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Nutrition & Fluids
Dr. D. Barry
1) Calories
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Requirements
Growth
Type of feeding
Supplements
Calorie Requirements
for Normal Growth
Age
Energy
(kcal/kg/day)
0-6 months
100 – 120
Protein
(g/kg/day)
2.5
6-12 months
90 – 100
2.5
1-2 years
80 – 90
2.0
2-13 years
1000 +
100 x age (yrs)
1.5
Post-pubertal
2000–2500 ♀ / ♂
1.0
Neonatal Calorie Requirements
Normal Weight Gain
Neonates
Infants
Children
(Birth to 3 Months)
(3 Months to 1 Year)
(2 Years until Puberty)
~30 g/day.
 ~20 g/day
 ~200g/wk
 ~150g/wk
 Regain birth
 birth wt. doubles
weight by 10 to 14 by 4-5 months &
days of life.
triples by one year.
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2 kg/year
The Diet/Feeding History
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What?
How often?
How much?
How long to feed?
Specific feeding concerns?
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Lactose free? Soya? Etc.
Any additions / supplements?
Previous feeds & why changed?
Growth?
Normal Feeding Patterns
1) Neonate; Breast / Formula
2) 4-6/12; begin introduce solids
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Important developmental milestones
3) 6/12; follow-on formula /
continue breast-feeding
4) 1 year; 3 meals +/- snacks
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Bottle; Cow’s Milk Bottle (not until > 1 year)
Breast milk vs. Formula
Breast milk
Formula
Convenience
Always available, premixed
and warmed.
May require some
preparation.
Hygiene
Sterile
Requires clean
containers and water.
Immunology
Maternal IgA
N/A
Bonding
Maternal-Infant bonding. Also
may pump.
Can bond with any
appropriate care giver.
Vitamins/
Minerals
Bioavailable iron.
Insufficient Vitamin D.
Iron usually added.
Vitamin D added.
Fat
↑ fat (50%),
+ Omega-3 fatty acids
Less fat than formula
Protein
Lactoferrin (E. coli protective
iron-binding protein) nb NEC
Whey / Caesin
Follow-on; Cow protein
Special Feeds
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Lactose-free
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For lactose intolerance
Profuse watery diarrhoea (eg post-gastro)
Can give Soya
Hydrolysed (pre-digested protein)
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For allergy/intolerence to Cow’s milk Protein
Soya not recommeded as X-reactivity
Nutritional Supplements
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Vitamin K: Prevents hemorrhagic disease
of the newborn. Injected into all infants
at birth.
Vitamin B12: Only necessary for
exclusively breastfed babies of vegan
mothers.
Iron
Vitamin D
Nutritional Supplements:
Vitamin D
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Required to prevent rickets
Supplemented in all standard infant
formulas
Not found in adequate supplies in breast
milk
Consider supplementation in exclusively
breastfed infants with low sun exposure
Nutritional Supplements: Iron
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Prevent Iron-def. Anemia.
Supplemented in all standard infant
formulas. (Beware the low-iron brands!)
Good supply in breast milk – also more
bioavailable.
NOT adequate amounts in cow’s milk
Introduction of Solid Foods
Normal, healthy infants do not require any
nutrition besides breast milk or formula until
4-6 months.
Why not earlier?
 Head control lacking
 Calories sufficient
Why not later?
 Oral motor skills important early in
development
 Protein/Iron/Zinc needs increase
 Total caloric need increases
Introduction of Solid Foods
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Weaning to solids begins with mineral fortified
cereals (iron and zinc) and advances to other
foods.
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Start with single grain cereals (rice, oatmeal, barley).
When starting new foods (pureed fruits,
vegetables or meats) offer single items
sequentially to identify any food allergies
Avoid peanuts, eggs, fish or other
common allergenic foods
Avoid Honey < 2 years; risk botulism
Why No Cow’s Milk Before
One Year of Age?
