2 crscm Key strategy to prevent stunting series : Early detection and prompt treatment of weight faltering in Top) JE RHOOD Damayanti Rusli Sjarif Div Pediatric Nutrition and Metabolic Diseases - Dent of ‘Dr Ciptomangunkucumo National Referral Hi Faculty of Medicine Universita “Ikaria INDONESIA ‘COPYRIGHT DRS 2020Africa and Asia bear the greatest share of all forms of malnutrition 4C HOH BOM In 2017, more than half of all In 2017, almost half of all In 2017, more than two thirds of stunted children under § lived overweight children under § all wasted children under 5 lived in Asia and more than one third lived in Asia and one quarter in Asia and more than one quarter lived in Africa. lived in Africa, lived in Africa, oup - Jonnt Child Mahutntion Estimates 2018 editorFood and Nutrition Bulletin, vol. 34, no. 2 (supplement) © 2013 Trend stunting in ASEAN countries 50 11996-2005 2000-2006 _m 2006-2010 p very high prevalence P Len pevaence 20 f Prevalence (%) L 1 ‘Cambodia Indonesia LaoPOR Malaysia Myanmar Philippines wgapore Vietnam FIG. 1. Changes in stunting prevalence betweep, 1996 ad 210 in Southeast Asian countries [7] with cutoffs indicating public health problem [8] “Why stunting received much attention ? * Childhood growth stunting has received much attention in public health because it erodes cognitive abilities and health outcomes during childhood and adulthood (Fernand and Grantham-McGregor, 2002; Grantham-McGregor et al., 2000; Grantham- McGregor, 1995; Pollitt et al.,1995) COPYRIGHT DRS 2020Stunting selalu diawali dengan penurunan berat badan (weight faltering) 050 § 2 | $f nee | = 050 LT é os Poe Ese 0 3 8 9 1215182124 27 30 33 98 39 42 45 48 51 54 57 60 Age (months) WAZ < -2 ~ Underweight (berat badan kurang) WAZ < -3 + Severely underweight (berat badan sangat kurang)Pendekatan Penyebab weight faltering untuk mencegah berlanjut menjadi stunting Weight faltering Kenaikkan BB tidak adekuat atau Ketidak mampuan mengonsumsi ‘makanan yang ada mis alergi makanan, kelainan metabolisme ‘bawaan, prematuritas dll COPYRIGHT DRS 2020Dampak weight faltering atau weight loss (Sjarif 2020) Weight faltering atau weight loss Dampak imunitas Imunitas tubuh menurun Dampak perkembangan otak Infeksi berulang Angka kesakitan dan kematia! ing! | Malnutrisi meningkat ORYRIGHT DRS 2020Dampak malnutrisi pada Imunitas Infection and MalnutritionGB rrommancers Child Mortality & Malnutrition Matnutrition is the #1 cause of preventable child deaths. When young chitdren are well nourished they are better able to fight off infection and lines. Vitamins and minerals help children combat the effects of malnutrition, so children can stay healthy, and stay alive% Adult During the first 1,000 days, the brain grows more quickly than at any other time in a person’s life and a child needs the right nutrients at the right time to feed her brain's rapid development 25% of a child's brain is developed during pregnancy & up to 80% before the age of 2 100 | ° o 3 Oe 60) 20 | | of brain size 20 | achieved 0 around 2 years 2 years old sommes KAt36 weeks pesation Newborn 3months — 6 months NTE Se NSURole of nutrition in synaptogenesis foc iapeeaes Second, Chon is used inthe mating ee of Brain Signals to Bet the Brain Active sonnet toiimprove Focus Fe orcaEffects of undernutrition on brain development Well-nourished infant Undernourished infant Impaired brain cells Limited branching copynicit ons 2020 Abnormal, shorter branches ‘Typical brain cells Extensive branchingLow invite ig 4 Schematic depiction of iterences between lowiQ ard high iQ niduak wih regard to bra vlume, neurite deny, and arbor eation of dendrite wees within the cortex HigIQ indus rely to possess more cortical volume than low-iQ individual which seated by dierent sized bras (elt side) and dtterenty sized panels showing exemplary magnaieations ol newton and neurite mcicatractare (right side) The diference i cores) volume i highihted by the shadow around the upper brain Due to thei larger cortices, & is conceratle that high individuals Benet from the ‘processing power of addlioal neurons. which are marked bythe dotted nein the lower pane The cerebral cortex of