Pediatrics Overview Flashcards
A child with cerebral palsy and a gastrostomy tube is admitted to the hospital for a fundoplication. This procedure is used to manage
gastroesophageal reflux
GER is most common in children with ____
neuroimpairment
What are the steps used to treat GER in children
change feeding regimen
change positioning during feeding
stat medications for reflux and motility
If treatment is refractory to GER, _____ is used a last resort management
Fundoplication or PEG-J extension
Premature infants with these types of conditions are at an increased risk for metabolic bone disease
- cholestasis
- immobilization
- Chronic steroid use
- very low birth weight <1500 grams
- chronic diuretic use
MBD is characterized by the development of
osteopenia and osteomalacia
When used in the assessment of critically ill children, how do predictive equations compare to indirect calorimetry
no consistent comparison can be found
Indirect calorimetry is the gold standard for the assessment of energy needs in the critically ill child and should be used whenever possible. When IC is not available, what should be used
Schofield or WHO equation
what is the most common nutrient deficiency in childhood
iron deficiency anemia
Term infants have enough iron stores for up to ____ months
6 months
Infant formulas are fortified with enough
iron
Iron content of breast milk is ______ than formula but more efficiently absorbed
less
exclusively breast fed infants require additional iron starting at ________ months old with supplementation or complementary foods
4-6 months old
Cows milk has iron but is ___________ because it is high in calcium
not efficiently absorbed
Children should not be introduced to cows milk before ___ months because they will be at risk for ______
12 months
iron deficient
An obese 12 year old is admitted to the hospital for an evaluation of sleep apnea. A diet history reveals she drinks 3 cans of soda, 24 oz of juice and 8 oz of chocolate milk a day. In what mineral may she be deficient
calcium
soda consumption in youth decreases ____ consumption
calcium
______ adolescents are at the highest risk of developing _____ deficiency
female
calcium
juice consumption should be
<8 oz a day school age/adolescence
<4-6 oz pre school children
<4 oz toddlers
Children should consume ____ servings a day of dairy to obtain enough calcium
2-3 servings
adolescents should consume ___ servings a day of dairy to obtain enough calcium
4
When does the American Academy of Pediatrics recommend universal screening for iron deficiency be performed in young children
12 months old
iron deficiency over time can lead to long term _______ deficits
neruodevelopmental
Selective screening for iron deficiency is done at any age for infants with the following risk factors
prematurity
low socioeconomic status
poor growth
exclusive Breast feeding without supplementation
When reviewing a child’s growth chart data , the child’s weight for length curve is falling below the 3rd percentile. What z-score indicates severely wasted
z score below =3
a z-score (also known as the std deviation) is where a child weight falls from the median or percentile in growth charts
50th
a positive change in standard deviation/z scores indicates
growth
a negative change in standard deviation/z scores indicates
slowing growth rate
what is the suggested daily amount of potassium required for maintenance of infants with PN
2-4 mEq/Kg
A 13 year old boy whose BMI is at the 97th percentile on the CDC’s growth chart for age and sex would be classified as
obese
BMI on growth charts is used for children ages over
2 years
a BMI between the 85th and 94th percentile is classified as
overweight
A BMI greater than or equal to the 95th percentile is classified as
obese
Which conditions are associated with delayed bone age in a child with a short stature (things that delay bone age)
hypothyroidism
Cushing syndrome
growth hormone deficiency
____ is a diagnostic test assessing a child with abnormal growth, using radiography of the knees or left wrist
bone age
Precocious Puberty is known as
advanced bone age
what type of pre-term growth chart allows for comparison for pre-term infants from 22 weeks gestation age up through 10 weeks post term age
Fenton
What are the pros of using a Fenton growth chart
large sample size
validated tool
assess rate of growth OVER TIME
In newborns, potassium is not added to the PN solution until
kidney function is established
what is the daily maintenance fluid requirement for a 5 kg infant
500mL
The Holliday Segar Method estimates fluid requirements. For each 100 kcals metabolized ____mL of water will be needed
100
The Holliday Segar Method to estimate fluid needs should be used for neonates greater than
14 days old
How is the holliday segar method used
1st 10 kg provide 100mL/kg/day
2nd 10 kg (over 10kg): provide 50mL/kg/day
each additional kg over 20 kg, provide 20mL/kg/day
On radiographic examination a pediatric patient is found to have osteopenia and multiple fractures in various stages of healing. Serum lab results show calcium is low, phos is low, creatinine is normal, alk phos is high, 25-OH vit D is low, 1,25 dihyroxyvitamin D is low, and PTH is high. What is the likely diagnosis
Vitamin D Type Rickets
Signs/Sx of vitamin D type rickets are ______ serum calcium, _____ serum phos, ____ alk phos, _____ PTH, _____ 25-OH vit D 2, and ______1,25OH vitamin D3
normal to low calcium normal to low phosphorous high alk phos increased PTH low vitamin D 2 low vitamin D3
In vitamin D dependent rickets type 2, whate are the signs and symptoms. ______ 25 OH vitamin D 2 and _______ 1,25 dihydroxy vitamin D 3
low vitamin D2
ELEVATED VITAMIN D3
What is the recommended daily enteral elemental iron dose for preterm infants 1 month after birth
2-4 mg/kg/day (during stable growth) because the rate of growth and erythropoiesis slows down s/p birth and iron requirements are lower.
