BASIC PEDIA

BREASTFEEDING AND COMPLEMENTARY FEEDING

Dr. Bautista
Sources: Dr. Bautista’s PPT and Lecture, Additional Notes from the 2020 Manual

INTRODUCTION Term vs. Preterm Milk

BREASTFEEDING o A mother who gave birth to a term baby will have a different
Breastfeeding and the Administration of Human Milk concentration of nutrients compared to a mother who gave birth to
o Normative practice for infant feeding and nutrition a preterm baby
o Has medical and neurodevelopmental advantages True during the 1st week
o There are rare contraindications o Physiologic
Public health issue, not a lifestyle choice A preterm baby cannot take in as much volume as a term baby
Exclusive breastfeeding/giving of breastmilk for 6 months More concentrated milk
o Recommended by national and international organizations o At 1 week onwards, there is no difference in the milk
WHO, Philippine Pediatric Society, American Association of Term Preterm
Pediatrics ↑↑ Protein, Electrolytes,
Colostrum ↓↓ Protein Minerals, Immune Properties
VARIATIONS IN BREASTMILK COMPOSITION ↓↓ Volume, Fat, Lactose
Breastmilk starts as colostrum, then transitional milk, then mature milk Transitional Negligible
↑↑ Caloric Density
Newborn Stomach Size Milk difference in protein
o Although the colostrum is only 5-7mL, it is adequate for the first At 1-12
Same Same
feeding of the newborn Weeks

Breastmilk Composition During Feeding

o Hindmilk has higher fat content than foremilk which is important
for satiety
o Transition is really sharp
Foremilk Hindmilk
Milk at the beginning of feeding Milk at the end of feeding
↑↑ Fat
↓↓ Fat Highest in the afternoons;
Lowest in the mornings

Colostrum
o Thicker, creamer, and has higher content of antibodies and other
nutrients compared to transitional and mature milk
o Also has higher concentration of leukocytes
o But has lower fat content Breastmilk Contents According to Type
Breastmilk Composition According to Type o Stored Milk: expressed milk that has been temporarily stored
Colostrum Transitional Milk Mature Milk o Pasteurized Milk
Thinner and whiter; From milk banks
First milk; Thick, Watery (80%); Increases the half-life
sticky, clear to deep Creamy Creamier towards Some nutrients are destroyed in the process
yellow to orange the end of feeding
Still better than milk formula
due to fats
The WHO recommends donated milk from milk banks to
Produced in late About 2-6 days after
About 10-15 days mothers who have contraindications to breastfeeding
pregnancy and until birth; Lasts 7-10
after birth Quite expensive ($5 for 30mL), but cost-effective (shortened
few days after birth days
Small in quantity Increasing amount Increasing amount duration of hospital stays, etc.)
↑↑ Protein, Vit. A, Fresh Sugar: lactose
↑↑ Lactose, Fats, Stored Sugar: lactose
Carbohydrates, ↑↑ Lactose, Fats,
Water-soluble Sugar: beta-lactose
Antibodies (IgA), Vitamins, Calories
Vitamins ↓↓ IgA, IgM, WBC, lactoferrin, lysozyme,
WBCs
↓↓ Protein, Pasteurized cytokines, growth factors, hormones
↓↓ Fats ↓↓ Protein Minerals, Fat- ↓↓ antioxidant capacity
soluble Vitamins Loss of lipase activity
Easy to digest
Alkaline in reaction
Higher sp. gravity Nutrition in the first 6 months should be breastmilk!

BENEFITS OF BREASTFEEDING
PROTECTIVE EFFECTS OF HUMAN MILK
Decreases incidence of diarrhea, otitis media, UTI, necrotizing
enterocolitis, septicemia, infant botulism
Has protective effects on the following non-infectious diseases: insulin-
dependent DM, celiac disease, childhood cancer, lymphoma, leukemia,
recurrent otitis media

littlemarmaid 1
 Also protective against the development of allergies Legal Mandates to BFHI
Decreases hospitalization and infant mortality o RA 7600 (Breastfeeding and Rooming-in Act)
Prevents or delays the onset of atopic dermatitis o EO 51 of 1986 (Milk Code)

BENEFICIAL PROPERTIES OF HUMAN MILK VS. INFANT FORMULA ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)
These factors cannot be found in milk formulas Some of the components aim to establish and initiate breastfeeding
Components of EINC:
Factor Action o Immediate and thorough drying of the NB
Secretory IgA Antigen-targeted anti-infective action Prevents hypothermia
Immunomodulation, iron chelation, o Early skin-to-skin contact between mother and the NB
Anti- Lactoferrin anti-adhesive, trophic for intestinal Whether the mother gave birth via normal delivery or CS,
bacterial growth skin-to-skin contact must be established as soon as the baby
Factors Oligosaccharides Prevention of bacterial attachment is dry
Anti-inflammatory, epithelial barrier o Properly timed cord clamping and cutting
Cytokines
function o Unang Yakap (first embrace) of the mother and her newborn for
Epidermal early breastfeeding initiation
Luminal surveillance, intestinal repair
Growth Growth Factor
Factors Nerve Growth COMPONENTS OF SAFE POSITIONING FOR NB WHILE SKIN-TO-SKIN
Promotes neural growth
Factor
Infant’s face can be seen
Enhances antibody responses,
Nucleotides Infant’s head is in the sniffing position
bacterial flora
Enzymes Infant’s nose and mouth are not covered
Glutathione
Prevents lipid oxidation Infant’s head is turned to one side
Peroxidase
Infant’s neck is straight, not bent
Infant’s shoulders and chest are facing the mother
BREASTFEEDING Infant’s legs are flexed
FOLLOW-UPS AND CONCERNS Infant’s back is covered with blankets
Follow up neonates within 24-48 hours after discharge/birth to assess o Prevents hypothermia
and address immediate breastfeeding concerns Mother-infant dyad is monitored continuously in the delivery and
The hospital setting is different from the home environment regularly in the postpartum unit
o There may be less support When the mother wants to sleep, the infant is placed in a bassinet or
o People may be more keen on how the mother starts to feel the pain with another support person who is awake and alert
after birth
BREASTFEEDING HEALTHY TERM INFANTS
o Sleepless nights, post-partum depression
o All of these can lead to the discontinuation of breastfeeding Exclusive breastfeeding/expressed mother’s milk/donor breastmilk
Delay in routine procedure (weighing, measuring, bathing, blood tests,
BABY FRIENDLY HOSPITAL INITIATIVE (BFHI) vaccines, eye prophylaxis) until the first feeding is completed
Global initiative by the WHO and UNICEF o Should be within the first few hours of life
o Started in 1991 Delay in the administration of Vitamin K until after the first feeding is
o Aims to support breastfeeding as the norm completed BUT within 6 hours of birth
Supported by the 10 Steps to Successful Breastfeeding: Ensure 8-12 feedings at the breast every 24 hours
o The number of feedings will promote breastmilk production
Give no supplements (water, glucose water, infant formula, or other
Critical Management Procedures
1a. Comply fully with the International Code of Marketing of Breastmilk fluids) UNLESS medically indicated
Substitutes and relevant WHA resolutions Avoid routine pacifier use in the postpartum period
1b. Have a written infant feeding policy that is routinely communicated Begin daily Vitamin D drops (400 IU) at hospital discharge
to staff and patients o Particularly if sun exposure is not possible
1c. Establish ongoing monitoring and data-management systems Evaluate hydration and elimination patterns
2. Ensure that staff have sufficient knowledge, competence, and skills to o Because babies need to get an adequate amount of breastmilk
support breastfeeding o Hydration and elimination patterns are signs of dehydration of
inadequate milk
Key Clinical Practices Evaluate body weight gain
3. Discuss the importance and management of breastfeeding with o Weight loss no more than 7% from birth during the first few days
pregnant women and their families o No further weight loss by day 5
4. Facilitate immediate and uninterrupted skin-to-skin contact and Observe feeding
support mothers to initiate breastfeeding as soon as possible after birth
Discuss maternal/infant issues
5. Support mothers to initiate and maintain breastfeeding and manage
Mother and infant should sleep in proximity to each other to facilitate
common difficulties
6. Do NOT provide breastfed newborns any food or fluids other than breastfeeding
breastmilk, unless medically indicated o Reason why rooming in is recommended
7. Enable mothers and their infants to remain together and to practice o Mother can respond to baby’s needs/cues to breastfeeding
rooming-in 24 hours a day Only offer pacifier while placing infant in back-to-sleep-position
Reason why there are no more nurseries in hospitals o No earlier than 3-4 weeks of age AND after feeding has been
All babies must be in the same room as the mothers unless established
contraindicated o Some mothers complain that it is difficult to put the baby to down
8. Support mothers to recognize and respond to their infants’ cues for after breastfeeding
feeding
9. Counsel mothers on the use and risks of feeding bottles, teats, and BREASTFEEDING PROMOTION
pacifiers Ban photos of babies on formula milk cans/boxes
10. Coordinate discharge so that patients and their infants have timely Infant formula (0-6 months) are not seen inside groceries
access to ongoing support and care
o Important for licensing and accreditation of grocery stores
o Only see formula for 6 months onwards

littlemarmaid 2
PROPER ATTACHMENT CROSS ARM POSITION
Integrated Management of Childhood Illness (IMCI) on Breastfeeding Useful for small or ill babies
o Proper Attachment During Breastfeeding Mother has good control of the
Infant’s body is turned towards the mother baby’s head and body
Infant’s body is close to the mother o May be useful when learning
Infant’s whole body is supported to breastfeed
Take care that the baby’s head is
Chin touching breast
not held too tightly preventing
Mouth wide open
movement
More areola visible above than below the mouth
Infant’s neck is straight or bent slightly back UNDER ARM POSITION
Lower lip turned outward
Good Attachment Useful for twins or to help drain all
o The nipple and areola are stretched out to form a long “teat” in the areas of the breast
Gives the mother a good view of
baby’s mouth
the attachment
o The large ducts that lie beneath the areola are inside the baby’s
Take care that the baby is not
mouth bending his or her neck forcing the
o The baby’s tongue reaches forward over the lower gum, so that it chin down to the chest
can press the milk out of the breast
This is called suckling
o When a baby takes the breast into his or her mouth in this way, the
baby is well attached and can easily get the milk BREASTFEEDING CONCERNS
Poor Attachment IMPROPER ATTACHMENT
o The nipple and areola are not stretched out to form a teat Leads to
o The milk ducts are not inside the baby’s mouth o Nipple pain
Milk is also expressed in the areola o Engorgement
Breast becomes engorged o Less milk production
o The baby’s tongue is back inside the mouth (cannot press out the o Poor weight gain
milk)
MILK LEAKAGE
o When poorly attached, the baby only sucks on the nipple
Can be painful for the mother Physiologic
Baby cannot suckle effectively or get the milk easily Stimuli: sight of baby, baby’s voice
o When the baby is well attached, it is comfortable and painless for Resolves spontaneously
the mother, and the baby can suckle effectively o May use breast pads to prevent obvious leakage

GOOD ATTACHMENT POOR ATTACHMENT NIPPLE PAIN

Observation and history taking for sore nipples
o Rule out infection
Improper attachment causes
o Pain at the start of the feed
o Broken skin
Infection: Candidiasis
o Red, shiny, itchy, flaky
o Anti-fungal cream for mother and oral anti-fungal medication for
baby
Dermatitis and other skin conditions
Tongue-tie (Ankyloglossia)
o Asymptomatic in 50% of affected infants, needs no intervention
When the baby is well attached, it is comfortable and painless for the o Consider frenotomy/observe in severe conditions
mother, and the baby can suckle effectively If infection is ruled out, DO NOT:
o Stop breastfeeding
o Limit the frequency or length of breastfeeds
BREASTFEEDING POSITIONS o Apply any substances to the nipples that would be harmful to the
Adapted from Breastfeeding Counseling: A Training Course, WHO/CHD infant
Management/Treatment
LYING DOWN ON SIDE POSITION o Help the mother improve attachment and positioning
Helps mothers to rest
o Treat skin conditions or remove source of irritation
Comfortable after caesarean
o Apply a warm, wet cloth to the breast before the feed to stimulate
section
Take care that the baby’s nose it at letdown
the level of the mother’s nipple o Begin each feed on the less sore breast
Baby should not need to bend his o Wash nipples only once a day, as for normal body hygiene, and not
or her neck to reach the breast for every feed
o Avoid using soap on nipples
CRADLE POSITION
Most common position ENGORGEMENT
The baby’s lower arm is tucked Delay in starting to breastfeed soon after baby’s birth
around the mother’s side 2nd stage of lactogenesis, physiologic fullness
o Not between the baby’s chest Firm, overfilled, and painful breasts
and the mother Due to incomplete removal of milk
Take care that the baby’s head is
o Poor attachment/poor technique
not too far into the crook of the
o Infrequent feeding
mother’s arm that the breast is
pulled to one side o Not feeding at night
Makes it difficult to stay attached o Short duration of feeds

littlemarmaid 3
 If milk is not removed, the feedback inhibitor of lactation reduces milk Breastmilk Jaundice Breastfeeding Jaundice
production Inadequate breastmilk
Unknown
Treatment/Management intake/insufficient
Glucoronyl transferase
o Frequent breastfeeding Cause frequency of feeding
o Manual milk expression Healthy infants; high Dehydration;
o Hot compress before feeding indirect bilirubin hypernatremia
o Supportive bra After 1 week of life;
o Cold compress between feeding Declines in the 3rd week of Declines after 2nd week
o NSAIDS life
Inhibitors of glucoronyl
o Check attachment: is baby able to attach well at the breast?
transferase
Jaundice
Rarely leads to
MASTITIS
complications
Pathologic breastfeeding concern
Phototherapy/infant
Can be caused by formula/continue
o Improper attachment leading to blockage of ductules breastfeeding
o Infrequent breastfeeding
o Inadequate removal of milk from one area of the breast
o Local pressure on one area of the breast or trauma to the breast
Signs and Symptoms
o Pain and redness in the area
o Fever, chills
o Tiredness or nausea
o Headache and myalgia
The important part of treatment is to improve the drainage of milk from
the affected part of the breast
o Check for proper attachment
o Breastfeed on demand
Causes: S. aureus, E. coli, Strep, H. influenzae, Klebsiella, Bacteroides
Treatment BREASTMILK COLLECTION AND STORAGE
o Antibiotics for 10-14 days COLLECTION
o Analgesic Considered by working mothers or those who are ill
o Effective feeding and/or milk expression Good handwashing and hygiene are important
Complication: Abscess May use electric breast pumps or do manual expression
o Do not mix expressed breastmilk. Keep one bottle/bag for each
INADEQUATE MILK INTAKE session
Signs and Symptoms
o Fretful, dehydrated, inconsolable crying, lethargy STORAGE
o Sunken fontanels Use thawed milk within 24 hours
o Delayed stooling Do not re-freeze thawed milk
If this is the only complaint, it can be normal for exclusively Apply the “first in first out” rule when using stored breastmilk
breastfed infants not to pass stool for several days
o Decreased urine output Storage Duration
o Weight loss of >7% of birth weight Room temperature (25oC) 4 hours
o Increased hunger Insulated Cooler with Ice Packs 24 hours
Treatment/Management Refrigerator (4oC) 4 days
o Breastfeed 8-12 a day Freezer (-18oC) 6-12 months
o Proper technique Freezer Inside a Refrigerator 2 weeks
Freezer of a Refrigerator-Freezer 3 months
JAUNDICE Chest Freezer 12 months
In severe or persistent jaundice, consider: 2 hours (room temperature)
Thawed Milk
o Galactosemia, hyperthyroidism, UTI, hemolysis 24 hours (refrigerator)
Treatment/Management Leftover from Feeding Within 2 hours after feeding
o Phototherapy with continued breastfeeding *italicized from manual
Depending on the bilirubin 1 level
o Shift to MF for 24-48 hours
o Continue breastmilk collection EXCLUSIVELY BREASTFED INFANTS
o Feeding bottles are NOT to be used BENEFITS
Use cup and spoon in giving expressed breastmilk Growth pattern of breastfed infants is the norm
Feed baby sitting upright or semi-upright on mother’s lap Less risk for excessive weight gain
Do NOT pour milk into baby’s mouth. Let it reach the lip o Attributed to lower protein content of breastmilk
Breastmilk vs. Breastfeeding Jaundice
o Breastmilk Jaundice GROWTH PATTERN
Physiologic Their growth slows down towards the end of the first year
Attributed to the contents of the breastmilk that inhibits o Can go below 1 growth line BUT NOT beyond 2 growth lines
glucoronyl transferase Those exclusively given milk formula have a faster growth pattern
o Exceed greater than 2 growth lines towards the first year of life

littlemarmaid 4
 Infant Feeding Recommendation for HIV-Positive Women
o Exclusive breastfeeding for the first 6 months of life if replacement
feeding is NOT acceptable, feasible, affordable, sustainable, and
safe (AFASS)
o When replacement feeding is AFASS, DO NOT breastfeed

Exclusive
Breastfeeding
breastfeeding for
beyond 6 months
the first 6 months
of life
of life
Replacement YES NO NO
feeding is
NO YES NO
AFASS?

