Nutrition & GI CPS SN Flashcards
Why are oral rehydration solutions preferred over oral rehydration powders?
Powders are more convenient to store, less expensive and have longer shelf life BUT there is a possibility for error of mixing and can get bad concentration of lytes
A parent asks if they can give juice or water to their child who has acute gastroenteritis. What do you say?
- Fluids containing nonphysiological concentrations of glucose and lytes (carbonated drinks, sweetened fruit juices) are not good because they have:
- high carb content,
- low lytes content and
- high osmolality and can produce osmotic diarrhea - -secondly, do not give plain water to children with acute gastro because water can lead to hyponatremia and hypoglycemia
How effective is ORT compared to IV fluid therapy for moderately dehydrated children?
- ORT is as effective, if not BETTER, than IV fluid therapy (as shown by meta-analyses)
- also less traumatic for child, cheaper, easier to administer and can be done at home
What are the contraindications to ORT? (5)
- Protacted vomiting
- Severe dehydration with hypovolemic shock
- Illnesses:
a. Impaired consciousness
b. Paralytic ileus
c. Monosaccharide malabsorption
How early should you refeed a child with acute gastroenteritis?
What are the benefits of early refeeding?
What fluid should you refeed child with?
- Should refeed with an age appropriate diet as soon as child is rehydrated!
- Benefits of early refeeding?
- early refeeding induces digestive enzymes,
- improves absorption of nutrients,
- enhances enterocyte regeneration,
- reduces diarrhea duration, maintains growth, etc.- - Do NOT need to dilute formula or give lactose free formula for nonbreastfed infants
What is the treatment of choice in children with mild or moderate dehydration secondary to acute gastroenteritis?
ORT!
What is the Rome III criteria for infantile colic?
Must include ALL of the following in an infant
A mother of an infant with colic asks you: “Should I start a hypoallergenic diet to improve my baby’s colic?”
How do you respond?
The evidence is conflicting on whether a hypoallergenic diet reduces colic or not
-maternal consumption of hypoallergenic diet may reduce colic in a small number of infants
A mother of an infant with colic asks you: “Should I feed my baby a hypoallergenic formula to improve colic?” How do you respond?
Extensively hydrolyzed protein formulas may reduce colic in a small number of bottle-fed infants
A mother of an infant with CMPA asks you: “Can I feed my baby this partially hydrolyzed formula? It’s cheaper!” How do you respond?
NO - partially hydrolyzed formulas are not hypoallergenic
A mother of an infant with colic asks you: “Should I feed my baby soy formula to improve colic?” How do you respond?
Soy formulas may reduce the symptoms of colic in some bottle-fed infants BUT this is not routinely recommended since soy protein is a frequent allergen in infancy
-AAP stated that routine use of soy formulas has no proven value in colic treatment
Is lactase useful in managing infantile colic?
-what about probiotics?
NO.
All evidence points to NO since congenital lactase deficiency is very rare
-insufficient evidence to recommend for or against the use of probiotics or prebiotics for colic
What is the overall recommendation on the effectiveness of dietary modifications in treatment of colic?
-what about in babies with severe colic?
Dietary modifications may reduce colic in only a very small minority of infants: evidence is conflicting and most studies were unblinded, small sample sizes and had inadequate outcome measures
***Overall, we should avoid making nutritional interventions in vast majority of infants with colic-in severe colic, if there is a possible history of CMPA, can try an empiric 2 wk therapeutic trial of a hypoallergenic diet (maternal elimination of cow’s milk from diet OR extensively hydrolyzed formula). If no benefit, then dietary restrictions should be lifted
What are the benefits of breastfeeding?
- for baby? (4)
- for mama? (4)
Baby:
- Decreased risk of infections: decreased bacterial meningitis, bacteremia, diarrhea, URTI, otitis media, UTI = for each additional month of exclusive BFing, have hospital admission reduction by 30% for infections in first year of life
- Decreased risk of SIDS (shown to be a link only, difficult to control for confounding factors such as sleeping position and smoking)
- Enhanced performance on neurocognitive testing
- Maternal-baby bonding
For Mama:
- Decrease in incidence of breast and ovarian cancer
- Delay in return of ovulation
- Greater postpartum weight loss
- Economical for family and society
What are the 10 steps to successful breastfeeding as promoted in the Baby Friendly Initiative?
- Have written breastfeeding policy that is communicated to all the health care workers
- Train all health care staff in skills necessary to implement breastfeeding policy
- Inform all pregnant women of benefits of breastfeeding
- Help moms initiate breastfeeding within half hour of birth
- Practice rooming in where mom and baby stay in same room at all times to encourageBFing
- Show moms how to BF and maintain lactation even when separated from their infants
- Only give newborns breastmilk (no formula)
- Encourage breastfeeding on demand
- Give no artificial teat or pacifier
- Foster establishment of breastfeeding support groups and refer moms to them at hospital discharge
What are the absolute contraindications to breastfeeding?-4relative contraindication? 1
Absolute contraindications:
- HIV positive moms
- Galactosemia positive baby
- Moms receiving chemotherapy
- moms receiving radiation therapy
Relative contraindication:
- Phenylketonuria: current practice is to breastfeed as a supplement to low phenylalanine formula, along with strict monitoring of phenylalanine levels
What is the Baby-Friendly Initiative?
