MI-LEND Video Resource: Nutrition and Diet Therapy in Neurodevelopmental Disabilities (Week 3)

Summary

This video, created by DDIatWSU, focuses on nutrition and diet therapy for children with neurodevelopmental disabilities. It highlights the crucial role of nutritional status in impacting health and quality of life for these children. The discussion includes an examination of malnutrition and overnutrition, featuring their impacts on growth, social involvement, and day-to-day care. The video reviews nutritional assessment methods, explores solutions for feeding difficulties and poor growth, and concludes with an analysis of obesity in the at-risk population.

Highlights

• Malnutrition and overnutrition impact children's growth and social activities 🤕.
• Nutritional assessments are crucial for understanding a child's unique needs 📏.
• Food chaining helps picky eaters widen their food options 🥙.
• A multidisciplinary approach, including dietitians and speech therapists, supports nutritional challenges 🩺.
• Obesity affects a significant percentage of children with disabilities, demanding attention 📈.
• Implementing community and family-based strategies aids in managing obesity 🌐.

Key Takeaways

• Nutrition significantly influences the health and quality of life in children with neurodevelopmental disabilities 🌱.
• Malnutrition can lead to growth issues and increased irritability, while overnutrition can limit participation in activities 🍽️.
• Nutritional assessments involve evaluating growth, diet history, and environmental factors 📊.
• For growth issues, increasing caloric intake with fats and proteins is recommended 🍕.
• Food chaining can help expand a picky eater's diet by gradually introducing new foods 🍟.
• A multidisciplinary feeding team is crucial for addressing nutritional challenges in these children 👩‍⚕️.
• Obesity is a growing concern among children with disabilities, requiring multifaceted approaches for management ⚖️.

Overview

Nutrition and diet therapy play vital roles in managing neurodevelopmental disabilities in children. The session underscores the impact of both malnutrition and overnutrition, discussing their effects on growth, social involvement, and the challenges they pose for caregivers. By reviewing current methods of nutritional assessment, the video provides strategies for optimizing dietary intake to enhance the children's quality of life.

The video introduces case studies and expert-proven methods like food chaining to address feeding difficulties. It also emphasizes the importance of a comprehensive nutritional assessment. This includes factors like growth charts tailored for specific disabilities and caloric intake modification, aiming to meet the individual needs of each child.

Lastly, the video addresses obesity as a significant issue for children with disabilities. Highlighting the need for a collaborative approach, it suggests integrating family, healthcare providers, and community systems to create supportive environments. The video concludes with a call to action for policies that actively promote healthier lifestyles and combat the risks associated with obesity in this vulnerable population.

