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Department of Nutrition Services | Morrison Healthcare Foodservice
Pediatric Nutrition Support Handbook

i

Pediatric Nutrition Support Handbook
Department of Nutrition Services
UVA Childrens Hospital
University of Virginia Health System
Charlottesville, Virginia 22908

Editors:
Ana Abad-Jorge, MS, RD, CNSC
Brandis Roman, MS, RD, CNSC

Contributing Authors:
Ana Abad-Jorge, MS, RD, CNSC
Marcia Buck, PharmD
Allie Hubbard, RD
Patti Perks, MS, RD, CNSD
Brandis Roman, MS, RD, CNSC

This handbook is intended to serve as a reference or guide in the area of pediatric
enteral and parenteral nutrition support for clinical nutritionists, medical and nursing
staff as well as dietetic interns and medical and nursing students.

Acknowledgements:

The administrative assistance of Nancy Carpenter in the preparation of this handbook
is greatly appreciated.

This handbook was funded by the Department of Nutrition Services.

Copyright 2012 University of Virginia Health System and Morrison Management
Specialists

ii

UVA Health System Nutrition Educational Programs

Dietetic Internship Program

The Dietetic Internship Program at the University of Virginia Health System, established in
1975, has as its mission to provide a broad-based, comprehensive dietetics education in both
traditional and emerging diverse settings. This progressive program furnishes the intern with
the skills to function as a competent entry-level dietitian with a specialization in the medical
nutrition therapy areas of paediatrics and adult nutrition support, while emphasizing a
commitment to life-long learning. Interns are also given the opportunity for advanced training
and multi-skilling in the areas of research, computer technology, effective oral and written
communication and clinical assessment. With a high staff/intern ratio, interns have the
opportunity to work one-on-one with nutritionist and management preceptors, but can also
work collaboratively with teams and other interns. This environment provides the intern with
theoretical, didactic, pre-planned and on-the-job learning experiences in a variety of
challenging and progressive settings.

The internship program, which is 43 weeks in length, starts at the beginning of September and
is completed during the last week of June. The program consists of a comprehensive 2 week
orientation to the program and rotations, supervised practice on-the-job learning experiences,
weekly classes and professional meetings. Rotations and affiliations are directed by
Registered Dietitians and department managers. During the program, interns will actively
participate in clinical, community and foodservice management rotations.

Program goals include:
- To provide the health care system with entry-level dietitians competent to practice in
general medical nutrition therapy areas, as well as the specialized areas, pediatrics
and adult nutrition support.

- To train and empower interns to enter the field with the necessary skills to conduct
basic practice based research, publish in the field of nutrition and dietetics, and
educate students, health care professionals and the public through a variety of formal
and informal training formats.

- To prepare interns to demonstrate exemplary professional behaviors, leadership within
their profession or community, and a commitment to active community service and life-
long learning.

Nutrition Support Traineeship

The UVA Health System Nutrition Support Traineeship provides a unique, five-day opportunity
to achieve a higher level of practice in nutrition support. Our evidence-based program utilizes
actual patient cases, physician-led nutrition support team rounds, small group discussions,
critical evaluation of research, and a practical, hands-on approach to learning. Our goal is to
optimize continuing educational time and expenses by focusing on the individual's learning
needs. Also included is an elaborate, fully referenced syllabus. Modules are based on the
most current evidence-based information, and provide a template for education at the
bedside. Experiences during the traineeship week are structured to spend time observing and
participating in completing nutrition support consults, nutrition team rounds, review of syllabus
modules, case studies and questions.

iii

Table of Contents

Chapter 1 - Pediatric Nutrition Services and Nutrition Screening at UVA HS ....... 1
Pediatric Nutrition Goals............................................................................................. 1
Pediatric Nutrition Services Provided at UVA Health System .................................... 2
Role of the Pediatric and Neonatal RDs..................................................................... 2

Chapter 2 - Nutritional Assessment of Pediatric Patients ....................................... 9
Growth and Anthropometric Measurements ............................................................... 9
Assessment of Malnutrition ...................................................................................... 12
Medical History ......................................................................................................... 13
Nutritional Intake History .......................................................................................... 14
Laboratory Data ...................................................................................................... 15

Chapter 3 - Nutritional Requirements in Term Infants and Children .................... 17
Non-Critically Ill Infants and Children ....................................................................... 17
Critically Ill Children .................................................................................................. 22
Catch-Up Growth in the Term Infant and Child ....................................................... 24
Energy Requirements for Pediatric Burn Patients ................................................... 25
Fluid Requirements .................................................................................................. 25

Chapter 4 - Nutritional Assessment, Requirements, and Enteral Nutrition
Management in the Preterm Infant .......................................................................... 27
Preterm Infant Weight Classification and Assessment ........................................... 27
Micronutrient and Macronutrient Requirements ....................................................... 28
Fluid Requirements .................................................................................................. 30
Meeting the Increased Needs of the Preterm Infant ................................................ 30
Preterm Formula Selection ...................................................................................... 32
Modifying Formula Caloric and Nutrient Density ...................................................... 33
Feeding Protocols for NICU Infants.......................................................................... 35

Chapter 5 - Enteral Nutrition Support ...................................................................... 37
Advantages of Enteral Nutrition................................................................................ 37
Indications for Enteral Feedings ............................................................................... 37
Enteral Tube Feeding Formula Selection ................................................................. 38
Modifying Formula Caloric and Nutrient Density ...................................................... 41
Tube Feeding Routes of Delivery ............................................................................. 44
Tube Feeding Administration Methods..................................................................... 46
General Guidelines for the Initiation and Progression of Tube Feedings ................. 47
Management of Combination Enteral and Oral Feedings ........................................ 49
Management of Complications Encountered with Enteral Feedings ........................ 49

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Chapter 6 - Nutrition Management of High Risk Nutrition Disease States ........... 55
Congenital Heart Defects ........................................................................................ 55
Cystic Fibrosis .......................................................................................................... 56
Renal Disease .......................................................................................................... 60
Severe Gastrointestinal Impairment ........................................................................ 65
Chylous Ascites/Chylothorax ................................................................................... 69
Burns ....................................................................................................................... 71

Chapter 7 - Parenteral Nutrition ............................................................................... 77
Peripheral vs. Central Parenteral Nutrition ............................................................... 77
Guidelines for Initiation & Advancement of Parenteral Nutrition ............................. 78
Monitoring of Pediatric Patients on Parenteral Nutrition .......................................... 87
Managing Metabolic and Long Term Complications of Parenteral Nutrition ............ 88

Chapter 8 - Pharmacology and Nutrition Support .................................................. 95
Medication Information Resources ........................................................................... 95
Common Drug-Nutrient Interactions Seen in Hospitalized Patients ......................... 95
Drug Interactions with Enteral Products ................................................................... 97
Drug Interactions with Parenteral Nutrition ............................................................... 99
Common Enteral Electrolyte Supplementation ....................................................... 101

APPENDIX ................................................................................................................ 103
A Growth Charts for Normal Infants and Children
World Health Organization Growth Standards for Infants (Charts 1 3)
National Center for Health Statistics (CDC) Growth Charts for Children
Aged 2-20 Years (Charts 4 8)
Fenton Growth Chart for Preterm Infants (Chart 9)
B - Specialized Growth Charts: Down Syndrome
C Triceps Skinfold Percentile Charts
D Mid Upper Arm Circumference Percentile Charts
E - Developmental Self-Feeding Checklist
F - Selected Lab Values with Nutritional Implications
G - Estimated Energy Requirements (EER) for Infants and Children
H - Guide to Number of Servings and Serving Size for Children
I - Electrolyte Conversion Information
J- Oral Multivitamin and Mineral Supplements Available at UVA
K - Tips for Increasing Calories for Children
L - Sites of Nutrient Malabsorption Resulting from Intestinal Resections
M Therapeutic Algorithm for Management of Post-operative Chylothorax
Chapter 1 Pediatric Nutrition Services and Nutrition Screening at University of Virginia Health System
1

Chapter 1

Pediatric Nutrition Services and Nutrition Screening
At University of Virginia Health System

The University of Virginia (UVA) Health System, located in Charlottesville and
comprised of the School of Medicine, School of Nursing, Claude Moore Health
Sciences Library and the Medical Center, has been declared time after time as one of
the Nations Top 100 Hospitals. The Medical Center, a teaching and research hospital
with over 550 beds, includes University Hospital, Kluge Childrens Rehabilitation
Center (KCRC), Northridge, the Primary Care Center and satellite clinics. UVA
provides quality care to a primarily rural population serving the community and the
Commonwealth, and receives referrals from other states and countries. At UVA,
patients receive specialized care in a variety of areas including pediatrics, womens
health, diabetes, cardiology and digestive health. Through the Continuum Home
Health Program, UVA professionals bring care and expertise into thousands of homes.
Our state-of-the art medical facility offers multi-disciplinary centers focused on
specialty areas such as the Cancer Center, the Childrens Hospital and the Womens
Place, to name a few. The Medical Center, designated as a Level I Trauma Center,
contains numerous intensive care units including the medical, surgical, pediatric and
newborn intensive care units.

Pediatric nutrition services at UVA Health System are provided by a number of
pediatric registered dietitians (RDs) in the areas of general pediatrics, the pediatric
intensive care unit (PICU), the newborn intensive care unit (NICU), KCRC and in the
outpatient areas including: pediatric nephrology, pediatric gastroenterology, inborn
errors of metabolism, childrens fitness clinic, and pediatric endocrinology. The
inpatient pediatric RDs work closely with the respective unit medical teams to provide
nutritional assessment, care plan development and patient and staff education. The
pediatric RDs also closely follow patients in the pediatric units, NICU and PICU who
are at nutrition risk and require specialized enteral or parenteral nutrition support.

Pediatric Nutrition Goals

1. To decrease the incidence of morbidity and mortality associated with nutritional
problems in our pediatric patient population.

2. To improve patient clinical outcomes by providing timely, optimum, safe and cost-
effective nutrition through either the oral route, or for those children who are
critically or chronically ill, using tube feedings or parenteral nutrition support.

3. To identify patients who will benefit from nutrition intervention.

4. To provide patient education in the areas of specialized or therapeutic diets, or for
specialized enteral or parenteral nutrition support, including but not limited to,
2

diabetes diet education, low fat or low sodium diets, and specialized formula
preparation.

5. To provide medical and health care staff and student education in the areas of
pediatric nutrition or specialized nutrition support via formal lectures and patient
unit and discharge planning rounds.

6. To develop and review hospital and departmental policies and procedures to
promote the appropriate and effective use of nutrition therapy and support.

Pediatric Nutrition Services Provided at UVA Health System

- Comprehensive nutrition assessment
- Follow-up assessment
- Nutrition intake analysis
- Patient and family education
- Staff and student education in the area of pediatric nutrition and nutrition
support
- Resource for health care team and staff in the area of pediatric nutrition support
- Active participation in unit-based quality improvement activities and projects
with the goal of improving patient care and clinical outcomes

Role of the Pediatric and Neonatal RDs

- Conduct in-depth nutritional assessment
- Provide medical nutrition therapy recommendations for children with a wide
variety of nutritional disorders or those at risk for malnutrition
- Provide nutrition support recommendations and pended orders for parenteral
nutrition.
- Provide nutrition support recommendations and verbal order for therapeutic
diets, enteral nutrition , and related laboratory values, in order to expedite the
timely ordering and delivery of effective nutrition support to infants and children.
- Provide monitoring for complications, lab abnormalities, response to nutritional
intervention and support, timely follow-up and intervention
- Conduct nutrient analyses and compare intake to estimated needs
- Assist in the provision of patient and family education on specialized and
therapeutic diets and home nutrition support, as related to formula preparation,
delivery and monitoring for enteral feeding complications
- Provide education to pediatric residents, nursing staff, medical and nursing
students, and dietetic interns
3

Pediatric Nutrition Services within the General Pediatric Units (7- Acute)

Nutrition Screening

The 7-Acute RDs screen pediatric patients on the unit to determine those at nutrition
risk. Per Nutrition Services policy, all children are screened for nutrition risk upon
admission by the unit nursing staff. The 7-Acute pediatric RD receives a nursing
referral for those children determined to be at risk. The initial screening by the
nursing staff is based on presence of the following:
- Special diet or formula
- Poor oral intake for > 5 days
- Pressure ulcer(s) or poor wound healing
- Burns > 15% total body surface area
- Problems chewing or swallowing
- Use of specialized nutrition support: enteral or parenteral
- Current diagnosis of malnutrition, cystic fibrosis, failure to thrive or new onset
diabetes mellitus

The patients family is also asked if they wish to see an RD during the admission.

Comprehensive Nutrition Assessment: High Risk Nutrition Diagnoses and
Conditions

The following conditions or diagnoses are often indicative of high nutrition risk.

1. Patients on nutrition support

2. High risk diagnoses or conditions
a. Anemia
b. Bronchopulmonary dysplasia/chronic lung disease
c. Burns
d. Cancer
e. Congenital heart defects
f. Cystic fibrosis
g. Diabetes mellitus
h. Failure to thrive
i. Gastrointestinal anomalies/disorders: gastroschesis, malrotation, necrotizing
enterocolitis, omphalocele, short gut syndrome, tracheo-esophageal fistula,
volvulus
j. Inflammatory bowel disease: Crohns disease, ulcerative colitis
k. Liver disease
l. Malabsorption syndromes
m. Neurologically/developmentally impaired
n. Preterm Infants particularly very low birth weight infants (<1500 grams)
o. Pulmonary disease
4

p. Renal disease
q. Trauma patients

3. Weight below or above standards
a. Weight/height < 3
rd
%-ile on age- and disease-appropriate growth charts
b. Height or Length< 3
rd
%-ile
c. Weight for height <3
rd
%ile or > 95
th
-ile
d. Recent weight loss (over the past 6 months) of > 10% of usual body weight

4. Catabolic state: sustained fever, major organ failure

5. Diet order and patient intake inadequate in meeting patient nutritional
requirements.
a. NPO > 3 days in previously malnourished children or NPO > 5 days in
previously well-nourished children, without parenteral or enteral nutrition
b. Patients on clear or full liquid diets for > 5 days

Pediatric Nutrition Services within the Pediatric Intensive Care Unit (PICU)

Nutrition support of the critically ill, post-trauma or post-operative pediatric patient
continues to develop as a clinical science in light of advances in nutrition,
pharmacology and technology. Given the wide diversity in pediatric critical care
states, we are challenged to accurately assess the nutritional requirements of our
patients and the best mode of nutrition support to optimize their recovery and their
nutritional and medical outcomes.

Role of the PICU RD

- Screen all PICU patients for nutritional risk
- Comprehensive nutritional assessment of all patients determined to be at risk
- Development of nutrition care plan with recommendations for enteral or
parenteral nutrition support, as needed (within 48 - 72 hours of PICU
admission)
- Monitoring of nutritional status; timely follow-up and intervention
- Conduct nutritional analysis and compare intake to nutrition goals
- Family and staff education on nutrition support
- Assist the PICU team with nutrition management through entering pended
orders for TPN, and verbal orders for enteral feedings, labs, and therapeutic
diets using the electronic medical record system (Epic).
5

Purpose and Goals of Nutrition Support in the PICU Patient

- Provision of adequate calories and protein during catabolism to prevent protein-
energy malnutrition (PEM), i.e., sepsis, trauma, post-surgery.
- Promote improved immunological status and wound healing to minimize the
risk of iatrogenic infections.
- Prevent or minimize the catabolic response and breakdown of both somatic and
visceral protein stores.
- Improvement of nutritional status; management of disease-specific deficiencies
- Reversal of growth failure and when applicable, promotion of catch-up growth.

Indications for Nutrition Support: Patients at Nutrition Risk

- Hypermetabolic states: trauma: closed head injury, spinal cord injury
- Post-surgical patients
- Cardiorespiratory illness: congenital heart defects, bronchopulmonary
dysplasia, cystic fibrosis
- Gastrointestinal disease and dysfunction: short gut syndrome, exacerbation of
inflammatory bowel disease with history of PEM, hepatic failure, biliary atresia,
pancreatitis
- Neurologic, muscular disease: genetic syndromes, Guillan-Barre, muscular
dystrophy, history of Cerebral Palsy or Mental Retardation requiring G-tube
feedings

Pediatric Nutrition Services within the Newborn Intensive Care Unit (NICU)

The Newborn Intensive Care Unit is a special care nursery for the medical
management of the preterm or critically ill neonate. The unit at UVA Health System is
comprised of more than 40 beds and is staffed by neonatologists, neonatology
fellows, neonatal nurse practitioners, and neonatal RNs. The NICU RD plays an
active role in the NICU.

Role of Neonatal RD

- Initial assessment for all at-risk infants within 72 hours of admission
- Assist NICU residents with entry of TPN orders and with enteral feeding orders
- Be available to the NNPs as a consultant regarding the nutrition management
of their infants
- Weekly follow-up for all infants
- Participation in team rounds
- Parent & caretaker education for infants being discharged on high calorie
formula or fortified breast milk or any other specialized formula, when needed
6

- Monthly Neonatal Nutrition lecture to the new interns
- Nutrition education and orientation of new NICU nurses

Screening in the Newborn Intensive Care Unit

In the NICU, interns and residents complete a thorough assessment within the first 24
hours which includes the following basic nutrition screening data:
- Birth weight, length and head circumference
- Intrauterine %-iles for weight, length and head circumference using the
Intrauterine growth charts
- Gestational age
- Major diagnoses

Based on the above documented nutrition screening data, the neonatal RD will
determine which infants are at risk and will complete a full assessment on the
following neonates:
- All infants under 1200 grams
- All infants requiring parenteral nutrition
- Infants with major gastrointestinal anomalies
- Infants with intrauterine growth retardation (IUGR) and who are small for
gestational age
- Infants with congenital heart defects requiring surgical repair
- Infants with severe respiratory distress syndrome (RDS)
- Infants with complex genetic disorders impacting nutritional status
7

Pediatric Nutrition Outpatient Services

UVA Childrens Hospital
University of Virginia Health System

SERVICE DIETITIANS PHONE/PAGER
Primary Care
Center
Nephrology Brandis Roman 243-7656, PIC 6433

Gastroenterology Brandis Roman 243-7656, PIC 6433

Inborn Errors of
Metabolism
Barbara Goodin

924-2665 or 979-6530
(beeper)

Continuum
Home Health
Pediatric Home Nutrition
Support Patients

Amy Mentrikoski 924-8193
Northridge

Weight management,
failure to thrive,
behavioral eating
issues, allergy, well child
issues

Ashleigh Sellman

243-7314
Kluge
Childrens
Rehab Center

CP, myelomengiocele,
muscular dystrophy,
trauma, infant & young
child clinic, Down
syndrome,
neurodevelopmental
clinic, autism, other

Audrey Kocher,
Amy Mentrikoski

924-8193

Childrens Fitness Clinic

Angela
Hasemann
982-1607
Diabetes

Amy Mentrikoski
Barbara Goodin
924-8193
924-2665

Feeding
encouragement, feeding
and swallowing

Audrey Kocher

924-8193

Cystic fibrosis Barbara Goodin 924-2665

8

Chapter 2 Nutritional Assessment of Pediatric Patients
9

Chapter 2

Nutritional Assessment of Pediatric Patients

Assessment of the nutritional status of pediatric patients while in the hospital setting is
important for identifying the goals of nutritional intervention, increasing the quality of
care and diagnosing malnutrition. Nutritional status can be determined by the
assessment of body weight, growth, adipose tissue, skeletal muscle, visceral protein
stores and cellular immune function (1, 2).

Components of a thorough nutritional assessment include (1, 2):

1. Growth assessment and anthropometric measurements
2. Medical, developmental, social and personal history
3. Nutritional intake history and history of food allergies
4. Laboratory evaluation of biochemical and metabolic changes
5. Review of nutrition-focused physical examination findings
6. Educational needs and potential barriers to learning

Growth and Anthropometric Measurements

Growth of infants, children, and adolescents from birth through 20 years of age is
evaluated routinely. World Health Organization (WHO) growth standards should be
used for children aged 0 to 2 years, and thereafter, National Center for Health
Statistics (NCHS) growth curves should be used until 20 years of age (Appendix A).
Growth charts exist for each gender. Knowledge of parental height and weight can
also be important in growth assessment to gauge genetic potential. Growth charts are
used to evaluate the following anthropometric measurements:

- Recumbent length (<2 years of age) or standing height (> 2 years) for age
- Weight for age
- Weight for height
- Head circumference for children under the age of 3 years
- BMI for 2-20 years

Weight for age serves as a valuable indicator of overall nutritional status.
Underweight for age may indicate acute malnutrition. A deficit in height or length
usually indicates chronic undernutrition and growth failure. Weight for height
assesses body weight in proportion to height and distinguishes wasting from dwarfism
(1, 2).
Specialized growth charts are available for specific disease states such as Down
syndrome (Appendix B).
10

Additional Anthropometric Measurements (1, 2)

Other anthropometric measurements which may be used to evaluate more precise
aspects of a childs nutritional status include:

Triceps Skinfold (TSF): a measurement of a double layer of skin and
subcutaneous fat on the back of the upper arm which reflects subcutaneous fat
stores. This measurement is taken using a tape measure and calipers, locating
the midpoint between the acronium and olecranon processes and using the caliper
jaws to grasp the skin and subcutaneous tissue 1 cm above the midpoint (3). To
maintain consistency when evaluating the TSF and mid arm circumference (MAC)
values for a given patient, the same individual should complete the measurement
over the evaluation period and take three serial measurements during each
assessment. See Appendix C for percentile tables to interpret measured values.

Midarm Muscle Circumference (MAMC): an index of lean muscle mass calculated
from the MAC and TSF using the following equation (3) (see Appendix D for
percentile tables):
MAMC (mm) = MAC (mm) - |3.14 x TSF (mm)|

Body Mass Index (BMI): the preferred measure of adiposity which is expressed as
weight in kg/height in meters
2
. BMI provides a more reliable measure of fatness
than triceps skinfold thickness.

Pediatric Obesity Assessment (3 5)

The classification system for pediatric overweight/obesity is most commonly evaluated
using BMI as follows for children (over 2 years of age) and adolescents (3):

- Obesity: BMI > 95
th
%-ile for age and gender
- Overweight: BMI 85
th
- 94
th
%-ile for age and gender

Refer to the BMI for age percentile charts developed by NCHS (Appendix A).

Growth Velocity

The best indicator of a childs long-term nutritional status is how fast he or she is
growing. Consequently, growth velocity is an especially sensitive indicator which
requires periodic evaluation (2). Deviations from a childs normal growth pattern
should be noted, especially an increase or decrease across 2 standard deviations or
measurements plotting below the 5th %-ile or above the 95
th
%-ile (3). It is important
to note, however, that approximately 2/3 of all children do cross growth curves in the
first 2 years of life due to genetic reasons. The following parameters (Tables 2.1, 2.2,
and 2.3) reflect growth velocity of normal term infants and children and are useful in
making adjustments in nutrition goals (2).

11

Table 2.1 Normal Weight Gain Velocity for Children 0 - 36 Months*

Age (months) Male (g)/day Female (g)/day
1 - 3 31 24
3 - 6 20 20
6 - 9 25 15
9 - 12 12 11
12 -15 8 8
15 - 36 6 6

* Infants and children with a history of failure to thrive, who are experiencing catch-up growth, may
demonstrate weight gain at 150-200% of normal.

Table 2.2 Normal Weight Gain Velocity for Children Ages 3 -13 Years (6)*

Age (yr) g/month
2 - 7 38
7 - 9 56 - 62
9 -11 66 - 77
11 -13 85 - 110

* Based on 50th %-ile, height and weight, NCHS Growth Charts

Table 2.3 Normal Linear Growth Velocity for Children Birth 10 Years (2)

Age Length (cm/month)
Birth to 3 months 2.6 - 3.5
3 - 6 months 1.6 - 2.5
6 - 12 months 1.2 - 1.7
1 - 3 years 0.7 - 1.1
4 - 6 years 0.5 - 0.8
7 - 10 years 0.4 - 0.6

Infants: Measure length weekly or biweekly. Toddlers: Measure height monthly.

Head Circumference (7): From birth up to 12 months of age: 0.5 - 0.8 cm/wk

12

Assessment of Malnutrition (1, 2, 8)

Weight is a good indicator of acute and chronic nutritional status and may be used to
assess a pediatric patients degree of malnutrition. Weight may be classified as a
percent of standard using the following equation:

th
actual weight measure
% standard
expected weight measure (50 % ile) *
=

* 50
th
%-ile for age or 50
th
%-ile wt/ht if the child was premature.

The Waterlow criteria (Table 2.4) can be used to assess the degree of both acute and
chronic malnutrition (9). It is important to realize, however, that chronic diseases,
such as renal failure, may affect linear growth independent of nutrition status; in these
cases, the Waterlow criteria may not apply for determination of chronic malnutrition.

Table 2.4 Waterlow Criteria to Assess Malnutrition Status (9)

Acute
(wt/50% wt for ht)
Chronic
(ht/50% ht for age)
Stage 0 >0.90 >0.95
Stage 1 (mild malnutrition) 0.80 - 0.90 0.90 - 0.95
Stage 2 (moderate malnutrition) 0.70 - 0.79 0.85 - 0.89
Stage 3 (severe malnutrition) <.70 <0.85

Clinical Assessment of Malnutrition

Although growth assessment is most commonly used for assessing nutritional status
in children, in advanced stages of malnutrition children will exhibit physical signs and
symptoms indicative of specific nutrient deficiencies. Table 2.5 reviews common
clinical changes which may become evident with prolonged malnutrition in children.

13

Table 2.5 Clinical Assessment of Malnutrition in Children: Physical Signs
of Nutrient Deficiency (10)

Physical Sign Nutrient Deficiency
General appearance: edema, muscle wasting,
decreased subcutaneous fat, growth failure
Protein, calories
Hair: dull, dry, may be thin and sparse, easily
pluckable; color changes
Protein, calories

Skin: Dry and flaky, follicular hyperkeratosis,
dyspigmentation, petechiae, pellagrous
dermatosis
Vitamin A, protein, niacin, Vitamin
C, riboflavin, vitamin B
6

Essential fatty acids

Eyes: Pale and dry membranes, or red and
inflamed membranes, Bitots spots, corneal
xerosis (dull & hazy) or scarring, cracking in the
corners of eyes
Vitamin A, iron, folate

Lips: Redness and swelling, angular stomatitis Niacin, riboflavin, vitamin B
6

Tongue: Swelling (glossitis), raw tongue,
magenta or purplish in color, smooth tongue,
sores
Riboflavin, niacin

Teeth and Gums: May be missing teeth, bad
color and visible decay or cavities, spongy,
swollen and bleeding gums, recession of gums
Fluoride, Vitamin C

Cardiovascular system: tachycardia, enlarged
heart, abnormal heart rate or rhythm
Potassium, selenium,
phosphorus, thiamine
GI System: spleen or liver enlargement, GI
dysfunction
Protein, calories
Adapted from: Isaacs, J, Cialone, J, Horsley, et al. Children with Special Health Care Needs: A
Community Nutrition Pocket Guide, 1997.

Medical History

A complete nutritional assessment should include information on the following (2):
- Past medical history including recent hospitalizations
- Review of systems and history of allergies
- Personal and social history
- Presence of chronic illness such as congenital heart disease, cystic fibrosis,
kidney disease, short bowel syndrome, and bowel atresias
- Previous growth pattern via examination of growth charts
14

- Recent surgeries, other deterioration in medical condition or procedures
impacting nutritional intake, status and management
- Medications
- Gestational age (for children < 3 years)
- Identification of low and very low birthweight infants
- Achievement of developmental milestones
- Presence of congenital abnormalities or genetic errors

Nutritional Intake History

Dietary history may be obtained by the following (2):

- Twenty-four hour recall
- Three day food intake
- Food frequency questionnaire
- General interview

The following should be assessed:

- For all infants:
o type of formula, brand name
o formula preparation (including water source) and storage
o addition of substances other than water i.e. rice cereal, Karo syrup
o volume and frequency of feedings
o other beverage intake i.e. water, Kool-aid, tea and soda
o solid food intake and texture progression
o history of formula changes
o history of emesis and/or diarrhea
o stooling frequency and consistency
- For breastfed infants:
o how long the infant feeds
o if the infant nurses from each breast during one feeding
o how frequently the infant nurses
o appearance and frequency of stools
o number of wet diapers per day
- For older infants and children:
o family eating patterns, cooking & storage
o vitamin and mineral supplementation
o history of food allergy/intolerances and/or loose stools
o evaluation of oral motor skills, feeding patterns, history of fatigue and/or
increased respiratory rate while feeding (Appendix E Developmental
Self-Feeding Checklist)
o interaction during feeding
o self-imposed diets and outcomes; assessment of childs own body image
o supplemental feeding programs (WIC, food stamps)

15

Laboratory Data (2, 11)

Various laboratory values are useful in the assessment of a patients nutritional status. Table 2.6 summarizes lab values
that are most often used for the nutritional assessment of pediatric patients. A more complete list of other labs with
nutrition related implications may be found in Appendix F.

