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Department of Nutrition Services | Morrison Healthcare Foodservice

Pediatric Nutrition Support Handbook

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Pediatric Nutrition Support Handbook

Department of Nutrition Services

UVA Children’s Hospital

University of Virginia Health System

Charlottesville, Virginia 22908

Editors:

Ana Abad-Jorge, MS, RD, CNSC

Brandis Roman, MS, RD, CNSC

Contributing Authors:

Ana Abad-Jorge, MS, RD, CNSC

Marcia Buck, PharmD

Allie Hubbard, RD

Patti Perks, MS, RD, CNSD

Brandis Roman, MS, RD, CNSC

This handbook is intended to serve as a reference or guide in the area of pediatric enteral and parenteral nutrition support for clinical nutritionists, medical and nursing staff as well as dietetic interns and medical and nursing students.

Acknowledgements:

The administrative assistance of Nancy Carpenter in the preparation of this handbook is greatly appreciated.

This handbook was funded by the Department of Nutrition Services.

Copyright 2012 University of Virginia Health System and Morrison Management

Specialists

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UVA Health System Nutrition Educational Programs

Dietetic Internship Program

The Dietetic Internship Program at the University of Virginia Health System, established in 1975, has as its mission to provide a broad-based, comprehensive dietetics education in both traditional and emerging diverse settings. This progressive program furnishes the intern with the skills to function as a competent entry-level dietitian with a specialization in the medical nutrition therapy areas of paediatrics and adult nutrition support, while emphasizing a commitment to life-long learning. Interns are also given the opportunity for advanced training and multi-skilling in the areas of research, computer technology, effective oral and written communication and clinical assessment. With a high staff/intern ratio, interns have the opportunity to work one-on-one with nutritionist and management preceptors, but can also work collaboratively with teams and other interns. This environment provides the intern with theoretical, didactic, pre-planned and on-the-job learning experiences in a variety of challenging and progressive settings. The internship program, which is 43 weeks in length, starts at the beginning of September and is completed during the last week of June. The program consists of a comprehensive 2 week orientation to the program and rotations, supervised practice on-the-job learning experiences, weekly classes and professional meetings. Rotations and affiliations are directed by Registered Dietitians and department managers. During the program, interns will actively participate in clinical, community and foodservice management rotations. Program goals include:

To provide the health care system with entry-level dietitians competent to practice in general medical nutrition therapy areas, as well as the specialized areas, pediatrics and adult nutrition support.

To train and empower interns to enter the field with the necessary skills to conduct basic practice based research, publish in the field of nutrition and dietetics, and educate students, health care professionals and the public through a variety of formal and informal training formats.

To prepare interns to demonstrate exemplary professional behaviors, leadership within their profession or community, and a commitment to active community service and life-long learning.

Nutrition Support Traineeship

The UVA Health System Nutrition Support Traineeship provides a unique, five-day opportunity to achieve a higher level of practice in nutrition support. Our evidence-based program utilizes actual patient cases, physician-led nutrition support team rounds, small group discussions, critical evaluation of research, and a practical, hands-on approach to learning. Our goal is to optimize continuing educational time and expenses by focusing on the individual's learning needs. Also included is an elaborate, fully referenced syllabus. Modules are based on the most current evidence-based information, and provide a template for education at the bedside. Experiences during the traineeship week are structured to spend time observing and participating in completing nutrition support consults, nutrition team rounds, review of syllabus modules, case studies and questions.

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Table of Contents

Chapter 1 - Pediatric Nutrition Services and Nutrition Screening at UVA HS ....... 1 Pediatric Nutrition Goals............................................................................................. 1 Pediatric Nutrition Services Provided at UVA Health System .................................... 2 Role of the Pediatric and Neonatal RDs..................................................................... 2

Chapter 2 - Nutritional Assessment of Pediatric Patients ....................................... 9 Growth and Anthropometric Measurements ............................................................... 9 Assessment of Malnutrition ...................................................................................... 12 Medical History ......................................................................................................... 13 Nutritional Intake History .......................................................................................... 14 Laboratory Data ...................................................................................................... 15

Chapter 3 - Nutritional Requirements in Term Infants and Children .................... 17 Non-Critically Ill Infants and Children ....................................................................... 17 Critically Ill Children .................................................................................................. 22 Catch-Up Growth in the Term Infant and Child ....................................................... 24 Energy Requirements for Pediatric Burn Patients ................................................... 25 Fluid Requirements .................................................................................................. 25

Chapter 4 - Nutritional Assessment, Requirements, and Enteral Nutrition

Management in the Preterm Infant .......................................................................... 27 Preterm Infant Weight Classification and Assessment ........................................... 27 Micronutrient and Macronutrient Requirements ....................................................... 28 Fluid Requirements .................................................................................................. 30 Meeting the Increased Needs of the Preterm Infant ................................................ 30 Preterm Formula Selection ...................................................................................... 32 Modifying Formula Caloric and Nutrient Density ...................................................... 33 Feeding Protocols for NICU Infants.......................................................................... 35

Chapter 5 - Enteral Nutrition Support ...................................................................... 37 Advantages of Enteral Nutrition................................................................................ 37 Indications for Enteral Feedings ............................................................................... 37 Enteral Tube Feeding Formula Selection ................................................................. 38 Modifying Formula Caloric and Nutrient Density ...................................................... 41 Tube Feeding Routes of Delivery ............................................................................. 44 Tube Feeding Administration Methods..................................................................... 46 General Guidelines for the Initiation and Progression of Tube Feedings ................. 47 Management of Combination Enteral and Oral Feedings ........................................ 49 Management of Complications Encountered with Enteral Feedings ........................ 49

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Chapter 6 - Nutrition Management of High Risk Nutrition Disease States ........... 55 Congenital Heart Defects ........................................................................................ 55 Cystic Fibrosis .......................................................................................................... 56 Renal Disease .......................................................................................................... 60 Severe Gastrointestinal Impairment ........................................................................ 65 Chylous Ascites/Chylothorax ................................................................................... 69 Burns ....................................................................................................................... 71

Chapter 7 - Parenteral Nutrition ............................................................................... 77 Peripheral vs. Central Parenteral Nutrition ............................................................... 77 Guidelines for Initiation & Advancement of Parenteral Nutrition ............................. 78 Monitoring of Pediatric Patients on Parenteral Nutrition .......................................... 87 Managing Metabolic and Long Term Complications of Parenteral Nutrition ............ 88

Chapter 8 - Pharmacology and Nutrition Support .................................................. 95 Medication Information Resources ........................................................................... 95 Common Drug-Nutrient Interactions Seen in Hospitalized Patients ......................... 95 Drug Interactions with Enteral Products ................................................................... 97 Drug Interactions with Parenteral Nutrition ............................................................... 99 Common Enteral Electrolyte Supplementation ....................................................... 101

APPENDIX ................................................................................................................ 103 A – Growth Charts for Normal Infants and Children

• World Health Organization Growth Standards for Infants (Charts 1 – 3) • National Center for Health Statistics (CDC) Growth Charts for Children

Aged 2-20 Years (Charts 4 – 8) • Fenton Growth Chart for Preterm Infants (Chart 9)

B - Specialized Growth Charts: Down Syndrome C – Triceps Skinfold Percentile Charts D – Mid Upper Arm Circumference Percentile Charts E - Developmental Self-Feeding Checklist F - Selected Lab Values with Nutritional Implications G - Estimated Energy Requirements (EER) for Infants and Children H - Guide to Number of Servings and Serving Size for Children I - Electrolyte Conversion Information J- Oral Multivitamin and Mineral Supplements Available at UVA K - Tips for Increasing Calories for Children L - Sites of Nutrient Malabsorption Resulting from Intestinal Resections M – Therapeutic Algorithm for Management of Post-operative Chylothorax

Chapter 1 Pediatric Nutrition Services and Nutrition Screening at University of Virginia Health System

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Chapter 1

Pediatric Nutrition Services and Nutrition Screening

At University of Virginia Health System

The University of Virginia (UVA) Health System, located in Charlottesville and comprised of the School of Medicine, School of Nursing, Claude Moore Health Sciences Library and the Medical Center, has been declared time after time as one of the Nation’s Top 100 Hospitals. The Medical Center, a teaching and research hospital with over 550 beds, includes University Hospital, Kluge Children’s Rehabilitation Center (KCRC), Northridge, the Primary Care Center and satellite clinics. UVA provides quality care to a primarily rural population serving the community and the Commonwealth, and receives referrals from other states and countries. At UVA, patients receive specialized care in a variety of areas including pediatrics, women’s health, diabetes, cardiology and digestive health. Through the Continuum Home Health Program, UVA professionals bring care and expertise into thousands of homes. Our state-of-the art medical facility offers multi-disciplinary centers focused on specialty areas such as the Cancer Center, the Children’s Hospital and the Women’s Place, to name a few. The Medical Center, designated as a Level I Trauma Center, contains numerous intensive care units including the medical, surgical, pediatric and newborn intensive care units.

Pediatric nutrition services at UVA Health System are provided by a number of pediatric registered dietitians (RDs) in the areas of general pediatrics, the pediatric intensive care unit (PICU), the newborn intensive care unit (NICU), KCRC and in the outpatient areas including: pediatric nephrology, pediatric gastroenterology, inborn errors of metabolism, children’s fitness clinic, and pediatric endocrinology. The inpatient pediatric RDs work closely with the respective unit medical teams to provide nutritional assessment, care plan development and patient and staff education. The pediatric RDs also closely follow patients in the pediatric units, NICU and PICU who are at nutrition risk and require specialized enteral or parenteral nutrition support.

Pediatric Nutrition Goals

1. To decrease the incidence of morbidity and mortality associated with nutritional problems in our pediatric patient population.

2. To improve patient clinical outcomes by providing timely, optimum, safe and cost-

effective nutrition through either the oral route, or for those children who are critically or chronically ill, using tube feedings or parenteral nutrition support.

3. To identify patients who will benefit from nutrition intervention. 4. To provide patient education in the areas of specialized or therapeutic diets, or for

specialized enteral or parenteral nutrition support, including but not limited to,


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diabetes diet education, low fat or low sodium diets, and specialized formula preparation.

5. To provide medical and health care staff and student education in the areas of

pediatric nutrition or specialized nutrition support via formal lectures and patient unit and discharge planning rounds.

6. To develop and review hospital and departmental policies and procedures to

promote the appropriate and effective use of nutrition therapy and support.

Pediatric Nutrition Services Provided at UVA Health System

Comprehensive nutrition assessment

Follow-up assessment

Nutrition intake analysis

Patient and family education

Staff and student education in the area of pediatric nutrition and nutrition support

Resource for health care team and staff in the area of pediatric nutrition support

Active participation in unit-based quality improvement activities and projects with the goal of improving patient care and clinical outcomes

Role of the Pediatric and Neonatal RDs

Conduct in-depth nutritional assessment

Provide medical nutrition therapy recommendations for children with a wide variety of nutritional disorders or those at risk for malnutrition

Provide nutrition support recommendations and pended orders for parenteral nutrition.

Provide nutrition support recommendations and verbal order for therapeutic diets, enteral nutrition , and related laboratory values, in order to expedite the timely ordering and delivery of effective nutrition support to infants and children.

Provide monitoring for complications, lab abnormalities, response to nutritional intervention and support, timely follow-up and intervention

Conduct nutrient analyses and compare intake to estimated needs

Assist in the provision of patient and family education on specialized and therapeutic diets and home nutrition support, as related to formula preparation, delivery and monitoring for enteral feeding complications

Provide education to pediatric residents, nursing staff, medical and nursing students, and dietetic interns


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Pediatric Nutrition Services within the General Pediatric Units (7- Acute)

Nutrition Screening

The 7-Acute RDs screen pediatric patients on the unit to determine those at nutrition risk. Per Nutrition Services policy, all children are screened for nutrition risk upon admission by the unit nursing staff. The 7-Acute pediatric RD receives a nursing referral for those children determined to be at risk. The initial screening by the nursing staff is based on presence of the following:

Special diet or formula

Poor oral intake for > 5 days

Pressure ulcer(s) or poor wound healing

Burns > 15% total body surface area

Problems chewing or swallowing

Use of specialized nutrition support: enteral or parenteral

Current diagnosis of malnutrition, cystic fibrosis, failure to thrive or new onset diabetes mellitus

The patient’s family is also asked if they wish to see an RD during the admission.

Comprehensive Nutrition Assessment: High Risk Nutrition Diagnoses and

Conditions The following conditions or diagnoses are often indicative of high nutrition risk. 1. Patients on nutrition support 2. High risk diagnoses or conditions

a. Anemia b. Bronchopulmonary dysplasia/chronic lung disease c. Burns d. Cancer e. Congenital heart defects f. Cystic fibrosis g. Diabetes mellitus h. Failure to thrive i. Gastrointestinal anomalies/disorders: gastroschesis, malrotation, necrotizing

enterocolitis, omphalocele, short gut syndrome, tracheo-esophageal fistula, volvulus

j. Inflammatory bowel disease: Crohn’s disease, ulcerative colitis k. Liver disease l. Malabsorption syndromes m. Neurologically/developmentally impaired n. Preterm Infants – particularly very low birth weight infants (<1500 grams) o. Pulmonary disease


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p. Renal disease q. Trauma patients

3. Weight below or above standards

a. Weight/height < 3rd

%-ile on age- and disease-appropriate growth charts b. Height or Length< 3

rd%-ile

c. Weight for height <3rd

%ile or > 95th

-ile d. Recent weight loss (over the past 6 months) of > 10% of usual body weight

4. Catabolic state: sustained fever, major organ failure 5. Diet order and patient intake inadequate in meeting patient nutritional

requirements. a. NPO > 3 days in previously malnourished children or NPO > 5 days in

previously well-nourished children, without parenteral or enteral nutrition b. Patients on clear or full liquid diets for > 5 days

Pediatric Nutrition Services within the Pediatric Intensive Care Unit (PICU)

Nutrition support of the critically ill, post-trauma or post-operative pediatric patient continues to develop as a clinical science in light of advances in nutrition, pharmacology and technology. Given the wide diversity in pediatric critical care states, we are challenged to accurately assess the nutritional requirements of our patients and the best mode of nutrition support to optimize their recovery and their nutritional and medical outcomes.

Role of the PICU RD

Screen all PICU patients for nutritional risk

Comprehensive nutritional assessment of all patients determined to be at risk

Development of nutrition care plan with recommendations for enteral or parenteral nutrition support, as needed (within 48 - 72 hours of PICU admission)

Monitoring of nutritional status; timely follow-up and intervention

Conduct nutritional analysis and compare intake to nutrition goals

Family and staff education on nutrition support

Assist the PICU team with nutrition management through entering pended orders for TPN, and verbal orders for enteral feedings, labs, and therapeutic diets using the electronic medical record system (Epic).


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Purpose and Goals of Nutrition Support in the PICU Patient

Provision of adequate calories and protein during catabolism to prevent protein-energy malnutrition (PEM), i.e., sepsis, trauma, post-surgery.

Promote improved immunological status and wound healing to minimize the risk of iatrogenic infections.

Prevent or minimize the catabolic response and breakdown of both somatic and visceral protein stores.

Improvement of nutritional status; management of disease-specific deficiencies

Reversal of growth failure and when applicable, promotion of “catch-up” growth.

Indications for Nutrition Support: Patients at Nutrition Risk

Hypermetabolic states: trauma: closed head injury, spinal cord injury

Post-surgical patients

Cardiorespiratory illness: congenital heart defects, bronchopulmonary dysplasia, cystic fibrosis

Gastrointestinal disease and dysfunction: short gut syndrome, exacerbation of inflammatory bowel disease with history of PEM, hepatic failure, biliary atresia, pancreatitis

Neurologic, muscular disease: genetic syndromes, Guillan-Barre’, muscular dystrophy, history of Cerebral Palsy or Mental Retardation requiring G-tube feedings

Pediatric Nutrition Services within the Newborn Intensive Care Unit (NICU)

The Newborn Intensive Care Unit is a special care nursery for the medical management of the preterm or critically ill neonate. The unit at UVA Health System is comprised of more than 40 beds and is staffed by neonatologists, neonatology fellows, neonatal nurse practitioners, and neonatal RNs. The NICU RD plays an active role in the NICU.

Role of Neonatal RD

Initial assessment for all at-risk infants within 72 hours of admission

Assist NICU residents with entry of TPN orders and with enteral feeding orders

Be available to the NNPs as a consultant regarding the nutrition management of their infants

Weekly follow-up for all infants

Participation in team rounds

Parent & caretaker education for infants being discharged on high calorie formula or fortified breast milk or any other specialized formula, when needed


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Monthly Neonatal Nutrition lecture to the new interns

Nutrition education and orientation of new NICU nurses

Screening in the Newborn Intensive Care Unit In the NICU, interns and residents complete a thorough assessment within the first 24 hours which includes the following basic nutrition screening data:

Birth weight, length and head circumference

Intrauterine %-iles for weight, length and head circumference using the Intrauterine growth charts

Gestational age

Major diagnoses

Based on the above documented nutrition screening data, the neonatal RD will

determine which infants are at risk and will complete a full assessment on the

following neonates:

All infants under 1200 grams

All infants requiring parenteral nutrition

Infants with major gastrointestinal anomalies

Infants with intrauterine growth retardation (IUGR) and who are small for gestational age

Infants with congenital heart defects requiring surgical repair

Infants with severe respiratory distress syndrome (RDS)

Infants with complex genetic disorders impacting nutritional status


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Pediatric Nutrition Outpatient Services

UVA Children’s Hospital

University of Virginia Health System

SERVICE DIETITIANS PHONE/PAGER

Primary Care

Center

Nephrology Brandis Roman 243-7656, PIC 6433

Gastroenterology Brandis Roman 243-7656, PIC 6433

Inborn Errors of Metabolism

Barbara Goodin

924-2665 or 979-6530 (beeper)

Continuum

Home Health

Pediatric Home Nutrition Support Patients

Amy Mentrikoski 924-8193

Northridge

Weight management, failure to thrive, behavioral eating issues, allergy, well child issues

Ashleigh Sellman

243-7314

Kluge

Children’s

Rehab Center

CP, myelomengiocele, muscular dystrophy, trauma, infant & young child clinic, Down syndrome, neurodevelopmental clinic, autism, other

Audrey Kocher, Amy Mentrikoski

924-8193

Children’s Fitness Clinic

Angela Hasemann

982-1607

Diabetes

Amy Mentrikoski Barbara Goodin

924-8193 924-2665

Feeding encouragement, feeding and swallowing

Audrey Kocher

924-8193

Cystic fibrosis Barbara Goodin 924-2665


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Chapter 2 – Nutritional Assessment of Pediatric Patients

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Chapter 2

Nutritional Assessment of Pediatric Patients Assessment of the nutritional status of pediatric patients while in the hospital setting is important for identifying the goals of nutritional intervention, increasing the quality of care and diagnosing malnutrition. Nutritional status can be determined by the assessment of body weight, growth, adipose tissue, skeletal muscle, visceral protein stores and cellular immune function (1, 2). Components of a thorough nutritional assessment include (1, 2): 1. Growth assessment and anthropometric measurements 2. Medical, developmental, social and personal history 3. Nutritional intake history and history of food allergies 4. Laboratory evaluation of biochemical and metabolic changes 5. Review of nutrition-focused physical examination findings 6. Educational needs and potential barriers to learning

Growth and Anthropometric Measurements

Growth of infants, children, and adolescents from birth through 20 years of age is evaluated routinely. World Health Organization (WHO) growth standards should be used for children aged 0 to 2 years, and thereafter, National Center for Health Statistics (NCHS) growth curves should be used until 20 years of age (Appendix A). Growth charts exist for each gender. Knowledge of parental height and weight can also be important in growth assessment to gauge genetic potential. Growth charts are used to evaluate the following anthropometric measurements:

Recumbent length (<2 years of age) or standing height (> 2 years) for age

Weight for age

Weight for height

Head circumference for children under the age of 3 years

BMI for 2-20 years

Weight for age serves as a valuable indicator of overall nutritional status. Underweight for age may indicate acute malnutrition. A deficit in height or length usually indicates chronic undernutrition and growth failure. Weight for height assesses body weight in proportion to height and distinguishes wasting from dwarfism (1, 2).

Specialized growth charts are available for specific disease states such as Down syndrome (Appendix B).


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Additional Anthropometric Measurements (1, 2) Other anthropometric measurements which may be used to evaluate more precise aspects of a child’s nutritional status include:

Triceps Skinfold (TSF): a measurement of a double layer of skin and subcutaneous fat on the back of the upper arm which reflects subcutaneous fat stores. This measurement is taken using a tape measure and calipers, locating the midpoint between the acronium and olecranon processes and using the caliper jaws to grasp the skin and subcutaneous tissue 1 cm above the midpoint (3). To maintain consistency when evaluating the TSF and mid arm circumference (MAC) values for a given patient, the same individual should complete the measurement over the evaluation period and take three serial measurements during each assessment. See Appendix C for percentile tables to interpret measured values.

Midarm Muscle Circumference (MAMC): an index of lean muscle mass calculated from the MAC and TSF using the following equation (3) (see Appendix D for percentile tables):

MAMC (mm) = MAC (mm) - 3.14 x TSF (mm)

Body Mass Index (BMI): the preferred measure of adiposity which is expressed as weight in kg/height in meters

2. BMI provides a more reliable measure of fatness

than triceps skinfold thickness.

Pediatric Obesity Assessment (3 – 5)

The classification system for pediatric overweight/obesity is most commonly evaluated using BMI as follows for children (over 2 years of age) and adolescents (3):

Obesity: BMI 95th

%-ile for age and gender

Overweight: BMI 85th

- 94th

%-ile for age and gender

Refer to the BMI for age percentile charts developed by NCHS (Appendix A).

Growth Velocity The best indicator of a child’s long-term nutritional status is how fast he or she is growing. Consequently, growth velocity is an especially sensitive indicator which requires periodic evaluation (2). Deviations from a child’s normal growth pattern should be noted, especially an increase or decrease across 2 standard deviations or measurements plotting below the 5th %-ile or above the 95

th %-ile (3). It is important

to note, however, that approximately 2/3 of all children do cross growth curves in the first 2 years of life due to genetic reasons. The following parameters (Tables 2.1, 2.2, and 2.3) reflect growth velocity of normal term infants and children and are useful in making adjustments in nutrition goals (2).


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Table 2.1 Normal Weight Gain Velocity for Children 0 - 36 Months*

Age (months) Male (g)/day Female (g)/day

1 - 3 31 24

3 - 6 20 20

6 - 9 25 15

9 - 12 12 11

12 -15 8 8

15 - 36 6 6

* Infants and children with a history of failure to thrive, who are experiencing catch-up growth, may demonstrate weight gain at 150-200% of normal.

Table 2.2 Normal Weight Gain Velocity for Children Ages 3 -13 Years (6)*

Age (yr) g/month

2 - 7 38

7 - 9 56 - 62

9 -11 66 - 77

11 -13 85 - 110 * Based on 50th %-ile, height and weight, NCHS Growth Charts

Table 2.3 Normal Linear Growth Velocity for Children Birth – 10 Years (2)

Age Length (cm/month)

Birth to 3 months 2.6 - 3.5

3 - 6 months 1.6 - 2.5

6 - 12 months 1.2 - 1.7

1 - 3 years 0.7 - 1.1

4 - 6 years 0.5 - 0.8

7 - 10 years 0.4 - 0.6

Infants: Measure length weekly or biweekly. Toddlers: Measure height monthly. Head Circumference (7): From birth up to 12 months of age: 0.5 - 0.8 cm/wk


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Assessment of Malnutrition (1, 2, 8)

Weight is a good indicator of acute and chronic nutritional status and may be used to assess a pediatric patient’s degree of malnutrition. Weight may be classified as a percent of standard using the following equation:

th

actual weight measure% standard

expected weight measure (50 % ile) *

* 50

th %-ile for age or 50

th %-ile wt/ht if the child was premature.

The Waterlow criteria (Table 2.4) can be used to assess the degree of both acute and chronic malnutrition (9). It is important to realize, however, that chronic diseases, such as renal failure, may affect linear growth independent of nutrition status; in these cases, the Waterlow criteria may not apply for determination of chronic malnutrition.

Table 2.4 Waterlow Criteria to Assess Malnutrition Status (9)

Acute

(wt/50% wt for ht)

Chronic

(ht/50% ht for age)

Stage 0 >0.90 >0.95

Stage 1 (mild malnutrition) 0.80 - 0.90 0.90 - 0.95

Stage 2 (moderate malnutrition) 0.70 - 0.79 0.85 - 0.89

Stage 3 (severe malnutrition) <.70 <0.85

Clinical Assessment of Malnutrition

Although growth assessment is most commonly used for assessing nutritional status in children, in advanced stages of malnutrition children will exhibit physical signs and symptoms indicative of specific nutrient deficiencies. Table 2.5 reviews common clinical changes which may become evident with prolonged malnutrition in children.


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Table 2.5 Clinical Assessment of Malnutrition in Children: Physical Signs

of Nutrient Deficiency (10)

Physical Sign Nutrient Deficiency

General appearance: edema, muscle wasting, decreased subcutaneous fat, growth failure

Protein, calories

Hair: dull, dry, may be thin and sparse, easily pluckable; color changes

Protein, calories

Skin: Dry and flaky, follicular hyperkeratosis, dyspigmentation, petechiae, pellagrous dermatosis

Vitamin A, protein, niacin, Vitamin C, riboflavin, vitamin B6 Essential fatty acids

Eyes: Pale and dry membranes, or red and inflamed membranes, Bitot’s spots, corneal xerosis (dull & hazy) or scarring, cracking in the corners of eyes

Vitamin A, iron, folate

Lips: Redness and swelling, angular stomatitis Niacin, riboflavin, vitamin B6

Tongue: Swelling (glossitis), raw tongue, magenta or purplish in color, smooth tongue, sores

Riboflavin, niacin

Teeth and Gums: May be missing teeth, bad color and visible decay or cavities, spongy, swollen and bleeding gums, recession of gums

Fluoride, Vitamin C

Cardiovascular system: tachycardia, enlarged heart, abnormal heart rate or rhythm

Potassium, selenium, phosphorus, thiamine

GI System: spleen or liver enlargement, GI dysfunction

Protein, calories

Adapted from: Isaacs, J, Cialone, J, Horsley, et al. Children with Special Health Care Needs: A Community Nutrition Pocket Guide, 1997.

Medical History A complete nutritional assessment should include information on the following (2):

Past medical history including recent hospitalizations

Review of systems and history of allergies

Personal and social history

Presence of chronic illness such as congenital heart disease, cystic fibrosis, kidney disease, short bowel syndrome, and bowel atresias

Previous growth pattern via examination of growth charts


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Recent surgeries, other deterioration in medical condition or procedures impacting nutritional intake, status and management

Medications

Gestational age (for children < 3 years)

Identification of low and very low birthweight infants

Achievement of developmental milestones

Presence of congenital abnormalities or genetic errors

Nutritional Intake History Dietary history may be obtained by the following (2):

Twenty-four hour recall

Three day food intake

Food frequency questionnaire

General interview The following should be assessed:

For all infants: o type of formula, brand name o formula preparation (including water source) and storage o addition of substances other than water i.e. rice cereal, Karo syrup o volume and frequency of feedings o other beverage intake i.e. water, Kool-aid, tea and soda o solid food intake and texture progression o history of formula changes o history of emesis and/or diarrhea o stooling frequency and consistency

For breastfed infants: o how long the infant feeds o if the infant nurses from each breast during one feeding o how frequently the infant nurses o appearance and frequency of stools o number of wet diapers per day

For older infants and children: o family eating patterns, cooking & storage o vitamin and mineral supplementation o history of food allergy/intolerances and/or loose stools o evaluation of oral motor skills, feeding patterns, history of fatigue and/or

increased respiratory rate while feeding (Appendix E – Developmental Self-Feeding Checklist)

o interaction during feeding o self-imposed diets and outcomes; assessment of child’s own body image o supplemental feeding programs (WIC, food stamps)


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Laboratory Data (2, 11)

Various laboratory values are useful in the assessment of a patient’s nutritional status. Table 2.6 summarizes lab values that are most often used for the nutritional assessment of pediatric patients. A more complete list of other labs with nutrition related implications may be found in Appendix F.

