Nutrition, Fluid Flashcards
what key nutrients do cow milk lacking?
Cow milk inadequate in Fe, Zinc, Vit E, essential FA’s, LCPUFA’s
early introduction of cow’s milk can increase blood loss from GI tract and contribute to Fe-deficiency anemia
Preterm infants fed standard infant formulas gain a higher proportion of their weight as FAT when compared with a fetus of the same maturity
True or False
True
The use of special preterm formulas and preterm HMF results in a composition of weight gain and bone mineralization closer to that of the reference fetus when compared to infants fed standard term formulas or straight human milk.
True or False
True
RCT’s of specially formulated preterm formulas have shown significant improvements in growth and cognitive development compared with standard formulas or unfortified EBM.
True or False
True
how much calories is needed (enterally) to balance energy expenditure and to allow for proper growth in low birth weight infant?
105-130 kcal/kg/day
Give the estimate energy need for each of the following (kcal/kg/day)
Energy expended:
Synthesis:
Energy Stored:
Energy Excreted:
Energy expended
(40-60. resting metabolic rate: 40-50, activity: 0-5, thermoregulation: 0-5)
Synthesis: 15
Energy Stored: 20-30
Energy Excreted: 15
is Z-score important?
Yes.
Be sure to not only use wt/length/FOC curves… also look at growth Z-score at appropriate frequent intervals
which position has lower energy expenditure?
prone or supine
Prone position has lower energy expenditure
10% lower than supine.
infant’s 1600g vs. 1800g wean from incubator to crib earlier or later
similar outcome
what is the estimate protein need for preterm infant
3.5 - 4.5 g/kg/day
American Academy of Pediatrics– 3.5 - 4.5 g/kg/day
European Society for Paediatric Gastroenterology, Hepatology, and Nutrition
– <1000 g: 4.0 - 4.5 g/kg/day
– 1000 – 1800 g: 3.5 - 4.0 g/kg/day
Nutrition of Preterm Infants– 3.5-4.5 g/kg/day
What enteral protein intake (g/kg/day) is literature supported to be non-toxic in the preterm infant?
3.0 - 4.0 g/kg/day
what happens if energy intake is adequate but protein intake is limited
protein retention will plateaus.
energy excess is used for fat deposition
what happens if energy intake is limited but protein intake is adequate
protein is used for energy
then if increasing energy intake, it will spare protein and improve nitrogen retention
whey to casein ratio in clostrum vs. mature milk
whey to casein ratio in predominantly casein frormula vs. predominantly whey formula
80:20 in colostrum
55:45 in mature milk
WHEY is WAY BETTER
predominant casein formula: 20: 80
predominant whey formula (i.e. enfamil premature): 80:20 or 60:40
compare the concentration of the following in foremilk vs. hindmilk
protein, carbohydrate, fat
protein concentration similar
foremilk has higher lactose
hindmilk has more fat
how much energy do you need to growth? (enteral vs. parenteral)
enteral: 115 - 130 (kcal/kg/day)
parenteral: 100-115
In formulas, approximately 40-50% of energy is provided by fat.
T or F
True
how much energy is provided by fat in human milk
50%
Oils rich in mixtures of MCT and ___ chain polyunsaturated triglycerides are in special formulas for preterm infants to help aid fat absorption.
Long
MCT and Long chain
What are DHA and ARA?
fatty acids.
DHA and ARA are transferred across the placenta to the developing fetus.
small amount in BM.
Term and preterm infant can synthesize them. but not enough.
docohexanoic acid (DHA) and arachidonic acid (ARA)
Most common fatty acids
Stearic acid (C18, fully saturated)
Oleic acid (C18, 1 double bond)
Palmitic acid (C16, fully satured)
Which fatty acids are essential in neonates
Linoleic Acid
Linolenic Acid
(aka alpha linolenic acid)
Length of fatty acids
Very Long chain: >/= 22 carbons
Long chain: > 12-20
Medium chain: 6-12 C
Short chain: < 6
most common fatty acid in human milk
palmitic
oleic
(P O)
side effect of fatty acid deficiency
SKIN:
* hemorrhagic dermatitis
* skin atrophy
* scaly dermatitis
OTHER:
* weakness
* impaired vision
* Edema
- high blood pressure * impaired growth
what is Triene:Tetraene ratio
T/T ratio is the marker used to diagnose essential fatty acid deficiency.
