
sugar) that requires dietary modification. Individuals with diabetes may need to adjust fixed
insulin doses based on recommendations from their endocrinologist or primary care
physician. Individuals with diabetes who regulate their own dosages of insulin using
capillary glucose monitoring should continue to do so while taking corticosteroids. Patients
with hyperglycemia should consult a registered dietitian for assistance with modifications to
carbohydrate intake, or may be advised to limit their intake of sugar and sugary foods.
Patients with fluid retention may be advised to limit high-sodium foods because sodium can
increase fluid retention.
Diet to reduce intake of sugars
Food Group Recommended Foods Foods to limit
Grains All, except for those listed
as foods to limit
Sweetened breakfast cereals
Fruit All, except for those listed
as foods to limit
Canned fruit packed in heavy
syrup
Milk All, except for those listed
as foods to limit
Milk flavored with sugared
flavorings
Other All, except for those listed
as foods to limit
Sugar, syrup, jams, jellies,
candy, honey, and regular soft
drinks
Diet to reduce sodium intake
Food Group Recommended Foods Foods to limit
Grains All, except for those listed
as foods to limit
Bagels, biscuits, croissants
Vegetables Fresh vegetables
prepared without salt
Canned or cooked dried
beans, baked beans, or lima
beans; canned creamed corn;
au gratin or scalloped potatoes;
canned mushrooms,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sauerkraut or tomatoes; tomato
paste, puree, or sauce;
spaghetti or marinara sauce;
canned vegetable juice
Fruit All fresh, frozen, or
canned fruit

Milk All, except for those listed
as foods to limit
American cheese, cottage
cheese, feta cheese, instant
pudding prepared with milk
Meat and Beans All, except for those listed
as foods to limit
Bacon, dried beef, salami (dry
or hard), tuna (canned in
water), veggie or soy patty
Other All, except for those listed
as foods to limit
Condiments such as catsup,
barbecue sauce, miso, pickles,
chips, pretzels, salad
dressings, salt, canned soup or
broth, soy sauce, or teriyaki
sauce

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > Anticoagulant
Anticoagulant

Anticoagulants and food/nutrient interactions
Drug Trade Name

Drug Class
Warfarin Coumadin®

Anticoagulant
Major Nutrient or Food Interaction: Patients who take warfarin may experience a
decrease in the anticoagulant effect of the drug if there are large increases in Vitamin K
(phyloquinone) intake. Formerly, patients taking warfarin were advised to avoid foods
known as sources of Vitamin K. However, a more current approach is for the patient to
maintain a consistent intake of Vitamin K while the physician, nurse practitioner or
pharmacist titrates the warfarin dose to maintain the desired prothrombin time (PTT) which
is expressed as the international normalized ratio or INR.

Recommendations:
Patients who take warfarin may maintain a normal pattern of eating except that they
should avoid large increases or decreases in the amount of foods high in Vitamin K.
Patients taking warfarin who increase or decrease their intake of green leafy
vegetables should discuss this change with their physician, pharmacist or nurse
practitioner.
Patients who experience an otherwise unexplained change in PTT or INR should
consult a registered dietitian who will evaluate the Vitamin K content of the diet and
make recommendations.
Food Group Recommended Foods Foods to avoid
Grains All None
Vegetables Maintain a consistent
intake of green
vegetables, especially
broccoli, Brussels
sprouts, greens, kale,
green onions, parsley,
spinach and chard
None
Fruit All None
Milk All None
Meat and Beans All None
Other None
Note: In 2003, a case report in the British Medical Journal described a man taking warfarin,
digoxin and phenytoin whose diet was composed of cranberry juice and little else for two
weeks. He died of gastrointestinal and pericardial hemorrhage (Suvarna 2003). The
authors of the report alluded to other cases, and recommended that patients taking
warfarin be cautioned to avoid cranberry juice. Since that time at least two other cases of
hemorrhage in patients taking warfarin and cranberry juice have been published (Grant
2004; Rindone 2006). The proposed mechanism is inhibition of the cytochrome P450
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
2004; Rindone 2006). The proposed mechanism is inhibition of the cytochrome P450
system by flavanoids in cranberry juice. At least three trials have since been published,
and in all three trials, authors concluded that cranberry juice had little effect on widely used
measures of coagulation (Li 2006; Lilja 2007; Greenblatt 2006).
The package insert for warfarin cautions patients to avoid cranberry juice and cranberry
products. Because of labeling, pharmacists and dietitians are concerned that they must
counsel patients to avoid all cranberry products. Some facilities have removed cranberry
juice from their menus because they are unable to distinguish between patients receiving
warfarin and those who do not. No doubt, further trials will appear. In the interim, each
institution is encouraged to remain current with newer research and to develop appropriate
policies. Dietitians working with individual clients have the opportunity to individualize care
of patients, and should make appropriate recommendations.

References: Anticoagulant

Grant P. Warfarin and cranberry juice: an interaction? J Heart Valve Dis. 2004;13:25-6.
Greenblatt DJ, von Moltke LL, Perloff ES, Luo Y, Harmatz JS, Zinny MA. Interaction of
flurbiprofen with cranberry juice, grape juice, tea, and fluconazole: in vitro and clinical
studies. Clin Pharmacol Ther. 2006;79(1):125-33.
Li Z, Seeram NP, Carpenter CL, Thames G, Minutti C, Bowerman S. Cranberry does not
affect prothrombin time in male subjects on warfarin. J Am Diet Assoc. 2006;106:2057-61.
Lilja JJ, Backman JT, Neuvonen PJ. Effects of daily ingestion of cranberry juice on the
pharmacokinetics of warfarin, tizanidine, and midazolam--probes of CYP2C9, CYP1A2, and
CYP3A4. Clin Pharmacol Ther. 2007 81:833-9
Rindone JP, Murphy TW. Warfarin-cranberry juice interaction resulting in profound
hypoprothrombinemia and bleeding. Am J Ther. 2006;13(3):283-4.
Suvarna R, Pirmohamed M, Henderson L. Possible interaction between warfarin and
cranberry juice. BMJ. 2003;327(7429):1454.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > Bisphosphonate
Bisphosphonate

Bisphosphonates and food/nutrient interactions
Drug Trade Name Drug Class
Alendronate Fosamax®
Bisphosphonate
Etidronate Disodium Didronate®
Ibandronate Boniva®
Pamidronate Aredia®
Risedronate Actonel®
Tiludronate Skelid®
Zoledronic Acid Reclast®, Zometa®
Major Nutrient or Food Interaction: Patients who take alendronate may have lower levels
of serum calcium, magnesium, phosphorus and may also develop ulcers. Calcium and
vitamin D supplements may be prescribed for patients receiving bisphosphonates.
Recommendations:
Patients who take alendronate may eat normally except that the drug should be taken
with water 30 minutes before eating.
Patients should avoid lying down for 30 minutes after taking the drug.
Patients who develop lower levels of serum calcium, magnesium, and phosphorus
while taking alendronate may consult a registered dietitian. The dietitian will review a
food and nutrient history, drug intake and lab results, the make recommendations
about foods high in calcium, magnesium and phosphorus as needed.
Diet to increase calcium intake
Food Group Recommended Foods Foods to avoid
Grains All None
Vegetables All, especially spinach
and okra
None
Fruit All None
Milk Milk, yogurt, cheese None
Meat and Beans All, especially soy beans None
Other None None
Diet to increase magnesium intake
Food Group Recommended Foods Foods to avoid
Grains Bran cereal, bran
muffins, oatmeal, brown
rice, whole wheat pasta
and spaghetti
None
Vegetables Artichoke, avocado,
greens, okra, baked
potato with skin, spinach,
Swiss chard,
None
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruit None
Milk Eggnog, chocolate milk,
soy milk
None
Meat and Beans Dried beans (black,
white, kidney, lima and
pole beans) and peas,
fish (halibut, yellowfin),
soy beans,
None
Other Nuts (almonds, cashews,
walnuts, hazlenute,
chestnuts, mixed,
peanuts) and peanut
butter, pumpkin or
squash seeds, tofu,
wheat germ
None
Diet to increase phosphorus intake
Food Group Recommended Foods Foods to avoid
Grains All, especially oatmeal
and wheat germ
None
Vegetables All, especially baked
potato with skin
None
Fruit All None
Milk All, especially cheese,
skimmed, low fat or
regular milk
None
Meat and Beans All, especially meat,
dried beans, nuts, soy
and tofu
None
Other None None

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > CYP450
CYP450

Drugs that are metabolized by the cytochrome P
450
system and related food/nutrient interactions
Drug Trade Name Drug Class
Itraconazole Sporanox® Anti fungal
Carbamazepine Carbatrol®, Tegretol® Anti seizure drugs
Buspirone
Clomipramine
Sertraline
Bu Spar®
Anafranil®
Zoloft®
Antidepressants
Diazepam
Midazolam
Triazolam
Valium®
None, generic only
Halcion®
Tranquilizers
Felodipine
Nimodipine
Nisoldipine
Nitrendipine
Pranidipine
Plendil®
Nimotop®
Sular®
Anti-hypertensives (calcium channel
blockers)
Saquinavir Invirase® HIV medications
Simvastatin
Lovastatin
Atorvastatin
Simvastatin-Ezetimibe
Zocor®
Mevacor®, Altoprev® Lipitor®
Vytorin®
Zetia®
HMG-CoA reductase inhibitors
Cyclosporine
Tacrolimus
Sirolimus
Neoral®, Sandimmune®
Prograf®
Rapamune®
Immunosuppressants
Amiodarone Cordarone® Anit-arrythmics
Methadone None, generic only Analgesics
Sildenafil Viagra® Erectile dysfunction
Major Food and Nutrient Interactions: These drugs are metabolized by the cytochrome
P
450
system (CYP
450
) which is found primarily in the liver and intestine. The cytochrome
P
450
system and some of its isoenzymes may be altered or inhibited by certain substances
in food. One food that has been studied with regard to its ability to inhibit the 3A4
isoenzyme of the P
450
system is grapefruit juice. The furanocoumarins present in
grapefruit juice are thought to inhibit metabolism of certain drugs. With some drugs, this
interaction is clinically significant, while with others it is of interest only to researchers.
Because different drugs are metabolized differently, it is inappropriate to assume that all
drugs within a particular class are impacted by grapefruit juice. It is also inappropriate to
assume that this interaction extends to all citrus fruits. For example Seville oranges may
contain furanocoumarins, but other varieties do not (Paine 2008).
Recommendations: The list above contains the names of drugs that are thought to have
clinically significant interactions with grapefruit juice (McCabe 2003). Patients taking these
drugs should avoid grapefruit juice.
Note: Because this is an area of ongoing research, published recommendations are likely
to change frequently. Clinicians are cautioned to distinguish whether interactions are
clinically significant and to consult an updated drug information source other than the PDR
or package insert for all drugs.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
References: CYP450

McCabe BJ, Frankel EH, Wolfe JJ eds. Handbook of Food and Drug Interactions. 2003
Boca Raton, CRC Press. pp. 447-449.

Paine MF, Widmer WW, Pusek SN, Beavers KL, Criss AB, Snyder J, Watkins PB. Further
characterization of a furanocoumarin-free grapefruit juice on drug disposition: studies with
cyclosporine. Am J Clin Nutr. 2008;87:863-71.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > MAOI
MAOI

Tyramine-Restricted (MAOI) Nutrition Therapy
Drug Trade Name Drug Class
Phenylzine
Sulfate
Nardil®
Antidepressant Monoamine
oxidase inhibitor (MAOI)
Isocarboxazid Marplan®
Tranylcypromine
sulfate
Parnate®
Linezolid Zyvox® Antibiotic (MAOI)
Rasagiline Azilect® Anti-Parkinsonian Agent
(MAOI)
Selegiline Eldepryl® tablet
Zelapar® oral disintegrating
tablet
Anti-Parkinsonian Agent
(MAOI)
Selegiline Emsam ® (Topical patch) Antidepressant (MAOI)
Monoamine oxidase inhibitors (MAOIs) and food/nutrient interactions
Major Nutrient or Food Interaction: Biogenic amines such as histamine and tyramine are
found in some foods in increasing amounts as the foods age or spoil. These amines are
typically deaminated in the gastrointestinal tract by monoamine oxidases. Monoamine
oxidase inhibitors (MAOI) interfere with the deamination process allowing biogenic amines
to accumulate and act on the vascular and/or nervous system. Patients taking MAOI may
experience symptoms ranging from headache to hypertensive crisis if they ingest more
than 6 mg/day of tyramine. Biogenic amines are not destroyed by cooking, but levels may
be reduced by washing the food in tap water.
Nonselective MAO inhibition occurs with transdermal selegiline delivery and is necessary
for antidepressant to be effective. Hypertensive crisis as a result of ingesting tyramine-rich
foods is always a concern with nonselective MAO inhibition. Although transdermal delivery
minimizes inhibition of MAO-A in the gut, there is limited data with higher transdermal
doses; dietary restrictions are recommended with doses >6 mg/24 hours. With oral
selegiline, MAO-B selective inhibition should not pose a problem with tyramine-containing
products as long as the typical oral doses are employed, however, rare reactions have
been reported. Increased risk of nonselective MAO inhibition occurs with oral
capsule/tablet doses >10 mg/day or orally disintegrating tablet doses >2.5 mg/day.
Recommendations: Patients taking phenylzine sulfate, isocarboxazid or tranylcypomine
sulfate may eat normally, except for avoiding foods high in histamine and tyramine.
Because histamine and tyramine content of foods increaseses as foods age or spoil, it is
recommended to eat foods that have been manufactured and stored under optimal
conditions with careful attention to sanitation and temperature. Generally, it is better to eat
fresh foods and to avoid aged foods. Spoiled foods such as meat or fish that has a strong
odor or fresh vegetables that feel soft or slimy may contain unacceptably high levels of
histamine and tyramine and should be avoided.
Food Group Recommended Foods Foods to avoid
Grains All None
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Grains All None
Vegetables Fresh, frozen or canned
vegetables
Fermented vegetables
such as sauerkraut and
kimchi. Fermented,
decomposed or spoiled
vegetables.
Fruit Fresh, frozen or canned
fruits
Fermented, decomposed
or spoiled fruit.
Milk Milk, American style or
processed cheese
Aged cheeses such as
gouda, muenster, feta
Meat and Beans Fresh meat and fish
including ham, smoked
meats. Pepperoni
produced in the US.
Fermented meat
products such as chorizo,
salchichon and other
fermented sausages;
corned beef; imported
pepperoni. Meat products
near or beyond the
expiration date.
Other Wine and beer;
fermented soy products
such as soy sauce,
soybean curd; yeast
extracts

Foods that may be used in limited amounts
Coffee, cola, and other caffeinated beverages should be limited to a total of 16 oz per
day.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > Non > Potassium > Sparing Diuretic
Non-Potassium-Sparing Diuretic

Non-potassium-sparing diuretics and food/nutrient interactions
Drug Trade Name Drug Class
Furosemide Lasix ®
Loop diuretic;
non-potassium sparing
Hydrochlorothiazide
Hydrodiuril ®, Esidrix®,
Microzide®
Distal tubule diuretic;
non-potassium sparing
Major Nutrient or Food Interaction(s):
Patients who take furosemide or hydrochlorothiazide may experience increased urine
volume or increased frequency of urination. As a result, patients taking furosemide
may excrete excess potassium, calcium, phosphorus, magnesium and fluid.
Excess urination may also result in constipation and elevated serum sodium levels.
Recommendations:
Patients who take furosemide or hydrochlorothiazide may eat normally.
Patients who take these drugs may develop lower than normal serum potassium
levels.
In some cases a potassium supplement will be prescribed.
Patients who develop lower levels of potassium, calcium, phosphorus, or magnesium
may also be referred to a registered dietitian. In such a case, the registered dietitian
will review their typical food and mineral intake and make recommendations about
foods that can help.
The information below may be individualized by the dietitian to meet the needs of the
patient.
Diet to increase potassium intake
Food Group Recommended Foods Foods to avoid
Grains

Bran cereal or muffins,
granola
None
Vegetables

Artichokes, broccoli,
Brussels sprouts,
greens, kale, kohlrabi,
parsnips, rutabagas,
mushrooms, white and
sweet potato, spinach,
chard, winter squash,
fresh or canned
tomatoes, tomato or
vegetable juice, zucchini
None
Fruit Apricots, avocados, None
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruit

Apricots, avocados,
bananas, cantaloupe,
dates, figs, grapefruit
juice, kiwi, orange juice,
melons, mangos,
nectarines, papaya,
pear, pomegranate,
prunes and prune juice,
raisins
None
Milk

Nonfat, low fat, whole,
chocolate and
buttermilk, plain or
fruited yogurt, soy milk
None
Meat and Beans

Canned, dried, fresh or
frozen beans and
lentils, roast or ground
beef, chicken, clams,
crab and fresh, frozen
or canned fish, nuts and
nut butters, pork, and
turkey, soy
None
Other

Chocolate, molasses,
potato chips, wheat
germ
None
Diet to increase calcium intake
Food Group Recommended Foods Foods to avoid
Grains All None
Vegetables All, especially spinach
and okra
None
Fruit All None
Milk Milk, yogurt, cheese None
Meat and Beans All, especially soy beans None
Other None None
Diet to increase magnesium intake
Food Group Recommended Foods Foods to avoid
Grains Bran cereal, bran
muffins, oatmeal, brown
rice, whole wheat pasta
and spaghetti
None
Vegetables Artichoke, avocado,
greens, okra, baked
potato with skin, spinach,
Swiss chard,
None
Fruit None
Milk Eggnog, chocolate milk, None
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk Eggnog, chocolate milk,
soy milk
None
Meat and Beans Dried beans (black,
white, kidney, lima and
pole beans) and peas,
fish (halibut, yellowfin),
soy beans,
None
Other Nuts (almonds, cashews,
walnuts, hazelnuts,
chestnuts, mixed,
peanuts) and peanut
butter, pumpkin or
squash seeds, tofu,
wheat germ
None
Diet to increase phosphorus intake
Food Group Recommended Foods Foods to avoid
Grains All, especially oatmeal
and wheat germ
None
Vegetables All, especially baked
potato with skin
None
Fruit All None
Milk All, especially cheese,
skimmed, low fat or
regular milk
None
Meat and Beans All, especially meat,
dried beans, nuts, soy
and tofu
None
Other None None

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > Potassium > Sparing Diuretic
Potassium-Sparing Diuretic

Potassium-sparing diuretics and food/nutrient interactions
Drug Trade Name Drug Class
Spironolactone Aldactone ® Potassium sparing
diuretic Triamterene Dyrenium®
Major Food or Nutrient Interaction(s): Patients who take spironolactone or triamterine
may experience increased volume and frequency of urination. Because these drugs do not
increase potassium excretion, elevated serum potassium levels may be noted.
Recommendations: Patients receiving spironolactone or triamterine may eat normally
unless elevated serum potassium levels (hyperkalemia) develop elevated potassium levels
may result in a change to a different medication such as hydrochlorothiazideIf reduced
potassium intake is needed, a registered dietitian may be consulted to make to review their
typical food and mineral intake and make recommendations about foods to limit or avoid.
The information below may be individualized by the dietitian to meet the needs of the
patient.
Diet to decrease potassium intake
Food Group Recommended Foods Foods to limit
Grains Bran cereal or muffins, granola
Vegetables Artichokes, broccoli, Brussels
sprouts, greens, kale, kohlrabi,
parsnips, rutabagas,
mushrooms, white and sweet
potato, spinach, chard, winter
squash, fresh or canned
tomatoes, tomato or vegetable
juice, zucchini
Fruit Apricots, avocados, bananas,
cantaloupe, dates, figs,
grapefruit juice, kiwi, orange
juice, melons, mangos,
nectarines, papaya, pear,
pomegranate, prunes and prune
juice, raisins
Milk Nonfat, lowfat, whole, chocolate
and buttermilk, plain or fruited
yogurt, soy milk
Meat and Beans Canned, dried, fresh or frozen
beans and lentils, roast or
ground beef, chicken, clams,
crab and fresh, frozen or canned
fish, nuts and nut butters, pork,
and turkey, soy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Other Chocolate, molasses, potato
chips, wheat germ

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Common Nutrient > Drug Interactions > Vitamin K
Vitamin K

Vitamin K and Medications

If a child is prescribed coumadin or warfarin to “thin” his or her blood, caregivers need to
watch how much vitamin K is ingested from food and dietary supplements.
Explain to caregivers:
Coumadin or warfarin interferes with vitamin K so that the blood clots more slowly. The
doctor uses a test called INR to make sure that the blood will not clot too quickly or too
slowly. Changing how much vitamin K your child gets can change your INR. This change
could result in bleeding or an unwanted blood clot.
How?
Give your child medicine exactly as his or her doctor directed.
Keep your child's vitamin K intake about the same. That is as simple as 1, 2, 3:
Keep intake of high vitamin K foods consistent. You might plan to feed your child no
more than ½ cup of these foods per day. If your child likes these foods and eats them
often, he or she can eat more--perhaps a cup of one of these foods on most days.
1.
High Vitamin K Foods (listed with the highest one first)
Dark green vegetables
Kale
Greens: collard, turnip, beet, mustard, dandelion
Endive
Spinach
Broccoli
Brussels sprouts
Green onions or scallions
Do not have large changes in the medium vitamin K foods your child eats. For
instance, it would not be wise to eat cole slaw at every meal and then stop eating it
entirely.
2.
Medium Vitamin K Foods (listed with higher ones first):
Dark green lettuce or salad greens, such as Bibb, Boston, leaf or romaine
Cabbage or cole slaw
Asparagus
Okra
Black-eyed peas
Prunes or dried plums
Parsley
3. Make careful decisions about dietary supplements.
Dietary supplements can affect how your child's blood clots. Use only supplements
approved by your child's doctor or registered dietitian.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Generally, it is not wise to take vitamin E or fish oil supplements.
Herbal supplements to avoid include: alfalfa, arnica, bilberry, butchers broom, cat's
claw, dong quai, feverfew, forskolin, garlic, ginger, ginkgo, horse chestnut, inositol
hexaphosphate, licorice, meililot (sweet clover), pau d'arco, red clover, St John's wort,
sweet woodruff, tumeric, willow bark, and wheat grass.
Your child can take a daily multi-vitamin, which can be helpful if he or she does not
regularly eat leafy green vegetables. Remember to take it every day.
Do not take supplements that contain large amounts of vitamin K (more than 100
micrograms/day).
Developed by Jo Ann S. Carson, PhD, RD with information from USDA National Nutrient
Database for Standard Reference, Release 21 and K-Card (Couris and Dwyer, 1997).
September, 2009. Adapted for PNCM November 2011.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices
Cultural Food Practices


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > African American
Food Practices

African-American cooking is usually associated with the history and culture of the South.
Soul food has been a major part of the African experience in America, but it is a separate
and small part of the vast array of foods that make up African-American cooking. Soul food
came about as a result of the many years of scarce resources (food) and cooking practices
Africans brought with them from their homeland. African-American women cooked with
compassion in a style of their own to create and nourish family and friends during difficult
times. The term "soul food" was introduced during the mid-1960s Civil Rights Movement.
The translation of soul food was food cooked with the senses (Randall, 2002). Pastry that
would melt in your mouth, fried chicken was turned when it made that just-right crackling
sound, greens were seasoned by touch rather than measured as were all foods that came
straight from the soul (Randall, 2002).
Tradition plays an important part in the choices made by African cooks. Culture influences
the role that certain foods play in our food practices, method of food preparation, and the
use of food to celebrate life events.
Food practices of Africans in America were mainly vegetarian dishes with fish, possum, or
squirrel added for flavoring. Foods were boiled, fried in lard, roasted in leaves, or baked on
hot stones in the ground. Stews fed many people, black molasses added sweetness, and
fatty gravies provided calories needed to work long hours in the field.
Soul food is fondly described as food made with feeling and caring, "down-home cookin',"
and comfort food, food prepared with loving hands from knowing how to prepare the dish,
and not from recipes. Africans, taken from their homeland, had little control or choice over
life, so cooking became a way to express feeling, share love, and nurture family and
friends. Africans were not allowed to read or write, so they didn't cook from recipes. The
foods on African-American tables are rich in family cooking tradition passed down orally
from generation to generation and these recipes are still orally handed down today.
The Africans who worked on the rice, sugar, cotton, and tobacco plantations of the South
and the Caribbean used the food practices from their homelands. Many new plants and
seeds were introduced to them in the United States. Other foods they were familiar with
were okra, watermelon, black-eyed peas, yam, eggplant, sesame seed or benne, leafy
green vegetables or pokeweed, and spices from Africa. Many plants came from South
America but had traveled to Africa, such as chilies, tomatoes, peanuts, and corn. The
Native Americans had used corn as a staple food and reintroduced it to the dishes cooked
by the Africans.
The West Indian influence was a rich, hot spicy flavor from garlic, pepper, bay leaves, and
hot peppers. Regionally, African-Americans influenced meals in New Orleans. Soul food
used gulf shrimp in French-influenced Creole dishes like jambalaya and okra in dishes like
gumbo, red beans and rice, and Cajun catfish.
Soul food was wholesome food that used everything available. Nothing was wasted in their
kitchens. Stale bread became a great dessert, bread pudding, and old rice a sweet
pudding for the family dinner. The flavor was in the hands of the cook to create a tasty
meal, not from the use of special ingredients.
As African food ingredients were introduced to the United States, so were African food
practices. Africans in the United States used spices to prepare one-pot meals because
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
scant cookware was available to them. Stewing meats, deep-frying foods, and roasting
foods over open pit fires were common. Meat was cooked and smoked in hot stone-lined
barbecue pits. The liquid from cooked vegetables, especially greens, pot likker, was used
to dip cornbread and to make soups and stews, and provided the Africans with needed
vitamins and minerals. The food bonded loved ones together at the end of a long day’s
work, provided a time for oral history to be passed down to the next generation, time for
forbidden religious ceremonies to take place, and a time to visit.
The landowners of the South lived on pork and the Africans were given the scraps or worst
parts of the cow, chicken, and pig to make their meals. The Africans were given the guts,
snouts, ears, cheeks, bones, feet, and inside of the animal. The sparse but fatty meats
scraps provided protein and a source of concentrated calories from fat, which was readily
burned off with daily work. The meats were smoked, used to flavor their food, and to make
stews. Some of the Africans had small kitchens and raised their own animals and began
cooking in a new way. Africans hunted squirrels, raccoons, possums, and birds for the
family meals. They were not permitted to use guns for hunting, but learned how to catch
the animals and fish in nearby lakes or streams.
The Africans who came to work in the kitchens in the South increased flavor of the food
prepared for the landowners. There were deep-fried meat dishes with irresistible flavors.
Many fried foods sealed in moisture like fried fish. Vegetables were cooked with new
flavors. Cornbread, biscuits, rice pilafs, puddings, fruit pies, and fried pies from leftover fruit
were a treat for them but also provided energy. Each region and state had a unique culture
that was added to the African dishes. The new cooks were given more freedom in the
kitchens to create a blend of African, English, and Native American food that led to
Southern cooking. The cooks in Louisiana combined the French and Spanish flavors to
create New Orleans cooking. Cajun cooking combines French, African, and Native
American cooking for spices to create a new food taste. Creole mixed Spanish flavor with
the French, African, and Native American flavors to produce a hot, spicy taste. The cooks
used rice in many dishes like stews and soups. Both dishes begin with onion, bell pepper,
and celery to create a soulful meal. Two well-known Creole dishes are jambalaya and
gumbo.
The crispy, nutty flavor of deep-fried breaded meat, chicken gumbo, barbecued ribs, or the
smooth taste of a slice of sweet potato pie, gives the taste of soul food at its best. The
foods prepared by African cooks remained in the South until the Emancipation
Proclamation in 1865 when slavery ended. The cooks took their cooking skills with them to
the North and West, continuing to improve their cooking practices. These African
Americans cooked in hotels, for wealthy families, as porters on railway, and were
chuckwagon cooks and cowboys. The Buffalo Soldiers used stew pots, iron skillets, and
were the cooks in restaurants. They brought their love to create flavorful food that has
been passed down for generations by oral tradition.
Resourceful and inventiveness became a distinctive culinary tradition as African-American
women used their own style of cooking. Years later, the cooks would start their own
catering businesses and opened small restaurants in their neighborhoods. After the
depression years, processed foods and ready-to-eat foods increased. More meat was
consumed, as were dairy products; canned, frozen, and dried foods; and ice cream with
less fruits and vegetables. Potato chips, french fries, or convenience foods became
popular in the United States and in the homes of some African-Americans. The South
continued its food practices. In the Midwest, poor African-Americans continued to eat
greens, cabbage, souse, chitterlings, beans, and pork. The same inexpensive meats were
roasted, smothered, and barbecued (Randall, 2002). When fresh meat was not in the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
roasted, smothered, and barbecued (Randall, 2002). When fresh meat was not in the
budget, smoked and pickled meats were used in the meal plan. Fruits were eaten when in
season.
Those living on the farm had more choices of meat and fish to eat than those in the city.
Food was preserved, canned, or pickled to help during lean economic times. Hot water
cornbread made a small amount of vegetables or beans feed more people. Rice, eggs, and
potatoes were inexpensive food items that were prepared in different ways.
Traditional eating choices are difficult to change. The cooks of today want to keep the flavor
of the past and some are aware of the need for healthful changes in the way soul foods are
prepared.There is a move to lower the fat content (saturated fat), cholesterol, sodium, and
sugar in meals.There is a gradual increased intake of vegetables and fruits.
African-American cooks are making low-fat soul dishes delicious with less saturated fat,
sodium, and less sugar.
It is a fact that many diseases like hypertension, diabetes, heart disease, obesity, and
certain cancers are more prevalent in African-Americans today. There are many
contributing factors to consider for the African-American women and research indicates the
following (Kumanyika, 1993):
A slower metabolism compared with Caucasian women;
A larger-framed body is more accepted in the African-American community;
Less time or desire for physical fitness, less access to parks and facilities;
Unaware of the importance of serving sizes;
Enjoying large portions that restaurants offer;
Not wanting to lose that soulful flavor of favorite dishes.
As the focus continues on health promotion, prevention in the African-American
community, churches, restaurants, schools, businesses (barbershops and beauty shops),
new food practices will be introduced to lose the fat, sodium, and sugar in the new low-fat
soul meals, but keep the flavor of the past foods.

Immigrants or Ancestors

Africa’s hundreds of native cultures have their own unique foods and over time, each
culture had established an individual way of cooking. Many of the cooking practices were
developed based on people’s belief and the world around them. From the hundreds of
plants and animals around them, they selected a few they considered acceptable for
consumption. The climate of Africa also influenced the type of foods that were grown and
eaten (Erdosh, 1999). Over centuries, they have adapted, as they learned how to survive
during dry periods and to store food during the wet years. They learned to preserve foods
and ways to keep them safe.
Africans cultivated mixed plants in the fields that allowed the exchange of soil nutrients,
saved soil moisture, reduced weeds, and pest problems to help the plants grow organically.
African food groups were as follows:
Grains: wheat, barley, rice, millet, teff, and sorghum, sesame seeds were cooked as
grain;
Legumes: dried beans, broad or fava beans, lentils, and black-eyed peas;
Vegetables: various green leaves, which were always cooked (never raw like in
salads) root vegetables, such as yams, taro roots, manioc (these are starchy
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vegetables), beets, and eggplants;
Meat: goat, chicken, fish, some beef, and wild game (Erdosh, 1999).
Many of the grains were prepared as fritters, porridges, mashes, and couscous-like dishes
throughout the African continent (Harris, 1998). The beans were used in soups and stews.
Other foods indigenous to the African continent and eaten before European arrivals were
pumpkins, calabashes, and gourds (Harris, 1998). They were reported by chroniclers as
being eaten in Timbuktu, in Gao on the Niger, and in other areas with the Niger basin
(Harris, 1995). By the fourteenth century, there were turnips, which were probably imported
from Morocco to the north; cabbage, which was probably arrived earlier form Morocco and
Muslim Spain; eggplant; and cucumber, which some scholars believe may have originally
come form central Africa (Harris, 1998). Africans cooked with onions and garlic. Okra is
indigenous to Africa and was used both fresh and dried, appeared in soups and stews, and
was used to thicken sauces.
Other native plants that were part of the African diet included coffee, olives, wild lemons
and oranges, dates, figs, grapes, pomegranates, melons and watermelons (cultivated in
Egypt), tamarind and many tropical fruits, and sugar cane (Erdosh, 1999). African cooking
used many spices and seasonings to add flavor to the flavorless staple grains and legumes.
The spices were also a way to keep food safe by discouraging bacteria growth in the
tropical climates of Africa.
Other, more unusual foods included ackee (Blighia sapida), which turns up in Jamaica
national dishes, and the fruit of the baobab tree (Adansonia digitata), which is eaten as a
vegetable (Harris, 1998). Ackee originated in West Africa; it was used more as medicinal
than culinary and is considered a sacred plant. The seeds are ground into a powder and
used to thicken sauces. For cooking, there was the oil of the palm tree (Elaeis guineensis),
which also provided palm wine (Harris, 1998). Sesame oil was also used for cooking, as
were butters like shea butter. Beverages were made from tree barks, from flowers of a
bush of the hibiscus family, and from millet beer. Milk products were available, with goat’s
and sheep’s milk being the most common. Cheese was also eaten. Ancient Egyptians also
sweetened and thickened their sauces with fruit purees and syrups (Harris, 1998).
Meat was used sparingly, mainly for seasoning. At times of feasting, meat was important.
In the coastal regions of Africa, the bounty of the sea, river, and lagoons were enjoyed. The
dishes tended to be soupy stews served over or alongside a starch (Harris, 1998). To spice
things up, there were native peppers that went under the names of grains of paradise or
melegueta, or ashanti or guinea pepper (Afronum melegueta and Piper guineense) (Harris,
1998). These were so prized that they were traded with Europe in limited competition with
pepper from the East (Piper nigrum) (Harris, 1998). Salt was used to cure meat into a form
of jerky and to preserve fish. It was highly prized and was used mainly as a preservative.
Salt was mined in great blocks from salt mines in northern Mali.
These ingredients were used according to time-honored recipes in time-honored manners
(Harris, 1998). The cooking methods of the people of Africa were boiling in water, steaming
in leaves, frying in deep oil, toasting beside the fire, roasting in the fire, and baking in
ashes. Cooking and eating utensils were made form earthenware, wood, or metal and
many of the dishes and food-storage vessels were prepared from calabashes and other
gourds (Harris, 1998).
African cooks prepared meats over a hot fire, simmering them into slow-cooked mixtures
that allowed the flavors in the stockpot to mingle (Randall, 2002). In Africa, palm oil was
squeezed from the berries of the palm trees for deep-frying. The Portuguese introduced
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
squeezed from the berries of the palm trees for deep-frying. The Portuguese introduced
peanut oil to Africa, and then Africans started to fry food in peanut oil (Erdosh, 1999).
African foods included okra, yam, eggplant, sesame seeds, several kinds of leafy greens,
and African spices (Erdosh, 1999). Many food plants were introduced that originally came
from South America, but traveled to Africa with the Portuguese (Erdosh, 1999). These
foods included chiles, peppers, tomatoes, peanuts, and corn.
In Africa, food was mostly from the garden and the sea. All sorts of vegetables and fruits,
including yams, wild greens, okra, dates, watermelon, grains such as millet, rice, and
couscous played an important role in the African diet (Randall, 2002). Foods ranged from
bland to highly seasoned, the vegetable included beans with coconut milk, spiced
black-eyed peas, and spices such as cardamom, cumin, cloves, coriander, fennel,
fenugreek, garlic, ginger, mint, saffron, and sesame created the unique dishes. The vitamin
and nutrient-rich greens, okra, beans, peas, squash, and melons that composed their diet
in West Africa also contributed to the soul food cooking (Harris, 1995).

Adaptation of Native Culture to American Culture

For centuries, Africans brought the piquant tastes of Africa to the New World (Harris,
1995). Cornmeal signals our link with the Native Americans, a rounded tablespoon of
biscuit dough with the Southern gentility, a mess of greens and dozen okra pods with our
African roots, and a good measure of molasses to recall the tribulations of slavery (Harris,
1995).There were regional foods like chilies for spicy flavor and corn liquor to give food a
kick. Lard, from the heavy fat rendered from pig, was used for cooking and provided
energy for the long hours of labor.
An important part of the African American experience is the way that Africans introduced
many aspects of their food practices to America. This influence goes far beyond the
chitterlings, grits, greens, cornbread, and hog maws that are described as Soul food.
African Americans were given very little meat. They usually ate more fresh vegetables,
poultry, cornmeal, fish, wild game, and the parts of the hog or cow that were thrown away.
Vegetables and grains were the larger portions of the meals. Soul food was created as a
coping mechanism since no food was ever wasted and it became a way for them to survive
in America.
The Africans who worked on the rice, sugar, cotton, and tobacco plantations of the South
and the Caribbean used the food practices from their homelands. Many new plants and
seeds came with them and they were able to grow these plants in their provision gardens.
The plants that grew well, became part of their daily meal. The new foods were okra,
watermelon, black-eyed peas, yam, eggplant, sesame seed or benne, leafy green
vegetables or pokeweed, and spices from Africa. Many plants came from South America,
but had traveled to Africa such as chilies, tomatoes, peanuts and corn. The Native
Americans had used corn as a staple food and re-introduced it through the dishes cooked
by the Africans.
The African cooks adapted many recipes from their homelands by making substitutions
such as the sweet potato was used instead of the yam, cornmeal for couscous for family
meals. The fields of the South where the settlers farmed the land, Native Americans and
Africans created new dishes with new ingredients and seasoning to produce a new food
tradition. To understand the African American food practices, we should take a look at the
food practices fromwhere the Africans had come. Each culture had a unique cooking
practice; some practices came from people’s beliefs about the world around them, climate,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
their refusal to eat animals, how crops were planted, and how food was preserved. Africa
had been a major part of the international spice trade. In West Africa, a late morning and
evening meal was consumed with small amounts of food eaten during the day. The African
Americans brought seeds to America, and became part of their provision gardens in the
South. Many of these foods became part of rich tradition of the new cooks of the South.
African foods were prepared with spices and seasonings that added taste to grains and
legumes. The hot spices were used to help keep food from spoiling. Food was cooked in
one-pot over an open fire; nutrient-dense soups and stews were created from scrap meats,
poultry, fish, many different vegetables and grains. Food cooked in fat was a common way
to cook meat, fish, vegetables, fruits, and breads. Some foods had a cornmeal coating and
were cooked to a crispy tasty food as today’s deep-frying provides. In Africa, the palm tree
provided oil for deep-frying, in the South, lard from the pig was used. The fat from the lard
provided the Africans with needed calories for the long days of work in the fields.
Food was also roasted on an open fire from holes in the ground lined with hot stones.
Large pieces of meat were buried for hours to cook until tender. This cooking method is
similar to barbecuing on the grill. If the meat was tough, citrus juice, herbs, spices and
onions were used to make the meat tender. The family meals were prepared in the big pot,
with spices that provided flavor and made tough meats tender. Lemonade and ice tea were
their favorite sweetened drinks for meals.
As African food ingredients were introduced to America, so were African food practices.
Africans in America used spices to prepare one-pot meals, stewing meats, and deep-fried
foods, while using open pit fires to roast foods. Meat was cooked and smoked in hot stone
lined barbecue pits. The liquid from cooked vegetables, pot likker, was used to dip
cornbread in, make soups, stews, and provided the African with needed vitamins and
minerals. The food bonded loved ones together at the end of a long day’s work, provided a
time for oral history to be passed down to the next generation, time for forbidden religious
ceremonies to take place, and a time to visit over good food.
The Africans that came to work in the kitchens in the South increased flavor of the food
prepared for the landowners. There were deep-fried meat dishes with irresistible flavors
that sealed in moisture like fried fish, vegetables with new flavors, cornbread and biscuits,
rice pilafs, delicious pies and puddings, and fruit pies. The fried pies from leftover fruit was
a treat for them, but also provided energy. Each region and state had a unique culture that
was added to the African dishes. The new cooks were given more freedom in the kitchens
to create a blend of African, English, and Native American food that led to Southern
cooking. The cooks in Louisiana combined the French and Spanish flavors to create New
Orleans-cooking. Cajun cooking combines French, African, and Native American cooking
with spices to create a new food taste. Creole mixed Spanish flavor to the French, African,
and American Indian produced a hot spicy taste. The cooks used stews and soups with
rice in many dishes. Two famous Creole dishes are Jambalaya and gumbo. Both dishes
begin with onion, bell pepper, and celery to create a soulful meal.
Many of the foods that make up Soul food are rich in nutrients and dietary fiber, but the
added fat, especially saturated fats used to add the flavor to the dish, increases the risk for
major health problems in African Americans. Cabbage, greens, and other cruciferous
vegetables are known to help fight cancer. The sweet potato is loaded with beta carotene,
black eyed-peas, and other legumes are loaded with protein and dietary fiber. We can
make changes to lose the health-harming effect of the traditional dishes while keeping the
memories and flavor. Today's cooks can combine the best of the past with new ingredients
that will help improve the health of its people.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Herbs give foods a burst of flavor and aroma without adding sodium or calories (Nash,
1998). Some of the herbs and spices to use are: allspice, cardamom, chili powder,
cinnamon, cloves, cumin, fennel, ginger, nutmeg, sage,and thyme. Use canola or olive oil,
low-fat whipped margarines instead of saturated fats like butter, lard, or hydrogenated
shortening. Vegetables are flavored with herbs, spices, vinegar, bell pepper, or crushed
red peppers to replace salt pork, fat back, or ham hocks. The natural flavors of the
vegetables can stand on its own or receive more healthful enhancement from broth or
low-sodium bouillon cubes, herbs and or aromatic vegetables such as onion, garlic and
shallots (Nash, 1998).
Fried chicken can be oven-fried instead of deep-fried and still be as delicious. Lightening
up the baked macaroni and cheese dish with light or reduced fat cheese will help keep the
cheese flavors, but cut the fat. Evaporated skim milk is a great substitute when it comes to
adding creamy texture to pies, cakes, and other baked goods (Nash, 1998). Open-faced
pies, crusts made without shortening can still be flaky.

Meal Planning in this Culture

The greatest impact on the lifestyle of many African-American families is the lifestyle of any
parents or grandparents who lived in the South. Like many ethnic groups removed from
their homelands, many practices were assimilated into American food culture.
Mealtime is still for family togetherness. Celebrations, from birth to death, are centered on
food. At holidays and family gatherings, food is the main focus. A spread of deep-fried
chicken, collard greens with fatback, candied sweet potatoes, cornbread, and fruit cobbler
is commonly a part of any family gathering, and grits and home fried potatoes are common
for Sunday breakfast. Chittlins and black-eyed peas are a New Year’s holiday tradition.
Barbecued spareribs and watermelon are a part of foods enjoyed in the summer for picnics
and family reunions.
There is no specific meal plan consumed by all African-Americans. Any stereotyping or
assumptions that all African-Americans like or eat the same foods should be avoided.
Neither do all adhere to foods high in fat, salt, or sugar; have unhealthy cooking habits; or
lack nutritional understanding. Family background, regional influences, and food
preparations are individual. For many, the main meal is late in the day and on Sundays
after church. Traditional southern meals have meat, fish, greens, rice or potatoes, corn or
sweet potatoes, bread, dessert, and sweetened drinks. Greens are seen as good for
health, and red and yellow vegetables are included in the meal plan. Fresh peaches, pears,
and watermelon are also a part of the meal plan. Most African-Americans are lactose
intolerant and dairy products are consumed infrequently. Skipping meals may be common.
Salt use or salty foods are common.
Like most people in the United States, African-Americans throughout the country are now
eating lighter breakfasts with more dry or cooked cereal and less eggs, bacon, and pork
sausages. Sandwiches are eaten at lunch with smaller portions of cold cuts or processed
meats. Dinner is eaten after work, and it has become the biggest meal of the day (Dixon,
1994). In many families, meal schedules are irregular and family members eat when it is
convenient (Dixon, 1994). Meals may consist of fried, baked, or grilled meat with starchy
foods like rice, pasta, or starchy vegetables, and only one vegetable or none. Snacks
include potato chips, hot chips, cookies, snack crackers, chocolate, hard candy, and soda.
Corner stores in urban areas are convenient, but have few if any fruits or other healthful
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
food choices. More sweetened drinks and sodas are used with infrequent water and milk.
Food is often prepared in large quantities for more than one meal or for company because
meals were often prepared in one large pot in the past. Many still prepare large pots of
stews, soups, and lots of deep-fried meats, gravy, and dessert with Sunday dinner or
during the week. Soul food in the South means hospitality and sharing with family and
friends that may visit.
African-American-owned restaurants have started to substitute canola oil for lard and serve
more chicken, especially oven-baked chicken, and fresh fruit instead of fruit cobblers and
bread pudding. The aroma that fills soul food restaurants lets everyone know the big pot is
cooking. Many people are too busy to prepare traditional meals daily, which may be
reserved for holidays and family gatherings.
Modern African-American cooks have kept many of the traditional ways of cooking while
modernizing others. Cooks and cookbook writers are making healthful changes in recipes
of the past to keep the flavor, but reduce the fat, sodium, and sugar content. The recipes
retain the flavor of traditional southern soul food cooking.
African-American rites are focused on food. The society is based on religious dates,
feasting, cooking, and growing food. Many African-Americans are Protestants and have no
specific food restrictions. However, a large number of families are members of religious
groups that may have restrictions or dietary preferences that influence their meal plans.
These may include Seven-Day Adventists, Muslims, Jehovah's Witnesses, and others.
Large selections of holiday foods are prepared for family gatherings. Besides all the formal
and traditional foods for holidays, many African-Americans now observe and celebrate
Kwaanza, an African-American cultural holiday created by Dr. Maulana Karenga in 1965.
Kwanza is celebrated December 26 through January 1. The name Kwaanza comes from
the Swahili word meaning "first fruits." It is a time for families to affirm the seven African
principles of Kwaanza. Many churches in the African-American community celebrate with
programs that place more religious focus on this holiday.
The art of African-American cooking is a celebration of African culture and tradition
(Medearis, 1997). Every time you eat gumbo, sesame seeds on a hamburger bun, a
handful of peanuts, or black-eyed peas for good luck on New Year’s Day, you are eating
some of the foods that African cooks introduced to the United States. African-American
cooks have ingeniously adapted many traditional recipes to give them a unique flavor and
appeal. The dishes have become a part of today meals. The survival foods eaten at the
parents' and grandparents; homes are a part of life today.
Today's meal plans can include other ethnic dishes and foods. The focus is on eating the
foods of the past making them more healthful to pass on to new cooks and plan low-fat soul
food family meals.
Soul Food Meal Choices (reserved for Sunday or Special Days)
Breakfast Grits
Pork sausage or bacon
Buttermilk biscuits with gravy
Home-style potatoes
Scrambled eggs
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Coffee or juice
Snack Boiled peanuts
Lunch Fried chicken
String beans
Mashed potatoes with gravy
Roll with butter or margarine
Iced tea
Peach cobbler
Snack Cornbread and buttermilk
Dinner Fried catfish
Coleslaw
Hush puppies
Beans with hot sauce
Lemonade
Pound cake
Snack Fried pies or fruits in season
Hoe cakes or hot water cornbread
Special Day Menus
Texas Juneteenth Deviled eggs
Ham spread
Cole slaw
Potato salad
Fried chicken
Red soda
Watermelon
Family Picnic Macaroni and cheese
Mixed greens
String beans and ham
Fried chicken
Potato salad
Pound cake
Iced tea
Funerals Baked ham
Fried chicken
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Green beans
Potato salad
Pecan pie
Classic Creole Gumbo Z’Herbes
Fried eggplant
Bread pudding
Café Brulot
Chess pie
Iced tea
Kwaanza Feast Roasted peanuts
Pickled black-eyed peas
Roasted pumpkin seeds
Chicken yassa
Plain white rice
Cucumber salad
Salade de fruits
New Year’s Chitterlings
Hoppin’ John
Southern succotash
Mixed greens
Jalapeno cornbread
Iced tea

Food Dictionary


Food Ingredients or Preparation
Acadian
(Cajun) cooking
Combined French-Canadian and African foods.
Beef bone
Bones from ox, cow, or bull. Boiled in water to
make soups or, if very meaty, cooked with or
added to vegetables to make stew.
Benne
A South Carolina term for sesame seeds, which
came to the United States from Africa. In
Charleston, the seeds can be found as
ingredients in Benne seed wafers and Benne
seed candy; both are thought to bring good luck.
Black-eyed
peas
A larger cousin of the cowpeas.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Blackstrap
Molasses
A very dark type of molasses. Traditionally used
in African-American cooking.
Boiled custard
Thin custard made with milk, eggs, sugar, and
vanilla. Served chilled.
Boiled peanuts
Fresh young, undried peanuts cooked in
saltwater. Usually consumed as a snack.
Brains
Pork brains are boiled, fried, or scrambled with
eggs.
Bread
Brown or light varieties. Brown bread is whole
wheat bread; light bread is white bread.
Brunswick
stew
Southern dish of chicken, rabbit, or ground meat
with some mixture of corn, onions, okra, salt
pork, tomatoes, and lima beans.
Butter beans Similar to lima beans. May be fresh or dried.
Buttermilk
Liquid left after butter has been churned from
milk or cream, or cultured milk by the addition of
lactobacillus to sweet milk (whole milk).
Cala
Hot rice fritters that were sold door-to-door in the
French Market in New Orleans.
Catfish
A favorite African-American food. It was
disdained by proper Southerns who did not want
to eat the scavenger fish. The fish is dipped in a
cornmeal batter and fried until crisp.
Caribbean
Creole
Cooking has more peppers, tomato paste, lard,
tubers, fruit, and various spices such as
cinnamon, nutmeg, ginger, cloves, and allspice.
Less butter, cream, celery, and basil is used.
Chitterlings or
chittlins
Pork intestines that are boiled or fried and
served with hot sauce or vinegar.
Clabber
Between buttermilk and butter, a thickened
buttermilk.
Collard
Variety of kale referred to as greens. The green
leaves are boiled with fatback, lard, or meat.
Cornbread
Bread made with cornmeal, eggs, milk, or
buttermilk and fat. Can be baked or fried on
skillet or griddle like pancakes.
Corn pone
Cornmeal mixed with hot water, shaped into oval
patties, and fried in skillet or griddle. Also know
as hot water cornbread.
Country ham
Heavily salted, cured, and aged pork. May be
sliced and fried or baked.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Country-style
Sausage links or ground sausage made into
patties.
Cracklings or
cracklin
Fresh crumbled pork skin cooked until crisp,
eaten alone or added to cornbread.
Creamed
potatoes
Mashed potatoes with milk and butter or
margarine
Crenshaw
Type of squash similar in texture and flavor to
pumpkin and used to make pies.
Croaker Freshwater fish, usually fried.
Croquettes
Leftover fish, egg, cornmeal or flour, seasoned,
breaded, and deep-fried.
Cowpea and
field peas
Native to Africa, at one time planted around the
edges of fields. Served with Hoppin' John on
New Year's Day for good luck.
Dressing
Prepared with cornbread, chopped vegetables,
and meat broth. Similar to stuffing.
Dried beans
Legumes such as lima beans, butter beans,
pinto beans, great northern beans, black-eyed
peas, crowder peas, and split peas.
Drinks Southern term for carbonated beverages.
Eggnog
Milk or cream, eggs, nutmeg, and sugar
combined with bourbon for holiday beverage.
English peas Green peas or garden peas.
Fatback
Clear fat from the back of a loin of pork. It is
salted and/or smoked, cut into small pieces, and
fried to become cracklins or cracklings. Rended
fatback is called lard.
File
Made from the leaves of the sassafras tree,
ground into a powder, and used to thicken soups
and stews.
Fish
Southern style was usually croaker, mullet,
flounder, perch, whiting, or catfish fried with
cornmeal.
Green beans Refers to lima beans.
Greens
Green, leafy vegetables such as collards, kale,
mustard, and turnip greens, often seasoned with
meat or fatback. May be cooked separately or in
combinations.
Grits
Coarsely ground hominy cooked as cereal,
served with butter, gravy, and cheese as a side
dish. Frequently served with eggs and bacon at
breakfast.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Gumbo Means okra in the Bantu languages of Africa.
Gumbo Z’
Herbs, chicken gumbo, red pepper, rice, and
okra were added to Creole cooking to create a
new dish.
Gut strut
Another name for a big pot of chitterlings or
chitlins.
Ham hock
Meat from lower end of ham shank, added to
vegetables for seasoning, boiled or simmered
and eaten as main dish.
Head cheese
Prepared by coarsely dicing the edible part of
the pig’s head or calf, these pieces were cooked
and pickled with spices until tender. When
cooled, has the consistency of jelly.
Hoecakes
On the greased side of a hoe, a mixture of meal
and water was mixed until thick enough to fry
over an open fire. Salt was added if available.
Made by Africans as a quick, hot meal during the
short break allowed at noontime.
Hominy
Dried corn that has been soaked in lye water to
remove the husk. Can be simmered until tender
or drained into grits.
Hog jowl
Jaw of a pig, cured and used as seasoning for
vegetables or served as main dish, fried like
bacon or boiled.
Hog maw Pig stomach, boiled and eaten as a main dish.
Hoppin’ John
Originated in West Africa, a popular dish in the
south. It was a combination of rice and
black-eyed peas.
Hot sauce
Found in traditional African-American
restaurants. Hot sauces under a variety of names
are a hallmark of African-American cooking.
Hush puppy
Ccornmeal batter with leftover catfish, milk, egg,
and finely minced onion that is deep-fried in fat.
Tossed to dogs to keep them quiet.
Iced Tea
The wine of the South. It's one of the cool drinks
that quenched the thirst of African-Americans.
Jambalaya
A highly seasoned rice dish that can include any
combination of pork, beef, seafood, or chicken.
The African Americans who cooked Creole style
added new ingredients and made it a tastier dish.
Kale
Hearty cabbage with crinkled leaves, cooked
with greens.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Karo syrup
Corn syrup with a taste between the lightness of
maple syrup and the thick, dark taste of
molasses. Used by many African-Americans
living in the North.
Lane cake
Named for creator, Emma Rylander Lane. Has
been a Southern favorite Christmas cake with 4
filled layers and boiled white frosting.
Lard solid or
semisolid
White fat obtained by rendering pig fat. Used in
baking, frying meat, and seasoning vegetables.
Milk or sweet
milk
Whole milk.
Molasses
A by-product of sugar production, used to
sweeten foods by African families.
Mountain
oyster
Cow or pig testicles, skinned and fried, served
as a main dish.
Mullet
Type of red or golden fish found in coastal
waters or freshwater streams.
Muscadine
Variety of grape, greenish purple in appearance,
may be used for jam.
Mustard
greens
Young green leaves used for vegetable dish,
often cooked with bacon grease, fatback, or ham
hock.
Neckbones
Also known as Shine bones. Used to season
vegetables or may be boiled and served as main
dish.
Okra
Tall, tropical or semitropical plant with edible
green pods that are used as a vegetable dish, in
soups and gumbo. Can be eaten boiled or fried.
Oxtails
Tail of cow used in soups or boiled and served
as main dish.
Peanuts
Appear in almost all courses of African and
African-inspired cooking. Most often eaten as a
snack, especially roasted peanuts.
Pig ear
Boiled or fried and served as main dish or in
sandwich.
Pig feet Boiled, fried, or pickled and served as main dish.
Poke salad
Dish made from pokeweeds, a herb with
poisonous roots and edible young shoots and
leaves. The young leaves were parboiled, the
water discarded, and leaves simmered again in
fresh water. Often cooked with fatback or ham
hock, served as a vegetable dish.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Pork rind Crispy fried rinds of fatback.
Possum or
Opossum
Popular game food hunted at night. Possum is
stewed or roasted.
Pot likker
Liquid that remains in bottom of pot after
vegetables (especially greens) or meat had been
cooked. Traditionally soaked up with bits of
cornbread and eaten at the end of the meal or as
a snack.
Potato pie Sweet potato pie, similar to pumpkin pie.
Red-eye gravy
Thin, transparent gravy made from country ham,
gravy drippings, and water or black coffee.
Red links or
hot links
Brightly colored, high-fat, spicy sausage that is
usually boiled or fried.
Red velvet
cake
Variety of chocolate cake tinted with red food
coloring. White icing boiled or beaten.
Roux
French-like gravy mixture of oil or butter and
flour is New Orleans Cajun-Creole based.
Salt pork Referred to as fatback, used for seasoning.
Sardines
Any of various small or half-grown edible
herrings or related fish. Canned in oil.
Sesame
wafers
Popular type of cracker in parts of the South.
Seven Steak
This particular type of steak is much used by
Creole cooks in New Orleans. According to Leah
Chase, it gets its name from the shape of the
bone in the cut, which resembles a seven.
Sousemeat or
head cheese
Cold cut made of mixture of various organ meats
and gelatinized broth.
Streak-o-lean
Cured, sliced thin fatback, eaten like bacon or
cooked with vegetables.
String beans
Green beans. May also be referred to as pole
beans or lima beans.
Succotash
Lima beans or shell beans cooked with corn or
okra.
Sweet potato
Tuberous root plant similar to yams in Africa,
eaten as a vegetable or made into a pie.
Tongue Boiled meat from the cow tongue.
Tripe Cow’s stomach, usually boiled or fried.
Turnip greens
Turnip greens, often cooked with fatback or
meat.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Vienna
sausage
Small sausage in a can.
White or red
clay
Dirt eaten by women who were anemic.
Whiting Small white fish, usually deep-fried in cornmeal.
Yam
Sweet potatoes are often called yams. True
yams are found in Africa and the Caribbean.
Yellow root tea Teas from the yellow roots of common shrubs.
Sources: Diabetes Care and Education Dietetic Practice Group of the American Dietetc
Association.Ethnic and Regional Food Practices A Series Soul and Traditional Southern
Food Practices, Customs, and Holidays. Chicago, Ill: American Dietetic Association; 1995.
Harris J. The African Cookbook Tastes of A Continent. New York: Simon and Schuster;
1998.

References


Kumanyika S, Wilson JE, Guildford-Davenport M. Weight related attitudes and behaviors of
black women. J Am Diet. Assoc. 93:416-422, 1993. Related Links: Abstract
Diabetes Care and Education Dietetic Practice Group of the American Dietetc
Association. Ethnic and Regional Food Practices A Series Soul and Traditional Southern
Food Practices, Customs, and Holidays. Chicago, Ill: American Dietetic Association; 1995.
Dixon B. Good Health for African Americans. New York: Crown Publisher, Inc; 1994:23-33.
Erdosh G. The African American Kitchen. New York: Rosen Publishing Group, Inc; 1999.
Harris J. The Welcome Table African American Heritage Cooking. New York: Simon and
Schuster; 1995.
Harris J. The African Cookbook Tastes of A Continent. New York: Simon and Schuster;
1998.
Medearis A, Medearis M. African American Arts Cooking. Brookfield, CT: Twenty-First
Century Books; 1997.
Nash J. Low-Fat Soul Food. New York: Ballantine; 1996.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Randall J, Martin T. A Taste of Heritage the New African American Cuisine. New York:
Wiley Publishing; 2002.















Web Links

Office of Minority Health (Accessed September 21, 2009)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Asian Indian
Food Practices

The term “Asian Indian” was first designated by the United States Census Bureau in 1980
to describe immigrants from the Asian subcontinent of India (Williams 1988).
Asian Indians constitute the third largest minority group in the Asian and Pacific Islander
category in the United States, numbering 1.68 million (Census 2000). This community is
relatively young with approximately 10% elders (Ghosh 2002) and consists of the following:
Academic and technical professionals;
Students pursuing higher education;
Individuals who own or work in commercial and service establishments such as gas
stations, restaurants, and motels;
Dependents – spouses, children, siblings, and elderly parents who visit from India for
extended periods of time and/or parents who have migrated to US and live with their
family as immigrants/citizens.
States with a high concentration of Asian Indians include New York, New Jersey,
Maryland, Illinois, Texas, California and Florida.
Linguistic, regional, and religious diversity exists within the Asian Indian community in the
United States. Immigrants from India come from 26 different states and 7 union territories,
which can be divided into 4 regions, namely, north, south, east, and west. Each state has
its own distinctive language, dialect, customs, and food practices.
Hinduism is the predominant religion practiced by more than 80% of Asian Indians followed
by Islam, Christianity, Sikhism, Buddhism, Jainism, Zorastrianism and Judaism (CIA 2002).
The followers of these different religions observe dietary laws and codes for fasting and
feasting, thereby influencing their overall eating patterns. An awareness of the diversity by
the local registered dietitians will be helpful in working with the growing number of clients of
Asian Indian origin.

Immigrants or Ancestors

The traditional Asian-Indian menu emphasizes the use of a variety of indigenous
plant-based products such as cereals, legumes, beans, roots and tubers, green leafy
vegetables, tropical fruits and vegetables, dairy products, and small to moderate quantities
of meat, eggs, and seafood.
Rice and wheat are used widely; use of barley, maize, corn, and millet varies by region and
local traditions. Rice is steamed or boiled, may be eaten plain, mixed with spices and
vegetables, or meat as pulao and biryani. Different types of shallow-fried, deep-fried, and
grilled breads such as roti, rotlis, chapattis, parathas, puris, kachoris, luchis, naan,
lachchas, and bhaturas are prepared using whole wheat flour and refined flour.
Legumes, beans (channa, rajmah), and peas have a prominent place in the menu, by
themselves as dal (mung, toor, bengal gram/chana dal, masur, urad, black-eyed peas), or
in mixed dishes when combined with cereal grains and/or vegetables.
Vegetables are consumed in different forms: Stir-fried, sautéed, pureed, minced, or
prepared as a sabji/bhaji plain, with spices, or with a paste of ginger, garlic, and onion, to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
prepared as a sabji/bhaji plain, with spices, or with a paste of ginger, garlic, and onion, to
which different combinations of spices are added. Fresh vegetables are served as a raw
salad or combined with yogurt and served as raitas or pachadis.
Nuts such as peanuts, almonds, walnuts, and cashew nuts are used to enhance flavors and
taste.
Herbs such as mint, dill, cilantro (coriander leaf), basil, and spices such as chili, turmeric,
cumin, mustard, and tamarind are commonly used in food preparation. Spices and herbs
are often roasted and blended either dry or moist and termed as masalas. Regional
variations exist with regard to the spice combinations. Examples include garam masala in
the north and west; panchphoran in the east; sambar, rasam and chutney powders in the
south. These spice combinations are added to curry dishes, which can be stir-fried
vegetables, or gravy with meat, vegetables, or lentils. Chutneys and pickles or achar are
made from vegetable and fruit combinations and may contain generous amounts of oil, salt,
and spices and are accompaniments to the main meal. Sweet chutneys are popular in the
eastern region.
Chicken is popular; small amounts of goat or lamb, poultry, and eggs are used. Although
beef and pork are to be avoided for religious reasons, they may be included routinely or at
special occasions. Seafood dishes are popular in coastal cuisines. Roasting, marinating,
deep-frying or baking in a Tandoor oven are popular techniques; meats are cooked in curry
sauces as macher jhols, kurma, and kheema.
Tropical fruits are consumed as a snack or dessert. Fresh fruits and dried fruits such as
figs and raisins are popular as snacks or used in desserts.
Milk is a popular beverage added generously to coffee and regular or spiced tea. Dahi, or
yogurt, is used as a side dish. Dahi may be sweetened with sugar, salt, and spices, mixed
with water as a beverage (lassi) or eaten as a salad with raw vegetables.
Paneer/chenna, or homemade cottage cheese, is a popular cheese product used in snack
preparations as well as cooked with vegetables.
Desserts or mithai such as barfis, peda, and doodhpak are prepared from
khoa/concentrated milk or chenna/coagulated milk (Rasgulla) with sugar or jaggery
(molasses). Grains, lentils, and nuts may also be present in ladoos. Desserts such as gulab
jamuns and jalebis, imarti are deep-fried and preserved in sugar syrup. Regional variations
exist with regard to ingredients and preparation methods. Kulfi, or ice cream, may be
prepared using mango or pistachio and/or other dried fruits. Regardless of the type, most of
these products are concentrated sources of calories.
Deep-fried snacks such as pakodas, samosa, and chakli are prepared from cereal flours,
semolina, refined white flour, whole wheat flour, and legume flours, either individually or in
combinations. Snacks such as upma are not deep-fried; others, such as bhel-puri and
pani-puri, contain a combination of deep-fried and raw ingredients. Non-vegetarian snacks
such as kababs and chicken or fish tikkas may be baked, grilled, or broiled. Roasted or
deep-fried papads, appalams, and vadagums made from seasonal vegetables, rice, or
lentil flour are popular as an appetizer or snack and meal accompaniment. The vegetables
are spiced, boiled, sun-dried, and stored for use throughout the year. Rice or lentil flour is
made into a batter, cooked, and molded into shapes and sun-dried for the same purpose.
Snacks also known as tiffin in southern India may be served in the afternoon with tea or
coffee or as appetizers during weekend parties.
Betel leaves and fennel seeds are used as mouth fresheners at the end of the meal.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cooking oils include seed oils such as peanut, mustard, sesame, hydrogenated vegetable
oils, and clarified butter or ghee.
Food preparation techniques:
Grinding: Techniques used for dry grinding of spices or wet grinding of spices and
herbs or grinding of batters containing cereals or cereal-lentil combinations;
traditionally done using a heavy stone slab with a round stone for grinding. In current
times, electric blenders, mixers, and spice grinders are used based on economic
status and affordability.
Soaking: To facilitate cooking of lentils; also used for cereal lentil combinations before
grinding and fermentation.
Fermentation: For natural yeast-leavened breads such as naan in the North and idlis
and dosas in the South; also for preparing dahi or yogurt.
Marinating: Meats and sometimes vegetables such as potatoes, using agents such as
lemon juice, vinegar, yogurt, and raw papaya. Indian pickles or achar are also
prepared by marinating fruits and vegetables in salt and oil.
Frying techniques: Include shallow frying on a tawa or flat, round griddle or deep
frying in a wok or kadai made from cast iron, stainless steel, or anodized aluminum.
Roasting: Spices, cereals, lentils, or flours without oil to remove the raw smell or
roasting in small quantities of oil for flavor. Roasting may also be used as a first step
in the preparation of dry or wet masalas.
Baking or grilling in a tandoor oven.
Steaming: Natural pressure cooking and boiling also used.
Seasoning: Some oil is heated in a flat pan and a chosen spice or spices are quickly
tempered at high heat and then added as a first step in preparation of some mixed
dishes or as a final step in the cooking of lentil, gravy, and vegetable/meat dishes.
This process is termed as baghar, tarka, or chonk.
Meals are eaten in a round or an oval stainless steel, brass, silver thali with contemporary
utensils containing katoris or sections (bowls) in which vegetables, lentil, dahi (yogurt), and
other accompaniments are served. Banana leaves are used in the South during religious
occasions and other traditional ceremonies. Food is eaten using the right hand as well as
traditional flatware. Food is served in courses by the women of the house who prepare the
food. Food practices and times of meals may be modified to suit the family schedule in
households with young children, elderly relatives, and working parents living in the US.

Asian Indian Regional Food Practices

Distinctive climatic conditions and seasonal cycles influence agricultural production. This
results in a diversity of food practices among Asian Indians. Generally speaking, regional
food practices can be categorized as northern, eastern, western, or southern food
practices. Inter-regional variations exist with regard to use of spices and preparation
methods (ADA 2000).
Northern Food Practices
Wheat, the staple crop in the North, is prepared into a variety of broiled, unleavened, and
leavened breads such as rotis, phulkas, or chappati; and shallow-fried breads (plain and
stuffed parathas) and deep-fried breads (puris and bhaturas). Chappatis made from corn
(Mukki ki roti) and wheat with chana or gram flour (Missi roti) are popular in northwestern
states. Accompaniments include plain or spiced basmati rice as pulao and biryani, sauteed
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
or stir-fried vegetables, plain yogurt or raita, raw salads, and achar. Garam masala, a
popular spice mixture consisting of spices such as asafoetida, cumin, coriander, turmeric,
chili peppers, and amchur, along with onion, garlic, and ginger, are used to marinate
vegetables and meat in the preparation of gravy dishes such as kofta, kheema, and
kurmas as well as lentil dishes. Spinach and mustard greens (Sarson ka saag) are
prepared as gravy dishes. Roasting and frying are popular preparation techniques.
Concentrated milk-based desserts such as pedas, kheer, kulfi, halwas, burfis, rasgulla, and
gulab jamun are popular. Plain or spiced tea, lemonade (nimbu pani), jeera pani, milk
shakes, thandai, and lassi are choice beverages.
Eastern Food Practices
Meals in this region include white parboiled or steamed rice as a staple along with fish. The
meal begins with a stew containing bitter vegetables, called shukto, followed by dals, a
fried green vegetable or saag, fish curry, and sweet chutneys made from tart fruits and
vegetables. Shrimp, lobster, and crabs are cooked in various ways with mustard and garlic.
Mutton, chicken, and eggs are common, although lamb and pork are not popular. Lightly
seasoned vegetables and meat and vegetable combinations using panchphoran are also
featured in the menus. The easy accessibility of coconut permits its use in a variety of
curries and chutneys. As in the North, tea, lemonade, coconut milk, and lassi are popular
beverages. Coagulated milk desserts made from chenna or paneer such as Rasagolla,
mishti doi, and sandesh are an integral feature of this region's cuisine.
Western Food Practices
Rice is a staple consumed with dal along with breads made from whole wheat, millet, and
maize. Specialty breads such as thepla and millet breads are popular. Sprouted lentils,
coconuts, peanuts, and sesame seeds are used in a variety of preparations. In the absence
of dal, mung, black-eyed peas, or moth beans may be used. Vegetable dishes such as
undhiyu, lentil flour-based dhoklas and khandvi, yogurt-based sauces known as kadhi and
sprouted beans are popular. Typical meals consist of cooked rice with dal, meat, poultry, or
fish, a salad with yogurt, one or two vegetable dishes, and rotlis or deep-fried puris. Meals
may be accompanied by dahi or chaas, Chundo, Gol Keri, Athanu and Kachumbar.
Desserts such as halwas, shakarpaali, and puranpolis are popular. Shrikand is a popular
dessert eaten with deep-fried bread or puris. Other desserts include basundi, lapsi, and
aamras when in season. While fish is popular in coastal cuisines, lamb and chicken are
consumed in other areas.
Southern Food Practices
Common features of South Indian food practices include the use of rice, the staple grain
served in three courses with sambar, rasam, and yogurt accompanied by vegetable or
pickle. White, parboiled rice, puffed rice, beaten rice, and spiced rice are different
preparations of this region. Dal is served plain or in the form of gravy dishes such as
sambar and rasam or may be combined with cereals, ground, fermented, and used to
prepare breakfast and snack items such as idlis, appams, crepes, or dosas (plain and
vegetable-filled masala dosa). Vegetables are sauteed and served as poriyals or prepared
with coconut and spices as kootus and avial. Raw vegetables may be prepared as
pachadis or kosumallis in which soaked/sprouted lentils are added to vegetables. Fish,
chicken, lamb, mutton, and eggs are common in non-vegetarian meals. Fruits are eaten as
snack or dessert items. Desserts include reduced-milk preparations with jaggery
(molasses) such as payasam, rice, or rice-lentil combinations with jaggery such as pongals
and appams in addition to desserts using ghee, nuts, and spices like cardamom.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Beverages include coffee grown in this region, sweetened with sugar to which milk may be
added. Commonly used spices include coriander, asaefoetida, cumin, fenugreek, red chili
peppers, ginger, pepper, turmeric, nutmeg, and saffron. Various spice powder
combinations are prepared in different regions. These powders are added to vegetable and
lentil dishes or may be mixed with cooked rice and ghee. Coconut, grated fresh or dried, is
used in many preparations; pickles and appalams, vadagums or papad are meal
accompaniments. Food may be served on banana leaves for special occasions.

