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NUTRITION 1PRETERI'l
Maint~nance is 50 kcal/kg/dayEach gram of ~eight gain requires 5-6 kcal
Therefore the desired wt gain of 15gm/day requir~~
50 + 75 kcal/kg/day
Fat:te:'l-Resting calories (8MR)
1st day6th day
14th dayIntermittent activityOccasional cold stres.Fecal 105sGrowth allowance
NUTRITION II
I<ccol/kg/day50344250151012
33-40
Fetal to full term biochemical accumulations in weeks
Nitrogen (mg)Sodium (mg)Pe.tassium (mg)Calcium (mg)F'hc.sphorus (mg)Magnes iLlm (mg)1¡-on (mg)
Ce.ppeu- (ugm)Z i ne (ugm)Fat (gm)Watel- (gm)
24 weeks319
2830
11870
3.81.6
582610.5
15.2
30 weeks334
2730
13378
3.81.8
582681.3
15.0
36 weeks350
2430
15186
3.72.0
572603.2
14.7
PRETERMNUTRITION ,111
F.~t :
CBH:
Fluid·:;;:
222
26-28 weeks 3.1 gm/100 kcal Oí 3.75/kg29-31 weeks 2.7 gm/100 kcal Oí 3.5/kg
ranges given are from 2.25 to 3.75but controversy existo
about 6 gm/kg/day
about 11-16 mg/kg/day
54-94 ml/kg/day
NUT¡=;: 1T 1·JN 1'/PRETERM PROTEINS
Protein intake > than 4 gm/kg/day may produce lethargy, acidosisazotemia, and hyperammcnemia.
Premature is unable to metabolize phenylalanine, tyrosine,homogentisic acid, methionine te cysteine and taurine.
Whey-casein ratio formulas 18:82 (cow milk) can increase plasmaphenylalanine and tyresine
Whey-casein ratio of 60:40 <human milk) is safer.
NUTRITION VFRETEPM LIPIDS
40-50% of calories should come as fats, but >60% may produceketosis
Línoleic acid i5 essential at 300 mg/l00 kcalBile salt synthesi5 í5 low, therefore unsaturated FFA bestPanera.tic lipase i5 low, and MCT 1s bestLingual lipase present from 25th week and therefore 60-70%
of f.t hydrolysis OCCUíS in the stomach.BH aids with BM lipase and bile-s.lt esterdse
NUTRITION VIPRETERM CeH
By 28 weeks most dissacharidases are activePancreatic amyla~~ i. low to absent, but salivary amylase is
presentGlucoamyla~e is present in brush borders <for polymers)BM amylase <10-30x serum) suppli&9 430 u/kg/day
Therefores milk amylasQ, s.livary amylase, and gluceamylase~ubstitut. fer low p~ncre.ti~ supplies
NUTRITION VIIPRETERM Gl PHYSIOLOGY
Gastric acid production pre.ent from 28-30 weeksLactose present by 28 weekaPancreatic tryp.in and lip~•• present by 30 week~
Lipolysis started by lingu.l lipase and continued by pancreatic"¡lip~$e, but th. bil. ~cid pool is low.
