Fluids, Electrolytes, and Nutrition

Transcription

1 Fluids, Electrolytes, and Nutrition Allison Beck Blackmer, Pharm.D., BCPS University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences Aurora, Colorado

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3 Fluids, Electrolytes, and Nutrition Allison Beck Blackmer, Pharm.D., BCPS University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences Aurora, Colorado 2-141

4 Learning Objectives 1. Identify the changes in total body water, body compartments, and electrolytes during human development. 2. Calculate maintenance intravenous fluid and electrolyte requirements in pediatric patients. 3. Interpret laboratory data and physical assessment in the evaluation of fluid status and dehydration. 4. Design intravenous fluid regimens to treat identified deficits. 5. Determine adequate nutrition across various states of human development. 6. Compare and contrast human milk to various infant formulas. 7. Explain the benefits of additives such as docosahexaenoic acid, arachidonic acid, and iron to infant formulas. 8. Recognize the indications for enteral and parenteral nutrition. 9. Design enteral and parenteral nutrition regimens according to the changing nutritional needs and clinical status of infants and children at various stages in their development. 10. Identify the characteristics, causes, risk factors, and treatment approaches to failure to thrive. Self-Assessment Questions Answers and explanations to these questions can be found at the end of this chapter. Questions 1 and 2 pertain to the following case: R.C. is a 9-year-old girl who presents to the emergency department (ED) with complaints of generalized abdominal pain and malaise for the past 3 days, which has steadily increased during the past 24 hours such that she cannot tolerate oral intake and has a decreased appetite. She will undergo a workup for acute appendicitis. Physical examination reveals a heart rate (HR) of 133 beats/minute, a respiratory rate (RR) of 20 breaths/minute, and a blood pressure (BP) of 112/61 mm Hg. Weight on admission is 32 kg. A. Dextrose 10% in 0.9% normal saline plus potassium chloride 40 meq/l at 108 ml/hour. B. Dextrose 5% in 0.225% normal saline plus potassium chloride 40 meq/l at 108 ml/hour. C. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 70 ml/hour. D. Dextrose 10% in 0.45% normal saline plus potassium chloride 40 meq/l at 70 ml/hour. 2. Twenty-four hours after your initial fluid recommendation, R.C. s laboratory values are as follows: The physician would like to increase the rate of the intravenous fluid to be 1.5 times the maintenance rate. Which is the most appropriate recommendation? A. Dextrose 5% in 0.45% normal saline plus potassium chloride 10 meq/l at 165 ml/hour. B. Dextrose 5% in 0.45% normal saline at 105 ml/hour. C. Dextrose 10% in 0.225% normal saline plus potassium chloride 10 meq/l at 105 ml/hour. D. Dextrose 10% in 0.45% normal saline plus potassium chloride 20 meq/l at 165 ml/hour. Questions 3 and 4 pertain to the following case: E.B., a 16-year-old female adolescent (weight 61.3 kg), presents in the ED after a snowboarding accident with severe hypotension (BP 65/45 mm Hg). She is disoriented, and her laboratory values point toward intravascular dehydration. 3. Which is the most appropriate fluid to recommend for initial resuscitation? A. Administer 25% albumin 10 ml/kg. B. Administer dextrose 5% in 0.225% normal saline plus potassium chloride 20 meq/l at 95 ml/hour. C. Administer 0.9% normal saline 20 ml/kg. D. Administer 5% albumin 50 ml/kg. 1. The ED physician consults you for assistance in determining the appropriate maintenance fluid and rate for R.C. Which is the most appropriate recommendation? 2-142

5 4. E.B. does not respond to the initial therapy given in the ED. An hour after her initial presentation, her abdomen is rigid, and an emergency computed tomography (CT) scan reveals a liver laceration. Repeat laboratory tests show a hematocrit of 17% (previously 26%). Which is the most appropriate fluid to recommend? A. Administer 5% albumin 10 ml/kg. B. Administer dextrose 5% in 0.225% normal saline plus potassium chloride 20 meq/l at 95 ml/hour. C. Administer 0.9% normal saline 40 ml/kg. D. Administer whole blood ml/kg. Questions 5 and 6 pertain to the following case: E.H. is a 19-month-old boy with a 3-day history of vomiting, diarrhea, and decreased urine output. He is given a diagnosis of gastroenteritis and dehydration. His current weight is 10 kg (previous weight kg). His BP is stable on admission. 5. Which set of physical signs and symptoms would be most expected for his severity of dehydration? A. Anuria, absent tears, capillary refill greater than 8 seconds. B. Decreased skin turgor, capillary refill greater than 5 seconds, slightly increased HR. C. Normal HR, slightly dry mucosa, capillary refill 2 seconds. D. Normal skin turgor, capillary refill greater than 8 seconds, dry mucosa. 6. Which is the best recommendation for correcting E.H. s dehydration at this time? A. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 70 ml/hour x 8 hours, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 56 ml/hour x 16 hours. B. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 19 ml/hour x 24 hours. C. 200 ml 0.9% normal saline bolus, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 43 ml/hour x 16 hours. D. 450 ml 0.9% normal saline bolus, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 43 ml/hour x 24 hours. 7. S.C. is a 7-day-old term infant (weight 3.8 kg) born at 41 weeks gestation who will receive standard infant formula. Which enteral nutrition regimen is most appropriate for S.C. to meet his caloric needs? A. Enfamil (20 kcal/oz), 72 ml every 3 hours. B. Similac Special Care Advance 24 (24 kcal/oz), 60 ml every 3 hours. C. Portagen (20 kcal/oz), 72 ml every 3 hours. D. Similac PM 60/40 (20 kcal/oz), 60 ml every 3 hours. 8. B.B. is a 6-month-old boy (weight 6 kg) with short bowel syndrome who is parenteral nutrition (PN)- dependent. On admission, his direct bilirubin is 3.2 mg/dl, and he is found to have scleral icterus. Which is the best approach to managing B.B. at this time? A. Hold PN for 48 hours. B. Add cysteine 40 mg per gram of amino acid. C. Decrease soybean oil based intravenous fat emulsion (IVFE) dose to 1 g/kg/day or less. D. Add heparin 0.5 unit/ml. 9. A.J. is a 45-day-old female infant (born at term) (weight 2.3 kg) who is receiving the following parenteral nutrition (PN) regimen (note: the PN infuses for 24 hours per day): Total volume 299 ml/day Lipids (20%) 12 ml Amino acids 2.6% (7.8 g) Dextrose 15.5% (46.4 g) Electrolytes Potassium acetate 3.4 meq Potassium chloride 4.1 meq Sodium acetate 1.1 meq Sodium chloride 5.2 meq Sodium phosphate 2.7 mmol Magnesium sulfate 1.3 meq Calcium gluconate 6.2 meq Multivitamin 3.3 ml Trace minerals 0.2 ml/kg Other additives: Famotidine 0.5 mg/kg Levocarnitine 10 mg/kg Which most accurately represents how many kilocalories per kilogram per day A.J. receives from this PN? A. 213 kcal/kg/day. B. 93 kcal/kg/day. C. 200 kcal/kg/day. D. 87 kcal/kg/day