Asian Indian Religious Food Practices

Religion is a way of life and an integral part of Indian traditions and food-related beliefs
(Achaya 1994). Among the Indian population, 80% practice Hinduism, 15% are Muslims,
2% practice Sikhism, with the remaining practicing Buddhism, Christianity, Jainism,
Zorastrianism, and Judaism. Religious following dictates prohibitions and proscription of
foods as well as feasting and fasting regimens.
Feasting
Each religion has festivals in which food plays an important role. Festivals such as
Deepavali, Diwali, or Festival of Lights are celebrated in winter to welcome light as a
symbol of hope. Traditions include fireworks and exchange of sweets. Additional feasting
days include celebrations and rituals surrounding birth, weddings, death, and many
milestones during the lifecycle, or the harvest season. Generous quantities of regular foods
and sweets are prepared and offered to the Gods before distribution for human
consumption. Specific foods such as ghee, rice, wheat and wheat flours, grits, urad dal,
indigenous vegetables, jaggery, spices, bananas, and coconut are frequently used and
have symbolic value. For example, bananas and rice symbolize fertility; coconuts represent
sacredness, whereas betel leaves are considered auspicious.
Asian Indians in the United States socialize on weekends in an effort to relax, maintain their
ethnic identity, connect with family and friends, and celebrate religious festivities together.
Traditional dishes as well as high-calorie snacks and desserts are prepared and served
along with mainstream foods such as pizzas, brownies, and cakes to satisfy the younger
generation's palate.
Fasting
Fasting is common among all religious sects in India. For example, Muslims fast during the
month of Ramadan while Orthodox Hindus fast on religious festivals as well as certain days
in the lunar months. Fasting for Muslims during Ramadan, the ninth month of the Muslim
Lunar year, entails a meal before sunrise and one after sunset and usually begins by
eating dates. The duration and frequency of fasting in all religious sects is highly variable
and individualistic. Fasting may involve abstinence from one food or an entire food
category, or consumption of fruits or raw foods only. For instance, Gujaratis may eat
tapioca-based Sabudana Khichidi, or broken or puffed rice, during a fast. Milk and fruits
may be allowed during fasting. Desserts such as ladoos and jalebis may also be consumed
during a fast.
Hinduism
Religious scriptures, in essence, describe food as life and therefore have an impact on
physical health, mental health, and well-being. Food-related beliefs stemming from
scriptures and teachings include the following:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Consider the cow sacred and therefore prohibit beef consumption; other meats such
as mutton, lamb, fish, chicken, and other poultry are permitted.
Advocate moderation by dictating that solid food should fill half the stomach, liquid
one fourth, and the remainder should be left empty for proper digestion.
Categorize foods into kacha and pukka foods. Kacha foods like cereals and lentils are
cooked in water, whereas pucca foods are cooked in ghee and milk, both of which are
considered ritualistically pure. Kacha foods are traditionally to be consumed in the
kitchen or house while pucca foods may be taken out of the house.
Attribute a relationship of food to mood, fitness, and longevity. Depending on the type
of physiological and emotional response invoked, foods are categorized as Sattvic
foods, Rajasic foods, and Tamasic foods.
Sattvic foods, such as dairy products, cereals, ghee, legumes, and certain
vegetables, are believed to invoke more humane and pure thoughts and
contribute to health and well-being.
Rajasic foods, which include meats, eggs, astringent, and highly spiced foods,
are believed to contribute feelings of aggression and desire for power.
Tamas means darkness. Therefore, consumption of Tamasic foods, like garlic,
pickled foods, rotten foods, and so forth, are believed to lead to darkness of
mind, contribute feelings of dullness and sluggishness, possibly leading to
physical illness.
Ayurveda
Ayurveda, or the classical system of Indian medicine, includes the categorization of foods
based on their ability to create balance in body humors as well as the use of food as a
healing agent. Some of these concepts led to the prescription and use of foods according
to season as well as humoral qualities.
Foods such as white sugar, millet, buttermilk, milk, and bananas are thought to be
kapha, or mucus-producing foods, which can aggravate respiratory ailments.
Wind- or vayu-producing foods such as legumes are responsible for flatulence; fatty
foods can cause pitha, or excessive bile, which deranges metabolism and produces
heat.
Hot, or ushna (ushma), foods such as garlic, cloves, lentil beans, papaya, pineapple,
and mango are believed to produce heat.
Sheeta, or cold foods, such as cereals, legumes, fruits, and vegetables, are believed
to contribute to cooling of the body.
Addition of spice or cooking can change the hot or cold status of a food. Also, regional
variations based on food availability and usage exist regarding what constitutes a hot or
cold food. For instance, wheat is a "hot" food in the South; lentils, except for "masur" dal,
are cold in the West, but "hot" in the North. In keeping with this belief system, heavy and
cold foods are avoided in spring, cold and sweet foods such as yogurt and green mango
are eaten in summer whereas hot foods are eaten during the monsoon or rainy season.
Winter foods include deep-fried foods, dried fruits, nuts, and products made from these
ingredients.
Food taboos during pregnancy, lactation, in infants, and young children may also be
practiced. For example, during pregnancy, heat-producing fruits such as mango and
papaya, and flatulent vegetables such as cabbage and cold foods are to be avoided. The
birth of a child means the household is considered impure for 12 days. The lactating
mother is given herbal preparations and foods prepared with ghee for revitalization. Other
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
therapeutic uses of food still in use today include the following:
Coconut water for treating excessive pitha or bile
Boiled rice and lightly seasoned meat for convalescing periods
Fruits, cooked roots, and special beverages for dyspepsia
Honey and ghee as throat soothers and turmeric as an antiseptic
Fenugreek seeds as a galactologue
Buttermilk is used as an antidote to diarrhea
Ginger and turmeric are used to treat respiratory ailments.
Based on limited scientific research conducted in India, there appears to be a
following of this theory even in present times (Storer 1977; Ramanamurthy 1969).
Preparation techniques for various categories of food
Eating rituals and ceremonies, who prepares the food, who eats first, rules regarding
hospitality to guests, and special foods for special occasions such as weddings,
births, and death. For instance, mourning periods are characterized by restrictions
such as frying of spices, abstinence from certain foods considered auspicious
otherwise, such as dairy products, lentils, and turmeric.
Islam
Dietary practices of Muslims are derived from the holy Quran. The Islam religion preaches
the judicious use of food with little or no wastage and the concept of sharing with others.
Islam also advocates moderation in food practices. Followers of Islam, namely Muslims,
avoid all pork and pork products but consume seafood. Animals must be slaughtered by
either of two ways (Jhatka and Halal): By cutting the jugular vein or piercing the hollow of
the throat with a sharpened knife during a religious utterance of Allah (Halal). Muslims
belonging to different sects of Islam may vary in the type of meat they prefer.
Christianity
Syrian Christians are followers of a form of Christianity that emerged from Syria. Marinated
beef, duck, and wild boar cooked with strong masalas and coconut are popular in this
religious segment. Goan Christians belong to a community that developed in the former
Portuguese colony of Goa. Pork curry (Sorpotel) with blood, meat, liver, and fat in vinegar
and tamarind juice, liquid vindaloos, pork with beans (Feijoda), and salted and pickled pork
are some specialities. Seafood dishes contain kingfish or prawns.
Sikhism
According to the Holy Granth Sahib (the religious teachings of Sikhs), there are few dietary
restrictions. In practice, tobacco, alcohol, and beef are forbidden, but not pork. Religious
offerings include kara prashad made from cream of wheat, water, ghee, and sugar. Sikh
temples have community kitchens that serve meals (Langar) consisting of black lentils,
rotis, a vegetable dish, and the kara prashad.
Jainism and Buddhism
These two religions have followers that make up less than 1% of religious Asian Indians;
they share many similarities with Hinduism, yet are distinct. Jainism, based on the tenet of
non-violence, or ahimsa, strictly prohibits all food that has the potential for life to manifest,
which includes rancid or putrid food, roots and tubers, honey, fruit with small seeds, and
tender greens. Traditional followers of Jainism may not eat any foods after sunset and may
also have strict dietary restrictions during fasts.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Strict followers of Buddhism are monks who lead a life of simplicity and piety. There are two
sects, namely, Theravada (Hinayana), which is followed in India and Southeast Asia, and
Mahayana Buddhism, which is practiced in China, Japan, Korea, Tibet, and Mongolia.
Buddhist monks give up the materialistic aspects of life and live on alms. They are allowed
to eat before noon. Their ultimate goal is to achieve the spiritual state of nirvana.
Non-monastic followers of Buddhism are lacto-ovo vegetarians, with some followers
abstaining from beef, others from meat (Kittler 2004).
Zorastrianism
Followers of this religion are of Iranian ancestry, worship the sacred fire, and preach the
virtues of good thought, word, and deed (Achaya 1994). Settled in the western coast of
India, their food customs reflect practices of the area, namely vegetarianism and that of
their ancestry. Nuts, raisins, falooda, sev, dhansak, eggs, baked fish, and quail meat are
some specialties.
Judaism
Small Jewish communities exist in the metropolitan cities in India. Dietary practices include
the avoidance of meat and dairy consumption at the same meal as well as very strict
dietary restrictions during festivals. Meat needs to be kosher and prepared in a certain way.

Vegetarianism

Vegetarianism became popular in India following the introduction of Buddhism and Jainism;
both religions emphasize the concept of non-violence, or ahimsa. Furthermore, the
generalized availability of indigenous grains, legumes, fruits, and vegetables facilitated the
spread of vegetarianism (Achaya 1994). Characteristics of vegetarianism among Asian
Indians are listed below.
Certain castes and communities strictly follow vegetarian practices. Regional
differences exist; for example, Brahmins in the state of Kashmir eat lamb and coastal
Brahmins eat fish.
Most vegetarians in India will consume dairy products and some even eat eggs.
Consumption of milk may vary with socioeconomic status and is preferred for males,
pregnant and lactating women, and children. Veganism is rarely practiced.
Non-vegetarians may or may not include animal products on religious occasions.

Adaptation of Native Culture to American Culture

Asian Indian immigrants in the US exhibit bicultural food acculturative patterns in which
many traditional food practices are retained, but complemented with US dietary practices.
The extent to which food patterns are altered in Asian Indian immigrants will be influenced
by their length of residence in the US, current lifestyle patterns, ability to cook, socialization
patterns with the members of the dominant US culture, family dynamics, as well as
economics.
Present-day immigrants to the US from India are familiar with American and European
foods, which are available in many supermarkets in India. Ready access and widespread
availability of familiar non-traditional foods can accelerate the dietary acculturation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
process. Currently, ethnic grocery stores carrying Asian Indian foods are widespread in the
US. Stores in large metropolitan cities carry a wide selection of spices, convenience
products, frozen dinners, and frozen and canned ethnic vegetables. Since availability of
fresh ethnic vegetables and fruits are limited to larger cities, Asian Indian immigrants in
smaller cities may include substitutions of locally available vegetables, a greater reliance
on roots and tubers and decreased consumption of vegetables and fruits.
The indigenous Asian Indian menu relies heavily on plant-based products, which are good
sources of complex carbohydrates, the frequent use of yogurt, the use of many fruits and
vegetables, and small quantities of animal products in the meal plan. Of particular
significance is the use of a variety of spices such as turmeric, curry powders, and herbs
(fresh and dried). Recent studies demonstrate the antioxidant and anti-inflammatory
potential of dietary curcumin, a primary ingredient in turmeric and curry powders (Tayyem
2006). The traditional mixed dish combinations of cereals and lentils offer nutritional
advantages by complementing proteins in a predominantly vegetarian meal plan.
Acculturative patterns can result in low fiber and higher fat intakes with detrimental effects,
particularly in a population that has a genetic predisposition to diabetes and cardiovascular
disease (Kamath 1997) as well as an increasing incidence of obesity (Abate 2007) and
metabolic syndrome (Balasubramanyam 2008; Misra 2008). This underscores the need for
awareness among dietitians about the traditional foods and cultural heritage as well as the
need to educate Asian Indian immigrants about locally available foods and assist them to
make healthier choices.
Research examining Asian Indian dietary and nutrient intake patterns in the U.S. and
abroad indicate that:
There is a preference for mostly Indian foods as seen in dinner and weekend food
consumption patterns (Raj 1999 ). Consumption of traditional mixed dishes and ghee
decreases with residence in the US while consumption of fruit juice, chips, fruits,
margarine, cola, cheese, coffee, and alcoholic beverages increases (Karim 1986).
Consumption of roots and tubers, vegetable oils, legumes, white bread, and tea does
not appear to change with length of residence. Many also give up previous vegetarian
practices with men acculturating faster than women (Gupta 1976). American-style
breads may be substituted for traditional Indian breads; local vegetables may be
substituted for not readily available ethnic vegetables. For instance, zucchini may be
substituted for ethnic gourds; ricotta cheese may be substituted for paneer. Egg
substitutes, non-dairy creamer, non-fat milk, peanut butter, hot dogs, and hamburgers
do not appear to be popular among adult Asian Indian immigrants (Raj 1999).
Meal patterns become irregular with breakfast skipped most often; lunch may consist
of a combination of traditional and American foods such as traditionally cooked dry
vegetables and white bread in the form of a sandwich. Women snack more frequently
than men (Raj 1999). Evening meals are large, consisting of traditional foods and are
high in energy and carbohydrates (56% of energy intake) (Yagalla 1996). This is of
concern since this population has a high susceptibility towards diabetes.
Fat intake though less than 30% of energy with a higher ratio of polyunsaturated to
saturated fat may exceed needs of this group and needs to be addressed given that
this population has a high risk for cardiovascular disease. The use of "invisible fat,"
especially in seasonings and mixed dish preparation, may be high and warrants
attention (ADA 2000).
Vegetarian diets, particularly the lacto and lacto-ovo patterns, tend to have high
intakes of saturated fat and total fat very similar to that of non-vegetarians (ADA
2000).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Age onset conditions such as lactose intolerance can also contribute to lowered
micro-nutrient intakes such as calcium and vitamin D; there is also an increased risk
for anemia in women and higher homocysteine levels arising from low iron, folic acid,
and vitamin B-12 intakes (Jonnalagadda 2002; Lawson 1999; Fischbacher 2001;
Chamber 2000).
Health Promotion for Asian Indians
Below are some general suggestions for health promotion and counseling strategies.
These are generalizations and strategies may have to be adopted based on individual
clients.
Health promotion activities with a nutrition and physical activity component must
evaluate the social, economic, educational, and cultural environment in which the
Asian Indian client resides.
1.
Assessment should include questions on:
Food intake patterns (weekdays versus weekends), frequency of eating out and
places visited over weekends, food preparation techniques, the use of fats and
oils, use of nuts such as almonds for health purposes, use of multivitamins and
single supplements
a.
Religious following, food prohibitions, fasting and feasting patterns b.
Length of residence in the US c.
Presence of children and elderly family members. For instance, children may be
allowed to try new/non-vegetarian foods while elderly parents may follow
traditional meal patterns and practices.
d.
The use of Ayurvedic/Homeopathic medicine concepts and traditional remedies.
Despite the familiarity of Asian Indians with Western medicine practices, cultural
and traditional belief and practice systems based on the Ayurveda concept often
prevail and coexist with Western medicine treatment. This can be seen in the
classification of hot and cold foods prevalent in this society. Food taboos
associated with conditions such as pregnancy can lead to avoidance of certain
foods and the therapeutic use of spices and herbs as home remedies. Use of
herbal supplements may be common for illness and may need to be asked
about and taken into account while planning for medical/nutrition issues.
e.
2.
Dietary intake assessments should employ multiple recall methods; food frequency
questionnaires should contain both traditional and non-traditional foods of American
origin and other ethnic foods such as Chinese, Mexican, and Thai as well.
3.
Dietary advice, when given, should include the woman of the household since
women are involved in procurement, preparation, and distribution of food.
4.
Clients may require information on how to read and interpret food labels. Some foods
available in ethnic grocery stores may not have adequate label information. Clients
may also need to be made aware of appropriate portion sizes and exchange lists.
They may benefit from information provided in resources targeted for this population
(ADA 2000; AAPI 2002).
5.
The benefits of physical activity need to be reiterated, particularly with reference to
improvement in total and abdominal fat and blood lipid risk factors (Yagalla 1996).
6.
Communication
Asian Indian immigrants may not be willing to discuss their medical, social, and financial
issues with an unfamiliar professional person. It will be beneficial if Registered Dietitians
(RD) and Dietetic Technicians, Registered (DTR) under the supervision of an RD,
recognize the close-knit family ties that are characteristic of this community, the
hierarchical roles of men and women as well as the desire of family members to participate
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
hierarchical roles of men and women as well as the desire of family members to participate
in the caring process. Elderly relatives may provide care during pregnancy and
post-delivery, often reinforcing traditional foods, beliefs, customs, and rituals. It may be
necessary to assess individual attitudes and comfort level (Segal 1991). Interpreters
well-versed in native Asian Indian languages may be of assistance while dealing with
elderly clients. Asian Indian clients may prefer a leisurely personal communication with the
RD and DTR.
Expectation of privileges such as getting an immediate appointment may not be unusual
(Kittler 2004). Health care expectations can differ between clients and will ultimately
influence compliance. Finally, clients need to be encouraged to follow-up with the physician
and/or a RD and DTR.

Meal Planning in this Culture

General Tips for Healthy Living and Meal Planning
Research indicates that the incidence of cardiovascular disease and type 2 diabetes is
escalating among Asian Indians both here in the United States and elsewhere (Abate
2007). Genetic differences in lipid metabolism, insulin resistance, impaired glucose
tolerance, obesity, and lifestyle changes including meal-planning changes, lowered
physical activity, and increased stress are thought to exacerbate risks. Food changes
resulting in substitutions, rejection of traditional foods, and inclusion of other ethnic and
U.S. fast foods and convenience foods can precipitate nutritional changes that can have an
impact on chronic disease risk.
Meal planning for Asian Indians should incorporate the food habits of each geographic
region and religion practiced as well as include information on current food consumption
practices. Examples of typical and modified menus for a North Indian client, an
Oriya/Bengali client, a South Indian client, and a Maharashtrian client are provided (AAPI
2002). Resources such as the Dietary Guidelines for Americans and the Indian Foods
document published by the American Association of Physicians from India (AAPI 2002) are
useful resources that can assist in this process. Efforts should be directed toward the
following:
Making healthful food choices and improving overall nutrient intake (Jonnalagadda
2002)
Attaining a desirable body weight regardless of age by following a
weight-management program stressing a combination of decreased caloric intake
together with sustained physical activity such as aerobic, strength, resistance, and
flexibility training. Yoga can also be suggested.
Encouraging consumption of unrefined carbohydrates such as brown rice over white
rice and traditional mixed dishes containing cereal-lentil combinations. Because of the
limited choice of well-liked protein sources in vegetarian cuisine, individuals tend to fill
up on carbohydrates, which constitute the majority of the plate at any meal.
Suggestions may be made to include soy products such as soy granules, soy milk, or
combinations of wheat flour and gram flour in broiled traditional breads and other
mixed dish preparations.
Exercising portion control, reading, and understanding labels
Decreasing or moderating use of alcohol at home or social occasions
Food selection alternatives while dining out by emphasizing moderation with regard to
fats, desserts, and portion size control (Kulkarni 2002)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
fats, desserts, and portion size control (Kulkarni 2002)
Reducing calorie consumption. The following tips may be helpful:
Use baking, boiling, broiling, or steaming foods instead of shallow and
deep-frying in a kadai.
Use non-stick pans or coat pans with vegetable-based cooking sprays. This will
reduce the generous amounts of oil that are typically used in seasoning for
traditional dishes.
Use monounsaturated oils such as canola and olive oil; moderate consumption
of fried snacks and appetizers. Use sprouted mung for snacks instead of
traditional deep and shallow fried snacks.
Sauté vegetables in water or vegetable juice rather than oil or ghee.
Consciously work toward reducing the intake of Indian savory snacks that are
almost always deep-fried and Indian sweets (mithai), loaded with ghee and
sugar.
Trim visible fats from poultry, beef, and pork, and remove skin from chicken.
Switch to low-fat or nonfat instead of whole or reduced-fat milk, which are
popularly consumed by Asian Indians.
Use egg whites more often than whole eggs. Limit whole egg use to no more
than three times a week.
Traditional condiments, seasonings, and pickles can be high in sodium and oil.
Suggest moderate consumption of these products; suggest use of spices and
lemon juice as alternatives. Limit or moderate the use of nuts, coconut, and
heavy cream for gravy in lentils, meat, fruit, and vegetable preparations.
Fresh fruits in season are better alternatives to daily consumption of
high-calorie, traditional desserts. Encourage fresh fruit and vegetable juice
consumption.
Asian Indian Foods to Use More Often
Breads
-Rotis, phulkas, chappatis with little or
no added fat
-Plain, cooked rice
-Steamed idlis
-Dosas made on non-stick pans
-Cracked wheat upma
-Roasted, puffed, or beaten rice in
snack preparations
Legumes, meat, fish,
poultry
-Cooked dal using minimal oil
-Sprouted dals
-Grilled, baked, pan-fried meats and fish
Dairy
-Skim milk, fat-free, 1% milk
-Fat-free yogurt and low-fat yogurt
-Low-fat paneer/part-skim ricotta cheese
Vegetables and fruits
-Seasonal vegetables stir-fried or
sautéed.
-Gravy-mixed dishes with minimal oil
-Fresh fruit or canned fruit in light juice
-Fresh herbs
-Margarine
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nuts, Fats and oils -Canola and olive oil
-Almonds, walnuts and peanuts
Asian Indian Foods to Limit or Use Moderately
Breads
-Parathas, puris, kachoris, lachchas,
nan, bhaturas
-Pulao, fried rice, and biriyani
-Idlis topped with lots of oil
-Dosa prepared using extra oil/butter
-Semolina upma using generous
quantities of oil
Lentils, meats, fish,
poultry

-Creamed dal
-Fried chicken, fish, calorie-rich meat
dishes
Dairy
-Regular paneer/ricotta cheese
-2% or whole milk
-Whole cream and half and half
Vegetables and fruits
-Roasted vegetables using lots of oil
-Curried vegetables using generous
quantities of coconut
-Creamed or fried vegetables
-Fruits in creamed desserts, custards
Fats, oils, nuts
-Butter, ghee
-Coconut

Food Dictionary

Food Ingredients or Preparation Picture
Aamras Mango juice or pulp.
Achar
Vegetable- or fruit-based pickles
prepared with spices and marinated in oil
and salt. Dried varieties may also be
eaten.

Ajwan or
Ajwain
Oregano seeds, also known as omum in
South India.

Amaranth
An annual plant high in protein whose
leaves and seeds can be used.

Amchur or
Aamchoor
Dried raw mango powder.
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Appam
Rice/wheat-based preparation. Batter is
fermented and baked in clay or cast iron
pan to yield a spongy, thick, soft, product
with a lacy, crisp, brown edge. Both
salted and sweet varieties are prepared.
Variations exist in preparation methods.

Appalam
Wafers made from lentil and rice flour
that can be broiled or fried.

Asafoetida
A resin with a sharp smell, used in small
quantities as a flavoring agent.

Ash Gourd Gourd is available in Asian grocery stores.
Athanu Spicy mango pickle.
Aviyal
South Indian dish with vegetables in
gravy, with added coconut and buttermilk.

Badaam Almonds.
Baghar or
Chonk or Tarka
Indian garnish consisting of frying spices
such as mustard, cumin, asafoetida, and
red chilies in hot oil, which is then added
to dishes.

Barfi
Sweets made from thickened /
condensed milk or khoa flavored with
coconut, rose water, cocoa, fruit, or nuts.

Basmati Rice
Narrow, long-grained rice, usually white,
with special flavor and smell.

Basundi
Thickened sweet milk flavored with
cardamom and saffron.

Bathura
Mildly leavened, deep-fried bread, made
with added fat.

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Bay Leaves
Aromatic herb that can be used fresh or
dried. Also known as Tez (j) pata.

Bengal Gram
Dal or Chana
Dal
Yellow split peas.
Besan
Chickpea or gram flour made from
chickpea only.

Betel Leaf or
Pan
A sharp-tasting leaf used as a base in
which a variety of mouth fresheners and
betel nuts are used as filling. Often stains
the mouth red as a result of the lime
paste used on the leaf.

Bhaji
Generic term for cooked vegetables.
Other names for vegetable dishes include
curry, bharta, sabzi, and sag.

Bharta
Cooked vegetable (eggplant, potatoes)
that is mashed or cooked to a pureed
consistency.

Bhel Puri
Raw, puffed rice together with gram flour
deep-fried noodles along with raw
vegetables, cilantro chutney, and sweet
and sour tamarind sauce.

Biryani
Fried rice with pieces of mutton and
vegetables.

Bitter Gourd
Bitter melon; looks like a cucumber with a
rough ribbed skin. Popular and consumed
by people with diabetes.

Black Gram
Dal or Urad Dal
Pale white lentil; may be used with or
without black skin; popular in South
Indian cuisine; combined with rice,
ground, and fermented to make idlis and
dosas.

Bonda
Small balls made with potato filling
dipped in gram flour batter and deep-fried.

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Brinjal Eggplant.

Cardamom
Flavorful spice seed within a green pod,
which is ground. Grown in India.

Chaas Buttermilk.
Chai Tea made with milk.
Chai Masala
Spiced tea with added milk and sugar.
Can become high in calories.

Chakli
Fritters made from spiced and fried wheat
flour.

Channa
Chickpeas or garbanzo beans, either
whole or hulled and split (when it is
known as channa dhal).

Chapatti
A pan-roasted bread, homemade, often
just before the meal.

Chenna or
Paneer
Homemade cottage cheese prepared by
boiling milk and curdling it with lemon
juice and/or yogurt. The curdled milk is
hung in a muslin cloth and the drained
whey is consumed separately. The
cheese is used in desserts or as a
deep-fried product added to other dishes.

Chevdo
Spiced and roasted flattened rice mixed
with deep fried nuts and whole pulses.

Chicken Curry Chicken in spicy sauce.
Chicken Tikka
Pieces of boneless, skinless, broiled
chicken marinated with spices.

Chilies
Also known as chili peppers; available in
fresh green variety or dried red variety.
Ground and added to dishes.

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Chole
A dish made with chickpeas, onion,
tomatoes, and spices

Choli Black-eyed peas.
Choko Chayote squash.
Chundo Sweet mango pickle.
Chutney
A sweet or salty dip or relish made to be
eaten as a dip with a variety of dishes.

Cinnamon Flavorful spice used as stick or powder.

Cloves
Spice used to season curry, rice and
used as a component of the spice mix
garam masala.

Colocasia White starch vegetable; similar to yam.
Copra Dried coconut.
Coriander or
Dhania
Spice seeds that can be used dried;
popular in South Indian cuisine; coriander
leaves or cilantro used as a herb.

Cumin or Jeera
May be used as a powder or lightly
roasted in oil; used as a seasoning.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Curry
A term for various dry vegetable or gravy
dishes eaten with the main starch of the
meal. Spice made from curry leaves.

Dahi Also known as curds; homemade yogurt.
Dal
A generic term for hulled, split pulses of
legumes, like mung beans.The main
varieties are toor (red gram), mung
(green gram), mung (black gram), channa
(split pea) and urad dal (black lentil).
Soaked and blended dals like sprouted
mung dal are used in many dishes.

Dhansak
A vegetable-lentil dish of semisolid
consistency.

Dhokla
A steamed dish of Western India, made
from lentils and/or a combination of lentil
and rice.

Dosa
A South Indian pan-fried crepe made
from a soaked and fermented rice urad
(split black lentil without skin) dal batter,
semolina, or whole wheat flour.

Drumstick
Indian vegetable, long thin sticks with a
fleshy interior; the fleshy portions are
cooked and consumed.

Falooda Drink made from tapioca granules.
Fenugreek
Leaves
Used as green leafy vegetables in
cooking.

Fried Gram Dal Roasted and puffed Bengal gram dal.
Garam Masala
Garam means hot and masala means
spices. A blend of spices (coriander,
cumin, cardamom, cinnamon , cloves,
pepper, nutmeg, black cumin powder,
and mace) with regional variation.
Versions may be sold as curry powder.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ghee
Butter that has been clarified or gently
warmed over low heat until it browns
lightly, giving a distinct aroma. It is used
as a flavoring or as a topping for rice and
breads.

Ghoogra
Savory snacks made with whole wheat
flour stuffed with crushed peas and deep
fried.

Ginger
Root whose skin is removed; may be
chopped, grated, or sliced; used as an
anti-flatulent agent, considered to be
preventive for throat ailments.

Gol Papdi
Wheat flour fried with clarified butter and
sweetened with jaggery.

Gram Flour
Usually refers to the flour made from
ground chickpeas.

Green Gram
Dal
Split mung beans.

Gulab Jamun
Deep-fried balls made from milk and
soaked in sugar syrup.

Halal
Food from animals slaughtered in
accordance with the Islamic food code.

Haldi
Turmeric powder, a commonly used
spice believed to have antiseptic
properties.

Halwa
A generic term for a common dessert
made from wheat, nuts, sugar, and often
vegetables.

Handva
Rice- and mung dal-based bread with a
combination of vegetables.

Haram
Food that observers of the Islamic
religion regard as forbidden.

Idli
A popular South Indian steamed dish
made from fermented cereal-lentil batter.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Jaggery
Unrefined brown sugar; also known as
gur.

Jheera Pani
A watery drink made mainly from jheera
(cumin seed).

Jilebi, or Jalebi
Fried dish made with chickpea flour and
dipped in sugar syrup.

Kababs
Rolls made of uncooked minced meat
and spices, put on skewers, and broiled
(Sheesh kabab); patties made from
cooked minced meat, lentils, and spices
and shallow fried (Shami kabab); pieces
of seasoned meat or fish skewered and
broiled over a fire.

Kacha Raw.
Kachori
A stuffed puri using urad dal or
vegetables mixed with spices.

Kachumbar Raw salad.
Kadai
A metal skillet or wok (usually made of
iron) used for roasting, broiling, and
frying.

Kadhi
Dish made from yogurt, spices,
vegetables, and lentil flour as thickening
agent.

Kalonji: Niger
Seeds or
Nigella
Also known as onion seeds. Used to
flavor many dishes.

Karela
A bitter gourd, believed to have medicinal
value.

Kathod Whole pulses (lentils).
Katoris
Small metal bowl used to hold a side dish
(holds about three to four ounces).

Khandvi
Rolled pancakes sprinkled with mustard
and coriander made from gram flour.

Kheema A minced meat dish.
Kheer
A milk-based liquid dessert with many
additions, like cereal, lentils, nuts, and
fruits.

Khichri, or
Khichuri
Dish containing lightly spiced, cooked
rice and lentils/tapioca. The latter is
prepared using four types of lentils and is
featured during special festivities in the
eastern region of India.

Khoa Reduced-milk dessert.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Khus-Khus
Poppy seeds, used to flavor drinks and
also in curried dishes such as kurmas.

Kofta
Round, deep-fried fritters made of cheese
or vegetables and gram flour, soaked in
gravy.

Kootu
Mixed dish with vegetable and dal.
Served as a side dish or with rice.

Kosumalli
Raw vegetables to which soaked lentils
(mung lentils) are added.

Kulfi
Ice cream made from reduced milk, often
with other ingredients like nuts and
mangoes.

Kurma or
Korma
A curry dish consisting of different
vegetables, sometimes a meat, and gravy
of yogurt and nuts.

Laddoo or
Laddu
A round, sweet ball of lentil flour,
semolina, or puffed rice, roasted with
butter and sugar and seasoning and nuts
added to taste before making laddoos.

Lassi
A buttermilk or yogurt drink, often diluted,
to which salt or sugar is added for
flavoring.

Maccher Jhol Fish curry.
Mace Spice used in Asian Indian cooking.

Malai Kofta
Cheese and vegetable deep-fried fritters
in a cream sauce.

Masur or
Masoor Dal
Bright orange in color; red split peas.
Popular in North and East India.

Mattar Green peas.
Methi
Fenugreek seeds. Common spice used in
cooking.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Mishti Doi A sweetened, yogurt-based dish.
Mithai A wide range of sweet snacks or desserts.
Mustard Seeds
Small, black seeds tempered in oil and
used as seasoning. Mustard oil used in
east and northeast regions of India
as cooking oil.

Naan
North Indian fermented bread made from
flour, yogurt, and egg. It is baked and
broiled in a clay oven (Tandoor).

Nimbu Paani Drink similar to lemonade.
Nutmeg Spice used in Asian Indian cooking

Oothapppam
Thick pancake made from batter
consisting of fermented rice and black
gram dal batter to which vegetables may
be added as topping.

Pakoda
A generic term for deep-fried fritters
made with vegetables, nuts, or plain gram
flour.

Panch Phoron
A seasoning in West Bengal state that is
a mixture of equal parts mustard seeds,
fenugreek seeds, fennel seeds, and
cumin seeds, which is then roasted or
fried and added to many dishes.

Paneer See Chenna.
Pani-Puri
Deep-fried cereal flour puris combined
with spiced tamarind sauce.

Pappad
A dehydrated wafer made from cereal or
a cereal and legume mixture; can be
eaten fried or stove-top puffed.

Paratha
A shallow, fried wheat bread that may be
stuffed with vegetables (e.g., potatoes) or
meat.

Patra
Paste of gram flour applied to colocasia
leaves and steamed.

Payasam
A sweet dish made with milk, ghee, and
sugar.

Peda A dessert of reduced milk.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Phulka, Sookhi
Roti, or Sookhi
Chappathi
Dry, boiled, unleavened wheat flatbread
with no added fat.

Plantain Green banana.
Pongal
Cooked rice and mung lentils to which
salt, ginger, and black pepper are added.
Sweet version is made using jaggery.

Poppy Seeds See Khus-khus.
Poriyal
South Indian term for cooked or stir-fried
vegetables.

Pudla
Thin, fried pancakes made with
combination of flours and vegetables.

Pulao
A rice dish containing vegetables, meat,
and seasoning.

Puranpoli
Stuffed bread containing stuffing made
from gram lentil and jaggery.

Puri A deep-fried bread.
Raita
A light yogurt dish that often includes a
vegetable like cucumber.

Rajmah Kidney beans. Prepared and spice-based.
Rasam
A spicy, watery soup made from
tomatoes or lemon juice and red gram
dal; served with cooked rice in the South.

Rasmalai
A dessert of soft balls of curdled milk
cheese soaked in sweetened milk.

Red Gram Dal Also known as pigeon peas.
Rice Flour
Made from rice and used as thickening
agent and in snack preparations.

Roti or Rotlis
A generic term for bread, a staple for
most people in Northern India.

Saag
Made from mixed greens such as spinach
or mustard greens.

Sabji Vegetable that is stir-fried or cooked.
Sabudana Tapioca.
Saffron
Small, red threads used for flavor and
color.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sambar
A spicy toor dal gravy from Southern
India, often made with tamarind juice,
vegetables, and eaten with rice, idlis, or
dosas.

Samosa
Deep-fried pastry with vegetables or meat
filling.

Sandesh A coagulated milk-based dessert.
Sesame or
Gingelly
Seeds or Til
Small, white seeds with a nutty flavor
used in masalas. Oil used in mixed rice
dishes for flavor.

Sev
A product shaped like vermicelli, usually
made from rice or lentil flour. Also known
as Seviyan.

Shakarpali
Diamond-shaped pieces made from fried
wheat flour, either sweetened or salted.

Sharbat
Essence of flower, bark, herbs, fruits, or
nuts made into syrup from which a cool,
refreshing drink is prepared.

Shrikhand A yogurt-based dessert.
Shukto
A bitter melon or vegetable stir-fry used
to start the meal in west Bengal.

Somph or Sonf
Fennel seeds used in cooking or at the
end of a meal as a mouth freshener.

Sooji
Semolina made from wheat or as rice
sooji made from rice.

Spice Box
Essential part of the Asian Indian kitchen,
which carries a variety of spices used in
everyday food preparation.

Tamarind
Fruit of the tamarind tree, very tart. Its
paste is used to flavor many dishes.

Tandoor
A clay, charcoal-heated oven for baking
and broiling.

Tarka
A term for garnish or seasoning in some
parts of India.

Tel Oil.
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Thali
A metal plate from which food is eaten.
Used with katoris.

Thepla
A flat bread made with wheat flour, gram
flour, and spices.

Tiffin
Term used to describe snacks, or a small
bite.

Til Sesame.
Turmeric or
Haldi
Spice looks like ginger root; gives yellow
color; thought to be an antiseptic and may
be applied to small wounds or mixed in
warm milk.

Upma
A cereal dish made from semolina or
beaten rice and vegetables and
seasoned with fat and spices.

Undhiyu
Delicious vegetable dish made with
potato, eggplant, and green beans among
several other vegetables.

Vada or vadai
Battered and fried vegetables served as
an appetizer.

Vadams
Seasonal vegetables are spiced, boiled,
sun-dried, and stored. Rice flour may be
spiced, made into a batter, cooked and
molded into shapes, sun-dried, and
stored. These products are deep-fried
and served as snacks or a meal
accompaniment.


References


American Association of Physicians of Indian Origin. Indian Foods: AAPI's Guide to
Nutrition, Health and Diabetes Oakbrook Terrace, Ill.: AAPI; 2002.
Abate N, Chandalia M. Ethnicity, type 2 diabetes and migrant Asian Indians. . Indian J
Med Res. 2007. Mar; 125(3): 251-8.
Achaya KT. Indian Food -- A Historical Companion. Oxford: Oxford University Press;
1994:61-76, 78-87.
American Dietetic Association. Ethnic and regional practices: A series--Indian and pakistani
food practices, customs and holidays. Chicago, Ill.: American Dietetic Association;
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food practices, customs and holidays. Chicago, Ill.: American Dietetic Association;
1998:14-15.
American Dietetic Association. Ethnic and Regional Practice Series-Asian Indian and
Pakistani. Chicago, Ill.:American Dietetic Association; 2000:4-7.
Balasubramanyam A, Rao S, Misra R, Sekhar RV, Ballantyne CM. Prevalence of metabolic
syndrome and associated risk factors in Asian Indians. J. Immig. Minor. Health. 2008. Aug;
10(4):313-23.
Chamber GC, Obid OA, Refsum H, et al. Plasma homocysteine and risk of coronary heart
disease in U.K. Indian Asian and European men. Lancet. 2000;355:523-27. Related Links:
Full Text
Fischbacher C, Bhopal R, Patel S, et al. Anemia in Chinese, South Asian and European
population in Newcastle upon Tyne: Cross-section study BMJ. 2001;322:958-959. Related
Links: Full Text
Ghosh A, Gupta R. Elderly Care A Brown Paper: The Health of South Asians in the United
States Berkeley, Calif.: South Asian Public Health Association; 2002:35.
Gupta SP. Changes in food habits of Asian Indians in the US: a case study. Soc Soc Res.
1975;60:87-99.
Gupta N. Socio-demographic profile A Brown Paper. The Health of South Asians in the
United States. Berkeley, Calif.: SAPHA; 2002:.8-11
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Kamath SK, Ravishanker C, Briones E, Chen EH. Macronutrient intake and blood
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Karim N, Bloch DS, Falciglia G, Murthy L. Modifications of food consumption patterns
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England: population survey. BMJ. 1999:318-28. Related Links: Abstract
Misra A, Jaiswal A, Shakti D, Wasir J, Vikram NK, Pandey RM, Kondal D, Bhushan B.
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Novel phenotypic markers and screening score for metabolic syndrome in adult Asian
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University Press; 1988

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Resources > Cultural Food Practices > Caribbean
Caribbean


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Caribbean > Trinidad and Tobago
Food Practices

The cuisine and food practices of Trinidad and Tobago draw upon the varied origins of its
people. Three influences predominate—Creole, Indian, and Chinese cuisine—but practices
are also influenced by the blends of Amerindian, European, African, and Lebanese tastes
to a lesser extent. Consequently, the multiethnic and multireligious characteristics of this
Republic as well as ancestral influences have had a direct impact on the development of
food practices. Many of these practices have been transferred from one generation to
another and some have been retained to current times. Additionally, the effects of
industrialization and changing lifestyles have also contributed to new food practices which
mirror some of the practices of the developed western world.
Trinidadians and Tobagonians have become accustomed to a merging of food practices
because one group adopts or adapts practices from other groups. During national or
religious observances, nearly the entire country engages in some food practices of the
group for whom the event is being commemorated. For example, at the Christian
celebration of Christmas, food practices are similar among Christians and many
non-Christians. Similar food practices are observed for the celebration of selected Hindu
and Muslim festivals as well.

Additionally, many persons of East Indian ancestry practice Christianity or Islam and some
persons of African ancestry practice Islam. In such cases, incorporation of food practices
based on their ancestry is common.

In spite of external influences, food practices are, to a large extent, fashioned by
application of the six Caribbean food groups. This food group system was developed by
the Caribbean Food and Nutrition Institute (CFNI) for the English-speaking Caribbean
people.

The six Caribbean food groups are:
Staples (cereals, starchy fruits, roots and tubersa—commonly called provisions) 1.
Legumes and nuts 2.
Fruits (fresh, canned, frozen, dried and fruit juices) 3.
Vegetables 4.
Food from animals (meats, poultry, seafoods, dairy products and all byproducts) 5.
Fats and oils 6.
In developing a food group system appropriate for the Caribbean cuisine, consideration
was given to the “foods with similar nutrients, what is produced in the region, what is
available, what we like and are accustomed to eating, and what we should eat.” Unlike in
the US, legumes and nuts are a separate group mainly because of the frequency and
amounts used in the Caribbean. Combining foods from the different food groups is known
as the “Multimix Principle” and this concept is taught and used as a guide for planning a
balanced diet at each stage of the life cycle and for almost all health situations. In this
regard, significant inroads have been made, but there is need for continuing advocacy in
Trinidad and Tobago as well as the Caribbean.
Dietary guidelines encourage the use of staples, especially complex carbohydrates, in the
greatest amount, followed by legumes; less fats and oils are encouraged. Increasing the
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consumption of fruits and vegetables and moderate use of food from animals are
advocated. This food group system is advocated for use by all sectors of the population for
meal planning according to their specific situation. Adaptations are therefore made to
accommodate vegetarians, a major group in the society.
Trinidad and Tobago is a multiethnic, multireligious, and multicultural country. There are
many diverse groups that constitute the population. These ethnic and religious groups in
the population, as well as ancestral influences, have contributed to shaping the food
practices in this country. However, Christians, Hindus, Muslims, and Asians constitute
significant numbers.
Christian Food Practices
Food practices among persons of Christian denominations span all ethnic groups, resulting
in a diversity of dishes and food choices. Foods are selected depending on individual
choices and health reasons; thus, food practices are not as distinguishable as with the
subsequent groups. There are some exceptions; Seventh-Day Adventists, for
example, conform to food choices and practices that are permitted by their religion.
Traditionally, certain practices are upheld at specific times of the year, especially during
Lent, which is the forty days preceding Easter. During this period, many persons make a
special effort to sacrifice some of their usual food choices and practices by abstaining and
fasting. Topping the list is abstinence from eating meat; thus, there is increased
consumption of seafood or adoption of vegetarian-style eating. Thus the demand for fish is
reflected in higher prices throughout the country during this period. An extra special effort
is made to practice these behaviors on Wednesdays and Fridays, culminating on Good
Friday—when almost all households will eat only fish dishes at all meals.

During the year, some many people of various Christian religions fast routinely. During
such times, less food is consumed; the main meal may be omitted or a reduced amount
may be consumed at either one or both of the other two main meals. Fasting is associated
with achieving a greater spiritual benefit.

Eating practices change dramatically during the last two months of the year, especially for
the working class, who indulges in an increased consumption of food during the Christmas
season and its numerous “staff parties”. Such occasions include larger amounts and a
variety of calorie-dense meals either during the day, early or late evening, or night. One
food item that is associated with Christmas is pastelle (see the Food Dictionary). This food
item is a variation of tamales popular in Spain and Latin America, and was adapted in
Trinidad and Tobago from their Spanish ancestry. Arepas is another local dish derived
from the Spanish empanadas, but it is not used widely or as often as pastelles.

Hindu Food Practices
This section presents a glimpse of Hindu food practices rather than East Indian because all
Hindus are East Indians, but all East Indians are not Hindus. This is a fairly homogeneous
group when it comes to food practices. The following examples are mentioned to support
this position.

Rice is a main staple food. It is used widely and daily with or without the addition of peas,
beans, or other vegetable of choice. A frequently used meal is rice, dhal (seasoned cooked
split peas with a thin consistency) and baghi (a dark green leafy vegetable that has a
similar nutritional content as spinach, mustard greens and the like).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Another popular staple food is roti, a flat, bread-like item made from flour to which is added
salt, water, baking powder, and sometimes oil, depending on the type. Roti is usually
cooked on a griddle-type cast iron baking stone called a tawah over chulha and one or two
wooden pallets; dabla(s) are used for turning the bake during cooking.


There are different types of roti as described in the Food Dictionary. The types are sada,
dhalpourie, paratha (“buss-up-shut”), dosti, aloo puree, and bara. The nutritional value,
especially energy, fat (type and amount), and protein content of roti, varies according to the
type. Roti is eaten either as part of a meal or it can be a complete meal on its own. For
example:
Sada roti: Usually eaten at breakfast and supper instead of bread
Paratha roti: Usually eaten at lunch or dinner instead of rice, pasta, or provisions
Dhalpourie roti: Same as paratha roti
Dosti roti: Used anytime at home; also used for breakfast, but is not as popular as
sada
Bara roti: Used for making doubles and is eaten anytime
Spicy curried dishes are pleasing to many, including children. Almost any food from
animals, including seafood and eggs, can be prepared this way but chicken is the most
popular. Some vegetables and legumes are also curried. Other spices are added to curried
dishes, but the inclusion or addition of hot pepper or pepper sauce (see Food Dictionary) is
a common practice. Chutneys and pickled items are often used as a meal complement.
Beef is omitted from the diet of Hindus because the cows are sacred to them.
Common religious practices such as fasting and “prayers” (an occasion when any of the
deities are worshiped for reasons such as the birth of a child, thanksgiving, or for
intercessory purposes) have an impact on food practices. During these times as well as
special festivals such as Divali, abstinence from eating meats is practiced, thus resulting in
the adoption of vegetarian eating habits. A wide assortment of “sweets” is also eaten during
these festivals and holidays. Examples include khurma/kurma, barfi, prasad, ladoo, peera,
jalebi, and goolab jamoon. These items are high in calories from fat (oil and ghee) and
carbohydrate, particularly sugars. Deep-fat frying is the method of preparation for many
items.


Muslim Food Practices

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Eating patterns and times for Muslims are similar to the rest of the population. However,
there are specific Islamic guidelines that must be adhered to regarding the type of meat or
meat by-products that can be consumed. In accordance with a Muslim’s faith, pork or any
by-product of swine is prohibited. All seafoods are permissible whilst all other meats must
be halal, that is, the animal must be slaughtered “in the name of God” and in a way of least
pain. Muslims are also prohibited from using alcohol. In addition, for good nutrition and
health, Muslims are encouraged to eat a variety of foods but in moderation.

One of the main principles of good health is a balanced diet. A Muslim believes that, like
any other good action, eating is an act of worship. Food is a blessing from God and should
not be criticized for any reason, despite personal dislikes. Mealtime begins in the name of
God and ends with a prayer giving praises to God. One is encouraged to eat with company
and share with others.

Like other religions, there are specific periods when special food habits are
mandatory. One such period is the ninth month of the Muslim calendar—the holy month of
Ramadan. During this month, all able-bodied and sane Muslims completely abstain from
food and drink from dawn to dusk. Guidelines are provided so that individuals’ health will
not be compromised. At the end of this 30-day period, Muslims celebrate the breaking of
the fast with a grand array of food such as curried and baked meats, vegetables, rotis,
pies, savories, cakes, and sweets. It is customary to eat a sweet dish called Sawine on the
day the fast is broken. Trinidadian and Tobagonian Muslims have built a tradition to serve
and share this delicacy amongst families and friends whether or not they are of the same
faith. Sawine is made with vermicelli as the main ingredient. This is parched and cooked in
water and sugar and spices (cardamum and cinnamon), evaporated milk, nuts, and a
choice of dried fruits (raisins, cherries) are added. The finished product can be either
semi-liquid or baked and served in squares. Sawine is nutrient rich and calorie dense. One
237-gram serving can provide approximately 425 kcal.

Asian Food Practices

Immigrants from Asia brought many seasonings with them, along with many of their
indigenous dishes. These have now been incorporated into the national cuisine, adding to
multicultural cuisine for which Trinidad and Tobago is known. In addition, there are
numerous Asian restaurants throughout the country, making accessibility easy. “Chinese
food” is often and easily substituted for any of the other dishes that can be eaten in the
country. Asian dishes are also prepared at home.

Immigrants or Ancestors

The twin islands of the Republic of Trinidad and Tobago are the most southern of
the Caribbean island archipelago, with the Republic of Trinidad situated approximately 11
km east of the Venezuelan coastline in South America and south of Grenada in the
Caribbean. The smaller island, Tobago, lies northeast of Trinidad.
The Republic is the second largest island in the English-speaking Caribbean. The total
area is approximately 5,128 square kilometers (1,981 sq mi) with the smaller island,
Tobago being 51 kilometers long and 18 kilometers wide with an area of 300 square
kilometers (116 sq mi). Trinidad is approximately 105 kilometres long and 77 kilometres
wide with an area of 4,828 square kilometers (1,864 sq mi). The climate is tropical with a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
dry season from January to May and rainy season from June to December with
overlapping periods. Depending on which island is being discussed, reference is made to
"Trinidadian" or "Tobagonian." Trinidadians, but not Tobagonians, often refer to citizens of
the Republic of Trinidad and Tobago as "Trinidadians" or "Trinis," but a more inclusive term
that has gained acceptance is "Trinbagonians." Trinidad and Tobago is internationally
famous for its pre-lenten festival: Carnival, music such as calypso, soca and chutney; and
dance such as limbo. The Republic is also recognized as the birthplace of the only musical
invention of the 20th century, the steelpan, on which any type of music can be played.
The population of Trinidad and Tobago is 1,267,366 persons (Census, 2000). Of this total,
96% reside in Trinidad and 4% in Tobago. Currently, reference is made to an estimated
population of 1.3 million persons comprising of a mixture of ethnic groups. The approximate
distribution by ethnicity or race is East Indian, 40%; African, 37.5%; Mixed, 20.5%; Other
persons account for 1.2% and Unspecified is approximately 0.8% (PAHO 2000).
Population Distribution by Ethnicity
Population Groups % Distribution
East Indian ancestry 40.0
African ancestry 37.5
Mixed 20.5
Others 1.2
Unspecified 0.8
Trinidadians and Tobagonians of African descent are called "Africans" and those of Indian
descent are called "East Indians" to differentiate them from Amerindians. More recently the
terms "Afro- or Indo-Trinidadian and "Afro- or Indo-Tobagonian" have gained popularity,
reflecting heightened ethnic claims to ancestral status. Trinidadians of European ancestry
are called "White" or "French Creole," whether or not their surname is French-derived.
Religious diversity also exists with the majority of persons belonging to one of many
Christian denominations, followed by Hinduism and Islam.
Population Distribution by Religion

Religion % Distribution
Christianity
Roman Catholic 26
Anglican 8
Baptist 7
Pentecostal 7
Seventh-Day Adventist 4
Other 6
Hinduism 2
Islam 6
None 2
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In earlier times, Trinidad was inhabited by the Arawaks and the Carib Indians inhabited
Tobago, while the country changed possession from Spanish, French, and British. Slavery
was abolished in 1834 and between 1845 and 1917, thousands of indentured workers
were brought from India to work on sugarcane plantations. Most of these plantations no
longer exist.
In 1889 the islands, Trinidad and Tobago, were made a single colony. The twin-island
nation gained independence in 1962 and became a Republic within the Commonwealth of
Nations in 1976 with a parliamentary democracy and an appointed President. Executive
power lies with the elected Prime Minister and designated Cabinet Ministers. Tobago has
its own political administrative structure under the executive power of the Tobago House of
Assembly Act. The official language is English but other languages such as Hindi; French,
or more often, Patois; Spanish; and Chinese can be heard in pockets throughout the
country.

Adaptation of Native Culture to American Culture

A large number of U.S. citizens and permanent residents of Trinidadian and Tobagonian
origin live throughout the United States, mostly in metropolitan areas and especially
in states such as New York and Florida. Concentration in these areas allows for retention
of cultural connections as well as food practices. Many supermarkets and
vegetable/produce markets carry many Caribbean foods and spices that make it easy for
individuals to obtain the required inputs to prepare familiar dishes. These residents have an
advantage over those who live in other states where the numbers are less and it is more
difficult to obtain the necessary ingredients for their native foods. If these ingredients are
available, they are likely to be expensive, but may still be purchased. Otherwise,
substitutions are sought, for example, chopped frozen spinach for dasheen bush and
evaporated milk for coconut milk, and butternut squash for pumpkin to make callaloo.
Concomitant with the increased migration over the years has been an increase in
Caribbean-style restaurants that cater to this target group as well as Americans, especially
those who would have been exposed to Caribbean food. Such establishments offer familiar
foods, allowing individuals to retain many of their practices. Additionally, basic and usual
food preparation methods such as stewing, frying, and currying, are often retained along
with the extensive seasonings with which they are accustomed.
Retention of native cultural food practices does by no means prevent Trinbigonians from
adopting food practices of the American culture. Before migrating, many individuals would
have been exposed to some American foods and food practices either from previous visits
or patronizing restaurants that offer American-style cuisine. Acculturation may be
challenging but much less traumatic than in previous years. Trinbigonians are known to
participate in national celebrations and festivities, many of which include food.
Adaptation to American culture is likely to depend on the length of residence in the US, the
extent of socialization and with whom, current lifestyle, family dynamics, and overall
socioeconomic status. Two notable changes are the consumption of the heaviest meal in
the evening instead of midday, and perhaps the inclusion of more fruit, given the
availability of canned fruits throughout the year. Nevertheless, living in the US carries with
it a mixture of native and local food practices.
Residing in the US, many individuals probably make an effort to comply with the USDA
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
MyPyramid, but it is possible that some persons may experience challenges integrating
their usual foods, especially combination foods, and food habits. Individuals with
knowledge of Trinbigonian foods and food practices are better poised to relate to persons
from their home country and to teach about food practices of their native country and how
best to integrate such foods and behaviors. Networking is essential and invaluable.
Many Americans enjoy Trinbigonians dishes and food preparation techniques.
Trinbigonians are proud to teach the preparation of some of their special dishes, which
include curried chicken and curried goat to accompany any of the various types of roti, rice,
potato salad, callaloo etc. Potato salad is made differently than a typical American recipe in
that sweet peas and carrots are added, and sometimes beets for additional color.
On special celebrations like Labor Day, when there is the Caribbean Carnival Parade,
Americans, Trinbigonians and natives of many other Caribbean countries join together to
sample and enjoy the variety of foods available.

Meal Planning in this Culture

Meal Times, Patterns, and Food Choices
Meal times are similar to other parts of the world. The majority of persons get breakfast
either from home or purchase it. In case of the former, it is usually eaten at home or in
transit to school or work. The composition of the meal varies depending on household
habits and preferences that are shaped by factors such as urban or rural living, religious
orientation, food availability and accessibility, education, preparation skills, overall
resources, and whether or not the caregiver is working or stays at home.
Meal patterns and practices from Monday to Friday are similar and tend to conform to the
previously described meals, while practices on the weekend may be different. On
Saturdays, the main meal is often a one-pot dish such as soup or pelau, while on Sundays
meals are larger and more complex. On Sundays, the main meal is likely to consist of one
or two meats, at least two staples, a legume, cooked vegetable (usually callaloo), raw
vegetable (salad), and a beverage. Family mealtime is still common on Sundays for both
breakfast and the main meal.

Food Choices

Breakfast
In Trinidad and Tobago, many dishes and food items are popular for this meal. Some
common breakfast foods include:

Staple Food Choices:
Bread: Sliced, commercial or homemade; hops bread
Bake: Roast (with or without coconut) or fried
Roti: Sada or dosti
Pita bread
Bagel
Crackers
Croissant
Muffins
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cereal: Cold or hot porridge
Fried potatoes (aloo): Mainly eaten by East Indians
In addition, some families (becoming a minority) still eat a heavy breakfast, which may be
leftovers from the previous day's meal or freshly cooked ground provisions (staples) with
steamed fish or some type of stewed meat. This depends on the structure and culture of
each individual family. Location also plays a role in menu planning. In rural
areas, many families have home-grown foods and fishing is prevalent. They tend to eat a
large breakfast to maintain energy for heavy work in the gardens/plantations. Individuals in
this setting often take some of these same breakfast foods for lunch.
Vegetables:
Intake of vegetables may be increasing in many nationalities because of the increased
intake of East Indians foods, including vegetable chokas made from foods like eggplant,
tomatoes, and their curried vegetables served with roti.
Choices from Food from Animals:
Egg, cheese, or ham
Sausages (cold cuts); black (blood) pudding
Vienna sausage or hot dogs/frankfurter
Sardines, smoked herring
Salt fish buljol (see Glossary)
Fried fish/shark
Corned beef (canned)
Hot milk-based beverage or with milk added or milk only
It should be noted that, unlike in the US, eggs are not used every morning for breakfast.
Traditionally, a hot beverage was always included to help “break the fast.” This practice is
not as common today, however, especially among the younger people, who prefer to have
a cold beverage such as a fruit drink or a soda.

Midday
The midday meal is called lunch, and in most cases it is the heaviest meal of the day. This
meal generally consists of cooked food for many persons, while the minority seems to
prefer the lighter, sandwich-type option. Rice is a predominant staple food and it may be
accompanied by another staple such as pasta or a provision such as plantain, cassava,
dasheen, potato (white or sweet), and yam, etc. Tobago is also known for its sumptuously
prepared provisions, collectively known as “blue food”, soups and stews which almost
always contain some coconut cream (“milk”). Blue food probably derived its name from the
color of cooked dasheen. Because of availability, fish is used often, and a popular and
favorite dish is curried crab and dumplings.
Legumes are used almost daily as part of this midday meal, either as an accompaniment, a
meat alternative, or as meat extenders, especially when small portions of meat are
served. All legumes except pigeon peas (cajanus cajun) are imported. Nuts are used
mostly as snacks, and are used in a beverage called peanut punch that peanut butter. Raw
and cooked vegetables are included with this meal but not as often as legumes.

The most widely and frequently used food from animals is chicken. It is prepared in a
variety of ways, such as stewed, curried, fried, baked or bar-be-qued, but stewed, curried,
or fried are more frequent and preferred. Within recent times, there seems to have been an
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
increasing demand for fish, given its importance in health, especially cardiovascular health.
Fish is prepared any style, but frying seems to be most frequent and liked. It is often said
that Trinbigonians do not like “white meat,” that is, meat without color. Other foods from
animals sometimes used include goat, pork, lamb, duck, shrimp, and beef. Although it is
well known that liver is an excellent source of iron, it is the least liked and used item from
this group.

Fruits are usually consumed as sweetened fruit drink. These are made from any of the local
fruits such as orange, grapefruit, portugals, pommecythre (golden apple), five-finger
(carembola/star fruit), passion fruit, W.I. cherry, mangoes, and any others that are
amenable to making a fruit drink.
It is normal practice to have a cold fruit based or non-fruit-based beverage with this meal.
Fruit-based options are usually a fruit drink made from any of the local fruits and less often
imported fruits. These beverages are hardly consumed as 100% juice. They are usually
diluted and sweetened according to individual tastes. Non-fruit-based options are either a
carbonated drink or soda (locally called “sweet drink”), water, or a local beverage such as
mauby. Fresh fruits are used more often as snacks and are highly dependant on seasonal
availability. Canned or frozen local fruits as substitutes for fresh fruits if they are
unavailable.
It is still a common practice by many to use generous amounts of fats and oils in cooking
and therefore hardly any is added to food after cooking.

Evening
Traditionally, the evening meal, supper, is lighter than the midday meal, especially if the
latter was heavy. This meal usually consists of a staple food such as bread, bake, or roti, a
food from animal, and either a hot beverage containing some milk or a cold fruit drink.
Should the evening meal be heavy, the composition will be similar to the midday meal as
described previously.

Dessert
Consumption of dessert with meals is not a daily occurrence by the majority of the
population. However, there are some persons for whom a “sweet” item completes a meal.
In these instances, choices available are fruit or any of the calorie- and nutrient-dense
items that are either home-made or purchased.

Social Events
Social events also contribute to shaping food practices. The use of food to demonstrate
hospitality is widespread throughout Trinidad and Tobago. There is hardly an occasion
when food is not served, but in many instances the choices tend to favor high-calorie,
high-fat options. Figure 7 depicts three commonly local sweet items that are used
nationally.

In an effort to respond to health promotion initiatives of nutrition and dietetic professionals,
and by extension other healthcare providers as well as the Ministry of Health, a trend
toward healthier choices has been observed in some environments recently.

Beverages
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There is a variety of popular beverages. These include various “sweet”/soft drinks (sodas),
fruit drinks, fruit, or non-fruit punches (these contain some milk), mauby, ginger beer, sorrel
(especially during the Christmas season), and water. These are consumed either with a
meal or between meals. There are a few food establishments that specialize in making
cold beverages only.
Nationally, any hot beverage, including milk, is called “tea.” Hot beverages may be served
with or without milk and they are usually sweetened. Black tea is called “green tea.” Hot
beverages such as coffee, tea, or a chocolate-based drink, are consumed mainly at
breakfast and supper. The population is often cautioned about consumption of the above
hot beverages as they affect iron absorption. Occasionally, tea may be consumed during
the day by a select minority.
Tea consumption has stemmed from our British heritage. Consumption of bush tea is still
common. Bush teas are infusions of various tropical shrubs, grasses or leaves stemming
from our African and East Indian heritage, and the tradition of using herbal medicines.
Additionally, they are promoted for relieving many ailments from the common cold to other
more severe illnesses. Examples include diarrhea, fever, general pain, headache,
indigestion, asthma, and even nutrition-related non-communicable diseases such as
diabetes and hypertension.

Snacks
There is a predominance of commercially made, attractively packaged and convenient food
items that are called snacks by the general population. Although some manufacturers have
reduced the salt and sugar content of their products, most “snack” foods continue to be
high in sodium and calories. These products are consumed primarily by children, and
include products such as chips, cookies (called sweet biscuits), candies, chocolates, and
nuts (plain, chocolate-coated, or with added sugar). Consumed less often are traditional
sweet items such as fudge, paw-paw balls, tamarind balls, sugar cake (made from
coconut), and bené balls (made from sesame seeds), toolum (made from coconut and
molasses), rice cake, and chip-chip (coconut and caramelized sugar). Fruits and selected
vegetables are recommended as healthy snacks but these are hardly viewed in like
manner by the general population. Among school-aged children, there seems to be a
preference for fruits in the form of chow – peeled, sliced fruit seasoned with salt, shadon
bené, and other seasonings.

Food Preparation
A variety of food preparation methods is used. The most common methods include
steaming, stewing, frying, currying, barbecuing, baking, roasting, smothering (frying then
steaming in gravy), and boiling. Stewing, currying, and frying are most frequently done
during the week while baking, roasting, and barbecuing are mostly on weekends.
Homemakers are encouraged to retain the water soluble vitamins in vegetables and rice by
steaming rather than boiling and straining the extra liquid. In this regard, some inroads
have been made but it is a common practice that needs frequent reminders.
Prior to cooking, meats are marinated or seasoned using salt and any combination of a
variety of fresh, bottled (commercially or home-made), or dried herbs and spices that are
available and often preferred. This is an essential pre-preparation step to flavor meats.
Standards regarding amounts or combinations vary based on individuals’ tastes and
preferences. Consequently, the taste of the end product varies. However, certain
condiments such as ketchup, mustard or pepper sauce may be added to selected dishes
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
by some individuals, but salt or other seasonings are not added after cooking.
Some dishes and food practices have their origin in the country’s history. A few examples
are as follows:
Pelau: A local one-pot dish that is an adaptation of the Spanish dish, paella. Pelau is
prepared and eaten by all sectors of the population and it is an excellent economical
choice for picnics, parties, and for a quick nutritious meal.
Caramelizing: Burning sugar in a pot until the crystals change to a thick golden-brown
consistency. The resulting product is used to add color and flavor to meats and other
products as well as to make black fruit cake, a Christmas tradition and a must for
most weddings.
Stewing: The practice of adding caramelized sugar to cook meats is an African
practice that became part of the Creole culinary tradition and has now been adopted
by everyone. The caramelized sugar gives the meat a distinctive but slightly sweet
taste.
Currying: This is a very popular cooking method that requires using curry powder and,
other spices and seasonings to give the dish a distinctive flavor. The population was
introduced to curried dishes by the East Indian inhabitants.
Marinating: Locally this is considered as seasoning. This process can assist with
tenderizing, flavoring, and even preserving meats. This practice links to our French
and British heritage.
Drying: This tradition is practiced by a small number of persons in pockets in the
country. It involves some salting and exposing the item to be dried in the sun. This
may be done especially in areas where fishing is predominant.
Eating Out
Eating out is herein defined as consuming food or drink that was not prepared at home.
There is an increasing trend towards eating out and the consumption of fewer
home-prepared meals. Over the years, changing practices have been observed in that
more eating out seems to be practiced, especially from Thursday to Saturday.
Trinidad and Tobago has numerous eating places, namely a variety of restaurants, food
courts, street-food vendors, and individual caterers. The cuisine is influenced by many of
the well-known fast food establishments from the US, Asian immigrants, East Indian
ancestry, local/”Creole” foods, and other immigrants from the Eastern hemisphere. In some
instances, satisfying one’s palate is only a phone call away or within proximity from home,
school, or the workplace. Many of these outlets and persons operate mainly for breakfast
and midday, while selected restaurants also operate in the evening and night.
A recent introduction in at least one area of the country is a privately operated system
similar to meals-on-wheels, whereby individuals select from the menu for the day, place
their requests, and the meal is delivered to the home. This is likely to be a budding
entrepreneurial initiative that can cater to individuals who are unable to prepare meals
every day.
Doubles, a national food item, has increased in popularity over the years. This is sold by
street-food vendors at any time. Because of its popularity and affordability, it is consumed
as breakfast, lunch, supper, or a snack. Although it is high in fat, it also provides some
protein from the channa (chick peas/garbanzo beans) that is used as the filler.
Bake and shark is another “must-have.” This mouth-watering sandwich is available
year-round. It is enjoyed by many either as a meal or as a snack. This is also a favorite at
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
many parties (“fetes” or “limes” – local terms) and other social gatherings. Other national
dishes on these occasions are souse, corn soup, geera pork or chicken and pholourie.

Food Dictionary

Trinidad and Tobago is one of the many Caribbean islands situated off the eastern coast of
the South American country of Venezuela. It is the second largest of all the Caribbean
islands, with a multiethnic, multireligious population approaching 1.3 million persons.
Historically, the country changed hands from the Spanish, French and British before
gaining independence in 1962. As a consequence of its history and population
composition, the country has much diversity regarding its food and food practices that are
respected by all and enjoyed by almost everyone, whether Christian, Hindu, Muslim,
Chinese, or from any other ancestral ethnic group. Traditional food practices still exist
today, although concomitantly, many factors have impacted on the emergence of new
habits and practices. Immigrants to the US have retained many native food practices and
still look forward to obtaining and enjoying the highly seasoned, spicy foods with which they
are accustomed. At the same time some foods and practices from their new environment
are skillfully incorporated into their new lifestyle. The accompanying Food Dictionary
provides a brief description of some common foods that are widely used by Trinidadians
and Tobagonians, whether at home or in the US.
Food Item Description Photo
Bake

A substitute for bread; a type
of flat bread that is roasted on
a tawah (platin or griddle) or in
a cast iron pot on top of a
stove. This is called roast
bake, because traditionally it is
roasted on both sides. Careful
attention is needed to prevent
burning because it cooks
quickly. Sometimes it is
cooked in the oven. Today
some homemakers have
adapted this method using the
oven.
Small balls of dough are
flattened and shallow fried to
make “fry bake.”
Bake:

Roast Bake:

Bake and shark

One of many local fast foods
that is very popular. Fried
shark is the filler for the fried
bake, in addition to lettuce and
tomato. Other vegetables that
may be used are cabbage
slaw and a slice or two of
Fried Shark:

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Bake and shark slaw and a slice or two of
fresh pineapple. Condiments
can include chutneys made
from chadon beni or mango;
choices of “sauces” are garlic,
tamarind, pepper, possibly
finished with a hint of ketchup
and/or mustard.
Bake and
shark:

Buljol
A combination dish consisting
of shredded saltfish (dried
salted cod, shark, or other
fish*) with chopped onions,
sliced or diced tomatoes and
oil (often olive oil). Diced bell
(“sweet”) peppers, cucumbers,
and even shredded carrots
may be optional. This is a
common accompaniment for
either roast bake, fried bake,
hops bread, sada roti, or even
crackers.
* Soaked well and drained to
remove some of the salt,
cooked, and then shredded.
Buljol with
hops bread:

Bread: Hops
A staple food usually made
from white flour, although
whole wheat hops bread is
also available. This is a
bun-like salt bread with a flaky
crust

Callaloo
This dish is often referred to as
a national dish. It is a
vegetable-based dish
consisting of okras, dasheen
bush/leaves (from the top of
tuber: dasheen), and pumpkin
as the three main ingredients.
Variations add of crab, salt
meat (pork or beef), coconut
cream (“milk”), seasonings,
and hot green
pepper. Chopped spinach can
be substituted if dasheen is
not available. After cooking,
the ingredients are blended to
a medium consistency. The
final product looks almost like
Chopped
dasheen bush:

Callaloo:

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creamed spinach but
consistency is not as smooth.
Corn Soup
Basic ingredients include
corn-on-the-cob cut into
bite-sized circles, split peas,
pumpkin, bits of dumpling, and
seasoning to taste. The end
product is a thick consistency;
it can be used as a main
course, but is often used as a
snack.

