1. Principle of Pediatric Nutrition Care for Consultant

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Pediatric Nutrition CarePediatric Nutrition Careas a strategy to prevent hospital

malnutrition

Damayanti Rusli SjarifDiv Pediatric Nutrition and Metabolic Diseases

l l

Damayanti Rusli Sjarif 2010

Dept of Child Health - University of Indonesia School of Medicine - Dr Cipto Mangunkusumo

General Hospital -Jakarta

Patient careMedical careMedical care• Drugs or surgery

Nursing care• Intensive care ?

Nutrition care ⇒ goal ?• Healthy child ⇒ optimal growth & development


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 livingEnergy of daily livingMaintenance of all body functionsVital to growth and development (infant , children & adolescent)Therapeutic benefits


Therapeutic benefits• Healing• Prevention


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Hippocrates c. 460 - 377 B.C

“If we could give every If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest


would have found the safest way to health."

Problem ?Hospital malnutrition:p

malnutrition during hospital admission

Hospitalized children up to 54% are malnourished, globallyPediatric Ward – RSCM (Ginting & Nasar, 2000)• 53% of of them experiencing decreased BW

hospitalized children was malnourished • 15 4% of them experiencing decreased BW


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

Damayanti Rusli Sjarif 2010 Damayanti Rusli Sjarif 2010

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Factors that cause malnutrition

Nutrition care ?Nutrition care ?• Unawareness of malnutrition by

physician• Inadequate skill, knowledge and

management strategies of nutrition therapy


py• High cost of nutrition support• Complication associated with

nutrition support, etc

How to solve the problem ?

To organize To perform nutrition To organize nutrition care team• Physician• Nurse

To perform nutrition care activities• Nutritional

assessment• Nutritional

i t


• Dietitian• Pharmacist

requirements• Routes of delivery• Formula/IVF selection• Monitoring

Nutritional assessment


What medical conditions/issues should I be aware of when assessing nutritional status?

Some conditions (e.g., pulmonary problems) can Som con t ons ( .g., pu monary pro ms) can increase energy needs. Other conditions (e.g., renal disorders) may change requirements of specific nutrients. Appetite may be decreased by symptoms associated with certain conditions. Medications can alter a child’s nutritional status as

ll


well. Some medications may change nutrient needs or may interfere with absorption and/or metabolism, while other medications can affect appetite

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Levels of assessment of nutritional status in clinic

Inadequate intakeDietary assessment

Laboratory assessment

MalabsorptionIncreased requirementsIncreased excretionIncreased destruction

⇓Depletion of reserves

⇓Physiologic and metabolic


Anthropometric assessment

Clinical assessment

Physiologic and metabolic alterations

⇓Wasting or decreased growth

⇓Spesific anatomic lesions

Nutritional status interpretation

If all 4 modalities can be If all 4 modalities can be performed ⇒ more accurate diagnosis can be determined

The fact : very difficult ⇒clinically + simple anthropometry


clinically + simple anthropometry

Assessment clinical & anthropometrics for individual nutritional status

Z-score classification ⇒• Obese Weight-for-height z-score (WHZ) <+2.00• Overweight Weight-for-height z-score (WHZ) <+1.00• 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


5 percentile ⇒ underweight• 5th - <85th percentile ⇒ normal variation• 85th - <95th percentile ⇒ overweight• ≥95th percentile ⇒ obese

Percent ideal body weight (Olsen et al, 2003)


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Percent of Ideal Body Weight (IBW)

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


Extending the vertical line from the 50percentile 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%

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

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

Classification of % of IBW ⇒ (Waterlow, 1972)• ≥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 h

Age( )

RDA (kcal/kgW )⇒ the most accurate

method Harris-Benedictequation (REE)WHO (REE)Schofield equation

(year) Wt)

0-11-34-67-9

100-1201009080


Schofield equation (REE)RDA ⇒ simplest method

10-12

12-18

M : 60-70 F : 50-60M : 50-60F : 40-50

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Calculation of Catch-Up Growth requirement in the Pediatrics

Indication• Children who are below normal growth parameters • 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