Evidence-based global program that protects, promotes and supports breastfeeding globally = has 10 steps that hospitals must adhere to in order to get the certification of being a “Baby Friendly” facility-shown to increase the initiation, duration and exclusivity of breastfeeding
What are the benefits of donor human breast milk for the premature infant? (5)
- Decreased NEC
- Decreased infections
- Decreased colonization by pathogenic organisms
- Decreased length of stay
- Improved neurodevelopmental outcome
***Remember that it’s hard to control for other factors that may lead to poor outcomes
What is the screening process for donors of human breast milk?
- Interview
- Serological screening: Hep B, C, HIV, Human T cell leukemia virus
- Physician consent-cannot be taking any medications, must be non smokers and non drinkers
How does the proecess of pasteurization change donor human breast milk?
- Inactivates all bacterial and viral contaminants-bacillus spores are known to survive routine pastuerization but this is a very rare contaminant of human breast milk (more common in cow’s milk)
- Denatures 13% of protein content but carbs, fats, salts are unchanged
- All beneficial immune cells are inactivated BUT
- IgA stays intact!
- IgG is reduced
- IgM is completely removed
In what population of neonates should donor breast milk be considered? (2)
- Premature babies (CPS doesn’t say cut off for GA)
- Babies requiring GI surgery
How long should corrected age be used for in premature infants when plotting them on a growth curve?
Should use corrected age until 2-3 yo (24-36 months)
At what age should we start using BMI for assessing growth?
2 yo and older
What is the definition of the following on a WHO growth curve:–overweight (birth-2 yo, 2-5 yo, 5-19 yo)
- obesity (birth - 2 yo, 2-5 yo, 5-19 yo)
- severe obesity: (birth-2 yo, 2-5 yo, 5-19 yo)
-
Overweight:
- 2 yo-5 yo: weight for age 97th%
BMI for age > 97th%
-5-19 yo: BMI for age > 85th%8.
Obesity:
- birth - 2 yo: weight for length > 99.9th%
- 2 yo-5 yo: BMI > 99.9th%
- 5 yo-19 yo: BMI > 97th%9.
Severe obesity:
- birth - 2 yo: N/A
- 2 yo - 5 yo: N/A
- 5 yo - 19 yo: BMI > 99.9th%
****Overall, weight for age is not recommended over 10 years of age
What are trans fats?
- why are they bad?-
- what are the components of a triglyceride molecule?
- Products of partial hydrogenation of unsaturated fat to extend shelf life-trans fats increase low density lipoprotein cholesterol and decrease high density lipoprotein cholesterol thus
- increasing risk of cardiovascular disease
- triglyceride molecule: glycerol backbone with 3 fatty acids attached
What is the chemical composition of:
- saturated fats
- unsaturated fats
Saturated fats: no double bonds between carbon atoms. Each carbon atom has 4 other atoms attached to it
-unsaturated fats: contain one or more double bonds between two atoms of carbon.
Come in cis form and trans form = TRANS FAT ARE UNSATURATED FATS WITH TRANS DOUBLE BONDS INSTEAD OF CIS BONDS
Is there a safe level of dietary trans fats?
-largest dietary source of trans fats?
NO!
Trans fats increase the risk of cardiovascular disease and offer NO benefit at all to human health! BAD BAD BAD-they do occur in small amounts in certain foods like dairy, meat, breast milk (depending on mothers’ dietary intake of trans fats) but
-largest dietary source of trans fats is processed foods
What is required for a food to be labelled “trans fat free”?
Food item must contain less than 0.2 g of trans fat per reference amount and per serving and must be low in saturated fat
In the neurologically impaired population, what improvements have been associated with nutritional rehabilitation? (6)
- Improved overall health
- Improved peripheral circulation
- Healing of decubitus ulcers
- Decreased spasticity
- Decreased irribility
- Improved GER
What are predictors of poor nutritional status in neurologicallly impaired children? (2)
- Spastic quadriplegia
- Presence of oromotor dysfunction
What are the nutritional causes of malnutrition in neurologically impaired children? (4)
- Increased losses:-GERD in CP = vomiting and regurgitation-reflux esophagitis may lead to food refusal due to GERD
- Decreased intake:-often rely on caregivers for feeding (caregivers overestimate the caloric intake of the child)-if able to feed independently, may lack hand mouth coordination and spill an excessive amount of food or have inadequate amount of time to eat as per school schedule-may not be able to communicate hunger or satiety to care giver
- Altered metabolism-children with increased muscle tone or with athetoid forms of CP may require an increased amount of calories-children with mild to moderate diplegic or hemiplegic CP who can ambulate often need more calories to do daily activities
- Oromotor dysfunction-up to 90% of pts with CP-poor suck/choking/coughing with feeds
What are important questions to ask on a nutritional history for a neurologically impaired child? (7)
- Does the child self-feed or depend on caregiver for feeds?
