Pediatrics Intro Part II Flashcards
Rapid decrease in weight
Likely dehydration
Rapid increase in weight?
Likely fluid overload
What is considered in fluid intake?
- IV fluids
- PN
- Blood products
- Medications
- EN
Decreased urine output or dark urine
Likely dehydration
Increased urine output?
Likely fluid overload
What is considered in fluid output?
- Urine
- Gastric
- Stool
- Bile
- Chest tube
- Wound
- Skin
Vitals suggestive of dehydration?
- Increased heart rate
- Increased losses with fever
Vitals suggestive of fluid overload?
-Increased respiratory rate
Addition of a diuretic or change in frequency of medications?
-May risk dehydration
Fluid retention with steroids or excessive Na intake?
May cause fluid overload
Physical exam showing potential dehydration?
-Thirst, dry lips, dry mucous membranes, dry skin, headache, dizziness
Physical exam showing potential fluid overload?
-Peripheral, facial and orbital edema, increased abdominal girth, shortness of breath
What does EBM mean?
Expressed Breast Milk
What does PHM mean?
- Processed human milk
- Typically pasteurized donor term breastmilk
Are the WHO DRIs for healthy children?
Yes, where patients receiving less than the DRI will often not experience normal growth
What do we want to achieve at least at a minimum?
The BMR
- -> often the first step to achieved
- -> Eventually we want to move-up to reaching the DRI, however it is unlikely possible in the intensive setting when fluids (and therefore nutrition) is quite limited
Acceptable AMDR of CHO for all ages?
45-65%
AMDR 5-10% protein?
1-3 years
AMDR 10-30% protein?
4-18 years oldr
AMDR 10-35% protein?
19 years old and over
AMDR 30-40% fat?
1-3 years old
AMDR 25-35% fat?
4-18 years old
AMDR 20-35% fat?
19 years and older
When is AMDR of 5-10% appropriate for n-6 PUFA?
All ages from 1-19 years old
When is AMDR 0.6-1.2% appropriate for n-3 PUFA?
All ages from 1-19 years old
What is maintenance fluid?
- 100% of requirements of fluids will provide 100% maintenance fluid
- Therefore, a certain % of the maintenance fluid will be allocated to tube feeds
A 5-year child has an allowance of 75% maintenance fluid weight 32.5 kg, what amount of fluid is permitted for tube feeds?
1) Calculation: 1500 ml +(20ml/kg x 12.5 kg) = 1750 = 100% of maintenance fluids
2) 0.75 x 1750 = 1312.5
- -> DECIMALS MAKE A DIFFERENCE IN INFANTS
How many calories is breastmilk
67 kcals per 100 mls, and then is concentrated and fortified as the baby is restricted.
Breastmilk is often concentrated and fortified if the baby is fluid restricted, what are the possible concentrations?
-67, 81, 91 and 100
What is premature formula? When is it used? What is the nutrient profile like?
- Cow’s milk based
- before 37 weeks or VLBW
- Increased kcals, protein, calcium, PO4, and vitamins and minerals
Examples of premature formulas?
- Enfamil Enfaprem
- Enfaprem HP
- Similac Special Care
What sis the preferred source of enteral nutrition in all infants, including premature and sick newborns?
Breastmilk
When is breastmilk contraindicated?
- Galactosemia
- Congenital lactase deficiency
- Maternal HIV
- Use of some medications
Which milk i more diluted than expressed breast milk?
PHM
–> breastmilk from a premie milk is actually more dense in kcals
(T/F) Breast-milk must be fortified to meet the needs of the premie
T
What is fortified in premature breastmilk? At what age?
- Increase kcal, protein, calcium, PO4 and other vitamins and minerals
- Will increase overall osmolarity
- When baby below 35 weeks or 1.8 kg
What is discharge formula?
Even after premies are at term, their growth is different a they were not grown in utero, therefore the discharge formula will be provided
-Increased kcals, protein and vitamins and minerals
When is regular formula used? What are they composed of?
- For >37 weeks tp to 1 year
- Cow milk based
- Transition milks are also available
examples of regular formulas?
- Enfamil A+
- Similac Advance
- Goodstart
Which formula is NOT hypoallergenic?
Partially hydrolyzed formulas
What is CMPI?
Cows Milk Protein Intolerance
(T/F) Partially hydrolyzed formulas are appropriate for CMPI
F
When is a partially hydrolyzed formula recommended?
- For infants who are not tolerating the normal formula
- Often colic–y
- Reduced to no lactose, and the proteins are hydrolyzed
Examples of partially hydrolyzed formulas?