Table 2.6 Laboratory Assessment of Nutritional Status

LAB PARAMETER INTERPRETATION OF VALUES POTENTIAL CAUSES FOR:
High Values Low Values
Prealbumin
used to assess protein status
sensitive indicator of recent protein
nutriture
Half life: 2-3 days

Preterm: 9-33 mg/dl
Term: 11-34 mg/dl
Older Children: 20-50 mg/dl

Dehydration
Steriods ( i.e. Prednisone)

Acute protein malnutrition
Trauma & Stress
Infection
Chronic liver disease
Aggressive hydration
Metabolic liver disease

Transferrin
synthesized in the liver to carry iron
in the blood; also acts as an acute
phase reactant
Half life: 8-10 days

Preterm: 140-370 mg/dl
Term: 200-370 mg/dl
Older Children: 180-260 mg/dl

Iron deficiency
Hypoxia
Chronic blood loss
Stress

Impaired synthesis
Protein malnutrition
Chronic infection
Protein-losing enteropathies

Albumin
poor indicator of early protein
depletion due to large body pool
Half life: 15-20 days

Preterm: 2.5-4.5 g/dl
Term: 2.5-5.0 g/dl
1-3 mo.: 3.0-4.2 g/dl
3-12 mo.: 2.7-5.0 g/dl
> 1 year: 3.2-5.0 g/dl

Dehydration

Protein malnutrition
Impaired digestion or
absorption of protein
Excessive protein losses
Advanced malignancies
Hypervolemic dilution
Chronic infection
Aggressive hydration
Nephrotic syndrome


16

References

1. American Academy of Pediatrics. Committee on Nutrition. Assessment of nutrition
status. In: Pediatric Nutrition Handbook. 2004:407-423.

2. Bessler S. Nutritional assessment. In: Samour PQ, King K, eds. Handbook of
Pediatric Nutrition. 3
rd
edition. Sudbury, MA: Jones and Bartlett Publishers Inc;
2005:11-34.

3. Spears B. Childhood obesity. In: Samour PQ, King K, eds. Handbook of Pediatric
Nutrition. 3
rd
edition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:181-212.

4. Barlow SE and the Expert Committee. Expert committee recommendations
regarding the prevention, assessment, and treatment of child and adolescent
overweight and obesity: summary report. Pediatrics. 2007; 120(S4): S164-192.

5. American Academy of Pediatrics. Committee on Nutrition. Pediatric obesity. In:
Pediatric Nutrition Handbook. 2004:551-592.

6. Schwenck WF, Olson D. Pediatrics. In: Gottschlich M, Fuhrman MP, Hammond KA,
Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support A
Case-Based Core Curriculum. American Society for Parenteral and Enteral
Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:347-372.

7. Katrine KF. Anthropometric assessment. In: Groh-Wargo S, Thompson M, Hovasi
Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press;
2000:11-22.

8. American Academy of Pediatrics. Committee on Nutrition. Failure to thrive.
Pediatric Nutrition Handbook. 2004:443-457.

9. Waterlow JC. Classification and definition of protein calorie malnutrition. In: Beaton
G, Bengoa X, eds. Nutrition in Preventive Medicine. WHO monograph series (62);
Geneva: WHO; 1976.

10. Miles A, Reed G. Feeding challenges in children with neurologic impairment.
Support Line. 2004;26(2):16-23.

11. Moyer-Mileur L. Laboratory assessment. In: Groh-Wargo S, Thompson M, Hovasi
Cox J, eds. Nutritional Care for High Risk Newborns. Chicago, IL: Precept Press;
2000:47-54.

Chapter 3 Nutritional Requirements in Term Infants and Children

17
Chapter 3

Nutritional Requirements in Term Infants and Children

The first step in providing infants and children who are established to be at nutritional risk
with the most appropriate nutrition intervention is to assess actual requirements. Nutritional
needs are highly individualized and vary widely, particularly with activity and disease.

Non-Critically Ill Infants and Children

The following tables review the range of enteral and parenteral nutrient requirements for term
infants (1, 2).

Table 3.1 Estimated Caloric, Protein, and Fluid Needs of Term Infants for
Enteral and Parenteral Nutrition

Infant
Condition/Disease
Enteral Parenteral

Calories
(kcal/kg)
Protein
(g/kg)
Fluid
(ml/kg)
Calories
(kcal/kg)
Protein
(g/kg)
Well-Nourished
Term/ AGA
90-110 2.0-3.0 150-200 85-110 2.5-3
BPD or CHD 120-150 3.0-4.0 120-130 90-130 2.5-3.5
Well-Nourished Term/AGA = Appropriate for Gestational Age (10-90
th
%-ile on growth chart for weight for age)
BPD = Bronchopulmonary Dysplasia
CHD = Congenital Heart Disease

Dietary Reference Intakes

Dietary Reference Intakes (DRIs) expand on and replace the Recommended Dietary
Allowances (RDAs) last published in 1989. DRIs consist of 4 categories (3):
- Estimated Average Requirement (EAR): the average daily nutrient intake level
estimated to meet the requirement of half the healthy individuals in a particular life
stage and gender group.
- Recommended Dietary Allowance (RDA): the average daily dietary nutrient intake
level sufficient to meet the nutrient requirement of nearly all (97 to 98 percent) healthy
individuals in a particular life stage and gender group.
- Adequate Intake (AI): the recommended average daily intake level based on observed
or experimentally determined approximations or estimates of nutrient intake by a
group (or groups) of apparently healthy people that are assumed to be adequate
used when an RDA cannot be determined.

18
- Tolerable Upper Intake Level (UL): the highest average daily nutrient intake level that
is likely to pose no risk of adverse health effects to almost all individuals in the general
population. As intake increases above the UL, the potential risk of adverse effects
may increase.

Energy

None of the above 4 DRI categories are used to describe estimated needs for energy;
instead, the Estimated Energy Requirement (EER) is used. This is defined as the average
dietary energy intake that is predicted to maintain energy balance in adults and energy
deposition (i.e., weight gain and growth) for infants and children (4).

Prediction equations for normal weight individuals were developed from data on total energy
expenditure (TEE) measured by the doubly labeled water technique. Equations for infants
and toddlers are based on weight and estimated needs for energy deposition. Equations for
children and adolescents are based on height, weight, age, physical activity level (ranging
from sedentary to high activity) and also take into account needs for energy deposition (4).
Table 3.2 presents the EER values for infants and children; data for infants and toddlers are
based on reference weights (normal weights for various ages), and data for older children
and adolescents are based on reference weights and heights and physical activity levels
corresponding to sedentary or low activity. For the development of calorie ranges, sedentary
and low activity levels were chosen for physical activity coefficients instead of active or very
active levels due to the thought that hospitalized children will not have high activity levels.
Published EER formulas and physical activity coefficients are available in Appendix G and
can be used to calculate more individualized needs, if necessary.

Overweight Children (4)

In general, for children who are overweight or obese, a goal weight loss of 1 pound per
month might be reasonable. The general goal for children who are at overweight or obese
is weight maintenance with the hope that BMI will improve as linear growth continues.
See Appendix G for formulas to estimate energy needs in overweight children.


19
Protein
The recommended intakes of protein for infants 0-6 months of age are based on an
Adequate Intake (AI) that reflects the observed mean protein intake of infants fed principally
with human milk. For older infants and children, the RDA is determined using data available
from nitrogen balance studies, measurement of the rates of protein deposition for growth,
and estimates of efficiency of protein utilization (3). Table 3.2 reflects the DRIs for protein for
various age groups.

Fiber
No DRIs exist for fiber for infants 0-12 months of age. This is because the gold standard for
feeding infants 0-6 months of age is breast milk, and breast milk contains no dietary fiber.
For infants 7-12 months of age, there are no data on dietary fiber intake and, according to
published information, no theoretical reason to establish a DRI for fiber. Dietary fiber
recommendations for children ages 1-18 years are based on data extrapolated from adult
studies that show that 14 grams of fiber per 1000 calories reduces risk of coronary heart
disease (3).

Table 3.2 Estimated Energy, Protein, and Fiber Requirements
for Infants and Children (4-6)
* Protein requirements for hospitalized children may vary significantly based on clinical condition.
ND = not determined

Micronutrients

Although clinical signs of vitamin and mineral deficiency are rare in the United States,
dietary intake studies have reported that the nutrients most likely to be low or deficient in
the diets of children and adolescents are calcium, iron, ascorbic acid, vitamin A, folic acid,
and vitamin B6. Certain populations of children, such as low-income, Native American,
Age Energy
(kcals/kg)
Protein*
(g/kg)
Fiber
(g/day)
Males Females Males Females
Infants 1-3 months 95-107 1.52 ND
4-6 months 82-83 1.52 ND
7-12 months 79-82 1.2 ND
Toddlers 1-3 years 81-83 1.05 19
Children 3-4 years 75-93 72-89 0.95 25
5-6 years 64-80 62-77 0.95 25
7-8 years 57-70 53-66 0.95 25
9-10 years 50-62 45-57 0.95 31 26
11-12 years 44-55 39-49 0.95 31 26
Adolescents 13-14 years 41-50 35-43 0.85 31 26
15-16 years 38-47 32-40 0.85 38 26
17-18 years 35-43 30-37 0.85 38 26

20
and other groups with limited food and health resources, are more at risk for nutrient
deficiencies.

Table 3.3 Dietary Reference Intakes: Recommended Dietary Allowance for Vitamins
for Infants and Children (7)

Age
(years)
Fat-Soluble Vitamins

Water-Soluble Vitamins
Vit A
(g)
Vit D
(IU)
Vit E
(mg)
Vit K

(g)
Vit C
(mg)
Thiamin
(mg)
Ribo-
flavin
(mg)
Niacin
(mg)
Vit B6
(mg)
Folate
(g)
Vit B12
(g)
Infants 0-6 mo. 400 400 4 2.0 40 0.2 0.3 2 0.1 65 0.4
7-12 mo. 500 400 5 2.5 50 0.3 0.4 4 0.3 80 0.5
Children 1-3 300 600 6 30 15 0.5 0.5 6 0.5 150 0.9
4-8 400 600 7 55 25 0.6 0.6 8 0.6 200 1.2
Males 9-13 600 600 11 60 45 0.9 0.9 12 1.0 300 1.8
14-18 900 600 15 75 75 1.2 1.3 16 1.3 400 2.4
Females 9-13 600 600 11 60 45 0.9 0.9 12 1.0 300 1.8
14-18 700 600 15 75 65 1.0 1.0 14 1.2 400 2.4
Values in bold type presents Recommended Dietary Allowances (RDAs), while Adequate Intakes (AIs) are in
ordinary type.
Vitamin A: 1 g Retinol = 1 RE; 0.3 RE = 1 IU

Table 3.4 Dietary Reference Intakes: Recommended Dietary Allowances for Selected
Minerals in Infants and Children (7)

Age
(years)
Calcium
(mg)
Phosphorus
(mg)
Magnesium
(mg)
Selenium
(g)
Iron
(mg)
Zinc
(mg)
Iodine
(g)
Copper
(g)
Infants 0-6 mo. 200 100 30 15 0.27 2 110 200
7-12 mo. 260 275 75 20 11 3 130 220
Children 1-3 700 460 80 20 7 3 90 340
4-8 1000 500 130 30 10 5 90 440
Males 9-13 1,300 1,250 240 40 8 8 120 700
14-18 1,300 1,250 410 55 11 11 150 890
Females 9-13 1,300 1,250 240 40 8 8 120 700
14-18 1,300 1,250 360 55 15 9 150 890
Values in bold type presents Recommended Dietary Allowances (RDAs), while Adequate Intakes (AIs) are in
ordinary type.

Vitamin and Mineral Supplementation

Breastfed term infants are recommended to take in vitamin supplements, as recommended
in Table 3.5, primarily to ensure adequate vitamin D intake. Additionally, term infants who are
fluid restricted or consistently unable to take in 750 ml of formula per day should also receive
a pediatric multivitamin supplement. Appendix J contains information on various pediatric
multivitamin supplements and their micronutrient contents.


21
Table 3.5 Recommendations for Vitamin Supplementation in the Term Infant

Formula Currently Receiving Supplementation needed per day
Breast milk (initiate as soon as
possible after birth)
1 ml/day of vitamin D or multivitamin drops
(consider changing to iron-containing
supplementation at 4-6 months of age,
depending on iron content of complementary
foods)
Term Formula with intake less than
750 ml per day
0.5 - 1 ml/day of vitamin D or multivitamin
drops
(consider changing to iron-containing
supplementation at 4-6 months of age,
depending on iron content of complementary
foods)
Formulations with iron do not contain folic acid; this may need to be supplemented separately.

Fluoride supplementation is only indicated after 6 months of age when (8):
1. Ready-to-feed formula is used
2. Formula concentrate or powder is mixed with non-fluoridated bottled water
3. Local tap water is < 0.6 parts per million (ppm)
4. Baby is breast fed past 6 months

Table 3.6 Recommendations for Fluoride Supplementation in Infants and
Children (8)

Water Fluoride (ppm) 6 mo. 3 yr. 3 6 yr. 6 16 yr.
< 0.3 0.25 mg 0.50 mg 1.0 mg
0.3 0.6 0 0.25 mg 0.50 mg
> 0.6 0 0 0

Examples of fluoride-containing liquid drops (see Appendix J for details):
- Poly-Vi-Flor and Tri-Vi-Flor (Mead Johnson) contain 0.25 mg fluoride per 1 ml
- Pediaflor (Abbott) contains 0.25 mg fluoride per 0.5 ml


22
Critically Ill Children

The nutritional requirements of critically ill children are often quite different from the EERs for
a variety of reasons. Depending on the extent or type of injury or illness, the medications
being used to manage the patient or the presence or degree of previously existing
malnutrition, calorie or protein requirements may be elevated or even decreased in the
critically ill pediatric patient (9, 10).

The following table reviews factors, which may increase or decrease nutrient requirements.

Table 3.7 Factors Affecting Calorie and Protein Requirements in
Critically Ill Children

Increasing Requirements Decreasing Requirements
Trauma
Surgery
Sepsis
Fever
Tumor
Burns
Athetoid CP, Hypertonia
Seizures
Spinal Cord Injury (acute)
Increased Work of Breathing
Weaning from Ventilator
Sustained Agitation
Lack of activity / Bed rest
Mechanical ventilation
Medical sedation
Medical paralysis
Hypotonia, Spastic CP
Reduced Insensible losses
Hypothyroid condition

Studies in critically ill pediatric patients have demonstrated the importance of not using
standard EER calorie calculations to calculate energy requirements as these are meant for
healthy, active children. Instead, using the patients basal energy needs and multiplying it by
a corrective stress factor provides an appropriate estimated of energy needs (9).

Determining total caloric and protein needs during critical illness:

1. Estimate basal energy needs (caloric requirements, post-
absorptive, recumbent, and at room temperature - Table 3.8)
2 Estimate patients protein requirements (RDAs - Table 3.2)
3. Determine patients stress factor (Table 3.9)

Total Calories = BEE x Stress Factor
Total Protein = Protein RDA x Stress Factor

4. Continue to evaluate and adjust recommendations based on response (weight
gain or weight loss)


23
Table 3.8 Basal Energy Needs for Infants and Children (9)

Adolescents

Alternatively, Harris and Benedict Equation may be more appropriately used in adolescents
for determination of basal energy expenditure (BEE):
For men:
BEE = 66 + (13.7 x ideal wt. in kg) + (5 x height in cm) (6.8 x age in years)
For women:
BEE = 655 + (9.6 x ideal wt in kg) + (1.7 x height in cm) (4.7 x age in years)

Table 3.9 Determining Stress Factor (9, 10)

Clinical State Stress Factor
Maintenance without stress
Fever
Routine surgery, minor sepsis
Cardiac failure
Elective Surgery
Major surgery
Sepsis
Major Trauma
Burns
1.0 - 1.2
12% per degree >37
o

1.1 - 1.3
1.25 - 1.5
1.0 - 1.2
1.2 -1.4
1.4 -1.8
1.5 - 1.7
1.5 - 2.0

Age 1 wk to 10 mo Age 11 to 36 mo Age 3 to 16 yr
Weight
(kg)
Metabolic Rate
(kcal/day)
Weig
ht
(kg)
Metabolic Rate
(kcal/day)
Weight
(kg)
Metabolic Rate
(kcal/day)
Male or
Female
Male Female Male Female
3.5 202 9.0 528 509 15 859 799
4.0 228 9.5 547 528 20 953 898
4.5 252 10.0 566 547 25 1046 996
5.0 278 10.5 586 566 30 1139 1092
5.5 305 11.0 605 586 35 1231 1190
6.0 331 11.5 624 605 40 1325 1289
6.5 358 12.0 643 624 45 1418 1387
7.0 384 12.5 662 646 50 1512 1486
7.5 410 13.0 682 665 55 1606 1584
8.0 437 13.5 701 684 60 1699 1680
8.5 463 14.0 720 703 65 1793 1776
9.0 490 14.5 739 722 70 1886 1874
9.5 514 15.0 758 741 75 1980 1973
10.0 540 15.5 778 760
10.5 566 16.0 797 782
11.0 593 16.5 816 802

24
Prevention and Complications of Overfeeding (11)

In many cases, critically ill children in the Pediatric Intensive Care Unit (PICU) have caloric
requirements at 60-80% of the EERs due to inhibited growth, reduced resting energy
expenditure, reduced insensible losses, medications and decreased activity.
Overfeeding involves the provision of calories and/or substrate in excess of the requirements
to maintain metabolic homeostasis. From a clinical standpoint, the harmful effects of
overfeeding may result in respiratory compromise, hepatic dysfunction, and an increased risk
of mortality.

Complications of overfeeding:
1. Excessive CO
2
production
2. Increased minute ventilation (VE)
3. Respiratory failure
4. Pulmonary edema
5. Hyperglycemia
6. Lipogenesis (increased insulin, decreased fatty oxidation)
7. Hepatic cellular injury (increased serum conc. of liver enzymes)
8. Fatty liver
9. Intrahepatic cholestasis
10. Immunosuppression

Catch-Up Growth in the Term Infant and Child (12)

Children who are below normal growth parameters due to chronic undernutrition or illness
affecting their nutritional intake and status require additional calories and protein to achieve
catch-up growth. During this phase of growth recovery, a child may grow at rates well above
the norm for his or her age.

EER* (kcal/kg) for weight age** x Ideal weight (kg)***
Catch-up calories (kcal/kg) =
Actual weight

* Use EER (Table 3.2)
** Age at which present weight is at the 50
th
%-ile
*** 50
th
%-ile for age or ideal body weight for height

Grams of Protein/Kg = 8% of catch-up growth calories

catch-up growth (kcal/kg) x 0.08
Protein catch-up calories =
4


25
Energy Requirements for Pediatric Burn Patients (13, 14)

Daily metabolic expenditure of burn patients can be estimated by numerous formulas,
predicted on data obtained from adults, but altered for children addressing their metabolic
differences. Clinicians may choose to use several of the following formulas in order to
develop a range of calories for individual patients.

Table 3.10 Selected Formulas for Calculating Energy Requirements of Burned
Children

* See Table 3.8 for estimations of basal energy needs
** BSA = body surface area (total), calculated as:
ht [cm] x wt [kg]
3600

Fluid Requirements

Fluid requirements can be calculated by estimating normal water requirements adjusted for
specific disease related factors. However, special consideration must be given to monitoring
fluid balance of infants and children receiving high calorie, high nitrogen formulas, those who
have severe neurological impairment or those with emesis, diarrhea, fever, or polyuria.

In order to prevent dehydration and ensure adequate provision of fluids during the
administration of enteral and parenteral nutrition, use Table 3.11 to assess fluid needs.

Table 3.11 Daily Fluid Maintenance Requirements

Weight (kg) Maintenance Fluid
Requirements
Fluid Requirements to Meet
Calorie and Nutrient Needs
2.0-3.0 120 ml/kg/day 150 180 ml/kg
3.0-10.0 100 ml/kg/day 140 165 ml/kg
11-20

1,000 ml plus 50 ml/kg
for each kg > 10 kg
Use maintenance fluids
Above 20 1,500 ml plus 20 ml/kg
for each kg > 20 kg
Use maintenance fluids

Formula
Name/Authors
Age % BSAB Calories/Day
Davies and
Liljedal
Child Any (60 kcal x weight [kg]) + (35 kcal x % burn)
Curreri Junior 0-1 years <50 Basal* + (15 kcal x % burn)
1-3 years <50 Basal* + (25 kcal x % burn)
4-15 years <50 Basal* + (40 kcal x % burn)
Hildreth 0-1 years (2100 kcal/m
2
BSA**) + (1000 kcal/m
2
burn)
<12 years (1800 kcal/m
2
BSA**) + (1300 kcal/m
2
burn)
12-18 years (1500 kcal/m
2
BSA**) + (1500 kcal/m
2
burn)

26

References

1. American Academy of Pediatrics. Committee on Nutrition. Protein. In: Pediatric Nutrition
Handbook. 2004:29-240.

2. American Academy of Pediatrics. Committee on Nutrition. Energy. In: Pediatric Nutrition
Handbook. 2004:241-259.

3. Institute of Medicine. Food and Nutrition Board. Energy: Dietary Reference Intakes for energy,
carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients).
2005:21-37.

2005:107-264.

2005:2005:589-768.

2005:2005:339-421.

7. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes. Available
at:http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutriti
on/DRIs/5_Summary%20Table%20Tables%201-4.pdf.

8. American Academy of Pediatrics. Committee on Nutrition. Nutrition and oral health. In:
Pediatric Nutrition Handbook, 6
th
ed. 2009:1041-1056.

9. Canete A, Duggan C. Nutrition support of the pediatric intensive care unit patient. Curr Opin
Pediatr. 1996;8:248-255.

10. Iyer P. Nutritional support in the critically ill child. Indian J Pediatr. 2002;69:405-410.

11. Chwals WJ. Overfeeding the critically ill child: fact or fantasy? New Horiz. 1994;2:147-155.

12. Peterson KE, Washington J, Rathburn JM. Team management of failure to thrive. J Am Diet
Assoc. 1984;84(7):810.

13. Gottschlich MM, Mayes T. Nutrition in the burned pediatric patient. In: Samour PQ, King K,
eds. Handbook of Pediatric Nutrition. 3
rd
edition. Sudbury, MA: Jones and Bartlett Publishers
Inc; 2005:483-498.

14. Rodriguez DJ. Nutrition in patients with severe burns: state of the art. J Burn Care Rehabil.
1996;17:62-70.

Chapter 4 Nutritional Assessment, Requirements and Enteral Nutrition Management in the Preterm Infant

27
Chapter 4

Nutritional Assessment, Requirements and Enteral
Nutrition Management in the Preterm Infant

Preterm infants are a challenge to manage nutritionally due to their complicated medical
treatment course, immature physiology, and numerous complications, which can delay
progression of enteral nutrition. Potential difficulties in providing adequate nutritional support
include respiratory instability, drug therapy, fluid restriction, predisposition to necrotizing
enterocolitis (NEC) and immature renal and gastrointestinal systems (1).

Preterm Infant Weight Classification and Assessment (2)

Preterm infants, those born less than 37 weeks, are frequently placed at higher risk for
impaired nutrition due to reduced stores, GI immaturity, and metabolic and/or digestive
deficiencies. Infants may be classified as the following:

- Low Birth Weight (LBW): Less than 2500 g
- Very Low Birth Weight (VLBW): Less than 1500 g
- Extremely Low Birth Weight (ELBW): Less than 1000 g

Assessment of Intrauterine Growth (2)

Premature infants rate of weight gain may be compared to infants of similar gestational age
using the following growth charts:

- Lubchenco growth charts: intrauterine growth curves often used to classify the infants
size at birth; fail to account for normal postnatal weight loss and differences in rates of
weight gain among different populations.

- Dancis growth curves: postnatal daily growth curves; reflect early postnatal weight loss
related to fluid changes, but in general may not reflect ideal growth of the preterm infant.
The Dancis grid is useful for monitoring growth trends and initially, changes in hydration
status.

- Fenton or updated Babson growth charts (Appendix A): intrauterine growth curves;
SGA and LGA are defined as two standard deviations from the mean birth weight. The
Babson charts are useful in the assessment of weekly premature infant growth through
the first year of life.

- Small for Gestational Age (SGA): Birth weight < 10
th
%-ile
- Appropriate for Gestational Age (AGA): Birth weight 10
th
-90
th
%-ile
- Large for Gestational Age (LGA): Birth weight > 90
th
%-ile


28
SGA infants are at greater nutritional risk due to decreased nutritional reserves, increased
nutritional requirements to allow for rapid catch-up growth, and frequently a lack of functional
maturity such as absent suck and swallow, and delayed gastric emptying. LGA infants are
common in mothers with diabetes. Frequent complications seen in LGA infants include
hypoglycemia and birth trauma.

Correcting for Prematurity

Growth of premature infants should be adjusted to reflect gestational age; weight should be
corrected until the child is 24 months of age, length until 36 months of age, and head
circumference until 18 months of age (2). Generally, correction for all 3 parameters up to 24
months of age is appropriate.

Growth Velocity in Preterm Infants (2)

Preterm infants, once having regained their birth weight and stable from both a respiratory
and clinical standpoint should approach intrauterine growth rates between 15-20 g/kg/day,
averaged over a minimum period of 5-7 days. Average rate of weight gain over days to
weeks is more important than single 1 or 2 day measurements, which can reflect changes in
fluid status or equipment differences. Weight gain based on intrauterine growth averages
10-20 g/day for infants <27 weeks and 20-35 g/day for infants 27-40 weeks gestation.

Weight Gain Goal

AGA (Appropriate for Gestational Age):

15-20 g/kg/day
SGA (Small for Gestational Age): 20 - 25 g/kg/day

When infants are > 2 kg, it is more appropriate to aim for weight gain of 20-40 g/day, no
longer adjusting per kg.
Assessment of linear growth with incremental gains in length and head circumference should
also be monitored. As with weight gain, once preterm infants are stable from a respiratory
and clinical standpoint, linear growth should proceed optimally at intrauterine rates. Length
should be measured weekly in the preterm infant. Length gain should average between
3.2 4.4 cm per month, or about 0.75 1 cm per week. Head circumference increase
should average 2-3 cm per month, or 0.5-0.7 cm/week.

Micronutrient and Macronutrient Requirements

Tables 4.1 and 4.2 review the range of enteral calorie, protein and micronutrient
requirements for preterm infants (3).


29

Table 4.1 Estimated Enteral Caloric, Protein, and Fluid Needs in the Preterm Infants

Infant
Condition/
Disease
Enteral Parenteral
Nutrient Calories
(kcal/kg)
Protein
(g/kg)
Fluid
(ml/kg)
Calories
(kcal/kg)
Protein
(g/kg)
Fluid
(ml/kg)
AGA

105-130 3.0-4.0 150-200 90-100 3.0-4.0 120
SGA or
ELBW
120-140 3.5-4.5 150-200 95-105 3.5-4.0 120-130
BPD, CHD,
or CLD
120-150 3.0-4.0 120-135
90-105
3.0-4.0 100-120
AGA = Appropriate for Gestational Age (10-90
th
SGA = Small for Gestational Age (<10
th
BPD = Bronchopulmonary Dysplasia
CHD = Congenital Heart Disease
CLD = Chronic Lung Disease

Growth measurements to monitor adequacy of intake include

- daily weight (goal = 15-20 g/kg/day if < 2 kg; 20-40 g/day if > 2 kg)
- weekly length (goal = 0.75-1.0 cm/week since birth)
- head circumference (goal = 0.5-0.7 cm/week since birth)

Table 4.2 Enteral and Parenteral Vitamin and Mineral Needs in Preterm Infants (3, 4)

VITAMINS MINERALS

Enteral Parenteral Enteral Parenteral
Vitamin A 700-1500 IU/kg 700-1500 IU/kg Calcium 120-230 mg/kg 50-80 mg/kg
Vitamin D 400 IU/day
(200-1000)
1.5 10 ug/kg Phosphorus 60-140 mg/kg 40-60 mg/kg
Vitamin E 6-12 IU/kg 2.8 3.5 IU/kg Magnesium 7.2-.9.6 mg/kg 4.3-7.2 mg/kg
Vitamin K 8-10 ug/kg 10 ug/kg Iron 2-4 mg/kg 250-670 ug/kg
Vitamin C 30-40 mg/kg 25 mg/kg Sodium 2-3 mEq/kg 3-4 mEq/kg
Thiamine 180-240 ug/kg 350 ug/kg Potassium 2-3 mEq/kg 2-4 mEq/kg
Riboflavin 250-360 ug/kg 0.15 mg (150
mcg)/kg
Chloride 2-3 mEq/kg 3-4 mEq/kg
Niacin 4.5-6 mg/kg 5-6.8 mg/kg Zinc 1000-2000 ug/kg 400 ug/kg
Vitamin B
6
180-300 ug/kg 180-400 ug/kg Copper 120-150 ug/kg 20 ug/kg
Vitamin B
12
0.3 ug/kg 0.3 ug/kg Manganese 0.75-7.5 ug/kg 1 ug/kg
Folic Acid 45-50 ug/kg 56 ug/kg Selenium 1.3-4.5 ug/kg 1.5-4.5 ug/kg
Pantothenic Acid 1.2-2 mg/kg 2 mg/kg Chromium 0.1-2.25 ug/kg 0..05-.3 ug/kg
Biotin 3.6-6.0 ug/kg 6-8 ug/kg Molybdenum 0.3-4ug/kg 0.25-1.0 ug/kg


30

Fluid Requirements
Fluid requirements can be calculated by estimating normal water requirements and adjusting
for specific disease related factors. However, special consideration must be given to
monitoring fluid balance of children receiving high calorie, high nitrogen formulas, those who
have severe neurological impairment or those with emesis, diarrhea, fever, or polyuria. Fluid
management of preterm infants or critically ill newborns is complex and affected by
numerous factors including cardiorespiratory status, renal status, degree of prematurity and
insensible losses.

In order to prevent dehydration and ensure adequate provision of fluids during the
administration of enteral and parenteral nutrition, use Table 4.3 for general guidelines in the
assessment of fluid needs.

