PEDIATRIC NUTRITION

S/Lt Ayesha Batool PN

Registered Dietitian &
Clinical Nutritionist
PNS Shifa Hospital
Karachi
Importance of Nutrition during Infancy
and childhood
 Rapid Growth
 Development of Immune System
 Neuro-physiological Development (visual acuity)
 Development of intellect.
What to feed?
BREAST FEED
 And then

 Breastfeed+Complimentary feed

 Then

 Family Food
 Feed
TO

 To ensure proper growth and

development.

 To stay healthy and disease free.

 Should contain
55-60% calories from carbohydrates,
10-12% from proteins
25-30% from fats.
What is malnutrition?

 Malnutrition is absolute or relative deficiency of

one or more macro or micronutrients .

 It could be less calories .

 unbalanced amounts of calories.

 Or it could be too many unbalanced calories.

Malnutrition

Under nutrition

and

Over nutrition.
 Under nutrition and child mortality

Perinatal &
Newborn
22%
 10.5 million children die before
their 5th birthday.
 under five mortality is 89/1000
Pneumonia live births.
20%
Malnutrition
54%
All other  54% of child mortality is
causes associated with underweight
29% condition
 The single largest common
Malaria denominator in global child deaths
8% is malnutrition
Measles
HIV/AIDS
5% Diarrhea 4%
12%
National nutritional survey 2011
 Underweight _________38%

 Stunted ___________36.8%

 Wasting ___________13.2%

 SAM (severely acute malnutrition)____________03%

 Anemic ____________50.9%

 Iron def. ____________35.9%

Undernutrition: Causes

 Improper or inadequate food intake

 Inadequate absorption of food
 Insufficient food supply
 Poor dietary habits
RISK FACTORS
MEDICAL, NUTRITIONAL FACTORS
 Low birth weight
 Twins
 Lactation failure
 Bottle feeding, over diluted milk
 Delayed weaning
 Food fads
 Inappropriate eating habits
 Lack of immunization
 Recurrent infections
 Measles
 Chronic diseases
RISK FACTORS
SOCIAL RISK FACTORS
 Maternal
 ill, working, incompetent
 Father
 ill, unemployed
 Parental loss
 Death, divorce, separation
 Drug addiction
 More than 2 children under 5 years of age
 Previous infant/ child death
 Large family size
 Poverty and in availability of food
 Girl child
 Under nutrition
Can take the form of
 Wasting (dangerously thin for one’s height)

 Stunting (too short for one’s age)



 Underweight (being underweight for one’s age)



 Micronutrient deficiencies (deficient in vitamins

and minerals)
NUTRITIONAL SCREENING
 ASSESSMENT METHODS

1) history & clinical examination

2) Anthropometry
3) Bio-Chemical
5) Proxy indicators(Vital Health Statistics)
6) Assessment of dietary intake
7) Ecological Studies
These methods are complimentary & not
mutually exclusive.
Nutritional Anthropometry
 ANTHROPOMETRY
1) Weight
2) Length / height
3) Weight for ht
4) Growth Velocity
5) Head circumference
6) Mid arm circumference
7) Head/Chest circumference Ratio
8) Skin Fold Thickness
9) Body Ratio
10) Body Mass Index (BMI)
Most Common Indicators

 Weight for Height (W/H) - "wasting"

 Height for Age (H/A) - "stunting"
 Weight for Age (W/A) – “growth faltering”
 Median Upper Arm Circumference (MUAC)
Growth
Charts
 9/1

Growth charts
 After completing this session participants will
be able to:
 explain the meaning of the standard curves
 plot a child’s weight on a growth chart
 interpret individual growth curves
 Definition: It is a visible display of a
child’s physical growth and development.
 First designed by David Morley .
 Growth chart offers a simple and inexpensive

way of monitoring weight gain.

 Any deviation from “normal” detected by

comparison with reference curves.

