Pediatric Nutrition Care

Damayanti Rusli Sjarif Division Pediatric Nutrition & Metabolic

Diseases Dept of Child Health – University of

Indonesia School of MedicineDr Cipto Mangunkusumo General Hospital

Jakarta - Indonesia

Objectives

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

• To understand that nutritional recommendations for children vary by age, stage of development,and gender

• To understand the principle of pediatric nutrition care

Pediatrics

• Pediatrics (or paediatrics) is the branch of medicine concerned with medical care of children from infancy through adolescence.

• The word pediatrics mean healer of children; they derive from two Greeks words: παῖς (pais = child) and ἰατρός (iatros = doctor or healer).

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)

Child is not a miniature adult !!!!!

Growth and Developmentan essential feature of life of a child and this

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 and

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

Infancy rapid body growth and brain development

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

Consequences of malnutrition

Severe malnutrition (marasmus & kwashiorkor)

The importance of ages 0-3 years:Brain growth & development

Overnutrition

Iodine deficiencies

• Short stature• Hernia

umbilicalis• IQ 13.5 point,

mentally retarded, cretinism, myelinization

Iron deficiency anemia

IQ 10-20 point

How big is the problems ???

Leading Causes of Death in Children Under Five

in Developing Countries

What physician should do to prevent malnutrition ?

Health Care

Child Health CareOptimizing 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

• 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

– Nutritional assessment– Nutritional requirements– Routes of delivery– Formula/IVF selection– 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 for height (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)

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• 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.

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)0-11-34-67-9

10-12

12-18

100-1201009080

M : 60-70 F : 50-60M : 50-60F : 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

Route of delivery

Type of feeding

Feeding the Infant

• What are the options?–Breast feeding

• The WHO recommends exclusive breast feeding at least for 6 months.

–Formula feeding–Complementary Feeding

Supporting Breast Feeding

• Ask patients if they plan to breast feed.• Give prenatal guidance, materials and support

numbers.• Support hospital initiatives to encourage breast

feeding, such as lactation counselors.• Ask about breast feeding support available to

mother.• Become familiar with how to manage common

problems such as mastitis and inverted nipples.• Understand issues related to pumping and

helping moms return to work or wean the infant.

Proper breast-feeding positions

Assessment of sufficient breast feeding

• Weight pattern - consistent weight gain.• 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 Formula

• 3 Forms:– Ready to feed - most expensive, does

not require water.– Concentrate - requires mixing with water

in equal parts.– Powder - requires mixing with water.

Composition of Standard Infant Formula (Codex Alimentarius for infant formula)

• Caloric density: – standard formulas contain 20 calories/oz (0.67

calories/cc).• Protein content:

– ratio of whey to casein varies-most are 60:40 similar to human milk.

• Fat: – most provide ~50% of calories from fat from

saturated and polyunsaturated fatty acids.• Carbohydrate:

– lactose, beneficial effect on mineral absorption (Ca, Zn, Mg), and on colonic flora.

• Micronutrients: – Higher vitamin and mineral content than human

milk to cover 97% of the population.

Special Formulas• Soymilk based formula

– used for vegetarians, lactase deficiency, galactosemia. • Lactose free: cow’s milk-based formula

– Lactose intolerance.• Protein extensivelly hydrolysate or free amino acids

– infants who can not digest or are allergic to intact protein. • Pre-term infant:

– predominant whey protein, cow’s milk based, – higher protein and calcium, 20-50% MCT.

• Post discharge formula• Inborn errors of metabolism milk products

– PKU, MSUD, etc

Infant Feeding Practice

• Depend on :–Maturation of neuromotoric system–Maturation of gastrointestinal

system–Maturation of immunological

system

Monitoring results of nutrition care

• Food acceptability, tolerance, efficacy

• Parameter–Acceptability : like or dislike–Tolerance : look for adverse food

reaction–Efficacy : growth monitoring

May occur in all individualls who eat sufficient quantity of food

Occur only in some susceptible individual

MicrobiologicalToxic Pharmacological

Food hypersensitivity Psychological food aversion

Immune mediatedFood Allergy

IgE mediated

Non- IgE mediated

Non- Immune MediatedFood intolerance

Other causes:* Mediator in food that mimic allergy inflamation* Food additives

Enzymatic deficiency

Adverse reaction to food

Monitoring Growth

• Use updated growth charts• Monitor trends in growth not one

value using weight, height, head circumference BMI.

• Evaluate changes in percentiles• Malnutrition results in:

– Decreased weight (acute) failure to thrive, then height, then head circumference (chronic).

Case Report

AH, 16 months old boy, weight 5 kg (4.2 kgs < 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

Age Daily weight gain (g)

0-4 mos 20-25

4-12 mos 15

1-3 yrs 8

4-6 yrs 6

• At 16 months the weight should be– 4 x 600 g = 2400 g– 8 x 450 g = 3600 g– 6 x 240 g = 1440 g

7440 g

BW 2500 g

9940 g

Risk factors for FTT• Reccurrent diarrhea and vomitus (+)

(inadequate caloric absorption)– since using milk formula (4 months old)– Soy based formula since 12 months

persistent diarrhea and vomitus

– Suspected cow milk allergy IgE RAST & occult blood tests (+) extensively hydrolized protein formula

• Metabolic acidosis persistent tubulopathy (defective used of caloric )– Blood gas analysis : pH 7.108, pCO2 18, HCO3

4.8, pO2 161.4 Bicarbonas natricus 8 dd 6 meq

Effects of metabolic acidosis on protein metabolism

Metabolic

acidosis

Decreased albumin

synthesis

Increased muscle

degradation

Malnutrition in

children

Increased amino acid catabolism

(Wiederkbr and Krapf, 2001)

Nutrition Care– Nutritional assessment

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

malnutrition)– 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 (-)

Nutrition Care Result

AH, boy, 16 monthsW 3.6 kg L 65 cm

9 monthslater

25 monthsW 10.7 kgs L 77 cm