Pediatric Nutrition

Dony by,
Dietitian intern Smaher Abudanqar
01 Contents

Title Page number

Estimated Energy and Protein requirement for PICU 2

Inatiation rate and advancement of enteral nutrition 2-3

Common Formulas 4

Modules to be added to the formula as needed 5

Fluid requirements 5

Estimated Energy and Protein requirement for pediatric patients 6-7

serving number and serving size according to age group 8

Common Nutritional Disturbances:

1- metabolic symptoms in children 8

2- Childhood overweight and obesity 9

3- Failure to thrive 10-11

4- Renal disease 12

5- Diabetes 13-15

Acceptable macronutrient distribution range 15

Interpretation of ht for age and wt for age plotted on standard CDC 16

growth chart

Interpretation of BMI for age plotted on standard CDC growth chart 16

Index (growth charts) 17-26

Reference 27
02
Pediatric Nutrition

Estimated Energy and Protein requirement for PICU

Energy and protein requirements for critically ill infants and children
Age Energy Energy Protein Protein
(in years) (Kcal/kg/d) (Kcal/kg/d) (g/kg/d) (g/kg/d)

Acute phase DRI DRI Injury

(BMR/paralysis/ (BMR/activity/new
sedation) tissue)
<1 55-45 107-79 1.5 3-2

1-3 55-40 89-79 1.05 2-1.5

4-6 50-40 81-62 0.95 2-1.5

7-10 40-35 60-45 0.95 2-1.5

11-18 35-25 47-30 0.85 2-1.5

• Acute phase energy requirements reflect BMR, But maybe increased x 1.3-1.6 stress factor.
• Energy needs vary greatly especially during an acute phase of illness.
From https://www.moh.gov.sa/Documents/Intensive-Care-for-Children.pdf

Stress or activity level

Bed rest 1.1 Infection 1.3 Major trauma 1.7

Minor surgery 1.1- 1.3 Fracture 1.3 Sepsis 1.7-1.9

Ambulatory 1.3 Major surgery 1.5 Burns 1.9-2.1

From https://www.moh.gov.sa/Documents/Intensive-Care-for-Children.pdf

Initiation rate and advancement of enteral nutrition

Weight Initiation rate Advancement rate

<10 kg Start at 1ml/kg/hr Increase by 0.5 ml/kg every 4 hrs

>10 kg Start at 0.5 ml/kg/hr Increase by 0.5 ml/kg every 4 hrs

From https://www.moh.gov.sa/Documents/Intensive-Care-for-Children.pdf
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Pediatric Nutrition

Stepwise algorithm for initiating and advancing enteral nutrition in the

pediatric intensive care unit

Found on pediatric critical care nutrition book (2015)

04
Pediatric Nutrition

Common formulas available

Infant formula : 0-1 y.o

Category Formula ( examples not Energy Standard preparation for
limited to) Kcal/ml powder formula scoop/
water
Cow’s Milk Based : Prenan 0.8 1scope/30ml
Premature
Cow’s Milk based Similac Advance, s-26 0.68 1scope/60ml

Nan,ronalac 1scope/30ml
Soy Based Isomil 0.68 1scope/60ml
Lactose free Plemil plus LF, Al110 0.67 1scope/30ml
High calorie Milk above infantrini 1 liquid
5kg
Protein & Fat Neocate (free amino acid) 0.68 1scope/30ml
Malabsorption
Semielemental formula
Fat malabsorption high in Monogen 0.74 1scoop/30ml
MCT Oil

PEDIATRIC FORMULAS 1-10 years (or above 7Kg)

Cow's milk based: Pediasure 1 liquid
Standard (oral or tube) Resurse junier
Malabsorption Peptamin Jr. 1 1scope/30ml
semielemental
Malabsorption Peptamin 1 1scope/30ml
Cow's milk based ( age Fortisip 1 liquid
>4y.o)
Cow's milk based (above Ensure 1 liquid
10yr)

Renal formula
Renal: Low electrolyte Renastart 1 1scope/30ml
(from birth)
Renal high protein (on Nepro HP 1.8 Liquid
dialysis) Renal novasourse 1.8
Age >4 y.o HDmax 1.5
Renal: Lower Protein &low Nepro LP 2 Liquid
electrolyte (pre dialysis)

NB: Infantrini should be used with caution in those < 5 kg.

