kale nutrition support & infants

male IBW

50kg + 2.3 (inches- 60)

female IBW

45.5kg + 2.3 (inches - 60)

daily water requirement (DWR)

35ml/kg

daily caloric requirement

30kcal/kg/day

daily protein requirement

1.5g/kg/day

1g protein= _______ cals

1g carbs= ________ cals

1 g fat= _______ cals

1g protein= 4 cals

1g carbs= 3.4 cals

1g fat= 9 cals

what does a % solution mean

g/ 100ml

fat yields ____cals/gram

10% lipids= _______ cal/ml

20% lipids= _______ cal/ml

30% lipids= ________ cal/ml

fat yields 9 cals/gram

10% lipids= ___1.1__ cal/ml

20% lipids= __2__ cal/ml

30% lipids= __3___ cal/ml

propofol yields _____cal/ml

1.1

adjusted body weight formula

ABW = IBW + 0.4(actual weight - IBW)

-> to be used if pt weights more than 1.3(IBW)

Males: IBW = 50 kg + 2.3 kg (inches- 60)

Females: IBW = 45.5 kg + 2.3 kg (inches -60)

when is pt actual weight used? IBW? ABW?

actual weight: if less than IBW

IBW: weights btwn IBW and 1.3(IBW)

ABW: if greater than 1.3(IBW)

t/f: a good nutritional assessment would have a positive nitrogen balance

true. more nitrogens in proteins in body than the amount we are losing in urine

which of the following would be the best monitoring parameter to ensure protein repletion (is pt receiving enough)?

a. albumin

b. transferrin

c. prealbumin

d. retinol binding protein

c. prealbumin. at baseline then q week

has short half life= 2days. albumin half life is 18 days- not good immediate indicator.

-transferrin is 8 days, also influenced by iron.

-retinol binding protein has rlly good half life (12hrs) but its more representative of vitA and kidney fxn, not protein

would the following lead to an increase or decrease in water requirement

a. renal impairment

b. cardiac impairment

c. fever

d. GI loss (ex: vomiting)

renal impairment= decrease

cardiac impairment= decrease

fever= increase

GI loss= increase

monitoring parameters for water requirement

- in and out amounts

- mucus membranes

- skin turgor

- weight

monitoring parameters for proper carb nutrition

- glucose

- LFTs to detect fatty infiltration (too many carbs-> converted and stored)

monitoring parameters for proper protein nutrition

- prealbumin: short half life

- BUN

- nitrogen balance

electrolyte requirements:

sum of CALCIUM and PHOSPHATE cannot exceed __________

45meq/L

might cause precipitation

(remember 1mM PO4= 2mEq PO4)

in a 1-liter TPN solution you add 12 mEq of calcium and 15 mmol of phosphate. is this appropriate and why

calcium and phosphate cannot exceed 45meq bc of precipitation

15mmol of phosphate= 30mEq (remember 1mmol PO4= 2meq bc of +2 charge)

12 + 30= 42 so yes thats ok

what can increase the chances of calcium and phosphate precipitating in an electrolyte solution

- increasing the concentrations of either

- increase temp or pH

- using CaCl2 salt form (rather than carbonate)

- mixing Ca before PO4

- decreased amino acids

t/f: mixing phosphate before calcium can increase the chances of precipitation

false. you should always add phosphate first and calcium last when compounding TPN

"phosphate first"

in which pts is folic acid and thiamine TPN supplementation necessary

folic acid= deficiency or pregnancy

thiamine= prevent alcohol induced wernickes encephalopathy (vitamin B1 deficiency)

t/f: basal insulin should be given once a day to maintain a constant amount, and rapid acting insulin should be given in bolus doses 1/2/3x a day along with meals prn

true. mimics body's natural insulin pattern: a constant baseline (basal) + spikes at mealtimes (bolus)

aspart, lispro, glusine:

regular:

NPH:

glargine, detemir

rapid-acting insulins (Aspart, Lispro, Glulisine): Fast onset, short duration; used for meals

regular insulin: Slower onset, moderate duration; used for meals or emergency

NPH: Intermediate duration; used for basal coverage, typically twice daily

long-acting insulins (Glargine, Detemir): Slow onset, no peak; used for basal coverage, typically once daily

what kind of insulin is used in TPNs?

regular insulin used in IV for TPN. this is administered continuously so theres no need to give a long acting insulin

(even if pt usually takes long acting insulin at home, give regular insulin IV in a 1:1 ratio. d/c the subq)

pt AB requires TPN. they usually inject insulin glargine 21 units QHS. how do you adjust this for the TPN

give 21 units of regular insulin IV. d/c subq one while he is receiving this one

sliding scale insulin

-adjusted doses dependent upon individual blood glucose

- pts on TPN are started on SSI and insulin amount is adjusted

what are acceptable blood sugar levels while on TPN? how is insulin adjusted if its above?

