A Case Study On A 1 Year and 8 Month Old Infant Diagnosed with Acute Gastroenteritis with

Moderate Dehydration and Intestinal Parasitism​1

KALAW, Maria Noreena F.

MANGABAN, Jose Mari M.

HNF 41 A-3L
May 24, 2019

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A case study submitted in partial fulfillment of the requirements of HNF 41 (Medical Nutrition
Therapy I) under the supervision of Prof. Zarah G. Sales, this 2nd semester A.Y. 2018-2019.
 Table of Contents

I. Introduction………………………………………………………………………………..2
A. Significance of the Study……………………………………………………….…3
B. Objectives……………………………………………………...………………….3
C. Limitations of the Study...…………………………………………………………3
II. Theoretical Considerations…………………………………………………..……………4
III. Methodology ………………………………………………………………...……………5
IV. The Patient………………………………………………………………………………...6
V. Results and Discussion……………………………………………………………………8
A. Anthropometric Assessment………………………………………………………8
B. Biochemical Assessment………………………………………..………………...8
C. Clinical Assessment……………………………………………..………………..8
D. Dietary Assessment………………………………………….………...………….9
VI. Evaluation of Nutrition Care Plan………………………………………………………. 11
VII. Recommendations………………………………………………………………………. 14
VIII. Glossary of Medical Nutrition Terms……………………………………...………….... 16
IX. References………………………………………………………………………….……16
X. Appendices

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I. Introduction

Health care teams continue to conceptualize ways on how to provide disease

prevention and treatment by utilizing nutrition-related concepts and, at the same time,
promote the well-being of the hospitalized (Nelms, et al., 2011) The objectives of
interdisciplinary nutritional care include a behavioral and lifestyle change in people of
all ages, increase in knowledge, improved nutritional status and quality of life, and
prevention, treatment, and management of diseases among others. For hospitalized
patients, diet modification may be necessary depending on their needs, and support in the
form of parenteral or enteral nutrition may be given. Medical nutrition therapy (MNT)
aims to utilize nutrition services to treat illnesses, signs and symptoms. It is vital that
nutritionist-dietitians are well-equipped with the knowledge and skills in delivering MNT
through the nutrition care process (NCP), which uses the ADIME format - nutrition
assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and
evaluation (Jamorabo-Ruiz, et al, 2011).
According to Jamorabo-Ruiz, et al. (2011), the gastrointestinal (GI) tract is the
"conduit from the external world into the internal body environment". Therefore, it is
prone to disorders caused by intake of contaminated food or drink from infectious
bacteria and parasites which can alter the GI function. GI complications are some of the
most difficult to determine the cause/s of, manage, and treat. A variety of therapeutic
diets and nutritional care approaches are to be considered (Roth, 2011). This case study
involves a 1 year and 8 month old hospitalized male infant diagnosed with acute
gastroenteritis (AGE) with moderate dehydration and intestinal parasitism.
Acute gastroenteritis (AGE) is characterized by the inflammation of both the
stomach and intestine, which effects symptoms of abdominal pain, vomiting, weakness,
and diarrhea, febrile or afebrile. In the Philippines, AGEs can cause epidemics, especially
during the colder, rainy season from November to March, often in infants and children.
The two main complications behind AGEs are malnutrition and dehydration. Because of
the underlying symptoms, patient may be unable to consume enough food to satisfy
his/her daily requirements for energy and nutrients, causing undernutrition. Dehydration
with electrolyte imbalance and metabolic acidosis is caused by excessive vomiting and
diarrhea due to an impaired small intestine (CMD, 2015). Prevention is key in controlling
the prevalence, but if treatment is needed, patients are admitted to the hospital and given
oral or intravenous (IV) fluids to minimize the risk of mild-moderate dehydration.
Afterwards, patients are given a regular diet as tolerated, or high calorie and high protein
diet if severely to moderately malnourished (Labeaud, et al, 2011).
In this case study, the patient was also diagnosed with intestinal parasitism. His
body was infested with helminths and parasitic worms, and this was expelled through his
vomit and stools. According to the World Health Organization, the most common

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intestinal parasites among Filipinos are hookworm, whipworm, ascaris, and trichuris.
Because of this, it is vital for parents and guardians to make sure that the children in the
household are dewormed, and proper sanitation and hygiene are practiced in their homes
to control the prevalence of helminthiasis or infestation of parasitic worms.
Antihelminthic drugs are also given as part of the treatment (WHO, 2017).

Significance of the study

The significance of this study is to provide a firsthand experience for the students
taking the course HNF 41 - Medical Nutrition Therapy I in applying the concepts on the
nutrition care process in the health care setting through an in-depth investigation of a
patient with acute gastroenteritis (AGE) and intestinal parasitism (IP). They were able to
analyze and understand the nutritional management of the said cases, as well as provide
key insights and nutrition-related recommendations in treating both AGE and IP for the
case patient through the use of Medical Nutrition Therapy (MNT) principles.

Objectives
The general objective of this study was to conduct and present a case study on a 1
year and 8 month old male patient diagnosed with Acute Gastroenteritis (AGE) with
moderate dehydration and Intestinal Parasitism (IP).
This study specifically aimed to:
1. Discuss the pathophysiology of AGE and IP, and their implications to
health & nutrition;
2. Discuss the nutrition-related problems of the patient and identify possible
interventions to combat such problems;
3. Formulate a Nutrition Care Plan (NCP) to address the nutrition-related
problems for an infant with AGE with moderate dehydration and IP.

