Pediatric Nutrition

TPN

  • Calculate the dose of protein
    • Protein = 4 kcal/gram
    • 6.25 g protein = 1 g N
    • Start at 0.5-1 g/kg/day & gradually increase as needed
      • Low birth weight neonates:  start at 2-3 g/kg/day
    • KNOW:  the younger the child, the higher the protein needs (up to 3-4 g/kg)
  • Calculate the dose of fat
    • Lipids = 9 kcal/g
    • 10 % lipids = 1.1 kcal/mL
    • 20 % lipids = 2 kcal/mL (use this for calculation)
    • Lipids should make up 30-50% of calories
    • 0.5-1 g/kg/day
      • Start at 0.5-1.5 g/kg/day & titrate up as needed
    • KNOW:  lipid dose increases in infants/kids as opposed to preterm neonates but then levels off in adolescents & adults (infants & children have the greatest need for lipids)
    • Infuse over 18-24 hrs in small infants
      • In older kids you may infuse over 12 h
      • Don’t exceed 0.15 g/kg/day
    • Complications of lipid therapy:  contamination, increased TGs, cholesterol, thrombocytopenia, sepsis, respiratory difficulties, abnormal leukocyte function
    • Helps w/ wound healing, dry skin, brittle hair, reduced growth
  • Calculate the dose of dextrose
    • Glucose/carbs = 3.4 kcal/g
    • Glucose infusion rate (GIR) =((Rate)(Dex Conc. %)) / (6(Weight in kg))
      • Converts to mg/kg/min of glucose
      • Typically GIR = 0.5-1.5 mg/kg/min
    • Start low (10%) & slowly increase in increments of 2.5%

Laboratory monitoring for patients receiving TPN

  • Protein:  BUN, LFTs, albumin, pre-albumin
    • Also watch out for hyperchloremic metabolic acidosis, high ammonia levels
  • Lipids:  serum TGs, bilirubin (jaundice)
  • Dextrose:  serum & urine glucose levels
    • Excessive carbs are converted into fat which results in increased CO2 & ketone production, watch out for hyperglycemia

Amino acids that change in preterm neonates

  • Increased: histidine, tyrosine, taurine, cysteine
  • Decreased:  phenylalanine, methionine

Factors that alter the solubility of calcium in a TPN

  • Solubility decreases with:  increased pH (more basic), Temp, concentration, exposure time
    • CaPO4 will precipitate out

Effects of Calcium and Multivitamins in TPNs

  • 20% rather than 10% lipid emulsions in preterm and term infants
  • Optimal calcium phosphate ratio
    • Ca & Phos are needed to help maintain cell membrane integrity, nerve conduction, coagulation, endocrine/exocrine activity, bone metabolism
    • Optimal Ca:PO4 ratio for preterm infants =  2.6 mEq : 1 mMOl
      • Older children should have equimolar concentrations of Ca & PO4
  • MVI-pediatric and MVI-12 products
    • If the kid < 2.5 kg:  give MVI-pediatric 2 mL/kg
    • If the kid > 2.5 kg:  give MVI-pediatric 5 mL/kg
    • If the kid > 11 years old:  give 10 mL of MVI-12
      • If the pt has been on a TPN for > 2 weeks, then they require vit. K supplements
    • The difference adult & pediatric MVIs:  pediatric formulations contain higher amounts of vitamins A, D, E, & K
      • Adult MVIs contain propylene glycol

Metabolic complications of parenteral nutrition

  • Cholestasis
    • Starts  between 2 weeks to 2 months after the TPN is instituted
    • GGT & bilirubin increase followed by increases in AST & ALT
    • Treatment:  d/c TPN solution & start enteral feedings.  Cycle TPN (tk off a few hours a day)
      • Drug options:  ursodiol (actigal), phenobarb, cholestyramine (questran)
  • Osteoporosis & rickets
    • Due to an inadequate absorption of Ca & PO4 b/c of the risk of precipitation
    • Decreased Vit D metabolism
  • Other line complications from TPNs:  infections, occlusion

Benefits of breast milk (GOLD STANDARD)

  • Superior & ideal form of nutrition for full-term neonates
  • Excellent bioavailability, emotional bonding between mother & child, provides immunologic protection, convenient & inexpensive
  • Anti-infective properties (reduces bacterial & viral illnesses), decreased risk of Crohn’s disease, DM, eczema, asthma, allergic gastroenteritis, psychological & long-term cognitive advantages
  • CI to breast feeding:  contagious lesions (syphilis, herpes), chickenpox, pertussis, TB, cytomegalovirus, HIV, hep B, infant intolerance, some meds, prematurity (< 34 weeks)