Pancreatic amylas. 15 low to .bsent
223
NUTRIT';ON 'jI11
Preterm formula vs breast milk vs standard formulas
l<cal/30ml F'rc, tei ii Fat CBH Osmols
Bl-east 2c)-22 1.1 3.8 6.8 273-300Enfamil 20 1.5 3.7 7.0 262-290Similac: se 24 2.2 4.4 8.6 260-300
NUTRITION IXPRETERM SPECIAL REQUIREMENTS
C3avage: <32 weeksinadequata gag reflexpoor suck and swallowROS
by drip
Gastric volumes are 3 rol in an 800 gro baby40 mi in a 4000 gm baby
Therefore, and N-J schedule may be necessary by pump at0.5 to 1.0 ml/hí Oí additional TPN
NUTRITION XPRETERM SCHEDULES
Weight (gms)
1(100-1200
1200-1500
1500-2(100
Age (hrs) Volume (mIs) Time
<24 1-2 q2hr24-48 2-4 q2hl-49-72 3-6 q2hr
>72 4-8 q2hr<12 2-3 q2-3h<24 4-6 q2-3h
24-48 6-9 q2-3h49-72 8-12 q2-3h
>72 10-15 q2-3h<24 5-15 q3-4h
24-48 10-25 q3-4h.>72 20-45 q3-4h
224
NUTRITrCN ~r
TER M BABY
1,000 kcal required to gain 3.5 kg between 0-4 months180,000 kcal required to gain another 3.5 kg between
4-12 month.Therefore, caloric requirements for the full term is:
100-120 kcal/kg/day from 0-10 monthsSO-lOO kcal/kg/day from 10-12 months
Protein is 1.35 to 1.80 gm/kg/day
225
TPN: INDIC~7~O~S
Short bowsl syndromeInflamm.tory bowel dise.seIntractable di_rrhe_ROS-BFDMajor anomalias of the 81 tractChemotherapyMajor trauma or burn~
Prolonged pancreatitisCachextic syndromes
TPN: Contamination Control
Central line placed in ORSilastic catheter securely anchoredInspection of site q.o.d~
Betadíne dressingsSystem used ONLY fo. TPNAIl solutions mixed in laminar hood0.22 u filter used with airtight systgemChest xray to assura SVC placement
TPN: Complications 1
Metabolic acidosis: a) A endogenous H load from ~A catabolismob) renal el shift {tubular disea.e).c) immatura kidney H &~cretion.
d) A HCD3 stool 109S.
Hyperammonemia <>300 ugm/dl): a) exogenous loadb) newborn livere) liver dis.as.
Hyperosmolarity:
Hypoglycemia:
Osteoporosis:
Anemia:
Trace metal def:
Thrombosis
Pulmonary:
226
a) too rapid ~ gluco•• , >1.2gm/kg/hr.~) early sepsis.
TPN: Complications 11
.> too rapid a withdrawal of glucosa
a) inadequate C., P, vit D, Cu
a) inadequate S12, folie .cid, iron, vit E
a) Cu --) anemia, leukopenia, osteomalaciab) Mg --> tetany, hyper-r.flaxiae) Zn --> acrodermatitis, poor wound healingd) Cr --) glucosa intolerance
a) foreign body
.> edema from overlo.db) emboli from air or thrombus
TPN: Complications III
Cholestasis: a) unknown etiologyb) cholelithiasis
Acute polymyopathy: a)fatty acid deficiency?
Fever: a) always a~sume sepsisb) culture from catheter for bacteria both
anerebic and aerebie and for funguse) dIe eatheter if no souree found andTPN Solutionsa General
Proteina Casein hydrolysate-bO% free AAFibrin hydrolys.te-bO% free AACrystalline AA- 100% free AA
CBH: Elemental glueD~e, up to 2~% central,12.5% pel-ipheral
Lipid: Soybean or safflowerEgg yolk phospholipidGlycerin 2.2~%
Water
TPN Solutionsl Lipid
Di 1 10%1.2Y.
54Y.26%
9%8"
LinoleicDleiePalmitic:Linolenic
Caloric value is 1.1 cal/mlDose i5 1 to 4 gm/kg/dayInfuse seperately; heparin to enhanee lipoprotein lipaseMonitor triglycerida ~nd eholesterol leve15Adversa reaetions: dyspnea, cyanosis, flushing, HSM
TPN Solutions: MinaraIs
Na1<MgF'04ClCa2nCl..l
Crt1nl.,Jitamins
2.5 mEq/100 kcal1-2 mEq/l00 kcal0.3 mEq/kg/day2 mM/kg/day <KP04 1 mEq = 0.b8 mM)2.5 mEq/100 kcal4(1)-700 mg/dC";y150-300 ugm/kg/day20-40 ugm/kg/day0.1-0.4 ugm/kg/day2-10 Llgm/kg/dayMVI o<~ B12~ fcollC inactivated by C)
221
TF'N S01~!t101"~S: Vlt¿'~l,~~;_____~~1~m~D 1Df~D~s_~~j~1~~ :n~~~c~D _
A (IU) 230/kg/dayO (IU) 40/kg/dayE (IU) O.7/kg/dayK (mg) O.02/kg/daye (mg> 8.0/kg/dayFolacin (ugm) 14.0/kgldayNiacin (mg) 1.7/kg/dayRiboflavin (mg)O.14/kq/dayThiamin (mg) O.12/kg/dayB6 (mg) O.10/kg/day812 (ugm) O.10/kg/dayPantothenic O.50/kg/day
elC id (mg)8iotin (ugm) 2.0/kg/day
2300/da"'f'400/day7.0/dayO.2/daySO/day140/day17/day1.4/day1.2/day1.0/day1 .O/day5.0/day
20/day
TPN: Cl~nical monitoring
Pal-ameter First week Follow-up-----------~------------------------------------------------
•
NB
WeightLenght~ HeU/s.g.~glu~ protLytes~ pH, BUN~glu
Ca, Pcee, TP, LFT, Mg,
cl-eat i ni neHemog 1clb i 11GasesAmmonia
228
daily (NB b.í.d.)weeklyq voíddailyq 2 days
weeklyb.i.s.dailyb.i.s.
