Nutritional management in children with disease-related malnutrition : what’s the guideline?

Background: Disease-related malnutrition (DRM) is one of the most common problems in pediatric patients. Both cancer and congenital heart diseases (CHD) are commonly associated with DRM. Altered nutrition utilization, reduced intake, malabsorption, and hypermetabolism are the main pathophysiology in DRM. Method: A systematic literature searching was performed through Pubmed and Google Scholar websites. Thirty-six articles were included into the study. Results: Malnutrition screening should be performed as soon as possible since early feeding can benefit the patients. One of the most commonly used tools is Screening Tool for Risk on Nutritional Status and Growth (STRONGkids), which was proven to be valid, reproducible, and applicable in pediatric patients with malnutrition. Following screening and assessment, nutrition support can ensue, preferably in the form of enteral nutrition, unless contraindicated. Nutrient-dense formula, also known as protein and energy-enriched formula, aims to aid infants to reach nutrition target rapidly and stimulate anabolism. This formula has been studied in various population, mostly infants with CHD and studies showed favorable outcomes with its administration, namely faster improvement, reduced diuretics use and oxygen supplementation, decreased length of hospital stay, and less antibiotic use. Nutrient-dense formula is also safe and well-tolerated. Conclusion: Proper screening and management should be performed with multidisciplinary approach to achieve the best outcome in children with DRM

Waist circumference and insulin levels in obese children

Background Childhood obesity is one of the most serious public health challenges of the 21st century. Its prevalence has increased at an alarming rate. Overweight and obese children are prone to obesity in adulthood and to developing non-communicable diseases (NCDs) like diabetes and cardiovascular diseases at a younger age. Increased waist circumference has been shown to contribute to the risk of metabolic syndrome in obese adults. Objective To assess for a correlation between waist circumference and insulin level in obese children. Methods In this cross-sectional study, obese children aged 6-10 years were included by consecutive sampling. We excluded children with infectious disease, malignancy, dyslipidemia, type 2 diabetes mellitus, or those who had not fasted before the blood draw. Subjects underwent waist circumference and fasting blood glucose measurements. Serum insulin levels were examined by enzyme-labeled chemiluminescent immunometric assay,after subjects had fasted for 10-14 hours. Data were analyzed by correlation analysis. Results Subjects had a mean waist circumference of 80.2 cm (SD 7.2) and mean insulin level of 10.70 (SD 7.5). µIU/mL Pearson’s correlation test revealed a significant, moderately positive correlation between waist circumference and elevated insulin level (r=0.45; P=0.006). Conclusion Waist circumference and insulin level have a significant, moderate, positive correlation in obese children. As such, waist circumference may be a simple method for early detection of hyperinsulinemia, as a risk factor for metabolic syndrome

High Blood Ammonia Levels Associated with Long-term Valproic Acids Therapy in Epileptic Children

Background: Valproic acid is an effective drug for controlling seizure in children with epilepsy and it is usually used for treatment as long as two years or more. Blood ammonia level often increased in epileptic children who were treated with long-term valproic acid. The study was conducted to determine the relationship between blood ammonia level with valproic acid therapy in epileptic children.Materials and Methods: This is an observational study with cross-sectional approach. The subjects were 64 children with epilepsy, average age of 6.2 years old. Subjects were 33 boys and 31 girls. Blood ammonia level was examined using enzymatic glutamate dehydrogenase. Subjects were divided into 2 therapeutic groups based on the duration, doses and combination therapy of valproic acid. Subjects were recruited from Pediatric Neurology Clinic, Sanglah General Hospital, Bali, Indonesia, from May to December 2017. Comparison of blood ammonia level between groups were analyzed using an Independent t-test with significances if the p<0.05.Results: A significant difference of blood ammonia level was found between subjects who were treated with valproic acid less than 2 years and more than 2 years (45.7±16.4 mmol/L vs. 70.9±43.6 mmol/L; p=0.032). However, significant difference was not found between the groups according to the doses and combination therapy (p=0.450 and p=0.647, respectively).Conclusion: Blood ammonia level was significantly higher in epileptic children who used long-term valproic acid, hence it was recommended to check the blood ammonia level routinely.Keywords: ammonia, epilepsy, valproic, childre

Correlation Between Pyridoxal 5’-Phospate Level And Valproic Acid In Epilepsy Children