Doubles
Cooked bara filled with curried
channa. Condiments such as
grated spicy cucumber, green
mangoes, pommecythre or
golden apple, shredded
coconut, or any other
amenable fruit or vegetable
can be added.
Unwrapped
using 2 baras:

Wrapped:

Mauby
A refreshing drink that
resembles iced tea in
color. Mauby is made when
mauby bark (colubrina
arborescens) from the carob
tree is steeped with spices
such as aniseed, cinnamon
sticks, clove, and bay
leaf. Water is added to some
of the concentrated liquid and
sweetened. The drink has a
sweet and slightly bitter taste,
depending on the amount of
concentrate used. Sweetened
concentrate is also available
commercially.
Mauby bark
with dried
aniseed:

Mauby drink:

Pastelle
Flattened cornmeal dough
stuffed with seasoned ground
meat (beef, pork, or chicken)
or vegetarian mixture. This is
Wrapped and
whole:

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wrapped and folded in a piece
of a banana leaf and steamed
before eating.
Inside view:

Pelau
A national one-pot dish
(complete meal) consisting of
stewed meat (usually chicken
or beef), pigeon peas, and
rice. Traditionally, this dish
consists of at least three
Caribbean food groups:
Staples (rice), legumes and
nuts (pigeon peas), and a food
from the animal group
(chicken or beef). Addition of
vegetables and other items is
optional.

Pepper Sauce
A blend of hot peppers, garlic,
onions, mustard, and
sometimes selected
vegetables. This is in no way
comparable to a sauce or
gravy. Compared to “hot
sauce,” it is probably 100
times hotter, so only a small
amount (thus the small spoon)
is needed to enhance the taste
of certain dishes.
Hot pepper:

Pepper sauce:

Pholourie
(pronounced
po-lor-ree)
A batter, fried in oil by the
spoonfuls and served with a
sauce or chutney of some kind.
Three sauces
shown (from
top left)
chadon beni
chutney,
tamarind
(tambran)
sauce, and
mango
chutney.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Pommecythere
(Pronounced
“Pom-see-tay”)
Also known as Golden Apple;
a round fruit with a green skin.
When ripe, the skin turns to a
golden yellowish color. The
fruit is interspersed with
somewhat prickly strings but
can be eaten green or
ripe. When green, it can be
made into chow or grated and
made into chutney. Somewhat
ripe, it can be made into a fruit
drink.

Pommerac
This fruit is bright to dark red in
color, usually ovid shaped,
with one large center seed. It
is juicy, and can be eaten
fresh or made into chow or
jams.

Portugal (locally
pronounced as
“poo-tee-gal”)
A member of the citrus family.
This fruit can easily be
considered a “finger
food.” After peeling, the edible
portion can be section into
“pegs.”

Roti: Aloo puree
This type of roti contains
seasoned mashed potatoes
that was folded into the loi and
cooked the same way as
dhalpourie.
Same as
dhalpourie
Roti: Bara
This can be considered a
smaller version of dhalpourie
but the ground split peas are
combined with the flour, water,
and seasonings to make a soft
dough. Scoops of the dough
are deep-fried.

Roti: Dhalpourie
The roti skin (flat pancake-like
product sometimes as large as
a dinner plate) contains
ground seasoned yellow split
peas (dried, crumbly)
imbedded in the skin; thus, the
inclusion of dhal in the
name. The flattened loi (ball of
dough) is covered with oil and
Roti skin:

Wrapped roti:
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cooked on the tawah. This is
usually served with curried
meat such as chicken, goat,
duck, or other meat of choice;
vegetable (s) and potatoes; all
combined with channa or chick
peas.

Roti: Dosti
Dosti means friends, thus two
flattened roti skins are cooked
together as close friends on
the tawah. These are also
rubbed with oil before cooking.

Roti: Paratha
This type of roti is similar to
dhalpourie but it does not
contain any split peas. It
contains more added fat,
usually ghee, than dhalpourie.
After the roti is cooked, it is
beaten with a dabla (long
wooden stick like a
palette)while still hot, causing
it to mash up or crumble
slightly in smaller pieces, thus
the name “buss-up-shut”
because it now resembles a
“burst up shirt”.

Roti: Sada
Similar to naan; a popular
breakfast item that is usually
filled with a cooked vegetable.

Shadon beni
(cilantro,
bhandhanya)
A strongly flavored and
pungent herb used to flavor
many foods, especially fish,
shark, souse, goat, duck; can
be easily grown in household
kitchen gardens.

Sorrel
(Roselle)
A member of the hibiscus
family; its flowers bloom just in
time for the Christmas
season. The red petals are
steeped and made into a
drink. The petals can also be
made into jams, jelly, or an
accompaniment for turkey and

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other meats with which
cranberry sauce is used.
Soup
One-pot dish (complete meal)
consisting of meat, any dried
peas or beans, vegetables,
provisions, and dumplings.

Souse
Marinating pig's feet, cow
tongue, chicken feet, green
banana, breadfruit, etc., in
salted water, seasoned with
onions, cucumbers, pepper,
shadon beni, and other
seasonings. The marinating
time is generally one or two
hours.
Pig's feet
souse:

Selected
Starchy Fruits:
Breadfruit;
Roots:
Cassava, sweet
potatoes,
tannia,
dasheen,
eddoes, yam;
Tubers: White
potatoes (not in
picture)
This sub-group of staple foods
is collectively called
"provisions." They are grown
in the country as well as
imported from neighboring
Caribbean islands. Availability
varies according to the time of
the year, but some are also
available frozen. They are rich
in complex carbohydrate and
fiber, and very versatile in
terms of preparation. They can
be boiled, mashed, roasted,
fried; used as substitute for
white potatoes to make salad
or pie; and used as substitute
to make porridge for infant
feeding. Starchy fruits, roots,
and tubers complement any
meat or fish dish, but they are
noted for being served with
salt fish or smoked
herring. Some can be used to
make chips, e.g., plantain and
cassava.
Sweet
potatoes:
Tannia:

Dasheen:
Eddoes:

Cassava:
Breadfruit:

Yam:
Plantains:

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Stewed
As used in Trinidad and
Tobago, stewing meat refers
to adding seasoned meat to
caramelized sugar and
allowing the meat to cook over
moderate heat. The finished
product is golden brown with a
slightly sweet taste. Bottled
browning may well be a
byproduct of caramelized
sugar.

West Indian
Cherry
The Cherry or Acerola fruit
(Malpighia Punicifolia L) is an
excellent source of Vitamin
C. It is also rich in Vitamin A,
potassium, calcium,
phosphorus, and
carbohydrate. This tree
thrives without much care and
can be seen in the landscape
of many homes.



References


Campbell V, Sinha, D. Nutrition Made Simple. 4th Edition. Jamaica: Caribbean Food and
Nutrition Institute; 2006.
Campbell, V. Caribbean Foodways. Jamaica: Caribbean Food and Nutrition Institute; 1988.
Caribbean Food and Nutrition Institute. Cajanus: Common Caribbean Foods and Your
Health. 2006;Volume 39(1)No. 2.
Caribbean Food and Nutrition Institute. Cajanus: Common Caribbean Foods and Your
Health. 2006;Volume 39(2)No. 2.
Naparima Girls’ High School. Cookbook: The Multi-Cultural Cuisine of Trinidad and Tobago
and the Caribbean. Updated and Revised Edition, 2002.
Pan American Health Organization. Health in the Americas: Volume II, Trinidad and
Tobago, 2007.
Wall, H. GIS-Based Dissemination of Census Data in Trinidad and Tobago: A Caribbean
Experience. Ministry of Planning and Development, Central Statistical Office (CSO);
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Experience. Ministry of Planning and Development, Central Statistical Office (CSO);
October, 2007.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Chinese
Food Practices

It is important to know the Chinese culture in order to understand the eating behaviors of
the Chinese immigrants. The Chinese food practice is an amalgamation of eating habits
and customs from different regions of China, which have been handed down from
generation to generation. Environmental factors have a great influence on these practices.
Throughout history, China has suffered from cycles of flood and famine; the Chinese food
practices are a reflection of hardship and poverty. Food supplies are the main governing
factor in the traditional Chinese food practices. Because of the long history of hardship, the
Chinese consider that every creature or plant can be eaten.
Chinese cooking uses fresh produce, combined with preserved, pickled, dried, salted,
fermented, or cured ingredients and condiments. Dried, preserved, and salted foods are
eaten during the winter months when fresh food supplies are scarce. Recent advances in
technology allow farmers to produce food year round and improvement of transportation
systems brings foods from all over the world within a short period of time. These factors, as
well as an improved economy, have brought about changes in the traditional Chinese
eating habits.
The Chinese believe that eating is the most enjoyable event in life. All social gatherings
and festivals are focused on food. Dinner with the family is considered the most important
event of the day. The menu reflects the family's social and economic status. A traditional
Chinese meal consists of a main staple food (rice or grain products) and 1 or 2 cooked
dishes. In general, at least one cooked dish of meat or fish with vegetables is served.
Vegetables or dried ingredients are added to a meat dish to increase the volume. Dishes
are served in common bowls for diners to select their own amount and choices. Therefore,
no definite portion size is designated for each diner. The well-off Chinese serve fewer grain
products (starch) and more meat and vegetable dishes, whereas rural residents will use
less meat and at time will use a tuber to substitute for grain products. At banquets, there is
an extensive selection of exotic meat dishes, but only a small bowl of rice or noodles is
served.
When selecting food, the Chinese choose by the maxim that "Food should have good
appearance, fragrance, flavor, and texture." Chinese also believe foods should be chosen
so as to maintain a balance between yin (cold) and yang (hot) in the body. Food served
within this principle should be able to prevent and/or cure diseases according to Chinese
culture. In general, meats are categorized as yang and need to be balanced by food on the
yin side. Most vegetables and fruits are classified on the cold side; therefore, it is important
to add ginger or other "hot" ingredients to vegetable dishes to balance out.
Traditionally, the Chinese consume more cereal and vegetables and less meat, fruit, and
dairy products. The most commonly consumed dairy products are condensed milk or
evaporated milk as bread spread or dessert sauce. Soy milk is a popular drink in China. It
can be served sweet or savory. The traditional Chinese diets are low in fat and protein but
high in complex carbohydrates and fiber.
Fruits are abundant in the South; therefore, fresh fruits are mostly served after dinner as a
dessert in Guangdong (Canton), whereas candied or preserved fruits are popular in the
North. Besides fruits, Cantonese like fresh pork, poultry, and seafood, whereas Beijing
people consume more mutton, garlic, and leeks.
Chinese like to have soup with their meals. Southern Chinese believe that soup should be
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chinese like to have soup with their meals. Southern Chinese believe that soup should be
cooked for 3 to 4 hours to bring out its taste and essence of the ingredients. Cantonese like
to serve soup with meals or in between meals, whereas Northern Chinese like to serve
soup as the last course of their meal. Animal fat such as chicken fat or lard are widely used
in traditional cooking.
Chinese tea is the main beverage in China. There are four types of tea commonly found in
China. They are unfermented green tea (Longjing tea), semifermented tea (Oolong tea),
fermented tea (black tea like Pu Er tea), and flower-blended tea (jasmine tea,
chrysanthemum tea). They are served without milk and mostly without sugar.
The lifestyle of Chinese people was greatly influenced by Confucianism, Taoism, and
Buddhism. As a result, a lot of Chinese people do not eat beef and consume a vegetarian
diet on the first and fifteenth day of every lunar month. The Chinese vegetarian diet does
not include certain plant products like garlic and leeks, which are considered to have
exciting effects on the human senses.
China is a vast country with a diverse population. Regional eating habits make Chinese
food more interesting. They also reflect the geographic and climatic differences of the
country. Basically, Chinese food practices can be divided into 4 geographical regions,
namely, Hua Bei area (Northern China) and Northeast, Hua Nan area (Southern China),
Hua Dong area (Eastern China), and Hua Xi area (Western China). The Northwest region,
which is geographical huge and relatively sparsely populated, has remained indigenous.
The Northwest people have little interaction or integration with the rest of China. Therefore,
the food behaviors of these regions are not included in this section.
Hua Bei (Northern) area and Northeast cooking refers to Beijing cooking, which was
influenced by the Mongolians in the Yuan Dynasty around the 1200s A.D. and the Manchu
in Qing Dynasty around the 1600s A.D. Mongolian mutton hot pot is one of the most
popular dishes in Beijing during winter months as cooking in the hot pot keeps the food
temperature throughout the entire meal and heats up the room. Beijing roast duck served
with thin pancakes, raw leeks, and sweet sauce is popular around the world. Dumplings
(jiaozi) filled with a mixture of pork and cabbages or chives are popular breakfast or lunch
food and are served with vinegar, soy sauce, raw garlic, and sesame oil. Wheat is ground
into flour to make noodles, pancakes, or various wrappers for dumplings. Northern
dumpling wrappers are thicker than Southern dumpling wrappers (wonton).
Hua Nan (Southern) area cooking is mainly Cantonese food, which is the style developed
in Guangzhou (Canton) and Hong Kong. Rice is the Southern Chinese staple food. It is
served plain or with meat and vegetables. Rice is cooked by steaming, boiling (in clay pots
or electric rice cookers), or frying. Rice is also ground into flour to make rice noodles or rice
sheets (cheung fan). Congee, rice cooked with a double portion of water to make a
porridge, is the first weaning food for Chinese babies and is a popular breakfast food.
Southern Chinese cooking has an extraordinary range of cooking methods, ranging from
steaming, poaching, boiling, braising, stewing, baking, stir-frying, and deep-frying.
Cantonese foods are famous for the freshness of ingredients. Timing and temperature
control is critical in Cantonese cooking in order to retain the natural characteristic of the
fresh ingredients. Fresh poultry or fish is slaughtered shortly before cooking to retain
freshness. Most Chinese would go to the local market 2 to 3 times a day to obtain their
daily groceries. As Guangzhou and Hong Kong are coastal areas, Cantonese cooking uses
a lot of fresh seafood. Special barbecued meat shops selling barbecued roast pork, roast
duck, and goose are commonly found in Guangzhou, Hong Kong, and Chinatowns
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
worldwide. Usually found in U.S. Chinese restaurants, chop suey and fortune cookies were
invented in the United States.
Dim sum, popular in Canton, is similar to hors d'oeuvre dishes. It is taken with tea either as
breakfast, lunch, or snack. Dim sum in Chinese means "a point to your heart"; therefore,
such foods are usually distinctively attractive but served in small amounts. Dim sum foods
are usually served in small dishes or in bamboo steamers. They can be either sweet or
savory and can be prepared by steaming, boiling, stewing, baking, stir-frying, and
deep-frying.
Hua Dong (Eastern) cooking is generally Huaiyang food and includes cooking of Shanghai,
Zhejiang, and Jiangsu. Huaiyang is an area of lakes, rivers, and seashores where fish and
rice are plentiful; therefore, fish, shrimp, and crab are delicacies of this area. Some of the
famous Huaiyang dishes are "lion head" meatballs, shrimp with longjing (dragon well) tea,
and chicken with chestnuts in a sweet sauce. The Huaiyang meal is also well known for its
array of sweet and savory dishes similar to hors d'oeuvres.
Hua Xi (Western) cooking generally refers to the spicy Sichuan food. Chili pepper and
Sichuan peppercorns in Sichuan food provide a mouth-burning sensation. It is believed
that this burning sensation is able to combat the cold climate and humidity in the Sichuan
province. It also acts as a preservative for meat and fish. Wild-grown mushrooms and
vegetables are abundant in Sichuan and are widely used in their dishes.
All regions in China use various forms of ginger, garlic, spring onion, chili, soy sauce,
sugar, and vinegar in their distinctive ways. The proportion of condiments and sauces is
what makes each regional food different. The choice of staple ingredients is also distinctive.
Southern Chinese prefer long-grained rice, whereas Eastern Chinese prefer glutinous rice.
Northern and Western Chinese prefer wheat products like noodles and steamed buns.


Immigrants or Ancestors

Migrating within China and from China to Overseas
Recent nutritional surveys conducted in China showed there is a changing trend in eating
habits in China after the economic reforms (Popkin, 1993; Leung, 1994; Chen, 1996;
Leung, 1997; Zhao, 2001).
In 1987, the meat consumption had increased twofold and fat consumption threefold when
compared with data from 1978 (Zhao, 2002). The traditional Chinese diet is low in fat
and protein, and high in fiber, for it is usually rich in plant-based foods. This includes the
use of soy and other lentils and legumes as the major source of protein instead of meat
(Chen, 1996; Xie, 1998; Campbell, 1999). Recent studies and national nutrition surveys
have shown there is a decreased consumption of grain and grain products, which originally
made up the major contribution of Chinese diet. Their position is being replaced by
increasing proportion of protein foods in the total food consumption. However, the
traditional soy and dried beans consumption is also witnessing a decreasing trend,
replaced by an increase in milk, meat, poultry, seafood, and egg consumption (Zhang Z,
1997; Xie, 1997; Chen, 2000; Wang, 2000; Wang, 2001; Zhao, 2001; Zhang B, 2002;
Zhang M, 2002). This leads to the consequence as reported by Zhao and Chen (2001) that
the urban Chinese have a high fat intake of approximately 30% of total energy. This is
higher than the 20% to 25% dietary fat contribution to daily energy intake stipulated by the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
higher than the 20% to 25% dietary fat contribution to daily energy intake stipulated by the
Chinese Recommended Dietary Allowance published in 1999 (Institute of Nutrition and
Food Hygiene, Chinese Academy of Preventive Medicine, 1999). This observation is similar
to findings of other studies (Leung, 1993a; Leung, 1993b; Leung, 1997; Zhang Z, 1997;
Woo, 1998; Woo, 2001).
Researchers are finding that the shift in eating preferences is mainly caused by shifts in
personal income, food price, and food availability (Ismail, 1997; Popkin, 2001). The dietary
pattern of Southeast Chinese women shows a greater consumption of vegetables, fruits,
and animal products and a lower consumption of cereal and tuber foods (Zhang M, 2002).
Moreover, the marked differences between urban and rural eating patterns are further
influenced by the choice of venue or location of food served. Meals consumed away from
home, which is practiced more frequently by urban populations, are usually higher in fat
and meat (Popkin, 2001). The energy and carbohydrate consumptions were greater among
Jiangsu rural residents whereas the urban residents had a higher protein intake (Wang,
2003). Moreover, despite the lower total protein content of their meal plan, their proportion
of dietary fat and fat contributed by animal products was higher in rural men than their
urban counterparts.
Regarding grain and cereal consumption, rice is still the main staple in the urban area in
Southeast China, but the rural residents at this time need to supplement their insufficient
rice supply with root vegetables and tubers, whereas wheat, millet, and maize consumption
is still high in Northwest China, especially in the rural areas (Shimbo, 1997).
As an obvious by-product of urbanization and economic prosperity, it was also reported that
the consumptions of soft drinks, sweet beverages, sweets, and candies are increasing in
China (Ismail, 1997).
Another change in dietary practice is people's daily intake pattern. A daily intake of mainly 3
meals per day has been the established and faithfully enforced eating pattern among
Chinese since ancient times. In the Chinese custom, breakfast usually is the lightest meal,
always eaten at home as the first activity at daybreak. Breakfast is usually consisted of
bland-tasting congee in the South and soy bean milk with steamed buns (mantou) in the
North. With the advance of economic growth and Westernization, people in the urban
areas are shifting to the heavy breakfast of egg, milk, meat, and bread (Leung, 1993c;
Leung, 1997). Lunch is almost inevitably eaten away from home, in worksite canteens or
fast-food restaurants. Beijing and Shanghai women are found to have a light lunch,
whereas Nanning women had a more substantial lunch (Zhang Z, 1997). Yet, the urban
light lunch practice is made up by the increasing trend of between-meal snacks, which was
unusual in the old days. This study also reported that 7% of the total energy intake of the
women in the Beijing, Shanghai, and Nanning study was contributed by snacks. Dinner
has been the most substantial meal of the day, regarded as the family's daily congregation,
and it has remained so amidst all the changes.
In addition, the urban population is adopting a trendy practice of having a night snack at
eat-out restaurants such as dim sum restaurants in the South and noodle-jiaozi shops or
street vendors in the North. The amount of food consumed is substantial and usually
consists of high-fat and high-protein foods.
As the people in mainland China are moving from rural agricultural areas to urban
industrialized centers, they are also migrating within China from the less-developed regions
to the highly urbanized cosmopolitan cities like Hong Kong. Their eating patterns have
become more Westernized as Western foods are easily available there.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In 1995, a territory-wide survey was conducted in Hong Kong (Leung, 1997; Woo, 1998),
with the objective of investigating the relationship between dietary habits and
cardiovascular risk. The study results indicated that of the 1,010 adult subjects (500 males
and 510 females) randomly recruited, more than 60% ate breakfast or lunch outside their
homes. Among subjects, 25% (mostly among the younger age groups) ate at fast-food
restaurants, food stalls, or street vendors 2 to 3 times/week. Similar to findings of other
researchers, more than 90% of the studied population was having dinner at home. Bread
and sweet rolls like pineapple bun, cocktail bun, and sausage rolls were popular breakfast
items. Only 4% of the subjects studied consumed whole wheat bread, whereas 56% ate
white bread and 35% of the population ate both white and whole wheat bread. The majority
(98%) of the population ate white rice, which is still their choice of staple food. The average
rice intake was 2 bowls (390 g) per day, usually eaten at lunch and dinner. Pork, chicken,
seafood, and eggs were the most popular source of protein among Hong Kong Chinese.
Chinese cabbages were commonly consumed. Orange, apple, and banana were the 3
most commonly consumed fruits in this population. Approximately 39% of the subjects did
not drink milk, whereas the rest consumed low-fat/skim, whole, or condensed milk. The
average energy intakes were 2,400 kcal kcal for males and and 1,800 kcal for females with
an energy distribution of 53% from carbohydrate, 18% from protein, and 29% from fat.
These results suggested that there was a shift toward higher protein and fat intakes in
Hong Kong
In a comparative study between Chinese in Singapore and mainland China, the
Westernization of food intake in Singapore Chinese had significantly affected their lipid risk
factors when compared with their Chinese counterparts living in mainland China with less
acculturation (Heng,1997).
Australian-born Chinese and those with a longer length of stay in Australia were more
acculturated toward Australian meal plans than those born in The People's Republic of
China or Vietnam and migrated to Australia at an older age (Hsu-Hage, 1995). These
Melbourne Chinese were replacing the traditional Chinese foods such as rice, pork, leafy
green vegetables, soups, and tea with Australian food such as wheat products, red meats,
and coffee. Other researchers found that these Melbourne Chinese were consuming a food
plan with an increasing contribution of energy from protein and fat with a decreased
percentage of caloric intakes from carbohydrate (Zhang H, 2002).
In summary, the eating pattern of Chinese has shifted from a low-fat, low-protein,
high-carbohydrate, and high-fiber diet to a high-protein, high-fat, low-carbohydrate, and
low-fiber intake.

Adaptation of Native Culture to American Culture

Acculturation is a term describing immigrant groups adapting the behavior and culture of
their host country. This includes food habit and lifestyle changes. It was not until the 1980s
that researchers started to look into the food habits of Chinese immigrants living in the
United States.
Chinese immigrants living in New York's Chinatown had fewer food habit changes than
those living in a mixed ethnic community (Newman, 1982). It was reported that both
groups, in fact, did not enforce entirely authentic practices before migrating to the new
environment. The researchers' findings also suggested that those Chinese immigrants
living in the United States for less than 2 years had a greater degree of acculturation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
whereas with a longer stay, a regressive trend occurred. Those immigrants with more than
5 years residency showed a reverse in their traditional food habits. The findings about food
choices and behavior traits are also in agreement with other studies that identified similar
changes in the immigrants' dietary habits. They included the following:
Increased consumption of meat and dairy products;
Decreased family meals eaten together at home;
Increased frequency of eating out;
Increased use of processed and convenience food, which then allowed for shortening
of meal preparation time without changing the cooking techniques (Newman, 1982;
Satia, 2001b).
It was also observed that family members' roles changed with migration, with the male
member more involved in food procurement and meal preparation, which was unheard of in
the old country.
Acculturation to the Western diet could be seen in Chinese Americans through an
increased consumption of Western foods such as dairy products, cold breakfast cereals,
fruit and fruit juices, luncheon meat, and increased nibbling of chips and other snack foods
(Yang, 1979; Newman, 1982; Maskarinec, 2000; Satia, 2000; Satia, 2001a; Satia, 2001b).
Researchers also reported that breakfast usually was the first meal to be Westernized in
these Chinese-American households (Yang, 1979; Maskarinec, 2000; Satia, 2000).
However, these families were still serving a traditional Chinese meal at dinnertime (Yang,
1979; Newman, 1982; Satia, 2000).
A study of the relationship among diet, acculturation, and health of Chinese immigrants
indicated that factors affecting U.S. acculturation were
convenience;
cost;
availability;
quality;
wholesomeness of the local food supply;
taste preference and attitudes of the young members in the family, especially
children, provoked further changes (Satia, 2000).
Nostalgic food preference; perceived inferior quality of non-living, chilled, or frozen livestock
and poultry; and the attitude of the predominating adult family members, especially the
senior members, are all negative attributes against acculturation.
Furthermore, researchers found that 7% of the surveyed Chinese immigrant families
reported to have no "American" foods in their households. Not surprisingly, these were
families having the shortest length of stay in the United States, suggesting that
acculturation is a gradual process (Satia, 2000). In addition, the majority of the female
members of these nonacculturated families were holding on to the old practice of 3 meals
per day, having no or very few between-meal snacks. They also regularly consumed a
Chinese-style lunch such as noodles or rice with stir-fried foods. All these observations are
indicative of the decisive role of the housewife in the family meal pattern.
Nonetheless, other studies on Chinese immigrants revealed that dietary acculturation were
seen in an increased consumption of high-fat foods including animal fat, processed meat,
and chips. This situation was especially dominant among immigrants with higher
educational level and increased duration of stay in the United States (Satia, 2001b).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
In summary, the first acculturated meal for Chinese immigrant is breakfast. Most Chinese
immigrants found that bread or breakfast cereals served with milk were acceptable
breakfast as these items required less preparation. In fact, most Chinese living in Hong
Kong had adopted the Western breakfast by eating eggs with toast or consuming modified
Western rolls like pineapple buns, cocktail buns, and sausage rolls. These breakfast items
are usually served with milk, soy bean milk, tea, or coffee. As for dinner, Chinese
immigrants continue to cook their dinner in the traditional Chinese way by modifying the
ingredients that are available in the local market. Moreover, more Chinese ingredients,
such as bean sprouts and bok choy, are available in U.S. supermarkets. Lunch is also
Westernized to fast foods or sandwiches for the working class. In addition, there is an
upward trend in the consumption of Western snacks. Generally, the consumption of
high-fat meat, especially beef and chicken, is increased, whereas the consumption of fish
and soy bean products is decreased because of availability and cost. Furthermore, the
consumption of dairy products, fruit juices, and soft drinks is growing rapidly in these
Chinese families. The fat intake of Chinese immigrants is found to be higher than fat intake
in the traditional Chinese diet.

Meal Planning in this Culture

Meal planning within different regions of China is basically very similar, with a staple food
plus 1 to 2 dishes of meat and vegetables. The difference is found mainly with the staple
foods. Rice is used in Hua Dong (Eastern) and Hua Nan (Southern) areas whereas wheat
products are consumed in Hua Bei (Northern) and Hua Xi (Western) areas.
Another distinction is found in the use of seasoning and condiments. The food of the Hua
Bei (Northern) area is more oily and substantial; the foods of the Hua Dong (Eastern) and
Hua Nan (Southern) areas are lighter, whereas the food of the Hua Xi (Western) area is
spicier.
Hua Bei (Northern China) Area: Mongolia, Shanxi, Henan, Hebei, Shangdong
Northeast: Heilongjiang, Jilin, and Liaoning
Breakfast Warm soy bean milk
Oily spring onion cake
Lunch Steamed bun (Mantou)
Sauteed green onion with mutton
Stir-fried bamboo shoot with salted kales
Evening
Meal
Pork and vegetable dumplings (Jiaozi) with soy
sauce and vinegar
Boiled vegetables with soup
Hua Nan (Southern China) Area: Fujian, Jiangxi, Hunan, Guangxi, Guangdong,
Hainan
Breakfast Congee with sliced fish and lettuce

Plain cheung fan with sweet sauce and peanut
sauce
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Lunch Dim sum
Steamed barbecued pork bun
Shark fin shao mai
Beef meatball
Egg tart
Chinese tea -- Pu Er
Evening
Meal
White rice
Steamed fish with ginger and green onion
Mushroom with sea cucumber on lettuce
White fungus and green papaya chicken soup

Fruit plate with custard apple, persimmon, longan,
pomelo, and pitaya

Hua Dong (Eastern China) Area: Hubei, Anhui, Jiangsu, Zheijiang
Breakfast Sweetened soy bean milk
Glutinous rice roll with shredded pork
Lunch
Fried Shanghai noodles with shredded vegetables
and pork
Evening
Meal
Shredded Shanghai cabbage with rice
Lion head meatballs (minced pork)

Soy bean curd sheets with fresh green beans and
salted kales


Hua Xi (Western China) Area: Sichuan, Guizhou, Yunnan
Breakfast
Yunnan rice noodles with minced beef and
shredded cabbage in soup
Lunch
Sichuan dandan noodles (noodles with minced pork
served with spicy Sichuan peanut sauce)
Evening
Meal
Rice
Poached sliced beef with Sichuan spicy sauce
Stir-fried wild mushrooms

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Food Dictionary

Food Ingredients or Preparation Picture
Abalone
(Canned)
Abalone is a mollusk. It is a Chinese
delicacy served only at festivals. Fresh,
dried, or canned abalones are commonly
found in Chinese markets. They can be
served with a vegetable or alone. Fresh
or dried abalone is used for soup. Dried
abalone needs to soak for a long time
before cooking.

Abalone
(Dried)
Abalone is a mollusk. It is a Chinese
delicacy served only at festivals. Fresh,
dried, or canned abalones are commonly
found in Chinese markets. They can be
served with a vegetable or alone. Fresh
or dried abalone is used for soup. Dried
abalone needs to soak for a long time
before cooking.

Bamboo Shoot
A bamboo shoot is the young, edible
portion of the bamboo plant. It is covered
with different layers of yellowish-brown
sheaths. The shoot-bud inside the
sheaths is used for cooking and eaten as
a vegetable. Fresh bamboo shoots
should be parboiled before cooking in
stews or dishes.

Barbecued
Roast Pork Bun
It is a steamed bun stuffed with
barbecued roast pork and hoisin sauce.

Bean Sprouts
There are two types of bean sprouts
commonly used in the Chinese diet. The
smaller bean sprout is from green mung
beans, and the bigger bean sprout is
from soy beans. They are inexpensive
and are extensively used as vegetables
in family dishes.

Beef Ball
Ground beef put on top of soy bean
sheet are steamed in a bamboo basket.
Sometimes, orange peels are added to
ground beef to enhance its taste.

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Beijing Duck
The theme of the roasted Beijing duck is
the crispy skin served with a pancake,
raw leeks, and sweet sauce. The meat,
which should be tender, is usually
served as a separate dish sauteed with
leeks, celery, and so forth. The
remaining bony carcass is then used for
making soup. It is a popular banquet
dish in Beijing and has become popular
worldwide.

Bird's Nest
Bird's nest is the saliva of a species of
swallow living in the high cliffs of the
South Pacific islands. Air-dried bird's
nest is usually sold in small packages
and is very expensive, as it is difficult to
obtain. It is used for soups or desserts
and is believed to have a good tonic or
medicinal effect.

Bitter Melon
Bitter melon is a green, oblong-shaped
melon with numerous irregular
longitudinal ridges and prominent
tubercles on the outside. It has a very
strong, bitter taste, which is believed to
have cleansing effect on the body.
Seeds should be removed before
cooking.

Black Moss
Fungus
Black moss fungus is a black-colored,
hair-like fungus (fa cai). Black moss
fungus is dried and needs to soak in
warm water before use. "Fa cai" in
Cantonese means wealth; therefore, it is
traditional to cook black moss fungus
with dried oysters, mushrooms, and
meat as festival dishes.

Chayote
This is also known as the "Buddha's
palm melon." The melon has a pear
shape and is whitish green in color with
a mellow, sweet taste. It is cooked as a
vegetable or stewed with meat.

Chinese Box
Thorn
Chinese box thorns are thorny shrubs.
Only the young leaves are used in soup
and stews. It is believe to enhance blood
formation. The fruit or berry of the
Chinese box thorn is red in color. It is
sweet in taste with small seeds. The
dried fruits are used in soup as an

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
important Chinese medicine to restore
energy and to improve eyesight.
Chinese
Cabbages
Chinese cabbages are the most
commonly used vegetables in China.
There are different types of Chinese
cabbage. White cabbage (bai cai or bok
choy) has white stems and bright green
leaves. Flowering cabbage (choy sum)
has a light-green stem and yellowish
flowers. These two species are more
commonly used in the Southern
provinces. Celery cabbage or long white
cabbage (shao cai), which is the most
predominant vegetable in the northern
provinces, has long, pale,
yellowish-green leaves and white
celery-like stems. Celery cabbage
usually is stored in the cellar or hangs to
dry in the house of northern Chinese to
use in winter.

Chinese
Chives
Chinese chives are dark green, flat
leaves with garlic-like flavor. Sometimes
they are grown covered with layers of
straw to keep them delicate and
pale-yellowish in color, called "Crown
chives" (Jiu huang). When the plant
bears buds and flowers, the stem is also
eaten as round chives. The entire plant
are used as a vegetable or seasoning.
Sometimes they are mixed with meat for
dumpling (jiaozi) stuffing.

Chinese Grain
Wine
Two types of grain wines are commonly
found in China. They can be classified
as white (bai jiu) or yellow (huang jiu).
White wines are distilled spirit with an
alcohol content between 40% to 60%.
The most famous brand of white wine is
Maotai. Yellow wine is distilled from
glutinous rice with an alcohol content of
around 14%. They are used in drinking
or for cooking.

Chinese
Chinese sausages are mostly used in
the winter as preserved meat. It is a
combination of pork or liver seasoned
with soy sauce and sugar to dry in the
summer sun. Usually very fatty cuts of

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sausages pork are used. Traditionally, Chinese
sausages are steamed on top of a clay
pot of rice so that all the oil and sauces
of the Chinese sausage are absorbed
into the rice.

Cocktail Bun
It is a baked roll stuffed with shredded
coconut and egg custard. Sesames are
sprinkled on top of the roll. This is a
popular breakfast item.

Congee, Rice,
and Soft Rice
Congee is a way of cooking rice by using
a lot of water to make into a porridge
form. Congee is a popular breakfast or
snack food. It can be eaten plain with a
number of savory side dishes or it can
be cooked with fish or meat and
vegetables. Plain congee is the first food
given to a weaning infant in China.

Conpoy
Conpoy is dried scallops. They are used
in soup or in cooking to enhance the
flavor.

Custard Apple
Custard apple has a scaly cover and is
yellowish-green in color. The white,
sweet pulp is eaten raw with black seeds
embedded in each pulp.

Dim Sum
Dim sum refers to small dishes of foods
served as side dishes or bamboo
steamers. They are usually served with
tea for breakfast, lunch, or snacks. Dim
sum can be sweet or savory. The
cooking method varies from boiling,
steaming, baking, stewing, and
deep-frying. This is a popular Cantonese
Sunday breakfast or lunch event.

Dried Fungus
There are different types of dried fungus.
The most popular ones are black and
white fungus. Black fungus is cooked
with meat as a combination dish. White
fungus is generally used in soup or
sweet soups. Fungus is extensively
used in vegetarian dishes.

Dried Oysters
Sun-dried oysters are used in congee or
stewing to add flavor to the food. Oyster
in Cantonese means "goodness";
therefore, it is traditionally used as
festival dishes.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Dried Red
Dates
Dried red dates have a prune-like flavor
and are added to soup or cooked in
vegetarian dish. It is believed that the
red date has a medicinal property to
enhance blood formation.

Dried Shrimp
Dried shrimps or prawns with the shell
on are used in cooking vegetable dishes
to enhance the flavor.

Dried
Tangerine
Peels
Dried tangerine peel is commonly added
to stews or slow-cooked food as well as
soup and desserts to bring out the
flavor. It is believed that it can neutralize
the "cooling" effects of foods. The aged,
dried tangerine peels are very expensive
because of their medicinal effects.

Dumplings
(Jiaozi)
Dumplings refer to "food parcels" with
meat, vegetables, and condiments
wrapped in different wrappers. The
Cantonese prefers thinner wrappers
(wonton), whereas the Northern Chinese
prefer thicker dumpling (jiaozi) wrappers.
The stuffing of the dumplings is different
regionally. They range from pork, beef,
mutton, seafood, or a combination of
these. Some dumplings have vegetables
added. Another popular dish, tea leaf
dumpling, is glutinous rice with mung
beans wrapped in leaves. This is a
festival food eaten in the Dragon Boat
Festival (5th date of lunar fifth month).

Egg Tart
Egg tart is a baked small individual pie
filled with egg custard.

Fermented
Beans
There are 2 kinds of fermented beans
used in China. They are fermented black
and soy beans (yellow beans). Usually
they are heavily salted and mashed into
a paste for seasoning of a dish. It is
extensively used in fish or meat dishes.

Five Spice
Powder
Five spice powder is a mixture of 5
ground spices, namely, star anise,
fennel, cloves, cinnamon, and Sichuan
pepper. It is commonly used in stewing
meat dishes.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Garlic
Garlic is an important ingredient in
Chinese cooking. It is used for its flavor
and its medicinal properties. Garlic is
finely chopped for cooking or could be
eaten raw. Preserved garlic is used for
pickling. It is important to note that
traditional Chinese vegetarians do not
include garlic in their diet.

Ginger
Fresh ginger is widely used in Chinese
dishes. Similar to garlic, it also has
medicinal properties. It is commonly
added to vegetable dishes, as it has a
property to balance out the "cooling"
effect of vegetables. Salted or pickled
gingers are also consumed as snacks or
served as a side dish.

Ginkgo
The Chinese name for ginkgo is "Pai
Goi" meaning white nut. The white shell
should be removed before use. The nuts
are used in soup, stews, and vegetarian
dishes or as desserts.

Ginseng
This is an expensive tuber used as
medicine. The dried, wild ginseng has a
particularly high value. It is commonly
steamed with poultry as a soup or dish.
It can also be served as a tea. Ginseng
is believed to have the property to
restore energy to the body; therefore, it
is extensively used by wealthy Chinese.

Hairy Melon
The hairy melon is cylindrical and has
hairy, dark green skin. The white pulp is
cooked as a vegetable or in soup.

Hoisin Sauce
Hoisin sauce is also known as "seafood
sauce." It is a brownish-red sauce made
from soy beans and sweet sauce. It is
used to season meat or served as a
dipping sauce.

Jack Fruit
Jack fruit is a barrel-shaped, large fruit.
The edible part is the yellowish pulp,
which has a strong odor. It is served
fresh as a fruit or dried as a snack. The
seed can be cooked and eaten as snack
or cooked with meat in a stew.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Kudzu
The Chinese name for kudzu is "Fun
Kot." It is a large root tuber with a
substantial amount of starch. Kudzu is
used in soup or stews.

Kumquat
Kumquat is a small citrus the size of a
date. It is orange in color when ripe. The
flesh is sour in taste. The whole fruit,
with the rind, may be eaten fresh or
preserved.

Longan
Longan is also known as "Dragon's Eye."
The fruit has a brittle and
brownish-yellow coat. The white,
translucent pulp is sweet with a dark
brown seed inside. The dried longan is
also used extensively in making soup or
in beverages.

Loofah
There are two common types of loofah
found in China, namely, "silk gourd" and
"water gourd." They are used as
vegetables or, if allowed to grow old,
dried as sponges.

Lotus Leaves
Lotus leaves (large, green leaf) are
large, bell-shape leaves. It is commonly
used to wrap rice or chicken before
steaming to add flavor to the food and to
protect it from overcooking.

Lotus Root
Lotus root (long root with holes in the
center of the leaf), cultivated in ponds,
has a beige-colored skin and crunchy
texture. When lotus root is sliced
cross-sectionally, the center has a lacy
pattern. It can be eaten fresh or cooked
with meats. Lotus root can also be
pickled as a side dish. Sugared lotus
roots are served on the Chinese New
Year as a symbol of harmony in the family.

Lotus Seeds
Lotus seeds are the seeds of the lotus
flower (white seeds on leaf). Normally
the hard core of the seeds should be
removed before use, as they have a
bitter taste. Fresh or dried lotus seeds
are commonly used in soups or cooked
with glutinous rice as a dessert. Sugared
lotus seeds are also served on the
Chinese New Year as a symbol of

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
having more children in the family. Lotus
seeds are mashed and mixed with sugar
into lotus seed paste. The paste is used
as Chinese dim sum filling in a sweet
steamed bun or in a Chinese pastry like
Chinese wedding cakes or moon cakes.
Lotus Seed
Steamed Bun
Lotus seeds are mashed with sugar and
lard into a paste as the fillings of a
steamed bun. Sometimes, salted egg
yolk is added to make it more tasty.

Lychee
The lychee fruit is covered with a red,
brittle peel. The fleshy, white pulp is
sweet with a dark brown seed inside. It
can be eaten fresh or cooked as a
dessert. The Chinese believe that, unlike
most fruits, lychee has the property of a
"hot" food.

Monosodium
Glutamate
(MSG)
MSG is widely used in Chinese cooking
as a flavor enhancer.

Moon Cake
with Salted
Egg Yolk
Moon cake is a traditional pastry using
lotus seeds or other beans mashed into
a paste as the filling. It is specifically
eaten during the mid-autumn festival
(mid-lunar eighth month). Besides the
bean paste filling base, sometimes
salted egg yolks and nuts are added.

Mung Bean
and Vermicelli
Mung beans are also known as "dried
green beans." Mung bean is a small,
green, hard seed commonly used in
soup or desserts. Split mung beans with
the husks removed are used for filling for
tea-leaf-wrapped dumplings. Mung
beans can also be soaked and seedlings
allowed to grow into bean sprouts. Mung
bean starch is made into bean vermicelli
noodles.

Mushrooms
There are different types of mushrooms
used in the Chinese diet. They are
black, straw, and wild mushrooms. Fresh
or dried mushrooms are commonly used
to cook with meat dishes or to make
vegetarian dishes. Sichuan is famous for
having a large variety of wild mushrooms.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Oyster Sauce
Oyster sauce is a popular Cantonese
condiment made from oyster juice. Most
Chinese use oyster sauce to make
brown gravy in stir-fried dishes. It is also
used as a dip for boiled vegetables
served in noodle shops.

Persimmon
Persimmon is an orange-red fruit with
the shape, size, and color of a tomato.
The skin should be removed before
eaten. The red pulp is soft and sweet. It
can be eaten raw, dried, or candied.

Pineapple Bun
Pineapple bun is a baked roll covered
with a crispy pastry top that resembled
pineapple. It is commonly consumed at
breakfast or at snack time in Hong Kong
and Guangzhou. Sometimes, butter is
added to make it more rich and tasty.

Pitaya
Pitaya is the fruit produced by warm
climate cacti. Two types of pitaya are
commonly found in the market namely
red and yellow. The sweet pulp is white
in color with many small sesame-like
edible seeds.

Plum Sauce
Plum sauce, a condiment with
brownish-red color, is a mixture of salted
plums, vinegar, and sugar to produce a
sweet and sour taste. It is commonly
used in meat dishes.

Pomelo
This is a large, pear-shaped, citrus fruit
yellowish in color with a thick rind. The
white, fresh pulp is fibrous, juicy, and
has a bittersweet taste, closely
resembling that of grapefruit. The rind
can be used as a vegetable after
parboiled. The pomelo peel is usually
cooked with meat.

Preserved
Eggs
There are 2 types of preserved eggs
commonly found in Chinese markets,
namely, salted eggs and thousand years
eggs (century eggs). Salted egg has a
heavy salty taste. Thousand years eggs
are coated with powdered lime, rice
husks, and salt. It gives a distinctive
taste of lime. The egg white becomes
translucent black, whereas the yolk is

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
greenish in color. Thousand years eggs
can be served with pickled garlic and
gingers as appetizer. Both of these eggs
are used in dishes or congees. Their
yolks are often used in making Chinese
pastries like moon cake or Chinese
wedding pastries.
Preserved
Vegetables
There are many preserved vegetables
including salted kales, vinegarette
mustard green, chili radish, preserved
salted radish, and dried bok choy.
Preserved vegetables are added to meat
dishes to enhance taste. Poor Chinese
families in rural areas may serve
preserved vegetables alone as their daily
main dish. Salted preserved vegetables
are widely consumed by Chinese elderly
as they find it is more palatable. Dried
vegetables are used to make soup.

Rice
In China, the short-grained rice is called
"Geng," whereas the long-grain rice is
called "Shin." Short-grain rice is stickier
after cooking. Rice is usually boiled,
steamed, or fried in China. In general,
the water to rice ratio is around 1 cup of
rice to 1.5 cup water, but it all depends
on the type of rice used. Sometimes rice
is cooked with a higher ratio of water to
make congee or soft rice. Soft rice has a
texture in between rice and congee. It is
commonly served to toddlers or the
elderly when they have chewing
problems. Besides white rice, there are
brown rice and coarse rice, which are
only partially milled. They are high in
fiber and vitamin B content.

Rice,
Glutinous
Glutinous rice is also known as sticky
rice. It is used for rice dish stuffings or as
snacks. They can be made into rice rolls
stuffed with meat or dessert. Glutinous
rice roll is a popular breakfast food in
Shanghai.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Rice Noodles
There are a variety of noodles used in
China. They range from fresh to dried.
They can be made of wheat, rice, or
mung bean flours. Fresh noodles should
be consumed within 1 to 2 days. Wheat
noodles are made with eggs, whereas
rice noodles are made of rice flour only.
Dried rice vermicelli and mung bean
noodles are also known as cellophane
noodles. They are transparent noodles.

Rice Sheet
(Cheung Fan)
Rice sheet is a popular Cantonese
steamed dim sum. It is made with rice
powder and water. Dried shrimps and
spring onions are often added to the
cheung fan mixture before steaming.
Some of the cheung fans are wrapped
around meat or seafood like beef or
shrimp. This is a popular breakfast or
lunch food. It can be found in dim sum
restaurants or noodle congee shops.

Salted Fish
The way to preserve the fish is by
placing the fish in salt to absorb water
before sun-drying. It is usually cooked
with other meats or fish to enhance
flavor. Sometimes it is used as one of
the ingredients in fried rice.

Sausage Roll
Sausage roll is a baked roll wrapped
around a sausage. This is a popular
breakfast item in Hong Kong.

Shark Fin
Shark fin is considered as an exotic
food. It is only served on special
occasions. Shark's fin does not have
any flavor; therefore, it must be cooked
with poultry or meat as a soup or as a
dish. Imitation shark's fin is made of a
gelatin-like substance to imitate the
texture of shark's fin.

Shark Fin
Shao Mai
Shao Mai is a popular steamed dim sum
in Southern part of China. The wrapper
is made of bean curd or egg white. It is
usually filled with pork or other meats.
Shark fin is added to make it an exotic
dim sum.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Shrimp
Dumpling
Shrimp dumpling is similar to Shao Mai
with different wrapper and fillings. It is
commonly found in Chinese dim sum
restaurant and Tea House. They are
served in a bamboo basket. The filling
contains shrimp and bamboo shoot and
the wrapper is transparent after
steaming.

Soy Bean
Products
The soybean is the edible portion of the
hairy green pod. It is a good source of
protein and is extensively used in the
vegetarian diet. Soybeans can be made
into soybean milk and other soybean
products.

Soybean Curd
(Tofu)
Soybean curd or tofu is made from
soybean milk. There are different types
of soy bean curds, which are widely
used by the rural or lower-income
population as a meat substitute or by
vegetarians as their major source of
protein. Soybean curd can be classified
as soft bean curd; hard bean curd;
dried, deep-fried bean curd; bean curd
sheets; and fermented bean curds (red
and white). Fermented bean curds are
used as condiments or as a savory side
dish for a vegetarian diet. Red fermented
bean curds are fermented bean curd
with chili added.

Soy Sauce
There are two types of soy sauces
commonly used in China, namely, light
soy sauce and dark soy sauce. Light soy
sauce is heavier in its salty taste and is
generally used in most Chinese cooking.
Dark soy sauce has a sweeter taste and
is used in stewing or adding color to
meat dishes when roasting or boiling. At
present, there is low-salt soy sauce
available in the market.

Steamed Bun
(Mantou)
Mantou is a plain steamed bun served in
the Northern China as the staple food.
The dough consists of flour, sugar, salt
and yeast.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Steamed Cake
Steamed cake is a popular dim sum. It is
a mixture of egg, flour, sugar, salt,
baking powder or yeast. They are mixed
together and steamed in a wok to a
spongy texture.

Sugar Cane
There are two types of sugar canes
commonly found in China. They are
green and black sugar canes. They can
be eaten raw or cooked as a soup.
Fresh sugar cane juice is a popular drink
in southern China.

Sugar, Brown
Block
Brown block sugar is brick-like and used
to make syrup for desserts or pastries.
Sometimes it is added to stew meat to
add taste.

Sugar, Rock
Rock sugar is a transparent, crystallized
sugar chunk. It is used in desserts or in
stewing meats/poultry. It is also
considered as having a "cooling" effect.
Rock sugar can be served with
chrysanthemum tea, a popular flower
blend tea.

Sweet Sauce
Sweet sauce is a condiment consisting
of water, sugar, plum sauce, tomato,
salt, and starch. There are several types
of sweet sauces in China and the most
commonly found are red and black. Red
sweet sauce is used as a dip for Beijing
roast duck and Cantonese "cheung fan,"
whereas black sweet sauce is used for
seasonings.

Tea Leaf
Dumpling
(Glutinous
Rice Wrapped
in Leaves)
Tea leaves are used as the wrapper of
the dumpling. Glutinous rice, mung
beans, mushroom, pork or sausage, and
/or other ingredients are used as the
edible portion of the dumpling. Tea leaf
dumplings need to boil for at least 3
hours. This is a festival food eaten
during the Dragon Boat Festival (5th
date of lunar fifth month every year).
Water
Chestnut
Water chestnuts are small, crispy,
brownish-black, skinned tubers that grow
under water in mud. It has a crunchy
texture and is sweet in taste. It can be
eaten raw or cooked with meat and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
vegetables.
White Radish
White radish can be cooked fresh as a
vegetable or preserved (pickled or
salted). Salted radish has a crunchy
texture and is served as a side dish for
congee. Fresh white radish can be
steamed with dried shrimp, dried
mushroom, Chinese sausage, and flour
into a white radish cake. White radish
cake is often served as dim sum in
Cantonese restaurants, either freshly
steamed or fried. It is also served as a
festive food during the Chinese New
Year.

Winter Melon
Winter melon is also known as "wax
melon." The winter melon is green and
oblong. The matured winter melon is
covered with a layer of white wax. It may
weigh up to 30-40 kg. The white pulp of
the fruit is the edible part. All seeds
should be removed before cooking. It is
generally used as a vegetable or as a
soup ingredient. The smaller melon can
be used as a pot to hold chicken broth,
diced meat, or diced vegetables, which
is then steamed for hours before serving
as a soup. It is served as "tung kwa
chung" meaning "winter melon pot." This
is a famous Cantonese delicacy served
on special occasions.

Vinegar
There are three kinds of Chinese vinegar
made from rice. They are black, red, and
white Chinese vinegar. White vinegar
has a mild flavor and is used in Chinese
cooking or inpickling vegetables. Red
Chinese vinegar has a light brown color
with a tangy taste, usually used as
seasoning for seafood. Black Chinese
vinegar has a slight caramel flavor and is
used as seasoning or as a dip for
northern Chinese dumplings (jiaozi).

Yunnan Ham
Yunnan ham is a famous smoked, salted
ham produced in southwestern China. It
has a firm texture and good flavor. It is
mainly used as a seasoning for soup or
dishes.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

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© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Ecuador
Immigrants or Ancestors

Ethnically diverse groups of immigrants from Ecuador have come to the United States from both rural and urban areas
since the 1940s, with two large waves noted in the past 25 years (Jokisch 2007). The most recent Census data
indicate that approximately half of the foreign-born United States population is from Latin America, of which
approximately 6% were born in South America. Ecuadorians comprise the second largest group of the South American
immigrants (U.S. Census Bureau 2002; Dixon 2006). It is estimated that the number of Ecuadorian immigrants
currently in the United States is 1 million to 2 million (US Department of State 2009).
Ecuadorians reside in each of the 50 states, as well as in Washington, DC, and Puerto Rico. The states with the largest
numbers of Ecuadorian immigrants are New York; New Jersey; Florida; California; Illinois; and Connecticut, where
approximately 86% of all immigrants are from Ecuador. Cities with high concentrations include metropolitan New
Jersey–New York, Miami, Los Angeles, and Chicago (Jokisch 2007; US Census Bureau 2000; Migration Policy
Institute).

The Republic of Ecuador is a small country that lies across the equator on the northwest side of South America.
Ecuador’s culture is influenced by the country’s very diverse geography. Literally in the middle of the world at Latitude
0° (the equator), Ecuador is bordered by the Pacific Ocean to the west, Peru to the east and south, and Colombia to
the north. The Andes Mountains cut north and south as a double range of volcanic peaks and 10,000-foot altitude
valleys ( la sierra). The tropical coastal zone (la costa) lies to the west, while the Amazon region sits to the east (el
oriente). The climate is hot and humid in the tropics and jungle regions, and drier and cooler in the highlands (CIA
2009; US Department of State 2009). Each region has a wet and a dry season instead of the four seasons experienced
further above and below the equator. Ecuador is divided into 24 provinces: 6 are in the coastal area, 11 in the sierra,
and 6 in the Amazon region. The Galapagos Islands, a territory that lies approximately 620 miles (1,000 km) off the
coast, is also a part of Ecuador and forms its own province (Chavez 2008a; Embassy of Ecuador).
One of the world’s developing countries, Ecuador’s population of nearly 14 million people is 80% mestizo (mixed
ancestry of indigenous peoples with Spanish descendents); 7% Indigenous/Amerindian (although indigenous
organizations estimate this figure may actually be nearly 30%); 5% blacks and mulattos, descended from African
slaves; 8% white; and 0.04% other (INEC 2006; CIA 2009; PAHO). Formerly part of the Incan Empire, the Spanish
arrived in the 1500s to claim the territory for their own. Disease and maltreatment in the early decades of Spanish rule
decimated 70% of the indigenous population. Today, at least 14 distinct indigenous groups remain (US Department of
State 2009; Jokisch 2007; Ecuadorian American Chamber of Commerce). Spanish is Ecuador’s official language,
although indigenous groups speak their own languages, predominantly Quechua. The majority of Ecuadorians are
Catholic (95%), but other religions are freely practiced, as guaranteed by the constitution (US Department of State
2006).
Approximately 60% of the population lives in urban centers and 40% in rural zones, some in highly remote areas. A
majority of the indigenous population lives in the Andean highlands and Amazon region. Greater numbers of mestizos
live in the coastal region, as well as on the Galapagos Islands. Approximately half of the population is considered poor
or extremely poor, with a disproportionate number among Amerindian groups and blacks. The Ecuadorian government
reports that 26% of children younger than 5 years have chronic malnutrition. Chronic and severe malnutrition is more
common among indigenous children and in rural areas (Chavez 2008b; PAHO). Anemia is another widespread
concern. The serious problems of malnutrition and nutritional deficiencies coexist with a growing concern in other
sectors of the population about overweight and obesity and the health problems that result (Aliméntate Ecuador 2009;
El Comercio 2009a/2009b).
Ecuador’s cuisine is a reflection of its ethnic groups, history, geography, local agricultural products, and socioeconomic
status of its people. As with other cultures, there are everyday foods, foods prepared for special occasions, and foods
associated with religious celebrations. There are special dishes that are unique to Ecuador, in addition to regional and
local culinary specialties. The result is a rich gastronomical diversity, tempered by the reality that economic limitations
experienced by a large segment of the population affect the variety and quantity of food available.
Many Ecuadorian dishes are made from combining grains and legumes, potatoes and milk, and other combinations that
provide protein, which are enhanced when meat, fish, milk, and eggs are available and affordable. A wide variety of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
provide protein, which are enhanced when meat, fish, milk, and eggs are available and affordable. A wide variety of
fruits, vegetables, cereals and legumes, and milk products contain key nutrients and are available virtually year round in
Ecuador, but regional and local variety may be limited by access, economic limitations, or economic needs. Foods high
in carbohydrates are frequently those that are the most available and affordable.

Food Practices

The three geographic regions of Ecuador—the highlands, the coastal zone, and the Amazon region—significantly affect
dietary practices. Traditional menus typically use unprocessed, fresh, and natural foods and locally available produce.
The menu is influenced by the harvests. In the highlands, a generally accepted weekly menu has been followed by
many families. On Monday, the main dish is arroz de cebada (barley soup) and so on throughout the week (Cuvi
2001). The following is a listing of many of the foods found in Ecuador.
Ecuador is known for its variety of fruits. The many possible selections include avocado, papaya, coconut, mango,
banana (numerous varieties, including the starchy plantain), babaco, cherimoya, passion fruit, tree tomato, taxo,
peach, strawberry, blackberry, guanabana, guava, fig, lemon, tangerine, orange, apple, pear, cantaloupe, watermelon,
naranjilla, mortiño, cherry, quince, pineapple, tamarind, grapefruit, cactus fruit, grapes, gooseberries, and tomato. Fruits
are either eaten fresh, cooked, in juices, in desserts, or in helados de paila, which is ice cream made from fruit pulp
and sugar, stirred in a large wide copper pan (paila) that is quickly spun over ice and straw (a highlands specialty).
Vegetables are served as salads, in soups, as side dishes, as fillings, or combined into main dishes. Potatoes and
yucca are staple foods in Ecuador. Additional vegetables used include lettuce, carrots, celery, several varieties of
onions, broccoli, cauliflower, garlic, green beans, Swiss chard, watercress, spinach, achogcha, chili pepper, red,
green and yellow bell peppers, eggplant, cabbage, brussels sprouts, turnip, varieties of squash including zambo and
zapallo, palm hearts, leek, radish, beet, parsnip, sweet potato, melloco, and oca.
Grains and beans are often grouped into the category of granos. Many dishes use these high-protein combinations in
soups, main dishes, and snacks. An elaborate dish called fanesca, served during Holy Week, uses at least a dozen
different grains and beans. One popular snack is chulpichochos, a mixture of toasted, salted corn kernels mixed with
the legume chocho (lupini bean). Menestra, a thick bean dish, is customarily served with rice. There are many uses for
corn, rice, barley, rye, quinoa, and wheat. One inventory lists more than 120 dishes just based on corn (Cuvi 2001).
Various types of beans are sold fresh and/or dried: peanuts, habas (broadbeans), lupini beans, lentils, garbanzo, soy,
peas, and more than 20 other types of beans.
Cereals, beans, and tubers are milled or processed into “flours” (harinas): Flour of yucca, potato, pea, barley,
broadbean, lupini bean, plantain, corn, wheat, and chulpi (a type of corn). They are often used to make thickened drinks
called coladas or are added to soups. Noodles may be made into noodle soup, served with tomato sauce or bits of
chicken and vegetables, or made into a torta de fideo (a savory noodle pudding).
Bread (pan) is widely consumed, especially in the highlands. Bakeries (panaderías) are ubiquitous in most places, and
produce a vast variety of rolls ( pancitos, or little breads), both sweet and plain, and loaves made from wheat flour. Corn
flour, yucca, whole wheat, and rye are also used. Pastries and savory snacks are also plentiful and include roscas,
bizcochos, quesadillas, empanadas (fried turnovers made from corn, plantain, or wheat flour), aplanchados, cookies,
cakes, and pies.
Meat sources in Ecuador include pork, beef, guinea pig, sheep and lamb, goat, rabbit, chicken, turkey, and quail. Fish
and seafood are plentiful, particularly in the coastal region. Ecuador is well known for its crab, lobster, and varieties of
shrimp. In the Amazon region, beef, chicken, fish, grubs, and the meat of wild animals, such as varieties of wild pig, are
eaten. In all regions, uses are found for most every animal part, including organ meats, tripe, hocks, and even chicken
feet. Animal blood is used to prepare a type of sausage, or is fried and added to a soup called yaguarlocro (yaguar is
the Quechua word for blood).
Eggs are widely consumed, mostly those from chickens. They are usually eaten soft-boiled or hard-boiled, scrambled,
or made into an omelet. Turkey and quail eggs are sometimes available. In the Amazon, turtle eggs may form part of
the diet.
Cow’s milk is usually offered at breakfast and in the late afternoon and is added to coffee. It is also used to make hot
chocolate, flan, pudding, arroz con leche (rice cooked with milk, sugar, and spices), and batidos (juice and/or fruit
whipped with milk) and is added to soups and sauces. Manjar de leche is a popular sweet made from milk that is boiled
until very thick and caramelized. Other commonly available milk products include fresh and aged cheeses, yogurt, and
ice cream. Goat milk is sometimes sold. Milk sold in larger grocery stores is usually factory packaged and
pasteurized; it is available as regular, low fat, nonfat, lactose reduced, with added fiber, and chocolate flavored.
Outside of the larger cities and towns, the options become fewer. In rural areas, milk is more likely to be fresh and
unpasteurized from cows milked in the vicinity. Unpasteurized milk is often boiled before use.
Lard and vegetable oil, often flavored and colored with achiote (annatto seed), and butter are the most common fats.
Palm oil is occasionally used. Pork rind is used in some preparations, such as in soups, or to give flavor to fried or
toasted foods (such as tostado, which is corn kernels toasted in pork fat), or it may be fried to a crunchy texture and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
eaten. Bacon (tocino) is used to add flavor to dishes, but it is not usually eaten by itself as in the Unites States.
Sweeteners include cane sugar, honey, raspadura, and panela (unrefined hard brown sugar). The majority of
Ecuadorians sweeten their coffee with sugar. Fruit juices often have added sugar as well. Many fruits are cooked into a
sweetened compote and served for dessert, as is fresh or canned fruit in syrup. Sweets in the form of cakes, cookies,
pan dulce (sweet bread), and pastries are readily available. Other sweet treats are made from milk, chocolate, coconut,
and nuts.
Common spices and herbs are garlic, salt, pepper, cumin, ginger, oregano, annatto seed, basil, parsley, cilantro,
chives, and cinnamon. Fresh herbs are available at markets or grocery stores or may be grown in the family garden.
Nuts and seeds are available as well (sesame seed, sunflower seed, and flaxseed). Walnuts are commonly referred to
as nueces, which is also the general term for nuts. Almonds, hazelnuts, and macadamia nuts are sometimes available.
Beverages include coffee, coffee with milk, hot chocolate, tea and infusions, fruit juice, coladas, and chicha. It is not
unusual for children to drink coffee. Coladas are drinks prepared with fruit juice or cooked fruit and combined with finely
milled oatmeal or other starch. Coladas (and soups) are thought to be very nutritious foods and are considered “comfort
foods,” as they are known in the United States. Chicha is a drink prepared from a starchy base, often yucca or corn,
and is sometimes lightly fermented. In spite of the widespread presence of sweetened carbonated drinks, juices and
juice-based drinks are still widely consumed at meals. Alcoholic beverages are also available, in the form of beer, wine,
and spirits. Aguardiente or puro (sugar cane alcohol) is commonly found. Alcoholic drinks are known by the general
term trago, meaning literally, “a drink.”
Typical Eating Patterns
Ecuadorians start the day by eating breakfast (desayuno) in the morning; lunch (almuerzo), usually the largest meal of
the day, at midday or early afternoon; a late afternoon or early evening light meal somewhat similar to breakfast (café
de la tarde, or coffee in the afternoon); and dinner (merienda or cena). Sometimes there is a mid-morning snack
(refrigerio). Families may forego dinner, depending on what they had in the late afternoon and at what time. The
evening meal may be as elaborate as the lunch, or a lighter meal. Dinner may be served in the mid to late evening.
For families with limited economic means, the menu is simpler and the number of meals is reduced. For example, in
one poor rural highland community, breakfast is typically a bean flour soup, tea, and bread. Lunch is composed of
several starches, and a soup made from cereal or bean flour. Dinner is soup with the occasional egg or piece of cheese
(Ordoñez 2001).
On the coast, a typical breakfast features bolón de verde (cooked plantain mashed with salt, lard, and cheese, formed
into a ball, and deep fried) or another form of plantain served with coffee. Among settlers on the Galapagos Islands,
the pattern is similar, given that many of the inhabitants migrated from the mainland, especially from the coastal area.
In the highlands, breakfast is usually bread with coffee or hot chocolate, accompanied by cheese or eggs, and fruit
juice. Chicha is consumed in the Amazon region. Laborers or others with physically demanding work often have a
much larger meal in the morning, such as the highlands breakfast of rice and beans or meat with a fried egg on top.
Lunch and dinner traditionally begin with soup (sopa) as the first course (la primera), followed by the segundo, or
second course of meat, starch, and vegetable or salad. Ceviche (shrimp marinated in a tomato- or lemon-based sauce)
or empanadas (fried, filled turnovers) may be substituted for soup. Ají (a chili pepper sauce) is the typical condiment
usually made fresh from chili pepper, tomato, onion, cilantro, and oil, and adds a bit of bite to the otherwise nonspicy
cuisine. Frequently, the beverage is fruit juice or a colada. Meals often end with dessert and coffee or tea.
For late afternoon café, coffee, tea, or hot chocolate is served, along with bread, cookies, or other specialty items, both
sweet and savory. Cheese is often set out, as well as butter and jam.
Food Preparation
The cuisine of Ecuador may be very laborious at times. There are generally accepted ways to prepare and serve a dish,
and specific foods that are considered appropriate to serve together. Food preparation is often shared between two or
more people, usually women, although it is not uncommon for men to participate in cooking in the coastal region. In the
highlands, however, it is usually women’s work. Although often time-consuming, traditional cooking methods are
appreciated for yielding the best results. For example, it might be faster to prepare a dish in a pressure cooker, but it
isn’t the same as making a soup over the stove where the flavor develops slowly, or baking in a clay oven ( fogón) that
imparts a special taste. There is pride in making a dish in the traditional way, with cooking secrets that are passed
down through the family. Quick and easy is not the goal in the traditional Ecuadorian kitchen. Cooking is seen as an art
and an expertise. Home-cooked meals are highly valued and families frequently eat meals together.
Food preparation methods include deep-frying or pan frying in lard, butter, or oil; roasting; toasting; boiling; steaming;
baking; and grilling. In rural areas without electricity, foods may be prepared over a wood or charcoal fire, or a gas
stove, sometimes using clay ovens, pots or griddles. Elsewhere there are electric and gas appliances used for food
preparation, such as an electric or gas stove, blender, mixer, and microwave oven, the latter used commonly to reheat
foods, rather than for cooking. In rural and urban kitchens, there may be a hand-cranked food grinder (as for grinding
fresh corn for humitas, corn dough steamed in corn husks) or a flat stone base for grinding.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Nutrition Implications
Ecuador undoubtedly has a wealth of natural resources when it comes to variety and selection of foods. People in
urban centers have greater access and more opportunities for variety than do those in the rural areas. Families in
remote regions are especially at risk, as infrastructure may be minimal, or blocked because of heavy rains or
mudslides. In addition to access concerns, economic limitations also reduce food choices and frequency. Milk products
generally form part of the Ecuadorian diet on a regular basis but quantities may be small, as when added to coffee or
soup. Meats are available, but may be prohibitive in cost, so consumption may be occasional. Animals or crops raised
by a family may be sold rather than eaten. For example, carrots may be sold for income rather than consumed by the
family that harvests them (Ordoñez 2001).
People in rural areas eat foods grown on their own property or in the vicinity. They supplement from what is available
in small neighborhood grocery stores (where only basic foodstuffs are sold, such as coffee, tea, sugar, flour, noodles,
oil, crackers, cookies, and eggs, as well as soft drinks and alcohol) and local bakeries, if the community has one. Foods
may be bought or bartered on periodic market days as well. It is not unusual in rural areas to walk great distances to
reach a weekly market. Food gifts and exchanges, and collection of wild foods are other means of acquiring foods
(Guerrón-Montero 2001).
Where tradition dictates food selections, it’s fortunate that there are many nutritious combinations. In spite of food
preparation methods that include the use of lard and deep-fat frying, the traditional diet has many healthful aspects, but
a lack of variety can be a concern.
In urban areas in Ecuador, obesity and its related diseases are emerging problems, including among schoolchildren,
even while a significant portion of Ecuador’s population is malnourished (Bernstein 2008; Yepez 2008). Coverage in the
Ecuadorian media has highlighted problems such as hypertension, diabetes, apnea, and joint pain that are seen in the
population. One study by the Central University (Quito, Ecuador) revealed that 17% of schoolchildren are overweight.
Experts observe that families are giving more priority to high-fat “junk” food, eating away from home more often, and
becoming more sedentary ( El Comercio 2009a/2009b). The Ecuadorian government is taking steps to increase
awareness about the importance of nutrition. The Nutrition Institute within the Ministry of Public Health sponsors
nutrition research and nutrition education programs. While nutrition has increasingly become a topic of interest, so have
fad diets and misinformation.

Adaptation of Native Culture to American Culture

When Ecuadorian immigrants come to the United States, they bring along their cultural traditions, beliefs, attitudes, and
food habits. Research shows that acculturation is a very individual and dynamic process (Satia-Abouta
2002; Satia-Abouta 2003).
It is well known that the eating patterns of immigrants change the longer they live in the United States. This seems
intuitive, but research on Hispanics in the United States confirms that the intake of traditional foods decreases as
immigrants become acculturated. As new foods are gradually adopted into the dietary repertoire, the use and
preparation of traditional foods may be modified or replaced with locally available food selections and practices.
Because many U.S. foods are available in Ecuador in supermarkets and restaurants, immigrants from urban areas or
those exposed to advertising may already be familiar with some products available in the United States. In many areas
of the United States, there are stores with ethnic foods that may be familiar to Ecuadorians or other foods that can be
substituted for ingredients in their traditional recipes (Romero-Gwynn 1997; Satia-Abouta 2002; Satia-Abouta 2003).

