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72 Cards in this Set
- Front
- Back
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Review Questions:
1) We have a 15 kg kid, calculate their maintence fluid 2) If Na is 123, what is corrected NA? 3) calculate fluid deficit - patient is down 1.5 kg |
1) 1000 mL + (50mL/kg *5) = 1250 mL
2) (135-123) *0.7*15kg = 126 mEq; replace 1/2 over 1st 8 - 12 hours = 63 mEq 3) 1.5*1000 mL = 1500 mL; replace 1/2 over 8 hours |
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Why is good nutrition important?
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- Energy balance - equilibrium between energy intake and energy loss plus storage
- Growth is possible when a positive energy balance is achieved. |
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Total Parental Nutrition (TPN)
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Dextrose & amino acids + electrolytes, minerals, trace elements, etc.
Lipid emulsion Can rarely provide complete needs with TPN |
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Indications for Parenteral Nutrition
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Premature neonates
Respiratory distress Congenital GI anomalies Abdominal wall defects Necrotizing enterocolitis Chronic diarrhea Inflammatory bowel disease Metabolic errors |
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Indications for Parenteral Nutrition
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Enteral feedings contraindicated
-Pancreatitis -Chylothorax -Pseudoobstruction Hypercatabolic states (e.g. trauma, cancer) Anorexia nervosa Cystic fibrosis Chronic renal failure Hepatic failure |
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Goals of TPN Therapy
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Promote fluid equilibrium
Maintain glucose homeostasis Achieve positive nitrogen balance Prevent acute nutrient deficiencies Provide adequate amount of nutrients for growth to occur |
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When giving Peripheral TPN, what are the limitations?
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- osmolarity of solution <900mOsm/l
- for short-term nutrition support - not to exceed: 10-12.5% glucose solutions 4% amino acid solutions 40 mEq/L potassium Calcium???? - Lipids may prolong patency |
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What can hyperosmolar solutions cause?
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Venous sclerosis and phlebitis
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Central Alimentation
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Provided through a central line or PICC
Allows use of higher concentrated solutions to provide adequate or nearly adequate nutrition Can run solutions of greater osmolarity |
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Protein
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- 4 kcal/g
Goal to meet demands of protein turnover - tissue synthesis, degradation, and elimination 1 gm of nitrogen = 6.25 gm of protein Ratio 150 non-protein calories for 1 gm of nitrogen ---Preterm neonates 150-200 |
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Protein
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Start Low 0.5-1g/kg/day and work up
Low birth weight neonates Initiate 2 – 3 g/kg/day Maintain 0.5 – 1 gm/kg/day Essential amino acids |
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Protein Monitoring
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BUN, LFT’s
Albumin, pre-albumin |
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Complications of Amino Acids
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Hyperchloremic metabolic acidosis
-Excessive Cl content High ammonia levels -If patients can not handle protein load -Insufficient fluids Liver dysfunction Increasing BUN |
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Lipids
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Provides essential fatty acids:
Linoleic acid Important for platelet and immunologic function Wound healing Dry skin Brittle hair Reduced growth |
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What is required for the catabolism of free fatty acids?
