The Dietitian he Dietitian - Association of Community Cancer Centers
Chris Smith Senior Paediatric Dietitian
Transcript of Chris Smith Senior Paediatric Dietitian
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Diet in
Chris Smith
Senior Paediatric Dietitian
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• What do you recommend ?
• How many calories does my child need ?
• How often should I weigh my child and how do I know if the growth is good ?
• What are the answers?
• What about the ketogenic diet?
• What about low fibre diets ?
• What supplements should I give?
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QUALITY NOT QUANTITY
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KNOW YOUR CHILDS NEEDS
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What calories does my child need ?
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AGE BOYS GIRLS
2 600 558
3 702 648
4 834 774
5 888 816
6 936 888
7 990 918
8 1050 978
9 1104 1032
10 1218 1164
11 1278 1212
12 1350 1260
13 1446 1332
14 1578 1404
15 1692 1434
16 1782 1446
17 1848 1476
18 1896 1476
PWS CALORIE DAILY REQUIRMENT
THIS IS A GUIDE ONLY
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• 20kg , 5 year old boy PWS plays football for 20minutes
• How many calories will he burn?
• What would be a good snack ?
105 calories 183 calories 145 calories
What about adjustments for activity ?
54kcals
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ESTABLISH ACTIVITY AS NORMAL PART OF LIFESTYLE
TAKE CARE TO PROVIDE APPROPRIATE SNACKS TO PREVENT PROVIDING POSITIVE CALORIE BALANCE
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Understand their growth pattern and stages
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HEIGHT
WEIGHT
AGE
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Standardized curves for weight of non–growth hormone–treated subjects (male subjects
[upper] and female subjects [lower]) with PWS (solid lines) and normative percentile ranges
(shaded area) with normative 97th to 50th percentiles in dark shading and 50th t...
Merlin G. Butler et al. Pediatrics 2015;135:e126-e135
©2015 by American Academy of Pediatrics
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Standardized curves for height of non–growth hormone–treated subjects (male subjects
[upper] and female subjects [lower]) with PWS (solid lines) and normative percentile ranges
(shaded area) with normative 97th to 50th percentiles in dark shading and 50th t...
Merlin G. Butler et al. Pediatrics 2015;135:e126-e135
©2015 by American Academy of Pediatrics
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BMI charts don’t account for body composition
Don’t account for inherent growth pattern difference in PWS
Can be used for monitoring but interpretation of results is very difficult
Growth charts better
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Expectation should be for proportional growth along UK centiles
Specific PWS charts act as good additional reference
Specific PWS charts describe how PWS children grow not how they should grow
Due to nature of body composition BMI on standard charts may be misleading
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PHASE 2b -Increased interest in food-Frequent food based questions-Will eat in line of sight
PHASE 2a-No increase in appetite-Appetite for age-Typically needs 60% -Will become obese if typical diet
PHASE 1b-No longer needs assisted feeding-Grows steadily along curve with N intake-Normal appetite
PHASE 1a-Weak suck-Oral feeds very slow-Decreased appetite -Doesn’t cry at feeding times-Weak cry
0-9 months
9-25 months
2.1-4.5years
4.5-8 years
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Importance of a team approach
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ROCKET SCIENCE ??
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• Your child is invited to a birthday party at McDonalds. Should they go?
• PRO Social, inclusive, exposure inevitable
• CON Exposes child to temptation/ well meaning peers/ represent poor quality food
PLAN AHEAD BE CONSISTENT
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• The school class is doing an optional cookery classes. Should your child be involved?
• PRO Great interest, opportunity for education
• CON Breaks structure, adds temptation, well meaning friends teachers
PLAN AHEAD BE CONSISTENT
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• Allow treats / seconds on special occasions?
• PRO Part of childhood
• CON Never forgotten, tightrope of calories
PLAN AHEAD BE CONSISTENT
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Good guys vs bad guys
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Food Security
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MISTAKEN BELIEF
This is because efforts to limit food, if attempted without establishing FOOD SECURITY ,cause increased stress in the form of doubts, hope and disappointments
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Provide food security
• Structure
• Consistent approach
• Visual menus
• Portion cups
• NO DOUBTS about what will be provided and when
• NO HOPES of obtaining food outside the plan
• NO DISAPPOINTMENTS concerning food
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LOCK AWAY TEMPTATIONOR
DON’T HAVE IT
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BECOME A NUTRITION EXPERT
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What is a normal portion size?
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Segmented lunch boxes
Structured, ensures consistent portions
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RE THINK HOW YOU THINK ABOUT FOODS
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Using food rewards (and withholding them) for behaviors which may be the result of stress or anxiety [e.g. refusals, tantrums, shutdowns] may worsen the situation
NON FOOD TREATS FOR PWS CHILDREN
LOVE MEANS SAYING “NO”
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WHAT EXTRA CAN I DO ?Special diets
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KETOGENIC DIET
• 108 families express interest
• 14 families completed requirements
• 10 families completed 6 months
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Ketogenic diet
• No good quality studies
• Large amount of work needed
• Risks of balancing the diet
CONCLUSION:Despite the burden of managing a structured diet 10 families found it was worthwhile and have continued beyond 9 months.
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LOW FIBRE
• Concerns about swallow / food lodging
• 1. Provide small, frequent meals. Avoid the three LARGE meals per day. Break up meals/snacks to three small meals and two snacks a day (six is only recommended if the person has diabetes). Reduce quantity of food being provided at one time.
• 2. Include more liquid or semi-liquid food items. Provide liquids during and between meals. Have person drink water or fluids between bites of food. (Helps moisten food and facilitate movement from mouth to the stomach; less work and time with food in stomach).
• 3. AVOID: RAW vegetables and fruits, nuts and salads. (YES, this is a change)
• 4. DO PROVIDE: vegetables that have been cooked (softened) and/or mashed, fruits in softer form – applesauce, fruits in natural juices, and cooked cerealDont eat too late
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WHAT EXTRA CAN I DO ?Supplements
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WHAT DOES IT MEAN ?
Very small number of PWS patients, also reduced calories, application to the real world not clear At best encouraging and paves the way for more work but insufficient to recommend to all
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• No significant differences in total and free carnitine or CoQ10 levels between individuals with PWS, obese individuals, and sibling control groups.
• 20 families elected to try carnitine supplementation (50 mg/kg/day divided twice a day) regardless of the serum carnitine profile results.
• 13 of these twenty families (65%) reported subjective improvement of exercise tolerance and daytime alertness with carnitine supplementation.
• 7 of the 20 families who tried carnitine supplementation discontinued it due to lack of benefit and/or side effects of therapy.
• 10 families started CoQ10 supplementation (50 mg/day) • 5 (50%) of these families reported benefits in daytime • All of the individuals who were reported to benefit from CoQ10 were under
3 years
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Co enzyme Q10
• Deficiency rare
• Associated with increased physical activity, increased muscle tone and strength, increased cognitive ability, less sleeping, increased "energy"
• Deficiency rare
• Associated with improved mental and physical lethargy, muscle weakness and hypotonia in the early presentation of PWS
• No studies in PWS
INSUFFICIENT EVIDENCE PARENT CHOICE
Carnitine
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Vitamins and minerals
BIRTH to 5 Vitamin D
FROM 3 Consider supplementIron, Zinc
FROM 5 Very likely will require standard multivitamin and mineral – iron, zinc, Vit D
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Always check the label
• NO IMPORTANT MINERALS
• NO IMPORTANT MINERALS
• UNECESSARY SUGAR
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>12years
From birthPrescription only Needs dose calculation
Contact producer
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TAKE HOME MESSAGES