Pediatric Inpatient Nutrition - Pediatric - Lecture Slides, Slides of Pediatrics

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The Science of Effective

Pediatric Inpatient

Nutrition

A hypothetical case

 Starvin Marvin is a 2 y.o. who presents with

a 2-3 week Hx of fevers, weight loss, pallor, decreased energy, appetite and activity

 PE reveals Wt 13kg , down 1.5 kg, pallor,

petechia,+ HSM

 Labs reveal WBC 26 K with 50% blasts,

anemia and thrombocytopenia

Teaching points

Nutritionally-at-risk from the word GO

• Debilitated Ortho spine patient
• Recurrent bowel obstruction patient

No nutrition plan, No monitoring, No

intervention

Hope is not a method

Could sepsis event been avoided??

Inpatient Nutrition Goals

 Think about nutritional status on every patient

 Outline the dynamic between illness, nutritional state and secondary morbidity

 Recognize need to estimate/calculate goals calories in order to reach the goal

• Individualized goals for time course, and disease process

 Institute effective nutrition support with the help of Pediatric nutritionist

The 5 W’s of Inpatient Nutrition

Why, Who, When, Where, What?

Acute Stress

 Major Surgery, Sepsis, Burns, Trauma

• Result in massive outpouring of catechols, ACTH, GH, ADH, glucagon, somatomedins - Insulin inhibition, elevation of glucose and free fatty acids
• ↑ Inflammatory Cytokines: TNF, IL 1, IL-
  • PMN release and degranulation  Mucosal permeability

 Stress hormones and mediators ↑ release of cAMP which down-regulate lymphoid immune activity

Bacterial Translocation

 Disruption of mucosal barrier

• Ischemia-reperfusion during shock  risk of ulceration and  permeability

 Bacterial translocation

• Culture(-), found bacterial DNA in blood stream

 Cytokine amplification in lymphatics and liver

WHY?

Is nutrition such a big deal?

Malnutrition Prevalence Nutrition Status and Outcomes Gut Bacterial Translocation

Malnutrition Prevalence

15 to 50 % of hospitalized pediatric

inpatients are malnourished on

presentation (down from 35-65%)

• 15 to 20 % of critically ill patients
• 33% patients with congenital heart disease
• 39% awaiting elective surgery

Parsons, AJCN,1980; Mize, Nutr Supt Ser, 1984; Merritt, Am J Clin Nutr, 1979, Huddleston KC, CC Clin of NA, 1993, Cameron, Arch Ped 1995, Cooper, J Ped Surg 1981

Nutrition and Outcome

State of nutrition vs. LOS and Cost

$7,

$14,

$16,

0

2

4

6

8

10

12

14

16

18

Normal Borderline Malnourished Robinson G, JPEN, 1987

Nutrition and Outcome

Low Prealbumin 95% specific, in 147 consecutive admissions

8 measures of malnutrition in 134 patients

50 cardiac surgery patients assessed

• Low Prealbumin predictive post-op infectious complication

0

2

4

6

8

10

12

14

16

18

20

LOS Mortality (%)

PCM No PCM PCM No PCM**

Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, Rev Paul Med, 1995

Nutrition and Outcome

60 PICU patients had nutrition status

evaluated, with PSI, and TISS applied

Acute PEM associated (P<0.01) with 

physiologic instability,  mortality and 

quantity of care

Malnutrition can result in delayed wound

healing, respiratory failure, increased

potential for infection, death

Pollack MM, JPEN, 1985

Nutrition and Outcome

Ventilator

Patients:

Weaned Died

No Specific

Nutrition Plan 18 15

Focused

Nutrtional Care 13 1

Bassili HR, JPEN,