Pediatrics Intro Flashcards
1
Q
What can paediatric nutrition issues be divided into?
A
- Feeding issues/social environments (non-illness related)
- Illness related causing increased energy and nutrient needs
- All with or without inflammation
2
Q
What are the key anthropometric measurements for peds?
A
- Weight, heigh or length
- Statistics using Z-score
- Reference growth charts
3
Q
Paediatric nutrition issues include both illness and non-illness related malnutrition. What are the two types of illness etiologies?
A
- Acute (<3 months)
- Chronic (>/= 3 months
4
Q
What may illness-related malnutrition lead to?
A
- Starvations
- Malabsorption
- Nutrient loss
- Hypermetabolism
5
Q
What doe non-illness related malnutrition lead to?
A
-Starvation
6
Q
What does starvation include?
A
-Anorexia, socio-economic, iatrogenic feeding interruption or intolerance
7
Q
(T/F) Malabsorption, nutrient losses and hypermetabolism cause decreased food intake, leading to malnutrition
A
F
Will cause increased nutrient requirements, leading to malnutrition
8
Q
What does inflammation lead to? (2)
A
- Hypermetabolism
- Altered utilization of nutrients
9
Q
What does starvation lead to?
A
decreased intake lead to malnutrition
10
Q
what are examples of outcomes of paediatric malnutrition?
A
- Loss of LBM
- Muscle weakness
- Developmental or intellectual delay
- Infections
- Immune dysfunction
- Delayed wound healing
- Prolonged hospital stays
11
Q
What is the goal in paediatric malnutrition?
A
To achieve normal growth and development from infancy through adolescents to adulthood
12
Q
What are 3 challenges in paediatric nutrition?
A
- Metabolic needs for rapid growth
- Low nutrient reserves
- macro and micronutrient needs mirrors the growth phase
13
Q
BMR energy requirements?
A
40-62 kcal/kg/day
14
Q
Thermogenic effect of feeding kcal requirements?
A
3-11 kcal/kg/day
15
Q
Activity kcal requirements?
A
2-4 kcal/kg/day
16
Q
Growth feeding requirement?
A
45-67 kcal/kg/day
17
Q
Total kcal requirements?
A
90-130 kcal/kg/day
–> Rarely 144
18
Q
What does 50% of the nutritional daily requirement go towards?
A
Roughly half towards BMR and half towards growth
19
Q
What will first be compromised when nutrition is insufficient in the paediatric population why?
A
- Often in the NICU, nutrition will be given via fluid but fluid is restricted, thus nutrition is compromised
- The majority of nutrition provided will be shunted to the “necessary” BMR requirements, thus compromising nutrition for growth
20
Q
What needs to be included in the nutritional assessment? (PLM-GNS-R)
A
- Prenatal history
- Labor, delivery and neonatal events
- Medical hx of child
- Growth hx
- Social hx
- Review of organ systems
21
Q
Why is it important to review prenatal hx?
A
-Obtain general obstetrical history to understand if there were any markable events (i.e. pre-eclampsia) which could explain impact on the child or infant today
22
Q
What should be reviewed in labor, delivery and neonatal events?
A
- Apgar scores
- Neonatal asphycia
- Prematurity
- SGA
- Birth weight/length
- Congenital malformations or infections
- Breastfeeding support
- Feeding difficulties
23
Q
What is an apgar score?
A
10 vitals of the newborn are measured 1 minute, 5 minute and 10 minutes after birth. A lower score is more detrimental, and may predict poor outcomes such as feeding difficulties later on
24
Q
What should be reviewed in nutrition history?
A
- Feeding behaviours
- Perceived sensitivities/allergies
- Quantitative food intake via food records or re-calls
25
What should be reviewed in social hx?
- Who feeds the child
| - Environmental and social stressors
26
What should be included in the review of organ systems?
-Anorexia, dysphagia, stooling pattern and consistencies, vomiting, GERD, recurrent fevers, dysuria, urinary frequency, activity level
27
What is the fenton growth curve used for?
Pre-mature infants, less than 37 weeks
28
Can the fenton growth curve assess proportionality in pre-mature infants?
