PROTEIN ENERGY MALNUTRITION (FAILURE TO THRIVE)

Transcription

1 PROTEIN ENERGY MALNUTRITION (FAILURE TO THRIVE) ALGORITHM Cnduct Initial Assessment Histry and physical (H&P), nutritin fcused Weight height, BMI, % f ideal bdy weight and exam: assess severity (symmetric edema = severe) Cnsider basic labs based n H&P; A cmplete bld cunt (CBC) is strngly recmmended due t risk f anemia Additinal labs based n H&P Assess micrnutrients: irn, zinc, vitamin D, and thers as indicated by H&P Baseline ptassium, phsphrus, and magnesium if cncerned abut re-feeding Calrie cunt up t 3 days Cnsults: Scial Wrk, Registered Dietician, Occupatinal Therapy, and Lactatin Is there a risk fr micrnutrient deficiencies? N What are the degrees f malnutritin and risk f refeeding? Yes Initiate treatment fr micrnutrients deficiencies: Empiric zinc therapy fr patients lder than 6 mnths fr 1 mnth Irn therapy in the absence f inflammatin Vitamin D and ther micrnutrients based n labs Inclusin criteria: Children newbrn t 21 years f age Inpatients admitted fr evaluatin and treatment f Prtein Energy Malnutritin (PEM) r Failure t thrive (FTT) OR Patients identified with PEM/FTT during their hspital stay. Exclusin criteria: Outpatients Patients with FTT/PEM secndary t an identified cncern (e.g., cancer, genetic cnditin, ther chrnic illness). Pts w/ suspected r cnfirmed eating disrder Mild, mderate, r severe malnutritin but NO RISK f refeeding Initiate feeding per recmmended daily allwance (RDA) fr current weight and age Use PO rute if patient is able t take 70% f estimated calries rally Severe malnutritin AND at risk f refeeding Initiate feeding at 30-50% f RDA fr current weight Mnitr ptassium, phsphrus, and magnesium nce t twice a day fr a ttal f 4 days Advance by 10-20% if labs are nrmal If labs abnrmal hld ff n advancing feed until crrected Start thiamine Advance calries t meet level fr catch up grwth. Depending n the severity f PEM, this may take several days t achieve. N Did pt demnstrate ability t gain weight when prvided with adequate calries? Yes Get additinal histry Assess feeding tlerance and malabsrptin Cnsider cnditins assciated with increased demands and genetic/ metablic cnditins Cnsider indirect calrimetry (IC) fr cmplicated patients Cmplete discharge check list: Input frm Occupatinal Therapy, Scial Wrk, Lactatin and Registered Dietician Caregiver(s) demnstrated the ability t prvide care independently fr hurs Prescriptin fr micrnutrients deficiencies prvided, fllw up planned Fllw up with Grwth and Parenting (GAP) r PCP arranged If patient is discharged n NGT feeding: Parents t rm in 24 hurs and handle all pump feeding Fllw up with Grwth and Parenting (GAP) clinic within 1 week after discharge. Refer t utpatient OT r feeding therapy Page 1 f 13

2 TABLE OF CONTENTS Algrithm Target Ppulatin Definitins and Classificatin Table 1. Nrmal Rate f Weight Gain Table 2. Nutritinal Status Assessment Initial Evaluatin Additinal Evaluatin and Cnsideratins fr Cnsults Clinical Management Table 3. Micrnutrient Indicatins and Dsing Refeeding Syndrme Table 4. Enteral Electrlyte Replacement Discharge Related Dcuments Labratry Studies Imaging n/a Therapeutics n/a Appendix A. Wrkup fr Suspected Inbrn Errr f Metablism/Genetics Appendix B. Cnsideratins fr Cystic Fibrsis/Pancreatic Insufficiency: Understanding the Newbrn Screen Appendix C. Estimated Energy Needs fr Pediatric Patients Appendix D. Catch Up Grwth Calculatins Appendix E. ICD 10 Cdes References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Children newbrn t 21 years f age Inpatients admitted fr evaluatin and treatment f Prtein Energy Malnutritin (PEM) r Failure t Thrive (FTT) OR Patients identified with PEM/FTT during their hspital stay Page 2 f 13

