Pediatrics Flashcards
What are the 4 unusual patterns of growth?
- Plateauing: child has stopped growing; usually a sign of chronic malnutrition
- Sharp decline: weight loss; usually an acute malnutrition: insult; trauma, new diagnosis, stopped eating etc.
- Falling off 50th %ile: Still growing but at a slower velocity than normal
- Incline in BMI: making an obese/overweight child; probably need to adjust intervention
What is failure to thrive?
o Weight (or weight for height) is less than 2 SDs below the mean for sex and age o Weight curve has crossed more than 2 percentile lines after having previously achieved stable growth
What are the possible causes of FTT?
Infant Characteristics - Chronic medical conditions (e.g. Inadequate intake (swallowing dysfunction, anorexia, etc.), Increased metabolic rate (Bronchopulmonary dysplasia, congenital heart disease, fevers, etc.), Breathing, heart beat is so difficult that they need more energy to do it, Malabsorption (CF, short gut, IBD, celiac disease)) --> Usually children grow well within first few months, and suddenly start to fall off the curve - Premature birth or IUGR - Developmental delay - Congenital abnormalities - Intrauterine toxin exposure Family characteristics - Poverty - Unusual health and nutritional beliefs - Social isolation - Disordered feeding technique - Substance abuse - Violence or abuse
What is short stature? How can we determine which child will probably have short stature?
Familial/genetic
Growth is parallel to the normal centile, usually below the 5th percentile
Final adult stature is short; does not change if child is fed more.
Use mid-parental height equation to get an estimation of the height of the child around 18-19 years old
What are the calculations for mid-parental height?
Girls: ((father’ s height-13 cm)+(mother’ s height))/2
Boys: ((mother^’ s height+13 cm)+(father’s height))/2
What is constitutional growth delay?
Child might be growing at the lower end for height and weight, but their mid-parental height is higher.
Some children will not grow as early and have their growth spurt later on: normal
Usually, parents will have had the same kind of pattern of growth when they were young
What is stunting/nutritional dwarfism in regards to growth charts?
Fall in length
– 2 SD below the height for age curves; not necessarily associated with emaciation; short stature or poor growth may be the sole manifestations of nutritional inadequacy
Typical pattern in stunting: Weight starts to fall first, and length is maintained (body will always protect brain growth and linear growth first) - first aspect affected is weight. Can see that malnutrition is a problem if weight falls first. Then, as weight continues to fall, height will start to fall later on.
How much time does it take to correct a stunting?
3x as long as the stunting/malnutrition period
For young children, how often do you monitor weight? length? stature? HC? mid upper arm circumference?
Weight: 7 days Length: 4 weeks Stature: 8 weeks HC: 7 days (infants, 4 weeks up to 2 years of age) Mid-upper arm circumference: 4 weeks
What are normal growth velocity charts based on for normal children? For ICU children?
Normal: Based on age
ICU and IUGR: Based on age and weight-for-age percentile
What defines a baby from 0-2 years old to be underweight?
Weight for age < 3rd %ils
Severely underweight < 0.1 %ile
What defines a baby from 0-2 years old as stunted?
Length for age < 3rd %ile
Severely stunted < 0.1 %ile
What defines a baby from 0-2 years old as wasted?
Weight for length < 3rd %ile
Severely wasted < 0.1 %ile
What defines a baby from 0-2 years old as at risk of being overweight?
Weight for length > 85th %ile
What defines a baby from 0-2 years old as overweight?
Weight for length > 97th %ile
What defines a baby from 0-2 years old as obese?
Weight for length > 99.9th %ile
What defines a child from 2-19 years old as underweight?
Weight for age < 3rd %ile
Severely underweight < 0.1 %ile
What defines a child from 2-19 years old as stunted?
Height for age < 3rd %ile
Severely stunted < 0.1 %ile
What defines a child from 2-19 years old as wasted?
BMI for age < 3rd %ile
Severely wasted < 0.1 %ile
What defines a child from 2-19 years old as obese?
Age 2-5: BMI for age > 99.9th %ile
Age 5-19: BMI for age > 97th %ile
What defines a child from 2-19 years old as severely obese?
Age 2-5: N/A
Age 5-19: BMI for age > 99.9th %ile
What defines a child from 2-19 years old as overweight?
