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Clinical Nutrition 3 > Pediatrics Intro Part II > Flashcards

Pediatrics Intro Part II Flashcards

1
Q

Rapid decrease in weight

A

Likely dehydration

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2
Q

Rapid increase in weight?

A

Likely fluid overload

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3
Q

What is considered in fluid intake?

A
  • IV fluids
  • PN
  • Blood products
  • Medications
  • EN
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4
Q

Decreased urine output or dark urine

A

Likely dehydration

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5
Q

Increased urine output?

A

Likely fluid overload

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6
Q

What is considered in fluid output?

A
  • Urine
  • Gastric
  • Stool
  • Bile
  • Chest tube
  • Wound
  • Skin
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7
Q

Vitals suggestive of dehydration?

A
  • Increased heart rate

- Increased losses with fever

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8
Q

Vitals suggestive of fluid overload?

A

-Increased respiratory rate

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9
Q

Addition of a diuretic or change in frequency of medications?

A

-May risk dehydration

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10
Q

Fluid retention with steroids or excessive Na intake?

A

May cause fluid overload

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11
Q

Physical exam showing potential dehydration?

A

-Thirst, dry lips, dry mucous membranes, dry skin, headache, dizziness

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12
Q

Physical exam showing potential fluid overload?

A

-Peripheral, facial and orbital edema, increased abdominal girth, shortness of breath

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13
Q

What does EBM mean?

A

Expressed Breast Milk

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14
Q

What does PHM mean?

A
  • Processed human milk

- Typically pasteurized donor term breastmilk

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15
Q

Are the WHO DRIs for healthy children?

A

Yes, where patients receiving less than the DRI will often not experience normal growth

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16
Q

What do we want to achieve at least at a minimum?

A

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
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17
Q

Acceptable AMDR of CHO for all ages?

A

45-65%

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18
Q

AMDR 5-10% protein?

A

1-3 years

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19
Q

AMDR 10-30% protein?

A

4-18 years oldr

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20
Q

AMDR 10-35% protein?

A

19 years old and over

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21
Q

AMDR 30-40% fat?

A

1-3 years old

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22
Q

AMDR 25-35% fat?

A

4-18 years old

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23
Q

AMDR 20-35% fat?

A

19 years and older

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24
Q

When is AMDR of 5-10% appropriate for n-6 PUFA?

A

All ages from 1-19 years old

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25
Q

When is AMDR 0.6-1.2% appropriate for n-3 PUFA?

A

All ages from 1-19 years old

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26
Q

What is maintenance fluid?

A
  • 100% of requirements of fluids will provide 100% maintenance fluid
  • Therefore, a certain % of the maintenance fluid will be allocated to tube feeds
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27
Q

A 5-year child has an allowance of 75% maintenance fluid weight 32.5 kg, what amount of fluid is permitted for tube feeds?

A

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

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28
Q

How many calories is breastmilk

A

67 kcals per 100 mls, and then is concentrated and fortified as the baby is restricted.

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29
Q

Breastmilk is often concentrated and fortified if the baby is fluid restricted, what are the possible concentrations?

A

-67, 81, 91 and 100

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30
Q

What is premature formula? When is it used? What is the nutrient profile like?

A
  • Cow’s milk based
  • before 37 weeks or VLBW
  • Increased kcals, protein, calcium, PO4, and vitamins and minerals
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31
Q

Examples of premature formulas?

A
  • Enfamil Enfaprem
  • Enfaprem HP
  • Similac Special Care
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32
Q

What sis the preferred source of enteral nutrition in all infants, including premature and sick newborns?

A

Breastmilk

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33
Q

When is breastmilk contraindicated?

A
  • Galactosemia
  • Congenital lactase deficiency
  • Maternal HIV
  • Use of some medications
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34
Q

Which milk i more diluted than expressed breast milk?

A

PHM

–> breastmilk from a premie milk is actually more dense in kcals

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35
Q

(T/F) Breast-milk must be fortified to meet the needs of the premie

A

T

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36
Q

What is fortified in premature breastmilk? At what age?

