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
MARASMUS KWASHIORKOR
GROWTH RETARDATION (LINEAR) ++ +
SEVERELY UNDERWEIGHT ++ -
MUSCLEWASTING + ++
EDEMA - +
APATHY, FATIGUE + ++
IRRITABILITY + +
ELECTROLYTE IMBALANCED (HYPO-K) + +
HYPOALBUNEMIA - +
ANEMIA + ++
FATTY LIVER - +
LOW BODY TEMPERATURE + ++
FLAKY PAIN DERMATITIS - +

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 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 1–3 100 1.5
4-6 thn 1550 39 4–6 90 1.0
7-9 thn 1800 45 7–9 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: cow’s 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: cow’s 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 (con’t)
 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 Cow’s 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

 130/680 X 100 = 19 mosmol/100kcal

 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
 Susu aman untuk bayi karena <33
 Bila ingin mengentalkan, perlu tambahan cairan supaya
tidak dehidrasi
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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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