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PDAT3 > 13/14 - Pediatric Nutrition > Flashcards

13/14 - Pediatric Nutrition Flashcards

(53 cards)

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1
Q

Protein Considerations
for PEDS

A
  • *24 to 32**
  • *non-protein Kcal** for every gram of protein

Excessive protein intake > 6 gm/kg/day

inadequate protein intake < 2.5 gm/kg/day​

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2
Q

Important Lipid Considerations
for PEDS

A
  • *to PREVENT EFAD (essential FA deficiency):**
  • can develop within 72 hours of life*

Minimum of 0.5 gm/kg per day (preterm/term/infants)
or
1.5 gm/kg twice a week
(older children/adolescents)

Still 30-35% of non-caloric intake

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3
Q

Factors associated with
HYPERTrigliceridemia

for Preterm Infants

A

Carnitine - Exclusive PN > 4 weeks and/or hypertriglyceridemia
Dose: 2-5 mg/kg/day (up to 20 mg/kg/day)

Low levels of lipoprotein lipase (LPL) and adipose tissues

Carnitine deficient
Accretion occurs during last trimester of gestation
Essential for transport of long-chain fatty acids via mitochondrial membrane for oxidation

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4
Q

Ideal

Calcium - Phosphate

RATIO

for peds

A

Calcium - Phosphate

2 : 1
(mEq per mMol)
or
1.7 : 1
(mg to mg)

  • Promote highest retention of Ca and P
  • Simulate in utero bone mineral accretion rates
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5
Q

0.9% NaCl

Na Equivelant Value
&
Osmolarity

A

154
mEq/L

308
mOsm/L

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6
Q

Maintanance Fluid Requirements

Infants / Children / Adolescents

A

Weights 3-10 kg
100 mL/kg
+
Weights 10-20 kg
50 mL/kg
+
Weights >20 kg
20 mL/kg

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7
Q

Maintanence Fluid Requirements

for NEONATES

A

PRENATES NEED MORE vs Normal Term

Very low birth weight infants
High surface area to mass ratio & immature renal fxn
–> increased water loss

Antidiuretic Period (24-28hrs of life)
**Table will be given**
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8
Q

Causes for INCREASED Water Loss
in PEDS

A

Fever
10-15% for each 1* > 38*

Radient Warmer

Burns / Diarhea

Tachypnea / Emesis

Nasogastric Suction / Polyuria / Surgical Drains

Decreased water needs
Incubator / Humidified Ventilator
Oliguria / anuria / HypoThyroidism

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9
Q

Routine IV Maintenance Fluids

A

NEONATES
D10% + electrolytes

INFANTS > 3kg

  • *D5% / 0.45% NaCl + KCL 20** mEq/L
  • younger infants may require D10%*

Children & Adolescents
D5%/0.45% NaCl + KCl 20 mEq/L
D5%/0.9% NaCl + KCl 20 mEq/L
0.9% NaCl + KCl 20 mEq/L

depends on sodium & free water needed

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10
Q

Calculating % Fluid Deficit
in PEDS with Dehydration

A

1kg weight loss = 1 Liter fluid deficit

  • *Previous Weight - Current Weight** x 100%
  • *Previous Weight**

Most common cause of Dehydration:
Vomiting / Diarrhea

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11
Q

3 Severities of DEHYDRATION
for
INFANTS

A

5-9-10(15)

Mild
5% (50 mL/kg)

  • *Moderate**
  • *9%** (90mL/kg)
  • *SEVERE DEHYDRATION**
  • *10-15%** (100-150mL/kg)
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12
Q

3 Severities of DEHYDRATION
for
OLDER CHILD

A

3 - 6 - 10

Mild
3% (30mL/kg)

  • *Moderate**
  • *6%**
  • *SEVERE DEHYDRATION**
  • *10%**
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13
Q

Which TYPE of DEHYDRATION?

Excessive Vomiting or Urine Loss

Hemorrhage

Decreased Fluid Intake

Gastroenteritis

A

ISOTONIC
MOST COMMON

Na = 130-150 mEq/L

&

280-300 moSm/L

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14
Q

Which TYPE of DEHYDRATION?

Heat Stroke

Child w/ diarrhea who has been replenished with:
WATER
to replace losses

improper infant formula mixing

A
  • *HypoTonic**
  • least common*

Na = <130 mEq/L

&

<280 moSm/L

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15
Q

Which TYPE of DEHYDRATION?

