Nutritional Support

Pediatric Gastrointestinal Disorders

Johana Titus
Diana Sunardi
Deparrment of Nutrition
FMUI-CM Hospital
 References
Aryono Hendarto, materi kuliah modul
nutrisi pada gangguan GI anak

Nutrition in pediatrics 4th ed., basic Science

Clinical Applications 2008 ---- Duggan.
Watkins.Walkers

Krause’s Food & Nutrition Therapy 12th ed.,

2008 ---- L.K. Mahan & S. Escott-Stump
2
 Nutritional problem on
Infant/child

• Differences of GI development
• Gastrointestinal disorders (malabsorption)

Inadequate Nutritional Intake

Nutritional Support
3
 Developmental Differences
• Control swallowing <  6 weeks
• Stomach capacity <  very small and
peristalsis improves with age
• Relaxed cardiac sphincter <
• Infants have a deficiency of several enzymes
needed for digestion(until 4-6 months of age)

Abdominal distention and gas occur

Gastrointestinal Disorders
4
 Nutritional Support Goals

• Healthy child : Optimum Growth &

Development

• Out-clinic patient : Prevent Failure To Thrive

• In-clinic patient : Prevent hospital

malnutrition

5
 Nutrition Care
1. Clinical and Nutritional Status Assessment
2. Nutritional requirement
- Calory
- Carbohydrate, protein, fat
- Vitamin, mineral
3. Determine :
- Formula
- Route of Delivery
4. Monitoring
6
 Infant Feeding Practice
Age
Feeding
(months)
0-6 Breast feeding
Breast feeding
6 - 12 Complimentary feeding
(semisolid & solid foods)
Breastmilk until 2 yo
> 12
family food (solid food)
7
 Route of Delivery

• Oral Feeding
• Enteral Nutrition
• Parenteral Nutrion

8
 Nutritional support route
• Oral Nutrition Supplementation (ONS)
• Enteral :
 Naso Gastric Tube (NGT)
 Transpyloric (Naso duodenal-/Naso
Jejunal -Tube)
 Percutaneous Endogastrotomy (PEG)
Percutaneoues Endojejunostomy(PEJ)
Bolus or intermitent or continues
9
Naso- gastric, Duodenal, transpiloric
tube

Naso Gastric Tube Nasoduodenal tube/Transpilorik

10
Percutaneous Endo Gastrotomy
 Enteral formula for pediatric
• Hospital standar formula
(milk, low lactose, free lactose, non milk
formula)
• Commercial formula
 Polimeric
 Oligomeric
 Elemental
• Specific formula
11
 Pediatric’S foods
• Breast Milk • Special formula
• Formula milk Low lactose/Free
Starting formula lactose
Follow on formula
Soy formula
Growing up
formula Hypo
• Liquid food osmoler/hypoaller
• Semi solid/solid genic formula
food

12
 Infant 0 – 6 month of age
Non dehydration or mild-moderate
dehydration
Infant on Breast feeding
• Continue breast feeding
• Oral Rehydration Solution (ORS)
Infant on Formula Milk
• Continue Formula Milk
• ORS
• Diluted formula milk has no benefit
13
Infant 0-6 months on formula milk

Severe dehydration
• IVFD
• Continue Formula Milk
• ORS
• Diluted formula milk has no benefit
• Free lactose formula

14
 Infant 6-12 months of age
Non dehydration, mild-moderate dehydration
• Continue breast feeding/formula milk
• ORS
• Semi solid/solid food should be continued
• Food high in simple sugar should be avoided
• Highly specific diet such as BRAT (bananas,
rice,apple sauce & toast) commonly
recommended
15
 Infant 6-12 months
Severe dehydration
• IVFD
• Continue breast milk/formula free lactose
milk & ORS
• Semi solid/solid food should be continued
• Food high in simple sugar should be avoided
• Highly specific diet such as BRAT (bananas,
rice,apple sauce & toast) commonly
recommended
16
 Children more than 1 year
• Continue breast milk/formula milk
• ORS
• Solid food should be continued
• Food high in simple sugar should be avoided
• Highly specific diet such as BRAT (bananas,
rice,apple sauce & toast) commonly
recommended

17
 Nutrisi Parenteral
Macro- micro nutrien NP
 Protein………………………….. Amino acid
 Carbohydrate…………….. Dextrose
 Fat………………………………… Fat Emulsion
 Vitamin……………………….. Multivitamin IV
 Mineral………………………… Electrolite
&Trace Elements

18
 Type of parenteral

central or peripheral vein

central Peripheral

Length > 2 weeks < 2weeks

Osmolality (mosm/L) > 960 600-800

Fluid retriction + -
19
 Gastrointestinal disorders
• Colic • GERD
• Constipation • Gastritis
• Vomiting, • IBD,
• Gastroentritis ; • Crohn Disesis
Diarhea Ulceratif Colitis
• Pyroric stenosis • Appendictcities
• Hernias • Hepatitis
• NEC • Cirrhosis

