Principle of Pediatric Nutrition Care For Consultant

4/28/2010
Patient care
Pediatric Nutrition Care
as a strategy to prevent hospital
malnutrition
Damayanti Rusli Sjarif
Div Pediatric Nutrition and Metabolic Diseases

Dept of Child
l Health
l - University of Indonesia
School of Medicine - Dr Cipto Mangunkusumo
General Hospital -Jakarta
Medical 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
Damayanti Rusli Sjarif 2010
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
4/28/2010
Hippocrates c. 460 - 377 B.C

If
If we could give every
individual the right amount of
nourishment and exercise, not
too little and not too much, we
would have found the safest
way to health."
Problem ?
Hospital
malnutrition:
p
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%
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
4/28/2010
How to solve the problem ?
Factors that cause malnutrition

Nutrition care ?
Unawareness of malnutrition by
physician
Inadequate skill, knowledge and
management strategies of nutrition
py
therapy
High cost of nutrition support
Complication associated with
nutrition support, etc
To organize
nutrition care
team
Physician
Nurse
Dietitian
Pharmacist
To perform nutrition
care activities
Nutritional
assessment
Nutritional
requirements
i
t
Routes of delivery
Formula/IVF selection
Monitoring
What medical conditions/issues should I be

aware of when assessing nutritional status?
Nutritional assessment
Som
t ons (e.g.,
( .g., pu
monary pro
ms) can
Some con
conditions
pulmonary
problems)
increase energy needs.
Other conditions (e.g., renal disorders) may change
requirements of specific nutrients.
Appetite may be decreased by symptoms
associated with certain conditions.
Medications can alter a childs nutritional status as
ll
well.
Some medications may change nutrient needs or
may interfere with absorption and/or metabolism,
while other medications can affect appetite
4/28/2010
Levels of assessment of
nutritional status in clinic
Inadequate intake
Malabsorption
Increased requirements
Increased excretion
Increased destruction
Dietary assessment
Laboratory assessment
Anthropometric
assessment
Clinical assessment
Nutritional status interpretation

If all 4 modalities can be
performed more accurate
diagnosis can be determined
Depletion of reserves
Physiologic and metabolic

alterations
The fact : very difficult

clinically + simple anthropometry
Wasting or decreased
growth
Spesific anatomic lesions

Assessment clinical & anthropometrics

for individual nutritional status
Z-score classification
Obese Weight-for-height z-score (WHZ) <+2.00
Overweight Weight-for-height z-score (WHZ) <+1.00
Wasting Weight-for-height z-score (WHZ) <-2.00
Moderate WHZ -3.00 to -2.01
Severe WHZ <-3.00
Weight for height (BMI for Age - CDC 2000) parameter
overweight & obesity

<5
5th percentile underweight
5th - <85th percentile normal variation
85th - <95th percentile overweight
95th percentile obese
Percent ideal body weight (Olsen et al, 2003)
4/28/2010
Percent of Ideal Body Weight (IBW)

Percentage of the childs actual weight compared to
ideal weight for actual height (Goldbloom
(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%
4/28/2010
IBW is used as a clinical weight goal

in the nutrition rehabilitation
Nutritional Status :
Actual weight/IBW (%)
Classification of % of IBW (Waterlow, 1972)
120%
obesity
110 -120%
overweight
90-110%
normal
80-90%
mild malnutrition
70-80%
moderate malnutrition
70%
severe malnutrition.
Calculation of energy requirement
Nutritional requirement
Indirect calorimetry
the
h most accurate
method
Harris-Benedict
equation (REE)
WHO (REE)
Schofield equation
(REE)
RDA simplest
method
Age
((year))
RDA (kcal/kg
Wt)
W )
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
4/28/2010
Calculation of Catch-Up Growth requirement

in the Pediatrics
Nutritional status & requirement
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
Determining Calorie and Protein

Needs in Critically Ill Children
gy needs (BEE)
(
)
Estimate basal energy
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
T t l Protein
P t i = Protein
P t i RDAs
RDA X Stress
St
F t
Total
Factor
Continue to evaluate and adjust recommendations based on nutrition
monitoring.
A , 2 y old boy
y
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
Table 2. Determining Stress Factor

