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
What are the options in the type of nutrition for preterm babies and when/in which cases are they used?
- Parenteral nutrition (total or partial) - If (e.g. severe respiratory distress syndrome, abdomen does not look great, MgSO4 high…)
- Enteral nutrition (total or partial) – for babies who cannot be breast- or bottle- fed, due to bad coordination of suck/swallow/breathe)
- Breast feeding (after 32-34 weeks)
- Bottle feeds (after 32-34 weeks)
What are the indications for PN in infants?
– Functional immaturity of GI tract or gestational age at birth < 30-32 weeks (no suck/swallow/breathe coordination) (baby born < 1750g –> TPN)
o Use PN as supplemental nutrition while advancing enteral feeds
– Necrotizing enterocolitis (NEC)
– Impaired GI perfusion that decreases GI motility o Patent ductus arteriosus (PDA) o Congenital heart disease (CHD) o Hypotension o Use of medication like ibuprofen
– Congenital GI anomalies requiring surgical repair o Gastroschisis (intestine sticking out of abdomen) o Bowel obstruction, etc.
– Impaired GI motility
o Ileus from sepsis, surgery, after surgical repair of gastroschisis, Hirschsprung disease
– Malabsorption syndromes (SBS, CF)
– Delayed initiation or advancement or enteral feeds (usually in bigger infants)
What are the main risks in long term TPN?
Sepsis
TPN cholestasis
What is the initial fluid intake to give by TPN
60-90 ml/kg/d to 120-150 ml/kg/d
Trophamine: Start at _____ and advance to a goal of _____.
start at 1.5-2 g/kg/d and advance up to a goal 3.5-4g/kg/d
Dextrose: Can begin at _____ to a maximum of _____.
can begin at 5-10g/kg/d to a maximum of 10- 18g/kg/d
Lipids (SMOF): Can begin at _____ to a maximum of _______.
0.5-1 g/kg/d to a maximum of 3g/kg/d
What is the minimum amount of calories needed to prevent a catabolic state in infants?
50 kcal/kg/d
When is it acceptable to stop PN when the infant is on EN as well?
when the infant tolerates at least 75-80% of energy goal or is within 2-3 days of achieving goal enteral volume
What are the indications for EN in infants?
All infants unable to meet nutritional requirements orally
o Premature infants < 34 weeks of GA (no coordination)
o Transition from PN towards oral intake
o Poor suck/swallow/breathe coordination
What are the contraindications for EN in infants?
Severe respiratory distress syndrome GI anomalies (esophageal atresia, bowel obstruction) Poor perfusion (HD instability) Bowel obstruction Perforated bowel Diffuse peritonitis Bowel hemorrhage (GI bleed) - “feed a bleed, fast a hemorrhage” Necrotizing enterocolitis Chylothorax
Explain the advancement of NS in infants from TPN to PO
- TPN only
- TPN + EN
Once EN = 75-80% of nutrition…. - EN + PO
- PO alone (goal)
When can we start PO feeding in preterm babies?
An infant born at ≥ 34 weeks GA or when it reaches ≥ 34 weeks of corrected gestational age (CGA), oral feed can be given as their suck, swallow and breathe coordination is better (breastfeeding or bottle feeds)
How frequent are bolus feeds in infants?
q 2-3h (small stomach)
Use gravity with syringe
Which is preferable: early or late EN? Why?
Early EN is better in preterm infants.
Infants < 35weeks gestation and below 10%ile for weight
Early (within 2 days of life)
VS.
Late feeds (6 days of life).
Results showed that full enteral feeds were reached earlier in the early feed group. There was no evidence of a difference in NEC
Early feeding resulted in shorter duration of PN
Why is breast milk preferable over formula for preemies?
- Optimal distribution of calories (7% protein, 55% fat, 38% CHO, easy digestibility)
- Immune factors (IgA, IgG), hormones, enzymes
- Decreased gastric transit time
- Better absorption of nutrients (fat, iron, Zn)
- Lower renal solute load
- Protection from NEC
- Long-term effects (better neurocognitive development, immunity, prevention of allergies)
What does preterm formula contain?
Contains higher amounts of nutrients than term infant formulas
• Protein: Cow’s milk protein (intact or partially hydrolyzed)
• Carbohydrate: Corn syrup solids or maltodextrin and 50% lactose
• Fat: Variety of vegetable oils and MCT
• Vitamins: Adapted to premature infant needs
• Minerals: Almost double the amount of calcium and phosphorus vs that of a term infant formula
What is oral immune therapy and when is it used?
Oral care with colostrum (breast milk filled with nutrients), to help stimulate the immune system
(0.05 mL q 2h between cheek and gums, not expected to reach the gut)
To start if contraindication to feed the gut
What are trophic feeds and when are they used?
Trophic feeds to begin as soon as clinically appropriate (10-24 ml/kg/d)
o Prepares the gut to be fed; need to start EN slowly, unlike TPN
o Helps to stimulate GI motility, development of microbial flora, growth of microvilli
o Increased milk tolerance, increased postnatal growth, decreases systemic sepsis, decreases LOS
What are the initial recommended volumes for babies < 1 kg? 1-1.5 kg? > 1.5 kg?
< 1 kg: 90-120 ml/kg/d (more if medically necessary)
1-1.5 kg: 70-90 mL/kd/d
> 1.5 kg: 60-80 ml/kg/d
What are the final recommended volumes for babies?
135-200 ml/kg/d (at least 150 ml/kg/d for optimal nutrition)
120 mL/kg/d is too little for EN but enough for PN
Why are the fluid needs of preterm infants high?
because surface to skin ratio is high, immature kidney, rapid growth rate and need for phototherapy
The more SGA a baby is, the more fluid they need
What is the allowed weight loss for fluids after birth?
10% (10-15% for MDs but focus on 10%)
Due to extracellular fluid loss
How are the energy needs of a preterm baby broken down?
o Intermittent activity: 15 kcal/kg/d o REE: 50 kcal/kg/d o Occasional cold stress: 10 kcal/kg/d o Specific dynamic action: 8 kcal/kg/d o Fecal loss of calories: 12 kcal/kg/d o Growth allowance: 25 kcal/kg/d o TOTAL: 120 kcal/kg/d (MINIMUM for EN feeds; babies with high caloric requirements may go up to 130-150 kcal/kg/d)
Why does breast milk need protein fortification in preterm infants?
Preterm milk is higher in protein than term milk (2.1 g/100mL vs 1.05 g/100mL)
Composition of mother’s milk changes after 14-21 days of life (but preemie is still a preemie! still make sure protein requirements are met, fortification)
Breastmilk to be fortified to meet requirements
Monitor growth, BUN and plasma protein
Why does breast milk need iron fortification in preterm infants?
o Very low in breast milk in general, even preterm
o Decreased reserves, supplement by 2-4 weeks of life
o Fortification of breast milk not adequate
o Preterm formulas enriched with iron
o Monitor blood Hgb levels closely, can affect growth
Why does breast milk need calcium, phosphorus and VD fortification in preterm infants?
Osteopenia is a common problem among premature infants
Need to fortify breast milk or give premature infant formulas
Supplement with calcium and vitamin D
To monitor calcium phosphorus ratio and alkaline phosphatase levels
If inadequate: Supplement with calcium phosphate
What are the indications for breast milk fortification?