elemental iron supplementation in preterm infants starts around ___ month and should last until ______ months
2-4mg/kg/day for 4-8 weeks starting until 12-15 months old
Infants not getting human milk should receive ______ formula and preterm infants should get at least ____ mg/kd/day of elemental iron from 1-12 months of age
iron fortified formula
2 mg/d/day from 1-12 months old
what trace element should be supplemented in a child with chronic diarrhea
zinc
acute diarrhea lasts for < ____ days, persistent diarrhea lasts for more than ____ days, and chronic diarrhea lasts for > ____ days
14 days
14 days
30 days
Studies show that ______ decreases the duration of diarrheal episodes, decreased hospitalizations and decreased mortality
zinc
____ mg of zinc should be given a day when a child has 10-14 days of acute diarrhea and children under 6 months old should only receive ____ mg o zinc
20 mg
10 mg
is pancreatic insufficiency a contraindication to nasogastric feedings in a pediatric patient with cystic fibrosis
No, pancreatic enzymes can be given to help with absorption
what are contraindications to NG tube placement in pediatric patients with CF? (will need stomach or small bowel access)
upper airway secretion
nasal polyps
recurrent sinusitis
otitis
what is the best indication for the use of a soy based infant formula
galactosemia
why are soy based infant formulas not used in children with cow’s milk allergy?
a high percentage of children who are allergic to cow’s milk protein are also allergic to soy
patients with soy or cow’s milk allergies require which type of infant formula
hydrolyzed or free amino acid formula
An inborn error of metabolism that affects the body’s ability to metabolize galactose
galactosemia
A child or infant with galactosemia must _______ from the diet and use ______ based formulas
eliminate galactose from the diet
use soy based formulas
What is recommended to prevent vitamin D deficiency in a 1 month old infant who is fed human milk
give 400 IU of vitamin D a day soon after birth
how much vitamin D is recommended for exclusively breast fed infants
400 IU vitamin D
A seven month old fed reconstituted infant formula and other age appropriate complementary foods may be at risk of over-supplemetnation of which mineral?
Fluoride due to the tap water
high amounts of fluoride in a child’s diet can cause
disrupted tooth enamel/mineralization (enamel fluorosis)
which pediatric patients are at the highest risk for enamel flurosis?
infants on re-constituted formulas used with tap water
non-nutritive sucking helps prevent ___________ in children
oral aversion
non-nutritive sucking should be used in the enterally fed neonate less than _______ weeks corrected gestational age to promote__________
< 32 weeks
to promote oral feeding when developmentally ready
suck/swallow coordination is usually developed between __ and ___ weeks gestation
32-34 weeks
what are the benefits of non nutritive sucking
improves digestion of EN feedings
encourages oral development
stimulates lingual lipase, gastrin, insulin, motilin and vagal innervation during EN feedings
which equation is typically used to measure energy needs in pediatrics
Schofield equation
if a child is under weight, which weight should you use to calculate energy needs in pediatrics
ideal body weight as they need rapid weight gain
children with cystic fibrosis require _____ energy needs
increased
why are energy needs elevated in children with cystic fibrosis
increased work of breathing, decreased nutrient absorption from pancreatic insufficiency
what is the maximum dose in units of lipase/kg/meal for PERT therapy
2,500 units
too high of a dose of lipase or PERT enzyme therapy can increase the risk of developing
fibrosing colonopathy
children with cystic fibrosis require _____% of energy needs for optimal growth
120%
supplement fat soluble vitamins in the _____ form for optimal vitamin absorption in children with CF
water miscible (children with CF have fat malabsorption)
Infants with cystic fibrosis require additional sodium due to high losses, so salt needs to be supplemented. Infants who are 0-6 months old require ____ teaspoons/day and ____ teaspoons if older than 6 months
1/8 teaspoon/day
1/4 teaspoon/day
when is enteral nutrition indicated in children with cystic fibrosis
if the child cannot meet their energy needs with po intake alone
other than fat soluble vitamins, what else important to supplement in children w/ CF
calcium as they have a high risk of osteoporosis
if a child’s health insurance does not cover enzymes in children with CF, can generic enzymes be supplemented?
no, they are not water miscible
A 14 year old female with cystic fibrosis weighs 50 kg and is 63” tall with pancreatic insufficiency. She takes PERT at meals at a dose of 25,000 units of lipase per capsule. What is her max per meal?
25,000 units x 50 kg = 125,000 units total divided by 25,000 units per capsule, is 5 capsules per meal
in the critically ill child, are standard equations used to calculate energy needs?
no, they are inaccurate
if indirect calorimetry is not available to measure energy needs in critically ill children, which equations should be used, should a stress factor be used?