Table 2.6 Laboratory Assessment of Nutritional Status

LAB PARAMETER INTERPRETATION OF VALUES POTENTIAL CAUSES FOR:

High Values Low Values

Prealbumin

used to assess protein status

sensitive indicator of recent protein nutriture

Half life: 2-3 days

Preterm: 9-33 mg/dl Term: 11-34 mg/dl Older Children: 20-50 mg/dl

Dehydration Steriods ( i.e. Prednisone)

Acute protein malnutrition Trauma & Stress Infection Chronic liver disease Aggressive hydration Metabolic liver disease

Transferrin


synthesized in the liver to carry iron in the blood; also acts as an acute phase reactant

Half life: 8-10 days

Preterm: 140-370 mg/dl Term: 200-370 mg/dl Older Children: 180-260 mg/dl

Iron deficiency Hypoxia Chronic blood loss Stress

Impaired synthesis Protein malnutrition Chronic infection Chronic liver disease Protein-losing enteropathies

Albumin


poor indicator of early protein depletion due to large body pool

Half life: 15-20 days

Preterm: 2.5-4.5 g/dl Term: 2.5-5.0 g/dl 1-3 mo.: 3.0-4.2 g/dl 3-12 mo.: 2.7-5.0 g/dl > 1 year: 3.2-5.0 g/dl

Dehydration

Protein malnutrition Impaired digestion or absorption of protein Excessive protein losses Chronic liver disease Advanced malignancies Hypervolemic dilution Chronic infection Aggressive hydration Nephrotic syndrome


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References

1. American Academy of Pediatrics. Committee on Nutrition. Assessment of nutrition status. In: Pediatric Nutrition Handbook. 2004:407-423.

2. Bessler S. Nutritional assessment. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3

rd edition. Sudbury, MA: Jones and Bartlett Publishers Inc;

2005:11-34. 3. Spears B. Childhood obesity. In: Samour PQ, King K, eds. Handbook of Pediatric

Nutrition. 3rd

edition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:181-212.

4. Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007; 120(S4): S164-192.

5. American Academy of Pediatrics. Committee on Nutrition. Pediatric obesity. In: Pediatric Nutrition Handbook. 2004:551-592.

6. Schwenck WF, Olson D. Pediatrics. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:347-372.

7. Katrine KF. Anthropometric assessment. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:11-22.

8. American Academy of Pediatrics. Committee on Nutrition. Failure to thrive. Pediatric Nutrition Handbook. 2004:443-457.

9. Waterlow JC. Classification and definition of protein calorie malnutrition. In: Beaton

G, Bengoa X, eds. Nutrition in Preventive Medicine. WHO monograph series (62); Geneva: WHO; 1976.

10. Miles A, Reed G. Feeding challenges in children with neurologic impairment.

Support Line. 2004;26(2):16-23.

11. Moyer-Mileur L. Laboratory assessment. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds. Nutritional Care for High Risk Newborns. Chicago, IL: Precept Press; 2000:47-54.

Chapter 3 Nutritional Requirements in Term Infants and Children

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Chapter 3

Nutritional Requirements in Term Infants and Children The first step in providing infants and children who are established to be at nutritional risk with the most appropriate nutrition intervention is to assess actual requirements. Nutritional needs are highly individualized and vary widely, particularly with activity and disease.

Non-Critically Ill Infants and Children The following tables review the range of enteral and parenteral nutrient requirements for term infants (1, 2).

Table 3.1 Estimated Caloric, Protein, and Fluid Needs of Term Infants for

Enteral and Parenteral Nutrition

Infant

Condition/Disease

Enteral Parenteral

Calories (kcal/kg)

Protein (g/kg)

Fluid (ml/kg)

Calories (kcal/kg)

Protein (g/kg)

Well-Nourished

Term/ AGA 90-110 2.0-3.0 150-200 85-110 2.5-3

BPD or CHD 120-150 3.0-4.0 120-130 90-130 2.5-3.5

Well-Nourished Term/AGA = Appropriate for Gestational Age (10-90th %-ile on growth chart for weight for age)

BPD = Bronchopulmonary Dysplasia CHD = Congenital Heart Disease

Dietary Reference Intakes Dietary Reference Intakes (DRIs) expand on and replace the Recommended Dietary Allowances (RDAs) last published in 1989. DRIs consist of 4 categories (3):

Estimated Average Requirement (EAR): the average daily nutrient intake level estimated to meet the requirement of half the healthy individuals in a particular life stage and gender group.

Recommended Dietary Allowance (RDA): the average daily dietary nutrient intake level sufficient to meet the nutrient requirement of nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group.

Adequate Intake (AI): the recommended average daily intake level based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate—used when an RDA cannot be determined.


18

Tolerable Upper Intake Level (UL): the highest average daily nutrient intake level that is likely to pose no risk of adverse health effects to almost all individuals in the general population. As intake increases above the UL, the potential risk of adverse effects may increase.

Energy

None of the above 4 DRI categories are used to describe estimated needs for energy; instead, the Estimated Energy Requirement (EER) is used. This is defined as the average dietary energy intake that is predicted to maintain energy balance in adults and energy deposition (i.e., weight gain and growth) for infants and children (4). Prediction equations for normal weight individuals were developed from data on total energy expenditure (TEE) measured by the doubly labeled water technique. Equations for infants and toddlers are based on weight and estimated needs for energy deposition. Equations for children and adolescents are based on height, weight, age, physical activity level (ranging from sedentary to high activity) and also take into account needs for energy deposition (4). Table 3.2 presents the EER values for infants and children; data for infants and toddlers are based on reference weights (normal weights for various ages), and data for older children and adolescents are based on reference weights and heights and physical activity levels corresponding to sedentary or low activity. For the development of calorie ranges, sedentary and low activity levels were chosen for physical activity coefficients instead of active or very active levels due to the thought that hospitalized children will not have high activity levels. Published EER formulas and physical activity coefficients are available in Appendix G and can be used to calculate more individualized needs, if necessary.

Overweight Children (4)

In general, for children who are overweight or obese, a goal weight loss of 1 pound per month might be reasonable. The general goal for children who are at overweight or obese is weight maintenance with the hope that BMI will improve as linear growth continues. See Appendix G for formulas to estimate energy needs in overweight children.


19

Protein

The recommended intakes of protein for infants 0-6 months of age are based on an Adequate Intake (AI) that reflects the observed mean protein intake of infants fed principally with human milk. For older infants and children, the RDA is determined using data available from nitrogen balance studies, measurement of the rates of protein deposition for growth, and estimates of efficiency of protein utilization (3). Table 3.2 reflects the DRIs for protein for various age groups.

Fiber

No DRIs exist for fiber for infants 0-12 months of age. This is because the gold standard for feeding infants 0-6 months of age is breast milk, and breast milk contains no dietary fiber. For infants 7-12 months of age, there are no data on dietary fiber intake and, according to published information, no theoretical reason to establish a DRI for fiber. Dietary fiber recommendations for children ages 1-18 years are based on data extrapolated from adult studies that show that 14 grams of fiber per 1000 calories reduces risk of coronary heart disease (3).

Table 3.2 Estimated Energy, Protein, and Fiber Requirements

for Infants and Children (4-6)

* Protein requirements for hospitalized children may vary significantly based on clinical condition.

ND = not determined

Micronutrients

Although clinical signs of vitamin and mineral deficiency are rare in the United States, dietary intake studies have reported that the nutrients most likely to be low or deficient in the diets of children and adolescents are calcium, iron, ascorbic acid, vitamin A, folic acid, and vitamin B6. Certain populations of children, such as low-income, Native American,

Age Energy (kcals/kg)

Protein* (g/kg)

Fiber (g/day)

Males Females Males Females

Infants 1-3 months 95-107 1.52 ND

4-6 months 82-83 1.52 ND

7-12 months 79-82 1.2 ND

Toddlers 1-3 years 81-83 1.05 19

Children 3-4 years 75-93 72-89 0.95 25

5-6 years 64-80 62-77 0.95 25

7-8 years 57-70 53-66 0.95 25

9-10 years 50-62 45-57 0.95 31 26

11-12 years 44-55 39-49 0.95 31 26

Adolescents 13-14 years 41-50 35-43 0.85 31 26

15-16 years 38-47 32-40 0.85 38 26

17-18 years 35-43 30-37 0.85 38 26


20

and other groups with limited food and health resources, are more at risk for nutrient deficiencies.

Table 3.3 Dietary Reference Intakes: Recommended Dietary Allowance for Vitamins

for Infants and Children (7)

Age

(years)

Fat-Soluble Vitamins

Water-Soluble Vitamins

Vit A

(g)

Vit D (IU)

Vit E (mg)

Vit K

(g)

Vit C (mg)

Thiamin (mg)

Ribo-

flavin (mg)

Niacin (mg)

Vit B6 (mg)

Folate

(g)

Vit B12

(g)

Infants 0-6 mo. 400 400 4 2.0 40 0.2 0.3 2 0.1 65 0.4

7-12 mo. 500 400 5 2.5 50 0.3 0.4 4 0.3 80 0.5

Children 1-3 300 600 6 30 15 0.5 0.5 6 0.5 150 0.9

4-8 400 600 7 55 25 0.6 0.6 8 0.6 200 1.2

Males 9-13 600 600 11 60 45 0.9 0.9 12 1.0 300 1.8

14-18 900 600 15 75 75 1.2 1.3 16 1.3 400 2.4

Females 9-13 600 600 11 60 45 0.9 0.9 12 1.0 300 1.8

14-18 700 600 15 75 65 1.0 1.0 14 1.2 400 2.4

Values in bold type presents Recommended Dietary Allowances (RDAs), while Adequate Intakes (AIs) are in ordinary type.

Vitamin A: 1 g Retinol = 1 RE; 0.3 RE = 1 IU

Table 3.4 Dietary Reference Intakes: Recommended Dietary Allowances for Selected

Minerals in Infants and Children (7)

Age

(years)

Calcium (mg)

Phosphorus (mg)

Magnesium (mg)

Selenium

(g)

Iron (mg)

Zinc (mg)

Iodine

(g)

Copper

(g)

Infants 0-6 mo. 200 100 30 15 0.27 2 110 200

7-12 mo. 260 275 75 20 11 3 130 220

Children 1-3 700 460 80 20 7 3 90 340

4-8 1000 500 130 30 10 5 90 440

Males 9-13 1,300 1,250 240 40 8 8 120 700

14-18 1,300 1,250 410 55 11 11 150 890

Females 9-13 1,300 1,250 240 40 8 8 120 700

14-18 1,300 1,250 360 55 15 9 150 890

Values in bold type presents Recommended Dietary Allowances (RDAs), while Adequate Intakes (AIs) are in ordinary type.

Vitamin and Mineral Supplementation

Breastfed term infants are recommended to take in vitamin supplements, as recommended in Table 3.5, primarily to ensure adequate vitamin D intake. Additionally, term infants who are fluid restricted or consistently unable to take in 750 ml of formula per day should also receive a pediatric multivitamin supplement. Appendix J contains information on various pediatric multivitamin supplements and their micronutrient contents.


21

Table 3.5 Recommendations for Vitamin Supplementation in the Term Infant

Formula Currently Receiving Supplementation needed per day

Breast milk (initiate as soon as possible after birth)

1 ml/day of vitamin D or multivitamin drops (consider changing to iron-containing supplementation at 4-6 months of age, depending on iron content of complementary foods)

Term Formula – with intake less than 750 ml per day

0.5 - 1 ml/day of vitamin D or multivitamin drops (consider changing to iron-containing supplementation at 4-6 months of age, depending on iron content of complementary foods)

Formulations “with iron” do not contain folic acid; this may need to be supplemented separately.

Fluoride supplementation is only indicated after 6 months of age when (8): 1. “Ready-to-feed” formula is used 2. Formula concentrate or powder is mixed with non-fluoridated bottled water 3. Local tap water is < 0.6 parts per million (ppm) 4. Baby is breast fed past 6 months

Table 3.6 Recommendations for Fluoride Supplementation in Infants and

Children (8)

Water Fluoride (ppm) 6 mo. – 3 yr. 3 – 6 yr. 6 – 16 yr.

< 0.3 0.25 mg 0.50 mg 1.0 mg

0.3 – 0.6 0 0.25 mg 0.50 mg

> 0.6 0 0 0

Examples of fluoride-containing liquid drops (see Appendix J for details):

Poly-Vi-Flor and Tri-Vi-Flor (Mead Johnson) contain 0.25 mg fluoride per 1 ml

Pediaflor (Abbott) contains 0.25 mg fluoride per 0.5 ml


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Critically Ill Children The nutritional requirements of critically ill children are often quite different from the EERs for a variety of reasons. Depending on the extent or type of injury or illness, the medications being used to manage the patient or the presence or degree of previously existing malnutrition, calorie or protein requirements may be elevated or even decreased in the critically ill pediatric patient (9, 10).

The following table reviews factors, which may increase or decrease nutrient requirements.

Table 3.7 Factors Affecting Calorie and Protein Requirements in

Critically Ill Children

Increasing Requirements Decreasing Requirements

Trauma Surgery Sepsis Fever Tumor Burns Athetoid CP, Hypertonia Seizures Spinal Cord Injury (acute) Increased Work of Breathing Weaning from Ventilator Sustained Agitation

Lack of activity / Bed rest Mechanical ventilation Medical sedation Medical paralysis Hypotonia, Spastic CP Reduced Insensible losses Hypothyroid condition

Studies in critically ill pediatric patients have demonstrated the importance of not using standard EER calorie calculations to calculate energy requirements as these are meant for healthy, active children. Instead, using the patient’s basal energy needs and multiplying it by a corrective stress factor provides an appropriate estimated of energy needs (9).

Determining total caloric and protein needs during critical illness:

1. Estimate basal energy needs (caloric requirements, post- absorptive, recumbent, and at room temperature - Table 3.8)

2 Estimate patient’s protein requirements (RDAs - Table 3.2)

3. Determine patient’s stress factor (Table 3.9)

Total Calories = BEE x Stress Factor Total Protein = Protein RDA x Stress Factor

4. Continue to evaluate and adjust recommendations based on response (weight

gain or weight loss)


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Table 3.8 Basal Energy Needs for Infants and Children (9)

Adolescents

Alternatively, Harris and Benedict Equation may be more appropriately used in adolescents for determination of basal energy expenditure (BEE): For men: BEE = 66 + (13.7 x ideal wt. in kg) + (5 x height in cm) – (6.8 x age in years) For women: BEE = 655 + (9.6 x ideal wt in kg) + (1.7 x height in cm) – (4.7 x age in years)

Table 3.9 Determining Stress Factor (9, 10)

Clinical State Stress Factor

Maintenance without stress Fever Routine surgery, minor sepsis Cardiac failure Elective Surgery Major surgery Sepsis Major Trauma Burns

1.0 - 1.2 12% per degree >37

o

1.1 - 1.3 1.25 - 1.5 1.0 - 1.2 1.2 -1.4 1.4 -1.8 1.5 - 1.7 1.5 - 2.0

Age 1 wk to 10 mo Age 11 to 36 mo Age 3 to 16 yr

Weight

(kg) Metabolic Rate

(kcal/day)

Weight

(kg)

Metabolic Rate (kcal/day)

Weight (kg)

Metabolic Rate (kcal/day)

Male or Female

Male Female Male Female

3.5 202 9.0 528 509 15 859 799

4.0 228 9.5 547 528 20 953 898

4.5 252 10.0 566 547 25 1046 996

5.0 278 10.5 586 566 30 1139 1092

5.5 305 11.0 605 586 35 1231 1190

6.0 331 11.5 624 605 40 1325 1289

6.5 358 12.0 643 624 45 1418 1387

7.0 384 12.5 662 646 50 1512 1486

7.5 410 13.0 682 665 55 1606 1584

8.0 437 13.5 701 684 60 1699 1680

8.5 463 14.0 720 703 65 1793 1776

9.0 490 14.5 739 722 70 1886 1874

9.5 514 15.0 758 741 75 1980 1973

10.0 540 15.5 778 760

10.5 566 16.0 797 782

11.0 593 16.5 816 802


24

Prevention and Complications of Overfeeding (11) In many cases, critically ill children in the Pediatric Intensive Care Unit (PICU) have caloric requirements at 60-80% of the EERs due to inhibited growth, reduced resting energy expenditure, reduced insensible losses, medications and decreased activity. Overfeeding involves the provision of calories and/or substrate in excess of the requirements to maintain metabolic homeostasis. From a clinical standpoint, the harmful effects of overfeeding may result in respiratory compromise, hepatic dysfunction, and an increased risk of mortality. Complications of overfeeding:

1. Excessive CO2 production 2. Increased minute ventilation (VE) 3. Respiratory failure 4. Pulmonary edema 5. Hyperglycemia 6. Lipogenesis (increased insulin, decreased fatty oxidation) 7. Hepatic cellular injury (increased serum conc. of liver enzymes) 8. Fatty liver 9. Intrahepatic cholestasis 10. Immunosuppression

Catch-Up Growth in the Term Infant and Child (12)

Children who are below normal growth parameters due to chronic undernutrition or illness affecting their nutritional intake and status require additional calories and protein to achieve catch-up growth. During this phase of growth recovery, a child may grow at rates well above the norm for his or her age.

EER* (kcal/kg) for weight age** x Ideal weight (kg)***Catch-up calories (kcal/kg) =

Actual weight

* Use EER (Table 3.2) ** Age at which present weight is at the 50

th %-ile

*** 50th

%-ile for age or ideal body weight for height

Grams of Protein/Kg = 8% of catch-up growth calories

catch-up growth (kcal/kg) x 0.08

Protein catch-up calories = 4


25

Energy Requirements for Pediatric Burn Patients (13, 14)

Daily metabolic expenditure of burn patients can be estimated by numerous formulas, predicted on data obtained from adults, but altered for children addressing their metabolic differences. Clinicians may choose to use several of the following formulas in order to develop a range of calories for individual patients.

Table 3.10 Selected Formulas for Calculating Energy Requirements of Burned

Children

* See Table 3.8 for estimations of basal energy needs

** BSA = body surface area (total), calculated as: ht [cm] x wt [kg]

3600

Fluid Requirements

Fluid requirements can be calculated by estimating normal water requirements adjusted for specific disease related factors. However, special consideration must be given to monitoring fluid balance of infants and children receiving high calorie, high nitrogen formulas, those who have severe neurological impairment or those with emesis, diarrhea, fever, or polyuria. In order to prevent dehydration and ensure adequate provision of fluids during the administration of enteral and parenteral nutrition, use Table 3.11 to assess fluid needs.

Table 3.11 Daily Fluid Maintenance Requirements

Weight (kg) Maintenance Fluid

Requirements

Fluid Requirements to Meet

Calorie and Nutrient Needs

2.0-3.0 120 ml/kg/day 150 – 180 ml/kg

3.0-10.0 100 ml/kg/day 140 – 165 ml/kg

11-20

1,000 ml plus 50 ml/kg for each kg > 10 kg

Use maintenance fluids

Above 20 1,500 ml plus 20 ml/kg for each kg > 20 kg

Use maintenance fluids

Formula

Name/Authors

Age % BSAB Calories/Day

Davies and

Liljedal

Child Any (60 kcal x weight [kg]) + (35 kcal x % burn)

Curreri Junior 0-1 years <50 Basal* + (15 kcal x % burn)

1-3 years <50 Basal* + (25 kcal x % burn)

4-15 years <50 Basal* + (40 kcal x % burn)

Hildreth 0-1 years (2100 kcal/m2 BSA**) + (1000 kcal/m2 burn)

<12 years (1800 kcal/m2 BSA**) + (1300 kcal/m2 burn)

12-18 years (1500 kcal/m2 BSA**) + (1500 kcal/m2 burn)


26

References

1. American Academy of Pediatrics. Committee on Nutrition. Protein. In: Pediatric Nutrition Handbook. 2004:29-240.

2. American Academy of Pediatrics. Committee on Nutrition. Energy. In: Pediatric Nutrition

Handbook. 2004:241-259.

3. Institute of Medicine. Food and Nutrition Board. Energy: Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). 2005:21-37.

4. Institute of Medicine. Food and Nutrition Board. Energy: Dietary Reference Intakes for energy,

carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). 2005:107-264.


carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). 2005:2005:589-768.


carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). 2005:2005:339-421.

7. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes. Available

at:http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf.

8. American Academy of Pediatrics. Committee on Nutrition. Nutrition and oral health. In:

Pediatric Nutrition Handbook, 6th ed. 2009:1041-1056.

9. Canete A, Duggan C. Nutrition support of the pediatric intensive care unit patient. Curr Opin

Pediatr. 1996;8:248-255.

10. Iyer P. Nutritional support in the critically ill child. Indian J Pediatr. 2002;69:405-410.

11. Chwals WJ. Overfeeding the critically ill child: fact or fantasy? New Horiz. 1994;2:147-155.

12. Peterson KE, Washington J, Rathburn JM. Team management of failure to thrive. J Am Diet Assoc. 1984;84(7):810.

13. Gottschlich MM, Mayes T. Nutrition in the burned pediatric patient. In: Samour PQ, King K,

eds. Handbook of Pediatric Nutrition. 3rd edition. Sudbury, MA: Jones and Bartlett Publishers

Inc; 2005:483-498.

14. Rodriguez DJ. Nutrition in patients with severe burns: state of the art. J Burn Care Rehabil. 1996;17:62-70.

http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf

http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf

Chapter 4 Nutritional Assessment, Requirements and Enteral Nutrition Management in the Preterm Infant

27

Chapter 4

Nutritional Assessment, Requirements and Enteral

Nutrition Management in the Preterm Infant

Preterm infants are a challenge to manage nutritionally due to their complicated medical treatment course, immature physiology, and numerous complications, which can delay progression of enteral nutrition. Potential difficulties in providing adequate nutritional support include respiratory instability, drug therapy, fluid restriction, predisposition to necrotizing enterocolitis (NEC) and immature renal and gastrointestinal systems (1).

Preterm Infant Weight Classification and Assessment (2) Preterm infants, those born less than 37 weeks, are frequently placed at higher risk for impaired nutrition due to reduced stores, GI immaturity, and metabolic and/or digestive deficiencies. Infants may be classified as the following:

Low Birth Weight (LBW): Less than 2500 g

Very Low Birth Weight (VLBW): Less than 1500 g

Extremely Low Birth Weight (ELBW): Less than 1000 g

Assessment of Intrauterine Growth (2) Premature infants’ rate of weight gain may be compared to infants of similar gestational age using the following growth charts:

Lubchenco growth charts: intrauterine growth curves often used to classify the infant’s size at birth; fail to account for normal postnatal weight loss and differences in rates of weight gain among different populations.

Dancis growth curves: postnatal daily growth curves; reflect early postnatal weight loss related to fluid changes, but in general may not reflect ideal growth of the preterm infant. The Dancis grid is useful for monitoring growth trends and initially, changes in hydration status.

Fenton or updated Babson growth charts (Appendix A): intrauterine growth curves; SGA and LGA are defined as two standard deviations from the mean birth weight. The Babson charts are useful in the assessment of weekly premature infant growth through the first year of life.

Small for Gestational Age (SGA): Birth weight < 10th

%-ile

Appropriate for Gestational Age (AGA): Birth weight 10th

-90th

%-ile

Large for Gestational Age (LGA): Birth weight > 90th

%-ile


28

SGA infants are at greater nutritional risk due to decreased nutritional reserves, increased nutritional requirements to allow for rapid catch-up growth, and frequently a lack of functional maturity such as absent suck and swallow, and delayed gastric emptying. LGA infants are common in mothers with diabetes. Frequent complications seen in LGA infants include hypoglycemia and birth trauma. Correcting for Prematurity Growth of premature infants should be adjusted to reflect gestational age; weight should be corrected until the child is 24 months of age, length until 36 months of age, and head circumference until 18 months of age (2). Generally, correction for all 3 parameters up to 24 months of age is appropriate.

Growth Velocity in Preterm Infants (2) Preterm infants, once having regained their birth weight and stable from both a respiratory and clinical standpoint should approach intrauterine growth rates between 15-20 g/kg/day, averaged over a minimum period of 5-7 days. Average rate of weight gain over days to weeks is more important than single 1 or 2 day measurements, which can reflect changes in fluid status or equipment differences. Weight gain based on intrauterine growth averages 10-20 g/day for infants <27 weeks and 20-35 g/day for infants 27-40 weeks gestation.

Weight Gain Goal AGA (Appropriate for Gestational Age):

15-20 g/kg/day

SGA (Small for Gestational Age): 20 - 25 g/kg/day

When infants are > 2 kg, it is more appropriate to aim for weight gain of 20-40 g/day, no

longer adjusting per kg.

Assessment of linear growth with incremental gains in length and head circumference should also be monitored. As with weight gain, once preterm infants are stable from a respiratory and clinical standpoint, linear growth should proceed optimally at intrauterine rates. Length

should be measured weekly in the preterm infant. Length gain should average between

3.2 – 4.4 cm per month, or about 0.75 – 1 cm per week. Head circumference increase

should average 2-3 cm per month, or 0.5-0.7 cm/week.

Micronutrient and Macronutrient Requirements Tables 4.1 and 4.2 review the range of enteral calorie, protein and micronutrient requirements for preterm infants (3).


29

Table 4.1 Estimated Enteral Caloric, Protein, and Fluid Needs in the Preterm Infants

Infant

Condition/

Disease

Enteral Parenteral

Nutrient Calories

(kcal/kg)

Protein

(g/kg)

Fluid

(ml/kg)

Calories

(kcal/kg)

Protein

(g/kg)

Fluid

(ml/kg)

AGA

105-130 3.0-4.0 150-200 90-100 3.0-4.0 120

SGA or

ELBW

120-140 3.5-4.5 150-200 95-105 3.5-4.0 120-130

BPD, CHD,

or CLD

120-150 3.0-4.0 120-135 90-105

3.0-4.0 100-120

AGA = Appropriate for Gestational Age (10-90th %-ile on growth chart for weight for age)

SGA = Small for Gestational Age (<10th %-ile on growth chart for weight for age)

BPD = Bronchopulmonary Dysplasia CHD = Congenital Heart Disease CLD = Chronic Lung Disease

Growth measurements to monitor adequacy of intake include

daily weight (goal = 15-20 g/kg/day if < 2 kg; 20-40 g/day if > 2 kg)

weekly length (goal = 0.75-1.0 cm/week since birth)

head circumference (goal = 0.5-0.7 cm/week since birth)

Table 4.2 Enteral and Parenteral Vitamin and Mineral Needs in Preterm Infants (3, 4)

VITAMINS MINERALS

Enteral Parenteral Enteral Parenteral

Vitamin A 700-1500 IU/kg 700-1500 IU/kg Calcium 120-230 mg/kg 50-80 mg/kg

Vitamin D 400 IU/day (200-1000)

1.5 – 10 ug/kg Phosphorus 60-140 mg/kg 40-60 mg/kg

Vitamin E 6-12 IU/kg 2.8 – 3.5 IU/kg Magnesium 7.2-.9.6 mg/kg 4.3-7.2 mg/kg

Vitamin K 8-10 ug/kg 10 ug/kg Iron 2-4 mg/kg 250-670 ug/kg

Vitamin C 30-40 mg/kg 25 mg/kg Sodium 2-3 mEq/kg 3-4 mEq/kg

Thiamine 180-240 ug/kg 350 ug/kg Potassium 2-3 mEq/kg 2-4 mEq/kg

Riboflavin 250-360 ug/kg 0.15 mg (150 mcg)/kg

Chloride 2-3 mEq/kg 3-4 mEq/kg

Niacin 4.5-6 mg/kg 5-6.8 mg/kg Zinc 1000-2000 ug/kg 400 ug/kg

Vitamin B6 180-300 ug/kg 180-400 ug/kg Copper 120-150 ug/kg 20 ug/kg

Vitamin B12 0.3 ug/kg 0.3 ug/kg Manganese 0.75-7.5 ug/kg 1 ug/kg

Folic Acid 45-50 ug/kg 56 ug/kg Selenium 1.3-4.5 ug/kg 1.5-4.5 ug/kg

Pantothenic Acid 1.2-2 mg/kg 2 mg/kg Chromium 0.1-2.25 ug/kg 0..05-.3 ug/kg

Biotin 3.6-6.0 ug/kg 6-8 ug/kg Molybdenum 0.3-4ug/kg 0.25-1.0 ug/kg


30

Fluid Requirements

Fluid requirements can be calculated by estimating normal water requirements and adjusting for specific disease related factors. However, special consideration must be given to monitoring fluid balance of children receiving high calorie, high nitrogen formulas, those who have severe neurological impairment or those with emesis, diarrhea, fever, or polyuria. Fluid management of preterm infants or critically ill newborns is complex and affected by numerous factors including cardiorespiratory status, renal status, degree of prematurity and insensible losses.

