Nutritional Support Pediatric Gastrointestinal Disorders

Johana Titus Deparrment of Nutrition FMUI-CM Hospital

References
Nutrition in pediatrics 4th ed., basic Science Clinical Applications 2008 ---Duggan. Watkins.Walkers
Krauses Food & Nutrition Therapy 12th ed., 2008 ---- L.K. Mahan & S. EscottStump
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Nutritional problem on Infant/child

Differences of GI development Gastrointestinal disorders (malabsorption)

Inadequate Nutritional Intake Nutritional Support !!

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Developmental Differences
Control swallowing < 6 weeks

Stomach capacity < very small and peristalsis improves with age Relaxed cardiac sphincter < Infants have a deficiency of several enzymes needed for digestion(until 4-6 months of age) abdominal distention and gas occur

Gastrointestinal Disorders
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Sucking is a primitive reflex that occurs when lips or cheeks are stroked Voluntary control over swallowing not until 6 weeks Stomach capacity of infant very small and peristalsis improves with age Relaxed cardiac sphincter These explain infants need for small, frequent feedings, regurgitation and frequent liquid stools Infants have a deficiency of several enzymes needed for digestion(until 4-6 months of age) Amylase- digests carbohydrates Lipase- enhances fat absorption Trypsin- catabolizes protein
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Sucking is a primitive reflex that occurs when lips or cheeks are stroked Voluntary control over swallowing not until 6 weeks Stomach capacity of infant very small and peristalsis improves with age Relaxed cardiac sphincter These explain infants need for small, frequent feedings, regurgitation and frequent liquid stools Infants have a deficiency of several enzymes needed for digestion(until 4-6 months of age) Amylase- digests carbohydrates Lipase- enhances fat absorption Trypsin- catabolizes protein
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Nutritional Support Goals

Healthy child : Optimum Growth & Development : Prevent Failure To Thrive
: Prevent hospital malnutrition
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Out-clinic patient
In-clinic patient

Nutrition Care
1. Clinical and Nutritional Status Assessment 2. Nutritional requirement Calory Carbohydrate, protein, fat Vitamin, mineral 3. Determine : - Formula - Route of Delivery 4. Monitoring
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Infant Feeding Practice

Age (months) 0-6 6 - 12 > 12 Feeding Breast feeding/ formula milk

BF/Formula milk semisolid & solid foods BF/Formula milk solid foods /family food
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Route of Delivery

Oral Feeding

Enteral Nutrition
Parenteral Nutrion

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Nutritional support route

Oral Nutrition Supplementation (ONS) Enteral : Naso Gastric Tube (NGT) Transpylorik (Naso duodenal-/Naso Jejunal -Tube) Percutaneous Endogastrotomy (PEG) Percutaneoues Endojejunostomy(PEJ) Bolus or intermitent or continues
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Naso- gastric, Duodenal, transpiloric tube

Naso Gastric Tube

Nasoduodenal tube/Transpilorik

Percutaneous Endo Gastrotomy

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Enteral formula for pediatric

Hospital standar formula (milk, low lactose, or free lactose) Commercial formula Polimeric Oligomeric Elemental Specific formula
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PediatricS foods
Brest Milk Special formula Formula milk Low lactose/Free Starting formula lactose Follow on formula Soy formula Growing up formula Hypo Liquid food osmoler/hypoaller Semi solid/solid genic formula food

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Infant 0 6 month of age

Non dehydration, mild-moderate dehydration Breast feeding Continue breast feeding Oral Rehydration Solution (ORS) Formula Milk Continue Formula Milk ORS Diluted formula milk has no benefit
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Infant 0-6 months on formula milk

Severe dehydration
IVFD Continue Formula Milk ORS Diluted formula milk has no benefit Free lactose formula

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Infant 6-12 months of age

Non dehydration, mild-moderate dehydration Continue breast feeding/formula milk ORS Semi solid/solid food should be continued Food high in simple sugar should be avoided Highly specific diet such as BRAT (bananas, rice,apple sauce & toast) commonly recommended
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Infant 6-12 months