Age 2-5: BMI for age > 97th %ile
Age 5-19: BMI for age > 85th %ile
What do Hgb, Hct, TIBC, and ferritin assess?
Iron, B12 and folate status (anemia)
What do albumin, transferrin and prealbumin assess?
Indicator of visceral protein status (if no inflammation), poor nutrition status, slow growth, edema
What does CRP assess?
Inflammatory marker, increased with infection
What does WBC assess?
Immune system marker, increased with infection
What does sodium assess?
Indicator of hydration and kidney function
What do urea and creat assess?
Indicator of kidney function, hydration, protein catabolism and intake
What do serum Ca and PO4 assess?
Indicator of bone osteopenia, RS
What does serum Mg assess?
Indicator of RS, GI losses
What does direct bilirubin assess?
Indicator of liver function, cholestasis
What do you want to look for in your physical assessment?
– Hair: Dry, flagged, brittle, coarse
o Flag sign: bands of discoloration of hair (reddish, blond, or gray, depending on original color) resulting from fluctuations in nutrition characteristic of kwashiorkor and in diseases with protein depletion such as ulcerative colitis.
– Skin: dry, scaly, slow healing wounds (children can take only 3 days to develop EFAD)
– Mouth: swollen/bleeding gum, decaying teeth
– Muscle mass: lean-emaciated, weak
– Abdomen: visible ribs, bloated stomach
– Subcutaneous fat mass (normal to be a bit chubby)
– Bones: visible temporal bone, bowed legs, stunted
– Fluid retention
– Proportionality HC to length to weight
– Energy level: irritability, lethargy
– Learning ability
What could be the cause of a skin that is pale? dry/scaly? Dermatitis?
Pallor: Iron, folate, B12 deficiency
Dry/scaly: Vit A, EFAD
Dermatitis: EFAD, zinc, niacin, riboflavin, or tryptophan deficiency
What could be the nutritional cause of spoon-shaped nails? nails lacking luster/dull? Mottled, pale, poor blanching?
Spoon shaped: Iron deficiency
Lack luster, dull: Protein deficiency
Mottled, pale, poor blanching: Vit A or C deficiency
What could be the nutritional cause of a moon face? bilateral temporal wasting?
Moon face: PEM
Temporal wasting: PEM
What could be the nutritional cause of an enlarged neck/thyroid?
Iodine deficiency
What could be the nutritional cause of dry/cracked/red lips? Bleeding gums? inflamed mucosa?
Dry/cracked: B2, B3, B6 deficiency
Bleeding gums: Vit C
Inflamed mucosa: Vitamin B complex, iron or Vit C deficiency
What could be the nutritional cause of a magenta-colored tongue? A tongue that is beefy red and diminished taste?
Magenta: B2 deficiency
Beefy red and less taste: B3, B9, iron, B2 and B12 deficiency
What could be the nutritional cause of night blindness, dull, dry sclera and milky cornea of eyes? cracked red corner of eyes?
Dry/night blindness…. : Vit A deficiency
Cracked red corners: B2 or B3 deficiency
What could be the nutritional cause of dull/lackluster, thin, sparse hair? Easily pluckable hair?
dull/thin/lackluster/sparse: Protein, iron, zinc or EFAD
Easily pluckable: Protein deficiency
What could be the nutritional cause of excessive dental caries?
Excessive simple CHO
What could be the cause of a rounded/distended abdomen?
Gas, edema, ascites, obesity
What could be the nutritional importance of an increase temperature?
Increased kcal and fluid requirements
What could be the nutritional importance of an increased RR?
Need more kcals if weaning from ventilator support or less kcal if chronically ventilator dependant
What is the age range for 80% of adolescent growth spurts?
10-15 years old
what is the tanner scale?
(maturation scale; breast development, menstruation, body hair…)
Development points not happening at the right time could be sign of malnutrition
What are some signs of undernutrition in adolescents?
o Wasting, stunting, cachexia, eating disorder behaviour, anemia, (absent) menstrual period
What are some signs of obesity in adolescents?
o Excessive subcutaneous fat, abdominal adiposity, purple striae, menstrual period
Explain the edema scale/grading for children
0: no edema
+: below the ankle pitting edema
++: Belot the knee pitting edema
+++: Generalized edema
What is the name for a greenish black, sticky stool? What is the meaning of it?