Clinical Condition
Maintenance minus stress
Fever
Routine/elective surgery,
minor sepsis
Cardiac failure
Major surgery
Sepsis
Catch-up Growth
Trauma or head injury
Stress Factor
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
4/28/2010
Nutrition Support
Route
R
t off delivery
d li
and
d ttype off
food/formula/IV fluids
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
f din )
feeding)
Nutrients into venous system (total parenteral
nutrition - TPN)
Benefits of enteral nutrition in

pediatric patients
Physiological presentation of nutrients
Trophic effects on the GI tract
Stimulation and maintenance of the gut mucosa
Reduced metabolic and infectious complications
Improved hepatic function versus parenteral
nutrition
Simplified
fluid and electrolyte
p
y management
g
More "complete" nutrition May reduce the incidence
of pathogen entry or bacterial translocation into
the peritoneal cavity or circulation
Less expensive
4/28/2010
When children need tube feeding &

how to choose route of delivery ?
Children with acute conditions
and increased requirements
requirements.
E.g. Burns Severe trauma,
Major surgery and Sepsis.
Children unable to eat due to
mental/physical disability. E.g.
mental retardation, Cerebral
palsy and congenital anomalies.
Children with chronic illnesses
who require long term
nutritional support. E.g. Cancer,
Inflammatory bowel disease,
Cystic fibrosis and congenital
heart disease.
Feeding routes of delivery
Nasogastric (NG) and

O
t i (OG) - usually
ll for
f
Orogastric
short term (< 3 months)
Gastrostomy (Surgical or
Percutaneous Endoscopic
Gastrostomy)- for long term
Transpyloric Feedings
those who are at high risk for

aspiration;
in pancreatitis patients best
to feed nasojejunally beyond
the ligament of Treitz
Gastrostomy
4/28/2010
Continuous versus Intermittent Feedings

Continuous Feedings
Intermittent Tube Feedings
Better tolerated than intermittent or

bolus delivery particularly in patients with
limited absorptive surface area results in
less reflux, dumping and diarrhea.
Better tolerated in critically ill children.
Recommended for delivery of nutrients
directly into the small bowel.
More p
physiological
y
g
and practical
p
for
home enteral feedings.
Indicated for children who are more
medically stable, have achieved full
tolerance of continuous feedings and
are ready to transition to a more
intermittent schedule.
Allows for greater patient mobility,
more appropriate
i t f
for b
both
th th
the rehab
h b
and the home setting.
Promotes cyclic bursts of GI
hormones such as gastrin in preterm
infants, thus promoting GI
development and maturation.
Enteral formula categories
Polymeric
Type
Polymeric
standard
caloric dense
Indication
composed of intact
macronutrients for
Normal GI function
Oligomeric (Elemental)
Predigested nutrients
Usually contains glucose polymer
partialy or extensively
hydrolyzed ,protein, MCT
(P
(Pepti-unior,
,Pregestimil
P
l,
Neocate)
consisting of a singular
macronutrient
(Fantomalt , Nutricom
Caloric)
Modular
Standard
Infant : breast-milk, standard infant-formula
(20 kcal/oz)
Children : cow milk (20 kcal/oz)
Calorie dense
Infant : premature formula (24 kcal/oz
N
l SGM-BBLR,
GM BBLR etc),
) post-discharge
d h
Nenatal,
formula (22 kcal/oz) Neosure
Children : ( Pediasure, Nutricia Complete,
Nutren Junior, Vitaplus, etc (1 kcal/ ml)
10
4/28/2010
Monitoring
Guidelines for Formula Selection