6 10. A 9-day-old neonate (weight kg) with congenital diaphragmatic hernia is currently NPO (nothing by mouth) and receiving PN. The PN formulation is as follows: 20% Intralipid 23 ml (3 g/ kg), TrophAmine 4% (3.5 g/kg), and dextrose 21.4% (28.7 g/day). The total volume of the PN is 134 ml, and it is infusing at a rate of 5.6 ml/hour. Which best represents the calculated dextrose infusion rate (DIR)? A mg/kg/minute. B. 13 mg/kg/minute. C mg/kg/minute. D. 14 mg/kg/minute. 11. E.N. is a 7-month-old ex 31-week gestation boy with mild gastroesophageal reflux (i.e., twice weekly) who now weighs 4 kg (birth weight 1.1 kg). When plotted on standardized growth charts, he is below the 5th percentile for age and is given a diagnosis of failure to thrive. Which is the most likely risk factor for this? A. Early hospitalization. B. Undiagnosed metabolic disorder. C. Low birth weight because of prematurity. D. Gastroesophageal reflux. C. PN at 5.5 ml/hour with final dextrose concentration 17%, amino acids 3 g/kg/day, and IVFE 3 g/kg/day. D. Similac PM 60/40 at 25 ml every 3 hours. Abbreviations DIR Dextrose infusion rate ECF Extracellular fluid ED Emergency department ICF Intracellular fluid IVFE Intravenous fat emulsion ORT Oral replacement therapy PN Parenteral nutrition PNALD Parenteral nutrition associated liver disease 12. A 1-day-old neonate (weight 800 g), 27 weeks gestational age, will receive PN. However, because of difficulty securing central venous access, she will receive nutrition through a peripheral venous catheter. Which most accurately reflects what the PN must be compounded to be? A. 900 mosm/l or less. B mosm/l or less. C mosm/l or less. D mosm/l or less. 13. T.W. is a 23-hour-old female neonate born at 28 weeks gestation (birth weight 1100 g). Admitted to the neonatal intensive care unit with pure esophageal atresia, she will require nutrition support. Central access is secured. Which initial nutrition support regimen is most appropriate for T.W.? A. Nutren Junior (1 kcal/ml) at 3.7 ml/hour plus dextrose 10% at 1.8 ml/hour. B. PN at 3.7 ml/hour with final dextrose concentration 10%, amino acids 4 g/kg/day, and IVFE 1 g/kg/day

7 I. COMPOSITION OF BODY FLUIDS A. Water is the largest compartment in the human body; as humans age, the percentage of total body water slowly decreases (Table 1). B. The ratio of extracellular fluid (ECF) to intracellular fluid (ICF) is highest during the neonatal period and decreases with increasing age (Table 1). C. Water turnover rate is higher in children than in adults. Table 1. Estimates of Human Composition Across the Age Spectrum Premature Neonate Term Neonate Infant Child Adult Total body water (%) Extracellular fluid (%) ~70 ~70 ~55 ~ Intracellular fluid (%) ~30 ~30 ~45 ~ II. TYPES OF INTRAVENOUS FLUID A. Crystalloids Indicated for most conditions and the mainstay of intravenous fluid therapy (Table 2): 1. Dextrose-containing fluids 2. Saline-containing fluids 3. Lactated Ringer solution B. Colloids Indicated in specific conditions such as capillary leak, third spacing, nephrotic syndrome/ hypoproteinemia, malnourished states, excessive blood loss, volume expansion 1. Albumin 2. Blood 3. Hetastarch and pentastarch 4. Dextran 2-145

8 Table 2. Content of Crystalloid Fluids Fluid Osmolality (mosm/l) Sodium (meq/l) Dextrose only 252 Chloride (meq/l) Other 0.9% normal saline (NS) % NS % NS a Lactated Ringer solution Potassium 4 meq/l, bicarbonate 28 meq/l, calcium 3 mg/dl a Note: 0.225% NS cannot be infused alone; it must be co-infused with a dextrose-containing solution % NS is hypotonic, and when infused alone, it may cause cell lysis, which may lead to hyperkalemia, cardiac arrhythmias, and death. III. MAINTENANCE FLUIDS AND ELECTROLYTES A. Goals of Maintenance Intravenous Fluid Therapy 1. To prevent dehydration, electrolyte disturbances, ketoacidosis, and protein degradation as well as maintain euglycemia 2. Maintain fluid balance in body and replace ongoing normal losses (e.g., insensible, urine, and fecal losses) (Table 3) Table 3. Ongoing Loss Across the Pediatric Age Spectrum Insensible (ml/kg/day) Urine (ml/kg/day) Fecal (ml/kg/day) Neonate to 6 months months to 5 years years Variable Adolescent Variable 3. Maintenance fluids do not provide adequate calories, fat, minerals, or vitamins for normal growth development of children. B. Main Components of Maintenance Intravenous Fluid Therapy 1. Water 2. Sodium 3. Potassium 4. Dextrose Note: Supplements such as calcium, magnesium, and phosphorus are not routinely added to maintenance fluid therapy. However, maintenance intravenous fluids for neonates may represent one instance in which some practitioners may consider adding calcium

