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Enteral Feeding in Paediatrics
Enteral Feeding in Paediatrics
Fiona Arrowsmith PhD
Enteral Nutrition Support Dietitian
The Children’s Hospital at Westmead
Objectives By the end of this session, participants will be
able to:
• Assess energy, protein and fluid requirements for
a paediatric tube-fed patient
• Understand calculating requirements of a tube-fed
child with a disability
• Troubleshoot problems with tube feeding in a
paediatric patient
Case study- Jack 7yo • Referred for nutrition assessment due to poor
weight gain
• Background: Spastic quadriplegic cerebral palsy (GMFCS-5)
Epilepsy
History of recurrent chest infections
Constipation
Reflux / vomiting
Osteopenia
Case study- Jack 7yo
Anthropometry: • Wt= 13kg (<3rd %ile)
• nil weight gain last 2 years
Social History:
• Attends a special school 5 days/week,
• Has 3 siblings, 2 older (10 & 13yrs), 1 younger (3yrs),
• Lives on a farm (5 hours drive from CHW)
Weight
Wheelchair scales
Height
Knee height
Fat stores
Triceps skinfold
Nutrition Assessment 3 measures
Case study – Jack 7yo Measuring height / knee height
• Length if no contractures
• Upper arm length - anthropometer
• Tibial length (lower leg length) – tape measure
Formula for estimating stature (S) birth to 12 years (Stevenson 1995)
Knee height S = (2.69 x KH) + 24.2
Formula for estimating stature (S) from knee height (Chumlea 1994)
Boys
6 - 18 years S = (2.22 x KH) + 40.54
Girls
6 - 18 years S = (2.15 x KH) + 43.21
Case study – Jack 7yo
Height = 115cm (~10th %ile) estimated from KH
Triceps skinfold = 3.5 mm (< 5th centile)
• W-H <10th centile (and BMI) failed to identify 45% of children with
severely depleted fat stores
• Triceps skinfold thickness <10th centile identified 96% of malnourished children
• “Use of triceps skinfold thickness, using a cut-off value of <10th centile for age and sex, is recommended to screen for suboptimal fat stores in children with CP”
L. Samson-Fang & RD Stevenson. Identification of malnutrition in children with cerebral palsy: poor performance of weight-for-height centiles. DMCN 2000, 42:162-168
Addo & Himes. Reference curves for triceps and subscapular skinfold thicknesses in US children and adolescents. AJCN 2010;91:635-42
Case study- Jack 7yo Biochemistry
• Nil recent
Clinical:
3 chest infections in the last year, one requiring hospitalisation.
MBS shows aspiration on thin fluids, safe for moderately thick fluids
and minced & moist foods.
Bowels opened every 3 – 4 days, stools hard to pass
Wet nappies x 2 - 3/day
Dietary
Prolonged meal times, taking 60 minutes to eat a meal
Diet nutritionally incomplete, mainly custard, fruit, weetbix
Poor fluid intake, around 250 ml/day
Case study- Jack 7yo
• A gastrostomy tube was advised
• John’s parents agreed
• Discussion with surgeon and
gastroenterologist about whether or not
a fundoplication was also required due
to history of vomiting and recurrent
chest infections
Family Resistance to Tube Feeding
Loss of mother-child interaction
Enjoyment of eating
Maintaining eating skills
Maintaining a normal family life
Surgical procedure
Giving up hope
Social relationships
Concerns of excess weight gain
Reflux
• Dietary Management:
– Small/frequent feeds or cont. feeds
• Medical Management:
– Losec (omeprazole – PPI)
– Zantac (ranitidine – H2 Receptor antagonist)
• Surgical Management:
– Fundoplication
Fundoplication
The gastric fundus (upper part) of the stomach is wrapped around the
lower end of the oesophagus and stitched in place, reinforcing the
closing function of the lower oesophageal sphincter
Assessing Nutritional Status Energy
Protein
Biochemistry
Micronutrients
Growth
Fluid
Speech therapy Occupational therapy Physiotherapy
Energy Requirements The feeding guide
Age (months) Total EER (kcal/day)
0-3 [89 x wt(kg) -100] + 175
4-6 [89 x wt(kg) -100] + 56
7-12 [89 x wt(kg) -100] + 22
13-35 [89 x wt(kg) -100] + 20