P i
Patient
Factors
F
F
Formula
l Factors
F
Osmolality (isotonic 150Age

250mOsm)
Diagnosis
Renal solute load
Associated nutritional
Caloric density and viscosity
problems
N t i t composition:
Nutrient
iti
ttype &
Nutritional requirements
amount of CHO, Fat and
Gastrointestinal
protein
function
Product availability and cost
Tolerance of formula
Diarrhea
Nausea
Cramping
Constipation
p
aspiration
Hydration status
Adequacy of nutrition support
Parenteral Nutrition
Parenteral Nutrition
Intravenous nutrition that provides energy

and essential nutrients and promotes
protein synthesis
Total parenteral nutrition (TPN) is the most
commonly used term
Used to be called hyperalimentation
Purpose:
To protect individuals from the effects of

starvation by providing all essential nutrients
intravenously
Peripheral (PPN)
Short term parenteral

support (up to 2 weeks)
Hypertonic solutions (> 900
mOsm/L) may cause phlebitis;
thus must limit PPN solutions
osmolarity
Energy and protein provided
by PPN are limited because
d t
d amino
i acids
id
dextrose
and
contribute significantly to
osmolarity
Electrolytes also contribute
to osmolarity
Central or Total (TPN)
For long term use,

catheters are surgically
placed
May have surgically
implanted catheters
which lie beneath the skin
and are accessed by
special needle to
decrease risk of infection
Can add solution of higher
osmolarity into central
vein (larger lumen)
11
4/28/2010
Pediatric parenteral amino acid

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

Aminosteril (Fresenius)]
Monitoring Indicators
Monitoring results of nutrition care
Body weight
Intake/output
Bowel function
Blood glucose
Serum electrolytes
Blood urea
nitrogen, creatinine
S
rum phosphorus
Serum
Liver function tests
Serum calcium and
magnesium
Serum transferrin
24 hour urinary
nitrogen
g
Serum albumin
Food acceptability,
tolerance,
acceptability tolerance
efficacy
Parameter
Acceptability : like or dislike

T l
kf
d
f d
Tolerance
: llook
for adverse
food
reactions
Efficacy : growth monitoring
12
4/28/2010
Food Safety Guidelines for

Child Care Programs
Food Purchasing
Food Storage
Preparing Meals
Serving Meals
Dish Washing
Handling Garbage
13
4/28/2010
Food Purchasing
meats
Use inspected meats.
Use pasteurized milk.
Use pasteurized, 100-percent juices.
Do not buy or use leaking or bulging
cans of food.
food
Food Storage
Put away frozen and cold foods promptly after purchasing.
Rinse fruits and vegetables before use. Even prepackaged,
prewashed foods like lettuce, spinach, and carrots can still
carry harmful bacteria and need to be washed.
Store foods in covered containers in the refrigerator.
Place thermometers in a visible location in refrigerators and
freezers. Check the temperature frequently.
Keep refrigerator temperature between 32 degrees 40
degrees F.
Keep
K p freezer
f
temperature
t mp
t
att 0 degrees
d
s F or less.
l ss
Clean the refrigerator, freezer, and dry food storage areas
frequently.
Store foods and cleaning supplies in separate cupboards.
Store cleaning supplies in a cupboard that is locked.
Preparing Meals
Serving Meals
Wash your hands often with soap and water.

Wash
and
and
W h and
d sanitize
iti counters
t
d tables
t bl before
b f
d after
ft use.
Wash and sanitize cutting boards and utensils before using and after each
use for different foods.
Use separate cutting boards and utensils for raw meats.
Wash and sanitize can openers after each use.
Put frozen meats into a pan before placing them in the refrigerator to
thaw. Never thaw meats on the kitchen counter.
Cook meats thoroughly. Use a food thermometer to be sure they are done.
Steaks and roasts: beef, veal, and lamb 145 degrees F
Ground pork, beef, veal, and lamb 160 degrees F
Whole poultry (take measurement in thigh) 165 degrees F
Fin fish 145 degrees F or until the flesh is opaque and separates
easily with a fork
Do not change diapers in areas where you prepare, store, and serve foods.
Keep pets in another room or outside when meals are being prepared and
served to children
p
y
Serve f
foods on a p
plate,, napkin
or bowl rather than directly
on the table.
Use serving utensils such as large spoons or tongs. Teach
children not to lick serving utensils.
Wear food service gloves or use bakery wrap when serving
foods that can't be picked up easily with utensils.
Discard cracked or chipped plates, cups, and bowls.
Give children clean utensils and napkins if these items are
dropped during meal service.
Store leftovers immediately after the meal. Discard all
leftovers on childrens plates; do not save them for later.
14
4/28/2010
Dish Washing
If
dishwasher
fad
shwasher iss used, the rrinse
nse temperature
should be 180 degrees F to sanitize dishes.
Follow these steps to wash and sanitize dishes
without a dishwasher:
Rinse or scrape dishes

