Nutritional Support Pediatric Gastrointestinal Disorders

Johana Titus Deparrment of Nutrition

FMUI-CM Hospital

References

Nutrition in pediatrics 4th ed., basic Science Clinical Applications 2008 ---- Duggan. Watkins.Walkers

Krause’s Food & Nutrition Therapy 12th ed., 2008 ---- L.K. Mahan & S. Escott-Stump

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Nutritional problem on Infant/child

• Differences of GI development• Gastrointestinal disorders (malabsorption)

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Inadequate Nutritional Intake Nutritional Support !!

Developmental Differences

• Control swallowing < 6 weeks• Stomach capacity < very small and

peristalsis improves with age• Relaxed cardiac sphincter <• Infants have a deficiency of several enzymes

needed for digestion(until 4-6 months of age) abdominal distention and gas occur

Gastrointestinal Disorders4

Sucking is a primitive reflex that occurs when lips or cheeks are stroked

• Voluntary control over swallowing not until 6 weeks• Stomach capacity of infant very small and peristalsis improves

with age• Relaxed cardiac sphincterThese explain infant’s need for small, frequent feedings,

regurgitation and frequent liquid stools Infants have a deficiency of several enzymes needed for

digestion(until 4-6 months of age)• Amylase- digests carbohydrates• Lipase- enhances fat absorption• Trypsin- catabolizes protein

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Sucking is a primitive reflex that occurs when lips or cheeks are stroked• Voluntary control over swallowing not until 6 weeks• Stomach capacity of infant very small and peristalsis improves with

age• Relaxed cardiac sphincterThese explain infant’s need for small, frequent feedings, regurgitation

and frequent liquid stools Infants have a deficiency of several enzymes needed for

digestion(until 4-6 months of age)• Amylase- digests carbohydrates• Lipase- enhances fat absorption• Trypsin- catabolizes protein

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Nutritional Support Goals

• Healthy child : Optimum Growth & Development

• Out-clinic patient : Prevent Failure To Thrive

• In-clinic patient : Prevent hospital malnutrition

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Nutrition Care

1. Clinical and Nutritional Status Assessment2. Nutritional requirement

- Calory- Carbohydrate, protein, fat- Vitamin, mineral

3. Determine :- Formula

- Route of Delivery4. Monitoring

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Infant Feeding Practice

Age (months) Feeding

0 - 6 Breast feeding/ formula milk

6 - 12BF/Formula milksemisolid & solid foods

> 12BF/Formula milksolid foods /family food

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Route of Delivery

• Oral Feeding

• Enteral Nutrition

• Parenteral Nutrion

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Nutritional support route

• Oral Nutrition Supplementation (ONS)

• Enteral : Naso Gastric Tube (NGT) Transpylorik (Naso duodenal-/Naso

Jejunal -Tube) Percutaneous Endogastrotomy (PEG)

Percutaneoues Endojejunostomy(PEJ)Bolus or intermitent or continues

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Naso- gastric, Duodenal, transpiloric tube

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Naso Gastric Tube Nasoduodenal tube/Transpilorik

Percutaneous Endo Gastrotomy

Enteral formula for pediatric

• Hospital standar formula (milk, low lactose, or free lactose)

• Commercial formula Polimeric Oligomeric Elemental • Specific formula

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Pediatric’S foods • Brest Milk• Formula milk

Starting formulaFollow on

formulaGrowing up

formula• Liquid food• Semi solid/solid

food

• Special formulaLow lactose/Free

lactoseSoy formulaHypo

osmoler/hypoallergenic formula

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Infant 0 – 6 month of age

Non dehydration, mild-moderate dehydrationBreast feeding• Continue breast feeding• Oral Rehydration Solution (ORS)Formula Milk• Continue Formula Milk• ORS• Diluted formula milk has no benefit

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Infant 0-6 months on formula milk

Severe dehydration• IVFD• Continue Formula Milk• ORS• Diluted formula milk has no benefit• Free lactose formula

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Infant 6-12 months of age

Non dehydration, mild-moderate dehydration• Continue breast feeding/formula milk• ORS• Semi solid/solid food should be continued• Food high in simple sugar should be avoided• Highly specific diet such as BRAT (bananas,

rice,apple sauce & toast) commonly recommended

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Infant 6-12 monthsSevere dehydration• IVFD• Continue breast milk/formula free lactose milk

