Nutritional Management

of Sick Children

dr. Afriyan Wahyudhi, SpA, MKes

 THE NUTRITIONAL VULNERABILITY OF INFANTS
AND CHILDREN

• Infants and children are more vulnerable to poor

nutrition than are adults  Low nutritional stores
 LOW NUTRITIONAL STORES

• Newborn infants (particularly preterm)

>> poor stores of fat and protein

• Smaller the child, the less the calorie reserve and the
shorter the period the child will be able to withstand
starvation
 HIGH NUTRITIONAL DEMANDS FOR
GROWTH
• Nourishment children require >> in infancy
• Rapid growth during this period
• At 4 months of age  30% used for growth
• 1 year of age this falls to 5%
• 3 years to 2%
• The risk of growth failure from restricted energy intake
is therefore greater in the first 6 months
• Recurrent of deficits in early childhood  cumulative
deficit in weight and height
RAPID NEURONAL DEVELOPMENT
Reference values for energy and protein requirements
 RAPID NEURONAL DEVELOPMENT
• The brain grows rapidly during the last trimester of
pregnancy and throughout the first 2 years of life
• The complexity of inter neuronal connections also
increases
• This appears to be sensitive to under nutrition
• Modest energy deprivation during periods of rapid brain
growth and differentiation
 increased risk of adverse neuro developmental
outcome
• Considers that at birth the brain accounts for
approximately two-thirds of basal metabolic rate, and at
1 year for about 50%
• Delayed development seen in children suffering from
protein-energy malnutrition due to inadequate food
intake
• Inadequate psychosocial stimulation may also
contribute
 The relative contribution to basal metabolic rate derived from brain, liver
and muscle changes with growth. Whereas the brain accounts for two-thirds
of the basal metabolic rate at birth, this falls to 25% in adults

Adapted from Halliday M A

Pediatrics 47(1) Suppl 2: 169
 Acute illness or surgery
• Acute illness or surgery  compromise child’s nutrition
• After a brief anabolic phase
catecholamine increased
 metabolic rate and energy requirement increased
• Urinary nitrogen losses may become so great that it is
impossible to achieve a positive nitrogen balance and
weight is lost
• After uncomplicated surgery this phase may last for a
week, but it can last several weeks after extensive
burns, complicated surgery or severe sepsis
• Thereafter, previously lost tissue is replaced and a
positive energy and nitrogen balance can be achieved
• Infants may not show catch-up growth unless their
energy intake is as high as 150-200 kcal/kg per day.
 The principles for feeding sick infants
and young children
• continue breastfeeding
• do not withhold food
• give frequent small feeds, every 2–3 hours
• coax, encourage, and be patient
• feed by nasogastric tube if the child is severely anorexic
• promote catch-up growth after the appetite returns
 The food provided should be:

• palatable (to the child)

• easily eaten (soft or liquid consistency)
• easily digested
• nutritious, and rich in energy and nutrients
• The basic principle of nutritional management is to
provide a diet with sufficient energy-producing foods and
high-quality proteins
• Foods with a high oil or fat content are recommended
• Up to 30–40% of the total calories can be given as fat
• Feeding at frequent intervals is necessary to achieve
high energy intakes
• Provide multivitamin and mineral supplements
• The child should be encouraged to eat relatively small
amounts frequently
• Young children are left to feed by themselves, or have to
compete with siblings for food, not get enough to eat
• A blocked nose, with dry or thick mucus, may interfere
with feeding
• Put drops of salted water or saline into the nose with a
moistened wick to help soften the mucus.
• In a minority of children who are unable to eat for a
number of days (e.g. Due impaired consciousness in
meningitis or respiratory distress in severe pneumonia)
 nasogastric tube.
• Risk of aspiration can be reduced if small volumes are
given frequently
• To supplement the child’s nutritional management in the
hospital, feeding should be increased during
convalescence to make up for any lost weight
• Mother or carer should offer food to the child more
frequently than normal (at least one additional meal a
day) after the child’s appetite increases.
• To supplement the child’s nutritional management in the
hospital, feeding should be increased during
convalescence to make up for any lost weight
• Mother or carer should offer food to the child more
frequently than normal (at least one additional meal a
day) after the child’s appetite increases.
 FLUID MANAGEMENT

The total daily fluid requirement of a child is calculated with the

following formula:
• 100 ml/kg for the first 10 kg, then 50 ml/kg for the next 10
kg, thereafter 25 ml/kg for each subsequent kg
• For example, an 8 kg baby receives 8 x 100 ml = 800 ml per
day, a 15 kg child (10 x 100) + (5 x 50) = 1250 ml per day
• Give the sick child more than the above amounts if there is
fever (increase by 10% for every 1 °C of fever).
 MONITORING FLUID INTAKE

• Pay careful attention to maintaining adequate hydration

in very sick children, who may have had no oral fluid
intake for some time
• Fluids should preferably be given orally (by mouth or
nasogastric tube)
• If fluids need to be given intravenously, it is important to
monitor closely any infusion of IV fluid given to a sick
child because of the risk of fluid overload leading to
heart failure or cerebral oedema
• If it is impossible to monitor the IV fluid infusion closely,
then the IV route should be used only for the
management of severe dehydration, septic shock, the
delivery of IV antibiotics, and in children in whom oral
fluids are contraindicated (such as in perforation of the
intestine or other surgical abdominal problems)
• Possible IV maintenance fluids include half-normal saline
plus 5% glucose
• Do not give 5% glucose alone for extended periods as
this can lead to hyponatraemia