PEDIATRIC NUTRITION

Adequate nutrition for the proper growth and development of a child is of great importance. The amount and type of fluid, calories, electrolytes, and trace elements are all based on age, weight, nutritional status, and disease state.

The total daily fluid requirement of any patient is equal to the normal daily maintenance fluids plus replacement of any fluid deficit plus replacement of any significant abnormal ongoing losses. Normal maintenance fluids provide replacement for normal body functions and for normal losses (for example, insensible water loss, urine output and stool losses).

Total daily fluid requirement = Normal Maintenance Fluids + Deficit + Ongoing Abnormal Losses

A) Daily maintenance fluid requirements calculated by body weight

Weight Daily maintenance fluid requirements

< 2.5 kg 120 ml/kg/day.

2.5 - 10 kg 100 ml/kg/day.

11 - 20 kg 1000 ml plus 50 ml/kg for every kg over 10 kg.

> 20 kg 1500 ml plus 20 ml/kg for every kg over 20 kg.

EXAMPLES:

Weight: Maintenance fluid

8 kg : 100 ml/kg/day = 800 ml/day

15 kg : 1000 ml + (50 ml/kg × 5) = 1000 + 250 = 1250 ml/day

27 kg : 1500 ml + (20 ml/kg × 7) = 1500 + 140 = 1640 ml/day

B) Fluid deficit is calculated by clinical assessment of dehydration

Mild Moderate Severe

Weight loss 4% 8% 12%Fluid deficit 40 ml/kg 80 ml/kg 120ml/kg

C) Ongoing losses also need to be replaced (e.g., NG tube losses, vomiting, etc). 1

Nutritional RequirementsFood consists of a combination of macronutrients (carbohydrate, protein and fat) and micronutrients (vitamins and minerals). Energy provided by carbohydrate is 4 kcal/g; that provided by fat is 9 kcal/g. Fat and carbohydrates are the principal dietary sources of energy; protein provides nitrogen for synthesis of tissues. Relative requirements for protein and energy (g or kcal/kg body weight) decline progressively from the end of infancy through adolescence, although absolute requirements increase.

Vitamins and minerals* Vitamin A 2000 IU/day * Vitamin D 400 IU/day* Vitamin B1 1 mg/day * Vitamin B2 1 mg/day* Vitamin B12 1 ug/day * Vitamin C 50 mg/day* Calcium 1 gm/day * Iron 10 mg/day

Nutritional Requirements

A. Breast-feeding: "Breast is best": Mature human milk better meets the nutritional demands of human infants than cow's milk. Human milk is the standard against which all infant formulas are compared. Most commercially available (cow's) milk-based infant formulas are designed to closely approximate human breast milk.

Advantages of breast feeding1-Anti-infective properties (Contains a specific growth enhancing factor for lactobacillus bifidus, lysosyme, macrophages, interferon, lactoferrin, and intestinal growth factor).2- Ideal nutritional properties (optimum protein quality, hypoallergenic, ideal Ca:Ph ratio, low solutes, iron content low but bio-available).3 - Good maternal - infant relationship. 4 - Economical & cheaper, sterile, free of contamination. 5 - Readily available and fresh.

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Comparison of nutrient composition of human milk, cow's milk and milk based infant formulas.

Drug secretion in breast milk- Breastfeeding mothers should avoid taking drugs if possible. When drug therapy is necessary, the mother should avoid contraindicated drugs and drugs that suppress lactation (eg, bromocriptine).- Most of antibiotics are safe e.g. penicillins and cephalosporins. Chloramphenicol or tetracyclines are not allowed.- Most of analgesics and antipyretics are safe in small doses (aspirin, paracetamol, ibuprofen).- Vitamins B and C are safe.- Hormones such as insulin and small doses of steroids are safe.- Sedatives and antihistamines are safe in small doses.- Drugs that should NOT be given to nursing mothers include anticoagulants, antithyroid drugs, antimetabolites, radioactive preparations, metronidazole and narcotics.

B. Formula FeedingTypes and uses of infant formulas(1) Standard humanized formulas- These formulas are modified to be very near to breast milk in composition & quality. They are used for normal term infants. Lactose is the carbohydrate source. Vitamins & iron are added. These formulas are the first choice under usual conditions.

