Pediatric Patients Joanna Cummings, MS RD Lao-American Nutrition Institute Vientiane, Lao PDR

Pediatric Malnutrition Indicators Indicators (< 2 years old) Indicators (>2 years old) # of Data points (value) Weight for Length (W/L) Body Mass Index (BMI) One (z score) Length Height MUAC (for 6 month-2 yr olds) MUAC (for 2-6 yr olds) Growth velocity Weight loss Two (% norm/usual) Decline in W/L z score Decline in BMI z score Two (difference) Dietary intake Two )% estimate) Illness- related malnutrition is associated with an acute incident (ie, trauma, burns, infection) or a chronic medical condition (eg, cancer, cystic fibrosis, inflammatory bowel disease, chronic renal disease, congenital heart disease). Whereas nonillness- related malnutrition has only 1 mechanism—decreased dietary intake (ie, starvation)—illness-related malnutrition has several possible mechanisms: decreased dietary intake, increased nutrient requirements, increased nutrient losses, and altered utilization of nutrients. Children with illness-related malnutrition may show signs of fat and muscle wasting, but depending on the etiology, a child with illness-related malnutrition can also appear proportionate. For example, sometimes both height and weight are affected by malabsorption, resulting in chronic malnutrition (ie, failure to grow and failure to gain weight). These children appear proportional, but they often show signs of developmental delay. Additionally, children who have a high body mass index (BMI) can be diagnosed with undernutrition if they experience an acute injury resulting in hypermetabolism. Increased nutrient requirements compounded by decreased nutrient intake in the setting of an acute injury can result in a dramatic weight loss, particularly muscle loss. Notes: Evaluate all age-appropriate indicators Need only one indicator to diagnose malnutrition Use the most severe indicator for the diagnosis

Cut offs for indicators that use one data point Mild Malnutrition Moderate Malnutrition Severe Malnutrition Reference/Standard Weight for Length (1 mo-2 yrs) -1 to -1.99 -2 to -2.99 -3 or below WHO 2006 BMI for age (2-20 yrs old) CDC 2000 MUAC (6 mo – 60 mos) WHO 2007 Height or Length No data BMI: body mass index MUAC: Mid-upper arm circumference

Cut offs for indicators which require 2 or more data points Mild Malnutrition Moderate Malnutrition Severe Malnutrition Growth velocity (<2 yrs of age) <75% of norm for expected wt gain* <50% of norm* <25% of norm* Weight loss (2-20 yrs of age) 5% of usual body weight 7.5% of usual body weight 10% of usual body weight Decline in weight for length/height z score Decrease of 1 z score Decrease of 2 z scores Decrease of 3 z scores Inadequate nutrient intake 51-75% of estimated energy/protein needs 26-50% estimated energy/protein needs </= 25% of estimated protein/energy needs The new definition specifies malnutrition by duration (acute, <3 months; chronic, >3 months) and severity (mild, moderate, severe) resulting in 6 possible permutations: acute mild, acute moderate, acute severe, chronic mild, chronic moderate, and chronic severe. ype of malnutrition that is unique to pediatrics is “retarded development following protein-calorie malnutrition” (code E45 of the International Classification of Diseases, Tenth Revision). This diagnosis is reserved for children who are chronically stunted as a result of undernutrition. Stunting, per the World Health Organization (WHO) definition, is a height-for-age or length-for-age z score ≤−2.16,17 Children who are stunted following protein calorie malnutrition are often at risk of becoming overweight or obese.18-20 an etiology-related defi- nition could include a child with a chronic disease who is chronically undernourished and working on growth recovery but is admitted to the hospital with acute malnutrition in the setting of an infection, surgery, or a disease “flare-up.” *using WHO growth velocity standards: http://www.who.int/childgrowth/standards/w_velocity/en/ Acute < 3 months Chronic > 3 months

Resting Energy Expenditure (REE) Pediatric Comparative Standards Age Gender WHO Schofield 1-3 yrs Male Female 60.9 x kg -54 61 x kg – 51 0.17 x kg +15.16 x Ht – 617.6 16.25 x kg + 10.232 x ht – 413.5 3-10 yrs 22.7 x kg +495 22.5 x kg + 499 19.6 x kg + 1.303 x ht + 414.9 16.97 x kg + 1.1618 x ht + 371.2 10-18 yrs 17.5 x kg + 651 12.2 x kg + 746 16.25 x kg + 1.372 x ht + 515.5 8.365 x kg + 4.65 x ht +200 >18 yrs Mifflin St. Jeor or Harris Benedict

Stress Factors Activity/ Stress Factors Definition REE x 1.2-1.3 Weight maintenance; Fever- add 12% per degree >37C REE x 1.3 Well-nourished child on bedrest with mild-to moderate stress REE x 1.4-1.5 Starvation REE x 1.5 Normally active child with mild-moderate stress; an inactive child with severe stress (trauma, burn, cancer) or a child with minimal activity and malnutrition requiring catch up growth REE x 1.7 Active child requiring catch up growth; active child with severe stress REE x 1.5-2.0 Burns