No, as there is no curve for the BMI
29
When can the WHO growth curve be used?
For normal term infants
| --> The timeline of the WHO growth curve start at "Birth" suggesting that a normal term pregnancy was experienced
30
The WHO growth curve can NEVER be used for pre-mature baby (T/F)
F
| The WHO growth curve ma be used if adjusted age is used
31
When a pre-mature baby reach 40 weeks, which growth curve is recommended? Why?
- Use the WHO growth curve (with corrected age) and the Fenton growth curve
- Allows for comparison between both the premature and the general populations
32
Why may the WHO be accurate?
They have pulled growth data from several countries with healthy, normal growth measurements
33
What is the cut-off to define a pre-mature baby?
Less that 37 weeks
- -> Full-term length is 40 weeks
- -> Even if they are 36.5, we will still use the Fenton curve
34
The WHO allows to track both height and weight, leading to proportionality. Why is this advantageous?
If we think we are trending well on weight, but the infant is stunted or not trending properly on length and we do not adjust our nutritional intervention, we could create an obese child.
35
What could impair the height if the weight growth is OK?
- Often if there are issues with bone growth
- There are also hormone issues, where no matter what the nutrition issue is, nothing will help
- Length is affected more on the chronic basis, we will usually see weight affected first, and then height
36
What is the most important thing to assess about growth curves?
The trends in the growth curves
| --> The nutritional intervention should NOT be based on only one point on the graphg
37
What does the first WHO growth curve consider? Second?
- Infants from birth to 24 months
| - Children 2 to 19 years
38
What does the first WHO growth chart for infants from birth to 24 month include?
-weight, height, weight for height and head circumference
39
What does the second growth chart for children aged 2-19 include?
Length for age, weight for age and BMI
40
Why is there a dotted line on the weight curve beginning at 10 years old?
During adolescence, peaks are at different time and therefore the weight is NOT the focus. The curve is "projections"
- Beginning at 10 years old we want to assess more on the BMI than the weight alone
- -> The solid line is based on population studies
- -> The dotted line is simply projections/estimates and is less important
41
Can WHO growth curves be used in hospitalized children?
Yes - although they are based on healthy populations. If there are certain conditions, use specialized growth charts
42
Examples of conditions requiring specialized growth charts?
- Prader-Willi syndrome
- Cornelia deLange syndrome
- Turner sundrome
- Trisomy 21 (Downs)
- Rubinstein-Taybi syndrome
- Marfan syndrome
- Achondroplasia
43
How does the growth of trisomy 21 differ from regular children?
During the first few months of life, there is a tendency to failure to thrive and are often smaller. However, over a couple years they have a propensity towards obesity, therefore we need to be careful that we are not following th e normal WHO curve, as per their population this would make them obese.
44
What are four key scenarios in which we should be worried about the childs weight?
- Plateauing
- Sharp declines
- Falling off the 50% ile
- Incline in BMI
45
Discuss plateauing
- When the weight was initially following the 50% percentile, and is crossing towards the 3rd over time
- The child is stopping growth
- This is more observed during chronic malnutrition
46
Discuss sharp decline
- The weight was initially on 50th percentile, an next measurement rapidly drops to the 3rd percentile
- This is more observed in acute trauma cases, where adequate nutrition was missed
47
Discuss falling the 50th percentile (or any percentile), what is the difference between plateauing?
- Weight was initially at the 50th percentile, but then drops off towards the 3rd percentile BUT the child is still growing (no plateau) but not growing to the velocity we want
- Likely chronic malnutrition, where the child isnt getting enough nutrition. We would likely need toadjust our nutrition intervention plan
48
Discuss incline in BMI
- It is always important to look at the proportionality of the child
- If we re seeing increases in BMI which sharply rises, it means that we are likely creating an obese child
49
Is there a strict definition of failure to thrive?
No, but there are more popular reference
50
What is the most accepted definition of failure to thrive?
