Div Pediatric Nutrition and Metabolic Diseases Dept of Child Health Pediatric Nutrition Care as a strategy to prevent hospital malnutrition Div Pediatric Nutrition and Metabolic Diseases Dept of Child Health

Child & Adolescent Child is not a miniature adult Pediatric stages development Infancy (<1 yr) Toddlerhood (1-2 yr) Preschool (3-5 yr) School age (6-9 yr) Adolescent (10-20 yr) Early adolescence (10-13 yr) Middle adolescence (14-16yr) Late adolescence (17-20 yr) Child is not a miniature adult Specific for child  growth and development

Patient care Nutrition care  goal ? Medical care Nursing care Drugs or surgery Nursing care Intensive care ? Nutrition care  goal ? 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 living Maintenance of all body functions Vital to growth and development (infant , children & adolescent) Therapeutic benefits Healing Prevention

Problem ? Hospital malnutrition: malnutrition during hospital admission Hospitalized children up to 54% are malnourished, globally Pediatric Ward – RSCM (Ginting & Nasar, 2000) 53% of of them experiencing decreased BW hospitalized children was malnourished 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

Factors that cause malnutrition Nutrition care ? Unawareness of malnutrition by physician Inadequate skill, knowledge and management strategies of nutrition therapy High cost of nutrition support Complication associated with nutrition support, etc

How to solve the problem ? To organize nutrition care team Physician Nurse Dietitian Pharmacist To perform nutrition care activities Nutritional assessment Nutritional requirements Routes of delivery Formula/IVF selection Monitoring

Nutritional assessment

Levels of assessment of nutritional status in clinic Dietary assessment Laboratory assessment Anthropometric assessment Clinical assessment Inadequate intake Malabsorption Increased requirements Increased excretion Increased destruction  Depletion of reserves Physiologic and metabolic alterations Wasting or decreased growth Spesific anatomic lesions

Nutritional status interpretation If all 4 modalities can be performed  more accurate diagnosis can be determined The fact : very difficult  clinically + simple anthropometry

Assessment anthropometrics for individual nutritional status 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)

Body mass index for age percentiles {Weight(kg)/Height(m)2}

Assessment anthropometrics for individual nutritional status 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)

Standard Growth Chart The NCHS (2000) standards have been recommended for worldwide use by the WHO regardless of racial or ethnic origin Infants with a history of premature birth should have their chronological age corrected by gestational age until age 24 months for weight measurements, 40 months for length, and 18 months for head circumference

Percent of Ideal Body Weight (IBW) Percentage of the child’s actual weight compared to ideal weight for actual height (Goldbloom, 1997) Percent of IBW  the best index & reflect nutritional status better (McLaren & Read, 1972) 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%

Nutrition status as percentage of Ideal Weight Weight for Height  the best index & reflect nutritional status better (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  the most accurate method Harris-Benedict equation (BEE) Schofield equation (BEE) RDA  simplest method Age (year) RDA (kcal/kg Wt) 0-1 1-3 4-6 7-9 10-12 12-18 100-120 100 90 80 M : 60-70 F : 50-60 M : 50-60 F : 40-50

Calculation of Catch-Up Growth requirement in the Infant and Child 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. 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 Wt : 10 kg (< P3) Ht : 85 cm (=P25) Nutritional status W/H :10/12.2 (82%)  H  50th percentile age 21 mos → RDA 100 kcal/kg Requirement → 12.2 x 100 kcal/kg = 1220 kcal

Determining Calorie and Protein Needs in Critically Ill Children Estimate basal energy needs (BEE) 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 Factor Estimate patient's protein requirements Total Protein = Protein RDAs X Stress Factor Continue to evaluate and adjust recommendations based on nutrition monitoring.

Table 2. Determining Stress Factor Clinical Condition Stress Factor Maintenance minus stress Fever Routine/elective surgery, minor sepsis Cardiac failure Major surgery Sepsis Catch-up Growth Trauma or head injury 1..0 - 1.2 12% per degree > 37° C 1.1 - 1.3 1.25 - 1.5 1.2 - 1.4 1.4 - 1.5 1.5 - 2.0 1.5 - 1.7

Route of delivery and type of food/formula/IV fluids

Nutrition Support Nutritional supplement to oral diet A variety of techniques available for use when a patient is not able to meet his or her nutrient needs by normal ingestion of food Options: Nutritional supplement to oral diet Formula fed by tube into GI tract (enteral feeding) Nutrients into venous system (total parenteral nutrition - TPN)

What you should know about enteral feeding ? Benefit of enteral feeding compare to parenteral feeding When child need tube feeding How to choose route of delivery Nasogastric, orogastric, gastrostomy, transpyloric Continuous or intermittent feeding Types of enteral formula Polymeric, oligomeric (elemental), modular Guidelines of formula selection Patient factor or formula factor Monitoring  Efficiency & Complications

Feeding routes of delivery

Gastrostomy

What you should know about parenteral nutrition ? Indication of parenteral feeding Types of parenteral feeding Composition of parenteral nutrition for infant and children compared to adult Monitoring : Efficiency & Complications

Pediatric parenteral amino acid solution Cysteine, taurine, tyrosine, histidine are conditionally essential in neonates and infants Infant Primene 5% (Baxter) Aminosteril Infant (Fresenius) Pediatric Aminofusin Paed (Baxter) Aminosteril (Fresenius)]

Complication of nutritional support

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

Practice Guidelines for Pediatric Nutrition Care Detect actual or potential malnutrition at an early stage Patients considered malnourished or at risk if they have inadequate intake for  7 days or if they have loss  10% of their pre-illness body weight Prevent or slow malnutrition by giving nutrition counseling and diets Patients who cannot maintain adequate oral intake and are candidates for nutrition support should be considered for tube feeding first

Practice Guidelines for Pediatric nutrition care Enteral feeding and parenteral nutrition should be combined when enteral feeding alone is not possible Parenteral nutrition should be used alone when enteral feeding has failed or when enteral feeding is contraindicated Malnutrition should be corrected at a judicious rate and overfeeding avoided

Pediatric Nutrition Care Result 9 months later AH, boy, 16 months W 3.6 kg L 65 cm 25 months W 10.7 kgs L 77 cm

Recent data After performed nutrition care in the pediatric ward -RSCM during period 2003-2004  96.4% of mild-severe malnutrition patients experienced weight gain during hospitalized.

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