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Transcript of PNC 2014
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Skills Lab Block 24
Pediatric Nutrition Care
Department of Child Health Dr. Mohammad Hoesin Hospital/Faculty of Medicine Sriwijaya University
Palembang 2014
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Objectives
• To recognize the changing nutritional needs of developing children, from infancy to adolescence.
• To understand the concept of malnutrition
• To understand the principles of pediatric nutrition care to prevent malnutrition
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Pediatric stages development
• Neonates (0-1 month)
• Infancy (0-1 yr)
• Toddlerhood (1-2 yr) young children
• Preschool (3-5 yr)
• School age (6-9 yr)
• Adolescent (10-20 yr) – Early adolescence (10-13 yr)
– Middle adolescence (14-16 yr)
– Late adolescence (17-20 yr)
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Growth and Development an essential feature of life of a child and
distinguishes him or her from an adult
• GROWTH is a process starts from the time of conception of the fertilized ovum (egg) and continuous until the child grows in to a fully mature adult.
• DEVELOPMENT is defined as maturation of functions.
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Assessment of growth and development
• Growth parameters
Physical growth of a child is evaluated by body measurement
• body weight
• length or height
• Head
circumference
• Development parameters – Motor development
(physical development) • Gross motor skills • Fine motor skills
– Cognitive (language) development
• Receptive • Expressive
– Psychosocial development • Emotional • Social • Adaptive
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Factors affecting growth and development
• Genetic factors – The tall parents
have tall children and so on.
– In girls growth spurt occurs earlier at puberty
• Environmental factors – Nutrition
– Chemicals : • food additives, etc
– Injury
– Infection
– Social Factors
– Emotional factors
– Cultural factors
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Why is Nutrition Important?
• Energy of daily living
• Maintenance of all body functions
• Vital to growth and development
• Therapeutic benefits
– Healing
– Prevention
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What are nutrients ?
• Macronutrients – Carbohydrates
– Protein
– Lipid
• Micronutrients – Vitamins
– Mineral
• Water
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How much nutrients are needed for growth and development ???
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Consequences of deficit/excess Malnutrition (Jelliffe,1966)
• Undernutrition
– Mild, moderate, severe malnutrition
• Overnutrition
– Overweight & obesity
• Specific nutrient deficiencies or imbalance
– Iron deficiency
– Iodine deficiency, etc
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Severe malnutrition (marasmus & kwashiorkor)
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Overnutrition
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Iodine deficiencies
• Short stature
• Hernia umbilicalis
• IQ 13.5 point, mentally retarded, cretinism, myelinization
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Iron deficiency anemia IQ 10-20 point
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Hypervitaminosis D
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80% mild-
moderate
20% severe
How big is the problems ??
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What physician should do to prevent malnutrition ?
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Health Care
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Child Health Care
Optimizing the growth, development and well being of infants, children and adolescents.
Healthy
• Primary Prevention – Promotion of well
being aims to prevent the initial occurrence of an illness
– Optimalization growth & development
Sick
• Secondary Prevention – Early intervention aims
to stop or slow an existing illness by early detection and appropriate treatment
• Tertiary Prevention (Cure) – Diseases management
aims to reduce the re-occurrence and establishment of chronic illness
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Principles of Pediatric Health Care
• Diagnostic
• Management – Drugs or Surgery
– Nursing Care • Ambulatory, Hospitalized:
intermediate care, ICU etc
– Nutrition Care – Rehabilitation Care
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Pediatric nutrition care activities
1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring
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Pediatric nutrition care activities
1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring
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Assessment clinical & anthropometrics for individual nutritional status
• Z-score classification Wasting : Weight-for-height z-score (WHZ) <-2.00 – Moderate WHZ -3.00 to -2.01 – Severe WHZ <-3.00
• Weight(kg) for height (m2) (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)
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Classification
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Percent of Ideal Body Weight (IBW)
• Percentage of the child’s actual weight compared to ideal weight for actual height (Goldbloom, 1997)
• 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%
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IBW is used as a clinical weight goal in the nutrition rehabilitation
• Nutritional Status : – Actual weight/IBW (%)
• Classification of Percent of IBW (Waterlow, 1972)
– ≥120% obesity – ≥110 -120% overweight – ≥90-110% normal – ≥80-90% mild malnutrition – ≥70-80% moderate malnutrition – ≤70% severe malnutrition
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BB aktual
TB aktual
UMUR TINGGI (Height Age)= 84 bln
BB ideal=22 kg
BB 18 kg, TB 120 cm
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10 bln, 70 cm
Menentukan RDA berdasarkan USIA TINGGI
(height age) = 9 bln