high 40 indie is chractrioad bya low degree of neurke dersty and eientation dapersion which is indcated by smaller and less tamed dendrite ees in the respective pel Inteectus! performance is Ukely to benet kom ths kindof microstucturd archtectine ance restricting smaptec connections town ecient iar ‘acitates the dterentition of signal om noise whe saving network and eneray resources. Newrons and neurites are depicted in tack ad gray to eate a serae of depth Please note ths depiction does not corregepmdth ertylenaentude ol llct sizes reported inthe sty. For the purpose oan fenier visual understanding. diferences both macrostructara and mcrostctural bran properties are highy accentuatedWeight Faltering in Infancy and IQ Levels at 8 Years in the Avon Longitudinal Study of Parents and Children Emond et al (Pediatrics 2007) Mean TQ levels according to weight gain from birth to 8 weeks. Shown are weight-gain z scores (eg, -1.5 represents greater than -1.75 to =1.25). no Mean 1Q 05% CD) 3 Dorless —-15 +10 0s 00 os 10 15 200rmore Multivariate analysis shows that early growth faltering (slowest gaining 5% of term infants in the first 8 weeks) is associated with an n average deficit of ~31Q points ryan ftsirSj2002018Impaired IQ and academic skills in lt who experienced it : A 40-year study (Waber et al Nutritional Rewecclence 2014) Figure 2 Distribution of 1@ scores for previcusty matnourished (MAL, W— 77) and healthy control (HC, N= 59) groups. 25% infants who experienced malnutrition will have IQ 51-70 at 40 years old 40% infants who experienced malnutrition will have IQ 71-90 at 40 years old COPYRIGHT DRS 2020Modern diet and Physical inactivity ty Ob Hypertension Diabetes 1, - Figure 3 ~ Association between stimting. obesity, hypertension and diabetes.Table 3. Conditions associated to stunting in children and adults Children Depressed immune function Defects of cognitive functions mpaired fat oxidation Reduced glucose tolerance Coronary heart disease Hypertension Osteoporosis wow(,Branca & Ferrari, 2002)Summary of immune parameters affected and not affected by malnutrition. ‘Affected in Unaffected by malnutrition [ff Affected in severe malnutrition moderate malnutrition Gastric acid production ‘otal leukocytes in blood Flow of saliva L x aia Secretory lgA (saliva and tears) Total lymphocytes in blood Gut permeability * T-cell count in blood Inflammatory cells in intestine C04 cel count in blood ‘Microbicidal activity of granulocytes Blood dendritic cells ‘Total immulogiobulins in blood Blood complement factors 4 te and itn thcod Delayed type hypersensitivity Proliferative response to PHA J ‘Secretory fA in urine and Effector T-cells L tenal fuld Apoptosis in lymphocytes ‘Becells in blood J CRP rise with infections ein blood * Inflammatory cytokines (IL6, ‘TWFa) Aytter MH, KolteL, Bnend A, Fis H, Christensen VB (2018) The Immune System in Unlgren with Malnutntion--A Systemate Review. PLOS ONE (8) €105017. https://éo1org/10.1371/journal pone 0105017 EPL OS ONRespons imun terhadap virus MERS-CoV MERS-Cov a a Recognition a . o 3 a 1FNG 1L-23/1L-17 Antigen ‘Antigen Presentation) 1La2 Presentation TCI tL tet orth _ LIENy TCcDs+ io Sor « cDB+ Proliferation proliferation Meo Wieeiceeal Controlled immune Response MMe Uncontrolled Immune Response FigureMean developmental quotient (DQ) scores of five groups of children over two years, The (groups are non-stunted children, and stunted children who received both stimulation and supplementation, supplementation alone, stimulation alone, and no intervention (contre!) [Grantham-MeGregor SM, Schofield W, Powell C 1987) 110 105 100 85 Baseline 6mo 12 mo 18 mo 24 mo --@- Control —-O-— Supplemented —O— Stimulated ~@-- Both —™— Non-stunted Infancy and toddlerhood2.0 - @Not stunted, age 2 y OStunted, age 2 y ill Highest Grade Mean cognitive test Z-score, age Il y ° FIGURE3 = Schooling was associated with improved cognitive test scores regardless of stunting status at age 2 y (The Cebu Longitudinal Health and Nutritional Survey) J. Nutr. 129: 1555-1562, 1999Pye) Ia @ SCORES (2009 - 2018) * Higher score is betterMalaysia Thailand Indonesia %15 year-olds in ASEAN nations