Limitations of the study

Since the case patient is just 1 year and 8 month old, information gathered on the
diet and medical history is limited to what answers were provided by the mother of the
patient. The dietary information was obtained from the 24-hour food recall which
includes the intake before and during the admission into the hospital, and only mere
estimations were given upon interview. Measurements of height and weight were
secondary data gathered from the medical chart. Confounders were present including the
environment, living conditions of the family, and socio-economic status among others.

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 II. Theoretical Considerations

Acute Gastroenteritis (AGE) and Intestinal Parasitism (IP) are prevalent in developing
countries, including the Philippines, where there is poor sanitation and hygiene among the
people. Undernourished infants and children are often the most affected because of poor
immunity from diseases and susceptibility to cross-contamination with virus, bacteria, and
parasites. Spreading of the disease is by respiratory or fecal-oral route.
AGE can also be caused by bacteria, viruses, and parasites. These pathogens invade the intestinal
lining which leads to inflammation. Infants and children with bacterial AGE may have fever and
presence of white blood cells in the stool. Electrolyte disturbance and metabolic acidosis leads to
dehydration (Elliot, 2007). In the occurence that there is intestinal inflammation, absorption of
fluid in the small intestine is affected, and the mechanism of toxins can cause the lining of the
intestine to excrete excessive fluid, which leads to watery, loose bowel movement (LBM). This
also affects nutrient absorption due to impaired stomach and intestines, which can lead to
deficiencies especially of iron (NCCWCH, 2009).
Meanwhile, the severity of the effects of IP depend on factors such as the type of parasite
present, the tissues inhabited, secretion released, growth and multiplication rate, and the capacity
of the immune system. In this case, however, the parasite was not specified. IP can cause tissue
damage and bleeding, inflammation, pain, blocking of passageways, infection by secretions, and
using the vitamin and nutrient supply of the host (Jamorabo-Ruiz, et al., 2012).
The observed clinical signs and symptoms of infants with AGE include severe abdominal
pain, bilious vomiting, watery, greenish stools with mucus streaks, and weakness. For patients
with mild to moderate dehydration signs include sunken eyes, dry oral mucosa, and weak body
(Elliot, 2007). For IP, patient may have melena or black stools, anemia, heart failure, and growth
retardation. These usually depend on which part of the body is infested. If the patient has a large
number of worms in his/her system, worms may be found in the vomit or stool, and weight loss
may be observed (Mayo Clinic, 2018).
Acute gastroenteritis can be diagnosed through evaluation of clinical assessment. Medical
history and physical examination can be used to determine whether the patient is affected with
the disease, as well as detect the presence of other underlying complications. Information on
fluid intake and urine output, nature and frequency of bowel movements and vomiting, and
severe abdominal pain will aid in diagnosis (Elliot, 2007). Physical examinations can provide an
estimate of the level of dehydration that often comes with this disease. This is essential because
severe dehydration can cause hemodynamic instability or when there isn't enough pressure in the
circulatory system for blood to flow all throughout the body. Laboratory tests such as urinalysis,
fecalysis, and CBC can also support the diagnosis of AGEs (Burkhart, 1999). IP may be
diagnosed through observation of clinical signs and complete physical examination. Fecalysis
can detect worm eggs in the stool as indication of the disease, but this is only applicable for at
least 40 days after infection. Blood test like CBC tests can detect if there is an increase number

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of eosinophilic white blood cells (WBC) which can indicate parasitic infection. Imaging tests
such as X-rays, ultrasound, and CT scans or MRIs can also detect infestation. In case of heavy
infestation, worms may be detected in the abdomen, lungs, pancreas, liver, and other internal
organs (Mayo Clinic, 2018).
For AGE, drugs are rarely needed for treatment for they can only deal a little with
symptoms rather than the causes and may even cause possible adverse effects to the patient.
Instead, management of AGEs aims to treat dehydration and attain or maintain good nutritional
status. Oral or intravenous rehydration therapy, with the former more preferred, can aid in
replacing water and electrolyte losses in patients with moderate dehydration (Elliot, 2007).
Symptoms are also treated in IP cases, and the disease will resolve on its own. Anti-parasitic
medicines like Albendazole, Mebendazole, and Ivermectin are initially given as treatment to kill
mature worms (Mayo Clinic, 2018). In cases like these, prevention of reinfection is prioritized.
According to the WHO, mass deworming and treatment is done during mass drug
administrations (MDAs), and programs on good personal hygiene, clean water, and sanitation are
practiced as preventive actions against intestinal parasitism in the Philippines (WHO, 2017).
Both AGE and IP can cause severe nutrition-related problems especially for infant and
children with compromised immune systems. Given the confounding factors of their
socio-economic status and living conditions, the risk is higher. Proper treatment and nutrition
management should be observed in order to combat these diseases and prevent recurrence in the
future.

