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Clinical 3 > pediatrics: nutr assessment > Flashcards

pediatrics: nutr assessment Flashcards

1
Q

what are the 2 categories of malnutrition in terms of its etiology

A

non-illness related: behavioral, socioeconomic or environmental

illness related

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2
Q

acute vs chronic illness related malnutrition: duration

A

acute: <3 months

chronic (more common): >= 3 months

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3
Q

challenges of providing adequate nutrition to babies

A

 Metabolic need for rapid growth: much higher than adult needs
 Low nutritional reserves; adults have large reserves
 Macro and micronutrient needs mirrors growth phase

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4
Q

components of energy needs and their kcal/kg/d

A

BMR: 40-62 kcal/kg/d
Activity (don’t move much-> small proportion): 2-4 kcal/kg/d
Growth (biggest proportion -> malnutrition = stunting): 45-67 kcal/kg/d
Total: 90-130 (rarely 144) kcal/kg/d

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5
Q

what are the possible findings of organs system review component pf nutritional assessment

A

Anorexia, dysphagia, stooling pattern and consistencies, vomiting, GERD, recurrent fevers, dysuria, urinary frequency, activity level

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6
Q

if the child is at third percentile for weight or height, can we conclude that it is malnourished?

A

it doesn’t necessarily mean that the child is malnourished but only that it is small

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7
Q

premature vs term babies: who have reflux more often

A

preterm

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8
Q

what are the complications of cardiac babies?

A

cardiac babies often have problems with feeding while also breathing-> breathing more-> higher caloric needs

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9
Q

solutions for calorie based problem vs absorption-based problem

A

calorie-based problems: increase volume or kcal/ml

absorption problems: adjust formula e.g change the type

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10
Q

what are the common definitions of failure to thrive?

A
  1. weight for age that falls below the 5th percentile on multiple occasions
    or
  2. weight deceleration that crosses two major percentile lines on a growth chart,
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11
Q

categories of failure to thrive

A
  • inadequate caloric intake
  • inadequate nutrient absorption
  • increased metabolism
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12
Q

causes of inadequate caloric intake that leads to failure to thrive

A 
Gastro-oesophageal reflux 
inadequate breastmilk supply or ineffective latching 
incorrect formula preparation 
mechanical feeding difficulties
poor feeding habits 
poor oral neuromotor coordination
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13
Q

causes of increased metabolism that leads to failure to thrive

A 
Chronic infection 
chronic lung disease 
congenital heart disease 
hyperthyroidism 
inflammatory conditions 
malignancy 
rental failure
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14
Q

percentiles to assess underweight and severely underweight in birth-2 years and the indicator

A

weight for age chart
underweight: <3rd %ile
severely underweight: <0.1st

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15
Q

percentiles to assess stunted and severely stunted in birt-2 years and the indicator

A

length for age chart
stunted: <3rd %ile
severely underwstuntedeight: <0.1st

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16
Q

percentiles to assess wasted and severely wasted in birt-2 years and the indicator

A

weight for length
wasted: <3rd or <89th IBW
severely wasted: <0.1st

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17
Q

percentiles to assess stunted and severely stunted in 2-19 years and the indicator

A

height for age chart
stunted: <3rd %ile
severely underwstuntedeight: <0.1st

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18
Q

percentiles to assess underweight and severely underweight in 2-19 years and the indicator

A

weight for age chart
underweight: <3rd %ile
severely underweight: <0.1st

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19
Q

percentiles to assess wasted and severely wasted in 2-19 years and the indicator

A

BMI for length
wasted: <3rd or <89th IBW
severely wasted: <0.1st

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20
Q

when can primary indicators of neonatal malnutrition be used (time from birth)

A

after 2 weeks until 2 yo

cannot be used for first 2 weeks of life as this is when wl happens

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21
Q

primary indicators requiring 1 indicator to diagnose neonatal malnutrition

A

mild:
Decline in weight-for-age z score: Decline of 0.8-1.2 SD
Weight gain velocity: <75% of expected rate of weight gain to maintain growth rate
Nutrient intake ≥3-5 consecutive days of
protein/energy intake; ≤75% of estimated needs