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Pediatric Nutrition

Modules to be added to the formula as needed

Category Formula (examples not Energy Standard preparation for

limited to) powder formula
(Scoop/ml water)

Protein Beneprotein 3.6kcal/g As Pt. Needs

0.9protein/g

Fat Corn oil 8.13 kcal/ml Min. 1ml/100ml

MCT oil 7.7 kcal /ml Max. 4ml/100ml

For MCT (intial: 0.5ml every

other feeding)
Increase 0.25-0.5 ml/feeding
at intervals of 2-3 days as
tolerated

Carbohydrate Polycose As Pt. Needs

3.8 kcal/g
Fantomalt 0.94g CHO /g As Pt. Needs

4.9 kcal/g
Fat & carbohydrates Doucal 0.73g CHO/g As Pt. Needs
0.22 g fat/g

Fluid requirements
Weight (kg) Fluid needs

1-10 100ml/kg

11-20 1000ml + 50ml/kg for each kg >10kg

>20 1500ml +20 ml/kg for each kg >20kg

06 Pediatric Nutrition

Estimate Energy and Protein requirement for pediatric patients

• The use of basal energy metabolism is useful in estimating the energy needs of compromised
infants and children.

kcal/day = Basal Metabolic Rate × Activity Factor × Stress Factor

Schofied Method to Estimate BMR

Age (yr) Male Female
0-3 (0.167 x wt) + (15.174 x ht) - 617.6 (16.252 x wt) + (10.23 x ht) - 413.5
3-10 (19.59 x wt) + (1.303 x ht) + 414.9 (16.969 x wt) + (1.618 x ht) + 371.2
10-18 (16.25 x wt) + (1.372 x ht) + 515.5 (8.365 x wt) + (4.65 x ht) +200
>18 (15.057 x wt) - (1.004 x ht) + 705.8 (13.623 x wt) + (2.83 x ht) + 98.2
Data from K. Dawn Bunting, et al., Texas Children’s Hospital Pediatric Nutrition Reference Guide, 10th ed. (Houston, TX: Texas Children’s Hospital, 2013).
Found on The Essential Pocket Guide for Clinical Nutrition (3rd ed.)

Activity factors / stress factor

Confined to 1.1 Infection 1.2-1.6 trauma 1.1-1.8
bed
Paralyzed 1.0 Growth failure 1.5-2 Surgery 1.2-1.5

Ambulatory 1.2-1.3 Starvation 0.70 Burns 1.5-2.5

Data from Carey Page, et al., Nutritional Assessment and Support (Baltimore, MD: Williams & Wilkins. 1994).
Found on The Essential Pocket Guide for Clinical Nutrition (3rd ed.)

Another method to Estimate Energy and Protein requirement for pediatric

patients
Age Energy Protein
(in years) (Kcal/kg/d) (g/kg/d)
Infants 0-0.5 108 2.2

0.5-1 98 1.6

Children 1-3 102 1.2

4-6 90 1.1

7-10 70 1
Boys 11-14 55 1

15-18 45 0.9

Girls 11-14 47 1

15-18 40 0.8

From Width, M., & Reinhard, T. (2008). The Clinicial Dietitian’s Essential Pocket Guide (1st ed.). Jones & Bartlett Learning.

Note that, both methods are correct ; you can choose one of them
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Pediatric Nutrition

Estimate Energy and Protein needs for catch-up growth

For pt. Who are malnourished or for those whose growth is compromised, the nutritional goal is to
accelerate growth. This increase in normal wt and ht velocity is referred to as catch-up growth.
Total energy needs for catch up growth maybe as high as 150% of expected needs.

