CHAPTER 20: Nutrition

Information gathering, growth assessment, estimation of needs, determination of risk factors, identification of goals and provide recommendations and education

ASSESSMENT

• Nutrition-focused medical history

  • ✓ Usual intake including types and portion sizes of foods consumed

  • ✓ Fluid intake: Juice, milk, water over 24-hour period

  • ✓ For Breast-fed children, assess minutes on each breast and frequency of feeding

  • ✓ Formula: Type, changes, and response

  • ✓ Oral supplements or tube feedings (delivery method, tolerance, formula, length of time)

  • ✓ Herbal, vitamin, or mineral supplements

  • ✓ Food aversions, allergies, appetite, and religious/ethnic restrictions

  • ✓ Access to food: Food insecurity, Women, Infants and Children (WIC), food stamps

  • ✓ Note specific conditions that may affect absorption, metabolism, and digestion or increase the caloric needs of the patient (fever, increased respiratory rate and effort, cardiac disease, etc.)

  • ✓ Deficiencies from inadequate intake or comorbidities: Vitamin D, iron deficiency anemia, zinc

• Gastrointestinal history including defecation patterns, nausea, vomiting, gastroesophageal reflux treatment, abdominal surgeries

• Medications and potential food/drug interactions:

  • ✓ Note side effects of drugs that may cause electrolyte wasting, change in stool patterns or malabsorption

  • ✓ Note whether the drug’s efficacy is reduced by food or food interferes with absorption or mechanism of action

• Family history: Food allergies/atopic disease, celiac disease, diabetes, obesity, heart disease, stroke

• Birth history: Prematurity, intrauterine growth retardation, small for gestational age, necrotizing enterocolitis

• Laboratory values:

  • ✓ Consider evaluating electrolytes, albumin, prealbumin, CBC, and hepatic function and lipid panels if indicated (e.g., in the setting of emesis, diarrhea, poor growth, obesity, supplemental nutrition or when otherwise warranted based on clinical evaluation)

  • ✓ Deficiencies (if diet history indicates): 25-OH vitamin D, zinc, iron profile

• Growth parameters:

  • ✓ Unintentional weight loss: 5–10% loss is moderate, >10% is severe

  • ✓ Length/height, weight, head circumference (if younger than 3 years) percentiles

    • ▪ Up to 2 years of age—Use 2006 World Health Organization (WHO) growth chart for weight, supine length, and head circumference

    • ▪ 2–20 years of age—Plot weight and standing height on the Center for Disease Control (CDC) 2000 growth charts and calculate BMI and plot

    • ▪ Plot on CDC growth chart or specialty chart (prematurity, disease specific, etc.) until 20 years of age

    • ▪ Correct for prematurity until 3 years of age

  • ✓ Optional: Obtain triceps skinfold and mid-arm circumference to calculate muscle and fat stores. Measure lower leg length, knee height, or arm span (when unable to obtain accurate height)

  • ✓ Typical growth velocity presented in Table 20-1

  • ✓ Use z score to express individual anthropometrics in relation to population standard (i.e., 25th percentile weight-for-age= z score of 1 indicates that weight-for-age is 1 standard deviation from the mean)

Stunting and Wasting

• Wasting is an indicator of acute malnutrition

• Stunting is an indicator of chronic malnutrition

Grading Malnutrition

• Acute (<3 months) and chronic (>3 months) malnutrition includes both undernutrition and obesity. Undernutrition can be classified based on a variety of measures including anthroprometrics: weight for length z score, BMI for age z score, length/height z score, mid-upper arm circumference, weight gain velocity, weight loss, deceleration of weight for length or BMI for age as well as nutrient intake

• Classification based on weight for length and BMI for age z scores: mild malnutrition – 1.0 to 2.0 z score, moderate malnutrition – 2.0 to 3.0 z score and severe malnutrition – <3.0 z score (also including length/height z score)

Body Mass Index

• Body mass index (BMI) = Weight (kg)/(Height (cm))² × 10,000

• Used for children older than 2 years of age for assessment of obesity

• BMI percentile 85–95% = overweight and BMI percentile >95% = obese

Estimating Nutrition Needs

There are a variety of methods to estimate energy (calorie) needs.

