Pediatrics I: Enteral Nutrition

Question 1

EN Protein requirements

Answer 1

• 0-2 months: 2.2 g/kg/d
• 3-11 months: 1.4 g/kg/d
• 1 yr: 1.2 g/kg/d
• 1-6 yrs: 1.2-1.5 g/kg/d
• 7-10 yrs: 1.0 g/kg/d
• Only about 6% more adults needed during puberty

Question 2

Protein function during growth

Answer 2

Required for synthesis of new body tissue during growth, synthesis of enzymes, hormones etc.
* Additional protein is NOT required for catch-up weight gain
* Protein needs vary. Use actual body weight for protein in this course.

Question 3

EN energy requirements

Answer 3

• 0-3 yrs: 100-110 kcal/kg (BF infants get ~95-100 kcal/kg in first month but goes up once GI tract working better)
• 4-6 yrs: 80-90 kcal/kg
• 7-10 yrs: 60-70 kcal/kg

Question 4

Predicted BMR

Dont memorize

Answer 4

Question 5

Activity factors

Answer 5

Need to consider both chronological/developmental age of child and what is normal activity for that age

Question 6

Fluid recommendations

Answer 6

Base on best estimate of dry weight
* An essential component of parenteral nutrition
* Need to consider TFI of pt (total fluid intake)
* Assess other sources of IV fluid, ex maintenance line, meds – does TPN meet req’ts or are other IV’s req’d?

Question 7

What weight to use in calculating energy, protein and fluid requirements

Answer 7

• Use IBW to calculate nutritional requirements (calories) when actual body weight < 90% IBW
• Always use best estimate of dry weight and/or actual weight for assessment of fluid/protein requirements

Question 8

Calculation of energy, protein and fluid needs for 4 year old boy:
* Wt= 13 kg (3%-ile); Ht= 103 cm (50%-ile)
* % IBW=13/16 =81% (mild risk of Malnutrition)

Answer 8

• Energy (kcal/kg): 90 kcal/kg so 1449 kcal/d (based on IBW=16 kg))
• Energy (BMRxAFxSF): BMR=22.7x16kg+495=858; TER = BMR x 1.7=1459 kcal/d
• Fluid: 100 mls/kg for first 10 kg + 50 mls/kg (for weights between 10-20 kg) = 100 mls/kg x 10 kg + (50 mls/kg x 3 kg) = 1150mL
  *

Question 9

How far apart should Energy in kcal/kg vs BMRxAFxSF be apart to be accurate?

Answer 9

most energy estimates are only accurate within 150- 300 kcal/d.

Question 10

Calculation of energy, protein and fluid needs for 5 year old girl:
* Wt= 17 kg (25%-ile); Ht= 112 cm (75%-ile)
* % IBW=17/20 =85% (mild risk of Malnutrition)

Answer 10

• Energy (kcal/kg): Use IBW so 80-90 kcal/kg x 20 kg =1600-1800 kcal/d
• Energy (BMRxAFxSF): =949x1.7=1613 (approximately 80 kcal/kg; within the 200-300 kcal/d expected difference)
• Protein: 1.2-1.5 g/kg/d x 17 kg=20-25.5 g/d
• Fluid: 100 mls/kg x 10 kg + 50 mls/kg x 7 kg=1350 mls (use actual weight for fluid)

Question 11

Definitions of overweight

Answer 11

Based on BMI kg/height in m2
* Risk of Obesity: BMI ≥ 95%-ile on growth curves (by gender, age)
* Risk of overweight:BMI ≤ 85%-ile - BMI < 95%-ile on growth curves (by gender, age)
* Limitations: fails to consider seasonal variations in growth of children

Question 12

Skin fold measures to assess body composition

Answer 12

• Tricep skinfold measures-reflective of body fat stores: values < 3%-ile indicative of energy depletion specifically related to subcutaneous fat stores (tells information on fat depletion)
• MAC: Mid-arm circumference reflective of both fat and lean body stores (energy: fat and protein).
• Mid-arm Muscle Circumference (MAMC) reflective of lean body mass: values <3%-ile indicative of energy/protein depletion
• Bioelectrical Impedance Analysis: FM and FFM

Question 13

Infants and BM

Answer 13

Gold Standard (immune properties, digestibility, DHA, ARA)
* 2800 kJ/L (20 kcal/oz)
* Fore milk – higher in CHO, satisfies thirst
* Hind milk – higher in fat, isolate in FTT
* Exclusive breastfeeding for the first 6 months of life
* Need Vitamin D supplementation (400 IU)