- Meconium
- Present in the first 3 days of a baby’s life
- First baby stool, if greenish black it contains bilirubin
- If yellowish-green : RBCs
What is the relevance of a yellow, seedy stool? What are its characteristics?
Breastfed babies have this type of stool
Mild smell
What is the relevance of a tan and thick stool? What is the meaning of it?
Typically occurs in formula-fed babies. Hummus looking, only a concern if watery or hard
What is the relevance of a greenish brown stool? What is the meaning of it?
Usually occurs in the first introduction to solid foods
Looks like leftover guacamole, will depend on food eaten
What is the relevance of a watery brown, loose stool? What is the meaning of it?
diarrhea
If more than 2 days and frequent risk of dehydration, sign of infection
What is the relevance of a dry brown and hard stool? What is the meaning of it?
Constipation
Looks like dirt clay or pellets
Not enough fluid or losing too much fluid
What is the relevance of a pinkish red stool? What is the meaning of it?
Partially digested food
Monitor what baby eats
What is the relevance of a black pasty, tarry stool? What is the meaning of it?
Melena
Sign of upper GI bleed
What is the relevance of a dark green stool? What is the meaning of it?
Iron supplementation
On iron sulfate in a supplement or iron fortified baby formula
What is the relevance of a Bright green frothy stool? What is the meaning of it?
Foremilk/hindmilk imbalance
Getting more foremilk, breastfed baby nurses for short periods of time on each breast. Could be virus
What is the relevance of a red streaked,hard stool with blood or mucous? What is the meaning of it?
Bloody stool
Possible rectal fissures, small cracks in anus. If large amount of blood when soft stool need medical attention
What is the relevance of a white and chalky stool? What is the meaning of it?
Pale, colorless, sign of liver or gallbladder problem
What should be used for E needs in infants?
DRIs (different formulas with diff ages)
MSJ and HB are not validated in the pediatrics population
How much energy (kcals) does a child need for catch up weight gain?
DRI x 1.5
What do the WHO equations measure in children?
Amount of energy needed to meet BMR (MINIMUM energy to provide)
How much protein do children need… 0-6 months? 7-12 months? 1-3 years? 4-8 years? 9.13 years? 14-18 years?
0-6 months: 1.52 7-12 months: 1.2 1-3 years: 1.05 4-8 years: 0.95 9-13 years: 0.95 14-18 years: 0.85 Requirements can increase depending on medical condition and stress factor
What are the daily fluid requirements in children?
≤ 10kg = 100ml/kg
> 10kg to ≤ 20 kg = 1000ml + 50ml/kg for wt > 10 kg
> 20 kg 1500ml + 20ml/kg for wt > 20 kg
However, in reality, the MD often gives the TFI.
For day 1 and 2 of life…
How much milk does a baby need? How many wet diapers are normal? How many soiled diapers are normal? How many feedings/d?
Need 10-100 ml/d Feed 8 times or + per day day 1: 1 wet diaper Day 2: at least 2 wet diapers 1-2 stools black or dark green
For day 3 and 4 of life…
How much milk does a baby need? How many wet diapers are normal? How many soiled diapers are normal? How many feedings/d?
Feed 8 times or + per day Milk: 200 -250 mL/d Day 3: at least 3 wet diapers Day 4: At least 4 At least 3 brown, green or yellow stools
For day 5 and 6 of life…
How much milk does a baby need? How many wet diapers are normal? How many soiled diapers are normal? How many feedings/d?
Feed 8 times or + per day
400-600 mL/d
At least 6 heavy wet with pale yellow or clear urine
At least 3 large, soft and seedy yellow stools
For day 7 to 3 weeks of life…
How much milk does a baby need? How many wet diapers are normal? How many soiled diapers are normal? How many feedings/d?
Feed 8 times or + per day
600-800 mL/d
At least 6 heavy wet with pale yellow or clear urine
At least 3 large, soft and seedy yellow stools
What are the characteristics of a premature formula? Give 3 examples
Cows milk based For infants < 37 weeks or VLBW High in calories, protein, calcium, phosphate and vitamins and minerals Examples: Enfamil Enfaprem Enfaprem HP Similac Special Care
Name contraindications for use of breast milk
Galactosemia, congenital lactase deficiency, maternal HIV or use of some medications
What is the whey:casein ratio in early milk vs mature milk?
