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PDAT3 > 13/14 - Pediatric Nutrition > Flashcards

13/14 - Pediatric Nutrition Flashcards

1
Q

Protein Considerations
for PEDS

A
  • *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​

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2
Q

Important Lipid Considerations
for PEDS

A
  • *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

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3
Q

Factors associated with
HYPERTrigliceridemia

for Preterm Infants

A

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

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4
Q

Ideal

Calcium - Phosphate

RATIO

for peds

A

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
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5
Q

0.9% NaCl

Na Equivelant Value
&
Osmolarity

A

154
mEq/L

308
mOsm/L

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6
Q

Maintanance Fluid Requirements

Infants / Children / Adolescents

A

Weights 3-10 kg
100 mL/kg
+
Weights 10-20 kg
50 mL/kg
+
Weights >20 kg
20 mL/kg

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7
Q

Maintanence Fluid Requirements

for NEONATES

A

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**
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8
Q

Causes for INCREASED Water Loss
in PEDS

A

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

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9
Q

Routine IV Maintenance Fluids

A

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

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10
Q

Calculating % Fluid Deficit
in PEDS with Dehydration

A

1kg weight loss = 1 Liter fluid deficit

  • *Previous Weight - Current Weight** x 100%
  • *Previous Weight**

Most common cause of Dehydration:
Vomiting / Diarrhea

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11
Q

3 Severities of DEHYDRATION
for
INFANTS

A

5-9-10(15)

Mild
5% (50 mL/kg)

  • *Moderate**
  • *9%** (90mL/kg)
  • *SEVERE DEHYDRATION**
  • *10-15%** (100-150mL/kg)
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12
Q

3 Severities of DEHYDRATION
for
OLDER CHILD

A

3 - 6 - 10

Mild
3% (30mL/kg)

  • *Moderate**
  • *6%**
  • *SEVERE DEHYDRATION**
  • *10%**
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13
Q

Which TYPE of DEHYDRATION?

Excessive Vomiting or Urine Loss

Hemorrhage

Decreased Fluid Intake

Gastroenteritis

A

ISOTONIC
MOST COMMON

Na = 130-150 mEq/L

&

280-300 moSm/L

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14
Q

Which TYPE of DEHYDRATION?

Heat Stroke

Child w/ diarrhea who has been replenished with:
WATER
to replace losses

improper infant formula mixing

A
  • *HypoTonic**
  • least common*

Na = <130 mEq/L

&

<280 moSm/L

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15
Q

Which TYPE of DEHYDRATION?

Diabetes Insipidus

Child w/ diarrhea who has been replenished with:
Hypertonic Soup / Boiled Milk
Improper Diluted Infant Formula

A

HYPERTONIC
second most common

Na = >150 mEq/L

&

>300 moSm/L

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16
Q

Lab Findings for DEHYDRATION / Volume Depletion
for PEDS

A

INCREASED BUN

HIGH HEMATOCRIT

low Serum Bicarbonate

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17
Q

Phase 3 of Fluid Management
for PEDS

A

For Isotonic & HypoTonic Dehydration

  • *NEXT 16 hours**
  • *replace** (1/2 deficit)
  • *+ 2/3 Maintenance Fluid**

only add POTASSIUM (K) if patient has MADE URINE

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18
Q

Phase 2 of Fluid Management
for PEDS

A

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

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19
Q

Phase 1 of Fluid Management
for PEDS

A

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

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20
Q

Special Considerations
for HYPERtonic Dehydration
Phase 2 & 3 - Rehydration Fluid Management

A

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

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21
Q

Max Sodium Correction Rate

HypoTonic Dehydration

Phase 2 & 3 - Rehydration Fluid Management

A

< 0.5
mEq/L/hr

to avoid CPM

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22
Q

Indications for PN
PEDS

A
  • *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

23
Q

Administration Concerns of PERIPHERAL PN
PEDS

Short Term - <2 weeks

Higher incidence of Phlebitis

Less risk of long-term complications

A

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%

24
Q

Which nutrient to CUT when too much Concentration?

Peripheral MAX:
900-1000 mOsm/L

A

AMINO ACIDS

NEVER cut
dextrose or Electrolytes

25
Q

Monitoring Glucose
for PEDS

A

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

26
Q

Maximum Glucose Infusion Rate
for PEDS

A

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

27
Q

Protein Requirements
for PEDS

A

> 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

28
Q

Starter PN / Standardized PN Solutions

A

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

29
Q

Pediatric Formulations for AMINO ACIDS
vs Adults

A

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*
30
Q

Advantages of Pediatric Formulations
AMINO ACIDS

A

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

31
Q

PROTEIN CONSIDERATIONS
PEDS

A

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

32
Q

MINIMUM LIPIDS, and why?
for PEDS

A

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

33
Q

Parenteral Lipid Products
comparison

A

Omega 3 > 6

Fish oil –> decrease inflammatory mediators

  • *OMEGAVEN 10%**
  • *MAX is 1g/kg/day** –> but may be givin with other lipids
34
Q

FAT INFUSION Considerations
PEDS

A

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**
35
Q

Factors Associated w/ HYPERTriglyceridemia
PEDS

A

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

36
Q

Four Major COMPLICATIONS with
FAT INFUSIONS

A

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**
37
Q

Ideal Calcium to Phosphorus Ratio

A

2** **: 1
(Ca) mEq per mMol (P)
or
1.7 mg : 1 mg

for preturm neonates exposed to MATERNAL MAG
OMIT MAG

38
Q

Factors Affecting

Ca & P solubility

A
  • *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

39
Q

Which Trace Elements do we need to DECREASE or HOLD
for KIDNEY FAILURE?

A

CHROMIUM

SELENIUM

40
Q

Which Trace Elements do we need to DECREASE or HOLD
for LIVER Dysfunction?

A

COPPER
but give additional for pts with jejustomies or excessive GI losses
10-15 mcg/kg/day

MANGANESE

41
Q

Zinc Considerations

A

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

42
Q

Other Supplementations for PEDS
in PN

A
  • *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

43
Q

Transition from PN->EN
PEDS

A

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

44
Q

Visceral Protein Measurements
PEDS

A

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

45
Q

PNAC

A

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

46
Q

PNAC RISK FACTORS

A

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

47
Q

PNAC - TREATMENT

A

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**

48
Q

When to use SMOFlipid?

A

PREVENTION of PNAC

When approaching PNAC <2 direct bilirubin

SMOFLipid @ 2-3 gm/kg/day

49
Q

Pharmacologic Agents for PNAC

A

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*
50
Q

Metabolic Bone Disease

A

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

51
Q
  • *Catheter Occlusion - TREATMENT**
  • *Complication of Long-Term PN for PEDS**
A
  • *Thrombosis**
  • *Thrombolytic Instillation = ALEPLASE 0.5-1mg**
  • *Precipitation**
  • *0.1 N-HCL (1mL**)
52
Q
  • *Phlebitis - TREATMENT**
  • *Complication of Long-Term PN for PEDS**
A
  • ways to decrease phlebitis:*
  • *Heparin 0.5-1 units/mL**

Osm <900-1000

Co-infused with IV FAT

IN-LINE FILTER = 0.22 micron

53
Q

Central Venous Catheter Infection

TREATMENT / PREVENTION

Complication of Long-Term PN for PEDS

A

Mainly caused by Gram POSITIVE organisms

Prevention
Catheter Locks = Ethanol 70% / Vancomycin
Continuous Infusion Heparin

  • *Treatment**
  • *Catheter REMOVAL**
  • *ANTIBIOTICS**

PDAT3 (23 decks)

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