Skills Lab Block 24

Pediatric Nutrition Care

Department of Child Health Dr. Mohammad Hoesin
Hospital/Faculty of Medicine Sriwijaya University
Palembang 2014

Objectives
To recognize the changing nutritional needs
of developing children, from infancy to
adolescence.
To understand the concept of malnutrition
To understand the principles of pediatric
nutrition care to prevent malnutrition

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)

Growth and Development

an essential feature of life of a child and

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 or 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

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

Severe malnutrition

(marasmus & kwashiorkor)

Overnutrition

Iodine deficiencies
Short stature
Hernia umbilicalis
IQ 13.5 point,
mentally retarded,
cretinism,
myelinization

Iron deficiency anemia

IQ 10-20 point

Hypervitaminosis D

How big is the problems ??

80% mildmoderate
20% severe

What physician should do

to prevent malnutrition ?

Health Care

Child Health Care

Optimizing the growth, development and well being of

infants, children and adolescents.

Healthy

Sick

Primary Prevention

Secondary Prevention

Promotion of well
being aims to
prevent the initial
occurrence of an
illness
Optimalization
growth &
development

Tertiary Prevention (Cure)

Early intervention aims

to stop or slow an existing
illness by early detection
and appropriate treatment
Diseases management
aims to reduce the reoccurrence 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

1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring

Pediatric nutrition care activities

1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring

Assessment clinical & anthropometrics for

individual nutritional status
Z-score classification Wasting : Weight-forheight z-score (WHZ) <-2.00
Moderate WHZ -3.00 to -2.01
Severe WHZ <-3.00
Weight(kg) for height (m2) (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)

Classification

Percent of Ideal Body Weight (IBW)

Percentage of the childs 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 childs 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
Nutritional Status :
Actual weight/IBW (%)
Classification of Percent of IBW

120%
110 -120%
90-110%
80-90%
70-80%
70%

(Waterlow, 1972)

obesity
overweight
normal
mild malnutrition
moderate malnutrition
severe malnutrition

BB 18 kg, TB 120 cm

UMUR TINGGI (Height Age)= 84 bln

TB aktual

BB ideal=22 kg
BB aktual

, 10 bln, 8 kg, 70 cm

10 bln, 70 cm

Menentukan RDA
berdasarkan
USIA TINGGI
(height age) = 9 bln

, 10 bln, 8 kg, 70 cm
W/L= IBW =
8 kg

Pediatric nutrition care activities

1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring

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)

0-1
1-3
4-6
7-9
10-12

100-120
100
90
80

12-18

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

Menentukan status gizi & kebutuhan kalori

Anak A : BB : 10 kg ( < P3)
24 bln
TB : 85 cm (= P25)
Status gizi :
BB/U = 10/12.6 ( 79%)
TB/U = 85/87 ( 97.5%)
BB/TB = 10/12.2 ( 82%)
=st gizi KURANG

Kebutuhan kalori :
12.2 x 100 kal = 1220 kalori

Menentukan status gizi & kebutuhan kalori

Anak B : BB : 10 kg ( < P3)
TB : 78 cm (= P25)
Status gizi :
BB/U = 10/12.6 (79%)
TB/U = 78/87 (89%)
BB/TB = 10/10.8 (92.6%)
= st gizi normal

Kebutuhan kalori :
10.8 x 100 kal = 1080 kalori

Pediatric nutrition care activities

1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring

Route of delivery

Enteral Nutrition
GI function

Standard
Nutrients

Peripheral PN

Central PN

Specialty
Formulas
GI Function returns

Nutrient Tolerance

Adequate
Progress to
Oral feeding

Long-term or
Fluid restriction

Short-term

Compromised

Normal

Parenteral Nutrition

Yes

No

Adequate progress
Inadequate
PN supplementation To more complex diet
& oral feeding tolerated
Progress to total
Enteral feedings

JPEN 2002:26(1);8SA

Pediatric nutrition care activities

1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring

Guidelines
How to choose Type of Nutrition
Patient Factors

Age (stage of
development)
Diagnosis associated
nutritional problems
Nutritional
requirements
Gastrointestinal
function

Nutritional Factors

Osmolality (isotonic
150-250mOsm)
Renal solute load
Caloric density and
viscosity
Nutrient composition:
type & amount of CHO,
Fat and protein
Product availability and
cost

Feeding the Infant / the Child

What are the options?
Breast feeding

The WHO recommends exclusive breast

feeding at least for 6 months.

Formula feeding

Complementary Feeding
Family foods

Pediatric nutrition care activities

1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring n Evaluation

Monitoring results of nutrition care

Food acceptability, tolerance, efficacy
Parameter :
Acceptability : like or dislike
Tolerance : look for adverse food reaction
Efficacy : growth monitoring

Assessment of sufficient breast feeding

Weight pattern - consistent weight gain
trimester 1 : 25-30 g/d
trimester 2 : 20 g/d
trimester 3 : 15 g/d
trimester 4 : 10 g/d

= 200 g/w = 750-900 g/mo

= 150 g/w = 600 g/mo
= 100 g/w = 400 g/mo
= 50-75 g/w = 200-300 g/mon

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 Feeding Practice

Depend on :
Maturation of neuromotoric system
Maturation of gastrointestinal system
Maturation of immunological system

Example
AH, 16 months old boy, weight 5 kg (4.2 kg < 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
0-3 mos

Daily weight
gain (g)
25-30

4-6 mos

20

7-9 mos

15

10-12 mos

8-10

13-36 mos

At 16 months the
weight should be:

3 x 750 g = 2250 g
3 x 600 g = 1800 g
3 x 450 g = 1350 g
3 x 250 g = 750 g
4 x 160 g = 640 g
6790 g
BW 3000 g
9790 g

Nutrition Care

Nutritional assessment

Specific growth chart (-) CDC/NCHS 2000

IBW for 65 cm 7.4 kg
Nutritional status 5/7.4 67.5% (severe
malnutrition)
Based on daily weight gain failure to thrive

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 2030 oz 600-900 mL/24 hours

Monitoring

Diarrhea & vomitus (-)

Growth (BW, BL)

Nutrition Care Result

AH, boy, 16 months
W : 3.6 kg
L : 65 cm
HA : 5 mos
IBW : 7.4 kg

9 months
later

25 months
W : 10.7 kg
L
: 77 cm
HA : 12 mos
IBW : 10 kg

Refeeding Syndrome
Metabolic complication associated with giving
nutritional 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.
Control by giving formula meeting 50-75% of
need and advance gradually and monitoring
electrolytes