Schofield or WHO equations
NO stress factors should NOT be used
overfeeding in critically ill children can cause _____ ,_____and _____ leading to increased time on the vent and increased PICU length of stay
cholestasis
hyperglycemia with increased infection
what is the gold standard for measuring energy needs in children with burns
indirect calorimetry
the general goal of % of energy needs for children with burns are about ____ to ___%of their REE
120-130%
children with burns greater than _____% BSA usually need nutrition support to meet their elevated nutrition needs
20% BSA
what types of children in the ICU require lower energy needs
traumatic brain injury
cerebral palsy
Trisomy 21
protein needs ____ during periods of stress, critical illness and short bowel syndrome in children
increase
as child ages, protein needs typically _____ in healthy children
decrease
children from 0-12 months usually require ____g/kg/day of protein
1.5 g/kg/day
children from 13 months to 3 years usually require ____ g/kg/day of protein
1.1g/kg/day
children 4 to 13 years old typically require ___ g/kg/day of protein
0.95
children between the ages of 14 and 18 years old typically require ___ g/kg/day of protein
0.85
protein needs during injury _________ due to nitrogen loss and acute inflammation
increase
protein needs roughly _____ during injury and illness . Children of 0-2 years require ___ to ___ g/kg/day protein, 2-13 years old require ___ to ___ g/kg/day and ages 2-18 years old need ___g/kg/day protein
double
2-3 g/kg/day
1.5-2 g/kg/day
1.5 g/kg/day
excessive protein intake of ____ to ___ g/kg/day can contribute to negative consequences such as ___ and ___
4-6 g/kg/day
metabolic acidosis
azotemia
In infants less than 6 months avoid giving ______ due to inadequate nutrient intake and possible electrolyte imbalances
free water
how are fluid needs calculated in children
Holiday-Segar Method
the holiday-segar method of fluid needs provides ____mL/kg for infants 1-10 kg
100mL/kg
the holliday-segar method of fluid needs provides _______mL + ______mL/kg for every kg over 10 kg up until 20 kg
1000 mL + 50mL/kg
The holliday-segar method of fluid needs provides _______mL + ____mL/kg for every kg over 20 kg of weight
1500 mL + 20mL/kg
what are the benefits of breast milk
increased resistance to infections, increased GI maturity, decreased risk of overfeeding, decreased risk of NEC in preemies, decreased risk of allergies
breast milk contains _____ kcal/oz
20 kcal/oz
breast milk contains ___ to ___ grams/mL of protein
0.9-1.4 grams/mL
breast milk contains __ to ___ grams of fat/mL
3.5-3.9 g fat/mL
pre-mature infants require ____ kcal/oz of formula for weight gain
24 kcal/oz
infant formula for pre-mature infants are higher in
protein, fat, calcium, phosphorous, and zinc
infant formula for pre-mature infants post discharge contain ____ kcal/oz until 9 months of age
22 kcal/oz
Standard infant formula contains ___kcal/oz
20 kcaloz
infants with ______ CANNOT have standard formula as they cannot consume lactose
galactosemia
infants with galactosemia require ____ based formula
soy
should infants with cow’s milk protein allergy use soy based infant formula’s?
no they usually also have soy allergy
low lactose infant formulas are used for infants with
suspected lactose intolerance
Anti-Reflux infant formula are for infants with severe ____ who are not gaining weight appropriately. It has a ____ component that makes the formula more viscous which makes it harder to bring back up
GER
starch component
if an infant is on an acid blocker medication, will anti-reflux medications work?
no because the starch relies on the stomach acid to thicken the ofrmula
caseine hydrolysate infant formula is used in infants with _____ protein allergy
milk
elemental infant formula is an amino acid based formula is used for infants with
severe food allergies, malabsorption
vitamin _____ is supplemented prophylactically to ALL newborns
vitamin K
_____IU a day of vitamin D is recommended for exclusively breast fed infants
400 IU/day
for infants breast fed and on formula, what is the recommendation for vitamin D?
routinely monitor levels and supplement as needed
for infants getting 100% goal volume of infant formula, what are the recommendations for vitamin D supplementation
NO supplementation of vitamin D is necessary unless they have a malabsorption disorder
which children/infants are at most risk for a vitamin D deficiency
breast feeding without supplementation
dark pigmented skin (melanin acts as SPF)
born earlier than 32 weeks gestation
geographic location
recent immigration from developing country
malabsorption disorders such as epilepsy, CP, SBS, biliary atresia, phenobarbital medications
phenobarbital medications in infants can lower _____ vitamin
vitamin D
when are vitamin B12 levels of concern in infants
if the baby is exclusively breast fed and mom is vegan s
when should iron be fortified in infants
by 4-6 months old
when does fluoride need to be supplemented ?
