nutrition in new born a paediatric surgeon
- 1. PARENTERAL AND ENTERAL NUTRITION PRESENTER- DR ADITYA BIRADAR 1 ST YEAR MCH RESIDENT MODERATOR-DR SAURAV SRIVASTAVA ASSISTANT PROFFESOR
- 2. OBJECTIVES INTRODUCTION PARENTERAL NUTRITION • INDICATIONS • COMPOSITION • PREPARATION OF TPN • COMPLICATIONS • CONTRAINDICATIONS ENTERAL NUTRTION • FORMULAS • COMPLICATION • CONTRAINDICATION NUTRITION IN SPECIAL CONDITIONS
- 3. INTRODUCTION Nutritional assessment is a critical aspect of the initial evaluation of all surgical patients The incidence of malnutrition in surgical patients has been well documented in several reviews, and this group comprises 35% to 45% of inpatients Patients at risk for malnutrition include those with large open wounds with concomitant loss of protein and increased metabolic needs, extensive burns, blunt trauma, and sepsis Cooper and colleagues showed that 18% to 40% of pediatric surgical patients have malnutrition
- 5. Parenteral nutrition Parenteral nutrition (PN) is the intravenous administration of balanced and complete nutrition to support anabolism, prevent weight loss, or promote weight gain. Causes mobilization of energy and protein stores Appropriate and timely nutrition should be provided to prevent malnutrition and promote speedy recovery. Studies indicate that early use minimises protein loss and improve growth outcomes in ELBW babies Recent meta-analysis showed that the incidence of complications resulting from enteral and parenteral nutrition are essentially the same
- 6. INDICATIONS 1) GI DISORDERS: • SHORT BOWEL SYN • MALABSORPTION • INTRACTABLE DIARRHEOA • BOWEL OBSTRUCTION • PROTRACTED VOMITING • IBD • ENETERCUTANEOUS FISTULA 2) CONGENITAL MALFORMATIONS: GASTROSCHISIS, BOWEL ATRESIA, VOLVULUS, MECONIUM ILEUS
- 7. INDICATIONS 3) TRAUMA/RADIATION/CHEMOTHERAPY TO GIT 4) Gestation <30 weeks and/or birth weight <1000g 5) Gestation >30 weeks, but unlikely to achieve full feeds, due to respiratory distress syndrome, bronchopulmonary dysplasia. 6)Young infants -periods of starvation extend beyond 4 to 5 days 7)Older children and adults -periods of starvation extend beyond 7 to 10 day
- 8. VENOUS ACCESS 1.PERIPHERAL VENOUS PARENETERAL NUTRITION 2. CENTRAL VENOUS PARENTERAL NUTRITION
- 9. PERIPHERAL PN (22-gauge) Placed through the child’s peripheral veins, and passed into the central venous system Limited number of days, High risk of extravasation of the solution Potential skin necrosis. Phlebitis in peripheral veins is greater when the PN solution osmolarity exceeds 600 to 900 mOsm/L Maximum dextrose concentration in peripherally solutions in infants and children is 12.5%
- 10. Lipid emulsions - isotonic solutions, coinfusion of lipids with peripheral PN protects the veins and prolongs the viability of peripheral intravenous catheters CALCIUM PHOSPHATE PRECIPITATES ARE POTENTIALLY LIFE THREATENING IN PN SOLUTIONS INFUSED THROUGH AN INLINE FILTER Avoid hypoglycemia or hyperglycemia, the rate of infusion needs to be reduced by half for 1 to 2 hours before terminating or starting up infusion each day .
- 11. CENTRAL VEIN CANNULATION. Double lumen broviac catheter2.7- or 4.0-F is used for central venous catheterization. Into IJV, subclavian vein , femoral vein. Young infants,20G outer cannula with inner 22G needleis used older children, 16 G outer cannula with 18 G needle is used children who weigh less than 750 g, the internal jugular or femoral vein may need to be used because of the small caliber of other vessels
- 12. MAINTENANCE OF CATHETERS Catheters are a common source of sepsis in neonates Skin site be cleansed with an antiseptic solution Dressed in a dry fashion every other day Tubing and infusion bags are changed every 72 hours, along with a new inline filter Tubing used to deliver lipids must be changed every 24 hours
- 13. IAPEN(Indian association for parenteral and enteral nutrition) GUIDELINES Parenteral nutrition to be used only when oral intake is grossly inadequate Use peripheral venous access when child is stable and TPN is indicated for less than 2 weeks Use central access when child is critically ill and requires TPN > 2 weeks Early enteral feeding should be the ultimate goal and TPN should be stopped when 70 % of total kilocalories are tolerated enterally
- 14. Infusion schedule CONTINOUS PN Non interrupted infusion over 24 hours via central or peripheral route. CYCLICAL PN – Intermittent administration over 12-18 hours especially for lipids.