<150mg/dL

if above: 2/3 of total SSI needed in 24hrs is added to TPN in the form of REGULAR insulin

(ex: if 9 SSI units were given to combat blood sugar, then 2/3(9)= 6. so you would add 6 units of insulin to the baseline)

pt AB has been started on 10 units regular insulin IV for his TPN. he has had a blood sugar of 132, 164, and 172. the nurse gave 6 units sliding scale. was this appropriate? how should his TPN be adjusted?

yes appropriate. we want blood sugar to be below 150.

we want to add 2/3 of the ssi to his baseline. so 6(2/3)= 4.

we add 4 to the 10 baseline. pt should be on 14 units REGULAR insulin

what is propofol used for

-induction and maintenance of general anesthesia

- sedation in critically ill

how much fat is in propofol and how many calories does it provide

100mg fat per mL

provides 1.1cal/ml

what should be monitored with the use of propofol

- blood pressure (may cause bp drop)

- triglycerides

indications for parenteral nutrition (avoiding gut)

1. cant absorb nutrients via GI

2. severe diarrhea/vomiting, cant eat 7-14days

3. bowel obstruction

4. cancer (malnourishment)

5. severe pancreatitis (>5-7days)

6. unable/cant ingest

7. critical care, burns, organ failure

what are the 2 forms of parenteral nutrition administration

1. peripheral (PPN)= short term, less concentrated, lower infection risk

-> use peripheral vein (arm)

2. total (TPN)= long term, complete nutritional support, higher infection risk

-> central (subclavian vein)

-> peripherally inserted central catheter (PICC)

-> cycle= increases mobility and freedom from pump

PPN indications and CIs

indication:

1. short term: less than 5-7 days

2. pt tolerates large volume of fluids

3. osmolarity of solution <900 mOsm (10%)

CIs:

1. long term (> 7 days)

2. pt is fluid restricted

3. very catabolic, needs high energy

if a severe burn victim requires nutrition for 2 weeks, what would be the best method of implementation

TPN. over 7 days and has high energy requirement

probs has GI dysfunction so EN isnt good option. PPN would have to be <7 days and lower energy requirements

PPN pros and cons

pros:

- less invasive/ easy vein access through standard vein

- lower risk of infection/complications

cons:

- risk of phlebitis

- hard to infuse a lot (<900 msom)

central TPN pros and cons

pros:

- easier to maintain access

- can sustain large nutrient requirements (>900 mosml)

cons:

- expensive, highly trained personnel

- complications, pneumothorax

t/f: a PICC line is an example of a PPN

false. TPN

what metabolic monitoring is necessary with PPN and TPN

- blood sugar q6hrs till stable then qd

- BUN and electrolytes daily

- LFTs at baseline then q2-3 days

- fluid balances every shift

- weight daily

- prealbumin baseline then q week

refeeding syndrome

what is it?

what can happen?

starvation causes loss of PO4 from cells. when you refeed, theres a shift from fat to carbs [within 4 days of refeeding)

cells begin to take in PO4, K+, Mg2+

= hypophosphatemia, hypokalemia, hypomagnesaemia

t/f: refeeding syndrome results in hyperphosphatemia and hypermagnesiumia

false. hypophosphatemia, hypokalemia, hypomagnesaemia

indications of enteral nutrition

-GI tract is functional

-inability to consume adequate nutrition orally

ex: anorexia, neck surgery, burns, trauma, IBD, demyelinating diseases

contraindications to enteral nutrition

- intractable vomiting

- intestinal obstruction

- adynamic ileus

- upper GI bleed

- enteric fistula

which form of EN nutrition has biggest risk of aspiration

nasogastric

for EN route choice, when is stomach preferred? small intestine? how do you choose?

