Weaning From PN

Question 1

Nutritional assessment for PN: requirements, initial assessment

Answer 1

• indications: increased nutrient requirements, inadequate intake, reduced absorption or utilisation of nutrients (inadequate or no gut function)
• initial assessment: symptoms, feeding history, activity level, social and cultural backgrounds, anthropometric measures (including previous so can plot on z score chart), nutritional requirements
• need to establish aims of nutritional intervention

Question 2

Working out a child’s nutritional requirements

Answer 2

• need to work on the basis of actual weight not expected weight
• requirements for PN differ from EN
• fluids for infants: amounts for maintenance are higher for premature babies relative to weight (150-200 mL/kg)
• will need increased kcal requirements if have malabsorption or cardiac abnormalities. Decreased requirements if ventilated, on bed rest/immobile or obese
• protein requirements based on height age (not actual) and need to make sure supplying at least the reference intake
• aim to meet full requirements through combination of EN and PN

Question 3

PROS/CONS of PN

Answer 3

• PROS: massively improves survival for infants otherwise would have died
• CONS: sepsis, line infections, cholestasis, micronutrient toxicity, cost

Question 4

enteral feeding and weaning from PN

Answer 4

• aims: to increase EN and decrease dependency on PN, ensure adequacy of feeding, allow cycling of PN, monitoring (using biochem and anthropometry), to get the child home
• aims of EN feeds during PN: prevent gut atrophy, enhance absorption, provide extra nutrients, encourage age appropriate feeding behaviour, enhance bile flow, promote synthesis of carrier proteins, brush border enzymes
• introducing EN ASAP can prevent PN related cholestasis

Question 5

Short bowel syndrome in infants and weaning from PN

Answer 5

• SBS can be caused by gastoschisis, necrotising enterocholitis, mid-gut volvulus, congenital intestinal atresia
• <50 cm working bowel
• considerations: length of gut remaining, colon/stoma, adaptation of the rest of the gut, ileum is better able to adapt than the jejunum
• protein: choosing complex proteins in EN may be better for adaptation
• fat: LCT stimulate GI adaptation, contains essential FA, MCTs however are water soluble and may be better absorbed
• CHO: lactase may not be induced
• some complete foods may be used such as expressed breast milk, polymeric feeds, hydrolysate feeds + MCT (hydrosylate may be better so as not to induce allergic reaction, by hydrolysing may help the gut cope better)
• methods of feeding: continuously, bolus feeding, aim to encourage normal feeding behaviour with small oral feeds

Question 6

GOSH advice on food reintroduction

Answer 6

• hypoallergenic: due to possible immune dysfunction and increased intestinal permeability
• low in disaccharides
• low in fructose as this is absorbed slowly by the GI tract
• ## first weaning foods: pureed meats and plain CHO, vegetables, fish. Move infants through the different textures

Question 7

Cycling PN

Answer 7

• need the body to adapt to different nutrient levels
• higher nutrient infusion rates, post infusion period where no nutrients infused
• allows individual to be disconnected from the infusion equipment, decreased incidence of cholestasis liver disease
• only disadvantage for acutely ill ventilated patients is the nitrogen balance and CHO and lipid metabolism

Question 8

Reducing the volume of PN: weaning

Answer 8

• ensure a good nutritional state
• consider the age of the child: in infants need to match mL with EN, in older children aim to have fewer infusions per week
• need to be especially cautious if aiming to do this at home
• need to anticipate problems: additional electrolytes/fluids, additional nutritional supplements, large volumes of PN can reduce feed tolerance
• reasons for failure: line infections, inappropriate feed selection, inappropriate method of administration (continuous, intermittent, jejunal), poor tolerance of total fluid infused (need to review GI function)