pediatric nutrition assessment
TRANSCRIPT
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Pediatric NutritionAssessment: The
Dietitians Toolbox
Caro lin e Steele, MS, RD, CSP, IBCLC
Manager, Clinical Nutrition & Lactation [email protected]
Childrens Hospital of Orange County
Orange, CA
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Objectives
1. Calculate calorie, protein, and fluid needs
for pediatric patients of various ages.
2. Evaluate anthropometric measurements in
the pediatric patient.3. Determine appropriate use of various
infant, pediatric, and adult enteral
formulas.
4. Discuss parenteral nutrition in the pediatric
patient.
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Pediatric Nutrition Assessment
nthropometrics
iochemical Data
linical Data
iet History
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Definitions
Infant: Birth to 1 year of age
Neonate: Birth to 1 month
Full Term: >37 weeks gestation
Premature: Less than or equal to 37 weeks
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A
Anthropometrics
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Growth Charts
CDC 2000 growth charts
Pre-term infants-Fenton
Down Syndrome
Cerebral Palsy
Turner Syndrome
Prader Willi Syndrome
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Weight
Infants-obtained nude
Children-minimal clothing, no shoes
Used to assess pts acute nutrition status
%Ideal wt-wt/length or height
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Infant Weight Classifications
LBW:
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X X34 week infant
5# (LBW)
AGA
Term (40 week) infant
5# (LBW)
SGA
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Length/Height
Infants-length, measuring board
Children-stadiometers
Used to assess chronic
nutrition status
%Height age
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Infant Linear Growth
Preterm goals:
1-1.75 cm/week until 3 mos. adjusted age
0.5 cm/week from 3-6 mos. adjusted age
0.3 cm/week from 6-12 mos. adjusted age
Term goals:
0.66-0.75 cm/week for first 6 months
0.5 cm/week from 6-12 months
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Alternative Measurements
Alternative measurements for children with special
health care needs
Arm span
Sitting height/crown rump length
Body segment lengths
TSF-triceps skinfolds-indirect measure of body fat
good for longitudinal tracking
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Head Circumference (OFC)
Should be plotted on all infants until at least 18
months adjusted age.
Typically decreases ~0.5 cm during the first week
due to contraction of extracellular fluid space.
Preterm goals:
0.5-1 cm/week until 3 mos. adjusted age
0.25 cm/week from 3-6 mos. adjusted age
Term goals:
0.33 cm/week
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Body Mass Index
BMI = kg/m2
Non invasive tool determining over/under weight
Formula
Wt kg divided by ht m
2
e.g. 50 kg/1.542= BMI 21.1
CDC Cut-Off Points
>85%tile-at risk for overweight
>95%tile-overweight
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Pediatric Nutrition
Assessment
Accurate heights- Why are they so
important??