Early milk: 90:10
Mature milk: 60:40
Why is PHM not suitable for preemies?
o Preemie moms make breast milk that is higher in protein, calcium, etc. more suited for preemies
o PHM are usually term moms (even 8 months – 1 year of BF mom…) because they are giving their “extra” milk –> not suited for preemie babies
what is the CHO and fat content of breast milk?
– CHO – lactose (40% of E)
– Fat – (40-50% of energy content); ≈ 12% of fatty acids are MC
In which circumstances do we fortify breast milk and what is the goal?
Below 35 weeks or 1.8 kg
Goal: To make the 81, 91 and 100 kcal/100mL BM formulas – to increase kcals, protein, calcium, PO4 and vitamins and minerals to help for growth
What is regular formula used for and what is it made of?
For > 37 weeks, up to 1 year
Cow milk based
What is partially hydrolyzed formula used for and what is it made of?
- Not hypoallergenic (e.g. people with cow’s milk protein allergy cannot use those formulas)
- Not adequate for CMPI
- Reduced to no lactose, protein is hydrolyzed
- Colic
What is extensively hydrolyzed formula used for and what is it made of?
- Hypoallergenic
- Has free AAs and small peptides, LCT & MCT and lactose free
- Higher osmolarity
- For GI intolerance, cow milk and soy protein intolerance and malabsorption (CF, SBS, cholestasis)
What is 100% AA formula?
- Hypoallergenic
- Free AAs
- For GI intolerance, extreme protein hypersensitivity, suitable CMPI, eosinophilic GI disorders and transitioning from PN to EN, SBS
What are the indications for use of a soy-based formula?
Galactosemia
Congenital lactase deficiency
Cultural or religious reasons
What are the indications for acute EN in children?
- Intact and functional GI tract
- Medical conditions where it is difficult or impossible to safely consume food or liquids by mouth
- Diagnosis which increase E needs, making it difficult for infants to take sufficient amounts by mouth
- EN is required for children unable to meet more than 80% of caloric needs by mouth or who require an extended period of time to eat (i.e. > 4 hours)
Start EN at any time during an admission for:
o Patients who have been unable to eat for 3-5 days
o Patients whose documented energy intake is ≤ 50-75% of recommended levels for ≥2-3 days for infants and ≥3-5 days for children and adolescents
Name 5 benefits of EN vs PN
- Maintain gut mucosal integrity
- Stimulates oral and GI enzymatic activity
- Prevents pancreatic and biliary flow dysfunction
- Has fewer complications/lower risk of infection
- Incurs lower costs
When should we start EN in HD stable patients?
Start EN as soon as possible, within 48-72 hours of admission
What are the indications for chronic EN in children < 2 years old?
o Poor growth or weight gain for more than 1 month
o Decrease of 2 or more weight or height growth channels
o Triceps skinfold < 5th percentile
What are the indications for chronic EN in children > 2 years old?
o Weight loss or lack of weight gain for 3 months
o Decrease of 2 or more weight or height growth channels
o Triceps skinfold < 5th percentiles
What are absolute and possible contraindications for EN?
Absolute contraindications:
o NEC
o Bowel obstructions or ileus
o HD instability (poor perfusion)
Possible contraindications that should be evaluated individually: o Persistent vomiting or diarrhea o Acute abdominal distention o Gastric, small or large bowel fistula o Upper GI bleeding
What is combination feeding and what is it used for?
- When a child cannot tolerate large volumes of bolus feeding
- 3-4 smaller bolus feeds during the day + overnight continuous infusion
- Daytime feeding to be compressed by 1-2 hours each day until desired number of boluses reached
- Bolus can be given over 30-60 min if well tolerated
Name signs of intolerance to EN in children. Can we use GRV?
Signs of intolerances: fussiness, irritability, choking, coughing, vomiting, retching, abdominal distension, diarrhea
Gastric residuals not recommended in peds
What are conditions for weaning off EN?
- Using spoon foods or baby food aim for 1-2 bites swallowed with no vomiting
- Increase bite amount if reaching goal 75% of the time, about every 3-4 days
- Bolus over 30 minutes per feed is well tolerated
- Able to take full volume of bottle PO
- Once 10 bites achieved per meal
- Taking 1-4 oz per meal consumed, start tube feeding reduction
- Reduce tube feeding early in the day to benefit meals. Reduce bedtime/evening feeds last.