1) Weight (or weight for height) is less than 2 standard deviations below the mean for sex and age
2) Weight curve has crossed more than 2 percentile lines after having previously achieved stable growth
51
(T/F) Infants at the 90th an 3rd percentile will always require adjustments to reach the 50th percentile
F
The goal is not necessarily at the 50th, but to allow the child to grow where they are supposed to grow. By looking at trends, we can understand the normal trajectory and then see if we need to adjust the nutritional intervention
52
(T/F) If a child crosses two percentile lines, they are off their trajectory and nutritional intervention is needed
F
Only when they have crossed MORE then 2 percentile lines after achieving stable growth is this a cause for concern
53
Discuss characteristic of constitutional delay of growth of adolescence
- Both height and weight are notably low at the third percentile, but are proportional
- Only in the teens, will they peak to follow the true potential for growth
- Often, we should ask if their parents experienced the same kind of delay
54
Discuss familial or genetic short stature
- Children that are small, no matter what we do
- Normal genetic potential, where our nutritional intervention will not change this
- They are proportional
55
Discuss primary nutritional deficiency in severe chronic illness
- The first thing that becomes affected in acute malnutrition is weight decreases, but overtime our length and head will continue to grow
- Once we are in chronic malnutrition, our length will be affected, and our body will always protect our brain first, therefore the head may be larger
- The weight deviate, the length is OK for awhile and then drops off
56
What other conditions or syndromes may have a growth curve similar to primary nutritional deficiencies, but will not respond to nutritional intervention?
- Congenital GH deficiency
| - Untreated Turner Syndrome
57
What is another word for stunting?
-Nutritional dwarfism
58
What is the definition of stunting?
- 2 Dm below the height for age curves
- Not necessarily associated with emaciation, where short stature or poor growth may be the sole manifestations of nutritional inadequacy
59
What is the adaptive response to suboptimal nutrition in stunting?
Growth deceleration
60
___ is a good indicator of acute nutritional status
Weight
61
_______ is a good indicator of chronic nutritional status
Height and head circumference
62
When we decide to begin nutritional support due to stunting, should we expect rapid increase in the childs weight or length?
No, it may take a few months to years depending on the childs age
63
Infant causes of failure to thrive?
- Chronic medical conditions
- Premature birth or IUGR
- Developmental delay
- Congenital abnormalities
- Intrauterine toxin exposure
64
Family causes of failure to thrive?
- Poverty
- Unusual health and nutritional belief
- Social isolations
- Disordered feeding technique
- Substance abuse
- Violence or abuse
65
When interpreting a linear growth chart with short stature, what is usually observed?
- Due to familial/genetic reasons
| - Growth is parallel to the normal percentile and usually below the 5% ile
66
How can genetic factors be interpreted?
By calculating the parenteral mid-parental height
67
Parenteral mid-parental height for girls?
(fathers height - 13cm ) + (mother's height)/2
68
Parenteral mid-parental height for body>
(mothers height + 13 cm) + (father's height)/2
69
What does growth velocity include?
Expected height and weight for the given age
| --> Important during the anthropometric assessment
70
<3 months velocity?
- 25-35 g/day
| - 2.6-3.5 cm/mo
71
3-6 months velocity?
- 15-21 g/day
| - 1.6-2.5 cm/mo
72
6-12 months velocity?
- 1.2-1.7 cm/mo
| - 10-13 g/day
73
1-3 year velocity?
- 4-10 g/day
| - 0.7-011 com/mo
74
4-6 year velocity?
- 5-8 g/day
| - 0.5-0.8 cm/mo
75
7-10 year velocity?
- 5-12 g/day
| - 0.4-0.6 cm/mo
76
(T/F) The growth velocity is the same independant of which percentile the child is born on
F
For example, if the child is born on the 3rd percentile, it's expected velocity is lower than the child born on the 85th percentile. These numbers cannot be used for premies
77
When can weight for age be used as an indicator (from birth to 2 years)?
- Underweight
| - Severely underweight
78
Underweight?
<3rd percentile
79
Severely underweight (from birth to 2 years)?
<0.1st
80
When can length for age be used as an indicator?
- Stunted
| - Severely studnted
81
Stunted (birth to 2 years)?