Background: It is important to maintain the adequate level of vitamin B6 to ensure stable metabolism. Vitamin B6 serum level might decreased by absorption disturbance or increasing demand. Valproic acid increase the synthesis of serum GABAergic in the other hand vitamin B6 is required as cofactor for gamma-amino butyric acid (GABA) formation. The dosage and duration of valproic acid therapy might be correlated with vitamin B6 serum level. The aim of this study is to know the correlation between vitamin B6 serum level against dosage and duration of valproic acid therapy in children with epilepsy.Materials and Methods: This is a cross sectional study to investigate the correlation between vitamin B6 serum level against dosage and duration of valproic acid therapy. The level of vitamin B6 serum was determined by checking vitamin B6 active form in serum, pyridoxal 5’-phospate (PLP).Results: In this study, 37 epilepsy children with valproic acid duration therapy more than 3 months was enrolled. Fifty six percent epilepsy children were male, commonly on children age 1-5 years old. Spearman correlation coefficient test showed a significant weak negative correlation between vitamin B6 serum level and dosage of valproic acid (r=–0.35; p=0.03), and very weak negative correlation with valproic acid duration therapy (r=-0.08; p=0.59), however it was not significant. Conclusion: There was a significant weak negative correlation between vitamin B6 serum level and very weak negative correlation with valproic acid duration therapy, but not significant in children with epilepsy.Keywords: correlation, valproic acid, vitamin B

Association of ferritin level with attention deficit hyperactivity disorder in children

Background: Dopamine is an important component in the pathophysiology of ADHD. Dopamine synthesis is regulated by the enzyme tyrosine hydroxylase and influenced by iron deposits in the brain. Several studies have shown that low ferritin levels in children with ADHD and iron supplementation are said to show good clinical outcomes, but this study has never been conducted at Sanglah General Hospital.Methods: This study used an observational analytic study design with unpaired case control design. Research held in Policlinic RSUP Sanglah from July 2018 to April 2019.Results: In a total of 25 children with ADHD and 25 children without ADHD, median ferritin level was 43.7(7.9-77.0) in the case group and 68.2(33.1-319.0) in control group. Bivariate analysis of ferritin level categories using the chi-square test showed significantly different results. Low ferritin levels (<45 ng/mL) was obtained in 56% of the case group and 16% in the control group. Odd ratios determine the relationship between ferritin and the incidence of ADHD at 6.7 (95% KI 1.8-25.2). The results of multivariate analysis showed that adjusted OR was 6.5(95% KI 1.2-34.6) and was statistically significant with p value 0.027.Conclusions: There was correlation between ferritin levels and ADHD in children

Age and HIV stage at initiation of highly active antiretroviral therapy determine non-reversal of stunting at 3 years of treatment

Background Highly active antiretroviral therapy (HAART) has been reported to improve growth, especially in the first 2 years of treatment. It is not clear whether catch up growth is maintained after 2 years of HAART. Objective To assess growth in stunted children with HIV after 3 years of HAART and analyze possible risk factors for non-reversal of stunting. Methods This study was done from May 2016 to April 2017 to follow children with HIV who started HAART between January 2009 and April 2014, and continued for 3 years. Inclusion criteria were children with HIV, aged < 18 years, compliance to the regimen, and stunting. Exclusion criteria were patients lost to follow up or who died prior to 3 years of HAART. Non-reversal of stunting was defined as HAZ ≤ -2SD after 3 years of HAART. Possible risk factors for non-reversal were analyzed using Chi-square test with P<0.05, as well as risk ratio (RR) and 95% confidence intervals (CI). Results Of 150 HIV-infected pediatric patients, 115 were on HAART and 55 (47.8%) were stunted at HAART initiation. Of the 55 stunted and HAART-treated children, 31 (56.4%) were male. Baseline median age was 3.6 years (interquartile range 0.37-8.48). Non-reversal occurred in 32 (58.2%) subjects. Multivariate Cox regression model analysis showed predictors of non-reversal after 3 years of HAART to be age >2 years (RR 16.05; 95%CI 2.89 to 89.02; P=0.002) and HIV stage III-IV (RR 8.93; 95%CI 1.47 to 54.37; P=0.017). Conclusion HAART initiation at age >2 years and HIV clinical stage III-IV at diagnosis are risk factors for non-reversal of stunting after 3 years of HAART