Chapters

• 00:00 - 01:00: Introduction to Nutrition and Diet Therapy This chapter provides a brief overview of the correlation between nutrition, diet therapy, and neurodevelopmental disabilities. It emphasizes the significant impact of nutritional status on the overall health and quality of life, particularly in children with these conditions. The chapter also highlights the common issue of malnutrition within this population.
• 01:00 - 02:00: Nutritional Challenges in Neurodevelopmental Disabilities The chapter 'Nutritional Challenges in Neurodevelopmental Disabilities' discusses the spectrum of nutritional issues facing individuals with neurodevelopmental disabilities such as cerebral palsy (CP). It highlights the problem of impaired linear growth and increased irritability as challenges associated with undernutrition in this population. On the other hand, it also addresses the issue of overnutrition, which can negatively impact the participation of these individuals in educational and social activities and add stigma. The chapter emphasizes how these nutritional challenges complicate caregiving efforts.
• 02:00 - 03:00: Nutrition Assessment Methodology In this chapter titled "Nutrition Assessment Methodology," the focus is on exploring the methodologies typically used by dietitians for nutrition assessment. The content suggests a review and definition of these methodologies. Additionally, the chapter aims to summarize common causes for delayed growth and poor oral skills development. It also involves evaluating possible solutions to these challenges, which can impact daily living activities such as bathing and toileting, making them more difficult for individuals.
• 03:00 - 05:00: Case Study: Jimmy The chapter opens with the introduction of a case study focusing on a young patient named Jimmy. Jimmy is a 5-year-old with quadriplegic cerebral palsy, who has been referred for a gastric tube insertion. This case is used as an example within the broader context of discussing obesity in at-risk populations. The chapter promises to explore the problems posed by Jimmy's condition and conclude with a brief analysis of obesity in similar at-risk groups.
• 05:00 - 07:00: Growth Assessment Using Alternative Growth Curves The chapter discusses concerns about a child's growth, noting that the child does not have speech and faces difficulties with chewing and swallowing. However, the child does not cough, choke, or have a history of aspiration. The child is fed exclusively orally with feeding times totaling approximately 120 minutes per day. The child's current height and weight are 85 cm and 12 kilos, respectively. The focus appears to be on assessing growth using alternative growth curves.
• 07:00 - 09:00: Different Growth Curves for Neurodevelopmental Disabilities The chapter discusses the challenges in assessing growth in individuals with neurodevelopmental disabilities using standard growth curves, such as those published by the United States CDC in 2000. It raises the point that when plotting the weight and stature of such individuals on these standard charts, they may inaccurately appear undernourished or below expected stature, highlighting the need for specialized growth curves or assessment methods.
• 09:00 - 11:00: Comprehensive Nutrition Assessment The chapter titled 'Comprehensive Nutrition Assessment' discusses alternative growth parameters for assessing height and weight in children with specific conditions, such as cerebral palsy, instead of using standard percentiles. It emphasizes the importance of using more appropriate and recent growth curves that are tailored to such conditions. The chapter highlights the availability of recently published cerebral palsy growth curves which can provide a more accurate assessment for patients with similar medical conditions.
• 11:00 - 15:00: Factors Affecting Growth and Oral Skills Development The chapter discusses factors affecting growth and development, focusing on height and weight trajectories over time. It emphasizes using a comparison with similar populations to evaluate an individual's growth pattern, using a specific reference from 2011 as a case point. The details of the reference can be found at the end of the presentation.
• 15:00 - 19:00: Solutions for Undernutrition The chapter explores the use of specialized growth curves for assessing the nutritional status of children with disabilities, specifically those with cerebral palsy. It highlights the Gross Motor Function Classification System as a tool for categorizing motor abilities.
• 19:00 - 23:00: Dealing with Picky Eaters The chapter 'Dealing with Picky Eaters' discusses various classifications and growth curves specifically relevant to picky eaters. It highlights five classifications of picky eaters, touching on motor function classification and its association with growth curves. Particularly, it mentions the well-established growth curves for individuals with Down Syndrome, which have been updated in 2017.
• 23:00 - 26:00: Feeding Teams and Support The chapter titled 'Feeding Teams and Support' discusses a study conducted by an author referred to as 'ZL'. The study focused on observing a group of children from birth to 20 years. The research was conducted in various settings, including general pediatric practices, community events, and schools, all within Philadelphia. The participants involved in the study were primarily drawn from a clinic at the Children's Hospital of Philadelphia. In total, there were 637 participants involved in this study.
• 26:00 - 30:00: Complexity of Swallowing and GI Issues This chapter discusses the importance of comparing the anthropometric data of children with standardized norms to understand their health status better. The study uses a convenience sample of contemporary children to provide insights into how individual patients are doing in comparison to a broader group. By using this method, healthcare providers can get a clearer idea of the patient's growth and development in relation to established standards.
• 30:00 - 33:00: Gastrostomy Tube and Nutrition Support The chapter discusses the role of a dietitian in assessing the nutritional status of a patient, with a focus on those with neurological disorders. It emphasizes the importance of reviewing a patient's medical history, age, feeding difficulties, and medications as part of a comprehensive nutrition assessment.
• 33:00 - 35:00: Obesity in Children with Neurodevelopmental Disabilities The chapter discusses the importance of gathering a dietary or feeding history when dealing with obesity in children with neurodevelopmental disabilities. This information is usually collected through a 3 to 7-day food diary that details what the child is eating and drinking. The diary helps in understanding the types and textures of food consumed.
• 35:00 - 40:00: Challenges and Strategies in Promoting Healthy Diets This chapter focuses on the complexities and approaches involved in promoting healthy diets, particularly discussing the viscosity, quantity, and quality of food, as well as the feeding routes used. It also explores how modified food textures, such as mashed foods, can be adapted for patients based on their oral and feeding skills. The discussion offers insights into the tactical considerations necessary for accommodating varying dietary needs and challenges in diet promotion.
• 40:00 - 43:00: Conclusion and References The chapter titled 'Conclusion and References' explores various factors affecting children's dietary intake. It discusses the time involved in feeding, frequency of meals and snacks, and the feeding environment. It also considers who typically feeds the child, such as a parent, caregiver, or daycare provider, and how these factors contribute to a child's nutrition.

