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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 • • • • • • • 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: – – – – – 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 • • • • 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 • • • • • • • • • • 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 • • • • • • • • 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 . • • • • • • • 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 – – – – Commercially Available Entral feeding products