pediatric nutrition assessment

7/21/2019 Pediatric Nutrition Assessment

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Pediatric NutritionAssessment: The

Dietitians Toolbox

Caro lin e Steele, MS, RD, CSP, IBCLC

Manager, Clinical Nutrition & Lactation [email protected]

Childrens Hospital of Orange County

Orange, CA


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Objectives

1. Calculate calorie, protein, and fluid needs

for pediatric patients of various ages.

2. Evaluate anthropometric measurements in

the pediatric patient.3. Determine appropriate use of various

infant, pediatric, and adult enteral

formulas.

4. Discuss parenteral nutrition in the pediatric

patient.


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Pediatric Nutrition Assessment

nthropometrics

iochemical Data

linical Data

iet History


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Definitions

Infant: Birth to 1 year of age

Neonate: Birth to 1 month

Full Term: >37 weeks gestation

Premature: Less than or equal to 37 weeks


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A

Anthropometrics


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Growth Charts

CDC 2000 growth charts

Pre-term infants-Fenton

Down Syndrome

Cerebral Palsy

Turner Syndrome

Prader Willi Syndrome


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Weight

Infants-obtained nude

Children-minimal clothing, no shoes

Used to assess pts acute nutrition status

%Ideal wt-wt/length or height


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Infant Weight Classifications

LBW:


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X X34 week infant

5# (LBW)

AGA

Term (40 week) infant

5# (LBW)

SGA


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Length/Height

Infants-length, measuring board

Children-stadiometers

Used to assess chronic

nutrition status

%Height age


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Infant Linear Growth

Preterm goals:

1-1.75 cm/week until 3 mos. adjusted age

0.5 cm/week from 3-6 mos. adjusted age


Term goals:

0.66-0.75 cm/week for first 6 months

0.5 cm/week from 6-12 months


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Alternative Measurements

Alternative measurements for children with special

health care needs

Arm span

Sitting height/crown rump length

Body segment lengths

TSF-triceps skinfolds-indirect measure of body fat

good for longitudinal tracking


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Head Circumference (OFC)

Should be plotted on all infants until at least 18

months adjusted age.

Typically decreases ~0.5 cm during the first week

due to contraction of extracellular fluid space.

Preterm goals:

0.5-1 cm/week until 3 mos. adjusted age


Term goals:

0.33 cm/week


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Body Mass Index

BMI = kg/m2

Non invasive tool determining over/under weight

Formula

Wt kg divided by ht m

2

e.g. 50 kg/1.542= BMI 21.1

CDC Cut-Off Points

>85%tile-at risk for overweight

>95%tile-overweight


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Pediatric Nutrition

Assessment

Accurate heights- Why are they so

important??

Degree of Malnutrition

Acute-wt/ht

Chronic-ht/age


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Waterlow Criteria

Grading of nutritional status

Acute Chronic

Grade %Ideal wt %Ht age

I-mild 80-90 90-95

II-moderate 70-79 85-89

III-severe


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B

Biochemical


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C

Clinical


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Clinical

Medical History

Physical Exam

Nutrition History

Medications


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D

Diet History


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Intake Assessment

24 hr diet recall

Food Records

Food Frequency

Calorie Count

Nursing flow sheet


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Nutrient Requirements


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Fluid Requirements

0-10 kg 100 ml/kg

10-20 kg 100 ml/kg + 50ml/kg (over 10kg)

>20 kg 1500 ml + 20 ml/kg (over 20kg)

OR

1500 cc x BSA


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Energy Requirements

Critically ill children stop growing & utilize the

energy conserved by this mechanism to fuel the

stress response

Excessive caloric provision during acute criticalillness has no beneficial effect & may be harmful

Although critically ill children tend not to lower

energy needs during critical illness, in the

chronic or convalescent phase of illness, many

may need additional calorie for catch up


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Approximate Energy Requirementsin Critically Ill Children

Age in Years Est Kcal/kg/day

0 4 100

4

6 906 8 80

8 10 70

10 12 60

12 18 50


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Protein Requirementsin Critically Ill Children

Age in Years Est g pro/kg/day

0 2 2-3

2-13 1.5-213-18 1.5


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Catch Up Growth Requirements

kcal/kg/d RDA Calories Ideal Body

for age weight

Kcal/kg/d X kg

Actual Weight (kg)


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Protein-RDA as a minimum

12% of total calorie needs

Carbohydrate-50-55% of total calorie needs

Excess can increase RQ


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Fat-30% of total calorie needs

3-4% EFA to prevent deficiency(3% as Linoleic, 1% alpha-linolenic)

Vits/minerals-DRIs

RDAs, AI, EAR and TUL


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Nutrition Support for

the Pediatric Patient


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Enteral Nutrition


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Enteral Nutrition in the Neonate

Initiate as soon after birth as clinical and GI status allow

Trophic feedings or GI priming

Colostrum for oral care

Trophic feeding

Small volumes (~2.5-20 mL/kg/d) for 1-2 weeks

Gut atrophy develops rapidly in preterm infants on TPN;

feeding may promote synthesis of gut hormones days to full enteral feeding and length of hospital stay

Yu VYH, Simmer K. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. 2005:311-332.

Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. 2004:23-54.

Akers S, Groh-Wargo S. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:75-106.

Anderson DM. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:53-73.

Wessel JJ. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:321-339.


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Gavage Feeding

Nasogastric or orogastric

Nonnutritive sucking during gavage feedings may

help improve maturation of the sucking reflex and

transition to oral feedings

Intermittent vs continuous feedings

Transpyloric feedings (nasoduodenal,oroduodenal, nasojejunal, orojejunal)

Absorption of nitrogen and fat is decreased

Yu VYH, Simmer K. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. 2005:311-

332.

Wessel JJ. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:321-339.


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Method of Delivery

NGT: 5F

Continuous

Bolus

Gavage

po/ng

po 1 of 3 feedings, 2 of 3, po q 3 hrs., po ad lib


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Nutrition Support

Methods Enteral Support

Acute-OG, NG, transpyloric

Functioning gut

Gut perfusion

Formula selection


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TF Administration

Continuous

1-2 cc/kg/hr

Advance 1-2 cc/kg/hr q 6-12 hoursAdolescents, begin 20-25 cc/hr


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TF Administration

Intermittent 2-5 cc/kg/feed q 3-4 hours

Advance 2-5 cc/kg/feed

Infuse over 30-60 min

Bolus

Not used often in critical patients Infuse over 10-15 min by gravity

Do not use in transplyoric feedings


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What to Feed?


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Benefits of Breast Milk

Breast milk is BEST! Use whenever possible

Ease of digestion

Whey-to-casein ratio~60:40

Low renal solute load (RSL)

Immune-enhancing properties/antibodies

Neurodevelopment

Preterm infants typically unable to meet increasedcalorie/nutrient needs on breast milk alone

Schanler RJ, Atkinson SA. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines.

2nd ed. 2005:333-356.

Sapsford AL. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:265-302.

Groh-Wargo S. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:231-263.

F tifi ti f B t Milk f


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Fortification of Breast Milk for

Preterm Infants

Human milk fortifier (HMF) For preterm infants weighing 2 kg

Schanler RJ, Atkinson SA. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines.

2nd ed. 2005:333-356.



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Fortification of Breast Milk forPreterm Infants (contd)

Use of nutrient-enriched discharge formulas in

conjunction with breast milk once HMF is stopped

may be appropriate for preterm infants ready for

discharge

Or for larger preterm infants who still need nutritional

fortification

Steele CL. Pediatric Perspectives. 2005;4(9).

Robbins ST, Beker LT, eds. Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities.2004:746-747.


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Breast MilkTerm Infants

Breast milk is BEST! Use whenever possible

Term infants typically able to meet nutrient needs on

breast milk alone unless volume restricted

Calories may be increased in breast milk if needed due

to poor growth, limited intake, or medical diagnoses

HMF is NOT appropriate for term infants

Choice of additives depends on clinical conditions and

reason for fortification tsp formula powder/90 mL breasmilk = 22 kcal/oz

1 tsp formula powder/90 mL breastmilk = 24 kcal/oz


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Preterm Formulas

Typically fed to smaller preterm infants (


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Nutrients in Preterm Formulas

Nutrient Preterm Formulas

Carbohydrate

41%-44% of total calories

50%-60% glucose polymers (corn syrup solids)

40%-50% lactose

Protein11%-12% of total calories

Whey predominate

Fat


40%-50% MCTs

50%-60% oil blend (including DHA and ARA)


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Preterm Discharge Formulas

Typically fed to larger preterm infants or as next stepformulas after preterm formula. May be used alone or in

conjunction with BF to increase total daily calories.

Contain higher nutrient levels than routine term

formulas but lower levels than preterm formulas tominimize the potential for toxicity

Standard dilution is 22 Cal/fl oz, but may be increased

as needed

Nutrient-enriched discharge formulas are recommended

until 9-12 months corrected age


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Nutrients in Discharge Formulas

Nutrient Discharge Formulas

Carbohydrate


50%-60% corn syrup solids

40%-50% lactose

Protein11% of total calories

Whey predominate

Fat


20%-25% MCTs

75%-80% LCTs (including DHA and ARA)


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Term Formulas

Designed for term infants

Standard dilution is 20 Cal/fl oz

If increased energy is needed for growth or

because of fluid restriction, may concentrate

calories

Nevin-Folino N, Miller M. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:499-524.