Pediatric enteral nutrition

  • Calculate calories from enteral nutrition
    • Infant caloric needs:  100-120 kcal/kg/day
    • Infant fluid needs:  140-160 mL/kg/day
      • So for a 20 kcal/ounce formula & the kid needs 150 mL/kg/day = 100 kcal/kg/day
  • Pre-term infant formula   (ex. Similac Special Care, Enfamil Premature Formula)
    • Low birth weight infants require rapid growth
    • Contain increased protein, Ca, PO4
    • Available in 20, 24, 30 kcal/oz
    • Require supplemental Fe
  • Transitional formulas (ex. Neosure, enfacare)
    • Used for infants requiring increased caloric intake when they get discharged from the hospital
    • Increased protein, Ca, vitamins & minerals compared to standard formulas but less so than the pre-term formulas above
    • Available OTC @ 22 kcal/ounce
  • Term formulas (milk protein; ex. Similac, enfamil, enfamil AR, similac sensitive RS)
    • For normal full-term infants that don’t have any special nutritional needs, but can also be used as a supplement breast-fed infants
    • Available OTC at 20 kcal/ounce with 1.5 g/dL protein & 3.5 g/dL fat
  • Lactose Free Formulas (ex. Lactofree, similac Sensitive Lactose Free)
    • Lactose free:  changes the carb source to a simple sugar  (20 kcal/ounce)
    • Soy formulas (ex. Isomil, prosobee) are indicated for kids that are sensitive to cow’s milk, following diarrhea, lactose intolerant, lactase deficient, galatosemia
      • 20 kcal/ounce
  • Casein Hydrolsate Based formula (ex. Pregestimil, alimentum, nutramigen)
    • Used for infants insensitive to cow’s milk & other food protein & carb sensitivities resulting in severe or persistent diarrhea & other GI disturbances.
    • 2-3 more expensive than others
  • Elemental formulas:  Portagen, Neocate, EleCare
  • “Advance”/”Lipil” formula means that it contains DHA or ARA
  • Older children formulas (ages 1-10):  approximately 1 kcal/mL  (ex. Pediasure & Kindercal)
  • Advantages of enteral nutrition over parenteral
    • Maintain structural & functional GI integrity, decreased potential for bacterial translocation, increased utilization of nutrients, improved glucose tolerance, ease & safety of admin, decreased cost, decreased hepatobiliary complications
  • Indications for enteral nutrition:  diminished ability to ingest nutrients, failure to meet full nutritional needs orally, altered absorption or metabolism of nutrients (chronic diarrhea, short bowel syndrome, inflammatory bowel disease, GERD)
  • CI for enteral nutrition:  necrotizing enterocolitis, GI obstruction, intestinal atresia, severe inflammatory bowel disease, acute pancreatitis
  • Complications associated w/ formula:  vomiting (due to too rapid advancement, delayed gastric emptying, hyperosmolar formula), constipation (due to low fluid intake), dehydration (due to inadequate fluid intake), diarrhea (due to lactose intolerance, hyperosmolar, contaminated, too rapid advancement, low fiber intake, fat malabsorption)

Maintenance caloric requires

  • Preterm neonates = 120-150 kcal/kg
  • < 6 months = 90-120 kcal/kg
  • 6-12 months = 80-100 kcal/kg
  • 1-7 years = 75-90 kcal/kg
  • 7-12 years = 60-75 kcal/kg
  • 12-18 years = 30-60 kcal/kg
  • > 18 years = 25-30 kcal/kg

Indications for TPN:  premature neonates, respiratory distress, congenital GI anomalies, abdominal wall defects, necrotizing enterocolitis, chronic diarrhea, inflammatory bowel disease, metabolic errors, pancreatitis, chylothorax, pseudo-obstruction, hypercatabolic states, anorexic, cystic fibrosis, chronic renal failure, hepatic failure

  • Goals of TPN therapy:  promote fluid equilibrium, maintain glucose homeostasis, achieve positive nitrogen balance (need plenty of protein), prevent acute nutrient deficiencies, provide an adequate amount of nutrients for growth to occur

Peripheral parenteral nutrition

  • Need to have an osmolarity of < 900 mOsmol/L
    • Hyperosmolar solution can cause venous sclerosis & phlebitis
  • Ok for short-term nutrition support
  • Don’t exceed these amounts in solution:  10-12.5 % glucose, 4% AA, 40 mEq/L Potassium
    • Could use a central line or PICC for administering these high concentration solutions

Ways to assess nutrition:  body weight, length, height, head circumference, skin fold thickness, arm muscle circumference, bone mineralization (Ca, Phos, alkaline phosphatase, X-ray/skeletal survey)

  • Visceral protein markers (albumin, transferrin, prealbumin, retinol binding protein) are generally decreased with malnutrition
  • Nitrogen excretion/balance

Zinc:  important for wound healing, a cofactor for many enzymes, GI losses
Copper:  RBC & WBC formation
Manganese:  important activator of enzymes
Chromium:  insulin reactions
Selenium:  protects cells from oxidative damage

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