Nutrition Therapy for Pediatric...

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Nutrition Therapy for Pediatric

GastroenterologyPresented by:

Erin Helmick, RD

About Me

Graduated from MSU with Bachelor of Science in Dietetics

Completed dietetic internship at University of Michigan Health System

Employed as Registered Dietitian at Children’s Hospital of Michigan since 2006

5 years experience providing nutritional care for inpatients in acute care from newborn to 18 years old

Outpatient pediatric GI since 2011

Nutrition Therapy for GI Disorders Multiple Food Protein Allergies

Cow’s milk protein allergy

Food Protein Induced Enterocolitis Syndrome

Eosinophilic Esophagitis

Inflammatory Bowel Disease

Celiac Disease

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Objectives

Describe pediatric gastrointestinal conditions

Identify nutritional risks associated with these conditions

Discuss nutritional management

Food Allergy Defined

“An adverse health affect arising from a specific immune response that occurs reproducibly following exposure to a given food”

Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010; 126:S1-58.

IgE Mediated vs. Non-IgE Mediated Food Allergies

IgE Mediated Antibodies called

Immunoglobulin E (IgE) are produced

Reaction is immediate

Usually involves respiratory symptoms and/or immediate nausea, vomiting, or diarrhea

Can be diagnosed by blood test and/or skin testing

Non-IgE Mediated

Do not involve IgE

Delayed onset (hours to days after ingestion)

More difficult to diagnose

Symptoms often GI related

Atkins, D. American Partnership for Eosinophilic Disorders. What’s the difference between a food allergy and food intolerance?, 2013. http://apfed.org/drupal/drupal/sites/default/files/files/IgE%20vs%20nonIgE%20reactions.pdf. 27 February 2014.

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Food Allergies

Most often present in the first 2 years of life

According to Food Allergy Research and Education (FARE), the top eight allergens are milk, egg, crustacean shellfish, fish, peanuts, tree nuts, wheat, and soy

These eight allergens account for 90% of all food-allergic reactions

Most allergies, except nuts and seafood, are outgrown during childhood

About Food Allergies. FARE. 2014. 11 March 2014.

Nutrition Therapy for Food Allergies

Complete diet elimination of food protein(s)

Can result in very restricted diets, inadequate in macronutrients and/or micronutrients

Label reading can be challenging

Consider multivitamin with minerals

Food Allergen Labeling and Consumer Protection Act of 2004

Food labels are required to state clearly whether the food contains a "major food allergen."

Must identify any of eight allergenic foods: milk; eggs; fish; crustacean shellfish; tree nuts; peanuts; wheat; and soybeans.

Statements of food processing handling are not mandatory

Food Allergen Labeling and Consumer Protection Act of 2004 Questions and Answers. FDA. 18 July 2006. 27 February 2014.

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Ingredients: Corn, Whole Grain Wheat, Sugar, Whole Grain Rolled Oats, Brown Sugar, Rice, Vegetable Oil (Canola Or Sunflower Oil), Wheat Flour, Malted Barley Flour, Salt, Corn Syrup, Whey (From Milk), Wildflower Honey, Malted Corn And Barley Syrup, Caramel Color, Natural And Artificial Flavor, Annatto Extract (Color). Bht Added To Packaging Material To Preserve Product Freshness.Vitamins and Minerals: Reduced Iron, Niacinamide, Vitamin B6, Vitamin A Palmitate, Riboflavin (Vitamin B2), Thiamin Mononitrate (Vitamin B1), Zinc Oxide (Source Of Zinc), Folic Acid, Vitamin B12, Vitamin D.Contains : Wheat, Milk.

Example

Calcium and Vitamin D Needs

Recommended Dietary Allowance for Children

Calcium 1-3 years: 700 mg/day 4-8 years: 1000 mg/day 9-18 years: 1300 mg/day

Vitamin D 1-13 years: 600 IU/day

Calcium/vitamin D supplement may be needed if needs cannot be met through alternative foods

National Academy of Sciences. Institute of Medicine. Food and Nutrition Board. http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-tables

Alternative “Milks”

Important to include as source of calcium and vitamin D

Options: Soy milk

Rice milk

Almond milk

Coconut milk

Extensively hydrolyzed or amino acid based formula (i.e. Nutramigen, Elecare, or Neocate)

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Cow’s Milk Protein Allergy (CMPA)

Most common food allergy in infants and children less than 3 years of age

Affects 2-3% of the infant population

Koletzko S, Niggemann B, Arato A, et al. Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. J Pediatr Gastroenterol Nutr 2012;55: 221-229.