& ORS• Semi solid/solid food should be continued• Food high in simple sugar should be avoided• Highly specific diet such as BRAT (bananas,

rice,apple sauce & toast) commonly recommended

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Children more than1 year

• Continue breast milk/formula milk• ORS• Solid food should be continued• Food high in simple sugar should be avoided• Highly specific diet such as BRAT (bananas,

rice,apple sauce & toast) commonly recommended

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Nutrisi Parenteral

Macro- micro nutrien NP Protein………………………….. Amino acid Carbohydrate…………….. Dextrose Fat…………………………………Fat Emulsion Vitamin……………………….. Multivitamin IV Mineral………………………… Electrolite

&Trace Elements

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Type of parenteral

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central Peripheral

Length > 2 weeks < 2weeks

Osmolality (mosm/L) > 960 600-800

Fluid retriction + -

central or peripheral vein

Gastrointestinal disorders • Colic • Constipation• Vomiting,• Gastroentritis ;

Diarhea • Pyroric stenosis• Hernias • NEC

• GERD • Gastritis• IBD, • Crohn Disesis

Ulceratif Colitis • Appendictcities• Hepatitis • Cirrhosis

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Colic• Feeding disorder characterized by paroxysmal

abdominal pain of intestinal origin and severe crying

• Sx: loud crying for several hours, face flushed, drawing up of legs and clenches hands, abdomen distended and firm

• Usually occurs under age of 3 mo• Proposed causes: feeding too fast or

swallowing large amounts of air

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Management for alleviating colic

• Thorough history of diet and daily schedule• Assess episodes of colic• Provide rhythmic movement• Alternate positions• Reduce environmental stimuli• Provide tactile stimuli• Alter Intake

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Constipation• Decrease in the frequency or passage of

stools, the formation of hard, dry stool, or the oozing of stool past an impaction

Causes:• Underlying disease or diet (frequent in

Toddlers and Preschool) change from formula to cow’s milk

• Remove constipating foods (banana’s, rice, cheese)

• Psychological factors and toilet training 25

Constipation

Treatments:

• Fluids & dietary intervention are the first line of therapy

• High fiber diets• Lactose intolerance: Lactose free diet• Toilet training

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Source of dietary fibers

• Fruits : apple, apricot, blueberries, dates, pear, raisin, strawberry, avocado

• Vegetables: beans, broccoli, etc

• Cereals, jelly, pudding

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Vomiting

1. Small frequent feeding2. Food choice according to child’s age

- Breast Feeding (BF)- Formula milk (FM)

- Semi solid/ solid food3. Nasogastric tube sometime is needed

- Formula milk- Liquid food

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Gastroenteritis

• Inflammation of the stomach and intestines that may be accompanied by vomiting and diarrhea.

• Cause may be viral, bacterial or parasitic or a chronic problem

• Under age of 5 average 2 episodes per year• Infants and young children may become

dehydrated quickly. At risk for hypovolemic shock and electrolyte imbalance

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Gastroenteritis

• Symptoms may be mild, moderate or severe• Mild: slight increase in number and more

liquid• Moderate: severe loose or watery stools, with

irritability, anorexia, nausea and vomiting• Severe: continuous watery stools, symptoms

of electrolyte and fluid imbalance, irritable and

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Gastroenteritis Interventions:• Monitor vital signs/ assess LOC, fontanels, skin

turgor, capillary refill• Observe stool for number, amount, color,

consistency• Test for occult blood, provide stool for culture

and ovum/parasite• Oral rehydration fluids and IV fluids• Prevent skin breakdown

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Gastroenteritis

Notification of Health Care Provider if:• Diarrhea or vomiting is increasing in

frequency or amount• Diarrhea does not improve after 24 hours• Vomiting continues for more than 24 hours• Stool or vomit material contains blood

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Management Acute Diarrhea

• Dietary management depend on the age & diet history of the patient

• Infant feeding practice0 – 6 month : Breast feeding/ formula milk6 – 12 months : BF/FM, semisolid & solid foods> 12 months : solid foods /family food

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Chronic (intractable) diarrhea (1)

Infant

Nutritional screening to identify

Nutrition risk

Nutritional assessment

Nutrition care plan

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Infant with intractable diarrhea are at nutrition risk & should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan.

Bayi dengan diare keras beresiko gizi & nutrisi harus menjalani pemeriksaan untuk mengidentifikasi mereka yang membutuhkan penilaian gizi formal dengan pengembangan rencana perawatan gizi.