20
 Colic
• Feeding disorder characterized by paroxysmal
abdominal pain of intestinal origin and
severe crying
• Sx: loud crying for several hours, face flushed,
drawing up of legs and clenches hands,
abdomen distended and firm
• Usually occurs under age of 3 mo
• Proposed causes: feeding too fast or
swallowing large amounts of air
21
 Management for alleviating colic

• Thorough history of diet and daily schedule

• Assess episodes of colic
• Provide rhythmic movement
• Alternate positions
• Reduce environmental stimuli
• Provide tactile stimuli
• Alter Intake

22
 Constipation
• Decrease in the frequency or passage of
stools, the formation of hard, dry stool, or
the oozing of stool past an impaction
Causes:
• Underlying disease or diet (frequent in
Toddlers and Preschool) change from formula
to cow’s milk
• Remove constipating foods (banana’s, rice,
cheese)
• Psychological factors and toilet training 23
 Constipation
Treatments:

• Fluids & dietary intervention are the first line

of therapy
• High fiber diets
• Lactose intolerance: Lactose free diet
• Toilet training
24
 Source of dietary fibers

• Fruits : apple, apricot, blueberries, dates,

pear, raisin, strawberry, avocado

• Vegetables: beans, broccoli, etc

• Cereals, jelly, pudding

25
 Vomiting
1. Small frequent feeding
2. Food choice according to child’s age
- Breast Feeding (BF)
- Formula milk (FM)
- Semi solid/ solid food
3. Nasogastric tube sometime is needed
- Formula milk
- Liquid food

26
 Gastroenteritis
• Inflammation of the stomach and intestines
that may be accompanied by vomiting and
diarrhea.
• Cause may be viral, bacterial or parasitic or a
chronic problem
• Under age of 5 average 2 episodes per year
• Infants and young children may become
dehydrated quickly. At risk for hypovolemic
shock and electrolyte imbalance
27
 Gastroenteritis
• Symptoms may be mild, moderate or severe
• Mild: slight increase in number and more
liquid
• Moderate: severe loose or watery stools, with
irritability, anorexia, nausea and vomiting
• Severe: continuous watery stools, symptoms
of electrolyte and fluid imbalance, irritable
and

28
 Gastroenteritis
Interventions:
• Monitor vital signs, fontanels, skin turgor,
capillary refill
• Observe stool for number, amount, color,
consistency
• Test for occult blood, provide stool for culture
and ovum/parasite
• Oral rehydration fluids and IV fluids
• Prevent skin breakdown
29
 Gastroenteritis
Notification of Health Care Provider if:
• Diarrhea or vomiting is increasing in
frequency or amount
• Diarrhea does not improve after 24 hours
• Vomiting continues for more than 24 hours
• Stool or vomit material contains blood

30
 Management Acute Diarrhea
• Dietary management depend on the age &
diet history of the patient
• Infant feeding practice
0 – 6 month : Breast feeding/ formula milk
6 – 12 months : BF/FM, semisolid & solid
foods
> 12 months : solid foods /family food

31
Chronic (intractable) diarrhea (1)
Infant

Nutritional screening to identify

Nutrition risk
Nutritional assessment
Nutrition care plan

32
Chronic (intractable) diarrhea (2)

children
Unable maintained nutritional status :
• Oral intake Enteral Nutrition  Parenteral
Nutrition
• Carbohydrate intolerant : EN formula with
• High fat, high MCT,

33
 Diarrhea in
severe malnutrition child
• Persistent diarrhea that occurs everyday for at
least 14 day
• Feeding guidelines are the same as for severe
malnutrition
• BF should be continued as often and for long as
the child wants
• Milk intolerance (rare)  replace cow milk with
commercial lactose free formula
34
 Formula diet for severe
malnutrition
Ingredient Amount

F-75 F-100

Dried skim milk 25 g 80 g

Sugar 70 g 50 g
Cereal flour 35 g -
Vegetable oil 27 g 60 g
Mineral mix 20 ml 20 ml
Vitamin mix 140 mg 140 mg
Water to make 1000 ml 1000 ml
35
 GER-GERD
• Return of gastric contents into esophagus
due to relaxation of the lower esophageal
sphincter
• Common in premature infants and children
with neuromuscular disorders
• Usually resolved without surgical intervention
by 12-18 months