after 6 months of age based on the water supply (rural areas and well water)
0.25mg/day of this is needed to be supplemented in some infants from 6 months to 3 years old
fluoride
Cow’s milk should not be given before
1 year
why is Cow’s milk inappropriate for children
low in iron
low in vitamin C and E
low in essential fatty acids
has a high renal solute land due to limited ability to concentrate the urin as I stooging high in milliosmoles
elemental formulas for children 1-10 years old is used for
malabsorption and food protein allergies
elemental formulas for children 1-10 years old contains
free amino acids, 240-3ckal/oz
semi elemental formulas for children 1-10 years old contains
protein as peptides and amino acids , 30-45 kcal/oz
when would Semi-Elemental formula for children 1-10 years old be used
malabsorption
a polymeric formula for children 1-10 years contains these properties
fiber is calorie dense 30kcal/oz 44-53% carbs 35-45% fat 12-15% protein
when are orogastric tubes recommended for children
premature infants <34 weeks with nose breathing, lack of gag reflux
basilar skull fractures
when are NG tube appropriate for children requiring enteral nutrition
normal gastric function
no risk of aspiration
short term use
when are Nasoenteric tubes recommended for children requiring enteral nutrition
short term with significant reglux
gastroparesis
high aspiration risk
when are gastrostomy tubes recommended for children requiring enteral nutrition
long term for at least 3 months
when are gastrojejunostomy tubes recommended for children requiring EN
long term
severe GER who aren’t a candidate for a Nissen Fundoplication
already have a gastrostomy but be but not tolerating their feeds
when children are given EN via bolus or gravity how should the be initiated and advanced
start at 25% of the goal
divide the # of feeds
increase the volume by 25% daily
when children are given EN via pump how should they be initiated and advanced
start at 1-2mL/kg/hr and advance by 0.5 to 1 mL/hr every 6-24 hours to the goal
if possible, don’t use powdered formula for these types of infants
immunocompromised
what is the recommended hang time of manipulated formula and human breast milk including powdered, re-constituted HBN, and EN formula with additives
4 hours
what are the indications for EN in children
insufficient oral intake to support adequate weight gain and growth, oral motor dysfunction, inborn errors of metabolism, Chron’s disease
a structural or functional GI abnormality such as congenital malformation, head/neck tumor, or injury/critical illness
what is the preferred method of feeding in a critically ill child
enteral nutrition (the stomach)
when should feeding be initiated in the PICU
within 24-48 hours of admit if feasible
by the end of 7 days (1 week) feeding should provide _____ energy needs
2/3 energy needs (60%)
when is PN indicated in the PICU
prematurity severe GI impairment volvulus intestines NEC intestinal atresia small bowel ischemia IBD short bowel syndrome Gastrochisis omphalacele hyper metabolic and unable to meet needs alone with EN, s/p bone marrow if not able to meet needs with EN alone Hirshcpurngs Disease
an opening in the abdominal wall muscles where the intestines, stomach and liver protrude outside of the body
Gastrochisis
what is assessed in pediatric malnutrition
food/nutrient intake, energy/protein needs, growth parameters, weight gain velocity, mid upper arm circumference, hand grip strength
when using z scores you can meet _____ number of criteria for malnutrition in pediatrics
1
categories of pediatric malnutrition using z scores
weight/height, BMI, length for height/age, MUAC
Mild Malnutrition Criteria (peds) Z scores
- 1 to -1.9 height/weight
- 1 to -1.9 BMI
- 1 to -1.9 MUAC
Moderate Malnutrition Criteria (PEDS) z scores
- 2 to -2.9 height/weight
- 2 to -2.9 BMI
- 2 to -2.9 MUAC
Severe Malnutrition Criteria (PEDS) z scores
- 3 or less height /weight
- 3 or less BMI
- 3 or less length/ht and length/age
- 3 or less MUAC
Mild Malnutrition Criteria PEDS (2+ needed)
weight gain velocity <75% of normal
5% loss of UBW
decline in 1 standard deviation of weight for length/weight for height z score
51%-75% EEN/EPN
Moderate Malnutrition Criteria PEDS (2+ needed)
weight gain velocity <50% of normal
7.5% loss of UBW
decline in 2 std deviations for weight for length/weight for height z score
26-50% EEN/EPN
Severe Malnutrition Criteria PEDS (2+ needed)
weight gain velocity <25% of normal
10% loss of UBW or greater
at least 3 standard deviations below wt/lenght and wt/ht z score
<25% EEN/EPN
phenotypic malnutrition criteria (weight) in GLIM
> 5% in = 6 months
>10% in > 6 months
phenotypic malnutrition criteria (BMI) in GLIM
<20 if >70 years old
<22 if 77 years old
<18.5 Asians <70 years old
<20 Asians >70 years old
phenotypic malnutrition criteria (Muscle mass)
decreased muscle mass
etiologic GLIM criteria
50% < food intake >1 week
any reduction > 2 weeks for any chronic GI absorption that impacts food assimilation
acute/chronic disease related inflammation
well defined, easy to palpate, slightly seen clavicle in females, curved shoulders, scapular bones not prominent describes ______ upper body muscle
normal
muscles around the knee visible but well rounded, patella not prominent, gastrocnemius is developed and rounded describes ____ lower body muscle
normal
temporalis muscle slightly depressed, decreased pectoralis major muscle moderately visible, clavicle present in females and males, shoulder blade/acromion process is more visible with a hollow trapezius, there is somewhat prominent scapular bones describes ______ upper body muscle
mild/moderate depletion
patella slightly prominent but rounded, inner thigh with concave gap when pressed together, gastrocnemius is less developed describes____ lower body muscle
mild/moderate depletion
depressed/hollow temporalis muscle, prominent facial bones, sharply protruded clavicle, minimal prese pectoralis muscle, scapula/ acromion process are sharply angular and there is deep concave interosseous muscle describes ___ upper body muscle
severe depletion
patella is sharply prominent, there is concaved shape between thighs with a large gam and the quadriceps lack definition indicates _____ lower body muscle
severe depletion
fat pads protrude slightly or are flat indicate, the skinfold underneath the triceps with ample fat tissue, iliac crest doesn’t protrude and ribs are visible indicates ____ fat assessment
normal fat assessment
faint, dark circles with a moderately concave eye area, skin fold pinch with some fat tissue but less space between the fingers, iliac crest visible and ribs are visible but without marked depressions between them indicates _____fat assessment
mild to moderate fat depletion
visible, dark circles, extremely concave eye socket, skin is loose, skin fold pinch yields fingers touching, little to no fat tissue present, iliac crest is protruding, ribs are protruding with sharp depressions in-between them indicate ___ fat assessment
severe fat depletion
the incidence of aspiration is directly caused by EN is _______ to be determined due to the lack of clinical research. There is no standard definition of aspiration
difficult
Critically ill children have decreased strength and coordination of pharyngeal muscles and a weak cough reflex making ___ more likely
aspiration
what is considered appropriate use of powdered infant formula in healthcare facilities?