- 15. CYCLING Parenteral nutrition solution is infused at higher rate for less than 24 hours, followed by several hours(6-8 hours) without infusion PRE-REQUISITES : Stable on PN > 1 week ADVANTAGES : 1) Approximates normal physiology of feeding 2)Allows normal activities ,improves quality of life 3) Allows the rise and fall of hormones a/w meals
- 16. Energy Requirement 60% CARBOHYDRATE 30% FATS 10-15% PROTEIN
- 17. COMPOSITION MACRO NUTRIENTS AA DEXTROSE LIPID EMULSIONS MICRO NUTRIENTS MULTIVITAMINS, TRACE MINREALS (zinc, copper, manganese, chromium and selenium) • FLUIDS • ELECTROLYTE
- 18. CALORIC REQUIREMENTS WEIGHT BASED • PREMATURE – 120 KCAL/KG • 1-10KG – 100KCAL/KG • 11-20KG – 1000KCAL + 50kcal/kg over 10 kg • >20kg – 1500kcal + 20kcal/kg over 20kg For utilization of each 100kcal – 100mlof water is required AGE BASED • 0-1 YR = 90-120kcal/kg/day • 1-7 yrs =75-90kcal/kg/day • 7-12 yrs= 60-75kcal/kg/day • 12-18 yrs= 30-60kcal/kg/day
- 19. Protein Requirement Protein Requirement (g/kg/day) • • Preterm neonate 0 -1 month: 3.0 – 3.5 • • Infant - 1 – 12 months: 2.5 – 3.0 • • Children - 1 – 12 years: 1.5 – 2.5 • • Adolescents: 1.0 – 1.5 Started at 1 g/kg/day and advanced to goal over 2 to 3 days. LBW infants may need up to 3.85 g/kg/day of amino acids. •
- 20. Amino acids Premature infants are at risk for taurine deficiency as a result of elevated renal taurine losses and their low capacity for taurine synthesis resulting from low cystathionase enzyme activity Taurine supplementation for premature infants is essential to promote Bile acid conjugation Improve bile flow Decrease the degree of PN-associated cholestasis. Higher amino acid -wound healing , in cases of dialysis. Lower amino acid -liver failure and hyperammonemia
- 21. CARBOHYDRATES -DEXTOSE The caloric value of hydrous dextrose is 3.4 kcal/g. PN dextrose infusion rate of 4 to 8 mg/kg/min increase by 1 to 2 mg/kg/min goal 12mg/kg/min PRE TERM infants with hypoglycaemia or failure to thrive may require higher dextrose infusion rates up to 20 mg/kg/min
- 22. LIPIDS EMULSIONS Lipid emulsions 10%- 1.1 kcal/mL, 20%- 2 kcal/mL 30%-3kcal/mL Initiated at a dose of 0.5 to 1 g/kg/day Advanced by 0.5 to 1 g/kg/day Maximum of 3g/kg/day Natural source of variable amounts of vitamin K and vitamin E isomers
- 23. MULTIVITAMINS VIT B1 Thiamine is a cofactor for normal dextrose metabolism. Dextrose is normally metabolized to pyruvate, which is then converted to acetyl coenzyme A, which undergoes oxidation through the citric acid cycle. If thiamine deficiency occurs, pyruvate is instead converted to lactate, which can result in lactic acidosis. Lactic acidosis has been reported in patients who received dextrose infusions without thiamine supplementation.