Moderate:
Decline in weight-for-age z score: Decline of >1.2-2 SD
Weight gain velocity: <50% of expected rate of weight gain to maintain growth rate
≥5-7 consecutive days of protein/energy intake
≤75% of estimated needs

Severe:
Decline in weight-for-age z score: Decline of >2 SD
Weight gain velocity: <25% of expected rate of weight gain to maintain growth rate
≥7 consecutive days of protein/energy intake
≤75% of estimated needs

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22
Q

primary indicators requiring 1 indicator to diagnose neonatal malnutrition

A

Mild:
Days to regain birthweight: 15-18
Linear growth velocity <75% of expected rate
Decline in length-for-age z score: Decline of 0.8-1.2 SD

Moderate
Days to regain birthweight: 19-21
Linear growth velocity <50% of expected rate
Decline in length-for-age z score: Decline of >1.2-2 SD

Severe
Days to regain birthweight: >21 Use in conjunction with nutrient intake
Linear growth velocity <25% of expected rate
Decline in length-for-age z score: Decline of >2 SD N

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23
Q

preterm vs late preterm vs term in terms of weeks

A

Preterm <34-0/7
Late Preterm 34-0/7 to 36-6/7
Term ≥37-0/7

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24
Q

Acute versus chronic undernutrition

A

Acute undernutrition:
Severe and sudden onset
Weight is primarily affected
Very low wt/ht (

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25
Q

what is is the order of parameters being affected in malnutriton

A

first thing that gets affected during malnutrition is weight then height
then head circumference

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26
Q

preterm definition

A

Preterm: an infant born at less than 37 weeks gestation.

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27
Q

neonate definition

A

Neonate: an infant born at 37 weeks or greater but who are less than 28 days old.

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28
Q

what are the dangers of anemia

A

neural development issues

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29
Q

Albumin, transferrin, prealbumin

Nutritional implication

A

Indicator of visceral protein status (if no inflammation), poor nutrition status, slow growth, edema

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30
Q

Nutritional implication

WBC

A

Immune system marker, increased with infection

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31
Q

Nutritional implication

Urea, creatinine

A

Indicator of kidney function, hydration, PRO catabolism & intake

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32
Q

Nutritional implication

Magnesium

A

Indicator of refeeding syndrome, GI losses Specific vitamin or trace element deficiencies

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33
Q

Nutritional implication

Vitamins/trace elements

A

Specific vitamin or trace element deficiencies

looked at in chronic cases more often than in acute

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34
Q

Nutritional implication of c-reactive protein

A

Inflammatory marker, increased with infection

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35
Q

Nutritional implication of sodium

A

indicator of hydration and kidney function

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36
Q

Nutritional implication of calcium and phosphate

A

Indicator of bone osteopenia, refeeding syndrome

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37
Q

Nutritional implication of direct bilirubin

A

indicator of liver function, cholestasis

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38
Q

Nutritional implication of Hgb, Hct, TIBC, ferritin

A

Assess iron, vitamin B12 and folate (anemia)

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39
Q

which indicators are better than albumin to reflect improving nutritional status? Why

A

Proteins with the shorter half-life (i.e. pre-albumin or retinol-binding protein) are better at reflecting improving nutritional status
Albumin will most likely be low due to acute phase response to inflammation and redistribution of protein. Thus hypoalbuminaemia should not be attributed to malnutrition.

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40
Q

do stunted kids look unhealthy?

A

no, they are just short

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41
Q

Clinical assessment - physical

A 
 Hair: dry, flagged, brittle, coarse
 Skin: dry, scaly, slow healing wounds
 Mouth: swollen/bleeding gum, decaying teeth
 Muscle mass: lean-emaciated, weak
 Abdomen: visible ribs, bloated stomach
 Subcutaneous fat mass
 Bones: visible temporal bone/ scapula/collar bone, bowed legs, stunted
 Fluid retention
 Proportionality HC to length to weight
 Energy level: irritability, lethargy
 Learning ability
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42
Q

which scale is used in ados

A

tanner

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43
Q

when does most adolescent growth occur? What is it an opportunity for?

