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Principles of Nutrition Support

in Sick Children: Roles of Enteral and Parenteral

Nutrition

Mercedita Magdaleno-Macalintal, MD, DPPS

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Objectives

Participants will be able to: Identify candidates for nutritional

support Describe and compare methods of

nutrition intervention Select the appropriate method of

nutrition support Describe and select appropriate

nutrition support access Monitor nutrition support to prevent or

manage complications and achievenutrition support objectives

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Content

Nutrition decision making – paradigms

Who needs nutritional support

Enteral vs. parenteral nutrition

Access and formulation Algorithm

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Provide appropriate amounts of energy

and nutrients for optimal growth and development while:• Preserving body composition• Minimizing gastrointestinal symptoms

• Promoting developmentally appropriate feeding habits and skills

The Goal of Nutritional Support

Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.

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High prevalence of malnutrition• 10% to 50% of patients are nutritionally compromised

Special nutritional requirements • Growth and development• Immature organs/systems• Limited reserves

Considerations in Nutritional Planning

Merritt RJ, et al. Am J Clin Nutr 1979;32:1320-1325. Secker DJ, et al. Am J Clin Nutr 2007;85:1083-1089. Pawellek I, et al. Clin Nutr 2008;27:72-76 .Marino LV, et al. S Afr Med 2006;96:993-995. Hendricks KM, et al. Arch Pediatr Adolesc Med 1995;149:1118-1122 .

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Severe and possible permanent sequelae• IQ• School performance• Cognition

Use of enteral or parenteral feeding may adversely affect normal development offeeding skills and behavior/attitudes

Specialized nutritional therapies are the treatment of choice for different disorders

Considerations in Nutritional Planning

Liu J, et al. Am J Psychiatry 2004;161:2005-2013. Daniels MC, et al. J Nutr 2004;134:1439-1446. Liu J, et al. Arch Pediatr Adolesc Med 2003;156:593-600 .Mason SJ, et al. Dysphagia 2005;20:46-66. Damen RS. Adv Perit Dial 1990;6:276-9.

Creating a Nutritional Plan

Identify at-risk children Set caloric/protein goals Establish feeding method Choose formula type and

composition Monitor

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Nutrition evaluation and support should be an essential part of clinical evaluation and care in the pediatric (hospital) setting and, therefore, should be performed routinely

Nutritional support should be implemented in all children with or at risk of developing malnutrition

Nutrition Decision-Making Paradigms

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Inadequate growth:• Inadequate growth or weight gainfor >1 month in a child <2 years

• Weight loss or no weight gain for aperiod >3 months over the age of 2 years

• Change in weight/age or weight/height (length) over 2 growth channels on the growth charts

• Triceps skin-fold consistently <5th percentile for age

Indications for Nutrition Support

Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.

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Inadequate intake:• Inability to consume at least 80%of energy needs orally

Inadequate feeding skills:• Total feeding time >4 hours/day for a neurologically impaired child

Indications for Nutrition Support

Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.

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Conditions That MayRequire Nutritional Intervention

Disorders causing inadequate oral intake

Disorders of digestion and absorption Disorders of gastrointestinal

motility Increased nutritional requirements

and losses Growth failure or chronic

malnutrition Crohn’s disease Inborn errors of metabolism

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Methods of Nutrition Intervention

4. Parenteral Nutrition

3. Enteral Feeding

2. Oral Nutritional Supplements

1. Nutritional Counseling

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Nutrition Interventions: Definitions

Nutritional counseling: A nutrition professional works with patient/caregiver to assess how to improve dietary intake and provides information, education materials, support and follow-up

Oral nutrition supplementation: Providingsupplementary nutrition by mouth

Enteral nutrition: Providing supplemental or total nutrition via a feeding tube• Includes all forms of nutritional support that involveuse of “dietary foods for special medical purposes”

Parenteral nutrition: Providing supplemental or totalnutrition intravenously

Lochs H, et al. Clin Nutr 2006;25:180-186 .Koletzko B, et al. J Pediatr Gastroenterol Nutr 2005;41 (suppl2):S1-S87.

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Enteral Nutrition Indications

If the gut works, use it!

