A busy newsletter this month with an eclectic mix of fussy eaters and QTc calculators, female genital mutilation and tonsillitis, healthy start vitamins and syncope. Do leave comments below.
Tag Archives: nutrition
Feeding disorders
Fussy eating is one of the most common things that parents present with to both primary and secondary care. My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject. I hope you find the structure as sensible, helpful and reassuring as we did.
FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica). We have not covered here eating disorders such as anorexia or bulimia.
Common presentations include:
- Dysphagia
- Food refusal
- Self feeding inadequacy
- Excessive meal duration
- Choking, gagging, vomiting
- Inappropriate mealtime behaviours
- Food selectivity by type and texture
Normal feeding development is as follows:
- Up to 6 mths – breast/bottle fed milk
- 6-12 mths – solids introduced and increased in variety & volume. Milk intake begins to decrease.
- At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
- 15 mths – hold spoon, messy feeding, use feeding cup
The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how. Some parents struggle to adapt to this:
- Messy
- Feeding cues can be missed
- Parental fear that insufficient food will be taken, child will lose weight
- Parents own food preferences
- Rejection of a food and assumption that child will never like it
- Time pressures
The health professional must look for an organic cause of food refusal:
| Organ system | GI disorder | Mechanism |
| Mouth | Carious teeth Structural with oral dysphagia |
Pain Reluctance to swallow |
| Pharynx | Tonsils Aspiration |
Pain, obstruction Choke, gag |
| Oesophagus | Reflux oesophagitis Cows milk allergy |
Pain, burning |
| Stomach | Motility disorder | Reduced appetite, discomfort |
| Colon | Constipation | Pain, discomfort, reduced appetite |
Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.
There are 5 key elements to the assessment:
- How is the problem manifested?
- Is the child suffering from any disease?
- Have child’s growth & development been affected?
- What is the emotional climate like during mealtimes?
- Are there any great stress factors in the family?
Red flags to look out for include:
- Swallowing difficulty with cough, choke or gag
- Vomiting/abdominal pain/arching/grimacing/eye watering
- Recurrent chest infections
- Stridor on feeding
- Snoring with sleep apnoeas
- Constipation
The history is, as always in medicine, of paramount importance and needs to be fairly detailed:
- Birth History
- Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
- Developmental progress
- Chronology of feeding problem
– Diet since birth - – Changes of milk formulae
– Introduction of solids - Current diet (typical day)
- What happens at meal times?
- Family & Social history
Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age. Refer children with red flags or significant faltering growth to secondary services.
- Management of the well child in primary care:
- Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
- Encourage family foods
- Meal time management (see NHS Lothian’s dietetic advice)
- Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship
The multidisciplinary approach:
- Health Visitor – can assess child within home situation
- Dietician
- – Nutritional assessment and feeding advice
- – Calorie enrichment
- – Calorie supplementation
- – Enteral feeds (very occasionally)
- Speech & Language therapist
- – Direct assessment of feeding & advice in home situation
- – Parent-child interaction
- – Is swallow safe?
- – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)
Summary points:
- Feeding disorders in children are common
- Occur in healthy children but assessment should be made for organic causes
- – GI tract problems
- – Developmental delay
- – Autistic spectrum disorder
- Watch out for obligate milk drinkers
- Meal time management is crucial
- Involve Health Visitor
Further resources:
Weaning your premature baby. Free download from Leicestershire Dietetic Service 2011
Help! My child won’t eat and My child still won’t eat. British Dietetic Association. Available to buy in packs from http://www.ndr-uk.org/
My Child Won’t Eat by C Gonzalez – these are both books and the links are to www.amazon.co.uk
New Toddler Taming by C Green
GP’s September 2011 issue now available
It’s the last day of September today so I’ve just got in by the skin of my teeth… In this month’s edition I have done a bit on BCG vaccination from the recently updated NICE guideline on TB, reminded you of where to get the new growth charts from and how to plot ex-prem babies on them and featured a somewhat depressing paper from Archives of Disease in Childhood this month on the effects of maternal obesity on the baby. Do leave comments and questions below.
Combined GP and ED versions for August 2011
Well the BMJ produces 2 journals in one in August so why can’t I? All the topics featured this month are relevant for both GPs and ED doctors – for once – so you have a joint newsletter. I have covered headache this month, Vitamin D (by popular request) and we have started the “Feeding” series requested by my ED senior colleagues. It seems appropriate to have covered breastfeeding first. Do leave comments below.
Common breastfeeding problems
My ED consultant colleagues requested that we run a series on “feeding issues” in Paediatric Pearls as it forms a part of the ED trainees curriculum and is a common subject to come up in conversation with parents in the ED. It seems appropriate to begin the series with an article on breastfeeding problems put together by our breastfeeding counsellor, Jo Naylor, and one of the current paediatric trainees, Dr Sarah Prentice. Their full article is downloadable here and I have reproduced some nuggets in this month’s Paediatric Pearls newsletter and below.
| Breastfeeding adequately? | Inadequate milk intake? |
| feeding every 2 – 5 hours for 20 – 40 minutes | infrequent feeds |
| 3-4 wet nappies and changing stool by day 3 | continued urates and/or meconium after day 3 |
| pain free breastfeeding | painful feeds, ineffective sucking |
| weight loss < 10% | weight loss > 10% |
| baby settled between feeds | fretful, hungry baby |
Reminder: handout of local breastfeeding drop-in groups available here.
I intend to cover the following topics over the next few months (some of which have actually already been touched on in previous months): vitamin supplementation, formula milk, gastro-oesophageal reflux, starting solids, allergy, fussy eating, food refusal, dentition and use of bottles, healthy eating, obesity, eating disorders. Please do leave requests for other topics below.