A

80% of adolescent growth occurs between age 10 to 15 years old, opportunity for catch up weight gain

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44
Q

Greenish black, sticky stool
Name?
Characteristics?

A

Name: Meconium
Characteristics: First baby stool, if greenish-black it contains For 3 days bilirubin, yellowish green- RBC

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45
Q

Yellow, seedy stool
Name?
Characteristics?

A

Name: breastfed
Characteristics: mild smell

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46
Q

Tan and thick stool
Name?
Characteristics?

A

Name: formula fed
Characteristics: Hummus looking, only a concern if watery or hard

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47
Q

Greenish brown stool
Name?
Characteristics?

A

Name: intro to solids
Characteristics: Leftover guacamole look, will depend on food eaten

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48
Q

Watery, brown, loose stool
Name?
Characteristics?

A

Name: diarrhea
Characteristics: If more than 2 days and frequent risk of dehydration, sign of infection

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49
Q

Dry brown and hard stool
Name?
Characteristics?

A

Name: Constipation
Characteristics: Looks like dirt clay or pellets
Not enough fluid or losing too much fluid

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50
Q

pinkish red
Name?
Characteristics?

A

Name: n/a
Characteristics: Partially digested food, monitor what baby eats

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51
Q

Black pasty, tarry
Name?
Characteristics?

A

Name: melena
Characteristics: Sign of upper GI bleed

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52
Q

dark green
Name?
Characteristics?

A

Name: iron supplementation
Characteristics: On iron sulfate in a supplement or iron fortified baby formula

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53
Q

Bright green frothy
Name?
Characteristics?

A

sign that bb only drinks foremilk which is less nutritious (less fat, more protein)
Name: Foremilk/hindmilk imbalance
Characteristics: Getting more foremilk, breastfed baby nurses for short periods of time on each breast. Could be virus

54
Q

Red streaked, hard stool with blood or mucus
Name?
Characteristics?

A

Name: bloody stool
Characteristics: Possible rectal fissures, small cracks in anus. If large amt of blood when soft stool need medical attention

55
Q

Name?

Characteristics?

A

Name: n/a
Characteristics: Pale, colorless, sign of liver or gallbladder problem

56
Q

WHO vs DRI energy calculation formulas

A

WHO:

  • basal metabolic rate
  • this gives 2/3 of DRI requirement and children won’t grow when provided this
  • she uses this in ICU as it is hard to get even this amount
  • in more stable (not ICU) - aim for DRI and then adjust according to growth curve results

DRI
- Patients receiving less than DRIs will not experience normal growth

57
Q

what should be used if IC is not available to determine energy expenditure?

A

Schofield/ Food Agriculture Organization/ World Health Organization/ United Nations University Equations may be used without the addition of stress factors

58
Q

PRO requirements (g/kg/day) across ages

A 
0-6 mths: 1.52
7-12 mths: 1.2
1-3 years: 1.05
4-8 years: 0.95
9-13 years: 0.95
14-18 years: 0.85

Protein requirement can increase depending on medical condition and stress factors

59
Q

PRO recommendations for critically ill children

A

ASPEN/SCCM 2017 guideline recommend minimum 1.5g/kg/d PRO for critically ill children. Positive protein balance may need much higher intake

60
Q

what is considered to be high protein intake?

A

High protein > 25% of total kcal

61
Q

AMDR
1-3 years
4-18 years
19+

A

1-3 years
CHO: 45-65%
PRO: 5-20%
Fat: 30-40%

4-18 years
CHO: 45-65%
PRO: 10-30%
Fat: 25-35%

19+
CHO: 45-65%
PRO: 10-35%
Fat: 20-35%

62
Q

how to calculate 100% maintenance fluid

A

≤ 10kg: 100ml/kg
> 10kg to ≤ 20 kg: 1000ml + 50ml/kg for wt > 10 kg
> 20 kg: 1500ml + 20ml/kg for wt > 20 kg

63
Q

common reasons for fluid restrictions in babies

A

kidney and lung dysfunction and heart failure

64
Q

what is a sign of dehydration

A

Hypernatremia + little wt gain or wt loss = likely dehydration

65
Q

what is a sign of fluid overload

A

Hyponatremia + weight gain = likely fluid overload

66
Q

Calculate Allowance of 75% maintenance fluid for 5-year-old weighing 32.5kg

A

calcualte the 100% and then multiply by 0.75

(1500+2012.5)0.75= 1312.5

67
Q

what might rapid weight changes be indicative of?

