Pediatric Nutrition Support Flashcards
1
Q
Premature
A
<37 weeks gestation
2
Q
When do you start PN for premature infant?
A
Started on day of birth
- <1800 g or 33 weeks or less
- used as supplement to enteral feedings during transition to complete enteral feedings
3
Q
Types of parenteral nutrition
A
- starter or vanilla
- custom
- protein solution
4
Q
Starter or vanilla TPN
A
- used in premature infants until custom TPN can be made
- dextrose and protein only
- may add calcium
5
Q
Custom TPN
A
- customized concentrations of dextrose, protein, electrolytes
- contains vitamins and minerals
- intralipids started at this time
6
Q
protein solution (PN)
A
- contain protein only
- used to keep lines open
7
Q
When are fluids initiated in a premature infant?
A
1st day of life
8
Q
What line does the starter TPN go into in pediatric?
A
UVC (umbilical venous catheter)
9
Q
What line dose the protein solution go into in pediatric?
A
UAC (umbilical arterial catcher)
10
Q
Fluid needs for preemie on day 1 of life
A
80 mL/kg/day
11
Q
Fluid needs on 2nd day of life
A
100 mL/kg/day
12
Q
Fluid needs on 3rd day of life
A
120 mL/kg/day
13
Q
Fluid needs on 4th day of life
A
140 mL/kg/day
14
Q
Fluid needs on 5th day of life
A
140 - 160 mL/kg/day
15
Q
What are parenteral fluids used for in pediatrics?
A
- maintain hydration
- help stabilize electrolytes
- maintain appropriate glucose level
- aid in A/B balance
- provide adequate nutrition for proper growth and development
16
Q
What component of PN is carbohydrates?
A
Dextrose
17
Q
What is the CHO rate in PN?
A
Initiate @ 4-6 mg/kg/min and increase by 2-3 mg/kg/min daily
GOAL: 8-12 mg/kg/min
(Needed to maintain cals.)
18
Q
What are the parenteral calorie requirements for a neonate?
A
90-110 kcal/kg/day
19
Q
What is the goal protein level for a neonate?
A
4 gm/kg/day
- Blend of AAs (trophamine)
- Add L-cysteine for neonates
- Always start at goal
20
Q
What is the goal lipid level for a neonate?
A
Initiate @ 1-2 gm/kg/day toward goal of ~3 gm/kg/day
- No less than 0.5 g/kg/day to prevent EFA deficiency
- Add L-carnitine
- Monitor TG level if hyperglycemic
21
Q
What are PN additives?
A
- Daily vitamin/minetals
- Adjust Na, K, Mg prn
- Acetate/Chloride for Acid:Base
* 4. Goal to Max. Ca and P content for bone mineralization*
22
Q
What is the most optimal source of of nutrition in a premature infant?
A
ENTERAL
-initiate as soon as stable @ 30 mL/kg/day and increase as tolerated
23
Q
What are the goals of pediatric nutrition support?
A
- Provide appropriate nutrition for growth
- Preserve existing tissue stores
- Provide catch-up growth for malnourished patients and rehab of nutritionally depleted patients
- Preserve oral motor skills
24
Q
What are the steps taken before PN in pediatrics?
A
- Oral intake
- Supplements (formulas0
- Modulars (add CHO, proteins, fats)
- Tube feedings
- PN
25
What are indications for TF in pediatrics?
1. Neure/NM disorders with impaired swallowing/oral motor skills
2. Congenital anomalies
3. Increased metabolic needs
4. Altered absorption/metabolism
5. Growth failure
26
Why is EN better than PN?
1. More physiologic
2. Maintains GI integrity
3. Decreased potential for bacterial translocation
4. Decreased hepatobilliary complications
5. Less expensive
6. Fewer technical/infectious complications
27
What are contraindications of TF?
1. Severe shock state
2. Severe peritonitis
3. Non-functional gut-ischemia, anatomic disruption, post-surg ileus
4. High output fistula
5. Diarrhea exacerbated by EN
28
What are the different enteral access devices?
1. OG
2. NG (most common <3 mo)
3. NJ
4. Gastrostomy/PEG (>3 mo)
5. GJ
6. Surgical jejunostomy/PEJ
29
What are the different formulas available for selection?
1. Polymeric--Pediasure
2. Semi-elemental--Peptamen Jr
3. Elemental--Elecare Jr
4. Blenderized TF
5. Specialized metabolic formulas (PKU, etc.)
30
What are complications associated with TF?
1. Mechanical: placement, clogging, leakage
2. GI: N/V/D, distention, aspiration, emptying, constipation
3. Impaired oral/motor skills
4. Psychosocial
31
When do you start PN in child?
1. Preterm infant: DOL 1
2. Term infant: 1-3 days
3. Children/Ado: 4-5 days
4. Mal.Nut. Child: 2-3 days
32
What is TPN?
1. Long term nutrition support via central line to provide 100% of nut needs
2. Central venous catheter must be placed with distal tip in the superior vena cava
33
What are the components of TPN compared to a normal diet?
```
Protein: Crystalline AA
CHO: Dextrose
Fat: Lipid emulsion
Vitamins: MV infusion
Minerals: E'lytes & Trace
```
34
What is PPN?
