WEEK 1 - NUTRITION & HYDRATION Flashcards
Outline a framework for Clinical Reasoning.
Outline a framework for Clinical Management - 2 examples of how this could be applied in the paediatric setting?
Outline how to communicate with and exam neonates, children and adolescents.
- Parents?
- Infants?
- Toddlers & Preschoolers?
- School age (Primary School)?
- Adolescents?
Adolescents
- Remember to consider the points above, but be yourself, and allow the adolescent to be themselves.
- Be honest and authentic
- Inform parents it is a routine for us to give adolescents an opportunity to share their health experience confidentially (including psychosocial or “HEADSS” screening) –this should not be routine for medical students unless it is explicitly facilitated by a clinical workplace supervisor.
- Give plenty of time for responses when interviewing adolescents.
What is the likelihood of hospital admission for each of the stages of life in the paediatric population?
- What is the volume requirment of a neonate?
- How can IV maintenance fluids for children >6months old be calculated?
- When should solids be introduced?
- How much milk should toddlers >1yr have?
- 4 Associated Diagnoses of Weight Faltering in paediatric patients?
- 4 Associated diagnoses of Morbid Obesity in paediatric patients?
- 3 Associated Diagnoses of Thirst & Lethargy in paediatric patients?
- 4 Associated Diagnoses of Anaemia in paediatric patients?
CAHS Guideline - Nutrition: Volume and Nutritional Requirements
- At what rate are fluids usually commenced for term and preterm infants? How are they increased?
- What fluid rate should infants with significant hypoxic ischaemic encephalopathy be on?
- Fluids are usually started at 60ml/kg/day for term infants and 80 mL/kg/day for preterm infants on day 1.
- Increments are progressively increased at 20 mL/kg/day (assuming no abnormal weight loss or gain or need for fluid restriction or fluid increase).
- Fluids are increased to a target of 150-170 mL/kg/day.
- Infants with significant hypoxic ischaemic encephalopathy may require fluid restriction 40-50ml/kg/day but need to ensure appropriate glucose delivery to achieve PGL>3.5.
CAHS Guideline - Nutrition: Volume and Nutritional Requirements
- When may you need to consider insensible losses and increase fluid requirements in infants?
Phototherapy/Radiant Warmers
Infants under phototherapy lights or on radiant warmers are prone to increased insensible water loss. In the omnibed incubator with newer technology, insensible water losses are not as significant as in other older incubators. An extra 10-20 mL/kg/day may be added to their daily fluid requirements if required.
CAHS Guideline - Nutrition: Volume and Nutritional Requirements
- How are fluids for infants calculated?
- Give a worked example.
Management
- Fluids are calculated on the infant’s birth weight until the birth weight has been reached. At certain times a predicted weight may be used instead of the current weight e.g. Oedema, PDA, failure to thrive.
- Fluid requirements are re-calculated each shift to ensure the volume being given is the same as the volume ordered.
- The weight is multiplied by the mL/kg/day in order to give the volume required for the 24 hour period.
- The total fluid requirement for the day is then divided by the number of feeds per day, or if on intravenous therapy it is divided by 24 to give the hourly rate of the infusion.
CAHS Guideline - Breastfeeding
- List 7 Health Benefits of Breastfeeding for the Infant & 3 Health Benefits for the Mother?
Principles
- Breast milk is specifically designed for human infants with both the mother and infant gaining physically and emotionally from the breastfeeding experience.
- Breast milk has the correct biochemical constituents necessary for optimal growth and development and assists in the prevention of respiratory and intestinal infections and the onset of allergies.
- Premature and some surgical infants may require individually tailored fortification of human milk to reach recommended intakes and acceptable
growth rates.
CAHS Guideline - Breastfeeding
- What should be done for mothers planning to breastfeed who are separated from their infants?
- When should the first expression occur?
- Why do introductory suck feeds need to be breast feeds?
- What are 5 Signs of readiness to suck?
- Any mother planning to breastfeed who is separated from her infant needs to start expressing to establish lactation.
- The first expression should be in the first hour after delivery of her infant and then around every 3-4 hours, culminating in 7–8 times each day including at least once overnight
- Introductory suck feeds are to be breast feeds; early breastfeeding is less
physiologically stressful than is early bottle feeding. The infant has a greater ability to control the flow of milk during breastfeeding and has more stable patterns of oxygenation.
CAHS Guideline - Breastfeeding
- Define Positioning and Attachment.
CAHS Guideline - Breastfeeding
- 4 Recommended Breastfeeding Positions for the Mother?
- 4 Recommended Breastfeeding Positions for the Infant?
CAHS Guideline - Breastfeeding
- 8 Signs of Correct Positioning and Attachment?
- 4 Signs of Poor Attachment?
Signs of Correct Positioning and Attachment
1. Lips widely flanged and sealed around the breast.
2. Infant’s chest in close contact with mother’s chest.
3. Head is slightly extended, with the chin pressed into the breast.
4. The nose is free without the mother holding back her breast.
5. Absence of clicking sounds.
6. Absence of dimpling in infants cheeks.
7. Movement of whole jaw with muscular movement visible around ears.
8. Once infant is attached and sucking effectively there is no nipple pain or
trauma.
CAHS Guideline - Breastfeeding
- 9 Questions to Ask the mother about Breastfeeding prior to discharge?
Infant Feeding Guidelines
- What are the 3 recommendations regarding breastfeeding?
Recommendations
1. Encourage, support and promote exclusive breastfeeding to around 6 months of age.
2. Continue breastfeeding while introducing appropriate solid
foods until 12 months of age and beyond, for as long as the mother and child desire.
3. While breastfeeding is recommended for the first 6 to 12 months and beyond, any breastfeeding is beneficial
to the infant and mother.
Infant Feeding Guidelines
- What are the 5 recommendations for individuals to promote a supportive social and physical environment for breastfeeding?
Recommendations for Individuals
1. Provide antenatal information and counselling about the benefits and practical aspects of breastfeeding (and the risks of not breastfeeding) to all potential mothers, fathers and primary carers.
2. Pay particular attention to positioning and attachment when advising on breastfeeding.
3. Take steps to identify breastfeeding difficulties by asking appropriate questions during any health-related visits with the mother. Manage those difficulties if appropriately qualified, or refer to a health professional for management (e.g. lactation consultant).
4. Provide postnatal breastfeeding support information.
5. A pacifier (dummy) may be offered, while placing infant in back-to-sleep-position, no earlier than 4 weeks of age and after breastfeeding has been established.
