Peds Flashcards
Screening tools
- STAMP (screening tool for assessment of malntr in peds)
- STRONGkids (screening tool for risk on nutritional status/growth)
- PYMS (pediatric yorkhill malnutr score)
All include high, medium, low classifications. Variable for starting age, but can go up to 16-18 YOA
Child is at nutrition risk:
Basic criteria when screening peds
- Weight for length, weight for height <10th%ile (-1.28 z score)
- BMI for age/gender <5th%ile (-1.64 z score)
- Increased metabolic requirements
- Impaired ability to ingest or tolerate oral feeding
- Documented inadequate provision of or tolerance to nutrients
- Inadequate weight gain or a significant decrease in usual growth percentile
Subjective Assessment
Nutrition-centered history:
– Feeding tolerance
– Feeding skills
– Intake patterns
– Cultural/religious factors
Inorganic Factors:
– Economic
– Educational
– Social
Inorganic, economic factor – recent formula shortage, parents trying to dilute remaining formula, transitioning child to cow’s milk sooner, or using juice
Subjective Assessment - things to document
- IBW
- Changes in weight
- Appropriateness of current intakes
- Any GI problems
Clinical assessment
- Admitting diagnosis
- Medical/surgical issues that may affect mode of nutrition delivery
Objective (growth) Assessment
Growth parameters
– Birth anthropometrics (infants/toddlers)
– Head circumference (<3 years of age)
– Length/height (length <2 YOA)
– Recumbent length for children less than
2 years of age
– Weight
Gestation
Normal gestation 37-42 weeks (~40 weeks)
Prematurity – Classifications
- Low birth weight infants
– birth wt <2500 g - Very low birth weight infants
– birth wt <1500 g - Extremely low birth weight infants
– birth wt <1000 g - Micronate
– <750 g
Note: An infant can be LBW, but yet full term 2/2 IUGR
Study
Small for gestational age
Birth weight <10th%ile on intrauterine growth curve
* Pregnancy-induced hypertension
* Maternal malnutrition
* Maternal substance abuse
* Chromosomal abnormalities
Study
Large for gestational age
Birth weight >90th%ile on intrauterine growth curve
* Maternal diabetes
* Genetic predisposition
* Miscalculation of due date
Types of Growth Charts
Based on age, gender, or diagnosis
– CDC growth charts (2-20 years)
– WHO growth charts (Birth to 2 years)
* Used bc data used on worldwide sample
– Preterm charts (e.g., NICU)
– Specialized charts (e.g., Cerebral palsy)
Key Points w/ Growth Charts
- Plotting WNL?
- Trending (is there a clear pattern?)
STUDY
BMI
- <5th%ile = underweight
- 5-85th%ile = normal
- 85-95th%ile = overweight
- > 95th%ile = obese
STUDY
General rules of thumb for infants
The infant should be:
* Doubling birth weight by 5-6 months
* Tripling birth weight by 1 year
Pediatric Malnutrition
- Ages 1 month-18 years
- Evaluate anthropometrics
- Evaluate dietary intake
- Factor in nutrition focused physical examination (is there muscle or fat loss?)
NFPE is NOT primary indicator of malnutrition
Mild Malnutrition
z score -1 to -1.99
* Cause is acute undernutrition (ex: illness)
* Effect is unintentional weight loss or below standard rate of weight gain
Patient still on the growth curve
Moderate malnutrition
z score -2 to -2.99
* Cause is longer lasting undernutrition
* Effect is below standard weight-for-length/height or BMI
Pt is below the growth curve
Severe malnutrition
z score of -3 or greater
* Cause is chronic undernutrition
* Effect is below standard linear growth/stunting
Pt is significantly below the growth curve
Determining malnutrition is dependent on what information at time of assessment?
Indicators for malnutrition vary based on the number of data points you have at time of assessment
Single Data Point
- Proportionality: BMI or Weight for length, z score
- MUAC, z score
- Height or length for age, z score
- Weight for age, z score
- Degree of malnutrition
2 or More Data Points
- Weight gain velocity (<2 yrs)
- Weight loss (2-20 yrs)
- Deceleration in weight for length/height (BMI) z score
- Inadequate nutrient intake
Estimating Calorie Needs:
Healthy Child
* Dietary Reference Intakes
* Estimated Energy Requirements (EER)
When child turns 3, can add AF to EER to provide additional kcal to compensate for energy utilized
Estimating Calorie Needs:
Decreased kcal
Basal Metabolic Rate (BMR)
* (ie. Schofield equation)
Resting Energy Expenditure (REE)
* (ie. WHO equation)
Stress factors can be added to both
Estimating Calorie Needs:
Weight Gain
Specifically, this is for infants to sustain a faster rate of weight gain to achieve an appropriate weight
Catch-up growth
How does Cystic Fibrosis alter nutrient needs?