Acculturation may progress at a slower pace if immigrants settle in or near their own ethnic community. In New York,
NY, for example, where approximately 102,000 Ecuadorians live in Queens, Ecuadorian culture thrives, with the
availability of typical foods and dishes like cuy and guatitas (guinea pig and tripe) (VivirLatino 2008). At the other end of
the spectrum, Hispanics are moving into rural areas where non-Hispanic whites predominate (Kandel 2004). With a
bigger contrast between cultures, the adaptation process can be more difficult (Satia-Abouta 2002; Satia-Abouta 2003).

Immigrants' dietary changes in the United States have been evaluated as both healthful and non-healthful. There is
strong evidence that a change toward an “Americanized” lifestyle increases the risk for obesity, hypertension, diabetes,
and cancer, which are also becoming more evident in Ecuador in recent years (Satia-Abouta 2002). Others have
bluntly stated that acculturation may actually downgrade the diet quality of the Hispanic people who come to the United
States (Aldrich 2000; Marquis 2000). Studies of Hispanic people's diets in the United States, including those of South
American ancestry, show that fruit and vegetable intake moderately increases, whereas the use of lard is significantly
decreased. This healthful change is counterbalanced by an increased use other high-fat foods. Sweet drinks often
replace juices or coladas traditionally consumed at meals (Satia-Abouta 2003; Romero-Gwynn 1997). As immigrants
adopt the dietary patterns of the United States, there is an increase in consumption of high-sugar cereals and other
high-fat, high-sugar foods. Fruit and vegetable intake still fails to reach the numbers of recommended servings
(Satia-Abouta 2002). Other factors that increase health risks and the potential for health problems are excessively large
portion sizes, wide availability of fast foods, and patterns of eating away from home (Mitchell 2008).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Meal Planning in this Culture

It is crucial to take into account that the Hispanic community is a heterogeneous group of people with diverse cultural
backgrounds (Romero-Gwynn 1997; Mitchell 2008). The Spanish language may be common for most Hispanics, but
food practices are widely variable. Similar foods may be prepared in entirely different ways, and eating patterns may be
very different. Vocabulary and terminology may also vary considerably. For example, the native diet of Ecuadorians is
distinct from that of Mexicans. An Ecuadorian tortilla, made from egg, yucca, mashed potato, corn, plantain, or fish, and
fried in oil, is very different from a Mexican tortilla. Nutrition information written in Spanish that is geared toward one
Hispanic group may contain terms that individuals from another background may not understand. Several terms with
potential for confusion, including the following, are included in the food dictionary: granos, pasta, menestra, tortilla, and
sopa. Because of the diversity among Hispanic groups, it is important for registered dietitians and others who work in
nutrition to understand that the cultural dietary patterns differ and to make an effort to become familiar with the dietary
details of the cultural groups with whom they interact; in this case, those with origins in Ecuador (Ivens 2008; Hispanic
Health Council 2006).
Meal planning for this population should integrate native dietary practices with an assessment of current dietary
practices. Factors to consider include cultural background, language spoken, length of time in the United States,
economic status, usual food intake patterns, food preparation methods, food avoidances and preferences, use of herbal
preparations and teas, use of vitamin and mineral supplements, health status, special diets, and so on. Negotiation
should take place to encourage healthful behaviors and reduce less-healthful practices. Practices that reflect “the best
of both worlds” should be encouraged: healthful traditional practices and healthful practices acquired during the
acculturation process (Satia-Abouta 2002; Satia-Abouta 2003).

Other menu planning and health promotion suggestions include the following:
Promote healthy eating habits: 1.
Validate traditional practices while negotiating desired dietary changes. Ecuadorian dishes are prepared in a
generally accepted way (varying by household, community, region, and so on), and specific foods are seen as
appropriate to serve together (eg, tortillas de papa are nearly always served with avocado, tomato, lettuce, and
onion). A counselor may find a client initially reluctant to change traditional food combinations. This contrasts with
greater flexibility in U.S. diets in swapping foods of similar type (eg, white bread for brown rice).
Reinforce the practice of using fresh and natural ingredients.
Give positive reinforcement for taking the time to prepare nutritious foods, eating at home, and eating together as
a family.
Discourage the use of lard and food preparation methods that rely on frying foods. Assist and empower clients to
modify traditional high-fat food preparation methods in favor of grilling, broiling, steaming, and baking, using pans
with nonstick surfaces and vegetable cooking spray, and using broth or water instead of oils. Encourage the use
of vegetable oils.
Discourage the use of coffee for children; suggest substituting other healthy drinks, such as batidos, using milk,
fruits, yogurt, and so forth.
Support a healthful eating pattern, for example, three meals a day with healthful snacks in between. Reinforce
the benefits of the traditional practice of the larger meal around midday, with a lighter meal in the evening.
Educate clients on how to read and understand food labels.
Promote adequate fiber intake by encouraging the use of whole grains, legumes, fruits, and vegetables.
Encourage clients to do the following:
Avoid excessive use of salt and salty foods.
Avoid excessive intake of caffeine-containing drinks.
Use alcohol in moderation.
Educate clients about safe food preparation and storage practices. Be aware of the risk of lead in clay pots, jugs,
griddles, and so on (Hispanic Health Council 2006).
Promote dental health. Encourage regular teeth-brushing and dental care. Help families wean children from
baby-bottle use at an appropriate age and developmental skill level (Ivens 2008).
Promote and support breastfeeding to realize the health, economic, and other benefits for mothers, babies, and
families. In Ecuador, 40% of infants younger than six months of age are exclusively breastfed, 77% are breastfed
as complementary foods are introduced, and 23% are still being breastfed up to 2 years of age. (UNICEF
2000-2006). The efforts made in the United States to strengthen breastfeeding as the optimal way to feed an
infant may resonate with Ecuadorian families (Ivens 2008).
Balance food intake: 2.
Encourage the selection of a variety of foods and the appropriate number of servings within all of the food groups.
Support native practices of fresh fruit and vegetable consumption and use of grains and legumes, fish and meats,
and dairy products.
Encourage the use of 100% juices and canned fruit packed in juice rather than syrup.
Encourage an adequate intake of fluids, without relying on drinks that are high in sugar and caffeine.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Encourage an adequate intake of fluids, without relying on drinks that are high in sugar and caffeine.
Suggest and encourage healthful snacks, with an emphasis on avoiding foods high in fat, salt, and sugar.
Direct clients, when appropriate, to food-assistance programs, such as the Special Supplemental Nutrition
Program for Women, Infants, and Children. Adaptation of Ecuadorians into U.S. culture may be accelerated by
participation in food assistance and nutrition programs. By participating in these programs, immigrants are
introduced to positive health and nutrition messages as they move along the acculturation continuum.
Promote attainment of a healthy weight for well-being and to prevent overweight, obesity, and the sequelae,
including hypertension and diabetes:
3.
Encourage physical activity on a regular basis.
Where indicated, encourage overweight or obese clients to participate in a healthy weight-management approach
or program.
Educate clients about appropriate portion sizes. Encourage the use of lean meats, removal of visible fat, and
low-fat or nonfat milk products.
Educate clients about balancing their food intake with foods from all food groups.

Food Dictionary

Comida(s) Meal(s)
Desayuno; café (de la
mañana)
Breakfast;coffee “in the morning” (implies breakfast)
Almuerzo Lunch; mid-day meal
Café; café de la tarde Coffee; late afternoon “coffee-time”—a light meal when coffee,
tea, or hot chocolate is served
Merienda Supper
Cena Dinner (more formal than merienda, maybe served late in the
evening)
Refrigerio Snack

Food Description Photo
Aceite; aceite
vegetal; aceite de
oliva
Oil; vegetable oil; olive oil
Acelga Swiss chard
Achiote Annatto seed, used to color fat yellow or orange
Achira A wide, green leaf used to steam foods
Achogcha A small, hollow vegetable
Agua Water
Aguado de gallina Soupy dish made of chicken, rice, potatoes, and
vegetables

Aguacate Avocado
Ají Chunky or smooth-blended sauce made from spicy
chili, tomato, onion, cilantro, oil, and salt

Ajiaco Soup made with refrito, milk, whole potatoes, and
cheese

Ajo Garlic
Almeja Clam
Almendra Almond
Apio Celery
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Aplanchado A sweet made of filo dough with a crunchy topping of
meringue

Arroz Rice
Arroz relleno Rice with added ingredients, such as shrimp,
seafood, bits of meat, peas and carrots, bell pepper,
and so on

Arroz con leche Rice cooked with milk and sugar
Arveja, alverja Pea
Ave Poultry
Avena Oatmeal
Ayacas Corn flour dough filled with a chicken and peanut
mixture steamed in a banana leaf

Azúcar; azúcar
moreno
Sugar; brown sugar
Babaco A papaya hybrid, a semi-acidic fruit similar in
appearance to a melon

Bacalao Codfish
Batido Blended drink made with milk and fruit or fruit juice
Berenjena Eggplant
Berro Watercress
Biche de pescado Fish soup with yucca, corn, plantain, peanut, and milk
Bizcocho Cookie
Bolas de verde Filled dumpling of mashed plantain boiled in soup
Bolón de verde Deep-fried ball of cheese filled mashed plantain
Borrego Sheep, mutton
Brócoli Broccoli
Caldo Broth
Camarón Shrimp
Camote Sweet potato
Cangrejo Crab
Canguíl Popcorn
Carne Meat
Carne en palito Meat grilled on a wooden skewer
Cebada; arroz de
cebada
Barley; cracked barley; barley soup
Cebolla Onion
Cebolla paiteña;
cebolla colorada
Red onion
Cebolla blanca Green onion
Cebolla perla pearl onion, white (round) onion
Centeno Rye
Ceviche Shrimp or other seafood marinated in a tomato- or
lemon juice–based sauce, served with popcorn or
fried plantain chips; also made with other foods, such
as chicken and lupini beans.

Chancho, cerdo,
puerco
Pork
Chicha Drink prepared from corn, yucca, or other starchy
bases, sometimes fermented

Chifles Fried banana slices
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chirimoya Fruit with a green “armadillo-like” exterior and a soft,
sweet, white interior

Chivo Goat
Chocho Lupini bean
Choclo Corn on the cob
Chocolate;
chocolate caliente
Chocolate; hot chocolate
Chulpi Toasted corn kernels
Chulpichochos A mixture of toasted corn kernels and lupini beans
Chupe de corvina Sea bass soup made with potatoes, peas, peanuts,
milk, onion, garlic, tomato, and pieces of fish

Claudia Plum
Coco; cocada Coconut; a sweet made from coconut, sugar, and
toasted ground peanuts

Col Cabbage
Col bruselas Brussels sprouts
Colada; colada
morada
Juice drink thickened with flour made from beans,
corn, finely milled oatmeal, yucca, barley, plantain, or
wheat; colada morada is a purple drink made from
blue corn flour and mortiño, a berry with blue skin.

Color Fat heated with achiote seeds to extract the subtle
flavor and yellow or orange color

Concha Oyster
Conejo Rabbit
Cordero Lamb
Cordoniz Quail
Corvina Sea bass
Cuero Pork skin, pork rind
Culantro Cilantro
Cuy Guinea pig
Dulce Candy; a sweet fruit compote or marmalade; a
description of something sweet

Durazno Peach
Emborrajado Fritter
Empanadas Small, fried turnovers made from wheat flour,
plantain, white corn, or rice, with fillings of meat and
vegetables or cheese

Encocado de
pescado, camarón
Fish or shrimp in coconut sauce
Fanesca Soup prepared during Holy Week that uses
numerous grains and legumes, dried codfish, milk,
and vegetables.

Fideos Noodles
Flan Custard
Fréjol blanco White bean
Fréjol negro Black bean
Fréjol rojo Red bean
Fresa, frutilla Strawberry
Galletas Cookies
Gallina Chicken (hen)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Golosinas;
goloso(a)
General term for sweets; someone who likes sweets
Granos Grains, also refers to “grains and beans”
Grasa Fat
Guagua de pan Holiday bread shaped and decorated like a
swaddled baby

Guanabana Guanabana
Guanta Species of wild pig
Guatita Beef tripe, often prepared grilled, in soup, or with
peanut sauce

Guayaba Guava
Guineo Banana, eaten raw
Haba Broad bean
Harina Flour
Helado de paila Ice cream specialty from the highlands made of fruit
pulp stirred in a wide copper pan while being spun on
ice and straw

Helado Ice cream
Higo Fig
Hoja de maíz Cornhusk, used to steam foods
Hoja de plátano Banana leaf, used to steam foods
Huevo de cordoníz Quail egg
Huevo duro Hard-boiled egg
Huevo Egg
Hongo Mushroom
Humita Fresh ground corn mixture steamed in corn husks
Jamón Ham
Jugo de fruta Fruit juice
Langosta Lobster
Leche de vaca;
leche de chiva
Cow milk; goat milk
Leche Milk
Lechuga Lettuce
Lenteja Lentil
Licuado Blender drink, often made with milk and fruit or fruit
juice; same as batido

Llapingachos See "Tortillas de papa"
Locro Thick potato soup with milk and white cheese; type
of locro varies with ingredients

Máchica Barley flour mixed with brown sugar
Maicena Cornstarch
Maiz; mote;
morocho
Corn; hominy; pearled white corn
Mandarina Tangerine
Mango Mango
Maní Peanut, often ground and made into sauce or added
to soup

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Manjar de leche A sweet paste made from boiled-down and
carmelized milk

Manteca de
chancho
Lard
Mantequilla;
margarina
Butter; margarine
Manzana Apple
Manzanilla Chamomile
Maqueño A type of banana that can be eaten raw or cooked
Mariscos Seafood
Melba A chocolate-dipped, shell-shaped cookie
Melcocha A taffy-like sweet
Melón Cantaloupe
Melloco A tuberous vegetable
Membrillo Quince
Menestra A thick bean dish, often made with lentils, served
with rice

Mermelada Jam
Mora A tart blackberry or huckleberry
Mortiño Berry with blue skin
Mote Hominy
Naranja Orange
Naranjilla Acid fruit with green flesh and shiny orange skin
Nata Creamy skin that forms on warmed milk, eaten on
bread

Nuez; nueces Nut, walnut; nuts
Oca A tuberous vegetable
Papanabo Turnip
Palmitos Palm hearts
Pan Bread
Pan de yucca, pan
de alimidón de
yucca
Yucca bread; bread made with yucca starch
Pan; pancitos; pan
de sal; pan dulce
Bread; small breads and rolls; plain bread; sweet
bread

Panela Unrefined brown sugar
Papa Potato
Papa con salsa de
maní
Boiled potato with peanut sauce
Papaya Papaya
Pasa Raisin
Pasta; pastel Pastry; baked goods; cake
Patacón Fried thick slices of plantain pounded flat
Patas (de
chancho, res, pollo)
Pork or beef hocks, chicken feet
Pato Duck
Pavo Turkey
Pera Pear
Pernil Pork leg roasted with garlic and spices
Perejil Parsley
Pescado Fish
Pimiento Bell pepper
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Piña Pineapple
Plátano Banana; there are 14 varieties listed in the
Ecuadorian Table of Food Composition, eaten fresh
or raw

Plátano de seda Fresh banana, eaten raw
Plátano maduro Ripe plantain, boiled, baked, fried, made into
croquettes

Plátano verde
(verde)
Plantain or green banana, boiled, mashed, baked,
fried, often added to soup, made into dumplings and
croquettes

Pollo Chicken
Postre Dessert
Pristiños Deep fried pastry served with syrup
Puerro Leek
Puro Sugar cane alcohol
Queique Cake
Quesadillas Cake-like pastry
Queso, queso
fresco
Cheese, fresh cheese
Quimbolito Sweet, cake-like batter steamed in leaves
Quinoa A high-protein grain native to South America
Rábano Radish
Raspadura Unrefined brown sugar
Refrito Sauté of onion in annatto-colored fat, sometimes with
added ingredients, which serves as a base for the
preparation of many dishes

Remolacha Beet
Repollo Cabbage
Requesón Cottage cheese
Res; ternera Beef; veal
Rosca Crisp, dry, ring-shaped pastry
Salchicha Sausage
Salsa Sauce
Sancocho Soup made with beef broth, yucca, corn, and plantain
Sandía Watermelon
Seco de chivo Goat meat stew, often made with lamb or mutton
Seco de gallina Chicken stew
Sopa Soup
Sopa de arroz Cooked or steamed rice (dry, not as a soup)
Soya Soy
Tamal Meat-filled dough steamed in leaves
Taxo Oval fruit with sweet and sour flavor
Té; té de hierbas Tea; herbal tea
Tienda Small grocery store that sells basic supplies
Tocino Bacon
Tomate de árbol Tree tomato
Torta Cake
Torta de fideo Noodles mixed with egg and cooked in a frying pan,
similar to a noodle pudding

Tortilla de huevo;
huevo revuelto
Omelet; scrambled egg
Tortillas de papa
(llapingachos)
Potato patties filled with white cheese, fried in oil
colored with annatto seed

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tortillas de maiz Small fried corn patties filled with fresh cheese
Tortuga; huevo de
tortuga
Turtle; turtle egg
Tostado Toasted corn kernels
Trago General term for an alcoholic drink
Trigo Wheat
Tripas, guatitas Tripe
Tuna Cactus fruit
Uva Grape
Uvilla Gooseberry
Vainas, vainitas Green beans
Yaguarlocro Thick potato cheese soup, garnished with fried
sheep blood

Yema de huevo;
clara de huevo
Egg yolk; egg white
Yogurth Yogurt
Yuca Yucca
Zambo White squash
Zanahoria;
zanahoria blanca
Carrot; Parsnip
Zapallo Yellow squash
Epicurious 2009; Fried 1997; Vallejo 1965

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Association; 2008:3-20.
Jokisch B. Ecuador: Diversity in migration. Migration Information Source. 2007. Available
at: http://www.migrationinformation.org/Profiles/display.cfm?ID=575. Accessed February 16, 2009.
Kandel W, Cromartie J. New patterns of Hispanic settlement in rural America. May 2004. United States Department of
Agriculture, Economic Research Service, Rural Development Report No. (RDRR-99). Available
at: http://www.ers.usda.gov/Publications/RDRR99/. Accessed February 24, 2009.
VivirLatino. Ecuadorians number four Latino Group in NYC (especially in Queens). Available
at: http://vivirlatino.com/2008/09/22/ecuadorians-number-4-latino-group-in-nyc-especially-in-queens.php#more-3443.
Accessed February 24, 2009.
Marquis G, Jensen H, Mazur R, Lee Y. Food assistance and nutrition programs: RIDGE Project Summary. USDA
Economic Research Service. 2000. Available
at: http://www.ers.usda.gov/briefing/foodnutritionassistance/funding/RIDGEprojectSummary.asp?Summary_ID=99.
Accessed February 24, 2009.
Migration Policy Institute. Who’s where: The foreign-born from Ecuador in California. Available
at: http://www.migrationinformation.org/datahub/whosresults.cfm Accessed February 16, 2009.
Mitchell BD. Diets of Hispanics and Latinos. Advameg Inc. 2008. Available
at: http://www.faqs.org/nutrition/Hea-Irr/Hispanics-and-Latinos-Diet-of.html. Accessed February 28, 2009.
Naranjo M. Cocina Popular and Medicina Popular in La Cultura Popular en el Ecuador, Tomo X, Chimborazo [Popular
Culture in Ecuador, Volume X, Chimborazo]. Quito, Ecuador: Centro Interamericano de Artesanías y Artes Populare
[CIDAP]. 1st ed. July 2002. Available
at: http://www.cidap.org.ec/aplicaciones/publicaciones/archivos/Tomo%20X%20Chimborazo.pdf. Accessed February
15, 2009.
Naranjo, M. Cocina Popular in La Cultura Popular en el Ecuador, Tomo IX, Manabí [Popular Culture in Ecuador,
Volume IX, Manabí]. Quito, Ecuador: Centro Interamericano de Artesanías y Artes Populares [CIDAP]. 1st ed. July,
2002. http://www.cidap.org.ec/aplicaciones/publicaciones/archivos/Tomo IX Manabi.pdf. Accessed 2/15/2009.
Ordoñez S. Studying the Women in Ecuador. Benson Agriculture & Food Institute. August 1, 2001. Available
at: http://www.bensoninstitute.org/Publication/BI/Lessons/volume22/women.asp. Accessed February 13, 2009.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Pan American Health Organization. Ecuador: Health situation analysis and trends summary. Available
at: http://www.paho.org/english/DD/AIS/cp_218.htm. Accessed February 15, 2009.
Romero-Gywnn E, Gwynn D. Dietary patterns and acculturation among Latinos of Mexican descent. East Lansing,
MI: The Julian Samora Research Institute, Michigan State University; 1997:1-8. JSRI Research Report #23.
Satia-Abouta J. Dietary acculturation: Definition, process, assessment, and implications. Int J Human Ecol.
2003;4(1):71-86.
Satia-Abouta J, Patterson R, Neuhouser M, Elder J. Dietary acculturation: Applications to nutrition research and
dietetics. J Am Diet Assoc. 2002;102(8):1105-1118.
U.S. Census Bureau, American Fact Finder. Region and Country or Area of Birth of the Foreign Born Population.
http://factfinder.census.gov. Accessed 2/10/09 and 2/12/2009.
U.S. Census Bureau, Census Brief-Coming from the Americas- A Profile of the Nation’s Latin American Foreign Born.
http://www.census.gov/prod/2000pubs/cenbr003.pdf
Accessed 2/10/2009

U.S. Department of State. Ecuador Profile. February 2009. Available at: http://www.state.gov/r/pa/ei/bgn/35761.htm.
Accessed February 16, 2009.
U.S. Department of State. Ecuador, International Religious Freedom Report. 2006.
Available at: http://www.state.gov/g/drl/rls/irf/2006/71459.htm. Accessed February 16, 2009.
UNICEF. Ecuador Statistics. State of the World’s Children.
2000-2006. Available at: http://www.unicef.org/infobycountry/ecuador_statistics.html. Accessed February 27, 2009.
Vallejo L. Tabla de Composición de los Alimentos Ecuatorianos [Table of Composition of Ecuadorian Foods]. National
Institution of Nutrition. Quito, Ecuador. 1965;1-35.
Yepez R, Carrasco F, Baldeón, M. Prevalencia de sobrepeso y obesidad en estudiantes adolescentes ecuatorianos del
área urbana [Prevalence of overweight and obesity in Ecuadorian adolescent students in the urbana area]. Arch
Latinoam Nutr. 2008;58(2):139-143.

Regional Food Practices

Regional Food Practices
The coast, highlands, and Amazon regions each have a distinctive cuisine; however, migration across areas has
influenced regional and local dishes. The various specialties from around the country are also enjoyed outside of their
point of origin. The following is a description of dishes specific to the regions of Ecuador.

Coastal region
Plantain (plátano verde or simply verde), rice, and seafood are the main staples of the coastal diet. Plantain is served
boiled, baked, fried, mashed, made into dumplings, empanadas, croquettes, and as patacones (flattened, fried
segments of plantain). Fish is often fried and served with rice, yucca, or plantain. There are numerous soups, including
a variety of specialties made with fish and seafood, that incorporate vegetables, plantain, corn, yucca, and sometimes
milk. Peanuts are incorporated into many dishes, including soups, sauces, and main dishes, prepared as a sweet snack
with raspadura, or eaten plain. Ceviche, one of the dishes for which Ecuador is famous, is made from shrimp or other
seafood marinated in a mixture of lemon, orange juice and tomato. It is served with popcorn and chifles (thinly sliced
fried plantain). (Throughout the country, ceviches are sometimes made with other ingredients, such as lupini beans,
chicken, and mushrooms.) Tropical fruits are frequently eaten fresh and prepared in juices. Coconut is used in many
ways in both sweet and savory dishes. Tomato, onion, and garlic are often used to prepare many of the dishes of the
coast.

Other typical coastal foods include rice dishes, beans, dumplings and croquettes made from plantain or yucca with
meat and vegetable or cheese fillings; chicken, beef, pork, goat, lamb or mutton dishes; sweet and savory dough
mixtures steamed in banana leaves; tortillas de maíz (ground corn patties with white cheese cooked on a griddle);
small breads made from yucca and yucca starch; fresh cheese; sweets made with coconut, fruit, milk, peanut, fruit,
cookies, among others. Cinnamon is a commonly used spice.
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Highlands
The staple foods of the highlands are potato, of which there are hundreds of varieties, and
rice. Other typical foods of the sierra are corn, barley, chicken, beef, pork, a variety of
legumes, tubers, carrots, onions, tomatoes, avocados, milk, cheese (mature and fresh), and
fruit. The multitude of soup preparations forms the basis of the main meals. The list is
endless, but one of the most traditional and popular is locro de papas, a thick potato soup
made with milk and fresh cheese and served with avocado. There are many variations of
locro, depending on the ingredients added (eg, squash, cheese, eggs, pork rind). Other examples of soups are caldo
de patas, a rich broth made from beef hocks and mote (hominy), lentil soup, barley soup, and ajiaco (similar to locro,
but made with whole potatoes). Potatoes are eaten boiled, fried, or made into many different dishes. Typical are
llapingachos (also called tortillas de papa), potato patties filled with white cheese and fried in oil colored and flavored
with annatto seed, often served with fritada or hornado (fried or roasted pork). Cuy (roasted guinea pig) is another
highlands specialty dish. Cuy, fritada, and hornado are frequently served with mote, avocado, and a garnish of tomato,
parsley, and onion marinated in lemon juice. Quinoa, considered a high-protein grain, is made into soup, chicha, or
prepared similarly to rice.

Additional typical dishes found in the Sierra include roasted, fried, and grilled chicken, beef, goat, lamb or mutton, and
fish and shellfish; numerous corn dishes using fresh, dried or ground corn; beans, including chocho, sometimes made
into ceviche de chocho but often served simply boiled with salt; plantain and yucca added to soup or cooked into many
different recipes; empanadas; dumplings; a number of coladas; juices; fruits; and vegetables. Commonly used spices
and flavorings are garlic, onion, and cumin. Onion sautéed with annatto-seed-colored fat serves as the first step in
making many soups and main dishes. Spicy ají is the main condiment. Coladas and juices are served at meals. Bread
is frequently served. One special dessert is dulce de higos, figs cooked in syrup and served with slices of fresh white
cheese.

Amazon
In the Amazon region, the variety of foods includes beef, fish, animals hunted for their meat (including varieties of wild
pig, birds, monkey, turtle, among others), yucca, and sweet potato, rice, corn, plantain, fruits, legumes such as lentil
and peanut, and grubs. Typical dishes include menestra, made from lentils, beans, or peas, and served with rice. One
version of ceviche made in the Amazon is made from mushrooms. As mentioned above, chicha is a typical beverage,
as is sugar cane juice. Many types of chicha are made, depending on the starchy base.

Special foods and foods for medicinal purposes
Special foods are made for family celebrations and religious and civic holidays. Often these are foods for which the
region, province, or town is known. These include fanesca, a soup served during Holy Week, which is a complex
delicacy made with numerous grains and beans, vegetables, peanut, bacalaó (dried cod), and milk. Colada
morada, prepared in anticipation of the Day of the Dead on November 2, is a purple-colored thick drink made from blue
corn flour and mortiño (a type of berry with deep blue skin) and served with guaguas de pan (bread babies), breads
shaped and decorated to look like swaddled infants. With a large Catholic population, fish is often eaten on Fridays
during Lent. Other special foods include humitas, quimbolitos, and tamales, sweet or savory dough mixtures filled and
steamed in banana leaves, achira leaves, or corn husks.

Foods are also used for medicinal purposes. Herbal teas and infusions are widely consumed. They are believed to
have special properties that may relieve a variety of symptoms and illnesses. Certain foods are considered appropriate
during pregnancy and lactation, such as morocho (a white corn dish) to promote milk production. Foods are
considered to have “hot” and “cold” properties, unrelated to actual temperature. In the highland province of Chimborazo,
for example, foods such as chamomile tea, red onion, and corn silk are considered to be ”hot.” They are used to make a
preparation to remedy stomach aches (Naranjo 2002). One home remedy calls for cooking chopped nuts in milk with a
cinnamon stick, until the mixture is slightly reduced. This concoction, when drunk at a warm temperature, is said to
alleviate a cough. Milk with garlic is believed to cure a cold. The faith in herbal medicine is widespread to greater and
lesser extents. In some communities, there is more faith in curanderos (herbal practitioners) than in medical
personnel (Naranjo 2002).

(Cuvi 2001; Juanita 1984; El Comercio 2003; Guerrón-Montero 2001; Naranjo 2002; Ordoñez 2001; Vallejo 1965)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Filipino
Food Practices

The Malaysian, Spanish, and Chinese have had major influences on the distinctive Filipino
cuisine, which starts from its variegated land and sea. The natural ingredients found in the
more than 7,100 islands and the surrounding waters and the tropical climate have formed
the multitextured cuisine. More than 80 ethnic groups and their different signature dishes
likewise depend on the available ingredients from the local terrain.
The major groups of islands are Luzon, Visayas, and Mindanao. There are differences in
the food patterns of these regions. Another group, Bicol, within the Luzon area, has a
distinctive flavor in its cuisine. Following are some of the regional differences:
Philippine Regions
Luzon
The indigenous vegetables (saluyot), root crops (yams, cassava), tropical fruits (banana,
papaya, mango, jackfruit) are plentiful. Bagoong (a type of anchovy paste) and patis
(shrimp/fish sauce) used in cooking. milkfish, prawns, and halibut are common.
Central Luzon
Dishes in the Central Luzon region are rich in sauces and influenced by the Spanish
cuisines. Tropical fruits such as atis, guyabano, watermelon, cantaloupe, papaya, and
honeydew melons are abundant. Freshwater fish are preferred to ocean fish as they are
more abundant in this area. Sautéeing is the preferred cooking method.
Southern Luzon
Spanish and the native Tagalog cuisines influence the cooking in the Southern Luzon part
of the country. The use of coconuts, dessicated and by-products, as well as spices and
sugar in cooking is evident in this region. Tropical fruits as the lanzones and langka are
favorites. Various sweet rice-cooked dishes are also found here.
Bicol
The Filipinos of the Bicol region prefer coconut-rich and spicy dishes. This is the region that
has the pili nut that is similar to hazelnut.
Visaya
The Visaya region is rich in fish, crabs, shells, and seaweeds. These are predominantly
used in cooking. Drying and salting fish are common methods of preservation. In
sugar-producing provinces, pastries and fruit preserves, peanut brittle, and rice cakes are
usual snack foods. Many bakeries use processes inherited from the Spanish colonizers.
Mindanao
Mindano is predominantly a Muslim region. Pork is restricted or limited. Food preparation
and cooking are influenced by the neighboring Malaysian and Indonesian cultures. Chili,
curry, and pepper are the favored spices.
Restaurants
Food can be obtained in the in the streets at barbecue stands, pushcarts, and strolling
vendors as well as restaurants. Some cooked foods are displayed in trays and customers
point to their choices. Such eateries are called turo-turo (point-point).
There are also specialty restaurants where customers are provided with fresh fish,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
crustaceans, and crabs. Exotic cuisines of the regions are also found in these restaurants.
Chinese and Spanish restaurants offer dishes that are the best in the country. Also popular
are restaurants offering Japanese, Thai, Vietnamese, and Korean food.
U.S. influence is seen in the establishment of fast-food restaurants and steak houses.
Although Chinese influence is found in the most basic level in Filipino cuisine and Spanish
in fine dining, it is presently the U.S. food that has gained prominence for its convenience.

Immigrants or Ancestors

Immigrants from the Philippines came as early as 1898 after the United States obtained the
Philippines as a colony from Spain through the Treaty of Paris. Many of the Filipino men
came to work in the sugarcane fields of Hawaii. They later migrated to the mainland.
Although they were U.S. nationals with U.S. passports, these immigrants were mostly
uneducated laborers and were not allowed to become citizens or to own land.
The exclusion laws of 1924 slowed the immigration of Asians, including the Filipinos.
Discrimination against Asians often forced Filipinos to form their own communities. They
did not assimilate into the U.S. mainstream.
In 1965, when the immigration laws were changed, the number of Filipino immigrants
increased. These immigrants were more educated and with greater economic means. They
settled mostly in urban areas. Many of these immigrants are found in the California cities,
Chicago, New York, New Jersey, Las Vegas, and Washington, D.C. Small businesses
were established by Filipinos to meet the needs of the Filipino communities.The number of
first to third generation Filipinos (Filipino-Americans) in the United States stands officially at
2 million. The number of Filipinos in the United States is expected to surpass the number of
Chinese in the United Sates in the 21st century.
The importance of food among Filipinos cannot be underestimated. There is no gathering
of Filipinos without food. Baptisms, weddings, birthdays, visits, or any function would
include food. Although the lavishness of the table depends on the wealth of the host, those
who are not economically well-off also consider a festivity with food important.
Rice is the foundation of the meals. Its variety included the tiny-grained milagrosa to the
malagkit, the glutinous rice that is used for dessert such as puto, bibingka, and suman.
The coconut is used in various ways. The soft flesh of a young coconut can be scooped
out with a spoon and eaten, the water providing a refreshing drink. Coconut milk is an
important ingredient in cooking in some regions of the Philippines. The mature coconut
flesh can be grated or squeezed out as coconut milk or cream. The coconut sap can be
fermented into tuba (toddy) or distilled into the potent lambanog. The leaves are used to
wrap rice cakes or meats for baking or grilling. The heart of the palm gives flavor to spring
rolls and salads.
Most of the cooking is done by sautéeing with garlic in olive oil or lard, combining
ingredients, resulting in a salty, sour taste. Economic means dictates the amount of meat,
poultry, and fish used. When available, these are cooked in combination with other
ingredients. Other parts of animals are also used. Blood, organs, and entrails make up
some of the Filipino delicacies.
The pancit, a noodle dish derived from China, is made from rice, wheat, or mung bean
flour. Every region, town, and home has its own version of this dish. This tasty dish is
usually combined with sautéed garlic, onions, vegetables, and cut-up meat or seafood. In
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
usually combined with sautéed garlic, onions, vegetables, and cut-up meat or seafood. In
fishing villages, squid, shrimp, and oyster are common ingredients. In other towns, Chinese
sausage, gourd, or smoked fish and pork crackling may be added.
Cow’s milk is not used much. Filipinos use the milk of the carabao (water buffalo) for
drinking and making a native cheese. Evaporated milk is popular for use as an ingredient
in desserts such as leche flan.
Fermented fish paste, bagoong, similar to anchovies, is a common ingredient, as is patis, a
transparent amber fish sauce. Soy sauce, salt, vinegar, calamansi (native lemons), and
chilies are also used.

Adaptation of Native Culture to American Culture

The food patterns of Filipinos in the United States are based on the cuisines “back home.”
Many have retained traditional eating habits while adopting the Western way of eating.
Many Filipinos eat highly salted meals. Fat intake is also high, as most meat dishes include
the fatty parts of meat. Rice, as the starch, is eaten in bigger quantities than the usual U.S.
helping. To summarize, the following are found among the Filipinos:
Filipino diets contain a lot of salt. The use of patis (fish sauce) and bagoong (shrimp
paste) as ingredients are common.
Filipino foods include ingredients from various cultures. Chinese ingredients, such as
oyster sauce, are used on a regular basis. Vinegar, coconut milk, lime, tamarind,
garlic, onion, and pepper are also key ingredients. The availability of ethnic Filipino
ingredients is very good. The affordability and variety found in local markets as
compared to the markets in the Philippines has increased the use of these products.
The traditional Filipino tasty dishes such as fried fish, roasted pork, pancit, lumpia,
adobo, and desserts rich in sugar and starch are eaten on a regular basis.
The traditional practice of paslubong (gift giving) with the use of food in social
gatherings continues to this day among Filipinos.
Traditional Filipino foods are used as comfort foods.
Many Filipino immigrants who were poor in the Philippines prefer to eat the
high-calorie, highly salted “fast foods” because these were not affordable to them
while in the Philippines.
Although many Filipinos are adapting to Western cuisines, families still cook according to
the recipes from the homeland. In dining out, restaurants that prepare the traditional
Filipino dishes (found especially in urban areas with Filipino communities) are more
popular than the non-Filipino restaurants. And because time is needed to prepare
traditional Filipino meals, many working Filipinos purchase their meals from these turo-turo
restaurants on their way home from work. During weekends or on special occasions,
Filipino traditional meals are prepared.
The food patterns of the Filipinos eating traditional Filipino meals may require needed
changes in quantity and seasonings to improve nutrition. Likewise, exercise and fitness
regimens are recommended because most Filipinos are not usually physically active.
Stress
Coping with the strain of immigration, changes in lifestyles, and the daily life in the United
States has Filipinos turning to the traditional foods as “comfort foods.”
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Socioeconomics Status
Socioeconomic needs often take precedence over personal health.
Lack of Time
Lack of time is especially true for physical activities. Time is mostly devoted to work and
social functions

Meal Planning in this Culture

Registered dietitians (RD) and dietetic technician, registered (DTR) should consider
socioeconomic status, literacy, and length of stay in the United States in meal
planning for Filipinos.
The use of the Food Guide Pyramid should be emphasized. Changes in planned
meals should incorporate the usual ingredients as much as possible.
Alternative seasonings should be used.
Modification of the usual 3 heavy meals and snacks per day can easily be modified.


Food Dictionary

Food Ingredients or Preparation
Abitsuwela Kidney beans or snap beans.
Achara Pickled vegetables or fruits.
Achuete Annatto seeds.
Adobado
An entrée similar to adobo, but differs in that the
meat with the spices are browned before simmering.
Adobo
A meat dish (pork, chicken, beef, or fish) marinated
in vinegar, soy sauce, garlic, and bay leaves
(optional).
Alamang Shrimp fry.
Alimango Large crab, usually black-shelled.
Alimasag Smaller crab, usually spotted.
Almondigas Meatballs.
Ampalaya
Asian gourd or bittersweet squash characterized
by its wrinkled, dark green skin and bitter taste.
Anis Anise seeds.
Apulid Water chestnuts.
Arroz caldo A rice gruel usually with chicken or tripe.
Atis Sugar apple fruit; light green in color.
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Bacalao
Dried salted codfish sold at Portuguese and
Spanish stores.
Bagoong
Shrimp or fish paste fermented in salt and used for
seasoning or as dips.
Bangus Mild fish similar to herring.
Bibingka
Rice cake with glutinuous rice or rice flour and
coconut milk.
Bigas Rice.
Bihon Thin rice noodles, also known as rice sticks.
Bistek
Thinly sliced beef, marinated in lemon or
kalamansi (Filipino lemons) juice, salt, soy sauce,
and pepper.
Bok choy
Chinese chard cabbage or Chinese white cabbage,
has thick white stalks and dark green leaves with
white veins. (See Pechay.)
Buko Fresh, young coconut with tender, gel-like meat.
Bulaklak
Flowers, buds, or blossoms such as squash
blossoms and banana buds.
Bulanglang
A regional dish mainly composed of vegetables
boiled with broiled of fried fish and seasoned with
bagoong.
Caldereta
Dish made of goat meat sautéed in garlic, onion,
potatoes, peas, bell pepper, and seasonings. Beef
or lamb may be used in place of goat meat.
Callos
A meat dish consisting of hock, tripe, or oxtail,
lapay, chorizo de Bilbao. The dish is sautéed in
garlic, onions, and tomatoes, then simmered.
Camaron Shrimp.
Cardillo
A fish dish. Preparation is similar to sarciado
except that beaten eggs are added a few minutes
before removal from the stove.
Cassava
Root crop; sometimes called yucca or kamoting
kahoy.
Cebolleta Chives.
Champorado
Chocolate flavored rice porridge usually eaten with
fried dilis (dried anchovies) or tapa (dried beef).
Chayote
Vegetable pear, a tropical summer squash
originally grown by the Aztecs and Mayans
centuries ago; has deeply ridged surface and a
single flat seed in the center.
Chicharo Snow peas; an edible peapod.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chorizo de
Bilbao
Spicy sausage from Bilbao, Spain. May be
substituted with garlic sausage or pepperoni.
Clavo Cloves.
Colantro Coriander.
Dahong sili Sweet pepper or chili pepper leaves.
Daing Dried fish. Daing na bangus is a favorite.
Dalag Mudfish or freshwater murrel.
Dalagang
bukid
Black-tailed caesio, a fleshy fish.
Dalanghita Native orange.
Dayap Lime.
Dila Tongue or lengua.
Dilaw Turmeric.
Dilis A long-jawed anchovy.
Dinengdeng
A dish made of leafy vegetables with some fruit,
vegetables, and dried fish.
Seasoned with bagoong.
Embotido Meat loaf wrapped in pork leaf fat.
Empanadas
Meat turnovers. Empanaditas are smaller
turnovers.
Escabeche Fried fish in sweet-sour, spicy sauce.
Eskarola Curly endive.
Espasol
Sweet ice flour cakes made with coconut milk and
sugar.
Estofado Spanish for braised meat dishes with vegetables.
Gabi Taro tubers
Galapong Dough made from powdered rice and water.
Garbanzos Chick peas.
Gata Coconut milk.
Gatas Milk.
Gisantes Green peas.
Goto Tripe.
Guinataan
Food cooked in coconut milk; process of cooking
with coconut milk.
Guisado Sautéed or pan-fried.
Gulaman
Gelatin from seaweeds, agar-agar. Purchased
unflavored and in dry bars.
Gurami Carp, a fleshy fish.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Guyabano Soursop, a white, pulpy, sour fruit.
Halaan Clams.
Halo-halo
Literal meaning is “a mixture.” Desserts, drinks,
sweets, meats, cold cuts
Has-hasa Short-bodied mackerel.
Heko A salty, pasty food seasoning.
Hipon Shrimp.
Hito Catfish.
Hopia
Mooncakes filled with sweet mung bean or black
bean paste or sweetened minced pork.
Hugas-bigas Rice washings.
Humba Tagalog term for estofado or stew.
Inabrao
A typical dish from Ilocos region consisting of
broiled pork boiled in rice water, seasoned with
bagoong, with string beans and lima beans.
Ispinaka New Zealand spinach.
Istroberi Strawberry.
Itlog na
maalat
Salted eggs, usually duck eggs pickled in saline
and then boiled.
Kabibi Large clams or seashells.
Kabuti Mushroom.
Kadyos
Bunga
Pigeon peapod.
Kakang gata Coconut cream.
Kakanin Snack foods.
Kalamansi Native lemons.
Kalamay
Glutinuous rice cooked in coconut milk, molasses,
or brown sugar, anise seeds, and usually packed in
coconut shells.
Kamatis Tomatoes.
Kambing Goat.
Kamote Yams.
Kamoteng
kahoy
Cassava or yucca.
Kandinga
A native dish popular in the Bicol region; consists
of internal organs, pamnton, red and green
peppers, and onions.
Kanduli A white catfish.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Kanela Cinnamon.
Kangkong A water plant; swamp cabbage.
Kaong Sugar plum; often served in syrup.
Kare-kare
Popular dish consisting of beef shank, oxtail and/or
tripe. Pork hocks may be used. The dish is sautéed
with garlic, bagoong, and vegetables. Ground
toasted rice and peanuts are added to thicken the
sauce. Achuete (annatto) is used for coloring.
Karot Carrot.
Kastanyas Chestnuts.
Kasubha Saffron.
Kasuy
Pear-shaped cashew, orange-yellow when ripe
with a seed growing outside the fruit from which
cashew nuts are taken.
Kenchi Foreshank or hindshank.
Keso de bola Edam cheese.
Kesong puti Cottage cheese.
Kintsay Chinese parsley.
Koliplawer Cauliflower.
Kondol Wax gourd.
Kuhol Snail; escargot.
Kulitis Philippine spinach.
Kutsay Leek.
Kutsinta
Dessert made from powdered rice, sugar and lye;
steamed until soft. The lye gives a light brown color
to it.
Labong Bamboo shoots.
Labuyo Tiny hot pepper.
Langka Jackfruit, the largest fruit in the world.
Lapulapu Grouper.
Latik
Resulting precipitate when coconut milk is made
into oil by boiling.
Laurel Bay leaf.
Leche flan Egg custard.
Lechon Rosted pig.
Lechon
sarsa
Liver sauce for lechon.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lengua
Spanish for tongue. Ox or calf tongue commonly
used in recipes.
Lihiya Lye water.
Linga Sesame seed.
Lomo Tenderloin.
Longaniza Sausage.
Lumpia Eggroll.
Luya Ginger root.
Mais Corn.
Maja blanca
Blanc mange. Sweet, molded, jelly-like dessert
made of a starchy substance and milk.
Makapuno
Mutant coconut fruit characterized by soft, slightly
sticky meat.
Malgkit Glutinous, sticky or sweet rice.
Malunggay Horseradish tree.
Mangga Mango.
Manok Chicken.
Maruya Fritters.
Matmis na
bao
Coconut jam.
Maya-maya Red snapper, a fleshy fish.
Mechado
Pork or beef dish. Stivers of fat are inserted in the
center and simmered in tomato sauce.
Miki Round, fresh, wheat noodles.
Miso Soy bean products.
Miswa White, fine wheat noodles.
Morcon Stuffed meat roll.
Mungo Mung beans.
Morisqueta
tostada
Fried rice.
Mustasang
buro
Salty, fermented green mustard.
Nangka Jackfruit, also called langka.
Nilaga Boiled meat or chicken dish wwith vegetables.
Niyog Coconut.
Niyog ubod Coconut shoot or coconut heart.
Paayap Cow pea.
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Pabo Turkey.
Paella
Spanish dish made with a combination of rice,
vegetables, chicken, meats, seafood; flavored with
saffron and peppers.
Pako Fern.
Paksiw
Process of pickling fish or meat in vinegar, water,
and spices.
Pakwan Watermelon.
Palabok Garnishing.
Palaka Frog.
Palitaw
‘To float.” Snack dumplings made with glutinous
rice dough.
Paminta Pepper.
Pamintang
buo
Peppercorns.
Paminton Red pepper.
Pompano Cavella, pompano fish.
Pandan Screw pine, aromatic leaves.
Pancit
Wheat, rice, or egg noodles pan fried with a variety
of vegetables, meats, seafood, seasoned with soy
sauce, pepper, onion, garlic, sesame oil.
Pasas Raisins.
Pata Hock.
Patani Lima beans.
Patatas Potatoes.
Patis Salty fish sauce.
Pato Duck.
Patola Sponge gourd.
Paypay Pig’s shoulder or Boston butt.
Penoy Boiled duck egg.
Peras Pears.
Pechay Chinese cabbage.
Pierna corta Beef round.
Pigi Fresh ham leg.
Pinakbet
Common dish in northern Luzon made with the
blending of ampalaya, eggplant, and sometimes
okra.
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Pinipig
Harvested unmatured rice, pounded and roasted .
Served as snack.
Pinya Pineapple.
Pipino Cucumber.
Pitso Chicken breast or white meat.
Pollo Spanish for chicken.
Putchero
Beef or chicken stewed with Spanish sausage,
ham bones, and vegetables.
Pugo Quail.
Pusit Squid.
Puso ng
saging
Banana heart or blossom.
Puto Glutinous rice cake.
Pulutan Appetizers.
Relleno Deboned poultry or fish with stuffing.
Remolatsa Beets.
Repolyo Cabbage.
Saba
Variety of banana, usually for cooking. Also
plantain.
Saging Banana.
Salabat Fresh gingerroot tea.
Salitre Saltpeter, niter, or potassium nitrate.
Saluyot Jute.
Sampalok Tamarind.
Sarciado
A dish similar to fritada except that there are no
potatoes and sweet pepper; has thick tomato gravy.
Sawsawan Dips, sauces.
Sibuyas Onions.
Sili Pepper.
Sinangag Fried rice.
Sinkamas Jicama.
Sinigang Meat or fish sour stew.
Sitsaro Sweet pea pod.
Sitsaron Pork crackling.
Solomillo Tenderloin.
Sotanghon Soybean noodles.
Sugpo Prawns.
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Suman
Dessert made from glutinous rice with a little salt
added; wrapped in banana leaves and steamed.
Suso Snail; escargot.
Taba sa likod Back fat.
Taho Soy bean curd; soft tofu eaten with syrup.
Tahong Saltwater mussel.
Tangang
daga
Black wood mushroom, forest mushroom.
Talaba Oyster.
Talinum Philippine spinach.
Talong Eggplant.
Tanglad Lemon grass.
Tanguigue Spanish mackerel.
Tapa
Thinly sliced or pounded meat. Salted and dried.
May be cured.
Tapdera Rump.
Tawre Fermented soybean paste.
Tawsi Soybean product with fermented balck beans.
Tawas Alum, a double salt of aluminum and potassium.
Tinapa Smoked fish.
Tinola
Meat or fish prepared by sautéing garlic, onion,
and ginger with the meat or fish.
Tofu Smooth, custard-like bean curd.
Toge Mung bean sprout.
Tokwa Soybean curd, firmer than tofu.
Torsilyo Barracuda.
Torta Omelet.
Tortilla Small omelet.
Tuba Toddy made from fermented coconut.
Toyo Soy sauce.
Tuyo Dried fish, usually young herring.
Ube Purple yams.
Ubod Heart of coconut tree.
Ukoy
A disk consisting of shreeded vegetables dipped in
a thick batter and deep-fried.
Ulang Freshwater shrimp.
Upo Bottle gourd.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Usa Deer.
Utaw Soybean.

References


Chesnoff RC. Philippines New York: Harry N. Abrams, Inc.; 1980.
Claudio V. Filipino American. Ethnic and Regional Food Practices. Chicago: The American
Dietetic Association; 1994.
Claudio V, Quirante R, eds. Filipino American Cookbook for Calorie Controlled
Diets. Audubon, IA: Filipino American Dietetic Association, Jumbo Jacks Cookbooks; 1998.
Francis D, ed. Insight Guide: Philippines. Maspeth, NY: Langenscheidt Publishers, Inc.;
2002.
Javellana R, Zialcita FN, Reyes EV. Filipino Style. Manila: Department of Tourism; 1998.
Kittler PG, Sucher K. Food and Culture, 4th ed. Belmont, Calif.: Thompson-Wadsworth.
Belmont; 2004
McWilliams M, Heller H. Food Around the World. Upper Saddle River, NJ: Prentice Hall;
2003.
National Institute of Health. National Heart, Lung, and Blood Institute. Cardiovascular risk in
Filipino community: formative research from Daly City and San Francisco, CA. Bethesda,
Md.: U.S. Dept of Health and Human Services; 2000.
Roces A, Roces G. Culture Shock: A Guide to Customs and Etiquette –
Philippines Portland, Ore.: Graphic Arts Center Publishing Co.; 2003.


References


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Hispanic
Food Practices

To be effective in working with Hispanic people, determine the following:
ethnic subgroup;
socioeconomic status;
regional demographics of the client.
Otherwise, Hispanic food or culture is as vague a term as "Asian," "European," or "Native
American." Almost the only constant across most of the groups classified as "Hispanic" is
the use of rice and beans. Mexico is the country that comes to mind fastest when the word
"Hispanic" is used, with 63% of the Hispanic population in the United States being of
Mexican decent.
The countries of origin or heritage grouped under Hispanic by the United States Census
Bureau include:
Mexico;
Puerto Rico (living in the United States);
Cuba;
Dominican Republic;
Central America (Belize, Cost Rica, El Salvador, Guatemala, Honduras, Nicaragua,
Panama);
South America (Argentina, Bolivia, Chile, Colombia, Ecuador, Paraguay, Peru,
Uruguay, Venezuela, etc.).
Spain and Portugal also belong in the list of Hispanic food cultures because of their
influence on the cuisines of these countries.
The diversity of this group becomes even more apparent as the cultural foods of this group
become mainstream foods in U.S. homes. The most important aspect in counseling
individuals of Hispanic descent is to get detailed food histories or food records and not
make assumptions about ingredients and preparation methods. (See websites with
Hispanic foods and recipes Cuban, Central America, Dominican Republic, Brazilian,
Guatemala, Puerto Rico, South America) and Cameron, 2004.)
There are many publications that discuss food practices of each of the Hispanic subgroups
(Kittler, 2000). For information about local ethnic group food practices, the Cooperative
Extension throughout the United States provides a wealth of information. Extension is
connected to community groups and basic issues about food access. Another important
body of work was done by Eunice Romero-Gwynn and her research on circles of
acculturation. This work outlines the core foods of several Hispanic cultures and others,
with an emphasis on the frequency of consumption of the core foods and assimilation into
mainstream U.S. food culture. The lines of acculturation may be harder to determine today
as the core foods of Mexico become more popular with the general public.
Registered dietitians (RD) and detetic technician, registered (DTR) need to become familiar
not only with the food preferences, but also with some of the history of the primary group.
(See Hispanic food practices: Central America, Cuban, Dominican Republic, Mexican,
Puerto Rican, South American).

Central American Food Practices
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Central America: Belize, Cost Rica, El Salvador, Guatemala, Honduras, Nicaragua,
Panamá
Central American foods are not as spicy as those found in Mexico although they are similar
and have similar names. The food is a blend of the Spanish, Central American Indian, and
European. European dishes such as mushroom quiche and profiteroles with ice cream and
chocolate sauce can be found alongside native dishes such as chiles rellenos (a mild or
spicy green chile stuffed with cheese, and/or meat, and/or mashed vegetables and dipped
in a whipped egg mixture and fried) and chicken pepian, similar to Mexican mole or pepian
(the chicken is roasted and cooked in a roasted pumpkin seed and sesame seed spicy
sauce). Other typical dishes include:
Shrimp ceviche;
Red snapper with cashews;
Mushrooms with garlic;
Rice and pork chops;
Chicken with mushrooms;
Grilled snapper;
Prawns in tomato sauce;
Leg of lamb.
Desserts include flan or hot bananas that may come with a chile-spiked chocolate sauce or
desserts with an island influences such as fried plantains or watermelon with liqueur.
This mountainous region also has an abundance of fresh fruits and vegetables available.
Some favorites include:
Sweet pineapple rings;
Cantaloupe crescents;
Pink papaya spears;
Peeled bananas;
Carrots;
Broccoli;
Spinach;
Corn,
Green beans;
Salads with sliced tomatoes and red onion rings;
Sprouts and avocado wedges
Sugar snaps,
Long beans
Artichokes;
Patty pan squash.

Dominican Republic Food Practices

Dominican Republic
People from the Dominican Republic represent Hispanics with the largest
African-American population. Some foods may be common between African-Americans
and Dominicans.
The food practices of the Dominican Republic and the other Hispanic islands such as Cuba
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and Puerto Rico are similar. The typical lunch is called Bandera Dominicana (the
Dominican Flag) and it consists of rice, beans, and meat. The Spanish word "habichuelas"
is used for beans. Many dishes have other names in this country. Some examples include:
Cocido, a meaty stew;
Bija, the red seeds called anato, annato, or achiote;
Batata, sweet potato, camote, or boniato;
Auyama, gem squash or calabaza;
Lechoza, pawpaw or papaya;
Tayota, christophines or chayote;
Mondongo, tripe also known as panza (stomach), tripas (intestines), menudos
(translates to little pieces), and in Spain, callos.
Sofrito is the base of this cuisine. Cooks often make this ahead to speed up meal
preparation. It is a mixture of spices and herbs that are sautéed in oil to release the flavors.
Common spices included in this mixture are as follows:
Thyme;
Salt;
Mashed garlic;
Parsley;
Finely diced onion;
Green pepper;
Coriander/cilantro leaves;
Tomatoes;
Tomato paste;
Vinegar.
National dishes include:
Sancocho, a stew made with up to seven types of meat;
Rabo encendido, a spicy oxtail soup that literally means "tail on fire";
Mangu, mashed plantains, yucca, or yautia
Holiday or special occasion foods include:
Te de jengibre, ginger tea;
Empanaditas, a meat-filled pastry similar to pasteles;
Moro de guandules con coco, rice with pigeon peas and coconut;
Ensalada rusa, "Russian salad" a potato salad made with hard boiled eggs and
carrots;
Puerco asada, a whole roasted pig;
Rum cake and ponche de ron, rum eggnog;
Licor de manadarina, a liquor made with Dominican rum and mandarins.
Depending on the cook, oil may be used in large amounts. Aunt Clara's Kitchen - About
Dominican Cooking provides a good index of foods and recipes.

Mexican Food Practices

México
Foods used by Mexican cooks include the following:
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Corn;
Rice;
Beans;
Beef;
Pork;
Goat;
Chicken;
Carrots;
Potatoes;
Green beans;
Lima beans;
Variety of greens;
Pastas made from enriched white flour;
Tomatoes, tomatillos (green husk tomatoes);
Peppers of all kinds (sweet and hot as well as fresh, dried and powdered);
Cactus;
Jicama;
Avocados;
Onions;
Garlic;
Cilantro;
Thyme;
Basil;
Lemons;
Oranges;
Bananas;
Mangos;
Papayas;
Guava;
Cantaloupe;
Watermelon;
Tamarind.
Cookbooks can be a helpful tool for someone not familiar with the foods of the regions of
Mexico. Two books with great pictures and narratives are The Beautiful Cookbook and The
Fiestas of Mexico. The Public Broadcast Series, "Mexico One Plate at a Time," is very
good. One drawback of this program is that it is filmed in Mexico and does not take into
consideration the complex nature of what happens to foods as they are moved north. The
cuisine of Mexico has deep roots in political unrest, nationalism, regionalism, and social
and economic status.
The most common bread at meal time is a tortilla. In southern Mexico, tortillas change and
by the time you reach Mexico City, they are mostly made of corn and they are very thin,
about the size of a dollar pancake. The flour tortilla that is popular in the United States is
from northern Mexico. There are many stories about the origins of the flour tortilla. One
was that it was developed and popularized by the farm workers that followed the harvest in
Texas, Arizona, New Mexico, and California. An interesting feature is the proportions of
southwestern Indian fry bread and flour tortillas are very similar. One is fried and the other
grilled on a lightly seasoned griddle.
Many Mexican pastries have much less sugar and fat than donuts, muffins, croissants, and
other U.S. pastries. Surprisingly, they are often made with whole wheat flour and some also
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
have less sugar. Mexican cakes resemble European tortes more than U.S. cakes; they
have a much higher egg/flour ratio and use a little less fat and sugar. The U.S. Department
of Agriculture nutrient database has the analysis of some of these favorites. U.S.
corporations also stock the shelves at groceries stores in Mexico; you will find gelatin,
familiar cake mixes, the blue box macaroni and cheese, and so forth. Wal-Mart is found in
Mexico and other South American countries.
One can’t have a discussion of Mexican cuisine without a discussion about lard in foods.
Lard is what makes a bollillo, Mexican bread, instead of French bread. Lard imparts flavor.
In tortillas, its shortening effect makes for a more pliable flour tortilla. In flour tortillas
individuals use the fat at hand to make them. Most individuals in Mexico eat corn tortillas.
In California, Texas, and other western states, individuals who make flour tortillas may
report using butter, lard, soft margarines, and oils including olive oil. More individuals use
lard, however.
The array of tortillas in grocery stores can confuse the average consumer. Most large flour
tortilla factories make a variety that is without lard. The fat-versions often are missing
texture, taste, and reheating qualities compared with the more traditional versions. Corn
tortillas are traditionally only made with a corn that has been treated with lye and mixed
with water. You may find white flour and sometimes fat in some store-bought corn tortillas.
Become familiar with the tortilla products in your area. In many food portion guides, the
diameter of the flour tortilla is emphasized. One should also look at the weight per tortilla.
You could have a gordita 6" tortilla that weighs the same as a 10” tortilla.
Ask about and encourage the consumption of boiled beans, fresh vegetable soups, and
stews of all kinds with more vegetables, fresh salsas, and corn tortillas daily. Enchiladas,
tacos, tamales, and others on many menus are company or special occasion foods.
Eateries in Mexico that serve tostadas, enchiladas, quesadillas, and other familiar foods are
often called anotjitos, which translates in to "food cravings" or "temptations."
The Mexican menu is very high in carbohydrates and it is important for the practitioner to
ask the client which carbohydrate foods are the most important to him or her before
creating a meal plan. For example, beans and rice are eaten at almost every meal.
Suggestions may be made for alternating these foods as well as figuring in the number of
tortillas eaten at every meal. For individuals with normal glucose tolerance, the
high-complex carbohydrates in beans and corn tortillas could be encouraged with advice
on reducing the fat.
Tacos and burritos mean very different things to different individuals. For example, in San
Antonio, Texas, tacos are sometimes soft, small, flour tortillas and burritos are large flour
tortillas and deep fried. In many parts of California, enchiladas are made with flour tortillas,
not corn. Burrito and a superburrito are not standardized; both may contain rice, beans,
and meat. This can vary from taqueria to taqueria (cafe specializing in tacos -- generally
fast, simple meals) in one area. Organizations are developing that follow trends in Mexican
food. (Personal interview with Guillermo Avila, El Paso, Texas; September 2003.)

Puerto Rican Food Practices

Puerto Rico (living in the United States):
The food practices include rice and beans as the core foods accompanied with chicken,
pork chops, beef, fish, and so forth. Bread is not part of the meal generally and rice or
beans may be served. Breads eaten in other countries, such as French or sandwich, may
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be included along with tortillas. The most common vegetables eaten in the United States
are carrots and potatoes. Puerto Rican vegetables lame, yautia, green bananas, ripe
bananas, and plantains are also eaten.
Holiday meals: Christmas includes arroz con ganulez, pastilles (meat-filled pastries), and
desserts. A favorite dessert served at many special occasions is arroz dulce. It is made with
coconut, raisins, brown sugar, and cinnamon. Thanksgiving is celebrated with turkey and
dressing and arroz dulce. No cranberries are served and the dressing is made with
sausage, bacon, celery, carrots, and dried bread cubes. (Personal interview with Consuelo
Morales Lopez, Salinas, California; September 2003.)

South American Food Practices

South América: Argentina, Bolivia, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay,
Venezuela
South American foods are similar to and yet different from the foods of Mexico and Central
America. A more global influence can be seen in some regions, especially in Brazil. There
is a great abundance of fresh fruits and vegetables, meats, poultry, and fish. The region is
very mountainous and so many large population centers are along the ocean. Brazil is the
largest county in this region. Brazil and other countries use equipment such as a pressure
cooker in making their rich stews and soups.
It is important not just to ask what foods are eaten from this and other regions, but also how
they are prepared. The cooking methods, ferventar, lightly boils food to sterilize it and
reduce the fat while refogar is similar to a Chinese stir-fry. Soups and stews use refogar as
the preferred cooking method. Annatto seeds are used as a coloring agent in many foods.
Brazil
Pamonhas a sweet tamale made with milk and farmers cheese in a cornhusk and
traditionally eaten for dessert.
Canijicais, referred to as hominy sweet meal, originally a Brazilian Indian recipe that is
made with white hominy and coconut and eaten for special occasions.
Feijaoda is a black bean and pork stew and there are many variations on this classic
dish.
Palm tree products are commonly used such as the oil and palmito, a delicacy from
inside the tree.
U.S. foods are popular such as pizza and lasagna as well as other countries foods
such as beef stroganoff from Eastern Europe.
A bread with much history is Pão De Queijo; it is made from the starch left over from
the processing of flour from the yucca root. Today this bread is made with milk and
cheese and a staple especially in the afternoon with coffee.
No list of foods from Brazil is complete without listing barbecue, churrasco. The
variety of grilled meats and sausages are served with white rice, farofa (seasoned
manioc flour, which comes from the yucca root), and a Brazilian salsa (made with
sweet peppers, onions, and tomatoes). The meat is not served with a sauce; rather, it
is either rubbed with salt or it can be marinated in a variety of styles such as the
following:
Gaucho Barbecue from southern Brazil along the Argentinean border (lamb,
chicken, or beef is rubbed with salt and crushed garlic);
Chicken Barbecue (chicken rubbed with olive oil, salt, and garlic);
Kabobs Brazilian style (beef tenderloin marinated in lemon juice, garlic, olive oil,
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Kabobs Brazilian style (beef tenderloin marinated in lemon juice, garlic, olive oil,
and onions then skewered alternating with bacon cubes and served over manioc
flour); it is a coarse meal some describe as having the texture of beach sand;
Minas Barbecue (the beef tenderloin is marinated similar to the kabobs and
roasted whole. Slices are carved off as it is cooked and the rare meat is left on
the spit to continue cooking).
Uruguay:
Uruguay gets its culinary roots from Spain, Italy, and many other European migrations. The
food practices reflect a cosmopolitan society. In contrast to most Latin American countries,
no significant vestiges of civilizations existing before the arrival of European settlers were
found in the territory of present-day Uruguay (Federal Research Div, 1990).
Asado: meat cooked over hot coals. Family gatherings typically center on outdoor
barbecues (asados), in which large quantities of meat are consumed. (for birthdays,
anniversaries, weddings).
Puchero: meat that is boiled, along with potatoes, yams, corn, squash, and cabbage.
The stock is used for soup, the meat and vegetables are served as the main course.
This was a poor men’s meal, but now it is one of the most expensive dishes to make,
because it has so many fresh ingredients.
Milanesas (Schnitzel): thin cutlets of meat, breaded and fried, served with mashed
potatoes
Uruguayans like to eat a quick breakfast, consisting of bread (French style), pastries, and
café con leche (coffee with milk). The main meal is eaten at lunch time, usually from 12 to
2 pm; the milanesas or puchero are eaten then. Fresh fruit is the choice for dessert. A
merienda or snack (like English high tea) is served at around 4:30 pm. Bread, salami,
cheese, and marmalade, along with a popular tea-like beverage, complete the merienda.
Dinner is a light meal, mostly lunch leftovers. Most businesses of Latin America, Spain,
Portugal, and other Spanish-speaking countries are closed from 12 to 3 pm. Children
attend school from 7:30 am to 12 noon and from 1:00 pm to 4:00 pm. This midday break
allows them to eat at home. (Personal interview with Christina Pitts, Monterey, Calif.;
March 2004.)

Immigrants or Ancestors

It is important not to assume that someone who is recently immigrated will be eating a
more native diet and that individuals whose families have resided in the United States for
several generations will eat a less native diet. The food ways of some recent immigrants
may be more affected by cheaper availability of U.S. foods at fast-food restaurants. This is
not a constant, though. Depending on the location that recent immigrants find themselves,
they may cling to familiar foods to cope with the loss of extended family and home.
Hispanic cultural foods are easier to find throughout the United States today. For many
decades, large cities throughout the United States have had an area that included cafes,
restaurants, grocery stores, and bakeries catering to the food needs of the predominant
Hispanic group in the area. The ingredients for most foods are not exotic. The challenge is
to determine the English name for the ingredients.
Moving north, immigrants from Mexico and Central and South America lose the abundant
variety of fresh fruits and vegetables that are available fresh for longer periods of time in
the native country. The availability of tropical fruits and vegetables has increased in the
past decade, although they can be expensive and not always in the stores frequented by
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
recent immigrants. If we can encourage the maintenance of old food ways and curb the
adoption of the negative aspects of United States food ways, everyone in the community
would benefit.
Why so many immigrants appear to be adopting U.S. food practices so quickly is the fact
that they are already familiar with the products in their native country. These foods are so
much cheaper here in the United States and in many cases, immigrants' income has
increased to allow these purchases. (Personal observation and conversations with
students, May 2001.)
It is important not to jump to any conclusions. You will find that many individuals are timid
at sharing their food practices with a stranger. The fear is that the foods they hold dear will
be labeled as bad.
Hispanic or Latino is a U.S. Census Bureau ethnic category that includes individuals from
all countries that speak Spanish. The designation has changed over the years. It was
Spanish, then for a time Latino, and it has evolved into Hispanic. The accuracy always
depends on how the demographic information is completed by the individual. In many
settings, the terms are used rather loosely and popular use refers only to those whose
ancestry is from the western hemisphere, not Spain or Portugal. Persons of Mexican
ancestry interpret use of Hispanic or Latino in many different ways. Some ignore it. For
example, in Mexico, individuals describe themselves as Mexican; individuals may identify
with states and cities and the only group that was separate were los indios (the indigenous
peoples). These individuals present a special challenge in both the United States and
Mexico because they often do not speak Spanish or some of their dialects are not well
known.
As a group, Hispanics are significantly younger than the national average, poorer, and less
educated. Among recent arrivals, single males are common. Although there is a tendency
to settle with others from the same country, a shared language such as Spanish and some
common traditions encourages a certain mixing of nationalities.
How immigration affects food practices is very dependent on circumstances, especially if
the individual lives in a community with other immigrants from their Mexican state or city.
Clusters and large groups of Hispanic immigrants tend to form throughout the United
States. This trend reinforces the keeping of cultural foods and language. This is true for
most Hispanic subgroups. Often there is a merging of Hispanic cultural groups with
Spanish being the unifying force. Food markets in cities may carry foods from Mexico,
Puerto Rico, or the Caribbean Islands, depending on the mix in the community.

Adaptation of Native Culture to American Culture

Early immigrants from this group cultivated foods that they needed. Hybrid chiles exist in
many southwestern states. (Hatch, New Mexico, is home of the best green chiles.) Visit the
NMSU Chile Institute at New Mexico State University, Las Cruces, New Mexico.
There are large Mexican food companies throughout the Southwest and California. Goya
Foods (origins not Mexican) is one of the largest and most diverse. Marquez Cheese
Company specializes in specialty cheeses similar to the ones found in Mexico.
More subtle adaptations to Hispanic foods in Mexico City are changes to family recipes that
evolve over time with local ingredients. Some changes are the merging of Mexican regional
dishes with recipes in the United States and the addition of other cultural dishes to the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
families regular meals, changes in meals, and/or changes in holiday food selections.
Adaptations will continue as this group becomes larger through immigration and
naturalization. Intermarriage between Hispanic cultural groups and other ethnic groups
makes this even more diverse and difficult to predict food and family behaviors.
The most apparent adaptation is in timing of meals. The United States has an 8 am to 5 pm
work day and many new immigrants work seasonal jobs that may have shifts around the
clock. No matter what the work day is, it does not include a long midday pause or siesta in
the United States.

Meal Planning in this Culture

Latin American Foods & Cooking is a good website. The links are listed in alphabetical
order by country.
Mexico
*Note there can be extensive discussion on how these meal names are interpreted in the
U.S. and even in Mexico.
Meal Time of Day Notes
Desayuno
Early
morning, 4
am-8 am
This meal is generally eaten very
early and is simple. Often consists of
coffee, chocolate, tea, juice, and bread
Almuerzo Morning
This meal is hearty and would include
rice, beans, eggs, meats, potatoes,
fresh fruit, bread, or tortillas. Dairy
products at this meal could include
yogurt, cottage cheese, or cheeses. In
some translations, this is called lunch,
but Mexico does not really have lunch.
Meals consisting of sandwiches and
burritos are considered snacks or
something to satisfy until the next
meal.
Comida
de Medio
Dia
Lunch
This is the main meal of the day and
it generally includes meat, vegetables,
beans, rice, dessert, fruit waters, or
sodas. It is generally eaten late,
around 1 pm, and a rest break is
considered traditional after this meal.
Merienda
Snack,
mid-afternoon
This meal is the most often skipped
or it is used as an early supper in
households where supper is served
later and is more formal. The foods
served are snacks such as chile con
queso and tortillas or toasts,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sandwiches, or taquitos.
Cena
Eveining
meal
Supper in Mexico is lighter and often
extended families get together or
family may eat this meal with friends
at their homes or in cafes. The time of
this meal varies and is dependent on
the other meals consumed throughout
the day.
Antojito
Snack, late
night
This is generally similar to the first
breakfast or merienda with hot
chocolate, atoles, coffee or tea, and
sweet bread or tortilla snacks.
An excellent resource: Dietary Patterns and Acculturation.Among Latinos of Mexican
Descent.
Puerto Rico
Meal
Time of
Day
Notes

Desayuno
Morning
It may be a simple meal of sweet bread
and milk or it can include fried ripe
bananas and scrambled eggs.

