Nutrition Support in Paediatric Surgical Patients

1. NUTRITION SUPPORT IN THE PAEDIATRIC SURGICAL PATIENT Dr. Mariama Mustapha SHO III- Paediatrics and Child Health Makerere University Mwanamugimu Nutrition Unit, Mulago Hospital

2. Outline • Introduction/Background • Conditions seen in MNU needing Surgical Interventions • Nutritional Rehabilitation in MNU • Role of the Paediatric Surgeons and Paediatricians • Conclusion

3. Introduction/Background • The WHO defines malnutrition as “the imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions”. • It is estimated that 34 million children under the age of 5 each year are affected by severe acute malnutrition (SAM). UNICEF 2012

4. Background: Uganda DHS 2011

5. Background • Work by Cooper and colleagues showed that 18% to 40% of paediatric surgical patients have malnutrition. • Paediatric surgical patients respond to surgical stress differently from older children or adults. • The metabolism of children is markedly affected by operative stress. Herman R et al, 2011.

6. Conditions seen in MNU needing Surgical Interventions • Cerebral Palsy • Congenital Heart Diseases • Massive Pleural Effusion/Empyema • Cleft Lip/Palate • Burns

7. Conditions seen in MNU needing Surgical Interventions • Hydrocephalus • Pyloric Stenosis • Hirschsprung’s Disease • Oesophageal Stricture

8. Summary of Nutritional Assessment and Classification

9. Nutritional Rehabilitation: Outpatient Therapeutic Care (OTC) Admission Criteria • Children with SAM who have appetite, are clinically well and alert and have oedema grade +/++ • For MAM with HIV or TB • Transfers in • Relapse or readmission

10. Nutritional Rehabilitation: OTC Dietary Therapy • Ready-to-Use Therapeutic Food (RUTF): • Contains 500 kcal per 92g • Need calculated based on 175-200kcal/kg/day • Breastfeeding on demand. • Adequate safe drinking water while on RUTF.

11. Nutritional Rehabilitation: Inpatient Therapeutic Care (ITC) Admission Criteria Children with Severe Acute Malnutrition with: • Medical complications • Severe 0edema (+++) • Poor appetite • IMCI danger signs

12. Nutritional Rehabilitation: ITC Dietary Therapy • F-75 • F-100 • RUTF • SDTM • Isomil

13. Preoperative Nutrition • In malnourished adults, provision of enteral feedings preoperatively for 2 to 3 weeks may reduce: • Postop wound infections • Anastomotic leakage • Hepatic and renal failure • Length of hospital stay • Data for PN support are less clear! Herman R et al, 2011

14. Postoperative Nutrition • When used, postop nutrition should be started early using a combination of PN and EN until the GIT fully recovers. • In the postop period, there are higher infection rates in patients on PN. • Postop PN should be restricted to: • Infants who do not tolerate enteral feedings. • Older children who probably cannot tolerate EN for at least 5 to 7 days. Herman R et al, 2011

15. How Can We Work Together? Role of the Paediatric Surgeons? • Identify patients needing nutritional interventions • Consult/Refer Role of the Paediatricians? • Identify patients needing surgical interventions • Consult/Refer

16. Conclusion • Maintaining adequate nutrition of paediatric surgical patients is critical. • Close follow-up is critical to maintain a child on target for growth objectives. • Paediatric Surgeons and Paediatricians need to work together to provide optimal nutrition support to paediatric surgical patients.

17. THANK YOU!!