Degree of Malnutrition
Acute-wt/ht
Chronic-ht/age
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Waterlow Criteria
Grading of nutritional status
Acute Chronic
Grade %Ideal wt %Ht age
I-mild 80-90 90-95
II-moderate 70-79 85-89
III-severe
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B
Biochemical
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C
Clinical
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Clinical
Medical History
Physical Exam
Nutrition History
Medications
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D
Diet History
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Intake Assessment
24 hr diet recall
Food Records
Food Frequency
Calorie Count
Nursing flow sheet
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Nutrient Requirements
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Fluid Requirements
0-10 kg 100 ml/kg
10-20 kg 100 ml/kg + 50ml/kg (over 10kg)
>20 kg 1500 ml + 20 ml/kg (over 20kg)
OR
1500 cc x BSA
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Energy Requirements
Critically ill children stop growing & utilize the
energy conserved by this mechanism to fuel the
stress response
Excessive caloric provision during acute criticalillness has no beneficial effect & may be harmful
Although critically ill children tend not to lower
energy needs during critical illness, in the
chronic or convalescent phase of illness, many
may need additional calorie for catch up
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Approximate Energy Requirementsin Critically Ill Children
Age in Years Est Kcal/kg/day
0 4 100
4
6 906 8 80
8 10 70
10 12 60
12 18 50
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Protein Requirementsin Critically Ill Children
Age in Years Est g pro/kg/day
0 2 2-3
2-13 1.5-213-18 1.5
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Catch Up Growth Requirements
kcal/kg/d RDA Calories Ideal Body
for age weight
Kcal/kg/d X kg
Actual Weight (kg)
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Nutrient Requirements
Protein-RDA as a minimum
12% of total calorie needs
Carbohydrate-50-55% of total calorie needs
Excess can increase RQ
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Nutrient Requirements
Fat-30% of total calorie needs
3-4% EFA to prevent deficiency(3% as Linoleic, 1% alpha-linolenic)
Vits/minerals-DRIs
RDAs, AI, EAR and TUL
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Nutrition Support for
the Pediatric Patient
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Enteral Nutrition
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Enteral Nutrition in the Neonate
Initiate as soon after birth as clinical and GI status allow
Trophic feedings or GI priming
Colostrum for oral care
Trophic feeding
Small volumes (~2.5-20 mL/kg/d) for 1-2 weeks
Gut atrophy develops rapidly in preterm infants on TPN;
feeding may promote synthesis of gut hormones days to full enteral feeding and length of hospital stay
Yu VYH, Simmer K. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. 2005:311-332.
Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. 2004:23-54.
Akers S, Groh-Wargo S. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:75-106.
Anderson DM. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:53-73.
Wessel JJ. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:321-339.
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Gavage Feeding
Nasogastric or orogastric
Nonnutritive sucking during gavage feedings may
help improve maturation of the sucking reflex and
transition to oral feedings
Intermittent vs continuous feedings
Transpyloric feedings (nasoduodenal,oroduodenal, nasojejunal, orojejunal)
Absorption of nitrogen and fat is decreased
Yu VYH, Simmer K. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. 2005:311-
332.
Wessel JJ. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:321-339.
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Method of Delivery
NGT: 5F
Continuous
Bolus
Gavage
po/ng
po 1 of 3 feedings, 2 of 3, po q 3 hrs., po ad lib
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Nutrition Support
Methods Enteral Support
Acute-OG, NG, transpyloric
Functioning gut
Gut perfusion
Formula selection
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TF Administration
Continuous
1-2 cc/kg/hr
Advance 1-2 cc/kg/hr q 6-12 hoursAdolescents, begin 20-25 cc/hr
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TF Administration
Intermittent 2-5 cc/kg/feed q 3-4 hours
Advance 2-5 cc/kg/feed
Infuse over 30-60 min
Bolus
Not used often in critical patients Infuse over 10-15 min by gravity
Do not use in transplyoric feedings
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What to Feed?
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Benefits of Breast Milk
Breast milk is BEST! Use whenever possible
Ease of digestion
Whey-to-casein ratio~60:40
Low renal solute load (RSL)
Immune-enhancing properties/antibodies
Neurodevelopment
Preterm infants typically unable to meet increasedcalorie/nutrient needs on breast milk alone
Schanler RJ, Atkinson SA. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines.
2nd ed. 2005:333-356.
Sapsford AL. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:265-302.
Groh-Wargo S. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:231-263.
F tifi ti f B t Milk f
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Fortification of Breast Milk for
Preterm Infants
Human milk fortifier (HMF) For preterm infants weighing 2 kg
Schanler RJ, Atkinson SA. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines.
2nd ed. 2005:333-356.
Sapsford AL. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:265-302.
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Fortification of Breast Milk forPreterm Infants (contd)
Use of nutrient-enriched discharge formulas in
conjunction with breast milk once HMF is stopped
may be appropriate for preterm infants ready for
discharge
Or for larger preterm infants who still need nutritional
fortification
Steele CL. Pediatric Perspectives. 2005;4(9).