Almuerzo
Midday
This meal is light; it can be soup, rice, or
beans, similar to U.S. lunch
Cena
Evening,
around 6
pm.
This is the main meal of the day when
the family gathers. It generally includes
rice and beans although rice and beans
may be substituted with a pasta dish.
An excellent resource: Puerto Rico Culture: Food and Drinks.
South America
An excellent resource: Global Gastronomer - South America.

Food Dictionary

Developing or finding a comprehensive lists of Hispanic foods with the correct Spanish and
English names can be a challenge. Individuals continue to develop resources on the
Internet and there are some good books available as well (Kiple, 2000).
When working with monolingual Hispanic clients, the California Nutrition Education &
Training Program has a very useful set of food cards with nutritional information on the
back of each card. The set contains 142 fruits and vegetables. Many foods have multiple
names throughout Mexico and other Spanish-speaking countries. Pictures assist in
identifying foods to encourage clients to consume (California Nutrition Education and
Training Program, 1997). The core list of foods and cooking descriptions below were
collected over many years. The sources were students learning English during nutrition
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
collected over many years. The sources were students learning English during nutrition
presentations and research for Spanish/ English recipes. The challenge are the multiple
names for one food and the sharing of names of different foods or recipes.
English-Spanish Hispanic Foods Dictionary
Food in English
Food in
Spanish
Ingredients or
Preparation
Achiote or Adobo Achiote
Annato seeds. Crushed
and/or ground and fried in
oil to release the color and
flavor of these seeds. It is
used as a paste for sauces
and meats. This is also
often mixed with recado.
Asadero cheese Queso Asadero
Goat milk and salt. This
cheese is very common in
the state of Chihuahua and
has a creamy stringy
texture. Mozzarella and
provolone cheeses can be
substituted.
Atole, beverage Atole
Flour or cornstarch, water,
sugar, and flavorings. A
paste is made with starch
and water, then heated until
it thickens. Cinnamon and
vanilla are common
additions as well as
crushed fruits or chocolate.
With chocolate, it can also
be called champurrado.
Avocado salad
Ensalada de
Aguacate
Avocado, lettuce, and
tomatoes with optional
onions, chilies, lemon,
cilantro, cumin, sour cream
or crema, shrimp, garlic,
salt, and pepper. The items
are all chopped generally
chunkier than for
guacamole. They may be
tossed or layered in the
serving platter or individual
dishes.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Bananas Platanos
Ripe or green bananas are
used extensively. The
green ones are generally
fried and served either as a
dessert or as a vegetable.
Yellow sweet bananas are
called platano amarillo
(yellow) or maduro
(mature-sweet).
Beans Frijoles
Beans with optional lard,
bacon, ham hocks, garlic,
onions, and cheese. Dried
pinto beans are sorted
(rocks and broken ones
removed) and then boiled
in water until tender. Salt is
added at the end of
cooking; otherwise, skins
get tough. Some cooks add
lard or bacon grease to
beans toward the end of
cooking. This is not
universal, so it is important
to ask a client what they
put in their boiled beans.
Beef, brains Sesos
Brains with optional eggs,
onions, and other
vegetables. This organ
meat can be pan-fried or
grilled. A very common way
of eating them is mixed
with eggs and pan-fried in
patties. They can be
served plain or with a fresh
chile, tomato, and onion
sauce.
Beef, head Cabesa
Meat from the head of an
animal, including pig or
goat. Roasted over coals
and then the meat is then
used mostly for tacos,
flautas, and other quick
dishes.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Beef, intestines Tripas
Intestines with salt and
pepper or optional onions
and garlic. The intestines
are cleaned very
thoroughly, then put to
roast for a long time until
they are crispy. They are
greasy and are eaten with
tortillas, salsas, and other
condiments.
Beef soup Caldo de Res
Beef with a marrow bone
or assorted bony pieces,
onions, and garlic with
optional tomatoes,
potatoes, carrots, zucchini,
beans, chayote, pasta,
other vegetables, and
herbs such as marjoram,
thyme, rosemary, and
cilantro. Homemade soups
or stews are made from
what is available and eaten
with salsas and tortillas.
Meat in soups can be
made to serve more people.
Beef stew Caldillo
Beef for stewing (maybe
pork), carrots, potatoes,
onions, garlic, tomatoes,
salt, pepper, cumin, and
cilantro, with optional green
chile, peas, corn, green
beans, or other vegetables.
Similar to making stew.
Caldillo does not generally
have thickeners. The
thickening comes from the
potatoes and tomato
products.
Beef tongue Lengua
Tongue (beef, but can be
from other animals),
onions, garlic, salt, and
pepper with optional red
chile sauce, green chile
sauce, or a la Espanola
(tomatoes, onion, olives,
sauce). Can be made in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
many ways. Plain, boiled
tongue is used in tacos,
burritos, and other fast
dishes. As a main entrée, it
is sliced and warmed in a
sauce along with rice.
Black beans Feijao
Black or turtle beans,
water, and salt, with
optional pork fat, broth,
spices, rice, or other
vegetables. Generally
boiled and seasoned with
fat. Sometimes they can be
pureed alone or with
plantains and cheese
(Oaxaca, Mexico).
Black beans and
rice
Morros y
Cristanos or
Congri
Black beans and white
rice. Cooked beans and
rice are tossed together
with seasonings
Black beans or
turtle beans
Frijoles Negros
or Caroatas
Negras
Black or turtle beans,
water, and salt with
optional pork fat, broth,
spices, rice, or other
vegetables. Generally
boiled and seasoned with
fat. Sometimes they can be
pureed alone or with
plantains and cheese
(Oaxaca, Mexico).
Bread pudding Capirotada
Bread, milk, butter or
margarine, eggs, vanilla,
cinnamon, raisins, peanuts,
piloncillo, and mild cheddar
cheese with optional
cloves, clove juice, other
cheeses, other nuts, brown
sugar, and cream. Bread
cubes are tossed with
ingredients and baked in an
oven. This dish is traditional
during the Catholic
celebration of Lent although
it can be made all year
round. It can be very high
in fat. It can also be served
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
with a sauce made from
warm sweetened
condensed milk or melted
piloncillo. Ice cream is also
a favorite topping.
Burrito Burrito
Flour tortilla (corn tortilla
very seldom used) with a
variety of filings including
chicken, beef, beans, rice,
and salsas. Almost any
meat entrée can be used
as a burrito filling. In some
areas, rice and beans are
included. Many packaged
and café burritos are deep
fat fried.
Butter coloring Achiote
Crushed annato seeds
used to color butter,
cheese, and other products.
Cabbage rolls
Tamales de
Repollo
Ground beef, parboiled
rice, boiled cabbage
leaves, onions, garlic,
tomatoes, cilantro, cumin,
and broth. Ground beef,
rice, and spices are
combined, then rolled into
the cabbage leaves to
make little bundles. This
mixture can be steamed on
the stove or baked in the
oven in a Dutch oven or
roasting pan. Crushed
tomatoes, butter or olive oil,
chopped onions, and
possibly chopped celery for
moisture while the product
steams. Best to use very
lean beef.
Cactus Nopales
Cactus paddles with
optional onions, tomatoes,
garlic, spices, other
vegetables, meats, and
bacon. Cleaned and cubed
cactus paddles are eaten
often mixed with scrambled
eggs; they are also
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
available in jars and
pickled. They are currently
popular as an addition to
raw salads or sautéed with
a variety of ingredients.
Cake Pastel torta
Flour, eggs, baking soda,
baking powder, salt, spices,
and vanilla with optional
fruits, nuts, chocolate, and
coconut. All the major
brands of cakes are
available and used. The
traditional cakes tend to be
more like U.S. pound
cakes. The filling in the
middle is often a custard
with fresh fruit and real
whipping cream maybe
used more often. Holidays
and major events are
celebrated with cakes.
Canary beans
Frijol Canerio or
Fijoles Peruano
A pale yellow bean with a
smooth skin that is usually
boiled and seasoned with
fat.
Cassava Yuca
Yuca or sweet cassava
(also known as manioc,
oca, oa, oxalis root). It can
be thinly sliced and fried as
an appetizer. Generally it is
grated or boiled and
mashed. It may be
combined with milk, eggs,
cheese, and other
ingredients to make small
cake or bread like dishes. It
is a staple in many Latin
American countries where
it is found all year round.
Commercial tapioca is
made from bitter cassava.
The uncooked juice and
meat from bitter cassava is
poisonous.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Casserole Macaroni
Macaroni pasta, cheeses,
vegetables, meat with
optional eggs, cream,
canned cream soups, and
spices. Similar to U.S.
prepared casseroles.
Green chiles and corn are
a popular mixture.
Chicken and rice Pollo y Arroz
Chicken, onions, and rice
with optional carrots,
zucchini, peas. Similar to
making chicken soup. This
dish generally has less
water. The proportion of
chicken to rice also varies
greatly.
Chicken soup Caldo de pollo
Chicken, onions, carrots,
and potatoes or pastas with
optional cabbage, zucchini,
green beans, peas,
chayote, and beans.
Preparation varies. Clients
can be encouraged to
discard the chicken skin
and skim fat after
refrigeration. Very popular
meal especially in the
winter. Often the chicken is
served separately from the
soup.
Chimichanga Chimichanga
Flour tortilla with a variety
of fillings including chicken,
beef, beans, rice, and
salsas. What makes this
different from a burrito is
that it is deep fat fried and
is generally made on a
large flour tortilla (12"-14"
in diameter). One fills a
plate and is very filling. I do
not think they are native to
Mexico and probably
started in California.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chocolate Chocolate
Mexican bar chocolate
and milk (or a combination
of canned milk and water)
with optional added
cinnamon and vanilla. The
milk is heated and stirred
while the chocolate melts.
To get a smooth mixture, it
must get really hot and
stirred cnstantly to prevent
sticking. In another cooking
method, the chocolate is
melted and boiled with
cinnamon and water then
the canned milk is added.
Canned milk adds a richer
taste. Fat-free canned milk
(fat free milk products) is
not readily available in
Mexican markets or
grocery stores in Hispanic
neighborhoods, but can be
recommended for lowering
the fat content of this
beverage.
Chocolate with
cornstarch
Chapurado
Mexican bar chocolate,
corn starch, water or milk
with optional added
cinnamon and vanilla.
Similar to hot chocolate. It
has less milk and is
thickened with cornstarch
and sometimes the corn
flour which is used to make
corn tortillas. See
Chocolate.
Chorizo Chorizo
Pork, beef, and red chile
paste with optional onions,
thyme, garlic, and oregano.
Generally sold in markets.
It is added most often to
scrambled eggs.
Sometimes served with
potatoes and wrapped in a
tortilla. Some homemade
varieties may be higher or
lower in fat.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Condensed milk,
Sweetened and
cooked
Cajeta, leche
Cow or goat milk, sugar,
and flavorings such as
cinnamon or vanilla.
Generally purchased
ready-made. It is a thick,
caramel-like product that is
spread on toast or on
desserts such as ice
cream. Some candy is
made from this product.
Cooked salsa Cooked salsa
Fresh chiles or roasted
chiles, onions, and garlic
with optional oil, tomatoes,
tomatillos, cilantro, cumin,
salt, pepper, lemon juice,
fruit juices, and fruit. All the
ingredients are chopped
and can be sauteed
together. The flavors
develop and it keeps
refrigerated for a few days.
The mixture can be
processed to a finer
texture. Cooked salsas can
be very high in fat,
especially ones made from
dried peppers that are
sauteed in oil and then
pureed.
Corn starch Maizena
Corn starch. This product
is packaged with flavorings
to make 1-2 servings of a
drink made often at
breakfast. It is similar to
atole in consistency. It is
the commercial name for
atole.
Corn, grilled Elote
Corn in its husk with
optional butter, ground red
chile powder, salt, and
pepper. The corn in its
husk is soaked, sometimes
the silk is removed, and the
husk retied over the
kernels; then it is roasted
over or buried under coals.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The burnt husk is removed.
A coal fire adds flavor and
a very rich texture to the
corn.
Crab salad
Ensalada de
Jaiba
Steamed crab meat,
lemon, mayonnaise,
onions, celery, and other
vegetables. A cold salad
served on top of shredded
lettuce. Sometimes it may
have lemon- and/or
tomato-based dressing
instead of mayonnaise.
Cracklings Chicharrones
Rendered beef suet. After
all the fat has been melted
out of suet, the remaining
thin, fibrous skin, which
holds the suet together, will
shrivel and brown.
Chicharrones are eaten
with bottled hot sauce and
lemon or crumbled on top
of refried beans and other
dishes. In the United
States, many substitute
pork skins.
Dried corn Chacales
Dried corn kernels,
cracked. Corn is stored in
many ways. Dried corn is
shucked and the dry
kernels are cooked with
tomatoes, onions, and
garlic. This is the same
product used to make corn
chowders in Ireland.
Egg patties Tortitas
Egg, shredded meat, or
vegetables with optional
tuna, flour, salt, and pepper
fried in oil. The egg whites
are beaten until soft peaks
form them a mixture of egg
yolk, pepper, salt, and flour
is folded in with the meat or
vegetables last. The patties
are then either pan-fried or
cooked on a lightly greased
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
grill. It can be a quick
family meal. Often served
with a sauce made from
thinly sliced onions, green
chiles, and tomatoes.
Enchiladas, red,
green or Swiss
Enchiladas
Rojas, Verdes
or Suisas
Corn tortillas, cheese,
onions, and red, green, or
tomato sauces. Shredded
chicken may be added to
green enchiladas with
optional sour cream
topping. The corn tortillas
are softened in oil. (A tip is
to brush the tortillas with oil
and warm tortilla in a
microwave.) The oil keeps
the tortillas from
disintegrating in the sauce.
The tortillas are dipped in
the sauce and filled with
cheese and onion mixture
then rolled and placed in a
baking pan or right onto the
plate. More sauce is
generally poured over the
tortillas and the dish is
topped with cheese and
warmed in the oven until
the cheese is melted.
Enchilada
casserole
Chilaquiles
Corn tortillas or tostadas,
cheese, onions, and red,
green, or tomato sauces
with optional sour cream
topping and shredded
chicken or beef may also
be added. The corn tortillas
are cut into wedges or
squares and softened in oil.
The oil keeps the tortillas
from disintegrating in the
sauce. Then the sauce,
cheese and onion mixture
is combined with the chips
or corn tortillas. Spread out
in a baking pan, the tortilla
is topped with more sauce
and cheese. This is served
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
with eggs at breakfast or
alone as a meal. It is a
quick way to use up stale
tortillas. This dish can be
made with flour tortillas,
which is a U.S. variation
not common in Mexico.
Served with shredded
lettuce and sour cream.
Enchilada, tomato Entomatadas
Corn tortillas, cheese,
tomatoes, onions, garlic,
and cumin with optional
cilantro, mild green chiles,
and cornstarch for
thickeningThis dish is like
an enchilada. It is often
made for children although
all ages like it. It is not
always rolled. They may be
served stacked like
pancakes.
Fish salad,
marinated
Ceviche
A mixture of seafood such
as shrimp, octopus, white
fish (often tilapia), lemon
juice, chopped tomatoes,
onions with optional
chopped celery, hot sauce,
shredded lettuce, and
avocado. Seafood is
marinated in lemon juice
until it appears opaque. All
the other ingredients are
then chopped and added to
the fish. The marinade
should be discarded. No fat
is generally added to this
dish, although olive oil can
be used.
Flan Flan
Egg yolks, cream or
evaporated canned milk,
vanilla, salt, and
caramelized sugar with
optional lemon or orange
rind, and dried fruits.
Similar to custard and
cooked in a bane marie.
This is much richer and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
denser than U.S. custards.
Flautas or taquitos
Flautas o
Taquitos
Corn tortillas, chicken,
beef, or beans with optional
onions, chile, and potatoes.
One or two tortillas are
rolled tightly with the meat
or bean filling then deep fat
fried until crispy. They are
served with sour cream
and/or guacamole. A
serving can be 2 large
ones or 3-4 small ones
(single length tortilla).
Fresh salsa Pico de Gallo
Fresh chiles, onions, and
garlic with optional
tomatoes, tomatillos,
cilantro, cumin, salt,
pepper, lemon juice, fruit
juices, and fruit. All the
ingredients are chopped
and tossed together. The
flavors develop and it
keeps for a few days under
refrigeration. The mixture
can be processed to a finer
texture. Fresh salsa can
provide a substantial
amount of fruits and
vegetables.
Fried bread Sopapillas
Flour, lard, oil, shortening,
or margarine, baking
powder or yeast, salt, and
water. A soft pliable dough
is rolled out and deep fat
fried. The dough is similar
to tortillas although many
use yeast for the leavening
instead of baking powder.
The pastry is usually a
triangle and served with
honey. Sometimes they are
dredged in cinnamon and
sugar after frying.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fritters, Mexican Buñuelos
Flour, lard (or
oil, shortening, or
margarine, baking powder,
salt, water, anise, and
cinnamon. With the added
sugar and spices, the
dough is tougher. It is
stretched and rolled out;
then deep fat fried. The
cooled disks are then
dredged in cinnamon and
sugar. Sometimes it is
simply a fried flour tortilla
that is dredged in the sugar
mixture. Commonly eaten
during the Christmas and
New Year's holidays.
Fruit leather,
Hispanic style
Cajeta, Fruta
Fruit purees and sugar.
Sold in blocks, it is served
as a dessert with other
sweets. The process is
very similar to fruit leathers.
Although it is formed into
loaves and sliced, it keeps
for a long time until it
crystallizes.
Goat Cabrito
Whole goat or pieces.
Goat is used a lot and the
meat is roasted and used
in many dishes. The most
common plates are soft
tacos with salsas and
condiments. The head is a
delicacy and found in many
cafes or butcher shops deli
sections for ready to eat
items.
Gorditas Gorditas
Thick corn patty, beef or
chicken, shredded lettuce,
cheese, tomatoes, salsa,
onions, sour cream, and/or
guacamole. The corn patty
is the same dough as a
corn tortilla, generally with
a little more baking powder
to keep them from getting
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
pasty. They are cooked on
an oiled grill (sometimes
deep fat fried). Sliced open
and stuffed much like a
taco. Found mostly in west
Texas. A sope is similar in
ingredients, but served
differently.
Grilled meat Carne Asada
Thinly sliced beef from
various parts of the cow
with optional marinade or
salt and pepper. An
important feature is the
cheaper cuts of beef cut
thinly. It may be grilled with
lots of thinly sliced onions
and served with corn
tortillas, salsa, shredded
lettuce, and tomatoes.
Ground beef stew Picadillo
Generally ground beef
(maybe pork), carrots,
potatoes, onions, garlic,
tomatoes, salt, pepper,
cumin, and cilantro with
optional green chile, peas,
corn, green beans or other
vegetables. Picadillo and
caldillo can be very similar
foods and the names vary
between family to family.
The word picadillo is the
diminutive for chopped;
therefore, it could be finely
diced stew meat. This dish
may only have potatoes
and onions and may be
used as the filling for
burritos.
Guacamole Guacamole
Avocado with optional
onions, chiles, lemon,
cilantro, cumin, sour cream
or crema, tomatoes, garlic,
salt, and pepper. All the
items are chopped and
mixed together. Proportions
and texture are regional or
personal taste. Adding sour
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
cream is not common in
Mexico. Served as a
condiment with breakfast,
tacos, tostadas, enchilada,
salads, steaks, or used as
a dip with snacks.
Guava Guava
A fruit grown in the
Carribean and Florida. It is
green on the ourside and
pink on the inside with lots
of seeds. It is eaten raw or
in a variety of food
mixtures. Throughout the
Spanish-speaking world,
guava juice is a common
beverage and it is seen in
U.S. grocery stores. The
juice generally has added
sugar. Guava paste is a
common sweet paste made
from guavas and sugar. It
is almost like jelly, but
thicker. In Mexico, it is
called cajeta and eaten as
a snack or dessert. It can
be eaten plain or with white
cheese and crackers.
Hamburgers Hamburguesas
Ground beef, onions,
garlic, and spices with
optional fresh chiles and
tomato. Beef patties may
be preformed at the market
or made at home with a
variety of ingredients. They
are served in U.S.
hamburger style buns with
the same condiments used
in the U.S. Cooking on
charcoal ("al carbon") is
very popular, especially
during the hot summer
months.
Generally pork (maybe
beef), hominy, onions,
garlic, spices, and chile
(generally green). Posole is
eaten at holidays and other
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Hominy and pork
stew
Posole
times. It is a menu item at
many restaurants. It can be
made very similarly to
menudo. It is more soup
like in consistency than
caldillo, picadillo, chile
verde, or chile colorado.
Hominy and tripe
soup
Menudo
Beef tripe, beef hoof,
hominy, onions, oregano,
and red chile with optional
garlic and thyme. A soup
made with tripe. This dish
is often described as fatty.
The tripe itself is very high
in protein. The fat attached
can be removed. The
greasiness in some
versions comes from the
preparation of the chile.
Many cooks take powdered
chile and cook it in oil or
lard then add it to the soup.
Others use a paste made
from dried chile pods or
powdered chile.
Italian frying
peppers
Pimentos de
cocina
2" wide and 3" to 5" long
with thin skin and mild
flavor. Peppers and oil.
Fried or stir fried with other
ingredients to make pastes
and sauces for vegetables
and meats.
Pork fat. Manteca just
means fat and a client
could be referring to
shortening or maybe even
butter, although butter is
called mantequilla.
Rendered from freshly
slaughtered pigs. Many
home cooks may use fresh
lard; others buy it in the
stores. Lard provides the
fat and flavor for many
traditional Mexican foods
and pastries. Most Mexican
cooks use a variety of fats,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lard Manteca especially in the United
States. Certain items don't
bake or taste the same
without it. Most pastries in
bakeries are made with lard
unless noted otherwise.
One may be able to trade a
low-fat cheese such as
part-skim mozzarella and
keep a little of the lard in a
favorite family dish. Some
regional dishes may use
nut or olive oils because
that is the oil produced in
that region and pigs may
not be as plentiful.
Meat with green
beans
Carne con
Judias verdes
Beef, beef broth, green
beans (other vegetables
may be used), and onions
with optional tomatoes,
garlic, and herbs. Meat
may be cooked in a Dutch
oven, boiled, or roasted. It
may be cut up before
cooking or after it is
cooked. Then it is
combined with vegetables
and stewed to develop the
flavors.
Meatball soup Albondigas
Ground beef, rice, onions,
garlic, tomatoes, cilantro,
cumin, and broth. Ground
beef, rice, and spices are
combined; then rolled into
balls about 1-1.5 ounces;
they are then simmered
gently in broth with onion,
garlic, salt, and pepper with
optional crushed tomatoes
and possibly chopped
celery and other vegetables
can be added.
Milk or fruit juice and
crushed fruit with optional
raw eggs, ice cream, sugar,
dried milk solids, and
cornstarch. Prepared in a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Milk shakes Batidos
blender. The most basic is
banana, vanilla extract,
milk, and cinnamon. Many
use vanilla ice cream as
the base with other fruits.
Popular quick breakfast or
snack.
Mole Mole
Sauce ingredients include
chile paste, nut pastes,
roasted spices, broth,
chocolate, and sugar. Mole
is as varied as the regions
and families in Mexico. It is
a thick sauce that takes a
long time to make from
scratch. It is a special
occasion dish. Many use
the prepackaged jars
available in most major
grocery store chains. This
paste can be thinned with
water or broth and added to
roasted meats and
vegetables. This sauce can
be used on enchiladas.
Oatmeal Avena
Oatmeal, milk, water,
cinnamon, and raisins with
optional piloncillo, brown
sugar or molasses, other
grains such as wheat,
bulgur, and corn. Cooked
on the stove. The
cinnamon is usually a stick
boiled in the water with the
raisins.
Oxtail soup Caldo de Cola
Beef tail joints, onions, and
garlic with optional
tomatoes, potatoes,
carrots, celery, Brussels
sprouts, zucchini, beans,
chayote, pasta, other
vegetables, and herbs such
as marjoram, thyme,
rosemary, and cilantro.
Homemade soups or stews
are made from what is
available and is eaten with
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
salsas and tortillas. A small
amount of meat can serve
more people in soup.
Paella Paella
Rice, saffron, peas, fresh
paprika, chicken, seafood,
beef, olive oil, and Spanish
chorizo. Prepared in a
large, flat pan. The rice is
not sautéed as long as for
Spanish rice. It can be
eaten as a side dish or as
the main entrée.
Pancake Pancake
White flour, eggs, oil,
butter or margarine, baking
powder, salt, and milk or
buttermilk with optional
bananas, nuts, fresh or
dried fruits, syrups or cajeta
(boiled, sweetened,
condensed milk often made
from goat milk). Prepared
like U.S. pancakes.
Generally heavier because
of added ingredients.
Papaya
Lechosa
(Domincan
Republic and
Puerto Rico),
Fruta Bomba
(Cuba), or
Papaya
Hawaiian or tropical
papaya has a golden skin
with thick, sweet, coral red
flesh. Fresh fruit. Used in
desserts, beverages, and
other dishes. This fruit can
be 20" long and weigh
more than 10 pounds. The
Mexican variety is larger
and less sweet.
Passion fruit
Parchuca or
Granadilla
An oval shaped fruit native
to Brazil and eaten all over
Latin America. It may have
a purple or orange skin
with orange flesh. Used
mostly with water and
sugar to make refreshing
drinks. Today other dishes
are made with this fruit.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Pasta Pastas
Pasta, tomatoes, onions,
garlic, broth, salt, and
pepper. Many pastas are
prepared similarly to
Spanish rice. The pasta is
sautéed in oil; then cooked
in broth The dish will
generally have more liquid
and may be served with
lemon wedges.
Pigeon peas Gandules
Other English names
include red gram, congo
peas, yellow dahl, or gunga
peas. A Carribean name is
goongoo. Cooked the same
as other beans and peas.
Plantains Platanos
A starchy green banana.
Plantains are generally
fried and served much like
potatoes.
Popcicles Paletas
Milk or cream, crushed fruit
ingredients, blended, and
poured into molds. Most
purchase these from street
vendors. Even in the United
States, immigrant popsicle
vendors can be seen
walking the streets of
Hispanic neighborhoods.
Purslane Verdolagas
Verdolaga or purslane with
optional onions, tomatoes,
garlic, spices, other
vegetables, meats, and
bacon. Dark greens that
grow abundantly as weeds.
They have a tart taste and
are often cooked like other
vegetables or added to
soups and other mixed
dishes.
Pork chops Chuletas
Pork chops and spices.
The pork may be rubbed
with chile and other spices.
The amount of added fat,
from none to almost deep
fried, can make a
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
difference in how this dish
is prepared.
Pork loin Lomo de Cerda
Pork loin, spices, salt, and
pepper. The pork loin may
be roasted whole or sliced
very thinly and cooked in a
way similar to carne asada.
Eaten with tortillas along
with salsas and other
condiments.
Quesadillas Quesadillas
Corn or flour tortillas,
cheese, onions, chiles with
optional meat, chicken, fish,
chorizo, and avocados. The
tortillas can be flat or folded
over. Sometimes they are
pan-fried with any of the
common fats used. They
are used as a snack or
quick meal.
Ranchero eggs
Huevos
Rancheros
Eggs, onions, tomatoes,
chile, and cheese with
optional other vegetables
and spices. A chile sauce
made with thin slices of
roasted or fresh green
chiles, tomatoes, and
onions is served over 2
fried eggs. The side dishes
are generally refried beans,
Spanish rice, shredded
lettuce, and tortillas.
Sometimes a corn tortilla is
placed under the eggs and
sauce.
Raw brown sugar Pilloncillo
Sugar in a hard cone
shape. Sugar is found in
the bulk area of many
ethnic markets. The flavor
is different from brown
sugar or molasses although
many recipes substitute
this product for them. It is
very hard and is generally
melted with water before
adding to a recipe.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Recado
Recado or
Recaito
Recado (a green, spiny
leaf), onions, Italian frying
peppers, garlic, sweet chili
peppers, and cilantro. This
is a paste used in cooking.
If the recado leaves are not
available, more cilantro can
be used. Sometimes
annato seeds are also
used.
Red chile or meat
with chile
Chile colorado
or carne con
chile or a la
diablo
Generally beef and red
chile paste with optional
flour for thickening, onions,
garlic and potatoes. The
meat for this dish can be
roasted or boiled. How the
chile is processed can
provide much variation
in the fat content of this
dish. When making the red
sauce from soaked dried
chiles, it can often be made
without any fat. This dish is
often served with rice,
beans, tortillas, and
shredded lettuce.
Sometimes it is served in a
big bowl with corn tortillas
without any side dishes. A
name given to this dish,
especially with fish, is "a la
Diablo" or "the devil's way."
Rice drink Horchata
White ice, cinnamon,
water, milk, and sugar.
Whole or cracked white rice
is soaked in water for
several hours; the mixture
is strained, then sweetened
and spiced. The amount of
milk added varies from
none to much.
Rice, milk, spices, and
sugar or piloncillo with
optional raisins, nuts, fruit
such as crushed pineapple.
Some cooks may use
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Rice pudding Arroz Dulce coconut milk, especially in
the island countries.
Generally made on top of
the stove and fresh. Many
rice puddings are made
with leftover white rice.
Roasted turkey Pavo Asado
Turkey, salt, and pepper.
Roasted and served plain
or with sauces.
Rolls, French
bread type
Bolillos
Flour, yeast, water, salt,
and lard. A denser, softer,
larger roll with pointed
ends. Sandwiches are
made with it and it is
served with soups and
stews, especially on
weekends.
Rolls, peasant
Semitas de
Agua
Flour, yeast, water, salt,
and lard. A peasant bread
used to make sandwiches
or to eat with foods such as
menudo. This roll is
generally flatter or rounder
than a bolillo and it can be
drier.
Root vegetables Viandas
Can include potatoes,
carrots, taro root, and
cassava. A collective name
for root vegetables that are
steamed, boiled,or roasted.
Sandwich Bocadilla
Mexican roll, mayonnaise,
cheese, lunch meats, and
lettuce with optional
jalapenos, vegetables, and
onions. Cold sandwiches
are sold in many grocery
stores and markets or
made at home
Sandwich bread Pan Bimbo
White flour, eggs, oil,
butter, or margarine, baking
powder, salt, and milk or
buttermilk. Similar to U.S.
white sandwich bread. It
can be found in many
ethnic markets in the
United States.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Seven seas soup Siete Mares
Seven different types of
seafood such as fish heads
and scraps, clams,
mussels, calamari, cod,
shrimp, and octopus with
carrots, zucchini, onions,
tomatoes, garlic, and
lemons. A fish broth is
made with heads and fish
bones then strained.
Vegetables are added to
the seafood. Served with
lemon, tortillas, and fresh
mild salsas. Ethnic
meat/fish markets sell the
makings for this soup all
bagged and ready to go.
Shortbread, large Polvorones
Flour, lard, oil, shortening,
or margarine, sugar, baking
powder, salt, almond
extract, and powdered
sugar. These cookies can
be made any size. They
are generally about 3" in
diameter and 1/2" thick.
They are dry and crumbly.
The name means "dust."
They are generally bright
pink or yellow and
sometimes make to match
the Mexican flag in yellow,
red (pink), and green.
Shredded beef Machaca
Beef roast such as chuck
cut, onions, garlic, bay leaf,
and other spices. The beef
may be boiled or roasted
and is then shredded by
hand. In some areas,
"carne seca" (dried beef) is
used. This method of
preparing beef stretches it
out for several meals. It is
a popular breakfast item
mixed with eggs.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Shrimp cocktail
Koctel de
Camaron
Shrimp, lemon juice,
catsup or crushed
tomatoes, and onions with
optional chopped celery,
hot sauce, shredded
lettuce, and avocado.
Shrimp may be steamed or
marinated in lemon juice
until it appears opaque. All
the other ingredients are
then chopped and added to
the shrimp. If the shrimp is
marinated, the marinade
should be discarded.
Generally, no fat is added
to this dish.
Sofrito Sofrito
Recado (a green, spiny
leaf), onions, Italian frying
peppers, garlic, sweet chili
peppers, cilantro, fat back,
and tomato sauce.This is a
sauce made from the
recado paste and added to
many dishes. If the recado
leaves are not available,
more cilantro can be used.
Sometimes annato seeds
are also used for a deeper
orange color.
Sopes Sopes
Thick corn patty, beef or
chicken, shredded lettuce,
cheese, tomatoes, salsa,
onions, sour cream, and/or
guacamole. The corn patty
is the same dough as a
corn tortilla. They are deep
fat fried. All the other
ingredients are served on
top. It is similar in
ingredients to a taco or
gordita. Most common in
Southern Mexico and its
Central American
neighbors.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Soup Sopa or Caldo
Chicken, pasta,
vegetables, and herbs.
Homemade soups or stews
are made with what is
available and eaten with
salsas and tortillas. See
Beef Soup
Sour cream Crema
Goat milk or cow milk and
salt. Crema is substituted in
the United States with sour
cream although it is more
like the French crème
fraiche in flavor. Crema is
made from skimming the
fat off of raw milk.
Sometimes it is called nata.
Yogurt cheese made with
fat-free yogurt and either
sour cream or a tiny bit of
buttermilk make a product
similar to crema. Crema is
found in many U.S. grocery
store chains today.
Soursop Guanabana
A fruit with green spine or
wart covered skin and
white-pink or yellow-orange
sweet pulp. Squeezed for
its juice and used in juice,
sorbets, and conserves.
This fruit does not travel
well and is usually not
found fresh in the United
States. A Puerto Rican dish
is called champola.
Spaghetti Espaguetis
Macaroni pasta, cheeses,
vegetables, and meat with
optional eggs, cream,
canned cream soups, and
spices. Similar to
U.S.-prepared spaghetti.
Spanish omelet Tortilla (Spain)
Eggs, onions, and potato
with optional tomatoes,
olives, other vegetables,
and spices. A large omelet
that is finished in the oven.
In Spain, this is often
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
served as an appetizer or a
light lunch.
Spanish rice Sopa
Rice, onions, tomatoes,
cilantro, garlic, salt, pepper,
and chicken broth (fresh or
dried) with optional
vegetables and cumin. The
browning of the rice in oil is
a necessary step. It
reduces the starchiness of
the rice and gives the rice
its texture. The amount of
oil used can be reduced .
Some cookbooks describe
this as sopa seca and in
English, it has picked up
the name Spanish rice
although it is a style found
in Mexico. In Spain, the rice
is warmed in oil just until it
turns white and saffron is
the herb that gives its
yellow color. It is also
called arroz or rice.
Stuffed peppers Chile Rellenos
Roasted and peeled green
chiles (Type may vary by
region. In the Southwest,
they are generally Anaheim
long green chiles and in
California, it can also be
the much spicier fresh
pasilla chiles. In New
Mexico, they use
jalapenos.), cheese,
onions, and egg batter with
optional various sauces on
top made from tomatoes,
onions, or just red chile
paste. The roasted green
chiles are stuffed with a
mixture of grated cheese
and onions or with a wedge
of cheese. Next chilies are
dredged in flour; dipped in
an egg batter made from
beaten egg whites that
have the yolk folded in, and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
then they are fried. Chiles
can be stuffed with other
items such as chicken or
beef.
Sweet bread Pan Dulce
Flour, eggs, lard,
margarine, or butter, baking
soda, baking powder, salt,
spices, and vanilla with
optional fruits, nuts,
chocolate, and coconut.
Some are made with a
yeast dough. The dough for
most sweet bread is the
same. The names are
related to the shapes and
toppings. Common spices
include cinnamon and
anise seeds. Examples are
conchas shaped like a shell
and the topping is a sugar
and egg yolk mixture that is
applied so that it forms the
ridges of a shell. Quernitos
horns are triangles that are
rolled up and laid in a semi
circle shape for baking.
Holidays and significant
events are celebrated with
these breads made into
special shapes. See Cakes
and Turnovers.
Sweet chili
peppers
Ajies Dulces
(Puerto Rico)
A small red pepper similar
to the Italian cherry
peppers in shape, not
taste.
Sweet potato Camote
Sweet potato. This
vegetable is found in many
desserts and pastries. A
candy is made from sweet
potatoes as well.
Corn tortillas, cheese,
shredded lettuce, sour
cream (or crema similar to
crème fraiche) onions, red
or green salsas, meat
(including chicken, ground
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tacos Tacos
beef, beans, shredded
beef, ceviche or fish),
potatoes, and other
vegetables. The tortillas
can be soft or fried until
crispy. There are ways to
get a crispy shell without
deep fat frying the tortilla
and filling. Brush one side
of the corn tortilla with oil,
then fill the non-oiled side,
fold in half and crisp by
turning frequently on a
griddle. Line the serving
tray with paper towels and
set the tacos upright next to
each other. The most
common fillings are chicken
and beef.
Tamales Tamales
Corn masa with more fat,
baking powder, and broth.
Filling can be cheese,
onions, chiles, meat,
chicken, beans, and
chorizo. This is a dumpling
is made for holiday meals.
They are very high in fat
although there are some
varieties called tamales de
maize fresco that has none
or much less. The size of a
dumpling can vary from 2
oz to 1/2 pound. The
amount of masa to filling
also varies a lot. They may
be wrapped in dried corn
husk, fresh corn husk,
banana leaves, paper, or
foil. They are steamed.
Tamarind Tamarindo
Tamarind seed pods,
sugar, and water. Used
extensively as a flavoring
for waters and teas. The
pods are soaked and then
the water is sweetened and
iced. It can also be an
ingredient in some sauces.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Taro Root Yautica
Taro root, also known as
Japanese county potatoes,
taro potatoes, or albi. Note
some varieties are higly
toxic unless thoroughly
cooked. Generally boiled
and mashed. This root is
very similar to cassava. It
has a hairy brown skin and
a grey interior. It can be
used similarly to a potato
with a more delicate flavor.
Taro Root Greens Callaloo
Leaves of the taro root
plant.These leaves are
used in soup. They must
be boiled.
Tomato/Cucumber
Soup
Gazpacho
Tomatoes, olive oil, garlic,
green onions, cucumber,
and fresh or canned
paprika with optional
croutons and a variety of
chopped vegetables for
garnish. Seeded and
peeled tomatoes are used
in this dish; it is generally
pureed and served cold. Its
origins are from Spain and
it is popular in most
Hispanic countries.
Tortilla, Corn Tortilla de Maiz
Masa harina (corn flour
made by processing dried
corn in lye and grinding and
drying it) and water.
Although most people buy
their tortillas, they can be
made easily in the home
and are low in fat. Check
the label on store-bought
tortillas. There are many
varieties with varying
amounts of white flour
added in the process.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Tortilla, Flour
Tortilla de
Harina
Flour, lard, oil, shortening,
or margarine, baking
powder, salt and water. A
soft, pliable dough is rolled
out and cooked on a
seasoned grill. Lard is the
most common fat used in
homemade tortillas. Whole
wheat flour is occasionally
used, especially in the
United States. For accurate
serving sizes, check weight
on package. Thickness and
diameter vary and diameter
is not always a good
measure of nutrient
content.
Tostadas Tostadas
Corn tortillas (sometimes
flour), cheese, shredded
lettuce, sour cream (or
crema similar to crème
fraiche), onions, red or
green salsas, meat
(including chicken, ground
beef, beans, shredded
beef, ceviche, or fish),
potatoes, and other
vegetables. This dish is like
a flat taco. It allows for
more filling and tortillas; not
fried.
Tuna and Potato
Salad
Ensalada de
Bonito y Patatas
Tuna, boiled potatoes,
lemon, and onions with
optional tomatoes,
mayonnaise, celery, olives,
and other vegetables. This
dish is served by layering
the ingredients over a bed
of lettuce with the tuna in
the center. Combine the
ingredients and refrigerate
to let the flavors develop.
Canned tuna is generally
used.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Turkey Breast
Pechuga de
Pavo
Turkey breast, salt, and
pepper. Pan-fried or
roasted served plain or with
sauces.
Turnovers, sweet Empanadas
Flour, lard, oil, shortening,
or margarine, sugar, egg,
salt, and water. Similar to
pie dough. Dark colored
empanadas, such as the
ones filled with pumpkin,
are made with whole wheat
flour. In Mexico, the
empanadas are often
sweet with fillings that
include apple, pineapple,
cream, raspberry,
strawberry, and many other
fruits in season. Other
countries may also include
meat-filled empanadas.
Vermicelli Sopa de Fideo
Rice, onions, tomatoes,
cilantro, garlic, salt, pepper,
and chicken broth (fresh or
dried) with optional
vegetables and cumin. The
browning of the pasta in oil
is a necessary step. It
reduces the starchiness of
the pasta and gives the
pasta its color and flavor.
The amount of oil used can
be reduced . This can also
be done with other shapes
of pasta such as wheels,
stars, or alphabets. This
dish is often made for
individuals with upset
stomachs or colds and is a
common side dish.
Waters, flavored Aguas
Water, sugar, and crushed
fruit. Ripe fruit is crushed
and then water and sugar
are added. It can be served
iced. Popular flavors are
watermelon, strawberry,
and any fruit in season.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Wheat bread/bun
Gorditas de
Trigo
Whole wheat flour, yeast,
a little sugar, and a little
lard or shortening with
optional cinnamon, anise,
and piloncillo. Made like
yeast bread. This bread is
generally dry with a hint of
sweetness. It is dusted with
flour. This bread may be
the base for other sweet
breads.
White cheese Queso Blanco
Goat milk or cow milk and
salt. This cheese is similar
to mild, white, aged
cheddar. Many substitute it
in cooking with Longhorn
cheddar cheese, Monterey
Jack cheese, or
mozzarella. The
substitutions change the
flavors of the dishes slightly.
Winter squash Calabasa
Winter squash. All squash,
winter and summer, are
called the same and they
are eaten in a variety of
ways.
Zucchini
Calabacines or
Calabacitas
Zucchini and other
summer or winter squashes
with optional onions,
tomatoes, garlic, spices,
other vegetables, meats,
and bacon. Stewed or
sautéed plain with a variety
of spices and other
vegetables. Butter,
margarine, or oil may be
used in the preparation.
The Spanish language
does not have a variety of
names for squash as there
is in English. Most squash
is available all year long in
most countries.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Sources:
Kiple KF, Ornelas KC. A Dictionary of the World's Plant Foods. New York, NY: Cambridge
University Press; 2000:1711-1886,2.
Description: Includes scientific and common names, as well as food uses and historical
information.
Romero-Gwynn E. Glossary of Selected Mexican Foods and Dishes of Interest in Nutrition
Education. Hayward, Calif: Cooperative Extension in Alameda County, University of
California; 1992:10.
Description: A glossary of foods common in Mexico and often consumed by people of
Mexican descent living in the
Von Welanetz D, Von Welanetz P. The Von Welanetz Guide to Ethnic Ingredients. Los
Angeles, Calif: JP Tarcher; 1982.

References


Diabetes Care and Education Dietetic Practice Group of the American Dietetic
Association. Mexican American Food Practices, Customs, and Holidays, 2nd ed. Chicago,
Ill.: American Dietetic Association; 1998. Article Summary:
Part of the Ethnic and Regional Food Practices Series, this booklet discusses traditional
food and health beliefs, traditiona,l and current food practices, holiday food customs, and
the implications of current dietary practices. Summarizes recommendations for the dietary
management of diabetes.
California Nutrition Education & Training Program. Fresh Fruit and Vegetable Photo
Cards. Sacramento, Calif.: California Dept. of Education; 1997. Article Summary:
Description: 142 photographs with names in both English and Spanish. A fresh fruit or
vegetable is pictured on the front of each card, with the name in both English and Spanish.
The backs of the cards contain a nutritional analysis in bar-graph form, a symbol depicting
the part of the plant most commonly eaten, and a map of the United States highlighting the
area that produces the greatest quantity of the fruit or vegetable pictures. The cards have
multiple uses from bulletin boards to one-on one counseling. Related
Links:http://www.cde.ca.gov/cdepress/catalog/nutried.html#photocards
Clark J, Hoffman CJ. Recursos en Espanol: Suggestions for meeting the health and
nutrition education needs of Hispanic and immigrant families. Topics Clin
Nutr. 1998;13:73-82.
Federal Research Division of the Library of Congress. Uruguay from Pre-Columbian times
to the conquest Washington, D.C.: Library of Congress, Countries Study, Section 1 of 1;
1990. Article Summary:
An overview of the history including colonization of Uruguay with dietary notes. Related
Links:File containing Uruguay's information
http://lcweb2.loc.gov/cgi-bin/query/r?frd/cstdy:@field(DOCID+uy0013) Master site for the
Country Studies http://lcweb2.loc.gov/frd/cs/cshome.html
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Country Studies http://lcweb2.loc.gov/frd/cs/cshome.html
Gans KM, et al. Implications of qualitative research for nutrition education geared to
selected Hispanic audiences. J Nutr Educ. 1999;31:331-338.
Kiple KF, Ornelas KC, eds. A Dictionary of the World's Plant Foods. Volume 2, in: Kiple KF,
Ornelas KC, eds. The Cambridge World History of Food. New York: Cambridge University
Press, 2000:2:1711-1886.
Kittler PG, Sucher KP. Cultural Foods, Traditiions and Trends. 2000: 189-240.
Kuczmarski MF, Kuczmarski RJ, Najjar M. Food usage among Mexican-American, Cuban,
and Puerto Rican adults: Findings from the hispanic HANES. Nutrition
Today. 1995;30:30-37.
Lassiter SM. Multicultural Clients: A Professional Handbook for Healthcare Providers and
Social Workers. Westport, Conn.: Greenwood Press; 1995.
Osborne H. Overcoming Communication Barriers in Patient Education. Gaithersburg, Md.:
Aspen Publishers; 2001.
Sanjur D. Hispanic Foodways, Nutrition, and Health. Boston, Mass.: Allyn and Bacon;
1995.
Shortridge BG, Shortridge JR, eds. The Taste of American Place: A Reader on Regional
and Ethnic Foods. Lanham, Md.: Rowman & Littlefield; 1998.
Syracuse CJ. Cultural Diversity: Eating in America Fact Sheets. JNE. 1998;30:178B.


Web Links

Dietary Patterns and Acculturation Among Latinos of Mexican Descent (Accessed
September 21, 2009)
Global Gastronomer - South America (Accessed September 21, 2009)
More effectively work with low income, culturally diverse audiences and develop nutrition
education programs. (Accessed September 21, 2009)
Eating Disorders Information Sheet: Latina Girls (Accessed September 21, 2009)
Aunt Clara's Kitchen - About Dominican Cooking (Accessed September 21, 2009)
Cook Brazil - Brazilian Food Recipes (Accessed September 21, 2009)
Folic Acid Fact Sheet in Spanish (Accessed September 21, 2009)
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Latin American Food & Cooking (Accessed September 21, 2009)
National Center for Nutrition and Dietetics Bibliography on Ethnic Food Habits (Accessed
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Puerto Rico Food and Drinks (Accessed September 21, 2009)
Welcome to Puerto Rico! (Accessed September 21, 2009)
We Take the Mystery Out of Cuban Restaurant Menus! (Accessed July 01, 2005)

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Resources > Cultural Food Practices > Jewish
Food Practices

Judaism has strong traditions of hospitality and fellowship that originated in Biblical times
and revolve around food. Guidelines regarding food preparation and diet, as well as the
ritual cleanliness of food and methods to abide by set laws, are embodied in the Torah, the
religious books of Judaism.
In a health care or counseling setting, a registered dietitian (RD) may not be able to
determine the religious beliefs of a client. It may be helpful if a portion of the intake form
addresses food aversions and food avoidances. Inquiring about a client’s religion may not
be enough to determine dietary needs, as there are some Jews who do follow the laws of
kashrut (kosher), some who follow only some of the rules, and others who do not follow the
food edicts of kosher at all. Avoidance of certain nonkosher foods, like shellfish or pork,
may hint to the practice of kashrut.
If a food intake form is not usd, the RD may simply ask if the client has any religious beliefs
or practices that would affect his or her dietary needs. If a patient does offer that he or she
keeps kosher, probing questions may guide the RD to the degree to which kosher is
observed.

Kosher

The word "kosher," or "kasher" in Hebrew, refers to the biblical Hebrew word meaning “fit”
as in fit for consumption. It refers not only to foods that the Torah declares acceptable for
consumption, but to the method in which food is prepared as well. A food is classified
“kosher” when it is fit to be consumed by a Jew who is observant of religious dietary laws.
The food must be prepared in accordance with the laws of kosher. If a food is unfit for
intake by a Jew who observes the laws of kosher, it is classified as “treif,” or unclean.
There are many variations to the observance of kosher and therefore it is necessary for
registered dietitians (RD) to get as much information from the client during the intake
process.
All flesh foods must originate from a kosher animal. An animal becomes kosher if it is
slaughtered as documented in Jewish law and has been washed clean of its blood. Egg
and dairy products must come from animals that are fit to be kosher. An egg is deemed
nonkosher if even a minute spot of blood is detected. The egg must be discarded, as blood
is considered impure and therefore not kosher.
The mixing of meat and milk or byproducts of the aforementioned animals is forbidden.
They are not to be cooked, mixed, processed, or eaten together in the same meal. This law
is derived from a statement in the Bible that declares the meat of a goat shall not be
cooked with its kids’ milk. Eggs, fish, fruits, vegetables, legumes, grains, nuts, and seeds
are considered “parve,” a neutral category. Because parve foods are neither meat nor dairy,
they can be eaten with either dairy or meat. When neutral foods are cooked in a meat pot
or with meat utensils, it becomes “meat” and vice versa for parve foods placed in dairy
containers. In other words, the neutral food takes on the characteristic of the vessel. In
Yiddish, meat is referred to as “fleishig” and dairy is “milchig.” These terms are commonly
used to describe the category of the food.
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Many kosher-observant families will have separate sets of dishes, utensils, and cookware
for meat and dairy. In addition, some may have a third set of dishes for parve foods. Others
may have separate sinks or refrigerators to avoid cross-contamination of meat and dairy
foods.
There is also a waiting period in between eating foods of opposing groups. After one
consumes “fleishig,” there is a 2-hour to 6-hour waiting period for the food to be digested.
Some may wait as long as 12 hours, depending on family tradition. After that waiting time,
dairy is again allowed. After “milchig” foods, people may wait 15 minutes to 6 hours. Again,
this waiting time is determined by family tradition and country of origin. Some will choose
not to wait between the categories of food, but will abstain from mixing the two in a meal or
in a dish.
Kosher Animals
Animals must have split or cloven hooves and be ruminant (chew their cud) to be classified
as kosher. Pigs have cloven hooves but do not have ruminant stomachs and therefore are
not kosher.
Chicken, ducks, geese, and turkey can be kosher if slaughtered by the rules of kosher.
Birds of prey and nondomesticated birds are never kosher. Some have deduced that
kosher poultry have the following traits in common: no front toes, a craw, and a
double-lined stomach (Eliasi 2002).
Kosher animals and birds are suitable for consumption only if slaughtered by a shokhet, a
specially trained religious man. Animals that have died of natural causes or have been shot
or killed in any other way are forbidden. Animals must be whole with no limbs or parts
missing. The shokhet will slaughter the animal in the best method to render the animal
unconscious and dead in one swift stroke as to prevent causing it any pain. Using a sharp
knife, the shokhet instantaneously severs the carotid, jugular veins, the esophagus, and
the trachea. Once killed, the animal is inspected for any adhesions, imperfections, or
blemishes that would indicate illness of the animal and make it inedible according to Jewish
law. An animal that has been inspected as such and passes is considered glatt kosher.
Blood, synonymous with life in Jewish faith, is forbidden for consumption. The animal, once
cut, is drained of its blood. The fat surrounding the organs and the sciatic nerve are
disposed of, as they are forbidden for consumption by Jews. For this reason, filet mignon is
not a kosher food. There are some specialty butchers who will skillfully cut the sciatic nerve
from around the beef, but the process is timely and costly. The items that are not used as
kosher meat are sent to a nonkosher butcher to avoid waste.
To further rid the meat of blood, any meat derived from a slaughtered animal is soaked in
lukewarm water for half an hour while covered in kosher salt, which is a salt of coarse
texture. For an additional hour, the blood is allowed to drain off. The meat is then rinsed 3
times. Once the meat is washed a final time, it is acceptable to be cooked and prepared for
consumption. For people who are on low-sodium diets, there is concern about the
additional sodium content of the koshered meat. Whereas poultry meat can have up to 4
times the salt content of nonsoaked and salted meats (Angel 1989), salting of red meat
does not greatly vary the sodium content from the nonkosher version (Burns 1984).
Furthermore, whereas soaking poultry in water does not change the sodium content,
soaking the red meat in water and rinsing might substantially lower the sodium content
(Angel 1989).
There are set rules for kosher related to seafood as well. A fish must have fins and scales
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
to be considered kosher. The scales must be permanent. Swordfish is generally not
considered a kosher fish, though it does have fins and scales in the earlier stages of its life.
The scales of the swordfish are released during the lifespan of the fish. Orthodox Jews do
not eat these fish, but others Jews may. Any other seafood is immediately nonkosher, as it
would not satisfy the law for fins and scales. Shellfish and sea mammals are not kosher.
See Kosher Fish and Seafood.
Milk
In antiquity, the milk of animals were blended to stretch quantity and then sold as cow milk.
As a result, Jews would not drink milk unless processed at a kosher dairy to prevent
contamination of cow milk, which is kosher with milk of a nonkosher animal. Today, in
countries where food must abide by a standard of identity, "milk" refers to cow milk, unless
otherwise specified. Furthermore, there are government regulations prohibiting the practice
of mixing milks to assure adherents of kosher those containers of milk contain cow milk
only. Some Jews are stricter and only drink milk and dairy products that are produced by
Jews, called “chalav yisroel” or “Milk of the Jews.” These products are found in areas
where there are large Jewish communities, as these areas may have a Jewish-owned dairy
or one supervised by Jews. This further assures followers of kosher that what is labeled as
cow milk is indeed cow milk. New Square, in New York, is an example of a Jewish dairy.
Grapes
Products that contain grapes that are not produced, grown, or processed under Jewish
supervision are not allowed, because in Ancient times, grapes were grown and used for
ceremonies involved with idolatry and idolatry goes against Jewish faith.
Kosher wines are flash-pasteurized, which makes the wine permissible to be handled by
non-Jews. Grape jelly, grape juice, and candies have similar restrictions. Because wine is
used in religious rituals and for holiday feasts, there are many vineyards that process
kosher wines. Kosher wines are becoming more sophisticated and there is greater variety
than ever before.
Other Food-Based Practices
For centuries, it was thought that eating fish and meat together would be a hazard to one’s
health. Therefore, the combination of meat and fish was prohibited. Though this medical
hazard is not a concern now, some Jewish people still choose to follow this practice today.
Fish and meat can be eaten at the same meal, as long as the fish is eaten first with
separate dishes and utensils.
Kosher Foods Available in Food Markets or Grocery Stores
Foods must be kosher for consumption by Jewish people who are kosher-observant. This
applies to prepared and packaged foods as well. A packaged item is kosher if it is prepared
with kosher ingredients. There are agencies that are able to certify that foods are kosher. A
product that is certified as kosher gets granted a hechsher, a symbol of kashrut. In the
United States, there are more than 345 hechshers in existence.
There are some items that are kosher may not have a hechsher on the package. To
determine if these foods are kosher, the person would have to refer to trade magazines that
specifically discuss kosher-related issues including acceptable foods. As with the laws of
kosher, not all people of the Jewish faith purchase goods that are solely labeled as kosher.
Those with a strict kosher home will only use products that are certified kosher by the
hechsher they follow. Others might choose items that seem kosher after reading through
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
the ingredients. Within this group, there are some who will not buy items that have grapes
or artificial flavors, as the origin is unclear. People who follow this rule of thumb will avoid
items that contain certain shortenings, including lard, natural flavors (for items that are
meat or fish flavored), gelatin, and other questionable items.
Fruits and vegetables are intrinsically kosher. Therefore, fresh fruits, fresh vegetables, and
unprocessed legumes, nuts, and seeds do not require a hechsher. Milk, sugar, flour, pure
juices (except grape), coffee, tea, eggs, and other pure products do not need to have
hechshers. Fruits and vegetables should be inspected to assure that they are free of
insects. There are some sects within Orthodox Judaism who do not believe that all
vegetables are kosher, as they deem removal of bugs impossible.
In Israel, the laws about produce are different. Every seventh year, land should remain
untilled and the fruits and grains of the land should be left alone. Canned foods, tomato and
blended juices, fruit juices mixed with grapes, sauces, and other canned processed foods
require a hechsher. If a hechsher is not accompanied by any other symbols, the food is
parve. Dairy products are marked D for dairy, meat products are marked M for meat, and
parve items contain a P.
Dining Out
Meals that are cooked in a nonkosher kitchen or using nonkosher dishes are not kosher. In
areas where there is a significant Jewish population, there are often restaurants that cater
to the kosher-observant populace. These restaurants will either serve all dairy or all meat
dishes, because they cannot be combined. Orthodox observers will look for a restaurant
that is closed on the Sabbath as food that is prepared on the Sabbath is not permitted. A
restaurant that follows the laws of Kosher and is closed on the Sabbath is called Shomer
Shabbat, or Sabbath observant. Today, some people refer to these establishments as glatt
kosher, though that refers to certain kosher meats. Shomer Shabbat restaurants are closed
for the duration of the Sabbath; they may close several hours before the start of the
Sabbath and open an hour or so after it ends. There are many kosher-style restaurants that
offer Jewish foods like cold cuts and other traditional foods. Though some of the menu
items may be kosher, the establishment may not be considered kosher.
Kosher restaurants will employ a mashgiach, a religious man who monitors the procedures
of the restaurant. Delivery of orders will be inspected and cooking of food will be monitored.
Jews who choose a more liberal approach to kashrut and opt to eat at nonkosher
restaurants may choose items on the menu that have the potential to be kosher. For
instance, some might eat pasta dishes that do not contain cheese, meat, or seafood. Some
opt for fish and yet others eat chicken. Cheese might be an issue for some, as rennet,
which is used to congeal the cheese, is obtained from animal sources.
Travel
Travel can be complicated for strictly kosher travelers. With a little advance research and
preparation, it can be made simpler. Airlines do include kosher options in their categories
of special meals, but advance notification is necessary. Similarly, some hotels may be able
to accommodate the need for kosher meals. Others will opt for strict vegan or vegetarian
meals.
Hospitalization
Although some hospitals have a kosher kitchen, this is not the norm. Hospitals would
benefit from ordering a stock of frozen kosher meals that can be heated in their own foil
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
dishes. In the event that a kosher-observant patient is admitted to the hospital, the kosher
meals would then be available for the patient.
If kosher meals are not available because of a lack of access or funds, uncooked items that
are kosher can be served instead. Yogurt, bread, crackers, individual containers of peanut
butter, cream cheese, and other spreads can be provided. Canned tuna, fresh fruits, and
vegetables are additional options. Asking what the client feels comfortable with may ensure
the client's intake of foods and a better line of communication between the client and RD.

Immigrants or Ancestors

Judaism, as a religion, has many followers, though these followers choose to observe the
laws at varying degrees. There are 3 branches of Judaism: Orthodox, Conservative, and
Reform. Each of these branches has set rules about abiding by the laws of the Bible as
translated by a Rabbi.
The Orthodox are further divided into several sects. Orthodox Jews are the strictest in their
observance of Judaism, as they apply the biblical laws on a more literal method.
Conservative Judaism believes that scholarly study of Jewish text indicates that Judaism
must evolve to meet the constantly changing needs of their people. The Conservative
movement believes practices are based on what meets the general religious needs. The
Reform Movement, which developed in Eastern Europe in the late nineteenth century,
believes that as the times change, religion must change too. Reform Jews have
self-autonomy, choosing which beliefs they abide by. All the movements are widespread
with various beliefs and customs about food.
Separate from the 3 sects of Judaism, Jews are referred to by their land of origin. Eastern
European Jews are called Ashkenazic Jews, and Sephardic refers to those from North
Africa, Spain, Portugal, the Mediterranean, and the Middle East. Ashkenazic and Sephardic
Jews have different customs, traditions, and food practices. This difference in observance
of the same laws came about as a result of centuries of being unable to communicate
because of wars and blocked channels of communication. The foods the Ashkenazic Jews
eat and that are considered “Jewish food” are from their countries of descent and the
resources that were available. Similarly, Sephardic foods are those foods that were
consumed in their native lands. For instance, Ashkenazic diets rely on potatoes and
breads, whereas rice is a staple of the Sephardic diet. (See Jewish food dictionary.)
Why Kosher?
Kosher is a religious belief that is followed but that does not have a documented
rationalization. Commentators on the Torah, but not the books of Torah themselves, offer a
rationale for the laws of kosher. One theory is that the dietary laws are to keep the Jews
separate and different from the other people of the world. Moses Maimonides, a medieval
philosopher, a great Spanish Rabbi, and a physician of the twelfth century, believed that
kosher eating enhanced health (Ben Maimon, 1963).
Another theory is that the dietary laws are a form of self-discipline, or a diet for the soul.
Moralists claim that because food is a divine gift, its processing should not induce pain on
the animal that is to be consumed. Perhaps kashrut is a means of reminding the Jews of
kindness that is necessary in all aspects of life. If milk is the nurturer of animal life and
meat is the destruction, it would be callous to mix them in one meal.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Adaptation of Native Culture to American Culture

Followers of Kashrut
There are many laws about the observance of kosher. Whereas there are people of the
Jewish faith who practice kosher 100%, there are many who choose which rules to follow
and dismiss others.
Some opt to keep kosher homes with kosher food and separate dishes, but then eat
nonkosher when out of the home. Not all Jewish homes have separate dishes for meat and
dairy. Others may choose to eat meats that were not slaughtered properly but avoid the
consumption of pork and shellfish. Others choose to avoid mixing meat and dairy but do
not avoid shellfish.
The decision to follow kosher laws is subjective and is a result of religious upbringing, the
form of Judaism being followed, rabbinical guidance, and personal choice. The statement “I
am kosher” or “I keep kosher” can have many implications depending on the individual.
Practices of Judiasm
Observant Jews will start meals with the recitation of a blessing over the food and end with
another prayer. The blessings are based on the food that is to be eaten. If a person is
eating a salad, the prayer said after the meal is shorter than if the person ate a meal with
salad and crackers. Before eating bread, one must wash both hands according to ritual and
say a blessing for hand washing. This long prayer and the hand washing are the reason
that some people opt not to add bread to meals. In addition, Jewish people are required to
pray 3 times a day.
The Sabbath, “shabbas,” or “Shabbat” begins on Friday at sundown. The day of rest ends
approximately 72 minutes after sundown on Saturday evening. Work is not permitted on
this day. Cooking is not permitted on the Sabbath, as kindling a flame and use of electricity
is forbidden. If a flame is left on before the Sabbath, food can be kept warm. This is why
cholent is eaten on the Sabbath. Foods prepared in a crockpot are convenient, as they can
be kept warm without kindling a flame. A metal plate can be placed over a stove with the
flames on. This plate, called a blech, conducts the heat of the flames while keeping foods
warm. Challah, a braided bread, is consumed at all meals on the Sabbath. Observant Jews
will not drive their cars or take rides from others, handle money, conduct business, or
speak on the phone. The television and radio are not used. Patients in a hospital may not
get in an elevator and press a button for a floor, but if it were a Sabbath elevator, one that
was programmed to automatically stop at each floor, they might use it. The Sabbath is
seen as a time to put aside the work of the week and to enjoy the company of family and
friends.
There are 6 days that are set fast days throughout the Jewish calendar. In Judaism, a fast
day entails abstinence from food and fluid. A fast can begin the night before and end after
sundown, just as the Sabbath, or it may begin before sunrise and end at sundown. Fasts
are meant to cleanse the soul. Pregnant women, nursing women, children (girls younger
than 12 years and boys younger than 13 years), the elderly, and people who are sick and
cannot fast are excused from the fast. Some Jews opt to abstain from foods but drink or
fast for half a day instead of a complete day. If a person is fasting, he or she is still allowed
to administer medications as directed, as one’s health is important. People with diabetes
are excused from fasting because it can be life-threatening. Special attention should be
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
given to medications that must be adminstered with food. Although people with diabetes
are excused from fasting, some patients who take insulin or oral hypoglycemics insist on
fasting. Counseling should be given to these patients.
Jewish Holidays
Seven Jewish holidays are celebrated in the Jewish year. The times and dates of these
holidays vary as Judaism follows a lunar calendar, but they do fall at approximately the
same time every year.
Rosh Hashanah marks the start of the Jewish New Year. Observed in September or
October, it is a date that is determined by the lunar calendar. Rosh Hashanah is a 2-day
holiday that is marked by family gatherings, dining, and prayers. Foods that are symbolic of
the year that people wish to have are eaten on this holiday. Apples dipped in honey
promise a sweet year and pomegranate seeds offer fertility. Sephardic Jews will eat beans,
organ meats, and squash as well.
Just 10 days after the New Year begins is Yom Kippur, the Day of Atonement, the holiest
of all days in Judaism. The day is marked by repentance for all sins, recitation of prayers,
and a 25-hour fast in which there is abstinence from food and drink.
The Feast of Tabernacles, or Sukkot, celebrates the autumn harvest. Because it also
serves as a reminder of the Israelites wandering in the desert after the exodus from Egypt,
temporary huts or sukkas are built to represent shelter. During the holiday, which lasts 8
days, meals are eaten in the huts. Fruits of the season are eaten to celebrate the harvest
season.
Commemorating the victory of the Jews over the Syrians, Chanukah is the Festival of
Lights. The 8-day holiday, which happens in December (or, occasionally, November), is
celebrated by lighting a menorah (candelabra), eating fried foods, and spending time with
families. Examples of fried foods are jelly doughnuts and potato pancakes, or latkes.
Chocolate coins, or Chanukah gelt, are given to young children.
Purim celebrates the liberation of the Persian Jews from a tyrant who planned to kill them.
Observed for one day in March, hamantashen are eaten and gift baskets are exchanged.
These baskets can incude cakes, candies, chocolates, and fruits.
Pesach, or Passover, is the celebration commemorating the exodus of the Jews from
Egypt. Passover lasts 8 days and is observed in the springtime. On this holiday, the laws of
kosher are further detailed. During the holiday of Passover, chametz, which are foods that
are leavened or have the ability to leaven, are not consumed. Bread, yeast, and foods that
can be permissible year-round are forbidden. All foods that could leaven or contain rising
agents cannot be consumed. Ashkenazic Jews will abstain from all grains, corn, and
legumes. Sephardic Jews will include foods during Passover that the Ashkenazi will
not, such as rice and legumes. Observant Jews will have an additional 2 sets of dishes,
one for Passover meat and another for Passover dairy. Matzo, which does not rise, is
substituted for bread. Less observant Jews will eat matzo for the symbolism but not
change the rest of their dietary practices.
Homeowners may opt to clean their homes of all remnants of chametz. Chametz is any
food product derived of wheat, barley, rye, oats, spelt, or their derivatives. The category of
chametz covers all foods that have the potential to become leavened. The original rabbinic
definitions of chametz expanded the category to include food and beverage derived from
the fermentation process involving any of these grains, specifically beer and other
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
grain-based spirits. Unprocessed grains or products that contain them are also removed
from the kitchen because they can easily become moist and thus spontaneously begin to
ferment. Some things that are chametz include bread, rice (for Eastern European Jews),
legumes, cakes, and cookies. People now use the word "chametz" to mean "not kosher for
Passover." Foodservice establishments in hospitals and nursing homes may choose to
cleanse their kitchens and eating areas of existing chametz. Before Passover,
supermarkets and groceries will stock a Passover section that will contain foods that are
kosher for Passover. Food manufacturers will cleanse their facilities according to the laws
of Passover. Packaged foods that are acceptable for consumption during Passover and do
not contain leavened items are labeled as kosher for Passover.
The Harvest Festival, or Shavuot, is also celebrated as the time that Moses was given the
Ten Commandments on Mount Sinai. During this 2-day holiday in the spring, it is
customary that people eat dairy foods, such as blintzes filled with fruit, cheese, or potato,
and cheesecake. This is because before the Ten Commandments were given, the laws of
kosher had not yet been given.
In the counseling process, it might be necessary to allow for the customary foods.
Registered dietitians should aim to recommend dietary changes that include these foods.

Meal Planning in this Culture

Effect of Keeping Kosher on Health Care
Counseling or caring for a client who is kosher can be complicated. But with a knowledge
of the laws of kosher and with some probing questions, the process can be made a
pleasant one. Upon introduction to a client, gettting information about religious observance
and food practices is imperative. Becoming familiar with that client's religious observance
can promote client comfort with the healthcare provider. With an improved and open line of
communication, compliance and therefore outcomes will often be better.
In the counseling process, the role of the registered dietitian (RD) involves the suggestion
of foods and meal patterns that will guide patients in reaching their goals. Having an idea of
the types of foods that are not permissible and the foods that cannot be consumed in one
meal can lead to a smooth counseling process.
One of the kosher rules of thumb is to avoid meals that contain meat and dairy together
and to abstain from including pork or shellfish in meal plans, so the RD should not include
this combination of items in any dietary suggestions. This is similar to the considerations
made when counseling a person with allergies or intolerances.
Observance of Jewish holidays can mean intake of more traditional Jewish foods, eating in
larger quantities, and more eating opportunities per day. Consideration of these factors
when developing meal plans or suggestions for foor changes can result in a more
successful nutrition intervention.
The relationship between the RD and the patient or client can be strengthened when there
is a better understanding of what the patient is willing to commit to and where limitations
exist. In counseling Jews who follow the rules of kosher, sensitivity to the client’s concern
about observance of dietary laws is critical. It is important to note that although a patient
may have a Jewish name, this does not mean the patient is religiously observant or follows
the dietary laws. It is the client, not the counselor, who determines the level of observance
when an eating plan is developed (Eliasi 2002).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
when an eating plan is developed (Eliasi 2002).