A

fluid loss/ gain

68
Q

Lab values indicative of dehydration

A

↑ BUN, ↑NA, ↑ serum osmolarity, ↑ urine specific gravity, ↑ albumin or Hgb

69
Q

vital indicative of dehydration and fluid overload

A

dehydration: ↑ heart rate

fluid overload: ↑ respiratory rate

70
Q

what is PHM

A

donor pasteurized human milk

71
Q

Characteristics of PHM/EBM vs premature formula

A

PHM/EBM
• “Breast is best”
• EBM/PHM 67 not optimal for preterm growth
• Not always available

Premature formula
• Cow’s milk based
• Before 37 weeks or VLBW
• Higher kcal, PRO, Ca, PO4 and vit & mineral

72
Q

link between bones and babies born before 3rd trimester

A

in the 3rd trimester theres is a lot of calcium transfer

babies born before 3rd trimester-> no bone mineralization

73
Q

what are the available calories for EBM

A

normal breast milk = 67kcal per 100ml then fortified to 81, 91 and 100

74
Q

what is the preferred source of enteral nutrition for all infants, including premature and sick newborn

A

EBM/PHM
or
Premature formula

75
Q

what is the contradiction for breastmilk

A

galactosemia, congenital lactase deficiency, maternal HIV or use of some medications

76
Q

What are the suggestions for fortification of breast milk

Consequences?

A

• when bb is below 35 weeks or 1.8kg
• To increase kcal, PRO, Ca, PO4, vit
& mineral

Causes increased osmolarity-> tolerance and fluid considerations

77
Q

What is the discharge formula, when is it appropriate and why do we use it?

A

Cow’s milk based
Used in babies below 35 weeks or 1.8kg
Has higher kcal, PRO, Ca, PO4 and vit & mineral

fortified formulas are not available outside the hospital thus pts have to switch to discharge formula when leaving the hospital

78
Q

types of formula for pre-term babies

A

EBM/PHM
Premature formula
Fortified formula
Discharge formula

79
Q

Types of infant formula

A

Regular
Partially hydrolyzed
Extensively hydrolyzed
100% amino acid

80
Q

infant formula:
regular
when can it be used?
Characteristics

A

For >37 weeks, up to 1 yo.
Cow milk based
Transition milk also available
equivalent of polymeric formula for babies

81
Q

infant formula:
Partially hydrolysed
when can it be used?
Characteristics

A 
• Not hypoallergenic
• Not adequate for CMPI (Cow's Milk Protein Intolerance)
• Reduced to no lactose, PRO
hydrolysed
• Colic or religious reasons
82
Q

infant formula:
Extensively hydrolysed
when can it be used?
Characteristics

A

• Hypoallergenic (compared to partially hydrolyzed)
• Has free amino acids & small peptide, LCT & MCT and lactose free
• Higher osmolarity
• For GI intolerance , cow milk & soy
protein intolerance and malabsorption (CF, SBS, cholestasis)

83
Q

infant formula:
100% AA
when can it be used?
Characteristics

A

• Hypoallergenic
• Free amino acids
• For GI intolerance , extreme protein
hypersensitivity, suitable CMPI, eosinophilic GI disorders and transitioning from PN to EN, SBS

84
Q

Which infants would benefit from MCT-containing formula?

A

bb with cholestasis or liver issues

85
Q

pediatric formula types and uses

A

Polymeric: For oral and enteral use
Semi elemental: For malabsorption SBS, transition to TPN
Elemental: For severe GI impairment
Specialty: For specific disease conditions

86
Q

adolescent formula types and uses

A

Speciality: For specific disease conditions
Polymeric: For oral and enteral use
Semi-elemental: For malabsorption SBS, transition to TPN
Elemental: For severe GI impairment

87
Q

Indication for EN- acute

A
  • Intact and functional gastrointestinal tract
  • Medical conditions where it is difficult or impossible to safely consume
    food or liquids by mouth
  • Diagnosis which increase energy needs, making it difficult for infant to take sufficient amount by mouth
  • EN required for children unable to meet more than 80% of caloric needs by mouth or who require an extended period of time to eat (ie. > 4hours)
88
Q

Start enteral feeding at any time during an admission for:

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.