only use when alternative, sterile liquid products are not available or when clinically necessary
powdered formulas are or are not sterile
are NOT!
use extra caution when providing powdered formulas to ______ children as they have a higher risk of bacterial contamination
immunocompromised chidren
in the hospital, what is the hang time for expressed human milk when used for continuous feedings?
4 hours
human milk is _____ sterile due to normal skin flora that is present. Never re use ___, ___ or _____ to reduce the chance of contamination
never sterile
bags, syringes, or tubing
A 1 month old has acute onset of diarrhea for 48 hours. The parents noticed that he hasn’t been wetting as many diapers and mucous membranes are slightly dry. It is anterior fontanel is soft and not sunken. He normally ingests milk based formula ad lib. What is the most appropriate intervention?
oral rehydration therapy. the infant is likely dehydrated from diarrhea/viral gastroenteritis and then return to age appropriate diet as tolerated and continue with milk
sunken eyes, sunken fontanel, poor skin turgor, dry mucous membranes and decreased numbers of wet diapers indicates
dehydration
what osmolarity is considered to be an upper limit for the osmolarity of infant formulas to avoid tolerance issues
460mOsm/kg
Osmolality of standard infant formulas has a caloric density of ______ kcal/oz with and osmolarity of _______ to ____ mOsm/kg
20 kcal/oz
200-380mOsm/kg
which infant formulas have the highest osmolarity
protein hydrolysate and free amino acid infant formulas
the osmolarity of a 30kcal/oz infant formula is
450 mOsm/kg
what distinguishes gastroesophageal reflux (GER) from gastroesophageal reflux disease (GERD) in infants?
GERD is characterized by significant complications including weight loss, failure to thrive, feeding difficulties, and back arching
GER commonly resolves spontaneously and without _____
significant complications
regurgitation is very common in infants and typically resolves between 7-12 months of age as the esophageal sphincter matures. Common causes of regurgitation are
rapid administration of EN or formula
delayed gastric emptying
Feeding tube migration
what is the max GIR for a term infant getting PN
14-18 mg/kg/min
a high eGFR in children can cause
fat production, hepatic steatosis, PNALD, hyperglycemia, hypertriglyceridemia
in an infant getting PN what is the minimum amount of soybean oil based ILE needed to prevent EFAD ?
0.5-1g/kg/day
fatty acids are important in infants/children because of their role in
brain development
standardized neonatal parenteral amino acid solutions differ from standard adult PN amino acids by having a higher content of
tyrosine and taurine
what 2 amino acids are considered essential in neonates due to enzyme immaturity
tyrosine and taurine
what 3 amino acids are given in lower amounts than adults
phenylalanine, methionine, glycine
_______ amino acid is not part of a standard infant PN amino acid solutions but can be added separately to lower the pH to optimize calcium and phosphorous solubility
cysteine
the amino acid cysteine is not part of standard pediatric amino acid solutions in PN but can be added for what benefit
optimizes calcium and phosphorous solubility by lowering the pH
What is the recommended daily intake of selenium for term infants receiving PN
2 mcg/kg/day
what are the functions of selenium
immune function, antioxidant function, thyroid hormone activity and regulation
selenium must be added ____ to PN in neonates
separately
immediately following neonatal cardiac surgery, which of the following is the best estimate of parenteral caloric requirements
55-60 kcal/kg/day (lower than 89)
what therapies most appropriate in the nutritional management of an infant with chronic lung disease
high calorie, fluid restriction using concentrated formulas
why are calorie needs increased in infants with chronic lung disease
due to increased work of breathing, emesis and chronic infections
_____ is necessary in infants with chronic lung disease to decrease fluid build up around the heart and lungs
fluid restriction
Pancreatic enzymes that are supplemented in high doses in children with cystic fibrosis could result in
fibrosing colonopathy
pancreatic enzymes are used are used in children with cystic fibrosis in order
to decrease steatorrhea, increased nutrient absorption
what is the maximum number of units of lipase/kg/day to avoid fibrosing colonopathy
<10,000 units/kg/day
Use of Lactobacillus rhamnosus GG (LGG) in pediatric practice has been found to be most effective in treating
infectious diarrhea/gastroenteritis
An infant has a complete ileal resection with preservation of the ileocecal valve. What would be the primary nutritional concern?
