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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