In order to prevent dehydration and ensure adequate provision of fluids during the administration of enteral and parenteral nutrition, use Table 4.3 for general guidelines in the assessment of fluid needs.

Table 4.3 Daily Fluid Maintenance Requirements in the Neonate

Weight (kg) Maintenance Fluid

Requirements

Fluid Requirements For

Enteral Nutrient Needs

0.5 – 3.0 kg 100 – 140 ml/kg/day 135 – 180 ml/kg

3.0 – 10.0 kg 100 ml/kg/kg/day 125 – 180 ml/kg

Meeting the Increased Needs of the Preterm Infant Preterm infants have increased requirements for Vitamins A, D, E, C and iron. Breast milk is

the preferred feeding for preterm infants. However, breast milk does not provide

adequate protein, calcium, phosphorous, magnesium, sodium, copper, zinc, folate, B-

vitamins, and iron for infants who weigh <1500 g at birth (4). Supplementation of Breast Milk

The caloric and nutrient density of breast milk can be increased by two methods:

Method 1 - Enfamil Human Milk Fortifier or Similac Human Milk Fortifier

Method 2 - Use of Powdered Infant Formula: EnfaCare or NeoSure Breast fed preterm infants who are admitted to the PICU, are still below 2500 grams and are unable to take in 180 ml/kg will need to receive fortified breast milk using: Method 1: Enfamil or Similac Human Milk Fortifier as follows:

Table 4.4 Fortification of Breast Milk with Human Milk Fortifier

Step Fortifier Breast Milk Caloric Density Increased mOsm

1 1 packet 50 ml 22 kcal/oz 32 mOsm/kg



31

Method 2: Breast milk caloric and nutrient density for older preterm infants > 3.0 kg infants

may be increased to 24 - 30 kcal/oz according to the following:

Table 4.5 Increasing Nutrient Density of Breast Milk Using NeoSure of Enfacare

Powder

Caloric Density

(kcal/oz.)

Breast Milk Volume

(oz.)

Formula Powder

(tsp.)

Endpoint Volume

24 3 1 3 oz.

27 3 2 4 oz.

30 3 3 5 oz.

Home Fortification: Fortification with NeoSure or Enfacare powder is the preferred method for fortification at discharge as human milk fortifiers are not readily available in retail establishments. Vitamin and Mineral Supplementation

Table 4.6 Recommendations for Vitamin Supplementation in the Preterm Infant

Feeding Fluid Currently Receiving Supplementation needed per day

Plain breast milk (no fortifier) 1 ml/day multivitamin with iron

Fortified breast milk Abbott HMF: 0.5 ml/d multivitamin with iron; if total volume/day is < 240 ml, add 0.5 ml/d multivitamin, or multivitamin with iron

Fortified formula Determine if need vitamins with iron or Fer-in-sol to treat anemia. (Therapeutic range for iron deficiency anemia = 4-6 mg/kg/d)

Use of vitamin supplements, as recommended in Table 4.6, is primarily to ensure adequate vitamin D and iron intake in preterm infants.

Similac Special Care 24 Advance contains marginal vitamin D to meet daily requirements until an infant is able to take more than 400 ml/day. If a preterm infant is on Similac Special Care, rather than Enfamil Premature Lipil, vitamin D may be supplemented via the addition of 0.5 ml of a pediatric multivitamin (see Table 4.6).

For treatment of iron deficiency anemia, supplement with 4 - 6 mg/kg/day of iron.

For prevention of iron deficiency anemia, provide iron fortified formula, fortified breast milk or at least 2 mg/kg/day of iron if on Similac Human Milk Fortifier. (Enfamil Human Milk Fortifier already contains extra iron).

For preterms or fluid-restricted infants not taking at least 750 ml of a standard infant formula per day, should receive 0.5 ml of multivitamin with iron per day.


32

Preterm Formula Selection

Selection of an optimal preterm formula depends upon a number of factors including patient factors such as degree of prematurity, diagnosis, associated nutritional problems and requirements, and GI function. Important formula factors which need to be considered include higher calorie, calcium, and phosphorus intakes (1).

Table 4.7 Overview of Preterm Formulas

Formula Type Description Indications/Formulations Formula Examples

Preterm

Formulas

Formulas designed to meet the increased nutritional and altered physiological needs of preterm infants. Used for infants born < 2000 grams or < 35 weeks gestational age.

Preterm infants < 2000 grams

Partial substitution of corn syrup solids for lactose

Increased protein concentration and higher whey composition

Partial substitution of long chain fatty acids with medium chain triglycerides (MCT)

Increased caloric density: 24-30 kcal/oz

Increased concentrations of sodium, calcium, phosphorus, and vitamins (specifically D and E)

Enfamil Premature Lipil 24

(Mead Johnson)

Similac Special Care Advance 24 (Abbott)

Similac Special Care Advance 30 (Abbott)

Gerber Good Start Premature 24 (Nestle)

Transitional

Preterm

Formulas

Preterm formulas have been developed to meet the increased needs of the preterm infant during the first 9 months to 1st year of life.

Preterm infants who can tolerate ≥ 165 mL/1g/day during the 1st year of life

Increased caloric density: 22 kcal/oz

Partial substitution corn syrup solids for lactose

Partial substitution of long chain fatty acids with MCT

Increased levels of protein, vitamins & minerals compared to term formula

EnfaCare Lipil (Mead Johnson)

Similac NeoSure Advance (Abbott)

Gerber Good Start Nourish (Nestle)

Table adapted from proprietary product literature.


33

Modifying Formula Caloric and Nutrient Density Preterm infants who are critically or chronically ill may be unable to take adequate formula volume to meet their nutritional needs. Infant and pediatric formulas may be prepared differently to provide a greater caloric or nutrient density. The caloric or nutrient density of an infant or enteral feeding formula can be increased by any one or a combination of the following methods (3,5):

1. Concentration - Increasing the amount of formula base or decreasing the amount of free water added when mixing the formula. This method will increase the concentration of all formula solutes and osmolality. Similarly, adding powdered formula to ready-to-feed formula will increase total nutrient density. The addition of ½ scoop of powdered infant formula to ready-to-feed formula will generally add an additional 4 kcal/oz.

2. Supplementation - Adding a macronutrient module in order to increase caloric density without increasing all other nutrient sources. This may be accomplished through the addition of:

Carbohydrate source: Powdered Polycose (Abbott), or Karo syrup

Fat source: Microlipid (Nestle), vegetable oil, or MCT oil (Nestle)

Protein source: Resource Beneprotein (Nestle)

Combined carbohydrate and fat source: Duocal (Nutricia)

Guidelines for Using Concentrated and High Nutrient Density Formulas

In general, formulas for use in infants should not be concentrated through the reduction of free water to a density greater than 27 kcal/oz as these preparations may not meet their free water needs.

Increases in formula caloric density should be done gradually by 2 – 3 kcal/oz to ensure patient tolerance.

Infants with gastroesophageal reflux (GER) may experience aggravated reflux with concentrated preparations. These infants may do better with the addition of additives such as Polycose or infant cereal.

Infants with renal insufficiency may need to have their formula caloric densities increased through the use of additives alone to prevent excessive increases in renal solute load.

Infants on concentrated formulas should be monitored closely for frequency of urination and urine specific gravity to ensure adequate fluid intake.

Excessive formula concentration may also result in diarrhea, dehydration or conversely, constipation.

Parents should be appropriately instructed on formula preparation prior to discharge from the hospital.

Modules may or may not be readily available outside the hospital; discharge needs should be considered.

Preterm infants > 1800 g or tolerating 165 mL/1g/day should be discharged home on preterm formula Neosure or EnfaCare (22 kcal/oz).


34

Enteral Feeding Recipes for the NICU Infant

The following tables provide recipes for increasing formula caloric density to more adequately meet the requirements of infants with increased nutritional needs.

Table 4.8 Preparation of Enfacare or Neosure Formula at Various Caloric

Concentrations

Caloric Density

(kcal/oz)

Formula Powder

and water (ml)

Ready to Feed and

Formula Powder

Approximate

Yield (ml)

22 4 scoops + 240 ml 240 ml 240 ml

24 4 scoops to 215 ml 240 ml + ½ scoop 240 ml

27 4 ½ scoops + 215 ml 240 ml + 1 scoop 240 ml

30 5 scoops + 215 ml 240 ml + 1 ½ scoops 250 ml

Table 4.9 Increasing the Caloric and Nutrient Density of Transitional Preterm Formula

EnfaCare through Supplementation with Powder

Caloric Density EnfaCare or Similac

Neosure - fluid oz

EnfaCare or Neosure

Powder

24 kcal/oz 5 1 teaspoon

26 kcal/oz 3 1 teaspoon

Table 4.10 Recipes for Preterm Infants

Formula

(kcals/oz)

Base

Component

Additive Recipe Volume

Premature 27 Premature 24 –80% ratio

Term Concentrate 20% ratio

200 ml Preterm 24 + 50 ml term concentrate

250 ml

Premature 27 Premature 24 50% ratio

Premature 30 cal/oz, 50% ratio

120 ml Preterm 24 + 120 ml Preterm 30

240 ml

Premature 26 Preterm 24 (2 parts)

Preterm 30 (1 part)


120 ml

Premature 27 Preterm 24 (1 part)

Preterm 30 (1 part)


120 ml

Premature 28 Preterm 24 (1 part)

Preterm 30 (2 parts)


120 ml


35

Feeding Protocols for NICU Infants

Trophic Feeding: Advantages and Guidelines for the NICU

Trophic feedings provide small volume enteral feedings for the promotion and protection of the structural and functional integrity of the GI tract (6, 7). Trophic feedings elicit a GI hormonal response in preterm infants thus mediating postnatal intestinal adaptation. Goals and Advantages of Trophic Feedings (6 - 9)

Stimulated GI hormonal response

Enhances GI growth and development

Promotes maturation of GI motor patterns

Decreases incidence of cholestatic jaundice and metabolic bone disease

Increases overall growth and feeding tolerance

Encourages earlier progression to full feedings and hospital discharge.

Accomplishes above goals without an increase in the risk of necrotizing enterocolitis (NEC)

Table 4.11 UVA Trophic Feeding Guidelines for Infants < 1200 grams

Day of Feedings Feeding Schedule Volume: ml/kg

1 & 2 2 ml/kg q 3 hours 16 ml/kg

3 & 4 2 ml/kg q 2 hours 24 ml/kg

Enteral Feeding Guidelines

Table 4.12 UVA Enteral Standard Feeding Guidelines

Birth Weight Schedule & Advance

< 1200 g Trophic feeds x 4 days; advance by 1ml/kg q 12 hrs.

1200-1800 g and < 35 weeks Begin at 2 ml/kg q 3 hr; advance by 1ml/kg q 9 hrs.

>1800 g and ≥ 35 weeks Begin at 5 ml q 3 hr; advance by 5 ml q 6 hrs.


36

References 1. Abad-Sinden, A, Bollinger R. Challenges and controversies in the nutrition support of the

preterm infant. Support Line. 2001;24(2):5-16.

2. Katrine KF. Anthropometric assessment. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:11-22.

3. Groh-Wargo S. Recommended enteral nutrient intakes. In: Groh-Wargo S, Thompson M,

Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:231-263.

4. Krug SK. Parenteral nutrition: vitamins, minerals and trace elements. In: Groh-Wargo S,

Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:151-175.

5. Abad-Sinden A, Sutphen JL. Enteral nutrition. In: Walker WA, Durie PR, Hamilton JR,

Walker-Smith JA, Watkins JB, eds. Pediatric Gastrointestinal Disease. Philadelphia, PA: B.C. Decker, Inc.; 2003:1981-1994

6. Schanler RJ, Shulman RJ, Lau C, et al. Feeding strategies for premature infants:

randomized trial of gastrointestinal priming and tube feeding method. Pediatrics. 1999;103(2):434-439.

7. Turner-McKinley LT. Dilemmas in feeding extremely low-birth-weight infants. Support

Line. 1996;1- 5. 8. Berseth CL. Minimal enteral feedings. J Perinatol. 1995;22(1):195-204. 9. Meetze WH, Valentine C, McGuigan JE, Conlon M, Sacks N, Neu J. Gastrointestinal

priming prior to full enteral nutrition in very low birth weight infants. J Pediatr Gastroenterol Nutr. 1992;15:163-170.

Chapter 5 Enteral Nutrition Support

37

Chapter 5

Enteral Nutrition Support

Introduction Pediatric patients unable to tolerate or voluntarily take in adequate oral feedings may be nutritionally managed with enteral tube feedings. 1. Hospitalized normally nourished infants and children with sub-optimal nutrient intake for at

least 3-5 and 5-7 days, respectively, should receive nutrition support, preferably from the enteral route (1).

2. Previously malnourished children, children who have experienced significant trauma or

those with underlying diagnoses which put them at increased nutritional risk and are unable to meet their nutritional intake goals should receive nutrition or nutrition support, preferably from the enteral route, within 48 hours of admission.

Advantages of Enteral Nutrition Enteral tube feedings are generally considered the preferred modality for critically and chronically ill pediatric patients for a number of reasons (2, 3):

Physiological presentation of nutrients

Trophic effects on the intestinal tract

Stimulation and maintenance of the gut mucosa

Reduced metabolic and infectious complications

Improved hepatic function versus parenteral nutrition

Simplified fluid and electrolyte management

More “complete” nutrition: glutamine, trace elements, fiber, and iron

Blunts hypermetabolic response in burn patients

May reduce the incidence of pathogen entry or bacterial translocation into the peritoneal cavity or circulation

Less expensive: $10 - $20 per day versus $200 - $300 per day for parenteral nutrition

Indications for Enteral Feedings Pediatric patients who are unable to meet their nutritional needs through oral nutrition may be nutritionally supported using enteral tube feedings. Tube feedings may also be used for patients who have lost 10% or more of their usual body weight and are unwilling or unable to take in sufficient calories using oral nutrition. Table 5.1 on the following page presents common indications for enteral feedings in pediatric patients (2).


38

Table 5.1 Conditions Under Which Enteral Feedings are Commonly Warranted in

Pediatric Patients

Preterm Infants

Cardiorespiratory Distress

Bronchopulmonary Dysplasia

Cystic Fibrosis

Congenital Heart Defects

Gastrointestinal Disease and Dysfunction

Inflammatory Bowel Disease

Short Gut Syndrome

Biliary Atresia

Severe Gastroesophageal Reflux

Protracted Diarrhea of Infancy

Post-Surgical Patients

Chronic Nonspecific Diarrhea

Renal Disease

Hypermetabolic States

Cancer

Burn Injury

Severe Trauma/Closed Head Injury/Spinal Cord Injury

Neurologic Disease/Cerebral Palsy

Enteral Tube Feeding Formula Selection Selection of an optimal infant or pediatric tube feeding formula depends upon a number of factors including patient factors such as diagnosis, associated nutritional problems and requirements, and GI function. Important formula factors which need to be considered include (2, 3):

osmolality (not to exceed 450 mOsm/kg for infant formula)

renal solute load

caloric density and viscosity

nutrient composition: type of carbohydrate, protein and fat

product availability (i.e., from WIC) and cost (especially if patient must pay out-of-pocket at home)


39

Table 5.2 Overview of Term Infant and Pediatric Formulas (2, 4 – 7)

Formula

Type

Description/Indication Formulations Formula Examples

Standard

Term Cow’s

Milk Based

For standard, term infant feeding during the first year of life.

Meets the recommendations of the American Academy of Pediatrics (AAP) for infant formulas (4).

Standard caloric density: 20 kcal/oz

24 kcal/oz (ready to feed) for hospital setting

Carbohydrate: lactose

Protein: casein/whey

Fat: vegetable oil blend, DHA/ARA

Enfamil Lipil (Mead Johnson)

Enfamil 24 Lipil (Mead Johnson)

Similac Advance (Abbott)

Similac Expert Care 24 (Abbott)

“Sensitive” May contain reduced lactose or partially hydrolyzed protein.


Carbohydrate: corn syrup solids and/or lactose

Protein: casein/whey (intact or partially hydrolysed)


Similac Sensitive (Abbott) – lactose free

Enfamil Gentlease (Mead Johnson) – reduced lactose, partially hydrolysed protein

Gerber Good Start (Nestle)– partially hydrolyzed whey

Added Rice Added rice starch for gastroesophageal reflux.


Carbohydrate: lactose or corn syrup solids, rice starch

Protein: cow’s milk protein, casein/whey


Enfamil AR (Mead Johnson)

Similac Sensitive for Spit-Up (Abbott)

Soy Protein Cow’s milk protein sensitivity, lactose intolerance, or galactosemia.


Carbohydrate: corn syrup solids, sucrose (lactose-free)

Protein: soy protein isolate and methionine

Fat: vegetable oil, DHA/ARA

Similac Soy Isomil (Abbott)

Enfamil Prosobee (Mead Johnson)

Extensively

Hydrolyzed

Extensively hydrolysed for milk and/or soy protein sensitivity; considered hypoallergenic

May have partial substitution of LCT as MCT for malabsorptive conditions (6, 7).

Standard caloric density: 20 kcal/oz, some available in 24 kcal/oz (ready to feed) for hospital setting

Carbohydrate: sucrose, tapioca starch, corn syrup solids (all are lactose free)

Protein: extensively hydrolyzed casein

Fat: vegetable oil blend, DHA/ARA, some MCT

Pregestimil Lipil (Mead Johnson) – 55% of fat as MCT

Similac Expert Care Alimentum (Abbott) – 33% of fat as MCT

Nutramigen Lipil (Mead Johnson) – 5% of fat as MCT

Elemental Amino acid based for severe malabsorption or allergy.


Carbohydrate: corn syrup solids (all are lactose free)

Protein: amino acids

Fat: vegetable oil blend, DHA/ARA, some MCT

Neocate Infant (Nutricia) – 33% of fat as MCT

Elecare Infant (Abbott) – 33% of fat as MCT

Fat

Modified

Significant fat malabsorption, lymphangectasia, chylothorax.

85% of fat as MCT

Standard caloric density: 30 kcal/oz (can be diluted)

Carbohydrate: corn syrup solids

Protein: casein Fat: soy oil, MCT oil, DHA/ARA

Enfaport (Mead Johnson)

Renal Chronic kidney disease, requirement for altered electrolyte composition


Carbohydrate: lactose

Protein: casein

Fat: vegetable oils

Simliac PM 60/40 (Abbott)


40

Table 5.2 Overview of Infant and Pediatric Formulas (2, 4 – 7) Continued

Formula Type Description/Indication Indications/Formulations Formula Examples

Pediatric

Enteral

Formulas

Balanced nutrition for the enteral feeding of children ages 1-13 years of age. Meets 100% of the RDA in 1000 - 1300 ml (depending on the age).

For children with normal GI function.

May be used as oral supplements.

Protein: casein and/or whey

Carbohydrate: maltodextrin, sucrose (lactose free)

Fat source: vegetable oil blend

Fiber source: can include pea fiber, FOS, inulin

PediaSure (oral product, with and without fiber) (Abbott)

PediaSure Enteral 1.0 (with and without fiber) (Abbott)

Pediasure 1.5 Cal (with and without fiber) (Abbott)

Nutren Junior (with and without fiber) (Nestle)

Boost Kid Essentials 1.0

Boost Kid Essentials 1.5 (with and without fiber) (Nestle)

Compleat Pediatric (Nestle) – blenderized food

Pediatric

Enteral

Formulas (Soy)

Balanced nutrition for the enteral feeding of children ages 1-10 years of age. Meets 100% of the RDA in 1000 - 1300 ml (depending on the age).

May be used as oral supplement.

Protein: soy protein based

Carbohydrate: maltodextrin, sucrose (lactose free)

Fat source: vegetable oil blend i.e. soy, high-oleic safflower oil, corn oil & MCT oil

Contains fiber

Bright Beginnings Soy (PBM Products)

Pediatric

Hydrolyzed

Balanced nutrition for the enteral feeding of children ages 1-13 with generalized malabsorption of protein and/or fat.

Potential indications: cystic fibrosis, short gut syndrome, inflammatory bowel disease, chronic diarrhea.


Protein: peptide based, usually milk-based

Carbohydrate: maltodextrin, sucrose, cornstarch (lactose free)

Fat: vegetable oils, MCT

Fiber source: can include FOS, inulin

Pediasure Peptide 1.0 (Abbott)

Pediasure Peptide 1.5 (Abbott)

Peptamen Jr (without fiber, with fiber, and with PreBio) (Nestle)

Peptamen Jr 1.5 (Nestle)

Pepdite Jr (Nutricia) – soy and pork based protein

Pediatric

Amino Acid

Balanced nutrition for the enteral feeding of children ages 1-13 with severe protein allergy or malabsorption


Protein: amino acids

Carbohydrate: corn syrup solids

Fat: vegetable oils, MCT oil

EleCare Jr (Abbott)

Neocate Jr (Nutricia) – with and without prebiotics

Neocate Splash (Nutricia) – oral product

Pediatric

Reduced

Calorie

Balanced nutrition (including optimal vitamin/minerals) for the enteral feeding of children ages 1-13 with reduced calorie needs

Protein: milk, soy protein

Carbohydrate: sucrose

Fat: vegetable oil

Caloric density: 0.63 – 0.66 kcal/oz

PediaSure SideKicks 0.63 Cal (Abbott)

Compleat Pediatric Reduced Calorie (Nestle)

Table 5.2 adapted from references 2, 6, 7 and proprietary enteral product literature.


41

Modifying Formula Caloric and Nutrient Density Children who are critically or chronically ill may be unable to take adequate formula volume to meet their nutritional needs. Infant and pediatric formulas may be prepared differently to provide a greater caloric or nutrient density. The caloric or nutrient density of an infant or enteral feeding formula can be increased by any one or a combination of the following methods (2, 6):

1. Concentration - Increasing the amount of formula base (powder or concentrate) or decreasing the amount of free water added when mixing the formula. This method will increase the concentration of all formula solutes and osmolality.

2. Supplementation - Adding a macronutrient module in order to increase caloric density without increasing all other nutrient sources. This may be accomplished through the addition of:

Carbohydrate source: Polycose (Abbott)

Fat source: Microlipid (Nestle), MCT oil (Nestle), or vegetable oil

Protein source: Beneprotein (Nestle), Prosource Liquid Protein (Active Home Nutrition)

Combined carbohydrate and fat source: Duocal (Nutricia) Guidelines for Using Concentrated and High Nutrient Density Formulas

In general, formulas for use in infants should not be concentrated through the reduction of free water to a density > 27 kcal/oz as these preparations may not meet their free water needs.

Increases in formula caloric density should be done gradually by 2 – 3 kcal/oz to ensure patient tolerance.

Infants with gastroesophageal reflux (GER) may experience aggravated reflux with concentrated preparations. These infants may do better with the addition of additives such as Polycose or infant cereal.

Infants with renal insufficiency may need to have their formula caloric densities increased through the use of additives alone to prevent excessive increases in renal solute load.

Children on concentrated formulas should be monitored closely for frequency of urination and urine specific gravity to ensure adequate fluid intake.

Excessive formula concentration may also result in diarrhea and dehydration or, conversely, constipation.

Parents should be appropriately instructed on formula preparation prior to discharge from the hospital.

Modules may or may not be readily available outside the hospital; discharge needs should be considered.

Formula Concentration Standard infant formulas in either ready-to-feed or prepared according to the manufacturer’s instructions provide 20 kcal/oz. Table 5.3 presents several methods for increasing the caloric density to 24 kcal/oz or 27 kcal/oz from these standard formulas.


42

Table 5.3 Increasing Formula Caloric Density to 24 - 27 kcal/oz through Concentration

Method Caloric Density

(kcal/oz)

Recipe

1 24 13 oz concentrate formula + 9 oz water

2 24 2 ½ scoops powdered formula + 4 oz water

3 24 ½ scoop powdered formula + 4 oz ready to feed

4 27 13 oz concentrate formula + 6 oz water

5 27 5 scoops powder + 7 oz water

Formula caloric density may be increased to 27 kcal/ounce via concentration using powdered or concentrate formulas. However, this method can increase formula osmolality to > 450 mOsm/kg, and can also result in increased renal solute load. Consequently, infants on higher caloric density formulas should be closely monitored for GI tolerance and hydration

status. For additional specific information on concentrating formulas to > 27

kcal/ounce, please contact the appropriate pediatric dietitian on your unit.

Formula Supplementation

Infants who require a 27 or 30 kcal/ounce formula may alternately receive a 24 kcal/ounce standard or preterm formula as the base with added modular products to achieve a caloric density of 27-30 kcal/ounce. Tables 5.4 and 5.5 present guidelines for increasing formula caloric density up to 33 kcal/ounce. In general, the use of polycose and vegetable oil may be more successful for orally fed patients, as it may be difficult to get vegetable oil to stay emulsified for longer hangtimes with enteral feeds. The effect of volume displacement caused by the addition of Polycose and Duocal (2 ml volume per tsp of powder) has been used to calculate all the caloric densities in Tables 5.4 and 5.5.

Table 5.4 Formula Supplementation with Polycose Powder and Vegetable Oil

Method Formula Volume Polycose Canola Oil kcal/ml kcal/oz

1 4 oz of 24 kcal/oz 1 tsp 1 ml 0.9 27



Table 5.5 Formula Supplementation with Duocal Powder

Method Formula Volume Duocal

(tsp)

Duocal

(scoops)

kcal/ml kcal/oz

1 4 oz of 24 kcal/oz 1 2.8 0.9 27

2 4 oz of 24 kcal/oz 2 5.7 1.0 30

3 4 oz of 24 kcal/oz 3 8.5 1.1 33


43

Formula Caloric Modification in Renal Patients When increasing formula caloric density for pediatric renal patients or for other pediatric patients who cannot tolerate increased electrolyte concentrations, it is preferable to use a specialized low electrolyte formula such as Similac PM 60/40 (Ross Labs) concentrate to 24 or even up to 27 kcal/oz. and then add modules, as needed, to achieve 27-30 kcal/oz.

Supplementation of Breast Milk

The caloric and nutrient density of breast milk can be increased by one of two methods:

Method 1 - Enfamil Human Milk Fortifier or Similac Human Milk Fortifier

Method 2 - Use of Powdered Infant Formula: Enfamil or Similac Powder Breast fed preterm infants who are admitted to the PICU, are still below 2500 grams and are unable to take in 180 ml/kg will need to receive fortified breast milk using: Method 1: Human Milk Fortifier as follows:

Table 5.6 Fortification of Breast Milk with Human Milk Fortifier

Step Human Milk Fortifier Breast Milk Caloric Density Increased mOsm



Method 2: Breast milk caloric and nutrient density for term infants may be increased to 24-

30 kcal/oz according to the following:

Table 5.7 Increasing Nutrient Density of Breast Milk Using Formula Powder

Method Product Preparation

A Standard Term or Discharge Preterm Powdered Formula

Mix ½ scoop powder per 120 ml breast milk (24 kcal/oz)

B Standard Term or Discharge Preterm Powdered Formula

Mix 1 scoop powder per 150 ml breast milk (27 kcal/oz)

Note: The caloric density of 24 kcal/oz breast milk may be increased further by following the formula supplementation guidelines found in Tables 5.4 and 5.5.

Home Fortification: Fortification with NeoSure of Enfacare powder is the preferred method for fortification at discharge as human milk fortifiers are not readily available in retail establishments.


44

Supplementation of Pediatric Enteral Formula

The caloric and nutrient density of enteral formula can be increased by one of two methods:

Method 1 - Use of Modulars: Duocal

Method 2 - Increasing Pediatric Enteral Formula Nutrient Density with Tube Feeding Mixers

Method 1: Increasing Pediatric Enteral Formula Nutrient Density with Modulars

Children ages 1 - 13 years of age who have elevated energy and/or protein needs in the face of limited fluid tolerance may require nutritional management with a pediatric formula such as PediaSure (1 kcal/ml), available with or without fiber, supplemented with modular components. The following tables present the gradual advancement of formula caloric density using Duocal.