9 C. Guiding Principles: 1. No two patients are exactly alike Therapy must be individualized. 2. Calculations provide estimates only; the patient s clinical condition dictates the therapeutic course, and adjustments should be made according to the patient s individual needs. 3. Maintenance fluids and electrolytes are needed to account for normal losses from basal metabolism. a. Metabolic rate is higher (kcal/kg of body weight) in younger patients than in older patients. b. Metabolic rate declines with increasing age. 4. Several estimates of maintenance fluid needs exist, including surface area method (may underestimate needs/be inaccurate when weight is less than 10 kg), basal caloric method (most accurate, but less practical), and estimations using weight. Estimations of maintenance needs using body weight are the most clinically practical, but they may overestimate needs. D. Estimates of Maintenance Fluid Needs Using Body Weight (Table 4 and Table 5) 1. Holliday-Segar method (provides estimates over a 24-hour period) Assumes that 100 calories are metabolized for each 100 ml of water required method (provides estimates over an hourly period) Table 4. Estimation of Maintenance Fluid Requirements Using Body Weight for Older Infants and Children Body Weight (kg) Holliday-Segar (24-hour requirement) (hourly requirement) ml/kg 4 ml/kg/hour ml plus 50 ml/kg for each kg > 10 kg > ml plus 20 ml/kg for each kg > 20 kg 40 ml/hour plus 2 ml/kg/hour for each kg > 10 kg 60 ml/hour plus 1 ml/kg/hour for each kg > 20 kg Table 5. Estimation of Maintenance Fluid Requirements Using Body Weight for Neonates < 1500 g g Term neonate ml/kg/day *depending on clinical status ml/kg/day *depending on clinical status ml/kg/day *depending on clinical status Note: Once the neonate weighs more than around 2 3 kg, the Holliday-Segar method is preferred. E. General Maintenance Requirements of Electrolytes: 1. Sodium: 2 5 meq/kg/day 2. Chloride: 3 5 meq/kg/day 3. Potassium: 1 2 meq/kg/day 4. Glucose: 3 g/kg/day 2-147

10 F. Using General Maintenance Requirements of Electrolytes Standard, basic intravenous fluids used in pediatric patients include: 1. Dextrose 5% in 0.225% normal saline plus potassium chloride 20 meq/l. Use cautiously in critically ill children; dextrose 5% in 0.225% normal saline may lead to hyponatremia in the critically ill child because fluid and electrolyte requirements are not the same as in an otherwise healthy individual. 2. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l 3. Neonates: a. First hours of life: Dextrose 10% i. Neonates require a higher amount of dextrose to maintain euglycemia. ii. Electrolytes (e.g., Na + and K + ) are typically avoided in the first hours of life to allow a physiologic period of diuresis (Na + ) to occur and because of immature renal function (K + ). b. Greater than 48 hours of life: Dextrose 10% in 0.225% normal saline G. Conditions That Increase Maintenance Fluid Requirements: 1. Phototherapy/radiant warmers 2. Fever 3. Increased sweating 4. Hyperventilation/hypermetabolic state 5. Inability of kidneys to conserve water 6. Vomiting/nasogastric suctioning 7. Intestinal losses 8. Gastroschisis/omphalocele H. Conditions That Decrease Maintenance Fluid Requirements 1. Mist tents/humidified environment 2. Endotracheal intubation 3. Respiratory distress syndrome 4. Decreased renal function 5. Hypometabolic state Patient Cases Questions 1 and 2 pertain to the following case: J.H. is a 9-year-old boy (weight 35 kg) who has had generalized abdominal pain, localized to the right lower quadrant, and malaise for the past 4 days. He has been unable to tolerate any oral intake because of persistent nausea and vomiting, and he has a decreased appetite. He now presents to the ED, where he will be evaluated for acute appendicitis. On examination, the patient feels warm to the touch. His initial temperature on admission was 36.5 C. However, in the ED, his temperature increased to greater than 38.5 C. He has an HR of 130 beats/ minute, a RR of 32 breaths/minute, and a BP of 111/60 mm Hg, with a pulse oximetry of 96%. Laboratory values: Ca: 10.4 mg/dl 2-148

11 Patient Cases (continued) 1. Which most accurately reflects J.H. s maintenance fluid needs using the Holliday-Segar method? A. 700 ml/day; 29.2 ml/hour. B ml/day; 75 ml/hour. C. 840 ml/day; 35 ml/hour. D ml/day; 62.5 ml/hour. 2. According to J.H. s laboratory values, which maintenance intravenous fluid would be best to recommend? A. Dextrose 5% in 0.225% normal saline plus potassium chloride 20 meq/l. B. Dextrose 10% plus potassium chloride 10 meq/l. C % normal saline. D. Dextrose 10% in 0.45% normal saline plus potassium chloride 20 meq/l. I. Additional and Ongoing Losses 1. If the patient has an additional source of loss (e.g., chest tube, gastrostomy tube), maintenance fluid requirements should account for these additional losses. 2. Consider these types of losses separately from maintenance and deficit requirements. 3. Choice of fluid therapy is determined according to the type of ongoing loss. a. Most precise: Volume and concentration of electrolytes of losses should be measured to aid in fluid choice. b. Practical: Reference tables (Table 6) aid in fluid choice. Table 6. Approximate Electrolyte Composition of Body Fluids Na (meq/l) K (meq/l) Cl (meq/l) Gastric Pancreatic Small Bowel Bile Ileostomy Diarrhea Burns Sweat Cl = chloride; K = potassium; Na = sodium. Patient Case 3. J.G., a 5-year-old boy with a history of bilateral renal artery stenosis complicated by renovascular hypertension and fibromuscular dysplasia, underwent bilateral renal artery-reimplantation, superior mesenteric artery bypass, and patch aortoplasty. He presents to the ED today and is admitted for concern about possible bowel obstruction secondary to poor appetite, no stools x 48 hours, and nausea/vomiting x 3 days. A nasogastric tube is placed, and on placement, copious bilious fluid is suctioned from his stomach. Which choice of fluids is best to replace J.G. s ongoing losses? A. Dextrose 5% in 0.45% normal saline. B. 0.9% normal saline plus potassium chloride 10 meq/l. C. 0.45% normal saline. D. Dextrose 5% in 0.9% normal saline

12 IV. DEHYDRATION A. General Principles of Dehydration: 1. Leading cause of morbidity and mortality 2. Dehydration occurs when intake of fluids and electrolytes is less than the combined normal and abnormal losses. 3. Main causes of dehydration in the United States are diarrhea, gastroenteritis, febrile illness, diabetic ketoacidosis, excessive heat, burns, inability to match intake with ongoing losses 4. Dehydration occurs more quickly in neonates/infants (i.e., within 4 6 hours) because of higher insensible losses than in older children (12 18 hours) 5. Source of loss a. Dehydration for less than 3 days: ECF 80%, ICF 20% b. Dehydration for more than 3 days: ECF 60%, ICF 40% c. Dehydration for more than 6 days: ECF 50%, ICF 50% B. Clinical Evaluation and Assessment of Severity 1. Assessment a. Age, weight change, concurrent diseases, quantification of recent fluid intake and losses, skin turgor, mucous membranes, fontanelle, cardiovascular status, neurologic state, serum electrolytes, whole blood measurements, urine output b. Physical examination i. First sign of mild dehydration is tachycardia, which can progress to hypotension in severe dehydration. ii. Skin is a reliable organ to assess dehydration (turgor, temperature, capillary refill). 2. Classification of severity (Table 7) a. Estimation of severity of dehydration calculation i. Severity of Dehydration: estimation of severity of dehyration (%) = [(pre illness weight (kg) illness weight (kg)) pre illness weight (kg)] 100% ii. Fluid deficit: Fluid deficit (L) = % dehydration pre illness weight (kg) /100 b. Mild dehydration i. Infant: 1% 5% ii. Children: 1% 3% c. Moderate dehydration i. Infant: 6% 9% ii. Children: 4% 6% d. Severe dehydration i. Infant: Greater than 10% (greater than 15% = shock) ii. Children: Greater than 6% (greater than 9% = shock) 2-150

