Transcript Practical Approach to Paediatric nutritional support

Practical Approach to
Paediatric nutritional support
Indicatons:
• Insufficient oral intake
• Inability to meet 60% to 80% of individual
requirements for >10 days
• In children older than 1 y, nutrition support should be
initiated within 5 days, and in a child younger than 1 y
within 3 days of the anticipated lack of oral intake
• Total feeding time in a disabled child >4 to 6 h/day
• Wasting and stunting
• Inadequate growth or weight gain for >1 mo in a child
younger than 2 years of age
Indicatons:
•Weight loss or no weight gain for a period of >3 mo in
a child older than 2 years of age
•Change in weight for age over 2 growth channels on
the growth charts
•Triceps skinfolds consistently <5th percentile for age
•Fall in height velocity >0.3 SD/y
•Decrease in height velocity >2 cm/y from the
preceding year during early/mid-puberty
‫تقسيم بندي ‪ Gomez‬براي شدت سوء تغذيه‬
‫‪* 100‬‬
‫وزن بيمار‬
‫آليشتر از‪%90‬‬
‫وزن ايده ب‬
‫طبيعي‬
‫وزن بيمار‬
‫‪* 100‬‬
‫وزن ايده آل‬
‫بين ‪ %76‬تا ‪ %90‬سوء تغذيه خفيف‬
‫وزن بيمار‬
‫‪* 100‬‬
‫وزن ايده آل بين ‪ %61‬تا ‪ %75‬سوء تغذيه متوسط‬
‫وزن بيمار‬
‫‪* 100‬‬
‫‪5‬‬
‫وزن ايده آلکمتر از‪%60‬‬
‫سوء تغذيه شديد‬
‫تقسيم بندي ‪ Waterlow‬براي تعيين شدت و زمان سوء تغذيه‬
‫حاد (وزن برحسب قد)‬
‫مزمن (قد برحسب سن)‬
‫درصد مقدارمتوسط (‪)Median‬‬
‫درصد مقدارمتوسط (‪)Median‬‬
‫نرمال ‪ > 90 :‬درصد‬
‫‪> 95‬‬
‫خفيف ‪ 80-90 :‬درصد‬
‫‪ 80-90‬درصد‬
‫متوسط ‪ 70-80 :‬درصد‬
‫‪ 70-80‬درصد‬
‫شديد ‪ > 70 :‬درصد‬
‫‪< 70‬‬
‫‪6‬‬
Nutrition Goals for the PICU
1. Minimize protein catabolism
2. Meet energy requirement
Mehta and Duggan (2009)
Selecting a Feeding Route
Nutrition & Diet Therapy (7th
Edition)
Energy Expenditure
• Pediatric patients may not exhibit significant
hypermetabolism post-injury
• Decreased physical activity, decreased
insensible losses, and transient absence of
growth during the acute illness may reduce
energy expenditure
Resting Energy Expenditure
Age (years)
REE (kcal/kg/day)
0–1
55
1–3
57
4 –6
48
7 –10
40
11-14 (Male/Female)
32
15-18 (Male/Female)
27
Factors adding to REE
Maintenance
Activity
Fever
Simple Trauma
Multiple Injuries
Burns
Sepsis
Growth
Multiplication factor
0.2
0.1-0.25
0.13/per degree > 38ºC
0.2
0.4
0.5-1
0.4
0.5
Nutritional requirements
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Energy: increased when :
compromised respiratory status,
sepsis,
thermal burns,
cardiac failure,
chronic growth failure,
who are recovering from surgery
Energy Provision
 Increased risk of overfeeding
Impair liver function by inducing steatosis/cholestasis
Increase risk of infection
Hyperglycemia
Prolonged mechanical ventilation
Increased PICU LOS
 No benefit to the maintenance of lean body mass
(LBM)
Agus and Jaksic (2002)
Protein Requirements
Age
0-6mon
7-12mon
13-23mon
24mon-3y
4-13y
14-18y
DRI (normal)
1.52g/kg/day
1.2
1.05
1.05
0.95
0.85
PICU
2-3g/kg/day
2-3
2-3
1.5-2
1.5-2
1.5
***may require further increases in protein provision with
burns, bacterial sepsis
Mmonitoring at the beginning
• Before starting nutritional support, assess:
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–
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nutritional status
hydration,
serum electrolytes(magnesium, phosphate, calcium)
urea, and creatinine,
cardiac status (pulse, heart failure, electrocardiogram,
ultrasonography).