(Mead acid : Arachidonic acid)
**Triene/Tetraene **ratio is also called: **Holman Index **
Triene : Tetraene ratio of **is considered EFAD (or use > 0.2)
how many kcal/gram of the following
Carbohydrate
Protein
Fat
For 20% Intralipid emulsion, what is ___ kcals/ml?
Carbohydrate: 3.4 kcal/g
Protein: 4 kcal/g
Fat: 10 kcal/g
IL: 2 kcal/ml
if D10, it means 10g glucose / 100ml.
infant’s requirement for carbonhydrate is estimated at __ % of calories
40-50%
Benefits of lactose
Content of lactose in premature formula
- enhance absorption of Ca and Magnesium.
- promote intestinal growth of lactobacilli
- premature formula often replace some of the lactose with corn syrup and short chain glucose polymers. (But still has 40-50% lactose and then 50-60% glucose polymers)
- short-chain glucose polymers are absorbed more easily than long-chain glucose polymers.
What is the predominant carbohydrate in breast milk and many standard formulas ?
Lactose
For positive nitrogen balance, how many __ g of glucose should be provided for each gram of protein
6 g glucose for 1 g of protein.
How to calculate Nitrogen balance
Nitrogen balance = nitrogen intake - nitrogen lost.
Nitrogen intake = protein g/day x 0.16
(each gram of protein has 16% nitrogen)
Nitrogen lost: urine loss (urinary urea concentration) + estimated stool losses (4g)
compare lactase activity in 34 week vs. term infant
34 week is 30% of term infants
lactase level reach adult level by 36 week
Preterm of formula have a higher fat content. which triglyceride is in greater proportion
medium chain triglyceride
To achieve optimal nutrition via Parenteral nutrition, what % of total daily calories should each of the follow macro-nutrient provide?
Fat
CHO
Protein
- 30-50% as Fat
(not > 60%, stay around 40%, 3-4g/kg/day) - 35 - 65% as CHO (9.7- 17 g/kg/day)
- 7-15% as Protein (3 - 4.2 g/kg/day)
As gestational age and body weight increases,
What decrease?
What increases?
Decrease (v): Total body H2O, extracellular H2O, Na, Cl
Increase ^: intracellular H2O, Protein, Fat, Ca, Ph, Mg, Fe
primary fetal energy source
maternal glucose
transferred across the placenta by facilitated diffusion (no ATP required)
what role does placental lactate play in fetal energy
Placental lactate is 1/4 of fetal energy source
(Glucose is 2/3 energy source)
what role does maternal amino acid place in fetal energy
- Remainder of fetal energy source (after glucose and placental lactate)
- active transport across placenta
- important for tissue growth (metabolic fuel). Source of gluconeogenic substrates (pyruvate)
What amino acids are NOT gluconeogenic substrates in fetus
Fetus:
Glycine (cannot be converted to pyruvate in fetus)
Leucine (give rise to acetylCoA and acetoacetyle CoA -> ketogenic)
In neonates:
Some say it is: Leucine and Lysine
Ketogenic amino acid
which amino acid is the primary fuel of enterocytes in the newborn
Glutamine
Glutamine is the largest amino acid concentration in human milk.
Essential / Indispensable Amino Acid
Lysine
Histidine
Threonine
Tryptophan
Methionine
Phenylalanine
Branched chain:
Valine, Leucine, Isoleucine
"Try THIS VIP MaLL" Tryptophan Threonine Histidine Valine Isoleucine Phenylalanine Methaionine Leucine Lysine
Conditionally Essential Amino Acid (in Preterm infant)
**Arginine (precursor to nitric oxide)
Cysteine
Taurine
Tyrosine **
Glutamine
Glycine
Proline
draw the conditional essential AA picture with the person
what is casein protein
- beta-casein in human milk
- human milk proteases (plasmin): increase infant capacity for protein digestion
what is whey protein
- alpha-lactalbumin
- lactoferrin
- secretory IgA
- serum albumin
(IgA and lactoferrin = 30% of milk protein)
Preterm infant glucose utilization rate
vs.