36
 GER-GERD
• Vomiting, dysphagia, esophagitis

• weight loss, Poor weight gain

• Frequent respiratory problems, including

pneumonia, reactive airway disease are
possible if aspiration

37
 GERD
• Diagnosis: Upper GI, Upper GI endoscopy, pH probe
• Treatment: Feeding modifications Add cereal to
formula ( 1-6 tsp per ounce of formula)
• Avoid fatty foods, orange juice
• Medications: cholinergics, antacids, histamine
antagonists
• Position of child during feedings

38
GERD Dietary management

• Dietary intervention
Thickening feeds
Small frequent feeding

• Positioning
• Drugs
• Surgery
39
 Maintaining the Position of an
Infant Diagnosed with GER

• 30 degree elevation of the head of the bed

can be maintained by using a wedge or extra
blanket UNDER the mattress

• A commercial or home-made harness can be

used to ensure the infant is safely secured in
the head elevated prone position.
40
 GERD Dietary management
• 14 RCT : use of thickened formula vs
Standard formula

• Outcomes:
1. Episode of regurgitation & Vomiting
2. Episode of irritability
3. Crying & dysphagia
4. Regurgitation symptoms (irritability,
coughing,choking, night awaking)
41
 Inflammatory Bowel Disease
• Different than Irritable Bowel Syndrome
• Inflammatory involves faulty regulation of
immune response of the intestinal mucosa
(in genetically predisposed people) to triggers
• Two different disorders:
Crohn’s Disease
Ulcerative Colitis

42
 Crohn’s Disease
• Chronic inflammatory process
• Occurs randomly throughout GI tract
• Ileum, colon, and rectum most common
• Develops fistulas between loops of bowel or
nearby organs
• More common in whites and those of Jewish
descent

43
 Ulcerative Colitis
• Chronic recurrent disease of the colon and
rectal mucosa
• Can involve entire length of bowel with
varying degrees of inflammation, ulceration,
hemorrhage and edema
• Develops before the age of 20 with peak
onset at age 12
• More prevalent in people of Jewish descent

44
 Ulcerative Colitis
Sx:
• Diarrhea
• Lower abdominal pain and cramps that occur
before and during bowel movement but
relieved by it
• Stool mixed with blood and mucus
• Weight loss, delayed growth, nutritional
deficiencies and arthralgias often occur
45
Diet Instruciton for Inflammatory
Bowel Disease
• Small frequent feedings
• Limit fiber
• Offer high calorie meals
• Liquid dietary supplements
• Watch for foods that cause problems and
avoid in future
• Avoid strife at mealtime

46
 Treatment
for Crohn’s Disease and UC
• Pharmocolgy
• Antibiotics
• Anti-inflammatory
• Immuno-suppresive
• Anti-diarrheal
• Corticosteroids (oral or enema)
• Aminosalicylates
• Sulfasalizine Teaching Children/Parents About
Sulfasalazine 47
 Celiac Disease
• Gluten-sensitive enteropathy
• Malabsorption syndrome of gluten, a protein
found in wheat,barley, rye, and oats
• Common in Caucasian children
• 1%-4& of children with Down’s have Disease

48
 Symptoms of Celiac Disease
• Occur after • Failure to grow If
introduction of treatment delayed
solids/glutens (first • Delayed dentition
2 years of life) • Protein deficiency
• Large bulky, greasy, • Protruding
foul smelling, frothy abdomen/ wasting
stools (streatorrhea) muscles
• Vomiting • Irritability
49
 Treatment of Celiac Disease
• Gluten free diet

• Vitamin supplements

• Growth improves steadily with height and

weight returning to normal within a year
15/11/2019 51
Tambahan

52
 Failure to Thrive (FTT)

• Syndrome in which infants or young children

fail to eat enough food to be adequately
noursihed

• Accounts for 1-5% of pediatric admissions

under the age of 1
 Failure to Thrive
Etiology:

• Organic – AIDS, Inborn errors of metabolism,

Congenital heart defects, neurological
disease, esophageal reflux

• Non organic – most common- parental

 Failure to Thrive
Assessments – Physical and Behavioral
Behavioral Indicators
• avoidance of eye contact/touch
• intense watchfulness
• sleep disturbances
• lack of age-appropriate development
• repeated self-stimulating behaviors
problematic affect
 Failure to Thrive
Clinical Manifestations

• No weight gain or weight loss, not associated

with other known causes
• Infants refuse food, may have erratic sleep
patterns, and are irritable and difficult to
soothe.
• Often are developmentally delayed.
 Failure to Thrive
Treatments

Infant/child
Hospitalized to establish routines and
assessments

Caregiver (s)
Education and support
 Failure to Thrive
Reasons for Inadequate Nutritional Intake
• Over-dilution of formula
• Large quantities of cereal in bottle
• Excessive intake other than formula
• No set feeding times/routines
• Distractions during feedings
• Struggle over feedings
• Inappropriate texture of foods
• Poor breast feeding skills