Table 4.3 Daily Fluid Maintenance Requirements in the Neonate

Weight (kg) Maintenance Fluid
Requirements
Fluid Requirements For
Enteral Nutrient Needs
0.5 3.0 kg 100 140 ml/kg/day 135 180 ml/kg
3.0 10.0 kg 100 ml/kg/kg/day 125 180 ml/kg

Meeting the Increased Needs of the Preterm Infant

Preterm infants have increased requirements for Vitamins A, D, E, C and iron. Breast milk is
the preferred feeding for preterm infants. However, breast milk does not provide
adequate protein, calcium, phosphorous, magnesium, sodium, copper, zinc, folate, B-
vitamins, and iron for infants who weigh <1500 g at birth (4).

Supplementation of Breast Milk

The caloric and nutrient density of breast milk can be increased by two methods:
- Method 1 - Enfamil Human Milk Fortifier or Similac Human Milk Fortifier
- Method 2 - Use of Powdered Infant Formula: EnfaCare or NeoSure

Breast fed preterm infants who are admitted to the PICU, are still below 2500 grams and are
unable to take in 180 ml/kg will need to receive fortified breast milk using:

Method 1: Enfamil or Similac Human Milk Fortifier as follows:

Table 4.4 Fortification of Breast Milk with Human Milk Fortifier

Step Fortifier Breast Milk Caloric Density Increased mOsm
1 1 packet 50 ml 22 kcal/oz 32 mOsm/kg


31
Method 2: Breast milk caloric and nutrient density for older preterm infants > 3.0 kg infants
may be increased to 24 - 30 kcal/oz according to the following:

Table 4.5 Increasing Nutrient Density of Breast Milk Using NeoSure of Enfacare
Powder

Caloric Density
(kcal/oz.)
Breast Milk Volume
(oz.)
Formula Powder
(tsp.)
Endpoint Volume
24 3 1 3 oz.
27 3 2 4 oz.
30 3 3 5 oz.

Home Fortification: Fortification with NeoSure or Enfacare powder is the preferred method for
fortification at discharge as human milk fortifiers are not readily available in retail
establishments.

Vitamin and Mineral Supplementation

Table 4.6 Recommendations for Vitamin Supplementation in the Preterm Infant

Feeding Fluid Currently Receiving Supplementation needed per day
Plain breast milk (no fortifier) 1 ml/day multivitamin with iron

Fortified breast milk Abbott HMF: 0.5 ml/d multivitamin with iron; if
total volume/day is < 240 ml, add 0.5 ml/d
multivitamin, or multivitamin with iron
Fortified formula Determine if need vitamins with iron or Fer-in-
sol to treat anemia. (Therapeutic range for iron
deficiency anemia = 4-6 mg/kg/d)
Use of vitamin supplements, as recommended in Table 4.6, is primarily to ensure adequate vitamin D and iron
intake in preterm infants.

- Similac Special Care 24 Advance contains marginal vitamin D to meet daily
requirements until an infant is able to take more than 400 ml/day. If a preterm
infant is on Similac Special Care, rather than Enfamil Premature Lipil, vitamin D
may be supplemented via the addition of 0.5 ml of a pediatric multivitamin (see
Table 4.6).
- For treatment of iron deficiency anemia, supplement with 4 - 6 mg/kg/day of iron.
- For prevention of iron deficiency anemia, provide iron fortified formula, fortified
breast milk or at least 2 mg/kg/day of iron if on Similac Human Milk Fortifier.
(Enfamil Human Milk Fortifier already contains extra iron).
- For preterms or fluid-restricted infants not taking at least 750 ml of a standard
infant formula per day, should receive 0.5 ml of multivitamin with iron per day.

32
Preterm Formula Selection

Selection of an optimal preterm formula depends upon a number of factors including patient factors such as degree of
prematurity, diagnosis, associated nutritional problems and requirements, and GI function. Important formula factors which
need to be considered include higher calorie, calcium, and phosphorus intakes (1).

Table 4.7 Overview of Preterm Formulas

Formula Type Description Indications/Formulations Formula Examples
Preterm
Formulas
Formulas designed to meet
the increased nutritional and
altered physiological needs
of preterm infants.
Used for infants born < 2000
grams or < 35 weeks
gestational age.
- Preterm infants < 2000 grams
- Partial substitution of corn syrup solids
for lactose
- Increased protein concentration and
higher whey composition
- Partial substitution of long chain fatty
acids with medium chain triglycerides
(MCT)
- Increased caloric density: 24-30
kcal/oz
- Increased concentrations of sodium,
calcium, phosphorus, and vitamins
(specifically D and E)
- Enfamil Premature
Lipil 24
(Mead Johnson)
- Similac Special Care
Advance 24 (Abbott)
- Similac Special Care
Advance 30 (Abbott)
- Gerber Good Start
Premature 24
(Nestle)
Transitional
Preterm
Formulas
Preterm formulas have been
developed to meet the
increased needs of the
preterm infant during the first
9 months to 1st year of life.
- Preterm infants who can tolerate 165
mL/1g/day during the 1st year of life
- Increased caloric density: 22 kcal/oz
- Partial substitution corn syrup solids for
lactose
- Partial substitution of long chain fatty
acids with MCT
- Increased levels of protein, vitamins &
minerals compared to term formula
- EnfaCare Lipil
(Mead Johnson)
- Similac NeoSure
Advance (Abbott)
- Gerber Good Start
Nourish (Nestle)
Table adapted from proprietary product literature.

33
Modifying Formula Caloric and Nutrient Density

Preterm infants who are critically or chronically ill may be unable to take adequate formula
volume to meet their nutritional needs. Infant and pediatric formulas may be prepared
differently to provide a greater caloric or nutrient density. The caloric or nutrient density of an
infant or enteral feeding formula can be increased by any one or a combination of the
following methods (3,5):

1. Concentration - Increasing the amount of formula base or decreasing the amount of
free water added when mixing the formula. This method will increase the
concentration of all formula solutes and osmolality. Similarly, adding powdered
formula to ready-to-feed formula will increase total nutrient density. The addition of
scoop of powdered infant formula to ready-to-feed formula will generally add an
additional 4 kcal/oz.

2. Supplementation - Adding a macronutrient module in order to increase caloric
density without increasing all other nutrient sources. This may be accomplished
through the addition of:
- Carbohydrate source: Powdered Polycose (Abbott), or Karo syrup
- Fat source: Microlipid (Nestle), vegetable oil, or MCT oil (Nestle)
- Protein source: Resource Beneprotein (Nestle)
- Combined carbohydrate and fat source: Duocal (Nutricia)

Guidelines for Using Concentrated and High Nutrient Density Formulas
- In general, formulas for use in infants should not be concentrated through the reduction of
free water to a density greater than 27 kcal/oz as these preparations may not meet their
free water needs.
- Increases in formula caloric density should be done gradually by 2 3 kcal/oz to ensure
patient tolerance.
- Infants with gastroesophageal reflux (GER) may experience aggravated reflux with
concentrated preparations. These infants may do better with the addition of additives
such as Polycose or infant cereal.
- Infants with renal insufficiency may need to have their formula caloric densities increased
through the use of additives alone to prevent excessive increases in renal solute load.
- Infants on concentrated formulas should be monitored closely for frequency of urination
and urine specific gravity to ensure adequate fluid intake.
- Excessive formula concentration may also result in diarrhea, dehydration or conversely,
constipation.
- Parents should be appropriately instructed on formula preparation prior to discharge from
the hospital.
- Modules may or may not be readily available outside the hospital; discharge needs
should be considered.
- Preterm infants > 1800 g or tolerating 165 mL/1g/day should be discharged home on
preterm formula Neosure or EnfaCare (22 kcal/oz).


34

Enteral Feeding Recipes for the NICU Infant

The following tables provide recipes for increasing formula caloric density to more adequately
meet the requirements of infants with increased nutritional needs.

Table 4.8 Preparation of Enfacare or Neosure Formula at Various Caloric
Concentrations

Caloric Density
(kcal/oz)
Formula Powder
and water (ml)
Ready to Feed and
Formula Powder
Approximate
Yield (ml)
22 4 scoops + 240 ml 240 ml 240 ml
24 4 scoops to 215 ml 240 ml + scoop 240 ml
27 4 scoops + 215 ml 240 ml + 1 scoop 240 ml
30 5 scoops + 215 ml 240 ml + 1 scoops 250 ml

Table 4.9 Increasing the Caloric and Nutrient Density of Transitional Preterm Formula
EnfaCare through Supplementation with Powder

Caloric Density EnfaCare or Similac
Neosure - fluid oz
EnfaCare or Neosure
Powder
24 kcal/oz 5 1 teaspoon
26 kcal/oz 3 1 teaspoon

Table 4.10 Recipes for Preterm Infants
Formula
(kcals/oz)
Base
Component
Additive Recipe Volume
Premature 27 Premature 24
80% ratio
Term
Concentrat
e
20% ratio
200 ml Preterm 24
+ 50 ml term
concentrate
250 ml
Premature 27 Premature 24
50% ratio
Premature
30 cal/oz,
50% ratio
120 ml Preterm 24
+ 120 ml Preterm
30
240 ml
Premature 26 Preterm 24
(2 parts)
Preterm 30
(1 part)
80 ml Preterm 24
+ 40 ml Preterm
30
120 ml
(1 part)
Preterm 30
(1 part)
60 ml Preterm 24
+ 60 ml Preterm
30
120 ml
(1 part)
Preterm 30
(2 parts)
40 ml Preterm 24
+ 80 ml Preterm
30
120 ml


35

Feeding Protocols for NICU Infants

Trophic Feeding: Advantages and Guidelines for the NICU

Trophic feedings provide small volume enteral feedings for the promotion and protection of
the structural and functional integrity of the GI tract (6, 7). Trophic feedings elicit a GI
hormonal response in preterm infants thus mediating postnatal intestinal adaptation.

Goals and Advantages of Trophic Feedings (6 - 9)
- Stimulated GI hormonal response
- Enhances GI growth and development
- Promotes maturation of GI motor patterns
- Decreases incidence of cholestatic jaundice and metabolic bone disease
- Increases overall growth and feeding tolerance
- Encourages earlier progression to full feedings and hospital discharge.
- Accomplishes above goals without an increase in the risk of necrotizing enterocolitis
(NEC)

Table 4.11 UVA Trophic Feeding Guidelines for Infants < 1200 grams

Day of Feedings Feeding Schedule Volume: ml/kg
1 & 2 2 ml/kg q 3 hours 16 ml/kg
3 & 4 2 ml/kg q 2 hours 24 ml/kg

Enteral Feeding Guidelines

Table 4.12 UVA Enteral Standard Feeding Guidelines

Birth Weight Schedule & Advance
< 1200 g Trophic feeds x 4 days; advance by 1ml/kg q 12 hrs.
1200-1800 g and < 35 weeks Begin at 2 ml/kg q 3 hr; advance by 1ml/kg q 9 hrs.
>1800 g and 35 weeks Begin at 5 ml q 3 hr; advance by 5 ml q 6 hrs.


36
References

1. Abad-Sinden, A, Bollinger R. Challenges and controversies in the nutrition support of the
preterm infant. Support Line. 2001;24(2):5-16.

2. Katrine KF. Anthropometric assessment. In: Groh-Wargo S, Thompson M, Hovasi Cox J,
eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:11-22.

3. Groh-Wargo S. Recommended enteral nutrient intakes. In: Groh-Wargo S, Thompson M,
Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press;
2000:231-263.

4. Krug SK. Parenteral nutrition: vitamins, minerals and trace elements. In: Groh-Wargo S,
Thompson M, Hovasi Cox J, eds. Nutritional Care for High-Risk Newborns. Chicago, IL:
Precept Press; 2000:151-175.

5. Abad-Sinden A, Sutphen JL. Enteral nutrition. In: Walker WA, Durie PR, Hamilton JR,
Walker-Smith JA, Watkins JB, eds. Pediatric Gastrointestinal Disease. Philadelphia, PA:
B.C. Decker, Inc.; 2003:1981-1994

6. Schanler RJ, Shulman RJ, Lau C, et al. Feeding strategies for premature infants:
randomized trial of gastrointestinal priming and tube feeding method. Pediatrics.
1999;103(2):434-439.

7. Turner-McKinley LT. Dilemmas in feeding extremely low-birth-weight infants. Support
Line. 1996;1- 5.

8. Berseth CL. Minimal enteral feedings. J Perinatol. 1995;22(1):195-204.

9. Meetze WH, Valentine C, McGuigan JE, Conlon M, Sacks N, Neu J. Gastrointestinal
priming prior to full enteral nutrition in very low birth weight infants. J Pediatr
Gastroenterol Nutr. 1992;15:163-170.

Chapter 5 Enteral Nutrition Support

37
Chapter 5

Enteral Nutrition Support

Introduction

Pediatric patients unable to tolerate or voluntarily take in adequate oral feedings may be
nutritionally managed with enteral tube feedings.

1. Hospitalized normally nourished infants and children with sub-optimal nutrient intake for at
least 3-5 and 5-7 days, respectively, should receive nutrition support, preferably from the
enteral route (1).

2. Previously malnourished children, children who have experienced significant trauma or
those with underlying diagnoses which put them at increased nutritional risk and are
unable to meet their nutritional intake goals should receive nutrition or nutrition support,
preferably from the enteral route, within 48 hours of admission.

Advantages of Enteral Nutrition

Enteral tube feedings are generally considered the preferred modality for critically and
chronically ill pediatric patients for a number of reasons (2, 3):

- Physiological presentation of nutrients
- Trophic effects on the intestinal tract
- Stimulation and maintenance of the gut mucosa
- Reduced metabolic and infectious complications
- Improved hepatic function versus parenteral nutrition
- Simplified fluid and electrolyte management
- More complete nutrition: glutamine, trace elements, fiber, and iron
- Blunts hypermetabolic response in burn patients
- May reduce the incidence of pathogen entry or bacterial translocation into the
peritoneal cavity or circulation
- Less expensive: $10 - $20 per day versus $200 - $300 per day for parenteral
nutrition

Indications for Enteral Feedings

Pediatric patients who are unable to meet their nutritional needs through oral nutrition may
be nutritionally supported using enteral tube feedings. Tube feedings may also be used for
patients who have lost 10% or more of their usual body weight and are unwilling or unable to
take in sufficient calories using oral nutrition. Table 5.1 on the following page presents
common indications for enteral feedings in pediatric patients (2).


38
Table 5.1 Conditions Under Which Enteral Feedings are Commonly Warranted in
Pediatric Patients

Preterm Infants
Cardiorespiratory Distress
- Bronchopulmonary Dysplasia
- Cystic Fibrosis
- Congenital Heart Defects
Gastrointestinal Disease and Dysfunction
- Inflammatory Bowel Disease
- Short Gut Syndrome
- Biliary Atresia
- Severe Gastroesophageal Reflux
- Protracted Diarrhea of Infancy
- Post-Surgical Patients
- Chronic Nonspecific Diarrhea
Renal Disease
Hypermetabolic States
- Cancer
- Burn Injury
- Severe Trauma/Closed Head Injury/Spinal Cord Injury
Neurologic Disease/Cerebral Palsy

Enteral Tube Feeding Formula Selection

Selection of an optimal infant or pediatric tube feeding formula depends upon a
number of factors including patient factors such as diagnosis, associated nutritional problems
and requirements, and GI function. Important formula factors which need to be considered
include (2, 3):
- osmolality (not to exceed 450 mOsm/kg for infant formula)
- renal solute load
- caloric density and viscosity
- nutrient composition: type of carbohydrate, protein and fat
- product availability (i.e., from WIC) and cost (especially if patient must pay out-of-
pocket at home)

39
Table 5.2 Overview of Term Infant and Pediatric Formulas (2, 4 7)

Formula
Type
Description/Indication Formulations Formula Examples
Standard
Term Cows
Milk Based
- For standard, term infant feeding
during the first year of life.
- Meets the recommendations of the
American Academy of Pediatrics
(AAP) for infant formulas (4).
- Standard caloric density: 20 kcal/oz
- 24 kcal/oz (ready to feed) for hospital setting
- Carbohydrate: lactose
- Protein: casein/whey
- Fat: vegetable oil blend, DHA/ARA
- Enfamil Lipil (Mead Johnson)
- Enfamil 24 Lipil (Mead Johnson)
- Similac Advance (Abbott)
- Similac Expert Care 24 (Abbott)

Sensitive
- May contain reduced lactose or
partially hydrolyzed protein.
- Carbohydrate: corn syrup solids and/or lactose
- Protein: casein/whey (intact or partially hydrolysed)
- Similac Sensitive (Abbott) lactose
free
- Enfamil Gentlease (Mead Johnson)
reduced lactose, partially
hydrolysed protein
- Gerber Good Start (Nestle)
partially hydrolyzed whey
Added Rice
- Added rice starch for
gastroesophageal reflux.
- Carbohydrate: lactose or corn syrup solids, rice starch
- Protein: cows milk protein, casein/whey
- Enfamil AR (Mead Johnson)
- Similac Sensitive for Spit-Up
(Abbott)
Soy Protein
- Cows milk protein sensitivity, lactose
intolerance, or galactosemia.

- Carbohydrate: corn syrup solids, sucrose (lactose-free)
- Protein: soy protein isolate and methionine
- Fat: vegetable oil, DHA/ARA
- Similac Soy Isomil (Abbott)
- Enfamil Prosobee (Mead Johnson)

Extensively
Hydrolyzed
- Extensively hydrolysed for milk and/or
soy protein sensitivity; considered
hypoallergenic
- May have partial substitution of LCT as
MCT for malabsorptive conditions (6,
7).
- Standard caloric density: 20 kcal/oz, some available in 24
kcal/oz (ready to feed) for hospital setting
- Carbohydrate: sucrose, tapioca starch, corn syrup solids (all
are lactose free)
- Protein: extensively hydrolyzed casein
- Fat: vegetable oil blend, DHA/ARA, some MCT
- Pregestimil Lipil (Mead Johnson)
55% of fat as MCT
- Similac Expert Care Alimentum
(Abbott) 33% of fat as MCT
- Nutramigen Lipil (Mead Johnson)
5% of fat as MCT
Elemental
- Amino acid based for severe
malabsorption or allergy.
- Carbohydrate: corn syrup solids (all are lactose free)
- Protein: amino acids
- Fat: vegetable oil blend, DHA/ARA, some MCT
- Neocate Infant (Nutricia) 33% of
fat as MCT
- Elecare Infant (Abbott) 33% of fat
as MCT
Fat
Modified
- Significant fat malabsorption,
lymphangectasia, chylothorax.
- 85% of fat as MCT
- Standard caloric density: 30 kcal/oz (can be diluted)
- Carbohydrate: corn syrup solids
- Protein: casein
Fat: soy oil, MCT oil, DHA/ARA
- Enfaport (Mead Johnson)

Renal
- Chronic kidney disease, requirement
for altered electrolyte composition
- Carbohydrate: lactose
- Protein: casein
- Fat: vegetable oils
- Simliac PM 60/40 (Abbott)

40
Table 5.2 Overview of Infant and Pediatric Formulas (2, 4 7) Continued

Formula Type Description/Indication Indications/Formulations Formula Examples
Pediatric
Enteral
Formulas
- Balanced nutrition for the enteral feeding of
children ages 1-13 years of age. Meets 100%
of the RDA in 1000 - 1300 ml (depending on
the age).
- For children with normal GI function.
- May be used as oral supplements.
- Protein: casein and/or whey
- Carbohydrate: maltodextrin, sucrose
(lactose free)
- Fat source: vegetable oil blend
- Fiber source: can include pea fiber,
FOS, inulin

- PediaSure (oral product, with
and without fiber) (Abbott)
- PediaSure Enteral 1.0 (with and
without fiber) (Abbott)
- Pediasure 1.5 Cal (with and
without fiber) (Abbott)
- Nutren Junior (with and without
fiber) (Nestle)
- Boost Kid Essentials 1.0
- Boost Kid Essentials 1.5 (with
and without fiber) (Nestle)
- Compleat Pediatric (Nestle)
blenderized food

Pediatric
Enteral
Formulas (Soy)
children ages 1-10 years of age. Meets 100%
of the RDA in 1000 - 1300 ml (depending on
the age).
- May be used as oral supplement.
- Protein: soy protein based
- Carbohydrate: maltodextrin, sucrose
(lactose free)
- Fat source: vegetable oil blend i.e.
soy, high-oleic safflower oil, corn oil &
MCT oil
- Contains fiber
- Bright Beginnings Soy (PBM
Products)
Pediatric
Hydrolyzed

children ages 1-13 with generalized
malabsorption of protein and/or fat.
- Potential indications: cystic fibrosis, short gut
syndrome, inflammatory bowel disease,
chronic diarrhea.
- Protein: peptide based, usually milk-
based
- Carbohydrate: maltodextrin, sucrose,
cornstarch (lactose free)
- Fat: vegetable oils, MCT
- Fiber source: can include FOS, inulin
- Pediasure Peptide 1.0 (Abbott)
- Pediasure Peptide 1.5 (Abbott)
- Peptamen Jr (without fiber, with
fiber, and with PreBio) (Nestle)
- Peptamen Jr 1.5 (Nestle)
- Pepdite Jr (Nutricia) soy and
pork based protein
Pediatric
Amino Acid
children ages 1-13 with severe protein allergy
or malabsorption
- Protein: amino acids
- Carbohydrate: corn syrup solids
- Fat: vegetable oils, MCT oil

- EleCare Jr (Abbott)
- Neocate Jr (Nutricia) with and
without prebiotics
- Neocate Splash (Nutricia) oral
product
Pediatric
Reduced
Calorie
- Balanced nutrition (including optimal
vitamin/minerals) for the enteral feeding of
children ages 1-13 with reduced calorie needs
- Protein: milk, soy protein
- Carbohydrate: sucrose
- Fat: vegetable oil
- Caloric density: 0.63 0.66 kcal/oz
- PediaSure SideKicks 0.63 Cal
(Abbott)
- Compleat Pediatric Reduced
Calorie (Nestle)
Table 5.2 adapted from references 2, 6, 7 and proprietary enteral product literature.

41
Modifying Formula Caloric and Nutrient Density

Children who are critically or chronically ill may be unable to take adequate formula
volume to meet their nutritional needs. Infant and pediatric formulas may be prepared
differently to provide a greater caloric or nutrient density. The caloric or nutrient density of an
infant or enteral feeding formula can be increased by any one or a combination of the
following methods (2, 6):

1. Concentration - Increasing the amount of formula base (powder or concentrate) or
decreasing the amount of free water added when mixing the formula. This method will
increase the concentration of all formula solutes and osmolality.

2. Supplementation - Adding a macronutrient module in order to increase caloric
density without increasing all other nutrient sources. This may be accomplished
through the addition of:
- Carbohydrate source: Polycose (Abbott)
- Fat source: Microlipid (Nestle), MCT oil (Nestle), or vegetable oil
- Protein source: Beneprotein (Nestle), Prosource Liquid Protein (Active Home
Nutrition)
- Combined carbohydrate and fat source: Duocal (Nutricia)

Guidelines for Using Concentrated and High Nutrient Density Formulas

- In general, formulas for use in infants should not be concentrated through the reduction of
free water to a density > 27 kcal/oz as these preparations may not meet their free water
needs.
- Increases in formula caloric density should be done gradually by 2 3 kcal/oz to ensure
patient tolerance.
- Infants with gastroesophageal reflux (GER) may experience aggravated reflux with
concentrated preparations. These infants may do better with the addition of additives
such as Polycose or infant cereal.
- Infants with renal insufficiency may need to have their formula caloric densities increased
through the use of additives alone to prevent excessive increases in renal solute load.
- Children on concentrated formulas should be monitored closely for frequency of urination
and urine specific gravity to ensure adequate fluid intake.
- Excessive formula concentration may also result in diarrhea and dehydration or,
conversely, constipation.
- Parents should be appropriately instructed on formula preparation prior to discharge from
the hospital.
- Modules may or may not be readily available outside the hospital; discharge needs
should be considered.

Formula Concentration

Standard infant formulas in either ready-to-feed or prepared according to the manufacturers
instructions provide 20 kcal/oz. Table 5.3 presents several methods for increasing the caloric
density to 24 kcal/oz or 27 kcal/oz from these standard formulas.


42
Table 5.3 Increasing Formula Caloric Density to 24 - 27 kcal/oz through Concentration

Method Caloric Density
(kcal/oz)
Recipe
1 24 13 oz concentrate formula + 9 oz water
2 24 2 scoops powdered formula + 4 oz water
3 24 scoop powdered formula + 4 oz ready to feed
4 27 13 oz concentrate formula + 6 oz water
5 27 5 scoops powder + 7 oz water

Formula caloric density may be increased to 27 kcal/ounce via concentration using powdered
or concentrate formulas. However, this method can increase formula osmolality to > 450
mOsm/kg, and can also result in increased renal solute load. Consequently, infants on
higher caloric density formulas should be closely monitored for GI tolerance and hydration
status. For additional specific information on concentrating formulas to > 27
kcal/ounce, please contact the appropriate pediatric dietitian on your unit.

Formula Supplementation

Infants who require a 27 or 30 kcal/ounce formula may alternately receive a 24 kcal/ounce
standard or preterm formula as the base with added modular products to achieve a caloric
density of 27-30 kcal/ounce. Tables 5.4 and 5.5 present guidelines for increasing formula
caloric density up to 33 kcal/ounce. In general, the use of polycose and vegetable oil may be
more successful for orally fed patients, as it may be difficult to get vegetable oil to stay
emulsified for longer hangtimes with enteral feeds. The effect of volume displacement
caused by the addition of Polycose and Duocal (2 ml volume per tsp of powder) has been
used to calculate all the caloric densities in Tables 5.4 and 5.5.

Table 5.4 Formula Supplementation with Polycose Powder and Vegetable Oil

Method Formula Volume Polycose Canola Oil kcal/ml kcal/oz
1 4 oz of 24 kcal/oz 1 tsp 1 ml 0.9 27

Table 5.5 Formula Supplementation with Duocal Powder

Method Formula Volume Duocal
(tsp)
Duocal
(scoops)
kcal/ml kcal/oz
1 4 oz of 24 kcal/oz 1 2.8 0.9 27
2 4 oz of 24 kcal/oz 2 5.7 1.0 30
3 4 oz of 24 kcal/oz 3 8.5 1.1 33


43
Formula Caloric Modification in Renal Patients

When increasing formula caloric density for pediatric renal patients or for other pediatric
patients who cannot tolerate increased electrolyte concentrations, it is preferable to use a
specialized low electrolyte formula such as Similac PM 60/40 (Ross Labs) concentrate to 24
or even up to 27 kcal/oz. and then add modules, as needed, to achieve 27-30 kcal/oz.

Supplementation of Breast Milk

The caloric and nutrient density of breast milk can be increased by one of two methods:
- Method 1 - Enfamil Human Milk Fortifier or Similac Human Milk Fortifier
- Method 2 - Use of Powdered Infant Formula: Enfamil or Similac Powder

Breast fed preterm infants who are admitted to the PICU, are still below 2500 grams and are
unable to take in 180 ml/kg will need to receive fortified breast milk using:

Method 1: Human Milk Fortifier as follows:

Table 5.6 Fortification of Breast Milk with Human Milk Fortifier

Step Human Milk Fortifier Breast Milk Caloric Density Increased mOsm

Method 2: Breast milk caloric and nutrient density for term infants may be increased to 24-
30 kcal/oz according to the following:

Table 5.7 Increasing Nutrient Density of Breast Milk Using Formula Powder

Method Product Preparation
A Standard Term or
Discharge Preterm
Powdered Formula
Mix scoop powder per 120 ml breast
milk (24 kcal/oz)
B Standard Term or
Discharge Preterm
Powdered Formula
Mix 1 scoop powder per 150 ml breast
milk (27 kcal/oz)
Note: The caloric density of 24 kcal/oz breast milk may be increased further by following the formula
supplementation guidelines found in Tables 5.4 and 5.5.

Home Fortification: Fortification with NeoSure of Enfacare powder is the preferred method for
fortification at discharge as human milk fortifiers are not readily available in retail
establishments.


44

Supplementation of Pediatric Enteral Formula

The caloric and nutrient density of enteral formula can be increased by one of two methods:
- Method 1 - Use of Modulars: Duocal
- Method 2 - Increasing Pediatric Enteral Formula Nutrient Density with Tube
Feeding Mixers

Method 1: Increasing Pediatric Enteral Formula Nutrient Density with Modulars

Children ages 1 - 13 years of age who have elevated energy and/or protein needs in the face
of limited fluid tolerance may require nutritional management with a pediatric formula such as
PediaSure (1 kcal/ml), available with or without fiber, supplemented with modular
components. The following tables present the gradual advancement of formula caloric
density using Duocal.

Table 5.8 Increasing Pediatric Enteral Formula Caloric Density with Modular

kcal/oz Standard pediatric
enteral formula
volume
Powdered
Duocal (tsp)
Powdered
Duocal (weight
in grams)
33 240 ml 2 5.7
36 240 ml 4 11.3
39 240 ml 6 17.0

Method 2: Increasing Pediatric Enteral Formula Nutrient Density with Tube Feeding Mixes

Alternatively, higher caloric densities may be achieved by mixing pediatric formula with
calorically dense pediatric or adult formulas. Pediatric tube feeding caloric density of 1.25
kcal/ml can be achieved by mixing 1:1 a standard 1.0 calorie pediatric formula and a
calorically dense 1.5 cal pediatric formula (or an adult 1.5 formula).