Food Dictionary

Food Ingredients or Preparation
Bagel
Donut-shaped bread that is boiled before it is
baked, giving it a chewy inside and crispy
exterior. This is typically consumed with butter,
cream cheese, lox, or a variety of spreads.
Bialy
A round bread that is softer than a bagel. A bialy
does not have a hole punched out; rather, the
center is used for fillings such as poppy seeds,
sesame seeds, onion, or garlic.
Blintzes
A thin, crepe-like pancake that is rolled around a
filling of potato and onion, ricotta or cottage
cheese, or fruit.
Borekas
Spinach pastry turnovers, often made with
phyllo dough; typically filled with cheese, potato,
or meat and then baked.
Borsht/Borscht
A soup made of beets and served with sour
cream or a boiled potato. Borsht may contain
beef broth. It can be served hot or cold and is
sometimes eaten with hard-boiled egg.
Bulgur
Cracked wheat used cold in salads or cooked in
dishes.
Challah
A braided egg bread that is used for the
Sabbath and holidays; can be coated in sesame
or poppy seeds or with raisins.
Cholent
A stew consisting of meat, beans, and potatoes
that is simmered overnight. This is a dish that is
typically served on the Sabbath because cooking
is forbidden.
Compote
French term adopted by Jewish culture that
refers to fresh or dried fruits being sweetened
and stewed.
Dafine
A Sephardic version of cholent; also called
chamin.
Falafel
A Middle Eastern fritter that is made with
chickpeas or fava beans that are ground, shaped
into small balls, and deep fried.
Flanken
A kosher cut of beef that is used in a variety of
dishes.
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Fleishig
Jewish word referring to meat or a meal that is
prepared with meat or meat items.
Gefilte Fish
A mixture of ground fish—typically pike, carp,
and whitefish—that is shaped into oblong balls
and cooked. It can be found canned or jarred as
well as frozen.
Hamantaschen
A triangular-shaped pastry that is eaten on the
Purim holiday. It is usually filled with poppy
seeds, prunes, apricots, or raspberries.
Haminados
A hard-boiled egg that is prepared with tea
leaves or onion to dye the eggshell a brown
color. This is popular in Sephardic culture.
Haroseth
Traditional Passover dish that is made from a
mixture of nuts, fruit, spices, and moistened with
wine.
Holishkes
Stuffed cabbage; a Sephardic alternative is
stuffed grape leaves or stuffed zucchini.
Horseradish
Ground horseradish root, which can
be store-bought in white or red (sold in jars) or
made from scratch. It is a spicy food usally eaten
with gefilte fish on Passover; may also be
referred to by its Hebrew name, chrain.
Hummus or
chummus
Pureed chickpeas and sesame paste (see
Tahini) used as a spread or a dip.
Kabab
Skewered and grilled meat, poultry, or
vegetables.
Kasha
Buckwheat groats; may be mixed with bowtie
pasta as a side dish.
Kishke Dish prepared of stuffed beef casings.
Knaidlach See Matzo Ball.
Knish
A potato and flour dumpling that is stuffed with
potato and onion, vegetables, or cheese; can be
baked or fried.
Kosher
Food or beverage that is fit for consumption by a
person who is observant of the Jewish dietary
laws.
Kosher salt
Coarse, noniodized salt that is used to remove
blood from meat in order to make it fit according
to Jewish dietary laws; used in popular food
culture for its distinctive taste and texture.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Kreplach
A version of a wonton or ravioli. Dough stuffed
with ground meat and onion that can be served
in soup or as a dish.
Kugel
A version of souffle. May be made with rice,
noodles, vegetables, or potatoes. Eggs are used
to congeal the mixture.
Labne Homemade yogurt common in the Middle East
Latke
Fried potato pancake eaten with apple sauce or
sour cream.
Lokshen Jewish word for egg noodles.
Lox Smoked salmon.
Matzo
Unleavened bread that is eaten on Passover to
remind Jews of the haste with which their
ancestors left Egypt.
Matzo Ball
Soup
Thin chicken soup or chicken broth with round
dumplings made from matzo meal, eggs, and oil.
Matzo Brei
Typical Passover dish that is made of egg and
matzo then fried in a pan; can be served with
sour cream, apple sauce, or maple syrup.
Matzo Meal
Made from finely ground matzo and used as a
flour substitute during Passover.
Milchig
Jewish word referring to milk or a meal that is
prepared with dairy items.
Parve
Neutral food that is neither meat nor dairy.
Fruits, vegetables, grains, legumes, nuts, seeds,
eggs, and fish are in this category.
Pirogen
Russian-style baked dumplings filled with
potato, meat, or kasha.
Pita
Pocket bread, used to make sandwiches in the
Middle East. Can be purchased in many varieties
including white or whole wheat.
Schmaltz
Rendered chicken fat that is used in recipes for
its strong taste.
Schug
Yemenite condiment made of ground hot
peppers.
Sufganiot Jelly-filled donuts eaten for Hanukkah.
Tabbouleh
Salad typically made with parsley, tomatoes,
cucumber, mint, and bulgur.
Tahini
Middle Eastern condiment that is made of
ground sesame seeds; eaten with falafel or on
salads.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Treif
Food or beverage that is unfit for consumption
by a person who is observant of the Jewish
dietary laws.
Tzimmes
Mixture of sweet potatoes, carrots, prunes, and
dried fruits then sweetened and stewed.

References


Angel S, Weinberg ZG, Jaffe R. Salt content of kosher chicken parts studied under
controlled conditions. J Food Quality. 1989;11:365-373.
Ben Maimon M.(editor and translator Pines S.) Guide of the Perplexed: translated with an
introd., endnotes by Shlomo Pines, with an introductory essay by Leo Strauss Chicago:
University of Chicago Press; 1963.
Burns ER, Neubort S. Sodium content of kosher meat. JAMA. 1984;252:2960. Related
Links: Abstract
DellaPergola S. World Jewish Population, 1996. American Jewish Yearbook,
1998. 1998;98:477-512.
Eliasi J, Dwyer J. Kosher and Halal: Religious Observances Affecting Dietary Intakes. J Am
Diet Assoc. 2002;102:911-914. Related Links: Abstract
Schwartz J, Scheckner J. Jewish Populations in the United States. American Jewish
Yearbook, 1998. 1998;98:168-169.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Korean
Food Practices

The traditional Korean meal plan is high in vegetable foods and low in animal foods.
Vegetable consumption is higher in Korea than in Western countries. Rice is a major staple
food in the menu, providing more than half of the total energy and a significant percentage
of total protein (Tchai 1993). Rice, soup, kimchi (pickled and fermented vegetables), and
several side dishes such as vegetables or roasted or broiled meat or fish are typical
components of the Korean meal (Kim 1996). Three to 12 side dishes can be served with
rice, soup, and kimchi; however, typical meals include three to five side dishes. Fresh fruits
are often served as an after-meal refresher. Sweet desserts are not usually consumed
except for special occasions like birthdays or holidays. Boiled water with roasted corn or
barley is often served with a meal (Kim 1996).
In recent years, with industrialization and economic growth, grain consumption has
declined somewhat and consumption of traditional dishes containing animal fats and
proteins has increased. However, it has been reported that there has not been a large
increase in overall fat intake, with 20% of total calories coming from fat (Kim 2000a, Park
2003). Dairy products are not part of traditional Korean meals. Dried anchovies and soy or
soy products (tofu) are primary sources of calcium in the traditional Korean diet (Kim
2000a). However, new dietary guidelines for Koreans recommend daily intake of dairy
products (Jang 2008).
The Korean Dietary Guidelines Advisory Committee recently revised Dietary Guidelines for
Koreans (Jang 2008). The following is the revised Dietary Guidelines for Koreans (Jang
2008):
Eat a variety of grains, vegetables, fruits, fish, meat, poultry, and dairy products.
Choose salt-preserved food less and prepare foods with less salt.
Increase physical activity for a healthy weight and balance what you eat with your
activity.
Enjoy every meal, and do not skip breakfast.
If you drink alcoholic beverages, do so in moderation.
Prepare foods properly and order foods in sensible amounts.
Enjoy our rice-based diet.

Immigrants or Ancestors

There are more than one million Korean-Americans in the United States, which is about
12% of Asian-Americans and 0.3% of the US population (Lee 1999). When Koreans
immigrate to the United States, their meal patterns may change. According to a study, the
food habits of Korean-Americans were closer to traditional Korean diets than to US food
patterns. Korean-Americans consumed an average of 60% and 16% of total calories from
carbohydrate and fat, respectively (Kim 2000a). In comparison, a report of carbohydrate
intake by native Koreans has shown 64% of total calories (Kim 2000b). Gordon and
colleagues (Gordon 2000) reported that Korean-Americans eat rice at least once a day
with increased frequency of rice intake in people older than 55 years. Rice was major
sources of energy and protein, while soybeans were also a major source of protein in
Korean-Americans (Cross 2002). Moreover, low-fat milk (2%) and kimchi were major
sources of calcium and sodium, respectively, in Korean-Americans' meals (Cross 2002).
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sources of calcium and sodium, respectively, in Korean-Americans' meals (Cross 2002).
The consumption of sodium, potassium, vegetables, and fruits was lower in
Korean-Americans than in native Koreans (Kim 2007). It was reported that as consumption
of Korean foods decreases, overall vegetable consumption decreases. Conversely, Chung
(Chung 1995) found no difference in vegetable consumption of Korean immigrants before
and after they came to the US.
It has been reported that the traditional Korean diet is associated with a high risk of
stomach cancer (Lee 1995). This may be the result of high consumption of salty and
pickled foods. In a study by Ubukata and colleagues (Ubukata 1987), the incidence of
stomach cancer was decreased in Koreans who have left Korea. It was suggested that
westernization of the food intake could be responsible for this decreased incidence
because the consumption of salted and fermented vegetables such as kimchi decreases.
Alternatively, retaining kimchi in the meal plan may be beneficial. It was noted that because
kimchi consumption remains high, the food intake can be adequate in vitamins A and C as
well as folate, riboflavin, niacin, and thiamin (Gordon 2000). Other commonly consumed
vegetables provide vitamins as well. Moreover, Korean-American men reported lower total
calories, fat, and cholesterol intake, and higher carbohydrate and vitamins A and C intake
compared with national averages determined in a previous US study (Kim 2000a).
Likewise, Korean-American women reported lower fat, cholesterol, and saturated fat and
higher protein, carbohydrate, fiber, and vitamins A and C intake (Kim 2000a). However,
studies of the Korean-American elderly (Kim 1993) showed that this population is at risk for
deficiency of vitamins A and C, along with protein deficiency.
Hypertension, digestive disease (gastric and duodenal ulcer, gastritis, and duodenitis),
arthritis, and diabetes are commonly reported chronic diseases by Korean-Americans
(Yang 2007, Sohn 2004). The prevalence of digestive disease was negatively related to the
length of residence in the US and positively related to the consumption of rice and rice
dishes (Yang 2007).
About one-third of Korean-American elderly reported seeking Asian and alternative medical
care to treat illness, and are uninsured (Sohn 2004). In addition, about one-half of
Korean-American elderly reported regular exercise (Sohn 2004).


Adaptation of Native Culture to American Culture

Dietary change can result from limited availability of traditional foods or ingredients or
increased involvement with the mainstream culture. The eating environment, such as
family structure and household size; the market environment, such as availability of Korean
grocery stores; health consciousness; and attitudes toward ethnic groups influenced the
food acculturation. The availability of Korean grocery stores was related to the diversity of
Korean food consumption. In addition, time and food purchasing power or household
income affected the frequency of Korean food intakes (Lee 1999b).
Geographic location is an important factor in the food acculturation because of the
availability of Korean foods. Korean-Americans living in large cities such as Los Angeles,
San Francisco, New York, or Dallas change the diet very slowly compared with
Korean-Americans living in small cities. A study of Korean-Americans in California (Gordon
2000) found that, overall, there was little change toward US-type food consumption among
the group studied. Specifically, consumption of rice and kimchi was very high. The slow
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
rate of dietary change may be influenced by the ethnic diversity of the area; if the Korean
population is high, traditional practices may be maintained longer.
In addition, the length of residence in the US affects dietary changes in Korean-Americans.
The Korean-Americans with a longer length of residence in the US consumed less
traditional Korean meals (Park 2003, Gordon 2000). However, vegetable, fruit and
traditional Korean meal consumption patterns were more similar to those of a native
Korean diet than a traditional American diet (Yang 2005). The vegetable and fruit
consumption was positively related to the length of residence in the US among
Korean-American women (Yang 2005).
The place of birth also affects health-related behaviors and dietary pattern. The prevalence
of overweight or obesity was higher in US-born Korean-American women than in
Korean-born Korean-American women (Park 2005). The US-born Korean-American
women had lower consumption of carbohydrate as a percentage of energy, sodium, vitamin
C, and β-carotene, but higher consumption of total fat and fat as a percentage of energy
than Korean-born Korean-American women (Kim 2007, Park 2005). The Korean-born
women had higher consumption of soy products, vegetables, and fruits, but less
consumption of whole grains, red meat, and nuts than US-born Korean-American women
(Park 2005). However, both US-born and Korean-born women did not meet the dairy food
recommendations (Park 2005).
More than one third of Korean immigrants reported eating more beef, fruit, dairy, bread,
soda, or coffee since coming to the United States; one third reported eating less fish, rice,
or other grains (Kim 2000a). Lee et al (Lee 1999b) found that acculturation resulted in
increased consumption of sweets and fats. In this study, commonly consumed US foods
included oranges, tomatoes, bagels, breads, and low-fat milk. Similarly, Chung (Chung
1995) found that the most frequently consumed non-traditional foods among
Korean-American women were orange juice, skim or low-fat milk, and breads. The first
meals to be altered to contain US foods instead of Korean foods were breakfast and lunch
(Lee 1999b, Sohn 2004, Yang 2005). This change in meals at busy times during the day
may reflect adaptation to the US social structure. The evening meal was more likely to
retain the use of Korean foods. Korean foods that are still consumed commonly in
acculturated groups included rice, soup, and kimchi (Lee 1999b). Korean-Americans used
traditional Korean seasonings such as garlic, ginger, green onion (scallion), soy sauce, red
pepper (red pepper powder or paste), soy bean paste, sesame oil, and sesame seeds
(Gordon 2000).
Dietary acculturation was influenced by American structural adaptation, namely
participating in US society and social networks, rather than by US cultural adaptation (Lee
1999a). Individuals who are highly involved in US social events showed increased US food
consumption. Participation of children in school lunch programs was another factor related
to increased use of US foods (Chung 1995). However, Koreans who show acculturation by
observing US holidays and reading US newspapers and magazines consume more US
foods (Chung 1995).
The young population, with proficiency in English and education in the United States, were
most acculturated to US culture. The older population, with less proficiency in English, less
education in the United States, and less participation in US social events kept traditional
Korean culture as well as traditional Korean food practices (Lee 1999b).
Mothers’ acculturation stage influenced food practice of the Korean family in the US. More
acculturated mothers cooked less Korean food and their family ate out more often
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
compared to the family with less acculturated mothers or family in Korea (Park 2003).
According to one study, a family’s favorite dishes may vary according to the mother's
Korean hometown. In addition, a family's favorite dishes also varied according to the
mothers’ acculturation stage. Galbi gui (grilled or broiled beef ribs marinated with soy
sauce and sugar) and kimchi jjigae (kimchi stew) were ranked first and second among the
family’s favorite dishes in Korean families with less acculturated mothers. However, family
with more acculturated mothers preferred spaghetti or pizza to deonjang jjigae (soy bean
paste stew). Kimchi was not ranked as one of the five favorite Korean dishes in families
with more acculturated mothers, whereas kimchi was ranked fourth favorite Korean dishes
in families with less acculturated mothers (Park 2003).
Food preparation for special occasions or functions also may change according to mothers’
acculturation stage. Galbi gui and japchae (a mixed dish of stir-fried clear noodles, beef or
pork, and vegetables) were the top two favorite Korean dishes for special occasions or
guests in Korean homes in both the United States and Korea. However, more acculturated
mothers preferred to prepare salad instead of jeon (pan fried vegetables, meat, or fish
that are lightly coated with flour and egg) for special occasions or guests (Park 2003).

Meal Planning in this Culture

Traditional Korean Meal Plan
Koreans eat similar foods throughout the day. There are no breakfast foods or lunch foods
although noodle dishes and one-pot dishes are often consumed for lunch. Because the
menus for breakfast and lunch are similar for Korean meals, many people eat the leftovers
from breakfast at lunch. The evening meal is also similar, but more side dishes are usually
included.
Meal Sample Pattern Sample Menu
Breakfast
Rice: short grain,
boiled rice (no
steamed rice or fried
rice)
Bap (boiled rice)

Soup or stew. People
usually prefer soup to
stew at breakfast.
Doenjang ghuk (soybean
paste soup)

Kimchi. Types of
kimchi vary according
to the season.
Baechu kimchi (whole
cabbage kimchi)

Side dishes; three to
five dishes including
cooked or fresh
vegetables, fish, or
meat
Geem gui (salted roasted
dried seaweed)

Yeon duboo jjim (seasoned
and steamed soft tofu)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sigeumchi muchim
(blanched and lightly
seasoned spinach)

Kongnamul muchim
(blanched and lightly
seasoned soybean sprout)
Chogi gui (broiled croaker)

Bori cha (roasted barley
water)
Lunch
Rice, soup or stew,
kimchi, three to five
side dishes
Or mixed/one-pot
dishes, kimchi, one to
two side dishes


Guksoo (noodle served in
anchovy or beef-based soup)
Kakdoogi (radish kimchi)

Nabak kimchi (napa cabbage
and radish kimchi in salted
water)

Bibimbap (rice dish) or
kimbap (rice dish)

Jajangmyeon (Korean-style
Chinese noodle dish) or
jambong (Korean-style
Chinese noodle dish).

Oee muchim (lightly
seasoned fresh cucumber)

Keatnip muchim (lightly
seasoned fresh perilla leaves)

Bori cha (roasted barley
water)
Evening
Meal
Rice
Gumjeongkongbap (boiled
rice and black bean)
Soup or stew Kimchi chigae (kimchi stew)
Kimchi
Baechu kimchi (whole
cabbage kimchi)

Side dishes; three to
five side dishes
Gaeran jjim (steamed egg in
a bowl)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Bulgogi (marinated and
broiled beef)

Kongnamul muchim
(blanched and lightly
seasoned soy bean sprout)

Doraji muchim (lightly
seasoned fresh bellflower)

Mu sangchae (lightly
seasoned fresh radish)

Bori cha (roasted barley
water)
Sakwa (apple)
Korean-American Adapted Meal Plan
Meal Sample Pattern Sample Menu
Breakfast Westernized meal Orange juice

Bagel, muffin, or toast
with jelly, jam, or
margarine
Coffee or tea
Cereal with milk
Lunch
Westernized meal; however,
depending on the
environments and work, it
can be a Korean meal.
Turkey or ham
sandwich
Green salad
Carbonated beverage
Evening
Meal
Rice Bap (boiled rice)
Soup or stew
Doenjang chigae
(soybean paste soup)
Kimchi
Baechu kimchi (whole
cabbage kimchi)
Soup or stew
Godeungoe gui
(broiled mackerel)

Side dishes; three to five
side dishes
Sigeumchi muchim
(blanched and lightly
seasoned spinach)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Kongnamul muchim
(blanched and lightly
seasoned soy bean
sprout)

Gaji muchim (steamed
and lightly seasoned
eggplant)
Mul (water)
Honey dew melon
Examples of Commonly Consumed Korean Food Items by Food Group
Food Group Foods
Grain Rice, barely, noodle, or rice cake
Meat
Beef, pork, or chicken (No restrictions on type of
meat for consumption; however, venison or turkey
consumption is not common in Korea.)
Fish/seafood
Mackerel, sardine, butterfish, hairtail (scabbard
fish), pollack, walleye, croaker, mackerel pike,
squid, shrimp, oyster, abalone, clamp, crab, mussel,
seaweed, kelp, or dried anchovy
Dairy
Whole milk (milk consumption is not common in
elderly people), yogurt, or ice cream
Dry
beans/nuts
Black beans, soy beans, red beans, green peas,
kidney beans, tofu, peanuts, chestnuts, walnuts, or
pine nuts.
Vegetables
Soy bean sprout (most popular), spinach (stem and
leaf), fernbrake, mung bean sprout, eggplant,
cucumber, zucchini, bellflower, potato, sweet
potato, pepper, mushroom, carrot, onion, green
onion, lettuce, perilla leaf, crown daisy, or Chinese
leek
Fruits
Apple, pear, grape, tangerine, nectarine, peach,
plum, apricot, melon (Japanese), watermelon,
strawberry, or persimmon
Fat Vegetable oils, sesame oils, or perilla oils

Food Dictionary


Food
Ingredients and
Preparation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Baechu kimchi (napa
cabbage kimchi, most
popular)
Napa cabbage, radish, red
pepper powder or flakes,
garlic, ginger, green onion
(scallion), salt, and fish sauce
(optional). Brined and
mixed with seasonings.
High in sodium and spicy.
Baek kimchi (without red
pepper powder, not spicy)
Napa cabbage, radish,
garlic, ginger, green onion
(scallion), salt, and fish sauce
(optional). Brined and
mixed with seasonings.
High in sodium.
Bap, Bop (rice)
Short-grain rice and water.
Boiled. Rice can be mixed
and cooked with other grains
such as barley or millet and
black beans, red beans,
peas, or kidney beans.
Basic seasonings
Garlic, green onion
(scallion), sesame oil,
sesame seeds, ginger,
mustard, soy sauce, soy
bean paste, red pepper
paste, red pepper powder or
flakes, salt, black pepper, rice
wine, sugar, and vinegar.
Bibimbap, Bibimbop
Short-grain rice, five to six
vegetables, beef, egg, red
pepper paste, sesame oil (for
flavor), sesame seeds, and
seasonings. Boiled,
blanched, pan-fried.
Blanched and lightly
seasoned vegetables,
seasoned and broiled beef,
pan-fried egg, and red pepper
paste are served over boiled
rice; high in sodium and fiber;
well balanced with
vegetables, carbohydrate,
and protein.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Bokeumbap, Bokeumbop
(fried rice)
Not a part of traditional
Korean meal. Short-grain
rice, vegetables, kimchi,
shrimp, pork, or beef.
Stir-fried. Stir-fried and
seasoned with salt.
Buchu kimchi (Chinese leek
kimchi)
Chinese leek, red pepper
powder or flakes, garlic,
ginger, green onion (scallion),
salt, and fish sauce (optional).
Brined and mixed with
seasonings. High in sodium
and spicy.
Bulgogi, Kalbi, Galbi
Beef (bulgogi) or beef rib
(kalbi, galbi), soy sauce,
garlic, black pepper, pear
juice or cooking wine,
sesame oil, sugar, and onion
or green onion (scallion).
Grilled or broiled. Marinated
beef or beef rib in soy sauce
and seasonings; high in
sodium and sugar; sugar
substitute is recommended
for diabetics.
Chang, Jang (fermented
bean products)
High in sodium content;
good source of protein and
calcium.
Chapchae, Japchae
Clear noodle (potato starch
noodle), beef, spinach,
carrot, mushroom, or other
choice of vegetables. Boiled,
blanched, stir-fried.
Blanched vegetables and
marinated beef are stir fried
individually, mixed with boiled
clear noodles, and seasoned
with soy sauce, sesame oil
and/or other seasonings;
moderately high in sodium
and fat.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Curry rice, Hirice
Curry powder (instant curry
powder package), potato,
carrot, zucchini, onion,
beef/pork, and boiled rice.
Boiled. Vegetables and meat
are stewed with curry powder
and served over boiled rice;
moderately high in sodium.
Dakdori tang (stewed
chicken)
Chicken, potato, carrot,
onion, red pepper paste or
powder, ginger, garlic, sugar,
black pepper, and salt.
Boiled. Stewed chicken with
vegetables, seasoned with
red pepper powder or paste;
high in sodium and spicy.
Dak jjim (stewed chicken)
Chicken, potato, carrot,
onion, soy sauce, sugar,
ginger, garlic, and black
pepper. Boiled. Stewed
chicken with vegetables,
seasoned with soy sauce;
high in sodium.
Doenchang, Doenjang (soy
bean paste)
Fermented soy bean lumps
and coarse salt; good source
of protein and calcium, high in
sodium.
Dongchimi kimchi (radish in
salted water, not spicy)
Radish, garlic, ginger, green
onion (scallion), and salt.
Brined and mixed with
seasonings and water. High
in sodium.
Dduk, Ddeok, Tteok (Rice
cake)
A festive and ceremonial
food. Steamed. Pulverized
rice or sticky rice can be
mixed and cooked with dried
fruits, legumes, pumpkins,
red beans or other choice of
grains.
Doenjang chigae, Doenjang
jjigae (soy bean paste stew)
Soy bean paste, tofu, potato,
zucchini, mushroom, onion or
other choice of vegetables,
and meat (optional). Boiled.
Soy bean paste stew; high in
sodium.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Ganjang (soy sauce)
Fermented soy bean lumps,
coarse salt, and water; high
in sodium.
Gireum (oil)
Vegetable oils (soy bean,
corn oil, or cottonseed oil):
used in pan frying or deep
frying of foods. Sesame oil
and perilla oil; used in
flavoring or seasoning of
foods.
Gochujang (red pepper
bean paste)
Red pepper powder,
glutinous rice powder, coarse
salt, malt, and fermented soy
bean lumps; high in sodium
and spicy.
Guksu, Ghuksoo, Guksoo
(Noodles)
Flour, egg, water, and beef
or dried anchovy. Boiled.
Boiled noodle served in beef-
or dried anchovy-based soup
or can be served as a mixed
dish. Mixed noodle dish:
boiled noodle mixed with
fresh vegetables and red
pepper paste; moderately
high in sodium and spicy
(mixed noodle dish).
Jangahchi, Julim
Preserved vegetables
(cucumber, perilla leaves,
garlic, radish, etc.) in soy
bean paste, soy sauce and
vinegar, red pepper paste, or
salt; high in sodium.
Jangjorim
Beef, soy sauce, sugar, and
water. Boiled. Boiled beef
brisket in soy sauce, sugar,
and water; high in sodium.
Janmoo kimchi, Jjanmoo
kimchi (napa cabbage or
radish)
Napa cabbage or radish, red
pepper powder or flakes,
garlic, ginger, green onion
(scallion), and fish sauce
(optional) with high amount of
salt; very high in sodium.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Japgok bap, Japgok bop
Short-grain rice, barley,
bean, and other grains.
Boiled. Mixed and cooked
rice with barley, bean, and
other grains.
Jeot, Jeotgal (fermented fish
or shellfish)
Salted fish, shrimp, or
shellfish. Very high in sodium;
however, the amount
consumed is very limited
compared to other foods.
Juk (porridge, thin gruel)
Rice and water. Boiled. Rice
can be mixed and cooked
with vegetables, ground
meat, sesame seeds, perilla
seeds, abalone, or pine nuts.
About 1/4 of carbohydrate is
content of boiled rice. Served
as a snack, appetizer, or light
meal for sick person.
Kangjung, Yakwa (Korean
traditional sweets)
Flour and syrup. Deep-fried.
Deep-fried and dipped in
syrup; high in sugar and fat.
Keatnip muchim
Perilla leaf and red pepper
powder or soy sauce.
Blanched or fresh perilla
leaves, seasoned with soy
sauce or red pepper powder.
Kimbap, Kimbop
Dried laver, spinach, carrot,
pickled radish, egg, beef or
ham, boiled rice, salt, and
sesame oil. Boiled,
blanched. Blanched then
lightly seasoned vegetables,
pan-fried eggs, and lightly
seasoned (with salt and
sesame oil) boiled rice are
rolled in dried laver.
Kimchi (pickled and
fermented vegetables)
Radish, napa cabbage or
other choice of vegetables,
red pepper powder or flakes,
garlic, ginger, salt, green
onion (scallion), and fish
sauce (optional). Brined
and mixed with
seasonings. High in sodium
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
and spicy; a good source of
vitamins A and C and fiber.
Kimchi chigae, Kimchi jjigae
(kimchi stew)
Kimchi, tofu, beef or pork,
red pepper (powder), garlic,
and green onion (scallion).
Boiled. High content of
sodium and red pepper and
spicy.
Kkakdugi, chonggak kimchi
(radish kimchi)
Radish, red pepper powder
or flakes, garlic, ginger, green
onion, salt, and fish sauce
(optional). Brined and
mixed with
seasonings. High in sodium
and spicy.
Kongjaban, Kongjang
Black bean, soy sauce, and
sugar or syrup. Boiled.
Boiled black beans in soy
sauce, sugar, and water until
the liquid becomes very thick
and concentrated; high in
sodium and sugar.
Kongnamul (soy bean
sprout)
Most frequently used
vegetable next to kimchi. Can
be served as a side dish or
soup.
Mandu (dumpling)
Flour, egg, water, beef or
pork, tofu, kimchi or cabbage,
clear noodle, and
seasonings. Steamed, fried,
or boiled. Can be served as
is or in beef soup.
Miyuk
Dried seaweed. Boiled or
blanched; can be served as a
side dish or in soup.
Muk
Acorn or green pea made
into acorn jelly or green pea
jelly.
Nabak kimchi (napa
cabbage and radish in salted
water)
Napa cabbage, radish, red
pepper powder, garlic, ginger,
green onion (scallion), and
salt. Brined and mixed with
seasonings and water. High
in sodium and spicy.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Namul
Vegetables, sesame oil,
sesame seeds, salt, red
pepper powder or paste, soy
sauce, garlic, and green
onion (scallion). Blanched,
steamed, or fresh. Lightly
seasoned blanched,
steamed, or fresh vegetables.
Oee kimchi (cucmber kimchi)
Cucumber, Chinese leek, red
pepper powder and flakes,
garlic, ginger, green onion
(scallion), salt, and fish sauce
(optional). Brined and
mixed with seasonings.
High in sodium and spicy.
Pajeon
Flour, seafood, and green
onion (scallion) or choice of
vegetables. Pan-fried.
Served with soy sauce.
Pa kimchi (scallion kimchi)
Green onion (scallion),
radish (optional), red pepper
powder and flakes, garlic,
ginger, salt, and fish sauce
(optional). Brined and
mixed with seasonings.
High in sodium and spicy.
Perilla seeds
Vegetable, similar to sesame
seeds and is used to make
perilla oil.
Pindeadduk (Bindaetteok),
Pajeon
Ground mung bean or flour,
pork or beef, and choice of
vegetables or kimchi.
Pan-fried. Served with soy
sauce.
Saengsun chigae, Saensun
maeuntang, Saengsun jjigae
(fish stew)
Fish, radish, onion, green
onion (scallion) or other
choice of vegetables, red
pepper paste, red pepper
powder or flakes, salt or soy
sauce, garlic, and ginger.
Boiled. Fish stew based on
red pepper paste or red
pepper powder or flakes,
seasoned with soy sauce or
salt; high in sodium and red
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
pepper and spicy.
Saengsunmuk, Oemuk (fish
cake)
Fish and flour. Deep-fried.
Saengsunhoe Raw, sliced fish.
Sullnongtang, Komtang,
Gomtang, Kalbitang,
Galbitaing
Beef, beef rib, and/or bones,
rice, and clear noodle.
Boiled. Beef soup (broth) is
served with boiled rice and
small amount of clear
noodles.
Yukgejang (spicy beef soup)
Beef, mung bean sprout,
fernbrake (vegetable), green
onion, and red pepper
oil. Boiled. Blanched
vegetables are mixed with red
pepper oil and added into
beef soup; high content of red
pepper and sodium.
Yukhoe
Raw, sliced and seasoned
beef.
Source of nutritional information (Kim 1996): Kim SH, Oh SY. Cultural and nutritional
aspects of traditional Korean diet. World Rev Nutr Diet. 1996;79:109-132.
Examples of Cooking Methods by the Word Ending or Food Name
Ending of the
Word or Food
Name
Cooking Method
Bap, Bop Boil (boiled short-grain rice)
Bokum, Bokeum Stir fry
Chorim, Jorim
Boil (reduce the liquid in half or less of
the original amount or until the liquid
becomes very thick and concentrated)
Dduk, Ddeok,
Tteok
Steam (rice cake)
Gui, Gu-E Broil, grill
Guksu,
Ghuksoo, Guksoo
Boil (boiled noodle served in beef or
anchovy soup or served as a mixed dish
with fresh vegetables and red pepper
paste)
Hoe, Hoi
Raw (sliced raw fish or shellfish or raw
beef)
Jeok Broil
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Jeon, Buchim
Pan fry (coat vegetables, fish, or meat
lightly with flour and egg, then pan fry)
Jeongol Casserole
Jjigae, Chigae Boil (stew)
Jjim
Steam, boil (adds very little amount of
liquid)
Juk Porridge
Muchim
Mixed (Ingredients are mixed and lightly
seasoned.)
Namul
Blanch or steam (blanched or steamed
and lightly seasoned vegetable dishes)
Po Dry (dried fish or meat)
Saingchai,
Sangchae
Uncooked (fresh vegetables)
Tang, Kuk, Guk,
Kook, Ghuk
Boil (soup)
Twigim, Tuiguim Deep fry


References


Chung SS. Dietary change: Food habits of Koreans in New Haven. Ph.D. dissertation,
University of Connecticut. 1995.
Cross NA, Kim KK, Yu ES, Chen E, Kim J. Assessment of the diet quality of middle-aged
and older adult Korean Americans living in Chicago. J Am Diet Assoc. 2002;102:552-554.
Gordon BH, Yom MS, Cho P, Sucher KP. Dietary habits and health beliefs of
Korean-Americans in the San Francisco Bay Area. J Am Diet Assoc. 2000;100:1198-1201.
Jang YI, Lee HS, Kim BH, Lee Y, Lee HJ, Moon JJ, Kim C. Revised dietary guidelines for
Koreans. Asia Pac J Clin Nutr. 2008;17:55-58.
Kim M, Lee S, Ahn YH, Bowen P, Lee H. Dietary acculturation and diet quality of
hypertensive Korean Americans. J Adv Nursing. 2007;58:436-445.
Kim KK, Yu ES, Chen EH, Cross N, Kim J, Brintnall RA. Nutritional status of Korean
Americans: Implications for cancer risk. Oncol Nurs Forum. 2000;27:1573-1583.
Kim S, Moon S, Popkin B. The nutrition transition in South Korea. Am J Clin Nutr.
2000;71:44-53.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Kim SH, Oh SY. Cultural and nutritional aspects of traditional Korean diet. World Rev Nutr
Diet. 1996;79:109-132.
Kim K, Yu ES, Liu WT, Kim H, Kohrs M. Nutritional status of Chinese-, Korean-, and
Japanese-American elderly. J Am Diet Assoc. 1993;93:1416-1422.
Lee SK, Sobal J, Frongillo EA. Acculturation and dietary practices among Korean
Americans. J Am Diet Assoc. 1999;99:1084-1089.
Lee SK, Sobal J, Frongillo EA. Acculturation, food consumption, and diet-related factors
among Korean Americans. J Nutr Educ Behav. 1999;31:321-330.
Lee JK, Park BJ, Yoo KY, Ahn YO. Dietary factors and stomach cancer: A case-control
study in Korea. Int J Epidemiol. 1995;24:33-41.
Park SY, Murphy SP, Sharma S, Kolonel LN. Dietary intakes and health-related behaviors
of Korean American women born in the USA and Korea: The multiethnic cohort study.
Public Health Nutr. 2005;8:904-911.
Park SY, Paik HY, Skinner JD, Ok SW, Spindler AA. Mothers’ acculturation and eating
behaviors of Korean American families in California. J Nutr Educ Behav. 2003;35:142-147.
Sohn L. The health and health status of older Korean Americans at the 100-year
anniversary of Korean immigration. J Cross Cult Gerontol. 2004;19:203-219.
Tchai BS. Changes in plasma lipids and biochemical markers for coronary artery disease
in Koreans. Ann NY Acad Sci. 1993;676:279-288.
Ubukata T, Oshima A, Morinaga K, Hiyama T, Kamiyama S, Shimada A, Kim JP. Cancer
patterns among Koreans in Japan, Koreans in Korea, and Japanese in Japan in relation to
lifestyle factors. Jpn J Cancer Res. 1987;78:437-446.
Yang E, Chung H, Kim W, Bianchi L, Song W. Chronic diseases and dietary changes in
relation to Korean Americans’ length of residence in the United States. J Am Diet Assoc.
2007;107:942-950.
Yang E, Kerver J, Song W. Dietary patterns of Korean Americans described by factor
analysis. J Am Coll Nutr. 2005;24:115-121.

Web Links

Korea Food and Drug Administration (select English version) (Accessed September 21,
2009)

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Korea Ministry of Culture and Tourism - History of the Development in the Culinary Culture
(Accessed September 21, 2009)

Korean Food (Accessed September 21, 2009)


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Mormon
Food Practices

Members of the Church of Jesus Christ of Latter-day Saints (the LDS Church) are also
known as Mormons, Latter-day Saints, or LDS. Food, nutrition, and health practices of
Mormons include moderation, focus on the basic food groups and avoidance of certain
harmful substances, exercise, and self-reliance. Most of the Mormon practices are
consistent with food practices and health counseling by dietetics and other health
professionals.
The following are foundations of principles of on which LDS church members base
their food, nutrition, and health practices:
They have been given a commandment related to health practices known as the
Word of Wisdom that is located in a book of scripture called the Doctrine and
Covenants.
The principle of self-reliance is taught and strongly encouraged by the church.
Most LDS health practices are very much in line with MyPyramid, the Dietary Guidelines
for Americans, and other mainstream medical recommendations in the United States
(USDA 2005; USDHHS 2005).
Latter-day Saints believe that the physical body is a gift from God, to be treated with
reverence and respect. Consequently, they believe in avoiding ingestion of substances that
may be harmful to their bodies or may dull sensitivity to spiritual promptings.

The Word of Wisdom is a commandment to the church members to follow healthful
practices. The Word of Wisdom outlines certain do’s and don’ts. Do’s include use of meat
sparingly and liberal use of grains, vegetables, and fruits. Don’ts include use of tobacco (in
any form), alcohol, coffee, tea, and harmful drugs. Vegetarianism (no meat) is neither
encouraged nor discouraged in LDS teachings.

Cola drinks present a unique situation. They have never been officially banned. Members
have been advised against the use of any drink containing harmful habit-forming drugs
under circumstances that would result in acquiring such a habit. Because caffeine is known
to have some addictive properties, some Latter-day Saints avoid caffeine-containing soft
drinks.

Most practicing Latter-day Saints are schooled in and practice principles of self-reliance.
Food storage, maintaining a garden, careful budgeting, meal planning, and a strong work
ethic are parts of the self-reliance program encouraged by church leaders. Members try to
maintain a good balance of spiritual, physical, and emotional health, adhering to most
mainstream medical practices.

Summary of Food Practices
Latter-day Saint food practices are quite consistent with national nutrition guidelines. The
Food Guide Pyramid and Dietary Guidelines for Americans mirror the guidelines used by
practicing Latter-day Saints. See LDS Compatibility with the Food Guide Pyramid. Grains,
fruits, and vegetables are encouraged in liberal amounts. Meat or protein are encouraged in
moderate amounts. Fats, oils, and sweets are to be used sparingly. The main difference
between mainstream nutrition guidelines and LDS practices is the extent of restriction in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
the use of alcohol, coffee, tea, and tobacco. In LDS practice, these products are not to be
used at all (McCaffree 2002).
*All information concerning LDS practices has been reviewed and approved by the Public
Affairs department of The Church of Jesus Christ of Latter-day Saints.

Meal Planning in this Culture

Suggestions for Patient Meals
When a client in a hospital, long-term care facility, or other health care facility is known to
be a member of the Latter-day Saints (also known as Mormons or members of LDS), care
should be taken in creating their menu with their religious beliefs in mind. For example:
Coffee or tea on the meal tray should be replaced with milk or fruit juice.
A nutrition department representative should visit the client early in his or her stay,
acknowledge his or her religious status, and determine food preferences in providing
meals.
Menu items prepared with alcohol might be a concern to Latter-day Saints (extract
flavorings are allowable) because alcohol retention in cooked foods can be as high as
85% (Augustin, 1992). The patient should be made aware of foods prepared with
alcohol so he or she can decide whether or not to order or consume these foods.
Suggestions for One-on-One Nutrition Counseling
During one-on-one client nutrition counseling, ask if any religious or cultural factors should
be considered. If the client is known to be a member of LDS, then LDS food
practices should be considered in designing the appropriate diet or meal plans.

References


Augustin J, Augustin E, Cutrufelli RL, Hagen SR, Teitzel C. Alcohol retention in food
preparation. J Am Diet Assoc. 1992;92:486-488. Article Summary:
The only study that addresses alcohol retention in cooked foods in much depth. Related
Links: Abstract
Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory
Committee on the Dietary Guidelines for Americans, 2005, to the Secretary of Health and
Human Services and the Secretary of Agriculture. Washington, D.C.: U.S. Dept of
Agriculture, Agricultural Research Service; 2005.
McCaffree J. Dietary restrictions of other religions. J Am Diet Assoc. 2002;102:912. Article
Summary:
Very brief summary of LDS nutrition practices.
Food Guide Pyramid: A Guide to Daily Food Choices. Washington, D.C.: U.S. Dept of
Agriculture, Human Nutrition Information Services; 2005. Home and Garden Bulletin No.
252. Article Summary:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Current gold standard of normal nutrition recommendations - the Food Guide Pyramid.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Muslim
Food Practices

An improved understanding of the dietary guidelines of Islam will increase practitioners'
awareness when counseling their Muslim patients and clients. This describes the food
practices of Muslims, regardless of their ethnic background, as these principles are
required of all Muslims. The dietary guidelines of Islam are based on the teachings of the
Quran (the holy book of Islam) and the Sunnah (the teachings of the Prophet Mohammed),
and provide clear direction regarding food cleanliness and preparation.
Halal and Haram
Two words are typically used to describe foods and beverages in Islam: Halal and Haram.
Halal is an Arabic word meaning "permitted or allowed." Haram is the opposite of Halal and
means prohibited (Twaigery, 1989). Food is determined to be Halal based on what it is and
how it is obtained and processed. The Quran emphasizes cleanliness and encourages
Muslims to eat only Halal foods to keep them faithful and pure. Most foods are considered
Halal. In addition, Muslims vary in the degree to which they observe Halal guidelines.
Cultural and family traditions play an important role in how closely these guidelines are
followed. Therefore, it is important that dietetics practitioners understand their client's level
of observance of Halal. According to the Islamic Food and Nutrition Council of America, all
foods are considered Halal, except:
Pork and its byproducts, such as bacon and lard, and any food containing pork or its
byproducts (e.g., a pie crust made with lard)
Meat from animals that have not been slaughtered according to Islamic practices or
are dead before slaughtering. The exception is all marine animals that did not die of
themselves, which are considered Halal
Bloody meat or rare meat.
Animals killed in the name of anyone other than Allah (God)
Carnivorous animals
Birds of prey
Land animals without external ears such as snakes and frogs
Blood, blood byproducts, and foods containing blood. The exceptions are liver and
spleen, which are considered Halal
Alcohol, including alcohol used in cooking.
Foods that are not allowed may be eaten if the individual is driven to eat them by necessity,
such as in the case that food is needed to sustain life.
Foods that are not clearly defined as Halal or Haram (called "mashbooh") include
marshmallows, gelatin, monoglycerides and diglycerides, emulsifiers, enzymes,
animal-based fats and oils of unknown origin, and certain dairy products because they may
or may not come from pork or its byproducts. Muslims are discouraged from consuming
foods in this category that contain these components (Eliasi, 2002). For Muslims who are
hospitalized and may be consuming a liquid nutrition prescription, attention must be paid to
assure that gelatin is from either beef or vegetable sources.
Halal meat and poultry are slaughtered by trained Muslims in such a way as to minimize
suffering to the animal. Under sanitary conditions, the butcher quickly draws a sharp knife
across the throat of the animal while reciting "Bismillah allahu akbar" ("with God's name,
God is greater"), cutting the jugular vein and carotid arteries in order to ensure a quick
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
death. Because blood is Haram, this method assures that the animal's blood is completely
drained. Meat and poultry from Halal animals that have been slaughtered in accordance
with Islam are called zabihah. Meats processed in this manner are preferred, but meats
that are not zabihah are acceptable to some Muslims (Eliasi, 2002). Halal also refers not
only to the slaughtering of animals or in the way foods are processed, but also refers to the
conditions under which animals are raised.
Halal Certification
As the Muslim population in the United States has grown in recent years, many food
companies have begun producing foods that meet Halal standards. The Islamic Food and
Nutrition Council of America is one of a few organizations that certify Halal products and
has authorized many North American food manufacturing companies to produce Halal food
products. Halal foods are designated with the symbol of the crescent moon and the letter M
on the label or with the word Halal on the package.
Islamic Holidays, Fasting, and Ramadan
Fasting during the month of Ramadan is one of the five pillars of Islam. Ramadan lasts 29
or 30 days and falls during the ninth month of the lunar calendar, which is approximately
12 days shorter than the Gregorian calendar. This is a time for reflection, devotion, and
self-control among Muslims. It is also a time to remember those less fortunate as a way to
strengthen the bond between people in society. The period of fasting starts each day at the
break of dawn and ends at sunset. During the day, Muslims abstain from all food and drink.
During Ramadan, the day begins with a prayer followed by a light, pre-fast meal (suhoor)
that is eaten before sunrise. Muslims are encouraged to break their fast as soon as
possible after sunset by eating an odd number of dates and drinking a glass of water, milk,
or some other beverage (Sakr, 1971). This is followed by an evening meal, called iftar,
which means "breakfast" in Arabic. Because each Islamic region of the world has its own
food traditions and habits, it is not possible to describe foods typically prepared and eaten
during iftar. Because Ramadan instills a sense of community in Muslims, many invite family
and friends to share iftar together.
Women who are pregnant, breastfeeding, or menstruating are exempt from fasting during
Ramadan, as are young children who have not yet reached puberty; the elderly, based on
physical condition; and adults who are ill, mentally unstable, or are traveling 50 miles or
greater. Women who are pregnant or breastfeeding and individuals who have a short-term
illness or are traveling during this time are required to make up the fast before the next
Ramadan, if possible (Sakr, 1971). Some individuals, despite their medical condition,
choose to observe fasting. However, Muslims are not encouraged to fast if it causes them
harm. Individuals with diabetes who take oral hypoglycemic agents or individuals with other
medical conditions requiring medication should be encouraged to discuss medication
adjustments with their physicians. Individuals with type 1 diabetes who wish to fast must be
closely monitored to adjust insulin dose, timing of insulin injections, and lifestyle changes
that may take place as a result of fasting. Frequently, by the time adjustments are made
and the diabetes is in good control, the month of Ramadan is over. For this reason, most
physicians do not encourage their patients who have Type 1 diabetes to fast unless their
diabetes is well controlled and they are motivated to make changes in their treatment
regimens (Shahzad, 2003).
Eid-ul-Fitr (Feast of Fast-Breaking) occurs on the first day after Ramadan and lasts three
days. Muslims typically celebrate by visiting family and friends, which may involve meals or
sweets and tea or Arabic coffee.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
sweets and tea or Arabic coffee.
Eid-ul-Adha (Feast of Sacrifice) is a three-day celebration of Hajj, which is the pilgrimage of
Muslims to Mecca. It starts on the tenth day of the month of Zul-Hijja (the twelfth month of
the lunar calendar).

Immigrants or Ancestors

Muslims should not be thought of as just Arabs. Though Muslims may be Arabic, the
majority of Muslims are non-Arabs. Muslims may also be Kurdish, Iranian, Turkish,
European, Eastern European, Pakistani, Indian, Malaysian, Indonesian, Filipino, African,
Chinese, American, or any other nationality. Arabs might be Christian or Jewish. In fact,
Arabs make up just 15% of the world population of Muslims.
Muslims come from a variety of nationalities and it is inappropriate to think of them as
having cultural food practices or eating foods that are unique to Islam. The food choices of
Muslims, other than not eating pork or foods containing pork byproducts and prohibiting the
intake of alcohol, are influenced by their culture and not their religion.
How many Muslims live in the United States? This is a difficult question to answer with any
degree of accuracy. By law, the US Census Bureau cannot ask individuals about their
religious affiliation, which makes estimating the population of Muslims living in the United
States difficult. Published estimations vary with a wide range between two million and
seven million, depending on the source.
According to the U.S. Department of State 2001 statistics, Muslims living in the United
States come from many countries and represent a wide diversity of cultures, each with its
own food traditions:
33% are South Asian (Pakistani, Indian, Bangladeshi, and Afghani)
30% are African-American
25% are Arab
3.4% are sub-Saharan African
2.1% are European (Bosnian, Kosovar, Chechen)
1.3% are Southeast Asian (Malaysian, Indonesian, Filipino)
1.2% are Caribbean
1.1% are Turkish
0.7% are Iranian
0.6% are Hispanic or Latino

Adaptation of Native Culture to American Culture

To our knowledge, no published research examining the degree of dietary acculturation
among Muslims living in the United States is available. However, for most Muslims, partial,
if not complete, adaptation to a US diet is highly likely, not only with respect to food choices
but also meal schedules.
In some Muslim countries, the main meal of the day is lunch, which is eaten mid-afternoon;
the evening meal is usually eaten well after sunset. It is highly unlikely, however, that
Muslims who have adapted to a US way of eating will begin eating pork or pork byproducts
or drink alcohol. Muslims who have adapted their diets may begin eating cereal and milk for
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
breakfast or have their largest meal of the day in the evening. They are more likely to
prepare and eat traditional foods for special occasions, such as holidays and eating with
family and friends.

Meal Planning in this Culture

An important point to remember when talking to Muslims about meal planning and their
meal patterns is that foods eaten must be Halal, or permitted. It is also important to discuss
their ethnic food practices, as Muslims from different countries eat different types of foods.
Unfortunately, to our knowledge, no studies describing the meal patterns of Muslims living
in the United States or how their meal patterns have changed over time have been
published. However, personal experiences with Muslims from Middle Eastern countries
may provide some insights on the meal patterns of Muslims who are new to the United
States. There is a tendency to follow a meal pattern similar to one followed from their
country of origin.
Middle Eastern Muslim Meal Pattern
Meal Sample Menu
Breakfast
(morning)
Arabic coffee, sweetened with sugar
Sliced fresh vegetables or fresh fruit
Pita bread
Lebaneh and olive oil
Lunch
(mid-afternoon)
Dish of lamb, chicken, or fish

Rice with pine nuts (or couscous for people
from North African countries like Libya or
Morocco)
Tomato-cucumber salad
Pita bread
Water, Arabic coffee, or hot tea with sugar
Fresh fruit for dessert
Snacks
(occasional)
Fresh fruit, vegetables, or dessert
Arabic coffee or tea with sugar
Roasted nuts or seeds
Evening Meal Hummus, foul, or falafel
Pita bread
Sliced raw vegetables
Fresh fruit or fruit juice
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Indian or Pakistani Muslim Meal Pattern
Meal Sample Menu
Breakfast (around 8 AM) Roti, naan, or paratha
Egg, kheema, or sabzi
Plain yogurt
Juice
Fresh fruit
Coffee or tea with milk
Lunch (around 1 PM) Meat or vegetable curry
Dhal
Paratha, rice, and/or naan
Plain yogurt
Fruit
Tea (around 4 PM) Vegetable samosa
Coffee or tea with milk
Evening Meal (around 7 PM) Chicken, meat or vegetable curry
Roti, naan, or rice
Dhal or plain yogurt
Ice cream
It is important to remember that the main meal in many countries, including Muslim
countries, is lunch. Lunch is usually in mid-afternoon, and the evening meal is perhaps well
after sunset.
Muslims born in the United States or who have lived in the United States for any length of
time may adapt a meal pattern that closely resembles that followed by most people in the
United States, either partially or entirely.

Food Dictionary

The foods eaten by Muslims are determined more by geography than religion. The foods
listed here reflect those foods and beverages consumed by people, Muslim and
non-Muslim alike, from Arabic-speaking countries (e.g., Lebanon, Jordan, and Egypt) or
India and Pakistan.
Arabic Muslim Food Dictionary
Food Ingredients or Preparation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Arabic coffee
A blend of Arabica coffee beans and roasted
cardamom, which is finely ground and boiled in
water. The coffee is typically preferred sweetened
with sugar.
Baba ganouj
Roasted, mashed eggplant, blended with tahini
(sesame seed paste), lemon juice, olive oil,
spices, and salt.
Burgul or bulgur Cracked wheat.
Couscous
A type of hard semolina wheat that has been
ground, then moistened and rolled in flour.
Baklava
A dessert of crushed nuts (either walnuts,
cashews, or pistachioes) between layers of phyllo
dough; sweetened with sugar syrup.
Falafel
Ground garbanzo and fava beans, coriander,
parsley, garlic, and salt. Formed into patties and
fried in vegetable oil. Typically eaten with pita
bread.
Foul (fool)
Cooked fava beans mixed with lemon juice, olive
oil, garlic, cumin, and salt. Served with pita bread.
Usually mashed, but can be served as whole
beans.
Hummus
Ground cooked garbanzo beans mixed with
tahini, lemon juice, olive oil, garlic, cumin, and
salt. Used as a dip with pita bread.
Kibbeh
Egg-shaped shell made of bulgur and stuffed with
seasoned ground lamb, sauteed onions, and pine
nuts. Deep-fried in vegetable oil.
Kofte
Ground meat, usually lamb, that is seasoned with
onion, salt, pepper, and allspice. Kofte is usually
molded into long strips on flat skewers and grilled.
Laban Plain yogurt made from whole milk.
Lebaneh
A spread made from plain yogurt; made by
straining whole milk yogurt through cheese cloth.
The consistency is similar to that of cream cheese.
Mahshi
(stuffed
zucchini)
Small zucchini stuffed with a mixture of white rice,
ground lamb, spices, and salt. Stuffed zucchini
are simmered in tomato sauce.
Mahshi
bathinjan
(stuffed
eggplant)
Small eggplant stuffed with a mixture of white
rice, ground lamb, spices, and salt. Stuffed
eggplant is simmered in tomato sauce.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Makhshi
(stuffed
zucchini,
another
version)
Small zucchini stuffed with a mixture of sauteed
onions, ground lamb, pine nuts, spices, and salt.
Stuffed zucchini is sauteed in vegetable oil and
served in yogurt sauce.
Mamoul
A pastry stuffed with dates or nuts. The outer
covering is made with either flour or finely ground
farina.
Mansaaf
A traditional Jordanian dish of lamb cooked in
yogurt sauce (jameed) and served over white rice
and pine nuts or almonds.
M'jedorah or
m'jedorah bil
burgul
A dish made of rice, lentils, and spices. Usually
served with tomato salad or plain yogurt. If made
with bulgur instead of rice, it is called m'jedorah
bil burgul.
Shish kebab
Marinated lamb that is skewered and grilled. The
marinade can contain lemon juice, olive oil, salt,
pepper, finely chopped onion, and garlic.
Shish tawook
Marinated boneless pieces of chicken that is
skewered and grilled. The marinade can contain
lemon juice, olive oil, salt, pepper, finely chopped
onion, and garlic.
Shwarma
A layered mix of thin slices of lamb and beef that
is seasoned and cooked on a spit. Another
variation is made with layers of chicken. The meat
is typically sliced, rolled in thin pita bread, and
served with a tahini-based sauce.
Tahina
Sesame butter; which has the consistency of thin,
natural peanut butter.
Waraq inab
Stuffed grape leaves; typically stuffed with rice
with or without seasoned ground lamb.
Indian and Pakistani Foods Dictionary
Food Ingredients or Preparation
Curry
A term for various dry vegetable or gravy
dishes.
Dhal
A generic term for hulled, split lentils or
peas.
Dosa
A South Indian pan-fried crepe made with
fermented rice and dhal butter.
Idli
A South Indian steamed dish made with
fermented lentil batter.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Kheem A minced meat dish.
Kheer
A milk-based liquid dessert made with
lentils, nuts, and fruit.
Korma
A spicy curry dish consisting of a variety of
vegetable, meat, and a gravy of nuts and
yogurt.
Lassi
Buttermilk or yogurt drink with salt or sugar
added to it.
Naan
Fermented bread made from flour, yogurt,
and egg. It is baked in a clay oven.
Pakoda
Deep-fried fritters made with vegetables or
plain graham flour.
Paneer Homemade cottage cheese.
Paratha/Roti/Chapathi Shallow, fried wheat bread.
Puri A deep-fried bread.
Rasam A spicy, thin soup.
Sabzi A generic term for cooked vegetables.

References


Eliasi JR, Dwyer JT. Kosher and Halal: religious observances affecting dietary intakes. J
Am Diet Assoc. 2002;101:911-914. Related Links: Abstract
Sakr AH. Dietary regulations and food habits of Muslims. J Am Diet
Assoc. 1971;57:123-126. Related Links: Abstract
Shahzad A. Diabetes in Ramadan [letter]. J Royal Soc Med. 2003;96:52. Related Links:
Abstract
Twaigery S, Spillman D. An introduction to Moslem dietary laws. Food
Technol. 1989;44:88-90.


Web Links

Islamic Holidays and Observances (Accessed September 21, 2009)

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Resources > Cultural Food Practices > Native American
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Resources > Cultural Food Practices > Native American > Apache & Navajo
Adaptation of Native Culture to American Culture

The way of life for both the Navajo and Apache values a balance of mind, body, and spirit,
integrating all into a healthy lifestyle. Prior to being taken from their homelands and placed
onto reservations, these Native Americans had a fairly healthful existence without the
epidemics of modern society (obesity, diabetes, and alcoholism). However, between 1860
and 1940, reservation life (and the maltreatment of Native Americans under military care at
that time) resulted in rampant under-nutrition and frank malnutrition in this population. Next
came a further shift in reservation communities away from traditional livelihood of hunting,
gathering, and farming as family members were forced to leave their reservation homes in
search of employment. Leaving the lands meant that gathered and garden foods slowly
disappeared to be replaced with more processed and commercially prepared foods. The
healthy diets of the ancestors, historically high in wild game meats and complex
carbohydrates, with high fiber fruits and vegetables and very little fat, were largely replaced
by foods common across the US, which were high in refined carbohydrates (especially
refined sugars and white flour), fat, sodium, and very low in fiber due to reduced
consumption of expensive (purchased rather than gathered or cultivated) fruits and
vegetables. This change also resulted in consumption of a selection of foods that were
lower in iron, calcium, vitamin A and vitamin C, so deficiencies in these nutrients increased
as well.
Unemployment and poverty still restrict access to purchasing healthy foods, which creates
more dependency on federal commodity programs. Some improvements in those programs
have been made to the content, quality, and variety of foods by focusing on reducing salt
and fat levels in canned meat and adding new products such as fresh fruits, vegetables,
spaghetti sauces, and dry cereals. Although commodities are sources for some, grocery
stores, food trading posts, convenience stores, fast-food restaurants, and supermarkets
currently supply most foods to family members and the foods are similar to those eaten by
other Americans: High in calories, especially fat and refined sugar, low in iron, fiber,
calcium, and vitamins A and C.

Many Navajos and Apache families continue to eat meat from sheep or goats if they have
a supply available. Sheep are central to life for many rural families, providing both food and
clothing. Even modern families believe that sheep or goats were given to the Navajos by
the Sun and without the sheep their lives would be considered poor. When families butcher
a sheep, every part of the sheep is consumed or used as clothing by traditional families.
Mutton is very versatile and can be grilled, baked, fried, and boiled. If stew is made, most
commonly potatoes and onions are added. Many traditional dishes are prepared and made
from parts of the sheep not normally found in a supermarket. These include organ meats,
head, and blood for sausage. To make blood sausage, blood is mixed with corn meal,
sometimes chili and potatoes are added for flavor and texture. This is considered a
delicacy. The head, intestines and ribs are traditionally roasted after a thorough cleaning.
Mutton is expected to be available during ceremonial events and social gatherings in many
homes even today.

Many traditional recipes required goat cheese and goat milk. Gazoo cheese is one such
delicacy and is prepared by mixing the center blades of the yucca with goat's milk. Yucca
was historically a valuable plant. Besides as a food, the blades were also used for making
brushes or as a combination needle and thread because they have both a sharp point and
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attached thread-fibers. The roots were prized as natural soap and shampoo.
One traditional dish was a substantial calcium source; unfortunately it is rarely prepared
today. It is a mixture of wild greens, wild yellow berries, and fresh goat's milk or goat
cheese. Another significant mineral source is the juniper ash, which was added to other
foods such as blue corn meal mush, bread, or dumplings. It is still prepared today by
burning juniper branches and sifting the ash through a screen. The basic ash intensifies
the pH-sensitive blueness of the blue corn products.

Ancestors

Although today the Apache and Navajo live as separate tribes, they both originate from the
Athapascan Tribe, which split apart a very long time ago in their southward migration. Even
with their diverse locations, they maintained a common language and their cultures remain
very similar to modern times.

The Navajo people refer to themselves as Dine or Dineh, which translates to The People.
The Navajo ancestors’ Creation story begins with Changing Woman, who is transformed
into a sacred being. Other Holy People followed the Four Worlds, the four directions of the
compass. It is believed that these Holy People put four sacred mountains in four different
directions for protection of all who lived in Navajoland. These defining mountains are Mt.
Blanca (NM) in the east, Mt. Taylor (NM) in the south, San Francisco Peaks (AZ) in the
west, and Mt. Hesperus (CO) in the north. Even today, elders respect the ancient boundary
and may hesitate to travel beyond this area.

Early Navajos learned to prosper in the hostile desert environment. They became expert
farmers, cultivating hundreds of species of corn, beans, potatoes, squash, and gourds.
They developed irrigation systems as well as terraces. Many hunted and gathered and
made nearly everything useable (edible or wearable). Common hunted animals included
deer, elk, bison, antelope, mountain sheep, rabbit, gophers, quail, turkey, and fish. Wild
plants were collected to be eaten in assorted dishes or prepared as herbs and teas for
maintenance of good health and to cure various illnesses. Important wild plants consumed
were berries, acorns, pinon-nuts, wild seeds, turnips, wild spinach (lamb’s quarter), and
wild onions. Many different species of cactus and their fruits were collected and eaten.
Eventually they learned to raise sheep and goats, which flourished in their environment,
migrating with them to the higher elevations for better feed in the spring and summer. Most
of the foods grown, hunted, and collected provided the basis for a nutritious diet for these
early Navajos. These foods were low in fat, salt, and sugar and contained high levels of
vitamins, minerals, and fiber.
Apache refer to themselves as Inde, which also translates as The People. They have been
mentioned in history books since early 1600s and, being nomadic buffalo hunters, were an
important source of bison meat, hides, and materials for stone tools in trade with the
Pueblo peoples of the southwest. Some settled near the Pueblo Indians and became
excellent farmers, cultivating maize, beans, pumpkins, and watermelons.
Marauding Comanches frequently attacked them in their fields, forcing them to move
further westward. They migrated in small bands and eventually settled in different states,
mostly in CO, NM, AZ and UT. They didn’t establish permanent homes in any one place
but moved almost constantly. In early spring, they chose low-altitude camps in Salt and
Gila River valleys, where they cultivated corn, beans, and squash. When the harvest was
completed, they gathered saguaro fruit, prickly pear pads, cholla cactus buds, mesquite
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pods, desert chia, tepary beans, and mescal (agave), which became a staple of the Apache.

Meal Planning in this Native Culture

Many Navajo and Apache families continue to live on the reservations; others have moved
to rural or urban areas that are very different. But for all, frequently there is no advance
meal planning at all. Foods used in the next meal are what is available or what will be
picked up at a convenience store or similar sources. Daily or weekly sit-down dinners with
a menu are rare. Meals prepared from dishes with recipes occur very infrequently, with the
exception of special celebrations.

Today’s elderly residents of the reservations may tend to select ready-made foods based
on more traditional food items such as corn, tortillas, mutton, or goat meat (available in
specialty markets even in moderate-sized cities near reservations) augmented with
whatever wild game and seasonal wild plants that might be available. Younger residents
living on reservations and certainly off reservations have access to many modern food
sources at food trading posts, convenience stores, fast-food restaurants, and
supermarkets, contributing to a decreased need to plan meals or prepare foods. Many
people also participate in either the Food Stamp Program, Special Supplemental Food
Program for Women, Infants, and Children (WIC) or the Food Distribution Programs, all of
which (perhaps unintentionally) encourage use of non-traditional foods with coupons or the
actual foods distributed.

It is essential to encourage all people to make healthier food selections and consume a
balance of important nutrients, taking into consideration individual and cultural preferences
and practices. Dietary interventions must be practical and available to the people they are
intended to help. There are various limitations that affect food choices. For example, food
selection is limited and cost for foods are extremely high at food trading posts for some
Navajos and Apaches who live on the reservations or in rural areas. Families may shop
infrequently and often do not have refrigeration, electricity, or running water. Therefore,
foods that are perishable must be consumed immediately. Infrequent shopping trips, food
selections based on habit rather than trying new items, and lack of refrigeration together
have large impacts on food practices of many. Also, grocery shopping depends on the
distance, transportation, and conditions on the roads (many of which are unpaved) and
weather (which makes travel on unpaved roads difficult).

When assessing nutritional intake and meal planning for Navajo and Apache families, it is
essential for healthcare professionals to become familiar with some of their traditional foods
and practices that may impact dietary compliance. Traditional foods possess significant
and, at times, forbidden impact on food preparation, food selections, preferences, and new
edible foods, especially for the elders. It is important to understand and appreciate that
certain foods may be forbidden by traditional medicine men participating in a ceremony or
singing and are then believed to impact health and healing. For example, a medicine man
may forbid round foods such as fish, pork, eggs, tortillas, and pancakes for certain people,
giving them instructions not to eat these foods again or their illnesses will return.

When carrying out a dietary assessment, it is important to keep the following critical
questions in mind. Where are foods purchased? At a trading post, supermarkets, or
convenience stores? Do they grow, gather, and hunt their own food? Who does the cooking
for family members? Is there access to electricity, running water, and refrigeration? What is
the total food budget, including commodity foods, food stamps, or family farming practices?
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the total food budget, including commodity foods, food stamps, or family farming practices?
Many families do still have gardens, with specific crops, and also may raise sheep, cattle,
or goats.

On the reservations, most fresh fruits and vegetables are unavailable except for seasonal,
locally grown produce (such as apricots), and they tend to be very costly. Additionally the
short shelf-life is not compatible with infrequent shopping. However canned fruits and
vegetables are available all year since they require no special storage and have a long
shelf-life. The short shelf-life of meats is even more of a detriment to the choices of many
unless they raise their own. Canned meat availability has traditionally been limited to
Vienna sausages, Spam, corned beef, and tuna. Fortunately pinto beans are stable,
enjoyed by most, and provide an economical protein source.
Because of abrupt changes in lifestyle, obesity rates of the Native American population
have increased to epidemic proportions, exceeding that of the US as a whole. The increase
in obesity has been attributed to a change from formerly active lifestyle to one which is far
more sedentary. Also contributing are the major negative changes in diet characterized by
increased consumption of fast food and other high-calorie foods and overall abundance of
food (excess portion sizes). Other contributing factors include excess sedentary activities
(watching television, using computers, playing video games), inadequate parenting skills,
high consumption of soft drinks and alcohol, school lunch programs with poor nutritional
content, reduced physical activity in schools, reliance on motor vehicles for even
short-distance transportation, and poverty. Additional contributing factors include lack of
confidence to change behaviors even when it is understood that the change would be
better for health and well-being as well as the lack of social support for any changes from
family members who may not want to make changes themselves.

Food Dictionary

Food Ingredients or Preparation
Milk
Goat milk cottage cheese;
goat Milk
The cheeses were frequently part
of the diet, because of their
stability compared to milk.
Vegetables
Wild spinach Once washed, they are boiled
and drained to remove the bitter
taste. These are added to mutton
stew
Wild potatoes A root bulb, that is boiled and the
tough outer skin is removed and
eaten like chalk-like white clay.
Without the clay the potatoes
taste bitter and rare.
Turnips Grown and used for home
consumption.
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Acorn Roasted in bed of ashes or top of
the stove. Some are stone-ground
after roasting and mixed with corn
meal for making bread.
Wild carrots Plant that is a fern-leaf that is
blue-gray in color. Its roots are
brittle and fibrous. It is eaten after
the bark-like covering is removed.
Wild onions The bulbs are small. Sometimes
eaten raw or cooked with either
potatoes or added to stew.
Roots Most are dug out after the
bark-like covering removed and
eaten. It is usually brittle.
Squash Home grown and either added to
corn dishes, fried in a pan or
eaten raw.
Pinyon Nuts Grow on pinyon trees. They are
roasted in the pans or eaten raw.
Fruits
Wild berries Sometimes eaten raw after
picking. Often it is stone-ground
into paste and mixed with white
clay. The clay reduces the sour
taste of the berries.
Juniper berries Sometimes eaten raw, toasted.
Water added to make cakes.
Often dried in the sun on a flat
surface and used as needed.
Yucca Fruit Fruit is shape like a banana. This
is placed in a bed of hot ashes to
cook for an hour. When it is done
it is cut in half and the seeds are
scraped out. The covering is used
as meat and eaten immediately or
dried for future use. The pulp has
flavor like dried figs.
Prickly Pear Cactus This fruit is dark red in color
when it is ripe. The pulp of the
fruit is eaten. The outer skin and
seeds are removed. The flavor
taste sweet.
Breads and Cereals
Corn Its pollen is considered the
source of life. It gives life and
good health.
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Blue corn Roasted, boiled, or used as
hominy. Cornmeal (white, yellow,
blue, and red corn was in the
basis for a variety of traditional
dishes.
Blue corn bread; blue corn
mush
Popular dish for pudding, juniper
ash is used to intensify the blue
color, flavor and increase the
calcium content
Navajo creamer Made from ground white corn
and contains protein, fiber,
calcium, magnesium and iron.
Kneel down bread Mostly prepared with corn and
water.
Pudding Fresh berries crushed and seeds
removed. Water is added and
mixed with flour. Then it is boiled.
Dumplings Made with flour, baking powder,
salt, shortening. Shape into a
small dough and drop into boiling
water for 15 mins.
Tamale Meat is usually added and made
with corn meal and wrapped in
corn husks. It is boiled or baked.
Pancake Made with juniper ash, blue corn
meal, and water. This is poured in
a hot skillet.
Piki bread Made from a mixture of blue corn
meal, water, and ashes. Cooked
on a hot stone in large
tissue-paper sheets, it is rolled up
like a newspaper after cooking.
Tortillas Made with wheat flour, water,
shortening and baking powder.
They are baked on the griddle or
over hot coals.
Navajo cake Made with yellow cornmeal,
raisins, sugar, wheat sprouted
and water. This is cooked in a
circular pit over night.
Paper bread Made with blue cornmeal, water,
and baking powder, sometimes
ashes are added. This is cooked
over a hot stone rolled up very
thin after it is cooked.
Meats
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Sheep mutton and goat Meat that is baked, boiled, grilled
or roasted over an open-fire.
Wild turkey Cooked as the usual meat.
Horse meat and donkey;
Ribs, beef
Cooked as the usual meat.
Venison and Antelope
meat
When this is available it is
cooked the same as mutton.
Prairie dog and rabbit Once they are cleaned, they are
roasted over hot coals.
Beans Pinto beans from commodity
foods or from mesquite beans.
The seed is high in protein.
Sheep feet; Sheep head This is usually cooked over a bed
of coals and is considered a
delicacy.
Squirrel Once it is cleaned, it is roasted
over hot coals
Intestines Once the intestines are cleaned it
is wrapped around the fat which is
then boiled, roasted and eaten
immediately.
Ribs Roasted, boiled, or grilled over
hot coals.
Internal organs (heart,
lungs, trachea, diaphragm)
These organs are used in stews,
roasted and boiled.
Liver; tongue Usually cut into large pieces, and
boiled with fat.
Fats
Intestine with mutton fat Once the intestines are cleaned it
is wrapped around the fat which is
then boiled, roasted and eaten
immediately.
Sheep brain The brain is roasted in a bed of
hot ashes.
Mutton fat Used to wrap intestines and liver.
Consider delicacy for others. The
perirenal fat is used for cooking
Blood sausage During slaughtering blood is
collected and mixed with corn
meal, salt, potatoes, and onions.
This is placed in the stomach and
boiled. It takes 2 -3 hours to boil
or until tender. This is eaten hot or
cold with tortillas or fried bread.
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Ribs (fat) This is roasted, or broiled over a
bed of coals.
Sweets
Corn cake Made with cornmeal, sugar,
sprouted corn and water

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Resources > Cultural Food Practices > Native American > Alaska Native
Adaption of Native Culture to American Culture

Transition from an older culture to a newer, more modernized world can be difficult. Often
the Elders of a community still practice a subsistence lifestyle (Nobmann 2005). Younger
Alaskan Natives are moving out of rural villages to more urban areas for work and to
pursue an education. While many Alaskan Natives come to urban areas for work,
traditional/subsistence foods are not readily available and the family must rely more on
grocery stores.
By promoting a healthy mix of subsistence foods and store-purchased foods, Alaska
Natives can have the best of both worlds. One impact of less subsistence is lower levels of
activity. Hunting, fishing, and gathering are excellent ways to increase physical activity and
consume whole, organic foods.