– Infants ≤ 34 weeks gestation
– ≤ 1500 g at birth (may choose to do this for all babies < 2 kg as well; or also with those > 2kg who are not regaining BW on time)
– On TPN > 2 weeks
– > 1500 g at birth with suboptimal growth
– > 1500 g at birth with limited ability to tolerate increased volume
What is the safe volume to start fortifying breast milk?
80-120 ml/kg/d
What is liquid protein for preterm babies made of? What is its protein concentration? When is it used?
- Made of hydrolyzed casein
- Sterile liquid -preferred choice in the NICU environment
- Helps customize feeds to meet a range of protein needs
- 6 mL of liquid protein = 1 g of protein
- Added to breast milk only after the process of fortification and if the fortification is well tolerated (After 24-48 hours of tolerated fortified breast milk –> add liquid protein)
- Use liquid protein until baby is 1800 g (protein needs change)
Discuss the importance of adequate protein intake in preterm infants. How much do they need to avoid -ve N balance? Minimum for +ve N balance?
- Preterm infants require at least 1 g/kg/d initially to avoid negative nitrogen balance
- At least 3g/kg/d promotes positive nitrogen balance
- ≈ 4 g/kg/d is needed to match fetal protein accretion rate
- Providing < 4g/kg/d in VLBW infants results in protein deficiency that contributes to EUGR (extrauterine)
How much protein does fortified breast milk provide?
2.15g/100 mL
At what point should a baby have regained his/her BW?
ideal is 10 days of life (from 10-14)
Once BW is regained, what is the desirable growth velocity in preterm infants? Length growth? HC growth?
Growth velocity: 15-20 g/kg/d
Length: 0.9-1.0 cm/week
HC: 0.5-0.9 cm/week
Weight measured daily, HC and ht weekly
How do we calculate growth velocity
((current weight - old weight) ÷ number of days) / current weight
What are the options if the growth velocity is inappropriate?
o To increase total fluid intake (TFI) if not at maximum level
o If only on expressed breast milk, can fortify breast milk (FBM)
o If already on FBM, can further enrich to provide more calories and protein
E.g. Add discharge formula to FBM
Used to give MCT oil but better off using nutritious supplementation than empty calories
What is catch-up growth? What catches up first in a preterm infant catch up growth?
Defined as the accelerated growth of an organism following a period of slowed development, particularly as a result of nutrient deprivation
There is no clear quantification of catch-up growth rate or velocity
When a preterm infant has catch up growth, it is the weight that catches up first, followed by the head circumference and finally the length
Do babies have increased nutrient needs for catch up growth? If so, which requirements are increased
Protein and energy needs are increased
Which biochemical parameters should you f/u in PN? EN?
For PN o Glucose o Electrolytes o Ca, Mg, P o TG o BUN/Creatinine o Serum proteins o Liver enzymes o Alkaline phosphatase o Blood cell count For EN o Electrolytes o BUN/Creatinine o BUN alone o Alkaline phosphatase/ Ca:P ratio o Vitamin D o Albumin, prealbumin o Liver enzymes o Blood cell count
What are clinical signs to look for in preterm babies?
Skin color Fluid status Vital signs Urine and stool output Feed tolerance
Skin color: What does it mean if a baby has: - Bluish skin, lips? - Whitish, pale skin? - Yellow skin? - Poor wound healing?
o Bluish skin, lips: Low O2 saturation, decreased gut perfusion (abdomen gets bluish)
o Whitish, pale: anemia
o Yellow: jaundice
o Poor wound healing: Zn or protein deficiency
Fluid status: What does it mean if a baby has generalized edema?
Overhydration, protein deficiency
Vital signs: What does it mean if a baby has:
- High/low temperature?
- tachypnea?
- Apnea?
- Tachycardia?
- Temperature (hypo/hyperthermia: High BMR, slow weight gain)
- Respiratory rate (tachypnea: no nipple feeding; apnea: feed cautiously)
- Heart rate (tachycardia: high energy consumption)
What is a normal range for urine output in babies?
1-3 ml/kg/d
What is RDS? What can it be caused by? What can it progress to? Which nutrients to look out for?
Respiratory distress syndrome: Characterised by cyanosis in room air, nasal flaring, grunting, retractions and tachypnea
Develops in preterm infants due to immaturity of the lung tissue structure and function
Other causes are meconium aspiration, pneumonia, lung hypoplasia, etc.
RDS may progress to severe, permanent condition: bronchopulmonary dysplasia (BPD)
IUGR infants are more likely to develop both RDS and BPD
Nutrients: Energy (increased), protein (3.5-4 g/kg/d - depends on weight), fluids (limit)
What should be the energy intake of babies with RDS?
PN: Initial intake of 85-115 kcal/kg/d to eventual 100-120 kcal/kg/d
EN: Initial intake of 90-130 kcal/kg/d to eventual 120-150 kcal/kg/d
Lower in PN because no energy needed for nutrient digestion and absorption
What should be the protein intake of babies with RDS?
Adequate intake is required to support lean tissue accretion and organ growth Goal intake of at least 3.5-4g/kg/d Baby < 1000g: aim for 4g/kg/d protein Baby 1000-1800g: 3.8 g/kg/d Baby > 1800g: 3.5 g/kg/d
What should be the fluid intake of babies with RDS?
Allow for initial diuresis with adequate weight loss (10-15%) to prevent pulmonary edema
Limit fluids to 70-80 ml/kg/d and adjust daily
Eventual fluid restriction of about 120-150 ml/kg/d (mostly 120) necessitating increased nutrient density
What feeding problems can a child with RDS develop?
May require prolonged EN
May need to consult a feeding therapist to help enhance oro-motor development
What are the main drug nutrient interactions in RDS?
Corticosteroids (dexamethasone): increase protein intake for better growth. May cause hyperglycemia –> monitor serum glucose levels and modify glucose infusion rates if on PN
Chlorothiazide Diuretics (HCTZ): may cause delayed growth due to low serum levels of sodium, potassium and chloride. May need to supplement those. Spironolactone may increase serum potassium levels but increase urinary sodium and chloride excretion. All diuretics cause increased renal phosphorus excretion, putting infants at high risk of osteopenia
What are the 3 Bell et al’s stages of NEC?
Stage 1: Suspected
Stage 2: Definite
Stage 3: Advanced disease (portal venous gas on abdominal X-ray)
What are the systemic and GI symptoms of NEC?
Systemic: temperature instability, lethargy, apnea, tachycardia, hypotension
GI: poor feeding, emesis, abdominal distension, abdominal wall discoloration, ileus with decreased bowel sounds, fresh blood in stool
How can NEC be prevented?
Use of human milk/breast milk (most effective way)
Development and use of a standardized approach to feeding can prevent NEC
Use of enteral probiotic supplementation for infants > 1000g has been shown to reduce NEC (optimal probiotic strain, dose, duration and safety remains TBD)
What is the treatment for NEC?
- Baby needs to be put NPO
- Antibiotic therapy
- No known optimal nutritional management
- Balanced and complete PN with cessation of EN for bowel rest ranging in clinical practice from days to weeks
- Usually NPO for ≈10 days on antibiotics
- Gradual reintroduction of enteral feedings as tolerated (10-35 ml/kg/d) –> start with plain breast milk, then fortified
Use human milk, donor breast milk, preterm formula if human milk available or hydrolysed formula
If bowel resection (NEC stage 3), review nutrients that may be maldigested or malabsorbed and supplement
Monitor for late complications such as cholestatic jaundice, bowel strictures and osteopenia (calcium and P absorption) –> check for osteopenia by looking at alkaline phosphatase levels and Ca:P ratio
What is the treatment for NEC?
