nutrition/fluids Flashcards
What is the other name for vitamin E?
Tocopherol
What is another name for vitamin A?
retinol
What is the other name for vitamin K?
Phylloquinone
What is the other name for vitamin b1?
Thiamine
What is the other name for vitamin B2?
Riboflavin
What is the other name for vitamin B3?
Niacin
What is pantothenic acid?
Vitamin B5
What is pyridoxine ?
Vitamin B6
What is the vitamin name for folate?
Vitamin B9
What is another name for vitamin B12?
Cyanocobalamin
What is the formal name for vitamin C?
Ascorbic acid
What can intoxication of vitamin A cause?
Pseudo tumor cerebri
What is the most common cause of blindness in young children worldwide?
Vitamin A deficiency
What can retinol deficiency cause?
Xerophthalmia (dry eyes)
Nyctalopia (night blindness)
Complete blindness
What is the cause of beri beri?
B1 deficiency
What are the symptoms of beri beri?
Mental confusion Peripheral paralysis Muscle weakness Tachycardia Cardiomegaly
Who is at risk for riboflavin deficiency?
Premies on phototherapy
What are the 3 typically symptoms of vitamin B2 deficiency?
Anemia, angular stomatitis, seborrheic dermatitis
What can occur with niacin toxicity?
Vasodilation
What are the symptoms of vitamin B3 deficiency?
Dermatitis, diarrhea and dementia = pellagra
What symptom is associated with vitamin b6 toxicity?
Neuropathy
What are symptoms of vitamins b6 deficiency?
Swelling if tongue and rash
What are symptoms of vitamin b9 deficiency?
Larger tongue and macrocytic anemia
What is one symptom of vitamin B9 toxicity?
Irritability
What are symptoms of vitamin b12 deficiency ?
Macrocytic anemia
What symptoms occur with vitamin c deficiency?
Leg tenderness
Poor wound healing
Bleeding gums
What type of crisis can be triggered by calcium toxicity?
Hemolytic crisis in a patient with G6PD deficiency
What are symptoms of vitamin E deficiency in premies?
Hemolytic anemia
What are symptoms of vitamin E deficiency?
Neuropathy
Muscle weakness
Peripheral edema
Thromocytosis
What are the vitamin K dependent factors?
2,7,9 and 10
What increases risk of hemorrhagic disease in a newborn?
Vitamin k not given
Breast feeding
What treatment is appropriate in a patient with hemorrhagic disease of the newborn if bleeding actively?
Vitamin K + FFP
What is the physiological effect of vitamin D toxicity?
Mobilization of calcium and phosphorus from bones and deposition into soft tissue
How is vitamin d toxicity managed?
Hydration
Corrections of Na and K depletion
LASIX
What metabolic disturbances occur Due to excessive vitamin D?
Hypercalcemia
Hyperphosphatemia
What are some symptoms of vitamin D toxicity?
Polyuria Poly displays Elevated BUN Kidney stones Renal failure
What is the other name for ergocalciferol?
Vitamin D2
What is the other name for cholecalciferol ?
Vitamin D3
What is the other name for activated calcitriol?
1,25 hydroxycalciferol
What are the lab findings used to diagnose rickets?
Low 25OH vitamin D
High PTH
Alkaline phosphatase elevated
Calcium and phosphorus may be normal
What are the findings in the physical exam of the head in a patient with rickets?
Craniotabes (delayed fontanel closure, skull thickening, frontal bossing, poor tooth enamel)
What occurs in the extremities secondary to rickets?
Wide physes of wrists and ankles
Femoral / tibial bowing
What occurs on the trunk in patients with rickets?
Pigeon chest, rachitic rosary
Other than lack of adequate sunlight, what could cause rickets?
Chronic liver disease causes decreased vitamin D absorption due to low bile salts
What is caused from zinc deficiency?
Acrodermatitis enteropathica
What is caused by copper deficiency?
Menkes kinky hair
Where is 25-OH vitamin D hydroxylated?
Liver
Where is 1,25 OH vitamin D hydroxylated?
Kidneys
How many kcal are required for a preterm and full term infant per day?
Both require 100-120kcal/kg/day
What is the appropriate protein requirement for a premature infant and term infant ?
3,5 g/kg per day (preterm)
2.5 g/kg per day (term)
What are 4 important components of renal solute load?
Sodium, potassium, chloride and phosphorus
What is an essential fatty acid?
Linoleic acid
What is the recommended concentration of iron in iron fortified formula?
12mg/L
When should iron supplementation occur?
4-6 months old
Also before 6 months in high risk (LBW, preterm)
What should you do for a child on iron supplements who develops constipation?
Add fruit juice to increase osmotic load - iron does NOT cause constipation
What is the definition of milk protein allergy?