- 24. Pediatric Intravenous Multivitamin Formulation and Requirements
- 26. Additives to parenteral nutrition • Heparin • Histamine-2 Receptor Antagonists • Regular Insulin • Iron Dextran • Carnitine
- 27. Preparation of TPN Calculated quantities of dextrose, amino acids and electrolytes are mixed under Laminar air flow work station Administer lipids via separate line Routes: Peripheral or a central vein The maximum osmolarity delivered via a peripheral vein is 900 mOsm/L
- 28. Of TPN
- 30. A 5-day-old neonate, with gestational age of 28 weeks and birth weight of 900 g with respiratory distress on a ventilator, on TPN since day one Step I: Total fluids 150 mL/kg = 135 mL Step II: Aminoacid (10%) 3 g/kg/day = 27 mL Step III: Lipids (10%) 3 g/kg/day = 27 mL Step IV: Supplementation 1. Sodium 3 meq/kg/day = 2.7 meq Conc. Ringer lactate = 0.9 mL 2. Potassium 2 meq/kg/day = 1.8 meq Potassium chloride = 0.9 mL
- 31. Calcium 2 meq/kg/day = 1.8 meq Calcium gluconate 10% = 4 mL Magnesium 0.3 meq/kg/d = 0.27 meq 50% Magnesium sulphate = 0.07 mL MVI 1 mL/kg/day MVI solution = 0.9 mL
- 32. Step V: Dextrose Infusion: 6 mg/kg/min = 7.8 g/24hours Total fluids – Total additives (Step II, III, IV) 135 – 60.77 = 74.23 mL This can be given as 10% dextrose 70 mL = 7000 mg 50% dextrose = 1.6 mL = 800mg Distilled water = 2.63mL = 0 mg Step VI: Calculation of Caloric Nitrogen Ratio Total carbohydrate calories + Total fat calories × 6.25 ÷ Amino acid (g) (7.8 × 3.4) + (2.7 × 9) × 6.25 –––––––––––––––––––––– 2.7 CNR = 117.63 cal/g
- 33. Step VII: Add heparin 1 unit/mL = 135 units Note: If the baby is unstable, calculations may have to be done every 12 hours instead of every 24 hours
- 35. ADVERSE EFFECTS OF PARENTRAL NUTRITION Hyperglycemia Hypoglycemia Hypertriglyceridemia Metabolic Acidosis Electrolyte Disturbances
- 36. ADVERSE EFFECTS OF PARENTRAL NUTRITION Hepatobiliary Complications Complications from Overfeeding Infectious Complications Technical Complications
- 37. Venous Access: Insertion of the central line catheter • Pneumothorax • Air embolism • Bleeding • Venous thrombosis • Vascular injury Catheter Site Infections • Central line-associated bloodstream infection(CLABSI) • Local skin infection at insertion or exit site
- 38. CONTRAINDICATIONS OF PARENTRAL NUTRITION • Infants with less than 8 cm of the small bowel • Irreversibly decerebrate patients • Patients with critical cardiovascular instability or metabolic instabilities; such instabilities require correction before administering intravenous nutrition. • When gastrointestinal feeding is possible • When the nutritional status is good, only short-term TPN is needed • TPN should not be used to prolong life when death is unescapable
- 40. ENTERAL NUTRITION Enteral Nutrition Enteral nutrition (EN) includes oral nutritional supplementation and tube feedings. EN should be the primary source of nutrients if the gastrointestinal tract is functional. Even when full feedings are not tolerated enterally, the provision of small volumes of “trophic” feedings may prevent further deterioration of intestinal function Once oral feeds are clinically possible they should begin. Delay in initiating oral nutrient swallowing will result in long-term oral aversion.
- 41. EQUIPMENTS Types of Enteral Feeding Tubes There are several types of enteral feeding tubes. They are usually made of polyurethane or silicone • Nasogastric tube • Nasoduodenal tube • Nasojejunal tube • Gastrostomy tube • Jejunostomy tube • Gastrojejunal tube
- 42. Tubes can be placed: Manually Endoscopically Surgically Interventional radiology
- 43. Verification Verification of the location of the tube is mandatory before beginning enteral tube feedings • Aspiration of enteric contents • Radiologic confirmation.