vitamin B 12 deficiency w/ bile acid deficiency
preterm infant formula or fortified human milk is used for premature infants becuase
after the 1st month, unfortified human milk may have inadequate protein amounts
preterm formulas contain ___ to __% of carbohydrate calories from lactose and medium chain triglycerides to aid with absorption
40-50%
premature infant formulas are higher in what macronutrient
protein
Necrotizing Enterocolitis (NECT) etiology is unclear. but ____ has been found not to increase the risk
early minimum enteral feeding does not increase the risk of NEC
what is the benefit of starting minimum enteral feedings on infants
shortens the time to get to full feeds faster weight gain improved feeing tolerance decreased hospital length of stay decreased incidence of infection for LBW/VLBW
in premature infants, when medically possible starting ))) can begin on the day of birth
minimum enteral feedings
exclusive EN has been shown to be effective in inducing remission of Chron’s disease in the pediatrics population. What EN formula is recommended as the first line treatment
polymeric formula
biliary atresia in infants is most frequently associated with
fat malabsorption
atrophy of the bile ducts causing obstruction of bile flow from the liver to the biliary system & small intestine is called
biliary atresia
biliary atresia will result in
a significant decrease in bile acids required for fat absorption, causing fat and fat soluble vitamin malabsorption . Essential fatty acid deficiency will not occur as long as LCTs are supplemented
what is a characteristic of cachexia in pediatric oncology patients
progressive lean tissue & body fat
what method of estimating energy requirements in critically ill children is LEAST accurate when compared to resting energy expenditure measurement by indirect calorimetry
RDA (recommended dietary allowance)
In the pediatric ICU, predictive equations are ___ consistent with measured energy expenditure leading to over or underfeeding
NOT
what is the gold standard for estimated energy needs in the pediatric ICU
Indirect Calorimetry
Nutrition therapy for pediatric patients with <20% total body surface area burn typically includes
oral intake of high calorie, high protein diet
In Chron’s disease ___ is thought to positively alter the gut microbiome and ______ is recommended unless there are symptoms of malabsorption of GI dysfunction
EN
polymeric
what are the clinical symptoms of celiac disease
failure to thrive, constipation, anemia, diarrhea, abd pain/distention, vomiting, short stature, weight loss, inadequate weight gain, dermatitis, decreased bone mineral density, fatigue, delayed puberty
a 2 month old infant who has been exclusively fed with cow’s milk based formula develops a full body rash, what would be the next step
switch to a protein hydrolysate based formula
what are signs/symptoms of a cow’s milk allergy
blood in stool diarrhea skin rash eczema wheezing
The biochemical defect in Phenylketonuria (PKU) prevents the hydroxyl of phenylalanine to tyrosine which causes a build up of phenylalanine in the blood and a subsequent deficiency of tyrosine
provide a phenylalanine restricted, tyrosine supplemented diet
what are the metabolic alterations noted during the ebb response following a burn injury to a pedi patient
decreased resting energy expenditure hyperglycemia low insulin low oxygen consumption decreased blood pressure, cardiac output and decreased body temperature
after the EBB phase of a burn, comes the flow phase which exhibit these metabolic alterations
increased catecholamines, increased insulin, increased glucagon/corticosteroids with hyperglycemia, catabolism, increased body temp, increased losses of nitrogen, magnesium, phos and potassium and accelerated gluconeogenesis
what is the diagnostic criteria of infantile anorexia
refusal to eat adequate amounts of food for 1 month or greater and or growth deficiency
what nutrition support therapy is essential to intestinal adaptation following significant bowel resection
Enteral nutrition (human milk preferred)
what is the maximum GIR of a pediatric patient
14 mg/kg/min
in PN, dextrose should provide between _______% kcals
40-60% kcals
in PN, fat should provide between _____% calories
20-40% kcals
providing over ____% of fat in pediatric patients can cause ketosis
60%
how much lipid is needed to prevent EFA deficiency
0.5 g/kd/day soy based lipids
what are symptoms of pediatric essential fatty acid disease
scaly rash
increased susceptibility to infection
poor wound healing
poor growth
are TNA’s recommended for neonates/infants
no
which amino acids are needed in greater amounts in infants less than 1 years old when TPN is given
tyrosine
histadine
which amino acids are needed in lesser amounts in infants less than 1 years old when TPN is given
phenylalanine
methionine
glycine
more acidic pH
which amino acid is conditionally essential in infants <1 years old as it is used for neural transmission and bile acid conjugation
taurine
why is taurine a conditionally essential amino acid in infants on PN <1 years old
it is needed for neural transmission and bile acid conjugation
why is a low pH desirable in infant PN
it increases phosphorous and calcium solubility
in infant PN , the amino acid profile is based on
human milk
preterm neonates, infants and children require how much sodium in PN
2-5 mEq/kg sodium
children over 50 kg require how much sodium in PN
1-2 mEq/kg
preterm neonates, infants and children require how much potassium
2-4 mEq/kg
children over 50 kg require how much potassium in PN
1-2 mEq/kg
preterm neonates require how much calcium in TPN
2-4 mEq/kg
infants and children require how much calcium in TPN
0.5-4 mEq/kg
children over 50 kg require how much calcium
10-20 mEq total
