pediatric nutrition: management of sbr, dehydration, & high ileostomy output -the influential...
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Pediatric Nutrition: Management of SBR, dehydration, & high ileostomy output -The influential role of a Clinical Dietitian
By Celina Chan
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Dartmouth Hitchcock Medical Center- Lebanon
Founded 1893Teaching
HospitalOutpatient
visits: 645, 857Employees
6,724
Our Mission“We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.”
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Dartmouth Hitchcock Medical Center- Lebanon Beds: 396 Mary Hitchcock
Memorial Hospital Geisel School of
Medicine at Dartmouth
Children’s Hospital at Dartmouth-Hitchcock (ChaD)
Norris Cotton Cancer Center
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Clinical Dietitian Consults, diet
orders follow ups, NPO, etc
Diet Techs: Nissen, 2gNa, Puree, Braden, NPO, s/p CABG, etc.
Pts distributed at morning meeting according to specialty
20+ dietitians
Bump to RD level: -BMT
-All Pedi
-NPOx5
-Gestational
-HA1C 8 or higher
-BUN <2
-Renal
-CHO counting
-GI
-Tube feeds
-TPN
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Outline
Pt introduction & historyDiagnosisAssessmentNutrition diagnosisIntervention (MNT)MonitoringEvaluation
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Patient History-Baby JMale, Full term 38 wk Birth date: 8/25/14 --- d/c 10/9
(~6wk old)Readmitted 10/12 GastroschisisIleal AtresiaShort Bowel Resection (SBR)IleostomyDehydration
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GastroschosisIntestines outside the body“vanishing” -resolved before birth
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Pathogenesis & Etiology◦Abdominal wall birth defect◦CDC estimates 1,871 babies/yr ◦Abdominal wall does not form
correctly◦Intestines are outside the body (not
covered by sac). Typically to the right of the umbilical cord
◦Damage occurs from exposure to amniotic fluid (irritation, swelling, twisting, atreasia)
◦Potential for future difficulty feeding pt
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Pathogenesis & Etiology cont…
◦Theories: Failure of differentiation of embryonic cells Rupture of amniotic membrane near umbilical
cord Abnormalities near umbilical cord Necrosis of cord leading to gut herniation Development failure at abdominal folds creating
improper closure
◦Many theories, but still unclear understanding of the disease
◦Risk factors: young mother, alcohol & tobacco, poor nutrition (or failure to take prenatal supplements)
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Treatment Treatment
◦Surgery ◦“vanishing” – self resolves (surgery
still needed to close the abdominal wall)
◦Further complications requiring treatment may occur
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Ileal AtresiaDistended loop of bowelNarrowing of the intestine
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SBRSmall bowel
resectionTotal small bowel
length is 130cm- ligament of treitz to the ileocecal valve. Includes 12cm segment of terminal ileum proximal to ileocecal valve.
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Ileostomy
Ileum brought up to the abdominal wall- stoma created.
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Dehydration -watery stool, gassy, not taking bottle, no wet
diaper for 12 hrs, mottling, lethargy, crying, irritable, vomiting, diarrhea, decreased urine volume, pallor
Took in about 300-360mL formula at home. Parents unsure
Mom mixing wrong recipeCurrent Weight: 2.9 kg Weight at previous discharge: 3.34 kg Na: 125mmol/L (L)K: 6.8 mmol/L (H)CL: 93mmol/L (L)CO2: 10 mmol/L (L)
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Nutrition ConsiderationsWeight Growth ChartElectrolytesI’s & O’s Ileostomy outputFood HistoryNeedsFormula
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PES Decreased energy intake related
to inadequate oral consumption as evidenced by parent report of pts food refusal
Altered GI function related to SBR and ileostomy placement, as evidenced by increased ileostomy output of >2ml/kg/hr and a positive fecal fat test.
*this is the primary PES statement.