- Baby needs to be put NPO
- Antibiotic therapy
- No known optimal nutritional management
- Balanced and complete PN with cessation of EN for bowel rest ranging in clinical practice from days to weeks
- Usually NPO for ≈10 days on antibiotics
- Gradual reintroduction of enteral feedings as tolerated (10-35 ml/kg/d) –> start with plain breast milk, then fortified
Use human milk, donor breast milk, preterm formula if human milk available or hydrolysed formula
Bell stages IA an IB
o Patient is kept NPO with antibiotics for 3 days. IV fluids are provided, including TPN
Bell stages IIA and IIB
o Treatment includes support for respiratory and cardiovascular failure, including fluid resuscitation, NPO, and antibiotics for 14 days. Surgical consultation should be considered. After stabilization, TPN should be provided during the period that the infant is NPO
Bell stage IIIA
o Treatment involves NPO for 14 days, fluid resuscitation, inotropic support, and ventilator support. Surgical consultation should be obtained. TPN should be provided during the period of NPO
Bell stage IIIB
o Surgical intervention is provided
review nutrients that may be maldigested or malabsorbed and supplement
Monitor for late complications such as cholestatic jaundice, bowel strictures and osteopenia (calcium and P absorption) –> check for osteopenia by looking at alkaline phosphatase levels and Ca:P ratio
What are the primary interventions for GERD?
Parental education and reassurance
What are possible nutrition interventions for GERD?
- Small frequent feeds or continuous feeds
- Prone (not advised post discharge home) and left lateral positioning have been associated with less reflux
- If symptoms due to cow’s milk protein intolerance, a change to hydrolyzed formulas or AA based formulas may be useful. Infants on human milk can be reintroduced to human milk if mother has followed a cow’s milk protein free diet for a specific number of days
- Thickened feeds: Use of carob and xanthan gum-based thickeners are not recommended for preterm infants. Dry infant cereal is a better option
What medications are used in GERD? what are their side effects?
- Acid suppressants and prokinetic medications may be beneficial. However, need to be cautious with regard to possible side effects. These medications with PPIs have been shown to increase the risk of NEC
What is the volume of trophic feeds?
10-24 ml/kg/d
In which unit should we always give volumes (fluid intake), energy intake and protein intake?
?/KG/D
What is the cutoff for IUGR for a baby that is born at term?
The most widely used definition of IUGR is a fetus whose estimated weight is below the 10th percentile for its gestational age.
At term, the cutoff birth weight for IUGR is 2,500 g (5 lb, 8 oz).
What is Meconium ileus? What condition is it associated with?
Obstruction of small bowel/terminal ileum due to inspissated meconium
Associated with CF
Meconium is very thick and sticky due to poorly hydrated mucus = won’t move along
Usually, meconium ileus does not perforate, but it can happen
– 10% CF babies present with meconium ileus (associated with severe genotypes)
– ≤ 80-90% of children with meconium ileus are found to have CF
– “complex” meconium ileus (perforation or surgery) ≈ 40% total; if with perforation, meconium, peritonitis, intestinal atresias, volvulus
What can be done medically to remove the meconium?
Can use endoscope to put in a hyperosmolar liquid to liquify the sticky stools, let it pass. (water-soluble hyperosmotic contrast enema)
Only goes to OR if cannot be reversed through hyperosmolar infusions
What are the symptoms of meconium ileus (MI)? When do they usually appear?
- Usually appear in first 3 days of life
- Abdominal distention
- Failure to pass meconium
- Vomiting (projectile)
What are the steps for the management of MI?
NG, NPO, fluid/lytes; +/- operation, test for CF
What is a mucous fistula? What are the purposes of a mucous fistula?
The second of two stomas when a single loop ostomy is created (distal stoma) – a part of the descending colon was cut off. They then attach the proximal functioning stoma (before the cut off part) to the surface of the skin. Distal stoma (mucous fistula) does not get nutrients but can excrete air and fluids
Present in temporary end ileostomy: Distal bowel is closed and left in abdomen exteriorized as a mucous fistula
It is a “non-working” stoma (no stools pass); stools get into bag.
Purpose: Discharge mucous or gases from the non-functioning portion of the colon and rectum
What can be done to prevent an ileostomy site from being affected by pancreatic enzymes?
Can tolerate more steatorrhea to habituate the skin to some enzymes
What are the symptoms of intestinal ileus? Can EN be given in cases of ileus?
Symptoms: No stools, firm and distended abdomen, no gas.
Can give trophic feeds
In which cases can we give both EN and PN?
- Any patient who cannot tolerate adequate volumes of EN, irrespective of the diagnosis, should receive TPN (preferably peripheral TPN) as an adjunctive nutritional therapy
TPN can either be an adjunctive therapy or the primary therapy with EN as an adjunct
Why do some infants have PN running through many different lines?
many infants have PN through many different lines because we want to keep the lines for the surgeons (keep the veins open; they usually do it with a dextrose solution, but we can rather use TPN (dextrose + AA…) instead)
What should we do to prevent catabolism in infants with PN?
Cannot meet DRI on first day but need to meet BMR otherwise “auto-catabolism”
Name 4 advantages of pediatric AA solutions over the adult ones.
Lower pH increases solubility of Ca and P into the solution
(decreases risk of osteopenia)
if the formula was not acidic enough = Ca and P can crystallize and cause thrombosis or infections
Lower incidence of cholestasis in VLBW infants (probably in all infants)
Adequate weight gain even with below normal caloric intake (more efficient use of energy)
Positive N balance
What are the 4 lipid components of SMOF lipids?
Explain the importance of each.
Soybean oil (30%) – provides linoleic (omega 6) and alpha-linolenic acid (omega 3) MCT (30%) – Rapidly oxidized and source of readily available energy Olive oil (25%) – source of MUFAs Fish oil (15%) – High content of EPA and DHA (omega 3s)
Why is SMOF lipids prefered to intralipid?
– Intralipid = 100% soybean oil
– High omega 6 = pro-inflammatory (prostaglandin precursors) – some inflammation is good in critical illness; but worsens current inflammations if too high
– High omega 3 = anti-inflammatory; precursors to prostaglandins are less inflammatory
SMOF is 2.5:1 + High alpha-tocopherol level (stabilizes double bonds of PUFAs, antioxidant)
Intralipid 20% 7:1 + very little alpha-tocopherol + presence of phytosterols (associated with TPN cholestasis)
Why are UV protection bags used for TPN in patients from 0-18 years old?
Shielding Parenteral Nutrition from direct light improves survival rate in premature infants (reduction of mortality)
(Free radicals production in lipids, niacin and thiamin in TPN)
What can third spacing (abdominal compartment syndrome) be caused by? what can it lead to?
Can be caused by sepsis
Can limit circulation to intestine and cause NEC
What is NEC?
