Pediatric Nutrition Case Studies Siti Hawa Mohd Taib Clinical Dietitian UM Medical Centre
Pediatric Nutrition Case
Studies
Siti Hawa Mohd Taib
Clinical Dietitian
UM Medical Centre
Case Studies
Discussion
2011 2
Ou
tlin
e
Case Study S F
ailu
re T
o
Th
rive (
FT
T)
with V
iral A
GE
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)
3.325 kg
Nutrition-focused Physical findings:
• Wasted
• Poor muscle bulk and fat stores
Fo
od
/Nu
tritio
n-
Re
late
d H
isto
ry
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), which was later changed to Lactogen 1 at similar dilution
Also given glucose drinks – at 1 scoop:2 oz
Case Study S
Nu
tritio
n
Inte
rve
ntion
Nutrition education
• Correct feeding dilution
• standard dilution
• Stop glucose drinks – ensure all feeds are from infant formula
• Good hygiene practices
• Hand washing
• Sterilization techniques - Feeding bottles and teats
Coordination of care
• Continuation of breastfeeding
Case Study S
1 scoop : 30 ml (1 oz)
1 scoop : 60 ml (2 oz)
2011 7
FT
T w
ith
A
GE
Baby M, 7 month-old Malay boy presented with AGE with mild dehydration and noted to be small for his age
Anthropometric data
• Weight – 6.075 kg (<3rd percentiles)
• Length – 67.5 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
6.075kg
Nutr
itio
nal
Asse
ssm
en
t 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
Case Study M
Fo
od
an
d N
utr
itio
n-
rela
ted H
isto
ry
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, 5 – 6 times/day
• Dilution – 1 scoop: 1 oz
Case Study M
Fo
od
an
d N
utr
itio
n-
rela
ted H
isto
ry
Complementary feeding • Age of introduction –started at 6/12
• Type and food texture – plain porridge with added soup, hardly and meat/chicken/vegetables
• Feeding technique – element of force feeding, child will cry during mealtimes
• Quantity – 2 tbsp twice daily
Other habits
• Thumb sucking
Case Study M
Nutr
itio
n
Dia
gn
osis
and
In
terv
ention
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. AAP(1999)
• Complementary feeding is not established yet
Other dietary emphasis
• Iron-rich foods
Case Study M
Mu
ltip
le
Pro
tein
Alle
rgy
Baby Y, 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
Case Study Y
Anthropometric data
• Birth weight – 3.81 kg
• Current weight – 3.495 kg (3rd –15th percentiles)
• Length – 54.3 cm (15th percentiles)
3.81 kg 3.495 kg
Fo
od/n
utr
itio
n-
rela
ted
his
tory
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
Case Study Y
Clie
nt
His
tory
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
Case Study Y
Pro
gre
ss
at
4/1
2
Tolerated Alimentum very well, 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
Case Study Y P
rogre
ss
at 6
/12 Tolerated Alimentum very well, BO –
soft stool 1-2X day
Feeding up to 150 ml every 2-3 hourly
Anthropometric data
• Weight – 6.93 kg (15th percentile)
• Length – 66 cm (15th percentile)
Complementary feeding
• Readiness for solid
• Only given rice porridge
Case Study F
• Referred from Ampang Hospital for further management of persistent diarrhea
1 ½ month-old Indonesian baby boy
• Born FT, Birth weight – 2.25 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 -1.89 kg
Clinical history
2011 20
Case Study F
Feedin
g
his
tory
Breastfed until 1st hospital admission
Had h/o loose stools when standard infant formula was introduced at D4 OL
2011 21
• On admission
– Physical examination - emaciated
– Plan – for partial PN and slow infusion of feed
2011 22
Which feed to
consider?
Cow’s milk based
formula ?
Lactose –free formulas ?
• Soy based
• Milk based
Extensively hydrolysed formula –
Alimentum ? Amino acid based
formula ?
Breast Milk ?