Table 5.8 Increasing Pediatric Enteral Formula Caloric Density with Modular

kcal/oz Standard pediatric

enteral formula

volume

Powdered

Duocal (tsp)

Powdered

Duocal (weight

in grams)

33 240 ml 2 5.7

36 240 ml 4 11.3

39 240 ml 6 17.0

Method 2: Increasing Pediatric Enteral Formula Nutrient Density with Tube Feeding Mixes

Alternatively, higher caloric densities may be achieved by mixing pediatric formula with calorically dense pediatric or adult formulas. Pediatric tube feeding caloric density of 1.25

kcal/ml can be achieved by mixing 1:1 a standard 1.0 calorie pediatric formula and a

calorically dense 1.5 cal pediatric formula (or an adult 1.5 formula).

Tube Feeding Routes of Delivery

The enteral nutrition delivery route chosen is highly individualized and dependent upon the anticipated duration of the tube feeding as well as individualized tolerance and the child’s medical history. The predominant routes of enteral nutrition include:

Nasogastric (NG) and orogastric (OG)

Gastrostomy (Surgical or Percutaneous Endoscopic Gastrostomy)

Transpyloric Table 5.9 on the following page summarizes the major indications for each of these enteral feeding routes. Even when providing tube feedings, it is important to provide oral stimulation, both nutritive and non-nutritive, whenever possible to preserve the development or preservation of normal suck and swallow. Therapy sessions with the occupational therapist or the speech language pathologist should be directed towards the prevention of oral motor dysfunction and oral tactile defensiveness.


45

Table 5.9 Routes of Tube Feeding Deliveries and their Indications

Delivery Method Common Indications

Or Advantages

Contraindications and/or

Precautions Nasogastric (NG) or Orogastric (OG)

Prematurity (< 32 wk EGA) Requires presence of functioning GI tract with non- obstructive passage from oral or nasal cavity to stomach Usually indicated for short term use (<3 months) Smaller bore tubes associated with increased comfort Often used for nocturnal feedings Tubes can be inserted, removed and reinserted with relative ease

Patients with intractable vomiting Patients with increased risk of aspiration, history of aspiration pneumonia Discouraged in the presence of severe gastroesophageal reflux Otitis media or sinusitis can be potential complications NG and OG tubes can be easily dislodged and thus must be secured

Transpyloric Feedings Nasoduodenal or Nasojejunal

For infants and children with a high risk for aspiration For infants with history of severe gastroesophageal reflux For those with impaired gastric motility or emptying (i.e. preterm infants) For use in patients with gastric dysfunction following head injury, general trauma or surgery

More difficult to place tube; may require fluoroscopic or endosco- py placement of tube Increased potential for GI intolerance while advancing to goal rate i.e. malabsorption Tube displacement and potential aspiration Must use continuous pump infusion to optimize tolerance

Gastrostomy Feedings Surgically Placed or PEG PEGs are generally less costly than surgical gastrostomies.

Indicated for long term feedings Requires normal emptying of gastric and duodenal contents Indicated for infants and children with swallowing dysfunction, or for those with esophageal obstruction but with functioning stomach and small intestine Patients should have intact gag Those with history of GE reflux

who do not respond to medical management may require a Nissen procedure

May be required for nutritional management of congenital anomalies i.e. TE fistula Large bore tubes provide less risk of tube occlusion with meds or viscous blenderized formulas

Should be discouraged under the following conditions: a. Severe GE reflux (may require a Nissen fundoplication) b. Poor gastric emptying c. Intractable vomiting Tube must be secured to prevent pyloric outlet obstruction Potential complications include: a. Aspiration with aspiration pneumonia b. Tube migration c. Localized skin breakdown, leakage of gastric contents An NG feeding trial may be

recommended prior to PEG placement to establish tube feeding tolerance

Jejunostomy Feedings Indicated for long term use Indicated for infants and children with obstructions above the jejunum or poor gastric motility Reduced risk of aspiration Requires slow continuous infusion

Use of intact formulas is possible if feeding into proximal intestine May require more elemental formula if feeding is delivered more distally Potential complications: dumping syndrome, malabsorption, skin breakdown, tube migration, or bacterial overgrowth

Adapted from References 3 and 9


46

Tube Feeding Administration Methods

Tube feedings can be administered via continuous drip using a pump or via intermittent feedings, using gravity drip or a pump. The method of feeding chosen is dependent upon the following:

Child’s diagnosis

Nutritional history and gastrointestinal status

Route of feeding delivery

Degree of patient mobility

Tolerance to oral feedings

Individual family and caretaker home situation Table 5.10 presents an overview of indications for and advantages of continuous versus intermittent feedings (3, 8).

Table 5.10 Continuous versus Intermittent/Bolus Feedings

Continuous Feedings Intermittent/Bolus Tube Feedings

Better tolerated than intermittent or bolus delivery particularly in patients with limited absorptive surface area; generally results in less reflux, dumping and diarrhea. Better tolerated in critically ill children. In the PICU, best to start with a continuous schedule and to progress to intermittent schedule once clinical status is improved. Recommended for delivery of nutrients directly into the small bowel. Recommended for infants with persistent feeding intolerance, significant respiratory instability or significant gut resection. Useful for overnight nasogastric for children with chronic diseases i.e. renal disease, CF, CHD.

More physiological and practical for home enteral feedings. Indicated for children who are more medically stable, have achieved full tolerance of continuous feedings and are ready to transition to a more intermittent schedule. Allows for greater patient mobility, more appropriate for both the rehab and the home setting. Promotes cyclic bursts of GI hormones such as gastrin in preterm infants, thus promoting GI development and maturation.


47

Transitioning from Continuous to Intermittent Feeds

Once the infant or child is medically stable and able to be transitioned over to a more physiological feeding method, the continuous feeding schedule may be transitioned to intermittent feedings via one of the following three methods:

Table 5.11 Transitioning from Continuous to Intermittent Feeds

Guidelines for Gradual Transition

from Continuous to Intermittent/Bolus Feedings

Method 1

Progressively increase the hours between feedings. Increase the tube feeding interval by 2, 3, and 4 hour intervals to provide 12, 8, and 6 feedings per day, respectively.

Method 2 When anticipating intolerance to intermittent feedings, the volume delivered in 4 hours can be delivered over gradually shorter time periods, over 3 hours, then 2 hours, then 1-1/2 hours, and finally over 1 hour using a constant infusion pump.

Method 3 Continue with continuous feeds overnight over 8 to 12 hours. Divide daily enteral feeding volume over intermittent feedings every 3 to 4 hours during the day.

General Guidelines for the Initiation and Progression of Tube Feedings

The following are some general guidelines for the initiation and progression of tube feedings (1, 3, 8). These represent “general” guidelines and the tube feeding management of each child needs to be individualized to meet specific needs and to ensure appropriate tolerance.

1. For pediatric patients with neurologic impairment and a high risk of aspiration, elevate the head of the bed to at least a 30 degree angle to minimize the risk of aspiration.

2. When using continuous feeds, a 4 hour cycle of tube feeding formula should be

placed in the administration set or syringe. Hang time in the hospital setting should not exceed 4 hours to minimize the risk of bacterial contamination.

3. When using intermittent feeds, place appropriate volume of feeding into the

administration set or syringe. The feeding can be administered via gravity drip, and should generally be administered in 30 - 45 minutes.

4. Initiation and Advancement – See Tables 5.12 and 5.13. 5. Administer tube feeding at room temperature. Refrigerate opened or mixed tube

feedings; discard all unused formula within 48 hours. 6. In children 2 years of age and older and not on a strict fluid restriction, administer at

least 5 - 10 ml of water, or more if needed, every 4 hours or after each intermittent feed to ensure tube patency.


48

7. In general tube feedings may be started at full strength, but at a sufficiently low rate or volume to ensure feeding tolerance.

8. If diluted formula is started, generally advance the formula strength first over the first

24 hours, and then advance the feeding volume. This will ensure that the child receives optimal nutritional intake as the parenteral nutrition or other intravenous fluids are being weaned.

9. In the hospital setting, the formula name, its rate and strength, gastric residual volume,

as well as urine and stool volume and consistency should be recorded in the patient’s bedside flowsheet.

10. Administration container and tubing should be changed every 24 hours.

Pediatric Tube Feeding Progression The following tables review tube feeding progression guidelines for both continuous and intermittent feeding schedules in pediatric patients. This table may be used when writing pediatric tube feeding orders.

Table 5.12 Continuous Tube Feeding Progression

Age/Weight Initial Infusion Rate Daily Increases Goal Rate

2.0 - 15 kg 2 - 15 ml/hr (1 ml/kg/hr)

2 - 15 ml/hr q 4-8 hr (1 ml/kg q 8 hr)

15 - 55 ml/hr

16 - 30 kg 8 - 25 ml/hr (0.5 - 1 ml/kg/hr)

8 - 15 ml/hr q 4-8 hr (0.5 ml/kg q 8 hr)

45 - 90 ml/hr

30 - 50 kg 15 - 25 ml/hr (0.5 ml/kg/hr)

15 - 25 ml/hr q 4-8 hr (0.5 ml/kg/ q 8 hr)

70 - 130 ml/hr

> 50 kg 25 ml/hr 25 ml/hr q 4-8 hr 90 - 150 ml/hr

Table 5.13 Intermittent Tube Feeding Progression

Age/Weight Initial Volumes Daily Increases Goal Volume

2.0 - 15 kg 5 - 30 ml q 3 - 4 hr 5 - 30 ml q 8 - 12 hr 50 - 200 q 4 hr

12 - 30 kg 20 - 60 ml q 4 hr 20 - 60 ml q 8 - 12 hr 150 - 350 ml q 4 hr

> 30 kg 30 - 60 ml q 4 h 30 - 60 ml q 8 - 12 hr 240 - 400 ml q 4 hr


49

Management of Combination Enteral and Oral Feedings A combination of both oral feedings and tube feedings, wherever possible, is recommended for the promotion of or maintenance of oral motor developmental skills. Pediatric patients on hospital or home enteral feedings may be managed with a combination of:

Continuous nocturnal feedings via NG tube or gastrostomy over a period of 10 - 14 hours.

Daytime intermittent every 3 - 4 hours to include a combination of oral intake of formula and/or solids as well as tube feedings to supplement the oral intake as needed.

The pediatric dietitian will work closely with the nursing staff as well as the child’s parents or caretakers to develop a feeding schedule/regimen that is appropriate and manageable in the home setting.

Management of Complications Encountered with Enteral Feedings

Complications associated with enteral feedings fall into three major categories:

1. Mechanical 2. Gastrointestinal 3. Infectious

While these complications may be seen in conjunction with enteral feedings, in most cases the complications may have nothing to do with the enteral formula itself, but rather to the method of delivery, administration, medications i.e. antibiotics, as well as the physiological/anatomical problems related to the patient’s illness or condition. Table 5.14 on the following pages reviews the most common complications in pediatric patients, potential causes and guidelines for prevention or intervention.


50

Table 5.14 Management of Complications Encountered During Tube Feedings

Problem Possible Causes Prevention/Intervention Nausea & Vomiting Gastric retention

Ileus or constipation High fat content of formula Gastric hypomotility Improper tube placement Infusion rate too rapid Hypertonic meds Unpleasant odor of formula Constipation

Maintain head of bed elevated Consider prokinetic medications Initiate tube feeding at low rates, advance slowly, as tolerated Consider alternate feeding route i.e. duodenal/jejunal Use lower fat content formula Use standard polymeric formulas unless contraindicated Monitor for correct tube placement

Abdominal distention, bloating, gas Delayed gastric emptying

Infusion rate too rapid Rapid infusion via syringe Rapid infusion of cold formula Delayed gastric emptying Malabsorption Medications (opiates) Constipation

Administer tube feeding via a continuous infusion at low rate, gradually increase as tolerated Administer feedings at room temperature Consult pharmacist for evaluation of medications impacting gastric emptying Consider prokinetic medications i.e. Metoclopramide

Constipation Inadequate fluid GI obstruction Inadequate fiber Inadequate physical activity Concentrated formula

Increase free water intake Digital disimpaction Choose fiber containing formula or add fiber or prune juice Increase physical activity Implementation of a bowel regimen

Diarrhea (Not formula related)

Concurrent drug therapy, such as antibiotic therapy Sorbitol containing medications GI disorder/disease Malnutrition, mucosal

atrophy

Constipation with overflow

Consult pharmacist for review of medications and possible discontinuation Look for Sorbitol on label of oral prescription medications Consider switch to continuous feedings. Begin tube feeding at slow infusion rate, advance slowly, as tolerated

Diarrhea (Formula related)

Inadequate fiber Rapid tube feeding infusion Bacterial contamination of formula Carbohydrate malabsorption or lactose intolerance Fat malabsorption Impaction

Use fiber containing formula or add fiber to the tube feeding Reduce tube feeding rate to previously tolerated rate, advance slowly, as tolerated Use commercially prepared formula Use lactose-free formula i.e. soy-based or a carbohydrate free formula & replace the carbohydrate Use low fat formula

Continued on following page.


51

Table 5.14 Management of Complications Encountered During Tube Feedings,

Continued

Problem Possible Causes Prevention/Intervention Clogged feeding tube Improper irrigation of

the feeding tube Administration of medications via the feeding tube High viscosity formula Undissolved formula due to poor mixing

Flush tube with water every 4 - 8 hours Replace tubing Use liquid elixirs when possible Consult pharmacist regarding crushed or diluted medications Blenderize powdered enteral formulas thoroughly Switch to lower viscosity formula Use appropriate size tube for formula viscosity or TF method

Aspiration Gastric hypomotility Gastroesophageal reflux Neurologic damage Displacement or migration of feeding tube to esophagus Oral-motor dysfunc-tion.

Infuse feedings past the pylorus Consider continuous infusion Child may need anti-reflux medications/surgical procedure for long term management Verify tube placement prior to each feed or every 4-8 hours on continuous feedings Replace tube

Electrolyte imbalance Medications which alter electrolyte Previous malnutrition, refeeding syndrome Cardiac or renal insufficiency Formula intolerance (unlikely)

Consult pharmacist regarding medications which may cause electrolyte wasting Infuse tube feeding at low rates; may need to supplement with potassium or phosphorus Manage underlying diagnosis to correct electrolyte imbalance

Dumping syndrome Too rapid infusion Bolus feeds into small bowel Hypertonic formula

Switch to continuous feedings Use a more elemental formula for children with severe malabsorption or short gut

Hyperglycemia Diabetes Trauma or sepsis Excess carbohydrate intake

Switch to a formula with fiber. Switch method of administration i.e. to continuous feedings Administer insulin (sliding scale)

Azotemia High protein intake Renal insufficiency or

renal immaturity Liver disease Metabolic disease (i.e. inborn error)

Reduce protein content of formula

Dehydration Inadequate fluid intake High caloric density formula

Increase fluid intake via free water flushed q 3 - 4 hours Decrease formula caloric density

Adapted from References 3 and 10


52

Transition from Enteral to Full Oral Feedings

The transition from enteral to full oral feedings can be prolonged. If infants and children are completely deprived of oral feedings during critical maturation phases, difficulties will be encountered when oral feedings are resumed. Reinstitution of oral feedings in children with G-tubes may evoke such responses as gagging, choking and vomiting. To promote oral feeding transition:

G-tube feedings should be arranged to stimulate oral feeding in timing and amount

Oral stimulation with the speech language pathologist or occupational therapist should occur to diminish the child’s oral defensiveness. Treatment may require weeks on an inpatient basis and up to years on an outpatient basis.

The pediatric and neonatal nutritionists will work closely with the speech language pathologist and/or occupational therapist, as appropriate, as well as the nursing staff on the following patients:

Enteral or parenteral nutrition patients who have been on nutrition support for an extended period of time and are thus unable to take oral feedings

ECMO patients who develop orally defensive behaviors

Bronchopulmonary dysplasia patients who are unable to meet their nutrition needs via oral intake


53

References

1. Schwenck WF, Olson D. Pediatrics. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:347-372.

2. Abad-Sinden A, Sutphen J. Enteral nutrition. In: Walker WA, Goulet O, Kleinman RE, Sherman PM, Shneider BL, Sanderson IR, eds. Pediatric Gastrointestinal Disease. 4

th

edition. Philadelphia, PA: B.C. Decker, Inc.; 2004:1981-1994. 3. Nevin-Folino N, Miller M. Enteral nutrition. In: Samour PQ, King K, eds. Handbook of

Pediatric Nutrition. 3rd


4. United States Congress: Infant Formulas Act of 1980, Public-Law 96-359, Sept. 26, 1980. 5. Committee on Nutrition. Soy protein formulas: recommendations for use in infant feeding.

Pediatrics. 1983;72:359-363. 6. American Academy of Pediatrics. Committee on Nutrition. Enteral nutrition. In: Pediatric

Nutrition Handbook. 2004:391-403. 7. Abad-Jorge A, Roman B. Enteral nutrition management of pediatric patients with severe

gastrointestinal impairment. Support Line. 2007; 29(3): 3–11. 8. Charney P. Enteral nutrition: indications, options and formulations. In: Gottschlich M,

Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:141-166.

9. Minard G, Lysen LK. Enteral access devices. In: Gottschlich M, Fuhrman MP, Hammond

KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:176 - 188.

10. Russell M, Cromer M, Grant J. Complications of enteral nutrition. In: Gottschlich M,

Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:189-210.


54

Chapter 6 Nutrition Management of High Risk Nutrition Disease States

55

Chapter 6

Nutrition Management of High Risk Nutrition Disease States

Congenital Heart Defects (1, 2)

Congenital heart defects (CHD) result from abnormal formation of the heart or major blood vessels, which either obstruct blood flow or cause abnormal blood flow. Infants with congenital heart defects have an increased incidence of malnutrition due to prenatal, genetic and postnatal factors. Postnatal factors contributing to malnutrition include:

Hypoxia and hemodynamic abnormalities: results in fatigue, discoordinated suck and swallow and increased work of breathing

Decreased nutritional intake: related to dyspnea, tachypnea and fatigue associated with chronic hypoxia; may also be related to imposed fluid restriction to prevent fluid overload and cor pulmonale; may be related to delayed or impaired gastric emptying or motility due to stomach pressure causing early satiety

Increased metabolic expenditure related to an increase in cardiac and respiratory work, also related to body composition due to decreased fat stores and increased lean body mass

Mild malabsorption may play a role in the etiology of malnutrition when combined with poor nutritional intake and increased metabolic rate

Nutrition Goal: to promote catch-up growth in previously malnourished infants and children or to maintain appropriate growth in well-nourished infants or children to allow for a more timely surgical repair of the cardiac defect and to promote normal growth potential and development.

Medical Nutrition Therapy

Estimated needs

Increase caloric and protein intake above the recommended levels of the DRIs. Refer to Table 6.1 for calorie, protein and sodium guidelines.

Table 6.1 Nutritional Requirements for Children with CHD

Age (years) Energy (kcal/kg) Protein (g/kg) Sodium (mg/day)

0-0.5 120 – 150 2.2 – 3.5 230

0.5-1 110 – 140 1.5 – 2.5 500

1-3 100 – 120 1.2 - 2 650

4-6 80 – 100 1.2 – 1.5 900

7-10 60 – 90 1.0- 1.5 1200

11-14 Male: 55 – 60 Female: 45 - 60

1.0 – 1.5 1800

15-18 45 – 55 1.0 – 1.5 1800


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Interventions

Increase formula caloric density via formula concentration or supplementation with caloric modulars. Formulas may be concentrated to 24 - 27 kcal/oz via concentration and if needed, up to 30 - 35 kcal/oz, by using Polycose and Microlipid. Refer to formula recipes in Chapter 5.

o Breast milk may be used if the caloric and nutrient density is appropriately increased via: a) supplementation with powdered infant formula or commercial fortifiers (for preterm infants), b) mixing breast milk with higher calorie formula, or c) supplementation with caloric modular.

Enteral nutrition support with either continuous feedings over 24 hours in the hospital setting or with oral intake by day of calorically dense formula and continuous nocturnal feeds over 8 - 12 hours

o 24-hour continuous feeds: achieves greatest caloric intake; safe and effective to improve nutritional status; may promote oral-motor dysfunction

o Oral + 12-hour nocturnal continuous feeds: promotes normal feeding development; infants should take as much of a calorically dense formula as possible during an 8-12-hour day, and provide the rest of goal via nocturnal feed

o Intermittent feeds every 3-4 hours: feeds are given every few hours; the goal volume is offered orally for those safe to po feed, and the balance is given via NGT or GT after a 20-minute oral feeding period.

The use of a lower-sodium formula may be desirable, as excessive sodium intake may exacerbate fluid retention and precipitate congestive heart failure.

Tips for increasing calories and protein with oral intake: o Oral intake can be maximized using a variety of every-day ingredients (see

Appendix K) o To increase calories for hospitalized patients, nutritional supplements such

as PediaSure, Mightyshakes, and Ensure are available. For outpatients, PediaSure, Ensure, and Boost are available in the grocery store; however, store brands (such as Target, Walmart, etc.) or Carnation Instant Breakfast may be more economical for families.

o Frequent snacking may be necessary to meet calorie and protein needs.

Cystic Fibrosis (3, 4)

Cystic fibrosis is a genetic, multisystem progressive disease causing the cells producing mucus, sweat, saliva, and digestive juices to create thick and sticky secretions resulting in pancreatic insufficiency, chronic lung disease, excessive loss of sweat electrolytes, and malnutrition.The nutritional needs of children with cystic fibrosis are increased due to pancreatic insufficiency and progressive pulmonary failure. Factors contributing to the nutritional implications include:

Malabsorption of fat and protein

Increased work of breathing and repeated pulmonary infections

Loss of fat-soluble vitamins and essential fatty acids

Decreased oral intake during respiratory exacerbations


57

Nutrition Goal: provision of adequate calories and protein to support normal growth and overcome the demands of increased respiratory effort and malabsorption.


Special Considerations in Nutrition Assessment

Yearly fat soluble vitamin levels (A, D, and E) should be checked. However, vitamin A is a negative acute phase reactant and should not be checked while a patient has active infection.

Estimated Needs

120-150% of the DRIs for calories is needed for optimal growth.

To prevent deficits of essential nutrients, provide additional vitamin A, D, E and K.

Table 6.2 Guidelines to Replace Essential Vitamins A, D, E and K

Essential Vitamin Amount/Day

Vitamin A 5,000 to 10,000 IU/day

Vitamin D 400 to 800 IU/day

Vitamin E 25 to 50 IU for infants; 100-200 IU < 8 years; 200-400 IU > 8 years

Vitamin K 2-5 mg each week or 2-5 mg twice a week for patients on chronic antibiotics or if with cholestatic liver disease; 300-500 mcg > 8 years

Usual dosage for supplemental water soluble vitamins is 1 ml per day pediatric multivitamin for infants 0-2 years old.

Interventions

Oral intake should be maximized as much as possible, through the use of calorically dense foods, double portions, frequent snacks, nutrition supplements (ie, Scandishakes), and caloric modules added to foods (dry milk powder, vegetable oil, butter, Duocal, etc).

A combination of oral and tube feeding is frequently necessary to meet nutritional needs. Nocturnal feeds are preferred, NG for short term; gastrostomy for long term.

Breast milk, standard infant formula or special MCT-containing formulas such as Pregestimil are appropriate. Breast milk and formulas should almost always be high caloric density > 24 kcal/oz.

NaCl supplementation for infants is recommended in the amount of 4 - 6 mEq/kg/day which can be achieved by giving 1/8 - 1/4 teaspoon table salt per day. This should be divided between the first few feedings per day.

For pancreatic enzyme replacement recommendations, see Table 6.3. o If an infant can swallow purees, enzyme beads can be given in an acidic

puree, like applesauce. Enzyme beads should not be given in an alkaline


58

fluid, because this will cause premature degradation of the bead’s enteric coating and subsequent denaturing in the stomach.

Table 6.3 Dosing Pancreatic Enzymes in CF Patients

Age

Meal Dose Adjusting Dose

Infants

2000-4000 units lipase/120 ml formula/nursing (mean of 1800 lipase units)

450-900 Units lipase/g of fat

Increase by 2000-2500 units lipase/feed as volume increases or malabsorption returns

Children < 4

years

1000-2000 units lipase/kg/meal

500-4000 units lipase/g fat

Snacks: ½ meal dose

Compare units lipase/g fat when weight dose appear above range

Children > 4

years

500-2000 units lipase/kg/meal

500-4000 units lipase/g fat

Snacks: ½ meal dose

Compare units lipase/g fat when weight dose appears above range

Note: Units of lipase provided for each gram of long chain triglycerides provided by the formula. A formula whose fat source is predominantly MCT oil, i.e., Pregestimil can be beneficial for decreasing the quantity of enzyme dosing.

o For continuous 24 hour feedings: The total calculated lipase dose provided per 24 hours of the selected formula should be 500-4000 lipase units (mean of 1800 lipase units) per gram of LCT divided in equal amounts and administered every 3 to 4 hours.

o For cycled overnight tube feedings: 50-75% of the calculated enzyme dosage should be administered at the beginning of the feeding and the remaining 25-50% at the end.

Option A: Taking enzyme orally: Provide meal dose of enzymes by mouth at the beginning of feeds. Following completion of feeds, give ½ of a meal dose by mouth.

Option B: Pre-digesting formula: Dissolve 1 3/4 tsp. sodium bicarbonate (baking soda) in 100 ml water. Mix beads from enzyme capsule in the sodium bicarbonate solution; use 5 ml of solution per capsule. Leave beads in solution for 15-20 minutes. Add mixture to formula after beads have dissolved.

o For intermittent tube feedings: The calculated enzyme dose should be given just prior to each feeding.

o Dosing should not exceed 4,000 units lipase per gram of fat.


59

Figure 6.1: Vitamin D Treatment Algorithm from the Cystic Fibrosis Foundation

Guidelines on Vitamin D for Children Age 1 – 10 Years Old

Age: 1-10 years Baseline Dose of Vitamin D3:

800-1000 IU Vit D3/day

Check 25-OH Vit D yearly, preferably at the end of winter

25-OH Vit D <30 ng/ml

25-OH Vit D >30 ng/ml

Double dose of adherent patient to:

1600-2000 IU Vit D3/day Continue Baseline Dose of 800-1000

IU Vit D3/day

Recheck 25-OH Vit D level in 3 months



Double dose of adherent patient to:

3200-4000 IU Vit D3/day




Continue adherent patient at present

IU Vit D3 dose/day

Confirm patient is adherent and has been receiving 4000 IU Vit D3/day for the past 3 months

For adherent patient taking <4000 IU Vit D3/day,

increase to 4000 IU/day



*Note: All Vitamin D dosage recommendations include vitamin D contained in multivitamin(s) + additional stand-alone vitamin D supplements

Refer to specialist 25-OH Vit D >30 ng/ml


60

Figure 6.2: Vitamin D Treatment Algorithm from the Cystic Fibrosis Foundation

Guidelines on Vitamin D for Children > 10 Years Old Through Adulthood



Double dose of adherent patient to: 3200-8000 IU Vit D3/day


Continue adherent patient at present

IU Vit D3 dose/day

*Note: All Vitamin D dosage recommendations include vitamin D contained in multivitamin(s) + additional stand-alone vitamin D supplements

Age: >10 years through Adulthood

Baseline Dose of Vitamin D3: 800-2000 IU Vit D3/day

Check 25-OH Vit D yearly, preferably at the end of winter




Continue Baseline Dose of 800-2000

IU Vit D3/day




Confirm patient is adherent and has been receiving 6400-10000 IU Vit D3/day for the past 3 months



Refer to specialist






For adherent patient taking

10000 IU Vit D3/day

For adherent patient taking <10000 IU Vit D3/day,

increase to 10000 IU/day


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Renal Disease (5 - 8)

Sudden removal of the renal regulating ability produces profound electrolyte and metabolic disturbances resulting in fluid retention, acidosis, hyperkalemia, hyperphosphatemia, nitrogen retention, hypocalcemia and hyperuricemia. Dietary manipulations may change dramatically during the course of renal disease.

Nutrition Goal in Acute Renal Failure: to provide sufficient nutrients to restrain the catabolic response and hasten renal recovery within the restrictions demanded by limited renal capacity.