- 44. ENTERAL FORMULAS Choice of formula depends on the age of the patient and the condition of the gastrointestinal tract Some formulas have arachidonic acid (ARA) and docosahexaenoic acid (DHA),believed to be essential for brain and eye development LACTOSE-BASED FORMULA is the first choice • physiologically similar to human milk • least expensive
- 45. SOY FORMULAS • Galactosemia • Primary and Secondary lactase deficiency • Not recommended for premature infants, because of their high aluminum content, which may contribute to osteopenia CONCENTRATED FORMULAS • Difficult for some infants to digest, • Higher renal solute load and it may take time for them to build up tolerance. • Associated with a necrotizing enterocolitis–type process
- 46. HUMAN MILK Water -87% Energy-0.64 to 0.67 kcal/Ml Fat content 3.4 g/dL. Protein content of human milk (0.9%) is lower than that of bovine milk or commercial formulas better absorbed because of the higher amounts of whey content Passive immunity by the transfer of both immunoglobulins and lymphocytes from the mother Taurine, which is needed for bile salt excretion and neurologic and retinal development
- 47. High demands for • calcium • phosphorus • electrolytes • vitamins • trace elements cannot be achieved with human milk alone Human milk fortifiers (one pack per ounce) should be added to breast milk fed to preterm infants. When human milk fortifier is added to human milk, the hang time of the final reconstituted formula is 2 hours.
- 48. PRE TERM INFANTS Increased risk for necrotizing enterocolitis. This risk is not increased with gastrointestinal (GI) priming feeds Excessive advancements in the rates put neonates at increased risk Feeding advancements should not exceed 20 mL/kg/day
- 49. TERM INFANTS Intermittent enteral feeding o Initiated at 2 to 5 mL/kg every 3 to 4 hours. o Advanced in increments of 2 to 5 mL/kg every two feedings to a goal rate as tolerated. Feeding residuals are checked before each intermittent feeding Enteral nutrition is held if the residual volume is greater than twice the administered volume
- 50. COMPLICATIONS Tube-Related Mechanical Complication Tube malposition Tube obstruction Accidental dislodgment of tube Breakage of the feeding tube Leakage of the feeding tube Erosion and ulceration near the site of insertion Intestinal obstruction Bleeding
- 51. Infectious Complications • Infection at the site of tube insertion • Aspiration pneumonia • Ear and nasopharyngeal infection • Infective gastroenteritis with diarrhea • Peritonitis
- 52. Short-term complications of surgically-placed J-tubes • Intra-abdominal abscess • Volvulus with bowel infarction. Long-term complications include • Intestinal obstruction and • Peritonitis. When using tubes passed distal to the pylorus, continuous drip feedings are recommended to prevent the development of diarrhea and other symptoms of dumping
- 53. COMPLICATIONS OF ENTERAL FEEDING LACTASE DEFICIENCY. o Symptoms -cramping, diarrhea, or emesis. o Start lactose-free diet SUBOPTIMAL ENTERAL NUTRITION DELIVERY o critically ill child, frequent interruptions of enteral feeding for procedures, feeding intolerances, fluid restriction, or gastrointestinal dysmotility result in suboptimal enteral nutrition delivery ASPIRATION
- 54. COMPLICATIONS OF ENTERAL FEEDING GASTROINTESTINAL DYSFUNCTION Git tolerates increased volume more readily than increased osmolarity. Initiating ¼-strength formula Slowly advancing the formula concentration. Administration of formula by continuous drip may be better tolerated than bolus feedings MEDIUM-CHAIN TRIGLYCERIDES (MCT) • Limited bile salt pool in young infants • Absorbed directly through the basolateral surface of the epithelial cell without the need for bile salts. • Cannot be used to prevent essential fatty acid deficiency (all of which are long-chain triglycerides).
- 55. Contraindications Absolute Contraindications • Hemodynamic instability with poor end-organ perfusion. • Active GI bleeding • Small or large bowel obstruction • Paralytic ileus secondary to electrolyte abnormalities • Peritonitis
- 56. Contraindications Relative Contraindications • Moderate to severe malabsorption • Diverticular disease • Fistula in the small bowel • SHORT BOWEL DISEASE-presence of a stool pH less than 5.5 or a reducing substance of greater than one-half percent indicates the passage of unabsorbed carbohydrates into the stool
- 57. Monitoring Weight, input output chart-Daily RBS-- Twice daily Electrolytes-- Thrice a week LFT, proteins, albumin, creatinine, blood culture.-- Weekly Haematocrit, urea,NH3,lipid profiles,calcium,phosphorous.-- Biweekly
- 58. Special Problems in the Nutritional Support of the Pediatric Surgical Patient Induction of anesthesia has profound effects on body metabolism, with agents such as fentanyl effect in reducing the catabolic effect. PN in surgical neonates is associated with increased production of oxygen- free radicals, and this may contribute to suppression of the immune status.
