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Failure to Thrive and Picky Eaters

Failure to Thrive and Picky Eaters. Why liquid calories are not the answer. Disclosures. I have no financial disclosures. Objectives. Definition of failure to thrive (FTT) Sugar guidelines ( AHA/WHO ) and addiction Why not Pediasure Weight gain and WIC foods When to supplement

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Failure to Thrive and Picky Eaters

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  1. Failure to Thrive and Picky Eaters Why liquid calories are not the answer

  2. Disclosures • I have no financial disclosures

  3. Objectives • Definition of failure to thrive (FTT) • Sugar guidelines (AHA/WHO) and addiction • Why not Pediasure • Weight gain and WIC foods • When to supplement • Picky eaters

  4. Definition FTT • Failure to thrive is defined as decelerated or arrested physical growth • It is a sign of undernutrition • FTT is a clinical finding and should never be a diagnosis on its own Cole, 2011

  5. Definition • BMI for age less than the 5th percentile • Length for age less than 5th percentile • Weight for age less than 5th percentile • Weight deceleration crossing two major percentile lines • Weight less than 75% of median weight for age • Weight less than 75% of median weight for length • Weight velocity less than 5th percentile Cole, 2011

  6. Diagnosis • Any single indicator has a low positive predictive value for true undernutrition • In one study, 27 percent of infants met at least one definition for FTT during the first year of life (Olsen, 2007) • Weight for length is a good indicator of acute undernutrition (Shah, 2002)

  7. Normal growth variants • Genetics- children of small parents • Large-for-gestational-age infants who regress toward the mean • Constitutional delay in growth • Premature infants whose growth parameters are normal when corrected for gestational age Cole, 2011

  8. Growth charts

  9. Source: Cole SZ, Lanham JS. Failure to Thrive: An Update. Am Fam Physician.2011;83(7):829-834.

  10. Why is FTT important? • Malnutrition can impact growth potential and cognitive development • Obese patients can have significant micronutrient deficiencies (Via, 2012) • Good nutrition is the goal, not just weight gain

  11. Dietary History Nutrition • Overall calories • Set meals vs grazing • Types of food • Juice and milk intake Occupational Therapy • Choking/gagging • Frequent respiratory infections • Overstuffing mouth • Issues with specific or mixed textures

  12. Why are juice and milk bad? • Can interfere with proper nutrition • Can fill kids up so they decrease their intake of solid foods • Excess milk can cause anemia • Juice causes cavities and can increase risk of obesity

  13. Excess juice contributes to FTT • Study looked at 8 children, 14-27 months old with FTT • 12 to 30oz per day of fruit juice which contributed to 25-60% of daily energy intake • Had lower dietary protein, fat, and micronutrient intake • Decrease in weight and linear growth that coincided with juice consumption • Their diet only provided 78% to 92% of recommended energy intake for age and weight • After nutritional intervention, dietary intake increased to 96% to 116% of recommended intakes. • Weight gain increased significantly in the first month and persisted for follow up of 5 to 18 months Smith, 1994

  14. Juice affects of stature • 163 children that were 2 and 5 years old • Dietary intake recorded over 14 days • Adjusted for child age, gender and energy intake (excluding fruit juice) and maternal height • Child height was inversely related to apple juice and grape juice intake (Dennison, 1999) • Related study showed >12oz juice per day to be correlated to short stature (Dennison, 1997)

  15. My child has FTT what should I give them? • Pediasure

  16. Liquid calories • Teaches kids to be picky eaters • Perpetuates sweet tooth • Can lead to obesity

  17. How much added sugar do we consume? • 1 to 3 year olds: 12 teaspoons/day • 4 to 8 year olds: 21 teaspoons/day • 14 to 18 year olds: 34.3 teaspoons/day Source: National Cancer Institute and National Health and Nutrition Examination Survey

  18. Is sugar addictive? • Chronic smokers could reduce tobacco cravings better than sugar cravings • Sugar affects dopamine receptors similarly to cocaine • After consuming sugar there is a surge in serotonin in the brain DiNicolantonio, 2018

  19. Oregon Research Institute

  20. Intense Sweetness Surpasses Cocaine Reward • Drug naive rats were allowed to choose between water sweetened with saccharin versus IV cocaine • 132 rats Lenoir, 2007

  21. S-/C+ S+/C- S+/C+ Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLoS ONE. 2007;2(8): e698.

  22. Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLoS ONE. 2007;2(8): e698.

