Nutrition InCHD Haritha

7/30/2019 Nutrition InCHD Haritha

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NUTRITIONAL CARE -PEDIATRIC CARDIOLOGY

-HARITASHYAM, RD

-CLINICAL NUTRITIONIST

-APOLLO HOSPITALS, HYDERABAD.


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MALNUTRITIONPREVALENCE

15 to 50 % of hospitalized pediatric inpatients aremalnourished on presentation (down from 35-65%)

15 to 20 % of critically ill patients

33% patients with congenital heart disease

39% awaiting elective surgeryParsons, AJCN,1980; Mize, Nutr Supt Ser, 1984; Merritt, Am J Clin Nutr, 1979, Huddleston KC, CCClin of NA, 1993, Cameron, Arch Ped 1995, Cooper, J Ped Surg 1981


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GROWTH AND NUTRITION

In children, growth depends on a permanent increasein fat and lean body mass, which requires positiveenergy and nitrogen balance.

Therefore, any increase in nutritional demandscompetes with the specific needs of growth, especiallyduring infancy and adolescence.


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GROWTH AND NUTRITION

Consequently, sustained nutritional imbalance inducesgrowth retardation, with a decrease in longitudinalgrowth (height gain over time) and height-for-age

ratio (height divided by the expected height for age,taken as 50th centile for height).

The most obvious and earliest sign of malnutrition insuch situations is the absence of normal weight gain,

followed by weight loss with visible decrease in fatand muscle mass.


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IDENTIFICATION OF CHILDREN AT NUTRITIONAL RISK

Children admitted to hospital are atrisk of developing malnutrition, evenwhen nutritional status is normal atthe time of admission.


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DIAGNOSIS OF MALNUTRITION

Failure to diagnosemalnutrition leads to neglect

of nutritional support duringillness.


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IDENTIFICATION OF CHILDREN AT NUTRITIONALRISK

Weight for age < 10th % tile

Weight for Height < 10th % tile

Acute weight loss > 5% over 1 month or >10% total

Birth weight < 2 SD below mean for gestational age

Increased metabolic requirements 2 chronic disease

Impaired ability to ingest or tolerate oral feeds

Weight % tile crossing 2 contour lines over time (FTT)


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Infants and children with CHD

exhibit a range of delays in weight gain and growth.

In some instances the delay can be relatively mild, the

failure to thrive can result in permanent physical ordevelopmental impairment .

While the cause of abnormal growth and development

is multifactorial.

reduced energy consumption and increased energyexpenditure, or both, may be the most importantplayers.


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Causes of Failure to Thrive

Decreased Energy Intake - (child to tire easily).

increased energy expenditure as compared to normal

children (have a 40% elevation in total energyexpenditure (TEE).

Inadequate caloric intake has been shown to be the mostimportant cause of growth disturbances in children withCHD.

Hansen and Dorup - showed that caloric intake in CHDpatients was 76% that of normal age matched controls.

Hansen SR; Dorup I. Energy and nutrient intakes in congenital heart disease. Acta Paediatr. 1993Feb;82(2):166-72.


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Nutrition Parameters Monitored

Intake of calories, protein,carbohydrate, fat (expressed aspercentage of RDA).

breastfeeding.

age at weaning.

type of weaning foods and adequacyof weaning.

Intake of any nutritional supplement.


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Nutritional requirement


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Calculation of energy requirement

Harris-Benedict equation (BEE)

RDA simplest method

Age(year) RDA (kcal/kg/wt)

0-1 100-120

1-3 1004-6 90


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Role of Dietary History

A nutritionist obtains a detailed dietary history byinterviewing the childs mother using a 24-hour recallmethod.

Dietary intake on a typical days diet at home is evaluatedfor 3 consecutive days; average intake was calculated.

The relative proportions of total calorie, protein,carbohydrate and fat intake is estimated by using standardcharts of nutritive values of common dietary items.


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Role of Dietary History

Dietary intake of calories and proteins can beexpressed as percentage of recommended dailyallowance for age and sex.

Details of feeding like breast feeding, age atweaning, type and adequacy of weaning foodstobe recorded.