• The recommended daily allowance (RDA) guideline is recommended for infants and may be used to estimate calorie (Table 20-2) and protein (Table 20-3) needs for healthy children

• Dietary Reference Intakes (DRI): A set of reference values for recommended intake of vitamins, minerals, and nutrients in healthy populations of Americans and Canadians

  • ✓ Estimated Average Requirements (EAR): Average daily intake of nutrient that will meet nutritional needs of half the individuals in the group

  • ✓ Recommended Dietary Allowance: Amount of nutrition that meets needs of 97–98% of healthy individuals

  • ✓ Adequate Intake (AI): Expected to meet nutritional need of everyone in the group to give guidance but is not a defined calculation

• The WHO equation (Table 20-4) provides a more detailed calculation of energy requirements for children and adolescents to provide the resting energy expenditure (REE). The REE is then modified by activity levels and stress factors, which are important considerations in hospitalized children

• Once the REE is calculated, an activity or stress factor must be incorporated to account for additional calorie needs under special circumstances. (REE × [Activity or Stress Factor] = estimated caloric needs)

  • ✓ REE × 1.3: Well-nourished child at bed rest with mild-to-moderate stress

  • ✓ REE × 1.5: Normally active child with mild-to-moderate stress; inactive child with severe stress (trauma, sepsis, cancer) or child with minimal activity and malnutrition requiring catch-up growth

  • ✓ REE × 1.7: Active child requiring catch-up growth or active child with severe stress

OBESE POPULATION

• Caloric needs vary significantly in the obese population and equations do not always accurately predict needs; consider evaluating REE if available

• Schofield height and weight equation is most accurate for calculating calorie needs

• When calculating calorie needs for an obese patient, consider using an adjusted body weight (BW) instead of the actual BW in the WHO equation

• Adjusted BW = Ideal BW + 0.25 × (Actual BW − Ideal BW)

CATCH-UP GROWTH

• Calorie requirements for catch-up growth can be calculated using the RDA Guideline table (see Table 20-2) and the following equation:

  $Daily Calorie Requirement for Catch-up Growth= RDA for Weight Age × Ideal Weight for Height Actual Weight$

• Protein requirements for catch-up growth can be calculated using the DRI for Protein table (see Table 20-3) and the following equation:

  $Protein Requirement for Catch-up Growth= ( Protein for Weight Age × Ideal Weight for Height ) Actual Weight$

  • ✓ Use weight in kilograms

  • ✓ Weight-age = kcal/kg/day = age at which present weight would be at the 50th percentile on the growth chart

  • ✓ To determine ideal weight for actual height, use the patient’s height to find the 50th-percentile point on the height curve, and then drop down vertically to the weight curve to the corresponding 50th-percentile point on the weight curve. Follow that point horizontally to determine the corresponding weight

TUBE FEEDING

Tube feeding should be considered if the patient has a functional gastrointestinal (GI) tract but is unable/unwilling to consume sufficient calories/protein intake for weight maintenance/growth. Feedings may be intermittent or continuous. Many children benefit from a combination of daytime bolus and overnight continuous feeding thus the regimen should be based on the individual child’s needs.

• Due to risk of bacterial contamination, hang time of formula should not exceed 4 hours for hospitalized patients, especially neonates

CONTINUOUS FEEDS

• Advantages of continuous feeds:

  • ✓ Enhanced tolerance and absorption (especially in short bowel patients)

  • ✓ Used for nocturnal supplemental feedings (with daytime oral intake)

  • ✓ Less likely to cause abdominal distention

  • ✓ Physiologic for small bowel feeds

• Disadvantages of continuous feeds:

  • ✓ Requires a pump and therefore decreases mobility

  • ✓ Risk of bacterial contamination if feeds are left at room temperature for a long period

  • ✓ May suppress appetite thus consider limiting to overnight feeds if possible

• Suggested initial regimen and advancement for continuous feeding:

  • ✓ For age 1 month–7 years: Initial regimen, 0.5–2 mL/kg/h; advance by 0.5–1 mg/kg/h every 4–24 hours as tolerated

  • ✓ For age greater than 7 years: Initial regimen, 10–20 mL/h; advance by 10–20 mL/h every 4–8 hours as tolerated

  • ✓ Individual tolerance must be closely monitored

INTERMITTENT (BOLUS) FEEDS

• Advantages of bolus feeds:

  • ✓ Easier to administer: Faster and do not always require a pump

  • ✓ Physiologic for gastric feeds: Pattern is similar to mealtimes

  • ✓ Enhances mobility: Not continuously connected to a pump

• Disadvantages of bolus feeds:

  • ✓ May worsen gastroesophageal reflux

  • ✓ Aspiration risk due to volume of feeding in stomach

  • ✓ May impinge on respiratory effort with large bolus feeds

• Suggested initial regimen and for advancement, refer to Table 20-5; individual tolerance must be closely monitored

MONITORING

• Elevated BUN/creatinine: Check for increased protein content of formula, decreased renal function, or inadequate fluid intake

• GI tolerance:

  • ✓ Constipation: Evaluate for inadequate fluid and fiber intake, inactivity, and consider evaluating for a fecal impaction

  • ✓ Diarrhea: Etiologies to consider: hyperosmolar medication or formula, rapid infusion, intolerance to particular component of formula (i.e., carbohydrate and fat content) or modular supplements, tube migration (i.e., from stomach to duodenum with bolus feeds), inadequate fiber intake, low albumin, impaction leading to overflow diarrhea, possible bacterial contamination of formula