Characterized by variable damage to the intestinal tract, ranging from mucosal injury to full-thickness necrosis and perforation
Typically occurs in the second to third week of life in premature, formula-fed infants (80% of people who develop NEC are preterm infants)
Mortality of 20%
Variable damage to the GI tract, ranging from mucosal injury to full-thickness necrosis and perforation
NEC in full-term neonates remains a rare pathology with an incidence of 12.5% among all neonates with NEC
Most patients (81.5%) presented an underlying cause (maternal or intrinsic disease) including Hirschsprung’s disease, cardiac malformations and CF)
Some had no evident cause
What are possible etiologies of NEC?
Abnormal intestinal flora o E-Coli o Klebsiella pneumoniae Intestinal ischemia Intestinal mucosal immaturity o Decreased HCl and pepsin o Immature mucin layer and incompletely developed tight junctions o Pancreatic exocrine insufficiency o Decreased mucus secretion o Impaired gut motility and peristalsis o IgA deficient in premature infants not breastfed o Exaggerated inflammatory response to intestinal injury Innate genetic predisposition Medications o Xanthine derivatives; theophylline, aminophylline, etc o Indomethacin o Vitamin E o Ranitinide
What can be done if a baby has TPN cholestasis but cannot be fed PO/EN?
Use cyclic TPN to rest liver
What is CF? How is diagnosis performed?
Autosomal recessively inherited disorder caused by mutations in the CFTR gene (CF Transmembrane Conductance Regulator)
Diagnosis now done on the basis of newborn screening with IRT (Immunoreactive Trypsinogen) followed by a sweat chloride test and identification of disease-causing CFTR gene mutation
What does the CFTR protein normally do? What are the 5 classes of CF? Explain them.
CFTR normal protein allows transfer of chloride and water across cell surface
• Class I: No functional CFTR is created
• Class II: CFTR protein is created but misfolded, keeping it from reaching the cell surface
• Class III: CFTR protein is created and reaches cell surface, but does not function properly
• Class IV: The opening in the CFTR protein ion channel is faulty
• Class V: CFTR is created in insufficient quantities
Reduced transport of chloride (and HCO3) across cell membranes –> thick viscous secretions
Mutations severity implicated in clinical symptoms seen
Therapies are based on the genotype; targeted.
Which is the most common CFTR mutation? Which class of CF is it included in?
F508 delta
Class I mutation
Most common mutation. 90% of European descendants with CF carry at least one copy of this gene mutation.
2/3rd of cases worldwide
Which CFTR mutation is particularly frequent in the Lac St Jean region? Which proportion of cases are from there? Which CF class is it included in?
Class I mutation: 621+1G>T
Rare CFTR mutation (0.7% of all CF patients) but relatively frequent in the Lac St Jean region (23% from this area)
Which CFTR modulators have been approved for use for > 50% of people with CF?
Ivacaftor/lumacaftor (Orkambi)
Ivacaftor (Kalydeco)
Which CFTR modulators have been approved for use for > 50% of people with CF?
Ivacaftor/lumacaftor (Orkambi) --> 2 copies of F508 delta (class 2) Ivacaftor (Kalydeco) --> class 3 G551D mutation
Name 5 organs with clinical manifestations of CF
Lung (1st cause of death in CF)
Hepatobiliary (2nd cause of death in CF)
Often, those who are affected in the liver are less affected in the lungs
Pancreas (Pancreatic enzymes replacement therapy; If CF-related DM –> Insulin)
Intestines (Probiotics; polyethylglycol)
Reproductive system (especially men) Class 5 men may only know they have CF while they are trying to have children and are sterile
How prevalent is pancreatic insufficiency in CF? What is the significance of PI? What is used for patients in those cases? what are the symptoms of PI?
In 85-90% of people with CF
“severe” mutations typically involved in PI
Exocrine function/Acini destroyed years before endocrine/islets
Pancreatic enzymes do not reach the duodenum
Little/no neutralization of stomach acid
Maldigestion/malabsorption (also due to lining of intestine that is full of thick, sticky mucus)
Also due to lack of lipase from pancreas
Treatment:
For those patients we give pork lipase (in any religion)
Require pancreatic enzymes to digest/grow (PERT) for the rest of your life
Symptoms: Steatorrhea, diarrhea, malnutrition, bloating, fat-soluble vitamin deficiencies (very unlikely to get fat-soluble vitamin deficiencies unless CF), FTT
How prevalent is pancreatic sufficiency in CF? Why can those patients better absorb food? Are they at risk of any other problem?
10-15% of people with CF
“Milder” mutations (class 4-5)
Secretions less thick –> not fully obstruct and autodigest pancreas but +/- intermittent blockages/inflammation (they often present with acute pancreatitis)
Risk: acute pancreatitis can also lead to pancreatic insufficiency in the end
Do not require pancreatic enzyme supplementation
Recurrent attacks of “Acute pancreatitis” in 10% PS – can be initial presentation of CF
Pancreas can “burn out” and develop EPI over time
How does CF affect the intestines?
Failure of crypt cells to secrete Cl- = increased viscosity of luminal contents, thick mucus, less HCO3- near cell surface
Low HCO3- affects intestinal pH –> acidic environment –> decreased mixed micelle formation and solubility
- -> Different bacteria in mucus
- -> Poorer digestion, absorption
How frequent is SIBO among patients with CF? What are the risk factors/ mechanism for occurence?
In around 30-50% of patients with CF
Risk factors:
o Stasis/slow motility/ dysmotility; prior intestinal surgery, gastric acid suppression; thick intestinal mucus- dysbiosis (spectrum?)
Mechanism:
Excess bacteria/ metabolites damage enterocytes, deconjugate bile salts –> malabsorption
What are the symptoms of SIBO?
Abdominal pain, bloating, nausea, flatulence, diarrhea, anemia
What is done to diagnose SIBO?
o Poor (oral glucose) breath test reliability; pH pill o +/- Empiric treatment: Antibiotics, Probiotics (not covered)
Why are probiotics useful for people with CF? When can they be used?
Antibiotics are taken for the lungs (and many other things) but there is a systemic effect and it also goes in the intestine –> altering normal biota
Very abnormal biota –> good to give probiotics to retrieve normal biota, but need to wait for recovery of NEC and surgery.
Off TPN (not intestinal failure; can maintain normal growth through EN only) = bowel is potent enough to sustain risks of probiotics Need to be cautious, but not too much; do not wait too much, it must be used routinely with care.
What are the BMI goals for children and adults and CF? What are the goals based on?
Children: Goal is 50th BMI percentile for best lung function (FEV1 percent predicted)
Adults: BMI goal is 22 for women and 23 for men (FEV1 percent predicted as an indicator of lung function)
BMI percentile improvement = so does lung function (linear correlation) especially at low BMI
Low BMI = poor lung function
Poor lung function increases energy of breathing –> low BMI (vicious cycle)
Abdominal obesity can also worsen lung function –> need a middle ground
____ is an independent predictor of survival in CF. Why?
Weight/BMI is an independent predictor of survival
Increased stroke volume of heart, increased diaphragm strength with improved nutrition using overnight gastrostomy feeds (Can be PEG or NG if children prefer it)
What is the proportion of CF female adults who are underweight?
What is the proportion of CF male adults who are underweight?
– 29.6% of Canadian CF female adults are underweight
– 18.1% of Canadian CF male adults are underweight
Why do women have a higher prevalence of undernutrition in CF?
