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Annexure 1
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Annexure 2
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SAMPLE SIZE CALCULATION
Single Mean - Hypothesis testing - one population mean Standard Deviation = 4 Sample mean = 3.8 Population mean = 4.5 Alpha Error(%) = 5 Power (%) = 80 sided = 2 Effect Size = .175 Number needed (n)= 256 Alpha Error(%) Power(%) Sample Size(n) 70 315 1 80 382 90 487 70 201 5 80 256 90 343 70 153 10 80 201 90 279
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Annexure 3
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Paediatric Nutritional Assessment Data Sheet
Name Photo Date of Admission I.P. No. Date of Surgery Age/sex Date of Discharge Date of Birth Total no. of NSD: Address: Phone No. Contact I.D Informant : Reliability: Family History
Marriage of parents: Consanguineous / Non- Consanguineous
Family tree:
Mother‘s name : Period of gestation:
Date of delivery : Birth weight:
Type of delivery : Normal/ Instrumental/ Operation
Place of delivery: Hospital/ Home
Any problems during birth: Yes/ No
If Yes explain:
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Antenatal history:
Mother‘s age: Height : Weight:
Nutritional status of mother:
Socio-economic background:
Literacy level:
Medical History
Presenting Problems:
Milestones:
Past Medical History:
Diagnosis:
Ventilation: Yes/ No Total no. of days:
Subjective data:
Appetite: Bowel:
Hunger: Micturition:
Thirst: Sleep:
Menstrual History ( > 12 yr and ≤ 18 yr girls) :
Anthropometric Data
Weight _______kg ______expected ______percentile (Chart enclosed)
Height _______cm ______ expected ______percentile (Chart enclosed)
Weight/height __________percentile
BMI _____percentile (Chart enclosed)
Head circumference______cm ______percentile
Chest circumference______cm ______percentile
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Skinfold thickness _______mm ______percentile
Arm circumference_______cm ______percentile
Biochemical Data
Data
Normal value
Current Value
Interpretation
HAEMOGLOBIN 12-15gm/dl
WBC 4500-1100m3
RBS 80-120mg/dl
UREA 7-18mg/dl
CREATININE 0.6-1.2mg/dl
SODIUM 134-144mmol/dl
POTASSIUM 3.5-5mmol/dl
BILIRUBIN.T 0.2-1mg/dl
BILIRUBIN.D <0.4mg/dl
SGPT 40 I.U
SGOT 40 I.U
T.PROTEIN 6-7.8g/dl
ALBUMIN 3.2-5.6g/dl
GLOBULIN 2.3-3.5g/dl
ALK PO4 50-115I . U
Calcium 7.5-9.5mg/dl
Any other
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Clinical Data
Signs or symptoms of nutrient deficiencies or excess:
Dietary Data
Colostrum given: Yes/No
Any problems observed during weaning:
Food allergies, intolerances, or special dietary concerns? Yes/ No
Explain:
Meal pattern at home:
Vegetarian/ Non vegetarian
Wake up Time/Bed Time
Diet (at hospital) Food frequency
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Subjective Global Assessment A.1 – Weight change over past six month A: Weight gain or No change or Mild weight loss B: Moderate weight loss C: Severe weight loss
A.2 – Weight change in past 2 weeks A: Weight is increasing B: No change in weight C: Weight is decreasing
