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Mercedita Magdaleno-Macalintal, MD, DPPS

Mercedita Magdaleno-Macalintal, MD, DPPS. Principles of Nutrition Support in Sick Children: Roles of Enteral and Parenteral Nutrition. Objectives. Participants will be able to : Identify candidates for nutritional support Describe and compare methods of nutrition intervention

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Mercedita Magdaleno-Macalintal, MD, DPPS

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  1. Mercedita Magdaleno-Macalintal, MD, DPPS Principles of Nutrition Support in Sick Children: Roles of Enteral and Parenteral Nutrition

  2. Objectives Participants will be able to: • Identify candidates for nutritional support • Describe and compare methods ofnutrition intervention • Select the appropriate method ofnutrition support • Describe and select appropriatenutrition support access • Monitor nutrition support to prevent ormanage complications and achievenutrition support objectives

  3. Content • Nutrition decision making – paradigms • Who needs nutritional support • Enteral vs. parenteral nutrition • Access and formulation • Algorithm

  4. The Goal of Nutritional Support • Provide appropriate amounts of energy and nutrients for optimal growth and development while: • Preserving body composition • Minimizing gastrointestinal symptoms • Promoting developmentally appropriate feeding habits and skills Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.

  5. Considerations in Nutritional Planning • High prevalence of malnutrition • 10% to 50% of patients are nutritionally compromised • Special nutritional requirements • Growth and development • Immature organs/systems • Limited reserves Merritt RJ, et al. Am J Clin Nutr 1979;32:1320-1325. Secker DJ, et al. Am J Clin Nutr 2007;85:1083-1089. Pawellek I, et al. Clin Nutr 2008;27:72-76. Marino LV, et al. S Afr Med 2006;96:993-995. Hendricks KM, et al. Arch Pediatr Adolesc Med 1995;149:1118-1122.

  6. Considerations in Nutritional Planning • Severe and possible permanent sequelae • IQ • School performance • Cognition • Use of enteral or parenteral feeding may adversely affect normal development offeeding skills and behavior/attitudes • Specialized nutritional therapies are the treatment of choice for different disorders Liu J, et al. Am J Psychiatry 2004;161:2005-2013. Daniels MC, et al. J Nutr 2004;134:1439-1446. Liu J, et al. Arch Pediatr Adolesc Med 2003;156:593-600. Mason SJ, et al. Dysphagia 2005;20:46-66. Damen RS. Adv Perit Dial 1990;6:276-9. Merritt RJ, et al. Am J Clin Nutr. 1979;2:1320-1325. Secker DJ, etal. Am J Clin Nutr. 2007;85:1083-1089. Pawellek I, et al. Clin Nutr. 2008;7:72-76. Marino LV, et al. S Afr Med J. 2006;96:993-995. Hendricks KM, et al.Arch Pediatr Adolesc Med. 1995;149:1118-22

  7. Creating a Nutritional Plan • Identifyat-risk children • Setcaloric/protein goals • Establishfeeding method • Choose formula type and composition • Monitor

  8. Nutrition Decision-Making Paradigms • Nutrition evaluation and support should be an essential part of clinical evaluation and care in the pediatric (hospital) setting and, therefore, should be performed routinely • Nutritional support should be implemented in all children with or at risk of developing malnutrition

  9. Indications for Nutrition Support • Inadequate growth: • Inadequate growth or weight gainfor >1 month in a child <2 years • Weight loss or no weight gain for aperiod >3 months over the age of 2 years • Change in weight/age or weight/height (length) over 2 growth channels on the growth charts • Triceps skin-fold consistently <5th percentile for age Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.

  10. Indications for Nutrition Support • Inadequate intake: • Inability to consume at least 80%of energy needs orally • Inadequate feeding skills: • Total feeding time >4 hours/day for a neurologically impaired child Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.

  11. Conditions That MayRequire Nutritional Intervention • Disorders causing inadequate oral intake • Disorders of digestion and absorption • Disorders of gastrointestinal motility • Increased nutritional requirementsand losses • Growth failure or chronic malnutrition • Crohn’s disease • Inborn errors of metabolism

  12. Methods of Nutrition Intervention 4. Parenteral Nutrition 3. Enteral Feeding 2. Oral Nutritional Supplements 1. Nutritional Counseling

  13. Nutrition Interventions: Definitions • Nutritional counseling: A nutrition professional works with patient/caregiver to assess how to improve dietary intake and provides information, education materials, support and follow-up • Oral nutrition supplementation: Providingsupplementary nutrition by mouth • Enteral nutrition: Providing supplemental or total nutrition via a feeding tube • Includes all forms of nutritional support that involveuse of “dietary foods for special medical purposes” • Parenteral nutrition: Providing supplemental or totalnutrition intravenously Lochs H, et al. Clin Nutr 2006;25:180-186. Koletzko B, et al. J Pediatr Gastroenterol Nutr 2005;41 (suppl2):S1-S87.