Women and young girls with CF can develop eating disorders - can not take their enzymes and not gain weight, have malabsorption etc. Can use this as a purging method
Often do not realize it is wrong before it affects their lives
What are the 3 main reasons why malnutrition is common in CF?
- Higher energy requirements
- Increased nutrient losses
- Decreased nutrient intakes
Why do people with CF have high energy requirements?
- Increased metabolic rate (genotype abnormality of CFTR gene already increases metabolism on a cellular level)
- Infections
- Work of breathing
Why do people with CF have increased nutrient losses?
- Malabsorption (even in the ones who take their pancreatic enzymes very well)
- The ones who are not given or who do not have access to enzymes die in the first year of life
- CF-related diabetes
- Mucus (glycoprotein: expensive to make from a metabolic point of view… –> loss of calories and protein in mucus)
Why do people with CF have decreased nutrient intakes?
- Anorexia (appetite stimulant may be used; or tube with agreement of child and parents; go slow)
- GERD
- Abdominal pain/constipation +/- DIOS (GI blockage)
- Medications (CF medications (e.g. antibiotics) can cause anorexia; other drugs such as attention deficit disorder drug (Concerta) –> major negative impact on appetite)
–> Straterra is better (has less of an impact on appetite)
OR can choose not to give meds in the summer, weekends etc.
Why do people with CF have decreased nutrient intakes?
- Anorexia (appetite stimulant may be used; or tube with agreement of child and parents; go slow)
- GERD
- Abdominal pain/constipation +/- DIOS (GI blockage)
- Medications (CF medications (e.g. antibiotics) can cause anorexia; other drugs such as attention deficit disorder drug (Concerta) –> major negative impact on appetite)
–> Strattera is better (has less of an impact on appetite)
OR can choose not to give meds in the summer, weekends etc.
How is PI diagnosed in children?
o Fecal elastase level o Strong genotype-phenotype correlation for pancreatic function (class I-III mutations associated with PI)
If the child is PS, how often should the fecal elastase test be performed?
If PS – repeat fecal elastase yearly for several years, and later, as symptoms require
What is the best method for pancreatic enzyme dosing?
Find the lowest effective dose
- -> symptoms well controlled
- -> normal weight gain on normal dietary intakes for age (Not eating too much for same results))
Start low and work dose up slowly so as to minimize harm (excoriation of the anus or mouth or stoma)
How much salt supplementation does a breastfed child with CF need?
2-4 mEq/kg/d ≈ ¼ - 1/8 tsp of salt
Why is breast milk preferred over formula in CF and SBS infants?
- Rich source of very long chain omega 3 FAs (DHA and AA) which are deficient in CF
- Immunoprotective
- Source of probiotics
Two cohort studies suggest that human milk provides pulmonary and other medical benefits to CF patients later in life (not immediate effect)
What should be looked at the most in infants with CF?
o Weight, height, and HC and full growth history
o Clinical appearance (Fat stores; muscle mass, abdomen) – skinfold measures may be taken
o Nutritional intakes and intake history
o Stool characteristics and stooling history
Is NS required in children with CF and FTT?
o FTT, if present at diagnosis, will improve with standard CF therapies
No invasive nutritional support required unless FTT refractory to standard therapies
No dietary supplementation is required until standard therapies are provided, and outcomes are observed
What are the main reasons for malnutrition in CF children?
– Higher energy requirements (minimal at this age)
o Increased metabolic rate
o Infections (daycare)
o Work of breathing
Increase chest physiotherapy, may need antibiotics or admission
– Increased nutrient losses: o Malabsorption (Difficulties taking enzymes, Maximal dose of enzymes often reached – multiple snacks and enzyme dose based on weight o CFRD (not common in this age group) o Mucus (minimal impact at this age)
– Decreased nutrient intakes o Anorexia (common issues: behavioural) o GERD o Abdominal pain/constipation +/- DIOS (common at this age; hydration, salt intake; fibre intake; enzyme issues) o Medications (ADHD medications concerta)
What are the main reasons for malnutrition in CF adolescents?
– Higher energy requirements o Increased metabolic rate o Infections o Work of breathing These issues worsen with age and progression of disease
– Increased nutrient losses
o Malabsorption – issues around enzyme adherence
o CFRF – more prevalent as patient ages
o Mucus – increases with age
– Decreased nutrient intakes
o Anorexia – multiple factors including body image
o GERD
o Abdominal pain/constipation +/- DIOS
o Medications – ADHD meds, antibiotics, etc.
What are the best treatments for growth failure in CF?
Treat the underlying problem; consider:
o Pulmonary infection therapies - Repeated infections can cause weight loss –> can talk to respirologist to get a clean up so there is less infections in the future and weight gain
o High energy/high protein diet
o Oral supplements
o Nocturnal EN
o Enzyme adjustments; consider acid suppressors; probiotics
o Constipation/DIOS therapies (PEG)
o Diabetes treatment (watch for DM after age 10)
o Behavioural interventions
o Appetite stimulants
o Motility agents
o Polypectomy (nasal polyps prevents tasting of food; sinusitis)
ETC.
What is the main treatment for TPN cholestasis?
Omegaven (100% fish oil)
Health Canada program; need to apply for the program
Only to be used in cases of children/infants with proven TPN cholestasis who are not going to go off TPN soon.
But this may change soon because SMOF lipids is on the market. Intralipid has a lot of phytosterols which are shown to contribute to TPN cholestasis
Name a common sign of cow’s milk protein allergy
Regurgitation/vomiting
However, it is also common in CF
Elevated eosinophils = indication of IgE-mediated allergy
What are the solutions to breastfeed when a child has cow’s milk protein allergy?
Mother needs to go on a cow’s milk protein and soya free diet.
What is an oral stimulation program and why is it used for?
Mom takes a little bit of breast milk and caresses lips, cheeks etc. positive interaction; loving and non-threatening
Used for children who got many surgeries and cannot be directly breastfed –> often have lost the window of time in which they usually learn how to coordinate suckling and breathing and swallowing; need to learn again by putting baby on the breast, smell the milk. Learn how to interact with the breast
Oral stimulation + non-nutritive suckling
What should you do if one HC measurement is off the curve
Wait for next measurement; easy to make an error for HC
How much E should you give in TPN vs EN?
10% less (no thermic effect of feeding)
What is the Barker hypothesis?
Barker hypothesis: forcing preterm infants into very rapid growth –> midlife + problems with CVD, HTN, obesity…
What does enteral starvation lead to?
• Blunting and loss of microvilli
• Reduced enzymatic activity
• Increased bowel permeability
*longer time without GI feeds –> less chance of tolerating the feeds afterwards
Name 6 benefits of trophic feeds
- Increase the intestinal mass and DNA synthetic rates
- Increased feeding tolerance
- Shorter time to full EN
- Improved weight gain
- Shorter time to hospital discharge
- No increase of NEC
What is the definition of SBS?
A malabsorptive state occurring as a result of surgical resection or congenital disease of a significant portion of the small intestine;
Amount of resection or remaining bowel affects degree of malabsorption and need for specialized enteral nutrition or parenteral nutrition (PN)
Define intestinal failure
Intestinal failure (IF), in the context of SBS, is defined as a dependence on PN to maintain minimal energy and fluid requirement for growth in children.
What are common causes of SBS in infants?
necrotizing enterocolitis, midgut volvulus, intestinal atresia, and gastroschisis.; also trauma.
