Paediatric clinical dietetics

Amaya Peñalva Arigita RD

Introduction

Dietetics is defined as the application of the principles of nutrition to the selection of food and the feeding of individuals and groups¹. Clinical dietetics covers the nutritional management of sick infants and children (either in an acute or chronic phase) to fulfill their requirements in a clinical and/or outpatient setting. This can be done in terms of adjusting the diet, adjusting menus, recommending certain foods, and/or using commercial nutritional supplements.

Table 16.1 Nutritional modules²

Nutrient	Module	Composition
Carbohydrates	Polycose®	Glucose polymers
1 g = 4 kcal	Fantomalt®	Glucose polymers
	Maxijul®	Glucose polymers
	Dextrinomaltose Resource®	Glucose polymers
Lipids	Resource MCT oil®	MCT
1 ml = 9 kcal	Liquigen®	MCT
	Solagen®	LCT
	Supracal®	LCT
Carbohydrates + lipids	Duocal/Duocal MCT®	Glucose polymers + LCT/MCT
1 g = 4.9 kcal	Duocal liquid® (1 ml = 1.6 kcal)	Glucose polymers + LCT/MCT
	Energivit®	Glucose polymers + LCT/MCT
	PFD-1® (1 g = 5.3 kcal)	Glucose polymers + LCT/MCT
	PFD-2® (1 g = 4 kcal)	Glucose polymers + LCT/MCT
Proteins	Promod®
1 g = 4.0 kcal	Protifar®	Whole protein

There are infants with certain diseases (metabolic, allergies) who need special enteral formulas to adapt the whole diet. Others may need supplementation, using nutritional modules that are added to a formula (Table 16.1).

Many studies demonstrate the advantages of nutritional supplementation in different groups of patients, improving the evolution of the disease, and decreasing the incidence of
complications³. Some children may require the use of paediatric supplements to increase their poor oral intake (Table 16.2). Other children may need a complete nutritional support via nasogastric tube (16.1), via gastrostomy (16.2), or by means of parenteral nutrition when the gastrointestinal tract is not functional. An adequate nutritional status allows a normal growth and development. Growth can be compromised in the presence of a chronic disease especially when it coincides with peaks of growth (infancy, puberty).

Table 16.2 Paediatric enteral formulae (for use in children older than 1 year)

Formula	Kcal/ml (per unit)	Proteins (g) (per unit)	Administration
Pediasure	1 (201)	5.6	Oral
Pediasure Fibre	1 (201)	5.6	Oral
Pediasure Plus	1.5 (300)	8.4	Oral
Isosource Junior	1.2 (305)	6.75	Oral
Isosource Junior Fibre	1.2 (300)	6.75	Oral
Resource CF	151/pack	4.9	Oral
Resource Protein	1.6/g (200/pot)	6 g per pot	Oral
Resource Junior	1.5 (300)	12	Oral
Fortini	1.5 (300)	6.8	Oral
Nutrini Energy	1.5 (300)	8.2	Enteral
Nutrini Energy Multi Fibre	1.5 (300)	8.2	Enteral
Novasource Junior Peptinex	1 (250)	7.5	Enteral/oral

16.1 A nasogastric tube may be useful for supplementing the oral intake. This is a girl with failure to thrive. She has a tracheostomy due to a laryngomalacia. She takes by mouth what she can and the rest is given by the nasogastric tube.

During growth, size increases and body composition changes. This implies certain nutritional requirements which are higher than those of the adult. Besides, the immaturity at birth involves special requirements in terms of
quality of nutrients, types of foods, and a limited response to overloading which can lead to complications. Therefore, there is a need to assess adequately nutritional status before starting any nutritional support.

16.2 A gastrostomy tube in a child with Menkes’ disease. As the disease progressed the child was unable to be fed normally and it became essential to find an alternative way: a gastrostomy tube placed by endoscopic procedure was the solution.

16.3 Algorithm of nutritional assessment.

Nutritional assessment

In the dietetic approach to a sick infant or child, it is essential to perform a correct nutritional assessment. There are a number of methods assessing specifics aspects of nutritional status, but no one measurement will give an overall picture of the status of all nutrients (16.3).

