Małgorzata Łyszkowska Department of Paediatric Surgery and Organ Transplantation The Children s Memorial Health Institute, Warsaw Poland Baltic Club 13-14.09.2013
Distinction Between Parenteral Nutrition in Paediatrics and in Adult Patients Baltic Club 13-14.09.2013
ADEQUATE / INADEQUATE NUTRITIONAL TREATMENT Nutritional factors Genetic factors Weight gain Growth velocity Environmental factors
Metabolic differencies Immaturity neonates, infants, children up to 2-3 years of age, eg.: physiologic jaundice physiolgic anaemia immaturity of kidney and liver febrile convulsions prematurity motor and enzymatic immaturity of gastrointestinal tract no suction Ca-P balance hipoproteinemia, hipoalbuminemia Environment diseases inflammation hipoxia medicins linked with albumin metabolised by liver excreted with bile, urine operations stress pain loss of protein, fluid, electrolytes, trace elements Inborn errors Galactosemia Fructosemia Phenyloketonuria Tyrozynemia L-CHAD Brain degradation: metabolic disorders convulsions: West s syndrome Lennoxa-Gastaut syndrome
The WHO Child Growth Standards Weight for - age Lenght / height for - age Weight for - height Body Mass Index for age Head circumference for age Arm circumference for age Subscapular skinfold for age Triceps skinfold for - age
BMI = body mass [kg] / height 2 [m 2 ] * < 15 cahexy 15 20 malnutrition 20 25 normal value 25 30 overweight > 30 - obesity 3 years old girl BMI = 13 / 0,95 = 14,4
Enteral Nutrition feeding directly into stomach or duodenum/jejunum over tube or stoma or / and oral provision of food of special purpose
General indications for EN: Growth failure Growth failure > 1 month in a child < 2y. Growth failure > 3 months in a child > 2y. Change of centil charts > 2 growth chanels Triceps skinfold < 5 th percentile / age Total feeding time > 4 h / day in disabled child EN as a treatment of the disease
Indications for EN Inability to take enough food primary and secondary neurologic disorders, anorexia in chronic diseases Maldigestion and/or malabsorption partial gut resection, Crohn s disease, pancretic failure, cholestatic liver diseases Increase of nutritional requirements loss of nutrients: fistulas, protein loss enteropathy, inborn or secondary enteropathy Altered metabolism inflammation, cancer diseases Specific diseases allergy, coeliac disease, metabolic disorders
Contraindications to EN Intestinal perforation Intestinal mechanical obstruction Paralytic ileus NEC (Necrotizing Enterocolitis)
General Indications for Parenteral Nutrition Enteral nutrition is impossible Enteral nutrition is insufficient Total Parenteral Nutrition Partial Parenteral Nutrition
Indications for Parenteral Nutrition in Children Prematurity and gastro-intestinal immaturity Necrotizing Enterocolitis (NEC) Perinatal injury Inborn malformation of gastrointestinal tract Acute pancreatitis Cystic fibrosis Neoplastic disease Sepsis Immunodeficiency Multiorgan trauma Burn Pre- and postoperative management Postoperative complications
Indications for long-term Parenteral Nutrition in Children Chronic intestinal failure Short bowel syndrome Intestinal wall damage (inflammation, chemotherapy, radiotherapy) Intractable diarrhoea Pseudoobstruction syndrome Aganglionosis / dysganglionosis Encapsulating Peritoneal Sclerosis Protein-loss enteropathy Intestinal fistula Crohn s disease Cystic fibrosis - some patients Autoimmune enteropathy NEC
Encapsulating Peritoneal Sclerosis operacja
n Direct causes of HPN in children 450 426 400 350 300 250 200 150 100 84 79 50 35 51 33 35 42 52 51 14 6 18 13 0 ESPEN 2004 SBS IBD Autoimmune diarrhoea Hereditary untreatable diarrhoea Protein loss enteropathy Hereditary immune deficiency AIDS Pseudoobstruction syn. Total gut aganglionosis Prematurity Cystic fibrosis Cancer diseases Radiation enteropathy Other
Formulas Type of formula Polimeric Osmolarity Semielemental (oligomeric) Elemental (monomeric) Proteins Whole proteins Small peptides (3-4 aa) Glucose polimers Fat LCT or LCT/MCT Carbohydrates Indications 300 Multiple indications 300 450 Allergy, malabsorption Amino acids 300 600 Multiple allergies, severe malabsorption All formulas are adapted to specific groups of patients age Pre-matures Full term neonates, infants Toddlers Older children Use adult formula only after 8 10 y.