A.3 – Change in dietary intake A: No change or slight change for short duration B: Intake borderline and decreasing; Intake poor and increasing; Intake poor, no change based on prior intake C: Intake poor and decreasing A.4 – Duration and degree of change A: Less than 2 weeks, little or no change B: More than 2 weeks, mild to moderate suboptimal diet C: Unable to eat or starvation A.5 – Presence of GI symptoms A: Few or no symptoms intermittently B: Some symptoms for >2 weeks; severe symptoms that are improving C: Symptoms daily or frequently >2 weeks A.6 –Functional status A: No impairment in strength, stamina and full functional capacity; mild-moderate loss and improving B: Mild to moderate loss of strength, stamina / some loss of daily activity or severe loss but now improving C: Severe loss of function, stamina and strength A.7 – Disease state and co-morbidity A: No stress B: Low or moderate stress C: High stress B.1 – Subcutaneous loss of fat A: Little or no loss B: Mild-moderate in all areas; severe loss in some areas C: Severe loss in most areas
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B.2 – Muscle wasting A: Little or no loss B: Mild to moderate in all areas; severe loss in some areas C: Severe loss in most areas B.3 – Edema A: Little or no edema B: Mild to moderate edema C: Severe edema
B.4 – Ascites A: No ascites or only on imaging B: Mild to moderate ascites or improving clinically C: Severe ascites or progressive ascites
Categories Nutritional Status Scores
A Well Nourished 0-11
B Moderately Undernourished 12-22
C Severely Undernourished 23-33
Estimated calorie intake from 24- hr recall
____________kcal/day ________________kcal/kg
___________g protein _____________protein/kg _____% kcals
_______________g fat _____________% calories
______g carbohydrate _____________% calories
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Rx:
Energy:
Protein:
Carbohydrate:
Fat:
Fluid:
Salt:
Fibre:
Oil:
Plan (Oral/ EN) as indicated:
Follow up:
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Annexure 4
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FLUID CALCULATION AND MICRONUTRIENT RDA
Holiday and Segar formula for fluid calculation
Upto 10 kg 100ml/kg
10- 20 kg 1000 ml + 50 ml/kg above 10 kg
Above 20 kg 1500 ml + 20 ml/kg above 20 kg
Micronutrient RDA
Vitamin A
Vitamin D
Vitamin E
Vitamin C
1500 IU/day
400 IU/day
5-15 IU/day
40mg/day
Vitamin B complex
Thiamine (B1)
Riboflavin (B2)
Pyridoxine (B6 )
Niacin (B3 )
Folic Acid (B11)
Cyanocobalamine (B12)
0.5- 1.5 mg/day
0.5- 1.5 mg/day
0.5- 1.5 mg/day
5.0- 15 mg/day
50- 150 µg/day
0.5- 1.5 µcg/day
Calcium
Phosphorous
Magnesium
500- 1000 mg/day
800- 1000 mg/day
200- 300 mg/day
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Iron
Iodine
Copper
Zinc
Fluoride
Manganese
Selenium
Molybdenum
Chromium
10- 20 mg/day
50- 150 µg/day
1-2 mg/day
5-15 mg/day
1-5 mg/day
1-5 mg/day
100 µg/day
200-500 µg/day
10 µg/day
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Annexure 5
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Type of Formula Quantity Energy (kcal)
Protein (g)
Infant formula (1) I, II,III
(1 scoop in 30 ml water)
30 ml 23 kcal 0.6
Infant formula (1) I, II,III
(1 scoop in 30 ml water + ½ tsp sugar)
30 ml
33 kcal
0.6
Infant formula (1) I,II,III
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30 ml
55 kcal
0.6
Infant formula (2) I, II,III
(1 scoop in 30 ml water)
30 ml
23 kcal
0.65
Infant formula (2) I, II,III
(1 scoop in 30 ml water + ½ tsp sugar)
30 ml
33 kcal
0.65
Infant formula (2) I,II,III
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30 ml
55 kcal
0.65
Infant formula (3)
(1 scoop in 30 ml water)
30ml
21 kcal
0.72
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar)
30ml
31 kcal
0.72
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30ml
53.5 kcal
0.72
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Infant formula (3)
(1 scoop in 30 ml water)
30ml
23 kcal
0.5