Ancestors

Alaska is the largest state in America,roughly one third the size of the continental United
States. It has more land area than Washington, Oregon, California, Arizona, Nevada,
Idaho, Utah, Wyoming, Colorado, New Mexico, and Montana combined. Its huge land
mass covers 533,000 square miles and is surrounded on three sides by water, with a total
coastline of 33,000 miles. The climate varies greatly throughout the state, depending on
the location. For example, the southeast has winters with mild temperatures and a great
deal of rainfall, while winter temperatures dip well below 0°F for months in the north. Along
the Aleutian and Pribilof Islands, the weather can be unpredictable, but typically includes
wind, mist, and gray skies. In Alaska's interior, the temperature on summer days can reach
90°F or hotter, and it can get as low as -50°F on winter nights, not counting a wind chill
factor!
Alaska’s native groups can be divided up into five categories: Aleut, Yupik Eskimo, Inupiat
Eskimo, Athabascan Indians, and Coastal Indians.

According to the 2006 US Census Bureau, 88,026 Alaskan individuals designated
themselves as Alaska Native only; an additional 35,213 designated themselves as Alaska
Native in combination with one or more other races. Approximately 55% are Eskimo, 32%
Indian (Tlingit, Haida, Tsimshian, and Athabascan), and 13% Aleut.”

The Eskimo, including the Inupiat, live in the northern and northwestern coastal regions.
The Yupik Eskimos typically live in the southwestern regions. The Athabaskan Indians live
in the interior of the state, and the Coastal Indians (Tlingit, Haida and Tsimshian) reside
along southeastern coastal Alaska. The Aleuts include residents of the Aleutian Islands,
the Pribilof Islands, the western tip of the Alaska Peninsula, the Kodiak area, and the
coastal regions of south central Alaska.

Counseling Tips

The counselor should keep in mind that different regions of Alaska have diverse food
practices due to the foods available in their area and the season. Knowing where the client
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is from can assist in how the counselor approaches the counseling session. The elder
population is more likely to still follow a subsistence lifestyle, whereas the younger
generations are moving toward commercially prepared foods, including foods purchased
from grocery stores, fast food restaurants, convenience stores, and other restaurants
(Nobmann 2005).
Interpreting the clients’ body language can assist in a successful counseling session.
Reflecting cues such as using silence to let the client respond when ready can improve
communication. Those living in more urban areas are more accustomed to eye contact and
participating in motivational interviewing (Treat 2009).

As in all populations, following the clients’ non-verbal cues will assist with building rapport
and individualizing the session. Respect is also shown by a soft handshake, avoiding eye
contact when speaking, and leaving long pauses between speaking. It is important to
remember that Alaska Natives traditionally are slow to trust newcomers and try to avoid
conflict, focusing more on building consensus among their community.
In a counseling situation and when meeting an Alaskan Native for the first time, it is
important to speak slowly and wait calmly for an answer. Observe the person to see if eye
contact is appropriate. Asking open-ended questions will assist you in knowing if an
interpreter is needed. Many Alaska Natives from small villages are shy and will not want to
“burden” you with questions. They are, however, generally highly appreciative of
information and education on their health.

Food Dictionary

Alaska Native Food Items
Agutuk, agutug
Eskimo or Indian ice cream, traditionally
made with berries and caribou fat and meat
or seal oil. Other variations include dry fish,
fish eggs, or sour dock. Today, agutuk is
made with berries (most commonly
salmonberries), shortening, and sugar.
Sometimes mashed potatoes are used as
the thickener. Agutuk is not frozen; it is
stored in the refrigerator and remains solid
at refrigerator temperature.
Beach asparagus
(Salicornia
pacifica)
A smaller, thinner wild asparagus similar to
cultivated asparagus, but with a saltier
taste. It is found on the beaches of
southeast Alaska. Young plants can be
used fresh for salads or for pickles.
Crowberry
(Empetrum
nigrum)
Also called blackberry. Berries grow on
creeping plants similar to some heathers.
Found in all parts of Alaska except the high
arctic.
Dog salmon Common name for chum salmon.
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Dried black
seaweed
(Porphyra
laciniata)
A long, narrow, thin, leaf-like structure about
one foot long and 1.5 to two inches wide,
with wavy edges. Seaweed is green when
fresh, but turns black when dried. Seaweed
is partially dried, ground in a food chopper,
then thoroughly dried. Dried seaweed is
eaten raw like popcorn and is often used in
soups or stews for flavor.
Dried meat Air-dried strips of caribou or moose.
Eulachon See hooligan.
Fiddlehead fern
(Dryopteris
austriaca)
A native fern found in southeast and south
central Alaska. Gathered in the spring, it
can be used raw in salads, steamed, or in
stir fry dishes.
Goose tongue
(Plantago
martima)
A wild green found in southeast Alaska and
the Gulf of Alaska coast. The leaves are
eaten fresh or cooked, and can be canned
for winter use.
Gumboots
Leathery chiton; a marine mollusk found in
southeast Alaska.
Highbush
cranberry
(Viburnum edule)
Very tart red berries, about the size of
blueberries, that grow on tall shrubs. Found
in the Alaska peninsula north to the Brooks
Range. They can be made into ketchup or a
sauce, both of which are tasty
accompaniments to meat.
Hooligan
Common name for eulachon. A small fish
resembling smelt, about three to six inches
long, with a high fat content. Also called
candle fish.
Hooligan oil Oil from eulachon (hooligan).
Humpy Common name for pink salmon.
Juice
Powdered soft drinks and other
sugar-sweetened, fruit-flavored drinks often
are called juice.
King salmon Common name for chinook salmon.
Lowbush
cranberry
(Vaccinium vitis)
Also called lingonberry. Berries that grow on
a creeping evergreen shrub are found all
over Alaska. They are best picked just after
the first frost. Less tart than highbush
cranberries, these berries are used for jam
and pies.
Muktuk
The skin and attached layer of blubber of
beluga whales.
Mush Common name for any cooked cereal.
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Pilot bread
Also called hardtack. Dense, round crackers
made from white flour with unsalted tops,
they have diameters of about four inches.
Potlatch
A gathering of community members for a
meal to show respect for a person who has
died or to celebrate a special occasion.
Elders are served first by younger
community members. People attending take
the extra food home.
Ptarmigan
Also called grouse. A game bird with
feathered feet, found in cold northern
regions.
Red salmon Common name for sockeye salmon.
Salmonberry
(Rubus
spectabilis)
Also called cloudberry. Found in western
and southeast Alaska, it resembles a
salmon-colored raspberry.
Seal oil Oil made from seal fat.
Silver salmon Common name for coho salmon.
Soapberry
(Shepherdia
canadensis)
A tiny, orange-red berry, found in most of
Alaska except the northeastern area. It has
a slightly bitter taste. When beaten, it forms
a frothy mass, owing to a property that
comes from saponin. When eaten in large
quantities, this berry can upset the digestive
tract, causing abdominal pain, vomiting, and
diarrhea. When eaten in moderation,
however, it is safe to eat and causes no
digestive difficulties.
Soup
Boiled meat (caribou, moose, venison),
duck, or fish with rice and macaroni.
Potatoes or canned tomatoes are
sometimes added.
Sour dock
(Runiex arcticus)
A wild green found in wet, marshy areas
along river banks and moist areas on the
tundra. The young, tender leaves are picked
in the spring or early summer and eaten as
a salad green or cooked vegetable. The
fresh leaves are good sources of vitamins A
and C.
Tundra tea, or
Hudson Bay tea
(Ledumpalustre)
A shrub with strongly aromatic leaves that
can be used to make a very palatable tea.
Venison Another name for deer meat.
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Wild celery
(Heracleum
lanatum)
A wild, perennial plant found in most of
Alaska except the northern regions. The
leaflets are somewhat like maple leaves and
the stalks are hairy. The small, white flowers
grow in large, umbrella-shaped clusters.
The stems are stripped of their outer, fibrous
layer and eaten raw. Abuits call this plant
pushki.
Willow (Salix
pulchra)
A shrub found throughout the Alaska
Range, Yukon River area, and the Bering
Sea. Eskimos gather the new, tender shoots
in early spring. Later, they collect the young,
tender leaves, mix them with seal oil, and
eat them raw. Young willow leaves are a
rich source of vitamin C.
Sources
Cooperative Extension Service. Wild Edible and Poisonous Plants. Fairbanks, Alaska:
university of Alaska, Fairbanks; 1989. 3000c-0o28.
Editors of Alaska magazine. Alaska Wild Berry Guide and Cookbook. Anchorage, Alaska:
Alaska Northwest Publishing Co; 1982.
Jones A. Nauriat Niginaqtuat Plants That We Eat. Kotzebue, Alaska: Maniilaq Association;
1983.

Food Practices

Alaska may still be called the last frontier. The lifestyle currently is a mix of subsistence
(hunting, fishing, gathering) and a modern world.
Although Alaska is vast, some common cultural food practices exist throughout the state.
Whether foods come from the sea or land, most Alaska Native groups traditionally had a
high-protein, high-fat diet. Hunting, fishing, and gathering are the traditional methods of
obtaining food, so quantity and food selection change with the season. Historically, Natives
would travel from place to place in search of food to feed the family and community during
different seasons. Now, Natives live in villages, and travel by boat, snow machine, and All
Terrain Vehicle (ATV or 4-wheeler) to obtain food. Animals have moved further away from
the villages and the cost of gasoline in remote villages can be more than families can
afford. Many families are purchasing foods from the grocery store and supplementing with
traditional foods when available. With more processed foods, the Alaskan Native diet is
higher in simple carbohydrates and saturated fat.

Alaska Natives traditionally hold Potlatches, which are ceremonial feasts that include
dancing and the distribution of goods to guests. These gatherings are held to honor a
deceased person or to celebrate a special occasion.

The small stores in villages have limited supplies of fresh foods and large quantities of soft
drinks and snack foods. Federal food programs—such as the Food Stamp Program, the
School Lunch Program, and the Supplemental Food Program for Women, Infants, and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Children—have encouraged the use of store-bought food.
Fish consumption is high among Alaska Natives. Research shows that fish consumption
among Alaskan Natives far exceeds that of the average American diet (Heller 1967,
Nobmann 1992). Eggs, chicken, frankfurters, ham, canned meats, and luncheon meats are
other protein sources in the current diet. Popular prepared foods include frozen dinners and
entrees. Dried beans and peas are not consumed frequently. Game meats are eaten more
often in the winter (Treat 2009).

Alaska Natives, historically, do not frequently eat fruit and vegetables. Fresh fruits and
vegetables are not always available in village stores. Those that are available can be
expensive, variety is generally limited, and the produce is often of poor quality. Potatoes,
lettuce, onions, and carrots are among the fresh vegetables that are generally available.
Many families gather wild berries, which are eaten fresh or are frozen for later use. Canned
fruits and vegetables are used more frequently than fresh produce (Treat 2009).

Fresh milk is not always available in villages. Moreover, it is expensive; for example, a
gallon costs $12 in one northern Alaska village. Thus, milk, when used, is often
evaporated, powdered or in shelf-stable containers. It is very common for a native
individual to be lactose intolerant.

Frequently consumed carbohydrates include sugar, bread (usually made with enriched
white flour), rice, pilot bread (large, round, dense crackers), sourdough pancakes, and
mush (cooked cereal) (Murphy 1995, Nobmann 1989, Heller 1967, Nobmann 1992,
Bersamin 2006). The most frequently consumed cooked cereals are oatmeal, cornmeal,
and Cream of Wheat.

A 2006 dietary survey of Alaska Native adults from 13 communities describes eating
practices of participants 13 to 88 years of age. In all regions except the Coastal Indian area,
sugared soda pop, Tang™, Koolaid™, Hi-C™, and fruit juice were the most consumed
beverage. The most consumed beverage for Coastal Indians was milk, followed by
sugared soda pop, Tang™, Koolaid™, Hi-C™, and fruit juice. At least 70% of Alaska
Natives consumed more than 30% of calories from fat (Ballew 2006).

A customary food practice by mothers is to pre-masticate food for the infant or young child.
This past and current custom is used as blenders and commercial baby foods are not
readily available. Education efforts are being made to decrease this practice due to the
transmission of bacteria and viruses from the mothers’ saliva.
Health professionals, community leaders, and others should encourage the consumption of
traditional foods such as fish, lean game meat, berries, greens, and seaweed for several
reasons: Their rich nutrient content, their ability to replace less nutritious foods, and their
strong association with cultural customs (Treat 2009, Nobmann 2005). The current diet can
be improved by adding more fruits and vegetables, substituting whole-grain breads for
white bread, and reducing the consumption of energy-dense sweets and beverages, total
fat, and cured meats.

Meal Patterns for this Native Culture

The food choices, as in all groups in Alaska, have been changing over the past 50 years.
Aleut and Alutiiq peoples are located in southwest Alaska on the Aleutian chain, Kodiak
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Island, and Pribilof Islands. Most foods in this area come from the sea. Common protein
foods for the Aleut are seal meat, salmon, herring, herring eggs, halibut, clams, crab,
mussels, ducks, geese, and bird eggs. Carbohydrate foods include cranberries,
salmonberries, mossberries, and wild celery. Fats are rendered from hooligan or seal. In
the twentieth century, lard was added as a staple and now liquid vegetable oils are
encouraged.
Most Yupik (‘yupik) Eskimos live in southwest Alaska and speak Yupik. In the traditional
belief system of the Yupik and lnupiat, success in hunting depends on maintaining a
positive relationship between the people and the spirits of the animals they hunt. Some of
the main protein sources for Yupik Eskimos are seal, herring, herring eggs, needle fish,
blackfish, tomcod, smelt, ling cod, pike, whitefish, salmon, beluga whale, caribou, beaver,
mink, hare, ptarmigan, ducks, geese, and bird eggs. Yupik Eskimos gather salmonberries,
lowbush cranberries, crowberries, blueberries, sour dock, and willow greens. Seal oil is
routinely used to season soups or used as a dipping sauce for frozen fish or caribou and
pilot crackers.

The Yupiit and Inupiat from the north gather food from the sea and land. Inupiat from the
northern coast of Alaska hunt bowhead whales. Whaling is still important in the community
and is celebrated with ceremonies. The whale harvest is shared among community
members. Common protein-rich foods for Inupiat Eskimos are caribou, bowhead whale,
seal, walrus, grayling, whitefish, tomcod, ling cod, trout, ducks, geese, and bird eggs.
Muktuk (the outer skin of whale with a portion of blubber attached) is eaten by the Inupiat.
Raw frozen meat and fish are consumed at meal times and seal oil is used as a condiment
in which to dip the raw frozen fish or meat.

The interior of Alaska is inhabited by the Athabascan (athabaskan) Indians. This region
extends south of the Brooks Mountain range to the Kenai Peninsula. These communities
utilize the rivers, land animals, and plants gathered from the tundra for traditional foods. A
traditional Athabascan Indian diet includes large amounts of protein from hunting moose,
beaver, muskrat, porcupine, rabbits, ptarmigan, ducks, and geese. They also fish for
salmon, shellfish, pike, and grayling. The eggs from these fish are also eaten. Fats use in
the Athabascan Indians' diet include moose and beaver fat as well as vegetable oils. The
majority of their carbohydrates are from gathering blueberries, salmonberries, highbush
cranberries, lowbush cranberries, and rose hips.

Tlingit (‘tlin(g)ét), Haida (hida), and Tsimshian (‘tsimshean) Indians live in southeast Alaska
stretching from the Copper River basin to the southeast Panhandle. It is a costal area
consisting of many islands. The people from this region depend on water and river ways for
their food and travel. Although these groups are neighbors, their languages are very
different.

Protein sources for the Tlingit, Haida, and Tsimshian Indians of southeast Alaska are
salmon, halibut, herring, herring eggs, cod, eulachon (“hooligan” fish), cockles, clams,
leathery chiton (“gumboots”), crab, seal, and deer. Indians of southeast Alaska use oil from
Eulachon, seal and other fish as fat sources. Because the climate of southeast Alaska is
milder, more plant foods are available offering rich sources of carbohydrates. These
include salmonberries, blueberries, huckleberries, soapberries, highbush cranberries,
lowbush cranberries, beach asparagus, fiddlehead fern, wild celery, and goose tongue.
Seaweed is also gathered and dried.

Improving food choices can be difficult for those living in the village or rural Alaska. One
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Improving food choices can be difficult for those living in the village or rural Alaska. One
reason is because many village locations are being connected to the main road system or
are located on an island. Also, there may be an unavailability of hunters and gatherers for
subsistence activities. Thus, store-bought foods are typically imported in through other
means of transportation. In southeast Alaska, the state ferry system is used to transport
food and other supplies. In other parts of Alaska, passenger planes are utilized to transport
food. Often due to treacherous weather conditions, grocery stores will often have to wait
a long time for a new shipment. People must then rely on their stock of food. Store-bought
food can be costly due to the difficulty that can come from delivering food to these villages.
It is economically beneficial for purchased foods to have a long shelf life; for instance,
canned or processed foods.
In addition, due to the changing generations and lifestyles, Alaska Natives are hunting and
gathering less. Often, individuals will hold a job that limits the time they can spend
collecting a healthier, more natural food source from the land or sea. Consuming these
more traditional foods rather than processed, store-bought foods should be encouraged
when possible.

Meal Planning for Traditional Alaska Native Foods

Food Group Food Portion
Carbohydrate Group
(15 gm=1 portion)

Starch Pilot bread, 4-in diameter 1
Fruit Highbush cranberries
Huckleberries
Salmonberries
1 cup
1 cup
1 ½ cup
Starchy Vegetable Willow greens 1 cup
Protein
Very lean meat Caribou
Gumboots (leathery
chiton)
Halibut**
Herring eggs, plain
Moose
Pike
Seal meat
Venison**
Whale, bonehead
1 oz
2 oz
1 oz
½ cup
1 oz
1 oz
1 oz
1 oz
1 oz
Lean meat Muskrat
Salmon, sockeye**
Walrus
1 oz
1 oz
1 oz
Medium-fat meat Dried fish (king salmon) ½ oz
High-fat meat Hooligan (eulachon),
smoked
1 oz
High-fat meat + 1 fat Muktuk, skin and fat 1 x 1 x 2 in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fat group
Fat Seal oil 1 tsp
Non-starchy vegetable
Beach asparagus
Fiddlehead Fern
Seaweed, black, dried
Sourdock
Free foods; eaten without
added oils
Meal planning may be individualized in which the Food Guide Pyramid; Rate your Plate, or
Exchange Lists may also be used.
Using self-monitoring blood glucose two hours after a meal is very beneficial to customize
carbohydrate portions.
**Nutrition information is taken from Nutrient Values of Alaska Native Foods, 1993.

References


Ballew C, Tzilkowski AR, Hamrick K, Nobmann ED, The contribution of Subsistence Foods
to the Total Diet of Alaska Natives in 13 Rural Communities. Ecology of Food and Nutrition
An International Journal. 45:1-26, 2006
Bersamin A, Luick BR, Ruppert E, Stern JS, Zidenberg-Cherr S, „Diet Quality among Yupik
Eskimos living in rural commmunities is low: The center for Alaska Native Health Research
Pilot Study“ Journal of the American Dietetic Association. 2006. 1055-1063
Heller CA, Scot EM. The Alaska Dietary Survey 1956-1961. Washington, DC: US Dept of
Health, Education, and Welfare; 1967. Public Health Service publication 999-AH-2.
Murphy N.J., C. D. Schraer, M. C. Thiele, E.J. Boyko, L. R. Bulkow, B. J. Doty, and L.P.
Lanier (1995). Dietary change and obesity associated with glucose intolerance in Alaska
Natives. J. Am. Diet. Assoc., 1995, 676-682
Nobmann ED, et., al., “Dietary Intakes Vary with Age among Eskimo Adults of Northwest
Alaska in the GOCADAN Study, 2000-2003” Nutritional Epidemology. American Society
for Nutritional Sciences. 856-387. 2005
Nobmann ED, Byers T, Lanier AP, Hankin HJ, Jackson MY. The diet of Alaska Native
adults. Am J Olin Nutr. 1992;55:1024-1 032.
Nobmann E.D. Assessment of Current Dietary Intakes of Alaska Native Adults, Final
Report. Anchorage, AK: Alaska native Health Service.1989
Treat CA, Champine I, Fowles K. Direct observation with a combined total of 25 years of
dietary interview with diet recalls statewide. 2001-2009

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Native American > Hopi
Food Practices

The Hopi Indians live in the northeast section of Arizona on a series of mesas. Mesa is a
Spanish word meaning "table." These hills have a level top and steep sides. They belong
to the huge language family of tribes known as the Uto-Aztecan. The Pima and Tohono
O'odham to the south of the Hopi in Arizona also belong to this language family. For
convenience, ethnologists group tribes together if traces of common beliefs or customs
were found, even though tribes were separated by great distances.
The Hopis are part of a group of people known as the Pueblo people. Long before
Columbus came to the New World, there were cities of apartment-like buildings that could
house 1,000 people at a time (Reid 1997). The southwestern states of Arizona, New
Mexico, Colorado, Utah, and Nevada were home to these people.
When the Spanish came, they named them the Pueblo people, pueblo meaning "village" in
Spanish. The Pueblo peoples always had a battle with Mother Nature over the lack of water
in the Southwest. The Hopis used underground springs from the mesas, a necessity in
sustaining their crops. Agriculture and religion were closely related, in that prayers for
rainfall and good harvests were made. Early seeds were precious and were guarded closely.
The early Hopi ate common and rare foods (Neithammer 1974).The common foods were
those they were able to grow on their mesa. The rare foods consisted of wild and domestic
meats, wild plants, salt, sugar, chili, and onions. The common foods are listed below:
Corn: The main food of the pueblo tribes was corn. By 700 AD, many varieties in
many different colors had been developed. Hopi corn was very drought resistant and
immune to many diseases. The Hopi hold a midsummer festival, usually
in July, called Niman, which celebrates the growth of the early corn in the fields. This
corn is roasted in outdoor pits. No direct fire is used, only intense heat, which bakes
the corn in its husk.
Beans: Two types of beans were a protein source to the Hopi. The pinto bean, a form
of the kidney bean, was harvested from their gardens, while the red, white and
spotted tepary beans grew wild in canyons of Arizona and northern Mexico. Every
year in February, the Hopi hold the ceremony called Powamu in which beans are
raised in kivis and then paraded throughout the village for good luck in summer
planting.
Squash: Squash was favored by the early Hopi people. Botanists say that these were
actually pumpkins. After being cultivated, they were cut in half and sun dried for a few
days. When soaked in water, the taste of pumpkin would return. Artificial squash
blossoms were placed on altars to lend their magic to the growing process.
Sunflower: Hopis raised the sunflower for the ornamentation of the flower and also for
a good source of oil. The seeds were also roasted and could be eaten raw, much as
people would eat nuts.
Pigweed: Hopis roasted Pigweed seeds ground into flour, which was used in bread
making.
Wild mint: Wild mint is used to flavor corn meal mush.
Lamb's quarter: The Hopis packed lamb's quarter around other foods when they were
pit-baking for seasoning.
Wild currents: Wild currents were dried and used for winter consumption.
Wolf berry: Wolf berry is ground up or used as a raisin-like dried fruit.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Wild onion: Wild onion is roasted and put in piki bread.
Other celebrations are important to the Hopi, such as the baby-naming ceremony. After the
baby is born, the mother and baby go home and stay for 20 days. The mother goes on a
strict diet without fat, meat, or salt. On the 20th day, the village comes for a feast of beef
stew and white corn pudding with piki bread. The baby's father's family will name the baby
at this celebration.

Ancestors

Members of the Hopi tribe consider themselves to be descendants of the ancient Anasazi,
who were known for their stunning pueblos. The Anasazi concentrated their homes in the
Four Corners region of New Mexico, Colorado, Utah, and Arizona. The Anasazi can be
grouped into eastern and western societies. The eastern Anasazi were responsible for the
Chaco culture in New Mexico. The western Anasazi lived in Arizona and southeastern Utah
(Reid 1997).
The Hopi word for these descendents is Hisatsinom, which means "our ancestors." These
ancestors were master farmers, architects, artists, and astronomers. The ancients were
cultivators of the crops known as the three sisters: corn, beans, and squash. The Hopis
today continue to be master farmers as they grow corn, beans, squash, melons, and other
crops.
The end of Hopi prehistory concludes with the Spaniard Pedro Tovar's arrival into Arizona
in 1540.

Adaptation of Native Culture to American Culture

Brown, in her study of Hopi school children, found their diets exceeded recommended
intakes for energy, fat, cholesterol, sodium, and refined sugars. Very few fresh fruits and
vegetables were consumed by the children in the study (Brown 1994). The Hopi diet today
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
is primarily one of beef or mutton, eggs, store-bought bread, potatoes, canned vegetables,
fruits and fruit juices, lard and other fats, soda, and sweet and salty snacks. Refined cereals
are consumed as well as sucrose-rich foods, all of which were not a part of the
traditional or ancestral meal plan.
During the years between 1860 and 1940, the government studies revealed undernutrition
and malnutrition on Indian reservations in the United States. In the 1960s, the trend toward
overnutrition began, which has led to massive rates of obesity among Indians. By the end
of the 20th century, the primary nutritional problems (Teufel 1999) among Native
Americans were these:
Exceeding energy needs by high calorie intake
More than 30% of total fat intake daily
More than two drinks of alcohol daily
Less than 20 g fiber daily
Less than 10 mg iron daily
Less than 1,200 mg calcium daily
Low intakes of vitamin A
Low intakes of vitamin C
When a registered dietitian counsels Native American clients, respect for the native culture
must be observed or the counseling will be fruitless. Native Americans love food and many
celebrations center around food and the family. Native Americans can be treated best with
nutrition therapy and behavior modification. Exercise and portion control are key factors.
Clients can be asked to reduce consumption of fried foods in their diets. Asking a client to
make wiser choices in dining out can reduce calories. Increasing the amount of fruits and
vegetables in the diet can increase fiber and vitamins A and C. Refer a client to an alcohol
or behavioral health counselor if alcohol is an issue.
Risk factors determine the possibility that American Indians and Alaska Natives will
develop diabetes. Risk factors include genetic factors and medical and lifestyle factors.
Obesity is a major risk factor for diabetes, and increasing rates of obesity correlate with
diabetes.

Meal Planning in this Native Culture

The Hopi Indians have lived in Northern Arizona for 500 years or more. They did not
wander in search of food because they raised beans, squash, and corn (Underhill 1991).
These three crops were known as the three sisters in native agriculture. Meat was eaten
only for special occasions because of the scarcity of animals.
Today, the tribe eats a more nontraditional meal plan mainly from foods through
government programs and grocery stores. The convenience of these foods is a major
factor in many society's decision to decrease the use of indigenous foods.
Melinda Aguirre of the Hopi Tribe assisted with listing the following items that the Hopi eat
on feast days. Aguirre grew up in old Oraibi, which is the longest-inhabited town in the
United States.
Breads are flour tortillas, fry bread, or piki bread. Blue corn meal is used to make blue
corn meal dumplings.
Many beans are eaten, including pinto, white lima, kidney, and yellow beans. Squash
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
is steamed and eaten with salt added. Wild spinach is boiled until tender and spices
added. Fresh corn is steamed and eaten with salt. Parched corn or dried corn can be
reboiled and eaten.
Beef stew is made with beef cubes. Hominy is added, and cooked until it is tender. In
addition, pork and hominy can be made into a stew called posole.
Fresh corn tamales are made with fresh corn on the cob. Spread on cornhusks, they
are rolled into cylinders and baked in the oven.
So-me-ve-kee is made from blue cornmeal, sugar, boiling water, and ashes. This dish
is similar to a tamale but meatless.

Food Dictionary

Food Ingredients or Preparation
Ashes
Wood ash is added to corn dishes, which raises
the nutritional content of the corn to balance
nutrients in the corn (Cox, 1991). Hopi favor the
chamisa bush for making ashes. Ashes are run
through strainers to clean and the resulting
powder is used for cooking.
Corn Meal
Dumplings
Blue corn meal and boiling water are added
together to make a dough. The mixture is rolled
into balls and put into boiling water to cook.
Dumplings can be added to stews and soups.
Corn Tamales
Fresh corn is cut off the cob and mixed with salt.
This mixture is spread on a corn husk, rolled into
cylinders, and baked in the oven.
Fry Bread
Dough made from flour, water, and baking
powder, which is then rolled into balls, flattened,
and fried.
Piki Bread
Made from a mixture of blue corn meal, water, and
ashes. Cooked on a hot stone in large
tissue-paper sheets, it is rolled up like a
newspaper after cooking.
Posole
Pork and hominy stew usually made with pork
hocks and hominy that has been prepared with
white corn soaked in lime water.
So-me-ve-kee
Like a meatless tamale. Blue corn meal dough is
spread on corn husks, rolled in cylinders, and
boiled.
Tortillas
Round, thin cake made of unleavened cornmeal or
wheat flour.
Wild spinach
Also known as lamb's quarter. Mild-tasting wild
greens included in soups, stews, and salads.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

References


Brown AC, Brenton B. Dietary Survey of Hopi Native American Elementary Students J Am
Diet Assoc. 1994; 94: 517-522. Related Links: Abstract
Cox B, Jacobs M. Spirit of the Harvest. New York, New York: Stewart,Tabori & Chang. Inc;
1991.
Neithammer CJ. American Indian Food and Lore. New York: Macmillan Publishing Co, Inc;
1974.
Reid J, Whittlesay S. The Archaelogy of Ancient Arizona. Tucson, Ariz: The University of
Arizona Press; 1997.
Teufel N. Nutritional Problems. In: Galloway M, Goldberg BW, Alpert J, eds. Primary Care
of Native American Patients. Boston, Mass: Butterworth Heinemann; 1999:283-292.
Underhill R. Life in the Pueblos. Santa Fe, N.Mex: Ancient City Press; 1991.
Regional Differences in Indian Health 2000-2001. Washington, D.C.: U.S. Dept of Health
and Human Services; 2001.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Native American > Ojibwe
Food Practices

Food Practices
Cultural food practices of the Northern Minnesota Bands of Ojibwe often depend on
economic status and level of acculturation into the dominant culture. Traditional cultural and
contemporary meal plans also need to be considered.
Generalizations have been made for convenience. The foods listed under traditional and
contemporary food practices are those that occur frequently in food recalls done by the
author. Individual clients may eat very differently.

Ancestors

Traditional Cultural Dietary Practices
The traditional cultural diet before frequent contact with non-Indian people consisted
heavily of wild rice and all kinds of wild meats, poultry, fish, and plant foods gathered from
the forests and harvested from their gardens. Some of these traditional foods are still
consumed but are seen more often during ceremonies, special occasions, or pow-wows. A
pow-wow is a large, organized, social and spiritual event where Indian people come
together to dance, drum, and sing their cultural traditions.
Some examples of traditional foods still used today are:
Grains - wild rice served plain, in a casserole dish, or in soup;
Proteins – deer meat, walleye pike, northern pike, sucker fish, whitefish, and rabbit;
Fruits – blueberries, raspberries, blackberries, chokecherries, pin cherries,
strawberries, cranberries, and rosehips;
Vegetables – hominy corn, beans, and squash;
Sweets – maple syrup;
Beverages – swamp (Labrador) tea and rosehip tea.
The majority of Ojibwe now purchase some of these foods in the local stores. Some are not
available in any stores and need to be gathered or hunted. Obviously, purchasing these
more traditional foods in the stores is quite expensive, which is why they are seen mainly
during ceremonies, special occasions, and pow-wows.

Adaptation of Native Culture to American Culture

The majority of the Ojibwe people have adapted their culture to the dominant culture of the
area. Even so, there are different levels of acculturation in this population. There are some
who have been able to keep more oftheir cultural practices and traditional cultural food
ways than others. They have been more successful at maintaining intact knowledge of how
to grow, gather, hunt, net, spear, process traditional foods, and possess the needed tools
and time. Others have lost much of the knowledge of traditional foodways and have
adopted the foodways of the area culture, which are probably not as healthful as were
traditional ways.
There are some individual efforts to teach and encourage relearning these more healthful
traditional food practices. It is hoped these efforts may be helpful in decreasing the rate of
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
type 2 diabetes. Even with the interest sparked, it is almost impossible to supply families
with traditional foods for the majority of their meals. Regulation of wild game limits,
pollution, decreased land base, and working full time at outside employment interferes
greatly with gathering traditional foods and even passing down the knowledge of traditional
food ways.
Economic Status
Those with a higher economic status generally have a more varied meal plan. They usually
have a higher fiber, lower fat, and more nutrient-dense food intake.
People in the lower economic bracket will generally be dependent on the U.S. Department
of Agriculture Food Distribution Program commonly referred to as the "Commodity Food
Program" or "Commods." They may have a higher fat/lower fiber intake because of the
commodity foods, especially because of higher-fat dairy products. This may lead to a
limited intake of a variety of fruits and vegetables, especially fresh fruits and vegetables.
There are some who grew up with limited food choices. These people want to provide their
grandchildren with sweets and carbonated beverages as a way to provide a better life for
them.
Contemporary Food Practices
Contemporary dietary practices of many Ojibwe today include eating refined foods high in
fat, sugar, and salt. As a result of the change from their nomadic cultural practices of food
gathering and hunting, the food choices of many Ojibwe today reflect the typical U.S. meal
plan.
The Ojibwe people are also suffering from a very high rate of type 2 diabetes, much of
which can be attributed to the large amounts of high-fat and high-sugar foods that are
consumed on a daily basis. Much of the population is obese and there have been some
cases of children developing type 2 diabetes at 9 years of age.
Some examples of contemporary cultural foods commonly eaten by many today are:
Grains – macaroni, spaghetti, white rice, white bread, crackers, and other refined
wheat products high in fat and sugar;
Proteins – bologna, wieners, sausage, bacon, pork steak and chops, beef roasts,
steaks and hamburger, eggs, meat pizzas, chicken, ham, and peanut butter;
Milk – 2% milk, whole milk, chocolate milk, sweetened yogurt, and processed cheese;
Fruits – orange and apple juice, mixed fruit juices, canned pears and peaches, apples,
grapes, bananas, and oranges;
Vegetables – potatoes and potato products, carrots, onion, celery, corn, peas, green
beans, and canned tomato products;
Sweets, fats, and other – ice cream products, candy, cookies, pies, chips and dips,
bacon grease, butter, margarine, vegetable oil, and jams and jellies;
Beverages - fruit punches and fruit-flavored drinks, regular soda pop, powdered drink
mixes, coffee, and tea;
Special occasion or pow-wow foods – frybread, frybread hot dogs, Indian tacos, cake
with frosting, strawberry shortcake, buffalo burgers, cotton candy, watermelon,
mini-donuts, and cheese curds.

Counseling Tips

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
If you are a non-Indian person counseling Ojibwe clients, there are some social behaviors
that are different from your culture.
Maintaining constant eye contact is considered rude and felt to be intimidating. There
is eye contact on an intermittent basis during conversations or counseling sessions.
Clients will be more at ease if you are not staring at them all the time.
Indian people think through their responses before speaking. Response time in a
conversation may be a little longer than non-Indian people are used to. Avoid filling
the silence with more questions before the client has a chance to answer. In addition,
wait a few seconds to be sure the client is done responding before you ask your next
question.
Indian people, in general, have a great sense of humor. If you can infuse some humor
into your session, this will help your clients feel more at ease.
In counseling sessions, always be sincere and open with your clients. If you need to
know something, ask a question rather than guess at an answer based on your
perception. Getting personal is encouraged during counseling sessions. Showing
genuine interest in their lives and families is helpful in building rapport . Don’t be
afraid to share a small part of your life with them. However, reference to "your long
lost Indian ancestors" may not be advisable.
American Indian people are highly visual learners. Displays showing actual amounts
of sugar or fat in common foods have a big impact. Consider adding examples or
stories. Many Ojibwe think of life as a whole, not separate parts.

Meal Planning in this Native Culture

Breakfasts may consist of:
either cold or cooked cereal and milk;
fried eggs and/or meat, bacon, or sausage;
fried potatoes or leftover foods from supper the night before;
Elders will occasionally have oatmeal with bacon grease drizzled on it;
A few adults on the way to work may pick up a breakfast pizza/sandwich, muffin, or
sweet roll at a fast-food establishment or convenience store.
In general, lunch and supper will often consist mainly of:
beef;
potatoes or starches.
You may find individuals who eat as much as 1 pound of meat at a meal. For some adults,
portions of starches or potatoes may be 2 cups or more. This is also “hot dish” country,
where the meat and starches would be combined with a can of cream soup. Pizza and/or
fast food is consumed at least once a week by many people younger than 50 years of age,
more often if they are younger adults or teens. The working adult most likely will eat at a
restaurant for lunch. The local restaurant fare has many fried foods on the menu or a large
serving "special," which may contain lots of starch and gravy.
Breads are usually included at every meal. It is usually white bread. Often, people will
tell you they eat "wheat bread," but it is not usually 100% whole wheat.
Some people are lactose intolerant with low intakes of fluid milk but could eat
substantial amounts of cheese. Low-lactose milk is available in local grocery stores
and is usually tolerated by those willing to try it.
Vegetables would typically be served with supper. The older adults are more likely to
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
eat more vegetables.
Fruits and fruit juices are consumed more by children and they are more likely to eat
at least 2 servings. Parents participating in the Special Supplemental Program for
Women, Infants, and Children (WIC) have fruit juice available and have learned juice
is good for their children. Some parents give their very young children 2 to 4 cups of
juice per day. You may need to counsel clients on serving sizes and leaving room for
other food groups that may be lacking because of the overabundance of juice.
Toddlers may get their juice in a bottle, which can lead to dental caries.
Sweetened beverages are consumed in a large amount, especially by teens and
young adults. A six-pack of cans or a few 20 oz bottles per day are not an unusual
amount for the teens. Some individuals will drink a 2 liter of soda pop/day. Many
young parents give their infants and toddlers soda pop or fruit-flavored drinks (as well
as fruit juice) in their bottles through out the day. There are high rates of dental caries
in these communities.
Try to get a good diet recall, including weekends. This will assist you in giving suggestions
and strategies for meal planning. Try to offer them a choice of inexpensive strategies. Most
people are willing to make 1 or 2 small specific changes that won’t alter their current meal
pattern too drastically.
Some suggestions for meal planning:
Substitute green beans, carrots, or other low-carbohydrate vegetables for 1/2 of the
potatoes or starch they usually eat for a meal.
Choose lower-fat meats or eat 1/2 the amount of the meat they usually eat for a meal.
Add vegetables or low-fat milk if they are willing.
Suggest a hot turkey sandwich with mashed potatoes instead of the cheeseburger
basket.
Switch water or diet carbonated beverages for some or all of the soda pop.
Some people are willing to pack a sandwich, fruit, and vegetables for lunch instead of
going to the restaurant.
Suggest bringing baby carrots, apples, small bagels, or english muffins with jelly or
low-fat cream cheese as a substitute for sweet rolls to share at work or a meeting.
Substitute cereal and milk now and then for the usual fried eggs in the morning.
These are just some basic suggestions that have been accepted by many clients in the
past. You will need to individualize suggestions depending on the disease or condition.
Keep in mind that these are very general suggestions..

Food Dictionary

Food Ingredients or Preparation
Beans
Served as soup or as a baked bean dish with brown
sugar, molasses, spices, bacon, or side pork.
Deer meat
Very lean cuts of meat may be fried in oil, braised in
water, boiled in soups or stews, or mixed with beef
fat and spices for sausage
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fruits
Blueberries, raspberries, blackberries,
chokecherries, pin cherries, strawberries,
cranberries, and rosehips will most often be made
into jams and jellies or a sweetened pudding, but the
blueberries and strawberries may be served fresh as
part of a fruit salad or canned.
Hominy
corn
Also known as Indian corn, processed by boiling
kernels with water and hardwood ashes or lye until
the hulls are removed and rinsed several more times;
often cooked with pork hocks or side pork and
onions into a stew.
Maple
syrup
May be used to sweeten tea or as a topping for
pancakes or waffles.
Rabbit
Very lean meat may be dredged in flour and fried in
oil or quickly browned and then boiled in a soup or
stew with wild rice, onions, potatoes, and carrots.
Rosehip
tea
Made from the berry of the wild rose plant,
sweetened with maple syrup or sugar.
Squash
Usually baked with brown sugar or maple syrup and
butter or margarine.
Sucker
A large, white, fleshed fish usually speared in the
spring, and is often served smoked, like smoked
salmon, or, less often, boiled by elders.
Swamp tea
Made from a certain plant found in swampy areas,
also known as Labrador tea, usually served
unsweetened.
Walleye
and
Northern
pike
Usually filleted and dredged in flour or breading and
fried in oil.
Whitefish
A large, white, fleshed fish baked with bacon in
between layers and on top.
Wild rice
Boiled rice can be served plain with margarine and
salt, as a casserole dish or in soup with beef or deer
meat. Wild rice is actually a grass (not a rice), which
harvested in a traditional canoe using sticks to knock
the grain off the stems and then parched in a large
kettle over an open fire to remove the husk. It can be
popped like corn.
Contemporary Foods
Food Ingredients or Preparation
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Frybread
A quick bread made with white flour, baking powder,
milk, sugar, salt, and shortening shaped into flat
rounds and deep fried in oil or vegetable shortening. It
is not a traditional food, but definitly a cultural food -
often served with butter or margarine and/or honey.
Frybread
hot dogs
A hot dog wrapped with frybread doughand deep
fried.
Indian
tacos
Taco ingredients on frybread instead of taco shells.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Native American > Pima
Food Practices

The Pima people of southern Arizona were farmers because they lived near large rivers.
Pima means "river people" and they were so named for their home near the Gila and Salt
Rivers (Webb, 1959).Their cousins, the Tohono O'odham, were desert people (the
meaning of "O'odham"). The Pima and the Tohono O'odham speak the same language but
different dialects. Their language is based on the Uto-Aztecan family of dialects, which
includes the Hopi.
The following information was recorded from a Salt River elder who grew up in the Salt
River Reservation and has many fine memories of her life there:
Basic foods grown on the reservation were corn, squash, wheat, beans, fruit trees
(apricots, peaches, figs), and chiles. Not many animals were raised, as there wasn't
room for livestock. The animals that were raised included chicken, turkeys, and an
occasional pig.
Foods eaten were cooked with a minimum of fat and foods were good for the people.
Many foods were high in fiber.Tepary beans (brown and white) were eaten (boiled
with pork rind). Long-necked squash and pumpkins were raised and stored for the
winter. Cholla buds were picked from the cactus and boiled in water and salted before
eating.
Ash bread was a favorite of this elder, who watched her mother prepare a thick batter
of wheat flour, salt, and water. This bread was cooked on a bed of hot ashes. When it
was done, her mother would use a towel to rub off the ash before eating. Tortillas
were also a staple.
Wheat was an important crop and was first introduced to the Pimas by Father Kino.This
elder described the wheat-gathering harvest as one of community involvement. People
would come around and help get a neighbor's wheat field harvested. After the wheat
berries were gathered, the elder's mother would build a mesquite wood fire and toast
berries in an earthen bowl. These berries would be ground up and used in a drink called
pinole. Pinole contained wheat, water, and sugar.
Mesquite beans were ground up and used to make cakes that were sweet. In addition, the
seeds could be ground for flour. Saguaro fruit was picked over by the Red Mountain and
made into the jams, jellies, and syrup.

Ancestors

The Pimas believe they are the descendents of the ancient Hohokam people, who lived in
the desert thousands of years ago. Huhugam is a Pima word meaning "Those who are
gone" and is also written as Hohokam (Webb, 1959). The Hohokam were master
engineers, designing and building the irrigation canals that surround Phoenix today.
Dry-farming and floodwater farming provided additional avenues for some of the best
farming in the Southwest. (Masse, 1991)
"Pima" means river people and they were traditionally farmers along the Gila and Salt River
Basins. Basic crops of corn, beans (white and yellow), squash, melons, wheat, tobacco,
and cotton were raised. Many of these same crops are raised on the Salt River today.
Father Eusebio Kino, in 1687, was the first recorded white man to meet the Pimas. Father
Kino bought with him the wheat seeds that would become a very important crop to the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Kino bought with him the wheat seeds that would become a very important crop to the
Pima people.

Adaptation of Native Culture to American Culture

During the years between 1860 to1940, the government studies revealed undernutrition
and malnutrition on Indian reservations in the United States. In the 1960s, the trend toward
overnutrition began, which has led to massive rates of obesity in Indian population. At the
end of the 20th century, the primary nutritional problems (Teufel, 1999) among Native
Americans are as follows:
Exceeding energy needs by high calorie intake;
More than 30% of total fat intake daily;
More than 2 drinks of alcohol daily;
Less than 20 g fiber daily;
Less than 10 mg iron daily;
Less than 1200 mg calcium daily;
Low intakes of vitamin A;
Low intakes of vitamin C.
When a registered dietitian (RD) counsels Native American clients, respect for the native
culture must be observed or the counseling will be fruitless. The Native American culture
loves food and many celebrations center around food and the family. Native Americans can
be treated best with dietary therapy and behavior modification. Exercise and portion control
are key units.
Clients can be asked to reduce consumption of fried foods in their diets. Asking a client to
make wiser choices in dining out can reduce calories. Increasing the amount of fruits and
vegetables in their diet can increase fiber and vitamins A and C. Refer a client to an
alcohol or behavioral health counselor if alcohol is an issue.
Risk factors determine chances that American Indians and Alaska Natives will develop
diabetes. Risk factors include genetic factors and medical/ lifestyle factors. Obesity is a
major risk factor for diabetes and increasing rates of obesity correlate with diabetes. The
Strong Heart Study, in 1995, estimated the prevalence rates of diabetes and impaired
glucose tolerance in three American Indian populations. Locations were in Oklahoma,
North and South Dakota, and in Arizona, the three Pima/Maricopa/Papago communities of
Salt River, Gila River and Ak-Chin. Arizona had the highest rates of diabetes with 65% in
men and 72% in women. Arizona had the highest prevalence of obesity of the locations
with 75% of the population having a body mass index greater or equal to 27.8 for men and
27.3 for women (Lee, 1995). Ravussin, in his study of comparisons among Pima Indians of
Arizona and the Pima Indians of Mexico, found that the impact of the environment and
lifestyle on individuals make a marked difference in obesity rates and diabetes prevalence
(Ravussin, 1994).

Meal Planning in this Native Culture

The Pima Indians have lived in the Sonoran desert for the last 500 to 1,000 years and have
been successful farmers, hunters, and gatherers. Crops were raised here, largely because
of the irrigation system the Pima and their ancestors, the Hohokam, initiated. Wheat, corn,
beans, and squash were important crops to the Pima. The desert provided foods such as
saguaro cactus fruit, cholla cactus buds, prickly pear fruit, wild berries, wild greens, and
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
saguaro cactus fruit, cholla cactus buds, prickly pear fruit, wild berries, wild greens, and
mesquite beans (Neithammer, 1974).

Food Dictionary

The Pimas use many of the following traditional foods in their preparation (Smith, 1991).
Food Ingredients or Preparation
Berry
pudding
Fresh wolfberries crushed, water added, and
seeds removed. Mixture of water and flour added,
then boiled.
Cholla
A form of cactus in many varieties: some delicate
and thin whereas others are plumb and sturdy. All
parts are edible, but the tastiest is the unopened
flower buds and fruits.
Cholla bud
stew
Cholla cactus buds are gathered and dried; rinsed,
boiled, and fried with lard and onion.
Chorizo
Spicy pork sausage seasoned with chili powder
and garlic.
Chorizo
sausage and
egg
Sausage is removed from casing and fried in own
fat, then added to almost scrambled egg and the
two are cooked together.
Chorizo
sausage and
potato
Sausage is removed from casing and fried in own
fat and then added to already fried potatoes.
Flour tortilla
Cooked on a griddle pan outside or inside on the
stove. These are made with flour, water, fat, salt,
and baking powder.
Fry Bread
Dough made from flour, water, and baking
powder, which is rolled into balls, flattened, and
fried. Also called popovers.
Menudo
Thick soup-like mixture boiled in water for 1 to 2
hours together with tripe, white corn, beef feet,
garlic, onion, chili powder, cilantro, oregano, and
water, boiled for 1 to 2 hours.
Mesquite
beans
Nutritious bean from the mesquite tree very
common to the Southwest. Used by Native
Americans as a dietary staple. The seed is 40%
protein, almost twice as high as other legumes.
Mesquite
bean pudding
Flour is made from dried bean pods, water is
added, seeds taken out, and mixture boiled with
wheat flour to thicken it. Stirred with a mesquite
stick while boiling to get the right flavor is
recommended.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Pinole
Drink made by using ground wheat berries that
have been toasted, mixed with water and sugar.
Popovers
Also called fry bread. Prepared by flattening balls
of dough and frying them in oil. Mixture includes
flour, water, oil, salt, and baking powder.
Posole
A pork and hominy stew, usually made from pork
hocks and hominy, which has been prepared with
white corn soaked in lime water.
Red Chili
Most widely available chili is the Anaheim chili,
which is 5 to 8 inches long and about 1 to 1.5
inches in diameter. In its green stage, it is known
as chili verde, but if it is left to hang on the vine, it
becomes red. After picking, it is dried and strung
on long loops or ristras. Red chili can also be
ground up and used as a spice in dishes.
Red chili
stew
Red chili sauce made with chili, lard, flour, beef
broth and added to boiled beef chuck and potatoes.
Tamale
Shredded meat placed on a mixture of corn flour
dough with red chili sauce and rolled up in a corn
husk and boiled.
Tepary
beans
Grows wild and domesticated in the Southwest.
Boiled with some form of fat, usually fat back or
pork rind and water. Takes several hours to cook.
Ranks high in niacin, calcium, and protein. Very
important food source for Indians in Sonoran
desert.
Wild Spinach
Also known as lamb's quarter. Mild tasting wild
greens included in soups, stews, and salads.
Washed several times, boiled until tender, and then
fried in lard.
Wolfberries
Also called box thorn, rabbit thorn, and
squawberry. These red to dark red berries are
edible, some having more juice than others. When
dried in the sun, they become much like raisins.

References


Lee ET, Howard BV, Savage PJ, Cowan LD, Fabsitz RR, Oopik AJ, Yeh J, Go O, Robbins
DC, Welty TK. Diabetes and impaired glucose tolerance in three American Indian
populations aged 45-74 years. Diabetes Care. 1995;18:599-610. Related Links: Abstract
Masse BW. The Quest for Subsistence Sufficiency and Civilization in the Sonoran Desert.
In: Crown PL, Judge JW, eds. Chaco & Hohokam. Santa Fe, N. Mex.: School of American
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Research Press; 1991:195-223.
Neithammer CJ. American Indian Food and Lore. New York: Macmillan Publishing Co, Inc;
1974.
Ravussin E, Valencia ME, Esparza J, Bennett PH, Schulz LO. Effects of a traditional
lifestyle on obesity in Pima Indians. Diabetes Care. 1994;17:1067-1074. Related Links:
Abstract
Smith CJ, Schakel SF, Nelson RG. Selected traditional and contemporary foods currently
used by the Pima Indians. J Am Diet Assoc. 1991;91:338-341. Related Links: Abstract
Teufel N. Nutritional Problems. In: Galloway M, Goldberg BW, Alpert J, eds. Primary Care
of Native American Patients. Boston, Mass: Butterworth Heinemann; 1999:283-292.
Regional Differences in Indian Health 2000-2001. Washington, D.C.: U.S. Dept of Health
and Human Services; 2001.
Webb G. A Pima Remembers. Tucson, Ariz.: The University of Arizona Press; 1959.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Native American > Sioux
Food Practices

The Sioux Nations occupied the majority of the states of Minnesota, Wisconsin, North
Dakota, South Dakota, Montana, Wyoming, and Nebraska. They were a hunter-gatherer
band of people indigenous to North America.The Indian people migrated with the bison, as
they were a main source of food. In addition, deer, elk, antelope, big horn sheep, wild
turkey, pheasant, duck, goose, and other small animals or birds were staples to their meal
plan. Wild fruit, such as buffalo berries, chokecherries, grapes, raspberries, sand cherries,
and currants, were also eaten fresh during season or dried for winter. Wild turnip,
asparagus, green shoots from dandelions, and other plants were also consumed.
Bison, deer, elk, and antelope were killed by the men and then skinned by the women, cut
up, rolled in the hide, and taken back to the camp. Some of the meat was eaten at the kill
site, the remainder taken back and made into soup or cut into strips and dried. Buffalo was
the meat of preference for drying and storage. Dried meat and fruit were carried in animal
skin bags for consumption during the winter months. All parts of the animal were used:
hide for teepees and clothing, bones for utensils and tools, and the stomach and bladder
for cooking pots.
Other tribes (e.g., Arikara, Hidatsa, Mandan, and Santee Sioux) planted corn, beans, and
squash. The nomadic tribes either traded with or raided these tribes for additional kinds of
food. Southern tribes traveled up the Missouri River with different vegetables and fruit for
trade. Corn has been a staple since early times.

Ancestors

American Indians/Alaska Natives are indigenous to North America. When the European
immigrants came to the Americas, they were met by Indian people with native foods.
Bands of Sioux, including Oglala, Sicanju, Hunkpapa, Minneconju, Brule, Yanktonai,
Santee, and Mdewankton, lived and roamed the north-central United States and Canada.
These people hunted and gathered during the spring/summer and stored what they could
for the winter months when they could not travel.
Communications with tribes other than Sioux were either through war or trade. Bands of
indigenous peoples traveled on horses to hunt for food or to defend their villages. They met
and shared and traded food stuff with other tribes. They also met with other tribes for
exchange of goods and ceremonial purposes.
French and Irishmen explored lands up the Mississippi River and brought bourbon,
whiskey, cloth, beads, and pans. Indian women used beads and quills to make beautiful
dresses, shirts, moccasins, and leggings to trade for the French and Irish goods. This
exposed American Indians to the food staples of European immigrants. Unfortunately,
alcohol, which was previously unknown, has had a negative impact on American Indians.

Adaptation of Native Culture to American Culture

In the 1800s, the buffalo population was decimated. When the Lakota were placed on
reservation lands, they were not free to roam and gather the food off the land as their
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
ancestors had. The movement on to the reservations did not happen quickly; it was long
and drawn out (Nurge, 1970). The patterns of free movement over the land continued as
the Lakota would leave the reservation and travel to camp sites to visit family membes, to
hunt, and collect food.
If the Lakota stayed on the reservation, each month they were rationed a cow, flour, lard,
sugar, and coffee. In the beginning of the reservation era, the Lakota still attemped to hunt
and gather food. They would slaughter the cattle and feast until it was gone, following their
pattern of hunting buffalo. There would be a scarcity of food after that because they had
not previously dealt with penned livestock or practiced animal husbandry. Often the
animals would be sick and scrawny, but the people still had to slaughter them for food. It
was during this time that cans of food would be given to them with broken seals, causing
the food to be spoiled. The Lakotas would eat the canned food and become ill and
sometimes die. There has been a fear of dented canned foods that has passed down to
current generations.
Later in the reservation era, the following monthly government rations were allocated to
each person:
25-40 pounds of beef;
10 pounds of salt pork was issued in lieu of beef twice a year;
15 pounds flour or hardtack (alternated);
2.5 pounds sugar;
2.5 pounds coffee;
2.5 pounds rice or beans (alternated);
1/4 pound baking powder;
laundry soap, 1 pound.
This distribution of these types of foods has contributed to the preference of food today.
Coffee is an important part of the meal plan today. Soup, either bean/ham, bacon, or salt
pork, rice/beef/meat, or beef/meat/potato are common meals for families today. Hardtack,
which is pilot bread, is eaten with soups or as a snack item.
Bread also became an important staple in the diet. Homemade or store-bought bread is
eaten regularly. Bread can be filling and when meat was scarce, it could be used to
appease hunger. Although bread was not a food item before the reservation era, it has
since become a staple. Kabubu, or skillet bread, was made from a baking powder or yeast
dough similar to fry bread mixture. It is cooked in a skillet on top of the stove. It is made
and enjoyed to this day and is often spread with peanut butter and syrup.
After the reservations, a local person, usually part Indian (boss farmer), was hired to teach
Indians to be farmers, as they had been hunter-gatherers. A few families had gardens and
provided some food for their families that way. The majority of the families did not do well
gardening; their plots would be dried out with a few stalks of corn. Sioux tribes that lived in
Eastern South Dakota and Western Minnesota were more agrarian than those who lived
west of the Mississippi River. Eastern Lakota grew corn, squash, and beans to add to their
food intake. The Three Sisters are corn, beans, and squash. Corn is planted in the middle
with beans to climb up the corn stalks and squash to provide shade, nutrients, and
moisture.
A "three sisters" garden is shown in the background of this photograph.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
By 1970, most of the Indian families were on welfare. The eating habits were formed and
starches or fried foods were the primary foods. Potatoes, rice, and macaroni were added to
soup with a small amount of meat to feed large families. Although Indian people have a
preference for meat as a main item, they were not able to eat that way. Because they no
longer hunted for their meat, they became less active and gained weight.
Diabetes, hypertension, and obesity have become major diseases among the Lakota. A
Northern Plains Indian Pyramid teaching guide presents the foods that are now commonly
consumed. A Northern Plains American Indian Plate graphic has been developed which
some RD's currently use to teach our patients.

Meal Planning in this Native Culture

Typical Menu
Alternative
Meal Choices
Alternative
Meal Choices
Breakfast 1 cup oatmeal

1/2 cup skim
milk


2 slices whole
wheat toast


2 tsp
margarine
2-3 T peanut
butter

2 cups coffee

2 tsp sugar or
2 packs
sweetener

Cream
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

1 medium
banana
Glass of juice
Orange
or apple
Mid-morning
Snack
8 oz yogurt,
flavored
String cheese Fruit
2 cups coffee
Diet
carbonated
beverage
Water
2 tsp sugar

1 medium
orange
Juice Nuts
Lunch
2 slices whole
wheat bread
2 slices whole
wheat bread

4 oz turkey
2 slices of
bologna and 1
slice of cheese
Indian taco
2 slices tomato
Bowl of
hamburger
vegetable soup

1 leaf lettuce

1 tsp
mayonnaise


1 can regular
or diet Coke,
coffee, or tea


Sugar or
sweetener

Cream
Afternoon
Snack
12 pretzels or
microwave
popcorn
Meat jerky or
string cheese
Cookie

Carbonated
beverage
Fruit juice
Coffee with
cream and
sugar
Evening Meal
6 oz fried
chicken
Ring bologna
Hamburger
casserole

1 medium
baked yam
Fried potatoes
1 tsp margarine

1 cup green
beans

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

2 slices whole
wheat bread

2 tsp margarine
2 cups coffee
2 tsp sugar
Evening
snack
Ice cream
Leftover meat
sandwich
Dry cereal
Milk

Food Dictionary

Food Ingredients or Preparation
Boiling
meat
A high-fat meat, can be short ribs, boiled with
potatoes, carrots, onion, and celery. Some people
boil the meat alone and eat it with other foods. Any
cut of beef can be boiling meat.
Dry meat
Venison, elk, beef, or bison sliced into thin strips
and dried by hanging on a rack or near a slow fire or
at a low temperature in the oven.
Fry bread
A deep-fried bread usually made from a mixture
consisting of flour, salt, water, lard, and sometimes
nonfat dry milk. The dough is cut into pieces and
stretched or rolled out into a circle then deep fat
fried. It is leavened with baking powder or yeast.
Hard tack
or Pilot
bread
A hard, flat, thick cracker
Papa saka
Dried meat. The papa saka is eaten boiled in soup,
eaten as is, or pounded into a finer form for wasna.
Pemmican
Pulverized dried meat mixed with tallow and dried
ground berries, usually chokecherries. Traditionally
dried and taken as food on a hunt or when moving
camp.
Skillet
bread
Made from the same type of dough mixture as fry
bread and cooked in a skilled on the top of the stove.
The bread rises to about 4 inches in height.
Soups
Any type of meat or poultry can be used in soup.
Venison, bison, elk, antelope, beef, chicken, turkey,
or pheasant can be made into soup. Some wild
game is boiled so that it becomes tender.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Timpsila
A wild turnip from the prairie, which is starchy and
bland in taste. It is either peeled and eaten raw or
dried and cooked in soup. Fresh turnips are braided
together to form a long turnip chain and dried in the
sun much like braids of garlic.They are also sliced
and dried and used in soup. It is referred to as the
prairie potato, Indian turnip, or wild turnip.
Taniga
Beef or bison tripe used in soup with dried corn and
wild turnips. Hominy is often used with and in place
of dried corn.
Wasna
Easily carried on the trail, ancestors prepared this
staple food by pounding dried meat and adding dried
berries with bone marrow to hold the mixture. This
mixture is still made today with lard or oil. A corn
meal mixture is also made with sugar and raisins.
Wojapi
A pudding-like mixture made with wild, dried, or
canned berries, sugar, or sweetener and thickened
with cornstarch or flour. A favorite at feasts, dinners,
and at gatherings.
Source: Woolf N, Zephier EM. Ethnic and Regional Food Practices Northern Plains Indian,
Food Practices, Customs and Holidays. Chicago, Ill.: American Dietetic Association and
American Diabetes Association; 1999. (Woolfe, 1999)

References


Graber K. The Memoirs of Elaine Goodale Eastman. 1885-91. Sister to the Sioux. Lincoln,
Neb: University of Nebraska Press; 1978
Nurge E. Dakota Diet: Traditional and Contemporary. The Modern Sioux: Social Systems
and Reservation Culture. Lincoln, Neb.: University of Nebraska Press; 1970:35-91.
Powers WK, Powers MN. Sacred Foods of the Lakota. Kendall Park, N.J.: Lakota Books;
1990.
Woolf N, Zephier EM. Ethnic and Regional Food Practices Northern Plains Indian, Food
Practices, Customs and Holidays. Chicago, Ill.: American Dietetic Association and
American Diabetes Association; 1999.


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Cultural Food Practices > Native American > Tohono O'odham
Food Practices

The Tohono O'odham people live in the Northern Sonoran desert. The Sonoran Desert
spans the Arizona/Mexico border. Their name, Tohono O'odham, means "desert people."
Their cousins, the Pima, live further North next to rivers and were so named the "river
people." The Pima and the Tohono O'odham speak the same language but different
dialects. Their language is based on the Uto-Aztecan linguistic form, which is similar to the
Hopi peoples.
The O'odham people were hunters and gatherers because of the lack of reliable water
sources. Villages had a dual existence with summer spent in the fields near the mouth of
washes and winter spent at existing wells or springs. These desert people's meal plan
consisted mainly of dried foods, cereals, dehydrated vegetables, and jerky. Fresh food was
available for short periods of time. Neithammer, in her study of Southwestern foods made
the following observations about the O'odham foods (Neithammer, 1974):
Corn: The O'odham people were able to plant two corn crops a year because of the
Southern location of their fields. The first crop would be planted in February and
another in August. The O'odham viewed a good corn crop as an ideal, a
good fortune. Much ceremony went into the different stages of the growth of the corn.
Corn played a very important part in tribal ceremonies. A form of gruel was a
year-round staple for the O'odham. This gruel was called waka and was made by
mixing parched corn in water.
Beans: Tepary beans grow well in the harsh conditions of the Southwest desert and
can avoid insect infestations. Tepary beans were preferred over pinto beans because
the O'odham could eat one meal of teparies and be satisfied as compared to having
to eat twice with regular beans. It is little wonder the O'odham were called the "Bean
People," because as late as the 1940s, the average tribal member consumed three
quarters of a pound of beans daily (Neithammer, 1987).
Mesquite Beans: Beans from the pods would be ground up into flour and used in
drinks. In addition, the beans could be made into small, hard cakes, which could be
fried.
Squash: Squash was raised in small garden patches and has been a Sothwest crop
since before the first Spanish explorers traveled northward through Northern Mexico.
The Spanish called these various squashes "calabasas." The squash blossoms can
be fried or stewed.
Wheat: This crop soon replaced maize as a leading crop among the O'odham. They
received their first wheat seeds from Father Kino when he arrived on horseback in
1687 (Underhill, 2000). A favorite drink was called "atole" and was made with flour
boiled with water and salt.
Prickly pear: This fruit has a tangy sweetness and an enticing color. The pads of the
prickly pear are called "nopales" and are crunchy in texture when raw. A jelly can be
made from the prickly pear pads. Prickly pear could be prepared by boiling with onion
or sauteed with scrambled eggs.
Saguaro: The saguaro cactus is the symbol of the American West as it typically raises
50 feet into the air, supporting 2 or 3 dozen arms. These saguaro are restricted to a
very small portion of growing area in the southern desert of Arizona and also in
California near the Colorado River. Jam and syrup were made from the saguaro and
was a great delicacy among the O'odham. Tribal members would wait for the fruit to
ripen in midsummer and knock the fruit off the plant. The gatherers would split the
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
fruit to take the pulp out while leaving the shell of the fruit on the ground. The shell
was placed on the ground with the red lining uppermost because this was thought to
hasten the rain. The pulp would be soaked in water to loosen the small black seeds,
which were sun-dried and ground into flour. The remaining pulp would be readied for
jam and syrup. The syrup was saved for making cactus wine, which was used only in
the rain ceremony.

Ancestors

The Tohono O'odham believe they are the descendants of the ancient Hohokam, who lived
in southern Arizona hundreds of years ago. These Hohokam were master engineers who
designed and built irrigation canals, many of which still exist. The O'odham had less of a
stable water supply than their Pima cousins in the North. Their homes had a dual existence
depending upon the time of the year. In the summer, camps would be set up close to the
mouth of washes to take advantage of flood waters. In the winter, they would move nearer
to the foothills, where they would benefit from more permanent spring waters (Fontana,
1989).
In 1687, Father Kino rode horseback into Sonora and remained there the rest of his life.
Kino, in his writings, never referred to the Tohono O'odhams as the Papagos. His
successor, Father Luis Velarde, spoke of the Papabotas, or Pima bean eaters, which
became Papago. The current name for the tribe is Tohono O'odham, Papago being the
name the Spanish gave them because they ate beans.
The ancestors of the modern-day tribe lived in the desert and dined on the desert foods.
Many wild plants, like the prickly pear, the cholla, and the giant saguaro, provided kinds of
fruit drinks and a sweet jam. Different kinds of roots from the century plant and the yucca
would be eaten like potatoes.
Usually the families would have a garden plot in which they raised the three staples of their
diet: corn, beans, and squash. Meat, in the form of small game, would be caught easily
and roasted over an open fire. Common animals eaten were ground squirrel, jackrabbits,
and cottontails. During the winter months, the men of the tribe would hunt deer, which were
plentiful in the mountain regions. Javelina or wild pig offered a lean meat to the
hunter.These javelina often produced twins.

Adaptation of Native Culture to American Culture

During the years between 1860 to1940, the government studies revealed undernutrition
and malnutrition on Indian reservations in the United States. In the 1960s, the trend toward
overnutrition began, which has led to massive rates of obesity in Indian country. At the end
of the 20th century, the primary nutritional problems (Teufel, 1999) among Native
Americans are as follows:
Exceeding energy needs by high calorie intake
More than 30% of total fat intake daily
More than 2 drinks of alcohol daily
Less than 20 g fiber daily
Less than 10 mg iron daily
Less than 1200 mg calcium daily
Low intakes of vitamin A
Low intakes of vitamin C
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Low intakes of vitamin C
When a registered dietitian (RD) counsels Native American clients, respect for the native
culture must be observed or the counseling will be fruitless. The Native American culture
loves food and many celebrations center around food and the family. Native Americans can
be treated best with nutrition therapy and behavior modification. Exercise and portion
control are key units.
Clients can be asked to reduce consumption of fried foods in their menus. Asking a client to
make wiser choices in dining out can reduce calories. Increasing the amount of fruits and
vegetables in their diet can increase fiber and vitamins A and C. Refer a client to an
alcohol or behavioral health counselor if alcohol is an issue.
Risk factors determine chances that American Indians and Alaska Natives will develop
diabetes. Risk factors include genetic factors and medical/ lifestyle factors. Obesity is a
major risk factor for diabetes and increasing rates of obesity correlate with diabetes.
The Native Seeds/Search conservation effort in Tucson, Arizona, is designed to promote
the use of traditional foods as a deterrent to diabetes. This organization studied the rates of
diabetes among indigenous groups throughout the world and found that the Australian
aborigines had similar rates of the disease compared to the O'odham. Foods of the desert
were studied and were found to have mucilage and gummy fibers, which helped them stay
moist in the arid environment. When these substances are ingested as food, the fiber
slows down the digestion rate, which helps the pancreas keep up with supply of insulin
needed to keep the blood glucose under control. Examples of foods promoted are cholla
cactus buds, saguaro fruit, prickly pear pads and fruit, mesquite pods, desert chia, and
tepary beans (Native Seeds/ Search, 2003).