Enteral nutrition should be implemented in children who:• Have some level of GI function but are unable to meet their full nutritional requirements orally• Are malnourished• Are at risk of malnutrition

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Contraindications to Enteral Nutrition :

Absolute contraindications:• Intestinal perforation, ischemia, peritonitis, necrotizing enterocolitis

• GI obstruction, paralytic ileus• Inability to access the GI tract (severe burns, trauma)

Relative contraindications:• Vomiting and diarrhea• Severe acute pancreatitis (pain, vomiting)

• High output enteric fistula• GI bleeding

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Indications to Parenteral Nutrition

Transient or permanent GI failure

GI tract failure is often partial•Some enteral nutrition may be possible

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Parenteral NutritionContraindications/Ethical Issues

When enteral feeding is possible

Terminal illness

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Enteral & ParenteralNutrition Disadvantages

Enteral NutritionParenteral NutritionFailure to meet

nutritional needsSpecialized

centers/teams

Less acceptable to patients

Expensive

Frequent tube replacement

Complications

Complications

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Nutritional Assessment

Functional Gastrointestinal Tract

Enteral nutrition

YES

No contraindications toenteral nutrition

NO

Parenteral nutrition

Specialized Nutritional Support

Contraindications toenteral nutrition

Decision Making forNutrition Support Method

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Enteral Formula Selection

ConsiderSite of deliveryRoute of deliveryMode of deliveryMonitoring

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Enteral Formula Selection

Nutrients and energy needs adjusted for the age and clinical condition of the child:• History of food intolerance or allergy• Intestinal function• Site and route of delivery• Taste preference (oral supplementation)

Formula characteristics:• Nutritional composition• Osmolarity and solute load• Caloric density• Cost

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Enteral Nutrition

Types of formulas according to degree of hydrolyzation Polymeric

• Intact nutrients, require digestion Semi-elemental/partially hydrolyzed

• Partially “digested” for easy absorption

Elemental• Composed of free amino acids, monosaccharides and little fat

Shaw V, Lawson M, eds. Clinical Paediatric Dietetics. 2nd ed. London: Blackwell; 2001 .Sobotka L. Basics in Clinical Nutrition, 3rd ed. Prague: Galen; 2004 .Lochs H, et al. Clin Nutr 2006;25:260–274 .A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. JPEN 2002;26:S97-S137 .

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Enteral Nutrition

Modular formulas Made of modular components to produce an individualized formula to meet special needs

Immunomodulating formulas Supplemented with functional ingredients

• Eg, glutamine, arginine, nucleotides, omega-3fatty acids, antioxidants

Disease-specific formulas Modified in nutrient content, amount and ratio Shaw V, Lawson M, eds. Clinical Paediatric Dietetics. 2nd ed. London: Blackwell; 2001 .Sobotka L. Basics in Clinical Nutrition, 3rd ed. Prague: Galen; 2004 .Lochs H, et al. Clin Nutr 2006;25:260–274 .A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. JPEN 2002;26:S97-S137 .

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Enteral and ParenteralNutrition Advantages

Enteral NutritionParenteral Nutrition Preserves

- GI structure & function - Gut hormonal response

- Normal gut flora - Normal blood supply to the

gut - GALT integrity

No risk of tube feeding aspiration

May help preventbacterial translocation

Better patient acceptance

Decreased risk of infectionMore reliable delivery

Less expensiveSupports survival in intestinal failure

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Enteral Nutrition

Sites of delivery:GastricPost-pyloric

Choice of the delivery site is based on:

Functional status of the gutRisk of aspiration

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Enteral Nutrition

Gastric feeding• Flexible feeding schedules• Reservoir capacity

Tolerance of volume and hyperosmolar feedings

• Less diarrhea, dumping syndrome• Gastric acidity has antibacterial function• Gastric tubes are relatively easy to place

Post-pyloric feeding• Allows delivery of EN in case of gastroparesis, severe GERD, or gastric outlet obstruction

• Not recommended for preterm infantsMcGuire W, McEwan P. Cochrane Database Syst Rev. 2007;3:CD003487.

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Enteral Nutrition

Nasogastric (NG) and nasoenteric feeding tubes

Feeding duration 6-8 weeks PVC, polyurethane, silicone NG tubes common

PVC can release phthalate ester PVC can become rigid Change PVC NG tubes q 3-4 d,transpyloric tubes q 8 d

Smallest tube diameter desirable Tube length Tube placement confirmation

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Enteral Nutrition

Gastrostomy/jejunostomy tubes For feeding duration >8 weeks Placement techniques

• Endoscopy• Surgery• Radiology

Loser C, et al. Clin Nutr 2005;24:848-61 .Caulfield M. Gastrointest Endosc Clin N Am 1994;4:179-93.