MI-LEND Video Resource: Nutrition and Diet Therapy in Neurodevelopmental Disabilities (Week 3) Transcription

• 00:00 - 00:30 the topic today is uh nutrition and diet therapy and neurodevelopmental disabilities just a very brief review of this topic um I'm sure many of you know that nutrition status has a significant impact on the overall health and certainly quality of life for these kids and often times malnutrition is
• 00:30 - 01:00 associated with impaired linear growth and perhaps some increased basicity and irritability certainly in our CP population and then at the other end of the spectrum overnutrition can also lead to uh reduced participation for these kids in educational and social activities in addition to other stigma that they may experience and overall make caregiving for them um certainly
• 01:00 - 01:30 with their activities of daily living such as bathing and toileting more difficult so over the next uh remaining minutes I thought uh we could just review and Define some nutrition assessment methodology that's typically used by the dietitians and perhaps some others on the care team uh summarize some common causes for delayed growth and uh and poor skills development oral skills development evaluate possible solutions to some
• 01:30 - 02:00 posed problems and lastly conclude with a short analysis of obesity in this um in this at risk population too so I thought we'd start with just a sample case study that I found in a textbook here where we have Jimmy who's a uh 5-year-old with quadriplegic um cerebal paly and he's been referred to you for um gastric tube insertion because um everyone's a little
• 02:00 - 02:30 concerned about his growth he doesn't have any speech um and know and he does have some difficulties with chewing and swallowing um but doesn't uh cough and uh choke and has no history of aspiration and um he is fed exclusively orally with um feeding times approximately 120 minutes per day and so the anthropometrics that we have bar that is current height is 85 cm and his weight is 12 kilos
• 02:30 - 03:00 so the question becomes would you assess him or assess his growth on a standard growth chart and this standard chart is one from the United States CDC and published in 2000 and so if you were to plot his weight and his stature on again a standard growth curve it would it would appear that he is undernourished or again um at least in terms of his stature growth at least uh nearly three
• 03:00 - 03:30 three standard deviations below uh the lowest percentile but instead because of his condition um I just wanted to make sure everybody was aware that there are other um growth parameters or growth standards that you could compare his height and his weight too which may be more appropriate for his condition and in fact there are recent um cerebal policy growth curves that have been published um they were published in
• 03:30 - 04:00 2011 and um and I've given you a uh the reference for that um appears at the end of the slide presentation which again might be more appropriate to again just comparing height and weight and certainly trajectory over over time using again a population that might be more similar to then um the patient that you have and this is where his height and
• 04:00 - 04:30 his weight for age would would plot then on these curves again that they do follow or at least they certainly appear on the curve when compared to a cohort with a similar um disability there are different cerebal paly growth curves depending on the uh motor ability of the condition and again I've I've given you the reference here that the gross motor function classification system is
• 04:30 - 05:00 classified in five um five ways um which I've highlighted here and again there are growth curves associated with each um motor function classification there are also growth curves that have been fairly well established for the Down Syndrome population and these curves have been recently updated um in 2017 um published
• 05:00 - 05:30 in Pediatrics with the first author ZL um this the study Behind These curves looked at um a group of children from birth to 20 years um in a general pece practice or other interest groups community events um schools again in Philadelphia they were all there from the clinic at the Children's Hospital of uh of Philadelphia so there 637 participants
• 05:30 - 06:00 in this study too and again it's a a convenience sample of contemporary children again what um what we find most helpful is again getting an idea of being able to compare you know your patients um anthropometrics to some other um group just to it just gives you an idea again of how well um your patient is doing as compared to some standardized Norm so in addition to anthropometric
• 06:00 - 06:30 measurements there are other components of nutrition assessment that a dietitian does consider when we're evaluating the nutritional status of a patient um we'd like to look again at the medical history of the patient um including again the the neurological disorder of the patient perhaps the age in which the um patient might have had some feeding difficulties and also reviewing their medications
• 06:30 - 07:00 um another important history that we prepare we um pay particular attention to is a diet history or quote a feeding history from the family and that's usually gathered in a 3 to 7day food diary which can detail again what the child is eating and drinking and we'll look at again what they're eating in particular um types textures of food
• 07:00 - 07:30 viscosity and quantity quality and and feeding route also I just put up some pictures here to help highlight for you um for example some modified food textures I've got a bowl of of mashed food again that may be altered and used depending on the patients oral and feeding skills um in particular we can we look at how