♀, 10 bln, 8 kg, 70 cm
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W/L= IBW =
8 kg
♀, 10 bln, 8 kg, 70 cm
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Pediatric nutrition care activities
1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring
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Calculation of energy requirement
• Indirect calorimetry the most accurate method
• Harris-Benedict equation (REE)
• WHO (REE) • Schofield equation
(REE) • RDA simplest
method
Age (year)
RDA (kcal/kg
Wt) 0-1
1-3
4-6
7-9
10-12
12-18
100-120
100
90
80 M : 60-70
F : 50-60
M : 50-60
F : 40-50
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Calculation of Catch-Up Growth requirement in the Pediatrics
• 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
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Menentukan status gizi & kebutuhan kalori
Anak A : BB : 10 kg ( < P3) 24 bln TB : 85 cm (= P25) Status gizi : BB/U = 10/12.6 ( 79%) TB/U = 85/87 ( 97.5%) BB/TB = 10/12.2 ( 82%) =st gizi KURANG Kebutuhan kalori : 12.2 x 100 kal = 1220 kalori
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Menentukan status gizi & kebutuhan kalori
Anak B : BB : 10 kg ( < P3) TB : 78 cm (= P25) Status gizi : BB/U = 10/12.6 (79%) TB/U = 78/87 (89%) BB/TB = 10/10.8 (92.6%) = st gizi normal Kebutuhan kalori : 10.8 x 100 kal = 1080 kalori
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Pediatric nutrition care activities
1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring
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Route of delivery
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Enteral Nutrition
GI function
Normal Compromised
Standard
Nutrients
Specialty
Formulas
Nutrient Tolerance
Adequate
Progress to
Oral feeding
Inadequate
PN supplementation
Progress to total
Enteral feedings
Adequate progress
To more complex diet
& oral feeding tolerated
Parenteral Nutrition
Short-term Long-term or
Fluid restriction
Peripheral PN Central PN
GI Function returns
No Yes
JPEN 2002:26(1);8SA
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Pediatric nutrition care activities
1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring
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Guidelines How to choose Type of Nutrition
• Patient Factors – Age (stage of
development) – Diagnosis associated
nutritional problems – Nutritional
requirements – Gastrointestinal
function
• Nutritional Factors – Osmolality (isotonic
150-250mOsm) – Renal solute load – Caloric density and
viscosity – Nutrient composition:
type & amount of CHO, Fat and protein
– Product availability and cost
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Feeding the Infant / the Child
• What are the options?
– Breast feeding • The WHO recommends exclusive breast
feeding at least for 6 months.
– Formula feeding
– Complementary Feeding
– Family foods
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Pediatric nutrition care activities
1.Nutritional assessment
2.Nutritional requirements
3.Routes of delivery
4.Formula/IVF selection
5.Monitoring n Evaluation
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Monitoring results of nutrition care
• Food acceptability, tolerance, efficacy
• Parameter : – Acceptability : like or dislike
– Tolerance : look for adverse food reaction
– Efficacy : growth monitoring
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Assessment of sufficient breast feeding
• Weight pattern - consistent weight gain
trimester 1 : 25-30 g/d = 200 g/w = 750-900 g/mo
trimester 2 : 20 g/d = 150 g/w = 600 g/mo trimester 3 : 15 g/d = 100 g/w = 400 g/mo trimester 4 : 10 g/d = 50-75 g/w = 200-300 g/mon
• Voiding – 6-8 wet diapers/day, soaked not only wet • Stooling - generally more stools than formula. • Feed-on-demand ~ every 2-3 hours (8-12 times a
day). • Duration of feedings - generally 10-20 min/side. • Need for high fat hind milk. • Activity and vigor of infant.
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Infant Feeding Practice
• Depend on :
– Maturation of neuromotoric system
– Maturation of gastrointestinal system
– Maturation of immunological system
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Example
AH, 16 months old boy, weight 5 kg (4.2 kg < p3), length 65 cm (9 cm < p3), HC 44 cm (<-2 SD Nellhauss)
Born aterm BW 3000 g 4 months: 4.5 kg Reccurrent diarrhea and vomitus (+) since using milk
formula
Diagnosis ? Pediatric Nutrition Care ?
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Pediatric Nutrition Care
• Assessment → Diagnosis
– History
– Physical Examination
– Investigations
– Dietary Analysis
• Requirement
• Route of delivery
• Type of diet
• Monitoring
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Approximately Daily Weight Gain
• At 16 months the weight should be:
– 3 x 750 g = 2250 g
– 3 x 600 g = 1800 g
– 3 x 450 g = 1350 g
– 3 x 250 g = 750 g
– 4 x 160 g = 640 g 6790 g
BW 3000 g
9790 g
Age Daily weight gain (g)
0-3 mos 25-30
4-6 mos 20
7-9 mos 15
10-12 mos 8-10
13-36 mos 6
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Nutrition Care – Nutritional assessment
• Specific growth chart (-) CDC/NCHS 2000 • IBW for 65 cm 7.4 kg • Nutritional status 5/7.4 67.5% (severe
malnutrition) • Based on daily weight gain failure to thrive
– Nutritional requirements • Height age 5 month RDA 110 kcal/kg • Requirement 7.4 X 110 kcal = 814 kcal • Prevent refeeding syndrome begin 50%-75%
requirement 400--600 kcal gradually increased to 814 kcal
– Routes of delivery • Oral or enteral
– Formula selection • Hypoallergenic formula 400-600kcal/20 kcal/oz 20-
30 oz ± 600-900 mL/24 hours – Monitoring
• Diarrhea & vomitus (-) • Growth (BW, BL)
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Nutrition Care Result
AH, boy, 16 months W : 3.6 kg L : 65 cm
HA : 5 mos
IBW : 7.4 kg
9 months later
25 months W : 10.7 kg L : 77 cm HA : 12 mos IBW : 10 kg
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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
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