3 Exclusin Criteria Outpatients Patients with PEM/FTT secndary t an identified cnditin (e.g., cancer, identified genetic cnditins, r ther chrnic illness) Patients with a suspected r cnfirmed eating disrder DEFINITIONS AND CLASSIFICATION Prtein Energy Malnutritin (PEM) r Failure t Thrive (FTT) is defined as an imbalance between nutrient requirement and intake, resulting in cumulative deficits f energy, prtein r micrnutrients that may negatively affect grwth, develpment and ther relevant utcmes [1]. Grwth assessment is based n the indicated grwth chart in Epic. Select grwth chart in Epic based n patient age and any relevant cnditins (e.g., Dwn syndrme, etc.). Table 1. Nrmal Rate f Weight Gain Age (mnths) Grams/day Refeeding (marasmus and Kwashirkr) Severe malnutritin (marasumus) is defined as weight fr height (r length) less than -3 Z-scre, r less than 70% f the median reference value. Kwashirkr is defined by the presence f symmetrical edema (edematus malnutritin). Marasmus and Kwashirkr cmmnly cexist and a simple unified apprach t clinical management can be applied t bth [1, 2]. Table 2. Nutritinal Status Assessment Methd Weight fr height percent f median [3] N Mild Mderate Severe malnutritin malnutritin malnutritin malnutritin >90% 80-89% 70-79% <70% Weight fr height z scre* [4] > -1-1 t t -2.9 < -3 BMI z scre* [4] > -1-1 t t -2.9 <-3 Length/height z scre* [4] Nt Applicable N data but z scre* less than -2 suggest stunting N data but z scre* less than -2 suggest stunting *Z scres can be fund by placing the cursr n any number n the grwth chart in Epic. <-3 Page 3 f 13

4 INITIAL EVALUATION Histry and physical exam Diagnstic Tests and Studies t be cnsidered in patients admitted fr management f malnutritin: CBC with differential and red cell indices (strngly recmmended due t the risk f anemia) Cmprehensive metablic panel Baseline magnesium (Mg), phsphrus (Phs), and ptassium (K) (in patients at risk fr refeeding syndrme) Inflammatry markers such as erythrcytes sedimentatin rate (ESR) and C reactive prtein (CRP) Irn studies with ferritin (in patients at risk fr irn deficiency). Vitamin D (based n the presence f risk factrs fr deficiency) Celiac screening (based n clues frm H&P) Stl examinatin fr fat (if cncerned abut fat malabsrptin based n H&P, r in infants wh fail t gain weight despite adequate breast milk r frmula intake). ADDITIONAL EVALUATION AND CONSIDERATION FOR CONSULTS When cnsidering endcrine etilgies fr pr grwth, please assess linear grwth, taking int cnsideratin family histry and being small fr gestatinal age. Keep in mind that endcrine causes f FTT seem t be rare even in the selected ppulatin f patients referred t pediatric endcrine utpatient clinics. Actually, the majrity f patients referred fr endcrine evaluatin in the setting f PEM had a pure nutritinal deficiency [5]. Refer t Appendix A fr infrmatin abut when t cnsider inbrn errrs f metablism/genetics [6]. Refer t Appendix B fr infrmatin abut Cystic Fibrsis (CF) and pancreatic insufficiency [7]. Renal tubular acidsis: is a rare cause f PEM, and when suspected it is recmmend t use a venus bld gas (VBG ) fr determinatin f serum bicarbnate cncentratin fr the evaluatin f a child with PEM wh is thught t have a metablic acidsis [8]. Cnsult Nutritin M.D. in all cases f severe malnutritin, edematus malnutritin (Kwashirkr), and fr patients n highly restrictive r unusual diets with pssible many micrnutrient deficiencies. CLINICAL MANAGEMENT 1. Initiate a multidisciplinary apprach including but nt limited t registered dietitians, scial wrker, ccupatinal and speech therapists and lactatin cnsultants [9]. 2. Inpatient admissin is nt necessary fr all children with FTT [10]. It is indicated fr severe malnutritin especially when there is cncern abut refeeding syndrme, and in cmplicated scial situatins [11]. 3. Dehydratin: Oral hydratin is preferred ver IV hydratin. Use standard pediatric electrlytes slutins. Recmmended rate is 5-10 ml/kg/hur fr 2-12 hurs [1]. IV hydratin: Refer t Intravenus Fluid Therapy Clinical Pathway. 4. Starting and advancing feeding: If the patient is nt at risk f refeeding syndrme it is reasnable t start with age apprpriate calric recmmended daily allwance (RDA). Refer t Appendix C. When there is risk f refeeding syndrme start at 30-50% f calric RDA and advance slwly by 10-20% per day. Page 4 f 13