CONTRAINDICATIONS DUE TO INFANT FACTORS

Inborn errors of metabolism
o Galactosemia (mother should NOT breastfeed – fatal for infant)
o Urea cycle enzyme deficiency (ABSOULTE contraindication)

BREASTFEEDING DURING THE COVID-19 PANDEMIC

A mother has COVID-19 or is a COVID-19 suspect must meet the
criteria for discontinuing isolation and precautions
WHO data from the average weight-for-age for a small set of infant boys
o Criteria
and girls who were breastfed for at least 12 months
Wait 10 days after 1st symptoms of fever/20 days in severe
cases,
CONTRAINDICATIONS FOR BREASTFEEDING
24 hours must have passed since their last fever (without the
CONTRAINDICATIONS DUE TO MOTHER
use of antidiuretics)
Mothers should NOT breastfeed or feed expressed breastmilk to their
Symptoms must have improved
infants if:
o Wash hands before touching the baby
o Mother is infected with HIV
o Wear a face covering
Different recommendations in other countries
o Wash hands touching pump or bottle parts and clean after use
o Mother is infected with HTLV type I or type II
Interim Guidance on Breastfeeding and Breastmilk Feeds in COVID-19
o Mother is using illicit drug/s (phenycyclidine or cocaine)
o It is unknown whether mothers with COVID-19 can transmit the
Exception: supervised methadone intake and other illicit drugs
virus via breastmilk
o Mother has suspected or confirmed Ebola virus disease
o Limited data suggests SARS CoV-2 is not likely to be transmitted via
o Mother is undergoing chemotherapy
breastmilk
Mothers should temporarily NOT breastfeed and should not feed
o Whether and how to start or continue breastfeeding should be
expressed breastmilk if:
determined by the mother in coordination with her family and
o Mother is infected with untreated brucellosis
healthcare providers
o Mother is taking certain medications (anticonvulsants)
o The risk of a neonate acquiring SARS CoV-2 from its mother is low
o Mother is undergoing diagnostic imaging
o There is no difference in risk of SARS CoV-2 infection to the
o Mother has an active herpes simplex virus infection with lesions neonate whether cared for in a separate room or remains in the
present on the breast mother’s room
Mother can breastfeed directly from the unaffected breast if o Practice skin to skin contact and rooming-in whether or not the
lesions on the affected breast are covered completely mother/infant has suspected, probable, or confirmed COVID-19
o Mother has active varicella infection that developed within 5 days
prior to delivery to 2 days following delivery
Other Relative Contraindications (from the manual) FORMULA
o HIV FORMULA FEEDING
o Recurrent CMV Infection <50% of women continue to breastfeed at 6 months
o Hepatitis B o Parental preference
o Cigarette Smoking Sometimes given as a supplement to support inadequate weight gain in
breastfed infants
BREASTFEEDING AND HIV Sterility
An HIV-positive mother CAN breastfeed Handwashing and hygiene
HIV Transmission Feeding
o Risk of HIV Transmission o Monitor weight gain to assess adequacy (25-30g/day)
15-25% by a non-breastfeeding mother o 140-200mL/kg/day
20-45% by a breastfeeding mother
Concerns about HIV-positive mothers who are not breastfeeding and TYPES OF MILK FORMULA
living in low socio-economic areas (developing countries) Cow Milk Protein-Based
o Costly milk substitutes Soy Formula
o Sanitation/hygiene Lactose-free
Risk of malnutrition Special Milk Formula
Risk of diarrheal diseases, pneumonia, infections o Preterm
Clean water is sometimes an issue o Hydrolysate formulas
Higher morbidity and mortality Partially/Extensively Hydrolyzed
HIV-positive mothers and breastfeeding Metabolic formulas
o Lesser risk for HIV transmission if exclusively breastfed for the first o Address certain congenital problems
6 months
o Risk of transmission increases among infants breastfed beyond 6
months of age

littlemarmaid 5
MILK FORMULA Different from:
Provide 20kcal/30mL o Weaning
Scoop size-specific Complete cessation of breastfeeding during the introduction
Powdered milk can be used within 4 weeks once the can is opened of other foods
Once feeding has started, formula should be used within 1 hour Not advisable
Weight gain of 25-30g/day Used for infants whose mothers with HIV
o Supplementary feeding
INDICATIONS
Cow Milk Protein-Based PRINCIPLES OF COMPLEMENTARY FEEDING
o Contains higher protein than in breastmilk Begin at 6 months of age (not earlier or later)
o Adequate for younger infants Introduce 1 food at a time every 3-7 days
o Excess protein for older infants o Check for possible food allergy
Breastmilk is adjusted for protein concentration according to Energy density should exceed that of breastmilk
the needs of the infant Give iron-containing foods and encourage zinc intake
o Predominant whey protein: β globulin o Common nutritional deficiencies in infants
o Major carbohydrate: lactose Phytate intake should be low
Soy Formula Continue breastfeeding
o Cow’s milk-based protein-free For infants who are not breastfed, give NO MORE than 24 oz/day of
o Lactose-free, contains sucrose cow’s milk formula
o Indications o Equivalent to 4 feedings of 6oz per feeding or 3 feedings of 8oz
Galactosemia Give NO MORE than 6 oz of FRESH fruit juices; NO sugar-sweetened
Hereditary lactase deficiency beverages
Preference for vegetarian diet o Anything beyond this may replace their intake of milk, which is also
Secondary lactose intolerance important
o NOT recommended for preterm infants
Hydrolysate formulas TIPS FOR PARENTS
o Partially Hydrolyzed Whey Reduce added sugars
Prevention of atopic disease Use canola, soybean, corn oil, or other unsaturated oils
First choice (less expensive) Use recommended portion sizes
o Extensively Hydrolyzed Whey Serve fresh fruits and vegetables every meal
Prevention of atopic disease Regularly give fish
Cow’s milk/soymilk intolerance Remove skin from poultry
malabsorption
Amino Acid Formula OPTIMAL COMPLEMENTARY FEEDING
o Peptide-free formulas Timely Introduction
o For those with cow’s milk-based protein allergy who failed to thrive o Started at 6 months of age onwards
on extensively hydrolyzed protein formula Nutritional requirements cannot be given with breastfeeding
Preterm Milk Formula alone
o Higher in protein Chewing, swallowing, digestion, and excretion are developed
o Different mixtures of fats and sugars (general and neurologic development)
Additional water requirement in infants with diabetes insipidus o Disadvantages of Early Complementary Feeding
Goat’s Milk Higher infant morbidity and mortality
o Parental preference Lower nutritional value than breastmilk
o NOT recommended Shortens the duration of breastfeeding
Causes significant electrolyte disturbances and anemia Increases risk for atopic dermatitis, asthma, Type I DM
Low folic acid concentrations Decreases uptake of iron and zinc from breastmilk
Reduces the efficiency of lactation in preventing new
Cow’s Milk and Soymilk Intolerance pregnancies
Caused by foreign proteins o Disadvantages of Late Complementary Feeding
Cannot always give soymilk to those with cow’s milk intolerance Infant growth stops or slows down
o 1 in 3 infants with cow’s milk intolerance also have soymilk Increases the risk of malnutrition
intolerance Increases incidence of micronutrient deficiencies
Adequate
o In amount, frequency, consistency, and variety
COMPLEMENTARY FEEDING o Must cover the nutritional needs of the child
DEFINITION Safe (preparation, serving, storage)
Introduction of all solid foods and liquids, given along with breastmilk to Appropriate (texture)
provide for the child’s increased nutrient requirements
Transition from exclusive breastfeeding to family foods while continuing BENEFITS OF OPTIMAL COMPLEMENTARY FEEDING
on demand breastfeeding
Giving infants foods or fluids other than breastmilk
Target Age Group: 6-24 months
o A vulnerable period
Before 6 months, exclusively breastfed infants are given
complete food
At 6 months, some infants are given inadequate
complementary food
Onset of malnutrition in many infants
Food can be specially prepared for the infant or the same foods available
for family members, modified in order to meet the eating skills and needs
of the infant

littlemarmaid 6
CHARACTERISTICS OF PROPER COMPLEMENTARY FEEDING o Sharp foods and/or foods with a hard consistency should be
Rich in energy and micronutrients avoided (carrots, nuts, grapes, apples)
Free of contamination o Complementary foods can be offered either before or after
Without much salt or spices breastfeeding
Easy to eat and easily accepted by the infant o Foods should be given using a spoon or a glass
o According to the age of the infant o Avoid using baby bottles
Appropriate amount Additional source of contamination
Easy to prepare from family foods at a cost that is acceptable by most Interfere with oral dynamics
families May cause nipple confusion
Breastfed infants tend to accept new food more easily than non-
breastfed infants
GUIDELINES IN COMPLEMENTARY FEEDING o Used to the variation in flavors and scents very early on
GUIDELINE 1: TIMELY INTRODUCTION Food Consistency should be gradually improved
Introduce complementary foods at 6 months of age WHILE continuing to Age Type of Food
breastfeed 6 mos. Pureed, mashed, semi-solid foods
Exclusively Breastfeeding Benefits 8 mos. Family foods (crushed, shredded, chopped, small pieces);
o Protective against GIT infections finger foods
o Enhanced motor development 10 mos. Grain foods, critical time for “lumpy” foods
o Prolongs lactational amenorrhea 12 mos. Same as family (provided that these have an appropriate
o Promotes maternal weight loss energy content & consistency)
Protein Content
o High quality and easily digestible proteins: breastmilk and animal GUIDELINE 4: VARIETY
products, rice mixed with beans Feed a variety of foods to ensure that nutrient needs are met
o Low protein foods: potato and cassava If the child is a picky eater, the child should be given supplements of
Fat Content multivitamins and minerals
o 30-35% of the total energy requirement A variety of foods should be eaten daily or if possible, at every meal
o Essential FAs and fat-soluble vitamins o Meat, poultry, fish, or eggs should be eaten daily or as often as
o If excessive, may exacerbate micronutrient malnutrition possible
invulnerable populations Varied Diet
o Guarantees the supply of micronutrients
GUIDELINE 2: FORTIFIED FOODS AND SUPPLEMENTS o Enhances good eating habits
Use fortified complementary foods or vitamin-mineral supplements for o Prevents anorexia caused by monotonous foods
the infant as needed o Initially offer low-sugar, low-salt foods
In some populations, mothers may need supplements Infants (and later on, adults) tend to prefer the foods the way they were
o Important to consider the health of both the mother and the baby initially introduced
Iron Vitamin A-rich fruits and vegetables should be eaten daily
o Iron deficiency is common, especially in the latter half of the 1st o Provide diets with adequate fat content
year of life Avoid giving drinks with low nutrient value
o Bioavailability of Iron o Ex: tea, coffee, SSBs (soda)
Higher Bioavailability Lower Bioavailability Vegetarian Diet
Egg yolk, beans, lentils, o At risk of deficiency in iron, zinc, and calcium
Red meat, liver soybean and dark green o Infant must be given supplements
vegetables (broccoli) Determinant of Adequate Intake
o Egg and milk hamper iron uptake o It is not the unavailability of foods but inappropriate feeding
o Infants >6 months of age practices
Depleted liver iron stores o Research has shown that caregivers require skilled support to
Require iron from complementary foods adequately feed their infants
o Preterm low-birth weight babies
Have fewer iron stores GUIDELINE 5: RESPONSIVE FEEDING
Should receive iron supplementation earlier than term infants Practice responsive feeding
o Iron Supplementation o Apply the principles of psycho-social care
6 to 24-month old infants who do not have access to iron- Active or Responsive Feeding
fortified foods o Feed infants directly
LBW and preterm infants should receive supplementation at 2 o Assist older children when they feed themselves
months of life (12.5mg of iron per day) Be sensitive to their hunger and satiety cues
o Feed slowly and patiently
GUIDELINE 3: HOW TO INTRODUCE NEW FOOD o Encourage children to eat, but do NOT force them
Gradually increase food consistency and variety as the infant gets older Responsive Feeding
to adapt to the infant’s requirements and abilities o If children refuse many foods, experiment with different food
How to Introduce Complementary Foods combinations, tastes, textures, and methods of encouragement
o New foods should be gradually introduced Ex: give toys or candy if they eat nutritious food as a reward
One at a time, every 3-7 days o Minimize distractions during meals
o Infants need to be exposed to a new food 8-10x until they accept it o Feeding times are periods of learning and love
o The foods should be initially semi-solid and soft (puree) and should Talk to children during feeding WITH eye-to-eye contact
be crushed A positive feeding experience is important, so the child does not
Maintains the consistency of food so infants can adapt to it associate negative feelings with eating
o Foods should never be sifted or blended Types of Feeding Practices
Makes food one texture/consistency o Controlling
May lead to picky eaters o Laissez-Faire
o Maximum of 240mL/day of fruit juices o Responsive
o Soups and soft foods DO NOT provide enough calories to meet
energy requirements for infants

littlemarmaid 7
GUIDELINE 6: AMOUNT FOOD AND NUTRITION REASEARCH INSTITUTE (FNRI)
Start at 6 months of age with small amounts of food and increase the Eat a variety of foods everyday
quantity as the child gets older Breastfeed infants exclusively from birth to 4-6 months, then give
o While maintaining frequent breastfeeding appropriate foods while continuing breastfeeding
Amount and Frequency Maintain children’s normal growth through proper diet and monitor their
o Based on infant’s acceptance, which varies according to: growth regularly
Individual needs Consume fish, lean meat, poultry, or dried beans
Amount of breastmilk ingested Eat more vegetables, fruits, and root crops
Content of complementary foods Eat foods cooked in edible/cooking oil daily
Nutritious Snacks Consume milk, milk products, or other calcium-rich foods
o Fruit, Bread, Homemade Cake, Cassava o Fish and dark green leafy vegetables everyday
Use iodized salt, but AVOID excessive intake of salty foods
GUIDELINE 7: FREQUENCY Eat clean and safe food
Increase the number of times the child is fed complementary foods as For a healthy lifestyle and good nutrition:
she/he gets older o Exercise regularly
The appropriate number of feedings depends on the energy density of o Do not smoke
the local foods and the usual amounts consumed at each feeding o Avoid drinking alcoholic beverages
WHO Recommendation

Age Frequency
6-8 mos. 2-3x/day
9-24 mos. 3-4x/day
With additional nutritious snacks
12-24 mos.
1-2x/day, as desired

GUIDELINE 8: HYGIENE
Practice good hygiene and proper food handling
Hygiene practices
o Higher incidence of diarrhea during the 2nd semester of life
o Wash hands before food preparation and eating
o Store food safely and serve food immediately after preparation
o Use clean utensils to prepare and serve food
o Use clean cups and bowls when feeding children
o Avoid using feeding bottles

GUIDELINE 9: ILLNESS
Increase fluid intake during illness
o Including more frequent breastfeeding
Encourage the child to eat soft, varied, appetizing, favorite foods
After illness, give food more often than usual and encourage the child to
eat more

GUIDELINE 10: LONGER BREASTFEEDING (from manual)

Continue frequent, on-demand breastfeeding until 2 years of age and
beyond
o High fat content
o Substantial source of micronutrients
o During illness, prevents dehydration and provides nutrients needed
for recovery
o Reduces child’s risk for morbidity and mortality in disadvantaged
populations
Longer Breastfeeding
o Greater linear growth
o Reduced risk of childhood chronic illnesses
o Reduced obesity
o Improved cognitive outcome

ADDITIONAL RESOURCES
CHOOSEMYPLATE.GOV/PINGGANG PINOY

Have at least 5 sources each meal.

