Pediatric Nutrition Careas a strategy to prevent hospital malnutrition

Div Pediatric Nutrition and Metabolic DiseasesDept of Child Health

Child & Adolescent

� Child is not a miniature adult

� Pediatric stages development

� Infancy (<1 yr)

� Toddlerhood (1-2 yr)

� Preschool (3-5 yr)

School age (6-9 yr)

� Specific for child → growth and development

� School age (6-9 yr)

� Adolescent (10-20 yr)

�Early adolescence (10-13 yr)

�Middle adolescence (14-16yr)

�Late adolescence (17-20 yr)

Patient care

�Medical care� Drugs or surgery

�Nursing careNursing care� Intensive care ?

�Nutrition care ⇒ goal ?

� Healthy child ⇒ optimal growth & development

� Outpatient child ⇒ prevention of failure to thrive

� Hospitalized child ⇒ prevention of hospital malnutrition

Why is nutrition important ?

�Energy of daily living�Maintenance of all body functions�Vital to growth and development (infant , children & adolescent)

�Vital to growth and development (infant , children & adolescent)

�Therapeutic benefits�Healing� Prevention

Problem ?

� Hospital malnutrition:malnutrition during hospital admission

� Hospitalized children up to 54% are malnourished, globally

Pediatric Ward – RSCM (Ginting & Nasar, 2000)� Pediatric Ward – RSCM (Ginting & Nasar, 2000)� 53% of of them experiencing decreased BW

hospitalized children was malnourished � 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

Factors that cause malnutrition

�Nutrition care ?

�Unawareness of malnutrition by physician

�Inadequate skill, knowledge and management strategies of nutrition

�Inadequate skill, knowledge and management strategies of nutrition therapy

�High cost of nutrition support

�Complication associated with nutrition support, etc

How to solve the problem ?

� To organize nutrition care team� Physician

� To perform nutrition care activities� Nutritional assessment

Nutritional requirements� Nurse

� Dietitian

� Pharmacist

� Nutritional requirements

� Routes of delivery

� Formula/IVF selection

� Monitoring

Nutritional assessment

Levels of assessment of nutritional status in clinic

� Dietary assessment� Inadequate intake� Malabsorption� Increased requirements� Increased excretion� Increased destruction

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� Laboratory assessment

� Anthropometric assessment

� Clinical assessment

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� Depletion of reserves⇓⇓⇓⇓

� Physiologic and metabolic alterations

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� Wasting or decreased growth⇓⇓⇓⇓

� Spesific anatomic lesions

Nutritional status interpretation

�If all 4 modalities can be performed ⇒⇒⇒⇒ more accurate diagnosis can be determined

�The fact : very difficult ⇒⇒⇒⇒clinically + simple anthropometry

Assessment anthropometrics for individual nutritional status

� Weight for height (BMI for Age - CDC 2000) ⇒ parameter overweight & obesity� <5th percentile ⇒ underweight

� 5th - <85th percentile ⇒ normal variation� 5th - <85th percentile ⇒ normal variation

� 85th - <95th percentile ⇒ overweight

� ≥95th percentile ⇒ obese

� Percent ideal body weight (Olsen et al, 2003)

Body mass index for age percentiles{Weight(kg)/Height(m)2}

Assessment anthropometrics for individual nutritional status

� Weight for height (BMI for Age - CDC 2000) ⇒ parameter overweight & obesity� <5th percentile ⇒ underweight

� 5th - <85th percentile ⇒ normal variation� 5th - <85th percentile ⇒ normal variation

� 85th - <95th percentile ⇒ overweight

� ≥95th percentile ⇒ obese

� Percent ideal body weight (Olsen et al, 2003)

Standard Growth Chart

� The NCHS (2000) standards have been recommended for worldwide use by the WHO regardless of racial or ethnic origin

Infants with a history of premature birth � Infants with a history of premature birth should have their chronological age corrected by gestational age � until age 24 months for weight measurements,

� 40 months for length, and

� 18 months for head circumference

Percent of Ideal Body Weight (IBW)

� Percentage of the child’s actual weight compared to ideal weight for actual height (Goldbloom, 1997)

� Percent of IBW ⇒ the best index & reflect nutritional status better (McLaren & Read, 1972)

� IBW is determined from the CDC growth chart (Olsen et al, 2003)� Plotting the child’s 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%

Nutrition status as percentage of Ideal Weight

�Weight for Height ⇒ the best index & reflect nutritional status better (Waterlow, 1972)� ≥120% ⇒⇒⇒⇒ obesity� ≥120% ⇒⇒⇒⇒ obesity

� ≥110 -120% ⇒⇒⇒⇒ overweight

� ≥90-110% ⇒⇒⇒⇒ normal

� ≥80-90% ⇒⇒⇒⇒ mild malnutrition

� ≥70-80% ⇒⇒⇒⇒ moderate malnutrition

� ≤70% ⇒⇒⇒⇒ severe malnutrition.