stomach: well tolerated and can accept high osmotic load! buffers and dilutes it

- BUT: risk of reflux and aspiration (especially nasogastric!)

intestines: preferred in pts with gastroparesis or high aspiration risk

- BUT: tolerates small volumes, and low osmotic load (dumping syndrome!), cramping/distention. harder to place tube

when should you use polymeric carbs/fats/proteins in EN? elemental?

if pt cant digest (ex: pancreatic insufficiency) then give elemental. if they can digest, give polymeric

indications for:

- low osmolality (1cal)

- high density (2cal)

- chemically defined/ elemental (1cal)

- low osmolality: all purpose

- high density: fluids or electrolytes restricted (renal, cardiac)

- chemically defined/ elemental: GI cant absorb or digest

of the following which is NOT nutritionally complete

- low osmolality (1cal)

- high density (2cal)

- chemically defined/ elemental (1cal)

chemically defined- elemental

t/f: EN supplements are usually nutritionally complete and palatable, with a high osmolality

true (ex: ensure)

dumping syndrome

Rapid emptying of gastric contents into small intestines. pt experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia.

tube lumen obstruction management

tap water, cranberry juice, coke syrup, adolph's meat tenderizer

what should be done if pt aspirates food during EN feeding

-discontinue feedings

- suction pt

- restart feeding past pylorus

what are the issues with the following meds and EN/TPN

phenytoin(DPH):

warfarin:

fluoroquinolones & tetracycline:

1. phenytoin(DPH): binds to tube. stop feed 1-2hrs pre and post OR give it IV

2. warfarin: know how much VitK in feed and adjust

3. fluoroquinolones (oxacin) and tetracycline: stop feed 1hr before and after

what are the issues with the following meds and EN/TPN

omeprazole/lansoprazole:

antacids:

SR and EC products:

omeprazole/lansoprazole: oral suspension over granules preferred

antacids: those w aluminum pay precipitate protein. give after feeding and flush w water

SR and EC products: DO NOT CRUSH. switch to immediate release

which of the following would be CORRECT monitoring parameters for TPN therapy

a. once daily glucose

b. daily prealbumin

c. weekly fluid balance

d. once daily weight

d. once daily weight= correct

a. once daily glucose= too infrequent

b. daily prealbumin= too frequent. should be once at baseline then every week (half life= 2 days)

c. weekly fluid balance= too infrequent. need to check way more often like q12hrs

d. once daily weight= good

match the following:

child, adolescent, neonate, infant

birth-1 month:

1-12 months:

1-12yrs:

12-18yrs:

birth-1 month: neonate

1-12 months: infant

1-12yrs: child

12-18yrs: adolescent

t/f: neonates and children have higher caloric and water requirements per kg than adults

true

for pediatric nutrition:

for carbs, you initially start with ___% dextrose and increase by ___% as tolerated

10%, 5%

what is the fat initiation for neonates and infants/children?

neonates: 0.5g/kg/day (must not exceed 60% of total cals)

infants/children: 0.5-1g/kg/day (must not exceed 30%)

children <____ should receive pediatric formulation of multivitamin products

11

what can a thiamine (B1) deficiency in children result in

1. wet beriberi: affects cardiovasc system (increases HR, SOB, leg swelling)

2. dry beriberi: affects CNS (numb hands and feet, confusion, lactic acidosis)

what can a B6 (pyridoxine) deficiency result in

seizures

pellagra

the niacin-deficiency disease, characterized by diarrhea, dermatitis, dementia, and eventually death

what is the difference between vitd3 and d2?

function of vitD?

deficiency leads to?

d3= cholecalciferol; synthesized from UV light

d2= ergocalciferol; yeast and plant sterols

fxn= calcium homeostasis, bone mineralization

deficiency=

rickets in children

osteomalacia in adults

zinc fxn=

deficiency=

protein, lipid, carb, bone metabolism

deficiency= skin lesions, alopecia, delayed wound healing, immunosuppression

copper fxn=

deficiency=

fxn= hemopoiesis, bone metabolism, CT metabolism

deficiency= anemia unresponsive to iron, neutropenia, bone changes

chromium fxn=

deficiency=

carb, cholesterol, protein metabolism

deficiency= abnormal glucose tolerance, weight loss, increased serum free fatty acids

manganese fxn=

deficiency=

fxn= amino acid metabolism

deficiency= growth retardation, wound healing

selenium fxn=

deficiency=

antioxidant activation, cardiac fxn, T4->T3 conversion

deficiency= cardiomyopathy, hair and nail loss

iodine fxn

deficiency=

thyroid fxn

deficiency= goiter, weight loss, tachycardia, feeling warm

what is Iron Dextran used for

parenteral formulation for iron deficiency or pts with end stage renal disease on erythropoietin

