Pediatric Nutrition Care Solo New
description
Transcript of Pediatric Nutrition Care Solo New
![Page 1: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/1.jpg)
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
![Page 2: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/2.jpg)
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
![Page 3: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/3.jpg)
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).
![Page 4: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/4.jpg)
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)
![Page 5: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/5.jpg)
Child is not a miniature adult !!!!!
![Page 6: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/6.jpg)
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.
![Page 7: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/7.jpg)
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
![Page 8: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/8.jpg)
Infancy rapid body growth and brain development
![Page 9: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/9.jpg)
![Page 10: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/10.jpg)
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
![Page 11: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/11.jpg)
Why is Nutrition Important?
• Energy of daily living• Maintenance of all body
functions• Vital to growth and development• Therapeutic benefits
–Healing–Prevention
![Page 12: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/12.jpg)
What are nutrients ?
• Macronutrients– Carbohydrates– Protein– Lipid
• Micronutrients– Vitamins– Mineral
• Water
![Page 13: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/13.jpg)
How much nutrients are needed for growth and
development ???
![Page 14: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/14.jpg)
![Page 15: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/15.jpg)
![Page 16: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/16.jpg)
![Page 17: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/17.jpg)
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
![Page 18: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/18.jpg)
Consequences of malnutrition
![Page 19: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/19.jpg)
Severe malnutrition (marasmus & kwashiorkor)
![Page 20: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/20.jpg)
![Page 21: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/21.jpg)
The importance of ages 0-3 years:Brain growth & development
![Page 22: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/22.jpg)
Overnutrition
![Page 23: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/23.jpg)
Iodine deficiencies
• Short stature• Hernia
umbilicalis• IQ 13.5 point,
mentally retarded, cretinism, myelinization
![Page 24: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/24.jpg)
Iron deficiency anemia
IQ 10-20 point
![Page 25: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/25.jpg)
How big is the problems ???
Leading Causes of Death in Children Under Five
in Developing Countries
![Page 26: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/26.jpg)
![Page 27: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/27.jpg)
What physician should do to prevent malnutrition ?
![Page 28: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/28.jpg)
Health Care
![Page 29: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/29.jpg)
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
![Page 30: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/30.jpg)
Principles of Pediatric Health Care
• Diagnostic • Management
– Drugs or Surgery– Nursing Care
• Ambulatory, Hospitalized: intermediate care, ICU etc
–Nutrition Care– Rehabilitation Care
![Page 31: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/31.jpg)
Pediatric nutrition care activities
– Nutritional assessment– Nutritional requirements– Routes of delivery– Formula/IVF selection– Monitoring
![Page 32: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/32.jpg)
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)
![Page 33: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/33.jpg)
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%
![Page 34: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/34.jpg)
![Page 35: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/35.jpg)
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.
![Page 36: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/36.jpg)
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
![Page 37: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/37.jpg)
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
![Page 38: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/38.jpg)
Route of delivery
![Page 39: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/39.jpg)
Type of feeding
![Page 40: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/40.jpg)
Feeding the Infant
• What are the options?–Breast feeding
• The WHO recommends exclusive breast feeding at least for 6 months.
–Formula feeding–Complementary Feeding
![Page 41: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/41.jpg)
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.
![Page 42: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/42.jpg)
Proper breast-feeding positions
![Page 43: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/43.jpg)
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.
![Page 44: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/44.jpg)
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.
![Page 45: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/45.jpg)
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.
![Page 46: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/46.jpg)
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
![Page 47: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/47.jpg)
![Page 48: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/48.jpg)
![Page 49: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/49.jpg)
Infant Feeding Practice
• Depend on :–Maturation of neuromotoric system–Maturation of gastrointestinal
system–Maturation of immunological
system
![Page 50: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/50.jpg)
![Page 51: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/51.jpg)
![Page 52: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/52.jpg)
![Page 53: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/53.jpg)
Monitoring results of nutrition care
• Food acceptability, tolerance, efficacy
• Parameter–Acceptability : like or dislike–Tolerance : look for adverse food
reaction–Efficacy : growth monitoring
![Page 54: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/54.jpg)
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
![Page 55: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/55.jpg)
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).
![Page 56: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/56.jpg)
![Page 57: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/57.jpg)
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 ?
![Page 58: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/58.jpg)
Pediatric Nutrition Care
• Assessment → Diagnosis– History– Physical Examination– Investigations– Dietary Analysis
• Requirement• Route of delivery• Type of diet• Monitoring
![Page 59: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/59.jpg)
![Page 60: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/60.jpg)
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
![Page 61: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/61.jpg)
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
![Page 62: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/62.jpg)
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)
![Page 63: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/63.jpg)
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 (-)
![Page 64: Pediatric Nutrition Care Solo New](https://reader033.fdocuments.us/reader033/viewer/2022061119/546af43ab4af9f76538b459e/html5/thumbnails/64.jpg)
Nutrition Care Result
AH, boy, 16 monthsW 3.6 kg L 65 cm
9 monthslater
25 monthsW 10.7 kgs L 77 cm