What is a normal full term infant intestinal length? Adults? What defines SBS in term infants?
Normal full-term infants have a small intestinal length of 210-350 cm at birth (in contrast, the adult intestine is 600-800 cm)
SBS usually occurs when less than 75 cm of the small bowel remains functional (term infants only)
Why do preterm infants have a shorter bowel?
The SI almost doubles in length during the last trimester of pregnancy
What is intestinal adaptation?
What are the best methods to promote intestinal adaptation in infants?
Over months or years, residual bowel lengthens and dilates;
Process of “compensation” for the loss of intestinal surface area;
Human breast milk and nutrition through the gut (EN or oral) is necessary for maximal intestinal adaptation to occur
What is the treatmend for refractory intestinal failure?
Bowel lengthening surgeries exist Intestinal transplantation (last resort)
Name 7 predictors of successful intestinal adaptation
- Patient age (young = better)
- Underlying diagnosis leading to SBS (NEC) – removing the cause helps for adaptation
- The length and portion of small and/or large bowel resected – more loss = harder to recover
- The presence or absence of the ileocecal valve and/or colon
- Health of other organs that assist with digestion and absorption (pancreatic insufficiency?)
- Presence of bacterial overgrowth of the SI
- Types and amounts of EN post-op
Name 7 complications of SBS
- Malabsorptive diarrhea
- Fluid and electrolyte abnormalities (also present in CF)
- Micronutrient deficiencies (rapid transit time, malabsorption)
- Gastric hypersecretion
- Bacterial overgrowth
- Central venous catheter complications (breakage, central venous thrombosis, and catheter-related bacterial or fungal sepsis)
- Failure to thrive
What is the survival rate in pediatric SBS?
73-89%
Why is EN preferred in SBS (vs TPN)?
– Direct trophic effect on intestinal epithelium
– Stimulation of trophic hormones and pancreatic biliary secretions
Why is breast milk preferred in SBS?
Breast milk is preferred and has been associated with:
– Decreased duration of PN: mean duration of PN 290 vs 720 days in non-breast milk infants (AL = 255 days)
– Immunoprotective properties
– Effects on intestinal microbiota
– Very long chain TG, free AAs, nucleotides and growth factors
Why should we initiate early oral feeding in babies with SBS?
– Early oral feeding for stimulation of oral feeding skills and to stimulate the suck and swallow reflexes (put child on the breast to make him/her learn)
– Early oral feeds also stimulate oral digestive enzymes (lingual lipase and amylase)
Should we start with continuous or bolus feeds on children with SBS?
Continuous
At what age should solid food be introduced? why? What about common allergens?
Solid food can be introduced at the age of 4 to 6 months to stimulate oral motor activity and to avoid feeding aversion behaviour
o Introduce highly allergic foods early to prevent allergies
o Peanut puree very early
Clinical decisions around the enteral feeding regimen are determined by which factors?
• Stool or ostomy output (How does it look like? Liquid?)
• Evidence of malabsorption
• Abdominal distension
• Vomiting/regurgitation
• Irritability/pain
Decisions related to advancing enteral feedings and weaning PN are based almost completely on experience and art, rather than evidence-based algorithms
What are the 5 principles of feeding advancement in infants with SBS?
- Quantify feeding intolerance primarily by stool or ostomy output and secondarily by reducing substances. Reducing substances should be measured twice daily
- Tolerance assessed no more than 2x per 24h. No more than 1 advance per 24h period
- Ultimate goals: 150-200 ml/kg/d; 100-140 kcal/kg/d
- If ostomy/stool output precludes advancement at 20 cal/oz for 7 days, then increasing caloric density of the formula can be performed
- Isocaloric reductions in PN support should be undertaken simultaneous with feeding advancement
What to do if stool output is < 10g/kg/d or < 10 stools/d? between 10-20 g/kg/d or 10-12 stools/d? > 20 g/kg/d or > 12 stools/d?
- advance rate by 10-20 ml/kg/d
- No change
- Reduce rate or hold feeds
What to do if ileostomy output is < 2g/kg/d? between 2-3 g/kg/d? > 3 g/kg/d?
- Advance rate by 10-20 ml/kg/d
- No change
- Reduce rate or hold feeds
What to do if stool reducing substance <1%? =1%? > 1%?
< 1% = advance feeds per stool or ostomy output
= 1% = no change
> 1% = reduce rate or hold feeds
What to do with feeds if signs of dehydration are absent? Present?
Absent: Advance feeds per stool or ostomy output
Present: Reduce rate or hold feeds
Name the pros and cons of hydrolyzed or AA-based EN formulas for SBS infants
PROS: (vs regular formula)
o Evidence of improved absorption with hydrolyzed or AA formulas
o Less risk of secondary intestinal allergic disease (prevalence of challenge-confirmed CMPA 2-4 folds higher in SBS than in control populations
CONS:
o Require calcium/phosphorus supplementation, especially in premature infants
o Hypophosphatemia –> at risk of rickets (although there should be enough P, Ca and VD in the formula… we do not know why rickets is so prevalent on this formula)
o Expensive
o Follow closely for bone health, especially for children on Neocate®
o Highly processed formulas contain more aluminum –> not good for children with kidney abnormalities
Why are regular infant formulas risky for SBS infants?
Regular infant formulas can induce allergy (risk) due to short bowel
In which cases can banked human milk be used?
Only used in preterm infants and infants with NEC (very expensive)
What is the main risk in using fortified breast milk to 81 kcal/100mL or greater?
Higher risk of osmotic diarrhea
What are the foods to avoid in SBS?
Milk protein in allergic patients
Juices (d/t sorbitol)
Fruits
Concentrated CHO in foods or oral medications
o Broken down by GI bacteria into small, osmotically active organic acids that can exert a significant osmotic load in the distal small intestine and colon
o Glucose may be absorbed without hydrolysis, but its small molecular weight increases osmolality
Where is protein absorbed?
Stomach and proximal SI
What are the 8 most common foods to cause allergy?
• Eggs • Fish • Milk • Peanuts • Shellfish • Soy • Tree nuts • Wheat To introduce one at a time
Are soluble fibers promoted in SBS? What are sources of soluble fiber?
- Avocado
- Banana (exception to the no-fruit recommendations)
- Potatoes
- Carrots
- Citrus fruit
- Oatmeal
- Peas
- Sweet potato
- Squash
- Legumes (beans, lentils)
Name 4 methods to nutritionally prevent TPN cholestasis (nutritional management of TPN cholestasis)
- avoid overfeeding (90-100 kcal/kg)
- Cycle PN off at least 2-6h per day (promote cyclic release of GI hormones)
- Aggressively treat and prevent infections (CVC care, bacterial overgrowth)
- Push EN
Excess _______ losses from excessive ostomy output or diarrhea may result in impaired growth despite adequate caloric intake
Sodium
often requires sodium supplementation in the enteral formula
• Infants may require up to 4–8 mEq/kg/day to achieve adequate growth (double normal requirements)
o Chronic hyponatremia impairs growth
• Infants with CF have even higher sodium requirements (sweating ++ Na and Cl)
Infants with SBS may require supplement of which vitamin(s)?
