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[Mine] core curric - 2016 > Peds > Flashcards

Peds Flashcards

1
Q

Screening tools

A
  • 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

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2
Q

Child is at nutrition risk:

Basic criteria when screening peds

A
  • 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
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3
Q

Subjective Assessment

A

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

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4
Q

Subjective Assessment - things to document

A
  • IBW
  • Changes in weight
  • Appropriateness of current intakes
  • Any GI problems
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5
Q

Clinical assessment

A
  • Admitting diagnosis
  • Medical/surgical issues that may affect mode of nutrition delivery
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6
Q

Objective (growth) Assessment

A

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

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7
Q

Gestation

A

Normal gestation 37-42 weeks (~40 weeks)

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8
Q

Prematurity – Classifications

A
  • 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

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9
Q

Study

Small for gestational age

A

Birth weight <10th%ile on intrauterine growth curve
* Pregnancy-induced hypertension
* Maternal malnutrition
* Maternal substance abuse
* Chromosomal abnormalities

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10
Q

Study

Large for gestational age

A

Birth weight >90th%ile on intrauterine growth curve
* Maternal diabetes
* Genetic predisposition
* Miscalculation of due date

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11
Q

Types of Growth Charts

A

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)

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12
Q

Key Points w/ Growth Charts

A
  • Plotting WNL?
  • Trending (is there a clear pattern?)
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13
Q

STUDY

BMI

A
  • <5th%ile = underweight
  • 5-85th%ile = normal
  • 85-95th%ile = overweight
  • > 95th%ile = obese
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14
Q

STUDY

General rules of thumb for infants

A

The infant should be:
* Doubling birth weight by 5-6 months
* Tripling birth weight by 1 year

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15
Q

Pediatric Malnutrition

A
  • 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

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16
Q

Mild Malnutrition

A

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

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17
Q

Moderate malnutrition

A

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

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18
Q

Severe malnutrition

A

z score of -3 or greater
* Cause is chronic undernutrition
* Effect is below standard linear growth/stunting

Pt is significantly below the growth curve

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19
Q

Determining malnutrition is dependent on what information at time of assessment?

A

Indicators for malnutrition vary based on the number of data points you have at time of assessment

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20
Q

Single Data Point

A
  • 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
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21
Q

2 or More Data Points

A
  • Weight gain velocity (<2 yrs)
  • Weight loss (2-20 yrs)
  • Deceleration in weight for length/height (BMI) z score
  • Inadequate nutrient intake
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22
Q

Estimating Calorie Needs:
Healthy Child

A

* 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

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23
Q

Estimating Calorie Needs:
Decreased kcal

A

Basal Metabolic Rate (BMR)
* (ie. Schofield equation)

Resting Energy Expenditure (REE)
* (ie. WHO equation)

Stress factors can be added to both

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24
Q

Estimating Calorie Needs:
Weight Gain

Specifically, this is for infants to sustain a faster rate of weight gain to achieve an appropriate weight

A

Catch-up growth

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25
Q

How does Cystic Fibrosis alter nutrient needs?

A

– 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

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26
Q

What is the max dosing for PERT?

A
  • <2500 units lipase/kg/meal
  • Do not exceed 10,000 units lipase/kg/day
  • Going above increases risk of fibrosing colonopathy
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27
Q

STUDY

Supplementation of salt for infants with CF

A

0-6 mos: 1/8 tsp per day
>6 mos: 1⁄4 tsp per day

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28
Q

Can you use standard equations for energy needs in critical illness?

A

NO!
* Standard equations are inaccurate in this population (risk of overfeeding)
* The inflammatory response effects energy needs (effect on LBM)

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29
Q

STUDY

What is the best approach to calculating energy needs in critical illness

A

Indirect calorimetry ideal for malnutr or altering metabolic state

If can’t measure needs, use:
Schofield or WHO equations w/o stress factors

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30
Q

Estimated needs for children with Burns

A
  • 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

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31
Q

Estimated needs for obesity

A
  • 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

32
Q

Children with lower energy needs

A
  • Avoid overfeeding
  • BMR or condition specific equations
  • Assure protein and vitamin/mineral needs are met in setting of decreased kcal provision
33
Q

Examples of children with lower energy needs

A

Traumatic brain injury, cerebral palsy, Trisomy 21, etc.