89
Q

Start enteral feeding as soon as possible, within 48 to 72 hours of admission for 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.

90
Q

Indications for EN - chronic- under the age of 2 and over the age of 2

A

Under the age of 2yo
Poor growth or weight gain for more than 1 month
Decrease of 2 or more weight or height growth channels (2SD)
Triceps skinfold < 5th percentile

Over the age of 2yo
Weight loss or lack of weight gain for than 3 months
Decrease of 2 or more weight or height growth channels
Triceps skinfold < 5th percentile

91
Q

Indications for EN: functional barriers

A

Neurological or neuromuscular disorders usually associated with swallowing difficulties, delayed gastric emptying or oral aversions.

  • SMA
  • Anoxic brain injury
  • Severe seizure disorders

Genetic or metabolic syndromes

Prematurity
- Unable to coordinate suck- - swallow-breathe pattern -

92
Q

Indications for EN: structural barriers

A

Congenital abnormalities

  • Tracheoesophageal fistula (TEF)
  • Esophageal atresia
  • Cleft palate
  • Pierre Robin syndrome

Obstructions

  • Head and neck cancers
  • Mechanical ventilation
Injuries
Caustic ingestions 
Trauma
Burns to head or neck
Mucositis from cancer tx
93
Q

Contradictions for EN

A

Absolute contraindications include

  • NEC: necrotizing enterocolitis
  • Bowel obstructions or ileus
  • Hemodynamic instability

Possible contraindications that should be evaluated individually

  • Persistent vomiting or diarrhea
  • Acute abdominal distention
  • Gastric, small or large bowel fistula
  • Upper gastrointestinal bleeding
94
Q

EN route selection: <3 months

A
  • Nasogastric tube: Intact GI, needed for short period, minimal gastroesophageal reflux, normal gastric emptying, low risk of aspiration, easily placed but easily dislodged, should be replaced q 30 days, encourage oral PO
  • Nasoduodenal/ nasojejunal tube: Longer passage bypassing the stomach for delayed gastric emptying, severe esophageal reflux, risk of aspiration, need specialized placement, continuous drip
  • Orogastric tube: To avoid nasal obstruction when NG cannot be based (choanal atresia), restrict PO intake, rare
95
Q

EN route selection: >3 months

A

 Gastrostomy: placed endoscopically or surgically, tube size 14 to 24 Fr, more discrete, can be changed by family if Mickey button, minimal gastroesophageal reflux, normal gastric emptying, low risk of aspiration, no pulling access
 Gastrojejunostomy: Inserted in wall of stomach but two ports: one in stomach for fluids/meds and venting and other port in jejunum. If cannot tolerate feeds in stomach due to delayed emptying, gastroesophageal reflux, risk of aspiration, need continuous drip
 Jejunostomy: Surgically placed usually but can be done endoscopically. Usually if need small bowel feeding for >6 months. Mandatory continuous feeds and risk of surgical emergencies such as volvulus

96
Q

Algorithm for selecting the route of nutritional support

A

https://docplayer.net/docs-images/43/15762125/images/page_7.jpg

97
Q

when and why would we use bolus feeding?

Pros and Cons? Way of administration?

A
  • Imitate mealtimes – more physiological
  • Administered into the stomach and should never be administered past the pylorus
  • By syringe, gravity or feeding pump
  • More flexible schedule
  • If supplemental for PO intake, usually better tolerated 30mins to 1hour post PO intake
98
Q

when and why would we use continuous feeding?

Cons? Way of administration?

A 
Cannot tolerate large volumes
Delayed gastric emptying, GERD, dumping syndrome 
Requires feeding pump
May limit ability to move
For ambulatory patients have backpack
99
Q

when and why would we use combination feeding?