preterm neonates require how much phosphate in TPN
1-2 mmol/kg
infants and children require how much phosphate in PN
0.5-2 mEq/kg
infants over 50 kg require how much phosphate
10-40 mol total
preterm neonates, infants and children require how much magnesium in PN
0.3 to 0.5 mEq/kg
children over 50 kg require how much magnesium in PN
10-30 mEq total
which trace element needs to be increased in infant TPN if there is enter cutaneous fistulae or diarrhea
zinc
which trace element needs decrease in infant TPN during cholestasis
manganese
patients with cholestasis can develop _____ within the first 3 weeks of starting PN as they have difficulty excreting it from lack of bile flow
hypermanganesemia
what are symptoms of hypermanganesemia in infants/neonates
irritability
seizures
if an infant develops hypermanganesemia during PN infusion, what should be done
decrease the amount or take it out of PN
Multitrace-4 Neonatal PN MVI and Multitrace-4 Pediatric PN MVI contains all trace elements as adults EXCEPT
selenium
which trace element is NOT in multi-trace 4 PN MVI
selenium
what are the important functions of selenium for infants and children
converts thyroid to its active form
antioxidant
needed for proper enzyme and immune function
Selenium is not included in the Multi-trace MVI for infant PN and infants are at risk for deficiency. If an infant or neonate is on PN for over 1 month how should selenium be supplemented
2 mcg/kg/day
_______ deficiency is associated with microcytic anemia & neutropenia
copper
________ (along with manganese) should be eliminated or decreased in PN in children with cholestasis as it is removed by bile which is inhibited in cholestasis
copper
_____ deficiency is associated with growth failure and hair loss and loss is exponential during high GI output including diarrhea
zinc
when should zinc be added to infant PN
diarrhea, high GI output
if a child has cholestasis, how can PN be altered to be more liver friendly
reduce lipids
cycle PN
decrease copper & manganese
keep the GIR within normal limits
there is no _____ in pediatric PN MVI and there needs to be an exogenous source given for long term PN infants
iron (and selenium)
______ is supplemented with long term TPN infants to assist in fat oxidation and use
Carnitine
______ is a shuttle for long chain fatty acids that bring fatty acids across the mitochondrial membrane for beta oxidation
carnitine
when carnitine is deficient, what are the consequences
increased triglycerides
increased total bilirubin
hypoglycemia
increased All Phos
how much carnitine should be supplemented in deficiency (PN) x
v
____ improves tolerance to IV fat emulsions in children/infants
carnitine
what amino acid is added to preterm infant/infant PN to decrease pH and increase calcium/phosphorous solubility
cysteine
how can aluminum be managed in PN
choose PN components with the lowest aluminum amount
what is the max amount of aluminum per FDA guidelines
5mcg/kg/day
which types of children are at an increased risk of aluminum toxicity
renal disease (cannot excrete well from the kidneys)
hyperaluminemia is associated with
Metabolic Bone Disease
Encephalopathy
how often should trace elements be checked on children with LT PN
check in 3 months after initiation, then every 3-6 months thereafter
how often should fat soluble vitamins Be checked on children with LT PN
check in 6 months then annual thereafter if results are normal
which anthropometric measures are used to evaluate if a child is malnourished
weight
height
mid upper arm circumference
a neonate is considered the first ___ days of life
28 days
premature infants usually need to start off with what type of artificial nutrition
parenteral nutrition
what are the indications to begin PN in neonates
very low birth weight <1500 grams severe respiratory distress syndrome Volvulus Meconium ileus atresia gastrochisis severe Hirschprung's enteric fistula diaphragmatic hernia
the time of starting PN on neonates depends on
their weight at birth
when is PN ideally started in Very Low Brith Weight Neonates
the first few hours of life
what type of PN is started in neonates
Vanilla/Starter/Base PN
how much grams of protein do neonates need when starting on PN
3-3.5g/kg/day
when is PN ideally started in low brith weight premature babies
within 24-48 hours
when can PN be stopped in premature babies
when adequate EN is established
what is the purpose of starter PN in premature infants
to provide immediate protein
what range of dextrose is given in base PN
5-10%
what range of amino acids is given in base PN
3-4%
why is heparin added to neonatal PN
there is not enough forward pressure in the baby’s lines this will prevent back flow and clotting
how much heparin is recommended for neonatal PN
0.25-1 unit/mL
what prevents clotting in the neonatal PN line
heparin 0.25-1 unit/mL
neonates require ______ fluid in the first 48 hours of life (about 70-90mL/kg/day) *it is better for the lungs
decreased fluid
over time, neonates will have _____ fluid needs from insensible losses associated with prematurity and phototherapy
increased
a preterm infant requires ____mL/kg/day of water
75-120mL/kg/day
a term infant requires ____mL/kg/day of water
60-120 mL/kg/day
an infant over 1 month old or 3-10 kg requires _____mL/kg/day of water
100mL/kg/day
how are total fluid needs calculated for neonatal TPN
Total fluid from calculation - fluid from drips - ILE volume- volume in feeds = volume left over for PN
Example: a 25 week gestational male is admit to the NICU. his brith weight is 515 grams, head circumference 21.5 cm and length is 30 cm. He is at the 4th percentile weight, 17% percentile HC and 14% tile length. On the Fenton curve his z-score is - 1.7. On his first day your hospital gives 70mL/kg/day of fluids, what is his hourly rate?
