Child rehabilitation case

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Child rehabilitation case

Katja Passchier works as a pediatric dietitian in the medical specialist child rehabilitation at Basalt. Within the multidisciplinary team of practitioners, Katja monitors the nutritional status of children with a disorder or syndrome. In addition, Katja regularly encounters nutrition-related problems for which there are no evidence-based treatments. In the section “Practice” Katja discusses a case of a girl with a syndrome and problematic behavior when feeling hungry.

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Here is Katja’s case:

Problematic behavior when hungry

Last month I received a referral from a patient with the so-called 22q11 deletion syndrome for her overweight (obesity) and problematic behavior when feeling hungry. The 14-year-old girl has an intellectual disability and when she feels hungry she becomes difficult to handle and aggressive. When the feeling of hunger has subsided after a relatively long time, she behaves normally again and is no longer fixated on food.

Mother’s request for help

When asked about this girl’s eating and drinking, her mother explains all the measures she herself has already taken to limit the increasing weight, but also the negative behavior of her daughter. And she does that very well, for example by omitting added sugars, offering fiber-rich foods and providing low-calorie snacks. She tells how her daughter, who is slow in itself, can pick up, eat and swallow food in the blink of an eye. The feeling of satiety after a meal is relatively long in coming. Mother would like to know how she can influence her daughter’s feeling of hunger by offering different foods.

Leptin resistance

Leptin resistance could play a role in this girl. The body then no longer responds properly to the hormone leptin. Leptin, also called the satiety hormone, signals to the brain when the body is full. Symptoms of leptin resistance include: regular feeling of hunger, not being full after a meal, being overweight, lethargy and not wanting to move. Mother recognizes these symptoms in her daughter. The causes of leptin resistance are diverse, of which ignoring the feeling of satiety, obesity with fat accumulation around the abdominal area and poor sleep quality apply to this girl. Her intellectual disability may also play a major role in this. Blood leptin levels could be determined and monitored. But because it is not known whether the leptin reference intervals are also valid in the 22q11 syndrome, we decide not to draw blood from this girl for now.

Nutritional advice

We discuss to try out whether we can limit the duration of the feeling of hunger in particular, with nutritional advice such as that given in leptin resistance but also in insulin resistance. Naturally, the advice fits within a full-fledged diet of a growing girl. The main advice is:

  • choose unprocessed products as much as possible
  • limit the amount of carbohydrates per day and per meal, appropriate to the girl’s age
  • give a maximum of 2 fruit portions per day, but a large vegetable portion
  • try to give a maximum of 3 meals a day and nothing more after dinner
  • If necessary, give a protein-rich, low-carbohydrate snack in the beginning
  • make sure each meal contains plenty of protein

In addition, omega-3 fatty acids could have a positive effect on leptin regulation. These fatty acids are found in foods that fit perfectly within the above advice, such as different oils and fatty fish. We translate the advice into foods that suit the girl and the family. Mother is happy with the tips and will try to apply them. We agree to be in touch again soon.

practice-based

Dieticians within child rehabilitation are often ‘one-persons’. In cases like this I often contact colleagues in child rehabilitation and care for the mentally disabled. In such a case, there is often no evidence-based treatment available and I mainly work practice-based, ie based on the knowledge and experience of colleagues and myself. For me, this keeps our already beautiful profession extra lively and fascinating.

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