Increasing one food type will lessen
the space for another food source.

littlemarmaid 8
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF CHILD HEALTH

Breastfeeding
BREASTFEEDING
 Outline
•Beneficial effects of breastmilk
•Steps to successful breastfeeding
•Breastfeeding concerns, attachment, positions
•Contraindications to breastfeeding
•Breastmilk expression
•Breastfeeding during COVID-19 pandemic
 Learning objectives
•To discuss the following:
benefits of exclusive breastfeeding
breastfeeding concerns
proper attachment
positions during breastfeeding
steps to successful breastfeeding
 Learning objectives
• To discuss the following:
contraindications
breast milk expression and storage
indications for the use of substitutes
breastfeeding and COVID-19
 Breastfeeding and administration
of human milk

•normative practice for infant feeding / nutrition

•medical and neurodevelopmental advantages
•rare contraindications
Breastfeeding

• A public health issue

• not a lifestyle choice
•Exclusive breastfeeding / giving of breast
milk for 6 months
•Breastfeeding should be continued for 1 year
or longer.

WHO
Philippine Pediatric Society
American Association of Pediatrics
•Exclusive breastfeeding global target
is 70% in 2030.

WHO
 Success of breastfeeding
•Education
•Hospital practices and policies
•Follow-up care
•Support
Nutrition in ≤ 6 mo: breastmilk
 Beneficial properties of
human milk
Factor Action
Antibacterial Secretory IgA Anti-infective
factors Lactoferrin antimicrobial
Oligosaccharides Prevents bacterial
attachment
Growth factors Epidermal GF Repairs intestine
(GF) Nerve GF Promotes of neural
growth
Enzymes Nucleotides Enhances antibody
Glutathione peroxidase response
Prevents lipid oxidation
 Contraindications to
breastfeeding
Maternal health Degree of risk
condition
HIV and HTLV In the US: breastfeeding is not
infection recommended

In other settings: health risk of

not breastfeeding against the
risk of virus transmission
HIV-positive mothers and not
breastfeeding

•Costly milk substitutes

•Diarrheal diseases, pneumonia, infections
•Higher infant/child mortality
Infant feeding recommendation
for HIV-positive women
Is replacement feeding
acceptable, feasible,
affordable, sustainable
and safe (AFASS)?

Yes Do not breastfeed

No May exclusively breastfeed for 6
Mothers on ART months and continue breastfeeding
until 1 year of age
 Contraindications to
breastfeeding
Maternal health Degree of risk
condition
Tuberculosis Until completion of 2-wk treatment
infection
Varicella-zoster Avoid direct contact to lesions
infection
Immune globulin
 Contraindications to
breastfeeding
Maternal Health Degree of Risk
Condition
Herpes simplex active lesions (breasts)
infection
CMV infection Symptomatic illness in term infants
is uncommon.
Hepatitis B infection Hepatitis B immune globulin and
hepatitis B vaccine
Alcohol intake Limit daily intake ( 2 cans of beer/ 2
glasses of wine/ 2 oz liquor)
 Mothers should temporarily
NOT breastfeed and should not
feed expressed breast milk if

with untreated brucellosis

taking certain medications (anticonvulsants)
undergoing diagnostic imaging
has an active herpes simplex virus infection
with lesions present on the breast
cdc.gov
 Mothers should temporarily
NOT breastfeed, but CAN feed
expressed breastmilk if

•has untreated, active tuberculosis

•has active varicella infection that
developed within 5 days prior to delivery to
the 2 days following delivery.

cdc.gov
 Contraindications to
breastfeeding due to infant
factors
•Inborn errors of metabolism
galactosemia
urea cycle enzyme deficiency
Protective effect
•Diarrhea
•Otitis media
•UTI
•NEC
•Septicemia
•Infant botulism
 Protective effect

•Insulin-dependent diabetes mellitus

•Celiac disease
•Chron disease
•Childhood cancer
•Lymphoma
•Leukemia
Protective effect
•Allergy
•Hospitalizations
•Infant mortality
Baby Friendly Hospital Initiative
(BFHI)
 Hospital practices to encourage and
support breastfeeding

1. Written policy
2. Staff training to implement policy
3. Educate pregnant women
4. Help mothers to initiate breastfeeding within
1 hour of birth
 Hospital practices to
encourage and support
breastfeeding
5. Proper breastfeeding, Maintenance of
lactation
6. Exclusive breastfeeding
7. Rooming-in
8. Breastfeeding on demand
 Hospital practices to
encourage and support
breastfeeding
9. Do not give pacifiers or artificial nipples
10. Establish support groups
 Legal mandates to BFHI

RA 7600
- Breastfeeding and Rooming In Act of 1992

EO 51 of 1986
- Milk Code
Components of safe positioning
for the newborn while skin to
skin
•face can be seen
•head in a sniffing position
•nose and mouth not covered
•head turned to one side
•neck straight
Components of safe positioning
for the newborn while skin to
skin

•shoulders and chest face mother

•legs flexed
•back covered with blanket
Components of Safe positioning for the newborn
while skinComponents
to skin of safe
positioning for the newborn
while skin to skin

•continuous monitoring of mother-infant dyad

•placed in bassinet when mother wants to
sleep OR
•infant with a support person who is awake
 Breastfeeding management
for healthy term infants

•Exclusive breastfeeding for 6 months /

expressed milk
•at least the first year and beyond
 Breastfeeding healthy
term infants
•Skin-to-skin contact
•Delay in routine procedures until first feeding
•Delay in Vit K administration until first feeding
within 6 hours of birth
•Ensure 8-12 feedings every 24 hours
 Breastfeeding healthy
term infants

•Evaluation / documentation of breastfeeding

•No supplements unless indicated
•Avoid routine pacifier use
•Vitamin D (400 IU) at discharge
 Breastfeeding healthy
term infants
•Follow-up within 48-72 hours after discharge
•Evaluate feeding, hydration and elimination
patterns
•Weight gain
•weight loss no more than 7% from birth
•No further weight loss by day 5
•Discuss maternal/infant issues
 Breastfeeding healthy
term infants

•Mother and infant should sleep in proximity to

each other
•Pacifier use after 1 month of age, only to
place infant in back-to-sleep position
•Mothers should nurse at each breast at each feeding.
•Empty the 1st breast before offering the 2nd breast.
Proper attachment during
breastfeeding
Breastfeeding Positions

WHO
 Lying down on side position

Adapted from Breastfeeding Counseling: a training course, WHO/CHD/

 Cradle position

Adapted from Breastfeeding Counseling: a training course, WHO/CHD/

 Cross arm position

Adapted from Breastfeeding Counseling: a training course, WHO/CHD/

 Underarm position

Adapted from Breastfeeding Counseling: a training course, WHO/CHD/

Breastfeeding concern:
improper attachment

•Nipple pain
•Engorgement
•Less milk production
•Poor weight gain
Breastfeeding concern:
nipple pain

•Poor infant positioning

•improper latch
•Candidiasis
•Tongue-tie (ankyloglossia)
 Breastfeeding concern:
engorgement

•delay in starting to breastfeed after birth

•poor attachment/poor technique
•infrequent feeding or short duration of feeds
 Breastfeeding concern:
mastitis

•usually unilateral, bacterial infection

•breast pain, myalgia, fever, n/v, headache
•warmth, tenderness, edema, erythema
•antibiotics, analgesics
•breastfeeding / breast milk expression
•complication: abscess
 Inadequate milk intake

•dehydration, jaundice
•lethargy, delayed stooling
•weight loss > 7 % of birth weight
•increased hunger, inconsolable crying
 Breast milk jaundice Breastfeeding jaundice

Cause Unknown inadequate breast milk

intake
Inhibitors of glucuronyl
transferase
Healthy infants, high B1 Dehydration,
hypernatremia
Jaundice After 1 week of life, Declines after 2nd week
declines in the 3rd week
of life
Rare complication

Treatment Phototherapy breastfeed frequently

infant formula OR manage dehydration
continue breastfeeding
 Duration
Refrigerator (4oC) 2 days
Freezer (-18oC) 6 months

Thawed milk 2 hours- room temperature

24 hours (refrigerator)

Leftover from a feeding Within 2 hours after feeding

 Growth of the
breastfed infant
•growth pattern – the norm
•less risk for excess weight gain

lower protein content of breastmilk

 Breastfeeding during
COVID-19 pandemic

•Risk of COVID-19 infection of the infant

•Risk of morbidity and mortality
associated with not breastfeeding
•Inappropriate use of infant formula
•Protective effects of skin-to-skin contact
 Breastfeeding during
COVID-19 pandemic
•Mothers with suspected or confirmed COVID-19
- initiate / continue to breastfeed
- benefits of breastfeeding outweigh risks of
transmission
- wearing of mask /handwashing/
disinfecting surfaces
- rooming-in
Breastfeeding and breast milk feeds in the
context of COVID-19

•SARS CoV-2 is not likely to be

transmitted via breast milk.
•The risk of a neonate acquiring SARS-
CoV-2 from his/her mother is low.
Breastfeeding and breast milk
feeds if mother has severe /
critical COVID-19

•Expressed breast milk

•Relactation
•Donor human milk
Formula feeding

• < 50% of women continue to breastfeed at 6 mo

• Parental preference
• With contraindication to breastfeeding
• As supplement to support inadequate weight gain
in breastfed infants
 Infant formulas

•19-20 kcal / 30 ml
•avoid over- or under dilution
•boiled water should be allowed to cool /
sterilized water
•good hygiene
 Infant formulas

•Use within
- 4 weeks once can is opened
- 24 hours once prepared
- 2 hr of removal from refrigerator
- 1 hr once feeding has started
 Formula feeding

• Ad libitum
• 140-200 ml/kg/day ( 2-3 oz every 3 hours) in the
1st 3 mo allows daily weight gain of 25-30g
 Cow’s milk protein-
based formulas
•higher protein content than breast milk
•predominant whey protein: 𝛃-globulin
•fat: plant and animal oils
- (PUFAs, DHAs, ARA)
•carbohydrate: lactose
 Soy formulas

•Free of cow’s milk-based protein and lactose

•CHO: sucrose, corn syrup solids, maltodextrins
•Protein: soy isolate
 Indications for soy
formulas
•galactosemia
•preference for a vegetarian diet
•lactase deficiency
 Protein hydrolysate
formulas
•Partially hydrolyzed (MW 3,000-10,000)

•Extensively hydrolyzed (MW <3,000)

 Partially hydrolyzed

•
•Delays or prevents childhood atopic dermatitis
 Extensively hydrolyzed
- lactose-free, with medium chain triglycerides
- for infants with GI malabsorption
- for infants intolerant to cow’s milk or soy
proteins
- delays / prevents childhood atopic dermatitis
Amino acid formulas

•for those with cow’s milk-based protein

allergy who failed to thrive on extensively
hydrolyzed protein formulas
 Milk and other fluids
in infants

•whole cow’s milk: ≥ 12 mo

•Animal milk should be pasteurized.
•Goat’s milk is not recommended.
•nut- based milk: ≥ 24 mo
•Additional water requirement in infants
with diabetes insipidus.
“Breastfeeding is not a choice,
it’s a responsibility.”
References

•Nelson Textbook of Pediatrics, 21st ed

•WHO
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF CHILD HEALTH

Complementary Feeding
 Complementary feeding

•from exclusive breastfeeding to family foods

•breastfeeding beyond 2 years of life
•from 6 months- 24 months
•vulnerable period for malnutrition in infants
 Complementary feeding

•especially prepared for the infant or

•same foods available for family members,

modified to meet the eating skills and
needs of the infant.
•Weaning foods
•Supplementary feeding

- not synonymous with complementary

feeding
 Optimal Complementary feeding

•Timely, from 6 months of age onwards

•Adequate- amount, frequency, consistency,
giving of variety of foods
•Safe
•appropriate
Timely Introduction of complementary
foods

•> 6 mo – Breastmilk is inadequate.

•developmental stage: enables them to be
fed other foods than breastmilk
 Disadvantages of early complementary
feeding

• higher infant morbidity and mortality

• lower nutritional value than breastmilk
• nutrient deficiencies
• reduces the efficiency of lactation in preventing new
pregnancies
• Increases risk for atopic dermatitis. Asthma,
diabetes type I
 Characteristics of proper
complementary feeding

•rich in energy and in micronutrients

•appropriate amount / free of contamination
•without much salt or spices
•easy to eat and easily accepted by the infant
•easy to prepare from family foods
•affordable
WHO Guiding Principles

• for breastfed infants (10)

•for non breastfed infants (9)
- with 7 guidelines similar for breastfed infants
 Guideline 1
- exclusive breastfeeding from birth to 6 mo

- introduce complementary foods at 6 mo of

age while continuing to breastfeed.
 Guideline 2

Continue frequent, on-demand

breastfeeding until 2 years of age or beyond
•Beneficial effects of longer duration of breastfeeding:
•key source of energy and essential fatty acids.
•During periods of illness, breast milk intake is
maintained.
•Increases birth intervals
•a longer duration of breastfeeding is associated with
greater linear growth / reduced risk of childhood chronic
illnesses / obesity/ improved cognitive outcomes
 Guideline 3
Practice responsive feeding, applying the
principles of psycho-social care
Active or Responsive Feeding
Responsive Feeding
 Guideline 4
Practice good hygiene and proper food
handling (preparation, feeding and storage)
 Safe preparation and storage of
complementary foods
•Handwashing before food preparation and
eating
•store foods safely / serve foods immediately
•use clean utensils to prepare and serve food
•use clean cups and bowls when feeding
•avoid use of feeding bottles
 Hygiene practices

•Higher incidence of diarrhea during the 2nd

semester of life
 Guideline 5
Start at six months of age with small amounts
of food and increase the quantity as the child
gets older, while maintaining frequent
breastfeeding.
 Guideline 6
Gradually increase food consistency and
variety as the infant gets older, adapting to the
infant’s requirements and abilities.
How to introduce complementary foods

• gradually introduce new food, one at a time,

every three to seven days.
• expose to a new food 8-10x accepted
• initially semi-solid and soft (puree) / crushed
• Foods should never be sifted / blenderized.
 How to introduce complementary foods
Age Type of food
6 months Pureed, mashed and semi-solid foods

8 months family foods

crushed, shredded, chopped or cut into
small pieces ( finger foods)
10 months grain foods

12 months same foods their family eats

provided that these foods have an
appropriate energy content and
consistency.
 Guideline 7
Increase the number of times that the child
is fed complementary foods as he/she gets
older.
Age Frequency
6-8 months 2-3x / day
9-24 months 3 -4x / day
12-24 months With additional nutritious snacks 1-
2x/day as desired
Fruit/ bread with nut paste
 Amount and Frequency

