PEDIATRIC NUTRITIONAL

CARE (PNC)

Divisi Nutrisi dan Penyakit Metabolik

Bag/SMF IKA FK UNUD/RSUP Sanglah

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 nutritional care medical care

nursing care

PATIENT CARE

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 PEDIATRIC NUTRITIONAL CARE (PNC)
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NUTRITIONAL
ASSESSMENT
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NUTRITIONAL
MONITORING
REQUIREMENT

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NUTRITIONAL NUTRITIONAL
ROUTES SELECTION
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 B
A
ANTHROPOMETRIC
DIETARY EVALUATION
MEASUREMENT

NUTRITIONAL
ASSESSMENT

D C
LABORATORY CLINICAL
ASSESSMENT EVALUATION

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 A. DIETARY EVALUATION
ROUTINE:
DIETARY PATTERN (FOOD PYRAMID, 13 PESAN DASAR GIZI SEIMBANG)
13 pesan dasar gizi seimbang :
VITAMIN AND MINERAL SUPPLEMENT 1. Makanlah aneka ragam makanan
2. Makanlah makanan untuk mencukupi kebutuhan
FAMILY EATING HABITS energi
3. Makanlah makanan sumber karbohidrat setengah

MIDLEVEL: 4.
dari kebutuhan energi
Batasi konsumsi lemak dan minyak sampai
seperempat dari kecukupan energi
24-HOUR RECALL 5. Gunakan garam beryodium
6. Makanlah makanan sumber zat besi
3 TO 7 DAY FOOD RECORDS 7. Berikan ASI saja pada bayi sampai umur 4 bulan
dan tambahkan MP-ASI sesudahnya
DEVELOPMENTAL EVALUATION 8. Biasakan makan pagi
9. Minumlah air bersih, aman yang cukup jumlahnya
OF FEEDING SKILLS 10.
11.
Lakukan aktifitas fisik secara teratur
Hindari minuman yang beralkohol
12. Makanlah makanan yang aman bagi kesehatan
IN-DEPTH: 13. Bacalah label pada makanan yang dikemas

OBSERVATION IN HOSPITAL

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 B. ANTHROPOMETRICS MEASUREMENT
ANTRHOPOMETRY: IS THE MEASUREMENT OF
PHYSICAL DIMENSIONS OF THE HUMAN BODY AT
DIFFERENT AGES

BODY WEIGHT
< 2 Y WITHOUT CLOTHING, 2 Y OR MORE WITH MINIMAL
CLOTHING
WEIGHT FOR AGE, WEIGHT FOR HEGHT, BMI

BODY LENGTH OR HEIGHT

< 2 Y : BODY LENGTH, 2 Y OR MORE : BODY HEIGHT
BODY LENGTH > 0.5 CM THAN BODY HEIGHT (CORRECTION)

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 HEAD CIRCUMFERENCE
CAN BE INFLUENCED BY NUTRITIONAL STATUS UNTIL THE AGE
OF 36 MONTHS
DEFICIENCIES ARE MANIFEST IN WEIGHT AND HEIGHT BEFORE IN
HEAD CIRCUMFERENCE
HC < 5th PERCENTILE INDICATE CHRONIC UNDERNUTRITION
DURING FETAL LIFE AND EARLY CHILDHOOD.
ARM CIRCUMFERENCE (LLA)
BATAS P-5 :
USIA 1-2: 14,2 CM 2-3: 14,1 CM 3-4: 15,0 CM 4-5: 14,9 CM
5-6: 15,3 CM 6-7: 15,5 CM 7-8: 16,2 CM 8-9: 16,2 CM
9-10: 17,5 CM 10-11: 18,1 CM 11-12: 18,6 CM

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 NUTRITIONAL STATUS
INDICATOR : WEIGHT FOR HEIGHT ACUTE
HEIGHT FOR AGE CHRONIC

