Pediatrics I: Enteral Nutrition Flashcards
EN Protein requirements
- 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
Protein function during growth
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.
EN energy requirements
- 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
Predicted BMR
Dont memorize
Activity factors
Need to consider both chronological/developmental age of child and what is normal activity for that age
Fluid recommendations
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?
What weight to use in calculating energy, protein and fluid requirements
- 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
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)
- 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
*
How far apart should Energy in kcal/kg vs BMRxAFxSF be apart to be accurate?
most energy estimates are only accurate within 150- 300 kcal/d.
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)
- 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)
Definitions of overweight
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
Skin fold measures to assess body composition
- 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
Infants and BM
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)
Formula selection for infants and children
A complete nutritional evaluation including
* Energy & protein requirements
* Fluid & electrolyte status
* Digestive capacity & diagnoses
* Age consideration n Product availability
Energy density of infant and child products
- 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
Premature infant formulas
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)
What is in infant/ children formulas?
- 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)
polymeric formula vs. semi-elemental and elemental
- 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
Indications for tube feeding
- 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
contraindications to EN
- 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
Adminstration of EN in infants and children
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
Case 4 EN feeds
Peds Nutrition I Notes
Preventing allergy development
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
Dietary Treatment of CMA/Soy Allergies
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