III. Methodology

The study was conducted on April 29, 2019 in Laguna Medical Center. The patient’s
mother agreed and signed an informed consent regarding her child’s condition. She was
interviewed about the details of the patient’s case. The medical chart filled up by the doctors and
nurses were also considered. Data collection was done through interview using forms developed
to obtain diet history and 24 hour food recall. Nutritional assessment was based on secondary
data obtained from the patient’s medical chart. The desirable body weight for the patient was
computed using the formula DBW (kg) = (age in months/2) + 3 based on the DBW calculations
for infants on the Nutritionist-Dietitians Association of the Philippines’ (NDAP) Diet Manual.
The total energy requirements were computed using the formula for infants in the Failure to
Thrive (FTT) classification. The kcal per kg DBW was obtained through RDA for age (kcal/kg)
* Ideal weight for height, and divided by the actual weight (Jamorabo-Ruiz & Serraon-Claudio,
2010). The TER was divided into 60-20-20 distribution for a high protein diet. Anthropometric,
Biochemical, Clinical, and Dietary Assessment were used in assessing the patient's condition.
The anthropometric assessment was done using his body measurements and was assessed using
the World Health Organization Child Growth Standards (WHO CGS). The WHO CGS provides
an international standard that represents the best description of physiological growth for all

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children from birth to five years of age. The patient’s urinary analysis results were looked into in
the biochemical assessment. The signs and symptoms observed and reported by the patient’s
mother were noted in the clinical assessment. The dietary assessment consisted of qualitative and
quantitative analyses of the patient’s 24 hour food recall form prior to admission (PTA) and
during confinement (DC). The patient’s 24-hour food recall was evaluated qualitatively and
quantitatively. For the qualitative assessment, the FNRI Food Pyramid for toddlers was used. For
the quantitative assessment, the FNRI Menu Eval Plus was used. An NCP using the Assessment,
Diagnosis, Intervention, Monitoring and Evaluation (ADIME) format based on the Academy of
Nutrition & Dietetics was also used in compiling the evidence.

IV. The Patient

The case patient is JAR, a one-year and eight-month old infant, born on August 17, 2017.
He is currently living with his parents and 2 siblings in Brgy. Concepcion, Lumban, Laguna. He
and his family are Roman Catholics. Both of his parents’ highest educational attainment is at
elementary level. His father is a fisherman and a farmer, while his mother takes care of them at
home. He is of normal spontaneous delivery (NSD), with complete vaccinations from the rural
health unit.
Patient’s admitting history showed that he has a fair appetite, a complete vaccination
from the Expanded Program on Immunization (EPI), and his developmental milestones are at par
with his age. Past illness includes only fever for more than 3 days. The chief complaint was
LBM and vomiting. History of present illness stated the presence of weight loss due to loss of
appetite, vomiting and diarrhea.
Four (4) days prior to admission (PTA), he experienced loose bowel movement (LBM) of
watery and greenish stools with worms and mucus streaks, no blood. Two (2) days PTA, there
was a perceived abdominal pain (epigastric) and loss of appetite. A day before admission, he
experienced vomiting with worms and body weakness. He was brought to the emergency room
(ER) on the night of April 19, 2019. He was admitted at the Pediatric-Gastro ward of Laguna
Medical Center, Sta. Cruz, on the night of April 19, 2019 with a chief complaint of LBM and
excessive vomiting. Patient was received with the admission and principal diagnosis of Acute
Gastroenteritis (AGE) with intestinal parasitism and moderate dehydration.
The patient's weight was 8.5 kg upon admission. It was noted that the patient lost weight
prior to experiencing the aforementioned symptoms, and that this was not his usual body weight.
He was not in respiratory distress, but was characterized with mild discomfort. His cardiac rate
(CR) was 120/min and his respiratory rate (RR) was 32/min. His body temperature was 36.7°C
upon admission. The doctor also ordered that his vital signs be checked every 4 hours. He was
hooked with intravenous (IV) fluid of D5O (dextrose 50%) and NaCl (Sodium Chloride) of 55 cc
per hour, and was initially prescribed with a diet of small frequent feedings. A Complete Blood
Count (CBC), urinalysis, fecalysis, and Serum Na, K were conducted for biochemical

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assessment. The patient was also given a medication of Omeprazole in his IVF (ten milligrams,
once a day), and Zinc Sulfate drops (two milliliters, once a day). The doctor also advised his the
patient’s family members to practice good personal hygiene and sanitation during feeding.
After a day in the hospital, it was observed that the patient’s LBM continued to be of
greenish tinge, and persistent epigastric pain. He was observed to be at risk for fluid volume
deficit. However, his vomiting had already surpassed. Patient does not have fever nor dry lips.
He was also scheduled for deworming at the out-patient department (OPD) of the hospital. It was
noted that it has been a year since his last deworming, which was on August 2018.
On April 22, the patient was found to have electrolyte imbalance due to moderate
dehydration and IVF was continued. On April 23, IVF was shifted to D5LR (Lactated Ringer's
and 5% Dextrose Injection), and was continued for hydration. His Omeprazole medication was
discontinued. Zinc Sulfate was continued together with multivitamin drops once a day.
Prior to the onset of disease, the case patient's food intake was fair according to the
mother, although this cannot be fully ensured. He is also being breastfed and given
complementary feeding. His food intake consists of prepared meals for the whole family, mashed
and chopped fruits and vegetables, and flaked meat in broth with rice. JAR does not eat much
green leafy vegetables, yet he likes to eat fruits like banana and guyabano. He also likes to drink
at least a cup of 3-in-1 coffee every other day. Because of AGE and IP, he was unable to eat
properly which led to weight loss. His usual weight was not recorded because his mother was not
able to recall it upon interview. At the date of data gathering, the patient was still unable to eat
enough, so he was still receiving IV fluid therapy together with breastfeeding and a small amount
of complementary food.