<3rd perecentile
82
Severely stunted (birth to 2 years?)
<0.1st
83
When can weight for length be used as an indicator?
- Wasted
- Severely wasted
- Risk of overweight
- Overweight
- Obese
84
Wasted (birth to 2 years)?
<3rd or <80th IBW
85
Severely wasted (birth to 2 years?)
<0.1st
86
Risk of overweight (birth to 2 years)?
>85th
87
Overweight (birth to 2 years)?
>97th
88
Obese (birth to 2 years)?
>99.9th
89
Which percentiles have the same cut-offs for children aged 2-19 and Birth-2 years?
- Underweight
- Severely underweight
- Stunted
- Severely stunted
- Severely wasted
90
(T/F) Length for age is used as an indicator in children age 2-19 years old to indicate stunted or severely stunted
False
| Height for age
91
Wasted (2-19)?
<3rd percentiles
92
Risk of overweight (2-19)?
>85th percentile
93
Obese (2-19)?
>99..0th to >97th
94
Severely obese (2-19)?
>99.9th
95
When is the neonatal malnutrition criteria used?
From the first week to first month of life
96
How does the neonatal malnutrition criteria used?
```
One indicator of:
-Decline in weight-for age score
-Weight-gain velocity
Nutrient intake
Two indicators of:
-Days to regain birth weight
-Linear growth velocity
-Decline in length for age z core
```
97
When is paediatric malnutrition criteria required?
After one month of life
98
Signs of clinical malnutrition with physical assessment?
- Dry, flagged brittle coarse hiar
- Dry, scaly and slow healing wounds
- Swollen, bleeding gums and decaying teeth
- Visible ribs, bloated stomach
99
What are other clinical signs of malnutrition?
- Decreased energy levels, irritability, lethargy
| - Decreased learning ability
100
What should be assessed in the adolescent pubertal assessment?
- This is the second period of rapid growth
- 80% of adolescent growth occurs between age 10-15
- Opportunity to catch-up weight-gain
101
What is used in the adolescent pubertal assessment? What doe it consider?
- Tanner scale
| - This scale defines physical measurements of development based on external primary and secondary sex characteristics
102
What are signs of undernutrition in the adolescent pubertal assessment?
-Wasting or stunting
-Cachexia
-ED behaviour
-Anemia
Menstrual period
103
What are sign of obesity in the adolescent pubertal assessment?
- Excessive SC fat
- Abdominal adiposity
- Purple striae (abdominal stretch marks)
- Menstrual period
104
Greenish, black and sticky stool?
- Meconium (first 3 days)
- If greenish black will contain bilirubin
- If yellow-ish green, contains RBC
105
Yellow, seedy stool?
- Breastfed
| - Mild smell
106
Tan and thick stool?
- Formula fed
| - Hummus looking, only a concern if watery or hard
107
Greenish brown stools?
- Intro to solids
| - Leftover guac look, will depend on food eaten
108
Watery, brown loose stools?
- Diarrhea
| - If more than 2 days and frequent risk of dehydration, sign of infection
109
Dry brown and hard stool?
- Constipation
- looks like dirt clay or pellets
- Not enough fluid or losing too much fluids
110
Pinkish red stool
-Partially digested food, monitor what baby eats
111
Black, pasty, tarry stools?
- Melena
| - Sign of upper Gi bleed
112
Dark green stools?
- Due to iron supplementation
| - baby on iron sulfate or iron-fortified baby formula
113
Bright green, frothy stools?
- Foremilk or hindmilk imbalance
- Getting more foremilk, where the breastfed babyy nurses for short periods of time on each breast
- Could also be a virus
114
Res streaked, hard stool with blood or mucus stools?
- Possibie rectal fissure
- Small cracks in anus
- If large amount of blood when soft stool need medical attention
115
White and chalky stools?
-Pale, colorless, sign of liver or gallbladder problem
116
Which types of stools are indicative of constipaton?
- Separate hard lumps
| - Sausage shape but lumpy
117
Which types of stools are normal or ideal?