A

 Ideal for pt who need significant amount but cannot tolerate large volume
 Smaller bolus during daytime and overnight continuous feed

100
Q

Initiation and advancement: Combination feeding

A
  • 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 to 2 hours each day until desired number of boluses reached make sure that bolus takes only 1-2h each day
  • Bolus can be given over 30 to 60 mins if well tolerated
101
Q

are gastric residuals recommended in pediatric

A

no

102
Q

signs of feed intolerance

A

fussiness or irritability, choking, coughing, vomiting, retching, abdominal distension, diarrhea

103
Q

flushing recommendations in pediatric

A

Routine flushing for bolus or interrupting continuous feed for water flushes is not recommended in children

104
Q

what and how often should be monito EN in critically ill?

A

Serum glucose, urea, creatinine, electrolytes, and osmolality, and urine-specific gravity.
Daily to biweekly

105
Q

how often should we measure height, weight and HC in infants and children with EN

A

Daily weight for infants and children. Monthly ht and HC.

106
Q

Signs that we can strat weaning off tube feeding

A

 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

107
Q

when can we remove tube access in chronic cases?

A

Need 2-3 month of normal growth without tube use before removing tube feeding access

108
Q

when do swallowing disorders develop

A

❑ Swallowing develops as early as 12 to 14 weeks of gestation

109
Q

causes of swallowing disorders

A 
❑ Congenital causes
- Neuromuscular diseases (CNS involvement) 
- Cerebral palsy
- Cleft lip and palate
- Spinal muscular dystrophy
- Prematurity
❑ Acquired causes
- Delayed introduction oral feeding 
- Unpleasant oral tactile experiences
110
Q

what is non-nutritive sucking

Benefits?

A

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

111
Q

maximum daily juice amount

A

4oz

112
Q

Recommend using__ food in place of __ to increase kcal density

A

Recommend using pureed table food in place of jarred to increase kcal density

113
Q

Initiate EN immediately if child is__ ideal body weight

A

 Initiate EN immediately if child is < 80% ideal body weight

114
Q

Indication for PN - Neonatal

A

“Consider PN for neonates in critical care setting, regardless of diagnosis, when EN is unable to meet energy requirements for energy expenditure and growth”
 Very low birth weight (Birth weight <1500g)

Intestinal dysfunction or impaired intestinal perfusion
 Short bowel syndrome 
 Gastroschisis
 Necrotizing enterocolitis 
 Meconium ileus
 Intestinal atresia

Expectation of slow progression of EN:

  • Congenital heart disease as they dont get enough oxygen-> risk of bowel ischemia-> usually start combo of PN and En
  • Severe respiratory failure with hypoxia and acidosis
115
Q

When would u administer PN when EN cannot be administered

A

Malnourished children if cannot tolerate or safely receive EN for >3days

116
Q

Indication for PN - Pediatric

A

“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.”

Common indications but not exclusive:

  • Neuromuscular disorders: Chronic intestinal pseudo-obstruction, Hirschsprung’s disease, mitochondrial disorders
  • Mucosal disorders: Microvillus inclusion disease, tufting enteropathy, autoimmune enteropathies, intractable diarrheas
  • Anatomical disorders: Decrease in intestinal length: SBS, atresias, gastroschisis, volvulus, meconium ileus, NEC, thromboses and trauma
  • Inflammatory bowel: Only in cases of fistulae, obstruction, toxic megacolon and bowel resection resulting in SBS.
  • 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.
  • 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.
  • Stem cell transplant: Severe mucositis, typhlitis, intestinal obstruction, intractable vomiting, intractable diarrhea.
117
Q

Timing for starting PN: neonatal

A
  • Delaying PN → negative nitrogen balance = postnatal growth failure
  • Early administration of PN within hours of birth considered safe
  • EFA deficiency can develop within 3 days on fat free diet
  • Begin PN promptly after birth in VLB weight infants (<1500g)
  • Insufficient data for more mature preterm and critically ill term neonates
118
Q

Timing for starting PN: pediatric

A
  • For infant, child or adolescent- reasonable to delay consideration of PN for a week
  • However, initiate PN within 1-3 days in infants, and within 4-5 days in older children and adolescent when EN or PO not tolerated
119
Q