Diabetes Insipidus

Child w/ diarrhea who has been replenished with:
Hypertonic Soup / Boiled Milk
Improper Diluted Infant Formula

A

HYPERTONIC
second most common

Na = >150 mEq/L

&

>300 moSm/L

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16
Q

Lab Findings for DEHYDRATION / Volume Depletion
for PEDS

A

INCREASED BUN

HIGH HEMATOCRIT

low Serum Bicarbonate

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17
Q

Phase 3 of Fluid Management
for PEDS

A

For Isotonic & HypoTonic Dehydration

  • *NEXT 16 hours**
  • *replace** (1/2 deficit)
  • *+ 2/3 Maintenance Fluid**

only add POTASSIUM (K) if patient has MADE URINE

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18
Q

Phase 2 of Fluid Management
for PEDS

A

For Isotonic & HypoTonic Dehydration

  • *1st 8 hours**
  • *replace** (1/2 deficit) - (bolus fluid)
  • *+ 1/3 Maintenance Fluid**

only add POTASSIUM (K) if patient has MADE URINE

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19
Q

Phase 1 of Fluid Management
for PEDS

A

Restore IVF
to PREVENT HypoVolemic Shock

  • *0.9% NaCL**:
  • *20 mL/kg** over 15-20 min

may repeat up to 60mL/kg within 1 hour

Applicable to:
all 3 types of dehydration

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20
Q

Special Considerations
for HYPERtonic Dehydration
Phase 2 & 3 - Rehydration Fluid Management

A

Deficit + Maintanence Volume needed for 48 hours
& infuse SLOWLY over 48 hours

D5%/0.45%NaCl +/- KCL 20 mEq/L

< 8-10 mEq/L/24hr
or < 0.3 - 0.4 mEq/L/hr

to avoid ceerebral edema / convulsions / death

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21
Q

Max Sodium Correction Rate

HypoTonic Dehydration

Phase 2 & 3 - Rehydration Fluid Management

A

< 0.5
mEq/L/hr

to avoid CPM

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22
Q

Indications for PN
PEDS

Study These Flashcards
A
  • *Premature Neonates** who
  • CANNOT* be fed or adequately fed by EN

Patients with congenital anomalies
omphalocele / gastroschisis

Patients with IBS / Necrotizing Enterocolitis / Short-bowel syndrome

Healthy infants & children
who are NOT fed within 3 days

Malnourished or/@ High-risk who are NPO

23
Q

Administration Concerns of PERIPHERAL PN
PEDS

Short Term - <2 weeks

Higher incidence of Phlebitis

Less risk of long-term complications

Study These Flashcards
A

Requires LARGE fluid volumes to provide adequate energy need

Calcium Gluconate < 10 mEq/L

Maximum’s
~900 - 1000 mOsm/L

Dextrose < 12.5%

AA’s < 2.5%

24
Q

Which nutrient to CUT when too much Concentration?