Tube Feeding Routes of Delivery

The enteral nutrition delivery route chosen is highly individualized and dependent upon the
anticipated duration of the tube feeding as well as individualized tolerance and the childs
medical history. The predominant routes of enteral nutrition include:
- Nasogastric (NG) and orogastric (OG)
- Gastrostomy (Surgical or Percutaneous Endoscopic Gastrostomy)
- Transpyloric

Table 5.9 on the following page summarizes the major indications for each of these enteral
feeding routes. Even when providing tube feedings, it is important to provide oral stimulation,
both nutritive and non-nutritive, whenever possible to preserve the development or
preservation of normal suck and swallow. Therapy sessions with the occupational therapist
or the speech language pathologist should be directed towards the prevention of oral motor
dysfunction and oral tactile defensiveness.


45
Table 5.9 Routes of Tube Feeding Deliveries and their Indications

Delivery Method Common Indications
Or Advantages
Contraindications and/or
Precautions
Nasogastric (NG)
or Orogastric (OG)
Prematurity (< 32 wk EGA)
Requires presence of func-
tioning GI tract with non-
obstructive passage from
oral or nasal cavity to stomach
Usually indicated for short term
use (<3 months)
Smaller bore tubes associated
with increased comfort
Often used for nocturnal feedings
Tubes can be inserted, removed
and reinserted with relative ease
Patients with intractable vomiting
Patients with increased risk of
aspiration, history of aspiration
pneumonia
Discouraged in the presence of
severe gastroesophageal reflux
Otitis media or sinusitis can be
potential complications
NG and OG tubes can be easily
dislodged and thus must be
secured

Transpyloric Feedings
Nasoduodenal or
Nasojejunal
For infants and children with a
high risk for aspiration
For infants with history of severe
gastroesophageal reflux
For those with impaired gastric
motility or emptying (i.e. preterm
infants)
For use in patients with gastric
dysfunction following head injury,
general trauma or surgery
More difficult to place tube; may
require fluoroscopic or endosco-
py placement of tube
Increased potential for GI intoler-
ance while advancing to goal
rate i.e. malabsorption
Tube displacement and potential
aspiration
Must use continuous pump
infusion to optimize tolerance
Gastrostomy Feedings
Surgically Placed
or PEG

PEGs are generally
less costly than
surgical gastrostomies.
Indicated for long term feedings
Requires normal emptying of
gastric and duodenal contents
Indicated for infants and children
with swallowing dysfunction, or
for those with esophageal ob-
struction but with functioning
stomach and small intestine
Patients should have intact gag
Those with history of GE reflux
who do not respond to medical
management may require a
Nissen procedure
May be required for nutritional
management of congenital
anomalies i.e. TE fistula
Large bore tubes provide less
risk of tube occlusion with meds
or viscous blenderized formulas
Should be discouraged under the
following conditions:
a. Severe GE reflux (may require
a Nissen fundoplication)
b. Poor gastric emptying
c. Intractable vomiting
Tube must be secured to
prevent pyloric outlet
obstruction
Potential complications include:
a. Aspiration with aspiration
pneumonia
b. Tube migration
c. Localized skin breakdown,
leakage of gastric contents
An NG feeding trial may be
recommended prior to PEG
placement to establish tube
feeding tolerance
Jejunostomy Feedings Indicated for long term use
Indicated for infants and children
with obstructions above the
jejunum or poor gastric motility
Reduced risk of aspiration
Requires slow continuous infusion
Use of intact formulas is possible
if feeding into proximal intestine
May require more elemental
formula if feeding is delivered
more distally
Potential complications: dumping
syndrome, malabsorption, skin
breakdown, tube migration, or
bacterial overgrowth
Adapted from References 3 and 9


46
Tube Feeding Administration Methods

Tube feedings can be administered via continuous drip using a pump or via intermittent
feedings, using gravity drip or a pump. The method of feeding chosen is dependent upon the
following:
- Childs diagnosis
- Nutritional history and gastrointestinal status
- Route of feeding delivery
- Degree of patient mobility
- Tolerance to oral feedings
- Individual family and caretaker home situation

Table 5.10 presents an overview of indications for and advantages of continuous versus
intermittent feedings (3, 8).

Table 5.10 Continuous versus Intermittent/Bolus Feedings

Continuous Feedings Intermittent/Bolus Tube Feedings
Better tolerated than intermittent or
bolus delivery particularly in patients
with limited absorptive surface area;
generally results in less reflux, dump-
ing and diarrhea.

Better tolerated in critically ill children.
In the PICU, best to start with a con-
tinuous schedule and to progress to
intermittent schedule once clinical
status is improved.

Recommended for delivery of nutrients
directly into the small bowel.

Recommended for infants with
persistent feeding intolerance,
significant respiratory instability or
significant gut resection.

Useful for overnight nasogastric
for children with chronic diseases
i.e. renal disease, CF, CHD.
More physiological and practical for
home enteral feedings.

Indicated for children who are more
medically stable, have achieved full
tolerance of continuous feedings and
are ready to transition to a more
intermittent schedule.

Allows for greater patient mobility,
more appropriate for both the rehab
and the home setting.

Promotes cyclic bursts of GI hormones
such as gastrin in preterm infants,
thus promoting GI development and
maturation.


47
Transitioning from Continuous to Intermittent Feeds

Once the infant or child is medically stable and able to be transitioned over to a more
physiological feeding method, the continuous feeding schedule may be transitioned to
intermittent feedings via one of the following three methods:

Table 5.11 Transitioning from Continuous to Intermittent Feeds

Guidelines for Gradual Transition
from Continuous to Intermittent/Bolus Feedings
Method 1

Progressively increase the hours between feedings. Increase
the tube feeding interval by 2, 3, and 4 hour intervals to
provide 12, 8, and 6 feedings per day, respectively.
Method 2 When anticipating intolerance to intermittent feedings, the
volume delivered in 4 hours can be delivered over gradually
shorter time periods, over 3 hours, then 2 hours, then 1-1/2
hours, and finally over 1 hour using a constant infusion pump.
Method 3 Continue with continuous feeds overnight over 8 to 12 hours.
Divide daily enteral feeding volume over intermittent feedings
every 3 to 4 hours during the day.

General Guidelines for the Initiation and Progression of Tube Feedings

The following are some general guidelines for the initiation and progression of tube feedings
(1, 3, 8). These represent general guidelines and the tube feeding management of each
child needs to be individualized to meet specific needs and to ensure appropriate tolerance.

1. For pediatric patients with neurologic impairment and a high risk of aspiration, elevate
the head of the bed to at least a 30 degree angle to minimize the risk of aspiration.

2. When using continuous feeds, a 4 hour cycle of tube feeding formula should be
placed in the administration set or syringe. Hang time in the hospital setting should
not exceed 4 hours to minimize the risk of bacterial contamination.

3. When using intermittent feeds, place appropriate volume of feeding into the
administration set or syringe. The feeding can be administered via gravity drip, and
should generally be administered in 30 - 45 minutes.

4. Initiation and Advancement See Tables 5.12 and 5.13.

5. Administer tube feeding at room temperature. Refrigerate opened or mixed tube
feedings; discard all unused formula within 48 hours.

6. In children 2 years of age and older and not on a strict fluid restriction, administer at
least 5 - 10 ml of water, or more if needed, every 4 hours or after each intermittent
feed to ensure tube patency.


48
7. In general tube feedings may be started at full strength, but at a sufficiently low rate or
volume to ensure feeding tolerance.

8. If diluted formula is started, generally advance the formula strength first over the first
24 hours, and then advance the feeding volume. This will ensure that the child
receives optimal nutritional intake as the parenteral nutrition or other intravenous fluids
are being weaned.

9. In the hospital setting, the formula name, its rate and strength, gastric residual volume,
as well as urine and stool volume and consistency should be recorded in the patients
bedside flowsheet.

10. Administration container and tubing should be changed every 24 hours.

Pediatric Tube Feeding Progression

The following tables review tube feeding progression guidelines for both continuous and
intermittent feeding schedules in pediatric patients. This table may be used when writing
pediatric tube feeding orders.

Table 5.12 Continuous Tube Feeding Progression

Age/Weight Initial Infusion Rate Daily Increases Goal Rate
2.0 - 15 kg 2 - 15 ml/hr
(1 ml/kg/hr)
2 - 15 ml/hr q 4-8 hr
(1 ml/kg q 8 hr)
15 - 55 ml/hr
16 - 30 kg 8 - 25 ml/hr
(0.5 - 1 ml/kg/hr)
8 - 15 ml/hr q 4-8 hr
(0.5 ml/kg q 8 hr)
45 - 90 ml/hr
30 - 50 kg 15 - 25 ml/hr
(0.5 ml/kg/hr)
15 - 25 ml/hr q 4-8 hr
(0.5 ml/kg/ q 8 hr)
70 - 130 ml/hr
> 50 kg 25 ml/hr 25 ml/hr q 4-8 hr 90 - 150 ml/hr

Table 5.13 Intermittent Tube Feeding Progression

Age/Weight Initial Volumes Daily Increases Goal Volume
2.0 - 15 kg 5 - 30 ml q 3 - 4 hr 5 - 30 ml q 8 - 12 hr 50 - 200 q 4 hr
12 - 30 kg 20 - 60 ml q 4 hr 20 - 60 ml q 8 - 12 hr 150 - 350 ml q 4 hr
> 30 kg 30 - 60 ml q 4 h 30 - 60 ml q 8 - 12 hr 240 - 400 ml q 4 hr


49
Management of Combination Enteral and Oral Feedings

A combination of both oral feedings and tube feedings, wherever possible, is recommended
for the promotion of or maintenance of oral motor developmental skills. Pediatric patients on
hospital or home enteral feedings may be managed with a combination of:
- Continuous nocturnal feedings via NG tube or gastrostomy over a period of 10 - 14
hours.
- Daytime intermittent every 3 - 4 hours to include a combination of oral intake of
formula and/or solids as well as tube feedings to supplement the oral intake as
needed.

The pediatric dietitian will work closely with the nursing staff as well as the childs parents or
caretakers to develop a feeding schedule/regimen that is appropriate and manageable in the
home setting.

Management of Complications Encountered with Enteral Feedings

Complications associated with enteral feedings fall into three major categories:
1. Mechanical
2. Gastrointestinal
3. Infectious

While these complications may be seen in conjunction with enteral feedings, in most cases
the complications may have nothing to do with the enteral formula itself, but rather to the
method of delivery, administration, medications i.e. antibiotics, as well as the
physiological/anatomical problems related to the patients illness or condition.

Table 5.14 on the following pages reviews the most common complications in pediatric
patients, potential causes and guidelines for prevention or intervention.


50
Table 5.14 Management of Complications Encountered During Tube Feedings

Problem Possible Causes Prevention/Intervention
Nausea & Vomiting Gastric retention
Ileus or constipation
High fat content of
formula
Gastric hypomotility
Improper tube
placement
Infusion rate too rapid
Hypertonic meds
Unpleasant odor of
formula
Constipation
Maintain head of bed elevated
Consider prokinetic medications
Initiate tube feeding at low rates,
advance slowly, as tolerated
Consider alternate feeding
route i.e. duodenal/jejunal
Use lower fat content formula
Use standard polymeric formulas
unless contraindicated
Monitor for correct tube
placement

Abdominal distention,
bloating, gas

Delayed gastric
emptying
Infusion rate too rapid
Rapid infusion via
syringe
Rapid infusion of cold
formula
Delayed gastric
emptying
Malabsorption
Medications (opiates)
Constipation
Administer tube feeding via a
continuous infusion at low rate,
gradually increase as tolerated
Administer feedings at room
temperature
Consult pharmacist for evalua-
tion of medications impacting
gastric emptying
Consider prokinetic medications
i.e. Metoclopramide
Constipation Inadequate fluid
GI obstruction
Inadequate fiber
Inadequate physical
activity
Concentrated formula
Increase free water intake
Digital disimpaction
Choose fiber containing formula
or add fiber or prune juice
Increase physical activity
Implementation of a bowel regimen
Diarrhea
(Not formula related)
Concurrent drug
therapy, such as
antibiotic therapy
Sorbitol containing
medications
GI disorder/disease
Malnutrition, mucosal
atrophy
Constipation with
overflow
Consult pharmacist for review
of medications and possible
discontinuation
Look for Sorbitol on label of oral
prescription medications
Consider switch to continuous
feedings. Begin tube feeding
at slow infusion rate, advance
slowly, as tolerated
Diarrhea
(Formula related)

Inadequate fiber
Rapid tube feeding
infusion
Bacterial contamina-
tion of formula
Carbohydrate malab-
sorption or lactose
intolerance
Fat malabsorption
Impaction
Use fiber containing formula or
add fiber to the tube feeding
Reduce tube feeding rate to
previously tolerated rate,
advance slowly, as tolerated
Use commercially prepared
formula
Use lactose-free formula i.e.
soy-based or a carbohydrate
free formula & replace the
carbohydrate
Use low fat formula
Continued on following page.


51
Table 5.14 Management of Complications Encountered During Tube Feedings,
Continued

Problem Possible Causes Prevention/Intervention
Clogged feeding tube Improper irrigation of
the feeding tube
Administration of
medications via the
feeding tube
High viscosity formula
Undissolved formula
due to poor mixing
Flush tube with water every
4 - 8 hours
Replace tubing
Use liquid elixirs when possible
Consult pharmacist regarding
crushed or diluted medications
Blenderize powdered enteral
formulas thoroughly
Switch to lower viscosity formula
Use appropriate size tube for
formula viscosity or TF method
Aspiration Gastric hypomotility
Gastroesophageal
reflux
Neurologic damage
Displacement or
migration of feeding
tube to esophagus
Oral-motor dysfunc-tion.
Infuse feedings past the pylorus
Consider continuous infusion
Child may need anti-reflux
medications/surgical procedure
for long term management
Verify tube placement prior to
each feed or every 4-8 hours
on continuous feedings
Replace tube
Electrolyte imbalance Medications which
alter electrolyte
Previous malnutrition,
refeeding syndrome
Cardiac or renal
insufficiency
Formula intolerance
(unlikely)
Consult pharmacist regarding
medications which may cause
electrolyte wasting
Infuse tube feeding at low rates;
may need to supplement with
potassium or phosphorus
Manage underlying diagnosis to
correct electrolyte imbalance
Dumping syndrome Too rapid infusion
Bolus feeds into small
bowel
Hypertonic formula
Switch to continuous feedings
Use a more elemental formula
for children with severe malab-
sorption or short gut
Hyperglycemia Diabetes
Trauma or sepsis
Excess carbohydrate
intake
Switch to a formula with fiber.
Switch method of administration
i.e. to continuous feedings
Administer insulin (sliding scale)
Azotemia High protein intake
Renal insufficiency or
renal immaturity
Liver disease
Metabolic disease
(i.e. inborn error)
Reduce protein content of
formula
Dehydration Inadequate fluid intake
High caloric density
formula
Increase fluid intake via free
water flushed q 3 - 4 hours
Decrease formula caloric density
Adapted from References 3 and 10


52
Transition from Enteral to Full Oral Feedings

The transition from enteral to full oral feedings can be prolonged. If infants and children are
completely deprived of oral feedings during critical maturation phases, difficulties will be
encountered when oral feedings are resumed. Reinstitution of oral feedings in children with
G-tubes may evoke such responses as gagging, choking and vomiting.

To promote oral feeding transition:
- G-tube feedings should be arranged to stimulate oral feeding in timing and amount
- Oral stimulation with the speech language pathologist or occupational therapist should
occur to diminish the childs oral defensiveness. Treatment may require weeks on an
inpatient basis and up to years on an outpatient basis.

The pediatric and neonatal nutritionists will work closely with the speech language pathologist
and/or occupational therapist, as appropriate, as well as the nursing staff on the following
patients:
- Enteral or parenteral nutrition patients who have been on nutrition support for an
extended period of time and are thus unable to take oral feedings
- ECMO patients who develop orally defensive behaviors
- Bronchopulmonary dysplasia patients who are unable to meet their nutrition needs via
oral intake


53
References

1. Schwenck WF, Olson D. Pediatrics. In: Gottschlich M, Fuhrman MP, Hammond KA,
Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support A Case-
Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque,
IA: Kendall/Hunt Publishing Co.; 2001:347-372.

2. Abad-Sinden A, Sutphen J. Enteral nutrition. In: Walker WA, Goulet O, Kleinman RE,
Sherman PM, Shneider BL, Sanderson IR, eds. Pediatric Gastrointestinal Disease. 4
th

edition. Philadelphia, PA: B.C. Decker, Inc.; 2004:1981-1994.

3. Nevin-Folino N, Miller M. Enteral nutrition. In: Samour PQ, King K, eds. Handbook of
Pediatric Nutrition. 3
rd
edition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:499-
524.

4. United States Congress: Infant Formulas Act of 1980, Public-Law 96-359, Sept. 26, 1980.

5. Committee on Nutrition. Soy protein formulas: recommendations for use in infant feeding.
Pediatrics. 1983;72:359-363.

6. American Academy of Pediatrics. Committee on Nutrition. Enteral nutrition. In: Pediatric
Nutrition Handbook. 2004:391-403.

7. Abad-Jorge A, Roman B. Enteral nutrition management of pediatric patients with severe
gastrointestinal impairment. Support Line. 2007; 29(3): 311.

8. Charney P. Enteral nutrition: indications, options and formulations. In: Gottschlich M,
Fuhrman MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice
of Nutrition Support A Case-Based Core Curriculum. American Society for Parenteral
and Enteral Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:141-166.

9. Minard G, Lysen LK. Enteral access devices. In: Gottschlich M, Fuhrman MP, Hammond
KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support A
Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition.
Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:176 - 188.

10. Russell M, Cromer M, Grant J. Complications of enteral nutrition. In: Gottschlich M,


54
Chapter 6 Nutrition Management of High Risk Nutrition Disease States

55
Chapter 6

Nutrition Management of High Risk Nutrition Disease States

Congenital Heart Defects (1, 2)

Congenital heart defects (CHD) result from abnormal formation of the heart or major blood
vessels, which either obstruct blood flow or cause abnormal blood flow. Infants with
congenital heart defects have an increased incidence of malnutrition due to prenatal, genetic
and postnatal factors. Postnatal factors contributing to malnutrition include:
- Hypoxia and hemodynamic abnormalities: results in fatigue, discoordinated suck
and swallow and increased work of breathing
- Decreased nutritional intake: related to dyspnea, tachypnea and fatigue
associated with chronic hypoxia; may also be related to imposed fluid restriction to
prevent fluid overload and cor pulmonale; may be related to delayed or impaired
gastric emptying or motility due to stomach pressure causing early satiety
- Increased metabolic expenditure related to an increase in cardiac and respiratory
work, also related to body composition due to decreased fat stores and increased
lean body mass
- Mild malabsorption may play a role in the etiology of malnutrition when combined
with poor nutritional intake and increased metabolic rate

Nutrition Goal: to promote catch-up growth in previously malnourished infants and children
or to maintain appropriate growth in well-nourished infants or children to allow for a more
timely surgical repair of the cardiac defect and to promote normal growth potential and
development.

Medical Nutrition Therapy

Estimated needs

- Increase caloric and protein intake above the recommended levels of the DRIs.
Refer to Table 6.1 for calorie, protein and sodium guidelines.

Table 6.1 Nutritional Requirements for Children with CHD

Age (years) Energy (kcal/kg) Protein (g/kg) Sodium (mg/day)
0-0.5 120 150 2.2 3.5 230
0.5-1 110 140 1.5 2.5 500
1-3 100 120 1.2 - 2 650
4-6 80 100 1.2 1.5 900
7-10 60 90 1.0- 1.5 1200
11-14 Male: 55 60
Female: 45 - 60
1.0 1.5 1800
15-18 45 55 1.0 1.5 1800


56
Interventions

- Increase formula caloric density via formula concentration or supplementation with
caloric modulars. Formulas may be concentrated to 24 - 27 kcal/oz via
concentration and if needed, up to 30 - 35 kcal/oz, by using Polycose and
Microlipid. Refer to formula recipes in Chapter 5.
o Breast milk may be used if the caloric and nutrient density is appropriately
increased via: a) supplementation with powdered infant formula or
commercial fortifiers (for preterm infants), b) mixing breast milk with higher
calorie formula, or c) supplementation with caloric modular.
- Enteral nutrition support with either continuous feedings over 24 hours in the
hospital setting or with oral intake by day of calorically dense formula and
continuous nocturnal feeds over 8 - 12 hours
o 24-hour continuous feeds: achieves greatest caloric intake; safe and
effective to improve nutritional status; may promote oral-motor dysfunction
o Oral + 12-hour nocturnal continuous feeds: promotes normal feeding
development; infants should take as much of a calorically dense formula as
possible during an 8-12-hour day, and provide the rest of goal via nocturnal
feed
o Intermittent feeds every 3-4 hours: feeds are given every few hours; the goal
volume is offered orally for those safe to po feed, and the balance is given
via NGT or GT after a 20-minute oral feeding period.
- The use of a lower-sodium formula may be desirable, as excessive sodium intake
may exacerbate fluid retention and precipitate congestive heart failure.
- Tips for increasing calories and protein with oral intake:
o Oral intake can be maximized using a variety of every-day ingredients (see
Appendix K)
o To increase calories for hospitalized patients, nutritional supplements such
as PediaSure, Mightyshakes, and Ensure are available. For outpatients,
PediaSure, Ensure, and Boost are available in the grocery store; however,
store brands (such as Target, Walmart, etc.) or Carnation Instant Breakfast
may be more economical for families.
o Frequent snacking may be necessary to meet calorie and protein needs.

Cystic Fibrosis (3, 4)

Cystic fibrosis is a genetic, multisystem progressive disease causing the cells producing
mucus, sweat, saliva, and digestive juices to create thick and sticky secretions resulting in
pancreatic insufficiency, chronic lung disease, excessive loss of sweat electrolytes, and
malnutrition.The nutritional needs of children with cystic fibrosis are increased due to
pancreatic insufficiency and progressive pulmonary failure. Factors contributing to the
nutritional implications include:
- Malabsorption of fat and protein
- Increased work of breathing and repeated pulmonary infections
- Loss of fat-soluble vitamins and essential fatty acids
- Decreased oral intake during respiratory exacerbations


57
Nutrition Goal: provision of adequate calories and protein to support normal growth and
overcome the demands of increased respiratory effort and malabsorption.


Special Considerations in Nutrition Assessment

- Yearly fat soluble vitamin levels (A, D, and E) should be checked. However,
vitamin A is a negative acute phase reactant and should not be checked while a
patient has active infection.

Estimated Needs

- 120-150% of the DRIs for calories is needed for optimal growth.
- To prevent deficits of essential nutrients, provide additional vitamin A, D, E and K.

Table 6.2 Guidelines to Replace Essential Vitamins A, D, E and K

Essential Vitamin Amount/Day
Vitamin A 5,000 to 10,000 IU/day
Vitamin D 400 to 800 IU/day
Vitamin E 25 to 50 IU for infants; 100-200 IU < 8 years; 200-400
IU > 8 years
Vitamin K 2-5 mg each week or 2-5 mg twice a week for patients
on chronic antibiotics or if with cholestatic liver
disease; 300-500 mcg > 8 years

- Usual dosage for supplemental water soluble vitamins is 1 ml per day pediatric
multivitamin for infants 0-2 years old.

Interventions

- Oral intake should be maximized as much as possible, through the use of
calorically dense foods, double portions, frequent snacks, nutrition supplements
(ie, Scandishakes), and caloric modules added to foods (dry milk powder,
vegetable oil, butter, Duocal, etc).
- A combination of oral and tube feeding is frequently necessary to meet nutritional
needs. Nocturnal feeds are preferred, NG for short term; gastrostomy for long
term.
- Breast milk, standard infant formula or special MCT-containing formulas such as
Pregestimil are appropriate. Breast milk and formulas should almost always be
high caloric density > 24 kcal/oz.
- NaCl supplementation for infants is recommended in the amount of 4 - 6
mEq/kg/day which can be achieved by giving 1/8 - 1/4 teaspoon table salt per day.
This should be divided between the first few feedings per day.
- For pancreatic enzyme replacement recommendations, see Table 6.3.
o If an infant can swallow purees, enzyme beads can be given in an acidic
puree, like applesauce. Enzyme beads should not be given in an alkaline

58
fluid, because this will cause premature degradation of the beads enteric
coating and subsequent denaturing in the stomach.

Table 6.3 Dosing Pancreatic Enzymes in CF Patients

Age

Meal Dose Adjusting Dose
Infants
- 2000-4000 units lipase/120 ml
formula/nursing (mean of 1800
lipase units)
- 450-900 Units lipase/g of fat
Increase by 2000-2500 units
lipase/feed as volume increases
or malabsorption returns
Children < 4
years
- 1000-2000 units
lipase/kg/meal
- 500-4000 units lipase/g fat
- Snacks: meal dose
- Compare units lipase/g fat
when weight dose appear
above range
Children > 4
years
- 500-2000 units lipase/kg/meal
- 500-4000 units lipase/g fat
- Snacks: meal dose
- Compare units lipase/g fat
when weight dose appears
above range
Note: Units of lipase provided for each gram of long chain triglycerides provided by the formula. A formula
whose fat source is predominantly MCT oil, i.e., Pregestimil can be beneficial for decreasing the quantity
of enzyme dosing.

o For continuous 24 hour feedings: The total calculated lipase dose
provided per 24 hours of the selected formula should be 500-4000 lipase
units (mean of 1800 lipase units) per gram of LCT divided in equal amounts
and administered every 3 to 4 hours.
o For cycled overnight tube feedings: 50-75% of the calculated enzyme
dosage should be administered at the beginning of the feeding and the
remaining 25-50% at the end.
Option A: Taking enzyme orally: Provide meal dose of enzymes by
mouth at the beginning of feeds. Following completion of feeds, give
of a meal dose by mouth.
Option B: Pre-digesting formula: Dissolve 1 3/4 tsp. sodium
bicarbonate (baking soda) in 100 ml water. Mix beads from enzyme
capsule in the sodium bicarbonate solution; use 5 ml of solution per
capsule. Leave beads in solution for 15-20 minutes. Add mixture to
formula after beads have dissolved.
o For intermittent tube feedings: The calculated enzyme dose should be
given just prior to each feeding.
o Dosing should not exceed 4,000 units lipase per gram of fat.


59

Figure 6.1: Vitamin D Treatment Algorithm from the Cystic Fibrosis Foundation
Guidelines on Vitamin D for Children Age 1 10 Years Old

Age: 1-10 years
Baseline Dose of Vitamin D3:

800-1000 IU Vit D3/day
Check 25-OH Vit D yearly,
preferably at the end of winter
25-OH Vit D
<30 ng/ml
25-OH Vit D
>30 ng/ml
Double dose of adherent patient
to:
1600-2000 IU Vit D3/day Continue Baseline
Dose of 800-1000
IU Vit D3/day
Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
25-OH Vit D
>30 ng/ml
Double dose of adherent patient
to:
3200-4000 IU Vit D3/day
Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
25-OH Vit D
>30 ng/ml
Continue adherent
patient at present
IU Vit D3 dose/day
Confirm patient is adherent and
has been receiving 4000 IU Vit
D3/day for the past 3 months
For adherent patient taking
<4000 IU Vit D3/day,
increase to 4000 IU/day
Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
*Note: All Vitamin D dosage
recommendations include vitamin D
contained in multivitamin(s) +
additional stand-alone vitamin D
supplements
Refer to specialist
25-OH Vit D
>30 ng/ml

60
Figure 6.2: Vitamin D Treatment Algorithm from the Cystic Fibrosis Foundation
Guidelines on Vitamin D for Children > 10 Years Old Through Adulthood

Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
Double dose of adherent patient to:
3200-8000 IU Vit D3/day
25-OH Vit D
>30 ng/ml
Continue adherent
patient at present
IU Vit D3 dose/day
*Note: All Vitamin D dosage
recommendations include vitamin D
contained in multivitamin(s) +
additional stand-alone vitamin D
supplements
Age: >10 years through
Adulthood
Baseline Dose of Vitamin D3:
800-2000 IU Vit D3/day
Check 25-OH Vit D yearly,
preferably at the end of winter
25-OH Vit D
<30 ng/ml
25-OH Vit D
>30 ng/ml
1600-4000 IU Vit D3/day
Continue Baseline
Dose of 800-2000
IU Vit D3/day
25-OH Vit D
>30 ng/ml
Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
Confirm patient is adherent and
has been receiving 6400-10000 IU
Vit D3/day for the past 3 months
Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
Refer to
specialist
25-OH Vit D
>30 ng/ml
6400-10000 IU Vit D3/day
Recheck 25-OH Vit D
level in 3 months
25-OH Vit D
<30 ng/ml
25-OH Vit D
>30 ng/ml
For adherent
patient taking
10000 IU
Vit D3/day
For adherent patient taking
<10000 IU Vit D3/day,
increase to 10000 IU/day

61
Renal Disease (5 - 8)

Sudden removal of the renal regulating ability produces profound electrolyte and metabolic
disturbances resulting in fluid retention, acidosis, hyperkalemia, hyperphosphatemia, nitrogen
retention, hypocalcemia and hyperuricemia. Dietary manipulations may change dramatically
during the course of renal disease.

Nutrition Goal in Acute Renal Failure: to provide sufficient nutrients to restrain the
catabolic response and hasten renal recovery within the restrictions demanded by limited
renal capacity.

Nutrition Goal in Chronic Renal Disease: to maintain nutrition sufficient for optimal growth
within the margins imposed by limited renal excretory and regulatory capacity while at the
same time avoiding excesses of nitrogen, phosphate, sodium, potassium and fluid.