- Like a sausage but with cracks on its surface
| - Like a sausage or snake,smooth and soft
118
Which types of stools indicate diarrhea or urgency?
- Soft blobs
- Fluffy pieces with ragged edges
- Watery
119
In the PICU, what does ASPEN suggest about energy requirements?
- IC is ideal
- If not available, Schofield, FAO, WHO, UN equations may be used WITHOUT the addition of stress factors to estimate energy expenditure
120
Protein requirements 0-6 months?
1.52
121
Protein requirements 7-12 months?
1.2
122
Protein requirements 1-3 years?
1.05
123
Protein requirements 4-13 years?
0.95
124
Protein requirements 14-18 years?
0.85
125
What doe protein requirements depend on?
Can increase depending on medical condition and stress factors
126
What is the minimum protein intake for critically-ill children as recommended by ASPEN?
1.5
127
What is high protein considered?
>25%
128
Fluid requirement = 10 kg?
100 ml/kg
129
Fluid requirement >10 kg and = 20 kg?
1000 ml + 50 ml/kg for wt >10 kg
130
>20 kg fluid requirement?
1500 ml + 20 ml/kg for wt >20 kg
131
When is there fluid restrictions?
Kidney, lung and heart failure
132
When is there likely dehydration?
Hypernatremia with little weight gain or weight loss
133
When is there likely fluid overload?
Hyponatremia and weight gain
134
Baby is one day old, tummy size and milk?
- Size of cherry
| - 10 to 100 ml of breastmilk
135
Baby is one day old, # of wet and soiled diapers ?
- At least on wet
| - At least 1-2 black or dark green (meconium)
136
Baby is 2 days old, # of wet and soiled diapers?
- At least 2 wet
| - At least 1-2 black or dark green
137
Baby is 3-4 days old, tummy size, milk and soiled and wet diapers?
- Size of walnut
- 200 ml or 1 cup
- 3 wet (3 days) or 4 wet (4 days)
- At least 3 brown, green or yellow
138
Baby is 5-7 days old, tummy size, milk and soiled and wet diapers?
- Size of apricot
- 400-600 ml per day
- At least 6 heavy wet with pale yellow or clear urine
- At least 3 soft and seedy yellow
139
Baby is 2 weeks old, tummy size, milk and soiled and wet diapers?
- Size of egg
- 600-800 ml
- At least 6 heavy wet with pale yellow or clear urine
- At least 3 soft and seedy yellow
140
From 1 day - 3 weeks, how often are feedings?
8 times or more per day
141
Nutrition milestones at 12-24 months?
- Growth lows compared to first year --> Results in decreased appetite ad erratic and unpredictable food intake
- Unfamiliar foods are often rejected the first time
142
Nutrition milestone at 12-18 months?
-Acquires full chewing movements
143
Nutrition milestone by 24 months?
-May only consume 4-5 well-accepted foods
144
Fluid guidelines for 12-24 months?
- Continue to breastfeed
- Provide Vit D supplement for breastfed children
- If not breastfed, 500ml of 3.25% cows milk each day (or soy)
- Offer water when child is thirst, limit or a avoid juice
- Transition from bottle feeding to open cup no later than 18 months
145
What may be an alternative to cows milk?
Pasteurized, full-fats goats milk with added vitamin D and folic acid
146
Is 1-2% milk routinely recommended?
No, if it is given ensure the child is growing well and eating an adequate variety and quantity of nutritious foods
147
Food guidelines for 12-24 months?
- Offer variety of foods, in various textures
- Iron-rich foods at each meal
- Portion sizes 1/4-1/2 of CFG
148
Beginning at 12 months, how should meals be spaced out?
3 mall meals an 2-3 nutrient dense snacks per day
149
Is a paediatric vitamin recommended?
No, only if the child is notgrowing well
150
Red flags at 12-24 months?
- Not following guidelines for foods and fluids
- Consumes vegetarian beverages as main milk source
- Consumes >750 ml cow or goats milk/dat and >175 ml juice
- Consumes fruit drinks, pop,
- Not supervised when eating
- Feeding is forced or restricted
- At 24 months, often coughs and chokes when eating