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- Available trade names: S-26, Similac, Bebelac1, Nan 1, Enfamil. (First 2 milks are reconstituted by adding one scoop to 60 ml water, others one scoop added to 30 ml water). (2) Lactose-free, soy-based formulas- Cow's milk protein is replaced by a vegetable protein (soy bean) and the lactose of milk is replaced by other sugars (sucrose or glucose), so they are used in cow's milk allergy and lactose intolerance which occur commonly following severe gastroenteritis. They are also used in cases of galactosemia. - Available trade names: Isomil, Nursoy, S26 FL, Bebelac FL. Reconstitution of first 3(one to 60 ml), while others one to 30 ml water).

(3) Elemental formulas (Hypo-allergenic formulas)- Indicated for infants allergic to cow’s milk and soy protein (malabsorption, chronic diarrhea), they are very expensive with bad taste.- Proteins are in the form of protein hydrolyste (amino acids and small peptides). - Fats are present as medium-chain triglycerides.- Available trade names as Pregestimil (one to 30 ml water). (4) Preterm infant formulas: Differences from standard formula include:a. Provides more calories (80Kcal/100ml).b. High protein and low lactose.c. Substitution of long-chain fatty acids with MCT.d. Increased vitamin D, calcium and phosphorus to promote bone growth.- Available trade names: S26 LBW, Enfalac premature, pre-Nan.

(5) Phenylalanine - free formulas - Used in cases of phenylketonuria. - Available trade names: Lofenalac, Milupa PKU1.

C. Supplemental foods are introduced at 4 to 6 months of age (after the infant has established the ability to swallow non-liquid foods). Introducing foods at this time is suitable as the infant has increased levels and maturation of digestive enzymes. Also, caloric requirements cannot be provided by milk alone.

Pediatric Total Parenteral Nutrition (TPN)

Introduction - Parenteral nutrition (PN) is the administration of nutrition directly into the bloodstream. It is the method of providing nutrition to infants or children who have severe intestinal failure. Parenteral nutrition may provide the full energy requirements (TPN) or be partial where it is not possible to give full requirements or if it is used in conjunction with

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enteral feeds. Parenteral nutrition is invasive, has associated risks and should only be used when there is no alternative method of feeding available.- Parenteral nutrition is compounded by pharmacy staff in a laminar airflow cabinet under clean room conditions.  The solutions are prepared individually for each child depending on their weight, height, clinical condition and the intravenous route available. Feeding regimens are built up over two to four days during which time the protein, fat and carbohydrate content are increased. Indications Prematurity Necrotizing enterocolitis Acute pancreatitis Intestinal failure:

Short gutProtracted diarrheaPost-operative abdominal surgery

Hyper-catabolism:Extensive burnsSevere trauma

Constituents of Parenteral NutritionSolution A (i.e. Amino Acid Solution)

Amino acids Glucose and electrolytes Zinc, Copper, Selenium, Manganese, Fluoride, Iodine and Chloride

Solution B (i.e. Lipid) Lipid emulsions Water-soluble vitamins Fat-soluble vitamins

These solutions provide very good growth media for micro-organisms so it is essential that they are provided free of such contamination.

Management Prior to starting PN the child’s weight and height should be recorded. Initially, PN usually contains 10% dextrose (D10); incremental increases occur by

approximately 5% every day or every other day to a final dextrose concentration of between 25 and 30% (D25–D30). The precise final concentration is dictated by the patient's caloric and medical needs and ability to tolerate glucose infusion without hyperglycemia.

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Initial rates of protein administration are 1.0 to 1.5 g/kg/day. The protein concentration is usually increased as tolerated to between 2.5 and 3 g/kg/day.

Intravenous lipid (Intralipid) infusion begins at 1 g/kg/day and is advanced in increments of 1 g/kg/day. Lipid generally provides 30 to 50% of calories and generally should not exceed 3 g/kg/day. In patients who cannot receive Intralipid, some form of lipid should be given intermittently to prevent essential fatty acid deficiency.

Multiple-lumen catheters are used to safely permit administration of PN and IV medication.

As nutrition improves, PN should decrease in parallel with the intravenous/oral intake to prevent overfeeding.

Monitoring the patient receiving TPN Weigh the patient daily. Measure intake and output and qualitative urine glucose and ketone concentrations. Measure serum sodium, potassium, chloride, blood urea nitrogen (BUN), and glucose

concentrations daily while increasing rates of fluid administration, and then weekly when fluid requirements have been reached.

Initially, measure CBC, magnesium, calcium, phosphorus, triglyceride, total protein, AST, ALT, alkaline phosphatase, bilirubin, and creatinine levels, and repeat the measurements weekly.