GI Symptoms of CMPA

Vomiting

Diarrhea +/- blood

Occult blood loss

Frequent regurgitation

Failure to thrive

Refusal to feed

Dysphagia

Colic

Constipation

Iron deficiency anemia


Other Symptoms of CMPA

Respiratory: wheezing, runny nose, chronic cough

Skin: hives, swelling of lips or eyelids, atopic eczema

General: anaphylaxis, food protein induced enterocolitis syndrome

Likeliness of CMPA increases when at least 2 organ systems are involved


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Diagnosis of CMPA

Blood serum for IgE or skin prick testing may be useful

According to the World Allergy Organization, “60% of milk allergic reactions are IgE mediated”

Atopy patch test not recommended at this time

Diagnostic elimination of cow’s milk


CMPA in Exclusively Breastfed Infant

Estimated to occur in 0.5-1% of exclusively breastfed infants

Infant reacts to small amounts of cow’s milk protein excreted in mom’s milk

Commonly present with blood in the stool but are well-appearing otherwise

The Academy of Breastfeeding Medicine. Allergic Proctocolitis in Exclusively Breastfed Infant. Breastfeeding Medicine. 2011;6:435-40.

CMPA in Exclusively Breastfed Infants

Initiate milk free diet in mother

Includes complete elimination of all dairy products such as milk, cheese, cream cheese, ice cream, yogurt, etc. as well as other foods with “hidden” milk ingredients

Proper diet education for mom is essential


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Will see symptom improvement in 72-96 hrs in most cases

Wait 2-4 weeks before considering further diet elimination

Further diet elimination may include restriction of soy, egg, citrus, nuts, peanuts, wheat, corn, and/or chocolate



Management of breastfed infants with severe symptoms Trial of therapeutic formula for up to 2 weeks while mother

transitions to milk free diet

Allows for child’s condition to stabilize while mother expresses milk

If symptoms reoccur when breast milk is reintroduced, further maternal diet restriction or use of therapeutic formula needs to be considered


CMPA in Formula Fed Infants

Eliminate cow’s milk based formula and supplementary foods containing cow’s milk protein

Soy based formula and other mammalian milks (i.e. goat’s milk, sheep’s milk) are not an ideal alternative

Common approaches to management: Start with extensively hydrolyzed infant formula If no improvement in 2 weeks, change to amino acid based

formula


Du Toit, G. Meyer, R. Shah, N. Heine, R. Thomson, M. Lack, G. Fox, A. Identifying and managing cow’s milk protein allergy. Arcj Dos Cjo;d Educ Pract Ed. 2010;95: 134-144.

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Infant Formulas for CMPAAmino acid basedExtensively hydrolyzed protein

Infant Foods and CMPA

Introduction of single ingredient infant foods at 6 months of age is encouraged

WIC approved infant cereals, fruits, and vegetables can be utilized

Parents still need to be educated to check ALL food labels for presence of milk protein

Infant must avoid all milk containing foods until advised by his/her doctor

Challenge with Cow’s Milk

Consider after at least 6 months on diet or at 9-12 months of age Patient should be asymptomatic

Should be demonstrating appropriate growth

Challenge in home setting vs. doctor’s office dependent on history of patient’s symptoms


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Failure of Challenge

Ideally RD is involved to assess child’s diet and recommend appropriate alternative

May still require extensively hydrolyzed or amino acid based formula beyond 1 year of age to meet nutritional needs

Continue elimination diet for 6-12 months before considering challenge again


Food Protein Induced Enterocolitis Syndrome (FPIES)

Food allergy affecting the GI tract

Most common in early infancy

Acute symptoms: profuse vomiting, diarrhea, and dehydration Leads to severe lethargy, changes in body temperature and

blood pressure

Chronic symptoms: weight loss, FTT

Food allergy testing is generally negative

Reaction to causative food is delayedNowak-Wegrzyn, Anna. “Food Protein Induced Enterocolitis (FPIES).” Up-to-Date. 28 Aug 2013. Web. 5 March 2014.

Triggers for FPIES

Cow’s milk or soy based infant formula

Reaction to proteins in breastmilk is less common

Solid foods: rice and oats are most common triggers

Other common triggers for solid foods: barley, poultry, peas, sweet potatoes, green beans, and squash

Nowak-Wegrzyn, Anna. “Food Protein Induced Enterocolitis (FPIES).” Up-to-Date. 28 Aug 2013. Web. 5 March 2014.

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Treatment for FPIES

Elimination of the offending protein(s)

Change to formula containing extensively hydrolyzed protein

“About 10-20% of infants may require amino acid based formula”

Introduce yellow fruits and vegetables at 6 months instead of cereal

Wait until >12 months of age to introduce grains, poultry, and legumes

Consider challenge with cow’s milk and/or soy after 12 months of age

Nowak-Wegrzyn, Anna. “Food Protein Induced Enterocolitis (FPIES).” Up-to-Date. 28 Aug 2013. Web. 5 March 2014.