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Chronic (intractable) diarrhea (2)

childrenUnable maintained nutritional status :

• Oral intake Enteral Nutrition Parenteral Nutrition

• Carbohydrate intolerant : EN formula with

• high fat, high MCT,

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Diarrhea in severe malnutrition child

• Persistent diarrhea that occurs everyday for at least 14 day

• Feeding guidelines are the same as for severe malnutrition

• BF should be continued as often and for long as the child wants

• Milk intolerance (rare) replace cow milk with commercial lactose free formula

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Formula diet for severe malnutrition

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Ingredient Amount

F-75 F-100

Dried skim milk 25 g 80 gSugar 70 g 50 gCereal flour 35 g -Vegetable oil 27 g 60 gMineral mix 20 ml 20 mlVitamin mix 140 mg 140 mgWater to make 1000 ml1000 ml

GER-GERD• Return of gastric contents into esophagus due

to relaxation of the lower esophageal sphincter

• Common in premature infants and children with neuromuscular disorders

• Usually resolved without surgical intervention by 12-18 months

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GER-GERD

• Vomiting, dysphagia, esophagitis

• weight loss, Poor weight gain

• Frequent respiratory problems, including pneumonia, reactive airway disease are possible if aspiration

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GERD

• Diagnosis: Upper GI, Upper GI endoscopy, pH probe• Treatment: Feeding modifications Add cereal to

formula ( 1-6 tsp per ounce of formula)• Avoid fatty foods, orange juice• Medications: cholinergics, antacids, histamine

antagonists• Position of child during feedings

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GERD Dietary management

• Dietary interventionThickening feeds

Small frequent feeding

• Positioning

• Drugs

• Surgery

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Maintaining the Position of an Infant Diagnosed with GER

• 30 degree elevation of the head of the bed can be maintained by using a wedge or extra blanket UNDER the mattress

• A commercial or home-made harness can be used to ensure the infant is safely secured in the head elevated prone position.

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GERD Dietary management

• 14 RCT : use of thickened formula vs Standard formula

• Outcomes: 1.Episode of regurgitation & Vomiting2.Episode of irritability3. Crying & dysphagia4.Regurgitation symptoms (irritability, coughing,choking, night awaking)

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Inflammatory Bowel Disease

• Different than Irritable Bowel Syndrome

• Inflammatory involves faulty regulation of immune response of the intestinal mucosa (in genetically predisposed people) to triggers

• Two different disorders:Crohn’s DiseaseUlcerative Colitis

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Crohn’s Disease

• Chronic inflammatory process• Occurs randomly throughout GI tract• Ileum, colon, and rectum most common• Develops fistulas between loops of bowel or

nearby organs• More common in whites and those of Jewish

descent

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Ulcerative Colitis

• Chronic recurrent disease of the colon and rectal mucosa

• Can involve entire length of bowel with varying degrees of inflammation, ulceration, hemorrhage and edema

• Develops before the age of 20 with peak onset at age 12

• More prevalent in people of Jewish descent

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Ulcerative Colitis

• Sx:• Diarrhea• Lower abdominal pain and cramps that occur

before and during bowel movement but relieved by it

• Stool mixed with blood and mucus• Weight loss, delayed growth, nutritional

deficiencies and arthralgias often occur

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Diet Instruciton for Inflammatory Bowel Disease

• Small frequent feedings• Limit fiber• Offer high calorie meals• Liquid dietary supplements• Watch for foods that cause problems and

avoid in future• Avoid strife at mealtime

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Treatment for Crohn’s Disease and UC

• Pharmocolgy• Antibiotics• Anti-inflammatory• Immuno-suppresive• Anti-diarrheal• Corticosteroids (oral or enema)• Aminosalicylates• Sulfasalizine Teaching Children/Parents

About Sulfasalazine 50

Celiac Disease

• Gluten-sensitive enteropathy• Malabsorption syndrome of gluten, a protein

found in wheat,barley, rye, and oats• Common in Caucasian children• 1%-4& of children with Down’s have Disease

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Symptoms of Celiac Disease

• Occur after introduction of solids/glutens (first 2 years of life)

• Large bulky, greasy, foul smelling, frothy stools (streatorrhea)

• Vomiting

• Failure to grow If treatment delayed

• Delayed dentition• Protein deficiency• Protruding

abdomen/ wasting muscles

• Irritability

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Treatment of Celiac Disease

• Gluten free diet

• Vitamin supplements

• Growth improves steadily with height and weight returning to normal within a year

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