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Carnitine
Drives fats to mitochondria Metabolizes fats more efficiently Pre-term neonates |
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Lipids
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9 kcal/g (from fat only)
10% = 1.1 kcal/ml 20% = 2 kcal/ml (use this for calculations) Dense calories Lipids should provide 30-50% of calories |
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Lipids
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Use 20% = 2kcal/ml
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Lipids
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0.5-1g/kg/day meets essential fatty acid requirements
Requirements vary Start low (0.5 – 1.5 g/kg/day) Increase gradually |
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Lipid monitoring
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Monitoring
Serum triglycerides (max 200) Bilirubin Infused over 18 - 24 hours in small infants Do not exceed 0.15 gm/kg/hr Older children over 12 hours |
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Complications of Lipid Therapy
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Microbial contamination
Increased triglycerides, cholesterol, etc. Preterm infants -Jaundice -FFA displaces bilirubin from albumin Thrombocytopenia |
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Complications of Lipid Therapy
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Sepsis
↓ triglyceride clearance Respiratory difficulties ↓ pulmonary diffusion capacity Abnormal leukocyte function |
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Carbohydrates
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Primary limitation
-Patient’s glucose intolerance Requirements vary based on age Hypoglycemia due to interruption of TPN can occur Especially in neonates |
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Carbohydrates
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3.4 Kcal/g
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Review question - calories from:
Protein Lipids Carbs |
Protein 4kcal/g
Lipids 9kcal/g Carb 3.4kcal/g |
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Carbohydrate monitoring
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Serum glucose
Urine glucose |
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Carbs - Glucose Infusion rate (GIR)
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GIR =((Rate)(Conc.)) / (6(Weight in kg))
Converts to mg/kg/min of glucose Small changes in the rate and/or concentration of the fluid can greatly impact the amount of glucose the infant receives -Especially in very low birth weight infants |
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GIR
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Start low (10%) and slowly increase
Typically in 2.5% increments GIR 0.5 – 1.5 mg/kg/min |
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Review - GIR units are?
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mg/kg/min of glucose
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Review - formula for GIR?
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=((Rate)(Conc.)) / (6(Weight in kg))
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Carbohydrates - Complications
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Excess converted to fat
-Results in ↑ CO2 and ketone production -Decrease glucose in patients with respiratory failure Hyperglycemia -Renal threshold > 240 mg/dl |
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Calcium and Phosphorus
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Required to maintain:
-Cell membrane integrity -Nerve conduction -Coagulation -Endocrine and exocrine activity -Bone metabolism |
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Calcium and Phosphorus
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Solubility decreases
↑ pH ↑ Temperature ↑ Concentration ↑ Exposure time |
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What is the optimal calcium/phosphate ratio?
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Preterm infants 2.6 mEq Ca : 1MMol PO4
Older children equimolar 1:1 |
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Pediatric vitamins contain higher amounts of these fat solubilbe vitamins?
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A,D,E, and K
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Zinc is good for?
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Wound healing
Co-factor for >70 enzymes GI lossess |
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Copper is for?
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RC and WBC formation
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Manganese is for?
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Activator of enzymes
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Complications from TPN
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Cholestasis
-Time course 2 weeks to 2 months after TPN is instituted -GGT & direct bilirubin increases followed by AST & ALT elevations |
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Treatment of Cholestatis includes:
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Withdrawal of TPN solutions
Enteral feedings - gut stimulation Cycling TPN (off TPN a few hours a day) Miscellaneous: ursodiol (Actigall®), phenobarbital, and cholestyramine (Questran®) |
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Which drug has shown the most efficacy in treating Cholestasis?
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Ursodiol (Actigal)
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Complications from TPN
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Osteoporosis & rickets
-Inadequate calcium & phosphorous -Vitamin D metabolism Line complicaitons -Infection -Occlusion |
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What are the advantages of Enteral nutrition?
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-Maintenance of structural and functional gastrointestinal integrity
↓ Potential for bacterial translocation Enhanced utilization of nutrients -Improved glucose tolerance and decreased hyperinsulinemia Greater ease and safety of administration ↓ Hepatobiliary complications associated with TPN ↓ Cost |
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What are the indications for Enteral Nutrition?
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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 |
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True or false: Breast milk is NOT the gold standard.
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False, breast milk is the gold standard. Has excellent biovailability, provide emotional bonding of mother and child, provides immunologic protection, convenient and inexpensive.
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Breast milk recommendation:
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breast feed for the first 6 months of life and continue for the second 6 months as optimum nutrition in infancy.
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Contraindications to breast feeding.
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Contagious lesions on the breast
Syphilis or herpes Chickenpox Pertussis Cytomegalovirus TB HIV Hep B if untreated Infant intolerance to breast milk Certain medications Prematurity 34 weeks gestation |
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Pre-Term formulas:
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Low birth-weight infants
More protein, calcium, phosphorous supplemental Iron 20 kcal/oz |
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What Pre-Term formulas are on the market?
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Similac Special CARE
Enfamil Premature formula |
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Transitional formulas
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Infants that need more caloric intake
Increase Ca, vitamins and mineral compared to standard forumlas 22 kcal/oz OTC |
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What are the transitional formulas?