Vitamin D guidance at last!
Take a look at this not-definitive-but-nevertheless-sensible guideline on Vitamin D deficiency in both adults and children which Barts and the London published in January 2011: http://www.icms.qmul.ac.uk/chs/Docs/42772.pdf. Please note that it is NOT a national guideline and the authors acknowledge that more research is needed in this area and that variations in practice are common, even across London.
The Paediatric Pearls newsletters are checked every month by my consultant colleagues. We have been keen to put something together for GPs on vitamin D for a few months now but are struggling with the lack of evidence and consensus in this area. Some of the comments I have received back from my colleagues concerning this guideline include:
- A cut off of 80nmol/l is too high as the lower limit of normal. Most hospitals (including Whipps) use 50nmol/l because symptoms do not tend to be evident until that level.
- The paediatric clinical guideline currently in use at the Royal London Hospital is not quite the same as their Clinical Effectiveness Guideline in that it advocates lower doses of vitamin D therapy (than the BNFc) for a longer period of time. The advantage of this is that no monitoring of calcium levels is required.
- Liquid ergo or colecalciferol are difficult to get hold of nationally and some patients find it hard to find a community pharmacist who will supply it. There is a shortage of it at the moment and it is expensive. It would make practical sense therefore to just treat the deficient ones (<25nmol/l) rather than the asymptomatic insufficient patients (25 to 50nmol/l). This is in practice what the majority of us do, ensuring that the insufficient (and even sometimes the asymptomatic deficient group) ones get vitamin supplementation (400IU/day).
- “Symptomatic” includes general aches and pains and does not just refer to hypocalcaemic tetany or rickets.
- Healthy Start vitamins are available again now and are a better long term option than Abidec or Dalivit as they are free to young mothers and their children and to people on benefits, see http://www.healthystart.nhs.uk/. They should be available at all health centres at low cost (if the family does not qualify for healthy start vouchers) to all breastfeeding babies and then for the over ones when they have moved on to cows’ milk.
- We all agree that children with rickets and bone deformities secondary to vitamin D deficiency should be seen in secondary care as they require a greater degree of monitoring, especially their calcium levels, when first started on high doses of colecalciferol. There is also a risk of cardiomyopathy in this group.
- The Clinical Effectiveness Guideline from the Barts and the London group states that 90% of South Asian people in their region (mainly Tower Hamlets in east London) are vitamin D deficient. We don’t yet seem to have found an answer as to why there are not even more cases of rickets or hypocalcaemic tetany in that region then.
I suspect, as usual, the answer to the vitamin D conundrum is not quite as straight forward as this guideline makes out. Do leave comments below.
This is the 2011 Barts Health Vitamin D guidance, with thanks to pharmacist Nanna Christiansen for allowing me to upload it to this site. Please note that the doses here are not the same as the BNFc. There is a wide range of doses which you can prescribe for Vitamin D deficiency and insufficiency and no national agreement on what constitutes either deficiency or insufficiency.
Gastro-oesophageal reflux
Any words of wisdom on this topic very welcome here! A slightly lax lower oesophageal sphincter is pretty normal in the under 1s but a lot of energy is expended in trying to do something about the symptoms. The paper cited in this month’s Paediatric Pearls from the Drugs and Therapeutics bulletin is really rather depressing in its comments on both pharmacological and non-pharmacological management of reflux. Even surgery doesn’t always work. It is particularly common among preterm babies and much has been written about that group of patients too – with similar levels of evidence generated as with term infants. You might want to read: Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas. J L Birch, S J Newell, Arch Dis Child Fetal Neonatal Ed 2009 or Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the NASPGHAN and the ESPGHAN. J Pediatr Gastroenterol Nutr; 2009 on this topic.
Contraindications to breastfeeding
I was encouraging a mother to breastfeed the other day when she asked if I was sure that was OK with her condition. Her baby is asymptomatic on a 10 day iv course of penicillin for presumed inadequately treated maternal syphilis. I wobbled momentarily and the junior doctor and I went away to look it up. It is OK apparently as long as the mother does not have syphilitic lesions around her nipples. Take a look at http://pedclerk.bsd.uchicago.edu/page/breastfeeding which is an American teaching site and has a nice summary of when you can and can’t breastfeed. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT is an American database of the evidence on the safety of various medicines when breastfeeding.
Faltering growth
I am teaching our local GPVTS trainees this week on faltering growth, food allergy and coeliac disease. As usual, I have learnt more from preparing their presentation than they are going to learn in the hour it will take me to present it! I have found a great GP training website set up by a GP in the north of the UK with similar altruistic aims to me. Have a look at what he has to say on faltering growth at http://www.gp-training.net/training/tutorials/clinical/paediatrics/pgrowth2.htm.
I have put together an algorithm for managing cows’ milk protein allergy and a table on various different infant formulas which you are welcome to download or comment on.
I used to work in Poole Hospital, Dorset and was pleased to find this patient information leaflet from the dieticians there on tips for families where a child is refusing to eat: http://www.poole.nhs.uk/documents/leaflets/nutrition/My%20Child%20Wont%20Eat.pdf. It is based on the leaflet “Help, my child won’t eat” which is put together by the Paediatric Group of the British Dietetic Association but not obviously available on-line.
Vitamin D
There has been a lot of interest in Vitamin D deficiency recently and a certain lack of consensus on what to do about it. We certainly do see rickets in our community which we treat with oral ergocalciferol which is notoriously difficult to get hold of in community pharmacies I know. But full blown rickets is just the tip of the iceberg. The Department of Health produced a leaflet in January 2010 (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_111302.pdf ) which is the nearest I can find to a national guideline dealing with the risk of Vitamin D deficiency.