Pediatric Nutrition Case StudiesSiti Hawa Mohd Taib Clinical Dietitian UM Medical Centre Outline 2011 Case Studies Discussion 2 Case Study S Failure To Thrive (FTT) with Viral AGE Baby S, 2 ½ month-old Indian boy born FT with BW 3.03 kg Admitted with dehydration 2º Viral AGE Referred to dietitian for nutritional assessment Anthropometric data • Weight on admission – 3.325 kg (<3rd percentiles) • Weight crossing percentiles from 50th (1/12) to 3rd percentiles (2/12) • Length – 57 cm (50th percentiles) Nutrition-focused Physical findings: 3.325 kg • Wasted • Poor muscle bulk and fat stores which was later changed to Lactogen 1 at similar dilution Also given glucose drinks – at 1 scoop:2 oz .Case Study S Food/NutritionRelated History Breastfeeding – until 1/12 of age • Supplemented with Infant formula – claimed not enough supply On standard infant formula Dutch Lady 1 – (dilution 2 scoops:3 oz). Feeding bottles and teats Coordination of care • Continuation of breastfeeding .Case Study S Nutrition Intervention Nutrition education • Correct feeding dilution • standard dilution • Stop glucose drinks – ensure all feeds are from infant formula • Good hygiene practices • Hand washing • Sterilization techniques . 1 scoop : 30 ml (1 oz) 1 scoop : 60 ml (2 oz) 2011 7 . 5 cm (15th percentiles) • Weight history – crossing percentiles (from 50th to 3rd) at 3/12 of age Nutrition-focused physical findings – small-for-age .Case Study M FTT with AGE Baby M.075 kg (<3rd percentiles) • Length – 67. 7 month-old Malay boy presented with AGE with mild dehydration and noted to be small for his age Anthropometric data • Weight – 6. 075kg .6. Case Study M Nutritional Assessment Referred to dietitian for nutritional assessment Which component of food/nutrition-related history need to be assessed? • Breastfeeding history • Intake of infant formula • Complementary feeding . 5 – 6 times/day • Dilution – 1 scoop: 1 oz .Case Study M Food and Nutritionrelated History Breastfeeding history • Still on breastfeeding – very frequent feeding when mom at home Likes to latch on Use of infant formulas • Type – Bio-Lac. supplemented since 3/12 of age • Frequency – 120 ml. hardly and meat/chicken/vegetables • Feeding technique – element of force feeding.Case Study M Food and Nutritionrelated History Complementary feeding • Age of introduction –started at 6/12 • Type and food texture – plain porridge with added soup. child will cry during mealtimes • Quantity – 2 tbsp twice daily Other habits • Thumb sucking . AAP(1999) • Complementary feeding is not established yet Other dietary emphasis • Iron-rich foods .Case Study M Nutrition Diagnosis and Intervention Inadequate oral intake • Poor weight gain Poor feeding practices • Choice of infant formula • Iron-fortified cow’s milk-based infant formula is the most appropriate milk feeding from birth to 12 months for infants who are not breastfed or who are partially breastfed. 6/52 old Chinese baby boy referred from Ampang Hospital for chronic diarrhea secondary to multiple protein allergy No other family history of allergy Negative stool reducing sugar Multiple Protein Allergy .Case Study Y Baby Y. Anthropometric data • Birth weight – 3.495 kg .495 kg (3rd –15th percentiles) • Length – 54.3 cm (15th percentiles) 3.81 kg 3.81 kg • Current weight – 3. Case Study Y Breast milk –first day On infant formula since D1 OL and feed up to 90 ml every 2-3 hourly Had frequent loose stools for 2/52 Admitted in Ampang Hospital at D19 OL with severe dehydration and metabolic acidosis Food/nutritionrelated history . Case Study Y Client History Responded well to Pregestimil • Less frequent BO with improved consistency Challenged with soy based formula at 5/52 old • Did not respond well Tried lactose-free formula once at home • Had diarrhea again and had to be readmitted • Back on Pregestimil • Feeds well at 90 ml every 2-3 hourly . BO – soft stool once a day Feeding up to 120 ml every 2-3 hourly Anthropometric data • Weight – 6.045 kg (15th percentile) • Length – 61.5 cm (15th percentile) Complementary feeding? Formula challenge ? .Case Study Y Progress at 4/12 Tolerated Alimentum very well. 93 kg (15th percentile) • Length – 66 cm (15th percentile) Complementary feeding • Readiness for solid • Only given rice porridge . BO – soft stool 1-2X day Feeding up to 150 ml every 2-3 hourly Anthropometric data • Weight – 6.Case Study Y Progress at 6/12 Tolerated Alimentum very well. 25 kg • Previously well until D19 OL presented with AGE with 15% dehydration and metabolic acidosis • Able to resume breastfeeding until 2 weeks later when he developed recurrent infection • NBM X 5/7 – noted no loose stools • Wt on admission in UMMC -1. Birth weight – 2.89 kg 2011 20 .Case Study F 1 ½ month-old Indonesian baby boy • Referred from Ampang Hospital for further management of persistent diarrhea Clinical history • Born FT. Case Study F Feeding history Breastfed until hospital admission Had h/o loose stools when standard infant formula was introduced at D4 OL 21 st 1 2011 . Case Study F • On admission – Physical examination .emaciated – Plan – for partialExtensively slow infusion of feed PN and Lactose –free formulas ? • Soy based • Milk based hydrolysed formula – Alimentum ? Amino acid based formula ? Cow’s milk based formula ? 