  23. Rats and sugar conclusions • 94% of rats preferred saccharin • Same preference observed with sucrose • Increased doses of cocaine were not able to overcome rats choice of saccharin

  24. Reward dysfunction and compulsive eating • Wanted to test effects of restricted or extended access to a palatable diet • Rats had timed access to palatable diet for 40 consecutive days • 0 hr (chow-only) • 1 hr (restricted access) • 18-23 h (extended access) • Also had ad lib access to standard chow • Palatable diet: bacon, sausage, cheesecake, pound cake, frosting, and chocolate Johnson, 2010

  25. 40 days of access to palpable diet Chow Only 0 hour Restricted Access 1 hour Extended Access 18-23 hour

  26. Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D2 receptors. Nature neuroscience. 2010;13(5):635-641.

  27. After 40 days of access to palpable diet Chow Only 0 hour Restricted Access 1 hour Extended Access 18-23 hour • Permitted only 30min access per day to palatable diet for 5-7 days until stable intake • Then split into 2 groups

  28. Unpunished Rats Punished Rats Chow Only Restricted Extended Chow Only Restricted Extended

  29. Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D2 receptors. Nature neuroscience. 2010;13(5):635-641.

  30. Infants and sugar A study of 200 infants showed preference for sugar • At birth all infants preferred a sweet solution over water • At age 6 months the preference for the sweet solution was linked to dietary experience • Infants repeatedly fed sweetened water had greater preference for it • Offering foods without added sugar should be advised to help set the infants threshold for sweetness at a lower level De Cosmi, 2017

  31. Sugar: 26gm Sugar: 28gm

  32. Healthy weight gain foods Proteins Fats • Full fat Greek yogurt • Cheese • Nut butters • Cottage cheese • Eggs • Beans • Meats • Chia or flax seeds • Whole milk (8-12oz per day) • Butter • Cream cheese • Cheese • Heavy cream • Dressings • Avocado • Hummus • Coconut oil • Olive oil

  33. Behaviors around weight gain • Three meals and two snacks per day • No grazing • Limit milk and juice intake • Eat at the table as a family (high chair/booster) • Avoid distractions such as screens

  34. WIC foods

  35. WIC foods Plain: Cal: 75 Fat: 2g Protein: 5.5g Sugar: 9g Vanilla: Cal: 105 Fat: 1.5g Protein: 5.5g Sugar: 17g Plain Lowfat: Cal: 75 Fat: 1.75g Protein: 5.5g Sugar: 8g Vanilla Lowfat: Cal: 100 Fat: 1.5g Protein: 5g Sugar: 17g Strawberry: Cal: 70 Fat: 0g Protein: 5g Sugar: 8g Vanilla: Cal: 70 Fat: 0g Protein: 5g Sugar: 9g

  36. WIC Foods Vanilla: Cal: 130 Fat: 7g Protein: 2g Sugar: 14g Plain Nonfat: Cal: 60 Fat: 0g Protein: 5g Sugar: 8g Vanilla Lowfat: Cal: 87 Fat: 1g Protein: 3g Sugar: 21g Plain Nonfat: Cal: 60 Fat: 0g Protein: 4.5g Sugar: 6.5g Vanilla Lowfat: Cal: 105 Fat: 1g Protein: 3g Sugar: 17g Plain Nonfat: Cal: 65 Fat: 0g Protein: 6g Sugar: 7.5g Vanilla Lowfat: Cal: 100 Fat: .75g Protein: 3.5g Sugar: 15g

  37. 1 Large Egg Cal: 78 Fat: 5g Protein: 6g

  38. An Egg a Day… • 163 infants age 6 to 9 months • 83 infants ate an egg per day for 6 months • Egg group • Increased length for age z score by 0.63 • Increased weight z score for age by 0.61 • Reduced stunting by 47% • Reduced underweight by 74% • Reduced intake of sugar sweetened foods Iannotti, 2017

  39. WIC Foods 2 Tbsp Cal: 188 Fat: 16g Protein: 8g Sugar: 3g

  40. Breakfast Ideas • Yogurt Parfait • ½-2/3 cup Whole fat yogurt • 2-3 Tbsp Frozen or fresh berries or other fruit • 2-3 Tbsp Cereal • 1 Tbsp Chopped nuts • Peanut butter roll up • 2-3 Tbsp peanut butter • 1 Whole grain tortilla • 1 Banana • Scrambled eggs with cheese and veggies • Can also add a splash of cream • Oatmeal • Add ins of butter and/or peanut butter

  41. Snack Ideas • Bean and cheese burrito/quesadilla • Peanut butter balls • Peanut butter • Oats • Chia/flax seeds • Cottage cheese with fruit or vegetables • Vegetables dipped in hummus or guacamole • Tuna salad • Tuna • Mayo or cream cheese • Celery

  42. When to supplement

  43. Source: Cole S, Lanham J. Failure to Thrive: An Update. Am Fam Physician. 2011 Apr 1;83(7):829-834.

  44. What to supplement • Home made high calorie smoothies • Fruits • Vegetables • Fats: cream, avocado, chia seeds, etc • Proteins: peanut butter, Greek yogurt, etc

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