Meal Planning in this Native Culture

The Tohono O'odham people have survived in the southern Sonoran desert for many
centuries by being hunters and gatherers. Their diets consisted of mainly dried foods,
cereals, dehydrated vegetables, and jerky (Cox, 1991). Because of modern conveniences,
many in the tribe now eat a nontraditional diet. Being so close to Mexico, the tribe has
Hispanic roots and this cultural tie blends into the foods that they eat. Their meal plan is
similar to their Pima cousins farther North (Smith, 1991). The O'odham people today
consume many types of burritos, beans, squash, spam, eggs with cheese, and chili
peppers.

Food Dictionary

Cecilia Baltazar, a member of the Tohono O'odham tribe who works at Phoenix Indian
Medical Center, helped with this list of food items:
Food Ingredients or Preparation
Chorizo
Spicy pork sausage seasoned with chili powder and
garlic.
Chorizo
sausage
and egg
Spicy sausage mixed into scrambled eggs.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Corn,
squash,
and
cheese
Squash is fried, canned corn added with shredded
cheese on top.
Flour
tortilla
Round, thin bread made with unleavened wheat flour,
baking powder, salt, fat, and water. The tortillas made
here can be very large, cooked outside on the fire or
inside on a large griddle pan. Tortillas are served with
most meals and can be filled with beans or scrambled
eggs and potatoes as a breakfast dish.
Fry bread
Also called popovers. Fried bread, made from flour,
water, baking powder and salt being mixed, formed
into balls and flattened before they are fried. These
fried pieces of bread are served with honey for a treat
or can be served an Indian taco with the bread on the
bottom and beans, hamburger, and cheese piled on
top of it. This is a very hearty dish.
Menudo
A spicy, soup-like dish made by boiling tripe, white
corn, beef feet, garlic, onion, chili powder, cilantro, and
oregano with water in a large pot for 1 to 2 hours.
Menudo is served with flour tortillas.
Posole
A pork and hominy stew, usually made with pork
hocks and hominy. Hominy is made by soaking white
corn in lime water which removes the tough outer hull
of the corn.
Red chili
The most widely available chili is the Anaheim chili,
which is 5 to 8 inches long and about 1 to 1.5 inches in
diameter. In its green stage, it is known as chili verde,
but if left to hang on the vine, it becomes red. After
picking, the chilies are strung on long loops which are
called ristras. Red chilies are ground up and used as
spices for many Southwestern dishes.
Red chili
stew
A hearty stew made with beef chuck and served as a
feast day staple.
Taco
Fried corn tortilla, usually folded, stuffed with meat,
lettuce, tomato, and cheese.
Tamale
Cornmeal dough wrapped usually in cornhusks with
shredded meat or beans, rolled up into a cylinder, and
steamed to cook.

References


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Cox B, Jacobs M. Spirit of the Harvest. New York: Stewart, Tabori & Chang, Inc; 1991.
Neithammer CJ. The Tumbleweed Gourmet. Tucson, Ariz.: The University of Arizona
Press; 1987.
Neithammer CJ. American Indian Food and Lore. New York: Macmillan Publishing Co, Inc;
1974.
Smith CJ, Schakel SF, Nelson RG. Selected traditional and contempory foods currently
used by the Pima Indians. J Am Diet Assoc. 1991;91:338-341. Related Links: Abstract
Teufel N. Nutritional Problems. In: Galloway M, Goldberg BW, Alpert J, eds. Primary Care
of Native American Patients. Boston, Mass.: Butterworth Heinemann; 1999:283-292.
Underhill RM. The Papago and Pima Indians of Arizona. Palmer Lake, Colo.: Filter Press;
2000.
Regional Differences in Indian Health 2000-2001. Washington, D.C.: U.S. Dept of Health
and Human Services; 2001. Related Links: Full Text


© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Dietary Guidelines for Americans, 2010
Dietary Guidelines for Americans, 2010

In January 2011, the U.S. Department of Agriculture and the U.S. Department of Health
and Human Services released the 2010 Dietary Guidelines for Americans, the federal
government's evidence-based nutritional guidance to promote health, reduce the risk of
chronic diseases, and reduce the prevalence of overweight and obesity through improved
nutrition and physical activity.
The 2010 Dietary Guidelines for Americans focus on balancing calories with physical
activity, and encourage Americans to consume more healthy foods such as vegetables,
fruits, whole grains, fat-free and low-fat dairy products, and seafood, and to consume less
sodium, saturated and trans fats, added sugars, and refined grains. These guidelines,
intended for Americans ages 2 and older, form the basis for nutrition policy in Federal food,
education and information programs. They also provide education and health professionals
with a compilation of the latest science-based recommendations.
The 2010 Dietary Guidelines for Americans include 23 Key Recommendations for the
general population and six additional Key Recommendations for specific population
groups, such as women who are pregnant. The recommendations are intended as an
integrated set of advice to achieve an overall healthy eating pattern.
Key Recommendations
Balancing Calories to Manage Weight
Prevent and/or reduce overweight and obesity through improved eating and physical
activity behaviors.
Control total calorie intake to manage body weight. For people who are overweight or
obese, this will mean consuming fewer calories from foods and beverages.
Increase physical activity and reduce time spent in sedentary behaviors.
Maintain appropriate calorie balance during each stage of life—childhood,
adolescence, adulthood, pregnancy and breastfeeding, and older age.
Foods and Food Components to Reduce
Reduce daily sodium intake to less than 2,300 milligrams (mg) and further reduce
intake to 1,500 mg among persons who are 51 and older and those of any age who
are African American or have hypertension, diabetes, or chronic kidney disease. The
1,500 mg recommendation applies to about half of the U.S. population, including
children, and the majority of adults.
Consume less than 10 percent of calories from saturated fatty acids by replacing
them with monounsaturated and polyunsaturated fatty acids.
Consume less than 300 mg per day of dietary cholesterol.
Keep trans fatty acid consumption as low as possible by limiting foods that contain
synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting
other solid fats.
Reduce the intake of calories from solid fats and added sugars.
Limit the consumption of foods that contain refined grains, especially refined grain
foods that contain solid fats, added sugars, and sodium.
If alcohol is consumed, it should be consumed in moderation—up to one drink per
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
If alcohol is consumed, it should be consumed in moderation—up to one drink per
day for women and two drinks per day for men—and only by adults of legal drinking
age.
Foods and Nutrients to Increase
Individuals should meet the following recommendations as part of a healthy eating pattern
while staying within their calorie needs.
Increase vegetable and fruit intake.
Eat a variety of vegetables, especially dark-green and red and orange vegetables and
beans and peas.
Consume at least half of all grains as whole grains. Increase whole-grain intake by
replacing refined grains with whole grains.
Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt,
cheese, or fortified soy beverages.
Choose a variety of protein foods, which include seafood, lean meat and poultry,
eggs, beans and peas, soy products, and unsalted nuts and seeds.
Increase the amount and variety of seafood consumed by choosing seafood in place
of some meat and poultry.
Replace protein foods that are higher in solid fats with choices that are lower in solid
fats and calories and/or are sources of oils.
Use oils to replace solid fats where possible.
Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D,
which are nutrients of concern in American diets. These foods include vegetables,
fruits, whole grains, and milk and milk products.
Recommendations for Specific Population Groups
Women capable of becoming pregnant
Choose foods that supply heme iron, which is more readily absorbed by the body,
additional iron sources, and enhancers of iron absorption such as vitamin C-rich
foods.
Consume 400 micrograms (mcg) per day of synthetic folic acid (from fortified foods
and/or supplements) in addition to food forms of folate from a varied diet.
Women Who are Pregnant or Breastfeeding
Consume 8 to 12 ounces of seafood per week from a variety of seafood types.
Due to their high methyl mercury content, limit white (albacore) tuna to 6 ounces per
week and do not eat the following four types of fish: tilefish, shark, swordfish, and king
mackerel.
If pregnant, take an iron supplement, as recommended by an obstetrician or other
health care provider.
Individuals Ages 50 Years and Older
Consume foods fortified with vitamin B12, such as fortified cereals, or dietary
supplements.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Building Healthy Eating Patterns
Select an eating pattern that meets nutrient needs over time at an appropriate calorie
level.
Account for all foods and beverages consumed and assess how they fit within a total
healthy eating pattern.
Follow food safety recommendations when preparing and eating foods to reduce the
risk of foodborne illnesses.
Dietary Guidelines Resources available at www.dietaryguidelines.gov:
Dietary Guidelines for Americans, 2010 – Executive Summary
Dietary Guidelines for Americans, 2010 - includes policy statement, detailed
recommendations, and appendices with USDA Food Patterns, vegetarian
adaptations of Food Patterns, DASH Eating Plan, and other reference materials.
Selected messages for consumers (PDF)
PowerPoint Dietary Guidelines presentation
Report of the Dietary Guidelines Advisory Committee, released June 2010
Source: Dietary Guidelines for Americans, 2010, www.dietaryguidelines.gov

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Dietary Reference Intakes
Dietary Reference Intakes

The USDA's Food and Nutrition Information Center (FNIC) includes pdfs of the Dietary
Reference Intakes (DRIs) tables. These tables serve as a quick reference guide to nutrient
needs by age and gender as formulated by the National Academy of Sciences, Institute of
Medicine, Food and Nutrition Board.
For full reports on the dietary reference values for the intake of nutrients by Americans and
Canadians, please visit the National Academies Press website.

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals
Comprehensive DRI table for vitamins, minerals and macronutrients; organized by age and
gender.

Dietary Reference Intakes: Electrolytes and Water
DRI table for sodium, chloride, potassium, inorganic sulfate and water.

Dietary Reference Intakes: Elements
DRI table for minerals arsenic, boron, calcium, chromium, copper, fluoride, iodine, iron,
magnesium, manganese, molybdenum, nickel, phosphorus, selenium, silicon, vanadium
and zinc.

Dietary Reference Intakes: Macronutrients
DRI table for carbohydrate, fiber, fat, fatty acids and protein.

Dietary Reference Intakes: Vitamins
DRI table for biotin, choline, folate, niacin, pantothenic acid, riboflavin, thiamin, vitamin A,
vitamin B6, vitamin B12, vitamin C, vitamin D, vitamn E and vitamin K.

The FNIC also provides an Interactive DRI for Healthcare Professionals tool to calculate
needs for individual clients.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Fluoride Supplementation
Fluoride Supplementation


Recommended Dietary Fluoride Supplement* Schedule
Level of Fluoride in Community Drinking Water
(ppm)

Age < 0.3 0.3-0.6 > 0.6
0-6 mo None None None
6 mo-3 y 0.25 mg/day None None
3-6 y 0.50 mg/day 0.25 mg/day None
6-16 y 1.0 mg/day 0.50 mg/day None
*Sodium fluoride (2.2 mg sodium fluoride contains 1 mg fluoride ion).

1.0 parts per million (ppm) = 1 mg/L
Source: Data are from US Department of Health and Human Services. Recommendations
for using fluoride to prevent and control dental caries in the United States. MMWR.
2001;50(RR-14).
Fluoride
Fluoride supplementation has been demonstrated to be beneficial in reducing the
incidence of childhood caries and has significantly improved the oral health of the nation
(Kleinman, 2004; AAPD, 2003; USDHHS, 2001). The need for fluoride supplementation
depends on the total amount of fluoride available from all sources, including infant formula,
tap and bottled water, and commercial and home-prepared foods. The AAP, the American
Academy of Pediatric Dentistry, and the Centers for Disease Control and Prevention
recommend that all children older than 6 months receive sodium fluoride daily, either
through fluoridated water or a fluoride supplement (Kleinman, 2004; AAPD, 2003;
USDHHS, 2001). This need is met by drinking water in communities where the public water
supply is fluoridated to contain greater than 0.6 ppm fluoride.
The table above lists the recommended dietary fluoride supplement schedule for children
living where the water supply contains ≤ 0.6 ppm fluoride. Careful assessment of all
sources of dietary fluoride, including fluoridated toothpaste, is essential to avoid excessive
intakes of fluoride, which can cause fluorosis and change the appearance of the teeth.

Reprinted with permission from: Leonberg BL. ADA Pocket Guide to Pediatric Nutrition
Assessment. Chicago, Ill: American Dietetic Association, 2008.

References:
Nutrition and oral health. In: Kleinman RE, ed. Pediatric Nutrition Handbook. 5
th
ed. Elk
Grove Village, Ill: American Academy of Pediatrics; 2004:789-800.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
American Academy of Pediatric Dentistry. Clinical guideline on fluoride therapy. Pediatr
Dent. 2003;25:67-68.
US Department of Health and Human Services. Recommendations for using fluoride to
prevent and control dental caries in the United States. MMWR. 2001;50(RR-14).

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Growth Charts
CDC Clinical Growth Charts Set 1

Interactive growth charts from MedCalc.com (link to external site)
Set 1: Clinical charts with 5th and 95th percentiles
Set 1 of the growth charts published by the Centers for Disease Control and Prevention
(CDC) has the outer limits of the curves at the 5th and 95th percentiles. These are the
charts that most users in the United States will find useful for the majority of routine clinical
assessments.
These charts are available in black and white (B&W) or color on this page and on the CDC
website in portable document format (PDF) for downloading and printing in Adobe Acrobat.
The color charts for boys are blue, and the color charts for girls are red. The CDC
recommends that charts for both sexes should be printed as two-sided copies, in the
following combinations:
Infants, Birth to 36 Months:
Side 1: Length for Age + Weight-for-Age
Side 2: Head Circumference–for-Age + Weight-for-Length
Children and Adolescents, 2 to 20 Years:
Side 1: Stature-for-Age + Weight-for-Length
Side 2: Body Mass Index (BMI)-for-Age
Alternate Side 2: Weight-for-Stature (Age 2 to 5 Years Only)
Birth to 36 Months (5th to 95th percentile)
Boys Length-for-Age and Weight-for-Age
B&W [PDF - 41 KB]
Color [PDF - 44 KB]
Spanish Version, Color [PDF - 44 KB]
Data Table of Length-for-Age Charts
Data Table of Weight-for-Age Charts

Boys Head Circumference–for-Age and Weight-for-Length
B&W [PDF - 48 KB]
Color [PDF - 48 KB]
Spanish Version Color [PDF - 52 KB]
Data Table of Head Circumference–for-Age Charts
Data Table of Weight-for-Length Charts

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Girls Length-for-Age and Weight-for-Age
B&W [PDF - 40 KB]
Color [PDF - 40 KB]
Spanish Version, Color [PDF - 50 KB]
Data Table of Length-for-Age Charts
Data Table of Weight-for-Age Charts
Girls Head Circumference–for-Age and Weight-for-Length
B&W [PDF - 48 KB]
Color [PDF - 55 KB]
Spanish Version, Color [PDF - 60 KB]
Data Table of Head Circumference–for-Age Charts
Data Table of Weight-for-Length Charts

Children 2 to 20 years (5th to 95th Percentile)
Boys Stature-for-Age and Weight-for-Age
B&W [PDF - 77 KB]
Color [PDF - 77 KB]
Spanish Version, Color [PDF - 63 KB]
Data Table of Stature-for-Age Charts
Data Table of Weight-for-Age Charts
Boys BMI-for-age
B&W [PDF - 61 KB]
Color [PDF - 61 KB]
Spanish Version, Color [PDF - 50 KB]
Data Table of BMI-for-Age Charts

Girls Stature-for-Age and Weight-for-Age
B&W [PDF - 77 KB]
Color [PDF - 77 KB]
Spanish Version, Color [PDF - 62 KB]
Data Table of Stature-for-Age Charts
Data Table of Weight-for-Age Charts

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Girls BMI-for-Age
B&W [PDF - 67 KB]
Color [PDF - 61 KB]
Spanish Version, Color [PDF - 51 KB]
Data Table of BMI-for-Age Charts

Optional Chart (5th to 95th Percentile)
Boys Weight-for-Stature (Ages 2 to 5 Years Only)
B&W [PDF - 40 KB]
Color [PDF - 41 KB]
Data Table of Weight-for-Stature Charts
Girls Weight-for-Stature (Ages 2 to 5 Years Only)
B&W [PDF - 40 KB]
Color [PDF - 41 KB]
Data Table of Weight-for-Stature Charts

Adapted from Centers for Disease Control and Prevention: Clinical Growth Charts. Full set
of charts and additional information available at CDC website. Accessed February 18, 2010.

CDC Clinical Growth Charts Set 2

Set 2: Clinical charts with 3rd and 97th percentiles
Set 2 of the growth charts published by the Centers for Disease Control and Prevention
(CDC) has the outer limits of the curves at the 3rd and 97th percentiles for selected
applications. Pediatric endocrinologists and other practitioners who assess the growth of
children with special health care requirements may wish to use the format in set 2 for these
selected applications.
These charts are available in black and white (B&W) and color on the CDC website and on
this page in portable document format (PDF) for downloading and printing in
Adobe Acrobat. For the color files, the charts for boys are blue, and the charts for girls are
red. The CDC recommends that charts for both sexes should be printed as two-sided
copies in the following combinations:
Infants, Birth to 36 Months:
Side 1: Length for Age + Weight for Age
Side 2: Head Circumference for Age + Weight for Length
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Children and Adolescents, 2 to 20 Years:
Side 1: Stature for Age + Weight for Length
Side 2: Body Mass Index (BMI) for Age
Alternate Side 2: Weight for Stature (age 2 to 5 years only)

Birth to 36 Months (3rd to 97th percentile)
Boys Length-for-Age and Weight-for-Age
B&W [PDF - 41 KB]
Color [PDF - 47 KB]
Spanish Version, Color [PDF - 47 KB]
Data Table of Length-for-Age Charts
Data table of Weight-for-age charts
Boys Head Circumference–for-Age and Weight-for-Length
B&W [PDF - 48 KB]
Color [PDF - 52 KB]
Spanish Version, Color [PDF - 53 KB]
Data Table of Head Circumference-for-Age Charts
Data Table of Weight-for-Length Charts
Girls Length-for-Age and Weight-for-Age
B&W [PDF - 41 KB]
Color [PDF - 48 KB]
Spanish Version, Color [PDF - 48 KB]

Data Table of Length-for-Age Charts
Data Table of Weight-for-Age Charts
Girls Head Circumference–for-Age and Weight-for-Length
B&W [PDF - 48 KB]
Color [PDF - 53 KB]
Spanish Version, Color [PDF - 54 KB]
Data Table of Head Circumference–for-Age Charts
Data Table of Weight-for-Length Charts
Children 2 to 20 years (3rd to 97th percentile)
Boys Stature-for-Age and Weight-for-Age
B&W [PDF - 79 KB]
Color [PDF - 83 KB]
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Spanish Version, Color [PDF - 61 KB]
Data Table of Stature-for-Age Charts
Data Table of Weight-for-Age Charts
Boys BMI-for-Age
B&W [PDF - 64 KB]
Color [PDF - 68 KB]
Spanish Version, Color [PDF - 52 KB]
Data Table of BMI-for-Age Charts
Girls Stature-for-Age and Weight-for-Age
B&W [PDF - 79 KB]
Color [PDF - 84 KB]
Spanish Version, Color [PDF - 62 KB]
Data Table of Stature-for-Age Charts
Data Table of Weight-for-Age Charts
Girls BMI-for-age
B&W [PDF - 54 KB]
Color [PDF - 58 KB]
Spanish Version, Color [PDF - 52 KB]

Data Table of BMI-for-Age Charts

Optional Chart (3rd to 97th percentile)
Boys Weight-for-Stature (Ages 2 to 5 Years Only)
B&W [PDF - 31 KB]
Color [PDF - 34 KB]
Data Table of Weight-for-Stature Charts
Girls Weight-for-Stature (Ages 2 to 5 years Only)
B&W [PDF - 40 KB]
Color [PDF - 46 KB]
Data Table of Weight-for-Stature Charts

Adapted from Centers for Disease Control and Prevention: Clinical Growth Charts. Full set
of charts and additional information available at CDC website. Accessed February 18, 2010.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Fenton Preterm Fetal-Infant Growth Chart

The fetal-infant growth chart for preterm infants developed by Fenton is an updated
Babson-type growth chart for use in neonatal intensive care units. This chart will allow a
comparison for preterm infants as young as 22 weeks of gestation first with intrauterine
and postterm growth reference data.
This chart can replace the one developed by Babson, which has been used in neonatal
intensive care for more than 25 years. The 10th percentile of this chart is accurate to the
source data prior to 36 weeks; therefore, it could be used for the assessment of size for
gestational age for infants smaller than 2 kg.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

© 2003 Fenton; licensee BioMed Central Ltd. This is an Open Access article: verbatim
copying and redistribution of this article are permitted in all media for any purpose, provided
this notice is preserved along with the article's original URL.
For more information, see the full article.
Babson SG, Benda GI. Growth graphs for the clinical assessment of infants of varying
gestational age. J Pediatr. 1976;89:814-820. PubMed Abstract

WHO Growth Charts

The executive summary for the World Health Organization child growth standards can be
accessed here.
Z-scores, growth charts, and tables in portable document format are available at the
following links:
Length/height-for-age
Weight-for-age
Weight-for-length
Weight-for-height
Body mass index-for-age
Head circumference-for-age


Introduction to Growth Charts

Anthropometry is the measurement of body size, weight, and proportion. It is only one
component of information used in a nutrition assessment. Growth data for infants and
children, regularly obtained by accurate measurements, are an indicator of health status.
These data are part of an effective nutrition screening and a core part of nutrition
assessment. Growth attainment is often the critical objective data on which clinical
interventions are based; therefore, accuracy is essential.
The basic measurements for any child are weight and length or height (stature). During the
first 3 years of life, the third basic measurement is head circumference. Equipment does
not have to be new or high-tech to provide reliable information about a child’s growth, but it
does need to be accurate and calibrated regularly. Trained personnel should receive
periodic evaluation of their techniques for weighing and measuring to ensure consistent and
reliable data.
The weight, length or height, and head circumference measurements should be recorded
on the appropriate growth chart for age and sex and then plotted and rechecked to ensure
that the proper growth points are recorded. It is important to have the child’s age, the date,
and actual measurement numbers recorded so that others may use this data if needed.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
The growth charts published by the Centers for Disease Control and Prevention (CDC)
are based on pooled data from five National Health and Nutrition Examination Surveys.
However, the most recent weight data were excluded for children older than 6 years
because of the increasing prevalence of childhood obesity. Preterm, very-low-birthweight
infants were not included on the new CDC charts. The growth charts that apply to
adolescents can be used for patients up to age 19. Body mass index charts are used for
children and adolescents aged 2 through 19 years.
The World Health Organization (WHO) has also developed growth charts for children from
birth to 60 months (5 years) of age. These charts are based exclusively on healthy children
living under optimal conditions for achieving their full genetic growth potential; all of the
children were breastfed and none of their mothers smoked tobacco. These charts are
available in the WHO Growth Chart section.
New growth charts have been published for infants born prematurely (Olsen, 2010). These
charts reflect data gathered from nearly 400,000 infants born in the United States at 22
weeks' to 42 weeks' gestational age.
For many children, arm anthropometry (arm circumference, arm muscle circumference, and
triceps skinfolds) can provide additional data on body composition, but clinicians must be
trained to collect consistent and replicable data.
Velocity, or incremental, growth charts are another assessment tool. They provide an
indication of how fast a child is growing over a period of time and can signal significant
decelerated or accelerated growth patterns. For children with special health care needs,
additional and/or alternative measurements may be appropriate.

Body Mass Index

Body mass index (BMI) is a noninvasive evaluation tool for individuals who are overweight
or underweight. BMI is an indirect measure of adiposity that accounts for the differences in
body composition. If the BMI calculation is routinely done in screening, it will not only
clearly identify a child who is visually obese but it will also identify children who previously
might not have been recognized as at risk for excessive weight gain. BMI seldom identifies
nonobese children as obese.
BMI is expressed as a ratio of weight in kilograms (kg) to height in meters squared (m
2
).
Length can be used, but it is preferable to use height as soon as a child can stand (after
age 2). Successive determinations of BMI with the collection of each weight and height
measurement can determine the degree of a child’s inadequate or excessive energy intake.
The use of metric measurements is recommended because the reference data currently
available for evaluation of BMI are metric. The 85th to 95th percentiles on the BMI chart
identify children and adolescents at risk for overweight, and overweight is identified in the
95th percentile. In the most recent Expert Committee recommendations regarding
childhood obesity (Barlow, 2007), the 85th to 95th percentile represents overweight and
above the 95th percentile represents obesity; however, the charts published by the Centers
for Disease Control and Prevention do not yet incorporate these
classifications. Underweight is determined by BMI below the 5th percentile.
A BMI and weight range calculator is available.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Growth of Premature Infants

For preterm infants, accurate growth data are essential. When using the growth charts
published by the Centers for Disease Control and Prevention, the infant’s age should
always be corrected (adjusted) and measurements plotted at this corrected age. On growth
charts where age is corrected, note directly on the chart the number of weeks or months to
be subtracted from the chronological age. For example, an 11-month-old child who was
born at 30 weeks' gestation (10 weeks early) is 8½ months corrected age.
Although some facilities plot both corrected and chronological age measurements, this
takes additional time and may be confusing. It may be easier to identify boldly on the chart
that age correction is needed. Some health care professionals contend that corrected age
should be used through age 36 months, whereas others think correction may be stopped
after the second birthday. A clinic policy should be established.

Interpretation of Growth Data

Once accurate measurements or other anthropometric data are obtained, the dietitian and
other health care professionals can evaluate them as part of the overall assessment.
Growth charts can help to separate normal growth patterns from abnormal ones.
Information from a chart is only as good as the accuracy of measurements, age
determination, and plotting.
The most useful growth information is shown through a series of plotted measurements
forming a growth curve. Regular sequential measurements recorded on growth charts may
indicate trends of excessive or inadequate increases in weight or length/height or reflect
genetic influence. For children whose growth is below what is typical for age, a series of
measurements that follows a curve can either reassure caregivers and health care
professionals that growth is occurring or serve as an indication of a need for referral or
further assessment. This is especially useful in children with special health care needs
and who may be at increased risk for inappropriate growth patterns because of their
disability, repeated medical crises, or inability to consume adequate amounts of food.
Individual interpretation of growth patterns for all children should be based on growth
charts as well as individual dietary, clinical, biochemical, developmental, and environmental
data. However, accurate anthropometric data enhances the nutrition assessment and
provides information for intervention strategies.

Specialized Growth Charts

Several specialized charts are available for a variety of conditions and syndromes. None
includes all the parameters of stature, weight, and weight for height or body mass index,
however. All the charts should be used in conjunction with the growth charts published by
the Centers for Disease Control and Prevention.
There are some limitations to these specialized charts. For all of them, the population base
from which the comparison data are obtained is small. The data may also portray a
population for which newer treatment standards are currently being used, but those
standards may not be reflected in the original data. Nevertheless, the specialized charts
can be used as an additional source of information in the overall nutrition assessment, as
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
long as the limitations of each individual chart are carefully considered. Interpretation of
growth measurements for children with special health care needs should include the
diagnosis, differences in body composition and prognosis.
The best way to assess growth is with accurate equipment and standard measurement
techniques, in order to establish a series of plotted measurements over time. Growth
assessment is a core part of a comprehensive nutrition assessment and a concrete
outcome measure of intervention. For children with special health care needs, the
evaluation of growth can be a distinctive challenge, because of the difficulty of obtaining
accurate measurements and the complexity of comparing data to charts for children who
are typically developing.
Growth charts for achondroplasia
Growth charts for cerebral palsy: These 2007 charts, available in portable document
format (PDF), should be used with caution when predicting growth; users should take into
account the difficulty in obtaining accurate measurements for many children with cerebral
palsy.
Growth charts for Down syndrome are available as PDFs via the National Down Syndrome
Society Web site.
Growth charts for Noonan syndrome
Growth charts for Prader-Willi syndrome
Growth chart for Turner syndrome


Growth Velocity Chart

Growth Velocity Chart

Olsen Intrauterine Growth Curves

New intrauterine growth curves are now available based on a large US pool of data. Olsen
and colleagues (2010) evaluated available data on 391,681 infants in the Pediatrix Medical
Group throughout the United States, which supplied information on a contemporary, large,
racially diverse US sample. Gestational age range curves are for infants aged 22 weeks to
42 weeks for birth weight, length, head circumference, estimated gestational age, sex, and
race data. Gender specific curves were created and validated from the final sample size of
257,855 singleton infants (surviving to discharge), using a method to smooth the curves
into a useful growth chart with separate charts for males and females.
The new curves also examined the distribution of the number of infants whose growth
measurements fell within the following categories:
Small for gestational age, or SGA (below the 10th percentile)
Appropriate for gestational age (10th to 90th percentiles)
Large for gestational age, or LGA (above the 90th percentile
Given the number of infants reviewed, the numbers in each of the categories were higher,
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
thus providing new definitions for SGA and LGA compared to the older intrauterine growth
charts and are illustrated by the curves on each chart.
This group compared their new smoothed growth curves with the existing Lubchenco
curves (Lubchenco, 1963; Lubchenco, 1966), and several differences were noted. For
example, the new curves had lower measurements at the younger gestational ages until 30
weeks to 36 weeks and higher average growth at older gestational ages. Overall, there
were statistically significant differences on the all of the curves. The older Lubchenco
curves demonstrated an underestimation for the SGA and LGA infants, most likely due to
the low numbers in these size categories.
The authors note that there remain concerns with regard to using intrauterine
measurements to determine appropriate growth throughout pregnancy and extrauterine
growth, as well as the results being not necessarily representative of all infants, but they
believe this method still continues to be the most accepted source at present for creating
neonatal growth curves.
In summary, these new intrauterine growth curves offer an updated set of curves that are
more representative of admissions to neonatal intensive care units in the United States and
represent an estimate of optimal growth.
Olsen Intrauterine Growth Curves
Lubchenco LO, Hansman C, Dressler M, Boyd E. Intrauterine growth as estimated from
liveborn birth-weight data at 24 to 42 weeks of gestation. Pediatrics. 1963;32:793-800.
Related Links: Abstract
Lubchenco LO, Hansman C, Boyd E. Intrauterine growth in length and head circumference
as estimated from live births at gestational ages from 26 to 42 weeks.
Pediatrics.1966;37(3):403- 408. Related Links: Abstract
Olsen IE, Groveman SA, Lawson ML, Reese CH, Zemal BS. New intrauterine growth
curves based on United States data. Pediatrics 2010;125(2):214-224. Related Links:
Abstract; Full text



© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Malnutrition
Obesity

In the United States, the obesity diagnosis is based on body mass index (body mass
index) as calculated according to the following formula:
Weight (lb) / [height (in)]
2
x 703

The registered dietitian can measure the individual's height and weight or verify that it is
measured rather than estimated for BMI calculations. BMI is classified by the National
Institutes of Health as shown in the following table.
Alignment of BMI Range and ICD-9-CM
a
Codes for Overweight and Obesity
BMI ICD-9 Code
18.5-24.9 None
25.0-29.9 278.2: Overweight
30.0-39.9
278.0: Obesity not
specified
40.0 and
above
278.1: Morbid obesity
a
ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification
b Source: NHLBI, 1998


Malnutrition

The diagnosis of malnutrition is not as straightforward as the diagnosis of obesity because
the terms (marasmus and kwashiorkor) associated with codes of the Clinical Modification
of the Ninth Revision of the International Classification of Diseases (ICD-9-CM) describe
situations that do not apply to patients seen by acute and chronic care clinicians in
developed countries (Jensen, 2010).
The 10th revision (ICD-10) of the codes is scheduled for implementation in 2013 and will
change some of the definitions as shown in the table found in the Coding Terms section.
The American Dietetic Association and the American Society for Parenteral and Enteral
Nutrition (ASPEN) have proposed new malnutrition codes to the National Center for Health
and Vital Statistics for inclusion into the ICD-9/ICD-10 Codes System used in the United
States. There is continuing discussion and reconciliation of the ADA/ASPEN proposal with
the National Center for Health Statistics policies and procedures for code revisions
acceptance. Readers are advised that based on reports of overuse or inappropriate use of
the kwashiorkor diagnosis, the National Center for Health and Vital Statistics may issue
some direction on use of existing malnutrition diagnosis codes during 2012.
In addition, an ADA task force has developed criteria for the diagnosis and documentation
of severe and non-severe malnutrition, which were subsequently accepted by an ASPEN
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Committee on Malnutrition. These criteria, as approved in August 2011, are meant for
adults and are presented in NCM under the Malnutrition Criteria section (available
to NCM subscribers). ADA and ASPEN experts agree that it is not possible to distinguish
mild malnutrition from normal nutritional status and therefore did not develop definitions
and criteria for mild malnutrition at this time. It is clearly understood that malnutrition,
whether severe or non-severe, should be treated with appropriate food and nutrition
intervention provided by a registered dietitian and the medical team.
It is also recognized that malnutrition occurs in the context of different situations, including
acute illness or injury, chronic disease, and social and environmental circumstances. The
context of malnutrition is an important consideration because individuals with inflammation
found in some acute and chronic diseases do not respond to nutrition intervention until the
inflammation is resolved. There are no widely agreed-upon markers of inflammation,
although these markers may be established as work on the topic of definitions of
malnutrition continues.

Coding Terms

Selected IDNT
a
, ICD-9-CM
b
and ICD-10
c
Terms Describing Undernutrition and
Overnutrition
d
IDNT ICD-9-CM
ICD-10-CM
NI-5.2 Malnutrition
Inadequate intake of protein
and/or energy over
prolonged periods of time
resulting in loss of fat stores
and/or muscle wasting.
Signs and symptoms (one
or more must be present)
BMI
e
<18.5 for adults
BMI <23 for adults
older than 65 years
Failure to thrive
Inadequate maternal
weight gain
Weight loss in adults
(>10% in 6 months,
>5% in 1 month)
Failure to gain weight
as expected and/or a
decline of 2 or more
percentiles on a
growth chart
Underweight with
muscle wasting
(260) Kwashiorkor
Nutritional edema
with dyspigmentation
of skin and hair
(261) Nutritional
marasmus
Nutritional atrophy
Severe energy
deficiency
(262) Other severe
protein–energy
malnutrition
Nutritional edema
without mention of
dyspigmentation of
skin and hair
(263) Other and
unspecified
protein–energy
malnutrition
(264) Vitamin A deficiency
(264.0) With conjunctival
E40 Kwashiorkor
Severe malnutrition with
nutritional edema with
dyspigmentation of skin
and hair.
Excludes: marasmic
kwashiorkor (E42)
E41 Nutritional marasmus
Severe malnutrition with
marasmus
Excludes: marasmic
kwashiorkor (E42)
E42 Marasmic kwashiorkor
Severe protein–energy
malnutrition [as in E43]
intermediate form
with signs of both
kwashiorkor and
marasmus
E43 Unspecified severe
protein–energy malnutrition
Severe loss of weight
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
muscle wasting
Uncomplicated
malnutrition: thin,
wasted appearance;
severe muscle
wasting; minimal body
fat; sparse, thin, dry,
easily pluckable hair,
dry, thin skin; obvious
bony prominences,
temporal wasting’
lowered body
temperature, blood
pressure, heart rate;
changes in hair of
nails consistent with
insufficient protein
intake
Disease/trauma
related malnutrition:
Thin to normal
appearance, with
peripheral edema,
ascites, or anasarca;
edema or the lower
extremities; some
muscle wasting with
retention of some body
fat; dyspigmentation of
hair (flag sign) and
skin
Delayed wound healing
Estimated energy
intake from diet less
than estimated or
measured resting
metabolic rate (RMR)
Estimated intake of
high-quality protein
less than estimated
requirements
Food avoidance
and/or lack of interest
in food
Excessive
consumption of
alcohol or other drugs
that reduce appetite
(264.0) With conjunctival
xerosis
(264.1) With conjunctival
xerosis and Bitot's spot
(264.2) With corneal
xerosis
(264.3) With corneal
ulceration and xerosis
(264.4) With keratomalacia
(264.5) With night
blindness
(264.6) With
xerophthalmic scars of
cornea
(264.7) Other ocular
manifestations of vitamin
A deficiency
(265) Thiamine and niacin
deficiency states
(265.0) Beriberi
(265.1) Other and
unspecified
manifestations of
thiamine deficiency
Wernike’s
encephalopathy
(265.2) Pellagra
(266) Deficiency of
B-complex components
(266.0) Ariboflavinosis
(266.2) B-12 deficiency
without anemia
(267) Ascorbic acid
deficiency
(268) Vitamin D deficiency
(269) Other nutritional
deficiencies
[wasting] in children or
adults, or lack of weight
gain in children leading to
an observed weight that is
at least 3 standard
deviations below the mean
value for the reference
population (or a similar
loss expressed through
other statistical
approaches). When only
one measurement is
available, there is a high
probability of severe
wasting when the
observed weight is 3 or
more standard deviations
below the mean of the
reference population.
Starvation oedema
E 44 Protein–energy
malnutrition of moderate and
mild degree
E44.0 Moderate
protein–energy malnutrition
Weight loss in children or
adults, or lack of weight
gain in children leading to
an observed weight that is
2 or more but less than 3
standard deviations below
the mean value for the
reference population (or a
similar loss expressed
through other statistical
approaches). When only
one measurement is
available, there is a high
probability of moderate
protein–energy malnutrition
when the observed weight
is 2 or more but less than 3
standard deviations below
the mean of the reference
population.
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Chronic or acute
disease or trauma
Geographic location
and socioeconomic
status associated with
altered nutrient intake
of indigenous
phenomenon
Severe protein and/or
nutrient malabsorption
Enlarged, fatty liver
NI 5.9.1 Inadequate
vitamin intake (specify)
Lower intake of one or more
vitamins compared to
established reference
standards or
recommendations based on
physiological needs.
NI 5.9.2 Excess vitamin
intake (specify)
Higher intake of one or
more vitamins compared to
established reference
standards or
recommendations based on
physiological needs.
NI-5.10.1 Inadequate
mineral intake (specify)
Lower intake of one or more
minerals compared to
established reference
standards or
recommendations based on
physiological needs.
NI-5.10.1 Excess mineral
intake (specify)
Higher intake of one or
more minerals compared to
established reference
standards or
recommendations based on
(269.1) Deficiency of other
vitamins
(269.0) Deficiency of
vitamin K
(269.1) Deficiency of other
vitamins
(269.2) Unspecified
vitamin deficiency
(269.3) Mineral
deficiency, not
elsewhere classified
Overweight, obesity,
and other
hyperalimentation
278.01 Morbid obesity
278.00 Obesity
unspecified
E44.1 Mild protein–energy
malnutrition
Weight loss in children or
adults, or lack of weight
gain in children leading to
an observed weight that is
1 or more but less than 2
standard deviations below
the mean value for the
reference population (or a
similar loss expressed
through other statistical
approaches). When only
one measurement is
available, there is a high
probability of mild
protein–energy malnutrition
when the observed weight
is 1 or more but less than 2
standard deviations below
the mean of the reference
population
E45 Retarded development
following protein–energy
malnutrition
Nutritional:
Short stature
Stunting
Physical retardation due to
malnutrition
E46 Unspecified
protein–energy malnutrition
Malnutrition NOSf
Protein–energy imbalance
NOS
Other nutritional
deficiencies (E50-E64)
Excludes nutritional
anemias (D50-D53)
E50 Vitamin A deficiency
Excludes sequelae of
vitamin A deficiency
(E64.1)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
physiological needs.
NC-3.3
Overweight/Obesity
Increased adiposity
compared to established
reference standards
ranging from overweight to
morbid obesity.
Signs and symptoms (one
or more must be present)
Measured RMR less
than expected and/or
estimated RMR
BMI more than
normative standard for
age and sex
Overweight:
25-29.9
Obesity-grade I:
30-34.9
Obesity grade II:
35-39.9
Obesity grade III:
40+
Inability to maintain
weight or regain of
weight
Waist circumference
more than normative
standard for age and
sex
Increased skinfold
thickness
Weight for height more
than normative
standard for age and
sex
Increased body
adiposity
Reports or observations of
the following:
Overconsumption of
high-fat and
energy-dense food or
beverage
E51 Thiamine deficiency
Excludes: sequelae of
thiamine deficiency (E64.8)
E52 Niacin deficiency
(pellagra)
Deficiency:
Niacin (tryptophan
Nicotinamide
Pellegra (alcoholic)
Excludes: sequelae of
niacin deficiency (E64.8)
E53 Deficiency of other
B-group vitamins
Excludes: sequelae of
vitamin B deficiency
(E64.8)
Vitamin B-12 deficiency
Anemia (D51-)
E53.0 Riboflavin deficiency
Ariboflavinosis
E53.1 Pyridoxine deficiency
Vitamin B-6 deficiency
Excludes:
pyridoxine-responsive
sideroblastic anemia
(D64.3)
E53.8 Deficiency of other
specified B-group vitamins
Deficiency:
Biotin
Cyanocobalamin
Folate
Folic acid
Pantothenic acid
Vitamin B-12
E53.9 Vitamin B deficiency,
unspecified
E54 Ascorbic acid deficiency
Deficiency of vitamin C
Scurvy
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Large portions of food
(portion size more
than twice what is
recommended)
Infrequent,
low-duration and/or
low intensity physical
activity
Large amounts of
sedentary activities
Uncertainty regarding
nutrition-related
recommendations
Inability to apply
nutrition-related
recommendations
Unwillingness or
disinterest in applying
nutrition-related
recommendations
Inability to loose a
significant amount of
excess weight through
conventional weight
loss intervention
Medications that affect
RMR
Conditions associated with
a diagnosis or treatment:
Physical disability or
limitation
History of familial
obesity
History of childhood
obesity
History of physical,
sexual, or emotional
abuse
Excludes: scorbutic
anemia (D53.2)
Sequelae of vitamin
C deficiency (F64.2)
E55 Vitamin D deficiency
Excludes: adult
osteomalacia (M83-)
Osteoporosis (M80-M81)
Sequelae of rickets (E64.3)
E55.9 Vitamin D deficiency,
unspecified
Avitaminosis D
E56 Other vitamin deficiencies
Excludes sequelae of other
vitamin deficiencies (E64.8)
E56.0 Deficiency of vitamin E
E56.1 Deficiency of vitamin K
Excludes:
Deficiency of
coagulation factor
due to vitamin K
deficiency (D68.4)
Vitamin K deficiency
of newborn (P53)
E56.8 Deficiency of other
vitamins
E56.9 Vitamin deficiency,
unspecified
E58 Dietary calcium deficiency
Excludes: disorder of
calcium metabolism (E83.5)
Sequelae of calcium
deficiency (E64.8)
E59 Dietary selenium
deficiency
Keshan disease
Excludes sequelae of
selenium deficiency (E64.8)
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
E60 Dietary zinc deficiency
E61 Deficiency of other
nutrient elements
Use additional external
cause code (Chapter XX),
if desired, to identify drug if
drug induced
Excludes:
Disorders of mineral
metabolism (E83.-)
Iodine-deficiency
related thyroid
disorders (E00-E02)
Sequelae of
malnutrition and other
nutritional
deficiencies (E64.-)
E61.0 Copper deficiency
E61.1 Iron deficiency
Excludes iron deficiency
anemia (D50.-)
E61.2 Magnesium deficiency
E61.3 Manganese deficiency
E61.4 Chromium deficiency
E61.5 Molybdenum deficiency
E61.6 Vanadium deficiency
E61.7 Deficiency of multiple
nutrient elements
E61.8 Deficiency of other
specified nutrient elements
E61.9 Deficiency of nutrient
element, unspecified
E63 Other nutritional
deficiencies
Excludes:
Dehydration (E86)
Failure to thrive
(R62.8)
Feeding problems in
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
newborn (P92-)
Sequelae of malnutrition
and other nutritional
deficiencies (E64-)
63.0 Essential fatty acid
deficiency deficiency
E63.1 Imbalance of
constituents of food intake
E63.8 Other specified
nutritional deficiencies
E63.9 Nutritional deficiency,
unspecified
Nutritional cardiomyopathy
NOS+ (143.2*)
E64 Sequelae of malnutrition
and other nutritional
deficiencies
E64.0 Sequelae of
protein–energy malnutrition
Excludes retarded
development following
retarded protein–energy
malnutrition (E45)
E64.1 Sequelae of vitamin A
deficiency
E64.2 Sequelae of vitamin C
deficiency
E64.3 Sequelae of rickets
Use additional code
(M40-), if desired, to
identify kyphosis
E64.8 Sequelae of other
nutritional deficiencies
Obesity and other
hyperalimentation
(E65-E68)
Excludes:
adiposogenital
dystrophy (E23.6)
Lipomatosis:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Lipomatosis:

NOS (E88.2)
Dolorosa
[Dercum] (E88.2)
Prader-Willi
syndrome
(O87.1)
E65 Localized adiposity
Fat pad
E66 Obesity due to excess
energy
E66.1 Drug-induced obesity
E66.2 Extreme obesity with
alveolar hypoventilation
E66.8 Other obesity
Morbid obesity
E66.9 Obesity, unspecified
Simple obesity NOS
E67 Other hyperalimentation
Excludes:
Hyperalimentation
NOS (R63.2)
sequelae of
hyperalimentation
(E68)
E67.0 Hypervitaminosis A
E67.1 Hypercarotenemia
E67.2 Megavitamin B-6
syndrome
E67.3 Hypervitaminosis D
E67.8 Other specified
hyperalimentation
E68 Sequelae of
hyperalimentation
a
IDNT = International Dietetics and Nutrition Terminology
b
ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
c
ICD-10 = ICD, Tenth Revision
d
Table created by Annalynn Skipper, PhD, RD, FADA. Sources: ADAIDNT, 2011; AMA,
2011; WHO 2011, CMS 2011
e
BMI = Body mass index
f
NOS = Not otherwise specified
*The National Centers for Health and Vital Statistics (NCHS) may provide direction on uses
for the kwashiorkor code in 2012. Consult with local coders who have access to NCHS
updates for the most current recommendations.
Note regarding ICD-10: The degree of malnutrition is usually measured in terms of weight,
expressed in standard deviations from the mean of the relevant reference population.
When one or more previous measurements are available, lack of weight gain in children, or
evidence of weight loss in children or adults, is usually indicative of malnutrition. When only
one measurement is available, the diagnosis is based on probabilities and is not definitive
without other clinical or laboratory tests. In the exceptional circumstances that no
measurement of weight is available, reliance should be placed on clinical evidence.
If an observed weight is below the mean value of the reference population, there is a high
probability of severe malnutrition if there is an observed value situated 3 or more standard
deviations below the mean value of the reference population; a high probability of
moderate malnutrition for an observed value located between 2 and less than 3 standard
deviations below this mean; and a high probability of mild malnutrition for an observed
value located between 1 and less than 2 standard deviations below this mean.
This is not applicable to the following conditions:
Intestinal malabsorption (K90.-)
Nutritional anemias (D50-D53)
Sequelae of protein-energy malnutrition (E64.0)
Slim disease (B22.2)
Starvation (T73.0)

References

American Dietetic Association. International Dietetics and Nutrition Terminology Reference
Manual. 3rd ed. Chicago, IL: American Dietetic Association; 2011.
American Dietetic Association. Evidence Analysis Library. Does serum prealbumin
correlate with weight loss in four models of prolonged protein-energy restriction: Anorexia
nervosa, non-malabsorptive gastric partitioning bariatric surgery, calorie-restricted diets or
starvation? American Dietetic Association 2009. Available at: website. Accessed August 1,
2011.
American Dietetic Association. Evidence Analysis Library. Does serum prealbumin
correlate with nitrogen balance? American Dietetic Association 2009. Available at: website.
Accessed August 1, 2011.
American Dietetic Association. Evidence Analysis Library. Does serum albumin correlate
with weight loss in four models of prolonged protein-energy restriction: anorexia nervosa,
non-malabsorptive gastric partitioning bariatric surgery, calorie-restricted diets or
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
starvation? American Dietetic Association 2009. Available at: website. Accessed August 1,
2011.
American Dietetic Association. Evidence Analysis Library. Does serum albumin correlate
with nitrogen balance? American Dietetic Association 2009. Available at: website.
Accessed August 1, 2011.
American Medical Association. ICD-9-CM 2011 Professional Edition for Physicians.
Chicago, IL: ADA; 2011.
Blackburn GL, Bistrian BR, Maini BS, Schlamm HT, Smith MF. Nutritional and metabolic
assessment of the hospitalized patient. JPEN J Parenter Enteral Nutr. 1977;1(1):11-22.
Centers for Medicare and Medicaid Services. Hospital Acquired Conditions. Available at:
website. Accessed August 20, 2011.
Detsky AS, McLaughlin JR, Baker JP et al. What is Subjective Global Assessment of
Nutritional Status? J Parenter Ent Nutr. 1987;11-8-13.
Hagan JC. Acute and Chronic Diseases. In: Mulner RM, ed. Encyclopedia of Health
Services Research. Vol 1. Thousand Oaks, CA: Sage; 2009:25.
Jensen GL, Mirtallo J, Compher C, Dhaliwal R, Forbes A, Grijalba RF, Hardy G, Kondrup
J, Labadarios D, Nyulasi I, Castillo Pineda JC, Waitzberg D; International Consensus
Guideline Committee. Adult starvation and disease-related malnutrition: A proposal for
etiology-based diagnosis in the clinical practice setting from the International Consensus
Guideline Committee.JPEN J Parenter Enteral Nutr. 2010;34(2):156-159. Related Links:
Abstract
Keys A. Chronic undernutrition and starvation with notes on protein deficiency. JAMA.
1948;138:500-511.
Klein S, Kinney J, Jeejeebhoy K, Alpers D, Hellerstein M, Murray M, Twomey P. Nutrition
support in clinical practice: Review of published data and recommendations for future
research directions. National Institutes of Health, American Society for Parenteral and
Enteral Nutrition, and American Society for Clinical Nutrition. JPEN J Parenter Enteral Nutr.
1997;21(3):133-156. Related Links: Abstract
Kondrup J. Can food intake in hospitals be improved? Clin Nutr. 2001;20:153-160.
National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification,
Evaluation and Treatment of Obesity in Adults. National Heart, Lung and Blood Institute;
September, 1998.
Norman K, Stobaus N, Gonzalez MC, Schulzke J-D, Pirlich M. Hand grip strength:
Outcome predictor and marker of nutritional status. Clin Ntr. 2011;30:135-142. Related
Links: Abstract
Rosenbaum K, Wang J, Pierson RN, Kotler DP. Time-dependent variation in weight and
body composition in healthy adults. JPEN J Parenter Enteral Nutr. 2000;24(2):52-55.
Related Links: Abstract
Sacks GS, Dearman K, Replogle WH, Cora VL, Meeks M, Canada T. Use of Subjective
Global Assessment to identify nutrition-associated complications and death in long-term
care facility residents. J Am Coll Nutr. 2000;19(5):570-577. Related Links: Abstract; Full
text
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
World Health Organization. International Classification of Diseases. Available at: website.
Accessed August 20, 2011.

Coding for Obesity, Malnutrition, and Other Nutrition Disorders

Undernutrition and overnutrition are among the nutrition problems that registered dietitians
(RD) diagnose using the terms, etiologies, and signs and symptoms of the International
Dietetics and Nutrition Terminology (IDNT) (ADA, 2011). Physicians and nurse practitioners
use another standardized language, the International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) to consistently describe medical diagnoses
(AMA, 2011). The 10th Revision of the ICD is in use in other countries and is scheduled for
introduction in the United States in 2013 (WHO, 2011).
In health care institutions, coders review medical records after patients are discharged and
assign ICD-9-CM codes to medical diagnoses that are then used for billing purposes.
Examples of obesity, malnutrition, and other nutrition-related diagnoses from the IDNT,
ICD-9-CM and ICD-10 standardized languages can be found in the table found in the
Coding Terms section.
The diagnoses, codes, definitions and degrees of obesity and malnutrition have become
more important to RDs and other clinicians since 2007, when the Centers for Medicare and
Medicaid Services revised the Hospital Inpatient Prospective Payment System to include
745 severity-adjusted, diagnosis-related groups (CMS, 2011). A part of this revision
included increased payments for the care of patients whose physicians diagnosed their
severe malnutrition or severe obesity. This revision also included a provision whereby the
RD can calculate and document each patient’s body mass index so that physicians can
use those data to diagnose obesity.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > MyPlate Food Guidance System
MyPlate Food Guidance System

In June 2011, the United States Department of Agriculture released the new food icon,
MyPlate, to serve as a reminder to help consumers make healthier food choices. The
MyPlate icon emphasizes the fruit, vegetable, grains, protein and dairy food groups
following the recommendations of the 2010 Dietary Guidelines for Americans. MyPlate
replaces the MyPyramid image as the government’s primary food group symbol and
serves as a visual cue to help consumer adopt healthy eating habits.
The new icon was created provide an easy-to-understand icon that will help deliver a series
of healthy eating messages to highlight key consumer actions based on the 2010 Dietary
Guidelines for Americans and to empower people with information they need to make
healthy food choices.
Key Messages for Consumers
Take action on the Dietary Guidelines by making changes in these three areas. Choose
steps that work for you and start today.
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.
Food 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.
ChooseMyPlate.gov
The new website, www.ChooseMyPlate.gov, provides practical information to individuals,
health professionals, nutrition educations and the food industry to help consumers build
healthier diets with resources and tools for dietary assessment, nutrition education and
other user-friendly nutrition information. These resources include:
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Let’s Eat for the Health of It consumer brochure with practical strategies to make
healthy food choices.
10 Tips Nutrition Education Series provides consumers and professionals with
easy-to-follow tips in a convenient, printable format.
Sample menus for a week and food group based recipes in a printable format
(available in the print materials section).
MyPlate Style Guide provides guidelines for appropriate use of the MyPlate icon in
educational materials and other applications.
Interactive tools for consumers include:
Personalized Daily Food Plan, with special plans for preschoolers, moms and
moms-to-be.
My Foodapedia with quick access to food information, food groups, calories and
comparisons.
Food Tracker provides feedback on food intake and physical activity.
Food Planner helps plan what to eat to help reach personal goals.
Note: MyPyramid resources will remain available to health professionals and nutrition
educators in “Tips and Resources” section of ChooseMyPlate.gov. A new web site is
planned for late 2011.
For more information, visit www.ChooseMyPlate.gov. Additional resources include:
www.DietaryGuidelines.gov and www.LetMove.gov.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Physical Signs of Malnutrition
Physical Signs of Malnutrition

When conducting a physical examination as part of the nutritional assessment of a client,
take care to note the signs of possible nutrient deficiencies.
Click on the following links to go straight to the table for that system:
Skin Examination
Hair and Nail Examination
Head and Neck Examination
Eye Examination
Nose, Lip, and Tongue Examination
Gum and Teeth Examination
Cardiovascular System Examination
Gastrointestinal Examination
Musculoskeletal Examination
Neurological System Examination
Sexual Maturation Examination

Skin Examination
Signs
Possible Nutrition-related
Causes
Possible Supportive
Objective Findings
Elastic, firm, slightly dry; no
lesions, rashes,
hyperpigmentation
Adequate/appropriate
nutrition
--
Decreased subcutaneous
tissue
Prolonged insufficient energy
↓ skinfold thicknesses, ↓
BMI
Delayed wound healing
Insufficient vitamin C ↓ serum ascorbic acid
Insufficient zinc ↓ serum zinc
Dermatitis (generalized) Insufficient zinc ↓ serum zinc
Dryness
Insufficient vitamin A ↓ plasma retinol
Insufficient essential and
unsaturated fatty acids
Triene:tetraene ratio > 0.4
Edema Insufficient protein ↓ serum proteins
Insufficient vitamin B-12
Macrocytosis on RBC
smear, ↓ serum B-12
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Hyperpigmentation
Insufficient folic acid
↓ serum folic acid, ↓ RBC
folic acid
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide
Pallor
Insufficient iron ↓ serum Fe, ↑ TIBC
Insufficient vitamin B-12
Macrocytosis on RBC
smear, ↓ serum B-12
Insufficient vitamin C ↓ serum ascorbic acid
Insufficient folic acid
↓ serum folic acid, ↓ RBC
folic acid
Insufficient pyridoxine
↓ plasma pyridoxal
phosphate
Poor skin turgor Insufficient water, sodium ↓ serum Na
Petechiae Insufficient vitamin C ↓ serum ascorbic acid
Swollen red pigmentation
(pellagrous dermatosis)
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide
Hair and Nail Examination
Signs
Possible Nutrition-related
Causes
Possible Supportive
Objective Findings
Shiny, firm, elastic hair
Adequate/appropriate
nutrition
--
Dull, dry, thin, brittle, sparse,
easily plucked hair
Insufficient protein, energy ↓ serum proteins
Thin, spoon-shaped nails Insufficient iron ↓ serum Fe, ↑ TIBC



Head and Neck Examination
Signs
Possible
Nutrition-related Causes
Possible Supportive
Objective Findings
Head
Head evenly molded, with
occipital prominence; facial
features symmetric
Adequate/appropriate
nutrition
--
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Hard, tender lumps in occipital
region
Excess vitamin A ↑ plasma retinol
Headache Excess thiamin None identified
Skull flattened, frontal bones
prominent
Insufficient vitamin D
↓ 25-OH-vitamin D, ↑ alk
phos, ± ↓ Ca, ↓ PO4; long
bone films
Sutures fused by 12 to 18
months
Adequate/appropriate
nutrition
--
Suture fusion delayed Insufficient vitamin D
↓ 25-OH-vit D, ↑ alk phos, ± ↓
Ca, ↓ PO4
Neck
Thyroid gland not obvious to
inspection, palpable in midline
Adequate/appropriate
nutrition
--
Thyroid gland enlarged,
obvious to inspection
Insufficient iodine ↓ total serum iodine

Eye Examination
Signs
Possible
Nutrition-related Causes
Possible Supportive
Objective Findings
Clear, bright, shiny eyes
Adequate/appropriate
nutrition
--
Dull, soft cornea; white or gray
spots on cornea (Bitot’s spots)
Insufficient vitamin A ↓ plasma retinol
Membranes pink and moist
Adequate/appropriate
nutrition
--
Burning, itching, photophobia Insufficient riboflavin ↓ RBC glutathione reductase
Pale membranes Insufficient iron ↓ serum Fe, ↑ TIBC
Night vision adequate
Adequate/appropriate
nutrition
--
Night blindness Insufficient vitamin A ↓ plasma retinol
Redness, fissuring at corners
of eyes
Insufficient riboflavin ↓ RBC glutathione reductase
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide

Nose, Lip, and Tongue Examination
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Signs
Possible
Nutrition-related Causes
Possible Supportive
Objective Findings
Nose
Smooth, intact nasal angle
Adequate/appropriate
nutrition
--
Cracks, irritation at nasal angle
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide
Excess vitamin A ↑ plasma retinol
Lips
Smooth, moist lips, no edema
Adequate/appropriate
nutrition
--
Angular fissures, redness, and
edema
Insufficient riboflavin ↓ RBC glutathione reductase
Insufficient pyridoxine
↓ plasma pyridoxal
phosphate
Excess vitamin A ↑ plasma retinol
Tongue
Deep-pink tongue, papillae
visible, moist, taste sensation,
no edema
Adequate/appropriate
nutrition
--
Magenta coloration Insufficient riboflavin ↓ RBC glutathione reductase
Paleness Insufficient iron ↓ serum Fe, ↑ TIBC
Red, swollen, raw
Insufficient folic acid
↓ serum folic acid, ↓ RBC
folic acid
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide
Insufficient vitamin B-12
Macrocytosis on RBC
smear, ↓ serum B-12

Gum and Teeth Examination
Signs Possible Nutrition-related Causes
Possible Supportive
Objective Findings
Gums
Firm, coral color Adequate/appropriate nutrition --
Spongy, bleed easily,
receding
Insufficient vitamin C ↓ serum ascorbic acid
Reddened gingival Excess vitamin A ↑ plasma retinol
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Teeth
White, smooth, free
of spots or pits
Adequate/appropriate nutrition --
Caries
Excess carbohydrates, poor hygiene,
insufficient fluoride
None identified
Defective enamel
Insufficient vitamin A ↓ plasma retinol
Insufficient vitamin C ↓ serum ascorbic acid
Insufficient vitamin D ↓ 25-OH-vit D, ↑ alk phos
Insufficient calcium ↓ Ca
Insufficient phosphorus ↓ PO4
Mottled enamel,
brown spots, pits
Excess fluoride, or discoloration from
antibiotics
None identified

Cardiovascular System Examination
Signs
Possible Nutrition-related
Causes
Possible Supportive
Objective Findings
Pulse and blood pressure
within normal limits for age
Adequate/appropriate
nutrition
--
Arrhythmia
Excess niacin None identified
Excess potassium ↑ serum potassium
Insufficient magnesium ↓ serum Mg
Insufficient potassium ↓ serum potassium
Decreased blood pressure Insufficient thiamin ↓ RBC transketolase
Palpitations Insufficient thiamin ↓ RBC transketolase
Rapid pulse Insufficient potassium ↓ serum potassium


Gastrointestinal Examination
Signs Possible Nutrition-related Causes
Possible Supportive
Objective Findings
Bowel habits
normal for age
Adequate/appropriate nutrition --
Constipation
Excess calcium; overly rigid toilet training;
inadequate intake of high-fiber foods or
fluids
None identified
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Diarrhea
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide
Excess vitamin C
High consumption of fresh fruit or other
high-fiber foods
Overconsumption of juice
None identified

Musculoskeletal Examination
Signs
Possible
Nutrition-Related
Causes
Possible Supportive
Objective Findings
Muscles firm and well developed,
joints flexible and pain free,
extremities symmetric and straight,
spinal nerves normal
Adequate/appropriate
nutrition
--
Beading on ribs
Insufficient vitamin C ↓ serum ascorbic acid
Insufficient vitamin D
↓ 25-OH-vit D, ↑ alk
phos, + ↓Ca, ↓ PO4,
long bone films
Bleeding into joints, pain Insufficient vitamin C ↓ serum ascorbic acid
Knock-knee, bowleg, epiphyseal
enlargement
Insufficient vitamin D
↓ 25-OH-vit D, ↑ alk
phos, + ↓ serum Ca, ↓
serum PO4
Disease processes Varies by disease
Muscles atrophied, dependent edema
Insufficient protein,
energy
None identified


Neurological System Examination
Signs
Possible
Nutrition-related Causes
Possible Supportive
Objective Findings
Behavior alert and responsive,
intact muscle innervation
Adequate/appropriate
nutrition
--
Convulsions
Insufficient thiamin ↓ RBC transketolase
Insufficient pyridoxine
↓ plasma pyridoxal
phosphate
Insufficient vitamin D ↓ 25-OH-vit D, ↑alk phos
Insufficient calcium ↓ serum calcium
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Excess phosphorus ↑ serum phosphorous
Diminished reflexes Insufficient thiamin ↓ RBC transketolase
Listlessness, irritability,
lethargy
Insufficient thiamin ↓ RBC transketolase
Insufficient niacin
↓ plasma tryptophan, ↓
urinary N-methyl
nicotinamide
Insufficient pyridoxine
↓ plasma pyridoxal
phosphate
Insufficient iron ↓ serum Fe, ↑TIBC
Insufficient protein, energy ↓ muscle and fat stores
Tetany Insufficient magnesium ↓ serum magnesium
Unsteadiness, numbness in
hands and feet
Excess pyridoxine None identified


Sexual Maturation Examination
Signs Possible Nutrition-related Causes
Possible
Supportive
Objective Findings
Age-appropriate
sexual development
Adequate/appropriate nutrition --
Delayed sexual
maturation
Less than expected growth, possibly related
to disease (especially endocrine dysfunction)
or genetic endowment
↓ growth hormone
Excess vitamin A ↑ plasma retinol
Excess vitamin D ↑ 25-OH vit D




Table data from Engel J. Pediatric Assessment. 4th ed. St. Louis, Mo: Mosby;
2002; Kerner A. Manual of Pediatric Parenteral Nutrition. New York, NY: WB Saunders;
1983:22-23; Olsen IE, Mascarenhas MR, Stallings VA. Clinical assessment of nutritional
status. In: Walker WA, Watkins JB, Duggan C, eds. Nutrition in Pediatrics. 3rd ed.
Hamilton, Ontario: BC Decker; 2003:6-16.

Reprinted with permission from Leonberg BL. ADA Pocket Guide to Pediatric
Nutrition Assessment. Chicago, Il; American Dietetic Association; 2008.

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Preterm Infants Terminology and Abbreviations
Preterm Infants Terminology and Abbreviations

Basic Terminology for Neonatal Nutrition
General
Neonate: newborn, birth to 28 days, but sometimes used to refer to a longer period of time
Neonatal: Occurring during the first 28 days of life or very early in infancy
Infancy: Occurring during the first year of life

Birth Weight
Low birth weight (LBW): Less than 2,500 g (5 lbs, 8 oz)
Very low birth weight (VLBW): Less than 1,500 g (3 lbs, 5 oz)
Extremely low birth weight (ELBW): Less than 1,000 g (2 lbs, 3 oz)
Micropremie: less than 750 g (1 lbs, 10 oz)

Gestational Age
Preterm (premature): Gestational age less than 37 weeks
Term: Gestational age 37 to 42 weeks
Postterm: Gestational age more than 42 weeks

Classification
Small for gestational age (SGA): Less than 10th percentile for birth weight for gestational
age
Appropriate for gestational age (AGA): 10th to 90th percentile for birth weight for
gestational age
Large for gestational age (LGA): Greater than 90th percentile for birth weight for
gestational age

Common Abbreviations
ABD: apnea, bradycardia, desaturations
AGA: appropriate for gestational age
ATN: acute tubular necrosis
BF: breastfeed or breastfeeding
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
BPD: bronchopulmonary dysplasia
CAA: crystalline amino acids
CLD: Chronic lung disease
CNG: continuous nasogastric (feeding)
COG: continuous oral gastric (feeding)
CPAP: continuous positive airway pressure
DBM: donor breast milk
EBM: expressed breast milk
ELBW: extremely low birth weight
EN: enteral nutrition
FT: full term
GA: gestational age
GFR: grunting, flaring, and retracting
GIR: glucose infusion rate
HM: human milk
HMF: human milk fortifier
IDM: infant of diabetic mother
IFE: intravenous fat emulsion
IHE: ischemic hypoxic encephalopathy
IUGR: intrauterine growth restriction
IVH: intraventricular hemorrhage
LBW: low birth weight
MBM: mother’s/maternal breast milk
MCT: medium-chain triglycerides
MEN: minimal enteral nutrition (also called priming, trophic and hypocaloric feeding, or
gut stimulation
NEC: necrotizing enterocolitis
NG: nasogastric
NICU: neonatal intensive care unit
OG: orogastric
PBLC: premature birth, live child
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
PDA: patent ductus arteriosus
PDF: preterm discharge formula; also called nutrient enriched, post-discharge and
transitional formula
PFC: persistent fetal circulation (also called PPHN)
PIE: pulmonary interstitial emphysema
PN: parenteral nutrition
PPHN: persistent pulmonary hypertension
PPROM: prolonged premature rupture of membranes
PROM: premature rupture of membranes
PT: preterm
PVL: periventricular leukomalacia
RDS: respiratory distress syndrome
SGA: small for gestation age
SVD: spontaneous vaginal delivery
T: term
TFL: total fluid limit
TPN: total parenteral nutrition
TTN: transient tachypnea of the newborn
UAC: umbilical arterial catheter
UVC: umbilical venous catheter
VLBW: very low birth weight

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved
Resources > Specialty Food Manufacturers
Specialty Food Manufacturers

This list includes names and websites of certain manufacturers of specialty foods, as well
as stores that are likely to carry these items. Note that availability of these products and
stores may change.

1-2-3 Gluten-Free Inc
www.123glutenfree.com

Allergy Friendly Foods (Allergaroo)
www.allergaroo.com

Amazing Grains ( Montina Ô)
www.amazinggrains.com

Amy’s Kitchen
www.amyskitchen.com

Ancient Harvest Quinoa Corporation
www.quinoa.net

Andean Dreams
www.andeandreams.com

Authentic Foods
www.authenticfoods.com

Baby Cakes Bakery NYC
www.babycakesnyc.com

Betty Crocker Gluten Free Mixes
www.bettycrocker.com/products/gluten-free

Birkett Mills
www.thebirkettmills.com

Blue Diamond Growers
www.bluediamond.com

Bob’s Red Mill Natural Foods, Inc
www.bobsredmill.com

Breads from Anna
www.glutenevolution.com

Celiac Specialties
www.celiacspecialties.com

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Chebe Bread
www.chebe.com

Cherrybrook Kitchen
www.cherrybrookkitchen.com

Chex
www.chex.com/Recipes/GlutenFree.aspx

Cream Hill Estates
www.creamhillestates.com

De Boles
www.deboles.com

Dietary Specialties
www.dietspec.com

El Peto Product, LTD
www.elpeto.com

Ener-G Foods, Inc.
www.ener-g.com

Enjoy Life Foods
www.enjoylifefoods.com

Foods by George
www.foodsbygeorge.com

Food For Life Baking Company
www.food-for-life.com

Food -Tek Inc
www.foodtek.com/GF.php

French Meadow Bakery
www.frenchmeadow.com

Gluten Free Oats
www.glutenfreeoats.com

Gluten Free Pantry
www.glutenfree.com

Gluten Solutions
www.glutensolutions.com

Glutino
www.glutino.com
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Ian’s Natural Foods
www.iansnaturalfoods.com

Kettle Cuisine
www.kettlecuisine.com

Kinnikinnick Foods, Inc
www.kinnikinnick.com

Laurels Sweet Treats
www.glutenfreemixes.com

Maple Grove Foods
www.maplegrovefoods.com

Masuya (USA) Inc
www.masuyanaturally.com

Miss Robens Inc
www.allergygrocer.com

Mona’s Gluten Free
www.madebymona.com

Mrs. Leepers
www.mrsleepers.com

Namaste Foods
www.namastefoods.com

Nature’s Path
www.naturespath.com

Nu-World Amaranth
www.nuworldfoods.com

Pamelas Products
www.pamelasproducts.com

Panne Rizo Bakery deli Café
www.pannerizo.com

Quinoa Corporation
www.quinoa.com

Rizopia Food Products, Inc.
www.rizopia.com

Schar
www.schar.com
© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

Sylvan Border farms
www.sylvanborder.com

The Allergy Grocer
www.allergygrocer.com

The Gluten Free Mall
www.glutenfreemall.com

The Ruby Range
www.therubyrange.com

Tinkyada
www.tinkyada.com

Trader Joes
www.traderjoes.com

Vans International Foods
www.vanswaffles.com

Whole Foods Market
www.wholefoodsmarket.com

© Copyright 2012 Academy of Nutrition and Dietetics. All Rights Reserved

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