•Based on infant’s acceptance, which varies

according to
- individual needs
- amount of breastmilk ingested and
- content of complementary foods
 Guideline 8
Feed a variety of foods to ensure that
nutrient needs are met.
 •0.7 gram/100 kcal of food
•High quality and easily digestible
Protein proteins
(breast milk and animal products,
rice mixed with beans)
 • 30-45% of the total energy required
• essential fatty acids and fat-soluble
Fat vitamins
content • if excessive, may exacerbate
micronutrient malnutrition in
vulnerable populations
Iron

Higher bioavailability Lower bioavailability

Red meat, liver egg yolk, beans, lentils,

soybean and dark green
vegetables (broccoli)
Varied diet

•should initially offered low-sugar, low-salt foods

feed variety of foods
 Guideline 9
Use fortified complementary foods or vitamin-
mineral supplements for the infant, as needed
 Complementary feeding

•use spoon / glass

•avoid use of baby bottles
•is offered before or after breastfeeding
•limit fruit juices to 240 ml/day (WHO) / 180
ml/day (AAP, NELSON)
 Guideline 10
Increase fluid intake during illness, including
more frequent breastfeeding, and encourage
the child to eat soft, varied, appetizing, favorite
foods. After illness, give food more often than
usual and encourage the child to eat more.
Determinant of adequate intake

• Inappropriate feeding practices- primary

• It is not the availability of foods
•Reading assignment:

Guiding principles for complementary feeding

of the non breastfed child
References
• World Health Organization
http://www.who.int/nutrition/topics/complementary_feeding/en/
• Guiding Principles on Complementary Feeding of the breastfed
Child:
http://www.who.int/nutrition/publications/infantfeeding/guiding_princi
ples_compfeeding_breastfed.pdf
• WHO Guiding Principles on Feeding Non-Breastfed Infants:
https://www.ennonline.net/attachments/161/guiding-principles-
compfeeding-breastfed-paho-who-2001.pdf
 Methods of Comprehensive Nutritional Assessment
DIRECT

Outline
1. Nutritional Assessment
a. Anthropometric measurements
b. Growth charts
c. Nutritional classification
2. Nutritional Requirements
a. Definition (A) Anthropometry
b. Determinants - It is the science that defines physical measurement of person’s
c. RENI size, form, and functional capacities
- It is the study of the human measurement of the body when it
comes to the measure of the bone, muscle, and the fat tissue
Pediatric Nutritional Assessment
- Nutritional Anthropometry: measurements of the physical
nagement
NUTRITIONAL ASSESSMENT
of Childhood Illness (IMCI) dimensions and gross composition of the human body as a
- An integral part of pediatric health care for both well and sick child means of assessing nutritional status
- Remember! As pediatrician or even as general practitioners, we (B) Biochemical
should not only address the illness of the child, but also treat the - It pertains to laboratory examinations ordered to help assist in
child holistically the diagnosis of nutritional deficiencies
- Nutritional status of a child is a product of many interrelated factors - The selection of specific tests should be guided by clinical
but is mainly influenced by 3 broad factors: assessment – we have to make sure that we only request
1. FOOD laboratory tests that are really needed by the child
2. CARE (C) Clinical
3. ENVIRONMENT - It is the careful visual assessment of the child
- It utilizes physical signs associated with malnutrition as well
Determinants of Good Nutritional Status as micronutrient deficiencies
(D) Dietary
- It is the assessment of actual food intake
- It is advised that parents who have a malnourished child
should have a food diary where breakfast, lunch, and dinner
as well as the type of food the child has taken for each day is
written in order to ensure that they are monitoring the child’s
health
- It utilizes qualitative methods (meaning, we need to educate
the caregivers and the family about the basic food groups or
food pyramid for them to be familiar to what type and how
much food should be given to the child) or quantitative method
(so as we can provide actual computation of caloric intake)
- Optimal nutritional status results when:
1. the children have access to affordable, diverse, nutrient-rich Remember!!!
food - Anthropometry and Clinical are both important for midwives. Why?
2. appropriate maternal and child-care exist Because they are the frontliners especially in the rural and remote places
3. adequate health services are provided as some doctors are not readily available in these areas
4. a healthy environment which includes safe water, sanitation,
and where good hygiene practices are available INDIRECT

- Adequate maternal nutrition is also considered when we are pertaining a) Ecological factors
b) Economic factors
to the determinants of good nutritional status of a child and so
c) Vital health statistics
whenever a mother is pregnant, it should be ensured that she is having
an adequate nutrition so that the baby she is giving birth with is healthy
ANTHROPOMETRY
- Used to assess GROWTH but its accuracy will depend on the
What happens when Optimal Nutritional Status is not achieved?
accuracy of the anthropometric measurements:
Malnutrition 1. Accurate equipment
a. Undernutrition – malnourished 2. Accurate measurement techniques
b. Overnutrition – obese 3. Accurate reference standards
- Measures:
Spectrum of Malnutrition can range from Obesity to Severe Undernutrition 1. Weight
2. Length or height
3. Head Circumference (HC) - up to 3 years old
4. Body Mass Index
5. Mid-Upper Arm Circumference (MUAC)
6. Triceps skinfold

Page 1 of 8
Remember!!! - If the child is > 2 years old = standing height
- The first four namely the weight, length or height, head circumference, 1. Movable board at one
and BMI are the most commonly measured end
2. Child standing with
Tasks to be performed in Growth Assessment body flat against the
foot piece
MEASURE - measure weight, length, and height; calculate BMI 3. Arms comfortable
PLOT - plot these measurements on growth charts straight, hands on side,
INTERPRET - interpret growth indicators shoulders level
ACT - act to address the causes of poor growth 4. Measurer’s line of sight
is perpendicular to the base of
(1) You measure the weight, length, and height, (2) you plot these on board.
growth charts, (3) you interpret the growth indicators then, (4) you need to
act to address the causes of poor growth Remember!!!
- It is because of the physiologic lordosis or exaggerated lumbar lordosis
Remember!!! that made recumbent length the one used for children less than 2 years
- Growth assessments that are not supported by appropriate response old
programs are not effective in improving child health - In general, standing height is about 0.7cm less than recumbent length

MEASURING WEIGHT What to do…

- It is recommended to weigh children using a scale with the following - If a child < 2 years old will not lie down for measurement of length,
features: measure standing height and add 0.7cm to convert it to length.
1. Solidly built and durable For example:
2. Electronic (digital reading) Standing height = 80cm
3. Measures up to 150kg 80 + 0.7cm = 80.7cm
4. Measures to a precision of 0.1kg (100g) Actual length = 80.7cm
5. Allows tared weighing
- If a child is 2 years old or older and cannot stand,
measure recumbent length and subtract 0.7 cm to convert it to
height.
For example:
Recumbent length = 95cm (Lying down)
95cm – 0.7cm = 94.3cm
Actual height = 94.3cm

DETERMINING BODY MASS INDEX (BMI)

BMI = Weight (kg) / Length or height (m2)
1st pic – for infants; 2nd pic – for older children; commonly used in rural areas
For example:
Weight = 16kg
- If the child is…
Height = 105cm à 105cm / 100 = 1.05m2
< 2 years old or is unable to stand Use tared weighing
> 2 years old Weigh the child alone if BMI = 16kg / 1.05m2 à 1.10m
he/she will stand still BMI = 16 / 1.10
- Babies should be weighed naked (make sure they are wearing dry = 14.545
diapers as wet diapers may lead to inaccurate measurement), wrap = 14.5kg/m2
them in a blanket to keep them warm until weighing
- Older children should remove all but minimal clothing, such as their Remember!!!
underclothes - BMI is rounded up to one decimal place

MEASURING LENGTH OR HEIGHT Interpretation:

- If the child is < 2 years old = recumbent length BMI CLINICAL SIGNIFICANCE MORBIDITY
1. Measuring device with fixed <16 Severe Underweight
board at one end and movable 16 – 16.9 Moderate Underweight Long term risk to health
board at the other end 17 – 18.49 Mild Underweight Associated with health
2. Needs two persons: problems
measurer and assistant 18.5 – 24.9 Normal Least risk for morbidity
3. Assistant – holds the head; and minimal mortality
hands cupped over the ear 25 – 29.5 Overweight Associated with health
and head against the base of problems to some
the board people
4. Child lying flat 30 – 34.5 Obesity Class I
5. Measurer – holds 35 – 39.5 Obesity Class II High degree of risk to
knees with legs ≥ 40 Obesity Class III health
straight (Morbidly obese)
6. Feet flat against Remember!!!
the end of the movable plate - Obesity Class III (Morbidly obese) has the highest degree of risk to
health
Page 2 of 8
MEASURING MID-UPPER ARM CIRCUMFERENCE (MUAC) - The boy is 6 weeks old and weighs 5kg
- Only for children 6 – 59 months - The plot fell on the 0 line, meaning to say, the child has normal weight
- Usually used in rural areas especially those with incomplete for his/her age
measuring devices
HEIGHT-FOR-AGE GIRLS
- Steps:
2 to 5 years old
1. Locate the tip of the
shoulder
2. Locate the tip of the
elbow
3. Place the tape at the
tip of the shoulder
4. Pull the tape past the
tip of the bent elbow
5. Mark the midpoint –
where correct tape
tension happens
6. Correct the tape
tension - Not too tight!!! Not too lose!!!
7. Correct the tape position for arm circumference

Now that you have already measured the weight, the length or the height,
and the BMI. It is time to plot and interpret them using growth charts!!! J

PLOTTING GROWTH INDICATORS - As you can see, there are three plots in the graph, meaning to say, the
- Growth indicators for a child: child was seen three times by the doctor. The first plot (2 years old, 4
• Length/Height-for-age months) tells that the child’s height is 92cm; the second plot (3 years
• Weight-for-age old, 3 months) tells that the child’s height is 98cm; the third plot (4
• Weight-for-length/height (only up to 5 years old) years old, 2 months) tells that the child’s height is 103cm and since it
• BMI-for-age fell within the 0 line à means that the height-for-age for that particular
- Use appropriate growth charts and Z-scores provided by WHO child is normal as she grows older.

Example of an Early INTERPRETING PLOTTED POINTS FOR GROWTH INDICATORS

Childhood Care and - The line labeled ”0” on each chart represents the median, which in
Development Card (ECCD), general, is average
distributed in all health - The other curved lines are z-score lines which indicate distance from
centers by the DOH. Now, the average
they have already issued a - The median and the z-score lines on each growth chart were derived
new version but almost the from measurements of children in the WHO Multicenter Growth
same content as the old one Reference Study
- Z-score lines on the growth charts are numbered positively (+1, +2, +3)
Whenever you encounter a
or negatively (-1, -2, -3)
child brought into your clinic,
- In general, a plotted point that is far from the median (0 z-score) in
make sure to always ask for
either direction (for example, close to the 3 or -3 z-score line) may
the ECCD card. All should
represent a growth problem, but consider the other factors like growth
have one except for those
trend, health condition of the child, and heights of the parents too
who have their checkup and
immunizations in private WEIGHT-FOR-AGE GIRLS
clinics, look for the baby book Birth to 5 years old
instead

WEIGHT-FOR-AGE BOYS
Birth to 6 months

- If it falls between +2 and -2 = normal

- If it falls between +3 and +2 = overweight
- If it falls between -2 and -3 = underweight
- If it falls below -3 = severe underweight
Page 3 of 8
HEIGHT-FOR-AGE GIRLS WEIGHT-FOR-LENGTH BOYS
5 to 19 years old Birth to 2 years old

- If it falls between +3 and -2 (the green area) = normal

- If it falls above +3 = tall Consider all growth charts and observations
- If it falls below -2 and above -3 = stunted - It is important to consider all of a child’s growth charts
- If it falls below -3 = severely stunted together, particularly if only one of the charts shows a problem

Remember!!! For example, if a child is underweight according to the weight-

- If it falls below -2 and above -3, there Is stunting or chronic malnutrition for-age chart, you must also consider the child’s length-for-age
already; there is a lag in the height velocity of the child and weight-for-length

WEIGHT-FOR-HEIGHT GIRLS Let’s have this example too!!! Imagine having this baby girl check her
2 to 5 years old weight-for-age, length-for-age, and weight-for-length charts. J

1. Weight-for-age

- If it falls below +1 and above -2 = normal

- If it falls between +1 and +2 = possible risk of overweight - Since it fell between -1 and -2, she has a normal weight
- If it falls between +3 and +2 = overweight for her age
- If it falls above +3 = obese - Now, let’s go to the second one…
- If it falls between -2 and -3 = wasted
- If it falls below -3 = severely wasted 2. Length-for-age

Remember!!!
- If it falls between -2 and -3, there is already an acute, newly onset
malnutrition

BMI-FOR-AGE GIRLS
5 to 19 years old

- Since it fell between -2 and -3 = she has a stunted

growth.
- Now, let’s go to third one…

Page 4 of 8
 3. Weight-for-length this, ask the parents or the caregivers in order to address the
problem immediately,

3. Child’s growth line remains flat

- The plot fell in the 0 line, meaning normal, the child is not
Here, we can see that there is no increase in the trend, meaning
wasted, there is no malnutrition going on
to say, there is something wrong with child – he or she is not
properly nourished.
- Focus more on the length/height-for-age and weight-for-
length/height charts!!!
Classification of Growth Status
§ Length/height-for-age - reflects attained growth in height
Length/height-for-age that is below -2 (meaning the child
is stunted) implies that the child received inadequate
nutrients to support normal growth and/or that the child
has suffered from repeated infections
§ A stunted child may have a normal weight-for-height, but
have low weight-for-age due to shortness
§ Weight-for-length/height is a reliable growth indicator
even when age is not known
Weight-for-length/height that is below -2 usually results
from a recent severe event, such as drastically reduced
food intake and/or illness that caused severe weight loss.
§ BMI-for-age classifies children in a similar manner to - Currently, WHO have 2 important indicators used to measure acute
weight-for-length/height malnutrition:
1. Moderate acute malnutrition (MAM)
Remember!!! 2. Severe acute malnutrition (SAM)
- Both length/height-for-age and weight-for-length/height help to identify - These publications have public health importance as interventions or
whether the child has excess weight relative to length/height management are geared towards them.