dailyweekly1-3/day2-3/wkweekly
weeklyb.i.s.
t. i. s
TF:ACE l'1ETALS I
Elements of established nutritional importance
Majer: C, 0, Ca, CIN, Na, P, MgH, K, S,
Fe, Cu, Se, Ni, Si1, Ce, Mn, Va, FZn, Mo, Cr, Sb, Ar
TRACE METALS IIZINC
Absorbtion occurs in duodenum and jejunumAbsorbtien is interfered by phytat~s, Cu, fiber, Ca, vit DConcentrated in bone, muscle, eyes, hair, testes, teeth, liverTotal body zinc is 2 gmCarried bound te albuminExcretion is 65% gut, 35% kidney
**ZINC
TRACE METALS 111
Functions as metalloenzyme in DNA and RNA polymerases,protein synthesis, carbonic anhydrase, alkaline phosphatase
Found in seafood and meat, therefore Vegans at risk60-70% ef 2n ~nd Cu is transfered te fetus during the last 10-12
weeks of gestationNeeds: Prematures 450 ugm/kg
FuIl term 150 ugm/kgAdult 10-15 mg/day
Deficiency: growth retardation, weeping eczemoid, alopecia,depressien, delayed sexual maturation, diarrhea, HSM, poorwound healing, anorexia, hyposmia, cerne.l opacities
TRACE METALS IVCOPPER
30X of dietary copper absorbed in the small bowelTotal body copper is 100 mg9SX carried in ceruloplasmin which binds 8 Cu ~toms
Stored in the liver, with infant 6-8x adult cenc. Falls by 6 mo.Essentíal fClr RBC, bone, and cuproenzyme$ sLlch as cytochrome
oxidase~ ferroxidase, sup&roxidase dismutaseNeeds: lnfants .5-1.0 mg/day
Child 1.0-3.0 mg/dayAdult 2.0-3.0 mg/day
Deficiency: microcytic hypochromic anemia, leuccpenia~
osteopenia, CNS abnormal~tie$, depigmentation.
229
T!=: r:~C,E I..';E T~1L =- '.. )CHROMIUM
Found naturally in most drinking water.Excretad primarily by the kidneysTotal body chromium is 6 mgActs as a insulin co-factor for receptor site.
chrc.mium-nicc.tinic.-3AA acid complex "glucc1sefactor"
Needs: Infants .01-.06 mg/day
FC11~ms a.to 1el~ance
Infants Cb(Ud.(16 mg.'d§yO.2 mg/dayDeficiency: rare~ sean in prolonged TPN without chromium
Geographically, in PEM o~ Jordan, Nigeria, Turkey. Theresults are impaired glucose toleranee and hyperlipidemia
TRACE METALS VIMANGANESE
Concentrated in liver mitochondriaTotal body mangdnese is 20 mgMetalloenzyme for oxidative phosphorylationIn infancy high, lika Cu, falling by 6 monthsTransportad by a B-1-g1obulin transmaganínNeeds: lnfants 0.5-1.0 mg/day
Child 1.0-5.0 mg/dayAdults 2.5-5.0 mg/day
Oeficiency: dermatitis. decreased hair growth,hypocholesterolemia
* SELENIUMTRACE METAL8 VII
Vitamin E eo-factorTotal body stores are 6-10 mgFound in seafood, kidney, liverNeeds: Infants .01-.06 mg/day
Child .02-0.2 mg/dayDeficiency: muscle pain, tenderness, pancreatic degeneration,
hemc.lytic anemia. No confirmad deficiencias however.COBALT NICKLE VANADIUM
812 component ? ?