13 Table 7. Signs and Symptoms of Dehydration: Categorized by Severity Mild Moderate Severe Pulse Full, normal rate Slightly increased Rapid, weak Systolic BP Normal Normal-low Shock Urine output Normal or decreased Markedly decreased Anuric Weight loss 3% 5% 6% 10% 9% 15% Thirst Slight Moderate Intense Mucosa Normal/slightly dry Dry Extremely dry Tears Present Reduced Absent Eyes Normal Deep set Markedly sunken Skin turgor Normal Decreased Tenting/increased Skin temperature Normal Cool Cool/mottling Fontanelle Flat Reduced Sunken Capillary refill 2 3 seconds > 5 seconds > 8 seconds Behavior Normal Irritable Irritable/lethargic Patient Cases Questions 4 and 5 pertain to the following case: K.K. is a 3-year-old girl admitted to the hospital with a 3-day history of severe diarrhea. On admission, her weight is 15 kg; however, her caregiver reports that she usually weighs 15.8 kg. 4. Which best describes K.K. s percentage of dehydration and her classification of dehydration? A. 5%; moderate. B. 8%; severe. C. 8%; moderate. D. 5%; mild. 5. Which best describes K.K. s fluid deficit? A. 790 ml. B. 750 ml. C. 75 ml. D. 79 ml

14 C. Management of Dehydration 1. Oral rehydration therapy (ORT) (preferred for mild and moderate dehydration) a. Less expensive, more convenient, and can be implemented in a variety of settings b. Commercial products available (e.g., Pedialyte), which contain appropriate electrolytes for rehydration c. Discourage use of juices, ginger ale, sodas, sports drinks, and broths because they do not contain the appropriate electrolytes for rehydration and their high carbohydrate content may worsen diarrhea and dehydration. d. Dosing ORT i. Mild dehydration: (a) 50 ml/kg of ORT plus 10 ml/kg for every stool or emesis (b) Reassess every 2 hours. ii. Moderate dehydration: (a) 100 ml/kg of ORT plus 10 ml/kg for every stool or emesis (b) Reassess every hour. Patient Case 6. P.L. s mother has called the pharmacy for a recommendation for an ORT for her 5-year-old son (weight 20 kg), who is currently experiencing a mild case of nausea, vomiting, and diarrhea. Which is the most appropriate recommendation to make? A. Gatorade 50 ml/hour for each stool or emesis. B. Pedialyte 100 ml/kg plus 10 ml/kg for each stool or emesis. C. Initiation of loperamide mg/kg/day divided into three daily doses. D. Pedialyte 50 ml/kg plus 10 ml/kg for every stool or emesis. 2. Intravenous rehydration therapy (indicated for moderate to severe dehydration) a. Indications: i. Failure after ORT trial ii. Severe dehydration/shock iii. Intractable vomiting/excessive stool loss iv. Acute abdomen v. Coma vi. Age younger than 3 months or weight less than 4.5 kg b. Phases of intravenous replacement i. Phase 1: Emergency phase (a) Goals: Maintain adequate intravascular volume, maintain hemodynamics, prevent tissue damage (b) Approach: Bolus ml/kg of crystalloid (e.g., 0.9% normal saline, lactated Ringer solution) or colloid (e.g., blood, 5% albumin) 2-152

15 Patient Cases Questions 7 and 8 pertain to the following case: S.B., a 13-year-old girl (weight 55 kg) who presents to the ED after a motor vehicle accident, has severe hypotension (60/40 mm Hg). She is lethargic and has the following signs on physical examination: rapid HR (180 beats/ minute) and delayed capillary refill (10 seconds). 7. Which is the best initial therapy to provide S.B.? A. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 92 ml/hour. B. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 meq/l at 1000 ml/hour x 1 hour. C. 0.9% normal saline at 92 ml/hour. D. 0.9% normal saline at 2000 ml/hour x 30 minutes. 8. S.B. is unresponsive to two normal saline boluses, and her abdomen is then found to be rigid. An emergency CT scan reveals a large hematoma in her abdomen. Subsequently, her hematocrit is 19%, and her BP remains at 60/40 mm Hg. Which therapy would be best to recommend at this time? A. 0.9% normal saline at 1000 ml/hour x 1 hour. B. Whole blood at 20 ml/kg. C. 0.9% normal saline at 92 ml/hour. D. Lactated Ringer solution at 92 ml/hour. ii. Phase 2: Maintenance phase/deficit management (a) Goals: Maintain perfusion, correct electrolyte disturbances, keep up with ongoing losses and maintenance requirements (b) Approach: (1) Calculation of replacement therapy (milliliter deficit) (2) Calculation of maintenance fluid and electrolyte therapy (3) Consideration of ongoing losses Note: Determining the patient s sodium status is important for choosing the appropriate fluid (see Section V. Sodium Homeostasis). c. End points of therapy Normalization of BP, urine output and specific gravity, serum electrolytes, clinical signs/symptoms of dehydration V. SODIUM HOMEOSTASIS A. Calculation of Fluid Deficit (section IV.B.2.a.ii) B. The Three Main Types of Dehydration: Isonatremia, hypernatremia, hyponatremia. Table 8 details these three main types and the therapeutic approach to each. C. Isonatremic Dehydration 1. Step 1: Calculate fluid deficit. 2. Step 2: Calculate sodium deficit. L kg meq L Fluid deficit (L) 0.6 x normal sodium concentration (135 ) 2-153