34
Q

Protein Needs

A
  • 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
35
Q

Fluid Needs

A

Holliday-Seegar

36
Q

Note about fluid needs in infants <6 months

A

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

37
Q

Risks associated with not breastfeeding

A
  • 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
38
Q

STUDY

If an infant has galactosemia, what formula should they NOT receive?

A

Lactose-containing formulas

Typically placed onto a soy formula

39
Q

STUDY

What do cow milk and soy formulas have in common?

A

Increased risk of soy allergy/intolerance if infant also is milk intolerant/allergic

Presenter would place on hydrolysate for infants with galactosemia

40
Q

STUDY

What is the difference in kcal
(NICU, post d/c, standard)?

A
  • 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
41
Q

STUDY

Vitamin K

A

Prophylactic supplementation in all newborns

42
Q

STUDY

Vitamin D

A
  • 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
43
Q

STUDY

Risk factors for Vit D deficiency

A

– 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

44
Q

STUDY

Vitamin B12

A

– Concern for breast fed infant if mother is vegan
– Possible concern in intestinal failure infants/children depending on portion of SB resected

45
Q

STUDY

Iron

A
  • 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
46
Q

STUDY

Fluoride

A
  • 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
47
Q

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?

A

Fluoride

48
Q

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

A

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

49
Q

EN Indications

A

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)

50
Q

EN Feeding Modalities:
OG

A
  • Preemies <34 weeks – nose breathers, no gag reflex
  • Basilar skull fxs who can’t eat
51
Q

EN Feeding Modalities:
NG

A

Short term
* Little/no reflux
* Normal gastric fx
* Low risk for aspiration

52
Q

EN Feeding Modalities:
NI

A

Short term
* Reflux
* At risk for aspiration

53
Q

EN Feeding Modalities:
G-tube

A

3 months

normally functioning GI tract

54
Q

EN Feeding Modalities:
GJ-tube

A
  • Severe GERD and not a good candidate for Nissen
  • Have a Gtube but temp can’t tol feeds
55
Q

EN Feeding Modalities:
Jtube

A
  • Severe GERD
  • Gastroparesis
  • High aspiration risk
56
Q

STUDY

EN - initiation & adv guidelines per ASPEN

A

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

57
Q

STUDY

What is the hang time for powdered, reconstituted formula, HBM, and EN formula with additives?

A

4-hour hang time

58
Q

Indications for PN

A
  • 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
59
Q

Timeline to initiate PN

A

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

60
Q

Timeline to initiate PN - critical illness

A
  • Not recommended within 24 hours of PICU admission
  • Starting is dependent on intake of EN and overall nutrition status
61
Q

PN comp - dextrose

A

Dextrose 40-60% of calories
* Glucose infusion rate (mg/kg/min)
* Up to 14 mg/kg/min in children is generally tolerated

62
Q

PN comp - fat

A

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

63
Q

ILE kcal provision

A
  • Soy based 2 kcal/ml
  • Fish oil based 1.12 kcal/ml
64
Q

Prevention of EFAD

A
  • 0.5g/kg/day infants/children (soy based)
  • 30% of kcal with multi-oil based
65
Q

Why do neonates/infants receive lipids as 2-in-1 vs TNA?

A

Increased risk of pulm fat accumulation & death

66
Q

Cross reactions noted between which 2 allergies in ILE?
egg, soy, fish, peanut

A

soy and peanut

67
Q

High Mn can develop how soon after PN initiation in peds?

A

3 weeks
- Sx may not be present, or patient may + confusion, irritability, seizures

68
Q

Which trace element is associated with Microcytic anemia and neutropenia?

A

Copper

69
Q

Which trace element is associated with Growth failure and hair loss

A

Zinc

70
Q

Carnitine def

A
  • hyperTG
  • elevated Tbili
  • hypoglycemia
  • elevated AlkPhos

20 mg/kg/d doing in PN, especially without enteral source of carnitine

71
Q

Carnitine benefits s/p supplementation

A
  • improved fatty acid oxidation
  • improved lipid tolerance
  • weight gain
72
Q

ASPEN rx for checking trace and fat sol vits?

A

Trace:
* 3 mo after start
* 3-6 mo after

Fat Sol:
* Q6 month
* if WNL –> annually

73
Q

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

A

c. Indirect calorimetry

74
Q

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

A

e. All of the above

75
Q

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

A

f. a, b, c

76
Q

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

A

c. Manganese

[Mine] core curric - 2016 (22 decks)

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