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GoalsResolve dehydration— provide
appropriate formula and monitor intake
Stool output <50ml/kg/day or <2ml/kg/hr
Electrolytes & labs wnlWeight maintenance gain
(recommend caloric goal of 150kcal/kg)
*treated as a “functional” short gut pt
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Current Diet order 10/17Gentlease 20kcal/oz ad lib Weight: 3.12 kgStool output last 24 hrs: 325ml
or, 104ml/kg/dayAvg intake: 550ml provided 372
kcal, 1.8 mEq Na/kg Na: 134mmol/l (L)K: 4.0 mmol/l
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Recommendations 230ml Gentlease 20kcal/oz &
40ml Ceralyte 90 per bottle- give four bottles po ad lib
Provides: 524 kcal, 20.1 mEq Na
Ceralyte: oral rehydration Provides:◦Na 50-90mmol/L ◦K 20mmol/L
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Follow up- 10/21230ml Gentlease 20kcal/oz &
40ml Ceralyte 90 per bottle- give four bottles po ad lib
Provides: 524 kcal, 20.1 mEq Na Previous weight: 3.12kg Current Weight: 3.17kg Na: 135mmol/L Stool output: 257mL =
3.3ml/kg/hr
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Recommendations 10/21Switch from Gentlease to Elecare-
more elemental formula◦33%MCT, hypoallergenic
Please add Alk phos to labs Elecare provides 7.2mg zinc vs Gentlease 6.2mg If alk phos low- recommend 0.5-1mg/kg/day
elemental zinc for 14 days Intestinal losses can be up to 12 mg/L zinc
Recommend caloric goal of 150kcal/kgFollow serum Na, weights,
intake/output daily
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Follow up 10/22Current Diet order: 230 ml Elecare
20kcal/oz & 40ml Ceralyte 90 per bottle daily po ad lib
Provides: 616kcal, 26.4 mEq Na
Weight: 3.17kg ~ avg week wt gain was 30g/wk)
Na: 138Stool output: 161ml = 2.1ml/kg/hr
(close to goal)Total intake: 512 kcal, 21.6meq Na
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Follow up 10/23Weight: 3.2kgNa 139, K 3.7Intake past 24 hrs: 880 ml Elecare
20kcal/oz & 40ml Ceralyte 90Provided 590 kcal, 19.4mEqNa, 22.1 mEqK, Stool 123ml = 1.6ml/kg/hr (meets
goal!)
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Recommendations D/c Ceralyte…try with pectin Start with 0.6ml pectin/120ml
Elecare can increase to 1.2ml/120ml if stool still has not thickened
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Follow up 10/24Diet order: Infant feeding formula Ad-
lib: Elecare 20kcal/oz & 0.6ml pectin/120ml Elecare
Took in 470ml Elecare This provides 517 kcal, 12.52 meq Na
10/23 10/24
Weight 3.2kg 3.13kg
Na (mmol/L) 139 138
K (mmol/L) 3.7 4.2
Stool output 1.6ml/kg/hr 2.7ml/kg/hr
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Follow up 10/27 Current diet order: Elecare
20kcal/oz + PectinOstomy output: 4.2ml/kg/hr Meeting goal with feeds
10/24 10/27
Weight 3.13kg 3.36kg
Ileostomy output
2.7ml/kg/hr 4.2ml/kg/hr
Na (mmol/L) 138 136
K (mmol/L) 4.2 5
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Follow ups….Elecare + Ceralyte Positive for fecal fatMedications added: flagyl,
immodium, AquAdek
10/27 10/30 10/31
Weight 3.36kg 3.33kg 3.43kg
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Recommendations Ceralyte not available at WIC and
is typically not covered by insurance. ◦Consider: Homemade cereal base
sol’n◦Recipe: 1/2c baby rice cereal, ½ tsp
table salt, 2c watergCHO/ml mEq
Na/mlmEq K/ml
Ceralyte 0.04 0.09 0.02
Homemade cereal sol’n
0.05 0.11 0.005
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Plans Reinfuse stool into distal mucus
fistula so that it goes into colon
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D/C Elecare 20kcal/oz ad lib + Rice Cereal
SolnWt: 3.7kgAvg daily intake: 168kcal/kg/dayDiet is meeting needs for growth
based on growth. Stool output has also decreased
Stool infusion going well-Refeeding stool with goal of whole bag TID about 30mL max over 15 min (per GI team)
“Mushy” in diaper Provided mixing as well as stool
reinfusion education to parents.
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SummaryGentlease Gentlease + Ceralyte
Elecare + Ceralyte Elecare + Pectin Elecare + Rice Sol’n (to mimic ceralyte)
Flagyl, aquadek
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Final Thoughts Initiation of Elecare Pectin? Complicated situation:
◦more than one solution: “many right answers, obvious wrong answers”
◦Team effort (Pedi MDs, Dietitians, GI team, pedi, etc)
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References Pediatric Nutrition Care Manual Hendricks, KM, Duggan, C. Chp 36- Short Bowel Syndrome.
In Manual of pediatric nutrition. Hamilton, Ontario: BC Decker; 2005: 718-735.
https://www.childrenshospital.org/~/media/Centers%20and%20Services/Programs/A_E/Center%20for%20Advanced%20Intestinal%20Rehabilitation/Hendricks%20Ch%2036.ashx Mattei, P. Fundamentals of pediatric surgery. New York: Springer;
2011. Weaver LT, Austin S, Cole TJ. Small intestinal length: a factor
essential for gut adaptation. Gut 1991;32(11):1321-1323. Leonberg, BL. ADA pocket guide to pediatric nutrition assessment.
Chicago: American Dietetic Association; 2008. Groh-Wargo, S, Thompson, M, Cox, JH. ADA pocket guide to neonatal
nutrition. Chicago, IL: American Dietetic Association; 2009. Wong, KKY, Lan, LCL, Lin, SCL, Chan, AWS, Tam, PKH. Mucous Fistula
Refeeding in Premature Neonates With Enterostomies. Journal of Pediatric Gastroenterology and Nutrition. 2004;39(1):43-45. doi:10.1097/00005176-200407000-00009.
http://www.cdc.gov/ncbddd/birthdefects/Gastroschisis.html
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