IgE mediated response that can cause rash, vomiting and irritability
What is milk intolerance?
Non igE mediated response to milk to can cause rash or vomiting
What is the difference between lactose intolerance and milk protein allergy?
Lactose intolerance does not cause rash or vomiting
What is Fpies?
Food protein induced enterocolitis syndrome / non igE mediated protein intolerance
How does FPIES present?
Within first 3 months with heme positive stools
What is the treatment for FPIES?
Switch to protein hydrosylate formula or eliminate milk protein from mothers diet
What symptoms may be seen with deficiency of essential fatty acids?
Scaly dermatitis, alopecia and thrombocytopenia
How do you treat fatty acid deficiency?
IV lipids
What should you consider in an infant recently weaned from breast milk with facial dermatitis and thin hair?
Zinc deficiency
What might be the diagnosis in an infant with dry skin, poor wound healing perioral rash?
Zinc deficiency
How do newborns absorb fat?
They have decreased bile acids and can not absorb long chain triglycerides
In terms of total triglycerides, what is the difference between premie formula and breast milk?
Premie formula has 50% medium chain triglycerides and breast milk has 12% plus high linolenic acid
How does TPN affect bone demineralization ? What labs would be abnormal?
Inadequate phosphorus due to prolonged TPN >1 month (May have normal calcium and phosphorus levels but high alkaline phosphatase)
What is higher in colostrum than in mature breast milk?
Arachidonic acid DHA Zinc Protein ( immunoglobulins ) Enzymes to increase digestion Carotene
Which type of breast milk is highest in fat?
Hind milk ( end of feeding )
What essential vitamin is low in colostrum? Why is this important ?
Ergocalciferol ( increases risk for rickets)
What can happen to an infant placed on cows milk prior to age one? Why?
Hypocalcemia - cows milk has significantly high phosphorus which leads to low calcium
What 6 drugs are contraindications to breast feeding?
Metronidazole Diazepam Thyroid meds Chemotherapy Sulfonamides Tetracycline
What 4 medical conditions would be contraindicated for breast feeding?
Tb
Cmv
HIV
Errors of metabolism (in baby)
What are 4 conditions that ARE NOT contraindications to breast feeding?
Mastitis
Candidiasis
Contact dermatitis
Fibrocystic breast disease
What is the whey to casein ratio in breast vs cows milk?
Breast: 70% whey, 30% casein
Cows milk: 20% whey, 80% casein
What is the difference between iron I’m breast milk vs formula?
Breast milk is lower in iron but has higher absorption
What is the difference between protein concentration in breast milk vs formula ?
- 9 g in breast milk
- 5 g in cows milk formula
- 4 g in modified formula
What is so special about the whey protein in breast milk?
It has alpha lactalbumin, lactoferrin, lysozyme and IgA
Are vitamins and minerals higher or lower in breast milk when compared to formula?
Minerals
What is the difference in renal solute load in breast milk vs cows formula?
Lower renal solute load in breast milk
How many calories are in one ounce of formula? And how many mL of formula are in one ounce?
20kcal per oz
30 ml per oz
What can happen if you mix too much powder formula with a given amount of water ?
Increased protein stresses the kidneys
What is the max caloric content of formula?
30kcal/oz
What may happen if you add a lipid supplement to formula?
Diarrhea or delayed gastric emptying
Why are non-protein calories important in very low birth weight infants?
To avoid negative nitrogen balance from high proteins
What is the average daily weight gain for a full term newborn?
20-30grams per day
What is the average daily weight of a premie?
15-20 grams per day
What is the term “overweight “ defined as?
BMI between 85-95th %
What are the chances that an obese 6 year old will be obese as an adult?
25% chance
What is the difference between an obese child secondary to overeating vs a hormonal reason?
If overeating, will usually be tall with advanced bone age
If hormonal problem, will usually be short with delayed bone age
What syndromes should you consider in a child who is obese with small hands, hypogonadism and delayed development?
Prader Willi or Bardet Biedel
What can occur in a child who drinks many diet sodas?
High risk for osteopenia due to high phosphoric acid
What should you beware of in a child taking goats milk?
Folate deficiency
What should breast feeding mothers who are vegan taken as a supplement?
Vitamin B12
What is the term for protein deficiency?
Kwashiorkor
What are physical signs of protein deficiency?
Pitting edema, rash, thin hair, pallor
What term describes general nutritional deficiency?
Marasmus
What are physical signs of marasmus?
Muscle wasting but no edema
Normal hair
What is the most common cause of NG feeds?
Diarrhea
What is the most severe complication of NG feeding?
vomiting and aspiration
How do you supply adequate nutrition in a child with heart failure ?
High caloric density while restricting fluids ( increase formula concentration)
How do you manage nutrition in a child with renal disease?