Eosinophilic Esophagitis (EoE)

According to the 2011 EoE Updated Consensus Recommendations, “Eosinophilic Esophagitis represents a chronic, immune/antigen mediated, esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation”

Symptoms of EoE

Dysphagia

Feeding difficulty

Chest pain

GERD, non-responsive to medical and surgical treatment

Vomiting

Abdominal pain

Early satiety

Food impaction

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Treatment of EoE

Topical swallowed corticosteroids Fluticasone: puffed and swallowed via inhaler

Budesonide: taken as a viscous suspension

Diet management

Acid suppression

Esophageal dilation

Liacouras, CA, Furuta GT, Hirano I, et al. Eosinophilic Esophagitis: Updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011;128:3-20.

Diet Therapy for EoE

Elemental diet

All food proteins removed from diet

Strict use of amino acid based formula

May require enteral feedings

Simple sugars, salt, and oils are allowed

Targeted elimination diet

Involves elimination of foods based on food allergy testing and history

Six food elimination diet

Involves elimination of six major food allergens

Milk, soy, wheat, tree nuts/peanuts, egg, fish/shellfishLiacouras, C. et. al. Eosinophilic Esophagitis: Updated Consensus Recommendations of Children and Adults. Journal of Allergy and Clinical Immunology. 2011;128:3-20.

Factors to Consider

Ability to manage complex diet

Potential nutritional risks

Access to amino acid based formula

Expected compliance

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Food Challenges

Usually managed by gastroenterologist and allergist

Repeat endoscopy(s) with biopsy may be performed to assess progress

Allergist may perform additional or repeat food allergy testing to identify ideal foods to introduce

One new food added at a time

Book, W. Leo, H. “Treatment of EGID’s.” American Partnership for Eosinophilic Disorders. 15 March 2013. Web. 5 March 2014.

Inflammatory Bowel Disease (IBD)

Crohn’s Disease Chronic inflammation of GI tract

Can affect any part of GI tract

Can affect entire thickness of bowel wall

Ulcerative Colitis Inflammation and ulceration of lining of colon

“What are Crohn’s and Colitis?” Crohn’s and Colitis Foundation of America. 2014. Web. 5 March 2014.

Epidemiology of IBD

According to the CDC, it is estimated that 1.4 million people in the United States suffer from IBD

Approximately 10% of these cases are individuals <18 years of age

Peak age of onset is 15-30 years

“Inflammatory Bowel Disease (IBD).” Centers for Disease Control and Prevention. n.p. Web. 14 January 2014.

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Inflammatory Bowel Disease

Micronutrient and macronutrient deficiencies are common in pediatrics

Result of inadequate intake, decreased absorption, and/or increased losses

Deficiency of certain micronutrients can depend on severity and location of disease

MVI with minerals recommended for all patients

Tietlebaum, J. Nutrient deficiencies in inflammatory bowel disease. 12 October 2011. Retrieved from: http://www.uptodate.com/contents/nutrient-deficiencies-in-inflammatory-bowel-disease?source=see_link

Poor Growth in Pediatric IBD

Is multifactorial: inadequate intake, inflammation, malabsorption, increased energy expenditure, use of glucocorticoids

Routine monitoring of growth parameters is key

Teitelnaum, J. Growth failure and poor weight gain in children with inflammatory bowel disease. 11 November 2012. Retrieved from: http://www.uptodate.com/contents/growth-failure-and-poor-weight-gain-in-children-with-inflammatory-bowel-disease?source=search_resultandsearch=growth+failure+and+poor+weight+gain+in+children+with+inflammatoryandselectedTitle=1%7E150

Nutrition Interventions for IBD

Counsel patient and family on well-balanced, calorically adequate diet to promote normal growth

Calorie requirements for catch-up growth range from 125-150% of the DRI for age/sex

No food restrictions unless specific intolerances are noted by the patient

Teitelnaum, J. Growth failure and poor weight gain in children with inflammatory bowel disease. 11 November 2012. Retrieved from: http://www.uptodate.com/contents/growth-failure-and-poor-weight-gain-in-children-with-inflammatory-bowel-disease?source=search_resultandsearch=growth+failure+and+poor+weight+gain+in+children+with+inflammatoryandselectedTitle=1%7E150

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Nutrition Interventions for IBD

Consider oral nutrition supplements such as Pediasure, Pediasure 1.5, or Boost Kid Essentials 1.5

Low cost alternative nutrition supplement for purchase such as Carnation Instant Breakfast

Scientific literature does not strongly support use of formula with intact proteins vs. semi-elemental or elemental

Semi-elemental formulas could be trialed if patient does not tolerate formula with intact proteins

Crtich, J. Day, A. Otley, A. King-Moore, C. Teitelbaum, J. Shashidhar, H. Use of Enteral Nutrition for Control of Intestinal Inflammation in Pediatric Crohn’s Disease. JPGN. 2012;54: 298-305.