STANDARD :
NCHS CDC-2000
WHO-2006
CRITERIA :
PERCENTILE : < P3
PERCENTAGE : < 70% SEVERE MALNUTRITION
Z-SCORE : < -3SD

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 NUTRITIONAL STATUS PERCENTAGE
INDICATOR NORMAL MILD MODERATE SEVERE BASED ON

W/H 110-90 90-85 85-75 < 75 McLAREN

W/H > 90 90-80 80-70 < 70 WATERLOW

W /A 110-90 90-81 80-61 < 60 JELLIFFE

W /A > 90 90-75 75-61 < 60 GOMEZ

H/A > 95 98-87 87-80 < 80 WATERLOW

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 Anak Perempuan
2 tahun, BB 10 kg,
TB 80 cm
Status Gizi ?

X X 10/11 x 100% =
90,9%
Gizi Baik
Kriteria Waterlo

X X

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 Anak Laki, 12 th,
BB 25 kg,
TB 125 cm
Status Gizi ?

Antropometri :
X BB/U < P3
25/43x100%
= 58,1%
X X X
TB/U < P3
125/150x100%
= 83,3%

BB/TB
25/26x100%
X = 96,1%
Gizi Baik
X X X

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 C. CLINICAL EVALUATION
MARASMU KWASHIORK
S OR
GROWTH RETARDATION ++ +
(LINEAR) ++ -
SEVERELY UNDERWEIGHT + ++
MUSCLEWASTING - +
EDEMA + ++
APATHY, FATIGUE + +
IRRITABILITY + +
ELECTROLYTE IMBALANCED - +
(HYPO-K) + ++
HYPOALBUNEMIA - +
ANEMIA + ++
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FATTY LIVER - +
 D. LABORATORY ASSESSMENT
NITROGEN BALANCE
N balance = N intake N output
= (24 h dietary protein intake in grams/6.25) 24 h UUN -
factor
UUN = urine urea nitrogen; factor in children 10 mg/kg/d

SERUM PROTEIN
ALBUMIN, PREALBUMIN, RBP, TRANSFERRIN, IGF-1

ESSENTIAL FATTY ACIDS

TOTAL LYMPHOCYTE COUNT (TLC)
MILD MALNUTRITION TLC < 1500 CELLS/MM3
MODERATE TLC : 800-1200 CELLS/MM3
SEVERE TLC : < 800 CELLS/MM3

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 2. NUTRITIONAL
REQUIREMENT
DALAM KEADAAN STABIL :
TEE = REE + E-activity + TEF
o TEE ~ TOTAL ENERGY EXPENDITURE
o REE ~ RESTING ENERGY EXPENDITURE
o E-activity ~ ENERGY REQUIREMENT FOR ACTIVITY = 25-35% TEE
o TEF ~ THERMIC EFFECT OF FOOD = 5-10% TEE
TEE = RDA (USIA TB) X BB (IDEAL~TB)
TEE = AKG (ANGKA KECUKUPAN GIZI) BILA STATURE NORMAL

DALAM KEADAAN KRITIS :

TEE = REE X STRESS FACTOR
ANAK SAKIT, STRESS FACTOR = 1.1-1.4; LUKA BAKAR= 1.6; KEJAR
TUMBUH= 2
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 Usia Energi Protein Usia Energi Proteins
(Kkal/hari) (g) (tahun) (Kkal/kg/h) (g)

0-6 bln 550 10 0 0.5 120 2.5

7-12 bln 650 16 0.5 - 1 110 2.0
1-3 thn 1000 25 13 100 1.5
4-6 thn 1550 39 46 90 1.0
7-9 thn 1800 45 79 80 1.0
10-12 thn 2050 50 10 12 70 0.9

15 Col UR, et al. Nutritional Support in the Critically Ill Child. MJAFI 2005;61:45-50
LAKI
0-3 th REE = 0,167W + 15,174H 617,6
3-10 th REE = 19,59W + 1,303H + 414,9
10-18 th REE = 16,25W + 1,372H + 515,5
18 th REE = 15,057W + 1,004H + 705,8
PEREMPUAN
0-3 th REE = 16,252W + 10,232H 413,5
3-10 th REE = 16,969W + 1,618H + 371,2
10-18 th REE = 8,365W + 4,65H + 200
18 th REE = 13,623W + 23,8H + 98,2