The WHO growth chart
 It has two reference curves.
 Upper reference curve -the median (50th
percentile)
Lower reference curve – 3rd percentile
 Space between two growth curves called
weight channel or road to health –
zone of normality for most population.
Interpretation

 Normal - growth line above 3rd percentile and

will run parallel to reference curves
 Abnormal- flattening or falling of child’s
weight curves signals growth failure
Earliest sign of PEM
Precede clinical signs by weeks or even months
such a child needs special care –objective; keep
child above 3rd percentile
Growth Chart Used
 It has four reference curves.
 Top most curve – 80 %of the median (50th
percentile) of the WHO reference standard
Lower lines represent 70% ,60% and 50% of
the standard.
 80% median weight approximately equal to
2 SD below the median which is the
conventional lower limit of “normal range”.
 Purpose of reference curve – indicates
degree of malnutrition.
INTERPRETATION
 1st degree (grade 1)malnutrition- child’s
weight between 80% and 70% lines.
 2nd degree (grade 2 or moderate)

malnutrition –child’s weight between 70%

and 60% lines.
 3rd degree (grade 3 severe) malnutrition

weight below 60% line.

 Grade 4-weight below 50% line.
 Weight b/w top 2 lines –considered

satisfactiory.
Management

 Weight b/w curves 1 & 3-

undernourished,require supplementary
feeding at home
 Weight below curve 3-consult the doctor and

follow his advice.

 Weight below curve 4-hospitalized for

treatment
9/2

Median

Low weight
for age

Very low
weight for
age
9/3
9/4

Median

Low weight
for age

Very low
weight for
age
9/5
Under nutrition
Classification of malnutrition

Moderate malnutrition Severe malnutrition

Symmetrical edema No Yes .edematous mal

Weight-for-height ˂-2≥-3 SD-Score, -3˂SD-score, (<70%)

(70-79%)e (severe wasting)

Height-for-age -3< SD-score <-2 SD-score <-3 (<85%)

(85-89%) (severe stunting)
Severe Malnutrition : Criteria

 Middle Upper Arm Circumference (MUAC) < 11.5cm in

children between 6 – 59 months of age

 Presence of Oedema on both feet

 Weight-for-height <70% or < -3SD of the median

Moderate Malnutrition : Criteria
 Middle Upper Arm Circumference (MUAC) < 12.5cm in
children between 6 – 59 months of age

 Oedema not present

 Weight-for-height <80% or < -2SD of the median

 CLASSIFICATION BASED ON Ht for age
Stunting
 Normal 100-95% of expected
 First degree of stunting 95-90% of
expected
 Second degree 90-85% of expected
 Third degree < 85% of expected
 WELLCOME OR INTERNATIONAL
CLASSIFICATION
 Weight between 80 and 60% of expected for
age
with edema kwashorkor
without edema
under nutrition
 Weight below 60% of expected for age

with edema marasmic

kwashorkor
without edema nutritional
marasmus
Spectrum of Malnutrition
Malnutrition has many faces

 Marasmus

 Kwashiorkor

 Marasmic Kwashiorkor

 Rickets

 Nutritional Anemia
MARASMUS

 Wise old man look

 Gross loss of subcutaneous fat
 Loose hanging skin folds in the axillary,
inguinal and buttock region
 Prominent eyes
 Alert look
 Good appetite
 No edema
 No skin and hair changes
KWASHIORKOR

 Generalized oedema (pitting oedema over

the ankles)

 Discolored easily pluck able hair (flag sign)

 Skin changes( flaky paint dermatitis)

 Apathic irritable, with poor appetite

 Hepatomegaly

 Multiple nutrient deficiencies

Management of malnourished child
Moderate Severe
Initial Treatment(1-7 days)

F-75 diet initial phase of treatment 80k cal/kg

to 100kcal/kg per day

Start 2-3hrly but gradually & frequency of

feeding & the volume till it is 4hrly (6
feeds/day)
REHABILITATION Phase (2-6wks)
Ready-to-Use Therapeutic Food (RUTF)
 Energy and nutrient dense:
500 kcal/92g
 No microbial growth even
when opened
 Safe and easy for home use
 Is ingested after breast milk
 Safe drinking water should be
provided
 Well liked by children
 Can be produced locally
 Is not given to infants under
6 months
Calculation of Caloric Target

 Expected Caloric intake for the age +

25% of expected caloric intake for
catch up growth

1-3 -1/2 of target will be started

50 cal/day will be increased from 0-

6 mo of age
100 cal/day will be increased from
7 months onward.
THANK YOU .