  14. Enteral Nutrition Indications If the gut works, use it! • Enteral nutrition should be implemented in children who: • Have some level of GI function but are unable to meet their full nutritional requirements orally • Are malnourished • Are at risk of malnutrition

  15. Contraindications to Enteral Nutrition : • Absolute contraindications: • Intestinal perforation, ischemia, peritonitis, necrotizing enterocolitis • GI obstruction, paralytic ileus • Inability to access the GI tract (severe burns, trauma) • Relative contraindications: • Vomiting and diarrhea • Severe acute pancreatitis (pain, vomiting) • High output enteric fistula • GI bleeding

  16. Indications to Parenteral Nutrition • Transient or permanent GI failure • GI tract failure is often partial • Some enteral nutrition may be possible

  17. Parenteral NutritionContraindications/Ethical Issues • When enteral feeding is possible • Terminal illness

  18. Enteral & ParenteralNutrition Disadvantages

  19. Decision Making forNutrition Support Method Nutritional Assessment Specialized Nutritional Support Functional Gastrointestinal Tract YES NO Contraindications toenteral nutrition No contraindications toenteral nutrition Parenteral nutrition Enteral nutrition

  20. Enteral Formula Selection Consider • Site of delivery • Route of delivery • Mode of delivery • Monitoring

  21. Nutrients and energy needs adjusted for the age and clinical condition of the child: History of food intolerance or allergy Intestinal function Site and route of delivery Taste preference (oral supplementation) Formula characteristics: Nutritional composition Osmolarity and solute load Caloric density Cost Enteral Formula Selection

  22. Types of formulas according to degree of hydrolyzation Polymeric Intact nutrients, require digestion Semi-elemental/partially hydrolyzed Partially “digested” for easy absorption Elemental Composed of free amino acids, monosaccharides and little fat Enteral Nutrition Shaw V, Lawson M, eds. Clinical Paediatric Dietetics. 2nd ed. London: Blackwell; 2001. Sobotka L. Basics in Clinical Nutrition, 3rd ed. Prague: Galen; 2004. Lochs H, et al. Clin Nutr 2006;25:260–274. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. JPEN 2002;26:S97-S137.

  23. Modular formulas Made of modular components to produce an individualized formula to meet special needs Immunomodulating formulas Supplemented with functional ingredients Eg, glutamine, arginine, nucleotides, omega-3fatty acids, antioxidants Disease-specific formulas Modified in nutrient content, amount and ratio Enteral Nutrition Shaw V, Lawson M, eds. Clinical Paediatric Dietetics. 2nd ed. London: Blackwell; 2001. Sobotka L. Basics in Clinical Nutrition, 3rd ed. Prague: Galen; 2004. Lochs H, et al. Clin Nutr 2006;25:260–274. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. JPEN 2002;26:S97-S137.

  24. Enteral and ParenteralNutrition Advantages

  25. Sites of delivery: Gastric Post-pyloric Choice of the delivery site is based on: Functional status of the gut Risk of aspiration Enteral Nutrition

  26. Gastric feeding Flexible feeding schedules Reservoir capacity Tolerance of volume and hyperosmolar feedings Less diarrhea, dumping syndrome Gastric acidity has antibacterial function Gastric tubes are relatively easy to place Post-pyloric feeding Allows delivery of EN in case of gastroparesis, severe GERD, or gastric outlet obstruction Not recommended for preterm infants Enteral Nutrition McGuire W, McEwan P. Cochrane Database Syst Rev. 2007;3:CD003487.

  27. Enteral Nutrition Nasogastric (NG) and nasoenteric feeding tubes • Feeding duration 6-8 weeks • PVC, polyurethane, silicone NG tubes common • PVC can release phthalate ester • PVC can become rigid • Change PVC NG tubes q 3-4 d,transpyloric tubes q 8 d • Smallest tube diameter desirable • Tube length • Tube placement confirmation

  28. Enteral Nutrition • Gastrostomy/jejunostomy tubes • For feeding duration >8 weeks • Placement techniques • Endoscopy • Surgery • Radiology • Loser C, et al. Clin Nutr 2005;24:848-61. • Caulfield M. Gastrointest Endosc Clin N Am 1994;4:179-93.