Age (years) BMR (MJ/day) Schofield equations
Boys 3-10 [0.095 x wt (kg)] + 2.110
Boys 10-18 [0.074 x wt (kg)] + 2.754
Girls 3-10 [0.085 x wt (kg)] + 2.033
Girls 10-18 [0.056 x wt (kg)] = 2.898
Energy Requirements
Physical activity levels
1.0 Ventilated
1.2 Bed rest
1.4 Very sedentary
1.6 Light activity
1.8 Moderate activity
2.0 Heavy activity
2.2 Vigorous activity
Energy Requirements
Disease factors
Burns 1.5 – 2.0
Cardiac 1.2
Cystic fibrosis 1.2 – 1.5
Liver disease 1.2 – 1.5
Malabsorption 1.2 – 1.5
Minor surgery 1.2
Respiratory 1.2 – 1.5
Sepsis 1.5
Skeletal trauma 1.35
Protein requirements The feeding guide
Gender Age g/kg/day
Boys & girls 0-16 mo AI 1.43
7-12 mo AI 1.60
Boys & girls 1-3 years RDI 1.08
4-8 years RDI 0.91
Boys 9-13 years RDI 0.94
14-18 years RDI 0.99
Girls 9-13 years RDI 0.87
14-18 years RDI 0.77
Do not exceed 4g/kg/day
Fluid
• Wet nappies, infants 6-8/day, older children 4-5/day
• Holliday-Seger equation based on 100ml/100 cal
Age Weight (kg) mL / kg / day
0 – 3 months 3 - 6 140 - 160
4 – 6 months 7 - 8 130 - 155
7 – 12 months 9 - 10 120 - 135
Children >10 1000 – 1500 ml /day
Adolescents >20 1500 – 2000 ml / day
Weight Calculation (Holliday-Seger equation)
1 - 10 kg 100 ml/kg
10 - 20 kg 1000 ml + 50 ml/kg for every kg over 10kg
>20 kg 1500 ml + 25 ml/kg for every kg over 20kg
Signs of dehydration • Dry and sticky mouth
• Decreased urine output (no wet nappies for 6-8 hours)
• Darker yellow urine
• Dry, cool skin
• Fewer tears when crying
Severe dehydration
• Sunken eyes
• Rapid heartbeat
• Breathing rapidly
• Listlessness
Constipation
• Fluid
• Fibre
• Physical activity
• Medical Issues:
– Mx
– Other conditions
Laxatives • Stimulant laxatives
– Enhances colonic contractions • Senna, durolax
• Lubricant laxatives
– Lubricates passage of stool • Mineral oil, liquid paraffin (parachoc), not for children with dysphagia / reflux
• Osmotic laxatives
– Absorbs water and makes stool softer and makes stools bulkier • Salts – magnesium hydroxide
• Sugars - lactulose (actilax)*, sorbitol*, barley malt extract, polyethelene glycol
(movicol)
• Bulk laxatives
– Increases colonic residue and stimulates peristalsis. • Psyllium (metamucil), benefibre, stimulance etc.
Routes of enteral feeding
Kids on HEN Guidelines
Steps to Planning Enteral Nutrition Support Intervention
1. Choosing appropriate formula
2. Starting a new feeding regimen
3. Target regimen
4. Practical Considerations
ACI Clinician’s Guide
A Clinician’s Guide: Caring for people with gastrostomy
tubes and devices.
• Key principles and practice points
• From pre-insertion to ongoing care and removal
• Does not include feeding instructions (e.g.
determination of requirements, selection of formula,
feeding rates) http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastr
ostomy_guide-web.pdf
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0016/251062/Gast
rostomy_Guide_Key_Principles.pdf
ACI Clinician’s Guide • Trouble shooting / device complications
– Hypergranulation, gastric fluid leak, excoriation,
• Tube or device dysfunction
– Blockage, displacement, deterioration
• Gastrointestinal complications
– Diarrhoea, constipation, nausea, vomiting,
• Accidental removal and planned replacement
• Transfer form, education checklist
Kids on HEN resources for parents
http://www.schn.health.nsw.gov.au/parents-and-carers/fact-sheets/#cat24
• A clean mouth is crucial
• Caring for your child’s nasogastric tube
• Common problems with tolerance
• Common problems with your child’s gastrostomy tube
• Looking after your child’s feeding equipment
• Trans-gastric Jejunal feeding device
• Transitioning from tube to oral feeding
• What is tube feeding?
• Your child’s new gastrostomy button
• Your child’s tube feeding formula
Kids on HEN resources for health professionals
• Discharge on HEN checklist
• HEN plan & summary
• Parent/carer HEN education checklist
• Paediatric Home Enteral Nutrition (HEN).