5 Patients n ral feed can be transitined t adlib feeding when tlerating full feed. It is nrmal fr patients recvering frm malnutritin t cnsume ver 200 Kcal/kg /day[2]. Patients with lw intake r n tube feeding need t be prvided with extra calries fr catch up grwth after they tlerate full feed. Depending n the severity f malnutritin, it may take 2-14 days t be able t initiate catch up grwth [11]. Catch up grwth calculatins: a rugh estimate is t prvide RDA calrie fr age based n ideal bdy weight. Fluid requirements: as apprpriate fr age. Fr edematus malnutritin, keep fluids at r less than maintenance. Calrie gal needs t be adjusted based n hw well the patient is gaining weight. Sme patients with severe malnutritin may require a high calric intake t initiate weight gain. Cnsult with a registered dietician and see Appendix D fr specific calculatins fr catch up grwth. 5. Feeding Mdality: Infants less than 1 year ld Breast milk r frmula. Make sure t assess the adequacy f nursing. D nt cncentrate breast milk r frmula beynd 24 kcal/z t avid the increase in smlality with assciated diarrhea and malabsrptin. Feed every 2-3 hurs t prevent hypglycemia. Tddlers and children lder than 1 year ld Use nutritinal supplements (e.g., Bst, Nutren, etc.) Start with the standard 1Kcal/1mL cncentratin. Offer 3 meals and 2-3 snacks n a cnsistent schedule. Educate parents t avid grazing and cnstant sipping n fluids. Cnsult RD if a higher cncentratin needed (i.e., fluid restrictin). NGT feeding is recmmended if the child cannt take 70% f the recmmended intake rally [1], but ffer the diet rally at each feed first. 6. Mnitring and gals: Daily weight: preferred pre-breakfast, pst-vid 3 days calrie cunt Fr breastfed infants: check weight befre and after feeding fr at least 24 hurs. Accepted gal fr catch up grwth is 150% the average weight gain fr age [11]. This may nt happen until the utpatient phase. 7. Micrnutrients: Zinc, Irn and Vitamin D, and Thiamine are cmmn deficiencies in the FTT patients. Hwever, a detailed diet histry is essential t diagnse ther micrnutrient deficiencies. Fr indicatins and dsing f micrnutrients, please refer t Table 3. Page 5 f 13