Infant Feeding Guidelines
- What are the 4 recommendations for creating a supportive environment for breastfeeding mothers?
Infant Feeding Guidelines
- Are there any situations where breastfeeding is contraindicated?
- There are very few contra-indications for breastfeeding. Maternal and paternal smoking is negatively associated with breastfeeding duration and predominant or exclusive breastfeeding, but smoking and environmental contaminants are not valid reasons to stop breastfeeding.
- In households where smoking occurs, infants who are breastfed have lower rates of respiratory infection.
- Consumption of moderate amounts of alcohol by breastfeeding women may be associated with increased risk of adverse infant outcomes, but moderate, infrequent use of alcohol is not an indicator for stopping breastfeeding.
- Most prescription and over-the-counter drugs, and most maternal illnesses are not indications for discontinuing breastfeeding
Infant Feeding Guidelines
- What are 12 recommendations when an infant is not receiving breastmilk?
When an infant is not receiving breastmilk
If an infant is not breastfed or is partially breastfed, commercial infant formulas should be used as an alternative to breastmilk until 12 months of age. It is important to prepare and store feeds correctly.
Infant Feeding Guidelines
- What are 6 recommendations regarding other fluids aside from milk in infant feeding?
Other fluids in infant feeding
For infants over the age of 6 months or for those who are not exclusively breastfed, tap water is preferred (as consistent with the Australian Dietary
Guidelines) but this should be boiled and cooled for infants until 12 months
of age. Consumption of fruit juice may interfere with the intake of nutrient dense foods and fluids and increase the risk of damaging emerging teeth.
Tea, herbal teas, coffee and other beverages are of no known benefit to an infant and could possibly be harmful.
Infant Feeding Guidelines
- What are the 8 recommendations regarding transition to solid foods ?
The transition to solid foods
At around the age of 6 months, infants are physiologically and developmentally
ready for new foods, textures and modes of feeding, and they need more
nutrients than can be provided by breastmilk or formula alone. By 12 months of age, a variety of nutritious foods from the Five Food Groups, as described in the Australian Guide to Healthy Eating, is recommended.
Infant Feeding Guidelines
- What are the 7 recommendations regarding feeding after 12 months?
After 12 months
Solid foods should provide an increasing proportion of the energy intake after 12 months of age. Offering a variety of nutritious foods is likely to help meet the need for most nutrients and provide a basis for healthy eating habits.
Infant Feeding Guidelines
- What are the 6 recommendations regarding Caring for infants’ food?
Caring for infants’ food
All foods given to infants should be nutritious and be fed in a safe way. Foods provided to an infant must be free of pathogens and of suitable quantity, size and texture. Infants should be supervised during feeding. Propping the bottle against the infant’s mouth and leaving the infant to feed from the bottle without supervision should be avoided as the infant may fall asleep with the bottle’s teat still attached to their mouth, increasing the risk of choking, ear infection and dental caries.
Infant Feeding Guidelines
- What are the 2 recommendations regarding Food allergies?
Food allergies
Breastfeeding may be associated with a reduced risk of atopic disease in
infants with and without a family history of atopy. Introducing a variety of
solid foods around the age of 6 months is consistent with reducing the risk
of developing allergic syndromes. There is no evidence that delaying the
introduction of solid foods beyond this age reduces the risk of atopic disease.
Delay in the introduction of solid foods until after the age of 6 months is
associated with increased risk of developing allergic syndromes.
Treatment of proven food allergies involves avoiding foods known to
cause symptoms
Infant Feeding Guidelines
- What is the recommendation regarding Colic?
- 2 recommendations regarding constipation?
Colic
- Changes in diets and restrictions on individual foods have had limited success in the treatment of colic.
- Research into this common area of concern is ongoing, but at this point no specific dietary recommendations for the treatment of colic can be made.
- Ensure that any dietary modification or pharmacological intervention is safe and does not result in nutritional deficiencies.
Infant Feeding Guidelines
- What are the 3 recommendations regarding dietary fats?
- 2 recommendations regarding diarrhoeal disease?
Dietary fat
- Dietary fat is an important source of energy. Some fats provide essential fatty acids. Fat is also needed for the absorption of essential fat-soluble vitamins.
- Restriction of dietary fat is not recommended during the first two years of life because it may compromise the intake of energy and essential fatty acids and adversely affect growth, development, and the myelination of the central nervous system.
- Consumption of nutrient-poor discretionary foods with high levels of saturated fat (e.g. cakes, biscuits and potato chips) should be avoided.
Healthy eating for children Guidelines
- What are the recommended servings of fruit, veg, and legumes/beans for children aged 2–3 years, 4-8 years, 9-11 years, 12-13 years, 14-18 years?
Healthy eating for children Guidelines
- What are the recommended servings of Grains and meat/ fish/ poultry for children aged 2–3 years, 4-8 years, 9-11 years, 12-13 years, 14-18 years?
Healthy eating for children Guidelines
- What are the recommended servings of dairy for children aged 2–3 years, 4-8 years, 9-11 years, 12-13 years, 14-18 years?
PCH ED Guideline - IV Fluid Therapy
- Resuscitation fluids - Reason?
- Resuscitation fluids - Fluid type?
- Resuscitation fluids - Rate/Volume?
PCH ED Guideline - IV Fluid Therapy
- Maintenance fluids - Reason?
- Maintenance fluids - Fluid type?
- Maintenance fluids - Rate/Volume?
PCH ED Guideline - IV Fluid Therapy
- Deficit replacement fluids - Reason?
- Deficit replacement fluids - Fluid type?
- Deficit replacement fluids - Rate/Volume?
PCH ED Guideline - IV Fluid Therapy
- What are the Standard fluids?
- Examples?
- High risk fluids?
Standard Fluids
- Standard intravenous fluids are those that are commercially pre-made and available at Perth Children’s Hospital. Standard (pre-mixed) intravenous fluids supplied by an external manufacturer are always preferred wherever possible.
- Standard intravenous fluids kept at PCH that are supplied from Baxter via Health Support Services (HSS) are described below in Table 1.
- High risk fluids, i.e. those containing potassium or those that are significantly hyper or hypo-osmolar are to be stocked within automated dispensing machines (ADMs) and not left in clinical areas. High risk fluids that are supplied from Baxter via pharmacy are described in Table 2.
CAHS Guideline: Feed Intolerance
- Risk of Feed intolerance?
- Background?
- Signs of Feed intolerance?
Risk: Feed intolerance can be indication of underlying or developing gastric problems. Delayed identification and management may lead to adverse outcomes.