Activity Factors Gender Sedentary Low Active Active Very Active Boys 1.0 1.13 1.26 1.42 Girls 1.16 1.31 1.56 Low active = 30-60 minutes daily moderate activity Active = 60 minutes daily moderate activity Very active = 120 minutes daily moderate activity; or 60 minutes moderate + 60 minutes vigorous activity

Average Growth Velocity Weight (grams) Height (cm/week) HC (cm/week) Premie <2 kg 15-20 g/kg/day 0.8-1.1 0.8-1 Premie >2 kg 20-30 g/day 0.8 – 1.1 0-4 months 23-35 g/day 0.8 – 0.93 0.38-0.48 4-8 months 10-16 g/day 0.37 – 0.47 0.16-0.2 8-12 months 6-11 g/day 0.28 – 0.37 0.08-0.11 12-16 months 5-9 g/day 0.24- 0.33 0.04-0.08 16-20 months 4-9 g/day 0.21 – 0.29 0.03-0.06 20-24 months 0.19- 0.26 0.02 – 0.04 2-10 years Age 2 through puberty average gain of 2-3 kg and 5-8 cm per year

Practice! Air noi was born on 17 May 2015 and weighed 2 kg. He was admitted to hospital on 15 September weighing 3.5 kg. His length was 55 cm and head circumference of 40 cm. What is his daily average weight gain since birth? What is his linear growth velocity? What his is HC growth velocity? Goal weight gain: 25-35 g /day – Current weight (3.5) – birth weight (2kg) – 1.5 kg gain. 1.5 / 1000 = 1500 g 120 days since birth 1500 g/ 120 days – 12.5 g/day =not meeting goal for growth. Linear growth: 55cm – 45 cm = 10 cm growth # of weeks since birth – 17.2 Length change since birth: 10 cm/ 17.2 weeks = 0.6 cm/week Slightly below goal for growth (0.8-0.9 is goal)

Growth Velocity Current weight – past weight = _____wt in kg Convert into grams (divide by 1000) Divide number of grams by number of days = gm/day

Linear Growth Velocity Current length – Birth length = ____cm Find number of weeks since birth = _____weeks Find the length change since birth: Length growth / weeks = _____cm/week

Head Circumference Current HC – Birth HC = ______growth in cm Find number of weeks since birth Divide HC growth by weeks = ______cm/week 40 cm current – 32 birth = 8 cm growth Weeks since birth = 17.2 HC change since birth per week = 0.5 cm/week Meets goal!

Catch-up Growth Requirements Peterson Equation Energy (kcal/day) = EER for age x Ideal weight for height (kg)/Actual wt (kg) Protein (g/day) = Protein at RDA for age x ideal weight for height / Actual wt (kg) OR IBW in kg x DRI for age Actual weight IBW = 50% percentile weight for height or weight corresponding to 50th percentile BMI for age.

Using the DRI table and growth chart, calculate the catch-up energy needs of a 14 month old girl. Weight is 7.8 kg and height is 76 cm. IBW in kg (9.2kg) x DRI for age (82 kcal/kg/day) / actual weight (7.8kg) = 96 kcal/kg/day for catch up growth.

Critically Ill Children Age Protein Recommendations 0-2 years 2-3 g/kg/day 2-13 years 1.5-2 g/kg/day 13-18 years 1.5 g/kg/day Energy is WHO or schofield Without stress factors!

Practice! Using your DRI table, estimate protein needs for a 13 month old girl weighing 12 kg. Calculate protein needs for a 5 year old boy who is post operative. His weight is 18 kg. 1.08 g/kg/day x 12 kg = 12.96 g/protein/day 18 kg x 1.5-2 g/kg/day = 27-36 g/Pro/day

Practice! Using DRI table (handout), estimate energy needs for a 1 year old girl weighing 12 kg. Using Schofield equation, estimate energy needs for a 5 year old boy who is post operative. His weight is 18 kg, height is 105 cm. 82 kcals/day x 12 kg = 984 kcal/day (19.59 x 18) + (1.303 x 105cm) +414.9 353 + 137 _414.9 = 905 kcals/day x 1.3-1.5 = 1177 – 1358kcals/day

Case Study 16 kg, normally active, 6 year old boy with history of moderate underweight is failing to catch-up his growth. Calculate REE using either WHO energy prediction equations and add stress factor to come up with Total Estimated Energy requirements (TEE). Use WHO calculation (b/c we do not have his height). PA coefficient is 1.5 (normally active) 900 x 1.5 – 1350 kcal/day Energy cost of 1 kilogram weight gain is ~7 kcal/kg, or about 7000 kcals(7kcal/g weight), to achieve 1 kg weight gain in 30 days 7000/30 = 233 kcal/day so he needs 1350 +233 = 1583 kcals per day gain.