營養狀況要怎麼評估? 營養狀況要怎麼評估

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(1)Outline 吃多少才夠? ? How much? 吃多少才夠. 兒科營養學. 營養狀況要怎麼評估? 營養狀況要怎麼評估?. What? How?. 耕莘醫院兒科部主治醫師文萬欣. 吃什麼? 吃什麼? 怎麼吃? 怎麼吃?. Other than oral 除了吃之外的其他方法? 除了吃之外的其他方法? feeding? 營養治療. 2. Calorie Requirements. Nutritional Assessment & Requirement. HolidayHoliday-Segar method (by weight) Body weight ml (kcal)/kg/day First 10 kg 100 Second 10 kg 50 Each additional kg 20. 3. 4. Calorie Requirements. Nutritional Requirements. (By age) Infant: 100 kcal/kg/day. . 每三年減少 10 kcal/kg/day. Estimated Average Requirements (EAR) Recommended Daily Allowance (RDA) Adequate Intake (AI) Tolerable Upper Intake Level (UL). Adult: 30~35 kcal/kg/day. 5. 6. 1.

(2) Anthropometry. Holiday-Segar Method. Growth curves (age(age-, sexsex-appropriate). Example: a boy weighting 25 (= 10+10+5) kg mL (kcal) /kg/day. Body weight Body height/length Head circumference/girth Body mass index (Body fatness) Weight gain/growth velocity . mL/kg/hr mL/kg/hr. 100 X 10 kg = 1000 mL/day mL/day /24. 4 X 10 kg = 40 mL/hr mL/hr. 50 X 10 kg = 500 mL/day mL/day. 2 X 10 kg = 20 mL/hr mL/hr. 20 X 5 kg = 100 mL/day mL/day. 1 X 5 kg =5 mL/hr mL/hr. Total: 1600 mL/day mL/day. Total: 65 mL/hr mL/hr 7. 8. 97 90 75 50 25 10 3. 97. Growth Curve. 90 75 50 25 10. Boy BW, HC. 3. Growth Curve Boy BL. 9. 10. Growth Curve. Growth Curve. Girl BW, HC. Girl BL. 11. 12. 2.

(3) Composition of Human Milk. Example. Human milk Calories Water. 87%. Protein whey:casein Carbohydrate Fat. A 1 monthmonth-old male baby, BW: 4 kg Feeding with expressed human milk 100 cc every 4 hrs (6 times a day). 0.7 kcal/ml. Fluid: Fluid: 100 x 6 = 600 cc/day → 150 cc/kg/day Calorie: Calorie: 100 x 6 x 0.7 = 420 kcal/day → 105 kcal/kg/day. 1~1.5% 75:25 6.5%~7% lactose 3.5% 13. 14. Causes of FTT. Failure to Thrive Physical growth (BW, BL, W/H ratio) significantly less than peers < 3rd or 5th percentile or change cross 2 major percentiles Organic FTT Non-organic (psychosocial) FTT. 15. Causes of FTT. 16. Causes of FTT. 17. 18. 3.

(4) Obesity. Body Mass Index. Body mass index: BW(kg)/BH2 (m2) BMI > 95th percentile obesity (age-gender-specific) BMI: 85th~95th percentile overweight Adult: BMI > 30 kg/m2 obesity High BMI excess body fat Skin folds measurement Bioelecterical impedance analysis (BIA). -34-32-30-28-26-24-22-20-18-16-14-12-. 19. Triceps Skinfold Thickness. 20. Feeding of Infants. 21. Breast Milk. 22. Timing of Breast Feeding. Best food for babies !. Shortly after birth, within 4-6 hrs Feeding schedule: Variable, every 1-4 hrs 1 wk/o, 6-9 feedings/24 hr Monitoring: BW, urine output. Contains hormones, immunologic factors, enzymes, live cells… cells… ↑ Such composition that formulas can never duplicate! 23. 24. 4.

