SPEECH PATHOLOGY FOUNDATIONS FOR PAEDIATRIC FEEDING Workshop Handouts – Session 7

ROLE OF THE DIETITIAN The role of the dietitian in the paediatric setting is to ensure that the children under our care receive optimal nutrition to promote adequate growth and development, whether that be via oral, enteral or parenteral routes.

Dietitian role Speech Pathologist role Joint role Insufficient food/fluid intake Coughing, choking, gagging Infant/maternal distress during feeds Poor weight gain or Maternal report Noisy breathing, inspirational Food refusal Lengthy feed times (Longer than stridor 30min) Constipation Drooling or pooling of secretions Slow to feed, fatigue Dehydration Recurrent chest infections

Assessing growth Often an issue in children with feeding difficulties. Being told your child has faltering growth can generate desperate behaviours in parents. Growth is important, however also want feeding to be a positive experience.

Faltering Growth (AKA “” / FTT) Otherwise known as symptom of under-nutrition, not a medical diagnosis. Used to describe a child who is not growing as expected i.e. not at the same rate as other children their age. At present, there is a lack of agreed consensus in current literature on the diagnosis of growth faltering. Generally defined as: ‘falling’ two or more percentiles for either weight or length/height.

Expected Rates of Growth in Children Weight Average birth weight: 3.5kg (50th percentile) Some weight loss in first 5-7 days, with birth weight regained by day 10-14. Weight triples in the first 12 months. In second year of life, average 2- 2.5kg weight gain per year until puberty growth spurt.

This information has been created and compiled by NSW Speech Pathology Advisors Network, Paediatric Feeding 1 Education Working Group and cannot be reproduced in any form without their express permission.

Average weekly weight gain in first 12 months of life 0-3 months 200-300g 180-250g 3-6 months 100-150g 100-150g 6-9 months 70-90g 70-90g 9-12 months 60-65g 60g

Length Average birth length: 50cm (50th percentile) Expected yearly increases in length in childhood 0-12 months 25cm 12-24 months 12cm 2 years of age until puberty 6-10cm

Using a growth chart Children should not lose weight or cross up or down percentile lines for weight or length/height. Weight and length/height should be proportional to each other.

Prematurity Any child born before 37 weeks gestation is classified as premature. Premature children need to be plotted using their corrected gestational age rather than their actual (chronological) age until 2 years old. Note: Use Fenton growth charts until 50 weeks in premature children.

WHO and CDC Charts: The Differences WHO = World Health Organisation CDC = US Centers for Disease Control WHO Charts are based on breastfed babies only. CDC Charts based on large proportion formula fed babies. In general, breast-fed infants tend to gain weight more rapidly in the first 2-3 months of life than formula fed infants. From 6-12 months, growth slows in breast fed infants and they tend to weigh less than formula fed infants in this time period. Therefore, from 3 months of age, healthy breast-fed infants track along the WHO growth centiles but start to falter on the CDC charts. More breastfed infants classified as ‘/FTT’ on CDC charts especially between 6-12months of age. Know which growth chart your organisation is using!

This information has been created and compiled by NSW Speech Pathology Advisors Network, Paediatric Feeding 2 Education Working Group and cannot be reproduced in any form without their express permission.

This information has been created and compiled by NSW Speech Pathology Advisors Network, Paediatric Feeding 3 Education Working Group and cannot be reproduced in any form without their express permission.

Intervention

Increasing caloric intake Food fortification Minimal dietary change. Can help feeding interaction. Nutritious, high calorie meals and snacks, as well as high calorie additions, for example: avocado, margarine, milk powder, oil. If breast/formula fed, can increase calories using a fat/carbohydrate solution, or concentrating the formula.

Enteral/Tube feeding Used when oral intake alone is insufficient. Can improve feeding interaction. Oral intake is still important to build oro-motor skills.

Milestones & expectations

Age Textures Oro -motor development

0-4 months Breast milk or formula Reflexive feeding skills 0-4 months

Around 6 months Start with smooth puree, after breast 4-6 months: sucking action from spoon milk/formula 6 months: opening mouth to spoon, more active lip involvement, vertical jaw movements 7-8 months Soft mashed food without lumps 7-8 months: tongue lateralisation emerging Finger foods Mashed/minced foods from 8 months From 9-10 months More coarsely mashed, finely chopped 9-10 months: active lip involvement, foods from 9-10 months. rotary jaw movements emerging, increasing tongue control Encourage finger foods and self-feeding Offer breast milk/formula after meals Introduce cup drinking 12 months plus Chopped family foods 12 months: controlled bite developing, cup drinking developing Regular use of a cup 18 months: chewing and cup drinking skills continue to refine

This information has been created and compiled by NSW Speech Pathology Advisors Network, Paediatric Feeding 4 Education Working Group and cannot be reproduced in any form without their express permission.

Referring to a Dietitian Reasons to refer may include: • Feeding difficulties resulting in dietary restriction • or deficiency • Poor growth • Unintended weight loss (in spite of previous weight) • Overweight and obesity, especially if <4 years of age (varying service provision depending on LHD) • Commencement of enteral nutrition (EN) - should already be known to dietetics!

Key messages Dietitians and Speech Pathologists have both individual and shared roles in the management of children with feeding difficulties. Growth is important, however we also want feeding to be a positive experience. Children should not lose weight or cross up or down percentile lines for weight or length/height. Weight and length/height should be proportional to each other. Know which growth chart your organisation is using. Contact or refer to a Dietitian for any concerns regarding feeding adequacy.

REFERENCES Goulet O, 2010, Growth Faltering: Setting the Scene, European Journal of Clinical Nutrition, 64:S2-S4 Shaw V & Lawson M 2007 ‘Clinical Paediatric Dietetics 3rd Edition’ Blackwell Publishing: Oxford Women and Children's Hospital SA, 2011, Clinical Nutrition Guidelines: Failure to Thrive for Infants and Children Less than 2 Years of Age

RESOURCES Start them right guide, 2015, Public Health Services, Department of Health and Human Services, Tasmania

This information has been created and compiled by NSW Speech Pathology Advisors Network, Paediatric Feeding 5 Education Working Group and cannot be reproduced in any form without their express permission.