Background: The decision whether the feeds should be continued, reduced, or stopped will be at the discretion of the attending neonatologist. Feeds are usually stopped if there are bile-stained or large gastric residuals and vomiting and/or abdominal distension and/or
blood in the stools. Investigations are carried out and an assessment is made after 12 to 24 hours. Feeds can generally be restarted when the infant has stabilised and has had a 12-24 hour absence of any significant clinical signs of feed intolerance.
CAHS Guideline: Feed Intolerance
- What is Bilious Vomiting? What can it be a sign of? Management?
- What are Bilious Aspirates? What can they be a sign of? Management for Infants <32 and >32 weeks?
CAHS Guideline: Feed Intolerance
- What can vomiting be a sign of with feed intolerance?
- What can Abdominal Distension be a sign of with feed intolerance?
Vomiting
Vomiting (without bile) may be the result of an over distended stomach, poorly positioned feeding tube, Gastro Oesophageal Reflux, overstimulation in a LBW infant or may be more sinister - infection, obstruction or a metabolic or neurological disorder.
Lecture: Paediatric Hydration
- 3 Basic Principles?
- Mild, Moderate, Severe Dehydration?
Basic Principles
1. ASSESS the level of dehydration
2. PLAN & implement your hydration intervention
3. REASSESS hydration according to level of severity
Assess the Level of Hydration
- Mild <3% of body weight lost
- Moderate ~5% of body weight lost
- Severe >7% of body weight lost
Lecture: Paediatric Hydration
- What clinical signs are associated with each of the levels of dehydration?
Lecture: Paediatric Hydration
- What level of dehydration does this child have?
= Mild, still able to produce tears and chlid is upset (no neurological demise)
Lecture: Paediatric Hydration
- What level of dehydration does this child have?
= Severe - look at skin turgor! But the child is still upset (not shocked/ neuro)
Lecture: Paediatric Hydration
- What are the 2 components of hydration intervention?
- What is the 4,2,1 rule of fluid maintenance in children? Give examples?
Plan a hydration intervention: MAINTAINENCE (4,2,1 rule)
+ REPLACEMENT
Lecture: Paediatric Hydration
- What are the principles of Fluid Replacement? (VoldeMorte Adjustments)
REPLACEMENT
* Replace a VOLUME determined according to the percentage of dehydration.
* The MODE and RATE of rehydration vary according to clinical scenario.
= B. NGT ORS - 700mL in 4hrs
- Moderate dehydration
- 50mls/kg = 700mls
- OR IV but if confident gastro then NGT is fine, would always opt for oral if possible as body can better self-regulate electrolytes
- Ceiling for IV fluid rates for maintenance = 100ml/hr
- ORS – oral rehydration solution
- Can often be better to learn rehydration based on the diagnosis
= B. 421 rule = 8kg = 4x8=32 and 2/3rds maintenance for bronchiolitis = 21ml
= NG ORS 21mL/hr
= C. IV 0.9% NaCl 460mL bolus
- Resus situation so normal saline is most likely option but 5% glucose solution also not a big deal at a 20ml/kg bolus = 23x20 = 460mL
= C. 0.9% NaCl at 88ml/hr post bolus
- Risk of cerebral oedema from too rapid a correction in hydration state (becuase there has usually been a period of cerebral compensation)
- Strategy: SLOW replacement of 5% + maintainence
- Volume: Maintainence + 5% (replaced over 48hrs) minus bolus provided initially (if bolusing, give 10ml/kg)
- Mode: IV
- Rate: Slow
- REview regularly (often in ICU)
PCH Pre-referral guideline - Failure to Thrive
- What is Failure to thrive? Definitions?
- 8 General Risk factors for failure to thrive?
- 5 Psychosocial Risk factors for failure to thrive?
Risk factors for failure to thrive:
1. prematurity
2. developmental delay
3. congenital or genetic anomalies
4. intrauterine exposures
5. medical conditions that cause
6. inadequate intake
7. increased metabolic rate
8. malabsorption.
Psychosocial risk factors:
1. social isolation
2. disordered feeding techniques
3. substance abuse
4. household violence/abuse
5. poverty.
PCH Pre-referral guideline - Failure to Thrive
- 8 Pre-referral investigations to consider?
- Pre-referral screening - When plotting growth?
- Pre-referral management?
Pre-referral investigations
1. Urine MC+S
2. Stool MC+S
3. Full blood picture
4. Iron studies
5. Thyroid function tests
6. Liver/renal function
7. B12/folate and vitamin D/bone biochemistry should be considered in at risk populations (e.g. vegetarian/ vegan or maternal deficiencies in breastfeeding infants).
8. For older infants/children consuming gluten, add coeliac serology in addition to the above.
PCH Pre-referral guideline - Failure to Thrive
- When to refer?
- Essential information to include in your referral?
When to refer
1. Receiving adequate calories but ongoing poor growth.
2. Abnormal screening investigations.
3. Unable to improve calorie intake with dietetic intervention.
If severe abnormalities on physical examination (e.g. neurological abnormality, syndromic features, hypotonia) or significant psychosocial risk factors please discuss with general paediatric team on call and place urgent referral.
Management strategies for Faltering Growth?
Food Protein-Induced Allergic Proctocolitis (FPIAP)
- What is it?
- How is it diagnosed?
Food protein-induced allergic proctocolitis (FPIAP) is a type of delayed inflammatory non-IgE mediated gut food allergy. Symptoms usually start at one to four weeks of age and range from having blood, which is sometimes seen with mucous in bowel movements, to blood stained loose stools or diarrhoea. Infants with FPIAP are usually otherwise healthy and growing well. FPIAP mostly occurs in breastfed infants, but can also occur once cow’s milk or soy based formula is commenced. The main triggers are cow’s milk or soy.
Food Protein-Induced Allergic Proctocolitis (FPIAP)
- Management if a child is breastfeeding?
- Management if an infant is formula fed?
- How often does it resolve?
Resolution of FPIAP
- Resolution of FPIAP usually occurs in 50% of infants by the age of six months, and 95% of infants by the age of nine months.
- It is generally recommended to reintroduce the offending food/s to the mother’s or infant’s diet after it has been eliminated for six months or at 12 months of age.
- For infants who have more severe symptoms, such as blood stained diarrhoea, the offending food/s may be gradually introduced under the supervision of a dietitian.
RCH Guide - Management of Overweight and Obesity
- 2 Environmental Causes of obesity in children?
- 4 Hormonal Causes of obesity in children?
- 3 Medication Causes of obesity in children?
- 2 Genetic syndrome Causes of obesity in children?