MOLYBDENUMMetalloenzyme of xanthine oxidase and sulfite oxidaseDeficiency produces headaches, lethargy
FLOURINEAs the flouride salt cariostatic at 1 ppm
230
TRACE METALS VIIIIRON
Absorbed from the small bowel10-30X of dietray iron 1S absorbedBinds to transferin and distributed throughout bodyStored in bone marrow for used by RBe, RE cellsLOSS occurs with gastrectomy, Gl bleeding, malabsorbtion,
binding agents <phosphates, oxalates)Needs: Infants, children, men 10 mg/day
Adolescents and females 18 mg/dayDeficiency: anemia and its pathophysiological consequences
VITAMINS 1
Fat-soluble vitamins are constituted by retinol, ergo-andcholecalciferols, tocopherols, and phyllo-and menaquinonefor A, 02, D3, E, VI, and K2.
AIl are $oluble in lipid and organic solventsDeficiency occurs with decreased intake or fat absorbtionAs opposed to water-soluble vitamins, these can be toxic
* * * * * * * * * * *Water-soluble vitamins are thiamin, riboflavin, niacin,
pyrido~ine, folie acid, cyanobalamin, ascorbic acid,pantothenic acid, biotin, cholina, inositol, carnitine,bioflavanoids
These are ubiquitous in natural foodsDeficien~y cccurs predominantly from malnutritionCholine, inositol, carnitine, bioflavanoids not true vitaminscarnitine~ bioflavanoidsnot ~uber~t~amieBzymaticco-factors.
VITAMINS 11VITAMIN A
Exists a$ carotenes in foods, which are vitamin A precursorsB-carotene in ileum split into retinal by dioxygenase,
then in liver to retlnol by reductase.Absorbtion in small bowel, stored in liver as palmitate es terNeeds: Infant 300 ugm (1 i.u. = 0.3 ugm>
Adoleseent 750 ugmSouree: milk fat, &gg, liver~ earotinoid pigments of plantsOeficiency: (levels <100 ugm/L) thickened bones, 1055 of lung
elasticity, salivary gland and epithelial keratinization,impaired hearing, corneal dryness, nightblindness, urinarycalculi
Toxieity: precocious skeletal growth, irritability, fatigue,increased ICP (pseudotumor eerebri), anoreXla. vomiting,nystagmus. gll,givitis and hypertrophy, H5M, lymphadenopathY~
alkallne phosphatasemia
231
VITAMINS IIrVITAMIN D
Absorbed along with TGC and carried by A2-g1obulin to liverD2 dietary, by UV light converted to 03D3 hydroxylated in liver to 25-DHD3 which is the major
circuldtinq form of O (30 mg/dl)In kidney cenverted to 1~25-DiOH cholecalciferolRegulated by Ca and PTH levelsD is needed to fDrm Ca transport protein in dubdenum~ facilitate
bone resorbtion, and P absorbtionSource: mllk (fortified)~ fish~ liver, sunlightNeeds: 10 ug (400 i.u.)/dayDeficiency: rickets, osteomalaciaToxicity: hypercalcemia, azotemia, poor growth, vomiting~
nephrocalcinosis
VITAMINS IVVITAMIN E
A-Tocopherol (B~G,D haya 1/3 activity of A>Stered in adiposa tissue, transported with B-lipoproteinAbsorbtion requires pancreatic and bile functionsActs as an antioxidant of polyunsaturated fatty acids te
stabilize membranesSource: grains~ oil5, peanuts, soy, milkfat, turnip greensNeeds: Infants 4 mg/day
Adolescents 15 mg/dayDeficiency: hemolytic anemia, peripheral neuropathy. In
prematures: BPD, anemia, edemaTexicity: known inhibitor of vitamin K
* VITAMIN kVITAMINS V
V1 i5 phylloquinone and dietaryK2 is menaquinone and bacterialV3 is phytonadione and syntheticV requires bile for absorbtion, intestinal b~cteria
