Nutrition education and the hospitalized child

very helpful in seeing the total care of a patient, the needs of the ward as a whole, and determining direction for one's own discipline on the ward.

Evaluate Material Through my official affi1iation in the Adolescent Clinic, I accumulated materials written for adolescents and often wondered what their opinions would be about them. It occurred to me that I had a ready population on the ward to do some evaluating for me, and I have since used patients for this purpose. The school teacher alerted me to a boy who was concerned about gaining weight so I asked him to read and evaluate a chapter on underweight from Margaret Salmon's book, Food Facts tor Teenagers. One of the girls was concerned about losing weight so I asked her to read a chapter

on calories. The teenagers seemed pleased I was interested in their opinions and, in addition, I had a chance to teach as they reported content of the chapters. Perhaps therapeutic dietitians should not focus all their attention on patients with modified diets but patients on house diets also. Possibly the clinic dietitian can be used on the ward to teach normal nutrition with the ward dietitian. Possibly the public health nutritionist should look to the hospital population as a ready audience and stimulate nutrition programs in this part of the community. Since the state or local public health nutritionist may often be the nutrition staff for a large population, it would behoove her to utilize all available resources. A hospital population is a captive audience and although it may not be the most teachable moment, it can be utilized and

be productive. In addition, there is usually at least one ADA dietitian in a hospital who could, if encouraged, teach nutrition to prevent disease rather than to treat disease. It is time to make a concerted effort to teach normal nutrition at all age levels in many situations to prevent food misinformation rather than waiting to combat it.

REFERENCES 1. "My Milkman, Joe." National Dairy

Council. 2. "Uncle Jim's Dairy Farm." National Dairy Council. 3. "Admirals in the Making." National Dairy Council. 4. "Hold High the Torch." National Dairy Council. 5. Salmon, R. B., Food Facts for Teen-agers, Illinois: C. C. Thomas, 1965, pp. 1-129.

NUTRITION EDUCATION AND THE HOSPITALIZED CHILD Carmelita Corrado There are many facets to a program of nutrition education for hospitalized children, whether on regular or special diets. There are many opportunities for nutrition education in the feeding of the hospitalized child. Education may be done formally or informally, on a one-to-one basis, or in groups. It may be promoted through other departments or auxiliary personnel. The type of food service-centralized, decentralized or cafeteria-styleinfluences the possibilities for nutrition education in a pediatric hospital or unit. In addition to normal or therapeutic nutrition, orientation concerning food customs, ethnic foods and recipes can be used for the education of the hospitalized child or the clinic out-patient. Consider nut,riti0n education for the child on a normal diet at Children's Hospital of Pittsburgh. With a decentralized tray system for all house diets, food carts available in several areas on each floor allow patients to observe the menu for the meal. Tray servers are aware of the age and mood of each patient and determine portion size accordingly. THE AUTHOR is Director, Dietary Dept., Children's Hospital of Pittsburgh. 24 / JOURNAL OF NUTRITION EDUCATION

The type of dish, portion size, and attractiveness of the tray can stimulate or negate the appetite and attitude of a child.! The importance of these considerations is emphasized to all personnel concerned with feeding the children. Tray service includes dishes and mugs with attractive circus pattern, small silverware and plain white tray cover and napkin. Children's tray covers with a nutrition education theme could be a good avenue for education. When older patients regard the tray appointments as degrading and insulting ("We arent babies," they say.), adult appointments are used for their trays. Patterned dishes can be used on plain tray covers, as we do, or a decorated tray cover may be complemented by plain dishes.

Check on Substitutions Not having a selective menu, we allow substitutions at the time of service. This system requires very careful checking by dietitians, nurses and dietary employes to insure food satisfaction along with adequate nutrition. House menus are nutri-

tionally sound, but if all substitutions are left to patient choice, the diet could become unbalanced very rapidly. Normal nutrition is explained by dietitians or nurses in making the substitutions and in diplomatically urging the children to eat. Compromises can be made. For example, "If you try to finish your tray or try this new food, I will send you your favorite food tonight." Care must be taken with compromises. If a child has taken advice, verbal reward and reinforcement must be given. Many children would substitute desserts and candy for protein foods or vegetables and fruits if not closely supervised. The basic four food groups, caloric requirements and other aspects of good nutrition can be explained when visiting patients as they eat individually or in groups. All age groups benefit from this type of discussion. The dietitian has even more opportunity for nutrition education with children on therapeutic diets who are visited more frequently. If the dietitian can establish rapport with the child, the patient will FALL, 1969

usually follow instructions and may comment, "She said I should taste it and I did. It was good."

