Skills Lab Block 24

Pediatric Nutrition Care

Department of Child Health Dr. Mohammad Hoesin Hospital/Faculty of Medicine Sriwijaya University

Palembang 2014

Objectives

• To recognize the changing nutritional needs of developing children, from infancy to adolescence.

• To understand the concept of malnutrition

• To understand the principles of pediatric nutrition care to prevent malnutrition

Pediatric stages development

• Neonates (0-1 month)

• Infancy (0-1 yr)

• Toddlerhood (1-2 yr) young children

• Preschool (3-5 yr)

• School age (6-9 yr)

• Adolescent (10-20 yr) – Early adolescence (10-13 yr)

– Middle adolescence (14-16 yr)

– Late adolescence (17-20 yr)

Growth and Development an essential feature of life of a child and

distinguishes him or her from an adult

• GROWTH is a process starts from the time of conception of the fertilized ovum (egg) and continuous until the child grows in to a fully mature adult.

• DEVELOPMENT is defined as maturation of functions.

Assessment of growth and development

• Growth parameters

Physical growth of a child is evaluated by body measurement

• body weight

• length or height

• Head

circumference

• Development parameters – Motor development

(physical development) • Gross motor skills • Fine motor skills

– Cognitive (language) development

• Receptive • Expressive

– Psychosocial development • Emotional • Social • Adaptive

Factors affecting growth and development

• Genetic factors – The tall parents

have tall children and so on.

– In girls growth spurt occurs earlier at puberty

• Environmental factors – Nutrition

– Chemicals : • food additives, etc

– Injury

– Infection

– Social Factors

– Emotional factors

– Cultural factors

Why is Nutrition Important?

• Energy of daily living

• Maintenance of all body functions

• Vital to growth and development

• Therapeutic benefits

– Healing

– Prevention

What are nutrients ?

• Macronutrients – Carbohydrates

– Protein

– Lipid

• Micronutrients – Vitamins

– Mineral

• Water

How much nutrients are needed for growth and development ???

Consequences of deficit/excess Malnutrition (Jelliffe,1966)

• Undernutrition

– Mild, moderate, severe malnutrition

• Overnutrition

– Overweight & obesity

• Specific nutrient deficiencies or imbalance

– Iron deficiency

– Iodine deficiency, etc

Severe malnutrition (marasmus & kwashiorkor)

Overnutrition

Iodine deficiencies

• Short stature

• Hernia umbilicalis

• IQ 13.5 point, mentally retarded, cretinism, myelinization

Iron deficiency anemia IQ 10-20 point

Hypervitaminosis D

80% mild-

moderate

20% severe

How big is the problems ??

What physician should do to prevent malnutrition ?

Health Care

Child Health Care

Optimizing the growth, development and well being of infants, children and adolescents.

Healthy

• Primary Prevention – Promotion of well

being aims to prevent the initial occurrence of an illness

– Optimalization growth & development

Sick

• Secondary Prevention – Early intervention aims

to stop or slow an existing illness by early detection and appropriate treatment

• Tertiary Prevention (Cure) – Diseases management

aims to reduce the re-occurrence and establishment of chronic illness

Principles of Pediatric Health Care

• Diagnostic

• Management – Drugs or Surgery

– Nursing Care • Ambulatory, Hospitalized:

intermediate care, ICU etc

– Nutrition Care – Rehabilitation Care

Pediatric nutrition care activities

1.Nutritional assessment

2.Nutritional requirements

3.Routes of delivery

4.Formula/IVF selection

5.Monitoring

Pediatric nutrition care activities

1.Nutritional assessment

2.Nutritional requirements

3.Routes of delivery

4.Formula/IVF selection

5.Monitoring

Assessment clinical & anthropometrics for individual nutritional status

• Z-score classification Wasting : Weight-for-height z-score (WHZ) <-2.00 – Moderate WHZ -3.00 to -2.01 – Severe WHZ <-3.00

• Weight(kg) for height (m2) (BMI for Age - CDC 2000) parameter overweight & obesity – <5th percentile underweight – 5th - <85th percentile normal variation – 85th - <95th percentile overweight – 95th percentile obese