Parenteral Nutrition
Nutritional requirements
• Energy: less than EN
• In children & infants approximately 7-15%
• In neonate approximately ~25%
Parenteral Lipids
Age
Initiate
Advance
Maximum
<1yr
1g/kg/day
1g/kg/day
3g/kg/day
1-10yr
1g/kg/day
1g/kg/day
2-3g/kg/day
>10yr
(adolescents)
1g/kg/day
1g/kg/day
1-2.5g/kg/day
***goals dependent on total kcal goals
***do not exceed 60% kcal via lipid (ketosis)
***maximum lipid clearance 0.15g/kg/H
Coss-Bu et al. (2001), ASPEN (2010)
Fat Emulsion
• When might Fat calories exceed carbohydrate
calories?
– Patients with an elevated CO2
– Fluid restricted patients
• Do not exceed 60% of total calories
Nutritional requirements
• Fat:
• Assessment:
• Tolerance is measured by an Intralipid level, a
measure of unmetabolized intravenous fat or
artificial chylomicrons. A level <1.0 g/L
indicates acceptable clearance.
Monitoring
Initial: weight, height, Total protein/Albumin
(TP/Alb), Transthyretin (TTR);
Daily Chem until stable
Stable: weekly Chem and bimonthly TG, LFT’s, TB/DB
Chronic: bimonthly Chem 10 and monthly TG, LFT’s,
TP/Alb/TTR
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Do not give intravenous lipids to patients with an
allergy to egg or soy due to the presence of egg
and soy protein in the intravenous preparation.
Essential Fatty Acid Deficiency
Can occur within “days to weeks” although clinical •
S/S may not been detected for months
Prevented by providing 0.5g/kg/day of lipid (2-4% of •
total kcal)
Symptoms of EFAD: •
Alopecia, scaly dermatitis, increased capillary fragility, poor –
wound healing, increased platelet aggregation, increased
susceptibility to infection, fatty liver, and growth
retardation in infants and children
Marcason (2007), ASPEN (2010)
Nutritional requirements
• Protein:
• Assessment:
• There is no good marker
Parenteral Dextrose
Glucose infusion rate (GIR) •
% dextrose x volume ÷ wt (kg) ÷ 1.44 –
Example: 15% dextrose @ 20ml/H (480ml total –
volume) for 5kg patient:
0.15 x 480 ÷ 5 ÷ 1.44 = GIR 10 •
3.4kcal/g dextrose •
Net fat synthesis may lead to hepatic •
steatosis; would not exceed GIR
>12.5mg/kg/min in term infants (maximum
glucose oxidation rate)
ASPEN (2010)
Nutritional requirements
• Carbohydrate:
• Solutions greater than 12.5% dextrose should
not be infused
• should be initiated in a stepwise fashion
• Assessment:
• evaluation of serum glucose levels
Suggested monitoring Protocol
Weight
Urine dip Bedside
for
glucose
glucose
Labs
First week
Daily
Q shift
Q shift
Subsequently
Daily
Q shift
Q shift
Daily SMA-7, Ca,
Mg, Phos,
triglycerides
Q OD LFTs
SMA-7, Ca, Mg,
Phos 2x/wk
CBC, LFTs
weekly
Triglycerides
2x/wk
PN-suggested guidelines for Initiation
and Maintenance
Substrate Initiation
Advance Goals
ment
Comments
Dextrose
10%
2-5%/day
Amino
acids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
20%
Lipids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Increase as tolerated.
Consider insulin if
hyperglycemic
Maintain
calorie:nitrogen ratio
at a pproximately
200:1
Only use 20%
25%
PN Electrolyte Dosing Guidelines
Electrolyte
Preterm
Neonates
Infants/
Children
Adolescents/
Children >50kg
Na
2-5meq/kg
2-5meq/kg
1-2meq/kg
K
2-4meq/kg
2-4meq/kg
1-2meq/kg
Ca
2-4meq/kg
0.5-4meq/kg
10-20meq/day
Phos
1-2mmol/kg
0.5-2mmol/kg
10-40mmol/day
Mg
0.3-0.5meq/kg
0.3-0.5meq/kg
10-30meq/day
Acetate
As needed to maintain acid-base balance
Chloride
As needed to maintain acid-base balance
ASPEN (2010)
Enteral Nutrition
Enteral Nutrition
Whenever possible, feed the gut 
reduce risk for bacterial translocation 
Trophic feeds: ≤20ml/kg/day 
Continuous feeds 
Initiate @~1ml/kg/H 
Advance by 0.5-1ml/kg Q4-6H 
CONTRAINDICATIONS of EN
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paralytic or mechanical ileus,
intestinal obstruction,
perforation,
necrotising enterocolitis ,
intestinal dysmotility,
toxic megacolon,
peritonitis,
gastrointestinal bleeding,
high-output enteric fistula,
severe vomiting, and sever diarrhoea
Sites (Gastric vs Postpyloric Feeding)
• gastric feeding is preferable to postpyloric feeding because:
Easier , more physiological , Bolus feeds , hyperosmolar
solutions
• Postpyloric access is indicated only in clinical conditions in which
aspiration, gastroparesis, gastric outlet obstruction, or
previous gastric surgery precludes gastric feeding or when early
postoperative feeding after major abdominal surgery is planned
• In preterm infants, postpyloric feeding should
be avoided
Complications of nasogastric and nasoenteric
feeding tubes
• Tube-related :
Plugging , Dislodgement Nasopharyngeal discomfort
(sore throat, thirst, dysphagia) , Tracheooesophageal fistula
• Tube misplacement :
Endobronchial , Intrapleural , Intrapericardial , Intracranial
• Visceral perforations and associated complications :
Oesophageal and tracheobronchial tree , Pneumothorax , Empyema ,
Mediastinitis , Pericardial sac , Pneumatosis intestinalis
Indications of PEG
PEG Complications
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In children, the early complication rate is 8% to 30%;
cellulitis,
feeding intolerance,
lacerations and perforations,
duodenal haematoma,
complicated pneumoperitoneum,
necrotising fasciitis,
catheter migration.
