FLUIDS: VITAMINS/MINERALS:

Disease

Condition

JOB AID: Nutrition Assessment of Special Diseases

Bariatric

(Lora Edwards

developing)

<10% TBSA: Close to normal estimated energy expenditure (EER). If <90% IBW use IBW in calculations for estimating energy needs. Use WHO equation with no activity factor added or use EER calculator to determine kcal needs.

>10% TBSA: Energy estimates can fluctuate and may need to be adjusted over time to account for changes in medical status. If <90% IBW use IBW

calculations for estimating energy needs. Use WHO equation with stress factor of 1.2-1.7 as outlined in “Nutrition Guidelines for Burn and Thermal Injuries” in the Nutrition Care Manual.

PROTEIN:

- <10% TBSA: 15% of total kcals as protein.

- >10% TBSA: Upper range should be used with larger burn size. Ages 0-6 years: 3-4 gm protein/kg/day. Ages 7 years and older: 2.5-3 gm protein/kg/day. - When % of TBSA of burn unknown: Provide protein equal to twice DRI forchronological age.

FLUIDS: Per medical team.

VITAMINS/MINERALS: “Burn Vitamins” as an order set. Choose appropriate age. Refer to “Nutrition Guidelines for Burn and Thermal Injuries”in the Nutrition Care Manual.

Celiac CALORIES:

-EER plus activity.

-Down Syndrome: 14.3 kcal/cm for girls ages 5-11 years. 16.1 kcal/cm for boys ages 5-11 years. 80-100% EER for all other ages. -Overweight/Obesity: EER based on IBW.

PROTEIN: DRI for age.

FLUIDS: Standard maintenance.

VITAMINS/MINERALS: Based on DRI for age paying close attention to calcium, zinc, and iron. DIET ORDER: Gluten Free.

Congenital Cardiac Defects

CALORIES: -EER x 1-1.25.

-100% EER for post-heart transplant or repaired heart defects with improved cardiac function, unless requires catch-up growth. -110-125% EER if experiencing active heart failure or requiring catch-up growth.

PROTEIN: -DRI x 1-2.

-Elevated needs post-surgical procedure and of experiencing active heart failure. May use “PICU Nutrition Guidelines” in the Nutrition Care Manual. -Elevated needs for protein-losing enteropathy (>2 gm protein/kg/day).

FLUIDS: Maintenance. May require fluid restriction per medical team. VITAMINS/MINERALS: DRI for age.

Continuous Renal Replacement Therapy

(CRRT) in the PICU

Refer to CRRT in the “PICU Nutrition Guidelines” in the Nutrition Care Manual.

Cystic Fibrosis CALORIES: EER with high activity factor x 1.2‐1.5 (may be higher with end-stage disease). PROTEIN: DRI for age x 1.5‐2.

FLUIDS: Maintenance. May need above maintenance needs if on nephrotoxic antibiotics. All patients on IVFs first 24 hours of inpatient stay. VITAMINS: Fat soluble vitamin supplement dosing per age.

Cystic Fibrosis (continued)

MINERALS: Salt. Dosing per age. ENZYMES: Dosing per guidelines.

DIET ORDER: High Calorie High Protein menu. If has CF-related diabetes use High Calorie High Protein menu and not a carbohydrate-controlled menu. Developmental

Disabilities

CALORIES:

-Down Syndrome: 14.3 kcal/cm for girls ages 5-11. 16.1 kcal/cm for boys ages 5-11. 80-100% EER for all other ages.

-Spina Bifida: >8 years, weight maintenance: 9-11 kcal/cm or 50% fewer of EER. >8 years, to promote weight loss: 7 kcal/cm.

-Prader-Willi Syndrome: All children/adolescents: 10-11 kcal/cm to maintain growth. 8.5 kcal/cm for slow weight loss and to support linear growth. -Cerebral Palsy: Ambulatory, ages 5-12 years: 13.9 kcal/cm. Non-ambulatory, ages 5-12 years: 11.1 kcal/cm. Mild to moderate activity: 15 kcal/cm. Severely restricted activity: 10 kcal/cm.

-If does not fit into above categories: EER for age/sex and adjust based on growth velocity. If no height available or height accuracy is questionable, use WHO equation and adjust based on growth velocity.

PROTEIN: DRI for age.