Follow-up evaluations should be scheduled at 3

months and then at 6 monthly intervals.


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Hypercaloric feeding can beintroduced if quantity of feedconsumed is less.

Not very freely available currentlyonly one brand with 1.5cal/mlavailable in the market


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Structured Feeding Programs

Unger, et al., showed that dietary interventionincluding nutritional analysis and counselingincreased mean intake from 90% to 104% ofthe RDA for calories and increased weight from

83.1% to 88.3% of ideal body weight.

The fact that counseling alone was enough toincrease the caloric intake and weight in thesechildren suggests that there is a definite role

for a parental education from a dietitian tooptimize feeding.


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What Determines nutritional Recoveryin Malnourished children AfterCorrection of Congenital HeartDefects?

Balu Vaidyanathan et al.Pediatrics-2009


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STUDY ADDS: Approximately onequarter of children with CHD continueto have persistent malnutrition evenafter corrective intervention.

Persistent malnutrition on follow-up ispredicted by the nutritional status at

the time of correction, birth weight,and parental anthropometry.


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On 3-month follow-up,

.


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The results of this study could have significantimplications for physicians caring for children with heartdisease in developing countries. Presence of CHF andage at correction were the only modifiable determinantsof malnutrition.

The results of the study underline the importance ofreferring patients with CHD and CHF for early correctiveintervention (6 months) before significant malnutrition

sets in.


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strategy used to feed infants with CHDis case dependent and thereforerequires the cooperation of parents,pediatricians and other health careprofessionals to develop the bestapproach.


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PLASMA PROTEIN IN USE AS NUTRITIONAL MARKERS

Albumin

Transferrin

Prealbumin

THE HALF LIFE DETERMINES THE SENSITIVITY

Source - Spiekerman AM.

Nutritional assessment (protein nurturer). Anal Chem 1995;67:429R


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CHARACTERISTICS OF PLASMA PROTEIN IN USE ASNUTRITIONAL MARKERS

Half-life and Range

Albumin - 20 days (3.30 to 4.80 g per

dL)

Transferrin 10 days ( 0.16 to 0.36 g perdL )

Prealbumin 2 days (15-40 mg/dLperdL) Usually

THE HALF LIFE DETERMINES THE SENSITIVITY OFTHE QI INDICATOR

Source - Spiekerman AM.Nutritional assessment (protein nurturer). Anal Chem 1995;67:429R


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PREALBUMIN RISK STRATIFICATION

Prealbumin level Risk level


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Prealbumin Serum Concentrations as a Useful Tool in theAssessment of Malnutrition in Hospitalized Patients, devotoetal;

Devoto et al. Clin Chem.2006; 52: 2281-2285


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Nutrition and Outcome

Low Prealbumin 95%specific, in 147consecutiveadmissions

8 measures ofmalnutrition in 134patients

50 cardiac surgerypatients assessed Low Prealbumin

predictive post-opinfectiouscomplication

0

2

4

6

8

10

12

14

16

18

20

LOS Mortality (%)

PCM

No PCM

PCM*

No PCM*

Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, RevPaul Med, 1995


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However, there is no generallyaccepted set of guidelines that defineappropriate caloric intake for catch-upgrowth..


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NUTRITION SUPPORT TEAM-

ESPGHAN Committee on Nutrition

Implementation of NSTs inhospitals is recommended toimprove nutritional managementof sick children.


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ROLE OF NUTRITION SUPPORT TEAM-

The main tasks of the NST are as follows:

To implement patient screening for nutritional risk.

To identify patients who require nutritional support.

To ensure provision of effective nutritional management forpatients.

To plan home nutrition after discharge.

To educate hospital staff with respect to identification andmanagement of nutritional problems.

To monitor and evaluate practice.


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Conclusions:

Malnutrition is common in children withCHD. Corrective intervention results insignificant improvement in nutritionalstatus on short-term follow-up.

From the Departments of Pediatric Cardiology, Biostatistics*

and Pediatric Cardiac Surgery**, Amrita Institute of MedicalSciences and Research Center, Elamakkara P.O., Kochi, Kerala682 026, India.

Nutrition InCHD Haritha

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