Estimated Energy Needs for Catch up Growth

Kcal/kg/day= IBW in kg (50th percentile wt/ht) x kcal/kg/day (DRI for age)
_________________________________________________
Actual weight (kg)
*Note that protein needs for catch-up growth are calculated using the same formula by substituting DRI of kcal (kcal/kg/day)
with DRI of protein (g/kg/day).

Estimate Energy needs for children with developmental disabilities

Children with Developmental Disabilities

Diagnosis Calorie needs

Cerebral palsy (ages 5-11 years old)

Mild to moderate activity 13.9 kcal/cm ht

Severe physical restrictions 11.1 kcal/cm ht

Athetoid cerebral palsy Up to 6000kcal/d

Down syndrome (ages 5-12 years old)

Male 16.1kcal/cm ht

Female 14.3 kcal/cm ht

Myelomeningocele (spina bifida)

Weight maintenance requirements 9-11 kcal/cm ht

Weight loss requirements 7 kcal/cm

>1 year old ~50% DRI/RDA for age

Prader–Willi Syndrome

Weight maintenance requirements 10-11 kcal/cm ht

Weight loss requirements 8.5 kcal/cm ht

08
Pediatric Nutrition

serving number and serving size according to age group

Age Vegetables Fruit Grain food Legumes, Milk and milk

nuts ' seeds, products
seafood, egg,
polutry, meat

1-2y/o 2-3 serving/d Half serving/d 4 servings 1 serving 1-1.5 servings

2-3 y/o At least 2.5 At least 1 serving At least 4 At least 1 serving At least 1.5
servings servings servings

4-8 y/o At least 4.5 At least 1.5 At least 4 At least 1.5 At least 2
servings servings servings servings servings for boys
and 1.5 servings
for girls

9-11 y/o At least 5 At least 2 At least 5 At least 2.5 At least 2.5

servings servings servings for boys servings servings for boys
and 4 servings and 3 servings
for girls for girls

12-13 y/o At least 5.5 At least 2 At least 6 At least 2.5 At least 3.5
servings for boys servings servings for boys servings servings
and 5 servings and 5 servings
for girls for girls

14-18 y/o At least 5.5 At least 2 At least 7 At least 2.5 At least 3.5
servings for boys servings servings servings servings
and 5 servings
for girls

Common Nutritional Disturbances

I. METABOLIC SYNDROME IN CHILDREN

• Metabolic syndrome in children is including central obesity, hypertension, dyslipidemia and
insulin resistance
• Encourage optimal nutrition, physical activity, wt maintenance to lessen CVD,
There are 9 points to prevent and treat metabolic syndrome include:
1. Limit sugar sweetened beverages
2. Encourage a healthful diet with at least 9 servings of fruits and vegetables daily.
3. Limit TV and screen time 2 hr or less.
4. Eating breakfast daily
5. Limit eating out away from home.
6. Encourage family meals
7. Limit portion sizes
8. Engaging in 1 hr or more of moderate to vigorous PA each day
9. Breastfeeding exclusively until 6 months of age

Identification of metabolic risk in a child may prove beneficial for several reasons:
1. The threat of evolving cardiovascular damage throughout the lifespan can be reversed
2. Wt Management is easier due to growth
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Pediatric Nutrition