performing poorly in science, maths and/or reading (Source: PISA 2015) Percentage performing below Level 2in: "Only one of three areas ca Tworofthree areas All three areas No areasele Lei Pendidikan CCT TUAW bedrest ereel TEL (Sjarif 2018)early adiposity rebound ‘hee: 1 mo Smo) Lscore 1BMI (Body Mass Inde, kin) ADIPOSITY REBOUND 4 Ss 6 7 8 “AGEyvears)ES (MES. Find incomational sent ae Timing of adiposity rebound in 805 Chilean children born in 2002, by Body Mass Index status at 7 years Acar hes toes srenbeed om WD S06, 1 Timing of Adiposity Rebound 12 Body Mass index = Bey BALD? 6 s zl f Gos * 4sy * Bs7 0 7 5 K B Ore eNnBeuneeane oO Age (months) BAz<1 12 mane ll ww wert ongImpact of various forms of malnutrition on productivity and lifetime earnings Form of malnutrition Estimated loss of productivity or earnings (%) Protein-energy malnutniticn PEM) Iron deficiency (Ganenyace:8 Susi: Alderman and Behrman; Harton and Rose; HortanThe World Health Organization's global target for reducing stunting by 2025 * Because stunting is not treatable, it calls for preventive measures; however, it remains unclear which actions and when in the life course are the most efficacious interventions to be implemented at scale within limited development budgets."The Journal of Nutiion. First publlahed ahead of print October 14, 2015 as dol: 10.3945/jn.115.211896. w Nutritional Epidemiology Successive 1-Month Weight Increments in Infancy Can Be Used to Screen for Faltering Linear Growth"? + Under the assumption that the prevention of poor weight gain would prevent stunting, the proportion of stunting that could be averted in the group who experienced the event is estimated at up to 34% at 12 mo and 24% at 24 mo.Stages of Growth and Development 5 if : a8 At Preterm — Newborn Infant Toddlers }Preschool School-age Adolescents Newborn (0-28 d (28 days — Child Child (12-48 years) = Y2merths) ‘TERS ths) (2-Syears) (6-11 years)Percentage of Adult Brain Weight Brain Growth by Age Age in Yearskg/yr 14 Weight gain Age yearsWeight increments toddler at 12 mo is 1/5 weight increments at 2 mo Toon 2 ue ee yer 9 64.84 84, ee nd a iFood refusal is a normal phase of toddlerhood — Most toddler will pass this normal phase without any problems Fear of new foods (neophobia) may be a survival mechanism to revent increasingly mobile oddlers from poisoning themselves through eating anything and everything — They need to taste ita few times to learn to like it, so always offer it the next time . Nutrition challenges in toddlerhood The quantity of food toddlers eat may vary from day-to-day. — Toddler may eat less food than other toddlers of the same age. — If toddler is growing and developing normally then he or she ts taking the right quantity of food for his or her own needs. Some parents get anxious about this and toddlers then tend to react to parental anxiety by reducing intake. COPYRIGHT DRS 2020T.M. Dovey et al. / Appetite $0 (2008) 181-193 First viewing of First taste of the novel food the novel food — ‘Picky/Fussy’ Child Food Neophobic Child Refusal of food After 15 Exposures Exposure Fig. 2. Likelihood for acceptance of fruits and Fege{abies in food neophobic and ‘picky/fussy’ eating children.Feeding Conflict Parental Feeding resistance pressure with decelerating to eat c weight gain ‘COPYRIGHT DR ‘Dragnosis end Treatment of Feeding Disarders in infants. Todsfers, shildren, Washington, DC: Zero to Three, 2009Prevalence of Feeding Problems * Physically normal children — 50% to 60% of parents report feeding difficulty — 20% to 30% of children are implicated — 1% to 2% have severe and prolonged problems Lindberg L, et al. Int J Eat Disord. 