Nutrition in School Aged Children

• Core 1 (Pre-Clerkship)
  • Cell Tissues and Biology – Connective Tissue; Lab 5: Cartilage and Bone
  • Biochemistry – Hemoglobin; Met Round 12
  • MDTI – Hemostasis Case; Wound healing; Iron deficiency; DNA metabolism, B12, Folate
  • Brain and Behavior – Eating disorders; Autism
• Core 2 (Clerkship)
  • Pediatric Clerkship - Growth and Nutrition Didactic
• Core 3 (Post-Clerkship) Electives that may further knowledge - Peds GI

Malnutrition includes both 

• Under-nutrition – encompasses stunting (low height for age which reflects chronic undernutrition), wasting (low weight for height), underweight (low weight for age), and micronutrient deficiencies 
  • Severe acute malnutrition, primarily concern in resource-limited settings – defined by anthropometric measurements (low mid-upper arm circumference, weight for length, or BMI); can be categorized by presence of nutritional edema
    • Marasmus- emaciated limbs, loose folds due to loss of subcutaneous fat
    • Kwashiorkor – presence of symmetric peripheral pitting edema
• Overnutrition – overweight, obesity, and metabolic syndromes 

Ethan is a 6-year-old boy with a known diagnosis of severe autism spectrum disorder (ASD), brought to your primary care clinic by his mother. Over the past few months mom has noticed bruising, bleeding gums, and fatigue over the past month. He is nonverbal and attends a special education program which is otherwise going well. His mother reports that he has extreme food sensitivities and will only eat dry cereal and plain white bread. Mom is overwhelmed and tearfully describes how hard she tried to get him to eat more variety. Attempts to introduce other foods result in intense and behavioral outbursts, that can last hours.  

She is coming in now as she has noticed that reports that over the last few weeks, Ethan has been more withdrawn and irritable. She has also noticed dark spots that are appearing on his legs randomly, and his gums bleed when brushing his teeth. He seems reluctant to walk long distances, occasionally crying and pointing to his knees. 

Objectives 

• Recognize clinical signs and symptoms of micronutrient deficiencies in children with neurodevelopmental disorders and highly selective eating patterns.
• Develop a systematic approach to evaluating malnutrition in school-aged children using history, physical exam, and risk factor assessment.
• Differentiate between common causes of restricted intake, including sensory-based feeding difficulties in autism spectrum disorder and ARFID 

• Obtain growth charts – inquire about growth patterns, developmental history/milestones
• Food history
  • Focus on quantity, variety, and types of food
    • Any food preferences/restrictions? Any driven by sensory or texture aversions?
  • Any changes in eating habits recently
  • Meal frequency/portion sizes
• Medical history
  • Any prior medical history that could contribute to food refusal – constipation, GI issues?
  • Any medications that could affect appetite (such as stimulant medications) or nutrient absorption (antacids, anti-seizure medication)?
  • Any supplements being used? 
  • Any family history of nutritional malabsorption or GI issues (IBD)? 
• Social environment
  • Any issues accessing food at home?
  • What are meal-time routines and environments? 
  • Any other changes in routine or behavior that could be contributing?
• Symptom history - OPQRST 

For malnutrition in school-aged child, can consider same three “buckets” as in FTT/growth faltering 

• “Not enough in” or Inadequate intake 
  • Socioeconomic factors – food insecurity, neglect
  • Psychosocial issues – depression, anxiety
  • Behavioral feeding difficulties – autism spectrum disorder, picky eating
  • Food refusal in Autism
    • Children with autism can have extreme limitations in their diet.
    • Likely from sensory processing issues and food characteristics like color, texture, smell, and temperature.
      • Tactile defensiveness, with limitations based around textures can initiate feeding difficulties
      • Patients with high sensory stimuli scores can show more feeding difficulties
    • Additionally, overstimulation around mealtimes can further these feeding difficulties as well perpetuating the issues caused by the numerous transitions related to starting and ending a meal. 
  • Restrictive diets – vegan diets 
  • Eating disorders – anorexia, bulimia, ARFID 
    • Avoidant/Restrictive Food Intake Disorder (ARFID)
      • A heterogenous group of eating disorders marked by a lack of interest or avoidance of food or difficulty eating. 
      • Unlike Bulimia or Anorexia, there is no distorted bodily image or desire to lose weight. Very often these patients may want to eat but find themselves unable to. 
      • These patients tend to be younger, male, and may have co-morbid diagnosis with other psychiatric condition including OCD and generalized anxiety disorder
      • ARFID can be triggered by negative associations with feeding or swallowing including choking events 
      • Treatment includes intensive feeding therapy or alternative to oral feeding including temporary NG tube feeding for severe malnutrition. 
• “Too much out” or Malabsorption/increased nutrient losses
  • GI – celiac, IBD, chronic diarrhea
  • Cystic fibrosis/pancreatic insufficiency 
• “Burning up too much” or Increased Nutrient needs
  • Chronic illness
  • Infections
  • Metabolic disorders 

1. What risk factors for malnutrition does the patient above have? 

He has severe autism spectrum disorder and has extremely restricted food variety. 

2. What micronutrient deficiency is consistent with his clinical presentation? 

He has joint pain, easy bruising, and gum bleeding, which are presentations of scurvy, or Vitamin C deficiency 

3. How do you diagnose vitamin C deficiency? 

Lab test for serum ascorbic acid (vitamin C).  

4.How do you treat scurvy? 

For children, the recommended treatment is high dose ascorbic acid (can be oral, intravenous in severe cases)  

Bruising and gingival bleeding usually resolve within a few weeks. 

• Vitamin C deficiency (scurvy) should be considered in children with restricted diets who present with bruising, gum bleeding, fatigue, and musculoskeletal complaints. 
• Children with autism spectrum disorder are at increased risk of nutritional deficiencies due to food selectivity, often related to sensory sensitivities to texture, color, or temperature. 

• Cermak, S. A., Curtin, C., & Bandini, L. G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238–246. https://doi.org/10.1016/j.jada.2009.10.032 

• Zimmerman, J., & Fisher, M. (2017). Avoidant/Restrictive Food Intake Disorder (ARFID). Current problems in pediatric and adolescent health care, 47(4), 95–103. https://doi.org/10.1016/j.cppeds.2017.02.005 

• Białek-Dratwa, A., Szymańska, D., Grajek, M., Krupa-Kotara, K., Szczepańska, E., & Kowalski, O. (2022). ARFID-Strategies for Dietary Management in Children. Nutrients, 14(9), 1739. https://doi.org/10.3390/nu14091739 

Answers:

Q1: Correct Answer: C. Avoidant/Restrictive Food Intake Disorder (ARFID) 
Rationale: ARFID presents with restricted food intake not related to body image concerns. This patient shows classic features: sensory sensitivities, fear of vomiting, and nutritional compromise without a drive for thinness. Unlike eating disorders like anorexia or bulimia, ARFID is not driven by body dissatisfaction. 

Food selectivities in Autism Spectrum Disorder, by Thomas Davis, MD