6 Table 3. Micrnutrient Indicatins and Dsing Medicatin Recmmended Dse Indicatins fr Use Clinical Pearls Zinc [7] PO: 1 mg/kg/day elemental zinc divided 1-3 times/day. Irn (Ferrus Sulfate) [10] Adult dse: 50 mg three times daily. PO: 3-6 mg/kg/day elemental irn divided 1-4 times daily. Adult dse: 300 mg given 2-4 times daily r 250 mg (extended release) 1-2 times daily Vitamin D Age 0-10: 25(OH)D<10 ng/ml: 2000 IU (4000 IU if bese) 10 t 20 ng/ml: 1000 IU (2000 IU if bese) 20 t 30 ng/ml: IU (1000 IU if bese) Age 10-18: 25(OH)D<10 ng/ml: 4000 IU (8000 IU if bese) 10 t 20 ng/ml: 2000 IU ( 4000 IU if bese) 20 t 30 ng/ml: 800 IU (1000 IU if bese) Thiamine [Green bk] IM/IV: mg/dse daily PO: mg/dse rally every day fr 2 weeks, then 5-10 mg/dse rally daily fr 1 mnth Over 6 mnths f age. Zinc supplementatin shuld be initiated empirically fr any patient with malnutritin/ftt. Initiate when ferritin is less than 20 with n inflammatin (nt fr use during acute phase f illness) Initiate when 25(OH)D levels are belw 30 ng/ml based n risk factrs. Refer t Vitamin D Deficiency Clinical Pathway fr details. Initiate in patients with severe malnutritin at risk fr refeeding syndrme. Larger dses may be needed with impaired absrptin r excessive lss f zinc in the intestines Separate frm ther supplements by 1-2 hurs fr maximal absrptin. Cnsider increased supplementatin in patients with at-risk medical cnditins. Dsing amunt shuld be inclusive f all supplements (i.e., Vitamin D, multivitamin, Omega-3, etc.). Fr the mst current recmmendatins n Vitamin D supplementatin, please refer t the Vitamin D Deficiency Clinical Pathway. Give thiamine IV/IM fr critically ill patients with malnutritin/ftt. REFEEDING SYNDROME Risk factrs Patients with marasmus r Kwashirkr particularly if there is greater than 10% weight lss ver a cuple f mnths Patients wh are nt fed fr 7-10 days with evidence stress and depletin Features [12, 13] Abnrmalities f fluid balance and electrlytes (lw ptassium, lw phsphrus, lw magnesium) Abnrmalities f glucse metablism (high glucse, high insulin level) Page 6 f 13

7 Treatment When electrlytes abnrmalities ccur, hld ff the advancement f feed t crrect. Fr enteral dsing recmmendatins, refer t Table 4. Fr IV electrlyte replacement recmmendatins please refer t the Intravenus Fluid Therapy Clinical Pathway. Mnitring Check refeeding labs (magnesium, ptassium, phsphrus) ne r twice a day fr 4 days. The risk f refeeding syndrme is minimal after 4 days f feeding. Table 4. Enteral Electrlyte Replacement Nte: Fr IV replacement, please refer t the Intravenus Fluid Therapy clinical pathway Electrlyte Phsphrus Enteral Dsing Recmmendatins 2-3 mml/kg/day divided three r fur times daily. Adult dse: mml/day divided three r fur times daily. Clinical Pearls 1 mml =31 mg Enteral phsphrus replacement can be given as a sdium salt, ptassium salt, r a cmbinatin f bth salt frms Frmulatins K-phs neutral: 8 mml phs, 13 meq Na, 1.1 meq K per tab Phs-NaK pwder: 8 mml phs, 6.9 meq Na, 7.1 meq K per packet Sdium Phsphate: 3 mml phs, 4 meq Na per ml Magnesium Ptassium PO: mg/kg/dse elemental magnesium 4 times/day Adult dse: 300 mg elemental magnesium 4 times daily PO: 2-5 meq/kg/day in 2-4 divided dses Adult: meq/day in 2-4 divided dses Separate frm phsphrus supplementatin 1-2 hurs t ensure maximal absrptin. Liquid frmulatins shuld be diluted t minimize gastric irritatin. Take tabs/caps with a full glass f water. Max single dse: meq Ptassium Phsphate: 3 mml phs, 4.4 meq K per ml Magnesium Oxide 140 mg cap= 84.5 mg elemental Magnesium, Magnesium Hydrxide 500 mg elemental magnesium per 15 ml, Magnesium Glucnate 54 mg elemental magnesium per 5 ml Ptassium Chlride liquid: 20 meq/15 ml (10%) r 40 meq/15 ml (20%) KCL Extended Release Caps: 8 r 10 meq caps (als available in sprinkle cap) KCL Extended Release Tabs: 8, 10, 15, r 20 meq tabs Page 7 f 13