Case Study F
• Tolerated breast milk well but noted poor supply of EBM. Supplemented with Comidagen
• Child was AOR discharged with breastfeeding and Comidagen. Given follow-up appt
• Weight - 2.1 kg
Progress
• He defaulted his follow-up appt
• At 3/12, readmitted with severe dehydration 2° aspiration pneumonia and post enteritis syndrome
• Weight - 3.12 kg
• Tried Similac NeoSure for 1 feed at home
BUT….
2011 23
Case Study F
• Management in the ward
– Short term goal
• Correct dehydration
• To resume feeding – Comidagen
– Long term plan
2011 24
Earlier formula
challenge
Cow’s milk based
formula
Extensively hydrolysed
formula
Soy based formula
Case Study F
Case Study C C
lien
t H
isto
ry Baby C, 2 month-old Chinese baby boy
Referred from Kuala Pilah Hospital
Born FT with BW 3.3 kg
At 2/52 old
• c/o recurrent vomiting, 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 A
t 2/1
2 O
L
Admitted to Kuala Pilah Hospital with c/o diarrhea, BO 8-10X with poor feeding
Treated as AGE with 5% dehydration
Case Study C P
rog
ress
in th
e w
ard
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
Anthropometric data
• Birth weight – 3.3 kg
• Current weight – 3.065 kg (<3rd percentile)
• Length – 52.6 cm (3rd percentile) 3.3 kg
3.065 kg
Case Study C F
oo
d/N
utr
itio
n-
Re
late
d H
isto
ry
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 P
rog
ress Feeding was resumed with
Comidagen at 1 ml/h with increments at 0.5 -1.0 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 3.675 kg
Case Study C A
t 4
/12
of
age
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
Anthropometric data
• Weight on 1st discharge – 3.67 kg
• Weight on 2nd discharge – 6.24 kg
• Current weight – 5.5 kg (3rd percentile)
• Length – 62 cm (15th percentile)
6.24 kg
3.67 kg
5.5 kg
Case Study C N
utr
itio
n
Ed
uca
tio
n
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
DISCUSSION
INFANT FORMULA SELECTION
So
y-b
ased f
orm
ula
s
•Lactose-free, Soy protein isolate
•Indications:
• Should be limited to infants with galactosemia or congenital lactase deficiency (Bhatia,2008)
• Strict vegan
•Should not be used as follows:
• Not recommended for low birth-weight preterm infants (ESPGHAN, 2005)
• Slower gains in weight and length
• Reduced bone mineralization in preterm <1800 g
• Prevention of colic or allergy
•Examples: Isomil, Nursoy, Enfalac A+ Soya (sucrose-free), Mamex GOLD Soya 1 (sucrose-free)
2011
35
2011 36
Milk-based and lactose-free formula
Lactose intolerance
• Not indicated for galactosemia
Similac LF
Enfalac A+ LF
Morinaga NL33
Dulac LF
Mamex Gold Tanpa Laktosa
Nan AL 110
• Soy and lactose-free formulas shorten the course of diarrhea, 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,2006)
• Younger than 3 months or
• Who are malnourish
Lactose-free Formulas
2011 37
2011 38
Form
ula
with
Exte
nsiv
ely
H
ydro
lyzed
Pro
tein
s
Peptides and amino acids
Partial MCT content
Pregestimil, Alimentum
Calories: 20 kcal/oz (0.67 kcal/ml)
Hypoallergenic formula is effective for the treatment of milk protein allergy and the prevention of atopic disease
Other indications:
• Chronic diarrhea, chronic liver disease, short bowel syndrome
2011 39
Am
ino A
cid
Form
ula
• Protein in form of amino acids
• Indications
• Severe cow’s milk protein or food allergies
• Severe cases of persistent diarrhea (Mattos,2004)
• Examples; Neocate, Comidagen
Hydrolysate and Amino Acid
Based Formulas
The more extensive the hydrolysis, the lesser the antigenicity and the greater the price
↑ hydrolysis
↓ antigenicity
↑ price
2011 40
Disadvantages
• Poor taste
• Greater cost
• Higher osmolarity
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
Right choice
of formula
2011 41