70% of calories should be carbohydrates. Lipids <20% and protein <2g/kg/day, with low phosphorus
How should you manage a child who presents with vomiting and diarrhea with mild dehydration ?
Oral rehydration and regular diet
Calculation for serum osmolality…
2 x Na + BUN/2.8 + glucose/18
What is the formula to correct acid bicarb for metabolic acidosis?
Weight x 0.3 x base deficit
How can you determine metabolic acidosis vs alkalosis from looking the bicarb ?
Bicarb > 25 = alkalosis
Bicarb < 25 = acidosis
How can you determine respiratory alkalosis vs acidosis by looking at the abg ?
PCO2 > 40 = resp acidosis
PCO2 < 40 = resp alkalosis
What medications can cause metabolic alkalosis?
Loop and thiazides diuretic s
How does the body compensate for metabolic alkalosis?
Hypoventilation
What ph and co2 levels do u expect to see in a patient with incomplete compensation for metabolic acidosis?
Low ph and low co2
What steps should you take to initially treat metabolic acidosis?
Adequate ventilation
Isotonic fluids
Sodium bicarb if severe (ph<7.1)
How does pyloric stenosis cause acid base imbalance?
Vomiting leads to low hydrogen and chloride –> bicarb reabsorption and metabolic alkalosis
What acid base inbalance occurs with hypoxia?
Hyperventilation leads to low co2 and alkalosis –> kidneys excrete bicarb to compensate
What diuretics can cause metabolic acidosis?
Acetal planned and spironolactone
What is the most common cause of non-gap metabolic acidosis in children ?
Diarrhea
What are three main causes on acidosis of normal anion gap?
Loss of bicarb (diarrhea, kidney dysfunction)
Addition of hydrochloric acid
Renal tubular dysfunction
What is the pathophysiology of distal tubular acidosis?
Inability of distal tubule to excrete H+ and acidify the urine –> ph >5.5
What can mimick RTA type 1?
Potassium sparing drugs (spironolactone)
What can mimick RTA type 2?
Carbonic anhydrase inhibitors like acetazolamide
What is the pathophysiology of Proximal RTA?
Inability of proximal tubule to absorb bicarb which leaves high bicarb in urine
Where does reabsorption of bicarb occur?
Proximal tubule
Between RTA type 1 and 2, which is distal and which is proximal?
Type 1 = distal
Type 2 = proximal
Where does secretion of hydrogen occur in the kidneys?
Collecting duct
What causes type 4 RTA?
Aldosterone resistance (deficiency) causing hyperkalemia
What are the conditions associated with elevated anion gap metabolic acidosis ?
MUDPILES = methanol, uremia, dka, paraldehyde, iron/INH, lactic acid, ethanol/ethylene glycol and salicylates
What should you consider in an infant who appears healthy at birth but later develops poor feeding, lethargy and seizures?
Inborn error of metabolism - organic acidemia
What condition causes high ammonia but no metabolic acidosis?
Urea cycle defects
What occurs With volume on a cellular level when there is hypernatremia?
If high sodium, water is dawn out of intracellular compartment into the extra cellular space causing increased volume
In a child with diabetes insipidus, what is the serum and urine osmolality?
High serum osmolality but dilute urine
How is nephrogenic diabetes insipidus transmitted?
X linked - only in males
What is the best study to order in order to determine which type of hyponatremia a patient has?
Fractional excretion of sodium
With diabetes insipidus, do you get high or low sodium?
High sodium
What may occur to sodium if there is excessive GI losses?
Hyponatremia–> Kidneys retain sodium –> low urine sodium (<10)
What is the cause of hyponatremia secondary too increased water retention ?
SIADH
What will the urine in a child with siadh be like?
High osmolality (>300) and high sodium (>25)
What is the first treatment of siadh?
Fluid restriction
What are the serum sodium and potassium levels in a child with siadh?
Low Na, normal K
What are the 5 main causes of SIADH?
Surgery Infection Pulmonary disorder Endocrine disorder Neurological disorder
What are two potential medications for SIADH?
Demeclocycline (only if >8y/o)
Lithium
A
What is the initial step in a hemodynamically unstable child with low urine output?
Isotonic fluid bolus 20/kg
What medication can cause siadh ?
Vincristine
How do diuretics affect sodium?
Thiazides and metolazone both block renal sodium reabsorption causing hyponatremia
What is dilutional hyponatremia? What lab findings are common?
Water intoxication
Sodium is NORMAL
Urine Na is high
How does third spacing occur after extensive surgery?
Endothelial damage / leakage
Hypoalbuminemia and low oncotic pressure
What happens to sodium levels with third spacing?
Low urine sodium (<10)
Edema
Hyponatremia
What is the measures and total body sodium in conditions with edema due to low oncotic pressure (ie. nephrotic syndrome)?