R ti C Milk B d


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Routine Cow MilkBased

Term Formula

NutrientRoutine Cow MilkBased

Term Formulas

Carbohydrate


100% lactose

Protein


Milk based

Fat48%-49% of total calories

Oil blend (with or without DHA and ARA)

C Milk B d F l


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Cow MilkBased Formula

with Added Rice Starch

Nutrient Added Rice Starch Formulas

Carbohydrate


Part of carbohydrate from rice starch

Protein


Cow milk based

Fat


Oil blend (including DHA and ARA)


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Lactose Free

Nutrient Lactose-Free Formulas

Carbohydrate


No lactose

Maltodextrin and sugar/corn syrup solids

Protein


Cow milk based (milk-protein isolate)

Fat



Not appropriate for infants with galactosemia

P ti ll H d l d


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Partially Hydrolyzed,

Reduced Lactose Formulas

Nutrient Partially Hydrolyzed,Reduced Lactose Formulas

Carbohydrate


Maltodextrin, corn syrup solids

Lactose

Protein

~9% of total calories

Partially hydrolyzed cow milk protein

Not hypoallergenic

Fat46%-48% of total calories



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Soy-Based Formulas

Christie L. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd

ed. 2005:161-180.

Nutrient Soy-Based Formulas

Carbohydrate 41%-42% of total calories

Protein

10% of total calories

IgE-mediated hypersensitivity to milk; 14% also

sensitive to soy

Non-IgEmediated enterocolitis and enteropathy

syndromes; 30%-50% also sensitive to soy

Fat




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Casein Hydrolysate Formulas

Failed trial of intact formula

GI problems/Colic

Hypoallergenic

Protein allergy (milk and/or soy)

Contain protein that has been broken down to

small peptides and free amino acids

May or may not contain MCT


American Academy of Pediatrics. Pediatrics. 2000;106:346-349.

Wessel JJ, Samour PQ. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:351-379.


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Elemental/Free AA Formulas

Elemental formulas

Contain free amino acids

Typically warranted after a failed trial

of an extensively hydrolyzed formula Hypoallergenic

MCT oil may or may not be present


Wessel JJ, Samour PQ. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:351-379.
http://elecare.com/


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Inborn Errors of Metabolism

Formulated to specifically treat an inborn error of

metabolism(s) by removing or limiting the offending

nutrient (s)

Many are enriched with carnitine and conditionally

essential nutrients.

Designed to be an adjunct in meeting the overall

MNT of the infant-some recipes include 3-4

formulas

Need gram scales to measure

for accuracy


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Macronutrient Goals

Calorie distribution

40%-50% carbohydrate

7%-11% protein

40%-50% fat

Akers S, Groh-Wargo S. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:75-106.

Groh-Wargo S. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:231-263.


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Increasing Caloric Density

Formulas typically mixed to 24-27 Cal/fl oz by adjusting amountof water added

30 Cal/fl oz typically considered maximum

Above 26-27 Cal/fl oz, may consider modulars to increase

calories and/or protein

Considerations for high-calorie formulations

Osmolality: 450 mOsm/kg water

pRSL:


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Calculating Osmolality

Use product information for osmolality on a standard

concentration to determine osmolality of a formula of different

caloric level

Example

Product literature shows a 20 Cal/fl oz infant formula has an

osmolality of 300 mOsm/kg water

You want to find out the osmolality of concentrating it to 27

Cal/fl oz

27 Cal/fl oz 20 Cal/fl oz = 1.35 (ie, 135% more

concentrated) Multiply 300 mOsm/kg water (osmolality of 20 Cal/fl oz

formula) by 1.35 (135% higher concentration)

ANSWER: The 27 Cal/fl oz infant formula has

an osmolality of ~405 mOsm/kg water


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Calculating pRSL

Max goal is


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Additives

Carbohydrate

Protein

Fat/CHO

Modular Components


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Modular Components

Carbohydrate and Protein

Carbohydrate

Polycose powder

Per tsp (~2 g powder)

8 Cal

1.88 g carbohydrate

Displaces ~1.2 mL volume

Protein

RESOURCE Beneprotein

Instant Protein Powder

Per g

3.57 Cal

0.86 g protein

Displaces ~0.6 mL volume

Per tsp (1.5 g)

5.4 Cal

1.3 g protein

Displaces ~1.02 mL

volume


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Modular ComponentsFat

Corn oil

8.4 Cal/mL (all from fat)

Microlipid

4.5 Cal/mL (0.5 g fat)

MCT oil requires special handling and does not

contain any EFAs 7.7 Cal/mL (all fat)