• Percent ideal body weight (Olsen et al, 2003)

Classification

Percent of Ideal Body Weight (IBW)

• Percentage of the child’s actual weight compared to ideal weight for actual height (Goldbloom, 1997)

• IBW is determined from the CDC growth chart (Olsen et al, 2003)

– Plotting the child’s height for age

– Extending the line horizontally to the 50th percentile height-for-age line

– Extending the vertical line from the 50th percentile height for age to the corresponding 50th percentile weight, noting this as IBW

– Percent IBW is calculated as (actual weight divided by IBW) X 100%

IBW is used as a clinical weight goal in the nutrition rehabilitation

• Nutritional Status : – Actual weight/IBW (%)

• Classification of Percent of IBW (Waterlow, 1972)

– ≥120% obesity – ≥110 -120% overweight – ≥90-110% normal – ≥80-90% mild malnutrition – ≥70-80% moderate malnutrition – ≤70% severe malnutrition

BB aktual

TB aktual

UMUR TINGGI (Height Age)= 84 bln

BB ideal=22 kg

BB 18 kg, TB 120 cm

10 bln, 70 cm

Menentukan RDA berdasarkan USIA TINGGI

(height age) = 9 bln

♀, 10 bln, 8 kg, 70 cm

W/L= IBW =

8 kg

♀, 10 bln, 8 kg, 70 cm

Pediatric nutrition care activities

1.Nutritional assessment

2.Nutritional requirements

3.Routes of delivery

4.Formula/IVF selection

5.Monitoring

Calculation of energy requirement

• Indirect calorimetry the most accurate method

• Harris-Benedict equation (REE)

• WHO (REE) • Schofield equation

(REE) • RDA simplest

method

Age (year)

RDA (kcal/kg

Wt) 0-1

1-3

4-6

7-9

10-12

12-18

100-120

100

90

80 M : 60-70

F : 50-60

M : 50-60

F : 40-50

Calculation of Catch-Up Growth requirement in the Pediatrics

• Indication – Children who are below normal growth

parameters due to chronic undernutrition or illness affecting their nutritional intake and status require additional calories and protein to achieve catch-up growth (nutritional support).

• Kcal = RDA (kcal/kg) for height age* x Ideal weight (kg)* – * Age at which actual height is at the 50th %-ile

** Ideal weight for actual height

Menentukan status gizi & kebutuhan kalori

Anak A : BB : 10 kg ( < P3) 24 bln TB : 85 cm (= P25) Status gizi : BB/U = 10/12.6 ( 79%) TB/U = 85/87 ( 97.5%) BB/TB = 10/12.2 ( 82%) =st gizi KURANG Kebutuhan kalori : 12.2 x 100 kal = 1220 kalori

Menentukan status gizi & kebutuhan kalori

Anak B : BB : 10 kg ( < P3) TB : 78 cm (= P25) Status gizi : BB/U = 10/12.6 (79%) TB/U = 78/87 (89%) BB/TB = 10/10.8 (92.6%) = st gizi normal Kebutuhan kalori : 10.8 x 100 kal = 1080 kalori

Pediatric nutrition care activities

1.Nutritional assessment

2.Nutritional requirements

3.Routes of delivery

4.Formula/IVF selection

5.Monitoring

Route of delivery

Enteral Nutrition

GI function

Normal Compromised

Standard

Nutrients

Specialty

Formulas

Nutrient Tolerance

Adequate

Progress to

Oral feeding

Inadequate

PN supplementation

Progress to total

Enteral feedings

Adequate progress

To more complex diet

& oral feeding tolerated

Parenteral Nutrition

Short-term Long-term or

Fluid restriction

Peripheral PN Central PN

GI Function returns

No Yes

JPEN 2002:26(1);8SA

Pediatric nutrition care activities

1.Nutritional assessment

2.Nutritional requirements

3.Routes of delivery

4.Formula/IVF selection

5.Monitoring

Guidelines How to choose Type of Nutrition

• Patient Factors – Age (stage of

development) – Diagnosis associated

nutritional problems – Nutritional

requirements – Gastrointestinal

function

• Nutritional Factors – Osmolality (isotonic

150-250mOsm) – Renal solute load – Caloric density and

viscosity – Nutrient composition:

type & amount of CHO, Fat and protein

– Product availability and cost

Feeding the Infant / the Child

• What are the options?