V. Results and Discussion

A. Anthropometric Assessment
Table 1. JAR’s Anthropometric Values.

Nutritional Status
(WHO)
Weight Weight for
Wt (kg) Ht (cm) Age (mos) for age length
8.5 83 20 0 to -2 -3
Patient JAR weighs 8.5 kg and is 83 cm tall. The nutritional assessment tools used
here are the WHO Child Growth Standards for boys. JAR is underweight and severely
wasted. His weight for age is below the 3rd percentile, therefore, he is under the Failure

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 to Thrive (FTT) classification. Infancy is a critical period in a person's life. If the patient
is unable to correct his nutritional status at this lifestage, this might cause medical and
nutrition-related complications such as deficiencies in his childhood until he grows into
adulthood. (Jamorabo-Ruiz & Serraon-Claudio, 2010).

B. Biochemical Assessment
The urinalysis revealed a presence of more urobilinogen, ketone, and white blood
cells (WBC). Urobilinogen is formed from the reduction of bilirubin in the body. Too
much urobilinogen in urine can indicate a liver disease such as hepatitis or cirrhosis
(“Urobilinogen in Urine”). Ketones in the urine can be a sign that the patient has recently
been experiencing chronic vomiting and diarrhea(“Ketones in Urine”). The presence of
white blood cells indicate that the patient’s body has an infection and the body has been
fighting it off. Although rare, there is also presence of epithelial cells and bacteria. The
organisms mentioned might be the cause of his disease. It is also noted that there is a
presence of many urates crystals tend to form acidic urine that may have a yellow or
yellow brown color (“Urinalysis: Crystals”). (APPENDIX VII)

C. Clinical Assessment
Clinical signs observed by the medical staff were weak body, sunken eyeballs,
pale lips, soft tympanitic hyperactive bowel sounds, faint pulse, and pale nail bed.
Sunken eyeballs and dry oral mucosa as characterized by pale lips is best correlated with
dehydration (Burkhart, 1999). Weak body and a faint pulse is also a sign of dehydration
(Knott, 2017). A pale nail bed may actually lead to iron deficiency anemia which could
also be a serious threat.

D. Dietary Evaluation
The 24 hour food recall below was based on the fourth day of confinement
(APPENDIX V). The student-researchers were able to obtain the patient’s 24-hour food
recall prior to admission which was also evaluated (APPENDIX IV).

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Table 3. Qualitative Analysis of patient’s 24-hour food recall during confinement.
Actual Intake Adequacy

Recommended PTA* DC*

Food Items Amounts PTA DC D* E* R* D * E* R*
Fish/Meat/
Poultry/ Dried
Beans/Nuts 1 to 1 ⅓ servings 0 3 servings ✓ ✓
Egg ½ piece 0 0 ✓ ✓
Meat and 2½
Alternatives Milk 1 glass 1 1/2 glasses glasses ✓ ✓
2½
Rice and Alternatives 2 - 4 ½ servings 1 1/2 servings servings ✓ ✓
Vegetables ⅓ - ½ servings 0 0 ✓ ✓
1 - 2 medium
Fruits servings 0 2 servings ✓ ✓
Sugar/Sweets 4-5 tsp 0 1 tsp ✓ ✓
Fats & Oils 6 tsp 0 3 tsp ✓ ✓
Water/Beverages 4-7 glasses 2 glasses 4 glasses ✓ ✓
PTA* - ​Prior to Admission, ​DC* ​- during confinement, ​D* - ​deficient, ​E* ​- excessive, ​R* ​- as
recommended

Prior to admission, all of JAR’s food intake were below recommended amounts. The only
intake that met recommended and even exceeded the recommended amounts is his milk intake
coming from breast milk. As for his food intake during confinement, his reported fair appetite is
being recovered meeting recommended requirements on rice, fruit, and water intake. However,
his food habits does not include vegetables, sweets, and egg resulting in their requirement below
recommended amounts. However, this is counteracted by his excessive meat and milk intake.