Causes of obesity in children
Environmental
1. Excess energy intake
2. Decreased activity levels
Hormone problems
1. Under functioning thyroid
2. Problems with the production of growth hormone
3. High steroid levels
4. Other hormonal problems
Medications
1. Behaviour-related medications (such as antidepressants
2. Medications for fits and seizures
3. Steroids
Genetic syndromes
1. Prader-Willi syndrome
2. Other genetic syndromes
RCH Guide - Management of Overweight and Obesity
- Outline a flowchart for the investigation and management of an overweight/obese child?
RCH Guide - Management of Overweight and Obesity
- What is involved in the GP/Paediatrician assessment of the overweight child?
- History?
- 2 Baseline Screening Investigations? 3 Additional investigations as needed?
- Management?
Diet and exercise history
- Average daily food intake (refer to dietitian)
- Activity levels
- Time spent watching TV/computer
Baseline Screening Investigations
1. Blood lipids
2. Liver function tests
Additional Investigations
1. Blood sugar and HbA1c or OGTT
2. Hormone function, such as thyroid hormone levels
3. Vitamin and nutrient levels (such as Iron, vitamin D, Vitamin B12)
RCH Guide - Management of Overweight and Obesity
- When is Referral to the a specialist weight management clinic is required for an overweight/obese child?
RCH Guideline - Dehydration
- What is the best measure of dehydration?
- What is the best measure of fluid rehydration?
- What history will you take?
- Weight loss is the best measure of dehydration. Clinicals signs can help estimate the severity of dehydration but are often imprecise.
- The most accurate assessment of degree of dehydration is based on the difference between the pre-morbid body weight (within last 2 weeks) and current body weight (eg a 10 kg child who now weighs 9.5 kg has a 500 mL water deficit and is 5% dehydrated).
- If a child is haemodynamically unstable (ie in shock), prompt fluid resuscitation with fluid boluses must be given. Sepsis must be considered.
- Rehydrate enterally (orally or via nasogastric route), unless severe dehydration or shock.
- When a recent weight is not available, use the history and clinical examination to estimate the degree of dehydration.
RCH Guideline - Dehydration
- 6 Risk factors for severe dehydration and electrolyte disturbances?
- 5 Conditions where dehydration carries a high risk for children?
Risk factors for severe dehydration and electrolyte disturbances
1. Infants <6 months old
2. Gastrointestinal pathology (eg short gut syndrome, ileostomy, colostomy, Hirschsprung disease)
3. Cystic fibrosis
4. Renal impairment
5. Use of diuretics
6. Metabolic disorders
RCH Guideline - Dehydration
- What will you include in your examination?
RCH Guideline - Dehydration
- Investigations - When should you check for electrolyte abnormalities and blood glucose level (BGL) in children? (5)
RCH Guideline - Dehydration
- Approach to rehydration? (4)
- Treatment?
Approach to rehydration
1. Assess the degree of dehydration. If severe - see Sepsis
2. Investigate the cause of dehydration
3. Manage any electrolyte or BGL abnormalities
4. Provide rehydration via the appropriate route with close monitoring
RCH Guideline - Dehydration
- Approach to rehydration algorithm?
RCH Guideline - Dehydration
- When should you consider consultation with local paediatric team? (2)
- When should you consider transfer? (2)
- When should you consider discharge? (2)
Consider consultation with local paediatric team when
1. Child presents with shock
2. Child has electrolyte disturbance and/or predisposing factors for severe or complicated dehydration
Consider transfer when
1. Clinical signs of shock persist after maximum of 40 mL/kg fluid given in boluses. Consider other possible causes of shock (eg sepsis and need for antibiotics) other than dehydration alone.
2. Severe electrolyte derangement
If a parent presents to PCH ED and says “‘My baby is breathing very fast or seems to stop breathing’. There is no colour change.
- What is the diagnosis?
- 6 Concerning features?
- What do you need to rule out?
- Which investigations would you consider?
If a parent presents to PCH ED and says “‘My baby’s lips turn blue when they feed.”
- What is the diagnosis?
- 6 Concerning features?
- What do you need to rule out?
- Which investigations would you consider?
If a parent presents to PCH ED and says “‘My baby hasn’t opened their bowels for 5 days.”
- What is the diagnosis?
- 6 Concerning features?
- What do you need to rule out?
If a parent presents to PCH ED and says “‘My baby vomits after every feed.”
- 7 Concerning features?
- 3 possible diagnoses?
Diagnosis: Posseting
All babies bring up a small amount of milk after feeding with resolution expected in the first year of life.
It is a normal mild form of gastro-oesophageal reflux – the muscle at the oesophageal-gastric entrance is weak and they are fed a liquid diet and spend most of the time lying down, they also swallow a lot of air whilst feeding and burping causes a small amount of milk to return. General measures, such as smaller frequent feeds, burping, holding the baby in an upright position after feeds and thickening agents, may help reduce the posseting.
Diagnosis: Over Feeding
A full term healthy baby should feed (from Day 4) about 150 mL/kg/day divided into regular 2-4 hourly feeds.
It is vital that all babies you see have a calculated total daily intake of milk written as mL/kg/day. For breast fed babies please document how often they are feeding and for how long and whether they are having bottle top-ups.
If a parent presents to PCH ED and says “There’s a lump sticking out of my baby’s belly button.”
- 2 possible diagnoses?
If a parent presents to PCH ED and says “My baby is bleeding from her vagina”
- What is the most likely diagnosis?
- What is a feature to be concerned about?
If a parent presents to PCH ED and says “My baby boy has boobs.”
- What is the most likely diagnosis?
- 3 Concerning features?
If a parent presents to PCH ED and says “My baby is moving funny, are they fitting?”
- What is the most likely diagnosis?
If a parent presents to PCH ED and says “My baby isn’t gaining weight.”
- How do you know if their weight is a concern?
If a parent presents to PCH ED and says “My baby has spots.”
- 4 possible diagnoses?
CAHS Guideline: Fluid Balance and Elimination
- When do most infants pass urine for the first time?
- When is renal failure diagnosed?
- 7 Causes of Haematuria in the infant?
Urine measurements and testing
- Most infants pass urine in the first 24 hours and all well infants should pass urine by 48 hours.
- Renal failure is diagnosed when the urinary output is <0.5 mL/kg/hr in the first day and <1.0 mL/kg/hr thereafter with a rising serum creatinine.
- Infants with renal malformations detected prenatally or within the neonatal period, require assessment and follow-up in all cases.