- Enfamil Gentlease
- Soy similac Sensitive
- Isomil Goodstart
Which formula is appropriate for infants with CMPI?
- Extensively hydrolyze formula
- It IS hypoallergenic
What does the extensively hydrolyzed infant formula contain?
-Free amino acids, small peptides, LCT and MCT, lactose free
When may extensively hydrolyzed formula be used?
- GI intolerance
- Cow and soy protein intolerance
- Malabsorption such as in CF, SBS and Cholestasis
Which extensively hydrolyzed formula has a higher proportion of MCT oil? When is it used?
- Pregestimil
- Often used if liver disease or if chylothorax
When is the 100% amino acid formula utilized?
- Hypoallergenic and has free amino acids
- For GI intolerance, extreme protein hypersensitivity, suitable for CMPI, eosinophilic GI disorders
- Also can be used for transitioning for PN to EN, or SBS
When are polymeric formulas used?
for oral and enteral use
When are semi-elemental forumalas used?
- For malabsorption SBS
- Transition to TPN
When is elemental used?
For severe GI impairment
When is specialty formula used?
For specific diseased conditions
When are metabolic formulas utilized?
For babies/children with confirmed inborn errors of metabolism
-These specialized formulas or food which is lacking in specific culprit amino acid,CHO or fat
When is EN required for children
-Unable to meet more than 80% of caloric needs by mouth or who require an extended period to time to eat (i.e. > 4 hours)
What are 2 scenarios where EN should be commenced at any time at admission?
- Patients who have been unable to eat for 3-5 days
- 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
What are the benefits of EN?
- Maintains gut mucosal integrity
- Stimulates oral and GI activity
- Prevents pancreatic and biliary flow dysfunction
- Has fewer complications an lower risk of infection
- Lower costs
When shouldEN should be started as soon as possible, within 48-72 hours of admission if hemodynamically stable
- Infants
- Patients who were malnourished before illness or injury
- Septic or injured patients in whom a prolonged intensive care course is anticipated
Chronic indication for EN under the age of 2?
- Poor growth or weight gain for more than 1 month
- Decrease of 2 or more weight or height growth channels
- Triceps skinfold <5th percentile
Chronic indication for EN over the age of 2 years old?
- Weight loss or lack of weight gain for 3 months
- Decrease of 2 or more weight or height growth channels
- Triceps skinfold <5th percentile
When does the swallowing reflex develop?
As soon as 12-14 weeks
Functional barriers which lead to indications for EN?
- Neurological or neuromuscular disorders which are associated with swallowing difficulties, delayed gastric emptying, or oral aversions
- Genetic or metabolic syndromes
- Prematurity
Which neurological or neuromuscular disorders may be indications for EN?
- SMA
- Anoxic brain injury
- Severe seizure disorders
Structural barriers which lead to indications for EN?
- Congenital abnormalities
- Obstructions
- Injuries
Congenital abnormalities which lead to indications for EN?
- tracheoesophageal fistula
- Esophageal atresia
- Cleft palate
- Pierre Robin syndrome
Obstructions which may lead to indications for EN?
- Head and neck cancers
- Mechanical ventilation
Injuries which may lead to indications for EN?
- Caustic ingestions
- Trauma
- Burns to head or neck
- Mucositis from cancer Tx
Absolute contraindication to EN?
- NEC (Necrotizing enterocolitis)
- Bowel obstruction or ileus
- HD instability
Possible contraindications to EN?
- Persistent vomiting or diarrhea
- Acute abdominal distention
- Gastric, small or large bowel fistula
- Upper GI bleeding
How should the EN route be selected?
- Important to include family as well as older children in the decision making process
- Tube size chose between age between 5-12 Fr
If <3 months, what are the options for EN?
- NG tube
- nasoduodenal, nasojejunal tube
- Orogastric tube
NG tube indications, pros and cons?
Idea if intact GI, short-supply, minimal reflex, normal gastric emptying
- Easily placed but easily dislodges, should be replaced q 30 days
- -> Encourage oral PO alongside it
Nasoduodenal/nasojejunal tube indications?
- Longer passage bypassing the stomach if delayed gastric emptying, severe GED, risk of aspiration
- Requires specialized placement and continuous drip
Orogastric tube indications?
- To avoid nasal obstruction, when NG tube cannot be used
- We need to restrict PO intake
- rare
If >3 months, what are the options for EN?
- Gastrostomy
- Gastrojejunostomy
- Jejunostomy
Gastrostomy indications? Pros?