Table 4. Quantitative assessment of JAR’s food recall prior to admission and during confinement
Energy Protein Calcium Phosphorus Iron Vitamin A Thiamin Riboflavin Niacin Vitamin C
(kcal) (g) (mg) (mg) (mg) (µg RE) (mg) (mg) (mg NE) (mg)

PRIOR TO ADMISSION
TOTAL 523 83.7 159 100 2.9 747 0.07 0.07 2.3 12
PDRI 1000 15 440 380 6.4 193 0.4 0.4 5 12

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 %
ADEQUACY 52.3 558.0 36.1 26.3 45.3 387.0 17.5 17.5 46.0 100.0
DURING CONFINEMENT
TOTAL 1555 49.4 386 381 372.8 2316 8.51 4.34 21.7 127
PDRI 1000 15 440 380 6.4 193 0.4 0.4 5 12
%
ADEQUACY 155.5 329.3 87.7 100.3 5825.0 1200.0 2127.5 1085.0 434.0 1058.3

Prior to admission, the patient has been eating less because of his condition of loose
bowel movement (LBM) and vomiting. This led to a decrease in his usually fair appetite causing
his intake to be only 523 kcal compared to the PDRI REI value of 1000 kcal. His vitamin and
mineral intakes suffered huge losses as well not including Vitamin A and Vitamin C with a %
adequacy of 387% and 100% respectively. His diet was lacked energy, calcium, phosphorus,
iron, thiamin, riboflavin and niacin prior to admission. During confinement, his appetite returned
and began to eat well again. He has 155% more than in Energy compared to the PDRI REI.
Vitamin and Mineral intakes are high as well mainly because the PDRI EAR levels are low for
1-2 years old but also because of the multivitamins introduced to his diet during confinement.
His calcium intake is low and needs to be addressed for proper bone growth. Due to his poor
nutrition status, this trend is dangerous as he could face vitamin toxicities. IV Fluids were not
considered in this analysis, however, if it was included, it would increase energy and protein
intake which is already very overadequate.

VI. Evaluation of Nutrition Care Plan

JAR was under the care of the hospital for 5 days, from April 19 up to the day of data
gathering, April 24.
For the nutrition assessment, the parameters are on the anthropometric, biochemical,
clinical, dietary, nutrient and drug interaction, and others. Table 6 shows the summarized
information gathered on assessment. Weight and height were measured upon admission, and
patient was found to have an underweight, stunted, and severely wasted nutritional status.
Laboratory tests show complications in urobilinogen, ketones, WBC, with urates crystals and
yellow color. Clinical signs and symptoms were observed by the doctor and nurse. Dietary intake
shows inadequacy in energy, vitamins, and minerals PTA and calcium DC. Antagonistic
mechanisms of medications are provided. Other problems include moderate dehydration and
intestinal parasitism.
A diagnosis of “malnourished” from the doctor was written on the chart. Malnutrition in
the form of undernutrition would have many underlying implications such as protein and/or
energy malnutrition, vitamin and mineral deficiencies. Nutrition interventions were applied such

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as replacement of fluid and electrolyte losses through IVF, giving of zinc sulfate and
multivitamins for supplementation, and a prescription of small frequent feedings for diet as
tolerated. Medical considerations were taken, patient was given Omeprazole which may have
possible adverse reactions. Other interventions are more medically inclined, and are beyond the
scope of this course. It was observed that the patient may be at risk for iron-deficiency anemia as
observed in his usual intake, signs, and as a usual complication of his disease condition, but no
interventions were performed to counteract this deficiency.
Monitoring and evaluation for signs and symptoms of AGE and dehydration was
recorded by the nurses and doctor. Practices on good hygiene and sanitation was also taught to
the parents. However, there were no RNDs who took charge of monitoring and evaluating the
nutritional status of the patient through assessment and interpretation by indices. Nutrition of
infants, especially those who are diagnosed with complications, plays a huge role in the overall
health, well-being, growth and development. Yet it was observed that no one, in particular, was
able to perform a more specific qualitative and quantitative assessment of the patient’s dietary
intake. Possible nutrient deficiencies were not given emphasis. During the day of data gathering,
no health care professional, still, was able to educate and counsel the patient’s mother on proper
breastfeeding practices and complementary feeding. Based from the 24 hour food recall during
confinement, the diet of the patient is poorly planned. Since the hospital does not provide a
special menu for the pediatric ward, pediatric patients consume the same food given to the adult
patients. Lastly, there were no follow ups for nutrition counseling and nutrition education. The
only follow-up made is for deworming of the patient.

Table 6. Identification of Nutrition and Nutrition-related problems.

Parameters Nutrition-related problems Other related problems

Anthropometry Underweight, stunted, N/A

severely wasted nutritional
status

Biochemical N/A Levels of urobilinogen,

ketones, and white blood
cells (WBC) above normal,
urates crystals, yellow hazy
urine

Clinical Diarrhea with greenish and Pale lips, weak body,

mucus-streaked stool, sunken eyeballs, pale nail
vomiting with and without bed, faint pulse
worms, soft tympanitic
hyperactive bowel sounds

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 Dietary PTA: Difficulty in eating N/A
due to excessive vomiting;
inadequate energy,
calcium, phosphorus, iron,
thiamin, riboflavin, and
niacin intake
DC: Inadequate calcium
intake

Nutrient and Drug May inhibit copper Risk for side effects
Interactions absorption and vitamin
B12

Others Moderate dehydration Intestinal Parasitism

Table 7. Analysis of the Doctor’s Diet Prescription.

Prescription Remarks Rationale

Small frequent feedings Agree Patient may still be unable to take large
(SFF) bulky meals which can cause loss of
appetite. SFF can also rest the affected
GI tract from bulk digestion and
absorption..