Measure serum copper, zinc, and iron levels at the beginning of therapy, and then monthly. Serum selenium and manganese levels are monitored in children on long-term PN.

Complications of TPN Infection is the most serious complication of TPN Fungi (usually Candida albicans) and bacteria are the common infectious agents. Care of the central venous line must be scrupulous. Fever is the most common presenting symptom. When sepsis is documented, the central venous line should be removed. Treatment: Broad-spectrum antibiotics with Vancomycin and Gentamicin. Mechanical problems and thrombosis

‒ Arrhythmias can occur with an improperly placed catheter. ‒ Venous thrombosis or air embolus may occur. ‒ Skin sloughing from infiltration of peripheral venous infusions.‒ Catheter occlusions are possible.

Metabolic complications‒ Hyperglycemia is common in septic patients and premature infants.‒ Severe hypoglycemia is a common complication if TPN is stopped abruptly. Hypoglycemia may be prevented in patients by reducing the infusion over 1 hour before the PN is stopped.

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‒ Hypocalcemia, hypermagnesemia or hypomagnesaemia. ‒ Hyperlipidemia can occur with excess lipid administration or sepsis.‒ Hyperammonemia.‒ Carnitine, selenium and copper deficiencies have been described.‒ Zinc deficiency is manifested by an erythematous, maculopapular ras (acrodermatitis enteropathica) involving the face, trunk, metacarpophalangeal joints, and perineum.

Hepatic complications‒ Cholestatic liver disease frequently develops in premature infants, and may develop in other patients on long-term PN.

Hepatomegaly with elevations of serum aminotransferases. Complications of Intralipid administration

‒ Lipid can displace bilirubin from albumin and may need to be stopped or infused at lower rates in jaundiced infants.

‒ Contraindications to the use of Intralipid include hyperlipidemic states.

Nutritional DisordersClassification- Under-nutrition (Protein-energy malnutrition) in underdeveloped countries- Over-nutrition (Obesity) in developed countries- Vitamin and mineral deficiencies

Protein-energy malnutrition 1) Nutritional dwarfism/ failure to thrive - Most common form * Mild and moderate form of chronic under-nutrition in infancy * Features - under-weight and short stature for age - No wasting or edema2) Marasmus: a severe form of chronic under nutrition characterized by emaciation and fair appetite. 3) Kwashiorkor: a severe form of acute malnutrition characterized by edema and poor appetite.Vitamin Deficiency DisordersVitamin A deficiency leads to:

‒ Night blindness & xerophthalmia ‒ Growth retardation‒ Acquired immune deficiency‒ Keritinization of epithelia in respiratory, urinary and gastrointestinal tracts.

Therapeutic uses of vitamin A include Vitamin A deficiency and boosting immunity of infants. Treatment of vitamin deficiency is by giving 5000-10,000 IU daily.

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Vitamin D Deficiency (Rickets)Rickets is the softening and weakening of bones in children, usually because of an extreme and prolonged vitamin D deficiency.

Clinical features• The earliest sign of rickets in infant is craniotabes (abnormal softness of skull)• Delayed closure of anterior fontanel• Widening of the forearm at the wrist • Rachitic rosary….swelling of the costo-chondral junction • Bowing of tibia and fibula may be observed at any age• Hypocalcaemic manifestations

– hypotonia – Seizure, tetany, muscle weakness, paraesthesia, numbness

Treatment1) Vitamin D therapy: 2000-4000IU/day for 2-4 weeks, then change to preventive

dosage (400IU). Alternatively, a single large dose, 200,000 IU, IM, can be given for severe or cases with complication, or those who are not compliant. The preventive dosage will be used after 2-3 months.

2) Calcium and iron supplementation 3) Treatment of infectionsPreventionVitamin D supplementation: In prematures, twins and weak babies, give Vitamin D 800 IU per day. For term babies and infants the demand of Vitamin D is 400 IU per day.

Hypervitaminosis DCause: excess intake of vitamin D e.g. repeated IM injectionsClinical Picture:

‒ Malaise, lassitude, anorexia & constipation‒ Polydipsia, polyuria. ‒ Renal stones (nephrocalcinosis)‒ Pallor, failure to thrive and wt loss

Prevention : careful vitamin D dosage Lab test: hypercalcemia Treatment : 1) Stop vitamin D intake2) Stop calcium intake 3) Steroids in severe cases.

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