515 grams / 1000 = kg - .515 kg
.515 x 70mL/day = 36mL of fluid in 24 hours = 36/24= 1.5mL/kg/day
why do neonates usually have high ammonia and BUN when given PN
they have higher protein needs due to an immature urea cycle activity This is common)
when is adding insulin considered in neonatal PN
when BG consistently >200mg/dL (response is variable)
should insulin be added to PN in neonates
no you’ll have better control if given separately
be careful when providing insulin to neonates as they are
very insulin sensitive
premature neonates can be deficient in fatty acids within ___ days
3-7 days
fatty acids are essential for neonates because t
they are essential for central nervous system development
if ____ lipids are used for ILE they need to be given at a higher rate to meet essential fatty acid requirements
SMOF
neonates can safely be at a GIR rate up to
14mg/kg/min
Calculate the GIR of a patient getting 12g/kg/day of dextrose
GIR: a mg per kg per min
12 grams * 1000 mg = 12000mg
24 hrs , 1 hr= 60 min x 24 = 1440 min
12000/1440= 8.3 mg/kg/min
how much sodium is required for preterm neonates in PN
2-5 meq/kg/day
why do neonates require higher amounts of calcium and phos
bone growth
___ and ____ are extremely important to prevent metabolic bone disease (they have lost out on bone mass accrual in their third trimester)
calcium and phos
what is the optimal calcium to phos ratio to promote the greatest retain
2.6 to 1 mEq:mM or 1.7 to 1.0 mg:mg
premature neonates may need a calcium to phosphorous ratio up to _____ especially if they were categorized as intrauterine growth restriction (they tend to reseed a little)
2:1 mEq/mM
if a neonate is <2.5 kg how much PEDI trace is needed
2mL/kg/day
if a neonate is greater than or equal to 2.5 kg how much PEDI trace is needed
5mL/day
_____ is the precursor too glutathione. It acts as an antioxidant, allows for the reduction of methionine, and lowers pH to improve calcium and phos solubility
L-cysteine
L-cystiene is not required unless
giving at least 4g/kg/day protein in PN
how much carnitine is given in neonatal PN
5-10mg/kg/day
_____ is added or given to neonates on PN to help better utilize triglycerides as it is required for transport of long chain fatty acids across the mitochondrial membrane for oxidation
Carnitine
when is supplemental carnitine required for premature neonates on PN
<32-34 weeks gestational age
_____ is added to neonatal PN to maintain catheter patency
heparin
when are labs typically drawn in neonates when started on PN
after the first 24 hours of life
a baby only has ____mL of blood/kg body weight
80 mL
some electrolytes are naturally _____ in neonates especially potassium and phosphorous
higher
what is the average potassium level in a neonate
4-6.2 Meq/L
what is the average BUN in a neonate
4-15 mg/dL
what is the average serum creatinine in a neonate
4-15 mg/dL
what is the average phosphorous level in neonates
4.1-9 mmol/L
what osmolarity is allowed In central PN
> 900mOsm/L
pediatric patients can tolerate a slightly higher ___ in PN due to increased elasticity of their veins
osmolarity about 1,000 mOsm
ILE in neonates is often y-site or piggy backed in order to
prevent phlebitis
what factors affect calcium and phos solubility
amino acids (not enough)
calcium and phos concentration (if exceeds 55)
calcium salt form (gluconate is preferred over chloride)
pH: lower pH is more desirable
temperature; don’t let it get hot
order of mixing : ALWAYS ADD PHOS FIRST in pn and ALWAYS ADD CALCIUM LAST in pn
what calcium salt form is preferred for mixing PN for optimal calcium-phosphorous solubility
calcium gluconate
should pH be low or high to promote optimal calcium-phosphorous solubility
LOWER (can add L cysteine to lower_
what can be added to PN to lower its pH for better ca-Phos solubility
L-cysteine amino acid
when mixing PN _____ should always be added first and _____ should always be added last
PHOS FIRST
CALCIUM LAST
on a calcium phosphorous curve does your calcium phos level want to be above or below the curve
BELOW THE CURVVE will decrease the risk of precipitation