A
  • Increase kcal, protein, calcium, PO4 and other vitamins and minerals
  • Will increase overall osmolarity
  • When baby below 35 weeks or 1.8 kg
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37
Q

What is discharge formula?

A

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

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38
Q

When is regular formula used? What are they composed of?

A
  • For >37 weeks tp to 1 year
  • Cow milk based
  • Transition milks are also available
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39
Q

examples of regular formulas?

A
  • Enfamil A+
  • Similac Advance
  • Goodstart
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40
Q

Which formula is NOT hypoallergenic?

A

Partially hydrolyzed formulas

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41
Q

What is CMPI?

A

Cows Milk Protein Intolerance

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42
Q

(T/F) Partially hydrolyzed formulas are appropriate for CMPI

A

F

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43
Q

When is a partially hydrolyzed formula recommended?

A
  • For infants who are not tolerating the normal formula
  • Often colic–y
  • Reduced to no lactose, and the proteins are hydrolyzed
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44
Q

Examples of partially hydrolyzed formulas?

A
  • Enfamil Gentlease
  • Soy similac Sensitive
  • Isomil Goodstart
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45
Q

Which formula is appropriate for infants with CMPI?

A
  • Extensively hydrolyze formula

- It IS hypoallergenic

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46
Q

What does the extensively hydrolyzed infant formula contain?

A

-Free amino acids, small peptides, LCT and MCT, lactose free

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47
Q

When may extensively hydrolyzed formula be used?

A
  • GI intolerance
  • Cow and soy protein intolerance
  • Malabsorption such as in CF, SBS and Cholestasis
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48
Q

Which extensively hydrolyzed formula has a higher proportion of MCT oil? When is it used?

A
  • Pregestimil

- Often used if liver disease or if chylothorax

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49
Q

When is the 100% amino acid formula utilized?

A
  • 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
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50
Q

When are polymeric formulas used?

A

for oral and enteral use

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51
Q

When are semi-elemental forumalas used?

A
  • For malabsorption SBS

- Transition to TPN

52
Q

When is elemental used?

A

For severe GI impairment

53
Q

When is specialty formula used?

A

For specific diseased conditions

54
Q

When are metabolic formulas utilized?

A

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

55
Q

When is EN required for children

A

-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)

56
Q

What are 2 scenarios where EN should be commenced at any time at admission?

A
  • 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
57
Q

What are the benefits of EN?

A
  • 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
58
Q

When shouldEN should be started as soon as possible, within 48-72 hours of admission if hemodynamically stable

A
  • Infants
  • Patients who were malnourished before illness or injury
  • Septic or injured patients in whom a prolonged intensive care course is anticipated
59
Q

Chronic indication for EN under the age of 2?

A
  • Poor growth or weight gain for more than 1 month
  • Decrease of 2 or more weight or height growth channels
  • Triceps skinfold <5th percentile
60
Q

Chronic indication for EN over the age of 2 years old?

A
  • Weight loss or lack of weight gain for 3 months
  • Decrease of 2 or more weight or height growth channels
  • Triceps skinfold <5th percentile
61
Q

When does the swallowing reflex develop?

A

As soon as 12-14 weeks

62
Q

Functional barriers which lead to indications for EN?

A
  • Neurological or neuromuscular disorders which are associated with swallowing difficulties, delayed gastric emptying, or oral aversions
  • Genetic or metabolic syndromes
  • Prematurity
63
Q

Which neurological or neuromuscular disorders may be indications for EN?

A
  • SMA
  • Anoxic brain injury
  • Severe seizure disorders
64
Q

Structural barriers which lead to indications for EN?

A
  • Congenital abnormalities
  • Obstructions
  • Injuries
65
Q

Congenital abnormalities which lead to indications for EN?

A
  • tracheoesophageal fistula
  • Esophageal atresia
  • Cleft palate
  • Pierre Robin syndrome
66
Q

Obstructions which may lead to indications for EN?

A
  • Head and neck cancers

- Mechanical ventilation

67
Q

Injuries which may lead to indications for EN?