CAHS Guideline: Fluid Balance and Elimination
- Causes of Proteinuria in the infant?
- Which infants need their renal function measured? How is this done?
Proteinuria - Is rare as a primary finding.
Causes
- Illnesses which compromise renal perfusion e.g. Sepsis, HIE, hypotension.
- Congenital nephrotic syndrome.
CAHS Guideline: Fluid Balance and Elimination
- When is failure to Pass meconium a concern?
- When is Faeces for Occult Blood testing indicated?
- Testing urine and faeces for reducing substances should be considered in which infants?
Passage of meconium
Failure to pass meconium within 48 hours of birth may indicate obstruction. Close observation is needed until the infant has passed meconium. Check for imperforate anus at birth. Passage of a meconium plug may be associated with Hirschsprung’s disease. Meconium ileus is strongly associated with cystic fibrosis.
Faeces for Occult Blood
Testing faeces for occult blood is indicated in infants with evidence of gastrointestinal disorders.
CAHS Guideline: Fluid Balance and Elimination
- What are the 2 components of prevention of an imbalance of fluid and electrolytes in infants?
- 6 Water loss Factors affecting fluid balance?
- 3 Overload Factors affecting fluid balance?
1) Maintenance needs - keeping the infant in a zero balance by recognising and accurately recording losses:
- Normal ~ urine, stool, IWL.
- Abnormal ~ loose stools, drain / gastric and ostomy losses.
2) Deficit needs - weight loss >10% in the first 7 days caused by:
- Unrecognised losses from 3rd spacing, VLBW infants (high IWL).
- Renal dysfunction, sepsis.
CAHS Guideline: Fluid Balance and Elimination
- How is an infants fluid status monitored?
- Normal urine output for an infant?
CAHS Guideline: Fluid Balance and Elimination
- How common is Acute Renal failure in the neonatal period? Why?
- 3 Categories of aetiology?
Acute Renal Failure
Acute renal failure (ARF) in the neonatal period is common and usually manifests as abnormal biochemistry (rising creatinine and urea) and decreased urine output (< 1 ml/kg/hr). A good history and careful examination are the starting point and may identify the most likely cause. The cause will, in most instances, dictate the direction of investigations needed and further management. Newborn kidneys are fully formed by 36 weeks’ gestation, but the tubules remain short and immature and even at term the kidneys are considered functionally immature. The GFR and blood flow are low in the newborn period and this immature tubular function affects its ability to concentrate urine or excrete a water load. The preterm infant is particularly susceptible as in addition to these factors they are also unable to conserve sodium.
CAHS Guideline: Fluid Balance and Elimination
- Investigations of ARF in neonates?
- Management of ARF in neonates?
- Fluid balance in ARF for neonates?
Investigations of ARF in Neonates
After detailed history and examination, complete the following as indicated:
1. Urinalysis - microscopy, culture and biochemistry.
2. U&Es and FBC.
3. Blood culture.
4. Coagulation studies.
5. Blood gas analysis.
6. Blood Pressure.
7. Ultrasound scan of the renal structures as indicated
PCH ED Guideline - Gastroenteritis
- Flowchart?
PCH ED Guideline - Gastroenteritis
- 2 Risk factors for developing gastroenteritis?
- 8 Differential diagnoses?
- Examination?
- 5 Investigations?
Risk factors for developing gastroenteritis
1. Attending childcare
2. Recent travel overseas
Differential Diagnoses
1. Urinary tract infection
2. Appendicitis
3. Meningitis
4. Diabetic ketoacidosis (DKA)
5. Haemolytic uraemic syndrome
6. Congenital adrenal hyperplasia
7. Irritable bowel disease
8. Intussusception
PCH ED Guideline - Gastroenteritis
- Management of Mild, Moderate, Severe dehydration?
PCH ED Guideline - Gastroenteritis
- Management if the child fails oral fluid trial?
- Management if the child fails NGT rapid rehydration (> 2 vomits)?
- Paediatric fluid rate calculator?
If the child fails oral fluid trial:
- Nasogastric tube (NGT) rapid rehydration: 50 mL/kg over 4 hours with oral rehydration solution (ORS). This corrects for 5% dehydration.
- Admit to the Emergency Department Short Stay Unit (ESSU).
- If the child vomits reduce the rapid rehydration rate to 50 mL/kg over 6 hours.
If the child fails NGT rapid rehydration (> 2 vomits):
- Admit to General Paediatric team.
- Option 1: NGT fluid (maintenance + deficit).
- Option 2: IV fluids sodium chloride 0.9% + glucose 5% (maintenance + deficit).
PCH ED Guideline - Gastroenteritis
- Medication options?
- Admission Criteria? (2)
- Referrals and follow-up?
- Nursing?
- Observations?
Medication
- Ondansetron can be used before a fluid trial or if the child vomits during rapid rehydration. It is not recommended as a discharge medication.
- No other anti-emetics or anti-diarrhoeal agents are to be used in infants or children with suspected gastroenteritis.
Admission criteria
1. Failed rapid rehydration with OGT or NGT
2. Severe dehydration requiring intravenous fluids.
Referrals and follow-up
- Patients with mild to moderate dehydration who are sent home after oral fluid trial should have a GP review at 24 hours.
RCH CPG - Slow Weight Gain
- Background?
- 4 Key Points?
- What history will you take?
Key points
1. Optimal growth assessment requires serial measurements plotted on appropriate growth charts.
1. Nutrition is the main driver of growth in children under 2 years of age. Most cases of slow weight gain are secondary to inadequate caloric intake.
1. Slow weight gain is commonly multifactorial in origin, with psychosocial stressors often a significant contributor.
1. Small and otherwise healthy babies following a growth percentile line may not need any investigations.
RCH CPG - Slow Weight Gain
- How will you examine a child with slow weight gain?
RCH CPG - Slow Weight Gain
- Use of growth charts?
Growth charts
- <2 years of age: WHO growth standards. Correct for prematurity (<37 weeks) until 2 years old
- ≥2 years of age: CDC growth reference charts
- Use specific growth charts (eg Down, Turner syndrome) where appropriate
RCH CPG - Slow Weight Gain
- Which health professionals may be involved in the multidisciplinary team?
- Which investigations should be considered?
RCH CPG - Causes of Slow Weight Gain
- Inadequate caloric intake/retention?
- Psychosocial factors?
- Inadequate absorption?
- Excessive caloric utilisation?
- Other?
RCH CPG - Slow Weight Gain
- Average weight gain of children?
RCH CPG - Iron deficiency
- 4 Key Points?