Oral Rehydration Therapy Agree After rehydration, patient should

followed by Diet as resume their normal diet once their
Tolerated (DAT) appetite returns to fulfill energy and
nutrient requirements, and promote
regular oral feeding

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VII. Recommendations

Dehydration
In Acute Gastroenteritis, dehydration is the most dangerous complication which must be
addressed immediately. Case patient was found to have a moderate dehydration (6-9%) as
observed in the assessment. Given that the patient continues his hydration therapy -
intravenously or orally, the RND should always monitor the condition of the patient. Water can
also be incorporated in meals such as in broths, soups, or porridges.

Breastfeeding and Complementary Feeding (UNICEF, 2018)

Continuous breastfeeding is encouraged so as to provide the necessary energy and
nutrients, as well as strengthen his immunity from diseases. It was observed that proper
complementary feeding practices was not followed by the parents, which resulted in fluctuations
on the nutrient and energy adequacy the patient gets from his food. Energy gap is already big for
his age, as breastmilk cannot provide more than half of his requirements. For a 20 month old
infant, it is recommended that chopped or mashed family foods are given with little to no salt
added. Frequency of feeding is 3-4 meals and 1-2 snacks throughout the day plus breastfeeding.
The amount of food to be given should be approximately ¾ to one 250 mL cup or bowl at each
meal.
It was observed that the patient has micronutrient deficiency. Provision of nutrient-dense
and calorie-dense foods at each meal and snack is recommended. JAR was said to consume
coffee due to personal liking. Coffee may reduce iron absorption. At 20 months, at the breast
milk cannot anymore fulfill the iron requirements of the infant (IYCF). Given that he has already
low levels of iron intake in food, then this could pose a health risk for iron deficiency anemia
(IDA). The students recommend that coffee intake be lessened (if possible, stopped), or it should
not be given during meal time or within 2 hours before or after. Vitamin A intake is normal and
should be maintained, also because it cannot be fully provided by the breastmilk
Parasitic infections can also constitute to blood loss, which increases the risk for IDA.
Deworming should be done at least every 3-4 months. After deworming, a daily dosage of
ferrous sulfate is required, followed by 3 months of oral iron supplementation. In addition to the
dietary requirements, parents should be educated more on personal hygiene and sanitation.
Practices such as washing hands, proper disposal of garbage and human excretions, wearing of
shoes and slippers must be observed. It should also be ensured that there is a safe water and food
source. If unsure, then water should be boiled before drinking and food must be thoroughly
washed and/or cooked especially fresh produce, meat, poultry, and seafood (Jamorabo-Ruiz,
2011).

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Correcting Nutritional Status
According to the World Health Organization (2007), it is essential to correct the nutritional
status of severely malnourished infants while they are still young, as this can highly affect their
overall growth and development. Children born in underprivileged families have a higher risk for
protein-energy malnutrition (PEM) due to inadequate food intake and poor feeding practices. To
combat this, it is recommended that the patient be fed with nutrient and caloric dense foods such
as legumes and animal-source foods, which can help stunted infants to grow in height without
excess weight gain. Porridges are to be made thick and with added fat for energy density.
Micronutrient deficiency is prevented through the provision of yellow-fleshed fruits and
vegetables, as well as dark green leafy vegetables which are high in vitamins and minerals for
body regulation. To promote variety of intake, the mother should introduce new foods gradually
to the infant. Micronutrient supplementation for Vitamin A and Iron is recommended but not
entirely required, except for iron supplementation required after deworming. Fortified foods such
as iodized salt and other locally available foods are also recommended (WHO, 2007).

Sample Meal Plan

A sample meal plan is recommended with a diet prescription of 1,450 kcal: 220 g CHO
(60%); 75 g Pro (20%); 30 g Fats (20%). Carbohydrates is important for energy in growth,
protein is for tissue repair due to gastroenteritis and parasitic infection and to combat PEM, and
fats for additional energy and for proper absorption of fat soluble vitamins. The diet Rx was
formulated also for the purpose of correcting his nutritional status.

Dx: Acute Gastroenteritis with Moderate Dehydration and Intestinal Parasitism

Age: 20 months
Ht: 83 cm
Wt: 8.5 kg
DBW: 13 kg
NS (WHO CGS): Severely wasted (W4A), Underweight (W4L), Stunted (L4A)
TER: 1,450 kcal
C: 220 g
P: 75g
F: 30g
Diet Rx: 1,450 kcal regular diet; 220 g CHO(60%); 75 g Pro (20%); 30 g Fats (20%)

The patient’s diet was translated to exchanges (APPENDIX VIII). The patient’s diet
exchanges was translated to meals (APPENDIX IX). His Sample Meal Plan was formulated with
the recommendations provided (APPENDIX X).

14
 For monitoring and evaluation, parents will be asked to keep a food record of the fluid
and food intake, as well as supplements taken by the patient. Monthly consultations and weekly
phone consultations are recommended so that both anthropometric assessment (weight and
height) and dietary assessment could be conducted, since the patient was found to be
underweight, severely wasted, and stunted. Food record would undergo qualitative and
quantitative assessment to ensure that patient is fulfilling his energy and nutrient requirements.
Upon consultation, dietitian would also perform nutrition education and counseling with
the parents on proper breastfeeding and complementary feeding practices. Given that the patient
is nearing 24 months, proper feeding practices for preschool children may be given as part of
long term intervention.
A summary of the Nutrition Care Plan (NCP) following the ADIME format is indicated
in APPENDIX VI.