Nutrition Goal in Chronic Renal Disease: to maintain nutrition sufficient for optimal growth within the margins imposed by limited renal excretory and regulatory capacity while at the same time avoiding excesses of nitrogen, phosphate, sodium, potassium and fluid. Medical Nutrition Therapy


Dry weight should be estimated, whenever possible, using nutrition-focused physical findings, such as blood pressure, edema, and weight change with fluid removal via dialysis.

BMI should be plotted against height age, for those patients who are prepubertal with significant stunting.

Skinfold measurements and arm anthropometry are not recommended in this population.

Serum electrolyte levels, parathyroid hormone, and renal profile are important laboratory components in this population.

Serum albumin is often used as a marker of nutrition status because hypoalbuminemia is a risk factor for mortality; however, serum albumin is a better indication of severity of disease and inflammation than it is of nutrition status.

25(OH) vitamin D levels should be measured at least yearly.

Estimated Needs

Initially, use DRI/EER for age and weight or catch-up growth, when appropriate, and adjust caloric delivery based on growth parameters. Provision of at least 80% of the DRI/EER for height age is recommended for normal growth.

Estimated protein needs are in Table 6.4.

Fluid needs are determined by the patient’s clinical status. o If fluid limitation becomes necessary due to edema or hypertension, provide

insensible losses (Table 6.5) plus measured urine output and amount to replace other losses (vomiting, diarrhea, ostomy output).

o Children with polyuria may require 180-240 ml/kg/day.

Generally, micronutrient needs are 100% of the DRI for age for B vitamins, zinc, copper, folic acid, and vitamins A, C, D, E, and K.


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Table 6.4 Protein Recommendations for Dialysis Patients

Table 6.5 Insensible Fluid Losses

Age Group

Fluid Loss

Preterm Infants Up to 40 ml/kg/d

Neonates 20-30 ml/kg/d

Children & Adolescents 20 ml/kg/d or 400 ml/m²

Interventions

Diets should be liberalized as much as possible, to allow a palatable diet with adequate variety to promote growth, development, and quality of life.

Oral supplements, either standard products like PediaSure or renal products like Nepro or Suplena, may be indicated for patients with anorexia related to dialysis.

Generally, a low renal solute load, low electrolyte formula such as Similac PM 60/40 is indicated for infants with renal insufficiency. Soy formulas should be avoided if at all possible due to their high phosphorus content. Formulas can be concentrated to 24-27 kcal/oz, and then supplemented to 30 kcal/oz using modulars.

Infants should be encouraged to start solid foods at ~6 months of age, as any normal infant would.

Enteral supplementation should be considered, particularly in infants and toddlers with poor growth and in those with polyuria requiring high fluid volumes. Table 6.7 provides a formula comparison. o Standard formulas may be appropriate for toddlers and younger children,

depending on electrolyte status. o Use of a high calorie (1.8 kcal/ml), defined renal formula i.e., Nepro may be

recommended for enteral nutrition support either continuous in the hospital setting or as an overnight feeding regimen for children over 24 months. In situations where Nepro provides too much protein for a child, Suplena (1.8 kcal/ml) can be used instead.

Intradialytic parenteral nutrition should be considered in patients on hemodialysis in whom oral and enteral supplementation are not effective in correcting malnutrition.

Use 1 ml multivitamin drops (need to supplement folic acid) or 1 children’s chewable multivitamin per day to provide vitamin and mineral needs, or use ½

Age Group Hemodialysis (g/kg)

Peritoneal dialysis (g/kg)

0-6 months 1.6 1.8

7-12 months 1.3 1.5

1-3 years 1.15 1.3

4-13 years 1.05 1.1

14-18 years 0.95 1.0


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tablet Nephrovite for children <3 years of age and 1 tablet for children >3 years of age.

Supplement salt as needed; table salt can be added to a daily supply of feeds. 1/8 teaspoon of table salt provides 11 mEq of sodium.

Iron may be supplemented in addition to erythropoietin for management of anemia.

Vitamin D should be replaced in the case of deficiency, as per Table 6.6, even if the child is receiving calcitriol to control PTH levels.

Growth hormone can be an important adjunct to nutrition management in treating growth retardation.

Table 6.6 Recommended Supplementation for Vitamin D Deficiency/Insufficiency in

Children

Serum 25

(OH) D

(ng/mL)

Definition Ergocalciferol (D2) or Cholecalciferol

(D3) Oral/Enteral

Duration

(mo)

< 5 Severe deficiency 8000 IU X 4 wk or (50000 IU 2X per mo for) X 2 mo

3

5-15 Mild deficiency 4000 IU/d x 12 wk or (50000 IU q other wk for 12 wk)

3

16-30 Insufficiency 2000 IU/d or (50000 IU q 4 wk) 3

≥ 30 Homeostasis 200-1000 IU/d daily


64

Table 6.7 Nutrient Content of Selected Renal Formula, per 100 kcals

Adapted from proprietary product literature.

Enfamil

Lipil

Similac PM

60/40

Gerber Good

Start Plus

DHA/ARA

Pediasure Nepro with

Carb

Steady

Suplena

with Carb

Steady

Fluid, ml 150 148.0 150 100.0 55.6 55.6

Protein, g 2.1 2.2 2.2 3.0 4.5 2.5

Fat, g 5.3 5.6 5.1 5.0 5.3 5.3

Carbohydrate, g 10.9 10.2 11.2 11.0 9.3 11.2

Fiber, g 0 0.0 0 0.5 0.9 0.9

Linoleic acid, mg 860 1300.0 900 1071.7 Not available Not available

Vitamin A, IU 300 300.0 300 257.4 176.7 176.7

Vitamin D, IU 60 60.0 60 50.6 4.7 4.7

Vitamin E, IU 2 2.5 2 2.3 5.3 5.3

Vitamin K, mcg 8 8.0 8 3.8 4.7 4.7

Thiamin (B1), mcg 80 100.0 100 270.0 133.3 144.4

Riboflavin (B2), mcg 140 150.0 140 211.0 150.0 144.4

Vitamin B6, mcg 60 60.0 75 261.6 472.2 472.2

Vitamin B12, mcg 0.3 0.3 0.33 0.6 0.5 0.5

Niacin, mcg 1000 1050.0 1050 1687.8 1777.8 1777.8

Folic acid, mcg 16 15.0 15 37.1 58.9 58.9

Pantothenic acid, mcg 500 450.0 450 1012.7 888.9 888.9

Biotin, mcg 3 4.5 4.4 32.1 26.4 26.4

Vitamin C, mg 12 9.0 9 10.1 5.8 5.8

Choline, mg 24 12.0 12 30.0 35.3 35.3

Inositol, mg 6 24.0 6 8.0 Not available Not available

L-carnitine, mg 2 Not available Not available Not available 14.7 14.7

Calcium, mg 78 56.0 64 97.0 58.9 58.9

Phosphorus, mg 43 28.0 36 80.2 38.9 38.9

Magnesium, mg 8 6.0 7 19.8 11.7 11.7

Iron, mg 1.8 0.7 1.5 1.4 1.1 1.1

Zinc, mg 1 0.8 0.8 1.2 1.4 1.4

Manganese, mcg 15 5.0 7 101.3 116.7 116.7

Copper, mcg 75 90.0 80 101.3 116.7 116.7

Iodine, mcg 10 6.0 12 9.7 8.9 8.9

Selenium, mcg 2.8 1.8 2 2.3 4.1 4.1

Sodium, mg 27 24.0 27 38.0 58.9 43.9

Potassium, mg 108 80.0 108 130.8 58.9 62.2

Chloride, mg 63 59.0 65 101.3 46.9 51.9

Osmolality, mosm/kg water

300 280.0 Not available 430.0 600.0 600.0

Osmolarity, mosm/L 270 254.0 Not available 364.0 556.0 344.0

Price (per 100 kcals) $0.64 $0.74 $0.64 $0.74 $0.30 $0.30


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Severe Gastrointestinal Impairment (8 - 13)

Severe gastrointestinal impairment caused by chronic diarrhea/malabsorption, cystic fibrosis, Crohn’s disease, radiation enteritis, delayed gastric emptying, pancreatitis, HIV/AIDS, or short bowel syndrome may be characterized by:

Malabsorption Diarrhea Electrolyte instability Malnutrition

Nutrition Goal: To provide adequate nutrition through appropriate formula selection to promote better total nutrient absorption and avert fat malabsorption, protein sensitivity, and carbohydrate intolerance in order to improve GI adaptation and deliver optimal nutrition. Medical Nutrition Therapy


Children on parenteral nutrition should have routine monitoring of serum electrolytes, trace element status, and iron status.

Children with malabsorptive conditions should have fat soluble vitamin levels, particularly vitamin D, measured

Children with an ileal resection should be evaluated for B12 deficiency.

Consider potential deficiencies based on site of intestinal resections (Appendix L). Estimated Needs

Estimated needs may be similar to that of other children of the same age and gender, but should be individualized based on disease acuity and need for catch-up growth. Malabsorption should also be considered in children with some conditions, such as short bowel syndrome.

Intervention

Formula selection: o The algorithm (Figure 6.2) may be used to aid in the decision-making process

to select a clinically appropriate formula. o Refer to Table 6.9 for an overview of semi-elemental and elemental infant and

pediatric formulas for use in children with severe GI impairment o First approach is to try intact protein formula or breast milk to promote intestinal

adaptation and improved GI tolerance. o Breast milk, although nutrients are not hydrolyzed, improves GI adaptation

compared to protein hydrolysate formulas due to bile salt lipase, lymphocytes, macrophages, well-absorbed peptides and amino acids, immunoglobins and growth factors.

o If intact formula or breast milk is not tolerated, a peptide based, higher fat formula may be used to avert allergies, bacterial overgrowth, and exert trophic effects on the GI tract.


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o Semi-elemental formulas are typically used for those with severe GI impairment or protein allergies.

o Elemental formulas are typically used when semi-elemental formulas are not tolerated.

o Formulas with higher fat content slow down transit time, promoting absorption, which improves GI adaptation.

o Long chain triglycerides: more trophic effect promoting intestinal adaptation o Medium chain triglycerides: more water soluble, improved absorption in some

children, higher osmotic effect o Trial time of formula should be about 3-5 days before evaluating the need to

change formulas.

Continuous EN provides slow delivery of nutrients to GI tract, promoting better tolerance and nutrient absorption.

Fiber: Addition of water-soluble fiber lengthens transit time and nutrient contact with mucosa increasing absorption and improving GI tolerance.

o Liquid fruit pectin: Certo, SureJell o Hydrolyzed guar gum: Resource Benefiber (institutional version)

Use of prebiotics and probiotics may reduce diarrhea and decrease symptoms of colic.

Oral rehydration solutions may be required in those with high ostomy outputs or those without a colon.

Certain medications containing sorbitol, potassium chloride elixirs, and certain antibiotics may be the cause of diarrhea.

Children with vomiting, diarrhea, abdominal distention, and metabolic acidosis should be evaluated for small bowel bacterial overgrowth.

Table 6.8 Guidelines for Formula Selection in Differing Disease States (Refer to Algorithm in Figure 6.1 and Specialized Formula Table 6.9)

Disease State

Recommended Formula

Cystic Fibrosis Standard polymeric; semi-elemental or partially hydrolyzed formula with appropriate pancreatic enzyme dosing.

Crohn’s Disease Standard polymeric or semi-elemental.

Short Bowel Syndrome Begin with semi-elemental, partially hydrolyzed formula. If not tolerated, back down to elemental formula. Eventually transition back from elemental to standard polymeric to promote better GI stimulation and adaptation.

Severe Malabsorption or Severe

Allergic Complications

Semi-elemental/ partially hydrolylzed; if not tolerated proceed to elemental formula.

Severe Protein Allergy Elemental formula


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.

67


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Table 6.9 Nutrient Information for Semi-Elemental & Elemental Formula for Use with Severe GI Impairment (per 100 kcal)

Nutrient Pregestimil Alimentum Neocate

Infant

Peptamen

Junior Pepdite Junior

PediaSure

Peptide Neocate Jr EleCare Jr

kcal/mL 0.67 0.67 0.67 1.0 1.0 1.0 1.0 1.0

Protein (g) 1.9 1.9 2.08 3.0 3.1 3.0 3.3-3.5 3.1

Protein

Source

Hydrolyzed casein

Hydrolyzed casein

Free amino acids

Whey hydrolysate

Soy and pork hydrolysates +

free amino acids

Whey hydrolysate,

caseine

Free amino acids

Free amino acids

Carbohydrate (g) 6.8 6.8 7.8 13.6 10.6 13.4 10.4-11 10.7

Carbohydrate

Source

Corn syrup and tapioca

Tapioca and sucrose

Corn syrup solids

Maltodextrin and sugar

Maltodextrin and corn syrup

(banana contains sucrose,

sweetener)

Maltodextrin, scFOS

Corn syrup solids (flavors

contain sucrose,

sweetener)

Corn syrup solids

Fat (g) 3.8 3.8 3.0 3.84 5 4.1 4.7-5 4.9

Fat

Source MCT oil, corn oil

MCT, soy, safflower oil

Safflower, soy, coconut

oil

Coconut, soy, canola, soy oil,

lecithin

Coconut, safflower, soy oil

Canola, MCT oil

Coconut, canola,

safflower oil

Safflower, coconut, soy

oil

Distribution

Protein 11% 11% 12% 12% 12% 12% 13-14% 15%

Carbohydrate 41% 41% 47% 54% 42% 53% 42-44% 43%

Fat

LCT

MCT

48% 48% 41% 34% 46% 35% 42-45% 42%

45% 67% 67% 40% 65% 50% 65% 67%

55% 33% 33% 60% 35% 50% 35% 33%

Osmolality

(mOsm/kg) 340 370 375

260 (unflavored) 360-400(flavors)

430 (unflavored) 440 (banana)

250 590(unflavored) 680-700(flavor)

590

Indications

Generalized malabsorption,

short bowel syndrome

Generalized malabsorption Short bowel syndrome

Cow’s milk or multiple food

allergies, GER

Malabsorption, gastrointestinal

impairment

Malabsorption, severe food

allergies, gastrointestinal tract impairment

Mal-absorption,

maldigestion

Multiple food allergy, gastro-intestinal tract impairment,

malabsorption

Malabsorption,

severe food allergies, GI tract

impairment

Adapted from proprietary product literature.


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Chylous Ascites/Chylothorax (13 - 18)

Chylous ascites is a condition caused by a complication in which there is an occlusion to a thoracic duct or division of the lymphatic channels leading to chyle leaks in the thoracic and peritoneal cavities. As a result, pleural effusions, abdominal pain, anorexia, hypoalbuminemia, hyponatremia, hypocalcemia, hypercholesterolemia, and elevated alkaline phosphatase are common, which present nutritional challenges to the clinician if left unmanaged. Factors contributing to the nutritional implications include:

Body protein loss White blood cell losses Immunosuppression Lipid losses

Nutrition Goal: To sustain electrolyte, fluid, and nutritional homeostasis by providing adequate nutrients without stimulating chyle flow and increasing lymph production.


Estimated Needs

Caloric needs are 1.7-1.8 x BEE.

Protein needs may be higher than normal for a hospitalized patient, if there is active chest tube output.

Interventions

Nutrition therapy is an important part of the UVA pediatric chylothorax management algorithm (Appendix M).

A low-fat diet (Table 6.10) or low LCT/high MCT formula is generally needed. o Elimination of long chain triglycerides (LCT) can decrease lymphatic flow

and enhance fistula healing. LCT should be restricted to 10-20 g/day. o In infants or those fed enterally, use special formulas that are high in MCT,

such as Enfaport (Mead Johnson), Monogen (Nutricia), Portagen (Mead Johnson) , or low in total fat, such as Lipisorb (Nutricia), Vivonex (Nestle), or Tolerex (Nestle).

o Nutrition supplements (Resource Breeze or Carnation Instant Breakfast with skim milk) should be utilized to ensure adequate intake.

If oral intake or enteral feeds are not tolerated or if extremely aggressive therapy is required, parenteral nutrition and IV lipids may be used.

To prevent essential fatty acid (EFA) deficiency, EFA should represent 2-4% of calories. Good sources of essential fatty acids include sunflower, safflower, flaxseed, and canola oils.

o Monitor for essential fatty acid (EFA) deficiency; an elevated triene:tetraene ratio is indicative of deficiency. Signs and symptoms of EFA deficiency include skin lesions, eczema, impaired wound healing, thrombocytopenia, and growth problems.

A therapeutic vitamin and mineral may need to be provided to ensure adequate micronutrient delivery.


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Table 6.10 Food Selection Guidelines for a Restricted Fat Diet

Food Group Recommended Avoid Tips

Grains

Fat-Free and Low-Fat: bread, pasta,

cereals, rice, barley, and crackers

Breads with eggs or cheese, granola

cereal, cereal with nuts, biscuits,

waffles, pancakes, croissants, muffins, doughnuts, high fat

crackers

Try French bread, pita bread, plain bagels, bread sticks, puffed

rice and Rice Krispies.

Fruits Fresh, frozen,

canned, or dried fruit, juices

Avocado, coconut Use as snacks

Vegetables Fresh, frozen, or

canned vegetables

Vegetables with added fat, cream, or cheese sauce, fried

vegetables

Cook in broth or sprinkle with herbs and

spices to add flavor

Dairy

Skim milk, nonfat cheese, nonfat yogurt, nonfat

cottage cheese, fat-free sour cream or

cream cheese

1%, 2%, whole, or flavored milk,

buttermilk, cream, and regular

processed cheeses

Whole milk can be substituted with skim milk, evaporated skim milk, or nonfat yogurt

Protein

Egg whites, powdered egg

whites, lean cuts of beef, pork, lamb,

veal, poultry without skin, fresh, frozen, or canned fish in

water, nonfat tofu, no added fat beans

Fried, fatty, or heavily marbled

beef, poultry, fish canned in oil,

luncheon meats, pizza, nuts, peanut

butter

Broil, roast, grill, or boil proteins, trim all visible fat before cooking, use natural juices instead of gravies and sauces

Other

Fat-free broths or soups, fruit ice,

popsicles, gelatin, angel food cake, graham crackers, nonfat desserts,

honey, hams, jellies, syrups, hard candy,

soda, fruit drinks

Cream or cheese sauces or soups,

gravy, mayonnaise, cakes, cookies,

pies, and ice cream, coconut, chocolate,

creamed candy, candy with nuts, chips, buttered

popcorn

Try lemon juice, vinegar, garlic, onion

powder, fat-free margarine, fat-free dressings, fat-free mayonnaise, and marshmallows.


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Burns (19-21)

Burns create an extreme state of physiologic stress; hypermetabolism is multifactorial and is due to increased circulating cytokines, catecholamines, glucagon, and cortisol; evaporative losses from burn wounds; and infectious complications. Patients with burns have elevated calorie, protein, fluid, and micronutrient needs.

Nutrition Goal: To provide adequate nutrition (including adequate calories, protein, fluid, and micronutrients) to blunt the hypermetabolic response, reduce lean body mass wasting, induce positive or neutral nitrogen balance, and promote wound healing.


Estimated Needs

See Table 3.10 for predictive energy expenditure equations.

Patients older than 6 months of age with >30% body surface area burned (BSAB) should receive 20-23% of calories from protein (2.4-4 g/kg protein). o Protein needs can also be determined by RDA for age + 1 gram of protein per

% BSAB. o Monitor fluid status and BUN when giving large amounts of protein; watch for

signs of azotemia, hyperammonemia, and acidosis.

Maintenance fluids for burn patients can be calculated as follows:

21500 ml x m2Total maintenance fluids = (35 % burn) x m (ml/hr)

24 hours

Interventions

Snacks and high-protein nutrition supplements are often needed to meet needs in those taking oral nutrition.

Enteral nutrition supplementation should be considered in those not able to meet needs orally, including those with >20% BSAB, facial injury, or inhalation injury.

The daily wound care/sedation schedule will need to be considered, as patients are generally NPO a few hours prior to sedation.

All children should receive an age-appropriate multivitamin. Those with burns > 20% BSAB should receive additional micronutrient supplementation according to Table 6.11.

Table 6.11 Micronutrient Supplementation for >20% BSAB

< 3 years old > 3 years old

Ascorbic acid 250 mg twice daily 500 mg twice daily

Vitamin A 5,000 IU daily 10,000 IU daily

Zinc sulfate 220 mg daily (~50 mg elemental zinc)

100 mg daily (~25 mg elemental zinc)


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Refeeding Syndrome (22-28)

Refeeding syndrome is a constellation of hypokalemia, hypomagnesemia, and hypophosphatemia that occurs with aggressive nutritional repletion of patients who are severely malnourished, underweight, or starved. Refeeding syndrome can result in severe neurologic, cardiac, respiratory, and hematologic abnormalities, and even death. At-risk patients include those with:

Classic marasmus/kwashiorkor

Anorexia nervosa

Chronic diseases causing undernutrition (cancer cachexia, Crohn’s disease, cystic fibrosis, HIV)

Acute weight loss of 10% within the past 1-2 months (even in the presence of morbid obesity)

<80% ideal body weight for height

Arm anthropometrics less than the 5th

percentile for age

Unfed for 7-14 days with evidence of stress/depletion

Prolonged IV hydration without provision of sufficient calories and protein

Failure to thrive due to starvation/neglect

Nutrition Goal: To identify patients at risk for refeeding syndrome and to prevent the metabolic complications of this syndrome while appropriately advancing nutrition support therapy to adequate levels.



Serum electrolytes, particularly potassium, phosphorus, and magnesium must be assessed, and should ideally be corrected with IV supplementation before beginning nutrition support. Electrolytes should be checked, initially, 2-3 times daily, and when the patient is more stable, can be checked once daily or once every other day.

Patients should receive an ECG to obtain baseline cardiac rhythm and check for arrhythmias.

Estimated Needs/Interventions

Calories should begin at 50% of BEE or 80% of current caloric intake. Increase by 10-15% per day to a goal. Daily intakes should be based on actual (not goal) intake from the day prior. Goal calories should be based on catch-up growth calculations or estimated basal needs, plus a factor for weight gain, if desired.

Protein should begin at 50-75% of goal levels, with a gradual increase to goal. Goals may be based on catch-up growth calculations, if accelerated weight gain is desired.

Fluid requirements are 75% of maintenance levels in severely malnourished patients, to prevent cardiac overload.


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Electrolyte requirements for parenteral nutrition in at risk patients are: o Na – 1 mEq/kg/day o K – 4 mEq/kg/day o Mg 0.6 - 1.2 mEq/kg/day o Phosphate – 3-4 mEq/kg/day for infants, 1-2 mEq/kg/day for toddlers and

adolescents o Adjust as needed per laboratory values

Standard vitamin/mineral supplementation is prudent: o Standard dosage for Peds or Adult MVI or trace element solutionin TPN (See

Chapter 7) o Enteral nutrition: provide 1 ml multivitamin drops + DRI for folic acid o Oral nutrition: provide children’s multivitamin with minerals for children over 4


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References

1. Abad-Sinden A, Sutphen JL. Growth and nutrition. In: Emmanoullides GC, Riemenschneider TA, Allen HD, Gutgessel HP, eds. Moss and Adams Heart Diseases in Infants, Children and Adolescents, Including the Fetus and Young Adult. 6

th edition.

Baltimore, MD: Lippincott, William & Wilkins; 2001:324-331. 2. Wessel JJ, Samour PQ. Cardiology. In: Samour PQ, King K, eds. Handbook of Pediatric

Nutrition. 3rd

edition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:407-420. 3. Goodin B. Nutrition issues in cystic fibrosis. Pract Gastroenterol. 2005;27(5):76-94. 4. Woolridge NH. Pulmonary diseases. In: Queen PM, King K, eds. Handbook of Pediatric

Nutrition. 3rd

edition, Sudbury, MA: Jones and Bartlett Publishers, 2005:307-350. 5. Spinozzi NS. Chronic renal disease. In: Queen PM, King K, eds. Handbook of Pediatric

Nutrition. 3rd

edition. Sudbury, MA: Jones and Bartlett Publishers, 2005:3851-390. 6. National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Pediatric

Guidelines, K/DOQI Update 2008. Available at: www.kidney.org. Accessed May 10, 2010. 7. Belay B, Esteban-Cruciani N, Walsh CA, Kaskel FJ. The use of levo-carnitine in children

with renal disease: a review and a call for future studies. Pediatr Nephrol. 2006;21:308-317.

8. Crill CM, Helms RA. The use of carnitine in pediatric nutrition. Nutr Clin Pract.

2007;22:204-213. 9. Abad-Jorge A, Roman B. Enteral nutrition management in pediatric patients with severe

gastrointestinal impairment. Support Line. 2007;29(3): 3-11. 10. Abad-Sinden A, Sutphen J. Nutritional management of pediatric short bowel syndrome.

Pract Gastroenterol. 2003;12(12):28-48. 11. Serrano MS, Schmidt-Sommerfeld E. Nutrition support of infants with short bowel

syndrome. Nutrition. 2002;18(11-12):966-970. 12. Wessel JJ. Short bowel syndrome. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds.

Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:469-487. 13. Suddaby EC, Schiller S. Management of chylothorax in children. Ped Nurs. 2004;30(4):

290-295. 14. Chan EH, Russell JL, Williams WG, et al. Postoperative chylothorax after cardiothoracic

surgery in children. Ann Thorac Surg. 2005;80:1864-1871. 15. McCray, S, Parrish CR. When chyle leaks: nutrition intervention. Practical Gastroenterol.

2004;28(5):60.


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16. Hamdan MA, Gaeta ML. Octreotide and low-fat breast milk in postoperative chylothorax.

Ann Thorac Surg. 2004;77: 2215-2217. 17. Cormack BE, Wilson NJ, Finucane K, West TM. Use of monogen for pediatric

postoperative chylothorax. Ann Thorac Surg. 2004;77:301-305. 18. Pettei MJ, Saftary S, Levine JS. Essential fatty acid deficiency associated with the use of

a medium-chain-triglyceride infant formula in pediatric hepatobiliary disease. Am J Clin Nutr. 1991;53:1217-1221.

19. Mayes T, Gottschlich MM, Warden GD. Clinical nutrition protocols for continuous quality

improvements in the outcomes of patients with burns. J Burn Care Rehabil. 1997;18:365-368.

20. Rodriguez DJ. Nutrition in patients with severe burns: state of the art. J Burn Care

Rehabil. 1996;17:62-70. 21. Gottschlich MM, Mayes T. Nutrition in the Burned Pediatric Patient. In: Samour PQ, King

K, eds. Handbook of Pediatric Nutrition. 3rd


22. Dunn RL, Stettler S, Mascarenhas MR. Refeeding syndrome in hospitalized pediatric

patients. Nutr Clin Pract. 2003;18:327-332. 23. Katzman DK. Medical complications in adolescents with anorexia nervosa: a review of the

literature. Int J Eat Disord. 2005;37:S52-S59. 24. Afzal NA, Addai S, Fagbemi A, Murch S, Thomson M. Heuschkel R. Refeeding syndrome

with enteral nutrition in children: a case report, literature review and clinical guidelines. Clin Nutr. 2005;21:515-520.

25. de Menezes FS, Leite HP, Fernandez J, Benzecry SG, de Carvalho WB.

Hypophosphatemia in children hospitalized within an intensive care unit. J Intensive Care Med. 2006;21:235-239.

26. Mezoff AG, Gremse DA, Farrell MK. Hypophosphatemia in the nutritional recovery

syndrome. AMDC. 1989;143:1111-1112. 27. de Menezes FS, Leite HP, Fernandez J, Benzecry SG, de Carvalho WB.

Hypophosphatemia in critically ill children. Rev Hosp Clin Fac Med S Paulo. 2004;59:306-311.

28. Worley G, Claerhout SJ, Combs SP. Hypophosphatemia in malnourished children during

refeeding. Clin Pediatr. 1998;37:347-352.