- Type and amount of food eaten
- How long is a typical meal?
- If self feeds, how much food is spilled?
- Any signs of oromotor dysfunction? -drooling, choking, coughing, delayed swallowing
- How much stress is associated with meals?
- What is the quality of the interaction between the caregiver, the child and the family at mealtimes?
What questions are important on medical history in evaluating nutrition in a neurologically impaired child? (6)
- GERD symptoms (emesis, regurgitation, pain, food refusal)
- Chronic respiratory problems/recurrent pneumonia/respiratory symptoms suggestive of chronic aspirations-progressive fatigue towards end of meal may be suggestive of desaturation
- Medications: anticonvulsants for ex can decrease appetite and impair growth
- Recurrent infections?
- Decubitus ulcers? = sign of malnutrition
- Constipation?
On a physical examination, you would like to assess growth of a child with CP but the child is unable to stand and has significant scoliosis.
What are 4 ways to measure growth in this child?
- Triceps skinfold thickness
- Mid-arm circumference
- Lower leg length
- Upper arm length= very helpful in assessing nutritional status and may even be more accurate than weight-for-height to detect malnutrition
What investigations may be appropriate in a neurologically impaired child who is FTT?
- CBC = look for iron deficiency
- Electrolytes and extended lytes
- Albumin: may reflect nutritional status but is not super reliable
- R/O suspected oromotor dysfunction: -swallowing study with different food textures-UGI study to r/o anatomical abnormalities (ie. SMA syndrome)
- R/O GERD:-based on clinical history or 24 hr pH probe
In a neurologically impaired patient with known history of aspiration, what two conditions are important to rule out?
- GERD = is the patient aspirating gastric contents?
- Oromotor dysfunction = is the patient unable to swallow properly and is thus aspirating saliva/food?
What factors lead to increased risk of osteopenia and osteoporosis in neurologically impaired children? (4)
- Reduced ambulation and weight bearing activity
- Malnutrition
- Limited sun exposure
- Use of anticonvulsant medication = alters vitamin D metabolism
What are the 3 methods of calculating energy needs of neurologically impaired patients?
- Krick method:-kcal/day = (basal metabolic rate x muscle tone factor x activity factor) + growth factor-growth factor = 5 kcal/g of desired weight gain
- Height based method (depends on whether they have motor dysfunction or not)
- REE based method: 1.1 x measured resting energy expenditure
What are complications of long term NG tube use for feeding in neurologically impaired children? (4)
-how long should NG feeds be used for in terms of nutritional support?
- Sinusitis
- Congestion
- Otitis
- Skin irritation
- should not be used for > 3 months-if needing > 3 months, consider G tube (gastrostomy)
A neurologically impaired patient presents to you with FTT and recurrent aspiration pneumonia. It is unclear from investigations whether the aspiration is secondary to GERD or swallowing dysfunction.
What is your next step in management?
- Insert NG tube and attempt trial of NG feeds for one month to assess tolerance
- if aspiration improves or resolves, then it was caused by swallowing dysfunction
= for this patient, recommend G tube only-if aspiration stays the same, then it was caused by GERD = for this patient, recommend G tube AND fundoscopy (fundoplication)
What is a common medical complication of gastrostomy for placement of G tube?
-treatment?
Development of GERD
- treatment: may require prokinetics, change in formula/rate/volume of feeds
- if nothing works, may need fundoscopy (fundoplication)
What enteral formulas should be used in the following:-patients 1 yo
-Patients 1 yo: pediatric 1 kcal/ml formula
***Avoid adult formulas since the calorie-to-nutrient ratio is inadequate for children (may get Ca, PO4, vitamin deficiency)
What is the ideal weight-for-height percentile for the following:-neurologically impaired children 3 yo with normal activity level-neurologically impaired children who are wheelchair bound but able to accomplish transfers-neurologically impaired children who are bedridden
neurologically impaired children 3 yo with:
- normal activity level: 50th %
- wheelchair bound but can do transfers: 25th %
- bedridden: 10th %
What are 2 indications for enteral tube feedings in neurologically impaired children?
- Oromotor dysfunction leading to clinically significant aspiration
- Inadequate oral intake leading to FTT
What are clinical features of dental fluorosis?
-cause?
Dental fluorosis:-caused by abnormal enamel development from too much fluoride exposure
-usually occurs in children
