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

2. 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

3. 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

4. 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:
Acute < 3 months
Chronic > 3 months

5. 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 x Ht – 617.6
16.25 x kg x ht – 413.5
3-10 yrs
22.7 x kg +495
22.5 x kg + 499
19.6 x kg x ht
16.97 x kg x ht
10-18 yrs
17.5 x kg + 651
12.2 x kg + 746
16.25 x kg x ht
8.365 x kg x ht +200
>18 yrs
Mifflin St. Jeor or Harris Benedict

6. 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
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
Burns

7. 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 = 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

8. Average Growth Velocity
Weight (grams)
Height (cm/week)
HC (cm/week)
Premie <2 kg
15-20 g/kg/day
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
4-8 months
10-16 g/day
0.37 – 0.47
8-12 months
6-11 g/day
0.28 – 0.37
12-16 months
5-9 g/day
16-20 months
4-9 g/day
0.21 – 0.29
20-24 months
0.02 – 0.04
2-10 years
Age 2 through puberty average gain of 2-3 kg and 5-8 cm per year

9. 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: 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 ( is goal)

10. 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

11. 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

12. 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!

13. 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.

14. 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.

15. 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!

16. 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 = g/protein/day
18 kg x g/kg/day = g/Pro/day

17. 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
= 905 kcals/day x = 1177 – 1358kcals/day

18. 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 = 1583 kcals per day gain.