• The initial enteral feeding regimen should be limited
in terms of volume and energy content to provide
around 75% of requirements in severe cases If
tolerated, initial intakes may be increased for 3 to 5
days; frequent small feeds with an energy density of
1 kcal/mL should be used to minimise fluid load.
estimating maintenance fluid needs
Initiating and Advancing EN in Infants and Children
Long-term complications of gastrostomy
and enterostomy tubes
Maintenance fluid
1st 10 Kg: 100 mL/kg/day •
2nd 10 Kg (10~20 kg): 50 mL/kg/day •
3rd 10 Kg (> 20 kg): 20 mL/kg/day •
Or
1500 ml/M2/Day •
How to estimate severity and degree •
of dehydration ??
Child
(infant)
Skin turgor
Skin
(touch)
Mucosa
Eyes
Mild
3% (5%)
Normal
Tenting
None
Normal
Dry
Clammy
Moist
Normal
Dry
Deep set
Cracked
Sunken
Soft
Irritable
Slightly ↑
Sunken
Lethargic
↑↑
Normal
Weak
Impalpable
Normal
Normal
= 2 sec
Decreased
> 3 sec
anuric
Fontanelle
Flat
CNS
Consolable
Pulse rate
Normal
Pulse
quality
Capillary
Urine
Moderate
Severe
6% (10%) 9% (15%)
How to monitor fluid status ??
Urine output
Heart rate
Pulse quality
Capillary refill time
Conscious level
Activity
Fontanel and Eye .
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Parenteral rehydration
Phase I (emergent) management •
20 cc / kg isotonic fluid infusion 30 mins
10 cc / kg colloid (plasma, blood..)
Phase II (maintenance, dehydration, ongoing •
loss)
Monitor (1)
BW QD, BL QW, HG QM •
Intake and output QD •
Baseline: sugar BUN, •
electrolytes including Ca, P, Mg,
CBC, A/G, ALT, AST, Bilirubin
T/D, GGT, TG, Cholesterol, PT,
PTT
Monitor (2)
Initial 3 days or until the final •
concentration is reached: Sugar QD,
BUN, electrolytes including Ca, Mg, P,
TG QD-Q2D
Maintenance stage: weekly or bi- •
weekly
ALT, AST, Bilirubin T/D, PT, PTT, A/G,
Cholesterol, TG, CBC and platelet, sugar,
BUN, electrolytes including Ca, P, Mg
Monitor (3)
Urine tests: urine sugar should be •
tested q6h during the first days or
whenever the glucose concentration
is changed
Signs of hypersensitivity, jaundice, •
infection, hyper- or hypoglycemia, or
other complications
Complications (1)
Infections: Staphylococcus, Gram- •
negative bacilli, Candida albicans
Clotting: heparin 0.5-1U/ml routinely, •
when clotted: urokinase
Metabolic: hyperglycemia, •
hypoglycemia, electrolyte
imbalance, hyperlipidemia, vitamin
deficiency, trace elements deficiency.
Complications (2)
liver disease, cholelithiasis •
Metabolic bone disease •
Psychosocial •
liver disease
Premature at higher risk
Biliary: sludge to stones
Hepatic: elevated AST, ALT, Bilirubin, ALT,
GGT, commonly during the second week of
TPN. Pathology: inflammation of portal
areas with steatosis
Cause: excessive carbohydrates and
amino acids, sepsis, lack of enteral
feeding, ileus, amino acid solutions
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Commercially Available Entral feeding
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