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Stres Factor
Kondisi Klinis Stres factor

Kelaparan 0,9
Bed rest 1,1
Bedah minor 1,1 1,3
Gagal jantung 1,15 1,25
Infeksi 1,3
Fraktur 1,3
Bedah mayor 1,5
Trauma mayor 1,7
Sepsis 1,7 1,9
Luka bakar 1,9 2,1
Kejar Tumbuh 2,0
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KEBUTUHAN AIR
Formula Holliday-Segar

Berat badan Kebutuhan air per-hari

1 10 kg 100 mL/kg
11 20 kg 1000 mL + 50 mL/kg tiap BB > 10 kg
> 20 kg 1500 mL + 20 mL/kg tiap BB > 20 kg

BILA DIBERIKAN PER-ORAL +20-30%

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 3. NUTRITIONAL SELECTION
MAKANAN DEWASA
MAKANAN NASI TIM
PADAT BUBUR SUSU

ASI

MAKANAN SUSU FORMULA

FORMULA STANDAR

CAIR FOTMULA KHUSUS

Prematur, hidrolisat, bebas laktosa,
kedelai, tinggi kalori, dll

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 4. NUTITIONAL ROUTES
FUNGSI
SALURAN
CERNA
Formula
standar
absorp baik
TIDAK BAIK si tidak Formula
khusus

PARENTERAL ENTERAL ORAL

JANGKA PANJANG :
JANGKA PENDEK : NGT,
GASTROSTOMI,
NDT, NJT, OGT
JEJUNOSTOMI

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 5. MONITORING
MUNTAH
TOLERANSI
DIARE

JUMLAH &
AKURASI JENIS BENAR
KENAIKAN BB
REFEEDING
KOMPLIKA
SI
SYNDROME
.
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 TOLERANSI
MUNTAH
ORAL :
RASA TIDAK SESUAI PERBAIKI RASA MAKANAN
VOLUME BERLEBIH SMALL FREQUENT
ENTERAL : BOLUS INTERMITEN KONTINYU
TRANSPILORIK : NDT (NASODUODENAL) ATAU NJT
(NASOJEJUNAL)
DIARE :
OSMOLARITAS NUTRISI
INTOLERANSI
ALERGI
LAIN .

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 AKURASI
JUMLAH DAN JENIS BENAR :
SESUAI DENGAN PERHITUNGAN KEBUTUHAN NUTRISI
JENIS NUTRISI SESUAI USIA DAN KEMAMPUAN PASIEN

KENAIKAN BB :
KENAIKAN BB KRONOLOGIS
KENAIKAN TUMBUH KEJAR : SESUAI KELEBIHAN KALORI YANG
DIBERIKAN
KELEBIHAN 500 KKAL/HARI BB NAIK 0,5 KG/MINGGU
HATI-HATI KENAIKAN BERLEBIH OVERLOAD CAIRAN ? ATAU
PASIEN TERREHIDRASI

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 KOMPLIKASI
REFEEDING SYNDROME
HYPOFOSFATEMIA CARDIAC ARREST

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 Disease-Specific Nutrition Therapy
HIV/AIDS
High protein
Oral : elemental formula (hydrolyzed protein) + fat modified
(MCT)
Pulmonary Disease
Higher fat (lowest RQ) than CH + high protein
CH (27-40%) : Prot (16.7-20%) : Fat (40-55%)
RQ = vCO2 / vO2; CH (RQ=1); Prot (RQ=0.8); Fat
(RQ=0.6)
Renal Disease
High energy
Restriction of protein, fluid and electrolyte

