2. Practical Approach to Paediatric nutritional support

3. 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

4. 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

5. 5 تقسيم بندي Gomez براي شدت سوء تغذيه وزن بيمار وزن ايده آل وزن بيمار وزن ايده آل 100 * بيشتر از 90% طبيعي 100 * بيشتر از 90% طبيعي 100 * بين 76% تا 90% سوء تغذيه خفيف 100 * بين 61% تا 75% سوء تغذيه متوسط 100 * کمتر از 60% سوء تغذيه شديد وزن بيمار وزن ايده آل وزن بيمار وزن ايده آل

6. 6 تقسيم بندي Waterlow براي تعيين شدت و زمان سوء تغذيه مزمن ( قد بر حسب سن ) حاد ( وزن بر حسب قد ) درصد مقدار متوسط (Median) 95> 90-80 درصد 80-70 درصد 70 < درصد مقدار متوسط (Median) نرمال : 90 > درصد خفيف : 90-80 درصد متوسط : 80-70 درصد شديد : 70 > درصد

7. Mehta and Duggan (2009) Nutrition Goals for the PICU 1.Minimize protein catabolism 2.Meet energy requirement

8. Nutrition & Diet Therapy (7 th Edition) Selecting a Feeding Route

9. 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

10. Resting Energy Expenditure Age (years)REE (kcal/kg/day) 0 – 155 1 – 357 4 –648 7 –1040 11-14 (Male/Female)32 15-18 (Male/Female)27

11. Factors adding to REE Multiplication factor Maintenance0.2 Activity0.1-0.25 Fever0.13/per degree > 38ºC Simple Trauma0.2 Multiple Injuries0.4 Burns0.5-1 Sepsis0.4 Growth0.5

12. Nutritional requirements Energy: increased when : compromised respiratory status, sepsis, thermal burns, cardiac failure, chronic growth failure, who are recovering from surgery

13. Agus and Jaksic (2002) Energy Provision Increased risk of overfeeding 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)

14. Protein Requirements AgeDRI (normal)PICU 0-6mon1.52g/kg/day2-3g/kg/day 7-12mon1.22-3 13-23mon1.052-3 24mon-3y1.051.5-2 4-13y0.951.5-2 14-18y0.851.5 ***may require further increases in protein provision with burns, bacterial sepsis

16. Before starting nutritional support, assess: – nutritional status – hydration, – serum electrolytes(magnesium, phosphate, calcium) – urea, and creatinine, – cardiac status (pulse, heart failure, electrocardiogram, ultrasonography). Mmonitoring at the beginning

17. Parenteral Nutrition

18. Nutritional requirements Energy: less than EN In children & infants approximately 7-15% In neonate approximately ~25%

19. Parenteral Lipids ***goals dependent on total kcal goals ***do not exceed 60% kcal via lipid (ketosis) ***maximum lipid clearance 0.15g/kg/H AgeInitiateAdvanceMaximum <1yr1g/kg/day 3g/kg/day 1-10yr1g/kg/day 2-3g/kg/day >10yr (adolescents) 1g/kg/day 1-2.5g/kg/day Coss-Bu et al. (2001), ASPEN (2010)

20. Fat Emulsion When might Fat calories exceed carbohydrate calories? – Patients with an elevated CO 2 – Fluid restricted patients Do not exceed 60% of total calories

21. 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.

22. 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

23. 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.

24. 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)

25. Parenteral AA Guidelines AgeInitiateAdvanceMaximum <1yr1-2g/kg/day1g/kg/day4g/kg/day 1-10yr1-2g/kg/day1g/kg/day1.5-3g/kg/day >10yr (adolescents)1g/kg/day 0.8-2.5g/kg/day ASPEN (2010) ***4kcal/g aa

27. Nutritional requirements Protein: Assessment: There is no good marker

28. 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)

29. GIR/Dextrose Guidelines AgeInitiateAdvanceMaximum <1yr~6-9mg/kg/min1-2mg/kg/minGoal: 10- 12mg/kg/min Max: 14mg/kg/min 1-10yr1-2mg/kg/min Max: 8- 10mg/kg/min >10yr (adolescents) 1-2mg/kg/min Max: 5- 6mg/kg/min ASPEN (2010)

30. 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

32. Suggested monitoring Protocol WeightUrine dip for glucose Bedside glucose Labs First weekDailyQ shift Daily SMA-7, Ca, Mg, Phos, triglycerides Q OD LFTs SubsequentlyDailyQ shift SMA-7, Ca, Mg, Phos 2x/wk CBC, LFTs weekly Triglycerides 2x/wk

33. PN-suggested guidelines for Initiation and Maintenance SubstrateInitiation Advance ment GoalsComments Dextrose10%2-5%/day25%Increase as tolerated. Consider insulin if hyperglycemic Amino acids 1 g/kg/day0.5-1 g/kg/day 2-3 g/kg/day Maintain calorie:nitrogen ratio at a pproximately 200:1 20% Lipids 1 g/kg/day0.5-1 g/kg/day 2-3 g/kg/day Only use 20%

34. PN Electrolyte Dosing Guidelines ElectrolytePreterm Neonates Infants/ Children Adolescents/ Children >50kg Na2-5meq/kg 1-2meq/kg K2-4meq/kg 1-2meq/kg Ca2-4meq/kg0.5-4meq/kg10-20meq/day Phos1-2mmol/kg0.5-2mmol/kg10-40mmol/day Mg0.3-0.5meq/kg 10-30meq/day AcetateAs needed to maintain acid-base balance ChlorideAs needed to maintain acid-base balance ASPEN (2010)

36. PN considerations Current trace elements contain no Se Parenteral requirement: 2mcg/kg/day  Se deficiency Cardiac and skeletal myopathy Risk factor for BPD Hypothyroidism Weakened immune system

37. Enteral Nutrition

38.  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

39. 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

40. 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

41. In preterm infants, postpyloric feeding should be avoided

42. 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

44. In children, the early complication rate is 8% to 30%; cellulitis, feeding intolerance, lacerations and perforations, duodenal haematoma, complicated pneumoperitoneum, necrotising fasciitis, catheter migration.

45. 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.

51. 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/M 2 /Day

52. How to estimate severity and degree of dehydration ??

53. MildModerateSevere Child (infant) 3% (5%)6% (10%)9% (15%) Skin turgorNormalTentingNone Skin (touch) NormalDryClammy MucosaMoistDryCracked EyesNormalDeep setSunken FontanelleFlatSoftSunken CNSConsolableIrritableLethargic Pulse rateNormalSlightly ↑↑ ↑↑ ↑ Pulse quality NormalWeakImpalpable CapillaryNormal= 2 sec> 3 sec Urine output NormalDecreasedanuric

54. Percent of deficit from ECF vs ICF Duration% ECF deficit% ICF deficit < 3 days80%20% > 3 days60%40%

55. Electrolyte composition of ECF & ICF ICF (mEq/L)ECF (mEq/L) Na20135-145 K1503-5 Cl-98-110 HCO31020-25 PO4110-1505 Protein7510

56. How to monitor fluid status ?? Urine output Heart rate Pulse quality Capillary refill time Conscious level Activity Fontanel and Eye.

57. 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)

58. 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

59. 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

60. 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

61. 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.

62. Complications (2) liver disease, cholelithiasis Metabolic bone disease Psychosocial

63. 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

64. Commercially Available Entral feeding products