Tube Feeding. A Multidisciplinary Resource
for Health Professionals. February 2013. Kids
on HEN Working Party
1. Choosing a formula
1. Availability & Cost
2. Requirements
3. Age
4. Route of feeding – osmolality of feed
5. Complete / incomplete (? Oral intake)
6. +/- Fibre
Tube Feeds
Specialised infant
Adolescent / Adult
Elemental
Semi-elemental
Feeds with fibre
High energy / high protein
Isotonic
Infant formula
Child
CHO Free
Adult vs Paediatric Formula Per 1000Cal Fibresource 1.2 Sustagen Kids Ess
Energy (cal) 1000 1000
Protein (g) 44 30
Fat (g) 33 39
Carbohydrate (g) 133 134
Osmolarity 490 340
Sodium (mmol) 43 21
Potassium (mmol) 43 28
Phosphorous (mg) 834 598
Calcium (mg) 834 897
Iron (mg) 14 10
Available formulas Below is a list of tube feeding formulas that are available in Australia. All of these formulas are nutritionally complete. Your
child’s dietitian can advise you on the most appropriate formula and where to purchase the formula.
PAEDIATRIC
Company Name of Feed Calories Per mL
Cost Per 100cal
Description
Pediasure Pediasure Plus Pediasure with Fibre
1.0
1.5
1.0
56c 56c
60c
63c
1-10y, Powder, 400g or 900g tin, or Liquid 235ml can Powder can be concentrated or diluted
Liquid 500ml pack Liquid 235ml can, contains 5g/L fibre
Sustagen Kid Essentials
1.0
34c
1-10y, Powder 900g tin Powder can be concentrated or diluted
Nutrini Nutrini Energy Nutrini Drink Powder NutriniMax NutriniMax Energy
1.0
1.5
1.5
1.0
1.5
72-79c
54-65c
33c
85-86c
61-63c
1-6y, Liquid 200ml bottle, 500ml pack, contains LCPs* 1-6y, Liquid 200ml bottle, 500ml pack, contains LCPs* 1-6y, Powder 400g tin, Powder can be concentrated or diluted
7-12y, Liquid, 500ml pack, contains LCPs*, 7-12y, Liquid, 500ml pack, contains LCPs* All Nutricia feeds are also available with fibre (8-11g/L) *LCP = long chain polyunsaturated fatty acids (omega 3)
Company Name of Feed Calories (per mL)
Cost Per 100cal
Description
Ensure Ensure Plus Jevity Jevity HiCal Osmolite Perative TwoCal
1.0
1.5
1.0
1.5
1.0
1.3
2.0
51c 47c
36-37c
43-45c
33-42c
42-45c
78-96c
36-48c
Powder (400g or 900g) contains fibre 8.4g/L, or Liquid 250ml can. Powder can be concentrated or diluted
Liquid 237ml can Liquid 237 can, or 500ml & 1000ml pack, contains fibre 14.4g/L Liquid 250ml can, or 500ml & 1000ml pack, contains fibre 12g/L Liquid 250ml can, or 500ml & 1000ml pack Liquid 237ml can, or 1000ml pack, semi-elemental Liquid 237ml can
Fibersource 1.2 Isosource 1.2 Isosource 1.5 Resource Plus
1.2
1.2
1.5
1.5
37-42c
40-47c
39-41c
34c
Liquid 237ml tetra or 1000ml pack RTH, high protein, soy protein based, contains 10g/L fibre Liquid 237ml tetra or 1000ml pack RTH, high protein, soy protein based in 1000ml pack Liquid 237ml tetra or 1000ml pack, high energy, high protein, contains 8g/L fibre Liquid 237ml tetra, high energy, high protein
Nutrison Nutrison Energy Nutrison Concentrated Nutrison Protein Plus
1.0
1.5
2.0
1.25
44-47c
36-44c
37-49c
40c
Liquid 500ml bottle or 1000ml pack, also available with fibre 15g/L. Contains fish oil (omega 3).
Liquid 500ml bottle or 1000ml pack, high energy, also available with fibre 15g/L. Contains fish oil (omega 3).
Liquid 500ml bottle or 500ml pack, high energy, high protein Liquid 1000ml pack, High Protein, also available with Fibre 15g/L. All Nutricia feeds are also available with fibre (8-11g/L) *LCP = long chain polyunsaturated fatty acids (omega 3)
Case study- Jack 7yo
John’s mother asks:
“Why can’t I just puree our family meals
and give that to him?”
What do you think?
What would you say?