Severe dehydration IVFD Continue breast milk/formula free lactose milk & ORS Semi solid/solid food should be continued Food high in simple sugar should be avoided Highly specific diet such as BRAT (bananas, rice,apple sauce & toast) commonly recommended
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Children more than1 year

Continue breast milk/formula milk ORS Solid food should be continued Food high in simple sugar should be avoided Highly specific diet such as BRAT (bananas, rice,apple sauce & toast) commonly recommended

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Nutrisi Parenteral
Macro- micro nutrien
Protein.. Carbohydrate.. Fat Vitamin.. Mineral

NP
Amino acid Dextrose Fat Emulsion Multivitamin IV Electrolite &Trace Elements

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Type of parenteral
central or peripheral vein
central Length > 2 weeks Peripheral < 2weeks

Osmolality (mosm/L) > 960

Fluid retriction +

600-800
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Gastrointestinal disorders
Colic Constipation Vomiting, Gastroentritis ; Diarhea Pyroric stenosis Hernias NEC GERD Gastritis IBD, Crohn Disesis Ulceratif Colitis Appendictcities Hepatitis Cirrhosis

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Colic
Feeding disorder characterized by paroxysmal abdominal pain of intestinal origin and severe crying Sx: loud crying for several hours, face flushed, drawing up of legs and clenches hands, abdomen distended and firm Usually occurs under age of 3 mo Proposed causes: feeding too fast or swallowing large amounts of air
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Management for alleviating colic

Thorough history of diet and daily schedule Assess episodes of colic Provide rhythmic movement Alternate positions Reduce environmental stimuli Provide tactile stimuli Alter Intake
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Constipation
Decrease in the frequency or passage of stools, the formation of hard, dry stool, or the oozing of stool past an impaction Causes: Underlying disease or diet (frequent in Toddlers and Preschool) change from formula to cows milk Remove constipating foods (bananas, rice, cheese) Psychological factors and toilet training

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Constipation
Treatments: Fluids & dietary intervention are the first line of therapy High fiber diets Lactose intolerance: Lactose free diet Toilet training
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Source of dietary fibers

Fruits : apple, apricot, blueberries, dates, pear, raisin, strawberry, avocado
Vegetables: beans, broccoli, etc Cereals, jelly, pudding
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Vomiting
1. Small frequent feeding 2. Food choice according to childs age - Breast Feeding (BF) - Formula milk (FM) - Semi solid/ solid food 3. Nasogastric tube sometime is needed - Formula milk - Liquid food
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Gastroenteritis
Inflammation of the stomach and intestines that may be accompanied by vomiting and diarrhea. Cause may be viral, bacterial or parasitic or a chronic problem Under age of 5 average 2 episodes per year Infants and young children may become dehydrated quickly. At risk for hypovolemic shock and electrolyte imbalance
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Gastroenteritis
Symptoms may be mild, moderate or severe Mild: slight increase in number and more liquid Moderate: severe loose or watery stools, with irritability, anorexia, nausea and vomiting Severe: continuous watery stools, symptoms of electrolyte and fluid imbalance, irritable and
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Gastroenteritis
Interventions: Monitor vital signs/ assess LOC, fontanels, skin turgor, capillary refill Observe stool for number, amount, color, consistency Test for occult blood, provide stool for culture and ovum/parasite Oral rehydration fluids and IV fluids Prevent skin breakdown
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Gastroenteritis
Notification of Health Care Provider if: Diarrhea or vomiting is increasing in frequency or amount Diarrhea does not improve after 24 hours Vomiting continues for more than 24 hours Stool or vomit material contains blood

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Management Acute Diarrhea

Dietary management depend on the age & diet history of the patient Infant feeding practice 0 6 month : Breast feeding/ formula milk 6 12 months : BF/FM, semisolid & solid foods > 12 months : solid foods /family food

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Chronic (intractable) diarrhea (1)

Infant
Nutritional screening to identify

Nutrition risk
Nutritional assessment

Nutrition care plan

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Infant with intractable diarrhea are at nutrition risk & should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. Bayi dengan diare keras beresiko gizi & nutrisi harus menjalani pemeriksaan untuk mengidentifikasi mereka yang membutuhkan penilaian gizi formal dengan pengembangan rencana perawatan gizi.
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Chronic (intractable) diarrhea (2)

children
Unable maintained nutritional status : Oral intake Enteral Nutrition Parenteral Nutrition Carbohydrate intolerant : EN formula with high fat, high MCT,
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Diarrhea in severe malnutrition child

