pediatric nutrition care as a strategy to prevent hospital...
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Pediatric Nutrition Careas a strategy to prevent hospital malnutrition
Div Pediatric Nutrition and Metabolic DiseasesDept of Child Health
Child & Adolescent
� Child is not a miniature adult
� Pediatric stages development
� Infancy (<1 yr)
� Toddlerhood (1-2 yr)
� Preschool (3-5 yr)
School age (6-9 yr)
� Specific for child → growth and development
� School age (6-9 yr)
� Adolescent (10-20 yr)
�Early adolescence (10-13 yr)
�Middle adolescence (14-16yr)
�Late adolescence (17-20 yr)
Patient care
�Medical care� Drugs or surgery
�Nursing careNursing care� Intensive care ?
�Nutrition care ⇒ goal ?
� Healthy child ⇒ optimal growth & development
� Outpatient child ⇒ prevention of failure to thrive
� Hospitalized child ⇒ prevention of hospital malnutrition
Why is nutrition important ?
�Energy of daily living�Maintenance of all body functions�Vital to growth and development (infant , children & adolescent)
�Vital to growth and development (infant , children & adolescent)
�Therapeutic benefits�Healing� Prevention
Problem ?
� Hospital malnutrition:malnutrition during hospital admission
� Hospitalized children up to 54% are malnourished, globally
Pediatric Ward – RSCM (Ginting & Nasar, 2000)� Pediatric Ward – RSCM (Ginting & Nasar, 2000)� 53% of of them experiencing decreased BW
hospitalized children was malnourished � 15,4% of them experiencing decreased BW� 35,8% only consumed < 2/3 of hospital food served
� Pediatric surgical ward – RSCM (2004)� 52.4% were malnourished
� 3.9% of them experiencing decreased BW
Factors that cause malnutrition
�Nutrition care ?
�Unawareness of malnutrition by physician
�Inadequate skill, knowledge and management strategies of nutrition
�Inadequate skill, knowledge and management strategies of nutrition therapy
�High cost of nutrition support
�Complication associated with nutrition support, etc
How to solve the problem ?
� To organize nutrition care team� Physician
� To perform nutrition care activities� Nutritional assessment
Nutritional requirements� Nurse
� Dietitian
� Pharmacist
� Nutritional requirements
� Routes of delivery
� Formula/IVF selection
� Monitoring
Nutritional assessment
Levels of assessment of nutritional status in clinic
� Dietary assessment� Inadequate intake� Malabsorption� Increased requirements� Increased excretion� Increased destruction
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� Laboratory assessment
� Anthropometric assessment
� Clinical assessment
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� Depletion of reserves⇓⇓⇓⇓
� Physiologic and metabolic alterations
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� Wasting or decreased growth⇓⇓⇓⇓
� Spesific anatomic lesions
Nutritional status interpretation
�If all 4 modalities can be performed ⇒⇒⇒⇒ more accurate diagnosis can be determined
�The fact : very difficult ⇒⇒⇒⇒clinically + simple anthropometry
Assessment anthropometrics for individual nutritional status
� Weight for height (BMI for Age - CDC 2000) ⇒ parameter overweight & obesity� <5th percentile ⇒ underweight
� 5th - <85th percentile ⇒ normal variation� 5th - <85th percentile ⇒ normal variation
� 85th - <95th percentile ⇒ overweight
� ≥95th percentile ⇒ obese
� Percent ideal body weight (Olsen et al, 2003)
Body mass index for age percentiles{Weight(kg)/Height(m)2}
Assessment anthropometrics for individual nutritional status
� Weight for height (BMI for Age - CDC 2000) ⇒ parameter overweight & obesity� <5th percentile ⇒ underweight
� 5th - <85th percentile ⇒ normal variation� 5th - <85th percentile ⇒ normal variation
� 85th - <95th percentile ⇒ overweight
� ≥95th percentile ⇒ obese
� Percent ideal body weight (Olsen et al, 2003)
Standard Growth Chart
� The NCHS (2000) standards have been recommended for worldwide use by the WHO regardless of racial or ethnic origin
Infants with a history of premature birth � Infants with a history of premature birth should have their chronological age corrected by gestational age � until age 24 months for weight measurements,
� 40 months for length, and
� 18 months for head circumference
Percent of Ideal Body Weight (IBW)
� Percentage of the child’s actual weight compared to ideal weight for actual height (Goldbloom, 1997)
� Percent of IBW ⇒ the best index & reflect nutritional status better (McLaren & Read, 1972)
� 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%
Nutrition status as percentage of Ideal Weight
�Weight for Height ⇒ the best index & reflect nutritional status better (Waterlow, 1972)� ≥120% ⇒⇒⇒⇒ obesity� ≥120% ⇒⇒⇒⇒ obesity
� ≥110 -120% ⇒⇒⇒⇒ overweight
� ≥90-110% ⇒⇒⇒⇒ normal
� ≥80-90% ⇒⇒⇒⇒ mild malnutrition
� ≥70-80% ⇒⇒⇒⇒ moderate malnutrition
� ≤70% ⇒⇒⇒⇒ severe malnutrition.
