13/14 - Pediatric Nutrition Flashcards
Protein Considerations
for PEDS
- *24 to 32**
- *non-protein Kcal** for every gram of protein
Excessive protein intake > 6 gm/kg/day
inadequate protein intake < 2.5 gm/kg/day
Important Lipid Considerations
for PEDS
- *to PREVENT EFAD (essential FA deficiency):**
- can develop within 72 hours of life*
Minimum of 0.5 gm/kg per day (preterm/term/infants)
or
1.5 gm/kg twice a week
(older children/adolescents)
Still 30-35% of non-caloric intake
Factors associated with
HYPERTrigliceridemia
for Preterm Infants
Carnitine - Exclusive PN > 4 weeks and/or hypertriglyceridemia
Dose: 2-5 mg/kg/day (up to 20 mg/kg/day)
Low levels of lipoprotein lipase (LPL) and adipose tissues
Carnitine deficient
Accretion occurs during last trimester of gestation
Essential for transport of long-chain fatty acids via mitochondrial membrane for oxidation
Ideal
Calcium - Phosphate
RATIO
for peds
Calcium - Phosphate
2 : 1
(mEq per mMol)
or
1.7 : 1
(mg to mg)
- Promote highest retention of Ca and P
- Simulate in utero bone mineral accretion rates
0.9% NaCl
Na Equivelant Value
&
Osmolarity
154
mEq/L
308
mOsm/L
Maintanance Fluid Requirements
Infants / Children / Adolescents
Weights 3-10 kg
100 mL/kg
+
Weights 10-20 kg
50 mL/kg
+
Weights >20 kg
20 mL/kg
Maintanence Fluid Requirements
for NEONATES
PRENATES NEED MORE vs Normal Term
Very low birth weight infants
High surface area to mass ratio & immature renal fxn
–> increased water loss
Antidiuretic Period (24-28hrs of life) **Table will be given**
Causes for INCREASED Water Loss
in PEDS
Fever
10-15% for each 1* > 38*
Radient Warmer
Burns / Diarhea
Tachypnea / Emesis
Nasogastric Suction / Polyuria / Surgical Drains
Decreased water needs
Incubator / Humidified Ventilator
Oliguria / anuria / HypoThyroidism
Routine IV Maintenance Fluids
NEONATES
D10% + electrolytes
INFANTS > 3kg
- *D5% / 0.45% NaCl + KCL 20** mEq/L
- younger infants may require D10%*
Children & Adolescents
D5%/0.45% NaCl + KCl 20 mEq/L
D5%/0.9% NaCl + KCl 20 mEq/L
0.9% NaCl + KCl 20 mEq/L
depends on sodium & free water needed
Calculating % Fluid Deficit
in PEDS with Dehydration
1kg weight loss = 1 Liter fluid deficit
- *Previous Weight - Current Weight** x 100%
- *Previous Weight**
Most common cause of Dehydration:
Vomiting / Diarrhea
3 Severities of DEHYDRATION
for
INFANTS
5-9-10(15)
Mild
5% (50 mL/kg)
- *Moderate**
- *9%** (90mL/kg)
- *SEVERE DEHYDRATION**
- *10-15%** (100-150mL/kg)
3 Severities of DEHYDRATION
for
OLDER CHILD
3 - 6 - 10
Mild
3% (30mL/kg)
- *Moderate**
- *6%**
- *SEVERE DEHYDRATION**
- *10%**
Which TYPE of DEHYDRATION?
Excessive Vomiting or Urine Loss
Hemorrhage
Decreased Fluid Intake
Gastroenteritis
ISOTONIC
MOST COMMON
Na = 130-150 mEq/L
&
280-300 moSm/L
Which TYPE of DEHYDRATION?
Heat Stroke
Child w/ diarrhea who has been replenished with:
WATER
to replace losses
improper infant formula mixing
- *HypoTonic**
- least common*
Na = <130 mEq/L
&
<280 moSm/L
Which TYPE of DEHYDRATION?