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Chapter 7 Parenteral Nutrition

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Chapter 7

Parenteral Nutrition

Introduction

Pediatric patients who are unable to meet their nutritional needs to promote growth and development via the oral or enteral route will require parenteral nutrition (PN) support (1). Preterm infants under 2000 g who are unable to be started on enteral feeds should be started on parenteral nutrition by no later than day of life 2-3. Pediatric patients who may require parenteral nutrition for either total or partial nutritional support include the following clinical examples (1-3):

Gastrointestinal (GI) anomalies

Necrotizing enterocolitis

Inflammatory bowel disease

Intractable diarrhea

Short gut syndrome

Extreme prematurity with gut dysmotility and severe respiratory distress

Cancer in the presence of underlying malnutrition and/or requiring intensive chemotherapy; inability to tolerate enteral feedings

Critical illness (trauma or sepsis) in the face of ileus, abdominal trauma or persistent GI intolerance

Peripheral vs. Central Parenteral Nutrition

In general, pediatric patients who will require parenteral nutrition for less than 2 weeks or neonates with adequate peripheral venous access and who are able to tolerate at least 140 – 150 ml/kg may be managed with peripheral parenteral nutrition (PPN). Generally a maximum solution osmolality of 1000 - 1200 mOsm/L is recommended for PPN (4-8). Pediatric patients who will require parenteral nutrition for greater than 2 weeks or those with

GI anomalies and surgery will require central parenteral nutrition (CPN). Percutaneously

inserted central catheters (PICC) lines are used for the infusion of parenteral nutrition. These lines are inserted by nurses in the NICU or by trained physicians. Generally, the lines are inserted via a vein in the antecubital area. Any concentration of dextrose may be given through PICC lines. Alternatively, pediatric patients who are not good candidates for PICC lines or those for which attempts at PICC line placement were unsuccessful, may receive surgically placed central lines for CPN.


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Guidelines for Initiation & Advancement of Parenteral Nutrition (1-13)

For a complete review of pediatric parenteral nutrition requirements, please refer to Chapters 3 and 4.

Use of Dextrose and Insulin

1. Preterm Infants: Begin dextrose at 4 – 6 mg glucose/kg/min and advance by 1 - 2 mg glucose/kg/min or 1 – 2% per day to an endpoint goal of:

D15 – 25% for CPN

D10 – 12.5% for PPN The endpoint goal should be sufficient to meet, but not exceed, nutritional requirements. In general, preterm infants on PN should not receive carbohydrate loads in excess of 12 mg glucose/kg/minute.

2. Term Infants and Children: Begin PN at 10 – 15% dextrose depending on whether the line is peripheral or central and the clinical status and age of the child. Advance by 2.5 – 5% in older infants and children and by 5 – 10% per day in adolescents until an endpoint of D10 – 12% dextrose for PPN or generally between 20 – 25% dextrose for CPN, as needed to meet nutritional needs.

a. In general, the carbohydrate load in children through adolescents generally falls in the range of 6 – 14 mg glucose/kg/min (9).

b. Specific recommendations include (10): i. Term infants – 5-15 mg/kg/min ii. 1-3 years – 5-12 mg/kg/min iii. 4-6 years – 5-11 mg/kg/min iv. 7-10 years – 6-10 mg/kg/min v. 11-18 years – 4-7 mg/kg/min

3. Glucose Infusion Rate (GIR): To minimize the risk of hyperglycemia, overfeeding and hepatic dysfunction including fatty liver and cholestasis, GIR should not exceed the values presented above. GIR can be calculated as follows:

GIR = Rate of TPN x % Dextrose

Wt (kg) x 6

4. Blood glucose should be monitored daily via a Basic Metabolic Profile prior to advancing the % dextrose in the PN solution.

5. Provision of excess carbohydrate calories may lead to the following adverse effects:

Hyperglycemia ● Glycosuria

Hepatotoxicity ● Osmotic diuresis

Cholestasis ● Post infusion hypoglycemia

6. Insulin Use: Preterm or term infants with persistent hyperglycemia allowing only maintenance calories (70-75 kcal/kg) for > 2 weeks or resulting in inadequate weight gain and growth may need to be started on a continuous insulin infusion. Insulin infusion is usually started at 0.05 unit/kg per hour. Blood glucose levels should be


79

checked hourly initially for the first 8 – 12 hours and the insulin infusion rate adjusted accordingly to reduce and maintain blood glucose level between 90 – 150 mg/dL. With older children and adolescents, insulin may be added using the sliding scale method, initially for management, and then adding 2/3 of the previous day’s insulin requirement to the bag of PN (12). Alternatively, insulin may be added to the PN bag. For adults, recommended insulin dosages are 1 unit for every 10 or 15 grams of dextrose in the PN solution (13); however, for children, it may be more prudent to start at a conservative dose of 1 unit of regular insulin per 20 – 30 g of dextrose.

Use of Protein 1. Preterm infants and term infants under 2 years of age should be started on a pediatric

parenteral amino acid solution such as TrophAmine (B. Braun). This amino acid formulation for pediatric patients provides the following advantages:

Provides essential amino acids for infants e.g. histidine, taurine

Promotes plasma amino acid profiles within normal neonatal target range

Decreases the tendency for development of cholestasis

Addition of cysteine hydrochloride, a conditionally essential amino acid in preterms, decreases the pH of the solution thus improving calcium and phosphorus solubility

2. Table 7.1 outlines initiation and advancement for parenteral protein.

Table 7.1 Protein Advancement in Infants (Preterm and Term) and Children

Birthweight Begin Advance By Endpoint Goal

<1 kg – 2 kg >2 kg preterm Term infants

2 g/kg 2-3 g/kg 2.5 -3 g/kg

1 g/kg 1-1.5 g/kg ---

3.5 – 4 g/kg 3 - 3.5 g/kg 2.5 - 3.5 g/kg

May go up to 4 g/kg in preterms with increased needs: post-surgery, bowel perforation

Do not decrease the protein in TPN with moderate elevations in BUN; generally <50.

3. The protein concentration in peripheral parenteral nutrition should not exceed 30 - 35

g protein/L or no more than 2.5 - 3 g protein/kg in infants in order to maintain the solution osmolality within the recommended range.

4. Provision of excess protein via PN may result in the following adverse effects:

Azotemia

Metabolic acidosis possibly secondary to cysteine in the PN

Serum amino acid imbalance

Hyperammonemia

Possible hepatotoxicity, cholestasis 5. Blood urea nitrogen and creatinine should be monitored daily initially via a Basic

Metabolic Profile until the full protein intake goal is reached. An elevated BUN in the face of a normal serum creatinine may not be indicative of excess protein intake, but rather fluid restriction and intravascular depletion. General monitoring guidelines for pediatric patients on PN will be discussed further in a forthcoming section.


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Use of Lipids 1. Lipids may be safely used on a daily basis in most patients. Begin lipids at 0.5 - 2.0

g/kg and advance by 0.5 - 1.0 g/kg per day depending on a child’s age and lipid clearance to the appropriate endpoint goal. Lipids should be advanced as follows: a. Preterm and Term Infants – see Table 7.2

Table 7.2 Lipid Initiation and Advancement in Term and Preterm Infants

b. Children and Adolescents – Begin 20 % IL at 1 - 2 g/kg and advance by 1 g/kg per day to a goal of 1 – 2.0 g/kg per day depending on age and clinical status.

2. Intravenous fat emulsion, which is only available as 20% Intralipid (2 kcal/ml) at UVA

Health System should be provided at least a minimum dose of 0.5 - 1.0 g/kg per day or for provision of essential fatty acid (EFA) requirements. Signs of EFA deficiency include:

reduced growth rate

impaired wound healing

increased susceptibility to infections

thrombocytopenia

flaky dry skin

poor hair growth 3. Intravenous lipids should be used with caution in infants and children under the

following conditions:

Severe hyperbilirubinemia in preterm infants

Presumed sepsis in light of deteriorating clinical status or confirmed sepsis; once an infant’s blood cultures have been confirmed to be negative for 48 hours and if triglycerides are within normal limits, lipids should be increased gradually back up to goal of 3.0 g/kg.

Hyperlipidemia with serum triglycerides >250. Even under these conditions, the minimal amount of lipids for provision of EFA needs of 0.5 - 1 g/kg may be safely administered.

4. Monitoring:

a. Check triglyceride levels weekly for infants and children on PN by selecting serum triglycerides along with the Hepatic Panel A profile in the other pediatric units.

b. Check triglyceride levels after each 1.0 g/kg increase and then weekly in: a) infants < 28 weeks gestational age or, b) infants with birthweights < 1.0 kg while on TPN.

c. Managing Elevated Serum Triglyceride Levels (UVA Guidelines):

If triglyceride > 250 but < 300, decrease lipids by 1.0 g/kg, then recheck

Birthweight Begin Level Advance By Endpoint Goal

< 1000 grams 0.5 g/kg 0.5-1 g/kg 3.0 g/kg

> 1000 grams & Term Infants

1.0 – 2.0 g/kg 1.0 g/kg 2.5 - 3.0 g/kg


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If triglyceride > 300, decrease lipids to 0.5 - 1 g/kg for EFA, then recheck

If triglyceride > 400, stop the Intralipid, recheck, and once < 300 restart at 0.5 g/kg for provision of EFA needs

Electrolytes (1, 4, 8) Electrolytes, particularly sodium, potassium, chloride, calcium, phosphorus and

magnesium should be ordered as per the guidelines found in the Table 7.4 Parenteral

Nutrition Guidelines in Pediatric Patients in mEq/kg or mEq per total volume depending on the ordering pathway chosen (neonatal versus pediatric). Acid-Base Balance

In pediatric PN at UVA, the amount of chloride required is included as part of the PN order. Acetate amount is not delineated in the order; the amount of acetate added to the PN bag will be calculated in the compounding pharmacy based on the amount of anions needed to balance ordered cations. There is an option to minimize chloride/maximize acetate OR maximize chloride/minimize acetate in the ordering system. In this case, the minimized ion will be left out of the PN bag, even if an amount has been ordered (ie, if 30 meq of chloride are ordered, but “minimize chloride/maximize acetate” is selected, no chloride will be added). The clinician should take care to understand use of minimize/maximize options, as using these can cause large fluctuations in the amounts of anions given in the PN. Guidelines:

If serum bicarbonate is < 18 and the child is acidotic, then maximize acetate/minimize chloride in the PN solution.

If serum bicarbonate is > 27 and the child is alkalotic, then minimize acetate/maximize chloride in the PN solution.

If the serum bicarbonate is within normal range, then select “none of the above”, the chloride and acetate in the PN solution will be balanced based on the chloride order.

Calcium and Phosphorus Requirements (1, 14, 15) Particular attention needs to be given to the ordering of calcium and phosphorus in preterm infants to promote bone mineralization while preventing calcium-phosphorus precipitation in the PN solution. The recommended parenteral calcium and phosphorus intake for infants and children is given in Table 7.3.

The optimal Calcium to Phosphorus ratio for preterm and term infants is 1.3 - 1.7:1 by weight, which is a 1 – 1.3:1 molar ratio.

The combined total of calcium and phosphate (0.5 mMol phos = 1 mEq) cannot exceed 5.2 mEq/100 ml using a standard amino acid preparation or 7.2 mEq/100


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ml using TrophAmine.

Calcium and phosphorus should be advanced daily, as tolerated, in preterm infants to meet their increased requirements and to minimize the risk for osteopenia of prematurity.

If the ionized calcium is > 6.0, the calcium in the PN may be slightly decreased, while optimizing the phosphorus. Once the serum Calcium is within normal limits, continue to advance the calcium in the PN to meet goals.

Table 7.3 Recommended Parenteral Calcium & Phosphorus Intake

Recommended Intake Calcium (mEq/kg) Phosphorus (mMol/kg)

Preterm, Term Infants 3.0 - 4.0 1.5 - 2.0

Older Children (10-40 kg) 1.0 - 3 0.5 – 1.5

Adolescents (>40 kg) 1.0 - 1.5 0.5 – 0.75

Guidelines for Ordering Protein, Calcium and Phosphorus to Prevent Precipitation

For every 100 ml/kg of PN solution, the following can be added:

4 g/kg TrophAmine

4 mEq/kg Calcium

1.5 mMol/kg Phosphorus


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Table 7.4 Parenteral Nutrition Guidelines in Pediatric Patients


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Pediatric Vitamins, Trace Elements and Minerals (1, 2, 4, 14)

Pediatric patients on parenteral nutrition will receive all or a portion of the 5 ml vial of Pediatric MVI solution (Astra Pharmaceuticals), depending on their weight as follows:

Infants < 2.5 kg: Use 2 ml/kg

Infants and children 2.5 kg: Use 5 ml

Children > 40 kg: Use 10 ml Adult MVI solution (needs to be a “type-in additive”); may need to add 60 – 75 mcg of vitamin K to meet pediatric requirements.

Table 7.5 Pediatric MVI Solution (Astra Pharmaceuticals)

Vitamin Amount (per 5 ml)

Ascorbic Acid 80 mg

Vitamin A 2300 IU

Vitamin D 400 IU

Thiamine 1.2 mg

Riboflavin 1.4 mg

Pyridoxine 1 mg

Niacinamide 17 mg

Pantothenic Acid 5 mg

Vitamin E 7 IU

Folic Acid 140 mcg

Vitamin B12 1 mcg

Biotin 20 mcg

Vitamin K 0.2 mg

Trace element dosing is also based on patient weight:

A total of 0.2 ml/kg/day should be used for children up to 5 years of age.

An additional 100 mcg/kg of zinc is added to the PN solution of preterm infants < 2.5 kg and in infants through 5 kg following open heart surgery.

Add an additional 50 – 100 mcg/kg of zinc for post-operative heart surgery infants < 15 kg.

Children > 40 kg, use Adult Trace Element Solution (ATES), which has selenium. As such, selenium does not need to be ordered separately using the Peds PN Pathway.

Table 7.6 Pediatric Trace Element Solution (PTES)

(American Regent Neonatal)

Trace Element Content (per 0.2 ml)

Zinc 300 mcg

Copper 20 mcg

Chromium 0.17 mcg

Manganese 5 mcg


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Special considerations for adjustments in the use of pediatric multivitamin and pediatric trace elements include the following:

Zinc: If child has increased diarrhea or ileostomy, add 10 mcg/ml of output (maximum of 5000 mcg/day)

Copper: In biliary obstruction/cholestasis, omit (16) or reduce by 50% (3)

Chromium: In renal insufficiency, omit (16) or reduce (3)

Manganese: In biliary obstruction/cholestasis, omit (16) or reduce by 50% (3)

Selenium: In renal insufficiency, omit (16) or reduce (3)

When omitting copper and manganese due to cholestasis, the PTES solution should be held, and additional zinc and chromium should then be added as a separate additive.

Selenium (14) Selenium should be administered to all infants and children on PN for > 4 weeks at a level of 1 - 2 mcg/kg/day. In the NICU, all preterm infants and neonates will automatically receive 2 mcg/kg/day. Selenium should be decreased in renal insufficiency. Selenium deficiency may occur in children receiving long term selenium free TPN. Severe deficiency leads to:

cardiomyopathy

skeletal muscle tenderness/pain

erythrocyte macrocytosis

loss of pigmentation of hair and skin Carnitine (8, 14) Carnitine is essential for optimal oxidation of fatty acids in the mitochondria. In the healthy child, carnitine is synthesized in the liver and kidney from the precursors, lysine and methionine. Preterm infants < 34 weeks gestational age or those that are SGA on PN may develop carnitine deficiency within 6 – 10 days. Clinical signs of carnitine deficiency include the following:

cardiomyopathy

encephalopathy

nonketotic hypoglycemia

hypotonia

poor growth Carnitine supplementation has been demonstrated to normalize serum carnitine, improve fatty acid metabolism and improve nitrogen balance. Whether preterm infants on PN for a period greater than 4 weeks should be placed on carnitine supplementation remains controversial at this time. Infants or children with persistent hyperlipidemia on long-term TPN, in the absence of other precipitating factors, may benefit from carnitine supplementation at a dose of 10 - 20 mg/kg/day.


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Parenteral Iron (14)

The use of iron dextran (Imferon) in PN continues to be controversial owing to the potential for the following adverse effects:

potential for increased risk of gram negative septicemia.

potential for hyersensitivity reaction (anaphylaxis); patients with a history of asthma or other allergies may be at higher risk for anaphylactic reaction.

Infants or children on long term PN or those with documented iron deficiency anemia may receive iron dextran according to the following administration guidelines:

1. When initiating therapy, full precautions should be followed including having epinephrine, methylprednisolone, intubation equipment at the bedside. A person skilled in intubation should be available to respond to any anaphylactic response.

2. A test dose of 12 - 25 mg may be given over 5 -15 minutes followed by an hour of

observation period to identify any adverse response.

3. Monitor the infant or child throughout the administration of the first dose as delayed reactions may occur.

4. Recommended Periodic Supplementation for Patients on TPN: At UVA Health

System, we have had some success using periodic administration in our patients on chronic TPN therapy. Use of iron supplementation for a 1 - 3 week period every 2 - 4 months appears adequate for most children.

Dose: 0.5 - 0.8 mg/kg/day in the PN

Imferon can be ordered as a separate additive.

Check indices of iron status prior to and at the end of the treatment including: hemoglobin, hematocrit, MCV, MCHC, serum iron and ferritin.

Ordering Pediatric Parenteral Nutrition

PN for pediatric patients may be ordered via two pathways in Epic:

Neonatal (<10 kg)

Pediatric (>10 kg) The pediatric nutritionists for the NICU, PICU and the pediatric floors may order PN as a “pended order,” which must be released by a physician. The neonatal nutritionist will work with the neonatal nurse practitioners to educate new interns on the ordering of PN in the NICU on a monthly basis. The neonatal nutritionist is available to assist interns and residents with the ordering of PN for NICU infants, as needed.


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Monitoring of Pediatric Patients on Parenteral Nutrition (4, 11, 17) Pediatric patients on PN should be monitored according to the following schedule:

Table 7.7 Monitoring Guidelines for Pediatric Patients on PN

Adapted from Reference 16 * Electrolytes should be checked daily for the first 1-2 weeks until stable, then twice weekly. ** Weekly PN labs may be decreased to biweekly to monthly once the child is stable.

At UVA Health System the following labs may be easily collected using the following lab order sets:

Table 7.8 Lab Order Sets for Pediatric Patients on PN (UVA-HS)

Unit Daily Lab Sets Weekly Lab Sets

Pediatric Units PICU

Basic Metabolic Panel Phosphorus/Magnesium

Hepatic Panel A Triglycerides Prealbumin (to assess disease acuity, if needed)

NICU

Basic Metabolic Panel Phosphorus/Magnesium

CMP (includes albumin, triglycerides, AST/ALT, Alk phos & conjugated bilirubin)

Parameter Initial/Daily* Weekly** As needed

Anthropometrics

Weight X

Length X

Head circumference X (for < 3 y.o.)

Metabolic/Serum

Sodium/chloride X

Potassium X

Bicarbonate X

BUN/creatinine X

Glucose X

Calcium/Phosphorus X

Ionized calcium X

Magnesium X

Prealbumin/CRP X

Triglycerides X

Liver function tests (including AST/ALT/Alk Phos/total bilirubin)

X

Conjugated bilirubin X

Trace elements: Copper, zinc, whole blood manganese, selenium, chromium

X (Quarterly in

long-term patients)

Vitamin D X

Iron studies X

Blood cultures X


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Managing Metabolic and Long Term Complications of Parenteral Nutrition

While parenteral nutrition can provide optimal nutritional therapy for infants and children whose GI tracts cannot be effectively used, the health care professional needs to become knowledgeable of the numerous potential complication which can arise and how to manage them. Infants and children on PN should be monitored regularly according to the above recommended guidelines. Most complications can be avoided or effectively managed through careful biochemical monitoring and timely intervention. Complication rates can also be minimized when PN is administered according to the established protocols by health care professionals who have been trained in administration and delivery of PN therapy (12, 16). Metabolic complications may be generally presented according the following categories (4, 17):

Glucose metabolism

Protein metabolism

Lipid metabolism

Mineral and electrolyte metabolism

Bone demineralization

Hepatic dysfunction and failure Cyclic PN (18) Infants and children on long-term PN, may benefit from cyclic PN infused over 12-20 hours. Constant infusion of dextrose solutions results in high circulating insulin levels which can result in lipogenesis, hepatomegaly, fatty liver and increased risk of cholestasis. Advantages of cyclic PN include:

mobilization of fat and glycogen stores

decreased incidence of cholestasis

increased time for physical activity Cyclic TPN is rarely used in neonates due to the concern of hypoglycemia. However, in metabolically stable infant, cyclic PN can be introduced as follows (16):

Incremental advancements of TPN “break” or “window” by 1-2 hour increments to a 16-20 hour delivery time.

Taper on and taper off period for ½ - 1 hour at ½ the full TPN rate to minimize the risk of hypo or hyperglycemia.

Blood glucose may need to be checked 1-2 hours after TPN is turned off to ensure euglycemia, per unit protocol.


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Table 7.9 Managing Complications of Pediatric Parenteral Nutrition (12, 14, 17)

Metabolic Complication Possible Causes Management

Glucose Metabolism

Hyperglycemia, glucosuria, osmotic diuresis

Excessive glucose administration, prematurity & insulin resistance Stress response

- Monitor blood glucose frequently - Decrease PN rate or % dextrose - May need to begin insulin therapy, begin at 0.05 units/kg/hr

Hypoglycemia Excess insulin production (i.e. IDM infants); too rapid weaning of dextrose solution

- Monitor blood glucose frequently - Increase PN rate or % dextrose - Wean PN gradually on cyclic PN

Protein Metabolism

Hyperammonemia

Liver disease or hepatic immaturity Excess intake of amino acids (usually > 3 g/kg) Inborn errors of protein metabolism

- Monitor serum ammonia, protein intake and albumin status - May need to decrease protein intake

Prerenal Azotemia Excessive protein intake (particularly in VLBW infants with immature renal systems Intravascular volume depletion

- Lower protein intake by 0.5 –1 g/kg - Monitor BUN and creatinine - Provide adequate calories - Increase fluid delivery

Lipid Metabolism

Hyperlipidemia Excess fat delivery (> 3 g/kg); rapid infusion of lipid (in < 18 hours), infection, stress, preterm (especially SGA infants), excess glucose intake

- Monitor serum triglyceride levels - Decrease IV lipids by 1-2 g/kg - Administer lipids slowly; in preterms, deliver over 24 hours, preferably

Essential Fatty Acid Deficiency

Inadequate provision of EFA (linoleic) Administration of long term fat free PN

- Provide minimal fat for EFA needs: 0.5-1 g/kg

Hyperbilirubinemia Excess lipid infusion may promote the displacement of bilirubin from albumin binding sites

- Limit lipid infusion to no more than 1-1.5 g/kg in the face of clinically significant hyperbilirubinemia


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Table 7.9 Managing Complications of Pediatric Parenteral Nutrition (12, 14, 17), Continued

Metabolic Complications Possible Causes Management

Hepatic Dysfunction and Hepatic

Failure

Excess caloric and carbohydrate delivery, excess protein as well as vitamin and mineral intake have all been suggested as possible etiological causes of hepatic dysfunction Lack of enteral feeding/stimulation results in decreased bile flow Lack of cycling the parenteral nutrition Phytosterols in soybean based lipid emulsion

-Monitor glucose, protein and total caloric delivery. Maintain caloric delivery at optimal level for infant (may need to decrease % dextrose). -Use pediatric amino acid solution. -Cycle PN for older infants or cycle with a lower dextrose IV solution -Start enteral feedings (even if trophic) as soon as clinically feasible -If cholestatic, remove manganese and copper from the solution (PTES) -Monitor liver function tests weekly. - Consider “rescue use” of fish-oil-

based lipid emulsions in place of soybean based lipid emulsions.

Bone Demineralization Inadequate calcium, phosphorus and/or vitamin D intake in the PN solution, leading to metabolic bone disease, fractures, elevation in alkaline phosphatase Lack of adequate cycling of the PN Excess diuretic dosing.

-Monitor serum calcium, phosphorus, ionized calcium, serum alkaline phosphatase. Optimize calcium and phosphorus intake at optimal parenteral ratios: 1.3-1.7:1 by weight or 1–1.3:1 (molar ratio)


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Mineral and Electrolyte Metabolism

Electrolyte imbalance

General imbalance of sodium, potassium, and chloride are commonly seen in preterm infants during the 1

st

week of life. Other causes include losses from diarrhea, renal disease or medication therapies

- Depending on extent of the imbalance, may need to replace electrolyte via and IV solution - Adjust electrolytes in the PN solution, daily, as indicated

Hypokalemia

Inadequate potassium delivery relative to requirements; diuretic treatment; treatment with Amphotericin B, beta-adrenergic agonists (i.e. Terbutaline)

- Monitor serum potassium daily - Adjust potassium in the PN solution - Alter medication profile, if appropriate

Hyperkalemia

Excessive potassium administration, metabolic acidosis, renal insufficiency

- Monitor serum potassium daily. - Decrease potassium in the PN Solution

Hypophosphatemia High glucose infusions, refeeding syndrome in previously malnourished children, inadequate phosphorus administration

- Monitorsserum phosphorus daily - Increase phosphorus content of PN Solution

Hyperphosphatemia

Excessive phosphorus administration, Impaired renal functions, PTH deficiency

- Decrease phosphorus content of PN solution. Monitor phosphorus and calcium intake and status

Hypocalcemia

Inadequate calcium intake in PN; diurectic administration (i.e. furosemide); PTH deficiency; inadequate magnesium intake.

- Gradually increase the calcium content of the PN solution


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Hypercalcemia

Excessive calcium intake, imbalance in calcium and phosphorus intake with resulting excess PTH

- Depending on degree of hypercalcemia, may need to decrease calcium in PN solution. Optimize phosphorus delivery and achieve optimal Ca: Phos ratio. Monitor calcium, phosphorus and alkaline phosphatase

Hypomagnesemia

Inadequate magnesium intake relative to requirements, refeeding syndrome in previously malnourished pediatric patient, chronic diarrhea, Amphotericin B administration

- Monitor serum magnesium daily. - Increase magnesium in the PN solution

Hypermagnesemia

Excessive magnesium intake, renal insufficiency, tocolysis in mother

- Monitor serum magnesium. - Decrease magnesium in the PN solution, as needed

Metabolic hyperchloremic acidosis

Excessive chloride content in PN solution If metabolic acidosis in the face of elevations in BUN/Cr, protein load may be contributing to acidosis

-Increase acetate salts in the PN solution - If amino acids playing a role in acidosis, decrease protein in PN by 0.5 – 1 g/kg

Metabolic hypochloremic alkalosis Excessive acetate salts in the PN solution

- Increase chloride content and decrease acetate content of the PN - Monitor blood chloride and bicarb

Adapted from Groh-Wargo, S., Thompson, M. and Hovasi-Cox, J. Nutritional Care of High Risk Newborns. Precept Press, 2000; Pg 97-100. (14)

Chapter 8 Pharmacology and Nutrition Support

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References

1. Baker SS, Baker RD. Parenteral nutrition. In: Walker WA, Goulet O, Kleinman RE, Sherman PM, Schneider BL, Sanderson IR, eds. Pediatric Gastrointestinal Disease. 4

th

edition. Philadelphia, PA: B.C. Decker, Inc.; 2004:1958-1980.

2. Shwenk WF, Olsen D. Pediatrics. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:347-372.

3. Reiter, P. Thureen, P.F. Nutrition Support in Neonatology. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:323-346.

4. Cox JH, Melbardis IM. Parenteral Nutrition. In: Samour PQ, King K, 3rd

edition. Handbook of Pediatric Nutrition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:525-558.

5. Isaacs JW, Millikan WJ, Stackhouse J, et al. Parenteral nutrition of adults with a 900 milliosmolar solution via peripheral veins. Am J Clin Nutr. 1977;30:552-559.

6. Correia MI, Guimaraes J, Cirino de Mattos L, et al. Peripheral parenteral nutrition: an option for patients with an indication for short-term parenteral nutrition. Nutr Hosp. 2004;19(1):14-18.

7. Bodoky A, Zbinden A, Muller J, et al. Peripheral venous tolerance of hyperosmolar infusion solutions. Helv Chir Acta. 1980;47:151-156.

8. Sapsford A. Parenteral nutrition: energy, carbohydrate, protein and fat. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:119-149.

9. Phillips SK. Pediatric parenteral nutrition. J Infus Nurs. 2004;27(3):166-170.

10. Hovasi Cox J, Mara Melbardis I. Parenteral nutrition. In: Samour PQ, King K, 3rd

edition. Handbook of Pediatric Nutrition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:483-498.

11. Mirtallo JM. Introduction to parenteral nutrition. In: Gottschlich M, Fuhrman MP,

Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:211 - 224.

12. Matarese LEM. Metabolic complications of parenteral nutrition therapy. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral


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and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:269-286.