Nutritional status & requirement

A , 2 y old boy, y yWt : 10 kg (< P3)Ht : 85 cm (=P25)Nutritional statusW/H :10/12.2 (82%)

⇓H ≈ 50th percentile age 21 mos → RDA


age 21 mos → RDA 100 kcal/kgRequirement → 12.2 x 100 kcal/kg = 1220 kcal

Determining Calorie and Protein Needs in Critically Ill Children

Estimate basal energy needs (BEE)gy ( )• WHO equations• Schofield equations• Harris Benedict equations (not recommended for use in

pediatrics ⇒ derived from adult measurements)Determine Stress Factor -Total Calories = BEE X Stress FactorEstimate patient's protein requirements T t l P t i P t i RDA X St F t


Total Protein = Protein RDAs X Stress FactorContinue to evaluate and adjust recommendations based on nutrition monitoring.

Table 2. Determining Stress Factor

Clinical Condition Stress Factor

Maintenance minus stressFeverRoutine/elective surgery, minor sepsisCardiac failureMajor surgery

1..0 - 1.212% per degree > 37° C

1.1 - 1.31.25 - 1.51.2 - 1.4


SepsisCatch-up GrowthTrauma or head injury

1.4 - 1.51.5 - 2.01.5 - 1.7

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R t f d li d t f Route of delivery and type of food/formula/IV fluids


Nutrition SupportA variety of techniques available for use when a A variety of techniques available for use when a patient is not able to meet his or her nutrient needs by normal ingestion of foodOptions:• Nutritional supplement to oral diet• Formula fed by tube into GI tract (enteral

f din )


feeding)• Nutrients into venous system (total parenteral

nutrition - TPN)


Benefits of enteral nutrition in pediatric patients

Physiological presentation of nutrients Physiological presentation of nutrients Trophic effects on the GI tract Stimulation and maintenance of the gut mucosa Reduced metabolic and infectious complications Improved hepatic function versus parenteral nutrition Simplified fluid and electrolyte management


p y gMore "complete" nutrition May reduce the incidence of pathogen entry or bacterial translocation into the peritoneal cavity or circulation Less expensive

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When children need tube feeding & how to choose route of delivery ?

Children with acute conditions and increased requirements Nasogastric (NG) and

O t i (OG) ll f and increased requirements.E.g. Burns Severe trauma, Major surgery and Sepsis.

Children unable to eat due to mental/physical disability. E.g. mental retardation, Cerebral palsy and congenital anomalies.

Orogastric (OG) - usually for short term (< 3 months)

Gastrostomy (Surgical or Percutaneous Endoscopic Gastrostomy)- for long term

Transpyloric Feedings• those who are at high risk for


Children with chronic illnesses who require long term nutritional support. E.g. Cancer, Inflammatory bowel disease, Cystic fibrosis and congenital heart disease.

• those who are at high risk for aspiration;

• in pancreatitis patients best to feed nasojejunally beyond the ligament of Treitz

Feeding routes of delivery



Gastrostomy


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Continuous versus Intermittent Feedings

Continuous Feedings Intermittent Tube FeedingsBetter tolerated than intermittent or More physiological and practical for bolus delivery particularly in patients with limited absorptive surface area results in less reflux, dumping and diarrhea.

Better tolerated in critically ill children.

Recommended for delivery of nutrients directly into the small bowel.

p y g phome enteral feedings.

Indicated for children who are more medically stable, have achieved full tolerance of continuous feedings and are ready to transition to a more intermittent schedule.

Allows for greater patient mobility, i t f b th th h b


more appropriate for both the rehab and the home setting.

Promotes cyclic bursts of GI hormones such as gastrin in preterm infants, thus promoting GI development and maturation.


