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Principles of Nutrition Support
in Sick Children: Roles of Enteral and Parenteral
Nutrition
Mercedita Magdaleno-Macalintal, MD, DPPS
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Objectives
Participants will be able to: Identify candidates for nutritional
support Describe and compare methods of
nutrition intervention Select the appropriate method of
nutrition support Describe and select appropriate
nutrition support access Monitor nutrition support to prevent or
manage complications and achievenutrition support objectives
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Content
Nutrition decision making – paradigms
Who needs nutritional support
Enteral vs. parenteral nutrition
Access and formulation Algorithm
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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
The Goal of Nutritional Support
Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.
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High prevalence of malnutrition• 10% to 50% of patients are nutritionally compromised
Special nutritional requirements • Growth and development• Immature organs/systems• Limited reserves
Considerations in Nutritional Planning
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 .
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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
Considerations in Nutritional Planning
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.
Creating a Nutritional Plan
Identify at-risk children Set caloric/protein goals Establish feeding method Choose formula type and
composition Monitor
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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
Nutrition Decision-Making Paradigms
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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
Indications for Nutrition Support
Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.
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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
Indications for Nutrition Support
Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.
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Conditions That MayRequire Nutritional Intervention
Disorders causing inadequate oral intake
Disorders of digestion and absorption Disorders of gastrointestinal
motility Increased nutritional requirements
and losses Growth failure or chronic
malnutrition Crohn’s disease Inborn errors of metabolism
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Methods of Nutrition Intervention
4. Parenteral Nutrition
3. Enteral Feeding
2. Oral Nutritional Supplements
1. Nutritional Counseling
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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.
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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
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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
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Indications to Parenteral Nutrition
Transient or permanent GI failure
GI tract failure is often partial•Some enteral nutrition may be possible
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Parenteral NutritionContraindications/Ethical Issues
When enteral feeding is possible
Terminal illness
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Enteral & ParenteralNutrition Disadvantages
Enteral NutritionParenteral NutritionFailure to meet
nutritional needsSpecialized
centers/teams
Less acceptable to patients
Expensive
Frequent tube replacement
Complications
Complications
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Nutritional Assessment
Functional Gastrointestinal Tract
Enteral nutrition
YES
No contraindications toenteral nutrition
NO
Parenteral nutrition
Specialized Nutritional Support
Contraindications toenteral nutrition
Decision Making forNutrition Support Method
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Enteral Formula Selection
ConsiderSite of deliveryRoute of deliveryMode of deliveryMonitoring
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Enteral Formula Selection
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
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Enteral Nutrition
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
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 .
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Enteral Nutrition
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 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 .
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Enteral and ParenteralNutrition Advantages
Enteral NutritionParenteral Nutrition Preserves
- GI structure & function - Gut hormonal response
- Normal gut flora - Normal blood supply to the
gut - GALT integrity
No risk of tube feeding aspiration
May help preventbacterial translocation
Better patient acceptance
Decreased risk of infectionMore reliable delivery
Less expensiveSupports survival in intestinal failure
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Enteral Nutrition
Sites of delivery:GastricPost-pyloric
Choice of the delivery site is based on:
Functional status of the gutRisk of aspiration
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Enteral Nutrition
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 infantsMcGuire W, McEwan P. Cochrane Database Syst Rev. 2007;3:CD003487.
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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
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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.
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Enteral Nutrition 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 feedingAynsley-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.
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Enteral Nutrition 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)
Jeejeebhoy KJ. Curr Opin Gastroenterol 2005;21:187-91.
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Parenteral Nutrition
Decision to institute parenteral nutrition
depends on:•Nutritional status•GI tract function
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Parenteral Nutrition
Rapid initiation for young, small children• Preterm infants cannot tolerate starvationInstitute parenteral nutritionimmediately after birth
• Older children can tolerate up to 7 days
Combine with oral or enteral nutrition
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Parenteral Nutrition
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
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Parenteral Nutrition
Parenteral solutions• Amino acids• Glucose• Lipids• Electrolytes, vitamins, trace elements
Tailored vs. standard solutions Computer prescription programs encouraged
Guidelines on Paediatric Parenteral Nutrition of ESPGHAN and ESPEN, Supported by ESPR. J Pediatr Gastroenterol Nutr 2005:41(suppl2):S1-S87.
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Parenteral Nutrition
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
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Parenteral NutritionComplications 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
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Parenteral Nutrition
Prevent complications Multi-disciplinary nutrition support team
Meticulous technique Avoid unbalanced/excessive substrates
Strict hygiene Emphasize enteral feeding Structured pathways
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Normal Gastrointestinal Absorption Function
Nasogastric Tube
YES
NO
Jejunostomy
Specialized Formula Standard Formula
Expected Period of Nutritional Support
Less than 4-6 weeks More than 4-6 weeks
Risk of Aspiration
Post-pyloric Tube
Gastrostomy
YES
NO
Enteral Nutrition Possible
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Enteral Nutrition not Possible
Intestinal Immaturity/FailureContraindications to Enteral Nutrition
Periodic monitoring/prevention and treatment of complications
Temporary need for PNLess than 7-10 days
Expected Period of PN Support
Peripheral venous access Central venous access
Establish/provide energy and nutrient requirements
Prolonged need for PNMore than 7-10 days
Periodic evaluation of nutritional status and GI function
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Prolonged PN SupportPermanent or Severe Intestinal Failure
Periodic monitoring/prevention and treatment of complications
Prolonged period of parenteral nutrition is expected. Patient condition, fluid/electrolytes status stable. Cyclic administration initiated
1. Teach family members aseptic technique for catheter dressing, tube connection and disconnection
2. Teach solution and pump handling3. Supply 24/7 assistance in case of emergency
Arrange for home parenteral nutrition support
Periodic evaluation of nutritional status and GI function
Evaluate the possibility of weaning from home parenteral nutrition
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Summary Nutrition decision making – paradigms
Who needs nutritional support Enteral vs. parenteral nutrition
Access and formulation Algorithm