Nutritional requirement
Calculation of energy requirement
� Indirect calorimetry ⇒ the most accurate method
� Harris-Benedict
Age(year)
RDA (kcal/kgWt)
0-1
1-3
100-120
100� Harris-Benedictequation (BEE)
� Schofield equation (BEE)
� RDA⇒ simplest method
1-3
4-6
7-9
10-12
12-18
100
90
80
M : 60-70
F : 50-60
M : 50-60
F : 40-50
Calculation of Catch-Up Growth requirement in the Infant and Child
� 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.achieve catch-up growth.
� 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
Nutritional status & requirement
� A , 2 y old boyWt : 10 kg (< P3)Ht : 85 cm (=P25)
� Nutritional status� Nutritional statusW/H :10/12.2 (82%)
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� H ≈ 50th percentile age 21 mos → RDA 100 kcal/kg
� Requirement → 12.2 x 100 kcal/kg = 1220 kcal
Determining Calorie and Protein Needs in Critically Ill Children
� Estimate basal energy needs (BEE)� WHO equations� Schofield equations� Harris Benedict equations (not recommended for use in
pediatrics ⇒⇒⇒⇒ derived from adult measurements)pediatrics ⇒⇒⇒⇒ derived from adult measurements)
� Determine Stress Factor -Total Calories = BEE X Stress Factor
� Estimate patient's protein requirements Total Protein = Protein RDAs X Stress Factor
� Continue to evaluate and adjust recommendations based on nutrition monitoring.
Table 2. Determining Stress Factor
Clinical Condition Stress Factor
Maintenance minus stressFeverRoutine/elective surgery,
1..0 - 1.212% per degree > 37° C
Routine/elective surgery, minor sepsisCardiac failureMajor surgerySepsisCatch-up GrowthTrauma or head injury
1.1 - 1.31.25 - 1.51.2 - 1.41.4 - 1.51.5 - 2.01.5 - 1.7
Route of delivery and type of food/formula/IV fluidsfood/formula/IV fluids
Nutrition Support
� A variety of techniques available for use when a patient is not able to meet his or her nutrient needs by normal ingestion of food
� Options:� Options:
� Nutritional supplement to oral diet
� Formula fed by tube into GI tract (enteral feeding)
� Nutrients into venous system (total parenteral nutrition - TPN)
What you should know about enteral feeding ?� Benefit of enteral feeding compare to parenteral feeding
� When child need tube feeding� How to choose route of delivery
Nasogastric, orogastric, gastrostomy, � Nasogastric, orogastric, gastrostomy, transpyloric
� Continuous or intermittent feeding� Types of enteral formula
� Polymeric, oligomeric (elemental), modular� Guidelines of formula selection
� Patient factor or formula factor� Monitoring → Efficiency & Complications
Feeding routes of delivery
Gastrostomy
What you should know about parenteral nutrition ?
� Indication of parenteral feeding
� Types of parenteral feeding
� Composition of parenteral nutrition for infant and children compared to
� Composition of parenteral nutrition for infant and children compared to adult
�Monitoring : Efficiency & Complications
Pediatric parenteral amino acid solution
� Cysteine, taurine, tyrosine, histidine are conditionally essential in neonates and infants
� Infant� Infant� Primene 5% (Baxter)� Aminosteril Infant (Fresenius)
� Pediatric� Aminofusin Paed (Baxter)� Aminosteril (Fresenius)]
Complication of nutritional support
Refeeding Syndrome
� metabolic complication associated with giving nutritional support (enteral or parenteral) to the severely malnourished
� Starved cells take up energy substrates � 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
Practice Guidelines for Pediatric Nutrition Care
� Detect actual or potential malnutrition at an early stage
� Patients considered malnourished or at risk if they have inadequate intake for ≥ 7 days or if they have loss ≥ 10% of their pre-illness body weight
� Prevent or slow malnutrition by giving nutrition counseling and diets
� Patients who cannot maintain adequate oral intake and are candidates for nutrition support should be considered for tube feeding first
Practice Guidelines for Pediatric nutrition care
� Enteral feeding and parenteral nutrition should be combined when enteral feeding alone is not possible
� Parenteral nutrition should be used alone when enteral feeding has failed or when enteral feeding
� Parenteral nutrition should be used alone when enteral feeding has failed or when enteral feeding is contraindicated
�Malnutrition should be corrected at a judicious rate and overfeeding avoided
Pediatric Nutrition Care Result
9 monthslater
AH, boy, 16 monthsW 3.6 kg L 65 cm
later
25 months
W 10.7 kgs L 77 cm
Recent data
�After performed nutrition care in the pediatric ward -RSCM during period 2003-2004 ⇒ 96.4% of mild-severe malnutrition patients experienced malnutrition patients experienced weight gain during hospitalized.