  • ✓ Vomiting: Etiologies to consider: delayed gastric emptying; GER; displacement of tube (i.e., in the distal esophagus); gastritis; intolerance of a particular component of formula (i.e., fat content or allergy); rapid infusion rate; also consider a behavioral component

• Hydration status: Monitor urine specific gravity, input, and output and check whether regimen meets the child’s free water requirements

• Glucose homeostasis: If high blood glucose or glucosuria, consider possible infection or medication side effect (i.e., steroids), check carbohydrate intake

• Anthropometrics: Weight, height, and head circumference (as appropriate for age); adjust calorie/protein intake accordingly

  • ✓ Consider following weights closely or daily while inpatient to guide adjustments

MECHANICAL PROBLEMS

Clogged Tube

• Usually avoided by scheduled water flushes, especially after interruption of feeds or following instillation of medications

  • ✓ Attempt to flush with warm water using progressively smaller syringes (e.g., 5, 3, 1 mL)

  • ✓ If the tube does not clear with warm water, consider using an enzymatic solution according to your institutional protocol (e.g., Clog Zapper™) to unclog the tube

  • ✓ If attempts to clear the clog fail, consider replacement of tube

Leakage of Gastric Contents Around the Gastrostomy Site

• Prevent leakage by minimizing tube movement (e.g., using a foam [Mepilex^®] dressing) and using protective skin care (such as gauze, petroleum jelly, Stomahesive^® protective powder)

• Check the amount of water in balloon (refer to manufacturer’s instructions)

• Ensure the tube size is appropriate. Do not increase the tube size to avoid progressive enlargement of the stoma site

• Consider calling the service that placed device to decide if further action needed

The Tube has Fallen Out

• If the tube has never been changed or the tract is immature (review your hospital policy, consider <12 weeks old for tubes placed in Interventional Radiology [IR] and 4 weeks old for surgically placed tubes), the patient should contact the team that placed the tube as soon as possible. If the team that placed the tube cannot be reached, the patient should go to the ER for evaluation and to preserve the stoma site. In the ER, a 10 Fr Foley can be carefully placed (without inflating the balloon) to maintain patency but should not be used for feeding. Once the appropriate team replaces the tube, consider obtaining a dye study to confirm placement to avoid complications such as peritonitis and death

• If the tube has been changed before and is >12 weeks old (or 4 weeks if surgically placed), the family should replace the tube or place a foley in the stoma to keep it patent until an appropriate tube is available

Granulomas at Gastrostomy Tube Site

• Consider a trial of silver nitrate or triamcinolone cream 1–2 times per day for up to 1–2 weeks. If not improved, contact the G-tube Nurse or the service that placed the tube

• Gastric mucosa prolapse through the stoma is not a granuloma and is a problematic complication that may require temporary removal of tube or surgical revision of site. Surgical consultation is recommended

Formula Choice: A variety of infant and pediatric formulas are available based on the individual child’s needs. Refer to Table 20-6 for a summary.

Modular Supplements: Can be used to add macronutrients and calories. Refer to Table 20-7 for a summary.

Indication: To maintain nutritional status and achieve growth in patients who cannot receive adequate nutrition enterally. Remember that enteral nutrition is the route of choice.

Peripheral parenteral nutrition (PPN): Used in peripheral veins and therefore is limited to maximum dextrose concentration of 10% (in some circumstances, 12.5%) and osmolality less than 1000 mOsm/L. It is intended for nutritional support of less than 10 days’ duration.

Central parenteral nutrition: Used in central veins, which allows for higher dextrose concentrations and osmolality greater than 1000 mOsm/L. It is used when the anticipated need is greater than 7–10 days.

Parenteral Energy Intake

• 10–20% lower than estimated enteral needs due to reduced energy cost for digestion/absorption (see estimating nutritional needs earlier in the chapter)

PARENTERAL NUTRITION (PN) COMPONENTS

• Carbohydrates: Given as dextrose (glucose)

  • ✓ Calorie density: 3.4kcal/g

  • ✓ Goal of 40–55% of caloric intake

  • ✓ Calculation of Glucose infusion rate (GIR) (mg/kg/min):

    $GIR (mg/kg/min):%<a class="drugLink" href="/drugs.aspx?GbosID=426572">Dextrose</a>(g/dL)×(Infusion Rate mL/h)×0.167Weight(kg)$

  • ✓ Begin at 10–12.5% and advance daily by 2.5–5.0% to a goal of about 20–25% (maximum GIR: 12.5 mg/kg/min in infants, 6 mg/kg/min in children and adolescents)

  • ✓ Monitor urine for glucose when PN is started and after changing GIR—If positive, check serum glucose and reduce GIR as appropriate