Robbins ST, Beker LT, eds. Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities.2004:746-747.
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Breast MilkTerm Infants
Breast milk is BEST! Use whenever possible
Term infants typically able to meet nutrient needs on
breast milk alone unless volume restricted
Calories may be increased in breast milk if needed due
to poor growth, limited intake, or medical diagnoses
HMF is NOT appropriate for term infants
Choice of additives depends on clinical conditions and
reason for fortification tsp formula powder/90 mL breasmilk = 22 kcal/oz
1 tsp formula powder/90 mL breastmilk = 24 kcal/oz
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Preterm Formulas
Typically fed to smaller preterm infants (
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Nutrients in Preterm Formulas
Nutrient Preterm Formulas
Carbohydrate
41%-44% of total calories
50%-60% glucose polymers (corn syrup solids)
40%-50% lactose
Protein11%-12% of total calories
Whey predominate
Fat
44%-49% of total calories
40%-50% MCTs
50%-60% oil blend (including DHA and ARA)
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Preterm Discharge Formulas
Typically fed to larger preterm infants or as next stepformulas after preterm formula. May be used alone or in
conjunction with BF to increase total daily calories.
Contain higher nutrient levels than routine term
formulas but lower levels than preterm formulas tominimize the potential for toxicity
Standard dilution is 22 Cal/fl oz, but may be increased
as needed
Nutrient-enriched discharge formulas are recommended
until 9-12 months corrected age
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Nutrients in Discharge Formulas
Nutrient Discharge Formulas
Carbohydrate
40%-42% of total calories
50%-60% corn syrup solids
40%-50% lactose
Protein11% of total calories
Whey predominate
Fat
47%-50% of total calories
20%-25% MCTs
75%-80% LCTs (including DHA and ARA)
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Term Formulas
Designed for term infants
Standard dilution is 20 Cal/fl oz
If increased energy is needed for growth or
because of fluid restriction, may concentrate
calories
Nevin-Folino N, Miller M. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:499-524.
R ti C Milk B d
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Routine Cow MilkBased
Term Formula
NutrientRoutine Cow MilkBased
Term Formulas
Carbohydrate
43%-45% of total calories
100% lactose
Protein
8%-9% of total calories
Milk based
Fat48%-49% of total calories
Oil blend (with or without DHA and ARA)
C Milk B d F l
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Cow MilkBased Formula
with Added Rice Starch
Nutrient Added Rice Starch Formulas
Carbohydrate
43%-45% of total calories
Part of carbohydrate from rice starch
Protein
9%-10% of total calories
Cow milk based
Fat
46%-49% of total calories
Oil blend (including DHA and ARA)
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Lactose Free
Nutrient Lactose-Free Formulas
Carbohydrate
43%-44% of total calories
No lactose
Maltodextrin and sugar/corn syrup solids
Protein
8%-9% of total calories
Cow milk based (milk-protein isolate)
Fat
48%-49% of total calories
Oil blend (including DHA and ARA)
Not appropriate for infants with galactosemia
P ti ll H d l d
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Partially Hydrolyzed,
Reduced Lactose Formulas
Nutrient Partially Hydrolyzed,Reduced Lactose Formulas
Carbohydrate
43%-45% of total calories
Maltodextrin, corn syrup solids
Lactose
Protein
~9% of total calories
Partially hydrolyzed cow milk protein
Not hypoallergenic
Fat46%-48% of total calories
Oil blend (including DHA and ARA)
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Soy-Based Formulas
Christie L. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd
ed. 2005:161-180.