Oral Nutrition Supplements

Intact protein oral supplements

Peptide based oral supplements

Enteral Nutrition for Crohn’s Disease

Enteral nutrition therapy Exclusive enteral feeds: sole dietary source utilized with

goal of inducing remission. All foods excluded

Partial enteral feeds: given overnight along with regular diet during the day to improve nutritional status

Not shown to be effective for ulcerative colitis

Parenteral nutrition therapy

Crtich, J. Day, A. Otley, A. King-Moore, C. Teitelbaum, J. Shashidhar, H. Use of Enteral Nutrition for Control of Intestinal Inflammation in Pediatric Crohn’s Disease. JPGN. 2012;54: 298-305.

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Celiac Disease

Chronic autoimmune intestinal disorder

Inflammation of the small intestine due to sensitivity to gluten

Villi in the intestine become inflamed and flattened resulting in malabsorption and GI symptoms

Golden diagnosis is endoscopy with intestinal biopsy

Must be exposed to gluten through diet for accurate diagnosis

Hill, I. Clinical Manifestations and diagnosis of celiac disease in children. 22 January 2013. Retrieved from: http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-celiac-disease-in-children?source=search_resultandsearch=celiac+diseaseandselectedTitle=3%7E150

Gluten Free Diet (GFD)

Only treatment option

Requires lifelong adherence

Complete dietary elimination of gluten (wheat, rye, barley)

Concern for cross-contamination

Possible lactose intolerance initially

Case, Shelley. Gluten Free Diet: A Comprehensive Resource Guide. Canada: Case Nutrition Counseling Inc., 2010. Print.

Oats and Gluten Free Diet

Commercial oat products likely to be contaminated with gluten

A small number of individuals may react to the protein in oats

Most experts agree that pure, uncontaminated gluten free oats can be safely consumed in limited amounts (1/4 cup of dry rolled oats for children)

Follow up with gastroenterologist and monitoring of antibody levels is important

Case, Shelley. Gluten Free Diet: A Comprehensive Resource Guide. Canada: Case Nutrition Counseling Inc., 2010. Print.

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Example

ExampleBEST INGREDIENTS: Gluten Free Toasted Oats (whole grain oats, organic cane sugar, canola oil, mixed tocopherols [contains soy]), Tapioca Syrup, Rice Crisp, Raisins, Palm Oil, Organic Tapioca Syrup Solids, Organic Cane Syrup, Rice Fiber, Organic Inulin, Natural Flavors, Organic Cinnamon, Organic Sunflower Lecithin, Sea Salt, Organic Annatto Extract (for color).CONTAINS SOY INGREDIENTS. Made on shared equipment that also processes tree nuts.

Gluten Free DietFoods to avoid:

Bread, cereal, pasta, baked goods, etc. containing wheat, rye, or barley as well as any cross-breeds or derivatives of these grains

Processed food products containing gluten

Foods allowed:

Fruits and vegetables

Most dairy products

Gluten free grains such as rice, corn, buckwheat, amaranth, quinoa, uncontaminated GF oats, etc.

Plain meat, fish, or poultry

Eggs

Beans, peas, lentils

Nuts and peanuts

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GF Options and WIC Package

Whole grains: rice, corn tortillas

Cereals: Rice and Corn Chex, Cream of Rice

Beans, lentils, and peas

Peanut butter

Milk, soy beverage, cheese, eggs

Juice

Gluten Free, Casein Free Diet for Autism

Involves dietary elimination of gluten and casein

Thought to help improve behavior, speech, and social skills of child with autism

Scientific evidence is lacking

If parent chooses to implement diet restrictions for their child, consultation with pediatric RD is strongly recommended

Mulloy, A. Lang, R., O’Reilly, M et al. Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders. 2010;4: 328-39.

Non-Celiac Gluten Sensitivity

Symptoms may include abdominal pain, bloating, diarrhea, constipation, headaches, fatigue, depression, etc.

Testing is negative for celiac disease and wheat allergy

Symptoms alleviated with elimination of gluten and return when gluten is reintroduced

Only treatment is gluten free diet

Quantity of gluten tolerated may vary from one individual to the next

Celiac Disease Foundation. Gluten Sensitivity. n.d. Web. 11 March 2014.

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