13. Hurley DL, Neven AK, McMahon MM. Diabetes Mellitus. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support – A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:269-286.

14. Krug SK. Parenteral nutrition: vitamin, minerals and trace elements. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:151-175.

15. Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition. Am J Clin Nutr. 1988; 48:1324-1342.

16. Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins,

trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition: report of the Subcommittee on Pediatric Parenteral Nutrient Rqeuirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition. Am J Clin Nutr. 1988;48:1324-1342.

17. Price PT. Parenteral nutrition: administration and monitoring. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:91-107.

18. Collier SB, Crouch J, Hendricks K, et al. Use of cyclic parenteral nutrition in infants less than 6 months of age. Nutr Clin Pract. 1994; 9:65.


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Chapter 8

Pharmacology and Nutrition Support

Introduction

Knowledge of a pediatric patient’s medication profile is important for optimizing nutritional support intake and delivery. The clinical nutritionist will review each patient’s medication profile and determine how these drugs impact nutrition. Topics covered in this chapter include:

Common drug-nutrient interactions seen in hospitalized patients

Medications which should be taken on an empty stomach or those that may be affected by enteral nutrition

Medications that are not compatible with parenteral nutrition.

Calcium and phosphorus balance and solubility in parenteral nutrition solutions

Electrolyte supplementation via the enteral route

Critical care medications and nutritional delivery.

Medication Information Resources

Micromedex – This evidence-based clinical information system is available through the Clinical Portal. Micromedex provides information on drug dosing, administration, adverse effects, and drug interactions. For IV drugs, it also provides information on drug compatibility. An on-line tutorial is available on the Micromedex website and the Health Sciences Library offers classes for those interested in learning more about the system.

Websites: Global RPh – www.globalrph.com General info www.noah-health.org/en/pharmacy/drugs/food.html FDA www.fda.gov National Consumers League www.nclnet.org Natural Standard www.naturalstandard.com NIH National Center for Complementary and Alternative Medicine

http://nccam.nih.gov/

For questions or additional information, contact the pediatric pharmacy at 2-0920

Common Drug-Nutrient Interactions Seen in Hospitalized Patients Interactions between certain foods and drugs may reduce or enhance the effect of the drug. Preventing and managing drug-nutrient interactions in the clinical setting are pivotal in order to avoid predisposing patients to treatment failure, toxicity, or life-threatening adverse events. The following table provides common drugs along with their interactions, mechanism of action, and therapeutic management.

http://www.globalrph.com/

http://www.noah-health.org/en/pharmacy/drugs/food.html

http://www.fda.gov/

http://www.nclnet.org/

http://www.naturalstandard.com/

http://nccam.nih.gov/


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Table 8.1 Common Drugs with Potential Nutrient Interactions

Drug or Class Interaction Mechanism Therapeutic

Management

ACE Inhibitors Excessive potassium intake

Pharmacodynamic interaction, risk of hyperkalaemic adverse effects

Avoid consuming large quantities of high potassium foods.

Digoxin Increased fiber intake

Pharmacokinetic interaction, reduced absorption

If fiber intake changes, may need to adjust dosage.

Felodipine Grapefruit, Citrus juice

Pharmacokinetic interaction, inhibition of metabolism

Avoid grapefruit juice.

Levodopa Pyridoxine Pharmacodynamic interaction, decreased dopamine availability

Maintain consistent vitamin B6 intake.

MAO Inhibitors Tyramine

Pharmacodynamic interaction, blocked deamination of dietary pressor amines, risk of hypertensive crisis

Avoid foods containing tyramine. See Table 8.2.

Phenytoin Vitamin D

Alterations in nutrition status, chelation, binding to protein components, decreases absorption

May need calcium + vitamin D supplement.

Spironolactone Excessive potassium intake

Pharmacodynamic interaction, risk of hyperkalaemic adverse effects

Avoid consuming large quantities of high potassium foods.

Tetracycline Calcium Physical interaction, chelation

Avoid dairy products, iron-containing products, or antacids containing calcium, magnesium, and aluminium 1 hr. before or 2 hrs. after medication delivery.

Theophylline Caffeine, fat Pharmacodynamic interaction, additive effects

Limit caffeine to 2-3 cups of coffee, tea, or colas per day. Avoid taking with meals high in fat.

Warfarin Excessive vitamin K intake

Pharmacodynamic interaction, direct antagonism by dietary vitamin K

Vitamin K intake needs to remain consistent. Avoid high doses (>400IU/d) of vitamin E.


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Table 8.2 Tyramine Containing Foods

Aged Cheeses Overripe Fruit

Eggplant Figs

Grapes Oranges

Pineapple Plum

Prune Raisin

Avocados Sauerkraut

Processed Foods Aged Meats

Canned Meats Dried Meats

Cured/Pickled Meats Meat by-products

Fava Beans Tofu

Miso Teriyaki Sauce

Soy Products Soy Sauce

Spinach Tomatoes

Alcoholic Beverages Yeast

Bouillon Cubes Commercial Gravies

Drug Interactions with Enteral Products General Guidelines

In most cases, giving drugs to patients receiving enteral nutritional products is similar to drug administration to patients who are eating.

Liquid dosage formulations are preferred for administration through a feeding tube. Solutions or suspensions are preferred. Syrups, especially those which are acidic such as metoproterenol (Alupent) or metoclopromide (Reglan), may cause clumping of the enteral feeding if given concurrently.

If a tablet must be used, it should be crushed and mixed with a small amount of water immediately prior to administration. The tubing should then be flushed with water to prevent clogging.

Enteric-coated, sublingual, and sustained release products should never be crushed. Some sustained release capsules can be opened so that the beads can be administered through a feeding tube. The beads should not be crushed, but should be mixed with a small amount of water immediately prior to administration. The tubing should then be flushed with water to prevent clogging.

If multiple drugs are scheduled for administration, each one should be given separately with a 5 ml water flush between drugs.


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Incompatibilities

Drugs that are normally given on an empty stomach should not be administered with tube feeds. Table 8.3 lists common examples of drugs that should be taken on an empty stomach:

Table 8.3 Drugs that Should be Taken on an Empty Stomach

Ampicillin Mercaptopurine

Atenolol Methotrexate

Bisacodyl Mycophenolate

Captopril Nafcillin

Cefibuten Norfloxacin

Ciprofloxacin Ofloxacin

Cloxacillin Oxacillin

Dicloxacillin Penicillin G

Didanosine (DDI) Rifabutin

Isoniazid Rifampin

Levothyroxine Sulfonamides

Lomustine Tetracycline

Melphalan Zidovudine

In addition to the drugs listed above, some drugs that normally can be given with food cannot be given with enteral feeds. Concomitant administration of these drugs (Table 8.4) with enteral feeds can result in a significant decrease in drug absorption.

Table 8.4 Additional Drugs that May be Affected by Enteral Feedings

Aspirin Phenytoin

Calcium supplements Potassium supplements (some products)

Carbamzepine Propantheline

Digoxin Rifampin

Furosemide Theophylline

Iron supplements Voriconazole

Methyldopa Warfarin

To minimize these drug-enteral feeding interactions, the following procedure should be used (when possible):

1. Stop the tube feeding 2. Flush the tube with 20-30 ml water, or an appropriate volume based on the

patient’s size 3. Administer the dose 4. Repeat step 2 5. Wait approximately 30 minutes – 1 hour before restarting feeds


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Drug Interactions with Parenteral Nutrition

General Guidelines

Many drugs are compatible with parenteral nutrition solutions when administered through the same tubing. When a drug is administered with parenteral nutrition, it

should be administered through the Y-site closest to the patient to minimize

contact time. An in-line filter may also be placed to trap any precipitants. Incompatibilities

Information on compatibility is best evaluated on an individual case basis. Compatibility may depend on the specific components of a parenteral nutrition solution or the concentration of those components (e.g. electrolytes) in the final solution. Table 8.5 provides a brief list of several drugs known to be incompatible with most parenteral nutrition solutions.

Table 8.5 Drugs that are Incompatible with Most Parenteral Nutrition Solutions

Acyclovir Milrinone

Calcium salts Phenobarbital

Diazepam Phenytoin

Ganciclovir Phosphate salts

Immune globulin products (IVIG)

Calcium/Phosphate Balance

Identifying the most appropriate balance of calcium and phosphate is one of most challenging aspects of pediatric parenteral nutrition. Excessive amounts of one or both of these electrolytes can result in formation of dibasic calcium phosphate, which may precipitate out of solution. Solubility is also affected by:

1. pH 2. temperature 3. fluid volume 4. the sequence of adding the electrolytes 5. protein dose and formulation

A general rule of thumb is that the total mEq of calcium and phosphate cannot exceed 5.2 mEq for every 100 mL for parenteral nutrition solutions made with

Travasol (standard amino acid solution) or 7.2 mEq for every 100 mL for

parenteral nutrition solutions made with TrophAmine (pediatric amino acid solution). To convert phosphorus units, use 0.5 mMol phos = 1 mEq.

When ordering calcium and phosphorus in parenteral nutrition, to prevent precipitation for every 100 mL of PN solution, the maximum amounts to be added are 4 mEq/kg Calcium and 3 mEq/kg Phosphorus (1.5 mMol/kg phos)


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Critical Care Medications and Nutritional Delivery

Critically ill infants and children are often fluid restricted and require multiple intravenous medications and infusions that are counted towards the overall fluid delivery. The pediatric nutritionists will work closely with the PICU and NICU team to optimize nutritional support delivery in the face of fluid restriction and multiple intravenous medication intake. Common intravenous infusions used in the pediatric and newborn intensive care unit settings are listed in Table 8.6.

Table 8.6 Critical Care Medications Commonly Used as Infusions

in the Pediatric and Newborn ICU

Medication Classification

Chlorothiazide (Diuril) Diuretic

Cisatracurium Neuromuscular blocker

Dobutamine Inotrope

Dopamine Inotrope

Epinephrine Inotrope

Fentanyl Analgesic

Furosemide (Lasix) Diuretic

Midazolam (Versed) Sedative

Milrinone Inotrope

Morphine Analgesic

Pentobarbital Sedative

Vasopressin Inotrope

Vecuronium Neuromuscular blocker

The PICU dietitian will work with the pharmacist, nurse, and medical team to determine how best to concentrate the intravenous medications, given the child’s dosage and plans for weaning, in order to allow for an increased delivery rate of the parenteral or enteral nutrition fluids. The physician, however, will enter in the medication with new concentration into the computer ordering system. .


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Common Enteral Electrolyte Supplementation

Table 8.7 Electrolyte Content of Selected Enteral Supplements (9)

Supplement

(Unit, Strength)

Sodium

(mEq)

[mg]

Potassium

(mEq)

[mg]

Chloride

(mEq)

Elemental

Phosphorus

(mEq)

[mg]

Elemental

Magnesium

(mEq)

[mg]

Elemental

Calcium

(mEq)

[mg]

Neutra-Phos (PhosNaK) (packet)

7.1 [164]

7.1 [278]

0 16 [250]

0 0

Neutra-PhosK (packet)

0 14.25 [556]

0 16 [250]

0 0

Calcium carbonate (ml, 1250 mg/5 ml)

0 0 0 0 0 5 [100]

Calcium glubionate (ie, Neo-Calglucon) (ml, 1.8g/5 ml)

0 0 0 0 0 1.15 [23]

Tums, Regular Strength (tab, 500 mg)

0 0 0 0 0 10 [200]

Tums, E-X Extra Strength (tab, 750 mg)

0 0 0 0 0 15 [300]

Tums, Ultra (Maximum) Strength (tab, 1000 mg)

0 0 0 0 0 20 [400]

Magnesium gluconate (ml, 1000 mg/5 ml)

0 0 0 0 0.9 [10.8]

0

Potassium chloride (ml, 20mEq/15 ml)

0 1.3 1.3 0 0 0

Table salt (tsp)

101 [2325]

0 101

0 0 0

Table 8.8 Recommended Initial Dosages* for Enteral Electrolyte Supplements

Electrolyte Supplements Dosage

Potassium Chloride 2 mEq/kg/day in divided doses

Sodium Chloride 2-4 mEq/kg/day * Dosages given in this table are only initial suggestions. Clinical parameters, such as laboratory values, should be closely monitored and dosages should be titrated accordingly. Dosages given are for replacement of low serum values only.


102

References

1. Wohlt PD, Zheng L, Gunderson S, et al. Recommendations for the use of medications

with continuous enteral nutrition. Am J Health-Syst Pharm 2009;66:1458-67. 2. Genser D. Food and drug interaction: consequences for the nutrition/health status. Ann

Nur Metab 2008;52 (Suppl 1):29-32. 3. Magnuson BL, Clifford TM, Hoskins LA, Bernard AC. Enteral nutrition and drug

administraction, interactions, and complications. JPEN J Parenter Enteral Nutr. 2005;20: 618-624.

4. Huang S, Lesko LJ. Drug-drug, drug-dietary supplement, and drug-citrus fruit and other food interactions: what have we learned? J Clin Pharmacol. 2004;44: 559-569.

5. Mertens-Talcott SU, Sadenzensky I, De Castro WV, Derendorf H, Butterweck V. Grapfruit-drug interactions: can interactions with drugs be avoided? J Clin Pharmacol. 2006;46:1390-1416.

6. Au Yeung SCS, Ensom MHH. Phenytoin and enteral feedings: does evidence support an interaction? Ann Pharmacother. 2000; 34:896-905.

7. Williams D. The effect of enteral nutrition supplements on serum voriconazole levels. J

Oncol Pharm Pract 2012;18:128-13. 8. Lenz GT, Mikrut BA. Calcium and phosphate solubility in neonatal parenteral nutrient

solutions containing Aminosyn-PF or TrophAmine. Am J Hosp Pharm. 1988;45;2367-71.

9. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 18th

edition. Hudson, OH: Lexi-Comp Publishing; 2011.

103

APPENDIX

A – Growth Charts for Normal Infants and Children • World Health Organization Growth Standards for Infants (Charts 1 – 3) • National Center for Health Statistics (CDC) Growth Charts for Children Aged 2-

20 Years (Charts 4 – 8) • Fenton Growth Chart for Preterm Infants (Chart 9)

B - Specialized Growth Charts: Down Syndrome C – Triceps Skinfold Percentile Charts D – Mid Upper Arm Circumference Percentile Charts E - Developmental Self-Feeding Checklist F - Selected Lab Values with Nutritional Implications G - Estimated Energy Requirements (EER) for Infants and Children H - Guide to Number of Servings and Serving Size for Children I - Electrolyte Conversion Information J - Oral Multivitamin and Mineral Supplements Available at UVA K - Tips for Increasing Calories for Children L - Sites of Nutrient Malabsorption Resulting from Intestinal Resections M – UVA Therapeutic Algorithm for Management of Pediatric Post-operative Chylothorax

Birth to 24 months: BoysLength-for-age and Weight-for-age percentiles

Published by the Centers for Disease Control and Prevention, November 1, 2009SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

9895857550251052

98

95

90

75

50

25

1052

Birth to 24 months: GirlsLength-for-age and Weight-for-age percentiles


98

95

90

75

50

25

1052

9895907550251052

12

Birth

40

38

36

32

20

19

18

17

16

15

14

13

in

HEAD

CIRCUMFERENCE

HEAD

CIRCUMFERENC

30

34

52

48

46

44

cm

20

19

18

in

17

Birth to 24 months: GirlsHead circumference-for-age andWeight-for-length percentiles

NAMERECORD #

42

44

46

52

50

cm

48

50

WEIGHT

WEIGHT

WEIGHT

WEIGHT

kg lb

WEIGHT

14

2018

1416

1210

8642

987

2

incmkglb1

3

WEIGHT

2224

101112

65

E

66 68 70 72 74 76 78 80 82 84 86 88 92 94 969810010210410610890 cmin


Date Age CommentWeight Length Head Circ.

64

24232221201918

46 4850 52 54 56 58 60 62

987

222018

1416

2426283032343638404244

121314

151617

12

1011

464850

1819202122

65

2324 52

242628

9895907550

251052

989590

75

50

25

1052

11041 424039383735 36343332313029282726 43

4 LENGTH

2 to 20 years: Boys

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

S

T

A

T

U

R

E

lb

30

40

50

60

70

80

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

cm

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

90

75

50

25

10

90

75

50

25

10

113 4 5 6 7 8 9 10

97

3

97

3

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

inDate

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Published May 30, 2000 (modified 11/21/00).

2 to 20 years: Boys

Body mass index-for-age percentilesNAME

RECORD #

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

90

75

50

25

10

85

Date Age Weight Stature BMI* Comments

97

3

95

SOURCE: Developed b

(2000).





2 to 20 years: Girls

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

S

T

A

T

U

R

E

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

160

cm 113 4 5 6 7 8 9 10

90

75

50

25

10

90

75

50

25

10

97

3

97

3

lb

30

40

50

60

70

80

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

Date

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

in

SOURCE: Developed b

(2000).





2 to 20 years: Girls

Body mass index-for-age percentilesNAME

RECORD #

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

Date Age Weight Stature BMI* Comments

90

85

75

50

10

25

97

3

95

SOURCE: Developed b

(2000).





APPENDIX B Source: www.growthcharts.com

http://www.growthcharts.com/

APPENDIX B

Source: www.growthcharts.com


Table 28 Triceps skinfold in millimeters for persons 3 months-19 years-number of examined persons, mean, standard error of the mean, and selected percentiles, by sex and age : United States, 1988-1994

Selected percentile Number of Standard

Sex and age examined error of persons Mean the mean 5th 10th 15th 25th 50th 75th 85th 90th 95th

Male

3-5 months .................................. 290 10.5 0.21 * 7.9 8.4 9.2 10.7 11.7 12.5 13.2 * 6-8 months .................................. 320 10.2 0.23 * 7.3 7.9 8.5 9.9 11.6 12.5 13.3 * 9-11 months ................................ 275 9.5 0.20 * 7.1 7.4 8.1 9.2 10.7 11.1 11.8 * 1 year .......................................... 647 9.4 0.15 6.4 6.9 7.2 7.9 9.1 10.7 11.7 12.1 13.1 2 years ........................................ 555 9.1 0.13 6.4 6.7 7.3 7.9 8.9 10.4 11.1 11.5 12.4 3 years ........................................ 479 8.9 0.20 * 6.4 6.8 7.3 8.6 10.0 10.8 11.6 * 4 years ........................................ 538 9.0 0.18 6.0 6.6 6.8 7.3 8.6 10.0 11.4 12.0 12.9 5 years ........................................ 493 8.7 0.20 6.0 6.3 6.8 7.2 8.1 9.5 10.3 11.3 13.0 6 years ........................................ 278 9.8 0.46 * 6.0 6.4 7.1 8.5 10.8 12.9 14.9 * 7 years ........................................ 268 9.7 0.45 * 6.1 6.4 7.1 8.7 10.7 13.3 16.8 * 8 years ........................................ 262 10.8 0.59 * 6.3 6.4 7.3 8.8 12.3 15.7 20.1 * 9 years ........................................ 276 12.4 0.69 * 6.6 6.8 7.4 9.7 15.4 21.3 23.9 * 10 years ...................................... 293 12.5 0.63 * 6.0 6.9 8.2 10.4 15.5 20.8 22.3 * 11 years ...................................... 282 13.6 0.70 * 6.7 7.2 8.6 11.3 18.2 19.5 22.3 * 12 years ...................................... 200 13.5 0.77 * * 7.6 8.6 12.9 17.4 19.2 * * 13 years ...................................... 182 12.4 0.89 * * 6.4 7.1 10.5 15.7 19.7 * * 14 years ...................................... 183 11.0 0.82 * * 6.2 6.7 8.3 13.4 17.0 * * 15 years ...................................... 182 12.1 1.00 * * 6.0 6.7 9.5 13.8 19.2 * * 16 years ...................................... 191 11.1 0.86 * * 6.6 7.1 8.6 13.6 17.0 * * 17 years ...................................... 191 11.3 0.82 * * 5.8 7.2 8.9 12.8 19.2 * * 18 years ...................................... 168 10.9 0.90 * * 5.7 6.3 8.3 12.6 16.8 * * 19 years ...................................... 160 12.1 1.05 * * 6.3 7.5 9.5 12.2 21.9 * *

Female

3-5 months .................................. 309 10.4 0.21 * 7.9 8.2 8.7 10.3 11.8 12.3 12.6 * 6-8 months .................................. 261 9.9 0.28 * * 7.6 8.2 9.4 11.3 12.2 * * 9-11 months ................................ 316 9.6 0.24 * 7.1 7.4 8.0 9.2 10.9 11.9 12.7 * 1 year .......................................... 626 9.7 0.16 6.5 7.1 7.4 8.1 9.6 11.0 11.9 12.4 13.5 2 years ........................................ 545 9.5 0.17 * 7.1 7.4 7.9 9.2 10.9 11.6 12.3 * 3 years ........................................ 554 9.7 0.21 * 7.1 7.4 8.1 9.1 10.9 11.6 12.4 * 4 years ........................................ 529 10.3 0.29 * 7.3 7.7 8.4 9.6 11.6 12.8 13.4 * 5 years ........................................ 554 10.3 0.27 * 7.3 7.6 8.2 9.6 11.4 12.8 14.4 * 6 years ........................................ 273 10.3 0.48 * * 7.1 7.5 9.3 11.1 13.6 * * 7 years ........................................ 269 11.9 0.59 * * 7.4 7.9 10.6 14.5 18.0 * * 8 years ........................................ 244 12.4 0.64 * * 7.8 8.5 10.7 14.2 17.6 * * 9 years ........................................ 270 14.4 0.84 * * 8.2 8.9 12.1 16.5 23.9 * * 10 years ...................................... 255 15.0 0.81 * * 8.7 10.1 12.9 18.1 21.7 * * 11 years ...................................... 268 15.1 0.78 * * 8.9 9.9 12.9 19.8 21.2 * * 12 years ...................................... 233 15.2 0.90 * * 8.2 9.6 13.2 19.4 23.4 * * 13 years ...................................... 218 17.5 0.89 * * 10.4 11.7 15.9 22.3 24.4 * * 14 years ...................................... 216 18.7 0.90 * * 11.6 12.4 17.5 22.5 25.4 * * 15 years ...................................... 188 17.8 0.98 * * 11.1 12.4 16.7 20.7 25.7 * * 16 years ...................................... 202 18.6 0.89 * * 12.0 14.0 16.8 21.8 25.4 * * 17 years ...................................... 191 20.0 0.98 * * 12.4 14.2 19.6 24.8 27.3 * * 18 years ...................................... 165 19.4 1.07 * * * 13.8 17.9 24.2 * * * 19 years ...................................... 167 19.6 1.18 * * * 14.0 18.5 24.1 * * *

* Figure does not meet standard of reliability or precision. NOTE: Pregnant women are excluded.

Table 41 Mid-upper arm circumference in centimeters for persons 3 months-19 years-number of examined persons, mean, standard error of the mean, and selected percentiles, by sex and age : United States, 1988-1994

Selected percentile Number of Standard

Sex and age examined error of persons Mean the mean 5th 10th 15th 25th 50th 75th 85th 90th 95th

Male

3-5 months .................................. 289 14.6 0.12 * 13.2 13.5 13.9 14.5 15.4 15.7 16.0 * 6-8 months .................................. 319 15.3 0.12 * 13.8 14.0 14.4 15.2 16.1 16.6 17.0 * 9-11 months ................................ 275 15.6 0.12 * 14.1 14.5 14.8 15.7 16.4 16.8 17.1 * 1 year .......................................... 651 16.1 0.08 14.4 14.8 15.0 15.4 16.0 16.9 17.3 17.7 18.3 2 years ........................................ 574 16.5 0.08 14.8 15.1 15.4 15.6 16.3 17.2 17.8 18.0 18.5 3 years ........................................ 483 16.9 0.13 15.0 15.4 15.7 15.9 16.8 17.7 18.2 18.6 19.0 4 years ........................................ 542 17.3 0.11 15.3 15.6 16.0 16.4 17.1 18.0 18.4 19.0 19.5 5 years ........................................ 495 17.9 0.13 15.5 16.0 16.2 16.8 17.7 18.6 19.3 19.6 20.7 6 years ........................................ 279 18.9 0.28 * 16.4 16.8 17.1 18.4 19.6 20.5 22.7 * 7 years ........................................ 268 19.3 0.24 * 17.1 17.6 17.9 18.9 20.3 21.3 21.7 * 8 years ........................................ 261 20.4 0.31 * 17.5 18.0 18.4 19.6 21.8 23.4 24.7 * 9 years ........................................ 276 21.7 0.34 * 18.3 18.6 19.2 20.7 24.2 25.3 27.0 * 10 years ...................................... 294 22.6 0.34 * 18.7 19.2 20.1 22.0 25.0 26.6 27.5 * 11 years ...................................... 281 23.6 0.38 * 19.7 20.0 21.1 22.7 25.5 27.4 28.1 * 12 years ...................................... 202 25.2 0.45 * * 21.6 23.1 24.1 27.3 28.5 * * 13 years ...................................... 181 25.7 0.49 * * 22.0 23.6 24.6 27.8 28.6 * * 14 years ...................................... 185 28.1 0.78 * * 23.9 24.3 27.0 29.8 30.6 * * 15 years ...................................... 183 28.5 0.51 * * 24.9 25.9 27.5 31.1 33.3 * * 16 years ...................................... 191 29.2 0.50 * * 25.6 26.6 28.4 31.2 32.6 * * 17 years ...................................... 193 30.7 0.51 * * 26.7 27.7 30.0 33.1 35.3 * * 18 years ...................................... 168 30.1 0.55 * * 25.9 27.4 29.6 31.8 34.5 * * 19 years ...................................... 161 31.5 0.52 * * 27.8 28.6 30.8 33.7 35.8 * *

Female

3-5 months .................................. 309 14.0 0.13 * 12.7 12.9 13.3 14.0 14.8 15.2 15.6 * 6-8 months .................................. 262 14.8 0.14 * * 13.6 13.9 14.7 15.4 16.1 * * 9-11 months ................................ 315 15.2 0.12 * 13.8 14.0 14.4 15.2 15.9 16.4 16.7 * 1 year .......................................... 627 15.9 0.09 14.0 14.4 14.7 15.0 15.9 16.7 17.0 17.5 17.9 2 years ........................................ 556 16.3 0.09 * 15.0 15.2 15.5 16.2 17.0 17.4 17.9 * 3 years ........................................ 561 17.0 0.11 15.1 15.5 15.8 16.1 16.8 17.6 18.1 18.5 19.3 4 years ........................................ 527 17.6 0.17 * 15.6 15.9 16.4 17.3 18.2 19.0 19.6 * 5 years ........................................ 555 18.1 0.15 * 16.1 16.3 16.8 17.8 19.0 19.7 20.6 * 6 years ........................................ 273 18.7 0.28 * * 16.7 17.2 18.1 19.5 21.1 * * 7 years ........................................ 270 19.9 0.34 * * 17.1 17.6 19.3 21.4 23.5 * * 8 years ........................................ 245 20.6 0.35 * * 17.9 18.6 20.0 21.5 23.3 * * 9 years ........................................ 272 22.1 0.47 * * 18.4 19.3 20.9 24.0 26.5 * * 10 years ...................................... 255 22.6 0.42 * * 19.0 19.8 21.8 24.6 26.5 * * 11 years ...................................... 268 23.7 0.40 * * 20.1 21.2 23.5 25.7 27.4 * * 12 years ...................................... 233 24.5 0.48 * * 20.0 21.5 23.8 27.1 28.3 * * 13 years ...................................... 217 26.3 0.53 * * 22.1 23.0 25.4 29.1 31.1 * * 14 years ...................................... 218 26.9 0.49 * * 23.0 24.0 25.9 29.5 31.1 * * 15 years ...................................... 189 26.7 0.49 * * 23.8 24.2 25.9 28.1 30.1 * * 16 years ...................................... 204 27.3 0.47 * * 23.5 24.7 26.4 29.5 31.3 * * 17 years ...................................... 195 27.7 0.50 * * 24.2 25.2 27.0 29.3 31.2 * * 18 years ...................................... 170 27.4 0.59 * * * 24.4 26.5 29.8 * * * 19 years ...................................... 168 28.2 0.63 * * * 25.2 27.2 29.6 * * *

* Figure does not meet standard of reliability or precision. NOTE: Pregnant women are excluded.