8 DISCHARGE Literature review did nt yield evidence based criteria fr discharge readiness. It is ur grup cnsensus t cnsider the fllwing factrs in additin t the patient demnstrating weight gain in the hspital: Caregiver shuld demnstrate ability t prvide respnsive feeding and understanding f hunger and satiety cues. Caregiver shuld demnstrate mastery f preparing frmula using the teach-back methd. Rm in fr 24 hurs and prviding all feeds with n assistance frm staff is essential t ensure the plan is practical fr pst discharge. Fllw up is planned with either Grwth and Parenting (GAP) clinic r PCP within 2-5 days frm discharge. RELATED DOCUMENTS Vitamin D Deficiency clinical pathway Intravenus Fluid Therapy clinical pathway Page 8 f 13

9 APPENDIX A. WORKUP FOR SUSPECTED INBORN ERROR OF METABOLISM/GENETICS [5] When t cnsider inbrn errr f metablism: Histry f acute life threatening symptms like ketacidsis and hypglycemia Recurrent attacks f vmiting, lethargy and diarrhea Liver dysfunctin Develpmental delay, hyptnia, strke, ataxia Cardimypathy, mypathy Hearing lss r visual impairment Organmegaly Dysmrphic features Pancytpenia Plan: metablic cnsult, labs t cnsider: Serum amin acids Plasma acycarnitine Ammnia Bld Lactate, pyruvate CK Urine rganic acids. APPENDIX B. CONSIDERATIONS FOR CYSTIC FIBROSIS/PANCREATIC INSUFFICIENCY: UNDERSTANDING THE NEWBORN SCREEN [6] The newbrn screen (NBS) identifies infants at risk fr CF by screening fr hypertrypsingenemia. Next then the CF transmambrane cnductance regulatr gene (CFTR) is interrgated fr mutatins. Individuals identified by the newbrn screen are diagnsed with CF if they have an elevated sweat chlride level, r they have inherited 2 disease causing mutatins in the CFTR gene. Nt all CFTR mutatins are disease causing. The term CFTR-related metablic syndrme (CRMS) refers t infants identified n the newbrn screen wh have nrmal sweat chlride test, and up t 2 mutatins in the CFTR gene, at least 1 f them nt a CF causing mutatin Infants with CRMS can be ttally asymptmatic. Hwever they can als present with pr weight gain due t pancreatic insufficiency. Other symptms include recurrent sinus infectins, wheezing, and recurrent diarrhea. Our apprach: check fat in stl when cnsidering CF r CRMS as a cause fr pr grwth. Page 9 f 13

10 APPENDIX C. ESTIMATED ENERGY NEEDS FOR PEDIATRIC PATIENTS Age Range f energy needs (Kcal/kg/day) Preterm Term 0-6 mnths mnths years years years years years, males years, females Adult APPENDIX D: CATCH UP GROWTH CALCUATIONS In cases f severe malnutritin where grwth may take a lng perid f time, these calculatins can be useful in cnsultatin with the registered dietician (RD): Cnsider the ttal weight deficit and the amunt f time desired t achieve ideal bdy weight (IBW). The energy cst f each gram f new grwth is 5 Kcal [14]. Patients 2 r yunger: Ttal Kcal/kg/day needed = (RDA Kcal/kg based n weight age IBW) actual weight [15]. Patients lder than 2: Extra Kcal/kg/day needed= [weight deficit (g) 5] days t crrect. APPENDIX E. ICD 10 CODES ICD-10 descriptin Severe prtein energy malnutritin ICD-10 cde E43 Mderate prtein energy malnutritin E44.0 Mild prtein energy malnutritin E44.1 Page 10 f 13