- 59. INDICATIONS FOR PREOPERATIVE NUTRITION MALNOURISHED ADULTS, provision of enteral feedings preoperatively for 2 to 3 weeks may reduce postoperative wound infections, anastomotic leakage, hepatic and renal failure, and length of hospital stay Metaanalysis demonstrated only a marginal benefit of preoperative PN Little benefit, and possible increase in complications, in mildly or moderately malnourished patients.
- 60. INDICATIONS FOR PREOPERATIVE NUTRITION SEVERELY MALNOURISHED patients who have developed fewer non infectious complications if receiving perioperative PN (PN presurgery for 7 to 15 days, and postsurgery for 3 days) PN patients were noted to have an increased infection rate that could not totally be explained by the use of central venous catheters. Delay in operative management in order to provide preoperative PN is not indicated.
- 61. SHORT-BOWEL SYNDROME Initially sole caloric source will be through PN Enteral feedings should be initiated as soon as possible after the onset of the short-bowel syndrome Enteral feedings will stimulate small-bowel adaptation and prevent the development of PN associated cholestasis. The ideal enteral solution should be isotonic. The protein source should be predominately elemental. Dipeptides and tripeptides have often been advocated, because this source of protein is most easily and efficiently absorbed. Formula should have at least 50% of medium-chain triglycerides because this type of fat is well absorbed
- 62. SHORT-BOWEL SYNDROME High stool output(infections, malabsorption, rapid transit, as well as bile acid irritation of the colonic epithelium) is associated with excessive losses of zinc, magnesium, sodium, bicarbonate, and potassium. high output may include urine sodium of less than 10 mEq/L may well indicate total-body sodium depletion, and supplementation (sodium chloride or sodium bicarbonate, as indicated) by the oral route should be given on a daily basis Stool pH less than 5.5 and an elevated reducing substance level (greater than 0.5%) indicate carbohydrate malabsorption Elevation in fecal fats will suggest fat malabsorption, which may require increase the percentage of medium-chain triglycerides Increase in stool alpha-1 antitrypsin would indicate a protein malabsorption
- 63. SHORT-BOWEL SYNDROME Resin binder (e.g., cholestyramine) will markedly reduce bile acid irritation . Excessive use causes depletion of the circulating bile acid pool and thereby further limit fatty acid absorption INFANTS WITH SHORT-BOWEL SYNDROME HAVE DYSMOTILITY ELIMINATE (I.E., INFECTIOUS, BACTERIAL OVERGROWTH, BILE ACID IRRITATION, AND POTENTIALLY CORRECTABLE MALABSORPTION) AGENT TO REDUCE MOTILITY (E.G., IMODIUM)
- 65. BILIARY ATRESIA Clinically successful hepatic portoenterostomy, will typically have profound defect in fat digestion and absorption Essential fatty acid deficiency and Inadequate absorption of fat-soluble vitamins. Lack of bone mineralization as well as failure to thrive
- 66. BILIARY ATRESIA Breastfeeding should be used cautiously in patients with biliary atresia. Breast milk has a much higher fat content than commercially available formulas and may not be well tolerated in these children.
- 67. Vitamin supplementation in BILIARY ATRESIA • water-soluble vitamins given by administration of a multivitamin preparation
- 68. BILIARY ATRESIA Protein metabolism is impaired in children with biliary atresia Energy expenditure increased from 4% to 9 in healthy infants to 17% in patients with biliary atresia. Pierro and colleagues have shown that resting energy expenditure was about 29% higher than expected in infants with biliary atresia and that only 35% of the metabolizable energy intake was retained for growth in these children Optimal growth and nutrition in infants with biliary atresia has recently been associated with improved outcomes and should be a major goal for pediatric surgeon
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