Question 14

Formula selection for infants and children

Answer 14

A complete nutritional evaluation including
* Energy & protein requirements
* Fluid & electrolyte status
* Digestive capacity & diagnoses
* Age consideration n Product availability

Question 15

Energy density of infant and child products

Answer 15

• Most infant formulas = 0.67 kcal/mL
• Enteral products for children 1-10 typically 1 kcal/mL
• Most formulas are isotonic (300 mOsm); easy to tolerate
• Protein concentrations can vary: Infant formulas .015 – 0.020 g/mL; Enteral products: 0.03 g/mL

Question 16

Premature infant formulas

Answer 16

Designed for premature infants weighing < 1800-2000 g
* Formulated to meet requirements for third trimester.
* Compared to BM & standard formulas: Higher content of calories, protein, calcium, phosphorus
* Not available in retail stores (Enfamil A+ Premature, Similac Special Care)

Question 17

What is in infant/ children formulas?

Answer 17

• Cow’s milk based infant formulas (eg Enfamil A+)
• Soy based infant formulas (Isomil)
• Whey hydrolysates infant formulas (eg Good Start)
• Casein hydrolysates infant formulas (eg Pregestimil, Nutramigen, Alimentum)
• Polymeric feeds (Resource Just for Kids, NUTREN Junior, Pediasure)
• Semielementatl (eg Peptamen Junior)
• Elemental infant formulas for liver babies (eg NEOCATE, NEOCATE JUNIOR)

Question 18

polymeric formula vs. semi-elemental and elemental

Answer 18

• Polymerics (eg Pediasure, Resource just for Kids, Nutren Junior); usually 1 kcal/ml, protein concentration = 30 g/L or 0.03 g/mL
• Semi-elementals: Peptamen Junior (hydrolyzed whey); GERD
• Elementals: Vivonex Pediatric, Neocate Junior (now NEOCATE 1); ready to feed usually 0.8-1.0 kcal/ml; protein varies

Question 19

Indications for tube feeding

Answer 19

• Inability to coordinate suck and swallow (prematurity of birth, brain injury, increased intracranial pressure)
• Debilitated newborns
• Orofacial malformations
• Severe respiratory illness
• Severe cardiac disease leading to FTT
• Failure to thrive (FTT)
• Severe GERD leading to high risk for aspiration
• Renal disease
• HIV
• Short-bowel syndrome
• Crohn’s Disease (nutritional rehabilitation and treatment of disease)
• Intestinal pseudoobstruction
• Anorexia nerovsa
• Muscular Dystrophy
• Liver Disease

Question 20

contraindications to EN

Answer 20

• Expected need less than 5-10 days (for adults); for children 24-48 hours
• Severe acute pancreatitis; may feed carefully be below Ligament of Trietz
• High-output proximal fistulas; where IV replacement of losses difficult
• Intractable diarrhea or vomiting (especially when chemotherapy places patient at high risk for upper GI bleed)
• Complete bowel obstruction; with partial bowel obstructions can feed distal to obstruction very carefully please!
• Severe coagulopathy
• Portal hypertension
• Abdominal wall infection
• Massive Ascites
• Careful: peritoneal dialysis

Question 21

Adminstration of EN in infants and children

Answer 21

Continuous feeds over 24 hours
* under 6 months usually do oral feeding + top up pump but not usually continuous unless super risk for aspiration, intestinal failure, cardiac/liver failure

Question 22

Case 4 EN feeds

Answer 22

Peds Nutrition I Notes

Question 23

Preventing allergy development

Answer 23

Encourage exclusive breastfeeding for at least the first 6 months of life to decrease the risk of allergy in infants with a positive family history (gold standard)
* Extensively hydrolyzed protein formulas-good alternatives for prevention if decision not to breast feed or insufficient breast milk available
* Efficacy of partially hydrolyzed formulas-not proven
* Restriction of maternal diet during lactation in children with positive family history of atopy not associated with a decreased risk in incidence or severity of atopy in offspring
* Soy is not an appropriate choice for prevention of atopy in high risk populations

Question 24

Dietary Treatment of CMA/Soy Allergies

Answer 24

Elemental or amino acid formulas-needed in severe cases of CMA/Soy allergies
* Goats milk NOT appropriate-shares similar antigenic properties to cow’s milk protein