11 REFERENCES 1. in Guideline: Updates n the Management f Severe Acute Malnutritin in Infants and Children. 2013: Geneva. 2. Duggan, C., J.B. Watkins, and W.A. Walker, Nutritin in pediatrics : basic science, clinical applicatin. 4th ed. 2008, Hamiltn: BC Decker. xvii, 923 p. 3. Waterlw, J.C., Classificatin and definitin f prtein-calrie malnutritin. Br Med J, (5826): p Becker, P., et al., Cnsensus statement f the Academy f Nutritin and Dietetics/American Sciety fr Parenteral and Enteral Nutritin: indicatrs recmmended fr the identificatin and dcumentatin f pediatric malnutritin (undernutritin). Nutr Clin Pract, (1): p Daniel, M., L. Kleis, and A.P. Cemerglu, Etilgy f failure t thrive in infants and tddlers referred t a pediatric endcrinlgy utpatient clinic. Clin Pediatr (Phila), (8): p Ficiciglu, C. and K. An Haack, Failure t thrive: when t suspect inbrn errrs f metablism. Pediatrics, (3): p Cystic Fibrsis, F., et al., Cystic Fibrsis Fundatin practice guidelines fr the management f infants with cystic fibrsis transmembrane cnductance regulatr-related metablic syndrme during the first tw years f life and beynd. J Pediatr, (6 Suppl): p. S Adedyin, O., et al., Evaluatin f failure t thrive: diagnstic yield f testing fr renal tubular acidsis. Pediatrics, (6 Pt 1): p. e Hbbs, C. and H.G. Hanks, A multidisciplinary apprach fr the treatment f children with failure t thrive. Child Care Health Dev, (4): p Fryer, G.E., Jr., The efficacy f hspitalizatin f nnrganic failure-t-thrive children: a metaanalysis. Child Abuse Negl, (3): p American Academy f Pediatrics. Cmmittee n Nutritin. and L.A. Barness, Pediatric nutritin handbk. 6th ed. 2009, Elk Grve Village, IL: American Academy f Pediatrics. xlix, 1470 p. 12. Crk, M.A., V. Hally, and J.V. Panteli, The imprtance f the refeeding syndrme. Nutritin, (7-8): p Kraft, M.D., I.F. Btaiche, and G.S. Sacks, Review f the refeeding syndrme. Nutr Clin Pract, (6): p Spady, D.W., et al., Energy balance during recvery frm malnutritin. Am J Clin Nutr, (10): p Frank, D.A. and S.H. Zeisel, Failure t thrive. Pediatr Clin Nrth Am, (6): p Page 11 f 13

12 CLINICAL IMPROVEMENT TEAM MEMBERS Liliane Diab, MD Clinical Nutritin Nancy Krebs, MD, MS Clinical Nutritin Jennifer Reese, MD Hspitalist Emma Rss, PharmD Clinical Pharmacist Sherry Archuleta, RD Clinical Nutritin Jillian Nyman, RD Clinical Nutritin Sarah Nickels, PhD Clinical Effectiveness APPROVED BY Nutritin Quality Imprvement Cmmittee December 15, 2016 Clinical Care Guideline and Measures Review Cmmittee February 14, 1017 Pharmacy & Therapeutics Cmmittee March 9, 2017 MANUAL/DEPARTMENT Clinical Care Guidelines/Quality ORIGINATION DATE March 9, 2017 LAST DATE OF REVIEW OR REVISION March 9, 2017 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW REVISION SCHEDULE Scheduled fr full review n March 9, 2021 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 12 f 13

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