Routes and methods of delivery orally via noso-gastric tube via gastrostomy Percutaneous Endoscopic Gastrostomy (PEG) inserted surgically via noso-jejunal tube via PEG-J via jejunostomy microjejunostomy clasic jejunostomy portions sip feeding continously pumps gravity infusion Difference: size of tubes, gastrostomy, devices 6 18 F
Complications of EN Baltic Club 13-14.09.2013
Acute Diseases Water balance Electrolyte balance Acid-base balance No shock Time Period for PN Starting adults and teenagers younger children infants neonates premature babies up to 5-7 days up to 3-4 days up to 2-3 days up to 24-48 hours up to 12-24 hours Body weight = 1 kg: 1% of fat! non-protein calories reserve of only 110 kcal/kg Parenteral Nutrition
Venous catheters temporary, tunnelled / non-tunnelled tunneled long-term = permanent subcutaneous port
Venous Access in Paediatric Patients No collaboration with patient (general anaesthesia) Small diameter of veins Small diameter of a venous catheter risk of catheter s occlusion Broviac s catheter Groshong s catheter Premature babies 2,7 F 3,5 F Difference: catheter s diameter Neonates 2,7F; 4,2 F 3,5 F Infants 4,2 F 3,5 F Young children 4,2 F; 6,6F 5,5 F Baltic Club 13-14.09.2013 Older children and adults 6,6F 5,5; 7,5F
The amount of total body water (TBW) TBW The water turnover 24 weeks old foetus 90% Born at term infant 75% Adult 50 60%
Evaporation of water from upper respiratory passages Premature Term neonates Children Adolescents 0,8-0,9 ml / kg / h 0,5 ml / kg / h 0,4 ml / kg / h 0,3 ml / kg / h
Recommended gradual increase of fluid volume, Na, K supplementation neonates Fluid volume (ml/kg/d) Days after birth I phase 1 st 2 nd 3 rd 4 th 5 th 6 th Term neonate Preterm neonate > 1500g Preterm neonate < 1500g Na (mmol/kg/d) K (mmol/kg/d) 60-120 80-120 100-130 120-150 140-160 140-180 60-80 80-100 100-120 120-150 140-160 140-160 80-90 100-110 120-130 130-150 140-160 160-180 0 3 (5) 0-2 Baltic Club 13-14.09.2013
Recommended fluid volume, Na, K supplementation Birth weight Water intake Na intake K intake ml/kg/day mmol/kg/day mmol/kg/day Infants 120 150 (180) 2-3 1 3 1 st 2 nd year of life 80 120 (150) 1-3 1-3 3 rd 5 th year of life 80-100 1-2 1-2 6 th 12 th year of 60-80 1 1,5 1 1,5 life Adolescents 50-70 1 1 Baltic Club 13-14.09.2013
Maximal supply of macro- / micronutrients per kg b.w. per day 18 16 14 12 10 8 6 4 2 0 aminoacids (g/kg/d) carbohydrates (g/kg/d) lipids (g/kg/d) Ca (mmol/kg/d) Pi (mmol/kg/d) Baltic Club 13-14.09.2013 neonates infants children adolescents
Essential amino acids cystine, cysteine tyrosine, taurine, glycine, histidine, aspartic acid, glutamic acid leucine, isoleucine, valine, lysine, methionine, phenylalanine, threonine, tryptophan premature babies full term neonates, infants, young children adults, adolescents
Amino acids Children Aminoven infant 6%, 10% (Fresenius Kabi) Primene 5%, 10% (Baxter) Vaminolact 6,5% (Fresenius Kabi)
Lipids LCT (soybean oil) LCT (olive oil + soybean oil) LCT (soybean oil) + MCT LCT n-3 (fish oil) ClinOleic 20% (Baxter) Lipofundin MCT/LCT 10%, 20% (B Braun) Omegaven 10% (Fresenius Kabi) Intralipid 10%, 20%, 30% (Fresenius Kabi) Ivelip 10%, 20% (Baxter) Lipofundin S 10%, 20% (B Braun) Lipovenoes 20% (Fresenius Kabi) LCT (soybean oil+ olive oil + fish oil) + MCT SMOF Lipid 20% (Fresenius Kabi)
Fatty acids in lipid emulsions and human milk Human milk SMOF Lipid Soybean oil (100%) Olive oil/soybean oil (80%/20%) MCT/LCT (50%/50%) Saturated faty acids Monounsaturated faty acids Essential faty acids (linoleic and alfa-linolenic faty acid)
Complications of PN Baltic Club 13-14.09.2013