• 07:30 - 08:00 much time it actually takes to feed the child if it's an excessive amount of time then that can also um contribute to poor dietary intake the frequency of meals themselves or the frequency of snacks so look at again um the environment and and perhaps who actually does the feeding is it mom is it some other caregiver babysitter daycare and then in regards to the environment is it
• 08:00 - 08:30 is it chaotic um this little girl it appears that she's enjoying herself too but perhaps there's other distractions going on and so these are all good questions to ask about meal time itself giving you here just an overview of some other factors that can impact um a child's growth and oral skill development in particular on the left-and side of the diagram looking at
• 08:30 - 09:00 other um like why they are um prone to perhaps some um poor growth outcome in terms of the communication abilities of the child themselves other feeding dysfunctions um physical um positioning of the of the child um their overall neurologic maturation again can all again contribute to a limited food intake
• 09:00 - 09:30 so we do have some tricks of the trade in regards to what to do if your patients growth does indicate undernutrition uh we can um try to again increase the calories that a that a child receives either by adding fat or adding protein to the food item or the actual meal or snack itself it usually doesn't work very well to
• 09:30 - 10:00 increase uh portion size or increase frequency of foods because um it provide it's it's a little bit more stressful and oftentimes it just doesn't work well into um the you know the daily routine of of the the family themselves but rather trying to concentrate calories into um what foods are actually that the kid will actually eat is is usually helpful so again adding fats would be um
• 10:00 - 10:30 again trying to use some gravies adding butter to things Now's the Time to try you know full fat dairy products for example other types of sauces and um an inexpensive way to increase protein into a child's diet would be to use some type of dry milk powder um which can be found easily on a grocery store shelf and um and as we know there are a number of oral supplements that are also available
• 10:30 - 11:00 um over the counter now which um a family can use in place of um for example some other dairy product or um that again that is more calorically dense and more and does contain more vitamins and minerals um so what do you do or what can be done with a a picky eater well there's um if you haven't heard about this before or This this term um you can try um something called food chaining um
• 11:00 - 11:30 there was a a book published about 10 years ago about this in terms of how to expand a a picky child's um repertoire or u in terms of food choices that they they would find acceptable and of course the goal is trying to prevent the the kid from any type of sensory overload and trying to again start with a food that the child already eats or that
• 11:30 - 12:00 already accepts and then trying to progress from one food to another one so for example what this um diagram illustrates is um in the first bubble you have a have someone that's um willing to eat french fries and where you could try to you know again expand the diet would be into something similar to a french fry but maybe a different shape such as a waffle fry um a tater
• 12:00 - 12:30 tot or perhaps hash brown so you are still in the same food type but yet it has you know it has a different appearance perhaps a slightly different texture and mouth feel and it's not it's certainly not an overnight um solution but instead the literature does support that you need to consistently try the same of the food item multiple times maybe even for
• 12:30 - 13:00 several meals or several days before giving up and um it is suggested that you try at least 15 to upwards of 25 times and then once the item is accepted then you'd want to then try something else again trying to again gradually change um the number of accepted items into this kind of format and of course this takes a lot of patience and and time but um certainly worth um worth
• 13:00 - 13:30 trying um like Dr phelp said earlier in um in her presentations there are certainly other team members that can assist um with you know these these types of of eating behaviors again um food aversions oral aversions and um and we do have something um called a feeding team which can again concentrate certainly on feeding dysfunction um the
• 13:30 - 14:00 positioning of the child and again assessment of the neurologic maturation of the of the um oral um abilities of the kid s and in addition to the dietitian a feeding team can consist of these other um Personnel such as um and I'll let you read that for yourself mainly at least at um the University of Michigan in my experience and then talking with some of
• 14:00 - 14:30 the other practitioners um it's really important to have your speech pathologist your physical therapist and your occupational therapist on board um and they are they are the experts in this whole area um gastrointestinal issues such as dysphasia and gastro sophal reflux are common in in children with neurodevelopmental disabilities um and then perhaps I'm already stating the obvious um but here just for review
• 14:30 - 15:00 swallowing is a complicated process and in fact just um doing the review for for this webinar um just reminding myself and others that eating and drinking actually involves 31 coordinated muscles and six cranial nerves so if we have if you're um patient or client has any type of physical dysfunction in any of these areas then you can see why um dysphasia