A
  • Caustic ingestions
  • Trauma
  • Burns to head or neck
  • Mucositis from cancer Tx
68
Q

Absolute contraindication to EN?

A
  • NEC (Necrotizing enterocolitis)
  • Bowel obstruction or ileus
  • HD instability
69
Q

Possible contraindications to EN?

A
  • Persistent vomiting or diarrhea
  • Acute abdominal distention
  • Gastric, small or large bowel fistula
  • Upper GI bleeding
70
Q

How should the EN route be selected?

A
  • Important to include family as well as older children in the decision making process
  • Tube size chose between age between 5-12 Fr
71
Q

If <3 months, what are the options for EN?

A
  • NG tube
  • nasoduodenal, nasojejunal tube
  • Orogastric tube
72
Q

NG tube indications, pros and cons?

A

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
73
Q

Nasoduodenal/nasojejunal tube indications?

A
  • Longer passage bypassing the stomach if delayed gastric emptying, severe GED, risk of aspiration
  • Requires specialized placement and continuous drip
74
Q

Orogastric tube indications?

A
  • To avoid nasal obstruction, when NG tube cannot be used
  • We need to restrict PO intake
  • rare
75
Q

If >3 months, what are the options for EN?

A
  • Gastrostomy
  • Gastrojejunostomy
  • Jejunostomy
76
Q

Gastrostomy indications? Pros?

A
  • Minimal GERD, normal gastric emptying, low risk of aspiration
  • Placed endoscopically or surgically, and can be changed by family if Mickey button in placed
77
Q

Gastrojejunostomy indications?Pros?

A
  • 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
78
Q

Jejunostomy indications?

A

-Usually needed if small bowel feeding for >6 months.

=Requires mandatory continuous feeds and risk of surgical emergencies such as volvulus

79
Q

When may combination feeding be used?

A
  • Ideal for patient who needs significant amount but cannot tolerate large volumes
  • Smaller bolus during daytime and overnight continuous feeds
80
Q

Initiation and advancement of combination feeding?

A
  • 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
81
Q

Are GRVS recommended in paediatric?

A

No

82
Q

Signs of intolerance in En feeds?

A
  • Fussiness or irritability

- Choking, coughing, vomiting, retching, abdominal distension, diarrhea

83
Q

(T/F) Routine flushing for bolus or interrupting continuous feed for water flushes is not recommended in children

A

T

84
Q

Advice for monitoring EN feeds?-

A
  • 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
85
Q

What biochem should be notably monitored in EN feeds?

A

-Serum glucose, urea, creatinine, electrolytes, osmolality and urine-specific gravity

86
Q

Recommendation for weaning off tube feeding? (1/2)

A
  • 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
87
Q

Recommendation for weaning off tube feeding? (1/2)

A
  • 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
88
Q

When can the tube feeding be removed?

A

When 2-3 months of normal growth without tube use before removing tube feeding acces

89
Q

What are the two causes of feeding and swallowing disorders?

A

-Congenital and acquired causes

90
Q

Congenital causes of feeding and swallowing disorders?

A
  • Neuromuscular diseases
  • Cerebral palsy
  • Cleft lip and palate
  • Spinal muscular dystrophy
  • Prematurity
91
Q

Acquired causes of feeding and swallowing disorder?

A
  • Delayed introduction oral feeding

- Unpleasant oral tactile experiences

92
Q

What are the three etiologies of feeding and swallowing disorders?

A
  • Physical and mechanical
  • Medical and nutrition
  • Behavioural
93
Q

Physical and mechanical feeding and swallowing disorder?

A

-Chewing, swallowing, sensory, self-feeding, positioning

94
Q

Medical and nutritional feeding and swallowing disorders?

A

-GI issues, problems with growth

95
Q

Behavioural swallowing and feeding disorders?

A

-Meal time structures, refusal behaviours, mealtime behaviours

96
Q

Common feeding problems?

A
  • 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)
97
Q

What is non nutritive sucking?