VIII. Glossary of Medical-Nutrition Terms

Acute gastroenteritis - acute inflammation of the stomach lining and small and/or large intestines
Diet as tolerated - regular oral diet according to age group
Febrile - with fever (afebrile: without fever)
Intestinal parasitism - infection caused by parasitic infestation of a living host’s intestines
Helminthiasis - infection caused by soil-thriving parasites or helminths
Iron deficiency anemia - anemia caused by iron intake lower than the requirement
Ketones - intermediate products of fatty acid degradation
Small frequent feeding - feeding small to moderate amount of food at multiple times (5-7)
distributed throughout the day
Urobilinogen - derivative of bile pigment bilirubin, causes brown color in stool

All definitions were obtained from Jamorabo-Ruiz, et al (2012).

IX. References

Burkhart, D. M. (1999). Management of Acute Gastroenteritis in Children. Retrieved May 14,

2019, from https://www.aafp.org/afp/1999/1201/p2555.html?fbclid=IwAR0O9p20iS_c9wY_Aj4
CphHKRuQW1JdUCby5AVCkFrkb0qEX_Tibf8zH_vA

Calamba Medical Center (2015). Acute Gastroenteritis. Retrieved on May 23, 2019 from
http://cmc.ph/health-conditions/acute-gastroenteritis/.

Elliott, E. J. (2007). Acute gastroenteritis in children. Bmj, 334(7583), 35-40. doi:10.1136/

15
bmj.39036.406169.80.

Jamorabo-Ruiz, A & Serraon-Claudio, V (2010). Basic Nutrition for Filipinos. 6th Ed. Manila;
Merriam & Webster Bookstore.

Jamorabo-Ruiz, A, et al. (2011). Medical Nutrition Therapy for Filipinos. 6th ed. Manila:
Merriam & Webster Bookstore.

Jamorabo-Ruiz, A, et al. (2012). Nutrition and Diet Therapy Reference Dictionary. Manila:
Merriam & Webster Bookstore.

Labeaud, A. D., et al (2015). Parasitism in Children Aged Three Years and Under: Relationship
between Infection and Growth in Rural Coastal Kenya. PLOS Neglected Tropical Diseases, 9(5).
doi:10.1371/journal.pntd.0003721.

Mayo Clinic. (2018). Ascariasis. Retrieved May 12, 2019, from https://www.mayoclinic.org/
diseases-conditions/ascariasis/symptoms-causes/syc-20369593

National Collaborating Centre for Women's and Children's Health (UK). (2009). Diarrhoea and
Vomiting Caused by Gastroenteritis: Diagnosis, Assessment and Management in Children
Younger than 5 Years. Retrieved on May 13, 2019 from https://www.ncbi.nlm.nih.gov/books
/NBK63838/?fbclid=IwAR2dzRG5UHUwFzID0C39qIl20QjqaYmu7BOIjfXXhOLmCF9oEWs
_T8vmr30.

Nelms, M., et al. (2011). Nutrition Therapy and Pathophysiology. Wadsworth: Cengage
Learning.

Roth, R. (2011). Nutrition and Diet Therapy. 10th ed. Delmar: Cengage Learning.

Tanchoco, C. & Jamorabo-Ruiz, A. (2010). Diet Manual. Quezon City: The

Nutritionist-Dietitians’ Association of the Philippines.

United Nations International Children's Fund. (2018). Infant and young child feeding. Retrieved
May 12, 2019, from https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/

World Health Organization (n.d.) Growth Charts - WHO Child Growth Standards. Retrieved
May 14, 2019, from https://www.cdc.gov/growthcharts/who_charts.htm.

16
World Health Organization (2007). Management of moderate malnutrition in under-5 children by
the health sector. Retrieved May 18, 2019 from https://www.who.int/nutrition/topics/MM_consul
tation_background.pdf&ved=2ahUKEwj7mq3QoKXiAhUF-2EKHbr_DbwQFjAKegQIARAB&
usg=AOvVaw2jokRJLXLZ7huK5ufq0YTS.

World Health Organization. (2017). WPRO | Neglected tropical diseases in the Philippines.
Retrieved May 12, 2019, from http://www.wpro.who.int/philippines/areas/communicable_
diseases/mvp/story_ntd/en/index2.html.

17
APPENDIX VII. Dietary Computations for the Case Patient

A. Desirable Body Weight (kg) = (age in months / 2) + 3

= (20/2) + 3
= 10 + 3
= 13 kg

B. Total Energy Requirement = [RDA for age (kcal/kg) * ideal weight-for-height] ÷

actual body weight
= (83.33 kcal/kg * 11.2 kg) ÷ 8.5 kg
= 109.79 ~ 110 kcal / kg DBW
= 13 kg * 110 kcal / kg
= 1,430 ~ ​1,450 kcal

C. TER to Carbohydrates, Protein, Fat in grams

C: 1,450 kcal * 0.60 = 870 kcal / 4 = 220 g CHO
P: 1,450 kcal * 0.20 = 290 kcal / 4 = 75 g Pro
F: 1,450 kcal * 0.20 = 290 kcal / 9 = 30 g Fat

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Appendix V. JAR’s food recall during confinement.
Time Food HH measure Weight(g)