- Infants with CF require fat-soluble vitamin supplements to prevent deficiencies
- SBS infants are at higher risk of vitamin and mineral deficiencies
- (This is only applicable to EN/oral because no malabsorption in TPN; do not supplement fat-soluble vitamins in TPN)
Name 2 complications of SBS
Since TPN is essential to start with in infants with SBS, this life-saving therapy has brought with it a set of serious and sometimes life-threatening acute and chronic complications, including
- PN-associated liver disease (PNALD) or
- PN-related cholestasis.
What is the frequency of PNALD in infants with prolonged TPN? What does PNALD lead to?
PNALD occurs in 40% to 60% of infants receiving prolonged courses of TPN.
Infants with PNALD can have progressive changes in liver histology, including fibrosis and eventually cirrhosis.
What are risk factors for TPN cholestasis?
o Prematurity o Multiple abdominal surgeries o Lack of enterally stimulated bile flow o Bacterial sepsis o Components or deficiencies or TPN o UV light exposure? o Phytosterols in soy-derived IV lipid solutions
Name reasons why incidence of TPN cholestasis is declining
o Vigilant daily catheter care
o Modifying TPN formulations
o Infusing TPN over < 24h (TPN cycling)
o Administration of pediatric amino acid formulations that include specific “targeted” AAs
o Limiting dextrose infusion to decrease steatosis (avoid overfeeding dextrose)
o Limiting manganese (and aluminium)
When direct bilirubin hits a certain number, hold manganese (give 1x/week)
When it hits another higher level, hold manganese
Deposits of heavy metals in organs of people on long-term TPN (Mn, Al, Zn)
o Decreasing and/or altering the type of lipids administered (fish oil reverses PNALD and resolves it in «< time than soybean oil)
o Protecting TPN from light at all steps and stages from TPN compounding to delivery
How much time does it take for fish oil to have an effect on cholestasis resolvement?
6 weeks
Which enzyme peaks when on TPN and declines when EN is started?
GGT
What are nursing techniques parents with a child on home TPN must learn?
- Central Venous Line (CVL) care
- Using the infusion pump
- Heparin locking CVL daily since TPN is cyclic
What are pharmacist techniques parents with a child on home TPN must learn?
- Aseptic techniques
- Adding vitamin/mineral mix prior to infusion
- Mix 2-in-1 bag
Why does a home need space for children on TPN?
a. TPN designated fridge
b. Back-up generator in case of power failure
House must also be clean and safe
Why do SBS patients develop oral aversion? When are solids typically introduced?
- May be a direct result from prolonged intubation, NG tube feedings, hospitalizations
- Eating is not pleasurable and maybe associated with very negative feelings
- Solids are typically introduced 4-6 months (corrected for GA)
- Significant feeding skills delay in SBS patients
Who is included in a specialized feeding team and what are the main roles?
– Behavioural psychologist
o Guide caretakers with their interaction during meals
– MD
o GI, ENT, general pediatrician
o Ensure no other medical problem is contributing to the feeding disorder
– Occupational therapist
o Sensory processing disorder or feeding disorder
o Feeding disorders that pertain to oral motor skills and swallowing
– Nutritionist/Dietitians
o Nutritional needs
o Transitional feeds (off TPN and off EN, increasing PO feeds)
What is the most common food allergy in infants and young children? What is the prevalence?
Allergy to cow’s milk is the most common food allergy in infant and young children. The prevalence of CMA in children living in the developed world is approximately 2-3%
What are symptoms of cow’s milk protein allergy?
can be mild like rash or severe, such as anaphylaxis
What are the 2 types of cow’s milk protein allergy? Explain them and the symptoms of each.
Cow milk allergy can be further split into IgE and non-IgE (mostly cellular) mediated.
o IgE-mediated reactions are well recognized with validated diagnostic tests.
IgE-mediated allergy is associated with atopic manifestations such as urticaria, angioedema, vomiting, diarrhea, eczema, rhinitis, and anaphylaxis.
o Non IgE-mediated immune reactions are not so well defined and more difficult to recognize.
Non-IgE-mediated allergy is associated with symptoms including gastro-esophageal reflux, vomiting, constipation, hemosiderosis, malabsorption, villous atrophy, eosinophilic proctocolitis, enterocolitis, and eosinophilic esophagitis
Why do SBS children have more cow’s milk protein allergies?
Increased intestinal contact with undigested food proteins and peptides remnants could increase the risk of food allergies.
2 to 4-fold increase in CMPA
Name 4 other conditions associated with higher CMPA
– Atresias,
– Hirsprung disease
– Congenital diaphragmatic hernia
– Hepatic transplant surgery
What are the proposed mechanisms for higher prevalence of CMPA in SBS?
– GIT dysfunction
– Surgical invasion
– Small bowel bacterial overgrowth
– Villous atrophy
Name 2 ways to prevent allergies in SBS children
Human milk contains the optimal macronutrient composition for human growth, as well as trophic factors which may foster intestinal adaptation, and immunoglobulins and other immune factors that may enhance mucosal barrier function;
Due to the risk of secondary intestinal allergic disease, a hypoallergenic hydrolysate (peptide based) or amino acid based formula is recommended in the absence of EBM.
Define “probiotics”.
“live microorganisms that when administered in adequate amounts confer a health benefit on the host”
What are the actions of probiotics?
– Colonization resistance by competing for nutrients and attachment sites with pathogenic bacteria.
– Production of antibacterial molecules such as SCFA, acetate and lactate which lower the luminal pH to inhibit the growth of pathogens.
Why are probiotics useful in CF?
– A state of dysbiosis has been demonstrated in the CF gut (wrong bacteria in the lung and GI in abundance)
o Abundance of pathogenic bacteria and paucity of beneficial bacteria
– Promising and consistent findings across a number of small clinical studies suggest that probiotics might:
o Reduce pulmonary exacerbations
o Decrease GI inflammation in people with CF (measured through calprotectin)
– There is not sufficient high-quality evidence at this time to recommend specific probiotic species, dose, etc.
– One RDBCT multicenter study showed a significant reduction in gut inflammatory marker (calprotectin) and an increase in intestinal comfort
– MUHC has chosen to use probiotics in CF care.
o Issue: COST
o Biogaia used at MUHC
Should probiotics be used in SBS?
– The fecal microbiome of children with SBS is significantly different than that of healthy controls
– A recent systematic review of the literature found a few available studies:
o Animal studies
Showed consistent benefits of probiotics in increasing bacterial translocation and improving intestinal adaptation in SBS
o Case control study
Positive impact of probiotic supplementation on growth (increased weight and length velocities), and serum proteins.
o 5/9 case reports
Cessation of diarrhea, improved fecal flora, improved weight gain, and faster weaning off PN
o 4/9 case reports
Reported adverse effects such as lactobacillus sepsis (n=3) and D-lactic acidosis (n=2)
What to do if a child transitioning from PN to EN losses 10% weight?
Go back to TPN
The WHO growth charts are based on a primarily (breast fed/bottle fed) population
based on longitudinal data for a Breast fed
How frequently should children from 2-19 be weighed and measured?
Once per year + at acute or emergent clinic and hospital visits + if concerns identified
How frequently should children from 0-2 be weighed and measured?
within 48 hours of discharge or 1 to 2 weeks of birth and at 1, 2, 4, 6, 9, 12, 18, and
24 months of age.
3 main activities of growth monitoring
Assess
Analyze
Advise
What was the main finding of the multicenter growth reference study (MGRS)?