- Minimal GERD, normal gastric emptying, low risk of aspiration
- Placed endoscopically or surgically, and can be changed by family if Mickey button in placed
Gastrojejunostomy indications?Pros?
- Inserted in wall of stomach but in two ports: one in stomach for fluids/meds and venting and the other port in the jejunum
- Often used if cannot tolerate feeds in stomach due to delayed emptying, gastroesophageal reflux, risk of aspiration and needs continuous drip
Jejunostomy indications?
-Usually needed if small bowel feeding for >6 months.
=Requires mandatory continuous feeds and risk of surgical emergencies such as volvulus
When may combination feeding be used?
- Ideal for patient who needs significant amount but cannot tolerate large volumes
- Smaller bolus during daytime and overnight continuous feeds
Initiation and advancement of combination feeding?
- When a child cannot tolerate large volumes of bolus feeds
- 3-4 smaller bolus feeds during day and overnight continuous infusion
- Daytime feeding to be compressed by 1-2 hours per day until desired number of boluses reached
- Bolus can be given over 30-60 minutes if well tolerated
Are GRVS recommended in paediatric?
No
Signs of intolerance in En feeds?
- Fussiness or irritability
- Choking, coughing, vomiting, retching, abdominal distension, diarrhea
(T/F) Routine flushing for bolus or interrupting continuous feed for water flushes is not recommended in children
T
Advice for monitoring EN feeds?-
- Use sterile or purified water over tap water
- HOB at least 30 degrees
- Daily to biweekly monitoring in malnourished, CI individuals or with renal/metabolic complications
- Daily weight for infants and children, monthly height and HC
What biochem should be notably monitored in EN feeds?
-Serum glucose, urea, creatinine, electrolytes, osmolality and urine-specific gravity
Recommendation for weaning off tube feeding? (1/2)
- using spoon foods or baby foods, aim for 1-2 bites swallowed with no vomiting
- Increase bite amount if reaching goal 75% of the time, about 3-4 days
- Bolus over 30 minutes per feed if well tolerates
- Able to take full volume of bottle PO
Recommendation for weaning off tube feeding? (1/2)
- Once 10 bites achieved per meal
- Taking 1-2 oz per meal consumed, and slowly taper off feeding
- reduce tube feeding early in the day to benefit meals, then reduce bedtime/evening feeds last
- Continue to advance oral motor and oral sensory
- Add water to tube feedings as needed during reduction
When can the tube feeding be removed?
When 2-3 months of normal growth without tube use before removing tube feeding acces
What are the two causes of feeding and swallowing disorders?
-Congenital and acquired causes
Congenital causes of feeding and swallowing disorders?
- Neuromuscular diseases
- Cerebral palsy
- Cleft lip and palate
- Spinal muscular dystrophy
- Prematurity
Acquired causes of feeding and swallowing disorder?
- Delayed introduction oral feeding
- Unpleasant oral tactile experiences
What are the three etiologies of feeding and swallowing disorders?
- Physical and mechanical
- Medical and nutrition
- Behavioural
Physical and mechanical feeding and swallowing disorder?
-Chewing, swallowing, sensory, self-feeding, positioning
Medical and nutritional feeding and swallowing disorders?
-GI issues, problems with growth
Behavioural swallowing and feeding disorders?
-Meal time structures, refusal behaviours, mealtime behaviours
Common feeding problems?
- Excessive liquid intake, impeding acceptance of solid foods
- Grazing, unstructured mealtimes
- Prolonged feeding time greater than 30 minutes
- Inadequate or immature oral-motor skills and unable to handle complex textures
- Sensory integration issues (will consume only foods of one colour or texture)
What is non nutritive sucking?
-Use of a pacifier during gavage feeding and in the transition of gavage to breast/bottle feeding in pre-term development of sucking behaviour
Why is non-nutritive sucking beneficial?
- For avoidance of oral aversion
- Reduce time of transition from tube to oral feeding
- Calming effect on infants
- May improve digestion during feeding
Behavioural strategies for feeding issue (1/3)
- Offer liquids primarily between meals, limit dinking during meals
- Encourage structured consistent schedule
- Limit meals to 20-30 minutes
- Eliminate grazing behaviours
- Use a time r to have the child sit at the table for a finite period of time
Behavioural strategies for feeding issues (2/3)
- Offer food in a divided plate
- Offer 1 new or non-preferred foods with 1-2 preferred food
- Encourage exploration of a non-preferred food
- Establish a non-food reward system (for children older than 1 year) were positive behaviour is praised
Behavioural strategies for feeding issue (3/3)
- Be as consistent as possible
- Encourage training and co-operation of all caregivers
- Encourage family mealtime
- Provide age appropriate portions and developmentally appropriate textures
Nutritional intervention in general? (1/2)
- Initiate an age appropriate MV if needed
- Offer nutrient-dense snacks and increase the caloric concentration in foods
- Offer modulars as appropriate
- Limit juice to 4 oz per day
- Recommend using pureed table food in place of jared to increase kcal density
Nutritional intervention in general (2/2)?
