Nutrition Support

13.1 Enteral Nutrition


Polly Lenssen
























Indications Associated Conditions
Oral motor dysfunction or dysphagia

  • Birth defects

    • Esophageal atresia
    • Tracheoesophageal fistula
    • Pierre Robin syndrome


  • Brain tumors
  • Descending aspiration by videofluoroscopic swallow study (VFSS)
  • Neurologic disorders

    • Cerebral palsy
    • Cranial nerve dysfunction
    • Muscular dystrophy
    • Guillain-Barré syndrome
    • Head injury/coma
    • Myasthenia gravis


  • Prematurity ( <34 weeks)
Increased metabolic needs

  • Bronchopulmonary dysplasia
  • Burns
  • Congenital heart disease
  • Cystic fibrosis
  • Sepsis
  • Trauma
  • Wounds
Anorexia: Inadequate oral intake

  • Cancer: leukemia, sarcoma, neuroblastoma, stem cell transplantation
  • FTT
  • Liver disease
  • Renal disease
Psychosocial disorders

  • Anorexia nervosa
Malabsorption: Altered metabolism and/or other increased caloric loss

  • Crohn’s disease
  • Cystic fibrosis
  • Eosinophilic gastroenteritis
  • Glycogen storage disease (type 1 and 2)
  • Gastroesophageal reflux
  • Liver failure
  • Pseudo-obstruction
  • Pancreatitis
  • Short bowel syndrome
Increased length of time feeding (>4–6 hours per day)

  • Batten disease
  • Cerebral palsy
  • Rett syndrome

13.1.1 When to Intervene with Enteral Nutrition



  • Nutrient intake (energy, protein, fluid) are <75% estimated needs with concurrent weight loss.
  • Child has failed trials of nutrient-dense oral supplements.
  • Decrease in weight velocity (malnutrition) crosses two weight channels.
  • Decrease in height velocity (stunting).
  • Diminished muscle and/or fat reserves results in upper arm anthropometry <5th percentile.
  • Dysphasia in NPO status.
  • Therapies when expected outcome is anorexia, poor oral intake, and malnutrition without nutrition support (e.g., intensive cycles of chemotherapy).
  • Weight reaches ≤90% ideal weight despite aggressive oral intervention.

13.1.2 Seattle Children’s Enteral Formulary


There are market equivalents to most formulas; below are listed examples of what is required to have a complete formulary. Closed system is ideal in the hospital setting; pediatric products available in both open and closed systems are starred (*).


Premature



  • Premature formula: Enfamil Premature.
  • Breast milk + Similac HMF (human milk fortifier).
  • Postpremature: NeoSure.

Infants



  • Breast milk (can concentrate nutrient density with infant formulas and/or modular products).
  • Standard infant formulas with iron: Similac.
  • Soy infant formula: Isomil.
  • Hydrolyzed protein: Alimentum, Nutramigen.
  • Elemental formula: EleCare Infant.

Children 1–10 Years



  • Standard pediatric formulas: Nutren Jr*, Nutren Jr with Fiber*, Compleat Pediatric, Bright Beginnings (soy).
  • Semi-elemental/elemental formulas: Peptamen Jr*, Peptamen Jr with Fiber*, Peptamen Jr 1.5*, Vivonex Pediatric, Elecare Jr.

Children >10 Years



  • Standard adult formulas: Osmolite*, Isosource HN* (soy).
  • Fiber formulas: Compleat*, FiberSource HN* (soy).
  • Semi-elemental/elemental: Peptamen*, Vivonex T.E.N.
  • High calorie: Nutren 2 *.

Modular Products



  • Protein: Beneprotein.
  • Carbohydrate: Polycose.
  • Fat: Microlipid.
  • Carbohydrate + fat: Duocal.
  • Fiber: Nutrisource Fiber.

Specialty Products



  • Renal failure, ketogenic, metabolic, critical care: Consult a dietitian.

























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Jun 18, 2016 | Posted by in NUTRITION | Comments Off on Nutrition Support

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Length of Therapy Route Tube Type/Size
Short term Nasogastric

  • Infants: 5–6 F

Nasoduodenal


  • Indicated if severe refl ux, emesis
  • Feeds must be given as continuous drip


  • Children and adolescents: 6–8 F
  • Corpak or Frederick-Miller (only 8F, 70-cm, 110-cm length)

Nasojejunal


  • Placed by Interventional Radiology under fl uoroscopy.


  • Frederick-Miller
Long term(>3 months) Gastrostomy: Surgical Placement


  • Order surgery consult for evaluation of tube placement.
  • Requires 2-day admission or longer.
  • Not generally used until 7 days after placement to allow healing of tract; NG feeds required in interim.
  • Surgery available to follow up with problems


  • Bard Button

Gastrostomy: Endoscopic Placement (PEG)


  • Order GI consult for evaluation of tube placement
  • Requires 2-day admission
  • May be used within 24 hours after placement


  • PEG tube: May be changed to MIC-KEY 12 weeks after placement; requires second surgical procedure
Long term (>3 months)