Enteral formula categoriesType IndicationPolymeric composed of intact

standard macronutrients forcaloric dense Normal GI function

Oligomeric (Elemental) Predigested nutrientsUsually contains glucose polymer partialy or extensively hydrolyzed ,protein, MCT(P ® P l


(Pepti-unior®, ,Pregestimil , Neocate®)

Modular consisting of a singular macronutrient(Fantomalt ®, Nutricom Caloric®)

PolymericStandardStandard• Infant : breast-milk, standard infant-formula

(20 kcal/oz)• Children : cow milk (20 kcal/oz)

Calorie dense• Infant : premature formula (24 kcal/oz→

N l® GM BBLR ) d h


Nenatal®, SGM-BBLR, etc), post-discharge formula (22 kcal/oz) → Neosure®

• Children : ( Pediasure®, Nutricia Complete®, Nutren Junior®, Vitaplus®, etc (1 kcal/ ml)

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Guidelines for Formula Selection

P i F F l FPatient Factors Formula Factors

Age DiagnosisAssociated nutritional problems

Osmolality (isotonic 150-250mOsm)Renal solute loadCaloric density and viscosityN t i t iti t &


problemsNutritional requirementsGastrointestinal function

Nutrient composition: type & amount of CHO, Fat and proteinProduct availability and cost

Monitoring

Tolerance of formulaTolerance of formula• Diarrhea• Nausea• Cramping• Constipation


p• aspirationHydration statusAdequacy of nutrition support

Parenteral Nutrition

Intravenous nutrition that provides energy Intravenous nutrition that provides energy and essential nutrients and promotes protein synthesis• Total parenteral nutrition (TPN) is the most

commonly used term• Used to be called hyperalimentation


Purpose:• To protect individuals from the effects of

starvation by providing all essential nutrients intravenously

Parenteral NutritionPeripheral (PPN) Central or Total (TPN)Peripheral (PPN)• Short term parenteral

support (up to 2 weeks)• Hypertonic solutions (> 900

mOsm/L) may cause phlebitis; thus must limit PPN solution’s osmolarity

• Energy and protein provided by PPN are limited because d t d i id

Central or Total (TPN)• For long term use,

catheters are surgically placed

• May have surgically implanted catheters which lie beneath the skin and are accessed by


dextrose and amino acids contribute significantly to osmolarity

• Electrolytes also contribute to osmolarity

and are accessed by special needle to decrease risk of infection

• Can add solution of higher osmolarity into central vein (larger lumen)

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Pediatric parenteral amino acid solution

Cysteine taurine tyrosine histidine are Cysteine, taurine, tyrosine, histidine are conditionally essential in neonates and infantsInfant• Primene 5% (Baxter®)• Aminosteril Infant (Fresenius®)


Pediatric• Aminofusin Paed (Baxter®)• Aminosteril (Fresenius®)]

Monitoring IndicatorsBody weight Serum phosphorusBody weightIntake/outputBowel functionBlood glucoseSerum electrolytes

S rum phosphorusLiver function testsSerum calcium and magnesiumSerum transferrin24 hour urinary nitrogen


Blood urea nitrogen, creatinine

gSerum albumin

Monitoring results of nutrition care

Food acceptability tolerance Food acceptability, tolerance, efficacyParameter• Acceptability : like or dislike

T l l k f d f d


• Tolerance : look for adverse food reactions

• Efficacy : growth monitoring

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Food Safety Guidelines for Child Care Programs

Food Purchasing Food Purchasing Food Storage Preparing Meals Serving Meals Dish Washing


Dish Washing Handling Garbage

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Food Purchasing

Use inspected meats Use inspected meats. Use pasteurized milk. Use pasteurized, 100-percent juices. Do not buy or use leaking or bulging cans of food


cans of food.

Food StoragePut away frozen and cold foods promptly after purchasing. Rinse fruits and vegetables before use. Even prepackaged, prewashed foods like lettuce, spinach, and carrots can still carry harmful bacteria and need to be washed. Store foods in covered containers in the refrigerator. Place thermometers in a visible location in refrigerators and freezers. Check the temperature frequently. • Keep refrigerator temperature between 32 degrees – 40

degrees F. K p f t mp t t 0 d s F l ss


• Keep freezer temperature at 0 degrees F or less. Clean the refrigerator, freezer, and dry food storage areas frequently. Store foods and cleaning supplies in separate cupboards. Store cleaning supplies in a cupboard that is locked.