“Home Brews”
NOT GENERALLY RECOMMENDED
• Possible low nutrient density
• Higher bacterial risk
• ?Higher risk of tube blockage
• ?Can shorten the life of the tube
• More difficult to assess adequacy
Micronutrients
Children with low energy needs receive
low volumes of formula and therefore may
not meet their micronutrient requirements
Case Study 2 - Bailey • 9yo male, undiagnosed syndrome, severe disability
• Weight: 35.2 kg (75th – 90th centile)
• Jevity 560ml / day
• Provides 560 cal (43% of EER), 25g protein (76%), 1250ml fluid
• Micronutrients low for
Mg (72%) Ca (51%)
Phos (34%) Se (60%)
Iodine (54%) K (29%)
• Add either “Paediatric seravit” (Nutricia) or “Fruiti vits” (VitaFlo)
Both available on script
• However, protein and K still low
Annual biochemistry
Full blood count VITAMINS
EUC Vitamins A, C, D and E
Total protein B12, Folate
Albumin
TRACE ELEMENTS MINERALS
Copper Calcium
Selenium Magnesium
Phosphate
Iron studies
Zinc
2.Starting a new feeding regimen Methods of feeding
• Oral + Bolus top-up
• Bolus only
• Bolus + continuous
• Continuous overnight only
• Continuous daytime only
Continuous Vs Bolus
• CONTINUOUS: • Advantages
– Well tolerated
– Assist in managing reflux
– Increased nutrient absorption
• Disadvantages
– Attached to equipment
– May interfere with absorption of medication
– Unable to supervise for the entire feed
– Increased risk of feed contamination (hang times)
Continuous Vs Bolus • BOLUS:
• Advantages
– Mimics normal feeding pattern
– Greater freedom/mobility
– Able to be supervised during the feed
– Supplement oral intake
• Disadvantages
– More time consuming for carer
– Highest risk of aspiration, reflux, diarrhoea
Kids on HEN Guidelines
Kids on HEN Guidelines
4. Practical considerations for HEN
The Basics:
Feeding equipment :
eg pumps, syringes, feed bags / tubes
Enteral formula:
is it easily accessible, affordable & practical?
Carers/Parents:
adequate education about enteral feeding and feel confidence to enterally feed child
Written enteral regime & recipe:
provided to parents/carers for reference and to respite / school
Ongoing Support:
Does the carer/parent have ongoing support from health care staff
Regular reviews:
assess growth/weight gain and tolerance
Positioning during/after feeds
Case study- Jack 7yo
Would you choose bolus or continuous
feeds for Jack?
Why would you choose this?
Case study- Jack 7yo
• Estimated Requirements:
– Goal Weight= current wt + 25%
– EER: Schofield BMR – x1.2
13kg = 795 – 955 cal/day
16kg = 875 – 1050 cal
– EPR: 13 (0.94g.kg)
– EFR: ~1000ml
Monitoring Tube Feeds Short term monitoring:
Tolerance - vomiting / diarrhoea
Constipation
Biochemistry
Longer term monitoring: Vitamins / minerals / trace elements
Growth – weight, height, skin-folds
Medical progress – oral intake
Regular follow-up – 6 monthly
Transition to oral feeding
Feed Intolerance
Symptom Cause Solution
Diarrhoea
Mx (antibiotics,
laxatives)
Consider Mx before
changing feed
Unable to tolerate
boluses
Smaller boluses or
continuous feeds
Unsuitable feed choice Change to hydrolysed
feed
Feed Intolerance
Symptom Cause Solution
Nausea &
Vomiting
Fast Rate Slow down rate of
feeds
Constipation Fluid, fibre, Mx
Delayed Gastric
Emptying Positioning, Mx
Feed Intolerance
Symptom Cause Solution
Regurgitation &
Aspiration
Reflux Mx, positioning, feed
thickener, surgery
Fast Rate Slow down rate of
feeds
Unable to tolerate
boluses
Smaller boluses or
continuous feeds
Case study- Jack 7yo
• Jack has his gastrostomy inserted and
after discussion with his family he is
discharged on the following feeding
plan: (see next slide)
Case study- Jack 7yo
– Dietary: (keep each oral meal to <30mins)
• Minced & moist with moderately thick fluids
• B’fast: ½ Weet Bix with FC milk + 50ml bolus
• M’tea: ½ Mashed banana or puree fruit + 50ml bolus
• Lunch: Few mouthfuls of leftovers from dinner plus few
mothfuls thickened juice + 150ml bolus
• A’tea: ½ cup thickened milk or 125ml bolus
• Dinner: Small dinner meal + 100ml bolus.
• Supper: ½ cup thickened juice or 100ml bolus
• Feeds provide up to: 550kCal (50% EER),16g protein (100% EPR),
550ml volume (~50% EFR)
Case study- Jack 7yo
– General assessment
• Anthro: looking for weight gain, increase fat stores
• Clinical: general health, bowels, urine
• Dietary: What has happened at home and school
with regards to eating, drinking and bolus feeds
– Adjust based on findings.
Questions?
Thankyou