Iron Deficiency Anemia
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Low iron content of cow’s milk
Replaces other iron sources in the toddler’s diet
Possible allergic colitis – GI blood loss
Allergic Potential
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Immune system less robust, higher risk of cow’s
milk protein allergy and eczema before 1 year
The Child with a
Chronic Disease
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Higher metabolic needs:
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Lower metabolic needs:
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Cerebral Palsy with Spasticity
Congenital Heart Disease
Hypotonia
Special diets:
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Cystic Fibrosis
Celiac
Diabetes
PKU
General Advise Parents
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< 1 food treat / week
Low-fat milk after age 2
Healthy balanced diet better than
supplements
Exercise
2) Fluids
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Physiology
Requirements
Dehydration
Calculations
Methods of Replacement
Electrolytes
Types of IV
Fluids; Basic Physiology
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Human Body is 60% Water
40% protein, minerals, fat &
carbohydrate (little)
Term Infant 75% water
Premature Baby 80% water
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75%  60% by 12 months old
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Body Composition In Children
% of total body weight
Total Body Water
60%
Intra- cellular Fluid
40%
Interstitial Fluid
15%
(ECF)
Plasma
5%
(ECF)
Blood volume
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Blood volume is 8% - 10% of body weight
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2 kg newborn has 200mls of blood
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600g premature baby has 60mls of blood
10kg child has 800 1000mls of blood
Physiology
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Children (particularly Infants) are sensitive
to changes in TBW
Young infants have poor urine
concentrating ability therefore get
dehydrated faster
Volume of TBW can be altered by
dehydration, anaemia, Heart Failure, abn
osmolality, hypoalbuminaemia etc.
More vulnerable to electrolyte imbalances
When Do You Need to Consider
Administering Fluids?
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NPO (eg. Pre-op, intra-op)
Intake insufficient to replace ongoing
losses (eg. Ileostomy / severe diarrhoea / DI / saltlosing crises etc.)
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Dehydration; mild / mod / severe
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↓ intake; systemic illness / resp dx in infant
↑ losses; vomiting / diarrhoea (eg. G/E), insensible
losses, shock (DD of causes)
IV vs. PO fluids
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If tolerating PO – can give PO (or NG)
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ORS / dioralyte / Water etc.
Indications IV
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Not tolerating adequate oral intake (eg. GE)
Mod – Severe Dehydration
NPO (? Pre-op)
Burns / Post Operative / DKA etc
Correcting Significant Electrolyte abnormalities
Oral Fluids
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Oral fluids are much more Physiological
than IV Fluids
Most cases of gastroenteritis can be
treated with Oral Fluids
Depending on Clinical history, examination
and severity of dehydration
Can use PO + IV concurrently
IV Fluids
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Maintenance
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Maintenance + Deficit
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(if dehydrated; as % of TBW est)
Maintenance + Replacement
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(calculated per weight)
(if ongoing losses; diarrhoea / ileostomy etc)
Check U&E for electrolyte imbalances
Calculating Fluid Requirements
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Obtain weight; weigh the child or estimate
Assess Hydration status (as % TBW)
Assess/measure ongoing losses
Consider cause of dehydration/losses & treat
Calculate MAINTENANCE
Calculate DEFICIT ie rehydration required
Calculate REPLACEMENTS
Add up total & administer over 24 hours min.
Choose fluid type; ie ? Sugars ? electrolytes
Estimating weight
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Full term; 3.5kg average (2.5 - 4.5kg)
By 1 year; 10 kg
1-10 years;
 Wt
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= 2 (age + 4)
[APLS guidelines]
Eg. 5 year old; est. wt = (5 + 4) x 2 = 18kg
Calculating Maintenance IV Fluid
Requirements
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0- 10 Kg; 100mls/Kg/day
11 – 20 Kg; (1000mls for 1st 10kg as above)
+ 50mls/Kg/day (for each kg >10kg)
> 20 Kg;
(1500mls for 1st 20kg as above)
+ 20mls/Kg/day
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(for each kg >20kg)
E.g. 23 Kg child 1000 + 500 + 60
= 1560mls/day
= 65mls / hour
Q.
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Calculate maintenance for 16kg child
(20/12 old)…
Calculate maintenance for 38kg child
(11 year old)…
Fluid Deficit
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Who has a fluid deficit;
Dehydration eg Gastroenteritis / ↓ intake
Burns
Post Operative
DKA
Some conditions show intravascular depletion with
oedema eg. Hypoalbuminaemia etc.
Assessing Hydration Status
Sign
Mild
(<5%)*
+
Mod
(5-10%)*
++
Severe
(>10%)*
too sickly
Mucus memb N - mild
dry
Very dry
eyes/
fontanelle
sunken
Very sunk,
dry
Skin turgor Normal
reduced
Grey , sick
Output
Normal
↓ wet nappy Oliguric
Stable
Stable
thirst
CVS
¶
Normal
¶; normal output; 1-2 ml / kg / hour
↑ HR, ↓BP
* % of total body weight
Emergency Fluids
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IV Bolus; 10 – 20 ml / kg Normal Saline
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For Mod – Severe deyhydration
In shock – can repeat ++
Resus management
This is NOT rehydration fluids!