- 7 Risk factors for Iron Deficiency in infants?
- 3 Risk factors for Iron Deficiency in Children?
- 5 Risk factors for Iron Deficiency in Adolescents?
Key points
1. Serum ferritin is the most useful screening test for assessing iron stores.
2. A reduced serum ferritin (<20 μg/L) indicates borderline/low iron stores.
3. Children with iron deficiency anaemia (IDA), symptomatic iron deficiency and iron deficiency with or without anaemia prior to surgery should be treated.
4. In most instances, IDA and iron deficiency can be treated safely and effectively with oral iron supplements.
RCH CPG - Iron deficiency
- Assessment?
RCH CPG - Iron deficiency - Management
- Dietary advice?
- Oral iron supplementation?
- Other Treatment Considerations?
Management - Suggest iron supplementation and dietary modification if low ferritin, with or without anaemia.
Dietary advice
- Increase iron-rich foods and reduce cow’s milk consumption.
- Cow’s milk should not be offered to children <12 months and should be limited to <500 mL/day in those older than 12 months.
- Consider referral to a dietitian.
RCH CPG - Iron deficiency - Management
- Oral Iron formulations?
- 6 Instances when IV iron should be considered?
IV Iron - Consider when:
1. Persistent iron deficiency despite. adequate oral therapy (3 month trial)
2. Contraindications to oral iron, or serious issues with compliance or tolerance.
3. Co-morbidities affecting absorption, e.g. gastrointestinal disease.
4. In patients receiving erythropoietin-stimulating agents.
5. Ongoing blood loss that exceeds the body’s iron absorptive capacity.
6. Requirement for rapid iron repletion e.g. preoperatively for non-deferrable surgery.
RCH CPG - Iron deficiency - Management
- Quick dose reference guide - Mild to moderate IDA?
- Quick dose reference guide - Severe IDA (Hb 80 g/L or less)?
CAHS Guideline - Neonatal Hypoglycaemia
- Definition of hypoglycaemia?
- CNS symptoms?
CAHS Guideline - Neonatal Hypoglycaemia
- 4 Inadequate supply or
reduced glycogen stores causes/risk factors for Hypoglycaemia?
- 6 Increased utilisation causes of hypoglycaemia?
- 7 Hormone/metabolism
imbalance causes of hypoglycaemia?
CAHS Guideline - Neonatal Hypoglycaemia
- Which infants are at risk of hypoglycaemia? (6)
CAHS Guideline - Neonatal Hypoglycaemia
- Early Energy Provision?
- Glucose monitoring of at risk infants?
Early Energy Provision - Within 1-2 Hours of Birth
- Offer early skin to skin under warm blankets.
- Encourage early first breast feed followed by 3 hourly feeds/more frequent if demanding.
- If poor breast feeding consider supplemented enteral feeding 3 hourly.
- Start at 60/kg/day (7.5mL/kg/feed) if not contra-indicated.
- If enteral feeding is not possible then admit to NICU and give IV 10% Glucose.
- Start at 60mL/kg/day (providing 4.2 mg/kg/min of glucose).
CAHS Guideline - Neonatal Hypoglycaemia
- Investigation of Neonatal Hypoglycaemia – “Hypoglycaemia
Screen”?
CAHS Guideline - Neonatal Hypoglycaemia
- Management of Hypoglycaemia in Asymptomatic Infants with PGL 1.5-2.5mmol/L?
CAHS Guideline - Neonatal Hypoglycaemia
- Management of Hypoglycaemia in Asymptomatic Infants with PGL <1.5mmol/L?
CAHS Guideline - Neonatal Hypoglycaemia
- Management of Hypoglycaemia in Symptomatic Infants?
CAHS Guideline - Neonatal Hypoglycaemia
- What is?
- Management?
Persistent Hyperinsulinaemic Hypoglycaemia of Infancy (PHHI)
PHHI is commonly seen in infants born to a mother with gestational diabetes, however can occur in mothers with a normal glucose tolerance test. It is diagnosed by finding an elevated insulin level during a period of hypoglycaemia. Infants with PHHI may require a significantly higher glucose delivery rate of up to 10-12mg/kg/min.
CAHS Guideline - Neonatal Hypoglycaemia
- Infants that cannot be weaned off diazoxide or have unstable PGLs on diazoxide may require further investigations to exclude which condition?
CAHS Guideline - Neonatal Hypoglycaemia
- Flow chart based on PRE-FEED PGL?
This boy has had watery diarrhoea several times a day for 2 days and a mild fever. He is refusing food and is drinking half his normal amount. He is passing regular wet nappies.
Which clinical features (whether present or not) of dehydration can you judge based on this clip?
- Skin Tugor
- Peripheral Perfusion
- Sunken eyes
- Hypotonia (Floppiness)
This baby girl is brought to an Emergency Department by her mother because she is concerned she has been vomiting for the last 3-4 days. She has been grizzly and only taking half her normal feeds. This child has a blood sugar level of 4.2. Which of the following statements are are correct?
- This level requires immediate treatment
- This is acceptable for the child’s age
- Sugar free fluids should be given
- This should be repeated in 30 minutes
This 15 month old boy has had a fever for three days and started vomitting 24 hours ago. His mother is concerned he isn’t as happy as he normally is and is difficult to console. The child’s Heart Rate is 180. An acceptable heart rate for this age of patient is:
- 60-100
- 150-200
- 110-140
- 70-200
= 110-140
This child has had profuse diarrhoea for 5 days and in the last 24 hours has been quiet and barely taken any feeds. Not grabbing mothers fingers. Pink mottled legs. This child demonstrates?
- Signs of hypernatraemic dehydration
- Potential signs of poor perfusion
- An AVPU of P
- Being well - as judged by a good suck reflex
= Potential signs of poor perfusion
Describe the important macronutrient and micronutrient needs of infants from birth to age 12 months. Include comparison of carbohydrate, fat, protein, vitamin D and iron sources.
Provide a list of resources which support clinical management of nutritional concerns in the paediatric population. (19)
Growth faltering (aka “failure to thrive”)
- Definition of Growth faltering?
- Definition of Childhood wasting?
- Definition of Growth Stunting?
Growth faltering (aka “failure to thrive”)
- Mechanisms of Overview of mechanisms of growth faltering and examples?
Growth faltering (aka “failure to thrive”)
- 8 Clinical Features of malnutrition?
- 6 Clinical Features of underlying conditions?
Features of underlying conditions:
1. Suspicious contusions or fractures; abnormal language, social, or psychological development in children who experience abuse.