16 3. Step 3: Choose intravenous solution (usually dextrose 5% in 0.45% normal saline [plus or minus potassium, depending on potassium deficit]). a. To calculate potassium deficit: L potassium deficit = fluid deficit (L) x 0.4 x 120 meq/l kg b. Give only half of replacement over the first 8 hours, and give the second half over the remaining 16 hours. D. Hypernatremic 1. Step 1: Calculate fluid deficit. 2. Step 2: Calculate sodium deficit. a. FWD (free water deficit) = 4 ml x (actual sodium desired sodium) x body weight (kg) b. Next, calculate solute fluid deficit (SFD): SFD = fluid deficit FWD c. Next, calculate sodium deficit: Sodium deficit = L meq SFD (L) x 0.6 x normal sodium concentration (140 ) kg 3. Step 3: Choose intravenous solution (usually dextrose 5% in 0.225% normal saline [plus or minus potassium, depending on potassium deficit]) a. To calculate potassium deficit L potassium deficit = SFD (L) x 0.4 x 120 meq/l kg b. Give only one-half of the replacement over first 24 hours and remaining one-half over the next hours E. Hyponatremic 1. Step 1: Calculate fluid deficit. 2. Step 2: Calculate sodium deficit. L meq Sodium deficit = Fluid deficit (L) x 0.6 x normal sodium concentration (140 ) kg L 3. Step 3: Calculate excess sodium deficit. meq (desired sodium (135 ) actual serum sodium ) x body weight (kg) 0.6 L/kg L 4. Step 4: Calculate total sodium deficit (= sodium deficit + excess sodium deficit). 5. Step 5: Choose intravenous solution (usually, dextrose 5% in 0.45% normal saline or dextrose 5% in 0.9% normal saline [plus or minus potassium, depending on potassium deficit]). a. To calculate potassium deficit L potassium deficit = fluid deficit (L) x 0.4 x 120 meq/l kg b. Give only one-half of the replacement over first 8 hours and remaining one-half over next hours. L 2-154

17 c. Special consideration for neurologic symptoms/acute management: i. If serum sodium is less than 130 meq/l, clinical signs and symptoms of neurologic compromise may be present. ii. When serum sodium falls below 120 meq/l, seizures may occur. iii. Replace deficits using hypertonic saline (i.e., 3% normal saline = sodium 513 meq/l). (a) ml/kg over 60 minutes (b) Must be infused through a central line Table 8. Disorders of Sodium Homeostasis Isonatremic (isotonic) Hypernatremic (hypertonic) Hyponatremic (hypotonic) Most common type (80%) Second most common type Least common type Serum sodium concentration and osmolarity near normal ( meq/l) Water and electrolyte losses equal to those found in ICF and ECF Examples: Diarrhea Decreased intake Serum sodium concentration and osmolarity above normal (> 150 meq/l and > 300 mosm/l) Water losses exceed salt losses Examples: Diabetes insipidus Serum sodium concentration and osmolarity below normal (< 130 meq/l and < 260 mosm/l) Salt losses exceed water losses Examples: Euvolemia: Syndrome of inappropriate antidiuretic hormone (SIADH), administration of hypotonic fluid Hypovolemia: Gastroenteritis, loop diuretics Replace 50% deficit over first 8 hours Replace remaining 50% over next 16 hours Usually require Na 8 10 meq/kg and K ~4 meq/kg Replace 50% deficit over first 24 hours Replace remaining 50% over the next hours Correction of sodium should not exceed 12 meq/l per 24 hours Usually require Na 2 4 meq/kg and K ~0 4 meq/kg Hypervolemia: Edema, heart failure, cirrhosis, nephrotic syndrome Avoid rapid correction Replace slowly over hours Correction of sodium should not exceed 12 meq/l per 24 hours Usually require Na meq/kg and K ~4 meq/kg 2-155

18 Box 1. Example Hyponatremic Dehydration A 2-month-old infant presents to the ED with a 3-day history of projectile vomiting and is given a diagnosis of pyloric stenosis. The infant appears physically dehydrated and has a serum sodium of 131 meq/l. Pre-illness weight is 5 kg; current weight on admission is 4.8 kg. Vital signs are stable. Determine the appropriate fluid and rate. Calculation of Deficits Step 1: Calculate fluid deficit. % dehydration = (5 kg 4.8 kg)/5 kg x 100 = 4% Fluid deficit = 0.04 x 5 kg = 0.2 L (200 ml) Step 2: Calculate sodium deficit. Sodium deficit = 0.2 L x 0.6 (L/kg) x 140 meq/l = 16.8 meq Excess sodium deficit = (135 meq/l 131 meq/l) x 0.6 (L/kg) x 5 kg = 12 meq Total sodium deficit = 12 meq meq = 28.8 meq Step 3: Calculate potassium deficit. Potassium deficit = 0.2 L x 0.4 (L/kg) x 120 meq/l = 9.6 meq Calculation of Maintenance Needs Fluid needs: 5 kg x 100 ml/kg = 500 ml Sodium needs: 3 meq/kg x 5 kg = 15 meq Potassium needs: 2 meq/kg x 5 kg = 10 meq (Note: Fluid needs calculated using Holliday-Segar method; sodium needs around 2 5 meq/kg/day; potassium needs around 1 2 meq/kg/day, see sections III.E.1. and III.E.3., respectively) Replacement: A. First 8 hours, give 50% of deficit needed plus 33.3% of maintenance needs. a. Volume = (0.5 x 200 ml) + (0.333 x 500 ml) = 267 ml b. Sodium = (0.5 x 28.8 meq) + (0.333 x 15 meq) = 19.4 meq c. Potassium = (0.5 x 9.6 meq) + (0.333 x 10 meq) = 8 meq Dextrose 5% in 0.45% normal saline plus potassium 20 meq/l at 33 ml/hour x 8 hour (Note: This fluid will provide 20 meq of sodium and 5 meq of potassium [close to goal].) B. Next 16 hours, give 50% of deficit needed plus 66.7% of maintenance needs. a. Volume = (0.5 x 200 ml) + (0.667 x 500 ml) = 433 ml b. Sodium = (0.5 x 28.8 meq) + (0.667 x 15 meq) = 24.4 meq c. Potassium = (0.5 x 9.6 meq) + (0.667 x 10 meq) = 11.5 meq Dextrose 5% in 0.45% normal saline plus potassium 30 meq/l at 27 ml/hour x 16 hours (Note: This fluid will provide 33 meq of sodium and 13 meq of potassium [close to goal].) 2-156

19 NUTRITION/FAILURE TO THRIVE VI. NUTRITION ASSESSMENT A. Growth Should be routinely monitored in healthy and hospitalized infants and children B. Measurements of Growth Plotted on growth curves and expressed as percentiles for age (Fenton growth charts exist for preterm infants from 22 to 50 weeks gestational age) 1. Weight 2. Length 3. Height 4. Head circumference C. Additional Anthropometric Measurements May be used to assess nutrition 1. Tricep skinfold thickness 2. Visceral protein (albumin, prealbumin) 3. Urine studies (e.g., urine sodium) 4. Nitrogen balance D. Nutritional Needs of Pediatric Patients Increased per kilogram compared with adults E. Pediatric Patients Have Reduced Nutritional Reserves Prematurity predisposes pediatric patients to nutritional deficits because most nutritional maturation occurs during the third trimester of gestation. F. Growth Velocity 1. Greatest during the first few months of life a. Neonates and infants should gain g/day (double birth weight by about 4 months of life). b years of life: Children gain 2 3 kg per year. 2. Length increases by around 50% during the first year; older children grow inches per year. VII. CALORIC REQUIREMENTS A. Table 9 Describes the typical caloric requirements across the pediatric age spectrum B. Determinant Factors of Specific Nutritional and Caloric Needs in Pediatric Patients 1. Growth rate and stage of growth 2. Body size 3. Base energy expenditure 4. State of health and illness 5. Physical activity 2-157