- Continue to advance oral motor and oral sensory
- Add water to tube feedings as needed during reduction
- Need 2-3 month of normal growth without tube use before removing tube feeding access
When does swallowing develop during gestation?
12-14 weeks of gestation
Name some congenital and some acquired causes of feeding/swallowing disorders
Congenital causes o Neuromuscular diseases (CNS involvement) o Cerebral palsy o Cleft lip and palate o Spinal muscular dystrophy o Prematurity
Acquired causes
o Delayed introduction oral feeding
o Unpleasant oral tactile experiences
Problem can me physical and mechanical (chewing,swallowing, sef-feeding, positioning…), medical and nutritional (GI issues, growth issues), and behavioural (meal time structure, refusal behaviour, mealtime behaviours)
What are common feeding problems in children?
- Excessive liquid intake, impeding acceptance of solid foods
- Grazing, unstructured mealtimes
- Prolonged feeding time (>30 minutes)
- Inadequate or immature oral-motor skills (unable to handle complex textures)
- Sensory integration issues (will consume only foods of one color and/or texture)
What are the benefits of non-nutritive sucking (e.g. use of pacifier (suce))
- Use of pacifier during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants to improve development of sucking behaviour
- For avoidance of oral aversion
- Reduce time of transition from tube to full oral feeding
- Calming effect on infants
- May improve digestion during feeding
Name some behavioural strategies for feeding issues
- Offer liquids primarily between meals, and limit drinking during meals
- Encourage a structured and consistent schedule for 3 meals and 2-3 snacks daily
- Limit meals to 20-30 minutes
- Eliminating grazing behaviour on liquids and foods between meals
- Use a timer to have the child sit at the table for a finite period of time
- Offer food in a divided plate
- Offer 1 new or non-preferred foods with 1 to 2 preferred foods
- Continue to offer non-preferred food in a positive way
- Encourage exploration of a non-preferred food (sensory)
- Establish a non-food reward system (for children older than 1 yo) were positive behaviour is praised
- Be as consistent as possible
- Encourage training and cooperation of all caregivers
- Encourage family mealtimes
- Provide age appropriate portions and developmentally appropriate textures
What are the indications for PN in neonates?
“Consider PN for neonates in critical care setting, regardless of diagnosis, when EN is unable to meet energy requirements for energy expenditure and growth” (JPEN, 2017)
o Very low birth weight (<1500g)
o Intestinal dysfunction or impaired intestinal perfusion
(SBS, Gastroschisis, NEC, meconium ileus, intestinal atresia)
o Expectation of slow progression of EN
(Congenital heart disease, Severe respiratory failure with hypoxia and acidosis)
What are the indications for PN in pediatrics?
“Use of PN for children when the intestinal tract is not functional or cannot be assessed or when nutrient needs to provide for growth are greater than that which can be provided through oral intake or EN support alone.” (JPEN, 2017)
– Malnourished children if cannot tolerate or safely receive EN for > 3 days
Common indications but not exclusive:
o Neuromuscular disorders (Chronic intestinal pseudo-obstruction, Hirschsprung’s disease, mitochondrial disorders)
o Mucosal disorders (Microvillus inclusion disease, tufting enteropathy, autoimmune enteropathies, intractable diarrhea)
o Anatomical disorders (Decrease in intestinal length: SBS, atresia, gastroschisis, volvulus, meconium ileus, NEC, thromboses and trauma)
o Inflammatory bowel (Only in cases of fistulae, obstruction, toxic megacolon and bowel resection resulting in SBS)
o Chronic liver disease (When awaiting liver transplant – organomegaly, ascites, limited gastric capacity, malabsorption related to cholestasis, increased kcal needs. Malnutrition associated with worse pre and post tx outcomes)
o Cardiac disease (Strongly recommend early PN in preop and continuing postop until EN is tolerated due to work of feeding on heart, need for fluid restriction, high metabolic demand)
o Stem cell transplant (Severe mucositis, typhlitis, intestinal obstruction, intractable vomiting, intractable diarrhea)
When do we start PN in neonates? in pediatrics?
Neonatal
o Delaying PN contributes to negative N balance = postnatal growth failure
o Early PN within hours of birth considered safe
o EAA deficiency develops in 3 days on fat-free diet
o Begin PN promptly after birth in VLB weight infants (< 1500 g)
o Insufficient data for more mature preterm and critically ill term neonates
Pediatric
o For infant, child or adolescent, reasonable to delay consideration of PN for a week
o However, initiate PN within 1-3 days in infants and 4-5 days in older children and adolescent when EN or PO not tolerated
What are considerations before starting PN?