- Dry weight should be estimated, whenever possible, using nutrition-focused
physical findings, such as blood pressure, edema, and weight change with fluid
removal via dialysis.
- BMI should be plotted against height age, for those patients who are prepubertal
with significant stunting.
- Skinfold measurements and arm anthropometry are not recommended in this
population.
- Serum electrolyte levels, parathyroid hormone, and renal profile are important
laboratory components in this population.
- Serum albumin is often used as a marker of nutrition status because
hypoalbuminemia is a risk factor for mortality; however, serum albumin is a better
indication of severity of disease and inflammation than it is of nutrition status.
- 25(OH) vitamin D levels should be measured at least yearly.

Estimated Needs

- Initially, use DRI/EER for age and weight or catch-up growth, when appropriate,
and adjust caloric delivery based on growth parameters. Provision of at least 80%
of the DRI/EER for height age is recommended for normal growth.
- Estimated protein needs are in Table 6.4.
- Fluid needs are determined by the patients clinical status.
o If fluid limitation becomes necessary due to edema or hypertension, provide
insensible losses (Table 6.5) plus measured urine output and amount to
replace other losses (vomiting, diarrhea, ostomy output).
o Children with polyuria may require 180-240 ml/kg/day.
- Generally, micronutrient needs are 100% of the DRI for age for B vitamins, zinc,
copper, folic acid, and vitamins A, C, D, E, and K.


62
Table 6.4 Protein Recommendations for Dialysis Patients

Table 6.5 Insensible Fluid Losses

Age Group

Fluid Loss
Preterm Infants Up to 40 ml/kg/d
Neonates 20-30 ml/kg/d
Children & Adolescents 20 ml/kg/d or 400 ml/m

Interventions

- Diets should be liberalized as much as possible, to allow a palatable diet with
adequate variety to promote growth, development, and quality of life.
- Oral supplements, either standard products like PediaSure or renal products like
Nepro or Suplena, may be indicated for patients with anorexia related to dialysis.
- Generally, a low renal solute load, low electrolyte formula such as Similac PM
60/40 is indicated for infants with renal insufficiency. Soy formulas should be
avoided if at all possible due to their high phosphorus content. Formulas can be
concentrated to 24-27 kcal/oz, and then supplemented to 30 kcal/oz using
modulars.
- Infants should be encouraged to start solid foods at ~6 months of age, as any
normal infant would.
- Enteral supplementation should be considered, particularly in infants and toddlers
with poor growth and in those with polyuria requiring high fluid volumes. Table 6.7
provides a formula comparison.
o Standard formulas may be appropriate for toddlers and younger children,
depending on electrolyte status.
o Use of a high calorie (1.8 kcal/ml), defined renal formula i.e., Nepro may be
recommended for enteral nutrition support either continuous in the hospital
setting or as an overnight feeding regimen for children over 24 months. In
situations where Nepro provides too much protein for a child, Suplena (1.8
kcal/ml) can be used instead.
- Intradialytic parenteral nutrition should be considered in patients on hemodialysis
in whom oral and enteral supplementation are not effective in correcting
malnutrition.
- Use 1 ml multivitamin drops (need to supplement folic acid) or 1 childrens
chewable multivitamin per day to provide vitamin and mineral needs, or use
Age Group Hemodialysis
(g/kg)
Peritoneal
dialysis (g/kg)
0-6 months 1.6 1.8
7-12 months 1.3 1.5
1-3 years 1.15 1.3
4-13 years 1.05 1.1
14-18 years 0.95 1.0

63
tablet Nephrovite for children <3 years of age and 1 tablet for children >3 years of
age.
- Supplement salt as needed; table salt can be added to a daily supply of feeds. 1/8
teaspoon of table salt provides 11 mEq of sodium.
- Iron may be supplemented in addition to erythropoietin for management of anemia.
- Vitamin D should be replaced in the case of deficiency, as per Table 6.6, even if
the child is receiving calcitriol to control PTH levels.
- Growth hormone can be an important adjunct to nutrition management in treating
growth retardation.

Table 6.6 Recommended Supplementation for Vitamin D Deficiency/Insufficiency in
Children

Serum 25
(OH) D
(ng/mL)
Definition Ergocalciferol (D2) or Cholecalciferol
(D3) Oral/Enteral
Duration
(mo)
< 5 Severe deficiency 8000 IU X 4 wk or (50000 IU 2X per mo
for) X 2 mo
3
5-15 Mild deficiency 4000 IU/d x 12 wk or (50000 IU q other
wk for 12 wk)
3
16-30 Insufficiency 2000 IU/d or (50000 IU q 4 wk) 3
30 Homeostasis 200-1000 IU/d daily


64
Table 6.7 Nutrient Content of Selected Renal Formula, per 100 kcals
Adapted from proprietary product literature.
Enfamil
Lipil
Similac PM
60/40
Gerber Good
Start Plus
DHA/ARA
Pediasure Nepro with
Carb
Steady
Suplena
with Carb
Steady
Fluid, ml 150 148.0 150 100.0 55.6 55.6
Protein, g 2.1 2.2 2.2 3.0 4.5 2.5
Fat, g 5.3 5.6 5.1 5.0 5.3 5.3
Carbohydrate, g 10.9 10.2 11.2 11.0 9.3 11.2
Fiber, g 0 0.0 0 0.5 0.9 0.9
Linoleic acid, mg 860 1300.0 900 1071.7 Not available Not
available
Vitamin A, IU 300 300.0 300 257.4 176.7 176.7
Vitamin D, IU 60 60.0 60 50.6 4.7 4.7
Vitamin E, IU 2 2.5 2 2.3 5.3 5.3
Vitamin K, mcg 8 8.0 8 3.8 4.7 4.7
Thiamin (B1), mcg 80 100.0 100 270.0 133.3 144.4
Riboflavin (B2), mcg 140 150.0 140 211.0 150.0 144.4
Vitamin B6, mcg 60 60.0 75 261.6 472.2 472.2
Vitamin B12, mcg 0.3 0.3 0.33 0.6 0.5 0.5
Niacin, mcg 1000 1050.0 1050 1687.8 1777.8 1777.8
Folic acid, mcg 16 15.0 15 37.1 58.9 58.9
Pantothenic acid, mcg 500 450.0 450 1012.7 888.9 888.9
Biotin, mcg 3 4.5 4.4 32.1 26.4 26.4
Vitamin C, mg 12 9.0 9 10.1 5.8 5.8
Choline, mg 24 12.0 12 30.0 35.3 35.3
Inositol, mg 6 24.0 6 8.0 Not available Not
available
L-carnitine, mg 2 Not available Not available Not available 14.7 14.7
Calcium, mg 78 56.0 64 97.0 58.9 58.9
Phosphorus, mg 43 28.0 36 80.2 38.9 38.9
Magnesium, mg 8 6.0 7 19.8 11.7 11.7
Iron, mg 1.8 0.7 1.5 1.4 1.1 1.1
Zinc, mg 1 0.8 0.8 1.2 1.4 1.4
Manganese, mcg 15 5.0 7 101.3 116.7 116.7
Copper, mcg 75 90.0 80 101.3 116.7 116.7
Iodine, mcg 10 6.0 12 9.7 8.9 8.9
Selenium, mcg 2.8 1.8 2 2.3 4.1 4.1
Sodium, mg 27 24.0 27 38.0 58.9 43.9
Potassium, mg 108 80.0 108 130.8 58.9 62.2
Chloride, mg 63 59.0 65 101.3 46.9 51.9
Osmolality, mosm/kg
water
300 280.0 Not available 430.0 600.0 600.0
Osmolarity, mosm/L 270 254.0 Not available 364.0 556.0 344.0
Price (per 100 kcals)
$0.64
$0.74
$0.64 $0.74 $0.30 $0.30

65
Severe Gastrointestinal Impairment (8 - 13)

Severe gastrointestinal impairment caused by chronic diarrhea/malabsorption, cystic fibrosis,
Crohns disease, radiation enteritis, delayed gastric emptying, pancreatitis, HIV/AIDS, or
short bowel syndrome may be characterized by:
- Malabsorption
- Diarrhea
- Electrolyte instability
- Malnutrition

Nutrition Goal: To provide adequate nutrition through appropriate formula selection to
promote better total nutrient absorption and avert fat malabsorption, protein sensitivity, and
carbohydrate intolerance in order to improve GI adaptation and deliver optimal nutrition.



- Children on parenteral nutrition should have routine monitoring of serum
electrolytes, trace element status, and iron status.
- Children with malabsorptive conditions should have fat soluble vitamin levels,
particularly vitamin D, measured
- Children with an ileal resection should be evaluated for B12 deficiency.
- Consider potential deficiencies based on site of intestinal resections (Appendix L).

Estimated Needs

- Estimated needs may be similar to that of other children of the same age and
gender, but should be individualized based on disease acuity and need for catch-
up growth. Malabsorption should also be considered in children with some
conditions, such as short bowel syndrome.

Intervention

- Formula selection:
o The algorithm (Figure 6.2) may be used to aid in the decision-making process
to select a clinically appropriate formula.
o Refer to Table 6.9 for an overview of semi-elemental and elemental infant and
pediatric formulas for use in children with severe GI impairment
o First approach is to try intact protein formula or breast milk to promote intestinal
adaptation and improved GI tolerance.
o Breast milk, although nutrients are not hydrolyzed, improves GI adaptation
compared to protein hydrolysate formulas due to bile salt lipase, lymphocytes,
macrophages, well-absorbed peptides and amino acids, immunoglobins and
growth factors.
o If intact formula or breast milk is not tolerated, a peptide based, higher fat
formula may be used to avert allergies, bacterial overgrowth, and exert trophic
effects on the GI tract.

66
o Semi-elemental formulas are typically used for those with severe GI impairment
or protein allergies.
o Elemental formulas are typically used when semi-elemental formulas are not
tolerated.
o Formulas with higher fat content slow down transit time, promoting absorption,
which improves GI adaptation.
o Long chain triglycerides: more trophic effect promoting intestinal adaptation
o Medium chain triglycerides: more water soluble, improved absorption in some
children, higher osmotic effect
o Trial time of formula should be about 3-5 days before evaluating the need to
change formulas.
- Continuous EN provides slow delivery of nutrients to GI tract, promoting better
tolerance and nutrient absorption.
- Fiber: Addition of water-soluble fiber lengthens transit time and nutrient contact with
mucosa increasing absorption and improving GI tolerance.
o Liquid fruit pectin: Certo, SureJell
o Hydrolyzed guar gum: Resource Benefiber (institutional version)
- Use of prebiotics and probiotics may reduce diarrhea and decrease symptoms of colic.
- Oral rehydration solutions may be required in those with high ostomy outputs or those
without a colon.
- Certain medications containing sorbitol, potassium chloride elixirs, and certain
antibiotics may be the cause of diarrhea.
- Children with vomiting, diarrhea, abdominal distention, and metabolic acidosis should
be evaluated for small bowel bacterial overgrowth.

Table 6.8 Guidelines for Formula Selection in Differing Disease States
(Refer to Algorithm in Figure 6.1 and Specialized Formula Table 6.9)

Disease State

Recommended Formula
Cystic Fibrosis Standard polymeric; semi-elemental or
partially hydrolyzed formula with appropriate
pancreatic enzyme dosing.
Crohns Disease Standard polymeric or semi-elemental.
Short Bowel Syndrome Begin with semi-elemental, partially
hydrolyzed formula. If not tolerated, back
down to elemental formula. Eventually
transition back from elemental to standard
polymeric to promote better GI stimulation
and adaptation.
Severe Malabsorption or Severe
Allergic Complications
Semi-elemental/ partially hydrolylzed; if not
tolerated proceed to elemental formula.
Severe Protein Allergy Elemental formula


67

.
67

68
Table 6.9 Nutrient Information for Semi-Elemental & Elemental Formula for Use with Severe GI Impairment (per 100 kcal)
Nutrient Pregestimil Alimentum
Neocate
Infant
Peptamen
Junior
Pepdite Junior
PediaSure
Peptide
Neocate Jr EleCare Jr
kcal/mL 0.67 0.67 0.67 1.0 1.0 1.0 1.0 1.0
Protein (g) 1.9 1.9 2.08 3.0 3.1 3.0 3.3-3.5 3.1
Protein
Source
Hydrolyzed
casein
Hydrolyzed
casein
Free amino
acids
Whey
hydrolysate
Soy and pork
hydrolysates +
free amino acids
Whey
hydrolysate,
caseine
Free amino
acids
Free amino
acids
Carbohydrate (g) 6.8 6.8 7.8 13.6 10.6 13.4 10.4-11 10.7
Carbohydrate
Source
Corn syrup and
tapioca
Tapioca and
sucrose
Corn syrup
solids
Maltodextrin
and sugar
Maltodextrin and
corn syrup
(banana contains
sucrose,
sweetener)
Maltodextrin,
scFOS
Corn syrup
solids (flavors
contain
sucrose,
sweetener)
Corn syrup
solids
Fat (g) 3.8 3.8 3.0 3.84 5 4.1 4.7-5 4.9
Fat
Source
MCT oil, corn oil
MCT, soy,
safflower oil
Safflower,
soy, coconut
oil
Coconut, soy,
canola, soy oil,
lecithin
Coconut,
safflower, soy oil
Canola, MCT
oil
Coconut,
canola,
safflower oil
Safflower,
coconut, soy
oil
Distribution
Protein 11% 11% 12% 12% 12% 12% 13-14% 15%
Carbohydrate 41% 41% 47% 54% 42% 53% 42-44% 43%
Fat
LCT
MCT
48% 48% 41% 34% 46% 35% 42-45% 42%
45% 67% 67% 40% 65% 50% 65% 67%
55% 33% 33% 60% 35% 50% 35% 33%
Osmolality
(mOsm/kg)
340 370 375
260 (unflavored)
360-400(flavors)
430 (unflavored)
440 (banana)
250
590(unflavored)
680-700(flavor)
590
Indications

Generalized
malabsorption,
short bowel
syndrome
Generalized
malabsorption
Short bowel
syndrome
Cows milk or
multiple food
allergies,
GER
Malabsorption,
gastrointestinal
impairment
Malabsorption,
severe food
allergies,
gastrointestinal
tract impairment
Mal-
absorption,
maldigestion
Multiple food
allergy, gastro-
intestinal tract
impairment,
malabsorption
Malabsorption,
severe food
allergies,
GI tract
impairment
Adapted from proprietary product literature.

69
Chylous Ascites/Chylothorax (13 - 18)

Chylous ascites is a condition caused by a complication in which there is an occlusion to a
thoracic duct or division of the lymphatic channels leading to chyle leaks in the thoracic and
peritoneal cavities. As a result, pleural effusions, abdominal pain, anorexia,
hypoalbuminemia, hyponatremia, hypocalcemia, hypercholesterolemia, and elevated alkaline
phosphatase are common, which present nutritional challenges to the clinician if left
unmanaged. Factors contributing to the nutritional implications include:
- Body protein loss
- White blood cell losses
- Immunosuppression
- Lipid losses

Nutrition Goal: To sustain electrolyte, fluid, and nutritional homeostasis by providing
adequate nutrients without stimulating chyle flow and increasing lymph production.


Estimated Needs

- Caloric needs are 1.7-1.8 x BEE.
- Protein needs may be higher than normal for a hospitalized patient, if there is
active chest tube output.

Interventions

- Nutrition therapy is an important part of the UVA pediatric chylothorax
management algorithm (Appendix M).
- A low-fat diet (Table 6.10) or low LCT/high MCT formula is generally needed.
o Elimination of long chain triglycerides (LCT) can decrease lymphatic flow
and enhance fistula healing. LCT should be restricted to 10-20 g/day.
o In infants or those fed enterally, use special formulas that are high in MCT,
such as Enfaport (Mead Johnson), Monogen (Nutricia), Portagen (Mead
Johnson) , or low in total fat, such as Lipisorb (Nutricia), Vivonex (Nestle), or
Tolerex (Nestle).
o Nutrition supplements (Resource Breeze or Carnation Instant Breakfast with
skim milk) should be utilized to ensure adequate intake.
- If oral intake or enteral feeds are not tolerated or if extremely aggressive therapy is
required, parenteral nutrition and IV lipids may be used.
- To prevent essential fatty acid (EFA) deficiency, EFA should represent 2-4% of
calories. Good sources of essential fatty acids include sunflower, safflower,
flaxseed, and canola oils.
o Monitor for essential fatty acid (EFA) deficiency; an elevated triene:tetraene
ratio is indicative of deficiency. Signs and symptoms of EFA deficiency
include skin lesions, eczema, impaired wound healing, thrombocytopenia,
and growth problems.
- A therapeutic vitamin and mineral may need to be provided to ensure adequate
micronutrient delivery.

70
Table 6.10 Food Selection Guidelines for a Restricted Fat Diet

Food Group Recommended Avoid Tips
Grains
Fat-Free and Low-
Fat: bread, pasta,
cereals, rice, barley,
and crackers
Breads with eggs or
cheese, granola
cereal, cereal with
nuts, biscuits,
waffles, pancakes,
croissants, muffins,
doughnuts, high fat
crackers
Try French bread, pita
bread, plain bagels,
bread sticks, puffed
rice and Rice Krispies.
Fruits
Fresh, frozen,
canned, or dried
fruit, juices
Avocado, coconut Use as snacks
Vegetables
Fresh, frozen, or
canned vegetables
Vegetables with
added fat, cream, or
cheese sauce, fried
vegetables
Cook in broth or
sprinkle with herbs and
spices to add flavor
Dairy
Skim milk, nonfat
cheese, nonfat
yogurt, nonfat
cottage cheese, fat-
free sour cream or
cream cheese
1%, 2%, whole, or
flavored milk,
buttermilk, cream,
and regular
processed cheeses
Whole milk can be
substituted with skim
milk, evaporated skim
milk, or nonfat yogurt
Protein
Egg whites,
powdered egg
whites, lean cuts of
beef, pork, lamb,
veal, poultry without
skin, fresh, frozen,
or canned fish in
water, nonfat tofu,
no added fat beans
Fried, fatty, or
heavily marbled
beef, poultry, fish
canned in oil,
luncheon meats,
pizza, nuts, peanut
butter
Broil, roast, grill, or boil
proteins, trim all visible
fat before cooking, use
natural juices instead
of gravies and sauces
Other
Fat-free broths or
soups, fruit ice,
popsicles, gelatin,
angel food cake,
graham crackers,
nonfat desserts,
honey, hams, jellies,
syrups, hard candy,
soda, fruit drinks
Cream or cheese
sauces or soups,
gravy, mayonnaise,
cakes, cookies,
pies, and ice cream,
coconut, chocolate,
creamed candy,
candy with nuts,
chips, buttered
popcorn
Try lemon juice,
vinegar, garlic, onion
powder, fat-free
margarine, fat-free
dressings, fat-free
mayonnaise, and
marshmallows.

71
Burns (19-21)

Burns create an extreme state of physiologic stress; hypermetabolism is multifactorial and is
due to increased circulating cytokines, catecholamines, glucagon, and cortisol; evaporative
losses from burn wounds; and infectious complications. Patients with burns have elevated
calorie, protein, fluid, and micronutrient needs.

Nutrition Goal: To provide adequate nutrition (including adequate calories, protein, fluid, and
micronutrients) to blunt the hypermetabolic response, reduce lean body mass wasting,
induce positive or neutral nitrogen balance, and promote wound healing.


Estimated Needs

- See Table 3.10 for predictive energy expenditure equations.
- Patients older than 6 months of age with >30% body surface area burned (BSAB)
should receive 20-23% of calories from protein (2.4-4 g/kg protein).
o Protein needs can also be determined by RDA for age + 1 gram of protein per
% BSAB.
o Monitor fluid status and BUN when giving large amounts of protein; watch for
signs of azotemia, hyperammonemia, and acidosis.
- Maintenance fluids for burn patients can be calculated as follows:
2
1500 ml x m2
Total maintenance fluids = (35 % burn) x m (ml/hr)
24 hours
+ +

Interventions

- Snacks and high-protein nutrition supplements are often needed to meet needs in
those taking oral nutrition.
- Enteral nutrition supplementation should be considered in those not able to meet
needs orally, including those with >20% BSAB, facial injury, or inhalation injury.
- The daily wound care/sedation schedule will need to be considered, as patients
are generally NPO a few hours prior to sedation.
- All children should receive an age-appropriate multivitamin. Those with burns >
20% BSAB should receive additional micronutrient supplementation according to
Table 6.11.

Table 6.11 Micronutrient Supplementation for >20% BSAB

< 3 years old > 3 years old
Ascorbic acid 250 mg twice daily 500 mg twice daily
Vitamin A 5,000 IU daily 10,000 IU daily
Zinc sulfate 220 mg daily
(~50 mg elemental zinc)
100 mg daily
(~25 mg elemental zinc)


72
Refeeding Syndrome (22-28)

Refeeding syndrome is a constellation of hypokalemia, hypomagnesemia, and
hypophosphatemia that occurs with aggressive nutritional repletion of patients who are
severely malnourished, underweight, or starved. Refeeding syndrome can result in severe
neurologic, cardiac, respiratory, and hematologic abnormalities, and even death.

At-risk patients include those with:
- Classic marasmus/kwashiorkor
- Anorexia nervosa
- Chronic diseases causing undernutrition (cancer cachexia, Crohns disease, cystic
fibrosis, HIV)
- Acute weight loss of 10% within the past 1-2 months (even in the presence of
morbid obesity)
- <80% ideal body weight for height
- Arm anthropometrics less than the 5
th
percentile for age
- Unfed for 7-14 days with evidence of stress/depletion
- Prolonged IV hydration without provision of sufficient calories and protein
- Failure to thrive due to starvation/neglect

Nutrition Goal: To identify patients at risk for refeeding syndrome and to prevent the
metabolic complications of this syndrome while appropriately advancing nutrition support
therapy to adequate levels.



- Serum electrolytes, particularly potassium, phosphorus, and magnesium must be
assessed, and should ideally be corrected with IV supplementation before
beginning nutrition support. Electrolytes should be checked, initially, 2-3 times
daily, and when the patient is more stable, can be checked once daily or once
every other day.
- Patients should receive an ECG to obtain baseline cardiac rhythm and check for
arrhythmias.

Estimated Needs/Interventions

- Calories should begin at 50% of BEE or 80% of current caloric intake. Increase by
10-15% per day to a goal. Daily intakes should be based on actual (not goal)
intake from the day prior. Goal calories should be based on catch-up growth
calculations or estimated basal needs, plus a factor for weight gain, if desired.
- Protein should begin at 50-75% of goal levels, with a gradual increase to goal.
Goals may be based on catch-up growth calculations, if accelerated weight gain is
desired.
- Fluid requirements are 75% of maintenance levels in severely malnourished
patients, to prevent cardiac overload.

73
- Electrolyte requirements for parenteral nutrition in at risk patients are:
o Na 1 mEq/kg/day
o K 4 mEq/kg/day
o Mg 0.6 - 1.2 mEq/kg/day
o Phosphate 3-4 mEq/kg/day for infants, 1-2 mEq/kg/day for toddlers and
adolescents
o Adjust as needed per laboratory values
- Standard vitamin/mineral supplementation is prudent:
o Standard dosage for Peds or Adult MVI or trace element solutionin TPN (See
Chapter 7)
o Enteral nutrition: provide 1 ml multivitamin drops + DRI for folic acid
o Oral nutrition: provide childrens multivitamin with minerals for children over 4


74
References

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th
edition.
Baltimore, MD: Lippincott, William & Wilkins; 2001:324-331.

2. Wessel JJ, Samour PQ. Cardiology. In: Samour PQ, King K, eds. Handbook of Pediatric
Nutrition. 3
rd
edition. Sudbury, MA: Jones and Bartlett Publishers Inc; 2005:407-420.

3. Goodin B. Nutrition issues in cystic fibrosis. Pract Gastroenterol. 2005;27(5):76-94.

4. Woolridge NH. Pulmonary diseases. In: Queen PM, King K, eds. Handbook of Pediatric
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rd
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5. Spinozzi NS. Chronic renal disease. In: Queen PM, King K, eds. Handbook of Pediatric
Nutrition. 3
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edition. Sudbury, MA: Jones and Bartlett Publishers, 2005:3851-390.

6. National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Pediatric
Guidelines, K/DOQI Update 2008. Available at: www.kidney.org. Accessed May 10, 2010.

7. Belay B, Esteban-Cruciani N, Walsh CA, Kaskel FJ. The use of levo-carnitine in children
with renal disease: a review and a call for future studies. Pediatr Nephrol. 2006;21:308-
317.

8. Crill CM, Helms RA. The use of carnitine in pediatric nutrition. Nutr Clin Pract.
2007;22:204-213.

9. Abad-Jorge A, Roman B. Enteral nutrition management in pediatric patients with severe
gastrointestinal impairment. Support Line. 2007;29(3): 3-11.

10. Abad-Sinden A, Sutphen J. Nutritional management of pediatric short bowel syndrome.
Pract Gastroenterol. 2003;12(12):28-48.

11. Serrano MS, Schmidt-Sommerfeld E. Nutrition support of infants with short bowel
syndrome. Nutrition. 2002;18(11-12):966-970.

12. Wessel JJ. Short bowel syndrome. In: Groh-Wargo S, Thompson M, Hovasi Cox J, eds.
Nutritional Care for High-Risk Newborns. Chicago, IL: Precept Press; 2000:469-487.

13. Suddaby EC, Schiller S. Management of chylothorax in children. Ped Nurs. 2004;30(4):
290-295.

14. Chan EH, Russell JL, Williams WG, et al. Postoperative chylothorax after cardiothoracic
surgery in children. Ann Thorac Surg. 2005;80:1864-1871.

15. McCray, S, Parrish CR. When chyle leaks: nutrition intervention. Practical Gastroenterol.
2004;28(5):60.

75

16. Hamdan MA, Gaeta ML. Octreotide and low-fat breast milk in postoperative chylothorax.
Ann Thorac Surg. 2004;77: 2215-2217.

17. Cormack BE, Wilson NJ, Finucane K, West TM. Use of monogen for pediatric
postoperative chylothorax. Ann Thorac Surg. 2004;77:301-305.

18. Pettei MJ, Saftary S, Levine JS. Essential fatty acid deficiency associated with the use of
a medium-chain-triglyceride infant formula in pediatric hepatobiliary disease. Am J Clin
Nutr. 1991;53:1217-1221.

19. Mayes T, Gottschlich MM, Warden GD. Clinical nutrition protocols for continuous quality
improvements in the outcomes of patients with burns. J Burn Care Rehabil. 1997;18:365-
368.

20. Rodriguez DJ. Nutrition in patients with severe burns: state of the art. J Burn Care
Rehabil. 1996;17:62-70.

21. Gottschlich MM, Mayes T. Nutrition in the Burned Pediatric Patient. In: Samour PQ, King
K, eds. Handbook of Pediatric Nutrition. 3
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edition. Sudbury, MA: Jones and Bartlett
Publishers Inc; 2005:483-498.

22. Dunn RL, Stettler S, Mascarenhas MR. Refeeding syndrome in hospitalized pediatric
patients. Nutr Clin Pract. 2003;18:327-332.

23. Katzman DK. Medical complications in adolescents with anorexia nervosa: a review of the
literature. Int J Eat Disord. 2005;37:S52-S59.

24. Afzal NA, Addai S, Fagbemi A, Murch S, Thomson M. Heuschkel R. Refeeding syndrome
with enteral nutrition in children: a case report, literature review and clinical guidelines.
Clin Nutr. 2005;21:515-520.

25. de Menezes FS, Leite HP, Fernandez J, Benzecry SG, de Carvalho WB.
Hypophosphatemia in children hospitalized within an intensive care unit. J Intensive Care
Med. 2006;21:235-239.

26. Mezoff AG, Gremse DA, Farrell MK. Hypophosphatemia in the nutritional recovery
syndrome. AMDC. 1989;143:1111-1112.

27. de Menezes FS, Leite HP, Fernandez J, Benzecry SG, de Carvalho WB.
Hypophosphatemia in critically ill children. Rev Hosp Clin Fac Med S Paulo. 2004;59:306-
311.

28. Worley G, Claerhout SJ, Combs SP. Hypophosphatemia in malnourished children during
refeeding. Clin Pediatr. 1998;37:347-352.

76
Chapter 7 Parenteral Nutrition

77
Chapter 7

Parenteral Nutrition

Introduction

Pediatric patients who are unable to meet their nutritional needs to promote growth and
development via the oral or enteral route will require parenteral nutrition (PN) support (1).
Preterm infants under 2000 g who are unable to be started on enteral feeds should be
started on parenteral nutrition by no later than day of life 2-3.

Pediatric patients who may require parenteral nutrition for either total or partial nutritional
support include the following clinical examples (1-3):
- Gastrointestinal (GI) anomalies
- Necrotizing enterocolitis
- Inflammatory bowel disease
- Intractable diarrhea
- Short gut syndrome
- Extreme prematurity with gut dysmotility and severe respiratory distress
- Cancer in the presence of underlying malnutrition and/or requiring intensive
chemotherapy; inability to tolerate enteral feedings
- Critical illness (trauma or sepsis) in the face of ileus, abdominal trauma or persistent
GI intolerance

Peripheral vs. Central Parenteral Nutrition

In general, pediatric patients who will require parenteral nutrition for less than 2 weeks or
neonates with adequate peripheral venous access and who are able to tolerate at least 140
150 ml/kg may be managed with peripheral parenteral nutrition (PPN). Generally a
maximum solution osmolality of 1000 - 1200 mOsm/L is recommended for PPN (4-8).