20 Table 9. Typical Caloric Requirements Across the Pediatric Age Spectrum Age Caloric Requirement (kcal/kg) Premature neonate Term neonate Infant Child Adolescent VIII. ENTERAL NUTRITION A. Administration of Nutrition to the Gastrointestinal Tract Typically, through a gastrostomy or jejunostomy tube and/or a nasogastric, orogastric, or nasojejunal or orojejunal tube B. Indications 1. Prematurity before suck-swallow reflex (less than weeks gestational age) 2. Critical illness/mechanical ventilation unable to meet needs by mouth C. Methods of Delivery 1. Bolus/intermittent infusion 2. Continuous infusion 3. Cycled infusion D. Types of Enteral Nutrition 1. Breast milk (recommended for the first 6 months of life) a. Expressed breast milk can be given to neonates and infants through enteral feeding tubes for those who cannot breastfeed. b. Donor breast milk available in some institutions c. Advantages to breast milk (child) i. Decreased rate of upper respiratory infections (i.e., otitis media), urinary tract infections, necrotizing enterocolitis, and other infections ii. Decreased rate of sudden infant death syndrome iii. Decreased incidence of allergy, asthma, cancer, diabetes, and obesity d. Advantages to breast milk (mother) i. Less postpartum bleeding ii. Uterus returns to normal size faster after delivery. iii. Decreased risk of certain types of cancers (e.g., ovarian, breast) iv. Improved weight loss after pregnancy v. Improves bone remineralization vi. Maternal bonding e. Human milk composition (typically around 20 kcal/oz) i. Varies between women/diet ii. Varies depending on the stage of lactation iii. Varies depending on the time of day and time into feeding 2-158

21 f. Stages of human milk i. Colostrum (milk that is produced during first several days after delivery) (a) Rich in antibodies (b) Lower in fat and energy than mature milk (c) Higher in protein, fat-soluble vitamins, minerals, and electrolytes compared with mature milk (d) Easier to digest (higher whey/casein ratio) ii. Transitional milk (milk that is produced between days 3 and 14 after delivery) iii. Mature milk (milk that is produced 2 weeks after delivery) 2. Infant formulas (available for feeding infants whose mothers are unable to breastfeed and/or provide expressed breast milk) a. Many types of enteral formulas i. Ready-to-feed ii. Dry powders iii. Concentrated liquids b. Choosing the right formula i. Patient-specific factors (a) Age (b) Nutritional requirements (c) Level of activity (d) Failure to thrive (e) Gastrointestinal function ii. Formula-specific factors (a) Nutrient composition (b) Osmolality (c) Renal solute load (d) Caloric density (e) Cost and availability iii. Other factors (a) Route of feeding (b) Family/lifestyle concerns c. Standard formulas provide 20 kcal/oz. d. Premature formulas provide kcal/oz. e. Caloric density may be altered by providing protein, carbohydrate, or fat source modular additive. 3. Summary of enteral infant formulas (Table 10) 2-159

22 Table 10. Examples of Enteral Infant Formulas Premature Formulas (infants < 36 weeks GA) Interim/ ex-premie formula Enfamil Similac Special Care Enfamil EnfaCare Similac NeoSure Advance Type Premature infant formula Premature infant formula Ex-premature infant formula Ex-premature infant formula Availability Enfamil LIPIL 20 Enfamil Premature LIPIL 24 Similac Special Care Advance 20 Similac Special Care Advance 24 Kilocalories per ounce Enfamil EnfaCare LIPIL 22 Similac NeoSure Advance 22 Term infant formulas Enfamil Premium LIPIL Type Cow based Claims/Advantages Prebiotics for immune support Respiratory and digestive health Similac Organic Cow based USDA organic, no growth hormone, antibiotics, or chemicals Similac Advance Early Shield Cow based Prebiotics for immune support, promotes calcium absorption Enfamil AR Cow based Added rice Thickens formula for infants with GERD Similac Sensitive RS Enfamil Restful LIPIL Enfamil Lactose Free Similac Sensitive Prosobee LIPIL, Isomil Advance Isomil Advance DF, Nestle Good Start Soy Gentlease LIPIL, Nutramigen LIP- IL, Pregestimil, Alimentum, Nutramigen AA, Nestle Good Start Nourish Plus Enfamil Premium LIPIL Cow based Cow based Lactose-free formulas Soy-based formula Protein/ hydrolysate/ semi-elemental Cow based Added rice Thickens formula for infants with GERD Designed to help infants sleep longer thickens to make infant feel full Used for infants with lactose intolerance (contain milk proteins) Milk-free, lactose-free products for children with milk allergy For infants with milk and soy allergies Prebiotics for immune support respiratory and digestive health GA = gestational age; GERD = gastroesophageal reflux disease; USDA = U.S. Department of Agriculture

23 4. Formulas for special medical conditions a. Nutramigen AA LIPIL i. Amino acid based, hypoallergenic formula ii. Designed for infants with severe cow s milk allergy or several food allergies b. Portagen i. Increases medium-chain triglycerides to bypass the lymphatic system ii. Used for infants with chylothorax iii. May lead to essential fatty acid deficiency c. Neocate i. Completely elemental formula ii. Designed for infants with severe allergies or gastrointestinal dysfunction d. Elecare i. Completely elemental formula ii. Designed for infants with severe allergies/gastrointestinal dysfunction iii. Increased percentage of medium-chain triglycerides compared with Neocate e. Similac PM 60/40 i. Infants with renal function or cardiovascular disease ii. Decreased potassium, calcium, and phosphorus f. Special formulas i. MSUD (maple syrup urine disease) ii. PKU (phenylketonuria) iii. Urea cycle disorders Patient Case 9. C.G. is a term neonate (weight 3.2 kg) with a caloric goal of 100 kcal/kg/day. She is receiving breast milk, and she feeds eight times per day. Which represents the best volume (milliliters) that C.G. must consume at each feed to meet her caloric goals for the day? A. 60 ml per feed. B. 27 ml per feed. C. 160 ml per feed. D. 40 ml per feed. 5. Pediatric formulas for older children (9 24 months of age) a. Standard formulas provide 30 kcal/oz. b. Marketed as nutritious alternatives to whole cow s milk to promote growth c. Contain increased amounts of vitamin C and E and iron d. Examples i. Enfamil Next Step LIPIL ii. Prosobee Next Step LIPIL iii. Similac Go and Grow (milk based), Similac Go and Grow (soy based) iv. Nestle Good Start Gentle Plus 2, Nestle Good Start Soy Plus 2, Nestle Good Start Protect Plus 2 6. Formulas for children 1 10 years of age a. Indicated for children with special medical conditions when caloric needs cannot be met with typical oral diet 2-161