Measured sodium is low BUT total body sodium is actually high
What are some classic symptoms of hypokalemia?
Muscle pain, weakness, paralysis
Constipation, ileus, polyuria
What are the 3 main causes of hypokalemia?
Poor intake
Gi losses
Renal losses
If a child comes to your office with 3 days of vomiting and is weak, what should you consider?
Hypokalemia
What are 4 possible EKG findings secondary to hypokalemia ?
Flattened T waves
ST depression
PVC
U wave
How do you treat hypokalemia in an emergency situation?
KCl 1 mEq/L over an hr (max 40)
If mild hypokalemia and dehydration, what is the appropriate management?
Fluid replacement with added K
If hypokalemia in a child with acidosis, what should you treat with?
Potassium acetate
What electrolyte abnormality causes prolonged QT interval?
Hypocalcemia and hypomagnesemia
What are 4 main causes of hyperkalemia?
Excess intake
Renal failure
Acidosis (redistribution)
Cell breakdown
What is the common EKG finding with hyperkalemia?
Peaked T waves
If K>10…absent p waves, wide QRS
What should you consider in a patient with wide QRS with muffled heart sounds or absence of pulses?
Hyperkalemia (severe)
How do you treat severe hyperkalemia in a patient showing signs of electromagnetic dissociation (distant heart sounds, non palpable pulses)?
Immediate IV calcium chloride
What 5 options can you use to treat mild hyperkalemia?
Glucose + insulin Sodium bicarb Albuterol LASIx Oral polystyrene resin
What happens to potassium during alkalosis?
H+ moves extracellular to compensate but then K+ moves into the cell causing low serum K
What happens to potassium levels during acidosis?
H+ moves into the cell and K+ moves into extra cellular fluid causing high measured K
What two lab findings would you find in a patient using loop diuretics?
Hypokalemia
Alkalosis
What is the equation for FeNa?
Urine Na / serum Na
Divided by
Urine creatinine / plasma creatinine
What is a low FeNa value and what does it indicate?
<1.5
Pre renal azotemia
When is hypertonic 3% saline indicated ?
In severe hyponatremia, after normal saline given with no improvement
What could be the diagnosis in a patient with dehydration that was rehydrated with water?
Hyponatremia dehydration (sodium <135)
What type of electrolyte disturbance can lead to cerebral pontine Damage?
Hyponatremia
Which type of electrolyte disturbance leads to tearing of bridging blood vessels and intracranial hemorrhage?
Hypernatremia which causes fluid shift to the extra cellular space and shrinkage of brain cell
What is the treatment for hypernatremia >170?
Assume 10% dehydration and slowly correct sodium over 48-72 hours at a rate of 0.5mEq/L/hr
What clinical findings would be seen in a patient with hypernatremic dehydration?
Doughy skin, irritable, high pitched cry, seizures
What is the equation for replacing low sodium?
Desired minus measured sodium x kg x 0.6 plus maintenance (3meq/kg/d)
What are the signs associated with 5% dehydration?
Tachycardia
Decreased tears
Decreased urine output
How do you correct 5% dehydration?
50ml/kg + maintenance
Give half over 8 hours and remainder over 16 hours
What are signs of 10% dehydration?
Tachycardia
Sunken eyes
Poor skin turgor
Sunken fontanelle
How do you treat 10% dehydration?
NS bolus then
100cc/kg + maintenance over 24 hours
What is the max you can decrease the sodium level in a 24 hr period? Why?
10-12
To avoid cerebral swelling
What are signs of 15% dehydration?
Shock and delayed cap refill
What is the treatment of 15% dehydration?
NS bolus (repeat until improvement) Over 24 hours give maintenance plus 150ml/kg
When is oral rehydration fluid used? What does this have and how should it be given?
If moderate to severe dehydration
75 mEq/L of sodium
Give 50 ml/kg over 1-4 hours
What is the classic electrolyte disturbance in pyloric stenosis ?
Hypochloremic hypokalemic metabolic alkalosis
What happens to the urine electrolytes with pyloric stenosis?
Kidneys retain chloride causing urine chloride <10
What is the common electrolyte disturbance associated with cystic fibrosis?
Hypochloremic hyponatremic metabolic alkalosis and dehydration
What is important to remember about post-op fluid management ?
Increased risk for increased ADH secretion and over hydration
What is similar and different between SIADH and hyponatremic dehydration?
Both have low sodium and chloride but dehydration gives high BUN
What’s the difference and similarity between diabetes insipidus and hypernatremic dehydration?
Both have high sodium and chloride and BUN.
Hypernatremic dehydration have high specific gravity but diabetes insipidus has low specific gravity
What do you do if lab findings show low sodium <120 and normal chloride ?
Repeat lab (lab error)