Pediatric patients who will require parenteral nutrition for greater than 2 weeks or those with
GI anomalies and surgery will require central parenteral nutrition (CPN). Percutaneously
inserted central catheters (PICC) lines are used for the infusion of parenteral nutrition.
These lines are inserted by nurses in the NICU or by trained physicians. Generally, the lines
are inserted via a vein in the antecubital area. Any concentration of dextrose may be given
through PICC lines. Alternatively, pediatric patients who are not good candidates for PICC
lines or those for which attempts at PICC line placement were unsuccessful, may receive
surgically placed central lines for CPN.


78
Guidelines for Initiation & Advancement of Parenteral Nutrition (1-13)

For a complete review of pediatric parenteral nutrition requirements, please refer to Chapters
3 and 4.

Use of Dextrose and Insulin

1. Preterm Infants: Begin dextrose at 4 6 mg glucose/kg/min and advance by 1 - 2
mg glucose/kg/min or 1 2% per day to an endpoint goal of:
- D15 25% for CPN
- D10 12.5% for PPN
The endpoint goal should be sufficient to meet, but not exceed, nutritional
requirements. In general, preterm infants on PN should not receive carbohydrate
loads in excess of 12 mg glucose/kg/minute.

2. Term Infants and Children: Begin PN at 10 15% dextrose depending on whether
the line is peripheral or central and the clinical status and age of the child. Advance
by 2.5 5% in older infants and children and by 5 10% per day in adolescents until
an endpoint of D10 12% dextrose for PPN or generally between 20 25% dextrose
for CPN, as needed to meet nutritional needs.
a. In general, the carbohydrate load in children through adolescents generally falls
in the range of 6 14 mg glucose/kg/min (9).
b. Specific recommendations include (10):
i. Term infants 5-15 mg/kg/min
ii. 1-3 years 5-12 mg/kg/min
iii. 4-6 years 5-11 mg/kg/min
iv. 7-10 years 6-10 mg/kg/min
v. 11-18 years 4-7 mg/kg/min

3. Glucose Infusion Rate (GIR): To minimize the risk of hyperglycemia, overfeeding
and hepatic dysfunction including fatty liver and cholestasis, GIR should not exceed
the values presented above. GIR can be calculated as follows:

GIR = Rate of TPN x % Dextrose
Wt (kg) x 6

4. Blood glucose should be monitored daily via a Basic Metabolic Profile prior to
advancing the % dextrose in the PN solution.

5. Provision of excess carbohydrate calories may lead to the following adverse effects:
- Hyperglycemia Glycosuria
- Hepatotoxicity Osmotic diuresis
- Cholestasis Post infusion hypoglycemia

6. Insulin Use: Preterm or term infants with persistent hyperglycemia allowing only
maintenance calories (70-75 kcal/kg) for > 2 weeks or resulting in inadequate weight
gain and growth may need to be started on a continuous insulin infusion. Insulin
infusion is usually started at 0.05 unit/kg per hour. Blood glucose levels should be

79
checked hourly initially for the first 8 12 hours and the insulin infusion rate adjusted
accordingly to reduce and maintain blood glucose level between 90 150 mg/dL.
With older children and adolescents, insulin may be added using the sliding scale
method, initially for management, and then adding 2/3 of the previous days insulin
requirement to the bag of PN (12). Alternatively, insulin may be added to the PN bag.
For adults, recommended insulin dosages are 1 unit for every 10 or 15 grams of
dextrose in the PN solution (13); however, for children, it may be more prudent to start
at a conservative dose of 1 unit of regular insulin per 20 30 g of dextrose.

Use of Protein

1. Preterm infants and term infants under 2 years of age should be started on a pediatric
parenteral amino acid solution such as TrophAmine (B. Braun). This amino acid
formulation for pediatric patients provides the following advantages:
- Provides essential amino acids for infants e.g. histidine, taurine
- Promotes plasma amino acid profiles within normal neonatal target range
- Decreases the tendency for development of cholestasis
- Addition of cysteine hydrochloride, a conditionally essential amino acid in preterms,
decreases the pH of the solution thus improving calcium and phosphorus solubility

2. Table 7.1 outlines initiation and advancement for parenteral protein.

Table 7.1 Protein Advancement in Infants (Preterm and Term) and Children

Birthweight Begin Advance By Endpoint Goal
<1 kg 2 kg
>2 kg preterm
Term infants
2 g/kg
2-3 g/kg
2.5 -3 g/kg
1 g/kg
1-1.5 g/kg
---
3.5 4 g/kg
3 - 3.5 g/kg
2.5 - 3.5 g/kg
- May go up to 4 g/kg in preterms with increased needs: post-surgery, bowel perforation
- Do not decrease the protein in TPN with moderate elevations in BUN; generally <50.

3. The protein concentration in peripheral parenteral nutrition should not exceed 30 - 35
g protein/L or no more than 2.5 - 3 g protein/kg in infants in order to maintain the
solution osmolality within the recommended range.

4. Provision of excess protein via PN may result in the following adverse effects:
- Azotemia
- Metabolic acidosis possibly secondary to cysteine in the PN
- Serum amino acid imbalance
- Hyperammonemia
- Possible hepatotoxicity, cholestasis

5. Blood urea nitrogen and creatinine should be monitored daily initially via a Basic
Metabolic Profile until the full protein intake goal is reached. An elevated BUN in the
face of a normal serum creatinine may not be indicative of excess protein intake, but
rather fluid restriction and intravascular depletion. General monitoring guidelines for
pediatric patients on PN will be discussed further in a forthcoming section.


80
Use of Lipids

1. Lipids may be safely used on a daily basis in most patients. Begin lipids at 0.5 - 2.0
g/kg and advance by 0.5 - 1.0 g/kg per day depending on a childs age and lipid
clearance to the appropriate endpoint goal. Lipids should be advanced as follows:

a. Preterm and Term Infants see Table 7.2

Table 7.2 Lipid Initiation and Advancement in Term and Preterm Infants

b. Children and Adolescents Begin 20 % IL at 1 - 2 g/kg and advance by 1 g/kg per
day to a goal of 1 2.0 g/kg per day depending on age and clinical status.

2. Intravenous fat emulsion, which is only available as 20% Intralipid (2 kcal/ml) at UVA
Health System should be provided at least a minimum dose of 0.5 - 1.0 g/kg per day
or for provision of essential fatty acid (EFA) requirements. Signs of EFA deficiency
include:
- reduced growth rate
- impaired wound healing
- increased susceptibility to infections
- thrombocytopenia
- flaky dry skin
- poor hair growth

3. Intravenous lipids should be used with caution in infants and children under the
following conditions:
- Severe hyperbilirubinemia in preterm infants
- Presumed sepsis in light of deteriorating clinical status or confirmed sepsis; once
an infants blood cultures have been confirmed to be negative for 48 hours and if
triglycerides are within normal limits, lipids should be increased gradually back up
to goal of 3.0 g/kg.
- Hyperlipidemia with serum triglycerides >250.
Even under these conditions, the minimal amount of lipids for provision of EFA
needs of 0.5 - 1 g/kg may be safely administered.

4. Monitoring:
a. Check triglyceride levels weekly for infants and children on PN by selecting serum
triglycerides along with the Hepatic Panel A profile in the other pediatric units.
b. Check triglyceride levels after each 1.0 g/kg increase and then weekly in: a) infants
< 28 weeks gestational age or, b) infants with birthweights < 1.0 kg while on TPN.
c. Managing Elevated Serum Triglyceride Levels (UVA Guidelines):
- If triglyceride > 250 but < 300, decrease lipids by 1.0 g/kg, then recheck
Birthweight Begin Level Advance By Endpoint Goal
< 1000 grams 0.5 g/kg 0.5-1 g/kg 3.0 g/kg
> 1000 grams &
Term Infants
1.0 2.0 g/kg 1.0 g/kg 2.5 - 3.0 g/kg

81
- If triglyceride > 300, decrease lipids to 0.5 - 1 g/kg for EFA, then recheck
- If triglyceride > 400, stop the Intralipid, recheck, and once < 300 restart at
0.5 g/kg for provision of EFA needs

Electrolytes (1, 4, 8)

Electrolytes, particularly sodium, potassium, chloride, calcium, phosphorus and
magnesium should be ordered as per the guidelines found in the Table 7.4 Parenteral
Nutrition Guidelines in Pediatric Patients in mEq/kg or mEq per total volume
depending on the ordering pathway chosen (neonatal versus pediatric).

Acid-Base Balance

In pediatric PN at UVA, the amount of chloride required is included as part of the PN
order. Acetate amount is not delineated in the order; the amount of acetate added to the
PN bag will be calculated in the compounding pharmacy based on the amount of anions
needed to balance ordered cations.

There is an option to minimize chloride/maximize acetate OR maximize chloride/minimize
acetate in the ordering system. In this case, the minimized ion will be left out of the PN
bag, even if an amount has been ordered (ie, if 30 meq of chloride are ordered, but
minimize chloride/maximize acetate is selected, no chloride will be added). The clinician
should take care to understand use of minimize/maximize options, as using these can
cause large fluctuations in the amounts of anions given in the PN.

Guidelines:
- If serum bicarbonate is < 18 and the child is acidotic, then maximize
acetate/minimize chloride in the PN solution.
- If serum bicarbonate is > 27 and the child is alkalotic, then minimize
acetate/maximize chloride in the PN solution.
- If the serum bicarbonate is within normal range, then select none of the above,
the chloride and acetate in the PN solution will be balanced based on the chloride
order.

Calcium and Phosphorus Requirements (1, 14, 15)

Particular attention needs to be given to the ordering of calcium and phosphorus in
preterm infants to promote bone mineralization while preventing calcium-phosphorus
precipitation in the PN solution. The recommended parenteral calcium and phosphorus
intake for infants and children is given in Table 7.3.

- The optimal Calcium to Phosphorus ratio for preterm and term infants is 1.3 - 1.7:1
by weight, which is a 1 1.3:1 molar ratio.
- The combined total of calcium and phosphate (0.5 mMol phos = 1 mEq) cannot
exceed 5.2 mEq/100 ml using a standard amino acid preparation or 7.2 mEq/100

82
ml using TrophAmine.
- Calcium and phosphorus should be advanced daily, as tolerated, in preterm infants
to meet their increased requirements and to minimize the risk for osteopenia of
prematurity.
- If the ionized calcium is > 6.0, the calcium in the PN may be slightly decreased,
while optimizing the phosphorus. Once the serum Calcium is within normal limits,
continue to advance the calcium in the PN to meet goals.

Table 7.3 Recommended Parenteral Calcium & Phosphorus Intake

Recommended Intake Calcium (mEq/kg) Phosphorus (mMol/kg)
Preterm, Term Infants 3.0 - 4.0 1.5 - 2.0
Older Children (10-40 kg) 1.0 - 3 0.5 1.5
Adolescents (>40 kg) 1.0 - 1.5 0.5 0.75

Guidelines for Ordering Protein, Calcium and Phosphorus to Prevent Precipitation

For every 100 ml/kg of PN solution, the following can be added:
- 4 g/kg TrophAmine
- 4 mEq/kg Calcium
- 1.5 mMol/kg Phosphorus


83

Table 7.4 Parenteral Nutrition Guidelines in Pediatric Patients

84
Pediatric Vitamins, Trace Elements and Minerals (1, 2, 4, 14)

Pediatric patients on parenteral nutrition will receive all or a portion of the 5 ml vial of
Pediatric MVI solution (Astra Pharmaceuticals), depending on their weight as follows:
- Infants < 2.5 kg: Use 2 ml/kg
- Infants and children > 2.5 kg: Use 5 ml
- Children > 40 kg: Use 10 ml Adult MVI solution (needs to be a type-in additive);
may need to add 60 75 mcg of vitamin K to meet pediatric requirements.

Table 7.5 Pediatric MVI Solution (Astra Pharmaceuticals)

Vitamin Amount (per 5 ml)
Ascorbic Acid 80 mg
Vitamin A 2300 IU
Vitamin D 400 IU
Thiamine 1.2 mg
Riboflavin 1.4 mg
Pyridoxine 1 mg
Niacinamide 17 mg
Pantothenic Acid 5 mg
Vitamin E 7 IU
Folic Acid 140 mcg
Vitamin B12 1 mcg
Biotin 20 mcg
Vitamin K 0.2 mg

Trace element dosing is also based on patient weight:
- A total of 0.2 ml/kg/day should be used for children up to 5 years of age.
- An additional 100 mcg/kg of zinc is added to the PN solution of preterm infants <
2.5 kg and in infants through 5 kg following open heart surgery.
- Add an additional 50 100 mcg/kg of zinc for post-operative heart surgery infants
< 15 kg.
- Children > 40 kg, use Adult Trace Element Solution (ATES), which has selenium.
As such, selenium does not need to be ordered separately using the Peds PN
Pathway.

Table 7.6 Pediatric Trace Element Solution (PTES)
(American Regent Neonatal)

Trace Element Content (per 0.2 ml)
Zinc 300 mcg
Copper 20 mcg
Chromium 0.17 mcg
Manganese 5 mcg


85
Special considerations for adjustments in the use of pediatric multivitamin and pediatric trace
elements include the following:
- Zinc: If child has increased diarrhea or ileostomy, add 10 mcg/ml of output
(maximum of 5000 mcg/day)
- Copper: In biliary obstruction/cholestasis, omit (16) or reduce by 50% (3)
- Chromium: In renal insufficiency, omit (16) or reduce (3)
- Manganese: In biliary obstruction/cholestasis, omit (16) or reduce by 50% (3)
- Selenium: In renal insufficiency, omit (16) or reduce (3)
- When omitting copper and manganese due to cholestasis, the PTES solution
should be held, and additional zinc and chromium should then be added as a
separate additive.

Selenium (14)

Selenium should be administered to all infants and children on PN for > 4 weeks at a level of
1 - 2 mcg/kg/day. In the NICU, all preterm infants and neonates will automatically receive 2
mcg/kg/day. Selenium should be decreased in renal insufficiency.

Selenium deficiency may occur in children receiving long term selenium free TPN. Severe
deficiency leads to:
- cardiomyopathy
- skeletal muscle tenderness/pain
- erythrocyte macrocytosis
- loss of pigmentation of hair and skin

Carnitine (8, 14)

Carnitine is essential for optimal oxidation of fatty acids in the mitochondria. In the healthy
child, carnitine is synthesized in the liver and kidney from the precursors, lysine and
methionine. Preterm infants < 34 weeks gestational age or those that are SGA on PN may
develop carnitine deficiency within 6 10 days. Clinical signs of carnitine deficiency include
the following:
- cardiomyopathy
- encephalopathy
- nonketotic hypoglycemia
- hypotonia
- poor growth

Carnitine supplementation has been demonstrated to normalize serum carnitine, improve
fatty acid metabolism and improve nitrogen balance. Whether preterm infants on PN for a
period greater than 4 weeks should be placed on carnitine supplementation remains
controversial at this time. Infants or children with persistent hyperlipidemia on long-term
TPN, in the absence of other precipitating factors, may benefit from carnitine
supplementation at a dose of 10 - 20 mg/kg/day.

86
Parenteral Iron (14)

The use of iron dextran (Imferon) in PN continues to be controversial owing to the potential
for the following adverse effects:
- potential for increased risk of gram negative septicemia.
- potential for hyersensitivity reaction (anaphylaxis); patients with a history of
asthma or other allergies may be at higher risk for anaphylactic reaction.

Infants or children on long term PN or those with documented iron deficiency anemia may
receive iron dextran according to the following administration guidelines:

1. When initiating therapy, full precautions should be followed including having
epinephrine, methylprednisolone, intubation equipment at the bedside. A person
skilled in intubation should be available to respond to any anaphylactic response.

2. A test dose of 12 - 25 mg may be given over 5 -15 minutes followed by an hour of
observation period to identify any adverse response.

3. Monitor the infant or child throughout the administration of the first dose as delayed
reactions may occur.

4. Recommended Periodic Supplementation for Patients on TPN: At UVA Health
System, we have had some success using periodic administration in our patients
on chronic TPN therapy. Use of iron supplementation for a 1 - 3 week period every
2 - 4 months appears adequate for most children.
- Dose: 0.5 - 0.8 mg/kg/day in the PN
- Imferon can be ordered as a separate additive.
- Check indices of iron status prior to and at the end of the treatment
including: hemoglobin, hematocrit, MCV, MCHC, serum iron and ferritin.

Ordering Pediatric Parenteral Nutrition

PN for pediatric patients may be ordered via two pathways in Epic:
- Neonatal (<10 kg)
- Pediatric (>10 kg)

The pediatric nutritionists for the NICU, PICU and the pediatric floors may order PN as a
pended order, which must be released by a physician.

The neonatal nutritionist will work with the neonatal nurse practitioners to educate new
interns on the ordering of PN in the NICU on a monthly basis. The neonatal nutritionist is
available to assist interns and residents with the ordering of PN for NICU infants, as needed.


87
Monitoring of Pediatric Patients on Parenteral Nutrition (4, 11, 17)

Pediatric patients on PN should be monitored according to the following schedule:

Table 7.7 Monitoring Guidelines for Pediatric Patients on PN

Adapted from Reference 16
* Electrolytes should be checked daily for the first 1-2 weeks until stable, then twice weekly.
** Weekly PN labs may be decreased to biweekly to monthly once the child is stable.

At UVA Health System the following labs may be easily collected using the following lab
order sets:

Table 7.8 Lab Order Sets for Pediatric Patients on PN (UVA-HS)

Unit Daily Lab Sets Weekly Lab Sets
Pediatric Units
PICU
Basic Metabolic Panel
Phosphorus/Magnesium

Hepatic Panel A
Triglycerides
Prealbumin (to assess disease acuity, if needed)
NICU

Basic Metabolic Panel
Phosphorus/Magnesium
CMP (includes albumin, triglycerides, AST/ALT,
Alk phos & conjugated bilirubin)
Parameter Initial/Daily* Weekly** As needed
Anthropometrics
Weight X
Length X
Head circumference X (for < 3 y.o.)
Metabolic/Serum
Sodium/chloride X
Potassium X
Bicarbonate X
BUN/creatinine X
Glucose X
Calcium/Phosphorus X
Ionized calcium X
Magnesium X
Prealbumin/CRP X
Triglycerides X
Liver function tests
(including AST/ALT/Alk
Phos/total bilirubin)
X
Conjugated bilirubin X
Trace elements: Copper,
zinc, whole blood
manganese, selenium,
chromium
X
(Quarterly in
long-term
patients)
Vitamin D X
Iron studies X
Blood cultures X

88

Managing Metabolic and Long Term Complications of Parenteral Nutrition

While parenteral nutrition can provide optimal nutritional therapy for infants and children
whose GI tracts cannot be effectively used, the health care professional needs to become
knowledgeable of the numerous potential complication which can arise and how to manage
them. Infants and children on PN should be monitored regularly according to the above
recommended guidelines. Most complications can be avoided or effectively managed
through careful biochemical monitoring and timely intervention. Complication rates can also
be minimized when PN is administered according to the established protocols by health care
professionals who have been trained in administration and delivery of PN therapy (12, 16).

Metabolic complications may be generally presented according the following categories (4,
17):
- Glucose metabolism
- Protein metabolism
- Lipid metabolism
- Mineral and electrolyte metabolism
- Bone demineralization
- Hepatic dysfunction and failure

Cyclic PN (18)

Infants and children on long-term PN, may benefit from cyclic PN infused over 12-20 hours.
Constant infusion of dextrose solutions results in high circulating insulin levels which can
result in lipogenesis, hepatomegaly, fatty liver and increased risk of cholestasis. Advantages
of cyclic PN include:
- mobilization of fat and glycogen stores
- decreased incidence of cholestasis
- increased time for physical activity

Cyclic TPN is rarely used in neonates due to the concern of hypoglycemia. However, in
metabolically stable infant, cyclic PN can be introduced as follows (16):
- Incremental advancements of TPN break or window by 1-2 hour increments to a
16-20 hour delivery time.
- Taper on and taper off period for - 1 hour at the full TPN rate to minimize the
risk of hypo or hyperglycemia.
- Blood glucose may need to be checked 1-2 hours after TPN is turned off to ensure
euglycemia, per unit protocol.

89
Table 7.9 Managing Complications of Pediatric Parenteral Nutrition (12, 14, 17)

Metabolic Complication Possible Causes Management
Glucose Metabolism
Hyperglycemia, glucosuria,
osmotic diuresis

Excessive glucose administration, prematurity
& insulin resistance
Stress response
- Monitor blood glucose frequently
- Decrease PN rate or % dextrose
- May need to begin insulin therapy,
begin at 0.05 units/kg/hr
Hypoglycemia Excess insulin production (i.e. IDM infants); too
rapid weaning of dextrose solution
- Monitor blood glucose frequently
- Increase PN rate or % dextrose
- Wean PN gradually on cyclic PN
Protein Metabolism
Hyperammonemia

Liver disease or hepatic immaturity
Excess intake of amino acids (usually > 3 g/kg)
Inborn errors of protein metabolism
- Monitor serum ammonia, protein
intake and albumin status
- May need to decrease protein intake

Prerenal Azotemia Excessive protein intake (particularly in VLBW
infants with immature renal systems
Intravascular volume depletion
- Lower protein intake by 0.5 1 g/kg
- Monitor BUN and creatinine
- Provide adequate calories
- Increase fluid delivery
Lipid Metabolism
Hyperlipidemia Excess fat delivery (> 3 g/kg); rapid infusion of
lipid (in < 18 hours), infection, stress, preterm
(especially SGA infants), excess glucose
intake
- Monitor serum triglyceride levels
- Decrease IV lipids by 1-2 g/kg
- Administer lipids slowly; in preterms,
deliver over 24 hours, preferably
Essential Fatty Acid Deficiency

Inadequate provision of EFA (linoleic)
Administration of long term fat free PN
- Provide minimal fat for EFA needs:
0.5-1 g/kg
Hyperbilirubinemia Excess lipid infusion may promote the
displacement of bilirubin from albumin binding
sites
- Limit lipid infusion to no more than
1-1.5 g/kg in the face of clinically
significant hyperbilirubinemia


90
Table 7.9 Managing Complications of Pediatric Parenteral Nutrition (12, 14, 17), Continued

Metabolic Complications Possible Causes Management

Hepatic Dysfunction and Hepatic
Failure
Excess caloric and carbohydrate
delivery, excess protein as well as
vitamin and mineral intake have all
been suggested as possible etiological
causes of hepatic dysfunction

Lack of enteral feeding/stimulation
results in decreased bile flow

Lack of cycling the parenteral nutrition

Phytosterols in soybean based lipid
emulsion
-Monitor glucose, protein and total
caloric delivery. Maintain caloric
delivery at optimal level for infant
(may need to decrease % dextrose).
-Use pediatric amino acid solution.
-Cycle PN for older infants or cycle
with a lower dextrose IV solution
-Start enteral feedings (even if trophic)
as soon as clinically feasible
-If cholestatic, remove manganese
and copper from the solution (PTES)
-Monitor liver function tests weekly.
- Consider rescue use of fish-oil-
based lipid emulsions in place of
soybean based lipid emulsions.

Bone Demineralization Inadequate calcium, phosphorus
and/or vitamin D intake in the PN
solution, leading to metabolic bone
disease, fractures, elevation in alkaline
phosphatase
Lack of adequate cycling of the PN
Excess diuretic dosing.
-Monitor serum calcium, phosphorus,
ionized calcium, serum alkaline
phosphatase. Optimize calcium and
phosphorus intake at optimal
parenteral ratios: 1.3-1.7:1 by weight
or 11.3:1 (molar ratio)


91


Mineral and Electrolyte Metabolism
Electrolyte imbalance

General imbalance of sodium,
potassium, and chloride are commonly
seen in preterm infants during the 1
st

week of life. Other causes include
losses from diarrhea, renal disease or
medication therapies

- Depending on extent of the
imbalance, may need to replace
electrolyte via and IV solution
- Adjust electrolytes in the PN solution,
daily, as indicated

Hypokalemia

Inadequate potassium delivery relative
to requirements; diuretic treatment;
treatment with Amphotericin B, beta-
adrenergic agonists (i.e. Terbutaline)

- Monitor serum potassium daily
- Adjust potassium in the PN solution
- Alter medication profile, if appropriate

Hyperkalemia

Excessive potassium administration,
metabolic acidosis, renal insufficiency

- Monitor serum potassium daily.
- Decrease potassium in the PN
Solution

Hypophosphatemia High glucose infusions, refeeding
syndrome in previously malnourished
children, inadequate phosphorus
administration

- Monitorsserum phosphorus daily
- Increase phosphorus content of PN
Solution

Hyperphosphatemia

Excessive phosphorus administration,
Impaired renal functions, PTH
deficiency

- Decrease phosphorus content of PN
solution. Monitor phosphorus and
calcium intake and status

Hypocalcemia

Inadequate calcium intake in PN;
diurectic administration (i.e.
furosemide); PTH deficiency;
inadequate magnesium intake.
- Gradually increase the calcium
content of the PN solution


92


Hypercalcemia

Excessive calcium intake, imbalance in
calcium and phosphorus intake with
resulting excess PTH

- Depending on degree of hyper-
calcemia, may need to decrease
calcium in PN solution. Optimize
phosphorus delivery and achieve
optimal Ca: Phos ratio. Monitor
calcium, phosphorus and alkaline
phosphatase
Hypomagnesemia

Inadequate magnesium intake relative
to requirements, refeeding syndrome
in previously malnourished pediatric
patient, chronic diarrhea, Amphotericin
B administration

- Monitor serum magnesium daily.
- Increase magnesium in the PN
solution

Hypermagnesemia

Excessive magnesium intake, renal
insufficiency, tocolysis in mother

- Monitor serum magnesium.
- Decrease magnesium in the PN
solution, as needed

Metabolic hyperchloremic acidosis

Excessive chloride content in PN
solution
If metabolic acidosis in the face of
elevations in BUN/Cr, protein load may
be contributing to acidosis

-Increase acetate salts in the PN
solution
- If amino acids playing a role in
acidosis, decrease protein in PN by
0.5 1 g/kg

Metabolic hypochloremic alkalosis Excessive acetate salts in the PN
solution
- Increase chloride content and
decrease acetate content of the PN
- Monitor blood chloride and bicarb
Adapted from Groh-Wargo, S., Thompson, M. and Hovasi-Cox, J. Nutritional Care of High Risk Newborns. Precept Press, 2000; Pg 97-100. (14)
Chapter 8 Pharmacology and Nutrition Support

93
References

1. Baker SS, Baker RD. Parenteral nutrition. In: Walker WA, Goulet O, Kleinman RE,
Sherman PM, Schneider BL, Sanderson IR, eds. Pediatric Gastrointestinal Disease. 4
th

edition. Philadelphia, PA: B.C. Decker, Inc.; 2004:1958-1980.

2. Shwenk WF, Olsen D. Pediatrics. In: Gottschlich M, Fuhrman MP, Hammond KA,
Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition Support A Case-
Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Dubuque,
IA: Kendall/Hunt Publishing Co.; 2001:347-372.

3. Reiter, P. Thureen, P.F. Nutrition Support in Neonatology. In: Gottschlich M, Fuhrman
MP, Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition
Support A Case-Based Core Curriculum. American Society for Parenteral and Enteral

4. Cox JH, Melbardis IM. Parenteral Nutrition. In: Samour PQ, King K, 3
rd
edition.
Handbook of Pediatric Nutrition. Sudbury, MA: Jones and Bartlett Publishers Inc;
2005:525-558.

5. Isaacs JW, Millikan WJ, Stackhouse J, et al. Parenteral nutrition of adults with a 900
milliosmolar solution via peripheral veins. Am J Clin Nutr. 1977;30:552-559.

6. Correia MI, Guimaraes J, Cirino de Mattos L, et al. Peripheral parenteral nutrition: an
option for patients with an indication for short-term parenteral nutrition. Nutr Hosp.
2004;19(1):14-18.

7. Bodoky A, Zbinden A, Muller J, et al. Peripheral venous tolerance of hyperosmolar
infusion solutions. Helv Chir Acta. 1980;47:151-156.

8. Sapsford A. Parenteral nutrition: energy, carbohydrate, protein and fat. In: Groh-Wargo S,

9. Phillips SK. Pediatric parenteral nutrition. J Infus Nurs. 2004;27(3):166-170.

10. Hovasi Cox J, Mara Melbardis I. Parenteral nutrition. In: Samour PQ, King K, 3
rd
edition.
Handbook of Pediatric Nutrition. Sudbury, MA: Jones and Bartlett Publishers Inc;
2005:483-498.

11. Mirtallo JM. Introduction to parenteral nutrition. In: Gottschlich M, Fuhrman MP,
Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition
Nutrition. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:211 - 224.

12. Matarese LEM. Metabolic complications of parenteral nutrition therapy. In: Gottschlich M,

94

13. Hurley DL, Neven AK, McMahon MM. Diabetes Mellitus. In: Gottschlich M, Fuhrman MP,
Hammond KA, Holcombe BJ, Seidner DL, eds. The Science and Practice of Nutrition

14. Krug SK. Parenteral nutrition: vitamin, minerals and trace elements. In: Groh-Wargo S,

15. Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins,
trace elements, calcium, magnesium, and phosphorus in infants and children receiving
total parenteral nutrition. Am J Clin Nutr. 1988; 48:1324-1342.

16. Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins,
trace elements, calcium, magnesium, and phosphorus in infants and children receiving
total parenteral nutrition: report of the Subcommittee on Pediatric Parenteral Nutrient
Rqeuirements from the Committee on Clinical Practice Issues of the American Society for
Clinical Nutrition. Am J Clin Nutr. 1988;48:1324-1342.