24 b. Examples i. Pediasure (1 kcal/ml), Nutren Junior (1 kcal/ml), Kindercal (1.06 kcal/ml), Boost Kid (1 kcal/ml and 1.5 kcal/ml): Oral supplement or enteral feeding for children 1 10 years of age; lactose free; with or without fiber; cow s milk based ii. Peptamen Junior (1 kcal/ml): Contains hydrolyzed casein, fatty acids, and proteins for improved absorption; considered elemental formula iii. Vivonex Pediatric (20 kcal/oz), Neocate One (1 kcal/ml), EleCare (1 kcal/ml): Completely elemental formulas E. Initiating and Advancement of Enteral Nutrition 1. Breastfeeding a. Should begin within the first hours after delivery (unless medical contraindications) b. Feedings should be on demand; frequency may be variable depending on the individual child s needs. i. Usually about 8 12 times/day for first 2 weeks ii. Seven to nine times daily by 4 weeks of age. Difficult to know exactly how much child is taking during each feed; therefore, appropriate growth should be used as a measurement of adequate nutrient intake 2. Infant formula a. Initiation depends on infant s medical status. b. If healthy, initiation can occur almost immediately i. Usually 1 2 oz every 3 hours, with advancement to meet nutritional needs ii. Most infants will eat on demand. c. If medical complications, slow advancement will occur until nutritional goals are reached F. Formula Additives 1. Docosahexaenoic acid a. Important for neurologic development (normally found in human milk) b. Synthesized from essential amino acid α-linolenic acid c. Large quantities of docosahexaenoic acid found in the brain and retina d. Important for neurologic development e. Highest concentration found in the photoreceptor membrane of the retina 2. Arachidonic acid a. Required for optimal growth (normally found in human milk) b. Synthesized from essential amino acid α-linoleic acid c. Arachidonic acid required to achieve optimal growth 3. Probiotics/prebiotics: Support healthy immune systems 4. Iron a. Critical for growth and development b. Most infant formulas provide elemental iron at around 2 mg/kg/day. 5. Others a. Dry rice cereal Usually added as thickener for babies with reflux or difficulty swallowing thin liquids b. Moducal Increased carbohydrate content and caloric density c. MCT oil Medium-chain fatty acids increase caloric density d. ProMod Increased protein content and caloric density G. Medication-Nutrient Considerations 1. Avoid administering enteric-coated or extended-release products by enteral feeding devices. 2. Immediate-release products, solutions, and suspensions must be carefully evaluated to verify their ability to administer by enteral feeding device

25 3. Site of absorption must also be considered when administering medications through enteral feeding devices (i.e., gastric vs. jejunal). 4. Avoid mixing medications directly with enteral formula; rather, administer separately, and flush enteral feeding device well after administration to avoid interactions. H. Complications of Enteral Nutrition 1. Mechanical obstruction of enteral feeding device 2. Tubing misconnections 3. Oral aversion IX. PARENTERAL NUTRITION: DELIVERY OF NUTRITION DIRECTLY INTO THE BLOODSTREAM THROUGH VENOUS CATHETERS A. Indications 1. Unable to meet nutritional needs by oral or enteral route 2. Nonfunctioning gastrointestinal tract (e.g., intestinal failure, small bowel resection, necrotizing enterocolitis, gastroschisis/omphalocele, atresias, malrotation, Hirschsprung disease) 3. Prematurity 4. Critical illness/trauma 5. ECMO (extracorporeal membrane oxygenation 6. Failure to thrive B. Components of PN 1. Macronutrients a. Amino acids b. Dextrose c. Intravenous fat emulsions 2. Micronutrients a. Vitamins b. Minerals c. Electrolytes 3. Water/fluid C. Administration 1. Central venous catheter 2. Peripheral venous catheter (maximum osmolarity of peripheral PN is 900 mosm/l) 3. Typically administered as 2-in-1 PN (all components except for IVFE infusion by 1 lumen plus IVFE infused separately). 3-in-1 PN typically avoided in pediatric patients for the following reasons: lower calcium-phosphorus solubility, inability to use 0.2-micron filter (IVFE requires larger filter), inability to visualize particulates, and intravenous incompatibility with other medications D. Macronutrients 1. Protein/amino acids a. Crystalline amino acid solutions that provide essential, semi-essential, and nonessential amino acids (e.g., Aminosyn, Premasol, Trophamine, Travasol, Freamine) b. Cysteine is conditionally essential during the neonatal period: A dose of 40 mg/g of amino acid may be added to neonatal solutions (additional benefit in lowering solution ph and improving calcium-phosphorus solubility)

26 c. Amino acid 4 kcal/g 2. Carbohydrates/dextrose a. Main source of energy b. Dextrose 3.4 kcal/g c. Measured in DIR Milligrams per kilogram per minute 3. Fat/IVFE a. Prevents essential fatty acid deficiency (EFAD) by providing linoleic and α-linolenic acid (minimum fat emulsion dose to prevent EFAD = g/kg/day) b. Provides 9 kcal/g (if using 20% solution, provides 2 kcal/ml) c. Approved products in the United States are soybean-based IVFEs; caution should be exercised in administering to patients with allergy to soy and/or eggs. Patient Case 10. A 2-month-old (weight 3.4 kg) is receiving PN with the following macronutrients: DIR 14 mg/kg/minute, amino acids 3.2 g/kg/day, and IVFE 3 g/kg/day (51 ml). Which most accurately reflects the infant s caloric intake for the day? A. 111 kcal/kg/day. B. 379 kcal/kg/day. C. 413 kcal/kg/day. D. 130 kcal/kg/day. E. Initiation and Advancement of Macronutrients (Table 11) Table 11. Macronutrients: Initiation, Advancement, and Goals Premature Neonate Term Neonate/ Infant Children Adolescent/Adult Initiation Lipids g/kg/day 1 g/kg/day 1 g/kg/day 1 g/kg/day Amino acids 3 4 g/kg/day 3 g/kg/day 1 3 g/kg/day 1 3 g/kg/day Dextrose 4 6 mg/kg/ minute 4 8 mg/kg/minute 5 8 mg/kg/ minute 3 5 mg/kg/minute Advancement Lipids g/kg/day g/kg/day g/kg/day g/kg/day Amino acids g/kg/day g/kg/day g/kg/day g/kg/day Dextrose 1 2 mg/kg/ minute 1 2 mg/kg/minute 1 2 mg/kg/ minute 1 2 mg/kg/minute Goal Lipids 3 g/kg/day 3 g/kg/day 2 3 g/kg/day 1 2 g/kg/day Amino acids 3 4 g/kg/day 2 3 g/kg/day 1-3 g/kg/day 1 2 g/kg/day Dextrose mg/kg/ minute mg/kg/ minute 8 10 mg/kg/ minute 4 7 mg/kg/minute 2-164