I.
II. CHILDHOOD OVERWEIGHT AND OBESITY
• Management of obesity:

1. Kcal controlled and portion controlled diet seem to be more conducive

to long term compliance
2. Before undertaking a diet , families should set reasonable and
reachable goal for wt loss.
3. The choice of a diet should address patient preference and
individualized to a family's needs and preferences
4. Eat 3 daily meals that include carbohydrates , protein and fats.
5. Don't skip meals
6. Avoid obssessing about dieting and eating and eat without feeling
guilty
7. Change one's environment to avoid overeating or eating foods one
does not really want
8. Creating an environment that increases cues for healthy eating and
activity behaviors.
9. Eating smaller portions at meals and snacks
10. Eating more foods that are baked, boiled, grilled instead of fried.
11. When eating out, select more healthful options or splitting larger
servings to share with other family member.
12. Low carb plans should not recommend due to potential low intake of
fiber, nutrients and kcal to support growth and development.
13. Consumption of > or = 5 servings of fruits and veg , and minimize or
eliminate sugar sweetened beverages.
14. Eating breakfast daily , limit meals outside, eating family meals at least
5 or 6 times/week, allowing the child to self-regulate his or her meals ,
avoid overly restrictive behaviors.
15. Use myplate method which is divided the main dish to half veg, quarter
carb and quarter protein and eat fruit and milk products as snacks
16. Do 60 min of PA each day
17. Limit screen time to 2 hr or less.
18. Drinking water as the main baverage

• When a patient's habits, medical condition, weight, or BMI percentile do

not improve in 3 – 6 months of planned treatment, the provider and
family should consider advancing to the next, more intensive stage of
treatment. (Including medication, multidisciplinary team, surgery (after
6 month of attempting*from pocket guide to bariatric surgery*)).
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Pediatric Nutrition
I.
II.J
III.FAILURE TO THRIVE
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Pediatric Nutrition
12
Pediatric
I. Nutrition
II.J
III.N
IV.RENAL DISEASE
 13 I.
Pediatric
II.J Nutrition
.N
IV.RENAL DISEASE
V.DIABETES
• Type 1 diabetes

Monitoring carbohydrate intake by carbohydrate counting to achieving optimal glycemic

control
Assess caloric and nutrition intake in relation to wt status and cardiovascular disease risk
factors and to inform macronutrients choices
Dietary management should be individualized according to family habits, food preferences,
cultural needs and physical activity
Exercise is recommended for children and adolescents with type 1 diabetes with the goal of 60
min of moderate (ex. Dancing, brisk walking) to vigorous (ex. Running, jumping rope) intensity
aerobic activity daily , with vigorous muscle-strengthening and bone strengthening activities at
least 3 days per week.
Ensuring pt have a pre-exercise glucose level of 90-250mg/dl and accessible carbohydrates
before, during, after engaging in activity with glucose monitoring before, during and after
exercise.
Eating bedtime snacks to prevent hypoglycemia while sleeping
A1C goals must be individualized and reassessed over time. An A1C of <7% is appropriate for
many children.

Carb counting
1. Calculating the ICR
If using rapid acting insulin use the 500 rule
If short acting (regular) insulin use 450

ICR= 500 or 450 / Total daily dose of insulin

2. Calculate an insulin dose for food

Step 1. Add up the grams of carb in the food you will eat:
Step 2. Total grams of carbohydrate to be eaten / ICR = units of insulin is needed for this amount
of carbohydrate

Food list with carb content

Starch: breads, cereals Fruits 15 g
and grains, starchy
vegetables, 15 g Milk and milk products 12 g
crackers and snacks,
and beans, peas, and Nonstarchy vegetables 5g
lentils

3. Calculating insulin sensitivity factor

If using rapid acting insulin use the 1800 rule
If using short acting (regular) insulin use 1500

SF= 1500 or 1800 / TDD

4. Use correction factor to reach the target blood glucose:

Correction dose= current blood glucose - target blood glucose

Correction factor

5- the total dose= the insulin needed for carbs (step 2) + the insulin to correct high blood glucose (step 4)
14
Pediatric Nutrition
.
15
Pediatric Nutrition

• Type 2 diabetes

Youth with overweight/obesity and type 2 diabetes should achieve

7-10% decrease in excess wt.
participate in at least 60 min of moderate to vigorous physical
activity daily (with muscle and bonestrength training at least 3 days/
week)
Nutrition for youth with pre-diabetes and type 2 diabetes, like for all
children, should focus on healthy eating patterns that emphasize
consumption of nutrient-dense, high-quality foods and dcreased
nutrient-poor foods, particularly sugar-added beverages.
Metabolic surgery may be considered for the treatment of adolescents with type 2
diabetes who have severe obesity (BMI > 35 kg/m2)and who have uncontrolled
glycemia and/or serious comorbidities despite lifestyle and pharmacologic
intervention.