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Enteral Nutrition Methods of enteral feeding administration • Continuous feeding

Continual delivery over 12 - 24 hours

Feeding pump regulates delivery• Intermittent bolus feeding

Discrete volumes of formula delivered several times daily

• Combined continuous and intermittent feedingAynsley-Green A, et al. Acta Paediatr Scand 1982;71:379-83 .

Jawaheer G, et al. J Pediatr 2001;138:822-5.Shulman RJ, et al. J Pediatr Gastroenterol Nutr 1994;18:350-4.

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Enteral Nutrition Required monitoring

• Biochemical monitoring To prevent electrolyte and fluid abnormalitiesand hypo- and hyperglycemia

• GI tolerance To prevent vomiting, abdominal distention,pain, constipation

• Tube/stoma placement and maintenance To prevent tube displacement, tube clogging, aspiration

• Growth and development • Psychological aspects (feeding aversion, loss of feeding skills)

Jeejeebhoy KJ. Curr Opin Gastroenterol 2005;21:187-91.

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Parenteral Nutrition

Decision to institute parenteral nutrition

depends on:•Nutritional status•GI tract function

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Parenteral Nutrition

Rapid initiation for young, small children• Preterm infants cannot tolerate starvationInstitute parenteral nutritionimmediately after birth

• Older children can tolerate up to 7 days

Combine with oral or enteral nutrition

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Parenteral Nutrition

Access• Peripheral access should be temporary• Trained personnel insert and care for central venous catheters Aseptic conditions are paramount

Methods of insertion• PICC• Tunneled central venous catheters

Insertion sites• Femoral• Jugular• Subclavian

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Parenteral Nutrition

Parenteral solutions• Amino acids• Glucose• Lipids• Electrolytes, vitamins, trace elements

Tailored vs. standard solutions Computer prescription programs encouraged

Guidelines on Paediatric Parenteral Nutrition of ESPGHAN and ESPEN, Supported by ESPR. J Pediatr Gastroenterol Nutr 2005:41(suppl2):S1-S87.

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Parenteral Nutrition

Monitoring Monitor Blood chem 2-3 times weekly

• Electrolytes, renal & liver function, blood lipids

Routine nutrition assessment Parenteral nutrition >3 months

• Trace elements / Ferritin• Folate / Vitamin B12

• Thyroid function• Coagulation status• Fat-soluble vitamins

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Parenteral NutritionComplications Catheter-related

• Infection, thrombosis, occlusion,accidental removal, catheter damage

Metabolic/nutritional• Fluid-electrolyte abnormalities,hypo-/hyperglycemia, failure to achieve optimal nutritional status and growth

Long-term parenteral nutrition• Cholestasis, renal and bone disease,growth impairment

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Parenteral Nutrition

Prevent complications Multi-disciplinary nutrition support team

Meticulous technique Avoid unbalanced/excessive substrates

Strict hygiene Emphasize enteral feeding Structured pathways

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Normal Gastrointestinal Absorption Function

Nasogastric Tube

YES

NO

Jejunostomy

Specialized Formula Standard Formula

Expected Period of Nutritional Support

Less than 4-6 weeks More than 4-6 weeks

Risk of Aspiration

Post-pyloric Tube

Gastrostomy

YES

NO

Enteral Nutrition Possible

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Enteral Nutrition not Possible

Intestinal Immaturity/FailureContraindications to Enteral Nutrition

Periodic monitoring/prevention and treatment of complications

Temporary need for PNLess than 7-10 days

Expected Period of PN Support

Peripheral venous access Central venous access

Establish/provide energy and nutrient requirements

Prolonged need for PNMore than 7-10 days

Periodic evaluation of nutritional status and GI function

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Prolonged PN SupportPermanent or Severe Intestinal Failure

Periodic monitoring/prevention and treatment of complications

Prolonged period of parenteral nutrition is expected. Patient condition, fluid/electrolytes status stable. Cyclic administration initiated

1. Teach family members aseptic technique for catheter dressing, tube connection and disconnection

2. Teach solution and pump handling3. Supply 24/7 assistance in case of emergency

Arrange for home parenteral nutrition support

Periodic evaluation of nutritional status and GI function

Evaluate the possibility of weaning from home parenteral nutrition

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Summary Nutrition decision making – paradigms

Who needs nutritional support Enteral vs. parenteral nutrition

Access and formulation Algorithm