Health Promotion: Physical Activity in Children and Adolescents
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Assessment and Counseling

 

 

 
Counseling must be opportunistic and thought of as a possiblity at each office visit but especially at well child visits


Infants (0-4 months)
Screening questions
  • How do you think your baby is doing with feeding?
Breastfeeding
Bottle feeding
How many times/day? (8-12)
What formula?
How long each time? (at least 15 min)
How do you prepare it?
Mom taking Prenatal Vitamins? (recommended)
How do you store it?
Mom on any meds/substance abuse?
May be transferred to infant via breastmilk)
Position for feeding?
Mom's HIV status? (Breastfeeding not recommended if HIV positive)
how many ounces/day
number of wet diapers and BMs? (at least 6 wet diapers and 1 or more BMs)
number of wet diapers and BMs?
weight gain? (0.5 - 1.0 ounces/day)
weight gain?

Counseling
  • feed on demand (8-12 /24 hr)
  • Until gains back birth weight don't let sleep > 4 hours before feeding
  • breastfeed for at least 6 months
  • Breastfeed or Iron-fortified formula x 12 months

Supplements
  • Fluoride
    • Not before 6 months
    • Test well before adding
  • Iron
    • If pre-term infant there are increased growth requirements
    • Already in formula and breast milk
  • Vit D
    • By 2 months if breastfed
    • Already in formula
      • If breastfed begin by 2 months of age

Infants (4 months)
Screening Questions
  • Any concerns about feeding?
  • any solid foods introduced yet?
  • hopefully non, but often have already
  • Still feeding at night?
  • Does anyone else feed teh baby?
  • Same breast/bottle questions as above

Counseling
  • No solids needed until 4-6 months
  • signs of developmental readiness: good control of head/neck when in sitting position
  • Use a spoon NOT a ottle
  • 1st food = iron-fortified single grain cereal
  • Next foods = vegetables and fruits
  • add singly 3-7 days apart

Infants (6 months)
Screening questions
  • What foods (if an) have you introduced?
  • How often and how much?
  • Same questions about breastmilk and formula as above
  • it is normal to have a decrease in milk intake as solids increase BUT 16-14 oz. is still recommended from 6-12 months.
  • Who else feeds your child and do youknow what is fed?
  • Assess all H20 sources and determine if fluoride supplement is need at this time


Flouride supplement doses
http://www.mchoralhealth.org/pediatricoh/images/fluoride_table.gif

Counseling
  • Continue introduction of solid foods with spoon
  • don't force it retry another time
  • expand variety
  • avoid salf, sugar & spices
  • try finger foods when developmentally ready (pincer grasp)
  • mising cereal with joice or fruit with vit C helps increase absorption
  • may intorduce meants at ~ 8 months
  • Discuss serving sizes
  • Begin with a teaspoon.  Usual serving size is ~ 4 ounces

Great pamphlet on baby foods
http://teamnutrition.usda.gov/Resources/feedinginfants-ch11.pdf#search=%22food%20serving%20size%20for%20infants%22

Infants (9 months)
Screening Questions
  • Do you have any concerns about eating behaviors?
  • Describe a typical day of feeding?
  • Breastmilk or formula the same as above
  • What is fed away from home
  • Assess for iron-deficiency anemia
  • screen if positive risk factors (see below)
  • Assess for lead exposure (is related to nutrition)
  • Low iron and low calcium intake and high fat intake increases lead absorption (Example: a child that drinks only mimal whole milk but soda, sweet tea or juice instead and eats mostly fast foods like french fries is at especially high risk for elevated lead levels)

Risk Factors for Iron-deficiency anemia
  • Preterm or low birth weight
  • non-iron fortified formula or cow's milk for longer than 2 months (iron stores take up to 90 days to deplete)
  • More than 24 oz of the above per day (too much liquid = too little solds and therefore decreased iron intake from solids)
  • Breastmilk only and no iron containing solid foods
  • eligble for WIC/migrant/recent refugee
  • Special healthcare needs that may interfere with iron absorption

Counseling
  • Begin to allow more self feeding (it's messy but an important part of development)
  • allow use of spoon
  • begin use of cup

General Concerns 12 months & older
  • Parent-Child feeding relationships (Fights over food/eating)
  • Parent is responsible for what, when and where child eats
  • Child is responsible for deciding whether to eat and how much
  • Schedule: meals & snacks
  • Servicngs: same number as older children only smaller
  • Size is 2/3 of older child servicng
  • Ex: serving of 1/2 cup fruit or vegetalbe = 1/2 of a cup for 1-4 years
  • Fat Intake
  • AAP still recommend whole milk until age 2 (this is being debated because of the increased obesity rates)
  • Behavior
  • Irregular appetite (normal)
  • Food jags i.e. wants to have same food at every meal  (normal)
  • control issues (Remember, the only things children can really control is what they eat/swallow and whether or not they poop so you don't want to get into a battle with them over either of these 2 things!)