17. Price PT. Parenteral nutrition: administration and monitoring. In: Groh-Wargo S,

18. Collier SB, Crouch J, Hendricks K, et al. Use of cyclic parenteral nutrition in infants less
than 6 months of age. Nutr Clin Pract. 1994; 9:65.


95
Chapter 8

Pharmacology and Nutrition Support

Introduction

Knowledge of a pediatric patients medication profile is important for optimizing nutritional
support intake and delivery. The clinical nutritionist will review each patients medication
profile and determine how these drugs impact nutrition. Topics covered in this chapter
include:
- Common drug-nutrient interactions seen in hospitalized patients
- Medications which should be taken on an empty stomach or those that may be
affected by enteral nutrition
- Medications that are not compatible with parenteral nutrition.
- Calcium and phosphorus balance and solubility in parenteral nutrition solutions
- Electrolyte supplementation via the enteral route
- Critical care medications and nutritional delivery.

Medication Information Resources

- Micromedex This evidence-based clinical information system is available through
the Clinical Portal. Micromedex provides information on drug dosing, administration,
adverse effects, and drug interactions. For IV drugs, it also provides information on
drug compatibility. An on-line tutorial is available on the Micromedex website and the
Health Sciences Library offers classes for those interested in learning more about the
system.
- Websites:
Global RPh www.globalrph.com
General info www.noah-health.org/en/pharmacy/drugs/food.html
FDA www.fda.gov
National Consumers League www.nclnet.org
Natural Standard www.naturalstandard.com
NIH National Center for Complementary and Alternative Medicine
http://nccam.nih.gov/
- For questions or additional information, contact the pediatric pharmacy at 2-0920

Common Drug-Nutrient Interactions Seen in Hospitalized Patients

Interactions between certain foods and drugs may reduce or enhance the effect of the drug.
Preventing and managing drug-nutrient interactions in the clinical setting are pivotal in order
to avoid predisposing patients to treatment failure, toxicity, or life-threatening adverse events.
The following table provides common drugs along with their interactions, mechanism of
action, and therapeutic management.


96
Table 8.1 Common Drugs with Potential Nutrient Interactions

Drug or Class Interaction Mechanism
Therapeutic
Management
ACE Inhibitors
Excessive
potassium intake
Pharmacodynamic
interaction, risk of
hyperkalaemic adverse
effects
Avoid consuming
large quantities of
high potassium foods.
Digoxin
Increased fiber
intake
Pharmacokinetic interaction,
reduced absorption
If fiber intake
changes, may need to
adjust dosage.
Felodipine
Grapefruit, Citrus
juice
Pharmacokinetic interaction,
inhibition of metabolism
Avoid grapefruit juice.
Levodopa Pyridoxine
Pharmacodynamic
interaction, decreased
dopamine availability
Maintain consistent
vitamin B6 intake.
MAO Inhibitors Tyramine
Pharmacodynamic
interaction, blocked
deamination of dietary
pressor amines, risk of
hypertensive crisis
Avoid foods
containing tyramine.
See Table 8.2.
Phenytoin Vitamin D
Alterations in nutrition status,
chelation, binding to protein
components, decreases
absorption
May need calcium +
vitamin D
supplement.
Spironolactone
Excessive
potassium intake
Pharmacodynamic
interaction, risk of
hyperkalaemic adverse
effects
Avoid consuming
large quantities of
high potassium foods.
Tetracycline Calcium Physical interaction, chelation
Avoid dairy products,
iron-containing
products, or antacids
containing calcium,
magnesium, and
aluminium 1 hr.
before or 2 hrs. after
medication delivery.
Theophylline Caffeine, fat
Pharmacodynamic
interaction, additive effects
Limit caffeine to 2-3
cups of coffee, tea, or
colas per day. Avoid
taking with meals high
in fat.
Warfarin
Excessive vitamin
K intake
Pharmacodynamic
interaction, direct antagonism
by dietary vitamin K
Vitamin K intake
needs to remain
consistent. Avoid high
doses (>400IU/d) of
vitamin E.


97
Table 8.2 Tyramine Containing Foods

Aged Cheeses Overripe Fruit
Eggplant Figs
Grapes Oranges
Pineapple Plum
Prune Raisin
Avocados Sauerkraut
Processed Foods Aged Meats
Canned Meats Dried Meats
Cured/Pickled Meats Meat by-products
Fava Beans Tofu
Miso Teriyaki Sauce
Soy Products Soy Sauce
Spinach Tomatoes
Alcoholic Beverages Yeast
Bouillon Cubes Commercial Gravies

Drug Interactions with Enteral Products

General Guidelines

- In most cases, giving drugs to patients receiving enteral nutritional products is
similar to drug administration to patients who are eating.

- Liquid dosage formulations are preferred for administration through a feeding
tube. Solutions or suspensions are preferred. Syrups, especially those which are
acidic such as metoproterenol (Alupent) or metoclopromide (Reglan), may cause
clumping of the enteral feeding if given concurrently.

- If a tablet must be used, it should be crushed and mixed with a small amount of
water immediately prior to administration. The tubing should then be flushed with
water to prevent clogging.

- Enteric-coated, sublingual, and sustained release products should never be
crushed. Some sustained release capsules can be opened so that the beads can
be administered through a feeding tube. The beads should not be crushed, but
should be mixed with a small amount of water immediately prior to administration.
The tubing should then be flushed with water to prevent clogging.

- If multiple drugs are scheduled for administration, each one should be given
separately with a 5 ml water flush between drugs.


98
Incompatibilities

- Drugs that are normally given on an empty stomach should not be administered
with tube feeds. Table 8.3 lists common examples of drugs that should be taken
on an empty stomach:

Table 8.3 Drugs that Should be Taken on an Empty Stomach

Ampicillin Mercaptopurine
Atenolol Methotrexate
Bisacodyl Mycophenolate
Captopril Nafcillin
Cefibuten Norfloxacin
Ciprofloxacin Ofloxacin
Cloxacillin Oxacillin
Dicloxacillin Penicillin G
Didanosine (DDI) Rifabutin
Isoniazid Rifampin
Levothyroxine Sulfonamides
Lomustine Tetracycline
Melphalan Zidovudine

- In addition to the drugs listed above, some drugs that normally can be given with
food cannot be given with enteral feeds. Concomitant administration of these
drugs (Table 8.4) with enteral feeds can result in a significant decrease in drug
absorption.

Table 8.4 Additional Drugs that May be Affected by Enteral Feedings

Aspirin Phenytoin
Calcium supplements Potassium supplements (some products)
Carbamzepine Propantheline
Digoxin Rifampin
Furosemide Theophylline
Iron supplements Voriconazole
Methyldopa Warfarin

- To minimize these drug-enteral feeding interactions, the following procedure
should be used (when possible):

1. Stop the tube feeding
2. Flush the tube with 20-30 ml water, or an appropriate volume based on the
patients size
3. Administer the dose
4. Repeat step 2
5. Wait approximately 30 minutes 1 hour before restarting feeds


99
Drug Interactions with Parenteral Nutrition

General Guidelines

- Many drugs are compatible with parenteral nutrition solutions when administered
through the same tubing. When a drug is administered with parenteral nutrition, it
should be administered through the Y-site closest to the patient to minimize
contact time. An in-line filter may also be placed to trap any precipitants.

Incompatibilities

- Information on compatibility is best evaluated on an individual case basis.
Compatibility may depend on the specific components of a parenteral nutrition
solution or the concentration of those components (e.g. electrolytes) in the final
solution. Table 8.5 provides a brief list of several drugs known to be incompatible
with most parenteral nutrition solutions.

Table 8.5 Drugs that are Incompatible with Most Parenteral Nutrition Solutions

Acyclovir Milrinone
Calcium salts Phenobarbital
Diazepam Phenytoin
Ganciclovir Phosphate salts
Immune globulin
products (IVIG)

Calcium/Phosphate Balance

- Identifying the most appropriate balance of calcium and phosphate is one of most
challenging aspects of pediatric parenteral nutrition. Excessive amounts of one or
both of these electrolytes can result in formation of dibasic calcium phosphate,
which may precipitate out of solution. Solubility is also affected by:
1. pH
2. temperature
3. fluid volume
4. the sequence of adding the electrolytes
5. protein dose and formulation

- A general rule of thumb is that the total mEq of calcium and phosphate cannot
exceed 5.2 mEq for every 100 mL for parenteral nutrition solutions made with
Travasol
(standard amino acid solution) or 7.2 mEq for every 100 mL for
parenteral nutrition solutions made with TrophAmine
(pediatric amino acid

solution). To convert phosphorus units, use 0.5 mMol phos = 1 mEq.

- When ordering calcium and phosphorus in parenteral nutrition, to prevent
precipitation for every 100 mL of PN solution, the maximum amounts to be added
are 4 mEq/kg Calcium and 3 mEq/kg Phosphorus (1.5 mMol/kg phos)


100

Critical Care Medications and Nutritional Delivery
Critically ill infants and children are often fluid restricted and require multiple intravenous
medications and infusions that are counted towards the overall fluid delivery. The pediatric
nutritionists will work closely with the PICU and NICU team to optimize nutritional support
delivery in the face of fluid restriction and multiple intravenous medication intake. Common
intravenous infusions used in the pediatric and newborn intensive care unit settings are listed
in Table 8.6.

Table 8.6 Critical Care Medications Commonly Used as Infusions
in the Pediatric and Newborn ICU

Medication Classification
Chlorothiazide (Diuril) Diuretic
Cisatracurium Neuromuscular blocker
Dobutamine Inotrope
Dopamine Inotrope
Epinephrine Inotrope
Fentanyl Analgesic
Furosemide (Lasix) Diuretic
Midazolam (Versed) Sedative
Milrinone Inotrope
Morphine Analgesic
Pentobarbital Sedative
Vasopressin Inotrope
Vecuronium Neuromuscular blocker

The PICU dietitian will work with the pharmacist, nurse, and medical team to determine how
best to concentrate the intravenous medications, given the childs dosage and plans for
weaning, in order to allow for an increased delivery rate of the parenteral or enteral nutrition
fluids. The physician, however, will enter in the medication with new concentration into the
computer ordering system.
.


101
Common Enteral Electrolyte Supplementation

Table 8.7 Electrolyte Content of Selected Enteral Supplements (9)

Supplement
(Unit, Strength)
Sodium
(mEq)
[mg]

Potassium
(mEq)
[mg]

Chloride
(mEq)

Elemental
Phosphorus
(mEq)
[mg]
Elemental
Magnesium
(mEq)
[mg]
Elemental
Calcium
(mEq)
[mg]
Neutra-Phos
(PhosNaK)
(packet)
7.1
[164]
7.1
[278]
0 16
[250]
0 0
Neutra-PhosK
(packet)
0 14.25
[556]
0 16
[250]
0 0
Calcium
carbonate
(ml, 1250 mg/5 ml)
0 0 0 0 0 5
[100]
Calcium
glubionate (ie,
Neo-Calglucon)
(ml, 1.8g/5 ml)
0 0 0 0 0 1.15
[23]
Tums, Regular
Strength
(tab, 500 mg)
0 0 0 0 0 10
[200]
Tums, E-X Extra
Strength
(tab, 750 mg)
0 0 0 0 0 15
[300]
Tums, Ultra
(Maximum)
Strength
(tab, 1000 mg)
0 0 0 0 0 20
[400]
Magnesium
gluconate
(ml, 1000 mg/5 ml)
0 0 0 0 0.9
[10.8]
0
Potassium
chloride
(ml, 20mEq/15 ml)
0 1.3 1.3 0 0 0

Table salt
(tsp)
101
[2325]
0 101

0 0 0

Table 8.8 Recommended Initial Dosages* for Enteral Electrolyte Supplements

Electrolyte Supplements Dosage
Potassium Chloride 2 mEq/kg/day in divided doses
Sodium Chloride 2-4 mEq/kg/day

* Dosages given in this table are only initial suggestions. Clinical parameters, such as laboratory values,
should be closely monitored and dosages should be titrated accordingly. Dosages given are for replacement of
low serum values only.

102
References

1. Wohlt PD, Zheng L, Gunderson S, et al. Recommendations for the use of medications
with continuous enteral nutrition. Am J Health-Syst Pharm 2009;66:1458-67.

2. Genser D. Food and drug interaction: consequences for the nutrition/health status. Ann
Nur Metab 2008;52 (Suppl 1):29-32.

3. Magnuson BL, Clifford TM, Hoskins LA, Bernard AC. Enteral nutrition and drug
administraction, interactions, and complications. JPEN J Parenter Enteral Nutr. 2005;20:
618-624.

4. Huang S, Lesko LJ. Drug-drug, drug-dietary supplement, and drug-citrus fruit and other
food interactions: what have we learned? J Clin Pharmacol. 2004;44: 559-569.

5. Mertens-Talcott SU, Sadenzensky I, De Castro WV, Derendorf H, Butterweck V.
Grapfruit-drug interactions: can interactions with drugs be avoided? J Clin Pharmacol.
2006;46:1390-1416.

6. Au Yeung SCS, Ensom MHH. Phenytoin and enteral feedings: does evidence support an
interaction? Ann Pharmacother. 2000; 34:896-905.

7. Williams D. The effect of enteral nutrition supplements on serum voriconazole levels. J
Oncol Pharm Pract 2012;18:128-13.

8. Lenz GT, Mikrut BA. Calcium and phosphate solubility in neonatal parenteral nutrient
solutions containing Aminosyn-PF or TrophAmine. Am J Hosp Pharm. 1988;45;2367-71.

9. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 18
th
edition. Hudson,
OH: Lexi-Comp Publishing; 2011.

103
APPENDIX

A Growth Charts for Normal Infants and Children
World Health Organization Growth Standards for Infants (Charts 1 3)
National Center for Health Statistics (CDC) Growth Charts for Children Aged 2-
20 Years (Charts 4 8)
Fenton Growth Chart for Preterm Infants (Chart 9)
B - Specialized Growth Charts: Down Syndrome

C Triceps Skinfold Percentile Charts

D Mid Upper Arm Circumference Percentile Charts

E - Developmental Self-Feeding Checklist

F - Selected Lab Values with Nutritional Implications

G - Estimated Energy Requirements (EER) for Infants and Children

H - Guide to Number of Servings and Serving Size for Children

I - Electrolyte Conversion Information

J - Oral Multivitamin and Mineral Supplements Available at UVA

K - Tips for Increasing Calories for Children

L - Sites of Nutrient Malabsorption Resulting from Intestinal Resections

M UVA Therapeutic Algorithm for Management of Pediatric Post-operative Chylothorax

Birth to 24 months: Boys
Length-for-age and Weight-for-age percentiles
Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)
98
95
85
75
50
25
10
5
2
98
95
90
75
50
25
10
5
2
Birth to 24 months: Girls
Length-for-age and Weight-for-age percentiles
98
95
90
75
50
25
10
5
2
98
95
90
75
50
25
10
5
2
12
Birth
40
38
36
32
20
19
18
17
16
15
14
13
in
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
E
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
30
34
52
48
46
44
cm
20
19
18
in
17
Birth to 24 months: Girls
Head circumference-for-age and
Weight-for-length percentiles
NAME
RECORD #
42
44
46
52
50
cm
48
50
W
E
I
G
H
T
W
E
I
G
H
T
W
E
I
G
H
T
W
E
I
G
H
T
kg lb
W
E
I
G
H
T
14
20
18
14
16
12
10
8
6
4
2
9
8
7
2
in
cm
kg lb
1
3
W
E
I
G
H
T
22
24
10
11
12
6
5
E
66 68 70 72 74 76 7880 82 84 86 88 92 94 9698100102104106108 90 cm
in
Date Age Comment Weight Length Head Circ.
64
24 23 22 21 20 19 18
46 4850 52 54 56 58 60 62
9
8
7
22
20
18
14
16
24
26
28
30
32
34
36
38
40
42
44
12
13
14
15
16
17
12
10
11
46
48
50
18
19
20
21
22
6
5
23
24
52
24
26
28
98
95
90
75
50
25
10
5
2
98
95
90
75
50
25
10
5
2
110
41 42 40 39 38 37 35 36 34 33 32 31 30 29 28 27 26 43
4
LENGTH
2 to 20 years: Boys
Stature Weight-for-age percentiles -for-age and
NAME
RECORD #
W
E
I
G
H
T
W
E
I
G
H
T
S
T
A
T
U
R
E
S
T
A
T
U
R
E
lb
30
40
50
60
70
80
lb
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
kg
10
15
20
25
30
35
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
cm
cm
150
155
160
165
170
175
180
185
190
kg
10
15
20
25
30
35
105
45
50
55
60
65
70
75
80
85
90
95
100
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
12 13 14 15 16 17 18 19 20
AGE (YEARS)
AGE (YEARS)
40
90
75
50
25
10
90
75
50
25
10
11 3 4 5 6 7 8 9 10
97
3
97
3
62
42
44
46
48
60
58
52
54
56
in
30
32
34
36
38
40
50
74
76
72
70
68
66
64
62
60
in
Date
Mothers Stature Fathers Stature
Age Weight Stature BMI*
SOURCE: Developed b
(2000).
y the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion
http://www.cdc.gov/growthcharts
Published May 30, 2000 (modified 11/21/00).
2 to 20 years: Boys
Body mass index-for-age percentiles
NAME
RECORD #
2 5 4 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
26
24
22
20
18
16
14
12
kg/m
2
28
26
24
22
20
18
16
14
12
kg/m
2
30
32
34
BMI
BMI
AGE (YEARS)
13
15
17
19
21
23
25
27
13
15
17
19
21
23
25
27
29
31
33
35
90
75
50
25
10
85
Date Age Weight Stature BMI* Comments
97
3
95
SOURCE: Developed b
(2000).
2 to 20 years: Girls
Stature Weight-for-age percentiles -for-age and
NAME
RECORD #
W
E
I
G
H
T
W
E
I
G
H
T
S
T
A
T
U
R
E
S
T
A
T
U
R
E
kg
10
15
20
25
30
35
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
cm
150
155
160
165
170
175
180
185
190
kg
10
15
20
25
30
35
105
45
50
55
60
65
70
75
80
85
90
95
100
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
12 13 14 15 16 17 18 19 20
AGE (YEARS)
AGE (YEARS)
40
160
cm
11 3 4 5 6 7 8 9 10
90
75
50
25
10
90
75
50
25
10
97
3
97
3
lb
30
40
50
60
70
80
lb
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
Date
Mothers Stature Fathers Stature
Age Weight Stature BMI*
62
42
44
46
48
60
58
52
54
56
in
30
32
34
36
38
40
50
74
76
72
70
68
66
64
62
60
in
SOURCE: Developed b
(2000).
2 to 20 years: Girls
Body mass index-for-age percentiles
NAME
RECORD #
2 5 4 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
26
24
22
20
18
16
14
12
kg/m
2
28
26
24
22
20
18
16
14
12
kg/m
2
30
32
34
BMI
BMI
AGE (YEARS)
13
15
17
19
21
23
25
27
13
15
17
19
21
23
25
27
29
31
33
35
Date Age Weight Stature BMI* Comments
90
85
75
50
10
25
97
3
95
SOURCE: Developed b
(2000).
APPENDIX B

Source: www.growthcharts.com
APPENDIX B

APPENDIX B

APPENDIX B


APPENDIX B


APPENDIX B


APPENDIX B


APPENDIX B


APPENDIX B


APPENDIX B


Table 28 Triceps skinfold in millimeters for persons 3 months-19 years-number of examined persons, mean, standard error of the mean, and selected
percentiles, by sex and age : United States, 1988-1994
Selected percentile
Number of Standard
Sex and age examined error of
persons Mean the mean 5th 10th 15th 25th 50th 75th 85th 90th 95th
Male
3-5 months .................................. 290 10.5 0.21 * 7.9 8.4 9.2 10.7 11.7 12.5 13.2 *
6-8 months .................................. 320 10.2 0.23 * 7.3 7.9 8.5 9.9 11.6 12.5 13.3 *
9-11 months ................................ 275 9.5 0.20 * 7.1 7.4 8.1 9.2 10.7 11.1 11.8 *
1 year .......................................... 647 9.4 0.15 6.4 6.9 7.2 7.9 9.1 10.7 11.7 12.1 13.1
2 years ........................................ 555 9.1 0.13 6.4 6.7 7.3 7.9 8.9 10.4 11.1 11.5 12.4
3 years ........................................ 479 8.9 0.20 * 6.4 6.8 7.3 8.6 10.0 10.8 11.6 *
4 years ........................................ 538 9.0 0.18 6.0 6.6 6.8 7.3 8.6 10.0 11.4 12.0 12.9
5 years ........................................ 493 8.7 0.20 6.0 6.3 6.8 7.2 8.1 9.5 10.3 11.3 13.0
6 years ........................................ 278 9.8 0.46 * 6.0 6.4 7.1 8.5 10.8 12.9 14.9 *
7 years ........................................ 268 9.7 0.45 * 6.1 6.4 7.1 8.7 10.7 13.3 16.8 *
8 years ........................................ 262 10.8 0.59 * 6.3 6.4 7.3 8.8 12.3 15.7 20.1 *
9 years ........................................ 276 12.4 0.69 * 6.6 6.8 7.4 9.7 15.4 21.3 23.9 *
10 years ...................................... 293 12.5 0.63 * 6.0 6.9 8.2 10.4 15.5 20.8 22.3 *
11 years ...................................... 282 13.6 0.70 * 6.7 7.2 8.6 11.3 18.2 19.5 22.3 *
12 years ...................................... 200 13.5 0.77 * * 7.6 8.6 12.9 17.4 19.2 * *
13 years ...................................... 182 12.4 0.89 * * 6.4 7.1 10.5 15.7 19.7 * *
14 years ...................................... 183 11.0 0.82 * * 6.2 6.7 8.3 13.4 17.0 * *
15 years ...................................... 182 12.1 1.00 * * 6.0 6.7 9.5 13.8 19.2 * *
16 years ...................................... 191 11.1 0.86 * * 6.6 7.1 8.6 13.6 17.0 * *
17 years ...................................... 191 11.3 0.82 * * 5.8 7.2 8.9 12.8 19.2 * *
18 years ...................................... 168 10.9 0.90 * * 5.7 6.3 8.3 12.6 16.8 * *
19 years ...................................... 160 12.1 1.05 * * 6.3 7.5 9.5 12.2 21.9 * *
Female
3-5 months .................................. 309 10.4 0.21 * 7.9 8.2 8.7 10.3 11.8 12.3 12.6 *
6-8 months .................................. 261 9.9 0.28 * * 7.6 8.2 9.4 11.3 12.2 * *
9-11 months ................................ 316 9.6 0.24 * 7.1 7.4 8.0 9.2 10.9 11.9 12.7 *
1 year .......................................... 626 9.7 0.16 6.5 7.1 7.4 8.1 9.6 11.0 11.9 12.4 13.5
2 years ........................................ 545 9.5 0.17 * 7.1 7.4 7.9 9.2 10.9 11.6 12.3 *
3 years ........................................ 554 9.7 0.21 * 7.1 7.4 8.1 9.1 10.9 11.6 12.4 *
4 years ........................................ 529 10.3 0.29 * 7.3 7.7 8.4 9.6 11.6 12.8 13.4 *
5 years ........................................ 554 10.3 0.27 * 7.3 7.6 8.2 9.6 11.4 12.8 14.4 *
6 years ........................................ 273 10.3 0.48 * * 7.1 7.5 9.3 11.1 13.6 * *
7 years ........................................ 269 11.9 0.59 * * 7.4 7.9 10.6 14.5 18.0 * *
8 years ........................................ 244 12.4 0.64 * * 7.8 8.5 10.7 14.2 17.6 * *
9 years ........................................ 270 14.4 0.84 * * 8.2 8.9 12.1 16.5 23.9 * *
10 years ...................................... 255 15.0 0.81 * * 8.7 10.1 12.9 18.1 21.7 * *
11 years ...................................... 268 15.1 0.78 * * 8.9 9.9 12.9 19.8 21.2 * *
12 years ...................................... 233 15.2 0.90 * * 8.2 9.6 13.2 19.4 23.4 * *
13 years ...................................... 218 17.5 0.89 * * 10.4 11.7 15.9 22.3 24.4 * *
14 years ...................................... 216 18.7 0.90 * * 11.6 12.4 17.5 22.5 25.4 * *
15 years ...................................... 188 17.8 0.98 * * 11.1 12.4 16.7 20.7 25.7 * *
16 years ...................................... 202 18.6 0.89 * * 12.0 14.0 16.8 21.8 25.4 * *
17 years ...................................... 191 20.0 0.98 * * 12.4 14.2 19.6 24.8 27.3 * *
18 years ...................................... 165 19.4 1.07 * * * 13.8 17.9 24.2 * * *
19 years ...................................... 167 19.6 1.18 * * * 14.0 18.5 24.1 * * *
* Figure does not meet standard of reliability or precision.
NOTE: Pregnant women are excluded.
Table 41 Mid-upper arm circumference in centimeters for persons 3 months-19 years-number of examined persons, mean, standard error of the mean,
and selected percentiles, by sex and age : United States, 1988-1994
Selected percentile
Number of Standard
Sex and age examined error of
persons Mean the mean 5th 10th 15th 25th 50th 75th 85th 90th 95th
Male
3-5 months .................................. 289 14.6 0.12 * 13.2 13.5 13.9 14.5 15.4 15.7 16.0 *
6-8 months .................................. 319 15.3 0.12 * 13.8 14.0 14.4 15.2 16.1 16.6 17.0 *
9-11 months ................................ 275 15.6 0.12 * 14.1 14.5 14.8 15.7 16.4 16.8 17.1 *
1 year .......................................... 651 16.1 0.08 14.4 14.8 15.0 15.4 16.0 16.9 17.3 17.7 18.3
2 years ........................................ 574 16.5 0.08 14.8 15.1 15.4 15.6 16.3 17.2 17.8 18.0 18.5
3 years ........................................ 483 16.9 0.13 15.0 15.4 15.7 15.9 16.8 17.7 18.2 18.6 19.0
4 years ........................................ 542 17.3 0.11 15.3 15.6 16.0 16.4 17.1 18.0 18.4 19.0 19.5
5 years ........................................ 495 17.9 0.13 15.5 16.0 16.2 16.8 17.7 18.6 19.3 19.6 20.7
6 years ........................................ 279 18.9 0.28 * 16.4 16.8 17.1 18.4 19.6 20.5 22.7 *
7 years ........................................ 268 19.3 0.24 * 17.1 17.6 17.9 18.9 20.3 21.3 21.7 *
8 years ........................................ 261 20.4 0.31 * 17.5 18.0 18.4 19.6 21.8 23.4 24.7 *
9 years ........................................ 276 21.7 0.34 * 18.3 18.6 19.2 20.7 24.2 25.3 27.0 *
10 years ...................................... 294 22.6 0.34 * 18.7 19.2 20.1 22.0 25.0 26.6 27.5 *
11 years ...................................... 281 23.6 0.38 * 19.7 20.0 21.1 22.7 25.5 27.4 28.1 *
12 years ...................................... 202 25.2 0.45 * * 21.6 23.1 24.1 27.3 28.5 * *
13 years ...................................... 181 25.7 0.49 * * 22.0 23.6 24.6 27.8 28.6 * *
14 years ...................................... 185 28.1 0.78 * * 23.9 24.3 27.0 29.8 30.6 * *
15 years ...................................... 183 28.5 0.51 * * 24.9 25.9 27.5 31.1 33.3 * *
16 years ...................................... 191 29.2 0.50 * * 25.6 26.6 28.4 31.2 32.6 * *
17 years ...................................... 193 30.7 0.51 * * 26.7 27.7 30.0 33.1 35.3 * *
18 years ...................................... 168 30.1 0.55 * * 25.9 27.4 29.6 31.8 34.5 * *
19 years ...................................... 161 31.5 0.52 * * 27.8 28.6 30.8 33.7 35.8 * *
Female
3-5 months .................................. 309 14.0 0.13 * 12.7 12.9 13.3 14.0 14.8 15.2 15.6 *
6-8 months .................................. 262 14.8 0.14 * * 13.6 13.9 14.7 15.4 16.1 * *
9-11 months ................................ 315 15.2 0.12 * 13.8 14.0 14.4 15.2 15.9 16.4 16.7 *
1 year .......................................... 627 15.9 0.09 14.0 14.4 14.7 15.0 15.9 16.7 17.0 17.5 17.9
2 years ........................................ 556 16.3 0.09 * 15.0 15.2 15.5 16.2 17.0 17.4 17.9 *
3 years ........................................ 561 17.0 0.11 15.1 15.5 15.8 16.1 16.8 17.6 18.1 18.5 19.3
4 years ........................................ 527 17.6 0.17 * 15.6 15.9 16.4 17.3 18.2 19.0 19.6 *
5 years ........................................ 555 18.1 0.15 * 16.1 16.3 16.8 17.8 19.0 19.7 20.6 *
6 years ........................................ 273 18.7 0.28 * * 16.7 17.2 18.1 19.5 21.1 * *
7 years ........................................ 270 19.9 0.34 * * 17.1 17.6 19.3 21.4 23.5 * *
8 years ........................................ 245 20.6 0.35 * * 17.9 18.6 20.0 21.5 23.3 * *
9 years ........................................ 272 22.1 0.47 * * 18.4 19.3 20.9 24.0 26.5 * *
10 years ...................................... 255 22.6 0.42 * * 19.0 19.8 21.8 24.6 26.5 * *
11 years ...................................... 268 23.7 0.40 * * 20.1 21.2 23.5 25.7 27.4 * *
12 years ...................................... 233 24.5 0.48 * * 20.0 21.5 23.8 27.1 28.3 * *
13 years ...................................... 217 26.3 0.53 * * 22.1 23.0 25.4 29.1 31.1 * *
14 years ...................................... 218 26.9 0.49 * * 23.0 24.0 25.9 29.5 31.1 * *
15 years ...................................... 189 26.7 0.49 * * 23.8 24.2 25.9 28.1 30.1 * *
16 years ...................................... 204 27.3 0.47 * * 23.5 24.7 26.4 29.5 31.3 * *
17 years ...................................... 195 27.7 0.50 * * 24.2 25.2 27.0 29.3 31.2 * *
18 years ...................................... 170 27.4 0.59 * * * 24.4 26.5 29.8 * * *
19 years ...................................... 168 28.2 0.63 * * * 25.2 27.2 29.6 * * *
* Figure does not meet standard of reliability or precision.
NOTE: Pregnant women are excluded.
APPENDIX E
Developmental Self-Feeding Checklist

Developmental Age*

Feeding Skill

Two months

Infant brings hands to mouth in both supine and prone.