Think about fluid status, appropriate venous access, nutrition needs, anticipated length of therapy, gut function (trophic feeds?).
What are short term risks of PN?
- Infection
- Hyperglycemia
- Electrolyte abnormalities
- Acid-base imbalances
- Hypertriglyceridemia
- Phlebitis
- Bacterial translocation
- Compromised gut integrity
What are long-term adverse effects of PN?
- Infection
- PN-associated cholestasis
- Metabolic complications
- Acid-base imbalances
- Osteopenia, poor bone mineralization
- Risk vitamin and mineral deficiency/toxicity
- Essential fatty acid deficiency
- Continued risk of bacterial translocation
- Adequate light protection of PN
When to wean-off PN?
Wean PN when oral intake and/or EN achieves 50-75% of requirements for energy and protein and micronutrients, unless impaired GI function precludes 100% absorption of nutrient needs
In which cases can we use PPN in children?
• Use only in previously well-nourished or mildly nutrition deficit
• Expect full EN within 7-10 days
• If after 5-7 days of PPN, no progression of EN- consider TPN
- Need stable electrolyte status without elevated needs
• Sufficient renal function to tolerate fluid overload, need to be able to tolerate 120-125ml/kg/d for neonates and 150% fluid maintenance needs in pediatric patients
Who are the patients especially at risk of refeeding?
- Severe underweight (BMI < 5th percentile for age)
- Acute weight loss of 5-10% in past 1-2 months
- No EN for 7-10 days or major stressors without food for several days
- Abnormal electrolytes prior to refeeding (phosphate, K, Mg)
- Prolonged and severe V
- Prolonged QTC interval on ECG
- Pre-existing cardiac or respiratory conditions
Highest risk is in the first 4 days after feeding is restarted but may develop up to 2 weeks after restarting nutrition
What is the proportion of children born premature in Canada?
1 out of 12
prematurity is the main cause of death among infants
What are the 5 main causes of prematurity
- Socio-economic factors (low income, close pregnancies, work-related stress, age, alcohol/drug abuse, smoking)
- Complications during pregnancy (placenta previa, pre-eclampsia, infection in mother)
- Fetal (congenital malformations, IUGR)
- Multiple pregnancy (twins, triplets)
- Gynaecological (uterine anomalies, incompetent or short cervix)
Why are preterm babies put in isolates?
They cannot maintain their body temperature
What are the 3 classifications for preterm babies?
- Extreme preterm (GA < 29 weeks)
- Preterm (or moderate preterm) (29-33 weeks)
- Late preterm (34-37 weeks)
What are the 4 categories of birth weight?
- ELBW (< 1000g)
- VLBW (1001-1500g)
- LBW (1501-2500g)
- Normal (>2500g)
Which types of infants get automatically admitted to the NICU?
- Born < 35 weeks
- less than 2300g
What are the 3 classifications for weight for GA?
- small for GA (SGA): Less than 10th %ile birthweight for GA
- Appropriate for GA (AGA): between 10th and 90th %ile
- Large for GA (LGA): greater than 90th %ile birthweight for GA (usually d/t GDM)
How was the Fenton’s growth chart developed?
– Large preterm birth sample size of 4 million infants
– Data from developed countries including Germany, US, Australia, Scotland and Canada
What are the 2 categories of IUGR?
Symmetric IUGR (Weight, length and head circumference less than 10th %ile. Indicative of chronic malnutrition)
Asymmetric IUGR: Length and head circumference are appropriate, but weight is below the 10th %ile. Better as head sparing (acute malnutrition)
What is the equation for CGA?
