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