 Age 1-2 years
Screening Questions
  • Any concerns about eating?
  • Waht kind of milk?  How much? Bottle or cup?
  • still need at least 16 oz/day
  • Any juice? How much?
  • 4 ounces MAX
  • Typical or range of foods for B/L/D and snacks?
  • What is eaten outside of the home?

Counseling
  • Small frequent feedings
  • 3 meals + snacks
  • Encourage use of cup and utensils
  • Behavior
  • limit testing
  • may remove from table
  • 1.2.3 Magic
  • WILL NOT STARVE THEMSELVES!

Age 2-4 years
Screening Questions
  • Same questions as 1-2 but add:
  • What do you do if your child won't eat a particular food?
  • Gets at the food "battles" issue

Counseling: Same as above

Here is the Food Pyramid for Children Ages 2-6

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http://www.mommynature.com/documents/food_guide_pyramid_preschooler.jpg

Middle Childhood (5-10)
Screening Questions
  • Remember now to really ask the child first
  • They are becoming better historians
  • Where & when do you eat besides at home?
  • Do you eat breakfast? (meal skipping starts to occur during this age)
  • What do you usually have?
  • Waht foods do you eat most often?  Any foods you won't eat?
  • 24 hour recal or typical day
  • Assess food groups, use food pyramid to compare last 24 hours with recommendations.  Kids like this activity.

Body Image Questions:
  • Younger: How do you feel about the way you look?
  • Do you feel like you weigh too litle or too much?
  • Older:  How much would you like to weigh?  Are you trying to change your weight?  Why?
  • Parents:  Any concerns about eating?
Screening Labs?
  • Iron or Lipids of at risk

Counseling
  • Use growth charts with children adn families to explain how you are evaluating nutritional status/health
  • Focus on health for life not weight for appearances sake
  • intake = output (energy balance is pretty simple concept)
  • Remember activity level
  • individualize advice - Remember Motivational Interviewing
  • continue to offer variety
  • have healthy foods available in the home
  • Help them make healthy eating choices
  • watch serving size
  • Set a good example

Stragtegies for promoting healthy eating behaviors
  • positive, non-judgemental
  • provide concrete examples
  • focus on short-term benefits as well
  • understand & respoect cultural influences
  • avoid using the term "diet"
  • assess readiness to change
  • moderation vs. forbidden foods
  • keep records if possible (diaries are on technique that has been shown to be effective)
  • assess portion size


Adolescents (11-20 years)
Screening Questions?
  • Do you have any concerns bout eating?
  • 24 hr recall
  • Do you skip any meals
  • where do you eat your B/L/D?
  • How do you feel about your weight?
  • Waht would you like to weigh?
  • Assess Physical Activity

Screening Labs?
  • Iron
    • Females if menstruating or history of anemia
    • males only if risk factors or history of anemia

If you need to do a more thorough nutritional assessment there is a great Questionnaire in the Appendix of Bright Futures
http://www.brightfutures.org/nutrition/pdf/tools.pdf

Counseling: Early and Middle Adolescence - 11-17
  • Discuss growth as r/t puberty
  • Show growth charts
  • discuss genetics r/t growth
  • discuss wide variation in normal (early vs. late maturers)
  • Caloric requirements
  • Female ~ 2000 kcal/day
  • Male ~ 2,500-3,000 kcal/day
  • Discuss eating behaviors
  • importance of not skipping meals
  • healthy choices based on:
  • dietary guidelines
  • food guide pyramid
  • Discuss safte and healthy wasy to maintain wt. OR achieve wt. loss
  • FOCUS on HEALTH

Counseling Late Adolescence (17-21)
  • Preparing to leave home
  • anticipatory guidance r/t:
  • food choices
  • meal planning and preparation
  • Growth has most likely stopped
  • caloric needs have decreased
  • discuss stabilization of weight






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The vegetarian resource group (www.vrg.org)


Additional Resources

Food and Beverage Refridgerator charts

Sports Nutrition
Bean, Anita (1993).  The complete guide to sports nutrition. Londaon, A&C Black Ltd.
Clark, Nancy (1997).  Sports Nutrition Guide Book.  Human Kinetics, Champaign, IL

Amreican Dietetic Association  (www.eatright.org) position statements

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