Medical Nutrition Therapy in Pediatric Diseases I PDF

NTD3107 Medical Nutrition Therapy in Pediatric Diseases I Lec. İLAYDA ÖZTÜRK ALTUNCEVAHİR Protein-Energy Malnutrition  Malnutrition Malnutrition occurs with various degrees of clinical and biochemical findings as a result of lacking intake of energy and all...

NTD3107 Medical Nutrition Therapy in Pediatric Diseases I Lec. İLAYDA ÖZTÜRK ALTUNCEVAHİR Protein-Energy Malnutrition  Malnutrition Malnutrition occurs with various degrees of clinical and biochemical findings as a result of lacking intake of energy and all nutrients for a long time. PROTEIN-ENERGY MALNUTRITION (PEM) It is a group of pathological syndromes that occur as a result of inadequate nutrition from both protein and energy, mostly seen in infants and young children, and frequently accompanied by infections. Immediate Causes of Childhood Deaths: 2008  Global Trends in the Prevalence of Moderate-Severe Malnutrition in Children Under Five Region 1990 1995 2000 2008 % Million % Million % Million % Million Africa 27.3 30.1 27.9 34.0 28.5 38.3 24 Asia 36.5 141.3 32.8 121.0 29.0 108.0 31 Latin- 10.2 5.6 8.3 4.5 6.3 3.4 7.0 America Developin 32.1 177.0 29.2 159.5 26.7 149.6 22 178.0 g world Primer Reasons Seconder of PEM Reasons of PEM Insufficient GIS dysfunctions feeding Chronic diseases (Lung, kidney, Education cardiovascular diseases) Infections Preterm birth, (Increased fetal malnutrition metabolic rate) Congenital abnormalities  Evaluation of Nutritional Status Short stature for age (Stunted/Bodur): Indicates long- term/chronic nutritional deficiency. Short ;-2SD for his/her age, very short; -3SD. Low weight/underweight for height (Wasted/Kavruk): Indicates malnutriton in acute period. low weight; -2SD, very low weight; -3SD Underweight for age (Underweight/Düşük kilolu): It indicates both acute and chronic malnutrition. Underweight for age; -2SD, very low weight for age; -3SD  2008-2013 TNSA (TDHS)* Short stature for age (Stunted/Bodur): -2SD (%10.3) %9.5 -3SD (%3.2) %3.2 Low weight/underweight for height (Wasted/Kavruk): -2SD (%0.9) %1.7 -3SD (%0.3) %0.4 Underweight for age (Underweight/Düşük kilolu): -2SD (%2.8) %1.9 -3SD (%0.3) %0.4 *Turkey Demographiv and Health Survey/Türkiye Nüfus ve Sağlık Araştırması  GOMEZ Classification Depends on weight measurement. Measured weight is compared with a healthy peer. Very common use for malnutrition detection. Weight for age (%)= Child’s current weight x 100 Healthy peer’s weight Calculated percentage Nutritional Status >90% Normal nutritional status 75-89% 1st degree (mild) malnutrition 60-74% 2nd degree (moderate) malnutrition 2 1-2 0  Assessment of Hydration Status: Physical Examination Mild Moderate Severe Mental Status Alert Depressed Coma Response to stimulus Cry Weak cry No cry Oral Mucosa Mild Dry Dry “parrot” Tenting (Chest) No 2 sec. Peripheral Pulses Present Weak No felt  ORS for Diarrhea and Malnutrition Component Normal ORS ReSoMal (mmol / L) Glucose 111 125 Sodium 90 - 75 45 Potassium 20 40 Chloride 80 70 Citrate 20 7 Magnesium - 3 Zinc - 0.3 Copper - 0.045 Osmolality 310 300  Treatment of Dehydration Mild Moderate Severe Rehydration ReSoMal ReSoMal IV Fluids* ◦ IV Fluids* ◦ 50cc/kg 80cc/kg 100 cc/Kg ◦ in 4 hrs 8 hrs 12 hrs Replacement Volume to Volume: ReSoMal. Maintenance Feeding immediately after rehydration.  