Term infant
Preterm:
5-8 mg/kg/min (after 5-7 days, can tolerate 11-12 mg/kg/min)
Term:
3-5 mg/kg/min
Preterm infant has increased brain-body weight ratio, decrease fat stores, increased total energy req.
20% lipid vs. 10% lipid
10% has lower TG content and lower calories per ml.
> higher phospholipid/TG ratio > this ratio impairs lipid lipase activities in preterm infant > not using 10%
Most important amino acid that assists in metabolism of fat
CARNITINE
preterm infant’s blood and tissue carnitine are low.
add carnitine in TPN (up to 10mg/kg/day)
what lipid is used in PN associated liver disease
Omegaven (100% Fish oil)
Intravenous lipids increase serum free fatty acid concentrations that can displace bilirubin from albumin binding sites
T or F
True
BUT:
Studies have demonstrated that if parenteral lipids are provided up to 2-3.5 g/kg/day continuously over 24 hours, free bilirubin is NOT affected and therefore IV lipids might need to be discontinued in jaundiced infants
lipids and fatty acids are highly bioactive and essential for what?
neurodevelopment (myelin is fat)
cell membrane structure/function
cell signaling
lipids are alternative fuel for gluconeogenesis
T or F
True
1 gram of protein is ___ g of nitrogen
0.16 g of Nitrogen (4kcal)
If cholestatic, which trace element must be reduced and what to keep
Reduce Mn and Cu
Keep Selenium (Se) and Chromium (Cr)
If renal dysfunction, what trace element to omit
Selenium (Se) and Chromium (Cr) to omit.
fat in human milk
- Fat provide 50% of calories in human milk
- > 98% of fat in human milk is TG
- made in mammary glands from medium chain fatty acid and LCFA
- Oleic acid and Palmitic acid (most abundant FA)
- High proportions of the essential FA’s (linoleic and linolenic acid) and of other LCPUFA’s (ARA, DHA) are also present
(LCPUFA’s are constituents of brain and neural tissue and are needed early in life for mental and visual development) - human milk has more LCFA compares to cow’s milk
what other CHO is contained in human milk
oligosaccharides
growth factors for intestinal microflora (B. bifidum, etc)
may alter cellular bacterial adhesion to intestinal epithelial cells.
What pass placenta by simple diffusion?
O2, CO2,
lipid
fat soluable multivitamin
Na, Cl
H2O
most medications
What pass placenta by facilitated diffusion?
Glucose
Cephalexin
What pass placenta by active transport ?
Amino Acids
Ca, Phos, Mg,
Fe, Iodine
H2O soluble Vitamin
What pass placenta by Pinocytosis/endocytosis
IgG
some other proteins
What pass placenta by Bulk flow
H2O, dissolved electrolytes
? importance
Other components of human milk are
- Hormones (cortisol, epidermal GF)
- Colostrum
- Lmphocytes, macrophages, IgA,
- limited cholesterol, phospholipids, lots of TG
- enzyme (bile salt-dependent lipase)
- cholesterol (precursor of bile salts and steroid hormones)
- carnitine
Comparing to cow’s milk, mature human milk is low in what electrolytes/other?
is high in what?
Low in Na, Ca, K, Cl, Mg, Phos.
low in protein
Human milk is high in Fe, Lactalbumin, Whey protein.
Colostrum is in higher protein than mature BM.
two major forms of iron
functional vs. stored
Functional: heme iron (hemoglobin and myoglobin)
Stored: ferritin and hemosiderin –> can mobilize when iron intake is low.