• 15:00 - 15:30 and reflux are are so common and typically swallowing um difficulties involves an impairment of one of the three phases of swallowing itself um these types of GI issues are a major chronic problem and it's estimated upwards of 80 to 90% of patients with cerebal policy and other disabilities experiences including reflux 2 reflux get stopage reflux can be caused by many
• 15:30 - 16:00 factors here that I've um I've documented for you so if you have a patient that again um has poor oral intake you've you've made your referral to a feeding team you've concentrated oral intake and yet still um unfortunately experiences poor growth um then natural nutrition support
• 16:00 - 16:30 um via typically a gastrostomy tube may be indicated certainly in patients that have growth failure and um you know whether um a peg or again how you place the tube whether it's percutaneously endoscopically placed or surgically placed um is again a medical decision along with the family but here I've pictured just um have for a picture of a a couple of gastrostomy tubes there and a child
• 16:30 - 17:00 who does have a g tube in place and now lastly I just wanted to conclude um at the other end of the spectrum um in regards to obesity among children with special needs and um just some uh just a few facts about the problem itself here um I I did forget to put in one line the Definition of
• 17:00 - 17:30 overweight is is usually measured is measured by children with a BMI greater than or equal to the 85th percentile on the growth turb and then the definition of obesity in children is a BMI greater than or equal to 95% um again for children of the same age and sex and we use um we have a a curve that is um is used along and again published by the CDC in fact um 20 as I stated here in
• 17:30 - 18:00 the second bullet 22% of children with disabilities are obese and that compares to approximately 16% of children without disabilities and this is in the United States uh more girls are impacted than boys and um one study even looks at um looking in 2010 um using um some well documented survey data that we have available in this country measuring the
• 18:00 - 18:30 BMI of 461 adolescents um ages 12 to 18 with a physical intellectual or behavioral disability and 67% of those teens on the um with the autism spectrum disorder are either overweight or obese um the number of um 86% of teens with Down Syndrome are either overweight or obese um and um upwards of 19% of teenagers cerebal paly are also obese so
• 18:30 - 19:00 um just wanted to make sure and make you aware of that there's there certainly are unique risk factors um for obesity in this population in addition to the documented risk factors for obesity um with with um non-disabled children that um these kids often have again a a complex relationship with food um when we talk
• 19:00 - 19:30 about um promoting a healthy diet in the family and the children um often times um families may be experiencing enough behavioral battles so they just really don't want to fight over food itself um they're also influenced by their peers and so they want to fit in and oftentimes that means that they're also drinking soda or eating fast food too uh these children have um physical barriers to exercise and sometimes they get tired they often may need U modified equipment
• 19:30 - 20:00 and this type of equipment or modification can come at a price and so there are some recent surveys that indicate that there that we do lack facilities and programs near um fam's homes um 75% of Special healthc Care needs children take at least one prescription medication and many of these medications are associated with weight gain so it's also something to keep in mind um Family stress can contribute too
• 20:00 - 20:30 because if you have a family that's worried about um you know has Financial issues perhaps even food security problems in addition to you know making multiple medical appointments or Transportation responsibilities eating you know your daily fruits and vegetables may definitely take a a backseat to that other unique property or um factors
• 20:30 - 21:00 that uh play in with this population um there are certain genetic disorders that have obesity as a clinical feature um sometimes um families um particularly um teachers maybe some School coaches might perceive risk with um certain activity and therefore may not promote that um with some kids um this population is also at risk for social isolation with just fewer friends
• 21:00 - 21:30 missing out on opportunities to have free play and screen time um certainly screen time is um a risk factor for all children in this country um but certainly in this in this group it's strongly associated with City uh one proposed model for obesity treatment which again um I think carries over to um just
• 21:30 - 22:00 the entire pediatric population is um certainly involving the the child in the center of the decisions about making about their own health and certainly about their own their own Fitness but um interpersonal um groups such as again the family the friends the peers trying to making sure that in addition to promoting and changing a child's eating and phys physical activity habits um
• 22:00 - 22:30 also making a conscious effort to perhaps change their own or uh commitment to their own um healthy lifestyle organizationally I'm looking at our schools again health care sites everyone that's working in the child's life trying to promote a healthy weight our communities can certainly do more and I think we're we're trying to address that in regards to our neighborhood WS our cities our towns um how can we change
• 22:30 - 23:00 our own environment and lastly Society certainly our own um State and National policies have a role to play in obesity treatment and prevention so my last slide here has um a number of references that I've I found helpful putting this together and thank you for your time