Diabetes Insipidus
Child w/ diarrhea who has been replenished with:
Hypertonic Soup / Boiled Milk
Improper Diluted Infant Formula
HYPERTONIC
second most common
Na = >150 mEq/L
&
>300 moSm/L
Lab Findings for DEHYDRATION / Volume Depletion
for PEDS
INCREASED BUN
HIGH HEMATOCRIT
low Serum Bicarbonate
Phase 3 of Fluid Management
for PEDS
For Isotonic & HypoTonic Dehydration
- *NEXT 16 hours**
- *replace** (1/2 deficit)
- *+ 2/3 Maintenance Fluid**
only add POTASSIUM (K) if patient has MADE URINE
Phase 2 of Fluid Management
for PEDS
For Isotonic & HypoTonic Dehydration
- *1st 8 hours**
- *replace** (1/2 deficit) - (bolus fluid)
- *+ 1/3 Maintenance Fluid**
only add POTASSIUM (K) if patient has MADE URINE
Phase 1 of Fluid Management
for PEDS
Restore IVF
to PREVENT HypoVolemic Shock
- *0.9% NaCL**:
- *20 mL/kg** over 15-20 min
may repeat up to 60mL/kg within 1 hour
Applicable to:
all 3 types of dehydration
Special Considerations
for HYPERtonic Dehydration
Phase 2 & 3 - Rehydration Fluid Management
Deficit + Maintanence Volume needed for 48 hours
& infuse SLOWLY over 48 hours
D5%/0.45%NaCl +/- KCL 20 mEq/L
< 8-10 mEq/L/24hr
or < 0.3 - 0.4 mEq/L/hr
to avoid ceerebral edema / convulsions / death
Max Sodium Correction Rate
HypoTonic Dehydration
Phase 2 & 3 - Rehydration Fluid Management
< 0.5
mEq/L/hr
to avoid CPM
Indications for PN
PEDS
- *Premature Neonates** who
- CANNOT* be fed or adequately fed by EN
Patients with congenital anomalies
omphalocele / gastroschisis
Patients with IBS / Necrotizing Enterocolitis / Short-bowel syndrome
Healthy infants & children
who are NOT fed within 3 days
Malnourished or/@ High-risk who are NPO
Administration Concerns of PERIPHERAL PN
PEDS
Short Term - <2 weeks
Higher incidence of Phlebitis
Less risk of long-term complications
Requires LARGE fluid volumes to provide adequate energy need
Calcium Gluconate < 10 mEq/L
Maximum’s
~900 - 1000 mOsm/L
Dextrose < 12.5%
AA’s < 2.5%
Which nutrient to CUT when too much Concentration?
Peripheral MAX:
900-1000 mOsm/L
AMINO ACIDS
NEVER cut
dextrose or Electrolytes
Monitoring Glucose
for PEDS
HypoGlycemia is MUCH MORE of a CONCERN vs HYPERgycemia
Maintain Serum Glucose:
120-150 mg/dL
Consider decreasing FAT if persistant HYPERglycemia
_early INSULIN infusion to PREVENT HYPERGLYCEMIA is:
NOT RECOMMENDED_
associated with significicant hypoglycemia & mortality
May be considered at 250-270mg/dL
Maximum Glucose Infusion Rate
for PEDS
12 - 14 mg/kg/min
- *55-65% of non-protein caloric intake**
- never give less than 4mg/kg/min, need 2-3 minimum for protein desposition*
Need ALOT for brain development
Child is 6-9 mg/kg/min
Adults is:
3-5 mg/kg/min
Protein Requirements
for PEDS
> 1.5 gm/kg/day
to prevent breakdown of endogenous tissue
Early Initiation of AA’s in Preterm Infants:
Prevents Catabolism / Promotes Anabolism
Stimulates Growth / Decrease HYPERglycemia + HYPERkalemia
Starter PN / Standardized PN Solutions
PRE-MADE Parenteral Nutrition (central or peripheral)
solutions that contain
DEXTROSE + AA’s
Limited to 80-90 mL/kg/day
Rationale:
Provides EARLY ADMIN of AA’s to
very-low-birth-weight infants (<1500gm)
can be used on First day of life
Pediatric Formulations for AMINO ACIDS
vs Adults
TROPHAMINE / Aminosyn PF
LOW concentrations of
methionine / phenylalanine / glycine
HIGH conc. of essential AA’s
(taurine / histadine / tyrosine)
L-Cysteines HCL 40 mg/gm of protein –> added at time of prep
Enzyme immaturity contributes to the need of essential AA’s
- for adults = Travasol*
- *OPPOSITE**, HIGH concentrations of met/phe/gly
- low concentrations of Essential AA’s*
Advantages of Pediatric Formulations
AMINO ACIDS
Adequate WEIGHT GAIN
even w/ below normal caloric intake
LOWER pH
increases solubility of Ca & Phos
- lower incidence of*
- *Cholestasis** in VLBW infants
Positive NITROGEN BALANCE
PROTEIN CONSIDERATIONS
PEDS
24 - 32 non-protein KCAL** for **EVERY GRAM of PROTEIN
to achieve optimal protein utilization
Excessive protein >6 gm/kg/day
Aminoacidemia / azotemia / acidosis / increased BUN / lower IQ
INADEQUATE protein intake < 2.5 gm/kg/day
decreased Nitrogen retention / low serum albumin
edema / slow growth
MINIMUM LIPIDS, and why?
for PEDS
MINIMUM OF:
0.5 gm/kg/day for preterm/term/infants
or
1.5 gm/kg twice a week for older children/adolescents
to PREVENT EFAD
Essential fatty acid deficiency, can develop within 72 hours of life
30-35% of non-protein caloric intake
important for brain development / cell membrane
& prolongs integrity of peripheral lines
Parenteral Lipid Products
comparison
Omega 3 > 6
Fish oil –> decrease inflammatory mediators
- *OMEGAVEN 10%**
- *MAX is 1g/kg/day** –> but may be givin with other lipids
FAT INFUSION Considerations
PEDS
MAX
<0.15 gm/kg/hrforpremature infants
vs 0.03-0.05 gm/kg/hr for adults
- *run over 12-24 hours**
- *Isotonic –> can be through PERIPHERAL vein**
Factors Associated w/ HYPERTriglyceridemia
PEDS
Premature Infants
Low levels of LPL & Adipose tissue
Carnitine Deficient
essential for xport of LCFA via mito for oxidation
Carnitine - Exclusive PN >4 weeks and or HyperTG
- *Sepsis or Trauma**
- *Liver / Renal Disease**
MONITOR
Serum TG’s –> HOLD fat if TG’s >250 mg/dL
Check for essential FA status in long-term PN or severe FAT malabsorption
Four Major COMPLICATIONS with
FAT INFUSIONS
Risk of KERNICTERUS
FFA displaces billirubin from albumin –> more unconjugated bilirubin
LIMIT fat to 0.5 gm/kg/day to prevent EFAD
Risk or exacerbation of Chronic Lung Disease
Lipid Overload Syndrome
HIGH TG’s / fever / lethargy / liver failure
- *PNAC**
- *PN-associated Cholestasis**
Ideal Calcium to Phosphorus Ratio
2** **: 1
(Ca) mEq per mMol (P)
or
1.7 mg : 1 mg
for preturm neonates exposed to MATERNAL MAG
OMIT MAG
Factors Affecting
Ca & P solubility
- *pH**
- *Cysteine /** High Conc of AA & Dextrose –> GOOD
- Lipid = High pH* –> BAD
High Temperature/Light –> BAD
Calcium & Phos concentrations
Calcium Salt
Order of adding Ca & Phos
Which Trace Elements do we need to DECREASE or HOLD
for KIDNEY FAILURE?
CHROMIUM
SELENIUM
Which Trace Elements do we need to DECREASE or HOLD
for LIVER Dysfunction?
