Transcript File

Pediatric Nutrition: Management
of SBR, dehydration, & high
ileostomy output -The influential
role of a Clinical Dietitian
By Celina Chan
Dartmouth Hitchcock Medical
Center- Lebanon
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Founded 1893
Teaching
Hospital
Outpatient
visits: 645, 857
Employees
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.”
Dartmouth Hitchcock Medical
Center- Lebanon
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Beds: 396
Mary Hitchcock
Memorial Hospital
Geisel School of
Medicine at
Dartmouth
Children’s Hospital at
Dartmouth-Hitchcock
(ChaD)
Norris Cotton Cancer
Center
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
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Bump to RD level:
-BMT
-All Pedi
-NPOx5
-Gestational
-HA1C 8 or higher
-BUN <2
-Renal
-CHO counting
-GI
-Tube feeds
-TPN
Outline
Pt introduction & history
 Diagnosis
 Assessment
 Nutrition diagnosis
 Intervention (MNT)
 Monitoring
 Evaluation
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Patient History-Baby J
Male, Full term 38 wk
 Birth date: 8/25/14 --- d/c 10/9 (~6wk old)
 Readmitted 10/12
 Gastroschisis
 Ileal Atresia
 Short Bowel Resection (SBR)
 Ileostomy
 Dehydration
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Gastroschosis
Intestines outside the body
 “vanishing” -resolved before birth
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Pathogenesis & Etiology
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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
Pathogenesis & Etiology cont…
◦ Theories:
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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)
Treatment
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Treatment
◦ Surgery
◦ “vanishing” – self resolves (surgery still
needed to close the abdominal wall)
◦ Further complications requiring treatment
may occur
Ileal Atresia
Distended loop of bowel
 Narrowing of the intestine
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SBR
Small bowel resection
 Total 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.
Dehydration
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-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 recipe
Current 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)
Nutrition Considerations
Weight
 Growth Chart
 Electrolytes
 I’s & O’s
 Ileostomy output
 Food History
 Needs
 Formula
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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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Goals
Resolve dehydration— provide
appropriate formula and monitor intake
 Stool output <50ml/kg/day or <2ml/kg/hr
 Electrolytes & labs wnl
 Weight maintenance  gain (recommend
caloric goal of 150kcal/kg)
 *treated as a “functional” short gut pt
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Current Diet order 10/17
Gentlease 20kcal/oz ad lib
 Weight: 3.12 kg
 Stool output last 24 hrs: 325ml or,
104ml/kg/day
 Avg 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
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Ceralyte: oral rehydration
Provides:
◦ Na 50-90mmol/L
◦ K 20mmol/L
Follow up- 10/21
230ml 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
10/21
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Switch 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
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Recommend caloric goal of 150kcal/kg
Follow serum Na, weights, intake/output
daily
Follow up 10/22
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Current Diet order: 230 ml Elecare 20kcal/oz &
40ml Ceralyte 90 per bottle daily po ad lib
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Provides: 616kcal, 26.4 mEq Na
Weight: 3.17kg ~ avg week wt gain was 30g/wk)
 Na: 138
 Stool output: 161ml = 2.1ml/kg/hr (close to
goal)
 Total intake: 512 kcal, 21.6meq Na
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Follow up 10/23
Weight: 3.2kg
 Na 139, K 3.7
 Intake past 24 hrs: 880 ml Elecare 20kcal/oz &
40ml Ceralyte 90
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Provided 590 kcal, 19.4mEqNa, 22.1 mEqK,
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Stool 123ml = 1.6ml/kg/hr (meets goal!)
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 10/24
Diet 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
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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
Follow up 10/27
Current diet order: Elecare 20kcal/oz +
Pectin
 Ostomy output: 4.2ml/kg/hr
 Meeting goal with feeds
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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
Follow ups….
Elecare + Ceralyte
 Positive for fecal fat
 Medications added: flagyl, immodium,
AquAdek
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Weight
10/27
10/30
10/31
3.36kg
3.33kg
3.43kg
Recommendations
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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 water
gCHO/ml
mEq Na/ml
mEq K/ml
Ceralyte
0.04
0.09
0.02
Homemade
cereal sol’n
0.05
0.11
0.005
Plans
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Reinfuse stool into distal mucus fistula so
that it goes into colon
D/C
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Elecare 20kcal/oz ad lib + Rice Cereal Soln
Wt: 3.7kg
Avg daily intake: 168kcal/kg/day
Diet 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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Summary
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Gentlease  Gentlease + Ceralyte  Elecare
+ Ceralyte  Elecare + Pectin  Elecare +
Rice Sol’n (to mimic ceralyte)
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Flagyl, aquadek
Final Thoughts
Initiation of Elecare
 Pectin?
 Complicated situation:
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◦ more than one solution: “many right
answers, obvious wrong answers”
◦ Team effort (Pedi MDs, Dietitians, GI team,
pedi, etc)
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/Pr
ograms/A_E/Center%20for%20Advanced%20Intestinal%20Rehabilitatio
n/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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References (photos)
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http://acareotc.caraudio.netdnacdn.com/media/catalog/product/cache/1/image/500x500/9df78eab33525d08d6e5fb8d27136e95/4
/0/404925.Jpg
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http://www.convatec.com/media/12324/ileostomy-copy.jpg
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http://www.columbusfetalmedicine.org/images/gastroschisis-1.png
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http://img.medscape.com/pi/emed/ckb/radiology/336139-409746-10248tn.jpg
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https://www.luriechildrens.org/en-us/care-services/conditions-treatments/fetal-intestinalatresia/PublishingImages/LowAtresia_sm_new.gif
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http://fce-study.netdna-ssl.com/2/images/upload-flashcards/60/80/54/5608054_m.jpg
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http://www.uofmchildrenshospital.org/fv/groups/public/documents/images/95145.jpg
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http://static.abbottnutrition.com/cms-prod/abbottnutrition.com/img/06-07-2011-01-1605_EleCare_Infant.jpg
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http://g-ecx.images-amazon.com/images/G/01/hpc/detail-page/c26-B0026RHUO4-1-l.jpg
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http://www.jocosarblog.org/.a/6a0105364e2a0e970b01157193be95970b-pi
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http://c4.diapers.com/images/products/p/ns/ns-688_1z.jpg
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http://www.chadkids.org/images/DHMC_location.jpg
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http://www.brplusa.com/images/projects/healthcare/dhmc_aerial_fs.jpg