27 F. Micronutrients 1. Electrolytes; added amounts vary according to age, clinical status, and concomitant medications (Table 12 provides typical daily requirements) Table 12. Electrolytes: Typical Daily Requirements Term Neonates (meq/kg) Sodium Potassium Chloride Phosphorus Magnesium Calcium Infants/Children (meq/kg) 2. Vitamins a. Cofactors for many metabolic functions in body b. Provided in PN as fat- and water-soluble vitamins c. Dosing i g or less: 3.3 ml/day ii. Greater than 1750 g: 5 ml/day 3. Trace elements (copper, chromium, zinc, selenium, manganese) a. Cofactors for many enzymes and crucial functions in body b. Recommended dosing (Table 13) Table 13. Trace Elements: Recommended Daily Dose Preterm Neonate (< 3 kg) Term Neonate (3 10 kg) Infants, Children, and Adolescents (10 40 kg) Adolescents (> 40 kg) Chromium mcg/kg 0.2 mcg/kg mcg/kg 5 15 mcg Copper 20 mcg/kg 20 mcg/kg 5 20 mcg/kg mcg Manganese 1 mcg/kg 1 mcg/kg 1 mcg/kg mcg Selenium mcg/kg 2 mcg/kg 1 2 mcg/kg mcg Zinc 400 mcg/kg mcg/kg mcg/kg 2 5 mg Note: Doses of trace elements may require individualization depending on clinical status. For example, the doses of copper and manganese may require dose adjustment in the setting of cholestasis/liver disorders, and the doses of chromium and selenium may require adjustment in the setting of renal dysfunction. 4. Other additives a. Levocarnitine: Cotransports fatty acids across mitochondrial membrane Doses of 5 20 mg/kg/day b. H 2 RAs (histamine-2 receptor antagonists) Reports of association with necrotizing enterocolitis in premature neonates 2-165

28 c. Heparin: Added to maintain line patency Dose of 0.5 unit/ml added for infusion rates less than 10 ml/hour (peripherally inserted central catheters, umbilical catheters), less than 3 ml/hour (Broviac catheters) X. SAFETY CONSIDERATIONS/COMPLICATIONS OF PARENTERAL NUTRITION A. Hypoglycemia/Hyperglycemia 1. Monitoring: Serum glucose concentrations daily 2. Management: Increase or decrease DIR for hypoglycemia and hyperglycemia, respectively. Insulin is not first-line therapy. B. Hypertriglyceridemia 1. Monitoring: Serum triglycerides once or twice weekly 2. Management: Decrease or hold (24 48 hours) fat emulsion infusion for elevated serum triglycerides (note: typically decrease fat emulsion dose if serum triglycerides mg/dl; if greater than 400 mg/dl, hold for hours). C. Acid-Base Disorders and Electrolyte Disturbances 1. Monitoring: Daily serum electrolytes during initiation of PN until stable; then once or twice weekly 2. Management: Adjust electrolytes added to PN as indicated. D. Refeeding Syndrome 1. Monitoring: Vital signs, serum electrolytes, particularly magnesium and phosphorus, trace elements, and vitamins 2. Management: Electrolyte replacement, slow initiation of nutrition E. Central Line Infection 1. Monitoring: Local signs of infection (e.g., erythema), systemic signs of infection (e.g., fever, positive blood cultures) 2. Management: Removal of central line (if able), systemic antibiotics, antibiotic lock therapy, ethanol lock therapy, aseptic technique with line care F. Metabolic Bone Disease 1. Monitoring: Physical examination, radiography, bone mineral density, serum vitamin D level, intact parathyroid hormone level, serum aluminum level can be considered 2. Management: Provision of adequate calcium, phosphorus, and vitamin D G. Parenteral Nutrition Associated Liver Disease (PNALD) 1. Typically diagnosed when direct bilirubin is greater than 2 mg/dl for 2 consecutive weeks 2. Risk factors a. Prolonged administration of PN (more than 2 weeks) b. Low gestational age and birth weight c. Inability to tolerate enteral nutrition d. Short bowel syndrome/intestinal failure e. Recurrent episodes of sepsis f. Administration of certain components of PN, specifically soybean oil based IVFE 3. Approaches to management a. Initiate enteral nutrition when clinically feasible

29 b. Avoidance of overfeeding c. Cycle PN (must be greater than 5 kg). d. Trace element management (e.g., if indicated, adjust doses of copper and manganese) e. Alternative IVFE strategies i. Use of alternative IVFEs such as fish oil based emulsions (available only under compassionate use) ii. Reduction in soybean oil based IVFE doses to 1 g/kg/day or less f. Use of ursodiol 10 mg/kg three times daily (only if patient can tolerate administration of enteral medications) XI. FAILURE TO THRIVE A. Weight for Age Less than 5th percentile on standardized growth charts B. Weight for Height Less than 5th percentile on standardized growth charts C. Decreased Growth Velocity Weight falls by at least 2 major percentile lines on a growth chart in a 6-month period D. Types of Malnourished States 1. Marasmus a. Energy-deficient state b. Generalized muscle wasting and absence of subcutaneous fat 2. Kwashiorkor Protein-deficient state 3. Marasmic-Kwashiorkor Clinical features of both marasmus and kwashiorkor E. Causes 1. Organic (30% 40%) a. Congenital b. Metabolic c. Immune system d. Medical 2. Inorganic (75% 90%) a. Overfeeding b. Unusual dietary beliefs c. Depression/poverty/isolation d. Hyperalertness e. History of feeding problems f. Hospitalization F. Diagnosis of Failure to Thrive History 1. Medical 2. Feeding 3. Social G. Risk Factors 1. Low birth weight 2. Behavior difficulties 2-167