Unreliable Signs of Dehydration in severely malnourished children *Sunken Eyes: Normal in Marasmus patients Can not be seen with edema *Tenting (abdomen) Normal in Marasmus patients Difficult to assess with edema or abdominal distention *Capillary refill Usually delayed: cold extremities (peripheral) edema  Dehydration Status Weight Loss Due to Dehydration Status %2.5-5.0 Mild Dehydration %6.0-9.0 Modarate Dehydration >%9.0 Severe Dehydration ORS (Oral Rehydration Solution) Treatment First 4-6 hours ORS amount (mL/kg) Mild Dehydration 50-80 Modarate Dehydration 80-100 Severe Dehydration 100-150 Treatment Plan A -Frequent feeding -Lots of liquids - 2 years 1 teaglass of ORS *ORS: Oral Rehydration Solution  Treatment Plan B -Feeding stops -80-100 ml/kg/hour ORS for 4 hours (If the patient gets better it doesn’t have to last 4 hours) -Checking infant’s/child’s condition  Treatment Plan C -Ideally IV treatment procedure should be followed -If there is no possibility for IV treatment; with the help of teaspoon or dropper/drip ORS should be given  ORS Amount (g) Measurement Sodium chloride 3.5 1 dessert spoon Sodium bicarbonate 2.5 ½ dessert spoon Potassium chloride 1.5 ½ dessert spoon Glucose 20 4 dessert spoons The ORS mixture is given by dissolving in 1L of boiled and cooled water.  ORS ORS Recipe: 1 L water (Clean) + 1 tsp salt + 8 tsp sugar + approx. 1 dessert spoon carbonate + apple juice (approx. 100 ml)  Sugar: For supporting Na+ absorption  Carbonate: For preventing acidosis  Apple juice: Pottasium for triggering active transport of Na+ ReSoMal Oral Rehydration Solution (WHO) 1. Water (Boiled&cooled) 2 L 2. WHO-ORS One/1 L 3. Sugar 50 g 4. Electrolyte/mineral solution 40 mL ReSoMal (Contains 45 mmol Na, 40 mmol K ve 3 mmol Mg /L)  ReSoMal Amount Water  Medical Nutrition Therapy (MNT) Breastfeeding should continue(Especially for infants!)  MNT For Mild and Modarate PEM; 1. For the first 4-6 hours  ORS Treatment 2. Energy & nutrient requirements  Should be calculated with ideal weight according to month/age 3. Food consumption history should be evaluated, the infant should not be introduced new foods 4. If Diarrhea (+), suitable foods should be preffered  MNT For Severe PEM; 1. For the first 4-6 hours  ORS Treatment 2. Energy & nutrient requirements should be calculated with current weight 3. Food consumption history should be evaluated, the infant should not be introduced new foods 4. If Diarrhea (+), suitable foods should be preffered or appropriate formulas should be preffered to support enzyme deficiencies  Severe PEM (MNT) Day Energy (kcal/kg) Protein (g/kg) 1,2,3 70-80 1 4 100-120 1.5 5 120 1.5 6, 7 150 2-3 8 175 2.5-3.0 9 200 3.0-3.5 10 200-250 4.0-4.5 If she/he cannot tolerate the given, return to the previous day or stay on the same diet longer. If she/he tolerates the given one very well, diet moves on to the next step faster. After ten days, the infant is monitored and evaluated in the process of catching weight gain and growth (Catch-up growth). Diet should be regulated by seeing infant once in 1 month or 3 months and should be followed up after 1 year.  Severe PEM (MNT) Diarrhea (+) ORS (4-6 hours only ORS) If the condition does not get better treatment should contunie with ORS If the condition is worse TPN + IV feeding procedure should be followe If the condition gets better (70-80 kcal/kg energy, 1 g/kg protein) Lactose Intolerance (-) Lactose Intolerance (+) Reduced Lactose Containing Formulas Lactose Free Formulas Almiron Peptijunior HN25 Nutrilon LF Humana HN Farley’s Soy, Milupa SOM AL110, Pregomin, Nutrisoya Infasoy, Caprilon  Severe PEM (MNT) Diarrhea (-), Infection (+) 80-100 kcal/kg, 1.0-1.5g/kg prt  Severe PEM (MNT) Chronic Diarrhea (+), Malabsorption (+), Infection (+) ORS (For 4-6 hours only ORS) Sucking Reflex (+) Sucking Reflex (-) 70-80 kcal/kg, 1 g/kg protein ORS Oral intake (-) Lactose-free formulas NG, IV feeding Peptijunior, Nutrilon LF TPN; Farley’s Soya, Milupa SOM Dextrose Al 110, Pregomin, Nutrisoya Trophamine Infasoy, Caprilon