Be alert of the following situations which may indicate a problem or

suggest risk:
1. Child’s growth line crosses a z-score line

- Acute malnutrition is best assessed using Weight-for-length

- If it falls between -2 and -3 = Moderate Acute Malnutrition (MAM)
Here, we can see that there is flattening of the curve. Ideally, - If it falls below -3 = Severe Acute Malnutrition (SAM)
there must be an increasing trend, meaning to say, the child is
supposed to increase in height and weight as he/she grows
older

2. Sharp incline or decline in the child’s growth line

Here, we are assuming that you have seen the child regularly
and then there’s a sudden drop in the child’s growth line. With

Page 5 of 8
 Nutritional Requirements
- Refer to the quantity of energy and of nutrients, expressed on a daily
basis, necessary for a given category of individuals that will allow
these individuals, when in good health, to develop and lead a normal
life.
Thomas A and Metz M. Implications of
Economic Policy for Food Security: A Training Manual. FAO 1999

- Have been established based on physiological studies (metabolic

balances) and field epidemiological studies
- Requirements vary according to:
o Age
o Sex
o Body weight
- Among children today, obesity is causing a wide range of health
o Level of activity
problems that are still seen up until adulthood – this includes high
o Physiological status (i.e., pregnancy and lactation)
blood pressure, type 2 diabetes, elevated blood cholesterol level, etc.
- Expressed as averages, taking into account individual variation
- There are also other psychological effects in children especially those
who are obese as they are prone to having low self-esteem and - From the basis of dietary reference standards related to adequacy of
depression nutrient intake
- Every nutrient has a distribution of requirements described by a
median (estimated average requirement or EAR) and a standard
deviation for different age and sex groups
- Usually assumed to be normally distributed
- Estimated Average Requirement (EAR): daily intake value estimated
to meet the requirements in 50% of the individuals in a life stage or
gender group
IOM, 1997
In the Philippines
- There is scarcity of data on nutrient requirements of Filipinos
- We are also still using foreign data used to derive the RNI’s
Rationale: “Physiologic requirements are expected to be similar
across healthy population groups” (USFNB)
- We use Recommended Energy and Nutrient Intake (RENI)
Just an example of the prevalence of malnourished children conducted by
DOST
RENI
- We shifted from Recommended Dietary Allowance (RDA) to
Summary!!!
Recommended Energy and Nutrient Intake (RENI) to emphasize that
1. Nutrition screening and assessment should be part of routine
standards are in terms of nutrients and not foods or diets
childcare
- Definition:
2. Comprehensive nutritional assessment includes:
“level of intake of energy and nutrients which, on the basis of
a. Anthropometry
current scientific knowledge, are considered adequate for the
b. Biochemical assessment
maintenance of health and well-being of nearly all healthy persons
c. Clinical assessment
in the population.”
d. Dietary assessment
- Utilize RNI: EAR + 2SD
3. Nutrition screening and assessment at the primary care level
- RNI for energy = EAR
involve mainly anthropometric measurements
- For infants, children, and adolescents, it may not be possible to
4. Anthropometry involves the following tasks:
measure requirements directly or with very limited data.
1. Measure
Alternative methods:
2. Plot
1. Extrapolation from adult requirements
3. Interpret
2. Based on estimates of amounts laid down during
4. Act
growth
5. Anthropometric measurements particularly weight, length/height,
3. Estimates of amounts supplied by breastmilk
and MUAC along with presence of pitting edema are the most
important screening indicators to identify acute malnutrition
Nutrient Adequacy
- Nutritional requirement is always related to a specified criterion of
Pediatric Nutritional Requirements
adequacy
nagement of Childhood Illness (IMCI) - The level of intake of energy or essential nutrient in relation to the
NUTRIENTS
- Active elements of food which are utilized in the functioning of the energy/nutrient requirement for adequate health; expressed as
body percentage (%) of RENI
o Proteins - 100% adequacy should be the goal!!!
o Fats Meaning to say, the state of the nutrient intake is sufficient to
o Carbohydrates maintain health and provide reasonable levels of reserves in
o Vitamins body tissues.
FNRI. NSCB Resolution No. 10 Series of 2008
o Minerals
o Trace elements
o Water
- Foods contain some or all of these nutrients in variable proportions
FAO 1999
Page 6 of 8
TERMINOLOGIES AT RISK NUTRIENTS

Philippine Dietary Reference Intake (PDRI) is the collective term comprising

reference values for energy and nutrient levels of intakes. Its components
are:
- Estimated Average Requirement (EAR). The daily nutrient intake
level that meets the median or average requirement of healthy
individuals in a particular life stage and sex group, corrected for
incomplete utilization or dietary nutrient bioavailability.
- Recommended Energy/Nutrient Intake (REI/RNI). The levels of
intake of energy and nutrients which, on the basis of current
scientific knowledge and consensus of the Committee, are
considered adequate for the maintenance of health and well-
- According to WHO, children of developing countries are at risk for
being of healthy persons in the population. The RNI is equal to
deficiencies of Vitamins A and D, Iron, Zinc, and Iodine
the EAR for nutrients, translated into dietary recommendation to
cover the needs of almost all individuals in the population (EAR
PREVALENCE OF MICRONUTRIENT DEFICIENCIES IN SCHOOL-AGED
+ 2SD). If the standard deviations (SD) is not known, a coefficient
CHILDREN
of variation (CV) is assumed based on the known physiology of
the nutrient. For energy, the recommended intake (REI) is the
computed average requirement of individuals in that group. The
procedure of adding 2 SDs or CVs to cover the needs of almost
all individuals in the population is not applicable to energy.
- Adequate Intake (AI). The daily nutrient intake level that is based
on observed or experimentally-determined approximation of the
average nutrient intake by a group (or groups) of apparently
healthy people that is assumed to sustain a defined nutritional
state. It is used when there is insufficient data to establish the
EAR. Global WHO 2008, J. Nutri 2011, Food Nutr Bull 2008
Philippines: 7th NNS FNRI-DOST 2008
- Tolerable Upper Intake Level or Upper Limit (UL). The highest
average daily nutrient intake level likely to pose no adverse - Even though there is still inadequacy, DOH is coming up with
health effects to almost all individuals in the general population. Micronutrient supplementation in every readily available food packs
Lack of suitable data could not establish ULs for other nutrients, to distribute to the people especially those who are underprivileged
but this does not mean that there are no potential effects - Food Fortification has also been a mandatory in the food production
resulting from high intake. When data about adverse effects are (i.e., In the groceries where you can see foods fortified with Vitamin
extremely limited, extra caution may be warranted. A or with Iodine)
- It is also important to educate the parents on how to properly read
INCLUDED NUTRIENTS PDRI 2015 labels when buying food for their family
- Eat fruits and vegetables!

- Omitted Manganese
- Added Omega 3 and Omega 6

- There are different kilocalories required for each age group

Page 7 of 8
 - Too much sugar is bad not only for adults but also for children!
- Too much salt is also not good. Imagine your fries!
As children grow older, they have higher requirements. Infants require
higher fat requirements than adults.
- Eat your banana since it is a good source of potassium!

Stay sunny side up, yolks! J

Resources:
§ Manapat-Celebrados,K. S. (2020, September). Nutritional
Assessment and Requirements of Infants and Young Children.
Lecture.
§ FEU-NRMF Department of Child Health and Basic Pediatrics Lecture
Guide and Manual

According to WHO, children of developing countries are at risk for

deficiencies of Vitamin A, Vitamin D, Iron, Zinc, and Iodine.

Page 8 of 8
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF CHILD HEALTH

NUTRITIONAL ASSESSMENT,
GROWTH MONITORING & REQUIREMENTS OF
INFANTS AND YOUNG CHILDREN
Outline
Nutritional Assessment
Anthropometric measurements
Growth Charts
Nutritional Classification

Nutritional Requirements:
definition
Determinants
RENI
 Intended Learning Outcomes

1. Stress the importance of proper nutrition and its outcome

2. Discuss/ Explain the basis of nutrient requirement for different growth periods
2.1 to explain why different growth periods will have different requirements for
nutrition
3. Illustrate the relationship of nutrition and diseases
3.1 to associate the effect of malnutrition with risk of certain diseases
4. Discuss the factors affecting the Estimated Energy Requirement (EER) in
different pediatric age group
4.1 Correlate the factors affecting the EER and the change in EER
5. Discuss essential nutrients, select micronutrients, and water and the important
role these play in the body.
5.1 Explain their importance in the diet
5.2 Cite recommended dietary allowance of these nutrients
5.3 Determine available local sources of these nutrients
5.4 Recognize clinical cases presenting with excess or deficiency of nutrients
6. Elucidate on common nutritional issues
6.1 Expound on nutrition issues in different age groups
correlate nutrition requirements with growth period
6.2 Correlate nutrition requirements with growth periods
6.3 Describe specific diets affecting nutrition
 FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF CHILD HEALTH

Pediatric Nutritional Assessment

Assessment of Nutritional Status

An integral part of pediatric health care: both in well and sick

child
Nutritional status of a child is a product of many interrelated
factors BUT influenced by 3 broad factors :
1. Food
2. Care
3. Environment
Determinants of Good Nutritional Status
GOOD NUTRITIONAL STATUS

Healthy
Optimal in Responsive environment;
Adequate
quantity and health services;
quality Active lifestyle

CARE

FOOD ENVIRONMENT

ADEQUATE MATERNAL NUTRITION

What will happen if optimal nutritional status is
NOT achieved?

MALNUTRITION:

Undernutrition

Overnutrition
 SPECTRUM of MALNUTRITION:
This ranges from Obesity to Severe Undernutrition

Normal Stunted Wasted Underweight Obese

-2 z-score
severe : if -3 z-score
 Methods of Comprehensive Nutritional Assessment

Nutritional
Assessment

Direct Indirect
- Individual - Community health

- Objective criteria indices

- Ecological factors
A B C D
- Economic factors
Anthropometry Biochemical Clinical Dietary
- Vital health stats
 ✔A B ✔C D
Anthropometry Biochemical Clinical Dietary

Science that defines Laboratory Careful visual

examinations Assessment of
physical measures of assessment of actual food intake
person’s size, form and ordered to help the child
functional capacities assist in the
CDC U.S.A. diagnosis of
nutritional
deficiencies Utilizes physical Utilizes qualitative
The study of the signs associated (basic food
measurement of the with groups/food
human body in terms malnutrition pyramid) or
of the dimensions of Selection of and quantitative (
specific tests actual
bone, muscle and fat micronutrient computation of
tissue CDC U.S.A should be guided deficiencies caloric intake)
by clinical methods
Nutritional assessment
anthropometry:
measurements of the
physical dimensions
and gross composition ✔ Important for midwives
of the human body as
a means of assessing
nutritional statusU.N. FAO
A : Anthropometry
Anthropometric measurements: used to assess GROWTH
Accuracy of growth assessment dependent on accuracy of
anthropometric measurements:
Accurate equipment
Accurate measurement techniques
Accurate reference standards
A : Anthropometry
Measure:
Weight
Most
Length or height Common
Head circumference ( up to 3 years)
Body mass index (BMI)
Mid-upper arm circumference
Triceps skinfold
Tasks to be Performed in Growth Assessment
measure weight, length, and height
calculate body mass index (BMI)

plot these measurements on growth charts

interpret growth indicators

act to address the causes of poor growth

Growth assessments that are not supported by appropriate

response programs are not effective in improving child health
WEIGHT
It is recommended to weigh
children using a scale with the
following features:
Solidly built and durable
Electronic (digital reading)
Measures up to 150 kg
Measures to a precision of 0.1 kg
(100g)
Allows tared weighing
 Tared means that the scale can be re- tared
person just weighed still on it

alone appears on the scale

Tared weighing has two clear advantages:

child likely to remain calm when held in the

For Infants
For Older Children
In measuring the weight
If the child is less than 2 years old or is unable to stand, you will do tared
weighing
If the child is 2 years or older, you will weigh the child alone if the child will
stand still
Babies should be weighed naked; wrap them in a blanket to keep them warm
until weighing
Older children should remove all but minimal clothing, such as their
underclothes
Measure length or height
Recumbent length :
For child less than 2 years old
1. Measuring device with fixed
board at one end and movable
board at the other end
2. Needs two persons : measurer
and assistant
3. Assistant to hold head; hands
cupped over the hear and head
against base of board
4. Child lying flat
5. Measurer holds knees with legs
straight
6. Feet flat against the end of the
movable plate
 Moveable footboard

Fixed headboard
Measure length or height
Standing height if the child is 2 years old and able to stand
1. Movable board at one end
2. Child standing with body flat against wall
3. Feet flat against footpiece
4. Arms comfortably straight, hands on side,
shoulders level
5.
base of board

In general, standing height is about

0.7 cm less than recumbent length
Moveable headboard
Measure length or height
What to do :
If a child less than 2 years old will not lie down for
measurement of length
measure standing height and add 0.7 cm to
convert it to length

Ex. Height = 80 cm (standing)

Actual length = 80cm + 0.7 cm = 80.7 cm
What to do :

If a child aged 2 years or older cannot stand,

measure recumbent length and subtract 0.7cm to
convert it to height

Ex. Length = 95 cm (lying down)

Actual height = 95 cm 0.7 cm = 94.3 cm
 Determine BMI
(Body Mass Index)

Formula:
BMI = Weight (kg) length or height (m2)
For example :
Given: weight = 16 kg height = 105 cm
BMI = 16 1.052
= 16 1.10 = 14.545 = 14.5
BMI = 14.5

BMI is rounded to one decimal place

Body Mass Index (BMI)

BMI Clinical Significance Morbidity

< 16 Severe Underweight High morbidity and mortality

16-16.9 Mod Underweight Long term risk to health

17-18.49 Mild Underweight Associated w/ health problems

18.5-24.9 Normal Least risk for morbidity & minimal

mortality

WHO expert consultation Lancet 2004; 363: 157–63

Body Mass Index (BMI)

BMI Clinical Significance Morbidity

25-29.5 Overweight Assoc. w/ health problem to
some people
30-34.5 Obesity Class I High degree of risk to
35-39.5 Obesity Class II health
> 40 Obesity Class III

WHO expert consultation Lancet 2004; 363: 157–63.

 MID- UPPER ARM
CIRCUMFERENCE (MUAC)
Only for children 6-59 mos.
Steps
1. Locate tip of shoulder
2. Tip of shoulder
3. Tip of elbow
4. Place tape at tip of shoulder
5. Pull tape past tip of bent
elbow
6. Mark midpoint
7. Correct tape tension
8. Tape too tight
9. Tape too loose
10.Correct tape position for arm
circumference

.
Plotting Growth Indicators
Growth indicators for a child:
length/height-for-age
weight-for-age
weight-for-length/height ( only up to 5 years old)
BMI (body mass index)-for-age
Use appropriate growth charts : WHO
Plot points for growth indicators
Interpret plotted points for growth indicators
median, which in general is the
average
The other curved lines are z-score lines which indicate distance from the average
The median and the z-score lines on each growth chart were derived from measurements
of children in the WHO Multicentre Growth Reference Study
Interpret plotted points for growth indicators
Z-score lines on the growth charts are numbered positively (1, 2, 3) or
negatively (-1,-2,-3)
In general, a plotted point that is far from the median ( 0 (zero) z-score) in
either direction (for example, close to the +3 or -3 z-score line) may represent
a growth problem
BUT consider other factors like growth trend, health condition of the child and the
heights of the parents
OVERWEIGHT
Obesity

Overweight

Normal

Thinness

Severe Thinness
If a point is plotted exactly on the
z-score line, it is considered in the
less severe category
Consider all growth charts and
observations

together, particularly if only one of the charts shows a

problem
For example, if a child is underweight according to the
weight-for-
length-for-age and weight-for-length
Consider all growth charts and observations
Focus more on the weight-for-length/height and the length/height-for-
age charts:
Length/height-for-age reflects attained growth in height.
Stunting (length/height-for-age below -2) implies that for a long period the child
received inadequate nutrients to support normal growth and/or that the child has
suffered from repeated infections
A stunted child may have a normal weight-for-height, but have low weight-for-age due
to shortness
Consider all growth charts and observations
Weight-for-length/height is a reliable growth indicator even when age is not
known.
Wasting (weight-for-length/height below -2) usually results from a recent severe
event, such as drastically reduced food intake and/or illness that caused severe
weight loss.
BMI-for-age classifies children in a similar manner to weight-for-length/height.
Both indicators also help to identify whether the child has excess weight relative to
length/height.
Interpret trends on growth charts
Be alert for the following situations, which may indicate a problem or
suggest risk:

a z-score line

sharp incline or decline in

Classification of Growth
Status*
Growth z-score between -2 and -3 z-score < -3
Indicators
Height (or Stunted Moderate Severely Severe
length)-for- age malnutrition stunted malnutrition

Weight-for- Wasted Moderate Severely Severe acute

height (or acute wasted malnutrition
length) malnutrition

BMI-for-age Wasted Severely

wasted

* From various WHO publications

 MAM

SAM
2015 Updating Survey, FNRI-DOST
SUMMARY
Nutrition screening and assessment should be part of routine child care.
Comprehensive nutritional assessment includes:
A = anthropometry B = biochemical assessment
C = clinical assessment D = dietary assessment
Nutrition screening and assessment at the primary care level involve mainly
anthropometric measurements.
Anthropometry involves the following tasks :
M = measure P = plot I = interpret A = act
Anthropometric measurements , in particular, weight, length and MUAC along
with presence of pitting bipedal edema are the most important screening
indicators to identify acute malnutrition.
FAR EASTERN UNIVERSITY NICANOR REYES MEDICAL FOUNDATION
DEPARTMENT OF CHILD HEALTH

