Nutrition standards for paediatric inpatients in NSW Hospitals (2011) were developed by an expert reference group, to indicate nutrient needs of children of varying ages and developmental feeding capabilities. The Paediatric Nutrition standards meet the needs of nutritionally well and nutritionally at-risk patients. The Paediatric Nutrition standards however do not meet the needs of children with therapeutic dietary requirements for recognised diagnoses. These Paediatric Diet Specifications have been developed to address the needs of patients with higher nutritional needs or special nutritional needs as dictated by medical diagnoses. The specifications were developed to define therapeutic diets for children in hospital.
Nutritionally well patients include previously healthy patients with good appetite and dietary needs in line with the general population admitted for minor illnesses and for a short stay. Nutritionally at-risk patients include those who have poor appetites, inadequate food intake, weight loss, physical difficulty eating or drinking, cognitive or communicative difficulties with ordering food.
Patients with higher nutritional needs include those with increased nutritional requirements due to cachexia, trauma, surgery and/or burns and failure-to-thrive. Patients with special nutritional needs include patients with cultural or religious dietary needs and practices, patients requiring therapeutic diets due to specific disease states; patients requiring texture modified food and fluids.
Principles for Paediatric Diet Specifications
The nutritional care of paediatric patients must address issues of growth and development as well as tissue maintenance, repair and nutrient metabolism.
Some therapeutic diet specifications developed for adults may be suitable for use in paediatrics.
For paediatrics, the following additional therapeutic diet specifications are required:
1. Age-appropriate diets
Nutritional requirements for children differ from adults and so differing quantities of food groups are needed to meet needs for growth and development. Developmental and age-related diets for children of ranging ages are required to ensure that serving sizes, type of food and texture of foods offered are suitable and that the diet meets nutrient needs for age. (Refer to the Nutrition standards for paediatric inpatients in NSW hospitals, 2011, for Minimum Menu Choice standard for serve size requirements for varying ages).
2. Therapeutic Diets
Macro/Micronutrient Specific Diets. Diets for macro-/micro-nutrients that provide appropriate restrictions for children are required while allowing adjustment for growth needs. Balance of the overall nutrient profile may be difficult to achieve if an ingredient or nutrient is set at a fixed level of intake. For diets that do require quantitative nutrient levels, the relevant nutrient target for each main meal component may need to be specified.
Diets for medical conditions. Medical conditions that mainly occur in paediatrics and require multiple nutrient adjustments require a specific therapeutic diet to ensure all diet requirements are included (eg ketogenic diet; metabolic diets; cystic fibrosis; paediatric diabetes).
Aims
The paediatric specifications describe the foods allowed and not allowed in each diet and provide nutrient targets for each main meal component, for those diets requiring quantitative nutrient levels.
The specifications aim to be:
- easy to read and interpreted by non-specialist staff (e.g. food service or nursing staff without access to a dietitian)
- sufficiently detailed to support safe and appropriate meal provision to patients on therapeutic diets
- based on the best available evidence.
As with the adult diet specifications, the names of the diets are, wherever possible, specific to the nutrient to be modified (e.g. high protein) rather than describing disease states (e.g. failure-to-thrive). Where several nutrients need to be addressed, multiple diets can be used for the same patient (e.g. high energy, high protein). An age-appropriate diet is used for all paediatric patients to ensure appropriate food and serve size for age (e.g. high energy, high protein, 1-3 years).
This clearly describes the exact nature of the diet, and recognises the importance of planning diets to meet patients’ individual needs, rather than applying standard protocols. The exceptions to this (ketogenic, diabetic and cystic fibrosis diets), acknowledge the widespread use and understanding of these terms.
Not all paediatric diets will be required by every hospital, speciality health network or Local Health District. Clinical need and the clinical nutrition service will determine the range of therapeutic diets required for each facility.
Methodology
The ACI Diet Specifications: Adult and Paediatric Reference Group is responsible for the development and review of the diet specifications. The paediatric specifications were originally developed by an engaged consultant, Sheridan Collins, Senior Paediatric Dietitian Sydney Children’s Hospital Network Westmead with input from the expert reference group.
Feedback about the documents is reviewed by the Reference group in collaboration with the clinical specialist groups where required. Current literature is accessed and considered before changes are finalised. Changes approved by the Reference Group are incorporated into the revised versions of the Diet Specifications. New diets are created to meet a clinical need. Diets will be rescinded (in consultation with expert clinicians) where there is no longer a clinical need for the diet. New and revised Diet Specifications are released individually or as a group and changes are communicated to all stakeholders. The diets are based on:
- existing diet standards used by NSW Health facilities
- the Dietitians Association of Australia Nutrition Manual (8th edition)
- the American Dietetic Association Paediatric Nutrition Care Manual
- nationally endorsed dietetic practice guidelines
- standard textbooks of dietetic practice.
Where these sources provided insufficient evidence-based information targeted literature searches were undertaken to locate primary published literature to inform the diet specifications.
Advice was sought of the expert reference group formed for the development of the Adult Diet Specifications and of paediatric dietitians in NSW. Draft diet specifications were circulated to Local Health Districts with invitation for comment. Appropriate suggested changes were incorporated and approved by the expert reference group, and a revised version was sent to the NSW Health Nutrition and Dietetic Advisors group and the Speech Pathology Advisors group for review. A final version was then submitted to the Nutrition and Food Committee of NSW Health for approval and endorsement.
Review of the specifications
Ongoing evaluation and revisions are managed by the Diet Specifications Adult and Paediatric Reference Group. Feedback received by email or via the feedback from is reviewed by this group on a monthly basis. Diet specifications will be reviewed every five years. The specifications last reviewed more than five years ago are programmed for review in the next twelve months.