1991;10:395405 Jin X, etal. Chinese J Child Health Care. 2009;17:3879The spectrum is remarkably wide > mostly should be identify and manage by general ped in/primary care provider Feeding team eS ee Oromotor specialist and/or Gastroenterologist Ne, —” DietitianBut in reality ,,,,,, Only 50% of mothers think pediatricians suggestions resolved feeding problems Not helptut Party heiptul; not resolved ‘Hetptut Mean 1 2 3 4 6 8 Age (years) Base: all respondents (n=) 1244 172 287 196 282 223 124 Jin X et al. Chinese J Child Health Care. 2009; 17:387-389,392ALGORITMA I PENDEKATAN DIAGNOSIS MASALAH MAKAN PADA BATITA di Indonesia (Sjarif 2012) Feeding problems or FTT | (1109) —— ) Normal Nutritional State 553 ‘Application Food Rules (-) Inappropriate | Feeding Misperception Practices COPYRIGHT DRS 2020 Application | Food Rules (+)ALGORITMA II PENDEKATAN DIAGNOSIS MASALAH MAKAN PADA BATITA di Indonesia (Sjarif 2012) Inappropriate Feeding Practices Application of Food Rules ——s Primary inaprroprite feeding practices COPYRIGHT DRS 2020Final Classification and Suggested Management Toddler Feeding Problems in Indonesia (Sjarif 2012) Misperception (5,2%) — Parental reassurances — Further application of Food Rules Primary inappropriate feeding practices (29,5%) — Further application of Food Rules Small eaters (55,9%) — Application of food rules — Oral nutrition Suplement (ONS) Selective Eaters (9,4%) — Systematic introduced of new/variety of food Study of Identification and Management Feeding Problems in Indonesia (Sjarif et al 2012)What is failure to thrive ? * Concept of FTT was described firstly by Holt (1897) — the infant or young child who fails to gain weight properly (weight faltering, flat growth (stagnation) or weight loss) * Problem — no consensus exists concerning the specific anthropometrical criteria > systematic reviews (Olsen 2006) COPYRIGHT DRS 2020‘SPECIFIC CRITERIA USED IN CONNECTION WITH GROWTH VELOCITY From ether: normal at birth or above the 3d percentile. Weight velocty < rd percent onthe Fels incremental growth chat 1 Fallin height-for-age of welght-Jorheight «10th percentie 1 Number Using Specitic Criteria Each Criterion Downward crossing (of weight-for-age) > 2 major percentile lines 9 9, 15, 20,21, 27, 32,37, 40, 42 Slowest gaining 5% on a conditional weight gaining chart 6 8,10, 15-17,41 Fallin weight-torage (or height-fr-age or weight-for-height) 4 21, 22,28, 96 << Sth percentile From either: normal at bith, above the Sth percentile or an earlier established growth curve Weight gaining rate less than a given threshold measured in grams per dy 3 20, 4,42 Documented werght loss. 2 20,42 Fallin weight-torage < 3rd percent 2 27,0 12 a Olsen,.Clin Pediatr. 2006;45:1-6Olsen’s Conclusions * Defining FTT solely by anthropometrical growth monitoring, not a diagnosis but a sign * Weight gain is predominant choice of indicator FTT — Failure to thrive does not mean failure to grow. — Weight gain is primarily affected, there is less effect on length and minimal effect on head circumference — More appropriate term are + weight faltering ~ weight loss ~ slow weight gain — Wasting is the condition of immediate concern AFTER weight faltering because of risk of death. COPYRIGHT DRS 2020LUPE Ter sy Pare Ly Complications Relative to Loss of Lean Body Mass* Lean Bony Mass ASSOCIATED (% toss OF TOTAL) bap ce ean Mortaury (%) Impaired immunity, Mild malnourished | increased infection Decreased healing, weakness, infection Moderate Fit WASTED 30 Too weak to sit, pressure Severe malnourished | sores, pneumonia, no healing RE WASTED Death, usually from pneumonia “Assuming no preexisting loss,To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis. J Child Psychol Psychiatry. 2004;45: 641-654 ee * + Meta-analysis, 11 ’ tI controlled studies which was based on Le! 502 cases and 523 controls shows that a early growth ates -— faltering is meen — associated with an : average deficit of 4.2 IQ points (95% Cl: 2-6) Standardised mean diterence, 25% Cl Corbett & Drewett 2004New indicator of FTT Newer growth indices from the World Health Organization use — weight velocities * in which a child's weight change in grams over a one- or two-month interval is compared with population data for that child's specific age. — Any weight change < 5th percentile may indicate a child is at risk of FTT — The use of weight velocities allows for rapid assessment of poor weight gain while accounting for age-dependent changes in growth. (http://www.who.int/childgrowth/standards /w_velocity/en/index.html),Menentukan weight faltering menggunakan Tabel Weight Increments WHO (hanya untuk 12 bulan), bagaimana untuk toddler ? Simplified field tables 1-month weight Increments (g) GIRLS World Health Birth to 12 months (percentiles) Organization 378 232 | 383 WHO Growth’ Veldcity'StandardsProposed Cara menentukan weight faltering pada batita Kenaikkan BB < 240 g/bulan ‘APPROXIMATE ‘APPROXIMATE GROWTH IN HEAD RECOMMENDED DAILY WEIGt MONTHLY GROWTH IN CIRCUMFERENCE DAILY ALLOWANCE AGE GAIN (g) WEIGHTGAIN. LENGTH (cr/mo) (aw/mo) (kcal/kg/day) Bb (Neison Textbook of Pediatrics 20th)Case Jakarta 58 A 12 mo old boy, consulted due to no gain weight since 2 months ago, with feeding problems. He refused to eat since 10 mos old and the mother induced it by eating >1 hour, playing or watching TV during eating., replace meals with milk. Eat only a small amount of food (cerelac, rice porridge) 3 times /day (same food) , 2 times snacks (fruit and Farley), GUM milk 5-6 times/day. Mother avoid to give egg and seafood except salmon due to allergy prevention He likes “adult food”, but his mother did not allowed him to eat because afraid that his gut is not mature enough.Evaluation of Failure to Thrive Are red flag signs or symptoms present (Table 3)? No Yes Proceed with Consider complete blood count, serum evaluation and electrolyte levels, blood urea nitrogen management measurement, creatinine levels, of appropriate urinalysis, urine culture, erythrocyte caloric intake sedimentation rate, thyroid function testing, liver function testing 4 If indicated by history, physical examination. or initial laboratory testing, Applied consider the following: complement levels, echocardiography, human Pediatric Nutrition Care cr cnodenciency virus or hepatitis serology, immunoglobulin levels, purified protein derivative test, stool culture for ova and parasites, stool analysis for fat content and reducing substances Figure 1. Algorithm for the evaluation of failure to thrive. Information from references 20, "33°37"% WHO Anthro 3.2 WHO Anthro provides information about the physical development of children pscore wom Weightforage | os Em MUAC tor age NANA Length-orege |} 56 EE TSF torege wom Bitoroge 09 EEE ssttorage wom B 0 2 50 75 10 CcoPmuGHT ORS 2020 0 25 50 75 100weight 7,250 g, length 72 cm “WAZ -2,60 = “LAZ — 1,59 WHZ - 2,53Table 3. Food rules applicable to children beyond infan SCHEDULING + Regular mealtimes; only planned snacks added + Mealtimes no longer than 30 min + Nothing offered between meals except water ENVIRONMENT + Neutral atmosphere (no forcing of food) * Sheet under chair to catch mess + No game playing + Food never given as reward or present PROCEDURES + Small portions + Solids first, fluids last + Self-feeding encouraged as much as possible + Food removed after 10-15 min if child plays without eating + Meal terminated if child throws food in anger ° Wi child's mouth and cleaning up occurs only after meal is completedInappropriate feeding practices (Multicenter feeding problems study, Sjarif et al 2012) CET N KS No scheduled mealtime OR eatmore than 680 75.8% 30 minutes Eating while watching TV 579 64.5% Eating while playing 814 90.7% Late/inadequate introduction of solids 798 89.9% Forcing child to eat 257 28.7% Food is not appropriate to age 604 67.3% - Milk >500 mL 145/604 24% - Breastfeeding >5 times/day 68/604 11.2% COPYRIGHT DRS 2020Appropriateness of Food Textures according to age cerelac, rice porridge for 18 mos toddler ? Food Texture Baby Led according to their neurology system development (rooting reflex, tongue thrust reflex, suck-swallow pattern, gag reflex dan bite reflex). 6to 8 months Liquid, puree, blended, mashed & soft food. 9 to 11 months Chopped. diced & nutritious finger food.Maternal strategies to address feeding problems in toddler (Multicenter feeding problems study, Sjarif et al 2012) Force child to eat 23.8% various food Offer other nutriments. Induce ‘the child to eat various food Other strategies: + Let the child not to eat till hungry, listening to music, ete.Redflags (-) Table 3. Red Flag Signs and Symptoms Suggesting Medical Causes of Failure to Thrive Cardiac findings suggesting congenital heart disease or heart failure (e¢.g., murmur, edema, jugular venous distention) Developmental