Acceptable macronutrient distribution range

 16
Pediatric Nutrition

Interpretation of BMI for age plotted on standard CDC growth chart

percentile interpretation
less than 5th Under weight

More than 5th and <85th Normal weight

More than 85th and >95th At risk of overweight

More than 95th overweight

Interpretation of ht for age and wt for age plotted on standard CDC

growth chart
percentile interpretation
50th Average for age

10th -90th Healthy for most pediatrics patients

3rd -10th or 90th -97th Further investigation needed

less than 3rd or >97th Unhealthy until proven otherwise

17
Index
Birth to 36 months: Boys NAME
Length-for-age and Weight-for-age percentiles RECORD #

Birth 3 6 9 12 15 18 21 24 27 30 33 36
in cm AGE (MONTHS)
cm in
41 41 L
40 95 40 E
100 90 100 N
39 39
75 G
38 38
95 50 95 T
37 37 H
25
36 36
90 10 90
35 5 35
34
85
33
32 95 38
80 17
31
L 90 36
30
E 75 16
N
29
75
34
G 28
70 15
T 27 32
H 26 50
65 14
25 30 W
24 25 E
60 13
23 28 I
10 G
22 55 12 H
5 26
21 T
20 50 11 24
19
18 45 10 22
17
16 40 9 20
15
8 18

16 16
7 AGE (MONTHS)
kg lb
12 15 18 21 24 27 30 33 36
14
6 Mother’s Stature Gestational
W Father’s Stature Age: Weeks Comment
E 12
Date Age Weight Length Head Circ.
I 5 Birth
G 10
H
T
4
8
3
6
2
lb kg
Birth 3 6 9
Published May 30, 2000 (modified 4/20/01).
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts
18 Index
19
Index
20
Index
21
Index
22
Index
23
Index
24
Index
25 Index
26 Index
27
Reference

1. https://www.moh.gov.sa/Documents/Intensive-Care-for-Children.pdf
2. Width, M., & Reinhard, T. (2008). The Clinicial Dietitian’s Essential Pocket Guide (1st ed.). Jones &
Bartlett Learning.
3. Corkins, M. (2015). The A.S.P.E.N. pediatric nutrition support core curriculum (2nd ed.).
4. Width, M., & Reinhard, T. (2020). The Essential Pocket Guide for Clinical Nutrition (3rd ed.). Jones
& Bartlett Learning.
5. K. Dawn Bunting, et al., Texas Children’s Hospital Pediatric Nutrition Reference Guide, 10th ed.
(Houston, TX: Texas Children’s Hospital, 2013).
6. Carey Page, et al., Nutritional Assessment and Support (Baltimore, MD: Williams & Wilkins. 1994
7. Shirley Ekvall, et al., Pediatric Nutrition in Chronic Disease and Developmental Disorders (Oxford,
UK: Oxford University Press, 2005), 140, and (ii) A. Davis, Pediatrics: Contemporary Nutrition
Support Practice (Philadelphia, PA: Saunders, 1998), 356.
8. https://www.healthnavigator.org.nz/healthy-living/f/food-groups-serving-size-children/
9. Suskind, D.L. and Lenssen, P. (2011). Pediatric nutrition handbook : an algorithmic approach.
Chichester, West Sussex: Wiley-Blackwell.
10. https://diabetesjournals.org/care/article/44/Supplement_1/S180/30606/13-Children-and-
Adolescents-Standards-of-Medical
11. https://www.wcu.edu/WebFiles/PDFs/6403AdvancedInsulinManagementFinal.pdf
12. Goday, Praveen S, and Nilesh M Mehta. Pediatric Critical Care Nutrition. New York, Mcgraw-Hill
Education Medical, 2015.