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Neosure and Enfacare.
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Term Formulas
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Normal full-term infants with no special nutritional needs
Supplement breast-fed infants 20 kcal/oz with protein at 1.5 gm/dL and fat at 3.5 gm/dL OTC |
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What are the Term formulas?
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Similac® and Enfamil®; Enfamil AR®; Similac Sensitive RS®
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Neosure and enfacare belong to which formula class?
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Transitional forumlas.
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Enfamil and similac special Care belong to which formula class?
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Pre-Term formulas.
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Lactose Free formulas?
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Changes only the carbohydrate source to a simple sugar
20 Kcal/oz OTC |
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What are the lactose free formulas?
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Lactofree and Similac Sensitive Lactose Free.
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Soy Formulas
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Indications
Children and adults sensitive to cow’s milk Following diarrhea Lactose intolerance Lactase deficiency Galatosemia 20 kcal/oz |
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Soy formulas on the market?
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Isomil
Prosobee |
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Casein Hydrolysate Based
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Infant’s sensitive to cow’s milk and other food protein and carbohydrate sensitivities resulting in severe or persistent diarrhea and other GI disturbances
2 -3 times more expensive Pregestimil®, Alimentum®, Nutramigen® |
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Potential Complications with formulas
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Vomiting
Too rapid advancement Delayed gastric emptying Hyperosmolar formula Constipation Low fluid intake |
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Potential Complications with formulas
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Dehydration
-Inadequate fluid intake Diarrhea -Lactose intolerance -Hyperosmolar -Contaminated -Too rapid advancement -Low fiber intake -Fat malabsorption |
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Pregestimil, Alimentum, and Nutramigen belong to which formula class?
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Casein Hydrolysate Based
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Calculation of Calories
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Infant caloric needs 100 - 120 kcal/kg/day
Infant fluid needs 140 -160 cc/kg/day 20 kcal/oz = 20 kcal/30 cc 150 cc/kg/day * 20 kcal/30 CC = 100 kcal/kg/day |
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TPN Case:
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HG is a ex-24 week infant now DOL# 45. Current weight is 1.2 kg. She is receiving the following TPN:
-Rate = 3.5 ml/hr over 24 hours -5.5% amino acids -18% dextrose -20% lipids at 0.5 ml/hr over 24 hours Enteral nutrition is 20 kcal/oz breastmilk continuously at 4 ml/hr |
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What is HG's GIR?
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3.5 X 18 / (6 X1.2) = 8.75 mg/kg/min
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How much protein is she receiving (gm/kg/day)?
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3.5 ml/hr X 24 hr / 1.2 kg = 70 ml/kg/day
5.5% = 0.055 gm/ml X 70 ml/kg/day = 3.85 gm/kg/day |
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How much fat is she receiving (gm/kg/day)?
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0.5 ml/hr X 24 hr / 1.2 kg = 10 ml/kg
10 ml/kg X 0.2 gm/ml = 2 gm/kg |
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How many total calories is she receiving from her TPN and lipids (kcal/kg/day)?
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Protein = 3.85 gm/kg/day
3.85 gm/kg/day X 4 kcal/gm = 15.4 kcal/kg/day Dextrose 70 ml/kg/day X 0.18 X 3.4 kcal/gm = 42.84 kcal/kg/day Fat 10 ml/kg/day X 2 kcal/ml = 20 kcal/kg/day Total 15.4 + 42.84 + 20 = 78.24 kcal/kg/day |
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How many enteral calories is she receiving (kcal/kg/day)?
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4 ml/hr X 24 hr / 1.2 kg = 80 ml/kg
20 kcal/oz = 20 kcal/30 ml = 0.67 kcal/ml 80 ml/kg X 0.67 kcal/ml = 53.6 kcal/kg/day |
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She is possibly being given too many IV calories
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Total TPN and enteral is 131.84 kcal/kg/day
53.6 + 78.24 |
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What two amino acids are given in low amounts in TPNs for babies?
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phenylalamine and methione
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Chromium is good for?
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Insulin reactions
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