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar)
30ml
33 kcal
0.5
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30ml
55.5kcal
0.5
Infant formula (3)
(1 scoop in 30 ml water)
30ml
23.5 kcal
0.55
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar)
30ml
33.5 kcal
0.55
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30ml
56Kcal
0.55
Infant formula (3)
(1 scoop in 30 ml water)
30ml
23 kcal
0.7
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar)
30ml
33 kcal
0.7
Infant formula (3)
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30ml
55.5kcal
0.7
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Infant formula (3)
Special Care for Lbwt child
(1 scoop in 30 ml water)
30ml
23 kcal
0.56
Infant formula (3)
Special Care for Lbwt child
(1 scoop in 30 ml water + ½ tsp sugar)
30ml
33 kcal
0.56
Infant formula (3)
Special Care for Lbwt child
(1 scoop in 30 ml water + ½ tsp sugar + ½ tsp oil)
30ml
55.5kcal
0.56
Infant formula (1) I, II,III
(1 scoop in 30 ml milk)
30 ml 43 kcal 1.6
Infant formula (1) I, II,III
(1 scoop in 30 ml milk + ½ tsp sugar)
30 ml
53 kcal
1.6
Infant formula (1) I,II,III
(1 scoop in 30 ml milk + ½ tsp sugar + ½ tsp oil)
30 ml
75 kcal
1.6
Infant formula (2) I, II,III
(1 scoop in 30 ml milk)
30 ml
43 kcal
1.65
Infant formula (2) I, II,III
(1 scoop in 30 ml milk + ½ tsp sugar)
30 ml
53 kcal
1.65
Infant formula (2) I,II,III
(1 scoop in 30 ml milk + ½
30 ml
75.5kcal
1.65
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tsp sugar + ½ tsp oil)
Infant formula (3)
(1 scoop in 30 ml milk)
30ml
40.5 kcal
1.7
Infant formula (3)
(1 scoop in 30 ml milk + ½ tsp sugar)
30ml
50.5 kcal
1.7
Infant formula (3)
(1 scoop in 30 ml milk + ½ tsp sugar + ½ tsp oil)
30ml
73 kcal
1.7
Infant formula (3)
(1 scoop in 30 ml milk)
30ml
42.5 kcal
1.5
Infant formula (3)
(1 scoop in 30 ml milk + ½ tsp sugar)
30ml
53.5 kcal
1.5
Infant formula (3)
(1 scoop in 30 ml milk + ½ tsp sugar + ½ tsp oil)
30ml
76 kcal
1.5
Infant formula (3) Premium
(1 scoop in 30 ml milk)
30ml
43 kcal
1.5
Infant formula (3) Premium
(1 scoop in 30 ml milk + ½ tsp sugar)
30ml
53 kcal
1.5
Infant formula (3) Premium
(1 scoop in 30 ml milk + ½ tsp sugar + ½ tsp oil)
30ml
75.5Kcal
1.5
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Infant formula (3) Premium
(1 scoop in 30 ml milk)
30ml
43 kcal
1.7
Infant formula (3) Premium
(1 scoop in 30 ml milk + ½ tsp sugar)
30ml
53 kcal
1.7
Infant formula (3) Premium
(1 scoop in 30 ml milk + ½ tsp sugar + ½ tsp oil)
30ml
75kcal
1.7
Infant formula (3) Special Care for Lbwt child
(1 scoop in 30 ml milk)
30ml
43 kcal
1.5
Infant formula (3) Special Care for Lbwt child
(1 scoop in 30 ml milk + ½ tsp sugar)
30ml
53 kcal
1.5
Infant formula (3) Special Care for Lbwt child
(1 scoop in 30 ml milk + ½ tsp sugar + ½ tsp oil)
30ml
75kcal
1.5
Milk 100ml 75 3.2
Milk (100ml +
1tsp Sugar)
100ml 120 3.2
Milk ( 100ml +2tsp Sugar) 100ml 140 3.2
Egg Flip ( 2 eggs + 200ml Milk + 4tsp sugar)
300ml
340
19.5
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Buttermilk
100ml
15
0.8
Clear Soup
150ml
85
1.2
Rice Kanjee
150ml
85
0.8
Dal water
150ml
85
2.8
Fruit juice
200ml
100
0
Fruit juice
( 200ml + 2tsp sugar)
200ml
140
0
Tender coconut water
100ml
30
0
Standard Pediatric Formula (>2year)
(5 scoops in 190 ml water)
225 ml
210
6.3
Soy protein isolate 1
( 1scoop in 60 ml water)
60 ml
65
1.74
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Soy protein isolate 2
(1 scoop in 30ml)
30ml
21
0.7
Soy protein isolate 3 (>2year)
( 10gm in 100ml water)
100ml 38 8.4
MCT formula 1 scoop in 30 ml water
23 0.67