Peripheral MAX:
900-1000 mOsm/L

Study These Flashcards
A

AMINO ACIDS

NEVER cut
dextrose or Electrolytes

25
**Monitoring Glucose** for PEDS
**HypoGlycemia** is **MUCH MORE of a CONCERN** vs **HYPERgycemia** Maintain Serum Glucose: **120-150 mg/dL** Consider ***_decreasing FAT_*** if persistant HYPERglycemia **_*early INSULIN infusion to PREVENT HYPERGLYCEMIA is: NOT RECOMMENDED*_** *associated with significicant hypoglycemia & mortality* May be considered at **250-270mg/dL**
26
**Maximum Glucose Infusion Rate** for PEDS
**12 - 14 mg/kg/min** ## Footnote * *55-65% of non-protein caloric intake** * never give less than 4mg/kg/min, need 2-3 minimum for protein desposition* Need ALOT for **brain development** Child is **6-9 mg/kg/min** Adults is: **3-5 mg/kg/min**
27
**Protein Requirements** for PEDS
**_\>_ 1.5 gm/kg/day** to prevent breakdown of endogenous tissue ## Footnote **_Early Initiation of AA's in Preterm Infants:_ Prevents Catabolism / Promotes Anabolism Stimulates Growth / *Decrease* HYPERglycemia + HYPERkalemia**
28
**Starter PN / Standardized PN Solutions**
**PRE-MADE Parenteral Nutrition** (central or peripheral) solutions that contain **DEXTROSE + AA's** Limited to **80-90 mL/kg/day** Rationale: Provides **_EARLY ADMIN of AA's_** to **very-low-birth-weight infants** (**\<1500gm)** can be used on **First day of life**
29
**Pediatric Formulations for AMINO ACIDS** vs Adults
**_TROPHAMINE / Aminosyn PF_** *LOW concentrations of* **methionine / phenylalanine / glycine** HIGH conc. of **essential AA's** (**taurine / histadine / tyrosine**) **L-Cysteines HCL 40 mg/gm of protein** --\> added at time of prep **Enzyme immaturity contributes to the need of essential AA's** * _for adults = Travasol_* * *OPPOSITE**, HIGH concentrations of met/phe/gly * low concentrations of Essential AA's*
30
**Advantages of Pediatric Formulations AMINO ACIDS**
Adequate **WEIGHT GAIN** even w/ *below normal caloric intake* **_LOWER pH_** increases solubility of **Ca & Phos** * lower incidence of* * *Cholestasis** in **VLBW infants** **Positive NITROGEN BALANCE**
31
**PROTEIN CONSIDERATIONS** PEDS
**_24 - 32 non-protein KCAL**_ for _**EVERY GRAM of PROTEIN_** to achieve optimal protein utilization **Excessive protein \>6 gm/kg/day** Aminoacidemia / azotemia / acidosis / increased BUN / *lower IQ* ***INADEQUATE* protein intake \< 2.5 gm/kg/day** *decreased Nitrogen retention / low serum albumin* edema / slow growth
32
**MINIMUM LIPIDS, and why?** for PEDS
MINIMUM OF: **_0.5 gm/kg/day_** for preterm/term/infants or **_1.5 gm/kg twice a week_** for older children/adolescents _to **PREVENT EFAD**_ Essential fatty acid deficiency, can develop within 72 hours of life **30-35% of non-protein caloric intake** important for brain development / cell membrane & prolongs integrity of peripheral lines
33
**Parenteral Lipid Products** comparison
**Omega 3 \> 6** **Fish oil --\> *decrease inflammatory mediators*** * *OMEGAVEN 10%** * *MAX is 1g/kg/day** --\> but may be givin with other lipids
34
**FAT INFUSION Considerations** PEDS
**MAX \<0.15 gm/kg/hr**for**premature infants** *vs 0.03-0.05 gm/kg/hr for adults* * *run over 12-24 hours** * *Isotonic --\> can be through PERIPHERAL vein**
35
**Factors Associated w/ HYPERTriglyceridemia** PEDS
_Premature Infants_ Low levels of LPL & Adipose tissue **Carnitine Deficient** essential for xport of LCFA via mito for oxidation **_Carnitine - Exclusive PN \>4 weeks_** and or **HyperTG** * *Sepsis or Trauma** * *Liver / Renal Disease** **_MONITOR_** **Serum TG's** --\> HOLD fat if **TG's \>250 mg/dL** Check for **essential FA status** in **long-term PN** or severe FAT malabsorption
36
**Four Major COMPLICATIONS with FAT INFUSIONS**
**_Risk of KERNICTERUS_** FFA displaces billirubin from albumin --\> more unconjugated bilirubin **LIMIT fat to 0.5 gm/kg/day** to prevent **EFAD** _Risk or exacerbation of **Chronic Lung Disease**_ **_Lipid Overload Syndrome_** HIGH TG's / fever / lethargy / liver failure * *_PNAC_** * *PN-associated Cholestasis**
37
**Ideal Calcium to Phosphorus Ratio**
**_2**_ _**: 1_** (Ca) **mEq per mMol** (P) or **1.7 mg : 1 mg** _for preturm neonates exposed to MATERNAL MAG_ *OMIT MAG*
38