Three months

Infant brings hands to mouth while holding an object.

Three-and-a-half months

Infant visually recognizes food and the bottle.

Four months

Infant pats bottle with one or both hands.

Four-and-a-half months

Infant holds both hands on the bottle.

Five-and-a-half months

Infant holds bottle independently with one or both hands.

Five or six months

Infant mouths and gums solid foods such as hard baby cookies.

Six months

Infant drinks from a cup held by an adult.

Six-and-a-half or seven months

Infant feeds self a cracker.

Nine months

Infant is capable of independent finger-feeding. Infant holds and bangs spoon.

Nine-and-a-half months

Infant stirs spoon in imitation.

Twelve months

Child holds cup and drinks with some spilling. Child holds the handle of a cup
while drinking.

Twelve to fourteen months

Child brings a filled spoon to the mouth, turning the spoon over enroute.

Fifteen to eighteen months

Child scoops food and brings it to the mouth, spilling some.

Eighteen to twenty-four months

Child gives up the bottle and drinks entirely from the cup.

Twenty to twenty-two months

Child can hold a cup in one hand while drinking.

Twenty-four months

Child brings a spoon or fork to the mouth with the hand palm-up.

Thirty months

Child can pour liquid from a small container.

Thirty-one or thirty-two months

Child feeds self with little spilling.

Thirty to thirty-six months

Child uses a fork to stab food.

*Developmental ages are approximate and may vary with individual children
Morris, S.E. and Klein, M., Pre-Feeding Skills. p. 306.

APPENDIX F

SELECTED LAB VALUES WITH NUTRITIONAL IMPLICATIONS

Lab Parameter Normal Range Possible Reasons for
High Value
Possible Reasons for
Low Value

BUN

10 20 mg/dl

Higher in elderly:
10 25 mg/dl

Dehydration
Renal disease
Increased protein metabolism
Starvation
Stress
Diabetes
Fever
Acute myocardial infarction
GI bleed
Congestive heart failure
Urinary obstruction

Liver failure
Increased protein synthesis
- Late pregnancy
- Infancy
Acromegaly
Nephrotic syndrome
Overhydration
Malabsorption
Low protein, high CHO diets

Creatinine

0.7 - 1.3 mg/dl

Large muscle mass
Muscle disease
Starvation
Renal disease

CO2 (Bicarbonate)

22 30 mEq/L

Metabolic alkalosis
Respiratory acidosis
Emphysema
Vomiting

Metabolic acidosis
Respiratory alkalosis
Hyperventilation
Fever
Lack of oxygen

APPENDIX F
SELECTED LAB VALUES WITH NUTRITIONAL IMPLICATIONS (cont.)

High Value
Low Value

Serum Osmolarity

Osm =serum sodium x 2 +

BUN +Glucose
2.8 18

275 295 mOsm/L

Calculated values are
generally lower than
measured values

Inadequate fluid intake
Diarrhea
Diabetes mellitus
Diabetes insipidus
Renal disease
Hyperlipidemia
Hyperglycemia

Excess fluid intake
Adrenal disease
Inappropriate ADH secretion
- Hypothyroidism
- Cerebral disease
Porphyria
- Bronchogenic cancer

Serum Glucose

* Elevated values may give
falsely low serum sodium
values. For every 100%
elevation in glucose, serum
sodium should be increased
2 mEq/L

65 115 mg/dl

Diabetes mellitus
Cushings syndrome
Acromegaly
Hemochromatosis
Pheochromocytoma
Burns, shock
Acute pancreatitis
Wernickes encephalopathy
Dehydration
Sepsis
Overfeeding
Corticosteroids

Liver disease
Neoplasms
Pancreatic disorders
Addisons disease
Hypothyroidism
Water overload

APPENDIX F

High Value
Possible reasons for
Low Value

Hematocrit (HCT)

Often used to diagnose iron
deficiency; not a conclusive
measure

Women: 35 47%
Men: 40 52%

Dehydration
Polycythemia

Hemorrhage
Anemia
Water overload
Advanced age
Late Pregnancy

Hemoglobin (Hgb)

More direct measure of iron
deficiency than HCT

Women: 12 16 gm/dl
Men: 14 18 gm/dl

Dehydration
Polycythemia

Hemorrhage
Iron deficiency anemia
Proteincalorie malnutrition
Advanced age
Late pregnancy
Renal failure
Water overload

Mean Corpuscular Volume
(MCV)

Indicates average size of the
red blood cells.

Calculated MCV =HCT x 10
RBC

83 95 microns

Macrocytosis
- Folate deficiency
- Vitamin B 12 deficiency
- Excess alcohol intake
Hemochromatosis

Microcytosis
- Advanced iron deficiency
- Blood loss
Iron deficiency
Iron malabsorption
Lead poisoning

APPENDIX F

High value
Low Value

Sodium

Body content of sodium is not
always reflected in serum
levels

137 145 mEq/L

Dehydration
Renal disease

Extreme sweating
Diuretic medication
Diabetic ketoacidosis
Malabsorption
Excessive GI losses
SIADH

Potassium

Required with nitrogen for
replacement of lost muscle
mass

3.5 5.0 mEq/L

Burns, shock
Crush injuries
Excess IV potassium
Renal failure
Diabetic ketoacidosis
Dehydration
Hyperglycemia

Refeeding Syndrome
Starvation
Vomiting
Excessive GI losses
Diarrhea
Hypomagnesemia
Cushings syndrome
Diuretic medication
Amphotericin

Chloride

98 107 mEq/L

Dehydration
Renal failure

Gastrointestinal losses
Excess urinary losses

APPENDIX F
High Value
Low Value

Calcium

Absorption decreased by
phytate, oxalate, phosphate,
fat malabsorption and high
protein diet

8.5 10.5 mg/dl

Cancer
Renal disease
Vitamin D intoxication
Hyperparathyroidism
Renal calculi
Immobilization

Hypoparathyroidism
Renal disease
Osteomalacia
Steatorrhea
Rickets
Hypomagnesemia

Phosphorous

4.0 7.0 mg/dl

Hemolyzed blood
Diabetes
Renal disease
Healing fractures
Vitamin D deficiency
Skeletal disease

Rickets
Insulin injections
Malnutrition
Malabsorption
Refeeding syndrome

Magnesium

1.6 2.3 mg/dl

Renal failure
Diabetic acidosis
Hypothyroidism
Addisons disease
Dehydration
Overuse of Mg supplements
or antacids

Chronic diarrhea
Alcoholism
Pancreatitis
Renal disease
Hepatic cirrhosis
Toxemia of pregnancy
Hyperthyroidism
Malabsorption
Ulcerative colitis
K- depleting diuretics
Refeeding syndrome

134
APPENDIX G

Estimated Energy Requirements (EER) for
Infants and Children

Normal Weight Infants and Children

EER for Ages 0- 36 Months

EER = total energy expenditure (TEE) + energy deposition
0-3 months (89 x weight [kg] 100) +175 kcal

Table 1. Total Energy Expenditure (TEE) For Infants and Children 0-36 Months of
Age
Kcals/kg determined as follows: TEE/reference weight (kg)

Boys Girls
Age
(months)
Reference
weight
(kg)
TEE
(kcals/day)
Kcals/kg Reference
weight (kg)
TEE
(kcals/day)
Kcals/kg
1 4.4 472 107 4.2 438 104
2 5.3 567 107 4.9 500 102
3 6.0 572 95 5.5 521 95
4 6.7 548 82 6.1 508 83
5 7.3 596 82 6.7 553 83
6 7.9 645 82 7.2 593 82
7 8.4 668 80 7.7 608 79
8 8.9 710 80 8.1 643 79
9 9.3 746 80 8.5 678 80
10 9.7 793 82 8.9 717 81
11 10.0 817 82 9.2 742 81
12 10.3 844 82 9.5 768 81
15 11.1 908 82 10.3 837 81
18 11.7 961 82 11.0 899 82
21 12.2 1006 82 11.6 952 82
24 12.7 1050 83 12.1 997 82
27 13.1 1086 83 12.5 1033 83
30 13.5 1121 83 13.0 1077 83
33 13.9 1157 83 13.4 1113 83
35 14.2 1184 83 13.7 1139 83
135
APPENDIX G
EER for Boys Ages 3-8 Years

EER =88.5 (61.9 x age [y]) +PA x (26.7 x weight [kg] +903 x height [m]) +20 kcal

EER for Boys 9-18 Years

EER =88.5 - (61.9 x age [y]) +PA x (26.7 x weight [kg] +903 x height [m]) +25 kcal

Physical Acti vity (PA) Coefficient for Boys:
1.00 (sedentary)
1.16 (low active)
1.31 (active)
1.56 (very active)

Table 2. Estimated Energy Requirements (EER) For Boys 3-18 Years of Age
PAL =physical activity level
Kcals/kg determined as follows: EER/reference weight (kg)

EER
Age
(yrs)
Reference
weight (kg)
Sedentary
PAL
Low Acti ve
PAL
Acti ve
PAL
Very Acti ve
PAL
Kcals/kg
3 14.3 1162 1324 1485 1683 81-93
4 16.2 1215 1390 1566 1783 75-86
5 18.4 1275 1466 1658 1894 69-80
6 20.7 1328 1535 1742 1997 64-74
7 23.1 1393 1617 1840 2115 60-70
8 25.6 1453 1692 1931 2225 57-66
9 28.6 1530 1787 2043 2359 53-62
10 31.9 1601 1875 2149 2486 50-59
11 35.9 1691 1985 2279 2640 47-55
12 40.5 1798 2113 2428 2817 44-52
13 45.6 1935 2276 2618 3038 42-50
14 51.0 2090 2459 2829 3283 41-48
15 56.3 2223 2618 3013 3499 39-47
16 60.9 2320 2736 3152 3663 38-45
17 64.6 2366 2796 3226 3754 37-43
18 67.2 2383 2823 3263 3804 35-42
136
APPENDIX G
EER for Girls 3-8 Years

EER =135.3 (30.8 x age [y] +PA x (10.0 x weight [kg] +934 x height [m]) +20 kcal

EER for Girls 9-18 Years

EER =135.3 (30.8 x age [y] +PA x (10.0 x weight [kg] +934 x height [m]) +25 kcal

Physical Acti vity (PA) Coefficient for Girls:
1.0 (sedentary)
1.13 (low active)
1.26 (active)
1.42 (very active)

Table 3. Estimated Energy Requirements (EER) For Girls 3-18 Years of Age

PAL =physical activity level
Kcals/kg determined as follows: EER/reference weight (kg)

EER
Age
(yrs)
Reference
weight (kg)
Sedentary
PAL
Low Acti ve
PAL
Acti ve
PAL
Very Acti ve
PAL
Kcals/kg
3 13.9 1080 1243 1395 1649 78-89
4 15.8 1133 1310 1475 1750 72-83
5 17.9 1189 1379 1557 1854 66-77
6 20.2 1247 1451 1642 1961 62-72
7 22.8 1298 1515 1719 2058 57-66
8 25.6 1360 1593 1810 2173 53-62
9 29.0 1415 1660 1890 2273 49-57
10 32.9 1470 1729 1972 2376 45-53
11 37.2 1538 1813 2071 2500 41-49
12 41.6 1617 1909 2183 2640 39-46
13 45.8 1684 1992 2281 2762 37-43
14 49.4 1718 2036 2334 2831 35-41
15 52.0 1731 2057 2362 2870 33-40
16 53.9 1729 2059 2368 2883 32-38
17 55.1 1710 2042 2353 2871 31-37
18 56.2 1690 2024 2336 2858 30-36
137
APPENDIX G
Overweight Children

EER for Weight Maintenance for Boys 3-18 Years of Age*

EER =114 - (50.9 x age [yr]) +PA x (19.5 x wt [kg] +1161.4 x ht [m])

Physical Acti vity (PA) Coefficient for Overweight Boys:
1.0 (sedentary)
1.12 (low active)
1.24 (active)
1.45 (very active)

PA: 1 sedentary, 1.18 low active, 1.35 active, 1.60 very active

EER for Weight Maintenance for Girls 3-18 Years of Age*

EER =389 - (41.2 x age [yr]) +PA x (15 x wt [kg] +701.6 x ht [m])

Physical Acti vity (PA) Coefficient for Overweight Girls:
1.0 (sedentary)
1.18 (low active)
1.35 (active)
1.605 (very active)

*For children who are overweight (>95
th
percentile BMI for age) or at risk for overweight
(85-95
th
percentile BMI for age) with existing comorbidities, a factor of 108 kcals/day
can be subtracted from the calculated weight maintenance EER to promote a slow
weight loss of 1 pound per month.

APPENDIX H

GUIDE TO NUMBER OF SERVINGS AND SERVING SIZES FOR CHILDREN

FOOD GROUPS CHILD 1-3 CHILD 4-6 CHILD 7-10
ADOLESCENT
11-14 15-18
Milk Group
Milk
Ice Cream Cheese

(3 cups)
6 oz.
(3 cups)
8 oz.
(3 cups)
8 oz.
(3-4 cups)
8 oz.
(3-4 cups)
8 oz.
Meat Group
Meat, Poultry or Fish
Eggs
Dried Beans, Peas
Peanut Butter

(2 servings)
2-3 oz.
1
cup
2T.
(2 servings)
2-3 oz.
1
cup
2T.
(2 servings)
2-3 oz.
1
1 cup
2T.
(2 servings)
2-3 oz.
1-2
1 cup
2T.
(2 servings)
2-3 oz.
1-2
1 cup
2T.
Breads & Cereals
Group
(Whole Grain or
Enriched)
Bread
Cereal

(4 small servings)

slice
cup
(4 servings)

1 slice
1/3 cup
(4-5 servings)

1 slice
cup
(4-6 servings)

1 slice
- 1 cup
(4-6 servings)

1 slice
1 cup
Fruits & Vegetables
Group
Vit. C good source
Vit. A good source
Others

(4 small servings)

cup
2 T.
4 T.
(4 servings)

cup
2-3/week
1/3 cup
(4-5 servings)

cup
2-3/week
cup
(4-6 servings)

1 cup
2-3/week
cup

(4-6 servings)

1 cup
2-3/week
cup

Miscellaneous
Group
Sweets
Snack Foods
Soft Drinks
Butter/Margarine

0
1 T.

0
1-2 T.

0
1-2 T.

0
2+T.

0
2+T.

APPENDIX I

ELECTROLYTE CONVERSION INFORMATION

1. Converting from milliequivalents (mEq) to milligrams (mg) and vice versa:

mg
mEq =
Conversion factor

Conversion Factors For Major Minerals

1 mEq Na =1 mmol Na =23 mg Na
1 g Na =43 mEq Na =43 mmol Na
1 mEq K =1 mmol K =39 mg K
1 g K =26 mEq K =26 mmol K
1 mEq Ca =0.5 mmol Ca =20 mg Ca
1 g Ca =50 mEq Ca =25 mmol Ca
1 mEq Mg =0.5 mmol Mg =12 mg Mg
1 g Mg =82 mEq Mg =41 mmol Mg
1 mmol P =2 mEq HPO
3
=31 mg P
1 mEq Cl =1 mmol Cl =35 mg Cl
1 g Cl =29 mEq Cl =29 mmol Cl

Major Mineral Content in Various Compounds and Solutions

1 g NaCl =393 mg Na =17 mEq Na
1 g NaHCO
3
=273 mg Na =12 mEq Na
1000 ml saline =9 g NaCl =3.5 g Na =154 mEq Na
1000 ml lactated Ringers solution =3 g Na =130 mEq Na
1 ampule (50 ml) 7.5% NaHCO
3
=1 g Na =44 mEq Na
1 g KCl =524 mg K =13 mEq K
1 g CaCl
2
2H
2
O =273 mg Ca =13.6 mEq Ca (when weighed in hydrated forms)
1 g Ca gluconate =93 mg Ca =4.6 mEq Ca
1 g MgSO
4
7H
2
O =99 mg Mg =8.1 mEq Mg (when weighed in hydrated forms)
1 mg Mg gluconate 2H
2
O =54 mg Mg =4.4 mEq Mg (when weighed in hydrated forms)
1 g CaCO
3
=400 mg Ca =20 mEq Ca
1 g FeSo
4
7H
2
O =201 mg Fe (when weighed in hydrated forms)
1 g Fe gluconate 2H
2
O =116 mg Fe (when weighed in hydrated forms)
1 ml Fe dextran (Imferon) =50 mg Fe

2. Converting sodium chloride to sodium:

NaCl (table salt) is 40% sodium and 60% chloride
Therefore: 1 gm sodium chloride =400 mg sodium
400 mg sodium =17 mEq sodium

3. Niacin equivalents:

1% available dietary protein =tryptophan
60 mg dietary tryptophan is equivalent to 1 mg niacin
APPENDIX J
Oral Multivitamin and Mineral Supplements Available at UVA
a

a
Brand names are representative of products purchased by the University of Virginia. Contact the pharmacy for additional information.

b
Nephro-vite also contains 300 mcg biotin.

Adult Products A
(IU)
D
(IU)
E
(IU)
B
1

(mg)
B
2

(mg)
B
3

(mg)
B
5

(mg)
B
6

(mg)
B
12

(mcg)
C
(mg)
Folate
(mg)
Ca
(mg)
Iron
(mg)
Fluo
(mg)
Multivitamin tablet

1 tab. 5,000 400 30 3.0 3.4 20 10 3.0 9.0 90 0.4 66 - -
Multivitamin liquid

5ml 5,000 400 - 10 10 100 21.4 4.1 5.0 200 - - -

-
Multivitamin with minerals
tablet
1 tab. 5,000 400 30 3.0 3.4 30 10 3.0 9.0 120 0.4 40 27 -
Multivitamin with minerals liquid

15 ml 2,500 400 30 1.5 1.7 20 10 2.0 6.0 60 - - - -
Pediatric Products
Multivitamin with minerals
Chewable Tab (Centrum J r.)
1 tab. 5,000 400 30 1.5 1.7 20 10 2 6 60 0.4 162 18 -
Multivitamin drops

1 ml 1,500 400 5 0.5 0.6 8 - 0.4 2 35 - - - -
Multivitamin drops with iron

1 ml 1,500 400 5 0.5 0.6 8 - 0.4 - 35 - - 10 -
Multivitamin drops with fluoride

1 ml 1,500 400 5 0.5 0.6 8 - 0.4 2 35 - - - 0.25
A, D, C drops

1 ml 1,500 400 - - - - - - - 35 - - - -
A, D, C drops with iron

1 ml 1,500 400 - - - - - - - 35 - - 10 -
Sodium fluoride drops

1 ml - - - - - - - - - - - - - 0.5
Ferrous sulfate drops

0.6
ml
- - - - - - - - - - - - 15 -
Special Products
ADEK tablet

1 tab. 4,000 400 150 1.2 1.3 10 10 1.5 12 60 0.2 - - -
ADEK liquid

1 ml 1500 400 40 0.5 0.6 6 3 0.6 4 45 - - - -
Nephro-vite for dialysis
patients
b 1 tab. - - - 1.5 1.7 20 10 10 6.0 60 0.8 - - -
APPENDIX K

Tips for Increasing Calories for Children

Increasing Calories for Children

Milk and Dairy Products
Use whole milk to make milkshakes, soups, cereals and puddings
Use evaporated milk in place of whole milk for desserts, meat dishes and
milkshakes
Add ice cream to milkshakes
Fats, Oils and Sweets
Margarine or butter (100 kcal/T): Add to cooked cereals, potatoes, breads
and crackers, rice, cooked vegetables, pasta and casseroles
Vegetable oil (110 kcal/T): Add to soups, casseroles, vegetables, gravies,
cooked cereals and spaghetti sauce
Sour cream (25 kcal/T): Add to vegetables, potatoes, salads and casseroles
Cream cheese (50 kcal/T): Add to breads, crackers, in dips, baked goods
Mayonnaise (100 kcal/T): Add to sandwiches, salads, dips, pasta etc.
Gravy (26 kcal/T): Add to meats, potatoes, pasta
Corn syrup (60 kcal/T): Add to cereals, fruit, formula, milkshakes
J ams, J ellies (50-55 kcal/T): Add to toast, bagels and other baked goods
Protein
Peanut butter (94 kcal/T): Add to bread, toast, crackers, fruits and
milkshakes
Cheese (120 kcal/oz): Serve on bread, vegetables, pasta, eggs, hotdogs,
salads, sandwiches
Eggs (60 kcal/yolk): Add egg yolks or hard boiled eggs to casseroles,
meatloaf, soups, salads, ie, tuna salad
Dry powdered milk (25 kcal/T): Add to whole milk, milkshakes, casseroles,
soups, scrambled eggs, meatloaf, gravies and sauces, mashed potatoes,
puddings, cereals
Adapted from: : Isaacs J, Cialone J, Horsley, et al. Children with Special Health Care Needs: A
Community Nutrition Pocket Guide, 1997.

APPENDIX L

Sites of Nutrient Malabsorption Resulting from
Intestinal Resections

Site of Bowel Resection

Implication for Nutrient Malabsorption
Duodenum and J ejunum Decreased surface area for general nutrient
absorption
Decreased enzyme production: secretin,
cholecytikinin.
Decreased disaccharidase levels: lactase,
sucrase
Decreased pancreatic and biliary secretions
Decreased fat digestion and absorption.
Decreased protein digestion and absorption
Decreased fat soluble vitamin absorption:
vitamins A, D, and E.
Increased water soluble losses: Vitamin C,
folate
Mineral malabsorption: Ca, Fe, Mg, Cu, Cr,
Mn, Zn.
Increased risk of bacterial overgrowth and
osmotic diarrhea
Ileum Significant decrease in Vitamin B
12
absorption
Decreased bile acid reasbsorption
Decrease in enterophepatic circulation
resulting in: decreases in bile acid pool, long
chain and fat soluble vitamin absorption
Increase in steatorrhea and cholerrheic
diarrhea
Trace element malabsorption and losses
Increased risk of renal oxalate stones
Ileocecal valve Decreases in Vitamin B
12
and folate absorption
Decreased intestinal transit time
Increased risk of bacterial overgrowth
Colon Decreased water absorption
Decreased sodium absorption
Decreased risk of renal oxalate stones
Adapted from: Jones-Wessel J. Short gut syndrome. In: Groh-Wargo, S., Thompson, M. and
Hovasi-Cox, J. Nutritional Care of High Risk Newborns. Chicago, IL: Precept Press, 2000.

APPENDIX M
UVA Therapeutic Algorithm for Management of Pediatric Post-operative Chylothorax
Initial Evaluation
1. Chylous fluid should be confirmed by laboratory analysis showing a triglyceride level > 110 mgs% (when
child is being fed) and a cell count > 1000 cells/microliter with lymphocytes > 80%.
2. If possible central venous pressure (above the diaphragm) should be assessed along with cardiac function by
echocardiography
3. Ultrasound and/or venography of major vessels to evaluate for thrombosis should be undertaken.
4. Serum analysis of immunoglobulion levels and coagulation studies should be sent.

Algorithm

Adjunctive Therapy
1. Placement of a central venous catheter should be considered (either PICC or surgically placed line) early
on if enteral nutrition is failing and TPN is going to be required. Note that both TPN and the malnutrition
consequent to chylous effusions place the child at particular risk for infection so every attempt should be
made to limited invasion of the central catheter.
2. If CVP > 15 mmHg standard approaches to lowering central venous pressure including diuretics, inotropes,
and afterload reduction should be considered in conjunction with cardiology.
3. Enoxaparin 0.5 mg/Kg subcutaneously every 12 h, adjusted according to anti-FXa levels (drawn 3-4 hrs
after 3
rd
dose)
4. Immunoglobulin levels should be drawn weekly and IVIG given as dictated by immunoglobulin levels.
Usual replacement dose is 500 mg/kg infused over 4-6 h. Similar following and supplementation of
albumin should be performed. When possible, administer no more than once over at least 2-4 h.
Consider use of 25% albumin to minimize fluid.
5. Nutrition is vitally important. As per the algorithm, if CVP < 15 and there is no evidence of SVC
thrombosis, enteral feeding with a MCT formula (currently Enfaport) should be rapidly escalated to
calculated fluid and nutritional needs. If CVP > 15 or enteral feeding has not decreased chylous effusion
then TPN should be advanced to full nutritional requirements as rapidly as tolerated. Nutritional consult is
recommended.
6. Octreotide dose should be doubled daily if no reduction in chylous effusion (> 10%) over the previous 24
hours beginning with 1 mcg/kg/hr to a maximum of 10 mcg/kg/hr. If substantive improvement (> 50%
reduction) in 5 days the drug should be stopped.

Surgical Management
Surgical consultation should be considered when the above protocol has failed or appears to be failing. Surgical
management should be individualized but in general:
1. If effusion < 25 ml/Kg/day and there is no contraindication (e.g., peritoneal dialysis) pleuroperitoneal
shunt should be considered
2. If effusion > 25 ml/Kg/day and/or there are contraindications to pleuroperitoneal shunts thoracic duct
ligation at the diaphragmatic entry of the duct.
3. Should a and b fail, bilateral pleurodesis should be performed

Additional Notes
1. Every patient is different and the algorithm should not preclude clinician judgment.
2. If the chylous effusion does not respond to the above measures the possibility of SVC thrombosis and/or
persistent high central venous pressure due to A-V valve incompetence or other cardiac dysfunction
should be investigated. Consider cardiac catheterization.

References
1. Panthongviriyakul C, Bines J. Post-operative Chylothorax in Children: An evidence-based management algorithm.
Journal of Paediatrics and Child Health. 2008. 44(12): 716-721.

Index

A
Anthropometrics, 10
Appropriate for gestational age, 28

B
Basal energy needs, 23
Body mass index (BMI):, 10
Breast milk
Fortification, 44
Supplementation, 30, 44
Burns, 74-76
Energy requirements, 25

C
Carnitine, 88
Catch-up growth, 24
Chylothorax, 7173
Chylous ascites. See Chylothorax
Congenital heart defects, 5758
Cystic fibrosis, 5862

D
Dietary Reference Intakes, 17, 20
Drug-nutrient interactions, 100
Duocal, 45

E
Electrolyte supplementation, 107
Energy, 18
Enteral nutrition, 3856, 3856
Advantages, 38
Complications, 51
Continuous feeds, 47
Delivery routes, 45
Feeding guidelines for preterms, 36
Formula selection, 39-40, 67
Indications, 38
Initiation and advancement, 49
Intermittent/bolus feeds, 47
Essential fatty acid deficiency, 71, 93
Estimated needs. See Nutritional
requirements
Extremely low birth weight, 27

F
Feeding protocols, 36
Fenton growth charts, 27
Fiber, 19
Fluid requirements
Preterm, 30
Term infants and children, 25
Fluoride, 21
Formula selection
Allergy, 67
Enteral, 39
GI, 67
Preterm, 33
Term infant, 40

G
Gastrointestinal impairment, 6770
Glucose infusion rate, 81
Growth, 910
Growth velocity, 10
Preterm infants, 28

H
Harris Benedict equation, 23

I
Increasing caloric density, 34, 42
Insulin, 81
Iron, 89

L
Laboratory data, 15
Large for gestational age, 28
Low birth weight, 27

M
Malnutrition, 12
Clinical assessment, 12
Medical history, 13
Microlipid, 34, 42, 58
Micronutrients, 19
Midarm muscle circumference, 10
Minerals, 20
N
Nepro, 64, 66
Nutrient deficiency
Physican signs, 13
Nutritional assessment, 916
Components, 9
Nutritional intake history, 14
Nutritional requirements, 1726
Chylothorax, 71
Congenital heart defects, 57
Critically ill children, 22
Cystic fibrosis, 59
GI, 67
Non-critically ill children, 17
Preterm, 29
Renal, 63

O
Obesity, 10
Overfeeding, 24

P
Pancreatic enzymes, 60
Parenteral nutrition, 80-98
Complications, 91
Initiation and advancement, 81
Pharmacology, 100108
Polycose, 34, 42, 43, 58
Preterm
weight classification, 27
Protein, 19
Refeeding syndrome, 75
Renal, 6366
Formula modification, 44

S
Scandishakes, 59
Small for gestational age, 28
Stress factor, 23
Suplena 64
Supplementation
Vitamin and mineral, 20, 31

T
TPN. See Parenteral nutrition
Triceps skinfold, 10
Trophic feeding, 36
Tube feeding. See Enteral nutrition
Tyramine, 103

V
Very low birth weight (VLBW, 27
Vitamin D deficiency, 65
Vitamins, 20

W
Waterlow criteria, 12

- NOTES -
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- NOTES -
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Pediatric Nutrition Support Handbook

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