Clinical assessment

This includes a complete medical history and physical examination (Table 16.3). It is important to watch out for the constitution of the child; especially differentiating those who are skinny by genetics from those who have lost muscle mass. The presence of malnutrition signs, such as abdominal distension, presence of oedema, and hepatomegaly, should be evaluated, along with mood and behaviour as children may be apathetic and irritable. Biochemistry and haematological tests are also useful (Table 16.4).

Anthropometry is a physical examination which provides an indirect assessment of body composition and development. The child is growing continuously, and in each moment there is an ideal weight for a determined height. In acute malnutrition the weight may be altered maintaining the rate of height, although in a chronic state this rate also appears altered. This growth retardation is an important sign of malnutrition.

Table 16.3 Physical signs of malnutrition⁴^, ⁵

•	Skin: dry, scale, paleness, bruising
•	Hair: thin, sparse, straight (‘lifeless’), change in colour
•	Lips/mouth: stomatitis, cheilosis, lingual atrophy, colour changes of tongue, problems with teeth, gums
•	Face: fullness of cheeks (oedematous malnutrition), thyroid enlargement
•	Eyes: xerosis, keratomalacia, pale conjuctiva
•	Nails: spoon shape, koilonychie

Weight measurement is an easy and routine procedure (16.4). Children can be weighed in beam balance scales or electronic scales. Weight shows variability during the day, and it would be advisable to weigh always at the same time and with the same conditions⁷. Height measurement for infants and children less than 2 years old, is measured supine (16.5). From 2 years old, standing height is then measured whenever possible (16.6).

Skinfolds provide information about the changes produced in the subcutaneous components of the fat and fat-free mass. There are seven sites of measure: triceps, abdomen, chest, thigh, suprailiac (iliac crest), mid-axillar, and subscapular. They are measured with a skinfold caliper. Mid-arm circumference is useful to determine the state of muscle mass, as this area is hardly affected by oedema. This measurement is used in conjunction with the skinfold
triceps to differentiate between lean and fat.

Table 16.4 Laboratory tests (biochemical and haematological)⁶

Laboratory test help to define protein status, vitamin-mineral status and alterations of metabolism or organ function with nutrition implications
Proteins:
•	Total plasma protein: serum level may detect liver function; availability of amino acids (protein intake); distribution of protein; rate of protein use by the body
•	Albumin: (half-life 20 days). It accounts for over 50% of total serum proteins. Low levels reflect prolonged protein depletion as it breaks down slowly. Albumin concentrations though may be depressed by many conditions besides malnutrition
•	Transferrin: (half-life 4-8 days). It reflects protein and iron (as it transports it) status. When an iron deficiency is present it is not a good indicator of protein status. A marked decrease means a severe malnutrition condition. It is not a good indicator of response to nutrition therapy as it responds slowly to changes in protein intake
•	Prealbumin: (half-life 2 days). It responds quickly to changes in protein intake and is a good indicator of nutritional therapy. There are other conditions which can lower prealbumin levels and others, such as kidney disease (treated with corticosteroids), which can elevate it
•	Retinol-binding protein: (half-life 12 hours). It responds quickly to changes in protein intake and is a good indicator of nutritional therapy
•	Serum enzymes: to monitor organ function
•	Urine test: to detect protein status (by urinary urea nitrogen and creatinine excretion)
•	Haemoglobin; haematocrit, mean corpuscular volume, mean corpuscular haemoglobin
•	Total lymphocyte count: when malnutrition is present there is a reduction in white blood cell count
•	Vitamins: water-soluble and fat-soluble
•	Minerals: calcium, chloride, magnesium, sodium, potassium, selenium, copper, and zinc (its deficiency retards growth and typically accompanies protein-energy malnutrition)

16.4 Infant scale (10 g precision). Ideally infants should be weighed naked or just with a clean nappy, but if this is not possible it is important to record the way the child has been measured.

16.5 Two people are needed to measure length precisely: one to hold the child in position and the other to record the measurement. Measurement of length is difficult and it requires carefully positioning of the infant, ensuring that the back, legs, and head are straight, the heels are against the footboard, the shoulders are touching the baseboard, and the crown of the head is touching the headboard.

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