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 DENSITAS KALORI
Ratio antara kebutuhan nutrisi dengan kebutuhan cairan.
Misalnya : kebutuhan kalori 900 kkal/hari, kebutuhan cairan
1000 ml/hr maka densitas kalori nutrisi yang dibutuhkan
adalah 900/1000 = 0,9
Densitas kalori beberapa Formula :
Pediasure = 1
Vitaplus = 1
SGM-1 (semua susu formula standar) = 0,67
Prenan (susu formula prematur/bblr) = 0,81
ASI = 0,7

Bila densitas kalori formula dinaikkan (dikentalkan) harus

memperhatikan PRSL (potential renal Solute Load).
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 POTENTIAL RENAL SOLUTE LOAD
PRSL = N/28 + Na + Cl + K + Pa
N units in mg other Units are in mmol (or mosmol) mmol =
meq/valence or meq = valence x mmol
N/28 represents excretion of N substances (with the assumption
that the number of N atoms per molecule is 2)
Pa is available phosphorus. Phytate P is not available for
absorption. In soy-based formulas, 30% of P is phytate bound and
does not contribute to P in circulation and filtered by the kidney.
Other non-soy formulas: ~all P is available

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 Milligrams to mEq
Milligrams/ atomic wt x valence = meq
Example: Phosphorus 280 mg / 31 mg/mmol x 2 = 18 meq
Example: Na 162 mg/23 x 1= 7 meq

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 Examples
Similac: cows milk based formula
680 Kcal/Liter
N: Protein = 14 g/6.25 g Pro per gr N= 2.24 g N =
2240 mg N/28=80
162 mg/23 mg/meq= 7.0 meq Na= 7 mmol
mg Cl Not given but can be estimated= 7 meq=7mmol

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 Examples
Similac: cows milk based formula
680 Kcal/Liter
N: Protein = 14 g/6.25 g Pro per gr N= 2.24 g N = 2240
mg N/28=80
162 mg/23 mg/meq= 7.0 meq Na= 7 mmol
mg Cl Not given but can be estimated= 7 meq=7mmol

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 Calculations (cont)
K: 710 mg/39 mg/meq =18 meq K = 18 mmol
280 mg/ 31mg/meq = 9 meq P X 2 = 18 mmol (P has
valence of 2) In Cows milk formula all P is available

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 Na to NaCl to Cl
Na has atomic wt of 23
Cl has atomic wt of 35.4
If you have wt of 162 mg Na that would mean that an
equivalent amount of Cl was also added or about 162/23 =
x/35.4= 249 mg Cl = 7 meq Cl

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 Calculations
PRSL= N/28 + Na + Cl + K + P
80 + 7 + 7 + 18 + 18 = 130 mmols per Liter
There are 680 Kcal / liter
130 / 6.8 = 19 mosmol/100 Kcal
Which is under the 33 mosmol/100 kcal limit

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 Situation: Infant needs more kcals
Powdered Formula: how much can you mix and not
cause problems with osmolality fluid shifts & renal solute
load in ill infant?
Example: Similac has PRSL of ~ 19 mosmol/100 kcal. If
want to increase to upper limit of acceptable ~33
33/19 = 1.7 times concentration so you can add about
1.7x the amount called in recipe

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 PRSL of Infant Foods
Mosmol/L mosm/100 kcal
Human Milk 93 14
Formula 135-260 20-39
Cow milk 308 46
Beikosta 153 23
a: any non-milk food

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 WEIGHT GAIN
Calculate weight gain : chronological weight gain according
for age and weight gain cause by excessive energy intake
The energy for growth is about 5 kcal/g weight gain
Anak laki usia 2 th, BB 7 kg, PB 75 cm
PB sesuai anak usia 1 th
BB ideal ~ PB 10 kg status gizi 70% (moderate
malnutrition)
Kebutuhan kalori : 100 kkal x 10 kg = 1000 kkal/hari
Kebutuhan BB aktual 100 x 7 = 700 kkal/hari
Kenaikan kronologis : 3 g/hari = 20 g/mg
Kelebihan kalori : 1000 700 = 300 kkal/hari kenaikan 60
g/hari = 420 g/mg
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