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
2
Q
acute vs chronic illness related malnutrition: duration
A
acute: <3 months
chronic (more common): >= 3 months
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
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
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
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
7
Q
premature vs term babies: who have reflux more often
A
preterm
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
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
10
Q
what are the common definitions of failure to thrive?
A
- weight for age that falls below the 5th percentile on multiple occasions
or - weight deceleration that crosses two major percentile lines on a growth chart,
11
Q
categories of failure to thrive
A
- inadequate caloric intake
- inadequate nutrient absorption
- increased metabolism
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
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
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
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
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
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
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
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
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
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
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
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
24
Q
Acute versus chronic undernutrition
A
Acute undernutrition:
Severe and sudden onset
Weight is primarily affected
Very low wt/ht (
25
what is is the order of parameters being affected in malnutriton
first thing that gets affected during malnutrition is weight then height
then head circumference
26
preterm definition
Preterm: an infant born at less than 37 weeks gestation.
27
neonate definition
Neonate: an infant born at 37 weeks or greater but who are less than 28 days old.
28
what are the dangers of anemia
neural development issues
29
Albumin, transferrin, prealbumin
| Nutritional implication
Indicator of visceral protein status (if no inflammation), poor nutrition status, slow growth, edema
30
Nutritional implication
| WBC
Immune system marker, increased with infection
31
Nutritional implication
| Urea, creatinine
Indicator of kidney function, hydration, PRO catabolism & intake
32
Nutritional implication
| Magnesium
Indicator of refeeding syndrome, GI losses Specific vitamin or trace element deficiencies
33
Nutritional implication
| Vitamins/trace elements
Specific vitamin or trace element deficiencies
| looked at in chronic cases more often than in acute
34
Nutritional implication of c-reactive protein
Inflammatory marker, increased with infection
35
Nutritional implication of sodium
indicator of hydration and kidney function
36
Nutritional implication of calcium and phosphate
Indicator of bone osteopenia, refeeding syndrome
37
Nutritional implication of direct bilirubin
indicator of liver function, cholestasis
38
Nutritional implication of Hgb, Hct, TIBC, ferritin
Assess iron, vitamin B12 and folate (anemia)
39
which indicators are better than albumin to reflect improving nutritional status? Why
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.
40
do stunted kids look unhealthy?
no, they are just short
41
Clinical assessment - physical
```
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
```
42
which scale is used in ados
tanner
43
when does most adolescent growth occur? What is it an opportunity for?
80% of adolescent growth occurs between age 10 to 15 years old, opportunity for catch up weight gain
44
Greenish black, sticky stool
Name?
Characteristics?
Name: Meconium
Characteristics: First baby stool, if greenish-black it contains For 3 days bilirubin, yellowish green- RBC
45
Yellow, seedy stool
Name?
Characteristics?
Name: breastfed
Characteristics: mild smell
46
Tan and thick stool
Name?
Characteristics?
Name: formula fed
Characteristics: Hummus looking, only a concern if watery or hard
47
Greenish brown stool
Name?
Characteristics?
Name: intro to solids
Characteristics: Leftover guacamole look, will depend on food eaten
48
Watery, brown, loose stool
Name?
Characteristics?
Name: diarrhea
Characteristics: If more than 2 days and frequent risk of dehydration, sign of infection
49
Dry brown and hard stool
Name?
Characteristics?
Name: Constipation
Characteristics: Looks like dirt clay or pellets
Not enough fluid or losing too much fluid
50
pinkish red
Name?
Characteristics?
Name: n/a
Characteristics: Partially digested food, monitor what baby eats
51
Black pasty, tarry
Name?
Characteristics?
Name: melena
Characteristics: Sign of upper GI bleed
52
dark green
Name?
Characteristics?
Name: iron supplementation
Characteristics: On iron sulfate in a supplement or iron fortified baby formula
53
Bright green frothy
Name?
Characteristics?
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
Red streaked, hard stool with blood or mucus
Name?
Characteristics?
Name: bloody stool
Characteristics: Possible rectal fissures, small cracks in anus. If large amt of blood when soft stool need medical attention
55
Name?
| Characteristics?
Name: n/a
Characteristics: Pale, colorless, sign of liver or gallbladder problem
56
WHO vs DRI energy calculation formulas
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
what should be used if IC is not available to determine energy expenditure?
Schofield/ Food Agriculture Organization/ World Health Organization/ United Nations University Equations may be used without the addition of stress factors
58
PRO requirements (g/kg/day) across ages
```
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
PRO recommendations for critically ill children
ASPEN/SCCM 2017 guideline recommend minimum 1.5g/kg/d PRO for critically ill children. Positive protein balance may need much higher intake
60
what is considered to be high protein intake?
High protein > 25% of total kcal
61
AMDR
1-3 years
4-18 years
19+
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
how to calculate 100% maintenance fluid
≤ 10kg: 100ml/kg
> 10kg to ≤ 20 kg: 1000ml + 50ml/kg for wt > 10 kg
> 20 kg: 1500ml + 20ml/kg for wt > 20 kg
63
common reasons for fluid restrictions in babies
kidney and lung dysfunction and heart failure
64
what is a sign of dehydration
Hypernatremia + little wt gain or wt loss = likely dehydration
65
what is a sign of fluid overload
Hyponatremia + weight gain = likely fluid overload
66
Calculate Allowance of 75% maintenance fluid for 5-year-old weighing 32.5kg
calcualte the 100% and then multiply by 0.75
| (1500+20*12.5)*0.75= 1312.5
67
what might rapid weight changes be indicative of?
fluid loss/ gain
68
Lab values indicative of dehydration
↑ BUN, ↑NA, ↑ serum osmolarity, ↑ urine specific gravity, ↑ albumin or Hgb
69
vital indicative of dehydration and fluid overload
dehydration: ↑ heart rate
| fluid overload: ↑ respiratory rate
70
what is PHM
donor pasteurized human milk
71
Characteristics of PHM/EBM vs premature formula
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
link between bones and babies born before 3rd trimester
in the 3rd trimester theres is a lot of calcium transfer
| babies born before 3rd trimester-> no bone mineralization
73
what are the available calories for EBM
normal breast milk = 67kcal per 100ml then fortified to 81, 91 and 100
74
what is the preferred source of enteral nutrition for all infants, including premature and sick newborn
EBM/PHM
or
Premature formula
75
what is the contradiction for breastmilk
galactosemia, congenital lactase deficiency, maternal HIV or use of some medications
76
What are the suggestions for fortification of breast milk
| Consequences?