– Breast feeding • The WHO recommends exclusive breast

feeding at least for 6 months.

– Formula feeding

– Complementary Feeding

– Family foods

Pediatric nutrition care activities

1.Nutritional assessment

2.Nutritional requirements

3.Routes of delivery

4.Formula/IVF selection

5.Monitoring n Evaluation

Monitoring results of nutrition care

• Food acceptability, tolerance, efficacy

• Parameter : – Acceptability : like or dislike

– Tolerance : look for adverse food reaction

– Efficacy : growth monitoring

Assessment of sufficient breast feeding

• Weight pattern - consistent weight gain

trimester 1 : 25-30 g/d = 200 g/w = 750-900 g/mo

trimester 2 : 20 g/d = 150 g/w = 600 g/mo trimester 3 : 15 g/d = 100 g/w = 400 g/mo trimester 4 : 10 g/d = 50-75 g/w = 200-300 g/mon

• Voiding – 6-8 wet diapers/day, soaked not only wet • Stooling - generally more stools than formula. • Feed-on-demand ~ every 2-3 hours (8-12 times a

day). • Duration of feedings - generally 10-20 min/side. • Need for high fat hind milk. • Activity and vigor of infant.

Infant Feeding Practice

• Depend on :

– Maturation of neuromotoric system

– Maturation of gastrointestinal system

– Maturation of immunological system

Example

AH, 16 months old boy, weight 5 kg (4.2 kg < p3), length 65 cm (9 cm < p3), HC 44 cm (<-2 SD Nellhauss)

Born aterm BW 3000 g 4 months: 4.5 kg Reccurrent diarrhea and vomitus (+) since using milk

formula

Diagnosis ? Pediatric Nutrition Care ?

Pediatric Nutrition Care

• Assessment → Diagnosis

– History

– Physical Examination

– Investigations

– Dietary Analysis

• Requirement

• Route of delivery

• Type of diet

• Monitoring

Approximately Daily Weight Gain

• At 16 months the weight should be:

– 3 x 750 g = 2250 g

– 3 x 600 g = 1800 g

– 3 x 450 g = 1350 g

– 3 x 250 g = 750 g

– 4 x 160 g = 640 g 6790 g

BW 3000 g

9790 g

Age Daily weight gain (g)

0-3 mos 25-30

4-6 mos 20

7-9 mos 15

10-12 mos 8-10

13-36 mos 6

Nutrition Care – Nutritional assessment

• Specific growth chart (-) CDC/NCHS 2000 • IBW for 65 cm 7.4 kg • Nutritional status 5/7.4 67.5% (severe

malnutrition) • Based on daily weight gain failure to thrive

– Nutritional requirements • Height age 5 month RDA 110 kcal/kg • Requirement 7.4 X 110 kcal = 814 kcal • Prevent refeeding syndrome begin 50%-75%

requirement 400--600 kcal gradually increased to 814 kcal

– Routes of delivery • Oral or enteral

– Formula selection • Hypoallergenic formula 400-600kcal/20 kcal/oz 20-

30 oz ± 600-900 mL/24 hours – Monitoring

• Diarrhea & vomitus (-) • Growth (BW, BL)

Nutrition Care Result

AH, boy, 16 months W : 3.6 kg L : 65 cm

HA : 5 mos

IBW : 7.4 kg

9 months later

25 months W : 10.7 kg L : 77 cm HA : 12 mos IBW : 10 kg

Refeeding Syndrome

• Metabolic complication associated with giving nutritional support (enteral or parenteral) to the severely malnourished

• Starved cells take up energy substrates – rapid fluxes in insulin production in

response to CHO load – hypophosphotemia and hypokalemia.

• Control by giving formula meeting 50-75% of need and advance gradually and monitoring electrolytes