Pediatric Nutrition Assessment (9/19): Reason for Consult: Wt Loss and poor PO intake

Transcription

1 AB is a 2 year old female admitted to 6 Kellogg on 9/18/2016 with a past medical history of congenital hypothyroidism, Hirschsprung's disease s/p ileostomy in 2013 and take down in 7/2014 (repair with re-anastomosis), h/o rhabdomyolysis, anastomotic ulcers seen on recent colonoscopy, hypokalemia (unknown etiology), anemia, moderate oral dysphagia related to oral aversion, and recent FTT. She was admitted for moderate dehydration and decreased PO intake secondary to vomiting and diarrheal illness. Pediatric Nutrition Assessment (9/19): Reason for Consult: Wt Loss and poor PO intake Admission Diagnosis: Vomiting without nausea, vomiting of unspecified type Anthropometrics: Length: 89 cm (2' 11.04") Weight: 8.23 kg (18 lb 2.3 oz) Head Circumference: 47.5 cm (18.7") Weight Percentile: Below 3% Height (Length) Percentile: Below 3% Weight for Length Percentile: Below 3% Weight for Calculation: 8.23 kg Weight gain velocity over past month: roughly -46 grams/day Wt Readings: 09/19/ kg (18 lb 2.3 oz) (<1 %, Z= -5.69)* 09/16/ kg (19 lb) (<1 %, Z= -5.04)* 09/09/ kg (19 lb 6.4 oz) (<1 %, Z= -4.74)* 08/25/ kg (20 lb 9.6 oz) (<1 %, Z= -3.91)* * Growth percentiles are based on CDC 2-20 Years data. Nutrition Requirements: Calories / kg: 102 cal/kg Calories per Day: 841 Protein g/kg: 1.2 Protein per Day: 10 Fluid ml/kg: 100 Fluid ml/day: 825 Tube Feeding?: No Nutritionally Significant Labs/Meds: Recent Labs 09/18/16

2 2322 NA 126* K 5.0 CL 84* CO2 13* BUN 16 CA 10.6 ALB 3.7 Intake /Output: Intake/Output Summary (Last 24 hours) at 09/19/ Last data filed at 09/19/ Gross per 24 hour Intake 272 ml Output 134 ml Net 138 ml Current Medications: ferrous sulfate 15 mg/ml oral drops (PEDS) 25.5 mg, 25.5 mg, Oral, DAILY levothyroxine (SYNTHROID) tablet 25 mcg, 25 mcg, Oral, Q24H (AM) NONFORMULARY MEDICATION 750 mg, 750 mg, Oral, DAILY J-tip injector with lidocaine 1% (BUFFERED), 0.25 ml, Subcutaneous, PRN dextrose 5% water/0.9% NaCl iv infusion (NEO-PEDS), 1,000 ml, IV Infusion, CONTINUOUS acetaminophen (TYLENOL) rectal suppository 120 mg, 120 mg, Rectal, Q6H PRN ondansetron (ZOFRAN) injection (PEDS) 2 mg, 2 mg, IV Push, Q6H PRN pantoprazole in NS (PROTONIX) 0.4 mg/ml injection DILUTION (PEDS) 8.4 mg, 1 mg/kg (Dosing Weight), IV Syringe Pump, DAILY fluconazole (DIFLUCAN) oral suspension (PEDS) 48 mg, 6 mg/kg (Dosing Weight), Oral, DAILY potassium chloride oral solution (PEDS) 4.16 meq, 0.5 meq/kg (Dosing Weight), Oral, DAILY [START ON 9/20/2016] fluconazole (DIFLUCAN) oral suspension (PEDS) 24 mg, 3 mg/kg (Dosing Weight), Oral, Q24H (AM) Current Diet Rx/Nutrition Therapy: General pediatric diet, ensure clear snack (3x per day) Food Allergies/Intolerances: Lactose intolerance, Peanuts GI Summary: # Bowel Movements (past 24hr): 2 Emesis: 0 ml Nutrition Assessment: Pt is at increased nutritional risk for nutrition related complications due to weight for age and length for age below the 3rd percentile, with