Pediatric Nutritional
Requirements
Nutrients
active elements of foods which are utilized in the functioning
of the body
proteins, fats, carbohydrates, vitamins, minerals,
trace elements, and water
foods contain some or all of these nutrients in variable
proportions
Nutritional requirements
refer to the quantity of energy and of nutrients, expressed
on a daily basis, necessary for a given category of
individuals that will allow these individuals, when in good
health, to develop and lead a normal life

Thomson A and Metz M. Implications of Economic Policy for

Food Security : A Training Manual. FAO 1999
Nutritional requirements
Have been established based on physiological studies (metabolic balances)
and field epidemiological studies
Requirements vary according to :
age
sex
body weight
level of activity
physiological status (e.g pregnancy and lactation)
Expressed as averages, taking into account individual variation
Form the basis for dietary reference standards related to adequacy of nutrient
intake
Nutritional requirements
Every nutrient has a distribution of requirements described by a median (
estimated average requirement or EAR) and a standard deviation for
different age and sex groups
Usually assumed to be normally distributed
EAR : is the daily intake value estimated to meet the requirement in 50% of
the individuals in a life stage or gender group (IOM, 1997)
 Recommended Energy and Nutrient Intake
RENI
shift from RDA (Recommended Dietary Allowances) to RENI:
to emphasize that standards are in terms of nutrients and not food or diets
Definition:

knowledge, are considered adequate for the maintenance of health and well-being of
nearly all healthy persons
Nutrient Adequacy
Nutritional requirement always related to a specified criterion of adequacy
The level of intake of energy or essential nutrient in relation to the energy/nutrient
requirement for adequate health
expressed as % of RENI
100% adequacy should be the goal
refers to the state of nutrient intake that is sufficient to maintain health and provide reasonable levels
of reserves in body tissues

FNRI. NSCB Resolution No. 10 Series of 2008

 Included nutrients in the Philippine Dietary
Reference Intake (PDRI) 2015

Macronutrients Vitamins
Proteins Carbohydrates A thiamine folate

Total Fat Dietary Fiber D riboflavin cobalamine

Ω -3 fatty acid Water E niacin vit. C

Ω -6 fatty acid K pyridoxine

Minerals
Iron Calcium Sodium
Zinc Magnesium Potassium
Iodine Phosphorus Chloride
Selenium Fluoride Manganese
AT RISK NUTRIENTS
at greatest risk for deficiencies of vitamins A and D,
iron, zinc, and iodine6-10
Prevalence of Micronutrient Deficiencies in School-
aged children
Global * Philippines**
(2005-2007) (2008)

Iron 47% 19.8 %

Zinc 33% 20.6%
Iodine 31.5% 19.7%
Vitamin A 21% 11.1%

*Global:
WHO 2008, **Philippines:
J.Nutr 2011, 7th NNS
Food Nutr Bull 2008 FNRI-DOST 2008
PDRI 2015 FNRI DOST
PDRI 2015 FNRI DOST
Thank you!
 malnutrition wherein you have either undernutrition or
overnutrition in the population of a developing country; back then,
you will only see overnutrition particularly in the developed
countries

OVERVIEW
I. Childhood obesity
II. Undernutrition and Protein/Energy Malnutrition

CHILDHOOD OBESITY
- Complex interplay between the environment and the body’s
predisposition to obesity based on genetics and epigenetic
programming
- Affects all of the pediatric populations, regardless of age, race, or
sex - Comparing 2015 from 2013, statistics went up
- Some prevalence disparities with race and age - Although Overweight considerably went down, persistence of
increase remains
Again, we will first look back to the different parameters used to define - This graph tells us that we failed to meet the Millennium
Obesity. Development Goals in 2015; its goal was to decrease by half
whatever parameters were in each country during those years
- Also tells us that our programs did not help that much in dealing
BODY MASS INDEX (BMI)
with the health problems of our people
(WHO) Boys and Girls
2 – 19 years old
2015 UPDATING SURVERY, FNRI-DOST
0 – 59 months, 2013 vs 2015
Months
Years

BMI (kg/m²)

Prevalence of Overweight
12

14

16

18

20

22

24

26

28

30

32

34

36
5

5 to 19 years (z-scores)
BMI-for-age BOYS
3 6 9
6
3 6 9
7

By wealth quintiles
3 6 9
8
3 6 9

- Economic status
9
3 6 9

- The richest people have

Age (completed months and years)
10
3 6 9
11

the highest prevalence

3 6 9
12
3 6 9

rate of obesity
13
3 6 9

- Even the poorest of poor

14
3 6 9
15

have prevalence rate of

3 6 9
16
3 6 9

obesity too
17
3 6 9
2007 WHO Reference

18
3 6 9

By place of residence
19

-3

-2

-1

3
12

14

16

18

20

22

24

26

28

30

32

34

36

- People living in urban

areas have the highest
CLINICAL BMI Z-SCORE PERCENTILE prevalence rate of
SIGNIFICANCE obesity
Overweight ≥ 25 – 29.5 ≥ + 1SD 85th – 94.9th
Obesity ≥ 30 – 39.5 ≥ + 2SD ≥ 95th
(Obese Class I)
Morbid obesity
By sex
Adolescent ≥ 99th - As per Doc Urtula,
Adult 35 – 39.5 “almost the same, both
(Obese Class II) gender, male and female,
≥ 40 there is no statistical
(Obese Class III) difference for that
matter”

WHAT IS THE PREVALENCE OF OVERWEIGHT & OBESITY IN

CHILDREN?
- Between 2000 and 2013, the number of overweight children
worldwide increased from 32 million to 42 million
- Globally, 42 million children who are younger than 5 years old (7%)
are overweight
- Up to now, it is still increasing and not a local problem anymore
rather, it is already known as “Globesity” as the issue is now
global

In the Philippines (local

setting)
2015 UPDATING SURVERY, - You can see the highest prevalence rate of overweight on the first
FNRI-DOST 0 – 5 months of life
- Drastically went down by 6 – 11 months, this explains that our
- The trend is quite a
population does not have a good way of feeding infants – our
plateau, we see here
complementary feeding is really poor in nutrition
a double burden of

Page 1 of 11
 LEVELS OF SATIETY AND APPETITE REGULATION
Cellular AMPK (AMP-activated Protein Kinase)
Ghrelin
Peripheral
CCK, GLP-1, PYY, Amylin, Obestatin,
(Episodic and Tonic)
Leptin, Estrogens
Homeostatic center (satiety vs hunger)
CNS
Hedonic (emotional / behavioral)
- Tightly regarded as control mechanism

CHILDHOOD OVERWEIGHT AND OBESITY OUTCOMES

- Insulin Resistance + Hyperinsulinemia
- Increased Glucagon

THE METABOLIC SYNDROME

Medical Complications of Obesity

Short term regulation of food intake

1. Food enters GIT
2. Stimulates production of inhibitory compounds (IC)
3. IC go to nucleus solitary tract (brain stem) & arcuate nucleus
(hypothalamus) inhibits release of Ghrelin
4. IC also stimulates liver, pancreas, adipose tissue release
other inhibitory compounds to the NST and ARC
5. Distention of GIT: inhibitory signal via Vagus nerve

- Affects not only one, but almost all systems of the body Result: Satiety is reached and food intake ceases.
- There are a lot of derangements particularly in the heart, lungs,
Remember!!!
liver, pancreas, and connective tissues like skin and joints
- Ghrelin is an orexigenic hormone – appetite stimulant
1. Hypertension
2. Dyslipidemia
If food intake is under strict physiologic controls, why does obesity occur?
3. Diabetes mellitus (glucose intolerance)
Overweight and Obesity Pathophysiology: Multifactorial
4. Sleep apnea
Polygenic
5. Atherosclerosis
Genetic determinants that predispose to metabolic alterations
6. Cardiovascular disease
Environmental factors – Nutrigenomics and Epigenetics
7. And all other secondary health consequences of the above
Obesogenic environment
Other variables
In the Philippines (local setting)
- Hypertension, Diabetes, Coronary heart disease are all increasing in
Remember!!!
unison with the incidence of obesity both in children and adult
- With Epigenetics and Nutrigenomics, there are certain genes (which at
population
a young age are still “asleep”) that make an individual obese. However,
if the individual is exposed to obesogenic environment or to a certain
WHAT CAUSES OBESITY? ARE THERE ANY RISK FACTORS? stress, that now causes methylation of that particular gene
Before we answer that, let’s take a look on how we regulate our energy unraveling and expressing itself in the body
balance…
OBESITY: GENETIC DETERMINANTS
Biologic mechanisms in energy balance
- To maintain our optimal MOUSE STUDIES - Obesity gene (ob) produces a gene
metabolic status, our energy product
(leptin) in adipose tissue
expenditure and energy intake
- Leptin signals satiety by interacting with
should be balanced
receptors in the brain
- Obese mice: mutations in the (ob) gene
- Whatever we take in is being results in abnormal leptin or complete
utilized by the body so that our absence of gene product no satiety
body can maintain our weight HUMAN STUDIES - Weight of adopted child correlates with
weights of biologic parents
- However, if the two is not - Monozygotic twins have similar weights
balanced – more food is taken and fat distribution
in proportion to the energy
expenditure stored as fats in Biologically Inactive Leptin and Early-Onset Extreme Obesity Study
the different systems of the The mutant protein is secreted but neither binds to nor activates the
body overweight, obesity leptin receptor
Leptin counteracts the function of Ghrelin
Page 2 of 11
 Obesity happens because you lack Leptin and your receptors are not OBESITY: ENVIRONMENTAL FACTORS
working - “Obesogenic" environment
Abundance of food, Fa(s)t food centers
HUMAN OBESITY: GENETIC DETERMINANTS Sedentary lifestyle, Lack of daily physical activity
Dietary preferences
FTO gene - “Fat mass & obesity associated” gene
Television viewing, TV dinners, ready-made food
(Chromosome 16)
Computer usage, iPod, iPad
- Homozygotes for the allele weigh 3 –
Sleep deprivation
4kg more and have 1.67-fold increased
- Obesity is a "disease of civilization”
risk for obesity
- Postulated role in regulation of food
Diagnostic workup
intake and lipolytic activity in adipose
tissue - Do a good history taking!!!
- Associated with BMI, obesity risk, type 2 Family history, prenatal, birth, and postnatal history
diabetes Any medical complications in childhood
Melanocortin 4 - Mutations in this gene causes - Hormonal problems, genetic problems
receptor gene hyperphagia Medications used for comorbid conditions
- 4% – 5% of early childhood obesity
(MC4R) - steroids
PPARy - insulin resistance, storage & metabolism Management of obesity
(Peroxisome Proliferator of fats - Do anthropometrics!!! One’s measurements carefully look at signs
Activator Receptor 2) and symptoms that may tell something else other than being obese
AdipoQ - BMI, weight, W/H ratio - Labs:
(adiponectin, Ch 3) FBS and/or Hg1c
Apo-A2 Lipid panel
(Apolipoprotein) ALT, AST, GTT, uric acid
Consider 25-OH Vitamin D
CHILDHOOD OBESITY RISK FACTORS
1. Pre-pregnancy TREATMENT OF OVERWEIGHT AND OBESE CHILDREN &
2. Pregnancy ADOLESCENTS
a. Undernutrition in 1st semester - The foundation of treatment is effecting behavioral change to
b. Excess weight gain improve long-term physical health through improved diet and
c. Gestational DM physical activity
1. Dietary
d. Smoking
A. Balanced Macronutrient Diet
e. Teenage pregnancy
Lower Calorie Diets
Remember!!!
- Undernutrition in the 1st trimester of pregnancy is associated with - 45% - 65% Carbohydrate
excess weight gain later in life – proven by the Dutch famine of World - 20% - 35% Fat
- 10 % - 35% Protein
War II. Those born during that era has been shown to have obesity later
in life
For infants and young children:
- 25% - 40% Fat
BREASTMILK B. Altered Macronutrient Diet
- Rates of obesity are significantly lower in breastfed infants Lower Glycemic Load Diets
- The duration of breastfeeding is inversely associated with the risk Low Carbohydrate Diets
of overweight; each month of breastfeeding was associated with Protein Sparing Modified Fast Diets
a 4% reduction in risk for overweight/obesity Low Fat Diets
- Protective effect of breastfeeding against overweight and obesity o Atkins Diet
appears to be greater for exclusively breastfed infants o South Beach Diet
o Paleo Diet
Fact or Myth: Breastfeeding is protective against obesity!?!? 2. Non-Dietary
What do RCT show? A. Multi-component Lifestyle Interventions:
- No compelling effect on obesity prevention Sedentary Behavior
- No important anti-obesity effects Physical Activity
Remember!!! Sleep Duration
- Breastfeeding has other potential health benefits (especially for the Screen Time
baby!!! stimulates immunity, less allergy, better brain development, etc.)

ODD’S RATION (95% CI) OF A BABY BECOMING OBESE BY 8 YEARS

OLD
Mother obese 2.8 (1.8 – 4.3)
Father obese 2.6 (1.6 – 4.2)
Both Father & Mother obese 6.3 (3.5 – 11.2)
Asian parents 1.9 (1.1 – 3.4)
Black parents 3.0 (1.4 – 6.9)
Gestational DM 3.4 (1.3 – 8.9)
Birthweight >4kg 1.8 (1.2 – 2.8)
Rapid early weight gain 2.7 (1.7 – 4.3)
Page 3 of 11
 DIETARY Remember!!!
- Ketogenic diets (very low protein, high fat, and 0 carbohydrate) are
BALANCED MACRONUTRIENT DIET
bad! It was particularly developed for children who have intractable
Low Calorie Diet seizures (status epilepticus). Instead of sugar being used as by the
2 – 5 years old brain, it is the ketones – ketones coming from the metabolism of fat
- no studies were identified in the body; may aggravate certain conditions like pre-existing
- a negative energy balance may have detrimental effects metabolic problems, heart disease, atherosclerosis, joint problems,
etc.
6 – 12 years old
- 900 – 1200kcal/day
- part of a clinically supervised, multi-component weight loss program And so, for children we recommend…
- associated with both short-term and longer-term reduction in adiposity
Adolescent
- balanced macronutrient diet: not lower than 1200kcal
- effective for short-term improvement in weight status
- treatment programs for less than one year since there is no evidence on
longer term treatment trials
ALTERED MACRONUTRIENT DIET

Low Glycemic Load Diets

- ad libitum, modest
- short-term weight loss in children; longer-term weight loss in
adolescents
- however!! It may increase satiety in children and adolescents
- inadvertently bring about a reduced caloric intake
Low Carbohydrate Diets
Children
- no studies were identified
Adolescents
- 12-week study
- calorie – unrestricted, low carbohydrate vs SUGARS
calorie - restricted, low fat WHO Recommendations
- ad libitum, low carbohydrate 1. Reduced intake of free sugars throughout the life course
- may be effective in reducing adiposity 2. Reducing the intake of free sugars to less than 10% of total
- short-term energy intake
Protein Sparing Modified Fast Diets (PSMF)
- high protein (50%) Remember!!!
- low carbohydrate (10%) - Both considered strong recommendations
- low calorie
- lean meats and seafoods, non-starchy vegetables FRUIT JUICES (100%)
- Balanced Group: balanced macronutrient, hypocaloric diet 1. For 1 to 6 years old = 4oz to 6oz per day
- 7.5 - 16.9 years of age 2. For 7 to 18 years old = 18oz to 12oz or 2 servings per day
Low Fat Diets
- deficit of 500-600 kcal/day below the energy balance requirements NON-DIETARY
- may result to weight reduction = 0.5 kg/week Multi-component Lifestyle Interventions
- long-term weight loss (beneficial changes in lipids, blood glucose and
Sedentary Behavior
blood pressure)
- can be combined with providing low glycemic index foods Physical Activity
Sleep Duration
ATKINS DIET
- high consumption of protein Screen Time
- high consumption of fiber
- substantial vitamin and mineral intake PHYISCAL ACTIVITY FOR CHILDREN 5 – 17 YEARS
- low amounts of sugar - At least 60 minutes of moderate-to vigorous-intensity of physical
- elimination of trans fats activity daily at least 3 times per week
- high protein, low carbohydrate - Activities in multiple shorter bouts spread throughout the day
- no long-term data to evaluate - The majority of children and youth around the world do not meet
SOUTH BEACH DIET current physical activity guidelines and are considered to be
- low-kilocalorie, high-protein, lower-carbohydrate inactive.
- allows healthy fats (Omega 3), high-fiber foods, and selected carbohydrate - High levels of habitual sedentary time (watching TV and playing
- adaptable for children (Phase III) videos) are associated with a range of negative health outcomes
Lifelong maintenance phase such as overweight and obesity
OK: "good" carbohydrates and fats - Reductions in sedentary behavior may be as effective as or even
NO: "bad" carbohydrates and fats more effective than increasing physical activity directly in
PALEO DIET decreasing BMI, and percentage overweight
- high-protein, high-fiber
- changing eating to resemble cavemen or Stone Age humans “Active” Video Games (AVG)
- fresh lean meats, eggs and fish, fruits and vegetables, nuts and seed, and - Require whole-body movement to play
"healthier" fats such as olive oil and coconut oil - Energy expenditure may be substantially increased when playing
- not allowed: processed foods, wheat and other grains and legumes, dairy, these type of games
potatoes, salt, refined sugar, and refined vegetable oils such as canola
- Example: dance revolutions, Wii, boxing, tennis