When Stable;
Maintenance + Deficit + Replacements
Calculate for 24 hour period minimum
Calculating Rehydration Fluids
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Clinical assessment % TBW
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Replace over 24-72 hours
Check U&E
Add to Maintenance (1560ml/day if 15kg child)
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5% (50ml/kg) of 23kg (23000g) child = 1150ml
10% (100ml/kg) of 23kg child = 2300ml
If over 48 hours; 1560 + 1560 = 3120ml
+ 2300ml (mod./ 10% dehydrated)
= 5420ml over 48 hours = 113ml/hr x 48 hrs
Which fluid to use?
Urine Output
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Normal output 1-2ml/kg/hr minimum
Catheterised
Weigh wet nappies (reliable indicator if
uncontaminated)
Input/output chart, +/- daily weights
If reduced output – assess hydration
status; clinical signs & vitals
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? Dehydrated ? Overloaded
palpate bladder ? Full ? obstruction
Q.
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2 year old
Poor intake
Dry MM, Eyes &
fontanelle sunken
No wet nappy all day
HR 180 bts/min
Extremities cool
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What’s est. weight?
What’s %
dehydration?
Immediate
management?
Fluid Replacement?
IV Fluids; choices
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Colloids
Larger insoluble
molecules
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blood a colloid
Albumin (4.5%, 20%)
gelatin (Gelofusine),
Remain intravascular for
between 1 and 4 hours
depending on the solution
used
Treatment shock / ongoing
intravascular depletion
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Crystalloids
Aqueous solutions of
mineral salts or other
water-soluble molecules.
Often close to the
concentration in the
blood (isotonic)
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normal saline, 0.9%NaCl
Hartman’s Solution
Ringer's lactate (isotonic
solution often used for largevolume fluid replacement)
IV Fluids; which to choose?
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Colloids if intravascular depletions / shock
Crystalloids for Maintenance fluids &
Rehydrating deficits as discussed above
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Hypotonic / Isotonic / Hypertonic?
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Electrolyte conc; Na / K
Sugar content; dextrose ? 2.5% / 5%
Maintenance IV Fluid
Requirements
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Neonates; 5 – 10% dextrose
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cannot tolerate fasting
 Hypoglycaemic if no sugar source
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Infants <10kg; 2.5% Dex + 0.9% NaCl
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> 10 kg; Hartman’s / O.9% NaCl
U&E
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Na (135 – 145);
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May be hyponatraemic (<130) or
hypernatraemic (>150) with dehyration
Choose replacement fluid & speed of
replacement accordingly
K (3.5 – 5.0);
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[requirement; 2–3 mmol/Kg/day]
[requirement; 1–2 mmol/Kg/day]
Often hypokalaemic if vomiting / diarrhoea
Add to IV fluids eg. 10mmol/1L IV fluids
Seldom need to be added if any PO intake
Hypernatraemic Dehydration
Sodium > 150
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Too Much Salt or Not enough Water
Intra- cellular loss greatest
Use 0.45% NaCl,
Correction MUST BE SLOW; 48-72 hours
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If Sodium falls too rapidly, it leads to reexpansion of intra-cellular space too quickly
 Odema------ Particularly of Brain cells
Hyponatraemic Dehydration
Sodium < 130
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Sodium losses exceed water losses
Fluid goes from extra  intracellular 
odema
Can cause convulsions
Use 0.9% NaCl
Ideally replace slowly, but if seizing, may
have to do over 24hours (very careful
monitoring)
IV fluids complications
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IV fluids are a medication
Must be prescribed by Doctors (ie. YOU!!!)
Side-effects;
Electrolyte imbalances
Potentially letal if wrong fluid or duration
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Eg cerebral oedema if correct hypernatraemic
dehydration too quickly
Eg. Fatal arrhythmias with K replacement
Overload
Overload
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Oedema; sacral, scrotum, periorbital,
(+/- ankle)
CVS; ↑ JVP, ↑ BP, tachycardic
Heart failure, Pulmonary Oedema,
hepatomegaly, ascites
↑ weight
Summary; Fluids
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Know how to assess Hydration
Know to calculate maintenance & deficit
Know to consider electrolytes;
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Na, K & Dex when administering IV +/- other
Know complications of IV fluids
PO is best if possible
Final Q.
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4 yr old boy
Vomiting & Diarrhoea x
2/7
Not tolerating anything
today; vomiting!
Wet nappies
Dry tongue, lips
Normal skin turgor
Miserable but alert
HR 100 bpm, BP 90/60
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What do you do?