Despite the differences in racial and ethnic background, there were minimal differences in rates of linear growth observed among the six countries. This attests to how the growth charts can be applicable worldwide.
WHO vs CDC: Longitudinal data or cross-sectional data
WHO: longitudinal (children sampled 21 times between birth and 24 months)
CDC: cross-sectional
WHO vs CDC: Based on a predominantly breastfed population vs not breastfed
WHO: Based on a predominantly breastfed population
CDC: Based on a predominantly not breastfed population
WHO vs CDC: based on 6 developed and developing nations or single country’s growth pattern
WHO: 6 developed and developing nations
CDC: Single country’s growth pattern
WHO vs CDC: prescriptive or descriptive
WHO: prescriptive
CDC: descriptive
Why did Canada adopt the WHO growth charts?
– The strengths of the WHO charts
– Multicultural nature of Canada
– The fact that there is no national Canadian database of anthropometrics for children less than 2 years of age.
Why does the canadian adaptations of the WHO growth charts include the 99.9th percentile?
to improve the ability to detect the extremes of obesity
What are the 2 issues in the application and interpretation of the growth charts with this population?
- Firstly, a larger number of children will be “moved up” in the growth curve, thus classified as obese or overweight, where previously they would have been borderline normal in weight or BMI
- Secondly, the new WHO growth curves may cause problems with the diagnosis of Fetal Alcohol Syndrome Disorder, which is based on growth retardation
What were the changes made to the WHO growth chartes in 2014?
• The shading used in the 2010 colour charts did not add to the meaningfulness of the charts and they also did not fax well.
• There were concerns that the inclusion of the 0.1 and 99.9 percentile curves led to some practitioners concluding that a child’s growth that fell within these curves (0.1-3 and 97- 99.9) was normal. The 0.1 percentile was removed from all charts. It is a cut-off for severe wasting/ underweight. Where the 99.9 percentile is a cut-off point, it remains on the appropriate charts, namely:
o 0-2 years –Weight-for- length – cut-off for obesity;
o BMI-for-age- 2-5 years – cut-off for obesity and
o 5-19 years – cut-off for severe obesity.
Note that the 99.9 curve is a dashed curve rather than solid curve to demonstrate that if a child’s growth falls between the 97 and 99.9 percentile or beyond the 99.9th then guidance for further assessment, referral or intervention is recommended.
What are the growth charts measuring for each of the 2 genders from 0-24 months?
Length for age
Weight for age
HC
Weight for length
What are the growth charts measuring for each of the 2 genders from 2-19 years?
Height for age
Weight for age
BMI for age
Should weight for age be used to monitor weight beyond age 10?
No. BMI-for Age rather than Weight for Age is considered by the WHO to be best indicator for monitoring a child’s weight beyond age 10. However, if a practitioner chooses to plot and monitor Weight for Age beyond 10 years of age, these results should be considered in conjunction with BMI-for-Age.
How should an infant’s length be measured in children <2?
- To measure an infant’s length, 2 trained people, or one trained person and a caregiver, are to use a calibrated length board with fixed head piece and a movable foot piece.
- Infant should be wearing light underclothing or diaper, placed on his back and lying flat.
- Both legs should be extended and toes pointing upwards with feet flat against the foot piece of the length board.
- Record measurement to the nearest 0.1 cm. One important thing to note is that common practice may be using only 1 trained person without a calibrated length board. Therefore we may need to be cautioned of the accuracy of these measurements.
What are the 3 components of accurate measurements?
- Quality equipment that is accurate and regularly calibrated
- Standardized measurement techniques
- Trained measurers
Which “age” should be used to plot on fenton’s growth chart based on corrected GA?
Plot on Fenton’s growth chart based on corrected gestational age
Plot on WHO growth chart based on corrected chronological age
How should head circumference be measured in children < 2?
The head circumference should be measured with a flexible, non-stretchable tape measure. Prior to measuring head circumference, remove or undo hairstyles or hair accessories that may interfere with the measurement.
– Position the tape measure
– just above the eyebrow
– and above the ears
– and around the biggest part on the back of the head.
– Record measurements to the nearest 0.1cm
– Ideally, obtain at least 2 separate measurements for accuracy. (repeat 3 times)
How should weight be measured in children and adolescents?
Children older than 2 years of age should be weighted standing in the middle of a beam balance or a digital scale while wearing lightweight outer clothing or light undergarments.
Record weight to the nearest 0.1 kilogram.
If child is unable or reluctant to stand still, he or she may need to be weighed while held by someone, with the weight of the person holding the child subtracted from the combined weight .
How should weight be measured in infants < 2?
An infant should be weighted nude on a calibrated beam or electronic scale which should be accurate and reliable with a maximum weight of 20 kilograms in 1 or 10 gram increments.
Weight should be recorded to the nearest 10 grams. It is important to note that when plotting an infant’s weight on the growth chart, you will need to plot to the nearest 100 grams even though you have recorded the weight to the nearest 10 grams.
How should height be measured in adolescents or children >2?
A child or an adolescent’s height should be measured using a stadiometer with a horizontal head piece that can come into contact with the top of the child’s head.
The child should be standing with his or her back against the stadiometer without shoes.
He or she should have heels together, legs straight, arms at sides, shoulders relaxed and looking straight ahead.
Record the measurement to the nearest 0.1cm.
What is the first indicator in assessing fatness in children and adolescents over 2 years of age
BMI-for-age
What defines a “normal” growth pattern?
- follows the same growth curve over time
- falls between the 3rd and 85th percentiles; AND
- is proportional with respect to the weight and the length or height.
When may it be normal to cross both the weight and length or height percentile curves?
the crossing of BOTH weight and length or height percentile curves may be normal in the first 2 to 3 years of life and at puberty
Although the WHO growth chart is applicable to the breast fed and non-breast fed babies, how do the pattern of growth of both differ within the first year?
Breastfed infants tend to grow slightly faster than non-breastfed infants in the first 6 months, some non breast-fed infants may appear to grow more slowly during the first 6 months and more rapidly from 6 to 12 months of age compared to the WHO growth chart
Why is the weight-for-age not plotted beyond 10 years of age in the WHO growth charts?
This is largely because of the difficulty in distinguishing change in weight due to an increase in height versus a change in body composition, or both which can happen around the time of pubertal growth spurt. This doesn’t mean you should not measure weight at all. Instead of plotting it against age, use the weight to calculate BMI.
Should we provide further assessment in children who cross 2 percentile lines on the growth chart?
crossing of two percentile curves on the growth chart has been used historically to identify the need for further assessment. This method has not been validated for identifying growth problems and could leave to delayed investigation of abnormal growth. Changes in height for weight, weight for length, and BMI for age percentiles should be assessed before crossing two percentile lines, particularly in children and adolescents.
What should we consider in evaluating growth that does not follow a healthy pattern?
- Parental height
- Nutritional intake
- Presence of chronic illness
- Special health care needs (e.g. Downs syndrome, cerebral palsy, cystic fibrosis)
- Gestational age, birth weight and feeding method (breast/formula) for infants
Can a growth chart signle point be used to screen for the need for further assessment?
Yes, single measurements can be used to screen for the need for further assessment while serial measurements will provide information on growth pattern and trends
Can cut-off points on growth charts be used as a diagnostic criteria?
No