2. Recurrent vomiting and diarrhea in gastrointestinal diseases.
3. Atopic dermatitis in food allergies.
4. Heart murmur in congenital cardiac disease.
5. Dysmorphic features in genetic abnormalities.
6. Edema in renal or liver failure
Growth faltering (aka “failure to thrive”)
- Clinical assessment?
- Common diagnostic studies?
- Further studies?
Growth faltering (aka “failure to thrive”)
- Management?
Which 7 childhood factors have the strongest correlation with adult obesity, and how should we manage childhood obesity?
Outline the different options for milk formulae in Cow Milk Protein Allergy?
How do you assess a child with diarrhoea? (5)
How to assess a child with diarrhoea
1. Ask the mother if the child has diarrhoea - how long? Is there blood in the stool? (dysentery)
2. General appearance – alert & oriented, irritability and tired but upset, lethargic & unconscious.
3. Sunken eyes
4. Offer the child fluid – is the child not able to drink or drinking poorly.
5. Abdominal skin turgor – thumb and 2 forefingers, lift skin and a bit of fat, longitudinally, pinch for 1 second and release (<2 seconds)
When should infant start on solids? Pros and cons of breast milk vs. bottle formula?
When does milk become supplementary for an infant’s diet? How much should they have at 12 months?
Milk at 10 months supplementary
- Volume decrease to 500 ml
- Offer foods not too much choice ANY foods
- 4/4 puree: 8/12 finger colour soft: 10/12 variety/choice = do not fight you will lose!
- Choking common: VERY rarely problem
- Avoid fashion eg lactose free gluten free KISS
- Starter food ??!!?? Anything KISS
- Common sense allow to copy
What are the 2 types of Hydrolysed formulae for infants? When would you use them?
What is Cows milk protein intolerance? How will a child with this present?
Cows milk protein intolerance
- Usually (>90%) non IgE mediated
- Most Mild to moderate self resolves over time
- Incidence < 5% children
- Severe – anemia FTT diarrhea (loss of protein, blood) vomiting (later age > 4 months)
- HISTORY NB NB NB
- Elimination then re-challenge 1/12
ASCIA Guidelines - Infant Feeding and Allergy Prevention
- Maternal diet during pregnancy and breastfeeding?
- Breastfeeding and infant formula?
Maternal diet during pregnancy and breastfeeding
- ASCIA recommends a healthy balanced diet, rich in fibre, vegetables and fruit. This provides many health benefits to the mother and infant during pregnancy and breastfeeding.
- Exclusion of any particular foods (including foods considered to be highly allergenic) from the maternal diet during pregnancy or breastfeeding is not recommended, as this has not been shown to prevent allergies.
- Up to 3 serves of oily fish per week may be beneficial, as there is some evidence that omega-3 fatty acids (found in oily fish) during pregnancy and breastfeeding may help prevent eczema in early life.
- Whilst there is moderate evidence that probiotics during pregnancy and breastfeeding may help prevent eczema in early life, recommendations about probiotic supplements cannot currently be made because the optimal species and dose of probiotics that might have an effect is unclear. More research is required in this area before clear and specific recommendations can be made.
ASCIA Guidelines - Infant Feeding and Allergy Prevention
- Introducing Solids?
Introducing Solids
- When your infant is ready, at around six months, but not before four months, start to introduce a variety of solid foods, starting with iron rich foods, while continuing breastfeeding.
- Foods should not be introduced before four months.
- Infants differ in the age that they are developmentally ready for solid foods.
- Signs that your infant may be developmentally ready to start solids include being able to sit relatively unaided, loss of the tongue-thrust reflex that pushes food back out and trying to reach out and grab food.
- ASCIA recommends the introduction of solid foods around six months, but not before four months, and preferably whilst breastfeeding. There is some evidence this is protective against the development of allergic disease.
9 Common allergy causing foods?
Can you introduce common allergy causing foods to all babies before one?
Common allergy causing foods
1. Wheat
2. Soy
3. Peanut
4. Fish
5. Shellfish
6. Sesame
7. Tree Nuts
8. Egg
9. Cow’s Milk
RCH Endocrinology Guidelines - Differences of sex development
- What is a DSD?
- Terminology?
- 10 Examples of DSD diagnoses?
Terminology
‘Differences’ or ‘disorders’ of sex development (DSD) is an umbrella term used to describe this group of conditions in a medical setting. DSD is a term used in the medical literature; however there are many alternative names to DSD such as ‘intersex variations’ or ‘variations of sex characteristics’. People may not have heard these terms used by their doctors as they may have mainly used the name of their particular condition.
Describe the causes of Relux/GORD in <6mo?
OSCE - The vomitting baby?
- Good weight gain vs. Poor weight gain?
- IN FIRST 12 WEEKS REMEMBER EXAM BIRTH WT AND CURRENT WEIGHT.
- Gain approx 150 gm/wk FTT <50 overfeed > 250 overfeeding is ok but aggravates vomiting
Role of Long term Omiprazole/PPIs in infants?
Cryptochoridism
- Definition?
- Epidemiology?
- Aetiology
- 2 Risk factors?
- 2 Clinical features?
Cryptochoridism
- Variants?
- Diagnosis?
- Differential diagnosis?
- Treatment?
- 4 Complications?
5 Causes of Vomiting in a child due to bowel obstruction?
What proportion of kids aged 2-17years are overweight/obese?
- Epidemiology?
- Social disparities?
= 1 in 4 kids
Is Australia meeting its preventive health targets for childhood obesity?
List 8 Complications of Childhood Obesity?
Why is there a link between SES and obesity?
“People from lower socioeconomic backgrounds are more than twice as likely to be obese as people from wealthier backgrounds. This happens because access to the things needed to live a healthy lifestyle just isn’t there for people experiencing poverty and disadvantage.”
“Families in the lowest quintile would need to spend 56% of their average weekly income on food to afford a healthy food basket”
List some of the factors contributing to the childhood obesity epidemic?
- Role of genetics?
- Excessive gestational weight?
Genetics - Obesity
- Varies widely from 6-85%
- Heritability of BMI 40-70%
Excessive gestational weight gain
- Increase in macrosomia, BMI, and obesity in infants and children
List the challenges for managing childhood obesity.
What does the best practice management of childhood obesity look like?
“Best practice management of childhood obesity supports multi-setting, community-wide strategies that combine healthcare systems and community programs to provide a comprehensive, equitable, and intergenerational response to the problem. Sustaining change over time is key, with some evidence that providing follow up over extended periods of times improves outcomes.”