Nutritional requirement

Calculation of energy requirement

� Indirect calorimetry ⇒ the most accurate method

� Harris-Benedict

Age(year)

RDA (kcal/kgWt)

0-1

1-3

100-120

100� Harris-Benedictequation (BEE)

� Schofield equation (BEE)

� RDA⇒ simplest method

1-3

4-6

7-9

10-12

12-18

100

90

80

M : 60-70

F : 50-60

M : 50-60

F : 40-50

Calculation of Catch-Up Growth requirement in the Infant and Child

� 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.achieve catch-up growth.

� 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

Nutritional status & requirement

� A , 2 y old boyWt : 10 kg (< P3)Ht : 85 cm (=P25)

� Nutritional status� Nutritional statusW/H :10/12.2 (82%)

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� H ≈ 50th percentile age 21 mos → RDA 100 kcal/kg

� Requirement → 12.2 x 100 kcal/kg = 1220 kcal

Determining Calorie and Protein Needs in Critically Ill Children

� Estimate basal energy needs (BEE)� WHO equations� Schofield equations� Harris Benedict equations (not recommended for use in

pediatrics ⇒⇒⇒⇒ derived from adult measurements)pediatrics ⇒⇒⇒⇒ derived from adult measurements)

� Determine Stress Factor -Total Calories = BEE X Stress Factor

� Estimate patient's protein requirements Total Protein = Protein RDAs X Stress Factor

� Continue to evaluate and adjust recommendations based on nutrition monitoring.

Table 2. Determining Stress Factor

Clinical Condition Stress Factor

Maintenance minus stressFeverRoutine/elective surgery,

1..0 - 1.212% per degree > 37° C

Routine/elective surgery, minor sepsisCardiac failureMajor surgerySepsisCatch-up GrowthTrauma or head injury

1.1 - 1.31.25 - 1.51.2 - 1.41.4 - 1.51.5 - 2.01.5 - 1.7

Route of delivery and type of food/formula/IV fluidsfood/formula/IV fluids

Nutrition Support

� 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:� Options:

� Nutritional supplement to oral diet

� Formula fed by tube into GI tract (enteral feeding)

� Nutrients into venous system (total parenteral nutrition - TPN)

What you should know about enteral feeding ?� Benefit of enteral feeding compare to parenteral feeding

� When child need tube feeding� How to choose route of delivery

Nasogastric, orogastric, gastrostomy, � Nasogastric, orogastric, gastrostomy, transpyloric

� Continuous or intermittent feeding� Types of enteral formula

� Polymeric, oligomeric (elemental), modular� Guidelines of formula selection

� Patient factor or formula factor� Monitoring → Efficiency & Complications

Feeding routes of delivery

Gastrostomy

What you should know about parenteral nutrition ?

� Indication of parenteral feeding

� Types of parenteral feeding

� Composition of parenteral nutrition for infant and children compared to

� Composition of parenteral nutrition for infant and children compared to adult

�Monitoring : Efficiency & Complications

Pediatric parenteral amino acid solution

� Cysteine, taurine, tyrosine, histidine are conditionally essential in neonates and infants

� Infant� Infant� Primene 5% (Baxter)� Aminosteril Infant (Fresenius)

� Pediatric� Aminofusin Paed (Baxter)� Aminosteril (Fresenius)]

Complication of nutritional support

Refeeding Syndrome

� metabolic complication associated with giving nutritional support (enteral or parenteral) to the severely malnourished

� Starved cells take up energy substrates � 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

Practice Guidelines for Pediatric nutrition care

� Enteral feeding and parenteral nutrition 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

� 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 avoided

Pediatric Nutrition Care Result

9 monthslater

AH, boy, 16 monthsW 3.6 kg L 65 cm

later

25 months

W 10.7 kgs L 77 cm

Recent data

�After performed nutrition care in the pediatric ward -RSCM during period 2003-2004 ⇒ 96.4% of mild-severe malnutrition patients experienced malnutrition patients experienced weight gain during hospitalized.