Adverse effect of PN: Short term & Long term

A

Short-term:

  • Infection
  • Hyperglycemia
  • Electrolyte abnormalities
  • Acid-base imbalances
  • Hypertriglyceridemia
  • Phlebitis
  • Bacterial translocation
  • Compromised gut integrity

Long-term

  • 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
120
Q

Monitor __ during tapering on TPN

A

Monitor glycemic control during tapering on TPN

121
Q

What % of requirements for energy and protein and micronutrients should be achieved by oral intake and/or EN to when PN

A

Wean PN when oral intake and /or EN achieves 50-75% of requirements for energy and protein and micronutrients, unless impaired gastrointestinal function precludes 100% absorption of nutrient needs

122
Q

what is the purpose of PPN?

A

Intended for short term use to supplement EN, when central venous access not possible

123
Q

which children can we use PPN in? hwy?

A

PPN can be used in children that :

  • and were previously well nourished or mildly nutrition deficit
  • and those who are expected to reach full EN within 7-10 days
  • and have stable electrolyte status, without elevated needs
  • and have 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

Hard to meet kcal and PRO needs with lower osmolality and volume

124
Q

after how many days on PPN w/o EN progression should we consider TPN?

A

If after 5-7 days of PPN, no progression of EN- consider TPN

125
Q

Hallmark of refeeding:

A
  • Salt and water retention leading to edema and heart failure which is
    exacerbated by cardiac atrophy
  • Hypokalemia due to rapid cellular uptake of K as glucose and AA are taken up during cellular synthesis of glycogen and protein
  • Hypophosphatemia due to increased phosphorylation of glucose
  • Rapid depletion of thiamine, cofactor of glycolysis leading to Wernicke’s
    encephalopathy and/or cardiomyopathy
  • Hypomagnesemia due to cellular uptake of Mg
126
Q

bone health concern with PN

A

calcium and phosphate takes up a lot of space in the fluid and u are often fluid restricted-> can’t meet the needs
You have to think how to optimize bone health, DEXA scans, how to provide calcium phosphate which also precipitates easily

127
Q

which organ function is especially imrpitant with TPN

why

A

kidney

TPN provides a lot of fluid

128
Q

when is the highest risk of refeeding? Thus, what are the monitoring guidelines

A

Highest risk is in the first 4 days after feeding is restarted but may develop
up to 2 weeks after restarting nutrition
-> monitor for at least 2 weeks

129
Q

Patients especially at risk of refeeding include:

A

▪ Severe underweight (Body Mass Index <5th centile for age),
▪ Acute weight loss of 5-10% in past 1-2 months ,
▪ No enteral nutrition for 7-10 days or major stressors without food for several days,
▪ Abnormal electrolytes prior to refeeding (phosphate, potassium, magnesium),
▪ Prolonged and severe vomiting,
▪ Prolonged QTC interval on ECG,
▪ Pre-existing cardiac or respiratory conditions

130
Q

Pediatric refeeding guidelines

A

ask yourself how long the condition has been going on e.g. flu for 4 days and little intake-> risk of refeeding

  1. Check electrolytes prior to starting feeds
  2. Supplement thiamine and multivitamins in all patients at risk prior to refeeding and consider phosphate supplementation if needed.
  3. Start refeeding at 50-75% of goal calories and increase over 3-5 days
  4. For those at risk, caloric intake should be restricted and feeding should be commenced slowly, with caloric intake spread over the day and increased gradually according to clinical stability.
  5. Feeds may need to be temporarily reduced or even ceased if electrolyte or clinical instability occurs.
  6. Protein does not need to be restricted
  7. Rehydrate carefully, careful not to fluid overload
  8. Refeeding syndrome can occur up to 2 weeks post initiation of enteral or parenteral nutrition.
  9. Monitor at least for the first 4 days and supplement electrolytes as required.– including weight, biochemistry, fluid balance and cardiovascular stability.
131
Q

when following the new guidelines of aggressive refeeding, what should u supplement?

A

supplement phosphate and calcium to avoid hypophosphatemia and hypocalcemia monitoring is extremely important

Clinical 3 (17 decks)

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