3 significant weight loss documented over the past month, continuing to drop. BMI for age plotting below the 3rd percentile, indicating severe protein-energy malnutrition (z score = -4.11). Patient with decreased PO intake (baseline picky eating) and 1-2 foul smelling BM per day. No fat seen in stool, typically darker when pt consumes ensure clear daily. Family report patient consumed 4-5 ensure clear per day prior to admission, however over past week was not having any PO intake. Provided education to pt and family on ways to increase calories and protein consumption to meet energy needs. Pt previously seen by eating therapist and family felt that helped to increase daily calorie/protein consumption, plans to meet again upon discharge. Recommended to family switching from ensure clear to Pediasure to provide more complete nutrition to best meet the macro- and micronutrient needs for her age. Foods patient currently tolerating: noodles, pizza, hot dogs, fries, eggs, broccoli (heavily spiced), fried fish, steak and fried rice *Mom reports that she feeds the pt whatever she will keep down during meal times (typically 3 meals per day). Typically eats meals first, then ensure clear consumed between meals. Nutrition Diagnosis: Evident protein-energy malnutrition related to poor appetite and PO intake as evidenced by weight loss over past month and BMI for age below the 3rd percentile. Nutrition Intervention/Plan: Continue current general pediatric diet Encourage pt and family to try Pediasure instead of Ensure clear to provide complete nutrition - providing family with variety of flavors to sample and coupons for home; aim for 4 per day between meals Monitor labs and replace as needed until WNL Monitor weight and Intake/Output Nutrition Goal: Patient to increase PO intake to at least 50-75% of meals, consistently within 3-5 days. Nutrition Follow-up: RD to Follow Up in 3 days or PRN unless patient is discharged. 9/22: o Continued to consume 2-3 Ensure clear/day o Plans for G-tube placement 9/23 to supplement PO intake o Nutrition Intervention/Plan: Encourage patient and family to increase PO intake, consistently with foods requested by pt Monitor tolerance to diet as advanced Will follow up with patient and family upon G-tube placement to provide formal education with feeding goal. Recommend advancing to goal bolus feedings of 4 cans of Pediasure per day, 1 after each meal with 1 additional snack.

4 Start at 10 ml per hour, advance by 10 ml/hr Q4 hours per protocol Goal continuous rate: Pediasure 40 ml per hour over 24 hours - once tolerating continuous feeds, advance to bolus feeds Goal to provide: 107 ml/kg, 102 kcal/kg, 2.8 g protein per kg 9/23: no changes awaiting G-tube placement 9/24: started feeds in evening - goal to tolerate within 48 hours once cleared by surgery o Per GI recs: Start 10 ml/hr x 3 hours and advance 10 ml/hr every 3 hours to 30 ml/hr. Start Pediasure once at 30 ml/hr and then advance to 40 ml/hr after 3 hours. If tolerating well can start compressing feeds to 60 ml/hr x 2 hours, 1 hour off for two cycles and then further compress to 120 ml/hr x 1 hour, 2 hours off. Continue to compress to get to a goal of Pediasure 240 ml via PO/GT QID 9/25 - Started feeds o Tolerating at 40 ml/hr 9/26 NPO o Significant emesis overnight with desaturation o NPO with concern for ileus or partial obstruction o Plan to possibly re-start feeds and advance slowly. If continues to be unable to tolerate Pediasure, consider trial of Pediasure Peptide 1.0 (semi-elemental formula) or Neocate Jr (elemental formula). Rush University Medical Center Department of Food and Nutrition Clinical Nutrition Feeding Follow-up (9/27) Feeding: Weight: kg (19 lb 14.4 oz) Enteral Feeding Name of Formula: Pediasure Peptide Calories in Formula (per ml): 1 kcal/ml Amount of Formula Needed (ml): 948 Protein in Formula (g/l): 30 Feeding Duration (hours): 24 Rate Needed to Meet Caloric Needs (ml/hr): 40 mls/hour Number of Feeds: 24 Amount per Feed: 39.5 Current Diet Rx/Feeding: NPO (to resume enteral feeds today)

5 Nutritionally Significant Labs/I/O/Meds: Lab Results Component Value Date NA /25/2016 K /25/2016 CL 94 09/25/2016 CO /25/2016 BUN 19 09/25/2016 CREAT /25/2016 IBEGFR NA 09/25/2016 IINBEGFR NA 09/25/2016 GLU /25/2016 CA /25/2016 Intake/Output Summary (Last 24 hours) at 09/27/ Last data filed at 09/27/ Gross per 24 hour Intake ml Output 823 ml Net ml Current Facility-Administered Medications: Same as previous note except for: ketorolac tromethamine (TORADOL) 15 mg/ml injection (PEDS) 4.5 mg, 0.5 mg/kg (Dosing Weight), IV Push, Q8H PRN simethicone (MYLICON) oral drops (PEDS) 20 mg, 20 mg, NG Tube, Q6H PRN lansoprazole oral compound suspension (PEDS) mg, 1.5 mg/kg (Dosing Weight), Oral, DAILY balsalazide (COLAZAL) capsule 750 mg, 750 mg, Oral, DAILY Estimated Needs: Nutrition Requirements Calories / kg: 115 cal/kg Calories per Day: 948 Protein g/kg: 3 Protein per Day: 25 Fluid ml/kg: 100 Fluid ml/day: 825 Tube Feeding?: Yes GI Summary: # Bowel Movements (past 24hr): 5 Emesis: 0 ml