1. Dextrose, AA, lipids, vitamins, m/e'lytes
2. Osm = 900 mOsm/L
3. Maximum dextrose concentration: 12.5% = thrombophlebitis
4. Difficult to meet all needs
35
What indicates the need for PPN?
1. Patient expected to be NPO for 5-7 days
2. Transitioning to oral diet or tube feeding
3. Oral intake not meeting needs
36
Indications for TPN?
Severe mal. nut., severe malabs./intestinal failure, IBS, fistula, obstruction, ileum, GI bleeding, intolerant to EN feedings, motility disorders
-Expected to need for at least SEVEN days
37
What are contraindications for PN?
1. Functioning GI tract
2. Unstable fluid and e'lyte status
3. Poor patient prognosis
4. Nutrition objectives cannot be met
38
What are complications related to PN?
1. Catheter related sepsis
2. Hyperglycemia & compromised immune function
3. Bacterial translocation
4. IFLAD
5. Impaired oral-motor skills
6. Psychosocial
39
What are fluid requirements?
Includes from all IV lines
1-10 kg = 100 mL/kg
> 10 = 1000 mL + 50 mL/kg
> 20 = 1500 mL + 20 mL/kg
40
When do you need to increase fluids?
fever, GI losses, insensible losses (burns, increased RR)
41
When do you need to decrease fluids?
cardiac disease, head trauma, renal insufficiency
42
When do you need to increase requirements for a neonate?
fever, catch-up growth, trauma, recent surgery, burns, hypotonia
-Actual numbers in notes-
43
When do you need to decrease requirements for a neonate?
immobility, mechanical ventilation, medical sedation/paralysis
-Actual numbers in notes-
44
What are the carbohydrate requirements of a TPN in pediatrics?
Infants: begin with 50-75 gm/day and increase by 50 gm/day
| Children/Ado: begin with 100 gm/day and increase by 50-100 gm/day
45
What are consequences of overfeeding?
1. Increased CO2 production
2. Hyperglycemia
3. Liver steatosis
46
What are the protein requirements of pediatric TPN?
```
Infants = 2-3 g/kg/day
Children = 1-2 g/kg/day
Ado = 0.8-1.5 g/kg/day
```
47
What do you need to raise the protein requirement to in patients who are in sepsis, premature, burns?
3.5 g/kg/day
48
What do you need to decrease protein requirements to in patients with renal/liver failure?
0.5 g/kg/day, but most give essential AAs to prevent breakdown of lean body mass
49
What are different Amino Acid formulations?
1. Travasol (>2, w/o liver disease
2. Trophamine/Premasol (infants, similar to BM, lower pH for higher Ca and P)
3. Novamine/Clinisol (fluid constriction)
50
What is SMOF?
soybean oil, MCT oil, olive oil, fish oil (few inflammatory FA)
51
What can you do to prevent EFA deficiency?
Minimum lipids of 0.5 g/kg/day in infants & 1.5 g/kg twice a week for children/ado
52
What electrolyte modifications need to be made in patients with *UPPER GI LOSSES*?
1. Sodium
2. Chloride
3. Potassium
4. Fluid
5. Magnesium
53
What electrolyte modifications need to be made in patients with *LOWER GI LOSSES*?
1. Acetate/bicarbonate
2. Sodium
3. Fluid
4. Chloride
54
What electrolytes needs to be modified in renal dysfunction?
Increased: acetate/bicarbonate
Decreased: K, P, Mg, Na
55
What is the maximum sum of Ca and P to have in a TPN with out precipitation?
40 mEq/L
| -Bolus Ca may be required
56
What trace elements are added to TPN?
1. Zinc
2. Chromium
3. Copper
4. Maganese
5. Selenium
6. Iron
57
What is the importance of zinc?
1. deficiency may cause alopecia, dermatitis, immune deficiencies
2. increased needs with growth, GI losses, wound healing
58
What is the importance of chromium?
plays role in glucose and lipid metabolism
59
What is the importance of copper?
deficiency results in anemia, skin, and hair depigmentation
60
What is the importance of manganese?
1. Toxicity- accretion in basal ganglia
| 2. Long-term PN--remove if conjugates bili >2.0
61
What is the importance of selenium?
deficiency can be fatal, symptoms can include depigmentation of hair, skin, and nails, and cardiomyopathy
62
What is the importance of iron?
- Deficiency is common in long term PN patients w/o transfusions
- Venofer (monthly infusion)
63
What issues does the pharmacy need to be aware of in patients on TPN?
1. Multiple drug therapy (line access, compatibility)
2. Calcium and Phosphorous solubility
3. Electrolyte and mineral content
4. IV antibiotics/fluids
64
What interactions do loop diuretics have with nutrients?
hyponatremia, hypokalemia, hypocalcemia, metabolic alkalosis
65
What interactions do H2-antagonists have with nutrients?
hyponatremia
66
What interactions do corticosteroids have with nutrients?
hypokalemia, hypocalcemia, hypophosphatemia, metabolic alkalosis
67
What interactions does ampB have with nutrients?
hypokalemia, hypomagnesemia, metabolic acidosis
68
What interactions do aminoglycosides have with nutrients?
metabolic acidosis