(5) Indications of Infant Formula As a substitute (or supplement) for human milk in infants whose mother choose not to breast feed (or not to do so exclusively) As a substitute for human milk in infants whom breastfeeding is medically contraindicated As a supplement for breastfed infants who do not gain weight adequately. Contraindications of Breast Feeding Maternal infections caused by organisms known to be transmitted by human milk (active TB, AIDS) Certain inborn errors of metabolism or other conditions causing intolerance to components of human milk, eg, galactosemia or tyrosinemia Maternal exposure to food, medications, or environmental agents that are excreted in human milk and harmful to the infants. 25. Comparisons of Human Milk and whole cow’ cow’s milk Human milk. Whole cow’s milk. Cow’s milk based formula. Formula for premie. 0.7 kcal/ml. 0.7 kcal/ml. 0.7 kcal/ml. 0.8 kcal/ml. Water. 87%. 87%. 87%. 84%. Protein. 1~1.5% 75:25. 3.3% 22:78. 1.5~2% variable. 1.8~2.4 variable. 6.5%~7% lactose. 4.5% lactose. 7%~8% lactose. 7%~9% lactose. 3.5%. 3.5%. 3.4%~4.4%. 3.4%~4.4%. Calories. whey:casein. CHO Fat. 26. Infant Formulas Cow’ Cow’s milkmilk-based formulas (Standard formulas) Soy formulas Special formulas. 27 Cow’s milk contains more minerals than human milk except iron and copper. Cow’s Milk-Based Formulas Cow’ Cow’s milk based, mimic human milk Higher protein levels than human milk IronIron-fortified formulas (> 6.7 mg/100 kcal; 10~12 mg/L) Ca/P: 1.1~2.0 . 29. 28. Soy Formulas No lactose, contains sucrose, corn starch hydrolysates Indications: Indications: 1. Lactase deficiency 2. Vegetarian 3. Galactosemia (4. Cow’ Cow’s milk protein allergy) (about 30% also have soy allergy) 30. 5.

(6) Cow’s Milk-Based Special Formulas 1. 2. 3. 4. 5. 6.. Protein Hydrolysate Formulas proteolytic enzymes. Protein peptides and/or amino acids 1. Partial hydrolysate formulas → Prevent allergic disorder 2. Extensive hydrolysate formulas (Semi(Semi-elemental formulas) → Treat cow’ cow’s milk allergy, protein malabsorption 3. Elemental formulas 100% free amino acids. For preterm or LBW infants LactoseLactose-free formulas Protein hydrolysate formulas MCT as the major component of fat For inborn errors of metabolism For severe cholestasis 31. Complementary Food . 32. Additional Nutrients. Additional foods, replacement foods After (4~)6 months of age Inadequate nutrient in breast milk, esp. iron Stepwise fashion Cereals, vegetables, fruits, meats… meats… Hyperallergic foods after 1 year Hyper such as eggegg-white, oranges, seasea-foods, nuts… nuts…. Premature babies: babies: iron, vitamins Exclusive BM: BM: iron (or ironiron-rich complementary food) after 4 m/o Other nutrients: Usually unnecessary to add, if adequate milk amount and normal growth. 33. 34. Feeding of children. Feeding of Children. Gradually decrease milk amount and increase solid food during 11-2 y/o After 2 y/o, y/o, a child diet should not differ from that of the rest of the family Food pyramid guidelines 35. 36. 6.

(7) Food Pyramid Guidelines. For 2-6 y/o children. For 4-6 y/o children. 37. 38. Food Pyramid Guidelines. Nutritional Therapy. 39. 40. Classification. Role of Nutritional Therapy. 1. Enteral nutrition. 1. Supplementary role. (1) Route (2) Formula. Severe illness, major operation, burn… burn…. 2. Prime therapeutic focus. 2. Parenteral nutrition (PN). Inflammatory bowel disease, cow’ cow’s milk protein allergy, lactose intolerance, celiac disease, shortshort-bowel syndrome… syndrome… 41. (1) (2) (3) (4). Total PN (TPN) Partial PN (PPN) Central PN Peripheral PN 42. 7.

(8) Effects of Improved Enteral Nutrition. NG. PPN. TPN. ND. Gastrostomy. Jejunostomy NJ. 1. 2. 3. 4. 5.. Improve nutrition Maintain normal gut flora Maintain normal gut immunity Avoid malabsorption, maldigestion Avoid complications of parenteral nutrition. 43. 44. . Indications of Parenteral Nutrition Patients who are unable to tolerate enteral feedings for a significant period of time Premature baby, congenital GI anomalies, severe GI diseases, s/p GI operation. Special Diseases & Nutritional Considerations. . . . Severely catabolic patients Major trauma, major surgery, severe burn, sepsis. . Severely malnourished patients Anorexia nervosa. 45. 46. . Special Diseases & Nutritional Considerations. References . 1. Nelson Textbook of Pediatrics. ed 17. Behrman RE, Kleigman RM, Jenson HB (eds ). Philadelphia, (eds). Saunders, 2004.. . . 2. Pediatric Gastrointestinal Disease: Pathophysiology, Pathophysiology, Diagnosis, Management. ed 4. Walker WA, Goulet O, Kleinman RE, Sherman PM, Shneider BL, Sanderson IR (eds ). Hamilton, B.C. Decker Inc., 2004. (eds).. . 3. Pediatric Gastrointestinal Disease: Pathophysiology, Pathophysiology, Diagnosis, Management. ed 2. Wyllie R, Hyams JS (eds). ). Philadelphia, W. B. Saunders, 1999. eds. 47. 48. 8.

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