delay Dysmorphic features Failure to gain weight despite adequate caloric intake Organomegaly or lymphadenopathy Recurrent or severe respiratory, mucocutaneous, or urinary infection Recurrent vomiting, diarrhea, or dehydration Information from references 20,,.23,,25,,26, and 29.Pediatric Nutrition Care Assessment — Underweight, normal stature & moderate malnutrition (wasted) — No weight gain for 2 mos — flat growth (stagnation) (FTT) — Feeding problems — inappropriate feeding practice — Inappropriate food textures — Looking for red flags — Laboratory : blood and urine culture Requirement — Application of Food Rules + Scheduled (no food except water between meals), neutral environment (sit, no play or TV, max 30 min, no force, stop feeding when he doesn’t want to eat anymore Application of Food Rules Route of delivery — oral Type of food —- Family Foods wiyh appropriate textures for age Monitoring — controlled next weekFeeding Rules (Scheduling) 06.00 08.00 10.00 12.00 14.00 16.00 18.00 20.00 Milk Breakfast (family food : nasi uduk, chicken porridge) Snacks (high calory fruits, milk shakes, lemper, kroket, ice cream, etc) Lunch (rice opor, fried noodle, etc) Milk Snacks Dinner (spaghetti, baked potatos/ macaroni) Milk15* Monitoring (2 weeks) Monitoring + Acceptability — He likes to eat family food but only small amount , however at meal times he looked happy and ask for meals (mam, mam) = parents so happy + Food adverse reaction - Lab no iron deficiency nor uTl + Effectivity — Weight gain 50g / 2 weeks (expected weight gained Bg/day x 14 days = 112 g/2 weeks)— weight faltering (failure to thrive) Diagnosis & Management + Working Diagnosis - Small eater & wasted + Management — Feeding rules reassurance — Boost food calories and ONS (on schedulled time) — Controlled next 2 weeksWhat is Oral nutritional supplements (ONS) ? + Supplementary oral intake of dietary food for grecial medical purposes in addition to the normal ‘ood. + Classify as enteral nutrition * Composition + Energy standard 0,9-1,2 kcal/mL or >1,2 kkal/ml as high energy + Protein 15-20% + ONS are usually liquid but they are also available in other forms like powder, dessert-style or bars. + Synonyms used in literature: sip feeds (ESPEN 2006, ESPGHAN 2010)ONS is FSMP + W 7250 — 7300 g.L 72cm Height Age = 9 mo—RDA 110 kcal/kg ; IBW 8,9 kg — Requirement : 8,9 x 110 kcal = 979 kcal — ONS (30%) — 294 kkal ~ + ONS 1 kcal/mL ~=3X100 mL + ONS 1,5 kcal/ml ~3X 65mlWorld Health Organization Weight-for-length BOYS Birth to 2 years (z-scores) World Health Organization cm -3 SD -2SD -1 SD 60.0 5.4 5.5 60.5 5.2 5.6 Zu5 LS 24 72.0 7.6 8.2 72.5 7.6 8.ONS is FSMP + W 7250 — 7300 g.L 72cm * Height Age = 9 mo—RDA 110 kcal/kg ; IBW 8,9 kg — Requirement : 8,9 x 110 kcal = 979 kcal — ONS (30%) — 294 kkal = * ONS 1 kcal/mL =3X100 mL + ONS 1,5 kcal/ml =3X 65mlple 38 otein and energy needs tor catch-up growth at different rats of weight gain Typical composition of weight High rate of fat deposition” gain" 3.29 6.12 5.99 nts: Rate of gain Protein Energy! Energy” Protein’ (g/kg per day) (g/kg/day) (keal/kg/day) teoatupiciay) eneray i 02 80 oF 42 2 122 93. 5.2 97 45 5 1.82 105 69 115 5.2 10 2.82 126 8.9 145 6.0 20 4.82 15 205 69 t equivalent to 14% protein and 27% fat. © 50:60 lean:fat equivalent to 9.6% protein and 50% fat * Based on 5.65 keal/g protein and 9.25 keal/g fat. “Net costs adjusted for a 90% and 73% metabol tabolizable eneray of additional non-utilized protein. tod for a 70% efficiency of utilization plus the safe level of maintenance at 1240.66 g/kg per day ~ 0.82 (cee cection 11). ' Maintenance eneray at 85 keal/g (which includes maintenance protein eneray) + gross energy costes 4.10 keal/g weight gain. ° 9.7% deposited tissue adjusted for a 70% efficiency of utilization plus the safe level of maintenance at 1.24x0.66 g/kg per day = 0.82 g/kg per day: 1.27x0.58 g/kg por day = 0.737 (see section 11) As in footnote “f except that gross energy costs are 5.99 keal/g weight gain, WHO technical report series ; no. 935, 2002Protein and energy needs for catch-up growth at different rates of weight gain WHO technical report series ; no. 935 Rate of gain _—Protein® Energy‘ Protein/ (g/kg per day) (g/kg/day) (kcal/kg/day) energy (%) 1 1.02 89 4.6 2 1.22 93 5.2 5 1.82 105 6.9 10 2.82 126 8.9 20 4.82 167 115Catch-up in height in stunted children WHO technical report series ; no. 935 Malcolm (British Journal of Nutrition, 1970,24:297-305) = markedly stimulated height growth by increasing the protein:energy ratio of children’s diets from 4,3% to 8,4%, — with evidence that such a diet was energy- rather than protein- limited, judging by the fall in adiposity that accompanied the accelerated linear growth. Fjeld, Schoeller & Brown (American Journal of Clinical Nutrition, 1989, 50:1266-1275) — reported faster linear growth with 11% compared with 8% protein calories. Kabir et al. (American Journal of Clinical Nutrition, 1993, 57:441-445) — increased linear growth in 2-4-year-old children by increasing the protein:energy ratio of a standard diet from 7.5% to 15%,PE% various ONS available in Indonesia (©Sjarif 2020) Protein Energy Protein Energy gram/? Kkal_—_| kkal/ml % Inf liq 2,6 g/100 kkal | 4 10,4 polymeric Pp 3g/M00kkal | 1 12 polymeric NJ 8g/250 kkal | 4 12,8 polymeric Pept 7,5/250 kkal | 1 12 oligomeric Neoc J 2,8 g/100 kkal | 4 11,2 monomeric E 6 g/200 kkal | 4 12 polymeric 8 69/270 kkal | 1,35 89 polymeric Nut Liq 6,6 g/300 kkal | 1,5 88 polymeric Supp 40g450kkal | 1,5,.,...., 26,7 polymericCategories of commercially prepared formula e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) Commercially prepared formula Oligomeric or Polymeric semi elemental formula enzymatically intact proteins hydrolyzed ree are casein or wheyLooking for Product Information of ONS Nutrition Fact Nutrient Unit Powder Dilution cores Per 100m! Energy kcal 464 100 — 1kcalimi Protein 9g 13.87 3 PER 12% Fat 9g 18.12 3.91 Linoleic acid mg 417 0.9 a-Linolenic acid mg 0.47 0.1 DHA mg 21 5 “The standard reconstitution is 216 g/L. A single serving is prepared by mixing 5 scoops (48.6 g) of powder with 190 mL of water to yield approximately 225 mL of beverage 1 scoops = 9,8 g, dilarutkan dengan 38 ml air untuk mendapatkan 1kkal/mlPOOL Quiz 1 PERMENKES NO 29 THN 2019 Pasal berapa yang mengharuskan dokter spesialis anak meresepkan PKMK ? a) Pasal 11 b) Pasal 12 c) Pasal 13 d) Pasal 14How to make prescription for ONS ? * 1 scoop ONS 9,8 g = 45,5 kcal , content of can of ONS 400g Periods of 2 weeks , he need 3X 2X14 = 84 scoops = 823,2 g (2 cans @ 400g or 1 can @ 800 g) Prescription R Oral Nutrition Supp! 1 kcal/m! 400 g no Il [3 dd 2 scoops (diluted with 76 mL water)2"4 Evaluation W 7600 (gain 300 g/2 weeks — >120g/2weeks Final diagnosis : small eaterTake home messages Stunting is not treatable but preventable Key strategy to prevent stunting is early detection and prompt treatment of weight faltering Criteria of weight faltering for toddler (WHO 2006) is available for 2 months interval, for monthly evaluation proposed is less than 240 g per month Toddler weight faltering etiologies could be classified through combination of nutrional states and application of food rules into misperception, small eaters and inappropriate feeding practices Application 1-2 weeks of food rules and its impact on weight gain could differentiate primary (due to ignorancy) and secondary inappropriate feeding problems (due to small eaters or selective eaters) Oral nutrition supplement is indicated in small eaters. Oral Nutrition Supplement classified as Food for Special Medically Purposed, so the used of it should be under prescription and supervision of pediatrician.Kasus Made Corvid (MC), anak laki-laki usia 18 bulan datang dibawa oleh ibunya karena sulit makan dan terlihat kurus. MC hanya makan nasi 3-4 sendok kecil saja, kadang-kadang makan daging sapi, ayam, dan ikan dengan porsi kecil dan sering dilepeh, juga tidak suka sayur dan buah. Minum susu UHT 2x120 mi. Ibu tetap mencoba memberi makan dan membujuknya dengan menonton televisi, bermain, dan digendong berjalan-jalan dengan waktu lebih dari 1 jam setiap kali makan. BB 8,6 kg, PB 80 cmTable 3. Food rules applicable to children beyond fan SCHEDULING + Regular mealtimes; only planned snacks added + Mealtimes no longer than 20 nin ——— xX * Nothing offered between meals except water ENVIRONMENT + Neutral atmosphere (no forcing of food) + Sheet under chair to catch mess e No game playing —————— xX + Food never given as reward or present PROCEDURES * Small portions * Solids first, fluids last + Self-feeding encouraged as much as possible + Food removed after 10-15 min if child plays without eating + Meal terminated if child throws food in anger * Wiping child's mouth and cleaning up occurs only after Bemard-Bont meal is completed en mJadwal Makan sesuai food rules Jam 06 : UHT 120 ml © Jadwal makan teratur : 3x Jam 08 : makan pagi utama + 2x selingan dan 3x UHT Jam 10 : selingan © Tiap episode makan < 30 menit © Tanpa distraksi : tidak bermain, nonton ty atau Jam 18 : makan malam berkeliling halaman. Jam 12 : makan siang Jam 14 : UHT 120 ml Jam 16 : selingan Jam 20 : UHT 120 mlFollow-up Setelah 2 minggu menerapkan feeding rules. MC mulai mau makan sesuai jadwal, makan tidak lebih dari 30 menit dan tanpa distraksi. Jadi food rules sudah benar. Tetapi berat badan tidak naik dalam 2 minggu. Dan porsi makan dan minumnya tetap sedikit.Q2. Apa diagnosis masalah makan saat ini ? A. Inappropriate feeding practice B. Small eater C. Selected eater D. Mispersepsi —Algoritma pendekatan diagnosis dan tata laksana masalah makanJadwal Mgsegiimtigys Uai food Jam 06: Jam 08 : Jam 10: Jam 12: Jam 14: Jam 16 Jam 20: ONS makan pagi selingan makan siang ONS : selingan Jam 18 makan malam ONS rules © UHT diganti dengan ONS (Oral Nutrition Supplement) © Pelaksanaan food rules tetap dijalankan. ¢ Jadwal makan teratur © Episode < 30’ © Tanpa distraksi e Variasi makanan tetap dilanjutkan, terutama sumber protein hewani.Q4. Kriteria ONS (oral nutrition supplement) adalah... A. > 0,67 keal/ml B. > 0,9 keal/ml C. > 1,0 keal/ml D. > 1,5 keal/ml ieneApa itu ONS ? © Menurut Codex Alimentarius : ¢ Asupan oral/enteral untuk tujuan medis khusus (FSMP/foods for special medical purposes) © Densitas energi 0,9-1,2 keal/ml © Penggunaannya diawasi/diresepkan oleh dokter ~ asuhan nutrisi pediatrik. © Permenkes No. 29 Tahun 2019 ¢ Pangan Olahan untuk Keperluan Medis Khusus (PKMK) © Resep Sp.A atas indikasi medis @ Pengawasan oleh Sp.A © Oral nutrition supplement (ONS) densitas > 0,9 keal/ml.Produk ONS: Nutrition Info Unit | Powderper | Standard Ts Da Ue Energy kcal 464 100 - Carbohydrate g 62,75 13,5 53,0 Protein g 13,87 3 12,0 Fat g 18,12 3,91 35,0 Linoleic acid mg 4,17 0,9 a-Linolenic acid mg 0,47 0.1 DHA mg 2 5 *The standard reconstitution is 216 g/L. A single serving is prepared by mixing 5 scoops (49 g) of powder with 190 ml of water to yield approximately 225 ml of beverage. 1 scoop = 9,8 g = 45 kcal. coop tambahkan air 38 ml untuk mendapatkan 1 keal/ml ng= 400 a vlAlternatif menggunakan Tabel WHO Simplified field tables Weight-for-age BOYS ¢ Ey) World Health Birth to 5 years (z-scores) ins ye Organization 1 ‘Year: Month | Months | _-3sD_| -2sD_| -1SD_| Median sD 2SD 3sD 4 1 x 1 1 slo jo |e joRecommended Dietary Allowance (RDA) Energi (kcal/kg/hari) Usia (tahun) 0-0,5 120 0.5-1,0 10 13 100 46 90 7-9 80 10-12 70Pedoman MP-ASI WHO STRUT me ic cotat MTSE 6-8 615 200 (30%) 23 415 (70%) 9-1 686 300 (50%) 3-4 386 (50%) 12-24 894 550(70%) 3-4+1-2 344 (30%) snack hy Zo)Q8. Bagaimana cara menuliskan resep ? © Bila ONS yang anda dipilih 1 keal/ml ® 1 takar/scoop ONS tersebut mengandung 45 kcal -_< 2 © 1 takar/scoop ONS = 988 / _ ) © | takar/scoop ONS diasiche dengan sm yy Kita butuh untuk 14 hari \ Silahkan tulis jawaban anda ey,Preskripsi ONS © Kebutuhan ONS = 30% x 1040 keal/hari ~ 300 kcal/hari ~ 300 mVhari © 1 scoop = 9.7 g=45 kcal © Perhitungan = 300/45 =+ 7 scoop x 9,8 = 68.6 g/hari x 14 hari = 960 gselama 14 hari. © 1 kaleng = 400 g > membutuhkan 960/400 = 2.4 kaleng ~ 3 kaleng selama 14 hari © Dosis per hari: 3 x 2 scoop © Cara pembuatan: © 2scoop + 76 ml air ~ 100 ml setiap kali minum © Diberikan 3x per hariJadwal makan sesuai food rules Jam 06 : ONS 100 ml © Follow-up 2 minggu Jam 08 : makan pagi kemudian Jam 10 : selingan © Evaluasi food rules Jam 12 : makan siang © Evaluasi berat badan Jam 14: ONS 100 ml Jam 16 : selingan Jam 18 : makan malam Jam 20: ONS 100 ml