Nutrient Soy-Based Formulas
Carbohydrate 41%-42% of total calories
Protein
10% of total calories
IgE-mediated hypersensitivity to milk; 14% also
sensitive to soy
Non-IgEmediated enterocolitis and enteropathy
syndromes; 30%-50% also sensitive to soy
Fat
48%-49% of total calories
Oil blend (including DHA and ARA)
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Casein Hydrolysate Formulas
Failed trial of intact formula
GI problems/Colic
Hypoallergenic
Protein allergy (milk and/or soy)
Contain protein that has been broken down to
small peptides and free amino acids
May or may not contain MCT
Nevin-Folino N, Miller M. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:499-524.
American Academy of Pediatrics. Pediatrics. 2000;106:346-349.
Wessel JJ, Samour PQ. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:351-379.
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Elemental/Free AA Formulas
Elemental formulas
Contain free amino acids
Typically warranted after a failed trial
of an extensively hydrolyzed formula Hypoallergenic
MCT oil may or may not be present
Nevin-Folino N, Miller M. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:499-524.
Wessel JJ, Samour PQ. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:351-379.
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Inborn Errors of Metabolism
Formulated to specifically treat an inborn error of
metabolism(s) by removing or limiting the offending
nutrient (s)
Many are enriched with carnitine and conditionally
essential nutrients.
Designed to be an adjunct in meeting the overall
MNT of the infant-some recipes include 3-4
formulas
Need gram scales to measure
for accuracy
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Macronutrient Goals
Calorie distribution
40%-50% carbohydrate
7%-11% protein
40%-50% fat
Akers S, Groh-Wargo S. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:75-106.
Groh-Wargo S. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:231-263.
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Increasing Caloric Density
Formulas typically mixed to 24-27 Cal/fl oz by adjusting amountof water added
30 Cal/fl oz typically considered maximum
Above 26-27 Cal/fl oz, may consider modulars to increase
calories and/or protein
Considerations for high-calorie formulations
Osmolality: 450 mOsm/kg water
pRSL:
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Calculating Osmolality
Use product information for osmolality on a standard
concentration to determine osmolality of a formula of different
caloric level
Example
Product literature shows a 20 Cal/fl oz infant formula has an
osmolality of 300 mOsm/kg water
You want to find out the osmolality of concentrating it to 27
Cal/fl oz
27 Cal/fl oz 20 Cal/fl oz = 1.35 (ie, 135% more
concentrated) Multiply 300 mOsm/kg water (osmolality of 20 Cal/fl oz
formula) by 1.35 (135% higher concentration)
ANSWER: The 27 Cal/fl oz infant formula has
an osmolality of ~405 mOsm/kg water
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Calculating pRSL
Max goal is
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Additives
Carbohydrate
Protein
Fat/CHO
Modular Components
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Modular Components
Carbohydrate and Protein
Carbohydrate
Polycose powder
Per tsp (~2 g powder)
8 Cal
1.88 g carbohydrate
Displaces ~1.2 mL volume
Protein
RESOURCE Beneprotein
Instant Protein Powder
Per g
3.57 Cal
0.86 g protein
Displaces ~0.6 mL volume
Per tsp (1.5 g)
5.4 Cal
1.3 g protein
Displaces ~1.02 mL
volume
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Modular ComponentsFat
Corn oil
8.4 Cal/mL (all from fat)
Microlipid
4.5 Cal/mL (0.5 g fat)
MCT oil requires special handling and does not
contain any EFAs 7.7 Cal/mL (all fat)
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Toddler Formulas
Similac 2 milk and soy
based
Enfagrow (formerly Next
Step) milk and soy
based
Fe fortified
Bridge gap between
formula and milk
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Pediatric Formulas
Ages 1-10 yrs
Oral supplements & TF
Oral products higher
in osmolality With and without Fiber
RDA met in 950-1300 mL
Available in 1.0 or 1.5 kcal/mL
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Pediatric Formulas
Ages 1-10 yrs
Elemental
Dipeptides
Free AA
LCT and/or
MCT
Available in 1.0and 1.5 kcal/mL