**Factors Affecting** **Ca & P solubility**
* *_pH_** * *Cysteine /** High Conc of **AA & Dextrose** --\> **GOOD** * **Lipid = High pH*** --\> ***BAD*** ***High Temperature/Light* --\> *BAD*** Calcium & Phos concentrations **Calcium Salt** Order of adding Ca & Phos
39
**Which Trace Elements do we need to DECREASE or HOLD** for **_KIDNEY FAILURE_****?**
**_CHROMIUM_** **_SELENIUM_**
40
**Which Trace Elements do we need to DECREASE or HOLD** for **_LIVER Dysfunction_?**
**_COPPER_** *but give additional for pts with jejustomies or excessive GI losses 10-15 mcg/kg/day* **_MANGANESE_**
41
**Zinc Considerations**
**GOOD FOR ALL DA BABIEZ babies need MORE** * *Give ADDITIONAL** for patients with * *STOMA or FISTULA** output or **Persistant Diarrhea** **100-200 mcg/kg/day**
42
**Other Supplementations for PEDS** in **PN**
* *VITAMIN K** * adult products don't have vitamin K* **HEPARIN** reduced phlebitis / improve lipid clearance / **0.5-1 units/mL** **_Intravenous Iron_** **ONLY for LONG-TERM PN-DEPENDENT** children who are *NOT recieving **frequent blood transfusions***
43
**Transition from PN-\>EN** PEDS
Depends on **DURATION of PN** * **DECREASE* amount of ALL PN** - -\> while **INCREASING EN** as tolerated * **do NOT dilute or concentrate*** * *formulas or breast milk** **_D/C PN_** when **3/4 or 75% of EN** in **neonates/infants** **2/3 or 67% of EN** in **children**
44
**Visceral Protein Measurements PEDS**
**_Serum Albumin_** LONG half life --\> 14-20 days May be affected by: **albumin infusion / dehydration / sepsis / liver disease / trauma** **_Pre-Albumin_** *short half life,* good indicator of **acute nutritional assessment / visceral protein pool** May be ***DECREASED in LIVER disease*** and **falsely ELEVATED in RENAL failure** **_BUN_** low **\<5mg/dl = *inadequate AA intake*** high is \>20 mg/dL
45
**PNAC**
**Metabolic Complication of Long-Term PN** Due to **impaired secretion of BILE** --\> resulting in **LIVER injury** **_DIRECT BILIRUBIN \> 2 mg/dL_** Can occur as early as **2 weeks** after PN initiation Associated w/ **sig. morbidity & mortality:** Progressive **Liver Damage --\> Liver Xplantation** **Cirrhosis & liver Failure**
46
**PNAC RISK FACTORS**
**Prematurity & Low Birth Weight** **Prolonged PN** // **SLEs** (**soybean IV lipids)** ***LACK of enteral feeding*** **Bacterial Overgrowth / Infections** (sepsis / recurrant) **Intestinal Resection** **Macronutrient OVERfeeding** **MALE Gender** **Mineral Trace Elements Toxicity**
47
**PNAC - TREATMENT**
1) Initiate **EN**, *typically can't do this* 2) **Limit Intralipid - 1gm/kg/day** over **12 hours** or **2-3x a week** **Use OMEGAVEN @ 1gm/kg/day** (most effective) or in combo ***SMOFlipid @ 2-3 gm/kg/day as PREVENTION*** used when **aproaching PNAC (\<2 direct bili)** **3) LIMIT GLUCOSE to 10-12 mg/kg/min** 4) **Cycling of Pn** 5) ***REMOVE or DECREASE* - COPPER or MANGANESE** 6) Pharmacologic Agents * *Ursodiol / Metronidazole / Bactrim - ORAL**
48
**When to use SMOFlipid?**
**_PREVENTION of PNAC_** When approaching **PNAC \<2 direct bilirubin** **SMOFLipid @ 2-3 gm/kg/day**
49
**Pharmacologic Agents for PNAC**
**_Ursodiol_** **20-30 mg/kg/day** **ORAL** in **2-3 div doses** stimulates bile flow & maintains gallbladder contractility _for **Bacterial Overgrowth PROPHYLAXIS**_ * *ORAL METRONIDAZOLE** or **BACTRIM** for **2 weeks** * do NOT give as IV*
50
**Metabolic Bone Disease**
**Metabolic Disorder of PN** **HIGH ALKALINE PHOSPHATASE** **\>650 iU/L** Normal Ca & *low Phos* Treat with: **2:1 Ca:P ratio** **Supplement Vitamin D** Human Milk
51
* *Catheter Occlusion - TREATMENT** * *Complication of Long-Term PN for PEDS**
* *_Thrombosis_** * *Thrombolytic Instillation = ALEPLASE 0.5-1mg** * *_Precipitation_** * *0.1 N-HCL (1mL**)
52
* *Phlebitis - TREATMENT** * *Complication of Long-Term PN for PEDS**
* ways to decrease phlebitis:* * *_Heparin 0.5-1 units/mL_** **_Osm \<900-1000_** **Co-infused with IV FAT** **IN-LINE FILTER = 0.22 micron**
53
**Central Venous Catheter Infection** **TREATMENT / PREVENTION** Complication of Long-Term PN for PEDS
Mainly caused by **Gram POSITIVE organisms** _Prevention_ **Catheter Locks = Ethanol 70% / Vancomycin Continuous Infusion Heparin** * *_Treatment_** * *Catheter REMOVAL** * *ANTIBIOTICS**

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