6 Nutrition Assessment: No emesis noted since 9/25/2016. Plan to re-start feeds using Pediasure Peptide 1.0 (semi-elemental formula) and advance slowly. Nutrition Diagnosis: Evident protein-energy malnutrition related to inadequate intake and emesis as evidenced by weight for age, height for age and weight for length percentiles below 3. Nutrition Goal: Patient to receive nutrition within the next 24 hours Nutrition Intervention: Recommend advancing per GI Start with continuous feeds once cleared by Pediatric Surgery. Start 10 ml/hr x 4 hours and advance 10 ml/hr every 4 hours to 30 ml/hr. Start Pediasure Peptide once at 30 ml/hr and then advance to 40 ml/hr after 4 hours. Hold feeds for 4 hours. If tolerating well can start compressing feeds to 53 ml/hr x 3 hours, 1 hour off for two cycles and then compress to 80 ml/hr x 2 hour, 2 hours off for two cycles and then compress to 160 ml/hr x 1 hour, 3 hours off. Continue to compress to get to a goal of Pediasure 240 ml via PO/GT QID. Nutrition Monitoring and Evaluation: Monitor tolerance to diet/feeding as advanced Monitor weight, labs and I/O Nutrition Plan: RD to follow-up in 1 day or PRN unless the patient is discharged. 9/ ml in past 24 hours (525 kcal; 16 g protein) of Pediasure Peptide 1 o Tolerating well o Pt requesting food like cheeseburgers o Was given 30 ml popsicle last PM o Noted would benefit from PO meal attempts prior to each bolus 9/ ml in past 24 hours (636 kcal; 19 g protein) o Feeds held due to abdominal distention and pain with residuals of 45, then 50 ml after increasing feeds from 40 to 53 ml/hr o To resume feeds once cleared by GI per their recs 9/30 NPO o KUB on 9/29 demonstrated dilated distal colon with concern for distal colonic obstruction. o Per GI, to be managed by Pediatric Surgery with discussion of possible barium enema. o Per surgery, feeds should be administered per GI recs (patient allowed to have ice chips). o Pt started on Miralax for possible constipation. o Lower GI scheduled for Monday (10/3).

7 o Recommend starting at 10 ml/hr and advancing 5 ml/hr Q4H to goal of 40 ml/hr x 24 hours as soon as medically feasible 10/1: o Remains NPO, goal for pt to receive nutrition within the next hours 10/2: o Plan to advance diet today per surgery and allow PO ad lib o NPO again tomorrow for lower GI o No emesis since 9/25 o Resume tube feeds in addition to PO as soon as medically feasible 10/3: o Lower GI and barium enema today o Diet: Pediatric General Diet o 25-50% of meals in past 24 hours o Patient advanced to pediatric general diet yesterday. o Tolerated noodles, crackers, pretzels, soup, cookies and water. o Mom noticed abdominal distention last night after pt consumed chicken noodle soup so stopped feeding. o No need for NPO status for lower GI/barium enema today. o If GI clears for no bowel obstruction resume enteral feeds: Recommend starting Pediasure Peptide 1 at 10 ml/hr and advancing 5 ml/hr Q4H to goal of 40 ml/hr x 24 hours 10/4: o Tolerating pediatric general diet with fair intake o Underwent lower GI yesterday continues to have rectal irrigations by surgery o NPO tonight or Wednesday for EUA, sigmoidoscopy and possible pouch revision o Resume PO diet + EN s/p surgery 10/5: o Over the past 24 hours patient took 500 ml PO with 25% of meals consumed and 163 ml enteral (only 60 ml of Pediasure Peptide; rest was Pedialyte) o Goal is to work patient back toward bolus feeds for home Plan: o Continue PO feeds as soon as medically feasible with enteral nutrition used in addition to PO feeds o Once consistent, work on picky eating