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Adolescent Formulas
Ages >11 yrs
Standard/Isotonic
+/- Fiber
Available in 1.0,
1.2, & 1.5
kcal/mL
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Parenteral Nutrition
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Parenteral Calorie Needs
Preterm Infants 80-105 NPC/kg/d
Infants 70-100 NPC/kg/d
Children 60-80 kcal/kg/d
Adolescents 40-60 kcal/kg/d
90% of enteral support
Provide at least BMR/REE
Avoid overfeeding
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Carbohydrate
50-55% of calories
3.4 kcal/gm
Maximum glucose infusion rate
Infants 12-14 mg/kg/min
Toddlers 10-12 mg/kg/min
School Age 8-10 mg/kg/min
Adolescents 6-8 mg/kg/min
Adults 4-6 mg/kg/min
Maximum dextrose concentration
D12.5W maximum concentration via PIV
D25W maximum concentration via central line
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Excessive Calorie/CHO Provision
Excess glucose administration increases CO2production rates & respiratory failure may be
exacerbated
Excess caloric administration does not spareprotein during critical illness and has shown to
increase RQ by increasing CO2 production more
than a high CHO diet
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Parenteral Protein Needs
Preterm Infants Children Adolescents
3-4 2-3 1.5-2.5 1-2
12-15% of total calories
4 kcal/gm
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Protein
Pediatric-specific solutions for infants
Crystalline amino acids
Examples: Trophamine and Aminosyn PF
Contain histidine (essential)
Contain taurine and tyrosine (conditionally essential)
Cysteine available as additive (essential)
Dose 30-40 mg/g amino acids
Carnitine (conditionally essential) may be added for infants
not receiving enteral nutrition beyond 2 weeks 10-20 mg/kg/d
Cox JH, Melbardis IM. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:525-557.
Sapsford AL. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:119-149.
Aminosyn is a registered trademark of an entity unrelated to Mead Johnson & Company.
TrophAmine is a registered trademark of an entity unrelated to Mead Johnson & Company.
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Lipids
Infants Children Adolescents (g/kg/d)
0.5-3 1-2.5 1-2.5
20% Intralipid (2 kcal/mL; 1 g = 5 mL)
EFA 6% total kcal (0.5-1 g/kg/d for neonates) Biochemical abnormalities precede clinical symptoms
(triene:tetraene ratio of >0.4)
Consequences of deficiency
Dermatitis
Infection
Thrombocytopenia
FTT
Do not exceed 60% total kcal
In infants/small children, best infused over 24 h
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Vitamins (MVI)
Contents
Vitamins C, A, D, E, B6, B12, K
Niacin, thiamin, riboflavin, biotin, folic acid, pantothenic
acid
Dosage
Infants & Children to age 10: Ped MVI 5 mL (1 vial)/day
Preterm Infants 10 yrs: MVI-12 10 mL/day
*
T El t
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Trace Elements
Contents Zinc, manganese, copper, chromium
Additional Zn for preterm and wounds
Selenium & molybdenum for long-term (>30 d)
May need to limit copper and manganese to 1-2
doses/wk in infants with cholestasis (d bili >2)
May need to limit selenium and chromium in infants
with renal dysfunction
Rao R, Georgieff M. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. 2005:277-310.
Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. 2004:23-54.
Cox JH, Melbardis IM. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:525-557.
Krug SK. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:151-175.
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Minerals/Electrolytes
Adjusted based on clinical condition
Adjusted as needed to maintain serum levels of
electrolytes
Used to maintain acid-base balance
Amounts may be limited based on their solubility(calcium and phosphorus)
Atkinson SA, Tsang R. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed.
2005:245-275.
Cox JH, Melbardis IM. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:525-557.
Sapsford AL. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:119-149.
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What We Eat May Determine Who We
Can Be!
Opt imum Goal of Nutr i tion Assessment
and Suppo rt in the Pediatr ic Pat ient?
Facilitate wound healing & immune response
Normal growth and development