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Pediatric Nutrition Case Studies

Siti Hawa Mohd Taib Clinical Dietitian UM Medical Centre

Outline
2011

Case Studies

Discussion
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Case Study S
Failure To Thrive (FTT) with Viral AGE
Baby S, 2 month-old Indian boy born FT with BW 3.03 kg Admitted with dehydration 2 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

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), which was later changed to Lactogen 1 at similar dilution Also given glucose drinks at 1 scoop:2 oz

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 - Feeding bottles and teats

Coordination of care
Continuation of breastfeeding

1 scoop : 30 ml (1 oz)

1 scoop : 60 ml (2 oz)

2011

Case Study M

FTT with AGE

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

6.075kg

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

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, 5 6 times/day Dilution 1 scoop: 1 oz

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, 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
Nutrition Diagnosis and Intervention
Inadequate oral intake
Poor weight gain

Poor feeding practices


Choice of infant formula Iron-fortified cows 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 Y
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

Multiple Protein Allergy

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

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

Case Study Y

Progress at 4/12

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

Progress 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
1 month-old Indonesian baby boy

Referred from Ampang Hospital for further management of persistent diarrhea Clinical history
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
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Case Study F

Feeding history

Breastfed until hospital admission Had h/o loose stools when standard infant formula was introduced at D4 OL
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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 ?

Cows milk based formula ?


2011

Which feed to consider?

Breast Milk ?

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Case Study F
Progress
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

BUT.
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
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Case Study F
Management in the ward
Short term goal
Correct dehydration To resume feeding Comidagen

Long term plan


Cows milk based formula

Extensively hydrolysed formula

Soy based formula


Earlier formula challenge

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Case Study C

Client History

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 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

Anthropometric data
Birth weight 3.3 kg Current weight 3.065 kg (<3rd percentile) Length 52.6 cm (3rd percentile)

3.065 kg 3.3 kg

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 hourly

Case Study C
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

Progress

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 Current weight 5.5 kg (3rd percentile) Length 62 cm (15th percentile)
6.24 kg

5.5 kg

3.67 kg

Case Study C
Resume feeding with Comidagen Defer introduction of cows 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

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Soy-based formulas

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 (sucrosefree), Mamex GOLD Soya 1 (sucrose-free)

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

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Lactose-free Formulas

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

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Formula with Extensively Hydrolyzed Proteins


2011

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

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Amino Acid Formula

Protein in form of amino acids Indications Severe cows milk protein or food allergies Severe cases of persistent diarrhea (Mattos,2004) Examples; Neocate, Comidagen

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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
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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
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Right choice of formula


2011