– Increased nutrient needs 2/2 increased WOB
– Decreased food consumption 2/2 current illnesses
– Reduced nutrient absorption 2/2 pancreatic insufficiency
– Secondary illnesses, such as CF related
diabetes, liver disease, and osteoporosis
What is the max dosing for PERT?
- <2500 units lipase/kg/meal
- Do not exceed 10,000 units lipase/kg/day
- Going above increases risk of fibrosing colonopathy
STUDY
Supplementation of salt for infants with CF
0-6 mos: 1/8 tsp per day
>6 mos: 1⁄4 tsp per day
Can you use standard equations for energy needs in critical illness?
NO!
* Standard equations are inaccurate in this population (risk of overfeeding)
* The inflammatory response effects energy needs (effect on LBM)
STUDY
What is the best approach to calculating energy needs in critical illness
Indirect calorimetry ideal for malnutr or altering metabolic state
If can’t measure needs, use:
Schofield or WHO equations w/o stress factors
Estimated needs for children with Burns
- Catabolic state lasting weeks post injury
- Gold standard is to use indirect calorimetry
- General goal is 120-130% of REE
Children with burns >20% BSA will likely not meet EEN via PO intakes alone and will require some form of nutrition support
Estimated needs for obesity
- Per ASPEN Guidelines use indirect calorimetry instead of predictive equations
- If no IC, use BMR
- Look for laboratory abnormalities (ex: lipid panel, glucose)
Note BMR can still provide excessive kcal
Children with lower energy needs
- Avoid overfeeding
- BMR or condition specific equations
- Assure protein and vitamin/mineral needs are met in setting of decreased kcal provision
Examples of children with lower energy needs
Traumatic brain injury, cerebral palsy, Trisomy 21, etc.
Protein Needs
- Dependent on age (decreases the older a child gets)
- Higher needs during stressed states or loss (e.g., SBS, critical illness) up to 1.5 g/kg
- Excessive protein intake (4-6 g/kg/day) can contribute to metabolic acidosis and azotemia
Fluid Needs
Holliday-Seegar
Note about fluid needs in infants <6 months
Avoid giving free water due to inadequate nutrient intake and possible electrolyte disturbances.
Lytes disturbances 2/2 kidneys not proficient early in life with concentrating urine
Risks associated with not breastfeeding
- Decreased resistance to infection
- Decreased gastrointestinal maturity
- Increased risk of overfeeding
- Increased risk of necrotizing enterocolitis in preemies
- Increased risk of allergy development into childhood
STUDY
If an infant has galactosemia, what formula should they NOT receive?
Lactose-containing formulas
Typically placed onto a soy formula
STUDY
What do cow milk and soy formulas have in common?
Increased risk of soy allergy/intolerance if infant also is milk intolerant/allergic
Presenter would place on hydrolysate for infants with galactosemia
STUDY
What is the difference in kcal
(NICU, post d/c, standard)?
- NICU/preemie: 24 kcal/oz
- Post-Discharge (from NICU): 22 kcal/oz
stay on this until 9 mo. corrected age - Both of these formulas are more calorically dense, higher in protein, higher in nutrients vs standard formula
- Standard formula = 20 kcal/oz to mimic breast milk
STUDY
Vitamin K
Prophylactic supplementation in all newborns
STUDY
Vitamin D
- Exclusively breast fed – provide 400 IU/day once d/c home
- Breast fed and formula fed – assess and supplement accordingly
- Formula fed – no supplementation if daily volume of formula consumed is adequate
STUDY
Risk factors for Vit D deficiency
– Breast-feeding w/o supplementation
– Dark pigmented skin
– Birth prior to 32 weeks gestation
– Location
– Recent immigration from a developing country
– At risk populations
* Malabsorptive conditions
* Epilepsy/Cerebral Palsy
Epilepsy/CP - on antiseizure meds which can impact Vit D metabolism
Birth prior 32 weeks - bone min density accumulation occurs in 3rd trim
Develop country - malnutrition and/or nutrient def
STUDY
Vitamin B12
– Concern for breast fed infant if mother is vegan
– Possible concern in intestinal failure infants/children depending on portion of SB resected
STUDY
Iron
- Fortify in breast fed infants by 4-6 months - this is when endogenous supply become depleted
- Formula contains iron
- May need to supplement in instances of malabsorption
STUDY
Fluoride
- No need to supplement from birth to 6 mo
-
After 6 mo may need to supplement based on water supply
Ex. 0.25 mg/d for 6 mos-3 yrs if less than 0.3 ppm
STUDY
If an infant >6 months lives out in the country and is dependent on well water, what vitamin/mineral would you need to supplement?