Gestational age + (Chronological age ÷ 7) = CGA
Explain how the gastrointestinal immaturity of a preterm baby can affect its nutritional status
- Reduced gastric capacity (≈ 5 cc)
- Decreased GI motility
- Reduced gastric emptying
- Decreased concentration of digestive enzymes
- Inadequate LES closure
- Inadequate capacity to suck and swallow
Explain how the thermoregulation of a preterm baby can affect its nutritional status
- Decreased fat reserves
- Unable to maintain body temperature (–> put in isolates)
Explain how the GI and respiration of a preterm baby can affect its nutritional status
- Poor suck/swallow/breathe coordination
- Preterm babies lose weight when they start being fed by bottles (hard work)
Explain how the respiration of a preterm baby can affect its nutritional status
- Immature lungs = increased work of breathing
Explain how the medical comorbidities of a preterm baby can affect its nutritional status
- Respiratory distress syndrome
- Hypoglycemia
- Hyperbilirubinemia
- Hemodynamic instability
- Risk of sepsis
Explain how the nutrient absorption of a preterm baby can affect its nutritional status
- Decreased bile salts and pancreatic lipase (< 32 weeks, only 65-75% of fat absorption)
- Lactose (26-34 weeks, 30% absorption)
- Protein (28-34 weeks, 70% absorption)
Explain how the nutrient reserves of a preterm baby can affect its nutritional status
- Age-related changes in body composition
Small premature infant has very low fat and normal protein stores
Large premature has a little more fat and protein stores
Term infant has high fat stores and normal protein stores
1 year old child- even more fat (more than adults) and protein (less than adults) stores
What are the fluid recommendations for preterm infants?
135-200 ml/kg/d
What are the energy recommendations for preterm infants?
110-135 kcal/kg/d
What are the protein recommendations for preterm infants?
3.5-4.5 g/kg/d
What are the lipid recommendations for preterm infants?
4.8-6.6 g/kg/d
What are the calcium recommendations for preterm infants?
120-200 mg/kg/d
What are the phosphate recommendations for preterm infants?
60-140 mg/kg/d
What are the iron recommendations for preterm infants?
2-3 mg/kg/d
What are the vitamin D recommendations for preterm infants?
400-1000 IU/d
What are the conditions for high nutritional risk in the Ohio Neonatal screening criteria?
< 1 week of age
- > 15% weight loss from birth weight
- < 1 kg at birth
1-2 weeks of age
- < 70 kcal/kg/d or any continued weight loss
> 2 weeks of age
- Intake < 80% of expected energy requirements
- < 15 g/kg/d weight gain (< 36 weeks GA)
- Prealbumin < 8 mg/dL or albumin < 2.5 g/dL
- BUN < 7 mg/dL
- Serum phosphorus < 4 mg/dL / Alkaline phosphatase > 600 mg/dL
> 2 months of age: same as > 2 weeks of age \+ - No source of dietary iron - Continued TPN
Initial nutrition assessment: What to look for in the maternal history?
PMHx: GDM?
PSHx: Procedures done?
PObsHx: Previous preemies?
Allergies: Need hydrolyzed formulas?
Medication (MgSO4): Magnesium sulfate: medication given to moms for pre-eclampsia and for neural protection of preemie baby. But: Reduces GI motility. Look at blood levels of baby to see if its high. If high = be careful in feeding of baby
Blood works taken on first day, but more reflective of mother’s blood. But MgSO4 is from the baby
Social Hx/support: Will you be getting breast milk on time? Is mother ready to breast feed?
Initial nutrition assessment: What to look for in the infant?
Gender Level of prematurity Weight category Days of life CGS APGAR score Cord pH (< 7 = be careful in feeding; acidosis)
Initial nutrition assessment: What to look for in the medications?
Caffeine, antibiotics
o Vaginal birth babies are better off than C-section.
o Antibiotics are bad for gut – need to consider
o Caffeine used to help babies to breathe well
Initial nutrition assessment: What to look for in the physical exam?
Length, head circumference, weight, plot on Fenton growth curve, SGA/AGA/LGA, IUGR
Initial nutrition assessment: What to look for in the GIT?
Is the baby ready to be fed? feed preemie babies sooner = better feeding tolerance (risk of NEC is low)
Abdomen (distended? Hard?, meconium (pass meconium (black stool)?), bowel sounds
If the meconium didn’t pass in 48h- may be worried; may cause blockage in GI
Initial nutrition assessment: What to look for in the biochemistry?
BUN, Cr, Na, K, Ca, Mg, Bilirubin total and conjugated, TG, Alb, Hgb (Hgb usually high; except in maternal fetal transfusion; when baby is held a certain way during labor, blood can go back to the mom –> baby can be anemic)
Initial nutrition assessment: What to look for in the clinical status?
Respiratory distress syndrome? Pulmonary hypertension?
When can the baby suck/swallow/breathe coordinate?
32-34 weeks