Page 4 of 11
 - Most studies reported its declined use over time ELECTRONIC ENTERTAINMENT & COMMUNICATION DEVICES
- Systematic review also showed that AVGs do not make a (EECDs)
significant contribution to meet guidelines of 60 minutes of - Access to and night-time use of EECDs are associated with
moderate-to-vigorous-intensity physical activity on a daily basis shortened sleep duration, excess body weight, poorer diet
- Inconsistent whether there is sustained physical activity behavior quality, and lower physical activity levels
change, or for how long the behavior change persists - Children with 2 – 3 screens in their bedroom had a significantly
higher percentage of body fat and significantly lower sleep
efficiency
Numerous studies and their results
- Children having only a TV in their bedroom had significantly
Impact of Dietary and Exercise Interventions on Weight Change and
higher adiposity than those having no screen at all
Metabolic Outcomes in Obese Children and Adolescents: A Systematic
Review and Meta-analysis of Randomized Trials
POLICY STATEMENT
the addition of exercise to dietary intervention led to greater
For Children, Adolescents, and the Media
improvements in levels of high-density lipoprotein cholesterol,
fasting glucose, and fasting insulin over 6 months Among the APP recommendations:
For children younger than 18 months:
Lifestyle intervention for improving school achievement in overweight - avoid use of screen media other than video-chatting.
or obese children and adolescents - parents of children 18 to 24 months of age who want to
physical intervention delivered for childhood wealth introduce digital media should choose high-quality
management could benefit mathematics achievement, programming, and watch it with their children to help them
executive function and working memory understand what they are seeing
For children ages 2 – 5 years:
Meta-analysis of school-based Physical Activity - limit screen use to 1 hour per day of high-quality programs
physical activity interventions, on average, achieved small to - parents should co-view media with children to help them
negligible increases in children’s total activity volume understand what they are seeing and apply it to the world
generally, school-based interventions had little effect on For children ages 6 and older:
physical activity rates, BMI, body weight, systolic and diastolic - place consistent limits on the time spent using media, and
blood pressure, and pulse rate the types of media, and make sure media does not take the
given that there are no harmful effects and that there is some place of adequate sleep, physical activity and other
evidence of positive effects on lifestyle behaviors and physical behaviors essential to health
health status measures, ongoing physical activity promotion - designate media-free times together, such as dinner or
in schools is recommended at this time driving, as well as media-free locations at home such as
bedrooms
SLEEP TIME - have ongoing communication about online citizenship and
- For children: “short sleep” is <10h or <10h per night unless stated safety, including treating others with respect online and
offline

NON-DIETARY TREATMENT
Pharmacotherapy
Orlistat (Xenical brand in PH)
- reduces dietary fat absorption by 30% by inhibiting pancreatic and
gastric lipase
- the only medication approved by the FDA for use in adolescents ≥12
years old
- the recommended dose is 120 mg three times daily
- Orlistat in obese adolescents reported a placebo-subtracted
reduction in BMI of 0.86 kg/m2 (BMI reduction of ≈2.4%) over a
treatment period of 1 year
- side effects: oily stools (50%), oily spotting (29%), oily evacuation
otherwise
(23%), abdominal pain (22%), and fecal urgency (21%)
- For adults: “short sleep” is <5hr or <5hr per night
Metformin
- There is 60% to 80% increase in the odds of being short sleeper
amongst obese children and adults - Biguanide primarily used for glycemic control in T2DM, reduced
hepatic glucose; increases insulin sensitivity
- Less sleep increases odds of obesity by 1.5 times
- has been evaluated for its effect on weight loss in several pediatric
studies but does not have FDA approval for this indication in children
Short sleep and Obesity
and adolescents
Remember!!! - a meta-analysis of 5 studies (with treatment periods ≥6 months) that
- If you have short sleep, you have less secretion of Leptin and used metformin in children and adolescents reported a placebo-
increased secretion of Ghrelin subtracted reduction in BMI of 1.42 kg/m2
- Leptin is anorexigenic while Ghrelin is orexigenic - reduced fasting insulin by 9.9 μU/ml (95% CI -13.8, -6.06)
- side effects: metallic taste in the mouth, mild anorexia, nausea,
abdominal discomfort, and soft bowel movements, or diarrhea

Page 5 of 11
 BARIATRIC SURGERY 1. Nutrient intake less than the required for normal growth
A variety of different procedures that anatomically alter the 2. Needs for growth are greater than can be supplied
gastrointestinal tract and result in restriction of stomach capacity, - Types:
interference with progression of a meal, or diversion of ingested contents 1. Primary Malnutrition
- Resulting from inadequate food intake
Candidacy for Bariatric Surgery in Pediatric Obesity: - Major percentage in developing countries
very severely obese (WHO BMI of 40kg/m2) 2. Secondary Malnutrition
have attained a majority of skeletal maturity (generally 13 years
- Resulting from increased nutrient needs, decreased
of age for girls and 15 years of age for boys)
nutrient absorption, and/or increased nutrient losses
experienced failure of 6 months of organized weight loss attempts
- Higher percentage in developed countries
have comorbidities related to obesity that cannot be remedied with
less invasive means
the patient and her/his family have received extensive preoperative ANTHROPOMETRIC INDICES
counselling and given informed consent - index of the cumulative effects of
Height-for-age
undernutrition in the life of the child
Most Common Procedures for Adolescents:
- reflects the combined effects of both
A. Adjustable gastric banding (AGB) Weight-for-age
recent and long-term levels of nutrition
B. Roux en Y gastric bypass (RYGB)
C. Sleeve Gastrectomy (SG) Weight-for-height - reflects recent nutritional experiences

A B C Remember!!!
- Weight-for-height is also known as Waterlow classification while
Weight-for-age is
also known as
Gomez classification

2015 UPDATING
SURVERY, FNRI-DOST
COMPARISON
Co-morbid Condition Outcomes: BETWEEN 2013&2015
surgical procedures result in 20% to 35% initial weight loss over at DOST-FRNI
least the first 2 years NUTRITION SURVEYS
between 28% – 37% reduction in BMI by 1 year
significant reductions in hyperinsulinemia, elevated fasting glucose,
hypertriglyceridemia, LDL
Cut-off points in determining magnitude & severity of Underweight, Stunted, and
improvement or resolution of OSAS, T2DM, metabolic syndrome,
Wasted children under 5 years old, as public health problem (WHO, 1995)
hypertension

Common Reported Complications

- Stunting: 33.4%
Band slippage and erosion
prevalence rate
Port/tube dysfunction
Hiatal hernia, pouch dilation HIGH
Pulmonary embolism, shock - Underweight:
Intestinal obstruction 21.5%
Postoperative bleeding, staple line leak prevalence rate
Severe malnutrition HIGH
Remember!!! - Wasting: 7.1%
- Bariatric surgery should be the last resort prevalence rate
Summary!!! POOR; the
- Pediatric Obesity is fast becoming a global health problem which is decline is not statistically significant
associated with a range of adverse health and psychological outcomes. - There was an increase in Underweight and Stunting
- A combination of diet, lifestyle/behavioral modification, pharmacologic - Decrease in Wasting and Overweight; but not statistically
therapy appears to have modest short-term efficacy in terms of significant
BMI/weight reduction and cardiometabolic risk factor improvement,
however, long-term sustainability of these improvements is poor. MAGNITUDE PREVALENCE
PREVALENCE GROUP OF
- Given the limited effectiveness of lifestyle and pharmacologic & GROUP OF
UNDERHEIGHT/STUNTING
interventions, Bariatric surgery is fast becoming broadly accepted in the SEVERITY UNDERWEIGHT
treatment of severe obesity in adolescents as results show more Low <10% <20%
effective and sustained outcomes on long-term co-morbidities.
Medium 10% - 19% 20% - 29%
- Prevention of pediatric obesity is the ultimate goal and ideal outcome
but may not be realized in the near future High 20% - 29% 30% - 39%
Very High ≥30% ≥40%
UNDERNUTRTION & PROTEIN/ENERGY MALNUTRTION
MAGNITUDE & PREVALENCE GROUP OF
UNDERNUTRITION SEVERITY THINNESS
- Lower than desired intake of one or more nutrients with either no Acceptable <5%
symptoms or only vague symptoms to sever mature malnutrition Poor 5% - 9%

PROTEIN/ENERGY MALNUTRITION Serious 10% - 14%

- Severe form of undernutrition Critical ≥15%
- Inadequate intake of protein and energy due to:

Page 6 of 11
NON-EDEMATOUS PROTEIN-ENERGY MALNUTRITION (MARASMUS) Who should be admitted to IPF?
- “Buto’t balat”
FACTOR IN-PATIENT CARE
- Clinical manifestations:
- caregiver chooses to start, continue, or
Initially, there is failure to gain weight and irritability, then Choice of
transfer to in-patient treatment.
weight loss leading to emaciation Caregiver
- the caregiver’s wishes must be respected
Loss of subcutaneous fat skin is wrinkled and loose, face
Appetite - failed or equivocal appetite test
is shrunken with “wisened” look
- bilateral pitting edema (irrespective of the
Abdomen with readily visible intestinal pattern
grade)
Muscle atrophy with hypotonia Edema
- both marasmus and kwashiorkor
Temperature is subnormal with low pulse rate
(W/H </= 3 z-score and edema)
Constipation or diarrhea with small, frequent mucoid stools Skin - open skin lesions
- any severe illness, using the IMCI criteria –
EDEMATOUS PROTEIN-ENERGY MALNUTRITION (KWASHIORKOR) Medical
respiratory tract infection, severe anemia,
complications
- Clinical manifestations: dehydration, fever, lethargy, etc.
Initially, there is lethargy, apathy, or irritability - presence of candidiasis or other signs of
Candidiasis
Loss of muscle tissue, increased infections, vomiting, severe immune-incompetence
diarrhea, anorexia, flabby, subcutaneous tissue, and edema Caregiver - no suitable or willing caregiver
which may mask failure to gain weight, enlarged liver Remember!!!
Edema in internal organs, face and limbs - At any stage of the management, the caregiver is often the best judge
Dermatitis – skin pigmentation in irritated areas, of severity
depigmentation with desquamation
Hair is sparse, thin, and coarse with streaks of red or gray ACUTE PHASE (PHASE 1)
(hypochromotrichia) - Give the feeds, give routine medicine, monitor the patient
Eventually, stupor, coma, and death - Prevent, Diagnose and Treat the Complications & Failure-
- Pathophysiology: to-Respond-to-Treatment
Inadequate intake activity and energy expenditure - Management of acute or life-threatening complications take
precedence over routine care
Fat stores are mobilized to meet energy requirements
- Designed for severe complicated malnutrition who have
once depleted, protein catabolism provides ongoing
impaired liver and kidney function and infection
substrates for maintaining basal metabolism
- F75 used in this phase
Edema development?
Designed for severe complicated malnutrition and has
o Variability in nutrient requirements and body
impaired liver and kidney function and infection
composition at the time of dietary deficit
No weight gain on this formula
o Giving excess CHO in clinical marasmus reverses
adaptive response to low CHON mobilization of
body CHON store decrease albumin synthesis
hypoalbuminemia edema
o Fatty liver – secondary to lipogenesis from excess
CHO
o Free radical damage in development of edematous
PEM
Remember!!!
- Here in the Philippines, we experience a mixture of the two called
Marasmic Kwashiorkor

PRINCIPLES OF MANAGEMENT
- Patients should not be treated in the ER for the first 24 – 28 hours Alternatives of F75
unless staff have been trained to manage complication of SAM
(Severe Acute Malnutrition)

- for those with inadequate appetite and/or

acute major complication
Acute Phase
- repair of physiological and metabolic
(Phase 1)
functions and electrolyte balance
- no weight gain
- ensures full restoration of physiological
function before a change to an energy dense
Transition Phase diet
- increased energy intake by 30% 6g/kg/day
weight gain
- transferred to OTP if with good appetite and
Recovery Phase
no major complications
(Phase 2)
- rapid weight gain – 8g/kg/day How to give how much?
- Most children are breastfed ½ hour before scheduled feed
- Use only one schedule
Most children will need 5-6 feeds/day
If not tolerated, 8 or more feeds/day
o Severely ill
o Refeeding diarrhea with routine schedule
o Have had very little during the day (new admissions)
Page 7 of 11
 o Vomited some or all their feeds
- Nystatin 100,000 UI PO qid (4x a day) for
o Had an episode of hypoglycemia
oral candidiasis and routinely for all
o Had hypothermia
patients in areas with a high prevalence of
o Staffing at night available
candidiasis (>20%) or HIV
- Fluconazole (3mg/kg OD) for those with
When to give Nasogastric (NG) feeds?
signs of severe sepsis or systemic
- Indications: Anti-fungal
candidiasis
Intake: <75% of prescribed diet (75kcal/kg/day)
- for skin lesions (ringworms/candida etc.)
Pneumonia with rapid RR
use metronidazole ointment/cream 2%
Painful mouth lesions
- duration of treatment is until patient is
Cleft palate or other deformity
transferred to OTP or acute phase + 4
Disturbance of consciousness
more days
- Treatment of the SAM takes precedence
Feeding technique
- Treatment can also be delayed for at least
- Use cup and saucer
2
- Dribbles that fall into the saucer are
weeks, except:
returned to the cup
Children with SAM o Military TB
- Do not force feed!!!
and TB o TB meningitis or Pott’s disease
- Avoid co-Artem (combination of Artmether
INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION (IMAM)
and Lumefantrine – antimalarial for P.
POSITION: Give systemic antibiotics to severely malnourished patients,
falciparum) & rifampicin if the patients have
even if they do not have clinical signs of systemic infection
SAM & are on antiretroviral drugs (ARVs)
- ARV is introduced after SAM treatment is
ANTIBIOTICS
started at a minimum of 2 weeks to
- Duration of Antibiotic Treatment:
diminish side effects from ARV drugs
1. For Outpatient care:
- Cotrimoxazole prophylaxis against
- Given for 7 days SAM and HIV/AIDS
Pneumocystis pneumonia
2. In-patient care: - Routine antibiotics
-
Given continuously during the acute phase + 4 more - Avoid Amphotericin B in SAM patients with
days or until transferred to outpatient care HIV
- Route: Should be given orally or by NG tube unless there is septic Medicines given under specific circumstances only
shock wherein parenteral antibiotics should be used
- Sufficient amount in F75 and RUTF to
Routine medicines: correct mild deficiency
- Antibiotics given to all severely malnourished children - High dose given if:
Vitamin A Clinical signs of vitamin A deficiency
- for patients without apparent signs of infection
include any eye infection
- oral amoxicillin/ampicillin, if with no high level of
Child is >9 months and with active
amoxicillin resistance in the region
measles epidemic and no measles shot
- or where there is amoxicillin resistance
First line
- daily IM injection of cefotaxime for 2 days
treatment
(50mg/kg) - Amount in F75 & RUTF are sufficient for
- or amoxicillin-clavulanic acid (25-50mg/kg/day) mild folate deficiency
Folic Acid
- and/or suppress small-bowel overgrowth with - If with a clinical anemia, give single dose
Metronidazole (10mg/kg/day) 5mg on admission
- systemic infection
Anthelminthics (Deworming)
- add gentamicin (5mg/kg/day) IM (do not stop first
line antibiotics) during the acute phase OR
MEDICATION DOSE ADMINISTRATION
- change to cefotaxime (50mg/kg) IM injection plus
Second line
ciprofloxacin orally (30mg/kg/day in three doses < 12 months Do not give to < 12 mos
treatment
per day) continue as long as the patient has any
Albendazole/ 12 to 23 mos:
signs of infection Give 1 dose on day 7
- is suspicion of Staphylococcus infection add Mebendazole 250mg
(unless received in the last
cloxacillin 41 (100-200 mg/kg/day 3 times daily) >24 mos: 500mg month)
- individual medical decision
- to reduce nosocomial spread of resistant
Remember!!!
organisms – oral ciprofloxacin should normally be
given along with cefotaxime - Anthelminthics delayed until admitted to OTP or if not possible to refer
- in severe sepsis, cefotaxime and ciprofloxacin are to OTC, then give at Phase 2
more reliable
Third line - Chloramphenicol is used where there is no Surveillance Recorded in IPF
treatment suitable alternative - Daily checks
- dose must be reduced to half that used for Weight, degree of edema
normally nourished children 25mg/kg/day (twice Stool, vomiting, dehydration, cough, respiration, & liver size
daily) - Body temperature taken 2x per day
- not used in those <3 months of age - Weekly MUAC
- use with extreme caution in infants <6 months of - Record if the patient is:
age or <4kg Absent, vomits or refuses a feed
Fed by NGT
Given an IV infusion or transfusion