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Toddler Formulas

Similac 2 milk and soy

based

Enfagrow (formerly Next

Step) milk and soy

based

Fe fortified

Bridge gap between

formula and milk


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Pediatric Formulas

Ages 1-10 yrs

Oral supplements & TF

Oral products higher

in osmolality With and without Fiber

RDA met in 950-1300 mL

Available in 1.0 or 1.5 kcal/mL


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Pediatric Formulas

Ages 1-10 yrs

Elemental

Dipeptides

Free AA

LCT and/or

MCT

Available in 1.0and 1.5 kcal/mL


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Adolescent Formulas

Ages >11 yrs

Standard/Isotonic

+/- Fiber

Available in 1.0,

1.2, & 1.5

kcal/mL


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Parenteral Nutrition


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Parenteral Calorie Needs

Preterm Infants 80-105 NPC/kg/d

Infants 70-100 NPC/kg/d

Children 60-80 kcal/kg/d

Adolescents 40-60 kcal/kg/d

90% of enteral support

Provide at least BMR/REE

Avoid overfeeding


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Carbohydrate

50-55% of calories

3.4 kcal/gm

Maximum glucose infusion rate

Infants 12-14 mg/kg/min

Toddlers 10-12 mg/kg/min

School Age 8-10 mg/kg/min

Adolescents 6-8 mg/kg/min

Adults 4-6 mg/kg/min

Maximum dextrose concentration

D12.5W maximum concentration via PIV

D25W maximum concentration via central line


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Excessive Calorie/CHO Provision

Excess glucose administration increases CO2production rates & respiratory failure may be

exacerbated

Excess caloric administration does not spareprotein during critical illness and has shown to

increase RQ by increasing CO2 production more

than a high CHO diet


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Parenteral Protein Needs

Preterm Infants Children Adolescents

3-4 2-3 1.5-2.5 1-2

12-15% of total calories

4 kcal/gm


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Protein

Pediatric-specific solutions for infants

Crystalline amino acids

Examples: Trophamine and Aminosyn PF

Contain histidine (essential)

Contain taurine and tyrosine (conditionally essential)

Cysteine available as additive (essential)

Dose 30-40 mg/g amino acids

Carnitine (conditionally essential) may be added for infants

not receiving enteral nutrition beyond 2 weeks 10-20 mg/kg/d

Cox JH, Melbardis IM. In: Samour PQ, King K, eds. Handbook of Pediatric Nutrition. 3rd ed. 2005:525-557.


Aminosyn is a registered trademark of an entity unrelated to Mead Johnson & Company.

TrophAmine is a registered trademark of an entity unrelated to Mead Johnson & Company.


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Lipids

Infants Children Adolescents (g/kg/d)

0.5-3 1-2.5 1-2.5

20% Intralipid (2 kcal/mL; 1 g = 5 mL)

EFA 6% total kcal (0.5-1 g/kg/d for neonates) Biochemical abnormalities precede clinical symptoms

(triene:tetraene ratio of >0.4)

Consequences of deficiency

Dermatitis

Infection

Thrombocytopenia

FTT

Do not exceed 60% total kcal

In infants/small children, best infused over 24 h


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Vitamins (MVI)

Contents

Vitamins C, A, D, E, B6, B12, K

Niacin, thiamin, riboflavin, biotin, folic acid, pantothenic

acid

Dosage

Infants & Children to age 10: Ped MVI 5 mL (1 vial)/day

Preterm Infants 10 yrs: MVI-12 10 mL/day

*

T El t


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Trace Elements

Contents Zinc, manganese, copper, chromium

Additional Zn for preterm and wounds

Selenium & molybdenum for long-term (>30 d)

May need to limit copper and manganese to 1-2

doses/wk in infants with cholestasis (d bili >2)

May need to limit selenium and chromium in infants

with renal dysfunction

Rao R, Georgieff M. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. 2005:277-310.

Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. 2004:23-54.


Krug SK. In: Groh-Wargo S et al, eds. Nutritional Care for High-Risk Newborns. Rev 3rd ed. 2000:151-175.


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Minerals/Electrolytes

Adjusted based on clinical condition

Adjusted as needed to maintain serum levels of

electrolytes

Used to maintain acid-base balance

Amounts may be limited based on their solubility(calcium and phosphorus)

Atkinson SA, Tsang R. In: Tsang RC et al, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed.

2005:245-275.




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What We Eat May Determine Who We

Can Be!

Opt imum Goal of Nutr i tion Assessment

and Suppo rt in the Pediatr ic Pat ient?

Facilitate wound healing & immune response

Normal growth and development

pediatric nutrition assessment

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