Transported by B-lipoprotsins to liverRequired fer activation o~'facters II,VII,IX,XSource: cow milk, green leafy vegetables, pork, liverNeeds: Infant 5 ug/day, others unknownDeficiency: hemorrhagic m.nifestation5
VITAMINS VI8IDTIN
Water soluble and made by gut bacteriaActs as a co-enzyme te carboxylases of CoASource: liver, egg yolk, peanutNeeds: unknown, but defi~iency treated with 10mg/d3YDeficiency: anorexia, dermatitis, myalqias, hyperesthesia,
50mnolence
*232
qbsorbed in ileum, requires gastric intrlnsic factorTr~ce metal cobalt essential componentActs a coenzyme for RBe maturatioh, CNS met~bolism, and
together with folate contributes to DNA synthesisTransmethylation requires B12
Total stores are 4 mgSource: animal only, me~ts, milk, eggNeeds: 1-2 ugm/dayDeficiency: pernicious anemia~ neurologic deterioration
(posterolater~l columns)~ glossitis
VITAMINS VIIIFOLACIN
AIso called folie acid, pteroylglutamin acidGroup of compounds containing a pteridine ring~ p-aminobenzoic
and glutamic acidsActive form is tetrahydrofolic acid and contributed to the
formation of purines, pyrimidines~ and methylationTotal body pool is 5-10 mgSource; liver~ green vegetables, cereal, orangesNeeds: Infants 50 ugmJday
Adolescents 400 ugm/dayDeficiency: megaloblastic anemia, apathy, irritability
VITAMINS IX
NIACIN
Nicotinic aeid acts as co-enzyme <NAD-NADP)60 mg of tryptophan yields 1 mg nicotinic .cidSource: meat, fish, grains, green vegetable.Needs: 6.6 mg/l000 caloríesDeficiency: pellegra, diarrhea, dementia, apathetic,
anorexia, myalgia
FOLACIN
AIso called folie acid, pteroylglutamin acidGroup of compounds cont~in~ng a pteridine ring~ p-aminobenzoic
and glutamic acid.Active form is tetr~hYdro~olic acid and contributed to the
formatlon of pUrln.~, pyrimidines, and methylationTotal body pool i5 5-10.mgSource: liver, gr••n veg.tables, cereal, orangesNeeds: Infants ~O ug~/day
.. Adolescents 400 ugm/dayDeflClency: megaloblastic anemia, apathy., irritability
233
NIACIN
N' t·· .1 ce, 11"11 e ae l.d C\~ ts as cc'''''''enzyme n'JAD-NADP)
60 mg of tryptophaD y~eld:5' 1 ro ni ·,t· .'Souree: m~at f" " Q '. CQ lnle aCld
, lsh, gralns~ green vegetablNeeds: 6.6 mg/l000 calaries esDeficiency: pellegra, diarrhea~ dementia apath t.
anorexIa, myalgi~ 'e lC~
'JITAMINS X
PANTOTHENIC ACID
Component of co-enzyme ASpecific functions unknownSc,ul-ce.: almost al1 f.c.C'~s
N~.d~: uriknown~ estimated at 5-10 mg/dayDefici~n~y: hypot.nsion~~mus~.leweakneses.
**PYRIDOXINE (86)
VITAMJNS Xl.
Enzymat~cco~ta~tor f9r'~n~bolie and catabolic AA metabólism:espe~i~li~~ ~he transferases.
Source: 1iver~ meats, grains, eorn~ soy~ eggs, avocadoNeeds: Infants 0.2 ~g/d~y"
Adults 2.0 mg/dayDeficieney: glossitis, cheilosis, peripheral neuropath~,
(infants, eonvu1sions>
JI TAMINS X.IlRIBOFLAVIN <B2)
Enzymat ie cafae te.! for any en.:ymes as flavin mancmuc leotide Orflavin adenin~ dinucleotid~. Paít of multiple oxidationreduction reactions
Source: meats, milk, eggs, graín~
Needs: 0.6 mg/lOOO caloriesDeficiency: P~lC't(;:.plic.biát che} ~o$is, gl'ós.ítis. sebo,,'"haa
VITAMINS )( lI1THIAMIN CBl)
Decarbo;<ylation coenzym¡¡¡o o'" A"'ket'ciacids to .lá~hydes andNAOPH
Adult stÚf";es are 30 mg~ depleted in 10-14 óaysSource: yeast, liver, meats~ milk, grainsNeeds: 0.5 mg/lOOO ealQriesDeficiency: beriberi, neuritis, edema, hoalseness, anorexia,
CHF, malaise, weakness. Infants: irritability, agitated,cCl\ivul s i 0115