Page 8 of 11
Acute phase to transition phase… Abandoned child without available orphanage
- No fixed time in Acute phase!!! Impossible home circumstances
- Transfer to Transition phase if all are present No other family willing to care for child
Return of appetite No operational OTP
Beginning loss of edema (accompanied by proportionate No supply of RUTF
weight loss - Feeding during recovery phase:
Appears to be clinically recovering Breastfeed before giving F100 or RUTF and on demand
Intake is unlimited but never >200kcal/kg/day
TRANSITION PHASE - If F100 is used, add iron:
For each 2 to 2.4L, add 1 crushed tablet of FeSO4 (200mg) o
- Ensures full restoration of physiological function before a change to
For each 1 to 1.2L of F100, dilute one tab of FeSO4 (200mg)
an energy dense diet
in 4 ml water and add 2 ml of the solution
- Increased energy intake by 30% 6g/kg/day weight gain
For 500ml to 600ml of F100, add 1ml of the solution
- Prepares the patient for Recovery Phase as an out-patient
Alternatively, if there are few children, iron syrup can be
- May be as an in-patient where there is no appropriate home for the
given to the children
child to go to, the caretaker chooses to remain in in-patient care
- Lasts between 1 and 5 days – but may be longer, particularly when
Monitoring
there is another pathology (e.g. TB or HIV)
- A prolonged transition phase is a criterion for failure-to- respond Surveillance in Phase 2 Frequency
- Recognize readiness for transition Weight in edema 3 times per week
Return of appetite (easily finishes 4-hourly feeds of F75)
Body temperature is
Reduced edema or minimal edema Every morning
The child may also smile at this stage measured
- Change in the diet from F75 to RUTF, or if the RUTF is not The standard clinical signs
Every day
accepted to F100. (stools, vomiting, etc.)
- When giving RUTF:
Advise the mother to breastfed the child 30 min before
MUAC is taken Every week
giving the RUTF
Offer plenty of water to the child Appetite is judged from the
Intake record is kept on chart
CHECK five times during the day the amount given by the amount taken
mother
Give other routine treatments:
F100 - Deworming
- Measles vaccination
- Vitamin A before being discharged

Transfer to OTP
- Good appetite!! - this means taking at least 90% of the RUTF (or
F100) prescribed for transition phase
- There is a definite and steady reduction in edema
- If there is a capable caretaker
- If the caretaker agrees to out-patient treatment
- If there are reasonable home circumstances
Transition phase back to acute phase…
- If there is sustained supply of RUTF
- Management of complications - If an OTP program is in operation in the area close to the patient’s
Dehydration home
Septic shock
Ileus Discharged Cured Criteria from Phase 2
Heart failure
- Admitted on WFH Z-scores only
Hypothermia
Children 6 – 59 - WFH or WFL ≥ -2SD for 2 days AND
Severe anemia o Hypoglycemia o Skin lesions
- Criteria: months - No edema for 10 days AND
Signs of fluid overload - Clinically well!
Rapid increase in the liver size - Child is gaining weight more than 5g/kg/day
Increased respiratory rate on breast milk or milk formula for 3
Weight gain more than 10g/kg/day Infants <6 consecutive days AND
If this abdominal distension develops (indicates abnormal months - Edema is absent AND
peristalsis, small bowel overgrowth and perhaps excess - Clinically well and childhood immunizations
carbohydrates intake)
have been checked
Significant re-feeding diarrhea with weight loss
A complication that necessitates an IV infusion (e.g. malaria,
Management of complications
dehydration, etc.)
- Transfer to Acute phase if patient develops complications!
Any deterioration in the child’s condition (see section on
Dehydration
refeeding syndrome)
Septic shock
Increasing edema or develops edema
Ileus
Heart failure
RECOVERY PHASE (PHASE 2)
Hypothermia
- Transferred to OTP if with good appetite and no major Severe anemia
complications Hypoglycemia
- Rapid weight gain – 8g/kg/day Skin lesions
- Patients should not be treated in the ER for the first 24-48 hours Summary and Recommendations!!!
unless staff have been trained to manage complications of SAM - Great care should be exercised in prescribing drugs to severely
- Recovery phase in ITC: malnourished patients,
No capable caretake

Page 9 of 11
- Drugs which affect the central nervous system such as anti- emetics, Problems…
those causing loss of appetite, and those with adverse reactions
With the Treatment Facility Of individual children
affecting the liver, pancreas, kidney, heart, circulation, or Intestine
should not be used, or used only under very special circumstances. - Failure to apply the protocol - A severe medical complication
appropriately - Drug toxicity
- Common drugs such as paracetamol do not work in the severely
- Poor environment for - Insufficient food givens
malnourished children during the acute phase and can cause serious
malnourished children - Food taken by siblings or
hepatic damage.
- Excessively intimidating, strict caretaker
- For conditions that are not rapidly fatal (e.g. HIV). Malnutrition is treated or cross staff - Sharing of caretaker’s food
for at least 1 week before standard doses of drugs are given. - No separate dedicated area - Malabsorption
- Certain drugs be avoided altogether until research shows that these are - Failure to complete the - Psychological trauma
safe and the dosages adjusted for the malnourished state. multichart correctly (or use of - Rumination (and other types
- Doses of drugs that have not been adequately tested in SAM patients traditional hospital records of severe psychosocial
be reduced when their use is absolutely necessary. only) deprivation)
- Standard doses of drugs be given to patients when they have lesser - Insufficient staff (particularly - Infection
at night) - Other serious underlying
degrees of malnutrition or are in the later stages of treatment in the
- Poorly trained staff disease: congenital
OTP
- Inaccurate weighing machines abnormalities (e.g. Down’s
(of failure to take and plot the Syndrome), neurological
REFEEDING SYNDROME weight changes routinely) damage (e.g. cerebral palsy),
- Occurs when a malnourished patient suddenly has a large increase - F75 not prepared or given inborn errors of metabolism
in food intake correctly
- Develop acute weakness, “floppiness”, lethargy, delirium, Remember!!!
neurological symptoms, acidosis, muscle necrosis, liver and - When appropriate, examine urine for pus cells and culture blood,
pancreatic failure, cardiac failure or sudden unexpected death culture sputum or tracheal aspirate for TB; examine the retina in a low
- It is due to nutritional disequilibrium with reduced plasma light for retinal tuberculosis.
phosphorus, potassium and magnesium - Do a chest x-ray
- Prevention: - Examine stool for blood, look for trophozoites or cysts of Giardia:
Start treatment with 100kcal/kg/d and increase to 130 Culture stool for bacterial pathogens. Test for HIV, hepatitis and malaria
kcal/kg/d for a few days - Examine and culture CSF
Before going to the full intake
NEVER force-fed more than 100 kcal/kg/day COMPUTING FOR CATCH-UP NUTRITION REQUIREMENTS FOR UP-
Fast for 1 day BUILDING
- Treatment:
Return to the Acute Phase
Start with 50% of the recommended intake of F75 until all
signs and symptoms disappears; then gradually increase
Check to make sure that there is sufficient K and Mg in the
diet

Remember!!!
- If the diet is not based on cow’s milk (or the mother is also giving
cereals/ pulse etc.) additional phosphorus should be given to prevent
re-feeding syndrome.

Investigation on causes of failure to respond

Criteria for Failure to Respond Time After Admission
Failure to improve/regain appetite Day 4 - Please be familiarized
Failure to start to lose edema Day 4
Edema still present Day 10
Failure to fulfill criteria for
Day 10
recovery-phase (OTP)
Clinical Deterioration AFTER
Anytime
admission

- This is more important!! Please be familiarized

- Doc Urtula’s example: If I have a 5-month old female infant, she
should be taking 560 kcal/day and 8g of that should be protein

Remember!!!
- This is the recommended nutrient intake per day!

Page 10 of 11
CATCH-UP CALORIE OR PROTEIN REQUIREMENT A. CATCH-UP CALORIES

𝐃𝐚𝐢𝐥𝐲 𝐜𝐚𝐥𝐨𝐫𝐢𝐜 𝐫𝐞𝐪𝐮𝐢𝐫𝐞𝐦𝐞𝐧𝐭 𝐟𝐨𝐫 𝐰𝐞𝐢𝐠𝐡𝐭 𝐚𝐠𝐞 𝐱 𝐈𝐁𝐖 𝐟𝐨𝐫 𝐚𝐠𝐞

𝐃𝐚𝐢𝐥𝐲 𝐜𝐚𝐥𝐨𝐫𝐢𝐜 𝐨𝐫 𝐂𝐇𝐎𝐍 𝐫𝐞𝐪𝐮𝐢𝐫𝐞𝐦𝐞𝐧𝐭 𝐟𝐨𝐫 𝐰𝐞𝐢𝐠𝐡𝐭 𝐚𝐠𝐞 𝐱 𝐈𝐁𝐖 𝐟𝐨𝐫 𝐚𝐠𝐞 =
= 𝐀𝐜𝐭𝐮𝐚𝐥 𝐁𝐨𝐝𝐲 𝐖𝐞𝐢𝐠𝐡𝐭 (𝐀𝐁𝐖)
𝐀𝐁𝐖

𝟗𝟐𝟎 𝐤𝐜𝐚𝐥 𝐩𝐞𝐫 𝐝𝐚𝐲 𝐱 𝟏𝟒𝐤𝐠

=
** IBW = Ideal Body Weight 𝟗𝐤𝐠
** ABW = Actual Body Weight
= 𝟏, 𝟒𝟑𝟏. 𝟏 𝒌𝒄𝒂𝒍 𝒑𝒆𝒓 𝒅𝒂𝒚
Let’s have this example…
B. CATCH-UP CHON REQUIREMENT

CASE: A 3-year-old girl was admitted at the Malward for nutritional 𝐃𝐚𝐢𝐥𝐲 𝐂𝐇𝐎𝐍 𝐫𝐞𝐪𝐮𝐢𝐫𝐞𝐦𝐞𝐧𝐭 𝐟𝐨𝐫 𝐰𝐞𝐢𝐠𝐡𝐭 𝐚𝐠𝐞 𝐱 𝐈𝐁𝐖 𝐟𝐨𝐫 𝐚𝐠𝐞
upbuilding. Her actual body weight is 9 kg. Compute for: =
𝐀𝐜𝐭𝐮𝐚𝐥 𝐁𝐨𝐝𝐲 𝐖𝐞𝐢𝐠𝐡𝐭 (𝐀𝐁𝐖)
A. Catch-up calories
B. Catch-up CHON requirement 𝟏𝟕𝐠 𝐩𝐞𝐫 𝐝𝐚𝐲 𝐱 𝟏𝟒𝐤𝐠
=
C. Calorie breakdown of macronutrients 𝟗𝐤𝐠
a. CHON
b. CHO = 𝟐𝟔. 𝟒𝟒𝒈 𝑪𝑯𝑶𝑵 𝒑𝒆𝒓 𝒅𝒂𝒚 105.77kcal/day
c. FATS
But! We still have to convert it into calories!
Convert g of CHON to calories: 26.44g x 4kcal/day =
Compute first the Ideal Body Weight
105.77kcal/day
𝐈𝐁𝐖 = (𝐀𝐠𝐞 𝐢𝐧 𝐲𝐞𝐚𝐫𝐬)(𝟐) + 𝟖
Remember!!!
IBW = (3)(2)+8
IBW = 14kg - 1g of CHON = 4kcal
C. CALORIC BREAKDOWN OF MACRONUTRIENTS
a. CHON = 105.77kcal/day

For CHO and FATS, you still have to subtract CHON from TCR to
get the remaining calories…

TCR = 1,431.1 kcal/day – 105.77kcal/day = 1.325.33kcal/day

Remaining calories = 1,325.33kcal/day

b. CHO = 795.19kcal/day c. FATS = 530.12kcal/day

Initiating Feeding
- Start with 50% of computed calories or calories derived from food
diary whichever is higher
- Advance caloric intake by 10-20 kcal/kg/day until the computed
total calorie requirement is reached
- 3 years old, 9kg ABW
Ordering in Patient’s Chart (sample)
- By looking at the graph, her AWG is only fit for a 1-year-old child
- TCR = 1450 kcal/day; CHO = 805 kcal/day; CHON = 112 kcal/day;
now considered as her weight-age
Fats = 533 kcal/day
- Ideally, she should weigh 14kg at her age
- Please start with 775 kcal/day and then gradually increase by »
100-180 kcal/day (10-20 kcal/kg/day) until 1450 kcal/day is
reached
- Divide the daily total calories in 3 major meals and 2 snacks
- Zinc 20 mg/5 ml give 5 ml once a day per Orem (oral)
- Folic acid 5mg/5ml, give 2.5 ml once a day per Orem
- Vit A 200,000 IU/capsule, give 1 capsule one dose only
- Multivitamins syrup, give 5 ml 2x a day

Disclaimer: There were no PPT for Obesity and video lecture for Malnutrition uploaded in the
moodle. Added information, aside from the ones included in the manual, are all based from
my notes
- Since her weigt-age is 1 year old, we will use the energy and
protein requirement of a 1-year-old child
Stay sunny side up, yolks!
- In this case, energy requirement = 920kcal/day;
Protein requirement = 17g

Age = 3 years old

Weight-age = 1 year old References:
ABW = 9kg FEU-NRMF Department of Child Health and Basic Pediatrics Lecture Guide
IBW = 14kg and Manual
Kliegman, R. (2020). Nelson textbook of pediatrics (Edition 21.). Philadelphia,
PA: Elsevier.
Urtula, R. P. (n.d.). Obesity and Malnutrition . Lecture.

Page 11 of 11