APPENDIX E Developmental Self-Feeding Checklist

Developmental Age*

Feeding Skill

Two months

Infant brings hands to mouth in both supine and prone.

Three months

Infant brings hands to mouth while holding an object.

Three-and-a-half months

Infant visually recognizes food and the bottle.

Four months

Infant pats bottle with one or both hands.

Four-and-a-half months

Infant holds both hands on the bottle.

Five-and-a-half months

Infant holds bottle independently with one or both hands.

Five or six months

Infant mouths and gums solid foods such as hard baby cookies.

Six months

Infant drinks from a cup held by an adult.

Six-and-a-half or seven months

Infant feeds self a cracker.

Nine months

Infant is capable of independent finger-feeding. Infant holds and bangs spoon.

Nine-and-a-half months

Infant stirs spoon in imitation.

Twelve months

Child holds cup and drinks with some spilling. Child holds the handle of a cup while drinking.

Twelve to fourteen months

Child brings a filled spoon to the mouth, turning the spoon over enroute.

Fifteen to eighteen months

Child scoops food and brings it to the mouth, spilling some.

Eighteen to twenty-four months

Child gives up the bottle and drinks entirely from the cup.

Twenty to twenty-two months

Child can hold a cup in one hand while drinking.

Twenty-four months

Child brings a spoon or fork to the mouth with the hand palm-up.

Thirty months

Child can pour liquid from a small container.

Thirty-one or thirty-two months

Child feeds self with little spilling.

Thirty to thirty-six months

Child uses a fork to stab food.

*Developmental ages are approximate and may vary with individual children Morris, S.E. and Klein, M., Pre-Feeding Skills. p. 306.

APPENDIX F

SELECTED LAB VALUES WITH NUTRITIONAL IMPLICATIONS Lab Parameter Normal Range Possible Reasons for

High Value Possible Reasons for Low Value

BUN

10 – 20 mg/dl Higher in elderly: 10 – 25 mg/dl

Dehydration Renal disease Increased protein metabolism Starvation Stress Diabetes Fever Acute myocardial infarction GI bleed Congestive heart failure Urinary obstruction

Liver failure Increased protein synthesis - Late pregnancy - Infancy Acromegaly Nephrotic syndrome Overhydration Malabsorption Low protein, high CHO diets

Creatinine

0.7 - 1.3 mg/dl

Large muscle mass Muscle disease Starvation Renal disease

CO2 (Bicarbonate)

22 – 30 mEq/L

Metabolic alkalosis Respiratory acidosis Emphysema Vomiting

Metabolic acidosis Respiratory alkalosis Hyperventilation Fever Lack of oxygen

APPENDIX F SELECTED LAB VALUES WITH NUTRITIONAL IMPLICATIONS (cont.)

Lab Parameter Normal Range Possible Reasons for

High Value Possible Reasons for Low Value

Serum Osmolarity Osm = serum sodium x 2 + BUN + Glucose 2.8 18

275 – 295 mOsm/L Calculated values are generally lower than measured values

Inadequate fluid intake Diarrhea Diabetes mellitus Diabetes insipidus Renal disease Hyperlipidemia Hyperglycemia

Excess fluid intake Adrenal disease Inappropriate ADH secretion - Hypothyroidism - Cerebral disease

Porphyria - Bronchogenic cancer

Serum Glucose * Elevated values may give falsely low serum sodium values. For every 100% elevation in glucose, serum sodium should be increased 2 mEq/L

65 – 115 mg/dl

Diabetes mellitus Cushing’s syndrome Acromegaly Hemochromatosis Pheochromocytoma Burns, shock Acute pancreatitis Wernicke’s encephalopathy Dehydration Sepsis Overfeeding Corticosteroids

Liver disease Neoplasms Pancreatic disorders Addison’s disease Hypothyroidism Water overload



High Value Possible reasons for Low Value

Hematocrit (HCT) Often used to diagnose iron deficiency; not a conclusive measure

Women: 35 – 47% Men: 40 – 52%

Dehydration Polycythemia

Hemorrhage Anemia Water overload Advanced age Late Pregnancy

Hemoglobin (Hgb) More direct measure of iron deficiency than HCT

Women: 12 – 16 gm/dl Men: 14 – 18 gm/dl

Dehydration Polycythemia

Hemorrhage Iron deficiency anemia Protein–calorie malnutrition Advanced age Late pregnancy Renal failure Water overload

Mean Corpuscular Volume (MCV) Indicates average size of the red blood cells. Calculated MCV = HCT x 10 RBC

83 – 95 microns

Macrocytosis - Folate deficiency

- Vitamin B 12 deficiency - Excess alcohol intake

Hemochromatosis

Microcytosis - Advanced iron deficiency - Blood loss

Iron deficiency Iron malabsorption Lead poisoning



High value Possible Reasons for Low Value

Sodium Body content of sodium is not always reflected in serum levels

137 – 145 mEq/L

Dehydration Renal disease

Extreme sweating Diuretic medication Diabetic ketoacidosis Malabsorption Excessive GI losses SIADH

Potassium Required with nitrogen for replacement of lost muscle mass

3.5 – 5.0 mEq/L

Burns, shock Crush injuries Excess IV potassium Renal failure Diabetic ketoacidosis Dehydration Hyperglycemia

Refeeding Syndrome Starvation Vomiting Excessive GI losses Diarrhea Hypomagnesemia Cushing’s syndrome Diuretic medication Amphotericin

Chloride

98 – 107 mEq/L

Dehydration Renal failure

Gastrointestinal losses Excess urinary losses


Lab Parameter Normal Range Possible Reasons for High Value

Possible Reasons for Low Value

Calcium Absorption decreased by phytate, oxalate, phosphate, fat malabsorption and high protein diet

8.5 – 10.5 mg/dl

Cancer Renal disease Vitamin D intoxication Hyperparathyroidism Renal calculi Immobilization

Hypoparathyroidism Renal disease Osteomalacia Steatorrhea Rickets Hypomagnesemia

Phosphorous

4.0 – 7.0 mg/dl

Hemolyzed blood Diabetes Renal disease Healing fractures Vitamin D deficiency Skeletal disease

Rickets Insulin injections Malnutrition Malabsorption Refeeding syndrome

Magnesium

1.6 – 2.3 mg/dl

Renal failure Diabetic acidosis Hypothyroidism Addison’s disease Dehydration Overuse of Mg supplements or antacids

Chronic diarrhea Alcoholism Pancreatitis Renal disease Hepatic cirrhosis Toxemia of pregnancy Hyperthyroidism Malabsorption Ulcerative colitis K- depleting diuretics Refeeding syndrome

134

APPENDIX G

Estimated Energy Requirements (EER) for Infants and Children

Normal Weight Infants and Children EER for Ages 0- 36 Months EER = total energy expenditure (TEE) + energy deposition 0-3 months (89 x weight [kg] – 100) + 175 kcal 4-6 months (89 x weight [kg] – 100) + 56 kcal 7-12 months (89 x weight [kg] – 100) + 22 kcal 13-36 months (89 x weight [kg] – 100) + 20 kcal Table 1. Total Energy Expenditure (TEE) For Infants and Children 0-36 Months of Age

Kcals/kg determined as follows: TEE/reference weight (kg)

Boys Girls Age

(months) Reference

weight (kg)

TEE (kcals/day)

Kcals/kg Reference weight (kg)

TEE (kcals/day)

Kcals/kg

1 4.4 472 107 4.2 438 104 2 5.3 567 107 4.9 500 102 3 6.0 572 95 5.5 521 95 4 6.7 548 82 6.1 508 83 5 7.3 596 82 6.7 553 83 6 7.9 645 82 7.2 593 82 7 8.4 668 80 7.7 608 79 8 8.9 710 80 8.1 643 79 9 9.3 746 80 8.5 678 80 10 9.7 793 82 8.9 717 81 11 10.0 817 82 9.2 742 81 12 10.3 844 82 9.5 768 81 15 11.1 908 82 10.3 837 81 18 11.7 961 82 11.0 899 82 21 12.2 1006 82 11.6 952 82 24 12.7 1050 83 12.1 997 82 27 13.1 1086 83 12.5 1033 83 30 13.5 1121 83 13.0 1077 83 33 13.9 1157 83 13.4 1113 83 35 14.2 1184 83 13.7 1139 83

135

APPENDIX G EER for Boys Ages 3-8 Years EER = 88.5 – (61.9 x age [y]) + PA x (26.7 x weight [kg] + 903 x height [m]) + 20 kcal EER for Boys 9-18 Years EER = 88.5 - (61.9 x age [y]) + PA x (26.7 x weight [kg] + 903 x height [m]) + 25 kcal Physical Activity (PA) Coefficient for Boys: 1.00 (sedentary) 1.16 (low active) 1.31 (active) 1.56 (very active) Table 2. Estimated Energy Requirements (EER) For Boys 3-18 Years of Age

PAL = physical activity level Kcals/kg determined as follows: EER/reference weight (kg)

EER Age (yrs)

Reference weight (kg)

Sedentary PAL

Low Active PAL

Active PAL

Very Active PAL

Kcals/kg

3 14.3 1162 1324 1485 1683 81-93 4 16.2 1215 1390 1566 1783 75-86 5 18.4 1275 1466 1658 1894 69-80 6 20.7 1328 1535 1742 1997 64-74 7 23.1 1393 1617 1840 2115 60-70 8 25.6 1453 1692 1931 2225 57-66 9 28.6 1530 1787 2043 2359 53-62 10 31.9 1601 1875 2149 2486 50-59 11 35.9 1691 1985 2279 2640 47-55 12 40.5 1798 2113 2428 2817 44-52 13 45.6 1935 2276 2618 3038 42-50 14 51.0 2090 2459 2829 3283 41-48 15 56.3 2223 2618 3013 3499 39-47 16 60.9 2320 2736 3152 3663 38-45 17 64.6 2366 2796 3226 3754 37-43 18 67.2 2383 2823 3263 3804 35-42

136

APPENDIX G EER for Girls 3-8 Years EER = 135.3 – (30.8 x age [y] + PA x (10.0 x weight [kg] + 934 x height [m]) + 20 kcal EER for Girls 9-18 Years EER = 135.3 – (30.8 x age [y] + PA x (10.0 x weight [kg] + 934 x height [m]) + 25 kcal Physical Activity (PA) Coefficient for Girls: 1.0 (sedentary) 1.13 (low active) 1.26 (active) 1.42 (very active) Table 3. Estimated Energy Requirements (EER) For Girls 3-18 Years of Age

PAL = physical activity level Kcals/kg determined as follows: EER/reference weight (kg)

EER Age (yrs)

Reference weight (kg)

Sedentary PAL

Low Active PAL

Active PAL

Very Active PAL

Kcals/kg

3 13.9 1080 1243 1395 1649 78-89 4 15.8 1133 1310 1475 1750 72-83 5 17.9 1189 1379 1557 1854 66-77 6 20.2 1247 1451 1642 1961 62-72 7 22.8 1298 1515 1719 2058 57-66 8 25.6 1360 1593 1810 2173 53-62 9 29.0 1415 1660 1890 2273 49-57 10 32.9 1470 1729 1972 2376 45-53 11 37.2 1538 1813 2071 2500 41-49 12 41.6 1617 1909 2183 2640 39-46 13 45.8 1684 1992 2281 2762 37-43 14 49.4 1718 2036 2334 2831 35-41 15 52.0 1731 2057 2362 2870 33-40 16 53.9 1729 2059 2368 2883 32-38 17 55.1 1710 2042 2353 2871 31-37 18 56.2 1690 2024 2336 2858 30-36

137

APPENDIX G Overweight Children EER for Weight Maintenance for Boys 3-18 Years of Age* EER = 114 - (50.9 x age [yr]) + PA x (19.5 x wt [kg] +1161.4 x ht [m]) Physical Activity (PA) Coefficient for Overweight Boys: 1.0 (sedentary) 1.12 (low active) 1.24 (active) 1.45 (very active) PA: 1 sedentary, 1.18 low active, 1.35 active, 1.60 very active EER for Weight Maintenance for Girls 3-18 Years of Age* EER = 389 - (41.2 x age [yr]) + PA x (15 x wt [kg] + 701.6 x ht [m]) Physical Activity (PA) Coefficient for Overweight Girls: 1.0 (sedentary) 1.18 (low active) 1.35 (active) 1.605 (very active) *For children who are overweight (>95th percentile BMI for age) or at risk for overweight (85-95th percentile BMI for age) with existing comorbidities, a factor of 108 kcals/day can be subtracted from the calculated weight maintenance EER to promote a slow weight loss of 1 pound per month.

APPENDIX H

GUIDE TO NUMBER OF SERVINGS AND SERVING SIZES FOR CHILDREN

FOOD GROUPS CHILD 1-3 CHILD 4-6 CHILD 7-10 ADOLESCENT 11-14 15-18

Milk Group Milk

Ice Cream Cheese

(3 cups) 6 oz.

(3 cups) 8 oz.

(3 cups) 8 oz.

(3-4 cups) 8 oz.

(3-4 cups) 8 oz.

Meat Group Meat, Poultry or Fish

Eggs Dried Beans, Peas

Peanut Butter

(2 servings) 2-3 oz.

1 ½ cup

2T.


1 ¾ cup

2T.


1 1 cup 2T.


1-2 1 cup 2T.


1-2 1 cup 2T.

Breads & Cereals Group

(Whole Grain or Enriched)

Bread Cereal

(4 small servings)

½ slice ¼ cup

(4 servings)

1 slice 1/3 cup

(4-5 servings)

1 slice ½ cup

(4-6 servings)

1 slice ¾ - 1 cup

(4-6 servings)

1 slice 1 cup

Fruits & Vegetables Group

Vit. C – good source Vit. A – good source

Others

(4 small servings)

¼ cup 2 T. 4 T.

(4 servings)

½ cup 2-3/week 1/3 cup

(4-5 servings)

¾ cup 2-3/week

½ cup

(4-6 servings)

1 cup 2-3/week

¾ cup

(4-6 servings)

1 cup 2-3/week

¾ cup

Miscellaneous Group Sweets

Snack Foods Soft Drinks

Butter/Margarine

0 1 T.

0 1-2 T.

0 1-2 T.

0 2+ T.

0 2+ T.

APPENDIX I

ELECTROLYTE CONVERSION INFORMATION

1. Converting from milliequivalents (mEq) to milligrams (mg) and vice versa:

mgmEq = Conversion factor

Conversion Factors For Major Minerals

• 1 mEq Na = 1 mmol Na = 23 mg Na • 1 g Na = 43 mEq Na = 43 mmol Na • 1 mEq K = 1 mmol K = 39 mg K • 1 g K = 26 mEq K = 26 mmol K • 1 mEq Ca = 0.5 mmol Ca = 20 mg Ca • 1 g Ca = 50 mEq Ca = 25 mmol Ca • 1 mEq Mg = 0.5 mmol Mg = 12 mg Mg • 1 g Mg = 82 mEq Mg = 41 mmol Mg • 1 mmol P = 2 mEq HPO3 = 31 mg P • 1 mEq Cl = 1 mmol Cl = 35 mg Cl • 1 g Cl = 29 mEq Cl = 29 mmol Cl

Major Mineral Content in Various Compounds and Solutions

• 1 g NaCl = 393 mg Na = 17 mEq Na • 1 g NaHCO3 = 273 mg Na = 12 mEq Na • 1000 ml saline = 9 g NaCl = 3.5 g Na = 154 mEq Na • 1000 ml lactated Ringer’s solution = 3 g Na = 130 mEq Na • 1 ampule (50 ml) 7.5% NaHCO3 = 1 g Na = 44 mEq Na • 1 g KCl = 524 mg K = 13 mEq K • 1 g CaCl2 2H2O = 273 mg Ca = 13.6 mEq Ca (when weighed in hydrated forms) • 1 g Ca gluconate = 93 mg Ca = 4.6 mEq Ca • 1 g MgSO4 7H2O = 99 mg Mg = 8.1 mEq Mg (when weighed in hydrated forms) • 1 mg Mg gluconate 2H2O = 54 mg Mg = 4.4 mEq Mg (when weighed in hydrated forms) • 1 g CaCO3 = 400 mg Ca = 20 mEq Ca • 1 g FeSo4 7H2O = 201 mg Fe (when weighed in hydrated forms) • 1 g Fe gluconate 2H2O = 116 mg Fe (when weighed in hydrated forms) • 1 ml Fe dextran (Imferon) = 50 mg Fe

2. Converting sodium chloride to sodium:

NaCl (table salt) is 40% sodium and 60% chloride Therefore: 1 gm sodium chloride = 400 mg sodium 400 mg sodium = 17 mEq sodium

3. Niacin equivalents: 1% available dietary protein = tryptophan 60 mg dietary tryptophan is equivalent to 1 mg niacin

APPENDIX J Oral Multivitamin and Mineral Supplements Available at UVAa

aBrand names are representative of products purchased by the University of Virginia. Contact the pharmacy for additional information. bNephro-vite also contains 300 mcg biotin.

Adult Products A (IU)

D (IU)

E (IU)

B1 (mg)

B2 (mg)

B3 (mg)

B5 (mg)

B6 (mg)

B12 (mcg)

C (mg)

Folate (mg)

Ca (mg)

Iron (mg)

Fluo (mg)

Multivitamin tablet 1 tab. 5,000 400 30 3.0 3.4 20 10 3.0 9.0 90 0.4 66 - -

Multivitamin liquid 5ml 5,000 400 - 10 10 100 21.4 4.1 5.0 200 - - -

- Multivitamin with minerals tablet 1 tab. 5,000 400 30 3.0 3.4 30 10 3.0 9.0 120 0.4 40 27 -

Multivitamin with minerals liquid 15 ml 2,500 400 30 1.5 1.7 20 10 2.0 6.0 60 - - - -

Pediatric Products Multivitamin with minerals Chewable Tab (Centrum Jr.) 1 tab. 5,000 400 30 1.5 1.7 20 10 2 6 60 0.4 162 18 -

Multivitamin drops 1 ml 1,500 400 5 0.5 0.6 8 - 0.4 2 35 - - - -

Multivitamin drops with iron 1 ml 1,500 400 5 0.5 0.6 8 - 0.4 - 35 - - 10 -

Multivitamin drops with fluoride 1 ml 1,500 400 5 0.5 0.6 8 - 0.4 2 35 - - - 0.25

A, D, C drops 1 ml 1,500 400 - - - - - - - 35 - - - -

A, D, C drops with iron 1 ml 1,500 400 - - - - - - - 35 - - 10 -

Sodium fluoride drops 1 ml - - - - - - - - - - - - - 0.5

Ferrous sulfate drops

0.6 ml - - - - - - - - - - - - 15 -

Special Products ADEK tablet 1 tab. 4,000 400 150 1.2 1.3 10 10 1.5 12 60 0.2 - - -

ADEK liquid 1 ml 1500 400 40 0.5 0.6 6 3 0.6 4 45 - - - -

Nephro-vite for dialysis patientsb 1 tab. - - - 1.5 1.7 20 10 10 6.0 60 0.8 - - -

APPENDIX K

Tips for Increasing Calories for Children

Increasing Calories for Children

Milk and Dairy Products • Use whole milk to make milkshakes, soups, cereals and puddings • Use evaporated milk in place of whole milk for desserts, meat dishes and

milkshakes • Add ice cream to milkshakes Fats, Oils and Sweets • Margarine or butter (100 kcal/T): Add to cooked cereals, potatoes, breads

and crackers, rice, cooked vegetables, pasta and casseroles • Vegetable oil (110 kcal/T): Add to soups, casseroles, vegetables, gravies,

cooked cereals and spaghetti sauce • Sour cream (25 kcal/T): Add to vegetables, potatoes, salads and casseroles • Cream cheese (50 kcal/T): Add to breads, crackers, in dips, baked goods • Mayonnaise (100 kcal/T): Add to sandwiches, salads, dips, pasta etc. • Gravy (26 kcal/T): Add to meats, potatoes, pasta • Corn syrup (60 kcal/T): Add to cereals, fruit, formula, milkshakes • Jams, Jellies (50-55 kcal/T): Add to toast, bagels and other baked goods Protein • Peanut butter (94 kcal/T): Add to bread, toast, crackers, fruits and

milkshakes • Cheese (120 kcal/oz): Serve on bread, vegetables, pasta, eggs, hotdogs,

salads, sandwiches • Eggs (60 kcal/yolk): Add egg yolks or hard boiled eggs to casseroles,

meatloaf, soups, salads, ie, tuna salad • Dry powdered milk (25 kcal/T): Add to whole milk, milkshakes, casseroles,

soups, scrambled eggs, meatloaf, gravies and sauces, mashed potatoes, puddings, cereals

Adapted from: : Isaacs J, Cialone J, Horsley, et al. Children with Special Health Care Needs: A Community Nutrition Pocket Guide, 1997.

APPENDIX L

Sites of Nutrient Malabsorption Resulting from Intestinal Resections

Site of Bowel Resection

Implication for Nutrient Malabsorption

Duodenum and Jejunum • Decreased surface area for general nutrient absorption

• Decreased enzyme production: secretin, cholecytikinin.

• Decreased disaccharidase levels: lactase, sucrase

• Decreased pancreatic and biliary secretions • Decreased fat digestion and absorption. • Decreased protein digestion and absorption • Decreased fat soluble vitamin absorption:

vitamins A, D, and E. • Increased water soluble losses: Vitamin C,

folate • Mineral malabsorption: Ca, Fe, Mg, Cu, Cr,

Mn, Zn. • Increased risk of bacterial overgrowth and

osmotic diarrhea Ileum • Significant decrease in Vitamin B12 absorption

• Decreased bile acid reasbsorption • Decrease in enterophepatic circulation

resulting in: decreases in bile acid pool, long chain and fat soluble vitamin absorption

• Increase in steatorrhea and cholerrheic diarrhea

• Trace element malabsorption and losses • Increased risk of renal oxalate stones

Ileocecal valve • Decreases in Vitamin B12 and folate absorption • Decreased intestinal transit time • Increased risk of bacterial overgrowth

Colon • Decreased water absorption • Decreased sodium absorption • Decreased risk of renal oxalate stones

Adapted from: Jones-Wessel J. Short gut syndrome. In: Groh-Wargo, S., Thompson, M. and Hovasi-Cox, J. Nutritional Care of High Risk Newborns. Chicago, IL: Precept Press, 2000.

APPENDIX M UVA Therapeutic Algorithm for Management of Pediatric Post-operative Chylothorax

Initial Evaluation

1. Chylous fluid should be confirmed by laboratory analysis showing a triglyceride level > 110 mgs% (when child is being fed) and a cell count > 1000 cells/microliter with lymphocytes > 80%.

2. If possible central venous pressure (above the diaphragm) should be assessed along with cardiac function by echocardiography

3. Ultrasound and/or venography of major vessels to evaluate for thrombosis should be undertaken. 4. Serum analysis of immunoglobulion levels and coagulation studies should be sent.

Algorithm

Adjunctive Therapy

1. Placement of a central venous catheter should be considered (either PICC or surgically placed line) early on if enteral nutrition is failing and TPN is going to be required. Note that both TPN and the malnutrition consequent to chylous effusions place the child at particular risk for infection so every attempt should be made to limited invasion of the central catheter.

2. If CVP > 15 mmHg standard approaches to lowering central venous pressure including diuretics, inotropes, and afterload reduction should be considered in conjunction with cardiology.

3. Enoxaparin 0.5 mg/Kg subcutaneously every 12 h, adjusted according to anti-FXa levels (drawn 3-4 hrs after 3rd dose)

4. Immunoglobulin levels should be drawn weekly and IVIG given as dictated by immunoglobulin levels. Usual replacement dose is 500 mg/kg infused over 4-6 h. Similar following and supplementation of albumin should be performed. When possible, administer no more than once over at least 2-4 h. Consider use of 25% albumin to minimize fluid.

5. Nutrition is vitally important. As per the algorithm, if CVP < 15 and there is no evidence of SVC thrombosis, enteral feeding with a MCT formula (currently Enfaport) should be rapidly escalated to calculated fluid and nutritional needs. If CVP > 15 or enteral feeding has not decreased chylous effusion then TPN should be advanced to full nutritional requirements as rapidly as tolerated. Nutritional consult is recommended.

6. Octreotide dose should be doubled daily if no reduction in chylous effusion (> 10%) over the previous 24 hours beginning with 1 mcg/kg/hr to a maximum of 10 mcg/kg/hr. If substantive improvement (> 50% reduction) in 5 days the drug should be stopped.

Surgical Management

Surgical consultation should be considered when the above protocol has failed or appears to be failing. Surgical management should be individualized but in general:

1. If effusion < 25 ml/Kg/day and there is no contraindication (e.g., peritoneal dialysis) pleuroperitoneal shunt should be considered

2. If effusion > 25 ml/Kg/day and/or there are contraindications to pleuroperitoneal shunts thoracic duct ligation at the diaphragmatic entry of the duct.

3. Should “a” and “b” fail, bilateral pleurodesis should be performed

Additional Notes

1. Every patient is different and the algorithm should not preclude clinician judgment. 2. If the chylous effusion does not respond to the above measures the possibility of SVC thrombosis and/or

persistent high central venous pressure due to A-V valve incompetence or other cardiac dysfunction should be investigated. Consider cardiac catheterization.

References

1. Panthongviriyakul C, Bines J. Post-operative Chylothorax in Children: An evidence-based management algorithm. Journal of Paediatrics and Child Health. 2008. 44(12): 716-721.

Index A Anthropometrics, 10 Appropriate for gestational age, 28 B Basal energy needs, 23 Body mass index (BMI):, 10 Breast milk

Fortification, 44 Supplementation, 30, 44

Burns, 74-76 Energy requirements, 25

C Carnitine, 88 Catch-up growth, 24 Chylothorax, 71–73 Chylous ascites. See Chylothorax Congenital heart defects, 57–58 Cystic fibrosis, 58–62 D Dietary Reference Intakes, 17, 20 Drug-nutrient interactions, 100 Duocal, 45 E Electrolyte supplementation, 107 Energy, 18 Enteral nutrition, 38–56, 38–56

Advantages, 38 Complications, 51 Continuous feeds, 47 Delivery routes, 45 Feeding guidelines for preterms, 36 Formula selection, 39-40, 67 Indications, 38 Initiation and advancement, 49 Intermittent/bolus feeds, 47

Essential fatty acid deficiency, 71, 93 Estimated needs. See Nutritional

requirements Extremely low birth weight, 27

F Feeding protocols, 36 Fenton growth charts, 27 Fiber, 19 Fluid requirements

Preterm, 30 Term infants and children, 25

Fluoride, 21 Formula selection

Allergy, 67 Enteral, 39 GI, 67 Preterm, 33 Term infant, 40

G Gastrointestinal impairment, 67–70 Glucose infusion rate, 81 Growth, 9–10 Growth velocity, 10

Preterm infants, 28 H Harris Benedict equation, 23 I Increasing caloric density, 34, 42 Insulin, 81 Iron, 89 L Laboratory data, 15 Large for gestational age, 28 Low birth weight, 27 M Malnutrition, 12

Clinical assessment, 12 Medical history, 13 Microlipid, 34, 42, 58 Micronutrients, 19 Midarm muscle circumference, 10 Minerals, 20

N Nepro, 64, 66 Nutrient deficiency

Physican signs, 13 Nutritional assessment, 9–16

Components, 9 Nutritional intake history, 14 Nutritional requirements, 17–26

Chylothorax, 71 Congenital heart defects, 57 Critically ill children, 22 Cystic fibrosis, 59 GI, 67 Non-critically ill children, 17 Preterm, 29 Renal, 63

O Obesity, 10 Overfeeding, 24

P Pancreatic enzymes, 60 Parenteral nutrition, 80-98

Complications, 91 Initiation and advancement, 81

Pharmacology, 100–108 Polycose, 34, 42, 43, 58 Preterm

weight classification, 27 Protein, 19 Refeeding syndrome, 75 Renal, 63–66

Formula modification, 44

S Scandishakes, 59 Small for gestational age, 28 Stress factor, 23 Suplena 64 Supplementation

Vitamin and mineral, 20, 31

T TPN. See Parenteral nutrition Triceps skinfold, 10 Trophic feeding, 36 Tube feeding. See Enteral nutrition Tyramine, 103

V Very low birth weight (VLBW, 27 Vitamin D deficiency, 65 Vitamins, 20

W Waterlow criteria, 12

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