  29. Methods of enteral feeding administration Continuous feeding Continual delivery over 12 - 24 hours Feeding pump regulates delivery Intermittent bolus feeding Discrete volumes of formula delivered several times daily Combined continuous and intermittent feeding Enteral Nutrition Aynsley-Green A, et al. Acta Paediatr Scand 1982;71:379-83. Jawaheer G, et al. J Pediatr 2001;138:822-5. Shulman RJ, et al. J Pediatr Gastroenterol Nutr 1994;18:350-4.

  30. Required monitoring Biochemical monitoring To prevent electrolyte and fluid abnormalitiesand hypo- and hyperglycemia GI tolerance To prevent vomiting, abdominal distention,pain, constipation Tube/stoma placement and maintenance To prevent tube displacement, tube clogging, aspiration Growth and development Psychological aspects (feeding aversion, loss of feeding skills) Enteral Nutrition Jeejeebhoy KJ. Curr Opin Gastroenterol 2005;21:187-91.

  31. Parenteral Nutrition • Decision to institute parenteral nutritiondepends on: • Nutritional status • GI tract function

  32. Parenteral Nutrition • Rapid initiation for young, small children • Preterm infants cannot tolerate starvation • Institute parenteral nutritionimmediately after birth • Older children can tolerate up to 7 days • Combine with oral or enteral nutrition

  33. Access Peripheral access should be temporary Trained personnel insert and care for central venous catheters Aseptic conditions are paramount Methods of insertion PICC Tunneled central venous catheters Insertion sites Femoral Jugular Subclavian Parenteral Nutrition

  34. Parenteral solutions Amino acids Glucose Lipids Electrolytes, vitamins, trace elements Tailored vs. standard solutions Computer prescription programs encouraged Parenteral Nutrition Guidelines on Paediatric Parenteral Nutrition of ESPGHAN and ESPEN, Supported by ESPR. J Pediatr Gastroenterol Nutr 2005:41(suppl2):S1-S87.

  35. Monitoring Monitor Blood chem 2-3 times weekly Electrolytes, renal & liver function, blood lipids Routine nutrition assessment Parenteral nutrition >3 months Trace elements / Ferritin Folate / Vitamin B12 Thyroid function Coagulation status Fat-soluble vitamins Parenteral Nutrition

  36. Complications Catheter-related Infection, thrombosis, occlusion,accidental removal, catheter damage Metabolic/nutritional Fluid-electrolyte abnormalities,hypo-/hyperglycemia, failure to achieve optimal nutritional status and growth Long-term parenteral nutrition Cholestasis, renal and bone disease,growth impairment Parenteral Nutrition

  37. Prevent complications Multi-disciplinary nutrition support team Meticulous technique Avoid unbalanced/excessive substrates Strict hygiene Emphasize enteral feeding Structured pathways Parenteral Nutrition

  38. Enteral Nutrition Possible Normal Gastrointestinal Absorption Function NO YES Specialized Formula Standard Formula Expected Period of Nutritional Support Less than 4-6 weeks More than 4-6 weeks Risk of Aspiration Gastrostomy Nasogastric Tube NO Post-pyloric Tube YES Jejunostomy

  39. Enteral Nutrition not Possible Intestinal Immaturity/Failure Contraindications to Enteral Nutrition Expected Period of PN Support Temporary need for PN Less than 7-10 days Prolonged need for PN More than 7-10 days Peripheral venous access Central venous access Establish/provide energy and nutrient requirements Periodic evaluation of nutritional status and GI function Periodic monitoring/prevention and treatment of complications

  40. Prolonged PN Support Permanent or Severe Intestinal Failure Prolonged period of parenteral nutrition is expected. Patient condition, fluid/electrolytes status stable. Cyclic administration initiated Arrange for home parenteral nutrition support • Teach family members aseptic technique for catheter dressing, tube connection and disconnection • Teach solution and pump handling • Supply 24/7 assistance in case of emergency Periodic evaluation of nutritional status and GI function Periodic monitoring/prevention and treatment of complications Evaluate the possibility of weaning from home parenteral nutrition

  41. Summary • Nutrition decision making – paradigms • Who needs nutritional support • Enteral vs. parenteral nutrition • Access and formulation • Algorithm

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