Persistent diarrhea that occurs everyday for at least 14 day Feeding guidelines are the same as for severe malnutrition BF should be continued as often and for long as the child wants Milk intolerance (rare) replace cow milk with commercial lactose free formula
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Formula diet for severe malnutrition

Ingredient F-75 Dried skim milk Sugar Cereal flour Vegetable oil Mineral mix Vitamin mix Water to make 25 g 70 g 35 g 27 g 20 ml 140 mg 1000 ml Amount F-100 80 g 50 g 60 g 20 ml 140 mg 1000 ml
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GER-GERD
Return of gastric contents into esophagus due to relaxation of the lower esophageal sphincter Common in premature infants and children with neuromuscular disorders Usually resolved without surgical intervention by 12-18 months

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GER-GERD
Vomiting, dysphagia, esophagitis weight loss, Poor weight gain Frequent respiratory problems, including pneumonia, reactive airway disease are possible if aspiration

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GERD
Diagnosis: Upper GI, Upper GI endoscopy, pH probe Treatment: Feeding modifications Add cereal to formula ( 1-6 tsp per ounce of formula) Avoid fatty foods, orange juice Medications: cholinergics, antacids, histamine antagonists Position of child during feedings

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GERD Dietary management

Dietary intervention
Thickening feeds Small frequent feeding

Positioning Drugs Surgery

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Maintaining the Position of an Infant Diagnosed with GER

30 degree elevation of the head of the bed can be maintained by using a wedge or extra blanket UNDER the mattress A commercial or home-made harness can be used to ensure the infant is safely secured in the head elevated prone position.
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GERD Dietary management

14 RCT : use of thickened formula vs Standard formula Outcomes: 1.Episode of regurgitation & Vomiting 2.Episode of irritability 3. Crying & dysphagia 4.Regurgitation symptoms (irritability, coughing,choking, night awaking)
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Inflammatory Bowel Disease

Different than Irritable Bowel Syndrome Inflammatory involves faulty regulation of immune response of the intestinal mucosa (in genetically predisposed people) to triggers Two different disorders: Crohns Disease Ulcerative Colitis
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Crohns Disease
Chronic inflammatory process Occurs randomly throughout GI tract Ileum, colon, and rectum most common Develops fistulas between loops of bowel or nearby organs More common in whites and those of Jewish descent

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Ulcerative Colitis
Chronic recurrent disease of the colon and rectal mucosa Can involve entire length of bowel with varying degrees of inflammation, ulceration, hemorrhage and edema Develops before the age of 20 with peak onset at age 12 More prevalent in people of Jewish descent
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Ulcerative Colitis
Sx: Diarrhea Lower abdominal pain and cramps that occur before and during bowel movement but relieved by it Stool mixed with blood and mucus Weight loss, delayed growth, nutritional deficiencies and arthralgias often occur
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Diet Instruciton for Inflammatory Bowel Disease

Small frequent feedings Limit fiber Offer high calorie meals Liquid dietary supplements Watch for foods that cause problems and avoid in future Avoid strife at mealtime
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Treatment for Crohns Disease and UC

Pharmocolgy Antibiotics Anti-inflammatory Immuno-suppresive Anti-diarrheal Corticosteroids (oral or enema) Aminosalicylates Sulfasalizine Teaching Children/Parents About Sulfasalazine

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Celiac Disease
Gluten-sensitive enteropathy Malabsorption syndrome of gluten, a protein found in wheat,barley, rye, and oats Common in Caucasian children 1%-4& of children with Downs have Disease

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Symptoms of Celiac Disease

Occur after introduction of solids/glutens (first 2 years of life) Large bulky, greasy, foul smelling, frothy stools (streatorrhea) Vomiting Failure to grow If treatment delayed Delayed dentition Protein deficiency Protruding abdomen/ wasting muscles Irritability
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Treatment of Celiac Disease

Gluten free diet Vitamin supplements Growth improves steadily with height and weight returning to normal within a year

07/05/2013

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