- Progress textures, thicker purees to advance to more complex textures
- Initial nutrition supplementation, either orally or via EN if unable to sustain age-appropriate weight gain
- Initiate EN immediately if child is <80% IBW
Why PN in the neonatal?
- metabolic reserves are limited; protein, lipids, glycogen stores are lower
- Needs to meet requirements for growth on top of disease/surgical needs
- Substantial energy requirements for growth on per body weight basis
- Provision of early nutrition is essential for infants and children
- Optimal energy delivery means early growth and neurodevelopment
Overall indications for PN in neonate?
-Consider PN for neonates in the critical care setting, regardless of diagnosis, when EN is unable to meet energy requirements for energy expenditure and growth
Specific indications for PN in the neonate?
- Very low birth weight (<1500g)
- Intestinal dysfunction or impaired intestinal perfusion
- Expectation of slow progression of EN
Intestinal dysfunction or impaired intestinal perfusion causing PN indication?
- SBS
- gastroschisis
- NEC
- meconium ileus
- Intestinal atresia
Expectation of slow progression of EN causing PN indication?
- Congenital heart disease
- Severe respiratory failure with hypoxia and acidosis
PN should be used when malnourished children cannot tolerate or safely receive EN for ___
greater than 3 days
What are common, but not exclusive indications for PN in the PEDIATRIC population?
- Neuromuscular disorders
- Mucosal disorders
- Anatomical disorders
- Inflammatory bowel disease
- Chronic liver disease
- Cardiac disease
- Stem cell transplants
Neuromuscular disorders and potential PN indications?
-Chronic pseudo-obstruction, hirshcsprung’s disease, mitochondrial disorders
Anatomical and potential PN indications?
SBS, atresias, gastroschisis, volvulus, meconium ileus, NEC, thromboses and trauma
Inflammatory bowel and potential PN indications?
-Only in cases of fistula, obstruction, toxic megacolon and bowel resection resulting in SBS
Chronic liver disease and potential PN indications?
-When awaiting liver transplant, malabsorption issues relating to cholestasis
CVD and potential PN indications?
-Strongly recommend early PN in pre-op and continue post-ip until En is tolerated due to work of feeding on heart, and need for fluid restriction, high metabolic demand
Timing for starting PN in the neonate?
- Delaying PN will contribute to negative nitrogen balance and post-natal growth failure
- Early administration of PN within hours of birth is considered safe
- EAA deficiency will develop in 3 days on fat free diet
- Begin PN promptly after birth in VLB weight infants (<1500g)
Timing for starting PN in the pediatric populationn?
- Reasonable to delay PN for up to a week
- However, initiate within 1-3 days in infants, within 4-5 days in older children and adolescent when EN or PO not tolerated
Assessment prior to starting PN?
- Fluid status
- Appropriate venous access
- Nutrition needs
- Anticipated length of therapy
- Gut function and possibility of trophic feeds
Short term-effects of PN?
- Infection
- HyperG
- Electrolytes
- Acid/base imbalances
- HyperTG
- Phlebitis
Long-term adverse effects of PN?
- Infection
- Cholestasis
- Metabolic complications
- Osteopenia
- EFAD
- risk of vitamin and mineral deficiency/toxicity
How should we wean off PN?
-Opportunity fo changing to EN should be periodically assessed, and efforts to transition from PN to En should take place
When should PN we weaned?
When oral intake and or EN achieves 50-75% of requirements for energy and protein and micronutrients, unless the impaired GI function precludes 100% absorption of nutrient need
–> Monitor glycemic control during tapering on TPN
When is PPN used?
- Short term use to supplement EN
- However, hard to meet kcal and pro needs with lower osmolality and volume
- Used only in previously well-nourished or mildly nutrition deficit
If using PPN, how should we expect EN to progress?
-Expect EN within 7-10 days and if after 5-7 days of PPN and no progression, consider TPN
___ is required in PPN to tolerate fluid overload
Sufficient renal function
How much fluid is required in neonates with PPN?
-120-125 ml/kg/day and 150% fluid maintenance needs in pediatric patients