COPPER
but give additional for pts with jejustomies or excessive GI losses
10-15 mcg/kg/day
MANGANESE
Zinc Considerations
GOOD FOR ALL DA BABIEZ
babies need MORE
- *Give ADDITIONAL** for patients with
- *STOMA or FISTULA** output or Persistant Diarrhea
100-200 mcg/kg/day
Other Supplementations for PEDS
in PN
- *VITAMIN K**
- adult products don’t have vitamin K*
HEPARIN
reduced phlebitis / improve lipid clearance / 0.5-1 units/mL
Intravenous Iron
ONLY for LONG-TERM PN-DEPENDENT children
who are NOT recieving frequent blood transfusions
Transition from PN->EN
PEDS
Depends on DURATION of PN
- DECREASE* amount of ALL PN
- -> while INCREASING EN as tolerated
- do NOT dilute or concentrate*
- *formulas or breast milk**
D/C PN
when 3/4 or 75% of EN in neonates/infants
2/3 or 67% of EN in children
Visceral Protein Measurements
PEDS
Serum Albumin
LONG half life –> 14-20 days
May be affected by:
albumin infusion / dehydration / sepsis / liver disease / trauma
Pre-Albumin
short half life,
good indicator of acute nutritional assessment / visceral protein pool
May be DECREASED in LIVER disease
and falsely ELEVATED in RENAL failure
BUN
low <5mg/dl = inadequate AA intake
high is >20 mg/dL
PNAC
Metabolic Complication of Long-Term PN
Due to impaired secretion of BILE –> resulting in LIVER injury
DIRECT BILIRUBIN > 2 mg/dL
Can occur as early as 2 weeks after PN initiation
Associated w/ sig. morbidity & mortality:
Progressive Liver Damage –> Liver Xplantation
Cirrhosis & liver Failure
PNAC RISK FACTORS
Prematurity & Low Birth Weight
Prolonged PN // SLEs (soybean IV lipids)
LACK of enteral feeding
Bacterial Overgrowth / Infections (sepsis / recurrant)
Intestinal Resection
Macronutrient OVERfeeding
MALE Gender
Mineral Trace Elements Toxicity
PNAC - TREATMENT
1) Initiate EN, typically can’t do this
2) Limit Intralipid - 1gm/kg/day over 12 hours or 2-3x a week
Use OMEGAVEN @ 1gm/kg/day (most effective) or in combo
SMOFlipid @ 2-3 gm/kg/day as PREVENTION
used when aproaching PNAC (<2 direct bili)
3) LIMIT GLUCOSE to 10-12 mg/kg/min
4) Cycling of Pn
5) REMOVE or DECREASE - COPPER or MANGANESE
6) Pharmacologic Agents
* *Ursodiol / Metronidazole / Bactrim - ORAL**
When to use SMOFlipid?
PREVENTION of PNAC
When approaching PNAC <2 direct bilirubin
SMOFLipid @ 2-3 gm/kg/day
Pharmacologic Agents for PNAC
Ursodiol
20-30 mg/kg/day ORAL in 2-3 div doses
stimulates bile flow & maintains gallbladder contractility
for Bacterial Overgrowth PROPHYLAXIS
- *ORAL METRONIDAZOLE** or BACTRIM for 2 weeks
- do NOT give as IV*
Metabolic Bone Disease
Metabolic Disorder of PN
HIGH ALKALINE PHOSPHATASE >650 iU/L
Normal Ca & low Phos
Treat with:
2:1 Ca:P ratio
Supplement Vitamin D
Human Milk
- *Catheter Occlusion - TREATMENT**
- *Complication of Long-Term PN for PEDS**
- *Thrombosis**
- *Thrombolytic Instillation = ALEPLASE 0.5-1mg**
- *Precipitation**
- *0.1 N-HCL (1mL**)
- *Phlebitis - TREATMENT**
- *Complication of Long-Term PN for PEDS**
- ways to decrease phlebitis:*
- *Heparin 0.5-1 units/mL**
Osm <900-1000
Co-infused with IV FAT
IN-LINE FILTER = 0.22 micron
Central Venous Catheter Infection
TREATMENT / PREVENTION
Complication of Long-Term PN for PEDS
Mainly caused by Gram POSITIVE organisms
Prevention
Catheter Locks = Ethanol 70% / Vancomycin
Continuous Infusion Heparin
- *Treatment**
- *Catheter REMOVAL**
- *ANTIBIOTICS**