Wash in hot sudsy water
Rinse in clear water
Sanitize dishes by submerging in a solution of 1 teaspoon
bleach per quart of water for one minute or in 170
degree F water for at least 30 seconds
Handling Garbage
childrenss
Throw out leftovers from children
plates. Do not save them for later
Cover garbage cans and use liners.
Empty garbage cans at the end of the
day,
y, or more
m
often
f n if
f full
fu
Air dry. Do not towel dry dishes

The Neutropenic Diet Guideline

( for cancer children)
Monitoring Growth
g
(
g and
Avoid raw vegetables
and fruit (Oranges
bananas are okay.)
Avoid take-out foods and fast foods and fountain
drinks.
Avoid aged cheese (blue, Roquefort, Brie).
Cook all produce to well done. Eggs must be hardboiled.
Avoid deli meats.
No raw nuts, nuts roasted in shell, or freshly
ground nutbutters from a healthfood store.
No well water
No yogurt
Use updated growth charts

M it trends
Monitor
t
d iin growth
th nott one value
l
using weight, height, head circumference
BMI.
Evaluate changes in percentiles
Malnutrition results in:
Decreased weight (acute) failure to
thrive, then height, then head
circumference (chronic).
15
4/28/2010
Weight faltering (Failure to thrive)

weight curve deviates downward across 2 major
percentile lines on the NCHS growth
Refeeding Syndrome
metabolic complication
associated with giving
p
g
g
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
16
4/28/2010
Practice Guidelines for Pediatric

nutrition care
Enteral feed
feeding
ng and parenteral nutrition
nutr t on 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
g avoided
Some medications may change nutrient needs or
may interfere with absorption and/or metabolism,
while other medications can affect appetite
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
Hospital Malnutrition in Pediatric Ward

RSCM 2009 (After Application of Pediatric
Nutrition Care Team)
Hospital Malnutrition 13.2%
13 2%
17

Principle of Pediatric Nutrition Care For Consultant

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4/28/2010

Div Pediatric Nutrition and Metabolic Diseases

Nutrition care goal ?

Healthy child optimal growth & development

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Why is nutrition important ?

Damayanti Rusli Sjarif 2010

Hippocrates c. 460 - 377 B.C

malnutrition during hospital admission

Hospitalized children up to 54% are malnourished,

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

How to solve the problem ?

Factors that cause malnutrition

Damayanti Rusli Sjarif 2010

What medical conditions/issues should I be

Damayanti Rusli Sjarif 2010

Nutritional status interpretation

Physiologic and metabolic

The fact : very difficult

Spesific anatomic lesions

Damayanti Rusli Sjarif 2010

Assessment clinical & anthropometrics

overweight & obesity

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Percent of Ideal Body Weight (IBW)

Damayanti Rusli Sjarif 2010

IBW is used as a clinical weight goal

Damayanti Rusli Sjarif 2010

Calculation of energy requirement

Damayanti Rusli Sjarif 2010

Calculation of Catch-Up Growth requirement

Nutritional status & requirement

Damayanti Rusli Sjarif 2010

Determining Calorie and Protein

Damayanti Rusli Sjarif 2010

Table 2. Determining Stress Factor

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

A variety of techniques available for use when a

Benefits of enteral nutrition in

Damayanti Rusli Sjarif 2010

When children need tube feeding &

Feeding routes of delivery

Nasogastric (NG) and

those who are at high risk for

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Continuous versus Intermittent Feedings

Intermittent Tube Feedings

Better tolerated than intermittent or

Damayanti Rusli Sjarif 2010

Damayanti Rusli Sjarif 2010

Enteral formula categories

Damayanti Rusli Sjarif 2010

Guidelines for Formula Selection