• 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
What is the discharge formula, when is it appropriate and why do we use it?
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
types of formula for pre-term babies
EBM/PHM
Premature formula
Fortified formula
Discharge formula
79
Types of infant formula
Regular
Partially hydrolyzed
Extensively hydrolyzed
100% amino acid
80
infant formula:
regular
when can it be used?
Characteristics
For >37 weeks, up to 1 yo.
Cow milk based
Transition milk also available
equivalent of polymeric formula for babies
81
infant formula:
Partially hydrolysed
when can it be used?
Characteristics
```
• Not hypoallergenic
• Not adequate for CMPI (Cow's Milk Protein Intolerance)
• Reduced to no lactose, PRO
hydrolysed
• Colic or religious reasons
```
82
infant formula:
Extensively hydrolysed
when can it be used?
Characteristics
• 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
infant formula:
100% AA
when can it be used?
Characteristics
• Hypoallergenic
• Free amino acids
• For GI intolerance , extreme protein
hypersensitivity, suitable CMPI, eosinophilic GI disorders and transitioning from PN to EN, SBS
84
Which infants would benefit from MCT-containing formula?
bb with cholestasis or liver issues
85
pediatric formula types and uses
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
adolescent formula types and uses
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
Indication for EN- acute
- 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
Start enteral feeding at any time during an admission for:
▪ 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
Start enteral feeding as soon as possible, within 48 to 72 hours of admission for hemodynamically stable:
Infants
Patients who were malnourished before illness or injury
Septic or injured patients in whom a prolonged intensive care course is anticipated.
90
Indications for EN - chronic- under the age of 2 and over the age of 2
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
Indications for EN: functional barriers
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
Indications for EN: structural barriers
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
Contradictions for EN
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
EN route selection: <3 months
- 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
EN route selection: >3 months
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
Algorithm for selecting the route of nutritional support
https://docplayer.net/docs-images/43/15762125/images/page_7.jpg
97
when and why would we use bolus feeding?
| Pros and Cons? Way of administration?
- 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
when and why would we use continuous feeding?
| Cons? Way of administration?
```
Cannot tolerate large volumes
Delayed gastric emptying, GERD, dumping syndrome
Requires feeding pump
May limit ability to move
For ambulatory patients have backpack
```
99
when and why would we use combination feeding?
Ideal for pt who need significant amount but cannot tolerate large volume
Smaller bolus during daytime and overnight continuous feed
100
Initiation and advancement: Combination feeding
- 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
are gastric residuals recommended in pediatric
no
102
signs of feed intolerance
fussiness or irritability, choking, coughing, vomiting, retching, abdominal distension, diarrhea
103
flushing recommendations in pediatric
Routine flushing for bolus or interrupting continuous feed for water flushes is not recommended in children
104
what and how often should be monito EN in critically ill?
Serum glucose, urea, creatinine, electrolytes, and osmolality, and urine-specific gravity.
Daily to biweekly
105
how often should we measure height, weight and HC in infants and children with EN
Daily weight for infants and children. Monthly ht and HC.
106
Signs that we can strat weaning off tube feeding
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
when can we remove tube access in chronic cases?
Need 2-3 month of normal growth without tube use before removing tube feeding access
108
when do swallowing disorders develop
❑ Swallowing develops as early as 12 to 14 weeks of gestation
109
causes of swallowing disorders
```
❑ 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
what is non-nutritive sucking
| Benefits?
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
maximum daily juice amount
4oz
112
Recommend using__ food in place of __ to increase kcal density
Recommend using pureed table food in place of jarred to increase kcal density
113
Initiate EN immediately if child is__ ideal body weight
Initiate EN immediately if child is < 80% ideal body weight
114
Indication for PN - Neonatal
“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
When would u administer PN when EN cannot be administered
Malnourished children if cannot tolerate or safely receive EN for >3days
116
Indication for PN - Pediatric
“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
Timing for starting PN: neonatal
- 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
Timing for starting PN: pediatric
- 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
Adverse effect of PN: Short term & Long term
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
Monitor __ during tapering on TPN
Monitor glycemic control during tapering on TPN
121
What % of requirements for energy and protein and micronutrients should be achieved by oral intake and/or EN to when PN
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
what is the purpose of PPN?
Intended for short term use to supplement EN, when central venous access not possible
123
which children can we use PPN in? hwy?
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
after how many days on PPN w/o EN progression should we consider TPN?
If after 5-7 days of PPN, no progression of EN- consider TPN
125
Hallmark of refeeding:
- 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
bone health concern with PN
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
which organ function is especially imrpitant with TPN
| why
kidney
| TPN provides a lot of fluid
128
when is the highest risk of refeeding? Thus, what are the monitoring guidelines
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
Patients especially at risk of refeeding include:
▪ 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
Pediatric refeeding guidelines
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
when following the new guidelines of aggressive refeeding, what should u supplement?
supplement phosphate and calcium to avoid hypophosphatemia and hypocalcemia monitoring is extremely important