Breakfast Rice 1 cup 160

Chicken Tinola
-chicken meat 1 slice 30
-oil 1 tsp 5
Coffee ¼ cup 62.5
-sugar 1 tsp 5
Breastmilk 4 oz 118
Water 1 glass 240
Multivitamins 1 tsp 5

AM Snack Chiz curls ½ pack 27.5

Breastmilk 4 oz 118
Water 1 glass 240

Lunch Rice 1 cup 160

Chicken Tinola
-chicken meat 1 slice 30
-oil 1 tsp 5
Banana 1 pc 40
Breastmilk 4 oz 118
Water 1 glass 240

PM Snack Chiz curls ½ pack 27.5

Breastmilk 4 oz 118

Dinner Rice ½ cup 80

Chicken Tinola
-chicken meat 1 slice 30
-oil 1 tsp 5
Guyabano 1 slice 60
Breastmilk 4 oz 118
Water 1 glass 240

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Appendix IV. JAR’s food recall prior to admission
Time Food HH measure Weight(g)

Breakfast Rice w/ sabaw ½ cup 80

Breastmilk 4 oz 118

AM Snack Skyflakes biscuit 2 crackers 16

Water 1 glass 240

Lunch Rice w/ sabaw ½ cup 80

Breastmilk 4 oz 118

Dinner Skyflakes biscuit 1 cracker 8

Breastmilk 4 oz 118
Water 1 glass 240

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21
Appendix VII. Results of urinalysis done on JAR.
Reference Range(if
Test Results stated)
Color Yellow Yellow
Transparency Hazy Clear
pH 5 5-9
Specific
Gravity 1.01 1.000 - 1.030
negative<50
Sugar negative mg/dL/100ml
negative<10
Protein negative mg/dL/100ml
Leukocytes negative negative<10 WBC/µl
Nitrite negative negative<0.05 mg/dL
Urobilinogen normal negative<1 EU/dL
negative<0.015 mg/dL
Blood negative Hgb
Ketone 2+ negative<5 mg/dL/100ml
Bilirubin negative negative<0.5 mg/dL
Ascorbic Acid negative negative<10 mg/dL
Microscopic
Exam
-RBC 0-2/hpf
-WBC 2-4/hpf
-Epithelial
cells rare
-Bacteria rare
-Crystals many urates

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Appendix VIII. Translation of JAR’s Diet to Exchanges.
Food List # of CHO (g) PRO (g) Fat (g) Energy (kcal)
exchange

Vegetable A 2 3 1 0 16
Vegetable B 2 6 2 0 32
Fruit 4 20 0 0 80
Sugar 3 15 0 0 60
Rice 5 138 12 0 600
Low Fat Meat 1 0 40 5 205
Medium Fat Meat 3 0 8 6 86
Breast Milk 41.04 7.2 23.04 403.2

TOTAL 24 223.04 70.2 34.04 1482.2

Appendix IX. Distribution of Exchanges to Meals.

Food List Breakfast AM Lunch PM Dinner Midnight Total
Snack Snack Snack

Vegetable A 2 2
Vegetable B 1 1 2
Fruit 1 1 2
Sugar 1 1 1 3
Rice 2 1 1 1 1 6
Low Fat Meat 2 2 1 5
Medium Fat Meat 1 1
Breast Milk 0.5 1 0.5 0.5 0.5 3

Appendix X. One-day Sample Meal Plan

Meal Food List # of Sample Menu HH Measure Wt (g)
/Time exchange

Breakfast Diced Omelette

7:00 am Medium Fat Meat 1 -chicken egg 1 piece 60
Vegetable B 0.5 -carrots ¼ cup cooked 22.5
Vegetable B 0.5 -mushroom ⅙ cup 55
Low Fat Meat 2 -ground beef 2 slices 60
Rice 2 Rice 1 cup 160
Breast Milk 0.5 Breast Milk ½ cup 120

AM Fruit jam sandwich

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Snack Sugar 1 -fruit jam 2 tsp 10
10:00 am Rice 1 -pan amerikano 2 slices 40
Breast Milk 1 Breast Milk 1 cup 250

Lunch Sinigang (cut into

12:00 pm smaller pieces)
Low fat meat 2 -pork lomo 2 slices, diced 60
Vegetable A 2 -kangkong 1 cup cooked 90
Rice 1 Rice ½ cup 80
Fruit 1 Banana, lakatan 1 piece 40
Sugar 1 Powdered fruit drink 1 tsp 5
Breast Milk 0.5 Breast Milk ½ cup 120

PM Fruit jam sandwich

Snack Sugar 1 -fruit jam 2 tsp 10
4:00 pm Rice 1 -pan amerikano 2 slices 40
Breast Milk 0.5 Breast Milk ½ cup 120

Ginisang Kalabasa
Dinner (cut into smaller
7:00 pm pieces)
Low Fat Meat 1 -pork lomo 1 slice 30
Vegetable B 0.5 -squash ¼ cup cooked 22.5
Vegetable B 0.5 -stringbeans ¼ cup cooked 22.5
Rice 1 Rice ½ cup 80
Fruit 1 Mango, ripe 1 slice 60
Breast Milk 0.5 Breast Milk ½ cup 120

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