Intralipid Peach & Apple Juice Vitamin & Mineral Supplement (Additional to MNT) Mg (OH)2 60-90 microgram/kg/day ZnSO4 50-60 mg/kg/day CuSO4 2-3 mg/kg/day Folbiol 5 mg/kg/day Vitamin A 100.000 IU oral (For the first 2 days) Then 1000-5000 IU oral Iron 6 mg/kg/day  Food Choice Simple, age/month appropriate Formula Yogurth Juice (Peach, apple) Rice flour Egg yolk (If tried before) SLOW TRANFORMATION, CLINICAL FOLLOW-UP FAST WEIGHT GAIN! (Catch up growth) 70 g/kg/week  Moderate PEM; ◦ 1 g tissue gain requires, 13.8 kkal/kg Severe PEM; ◦ 1 g tissue gain requires, 24 kkal/kg 1 g protein synthesis requires 7.5 kkal 1 g fat synthesis requires 11.6 kkal Diet (Formula) Composition 1. Energy provided by: Protein 8-10 % Fat 45 % Carbohydrate 45 % 2. Volume: Marasmus 100 - 120ml/kg/day MK - K 75 ml/kg/day  Diet (Formula) Composition 3. Caloric Density 0.75 - 1.2 kcal/ml 4. Osmolality < 300 m 0sm/L 5 Sodium 2 mEq/Kg/day 6. Potassium: Marasmus: 3 mEq/Kg/day Kwashiorkor: 5-8 mEq/Kg/day 7. Vitamins & Minerals > 1.5 RDA  Useful Diets for the Treatment of Severe Malnutrition DIET Breast Milk Use it when available Cow’s Milk Lactose-malabsorption possible Lactose - Free Formulas Expensive- Not available Milk- Staple + Oil Safe, inexpensive, available Cereal – Legume Inexpensive, available Chicken Based Also Useful WHO: F75, F100 No kitchen , out-patient  Preparation of WHO F-75 and F-100 diets Ingredients F-75 F-100 Dry skimmed 25 80 milk (g) Sugar (g) 70 50 Cereal flour (g) 35 - Vegetable oil (g) 27 60 Additional: vitamin mix 140 mg, mineral mix 20 ml and water to make 1,000 ml  Nutrient in 100 ml of F-75 and F-100 diets F-75 F-100 Energy (kcal) 75 100 Protein (g) 0.9 2.9 Fat (g) 2.7 5.9 CHO (g) 11.8 8.75 Lactose (g) 1.3 4.2 Potassium (mmol) 3.6 5.9 Sodium (mmol) 0.6 1.9 Magnesium(mmol) 0.43 0.73 Zinc (mg) 2.0 2.3 Cooper (mg) 0.25 0.25 mOsmol/L 333 419  Volume (ml) of F-75 per feed to provide 100 Kcal/kg/day Wt (kg) Q 2h Q 3h Q 4h 2.8 30 45 60 3.2 35 55 70 3.6 40 60 80 4.0 45 65 90 4.6 50 75 100 5.0 55 80 110 5.4 60 90 120 6.0 65 100 130  Management of Infections in PEM Effect of PEM in the Immune System Cell Mediated Immunity Ig A levels in secretions Phagocyte Killing Inflammatory response Signs of infection ( Fever, WBC count) Hypoglycemia and Hypothermia are signs of severe infection or septic shock  Management of Infections in PEM Multiple infections coexist Diagnosis as aggressive as possible Empiric treatment should be started immediately  Infections in Severely Malnourished Children Points to Remember * PEM patients are immunosuppressed (Cellular) * Gram Negative enteric bacteria are common * Rule out sepsis: Fever, hypothermia, poor feeding, abdominal distention, paralytic ileus, lethargy * Most deaths occur in 1st 48 hours of admission * Risk factors: Age Hypothermia -------- - - - - - - > Infections -------------------------- Feeding Begin------------------- Increase-------------------------- Micro nut. No iron ----------------- With Iron- Deficits Psycho- --------------------------------------------------------------------------- sensorial * Modified from Management of severe malnutrition: a manual for physicians and other senior health workers, WHO Geneva 1999  Prevention of Malnutrition Interventions that work Maternal and birth outcomes: ◦ Maternal supplements micronutrients* ◦ Reduce tobacco consumption* Newborn babies: Promotion of breast feeding by Individual and group counseling  Prevention of Malnutrition Interventions that work Immunization* Hygiene: Hand washing, excretal disposal* Vitamin A, Zn, Iodine* Treatment of diarrhea and acute malnutrition* Malaria prevention* Education for complementary feedings* -Thank You-