Preparing MealsWash your hands often with soap and water. W h d iti t d t bl b f d ft Wash and sanitize counters and tables before and after use. Wash and sanitize cutting boards and utensils before using and after each use for different foods. Use separate cutting boards and utensils for raw meats. Wash and sanitize can openers after each use. Put frozen meats into a pan before placing them in the refrigerator to thaw. Never thaw meats on the kitchen counter. Cook meats thoroughly. Use a food thermometer to be sure they are done. • Steaks and roasts: beef, veal, and lamb – 145 degrees F • Ground pork, beef, veal, and lamb – 160 degrees F


• Whole poultry (take measurement in thigh) – 165 degrees F • Fin fish – 145 degrees F or until the flesh is opaque and separates

easily with a fork Do not change diapers in areas where you prepare, store, and serve foods. Keep pets in another room or outside when meals are being prepared and served to children

Serving MealsServe foods on a plate, napkin or bowl rather than directly f p , p yon the table. Use serving utensils such as large spoons or tongs. Teach children not to lick serving utensils. Wear food service gloves or use bakery wrap when serving foods that can't be picked up easily with utensils. Discard cracked or chipped plates, cups, and bowls. Give children clean utensils and napkins if these items are


Give children clean utensils and napkins if these items are dropped during meal service. Store leftovers immediately after the meal. Discard all leftovers on children’s plates; do not save them for later.

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Dish WashingIf a dishwasher is used, the rinse temperature f a d shwasher s used, the r nse temperature should be 180 degrees F to sanitize dishes. Follow these steps to wash and sanitize dishes without a dishwasher: • Rinse or scrape dishes • Wash in hot sudsy water • Rinse in clear water • Sanitize dishes by submerging in a solution of 1 teaspoon


• Sanitize dishes by submerging in a solution of 1 teaspoon bleach per quart of water for one minute or in 170 degree F water for at least 30 seconds

Air dry. Do not towel dry dishes

Handling Garbage

Throw out leftovers from children’s Throw out leftovers from children s plates. Do not save them for later Cover garbage cans and use liners. Empty garbage cans at the end of the day, or more often if full


y, m f n f fu

The Neutropenic Diet Guideline ( for cancer children)

Avoid raw vegetables and fruit (Oranges and g ( gbananas are okay.) Avoid take-out foods and fast foods and fountain drinks. Avoid aged cheese (blue, Roquefort, Brie). Cook all produce to well done. Eggs must be hard-boiled. Avoid deli meats.


Avoid deli meats. No raw nuts, nuts roasted in shell, or freshly ground nutbutters from a healthfood store. No well water No yogurt

Monitoring GrowthUse updated growth chartsM it t d i th t l Monitor trends in growth not one value using weight, height, head circumference BMI.Evaluate changes in percentilesMalnutrition results in:


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

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Weight faltering (Failure to thrive) weight curve deviates downward across ≥ 2 major

percentile lines on the NCHS growth


Refeeding Syndromemetabolic complication associated with giving p g gnutritional 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.


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 stagestagePatients considered malnourished or at risk if they have inadequate intake for ≥ 7 days or if they have loss ≥ 10% of their pre-illness body weightPrevent or slow malnutrition by giving nutrition counseling and dietsPatients who cannot maintain adequate oral intake


Patients who cannot maintain adequate oral intake and are candidates for nutrition support should be considered for tube feeding first

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Practice Guidelines for Pediatric nutrition care

Enteral feeding and parenteral nutrition should be Enteral feed ng and parenteral nutr t on should be combined when enteral feeding alone is not possibleParenteral nutrition should be used alone when enteral feeding has failed or when enteral feeding is contraindicatedMalnutrition should be corrected at a judicious rate and overfeeding avoided


gSome medications may change nutrient needs or may interfere with absorption and/or metabolism, while other medications can affect appetite

Pediatric Nutrition Care Result

9 monthslater


AH, boy, 16 monthsW 3.6 kg L 65 cm

25 monthsW 10.7 kgs L 77 cm

Hospital Malnutrition in Pediatric Ward RSCM 2009 (After Application of Pediatric

Nutrition Care Team)Hospital Malnutrition 13 2%Hospital Malnutrition 13.2%


1. Principle of Pediatric Nutrition Care for Consultant

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