A

-Use of a pacifier during gavage feeding and in the transition of gavage to breast/bottle feeding in pre-term development of sucking behaviour

98
Q

Why is non-nutritive sucking beneficial?

A
  • For avoidance of oral aversion
  • Reduce time of transition from tube to oral feeding
  • Calming effect on infants
  • May improve digestion during feeding
99
Q

Behavioural strategies for feeding issue (1/3)

A
  • 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
100
Q

Behavioural strategies for feeding issues (2/3)

A
  • 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
101
Q

Behavioural strategies for feeding issue (3/3)

A
  • Be as consistent as possible
  • Encourage training and co-operation of all caregivers
  • Encourage family mealtime
  • Provide age appropriate portions and developmentally appropriate textures
102
Q

Nutritional intervention in general? (1/2)

A
  • 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
103
Q

Nutritional intervention in general (2/2)?

A
  • 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
104
Q

Why PN in the neonatal?

A
  • 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
105
Q

Overall indications for PN in neonate?

A

-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

106
Q

Specific indications for PN in the neonate?

A
  • Very low birth weight (<1500g)
  • Intestinal dysfunction or impaired intestinal perfusion
  • Expectation of slow progression of EN
107
Q

Intestinal dysfunction or impaired intestinal perfusion causing PN indication?

A
  • SBS
  • gastroschisis
  • NEC
  • meconium ileus
  • Intestinal atresia
108
Q

Expectation of slow progression of EN causing PN indication?

A
  • Congenital heart disease

- Severe respiratory failure with hypoxia and acidosis

109
Q

PN should be used when malnourished children cannot tolerate or safely receive EN for ___

A

greater than 3 days

110
Q

What are common, but not exclusive indications for PN in the PEDIATRIC population?

A
  • Neuromuscular disorders
  • Mucosal disorders
  • Anatomical disorders
  • Inflammatory bowel disease
  • Chronic liver disease
  • Cardiac disease
  • Stem cell transplants
111
Q

Neuromuscular disorders and potential PN indications?

A

-Chronic pseudo-obstruction, hirshcsprung’s disease, mitochondrial disorders

112
Q

Anatomical and potential PN indications?

A

SBS, atresias, gastroschisis, volvulus, meconium ileus, NEC, thromboses and trauma

113
Q

Inflammatory bowel and potential PN indications?

A

-Only in cases of fistula, obstruction, toxic megacolon and bowel resection resulting in SBS

114
Q

Chronic liver disease and potential PN indications?

A

-When awaiting liver transplant, malabsorption issues relating to cholestasis

115
Q

CVD and potential PN indications?

A

-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

116
Q

Timing for starting PN in the neonate?

A
  • 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)
117
Q

Timing for starting PN in the pediatric populationn?

A
  • 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
118
Q

Assessment prior to starting PN?

A
  • Fluid status
  • Appropriate venous access
  • Nutrition needs
  • Anticipated length of therapy
  • Gut function and possibility of trophic feeds
119
Q

Short term-effects of PN?

A
  • Infection
  • HyperG
  • Electrolytes
  • Acid/base imbalances
  • HyperTG
  • Phlebitis
120
Q

Long-term adverse effects of PN?

A
  • Infection
  • Cholestasis
  • Metabolic complications
  • Osteopenia
  • EFAD
  • risk of vitamin and mineral deficiency/toxicity
121
Q

How should we wean off PN?

A

-Opportunity fo changing to EN should be periodically assessed, and efforts to transition from PN to En should take place

122
Q

When should PN we weaned?

A

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

123
Q

When is PPN used?

A
  • 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
124
Q

If using PPN, how should we expect EN to progress?

A

-Expect EN within 7-10 days and if after 5-7 days of PPN and no progression, consider TPN

125
Q

___ is required in PPN to tolerate fluid overload

A

Sufficient renal function

126
Q

How much fluid is required in neonates with PPN?

A

-120-125 ml/kg/day and 150% fluid maintenance needs in pediatric patients

Clinical Nutrition 3 (30 decks)

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