• Protein: Given as amino acids

  • ✓ Calorie density: 4kcal/g

  • ✓ Goal of 10–16% of total calories

  • ✓ Protein goals as per Table 20-8. Neonates can start at 2g/kg/day and advance daily by 1.0g/kg/day to goal, whereas non-neonates can be started at or near goal

Exceptions: Less protein is indicated in the setting of renal or hepatic failure. More protein may be indicated in the setting of trauma, sepsis, or increased protein needs (i.e., ongoing losses, healing from injury or surgery)

• Fat: Given as intravenous lipid

  • ✓ Calorie density: 2kcal/mL of 20% solution (20g/100 mL)

  • ✓ Goal lipid content should account for 25–40% of calories. A minimum of 1–2% total calories is needed to prevent essential fatty acid deficiency. Lipid content should generally not exceed 3.0g/kg/day or 50% of total daily calories

  • ✓ Initial rate of lipid administration: Refer to Table 20-8

  • ✓ Neonates can advance daily by 1.0g/kg/day to goal, whereas non-neonates can be started at or near goal. Do not advance beyond 1g/kg/day in patients with cholestasis

  • ✓ Volume of lipid solution needed is calculated as follows:

    $Weight(kg)×Goal Grams IVFat/kg/day×100mL/20gIV Fat=mLof20%IV Fat$

  • ✓ Triglyceride level should be monitored with a goal <200 mg/dL in neonates, <400 mg/dL in children and adolescents. Consider reducing lipid dose if the triglyceride level is elevated. Carnitine may be added to improve lipid tolerance (however data is limited).

• Minerals and electrolytes: Refer to Tables 20-9 and 20-10

• Vitamins: A pediatric multivitamin should be added for children <11 years of age and <40kg (dose is 5 mL/day for children and 2 mL/kg/day to a maximum of 5 mL/day for neonates). For children >40kg or >11 years of age, use adult multivitamin (10 mL/day)

MONITORING LABORATORY STUDIES

• Initial laboratory studies (within 48 hours of PN initiation): CBC, electrolytes, calcium, phosphorus, magnesium, triglycerides, alanine transaminase (ALT), gamma-glutamyl transferase (GGT), total and conjugated bilirubin, albumin, prealbumin. Severe abnormalities in electrolytes should be corrected before initiating PN

• Daily or every-other-day laboratory studies: Electrolytes, phosphorus, magnesium, and calcium until stable and at full kcal and protein goal. Check a triglyceride level with every increase in IV fat

• Weekly laboratory studies (once stable): Electrolytes, calcium, phosphorus, magnesium, triglycerides, ALT, GGT, albumin, prealbumin, total and conjugated bilirubin

• Long-term PN and minimal enteral nutrition: Check vitamin status, trace elements, cholesterol, iron panel, CBC, reticulocyte count, and triene to tetraene ratio in patients receiving a low-fat regimen

SPECIAL CIRCUMSTANCES: PARENTERAL NUTRITION CYCLE REGIMEN

• Cycling is used in long-term PN to promote normal daily activity and oral intake and to possibly lower the risk of PN-associated steatosis

• The infusion rate of PN solutions with greater than 10% dextrose should be decreased by 50% during the last hour of the infusion to prevent rebound hypoglycemia

• Complications of Total Parenteral Nutrition and Central Venous Catheters

• Metabolic and electrolyte imbalances: Follow laboratory monitoring as above

• Catheter occlusion: May be related to clot, fibrin deposition, or precipitate. Review your hospital policy regarding management

• Air embolus: Presents with sudden onset of respiratory distress. Clamp the catheter and place the patient left side down in the Trendelenburg position and seek emergent care

• Catheter breakage, crack, or aneurysm: Stop infusion, clamp catheter, and contact the team that placed the catheter

• Catheter related blood-stream infection (CR-BSI): After routine treatment cultures and treatment, consider central line lock therapies (i.e., ethanol) according to your hospital policy to prevent recurrent infections

• Malpositioning of a central catheter with extravasation of fluid: Stop infusion, clamp the catheter, and evaluate catheter position

• Parenteral Nutrition-Associated Liver Disease (PNALD):

  • ✓ Prevent overfeeding

  • ✓ Cycle PN: Decrease the duration of PN (e.g., decrease from 24 hours per day to a goal of 10–12 hours per day) to rest the liver from constant exposure to glucose and other nutrients

    • ▪ Blood sugar should be monitored while cycling TPN

  • ✓ Decrease IV fat (to a goal of 1g/kg/day)

    • ▪ Monitor for essential fatty acid deficiency in this circumstance

  • ✓ Copper and magnesium are both excreted in bile and can accumulate in liver disease. Consider decreasing the copper dosage (generally by 50%) and consider removing magnesium

  • ✓ Start enteral trophic feeds as soon as possible