CI for enteral nutrition in children

1. non function gut/ disruption/ ischemia

2. severe peritonitis

3. shock= systolic <90

monitoring parameters for children

-weight, height, diet

-head circumference (pts <3yo)

-developmental assessment

- psych function

-clinical exam

what does AAP recommend regarding breastfeeding length

- breastfeed exclusively for first 6 months

-12 months or longer encouraged

- especially for premies

advantages of breastfeeding

- probiotic bacteria enhances infant immunity

- reduced diseases seen in infant (asthma, RSV, obesity, etc)

-reduced risk of diabetes, leukemia, SIDS

- promotes neuro development

- has hormones, IGs, enzymes

20cal/30ml avg

what are the 3 infant formula categories

1. Term infant

- standard cow milk

- lactose free

-partially hydrolyzed whey

- follow up

2. Preterm Infant

- human milk fortifiers

- standardized in hospital preterm

- post discharge

3. Specialty formula

- soy

-hydrolyzed

-high MCT

which Term formula is preferred for all infants

preferred= breast milk

appropriate= Cow's milk

what is the difference between cows milk and partially hydrolyzed whey? when is the latter recommended?

cows milk has whole casein and whey, while the partially hydrolyzed formula is more easier to digest. its an alternate for infants that are intolerant to cows milk but will NOT help in cow milk allergy

- may also increase weight gain and reduce atopic conditions

predominant whey protein in cows milk vs human milk

cow= beta lactoglobulin

human= alpha lactalbumin

when is a follow-up formula used

9-24 months

- has higher iron, calcium, and phosphate

t/f: partially hydrolyzed whey formula may be used for infants with a cow milk allergy

false. can be used for intolerance but not allergy

how many calories are in normal human breast milk

20cal/30ml

what are the 3 types of Pre-term formulas available (other than breast milk)

1. Human milk Fortifiers

- add this to human milk to increase calories, protein, calcium, and phosphorus

- expensive

2. In hospital

- high cal, protein, 40-50% MCT

- fortified with vit d, calcium, iron, phosphorus

3. Post discharge

- cheaper than human milk fortifiers

- 22cal/30ml

- 20-25% MCT

- fortified with vit d, calcium, iron, phosphorus

what are the specialty formulas available for infants

1. Soy

- for lactose intolerant infants, vegans

- 30-50% cross sensitivity with CMA!!

2. Hydrolyzed protein/ free AA

- lactose free

-MCT ranges 0-55%

- INDICATED FOR SEVERE CMA

3. high MCT

-80-87%

-INDICATED FOR PANCREATIC, BILIARY, OR SHORT BOWEL SYNDROME

what is MCT and when would a high % be preferred for infants

medium chain triglycerides. they are absorbed directly into portal circulation and dont require pancreatic enzymes.

good for babies with pancreatic, biliary, or short bowel syndrome

which formula would you give the following infant

healthy infant:

infant with CMA:

infant with lactose intolerance:

pre-term baby:

pancreatic/biliary/short bowel syndrome:

healthy infant: breast milk preferred. cows milk appropriate

infant with CMA: hydrolyzed protein/ free amino acid (NOT soy. still cross sensitivity)

infant with lactose intolerance: lactose free, partially hydrolyzed, or soy

pre-term baby: human milk fortifier, in hospital, or post discharge formula with higher cals, protein, MCT

pancreatic/biliary/short bowel syndrome: high MCT

when is vitamin D supplementation indicated for babies getting human milk

if baby is getting <1L per day

when is iron supplementation indicated for baby? not?

indicated= if shows sign of deficiency at a dose of 2mg/kg/day

not=

1. infant is <4-6 months of age

2. infant is eating iron fortified cereal