Give an example of a community-based program in WA targeting childhood obesity?
- What are the OWL project goals?
- How can you raise the issue of weight and obesity of a child in a consultation?
Raising the issue
- You are seeing a child for an apparently unrelated reason (asthma, constipation) and think the child /teen may have a weight issue…..
◦ How do you raise the issue?
◦ What are the potential difficulties in doing so?
- Routinely measure height and weight, calculate BMI and plot on growth chart
- Discuss growth chart sensitively
What is fussy eating? How common is it? Types? How does it differ from a Avoidant Restrictive Food Intake Disorder?
Fussy eating
- Picky eaters are people who avoid many foods because they dislike their taste, smell, texture, or appearance.
- Picky eating is common in childhood, between 13 – 22% children between 3- 11years considered picky eaters at any given time.
- Up to 50% of children are picky eaters at some time
Types of fussy/restrictive eating: Colour, Texture, Limited food groups, Fear of …, Allergies
- 6 Causes of fussy/restrictive eating?
- Selective eating criteria?
- Criteria for Childhood Eating Disorders?
Causes of fussy/restrictive eating
1. Structural (anatomic)
2. Neurological
3. Metabolic/Malabsorption
4. Underlying medical condition
5. Psychological
6. Abuse/Neglect/Trauma
Growth Faltering - Case 1
- Growth chart shows trend along lower weight percentile line.
- Diagnosis?
= Normal growth
Growth Faltering - Case 2
- Growth chart shows upward trend but lower than a normal weight percentile line.
- Investigations? Diagnosis?
= Constitutional Growth Pattern (a kind of normal)
- It’s definitely worth doing some investigations given his background but Normal growth tracking along percentile. Maybe just monitor more frequently.
Growth Faltering - Case 3
- Growth chart shows upward trend but then a faltering/drop in weight.
- Normal Tissue transglutaminase antibody levels?
- Investigations? Diagnosis?
- Tissue transglutaminase antibodies should be <7.
- Diagnosis = Coeliac Disease
- Also check IgA level to ensure that is not low.
- Inflammarotry bowel disease as a differential – so could do CRP, ESR, but more common in adolescents and not very commin in 4yos.
- Chronic parasitic infection – eg. Giardiasis (pets?)
Growth Faltering - Case 4
- Growth chart shows upward trend but then a faltering/drop in weight.
- Investigations? Diagnosis?
- Diagnosis = Subacute Urinary Tract Infection
Growth Faltering - Case 5
- Growth chart shows the child started above the average weight percentile and trended upwards but then flatlined a bit.
- What does an erythematous bottom suggest?
- Investigations? Diagnosis?
- Erythematous bottom – suggests child isn’t absorbing all nutrients (particularly sugars can be acidic on the way out = nappy rash).
- Diagnosis = Cow milk protein allergy (food protein induced proctocolitis)
- Differentials for blood in the stool – enteral infection, systemic inflammation (mucus + blood), Ano-rectal fistulas (blood only)
What is the usual daily intake of milk of a 2 month old child weighing 5kg?
= 150x5 = 750ml/24 hours.
(150ml/kg/day)
At about 2 months, your baby may drink about 4–5 ounces (120–150 milliliters) every 3–4 hours. At 4 months, your baby may drink about 4–6 ounces (120-180 milliliters) at each feeding, depending on how often they eat. By 6 months, your baby may drink 6–8 ounces (180–230 milliliters) about 4–5 times a day.
A 15kg child is fasting prior to a general anaesthetic. The wait is longer than usual & an RMO is requested to write up some maintenance fluids. What is the best maintenance fluid strategy?
15kg child = toddler (not a neonate) = 5% glucose & 0.9NaCl
421 rule = 50mL/hr
A 6yo child presents with tachypnoea, polydipsia, polyuria, and 1.5kg weight loss, CR 3seconds. BSL 33mmol/L, pH 7.08, Na: 159mmol/L, weighs 28kg. Best fluid strategy?
Maintenance rate (421 rule)
- 10kg x 4ml = 40
- 10kg x 2ml = 20
- 8kg x 1ml = 8
- 40+20+8 = 68ml/hr
5% replacement
Slowly over 2 days
= 99ml/hr post of 560mL
A 5yo presents pale, lethargic, listless, and febrile. SBP 70mmHg, CR 5s, HR 174bpm, weighs 23kg. What fluid strategy is best?
= Bolus 460mL 0.9mL NaCl
A 6mo with bronchiolitis is feeding less than 50% of usual. Tachypnoeic & wheezy, CR<2s, HR128, weighs 8kg. What fluid strategy is best?
= 150ml/kg (neonate) but 2/3rds for NGT
100x8 = 800/24 = 33ml/hr or 21ml/hr (2/3) BUT can be more liberal with NGT
A 4yo presents with diarrhoea for 2/7. Child is thirsty, CR is 3 seconds, mild tachycardia, weight is 14kg. What fluid strategy is best?
= Rapid rehydration protocol = NGT ORS 700ml in 4hrs
= Gastroenteritis
9mo presents with 5d of diarrhoea and vomiting. What does the VBG show?
- Mild respiratory acidosis
- Diabetic ketoacidosis
- Metabolic acidosis uncompensated
- Acidotic methoglobinaemia
- Hyperchloraemic Metabolic acidosis
= Hyperchloremic metabolic acidosis = (normal saline) too rapidly
A 6week old present with these nappies, irritability and weight faltering. What is the diagnosis?
- Rectal polyp
- Lactose intolerance
- Dysentry
- Meckel’s diverticulum
- Cow’s milk protein allergy
= Cow’s milk protein allergy
= Rapid rehydration = NG ORS @200mL/hr for 4h
Describe appropriate nutrition & hydration management strategies for the following scenarios:
- a. A 2kg neonate (<24 hours old), of a mother with gestational diabetes.
Describe appropriate nutrition & hydration management strategies for the following scenarios:
- b. A 3kg neonate with neonatal respiratory distress syndrome who is unable to feed (from birth to 72 hours)
Describe appropriate nutrition & hydration management strategies for the following scenarios:
- c. A 6kg four-month-old infant with bronchiolitis
Describe appropriate nutrition & hydration management strategies for the following scenarios:
- d. A 12kg two year old with viral gastroenteritis and moderate dehydration
Describe appropriate nutrition & hydration management strategies for the following scenarios:
- f. An 18kg five year old with diabetic ketoacidosis
Describe appropriate nutrition & hydration management strategies for the following scenarios:
- g. A 24kg 8 year old with appendicitis who has to fast overnight (10 hours).