2011 Which feed to consider? Breast Milk ? 22 . • He defaulted his follow-up appt • At 3/12.3.Case Study F Progress • Tolerated breast milk well but noted poor supply of EBM. Given follow-up appt • Weight .2. Supplemented with Comidagen • Child was AOR discharged with breastfeeding and Comidagen.12 kg • Tried Similac NeoSure for 1 feed at home 2011 23 . readmitted with severe dehydration 2° aspiration pneumonia and post enteritis syndrome • Weight .1 kg BUT…. Case Study F • Management in the ward – Short term goal • Correct dehydration • To resume feeding – Comidagen – Long term plan Cow’s milk based formula Extensively hydrolysed formula Soy based formula Earlier formula challenge 2011 24 . Case Study C Client History Baby C.3 kg At 2/52 old • c/o recurrent vomiting. 2 month-old Chinese baby boy Referred from Kuala Pilah Hospital Born FT with BW 3. diarrhea and intermittent fever and admitted in a private hospital in Kajang • Discharged with soy based formula At 1 ½ months • Brought back with c/o intermittent fever and diarrhea 8-10X/day . Case Study C Admitted to Kuala Pilah Hospital with c/o diarrhea. BO 8-10X with poor feeding Treated as AGE with 5% dehydration At 2/12 OL . Case Study C Progress in the ward Complicated with sick thyroid 2° intercurrent illness NBM after an episode of blood-stained stool • US Abdomen noted no evidence of intussusception • Planned for parenteral nutrition . 065 kg 3.3 kg .065 kg (<3rd percentile) • Length – 52.3 kg • Current weight – 3.Anthropometric data • Birth weight – 3.6 cm (3rd percentile) 3. Case Study C Food/NutritionRelated History Breastfeeding with mixed with standard infant formula until 2/52 old. Then switched to soy based formula (Isomil) Initially able to feed up at 60 ml but later reduced to 30ml every ½ hourly . Case Study C Feeding was resumed with Comidagen at 1 ml/h with increments at 0.675 kg Progress .0 ml/kg/h A week later. he tolerated feeding well up to 15 ml/h and PN was discontinued Off tube feeding and later discharged with oral feed of Comidagen Weight on discharged 3.5 -1. Case Study C Readmitted with c/o watery stools and vomiting after given one feed of 60 ml standard infant formula at home Had recent admission for RSV bronchiolitis At 4/12 of age . Anthropometric data • • • • Weight on 1st discharge – 3.67 kg Weight on 2nd discharge – 6.24 kg 5.5 kg 3.5 kg (3rd percentile) Length – 62 cm (15th percentile) 6.67 kg .24 kg Current weight – 5. Case Study C Resume feeding with Comidagen Defer introduction of cow’s milk protein based formula after one year of age Complementary feeding at 6 month KIV for formula challenge after introduction of complementary foods with Alimentum Nutrition Education . INFANT FORMULA SELECTION DISCUSSION . 2005) • Slower gains in weight and length • Reduced bone mineralization in preterm <1800 g • Prevention of colic or allergy •Examples: Isomil.2008) • Strict vegan •Should not be used as follows: • Not recommended for low birth-weight preterm infants (ESPGHAN. Soy protein isolate •Indications: • Should be limited to infants with galactosemia or congenital lactase deficiency (Bhatia.2011 35 Soy-based formulas •Lactose-free. Enfalac A+ Soya (sucrosefree). Mamex GOLD Soya 1 (sucrose-free) . Nursoy. Milk-based and lactose-free formula Lactose intolerance Similac LF Enfalac A+ LF • Not indicated Morinaga NL33 Dulac LF for galactosemia Mamex Gold Tanpa Laktosa Nan AL 110 2011 36 . Lactose-free Formulas • Soy and lactose-free formulas shorten the course of diarrhea.2006) • Younger than 3 months or • Who are malnourish 2011 37 . but do not change overall recovery or weight 2 weeks after illness • Most infants can safely continue breast milk or standard formula during diarrheal illnesses (Sandhu. 1997) • At-risk infants might benefit from a switch to lactose-free formula following AGE (Heyman. 67 kcal/ml) Hypoallergenic formula is effective for the treatment of milk protein allergy and the prevention of atopic disease Other indications: • Chronic diarrhea. short bowel syndrome 38 . chronic liver disease.Formula with Extensively Hydrolyzed Proteins 2011 Peptides and amino acids Partial MCT content Pregestimil. Alimentum Calories: 20 kcal/oz (0. Amino Acid Formula • Protein in form of amino acids • Indications • Severe cow’s milk protein or food allergies • Severe cases of persistent diarrhea (Mattos. Neocate.2004) • Examples. Comidagen 2011 39 . Hydrolysate and Amino Acid Based Formulas The more extensive the hydrolysis. the lesser the antigenicity and the greater the price ↑ price ↓ antigenicity ↑ hydrolysis Disadvantages • Poor taste • Greater cost • Higher osmolarity 40 2011 . TAKE HOME MESSAGE • Can be a life saver • Part of medical intervention or treatment • Should be evidenced based • Will be determined after a comprehensive nutrition assessment 41 Right choice of formula 2011 .