Fluoride
STUDY
No cow milk prior to 1 year of age because it …
A. Is low in iron
B. Is low in vitamins C & E
C. Is low in essential fatty acids
D. Has a high renal solute load
E. A & C
F. All of the above
F. All of the above
Infants have limited ability to concentrate urine. Fluid may not be retained when infants are fed a high renal solute formula
No more than 33 mOsm/100 kcal
Formula: 20 mOsm/100 kcal
Cow’s milk: 45 mOsm/100 kcal
EN Indications
Insufficient oral intake to support adequate weight gain/growth
- Decreased appetite, elevated needs (ex: CF)
Oral motor dysfunction
- Neurological impairment, prematurity
Primary therapy
- Crohn’s disease, inborn errors of metabolism
Structural/functional GI abnormality
- Congenital malformation, tumor (ex: head/neck), caustic ingestion
Injury/critical illness (ex: burns)
EN Feeding Modalities:
OG
- Preemies <34 weeks – nose breathers, no gag reflex
- Basilar skull fxs who can’t eat
EN Feeding Modalities:
NG
Short term
* Little/no reflux
* Normal gastric fx
* Low risk for aspiration
EN Feeding Modalities:
NI
Short term
* Reflux
* At risk for aspiration
EN Feeding Modalities:
G-tube
3 months
normally functioning GI tract
EN Feeding Modalities:
GJ-tube
- Severe GERD and not a good candidate for Nissen
- Have a Gtube but temp can’t tol feeds
EN Feeding Modalities:
Jtube
- Severe GERD
- Gastroparesis
- High aspiration risk
STUDY
EN - initiation & adv guidelines per ASPEN
Bolus/gravity
* Initiate at 25% of goal & divide by number of preferred feeds
* ↑ volume by 25% daily
Pump
* Initiate at 1-2 mL/kg/h
* Advance by 0.5-1 mL/kg/h every 6-24 hours to goal
STUDY
What is the hang time for powdered, reconstituted formula, HBM, and EN formula with additives?
4-hour hang time
Indications for PN
- Prematurity
- Severe GI impairment (malrotation/volvulus, necrotizing enterocolitis, intestinal atresia, small bowel ischemia, IBD, short bowel syndrome, Hirschsprung’s disease, gastroschisis)
- Omphalocele (a birth defect of the abdominal (belly) wall. The infant’s intestines, liver, or other organs stick outside of the belly through the belly button)
- S/p bone marrow transplant with inability to meet nutrient needs orally
- Hypermetabolism w/inability to meet nutrient needs w/EN alone
Timeline to initiate PN
If it is evident that full po feeds or EN goals are not going to be reached for quite some time start PN:
– Infants: Within 1-3 days
– Children/adolescents: Within 4-5 days
Timeline to initiate PN - critical illness
- Not recommended within 24 hours of PICU admission
- Starting is dependent on intake of EN and overall nutrition status
PN comp - dextrose
Dextrose 40-60% of calories
* Glucose infusion rate (mg/kg/min)
* Up to 14 mg/kg/min in children is generally tolerated
PN comp - fat
Fat 20-40% of calories
* Pediatric options: soy based or fish oil based
* Fish oil based used for instances of cholestasis (d bili >2 mg/dL)
– Dosage: 1 g/kg/day
* >60% of calories from fat may cause ketosis
ILE kcal provision
- Soy based 2 kcal/ml
- Fish oil based 1.12 kcal/ml
Prevention of EFAD
- 0.5g/kg/day infants/children (soy based)
- 30% of kcal with multi-oil based
Why do neonates/infants receive lipids as 2-in-1 vs TNA?
Increased risk of pulm fat accumulation & death
Cross reactions noted between which 2 allergies in ILE?
egg, soy, fish, peanut
soy and peanut
High Mn can develop how soon after PN initiation in peds?
3 weeks
- Sx may not be present, or patient may + confusion, irritability, seizures
Which trace element is associated with Microcytic anemia and neutropenia?
Copper
Which trace element is associated with Growth failure and hair loss
Zinc
Carnitine def
- hyperTG
- elevated Tbili
- hypoglycemia
- elevated AlkPhos
20 mg/kg/d doing in PN, especially without enteral source of carnitine
Carnitine benefits s/p supplementation
- improved fatty acid oxidation
- improved lipid tolerance
- weight gain
ASPEN rx for checking trace and fat sol vits?
Trace:
* 3 mo after start
* 3-6 mo after
Fat Sol:
* Q6 month
* if WNL –> annually
When determining calorie needs for an obese hospitalized child, which of the following is recommended?
a. The Harris-Benedict equation
b. The Schofield equation
c. Indirect calorimetry
d. EER using adjusted body weight
c. Indirect calorimetry
Which of the following are indications for enteral nutrition support?
a. Short-bowel syndrome
b. Prematurity
c. Cerebralpalsy
d. Biliary atresia
e. All of the above
e. All of the above
Which of the following measures are used to evaluate if a child is malnourished?
a. Weight
b. Height
c. MUAC
d. TSF
e. a, b, c, d
f. a, b, c
TSF = tricep skinfold
f. a, b, c
If a child on parenteral nutrition support is cholestatic, which trace element may need to be removed from the parenteral nutrition?
a. Selenium
b. Zinc
c. Manganese
d. Chromium
c. Manganese
