1. Div Pediatric Nutrition and Metabolic Diseases Dept of Child Health
Pediatric Nutrition Care as a strategy to prevent hospital malnutrition
Div Pediatric Nutrition and Metabolic Diseases
Dept of Child Health

2. 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)
Adolescent (10-20 yr)
Early adolescence (10-13 yr)
Middle adolescence (14-16yr)
Late adolescence (17-20 yr)
Child is not a miniature adult
Specific for child  growth and development

3. Patient care Nutrition care  goal ? Medical care Nursing 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

4. 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

6. Problem ? Hospital malnutrition:
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% 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

8. Factors that cause malnutrition
Nutrition care ?
Unawareness of malnutrition by physician
Inadequate skill, knowledge and management strategies of nutrition therapy
High cost of nutrition support
Complication associated with nutrition support, etc

9. How to solve the problem ?
To organize nutrition care team
Physician
Nurse
Dietitian
Pharmacist
To perform nutrition care activities
Nutritional assessment
Nutritional requirements
Routes of delivery
Formula/IVF selection
Monitoring

10. Nutritional assessment

11. Levels of assessment of nutritional status in clinic
Dietary assessment
Laboratory assessment
Anthropometric assessment
Clinical assessment
Inadequate intake
Malabsorption
Increased requirements
Increased excretion
Increased destruction 
Depletion of reserves
Physiologic and metabolic alterations
Wasting or decreased growth
Spesific anatomic lesions

12. Nutritional status interpretation
If all 4 modalities can be performed  more accurate diagnosis can be determined
The fact : very difficult  clinically + simple anthropometry

13. 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
85th - <95th percentile  overweight
95th percentile  obese
Percent ideal body weight (Olsen et al, 2003)

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

15. 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
85th - <95th percentile  overweight
95th percentile  obese
Percent ideal body weight (Olsen et al, 2003)

16. 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 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

17. 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%

19. Nutrition status as percentage of Ideal Weight
Weight for Height  the best index & reflect nutritional status better (Waterlow, 1972)
≥120%  obesity
≥ %  overweight
≥90-110%  normal
≥80-90%  mild malnutrition
≥70-80%  moderate malnutrition
≤70%  severe malnutrition.

20. Nutritional requirement

21. Calculation of energy requirement
Indirect calorimetry  the most accurate method
Harris-Benedict equation (BEE)
Schofield equation (BEE)
RDA  simplest method
Age (year)
RDA (kcal/kg Wt)
0-1
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

22. 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.
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

23. Nutritional status & requirement
A , 2 y old boy
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

24. 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)
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.

25. Table 2. Determining Stress Factor
Clinical Condition
Stress Factor
Maintenance minus stress Fever Routine/elective surgery, minor sepsis Cardiac failure Major surgery Sepsis Catch-up Growth Trauma or head injury
% per degree > 37° C

26. Route of delivery and type of food/formula/IV fluids

27. Nutrition Support Nutritional supplement to oral diet
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 feeding)
Nutrients into venous system (total parenteral nutrition - TPN)

29. 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, 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

30. Feeding routes of delivery

32. Gastrostomy

33. 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 adult
Monitoring : Efficiency & Complications

35. Pediatric parenteral amino acid solution
Cysteine, taurine, tyrosine, histidine are conditionally essential in neonates and infants
Infant
Primene 5% (Baxter)
Aminosteril Infant (Fresenius)
Pediatric
Aminofusin Paed (Baxter)
Aminosteril (Fresenius)]

36. Complication of nutritional support

37. Refeeding Syndrome
metabolic complication associated with giving 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

39. 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

40. 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 is contraindicated
Malnutrition should be corrected at a judicious rate and overfeeding avoided

41. Pediatric Nutrition Care Result
9 months
later
AH, boy, 16 months
W 3.6 kg L 65 cm
25 months
W kgs L 77 cm

43. Recent data
After performed nutrition care in the pediatric ward -RSCM during period  96.4% of mild-severe malnutrition patients experienced weight gain during hospitalized.

44. Thank you