Explain Diets At Children's Hospital of Pittsburgh, when a patient is old enough to understand the complexities of his diet, it is gradually explained to him. This gives the child a feeling of importance. When possible, the interview or instruction should be directed to the child rather than the parent to establish good rapport. The dietitian can stimulate interest by referring to clear complexion or latest fashion with a girl and the dividends of physical fitness with a boy. There are many illustrated booklets published on these subjects; three that we have used with good results are: "Your Health-How Can You Help,"2 illustrated and written in a style that appeals to young children; "A Girl and Her Figure"3 and "A Boy and His Physsique"4 are excellent for teenagers. Many patients on therapeutic diets have difficulty understanding why certain foods are eliminated from their diets and foods they may not care for are included. When rapport is established by the dietitian, she can easily explain the reasons. A number of obese teen-agers on the research unit benefit a great deal from discussions about food and nutrition. They undergo a period of complete fast before starting a reduction diet, and during this period they usually experience an immediate weight loss. This dramatic loss motivates these patients to adhere to their weight reduction diet and to learn as much as possible about their diets.

Problem Eaters This is the beginning of their nutrition education. Previous poor eating habits can be discussed and a plausible solution presented. At our hospital, problem eaters are placed on selective diets and served with therapeutic diets in a centralized service. Detailed counseling is necessary for these patients because many of them have acquired very unusual and poor eating habits. The theory that breakfast always consists of eggs, bacon, cereal, juice, etc., can be violated. We have had requests for soup, hamburgers and vegetables for breakfast. Though atypical requests, such breakfasts are nutritionally sound. Some patients have never seen an institutional kitchen and show an interest in touring the dietary department. These tours afford the patient concrete examFALL, 1969

pIes of how they are given individual attention and stimulate interest in their food. Clinic out-patients are a very good audience for nutrition education. They keep diet records which present limitless opportunities for identifying nutrition education needs. Our hospital maintains in an underprivileged area a clinic with a part-time nutritionist who works closely with these children. Since their diets at home usually are inadequate, basic nutrition teaching is a necessity. To teach obese children basic nutrition and availability of low caloric foods, a garden is cultivated. The patients maintain this garden to become familiar with new foods and use them in weight reduction diets. Another approach to nutrition education is the use of fliers on patients' trays to teach food customs or introduce ethnic foods or new recipes. Fliers require research and must contain catchy wording or cartoons to attract children's attention. We have done various fliers; for example, some on Swiss cheese, beef Stroganoff and egg rolls. Parents or nurses can read these to younger children. Many times this type of juvenile orientation influences a child to try a new food.

Delegate Nutrition Education Some of our nutrition education program is delegated to other departments and auxiliary personnel. Since nurses and nurses aides spend more time with patients than anyone else, they are oriented to dietary procedures, the importance of nutrition, and their role in teaching the patients good normal nutrition. The volunteers are given less extensive orientation but are also closely associated with the patients, helping at mealtime with younger children or those unable to feed themselves. All personnel responsible for feeding assistance are reminded: "Most children eat much better with companionship."5 This one-to-one relationship gives the nurse, nurses aide or volunteer the opportunity to emphasize the importance of nutrition. Dietitians often go to other department meetings to relate our policies and the need for good nutrition. All personnel, especially dietary employees, involved in feeding the children should be periodically oriented to their role in nutrition education. At Children's Hospital of Pittsburgh, most nutrition education is done informally, but couldn't it also be done in a formal manner? Most pediatric hospitals or units have a school program of some type. The teachers could be instructed to

include nutrition in many classes. The dietitians could give a class on normal nutrition to various age groups of patients. Classes could also be set up for different clinics, whether for diabetic, allergic, or obese patients. The types of food service can affect nutrition education in the hospital. We have discussed the decentralized system. It is possible the centralized system could employ the same techniques.

Other Techniques Cafeteria service provides the greatest opportunity for nutrition education. Many pediatric units have this type of operation. As a teaching aid, the basic four food groups can be depicted in colorful panels on the walls. Foods can be grouped by a color code to show different house diets, various therapeutic diets and the basic food groups. The food supervisor can urge the children to make selections resulting in a balanced diet. New items, ethnic foods and special food customs could be introduced with posters or color slides. A cafeteria display impresses upon children the role of food in their development. It also gives beneficial results in social consciousness, selfhelp and personal hygiene. It has been noted that children eat better in the dining room atmosphere than they do when served trays in their rooms. Children imitate others; if they see others eating carrots and spinach, they may also try to eat their own vegetables. There are many opportunities for nutrition education in a pediatric hospital. I am sure that in the future, all pediatric hospitals and units will include a cafeteria for ambulatory patients. With such facilities, the two programs described above can provide nutrition education to the young patients and possibly give them a foundation in good nutrition practices. As we have found out at Children's Hospital of Pittsburgh, much can be done whether with an informal or formal program. REFERENCES 1. Weng, L., Heseltine, M. and Bain, K., "Children Will Eat Hospital Food," Parts I & II, Hospitals, J.A.H.A., June 1 and June 16, 1956. 2. Pursel, Marjorie, "Your Health-How Can You Help?", National Dairy Council, Chicago, 1964. 3. Leverton, Ruth M., "A Girl and Her Figure," National Dairy Council, Chicago, 1966. 4. Gregg, Walter H., "A Boy and His Phy-

sique," National Dairy Council, Chicago,

1968. 5. Smith, Hazel A., "Pediatric Cafeteria," Hospital Progress, February 1962. JOURNAL OF NUTRITION EDUCATION I 25