Four factors determine Fe requirement
- expansion of RBC mass with growth
- ^ in tissue Fe for enzymatic process
- expansion of Fe storage pool (not until 7-18 m PMA)
- Compensation of Fe losses in stool
% of Fe absorption from human milk
50%
(perterm infant 33%)
content of Fe in human milk = same as non-Fe-fortified formula.
But human milk Fe much better absorbed.
Vitamin K deficiency
Hemorrhagic disease of newborn.
Vitamin A deficiency
Vitamin A’s other name
Retinol
BPD, abnormal epiphyseal formation and tooth enamel
photophobia and conjunctivitis
generalized scaling
Vitamin B1 deficiency
(also B1’s other name)
Thiamine
Assoc w/ Pyruvate Dehydrogenase complex deficiency, MSUD, beriberi (fatigue, irritablity, constipation, cardiac failure)
Vitamin B2 deficiency
(B2’s other name)
Riboflavin
FTT, dermatitis, mucositis, photophobia, blurred vision
Assoc w/ Glutaric aciduria Type I
Vitamin B6 deficiency
(B6’s other name)
Pyridoxine
Dermatitis, mucositis, seizures; hypochromic anemia
Assoc w/ homocysteinuria
Vitamin C deficiency
(C’s other name)
Ascorbic acid
Poor wound healing,
Assoc w/ transient tyrosinemia
Vitamin D deficiency
Osteopenia/rickets, FTT, tetany
Biotin Deficiency
Dermatitis, scaling, dermatitis, seborrhea
Assoc w/
biotinidase def.,
propionic acidemia,
pyruvate dehydrogenase complex def.,
B-methylcrotonyl glycinuria
Vitamin B12 and Folic acid (folate) deficiency
(B12 is aka)
B12 = Cobalamin
- Folate deficiency in infant fed goat’s milk or evaporated milk
- B12 deficiency in breast fed infants of vegetarian mother who don’t ingest egg or diary.
megaloblastic macrocytic anemia
Assoc w/ methylmalonic acidemia & homocystinuria
co-exist with iron deficiency
Vitamin E deficiency
(E is aka)
Alpha-tocopherol
Vitamin E is an anti-oxidant, given with iron administration to prevent iron-induced hemolysis
increased sensitivity of RBC to H2O2 and hemolysis
anemia, reticulocytosis, thrombocytosis, acanthocytosis
neurological deficits
Chromium
insulin metabolism.
(remove from TPN if poor renal fxn, but keep if TPN cholestasis)
Copper
RBC production and Hb formation.
in deficiency:
anemia, neutropenia, osteoporosis
Depigmentation of hair and skin
poor weight gain, hypotonia, ataxia later in life
Manganese
enzyme activation, important for normal bone structure. CHO metabolism.
clinical effect of deficiency is unknown.
Selenium
cofactor in glutathione peroxidase (rbc membrane stabilization versus oxidative stress)
in deficiency: cardiomyopathy
Zinc
enzyme component, important for growth
Deficient in acrodermatitis enteropathica (AR).
Deficiency causes FTT, alopecia, diarrhea, perianal dermatitis, nail hypoplasia.
Preterm with poor wt. gain, malabsorption, poor wound healing.
Maternal deficiency can cause IUGR/anomalies or preterm infant receiving inadequate zinc.
Schwartz equation
= k x Height (cm) / Serum Cr = GFR (ml/min/1.73 m2)
Term k=0.45
Preterm k=0.33
Plasma Osmolality
2 [Na] + [Glucose] / 18 + [ BUN ] / 2.8
Creatinine clearance
Urine Cr x V (ml/min) / Plasma Cr
Tubular reabsorption of phosphorus (TRP)
1 - [(Urine Ph x Plasma Cr) / (Urine Cr x Plasma Ph)] x 100
colostrum is high
high in protein, whey protein, fat,
Also high in (but less critical/tested)
lactalbumin
Na, K, Cl.
Fe (not too much)
low in Ca (slightly)
Na deficit calculation
0.6 x wt (kg) x (desired Na - current Na)
Free water deficient calculation
4ml/kg x weight (kg) x (Na now - desire Na)