FLUIDS: Standard maintenance. VITAMINS/MINERALS: DRI for age. Diabetes Type 1

and Type 2

CALORIES: EER based on Activity Factor at that time (x 1 if inpatient). PROTEIN: DRI for age.

CARBOHYDRATE: 45-60% of kcals. FLUIDS: Maintenance.

VITAMINS/MINERALS: DRI for age.

MENU: Diabetes Carbohydrate Counting Diet or Diabetes Carbohydrate Counting Gluten Free Diet. FETAL HEALTH CENTER: Refer to “Fetal Health Center Diabetes Guidelines” in Nutrition Care Manual.

CALORIES: Pregnancy – 2nd _{trimester: Adult EER + 340 kcals/day. 3}rd _{trimester: Adult EER +452 kcals/day. Minimum 1800 kcals/day. Overweight or obese} pregnant womenwith gestational diabetes: 70% of DRI kcals for pregnancy. Postpartum: Adult EER + Activity. Breastfeeding first 6 months: Adult EER + 330 kcals/day. Breastfeeding second 6 months: Adult EER + 400 kcals/day.

CARBOHYDRATE: Pregnancy: Minimum 175 gm carbohydrate/day. Postpartum: 45-65% of kcal needs or as otherwise determined by RD. Breastfeeding: 210 gm carbohydrate/day.

-PROTEIN: Pregnancy 2nd _{and 3}rd _{trimesters: 1.1 gm protein/kg/day or an extra 25 gm protein/day. Extra 50 gm protein/day for twin gestation. Postpartum:}

0.8 gm protein/kg/day. Breastfeeding: 1.1 gm protein/kg/day or extra 25 gm protein/day. -FAT: Pregnancy, postpartum, and breastfeeding: 20-35% total kcal needs.

Eating Disorders (Inpatient)

CALORIES: EER (using 1.2 Activity Factor) + 500-1000 kcals for weight restoration. Not all patients require weight restoration. PROTEIN: DRI.

FLUIDS: Maintenance or per medical team.

VITAMINS/MINERALS: MV/Mineral, 1000 IU Vitamin D, 100 mg thiamine x 5 days.

MEAL PLANS: A (1000 kcals) through M (4700 kcals). Check Scope for all kcal levels. Typically start with 1500 kcals (severe malnutrition) or 1800 kcals (mild to moderate malnutrition). Increase by 1 meal plan (200-300 kcals) daily until goal kcals achieved.

ENSURE PLUS SUPPLEMENT: Each meal plan kcal level has a separate supplement order. Can be provided PO or NG.

REFEEDING SYNDROME RISK: Refer to page 6 of “Nutrition Related Guidelines for Patients at Risk of Refeeding Syndrome” in Nutrition Care Manual. Enteral Tube

Feeds (Excludes ICN which has its own

protocol)

-

-BOLUS, INTERMITTENT, CONTINUOUS, OR COMBINATION(BOLUS BY DAY AND CONTINUOUS AT NIGHT). All jejunal feeds must be continuous. -ISOTONIC FORMULA is typically better tolerated than hypertonic.

Enteral Tube Feeds (continued)

-INITIATION AND ADVANCEMENT per “Initiation, Advancement, and Monitoring of Enteral Feeds” in Nutrition Care Manual. THIS IS DONE BUT IS NOT IN THE NUTRITION CARE MANUAL YET.

Hematology/ Oncology

CALORIES: 100% (using current body weight, even if obese), elevated to 110-130% of EER for catch-up weight gain. PROTEIN: 1.5-2x DRI for age

FLUIDS: Maintenance or per medical team. May be fluid restricted. May receive above maintenance fluids if admitted for chemotherapy or with high output and/or fever, as determined by medical team.

VITAMINS/MINERALS: Multivitamin in most cases but needs to be determined by physician due to possible interactions with chemotherapy. DIET ORDER: Regular. May need high calorie, high protein meals and snacks, or nutrition supplements.

REFEEDING SYNDROME: Patients with an oncology diagnosis and malnutrition may be at elevated risk for refeeding syndrome. Refer to “Nutrition Related Guidelines for Patients at Risk of Refeeding Syndrome“ in Nutrition Care Manual.

TUBE FEEDINGS: Begin with continuous feeds. Pediasure or Compleat Pediatric Organic Blends. If intolerance issues could trial Pediasure Peptide. Liver Disease

(Chronic) (Last updated

2015)

CALORIES: Resting energy expenditure may be 30% higher in chronic liver disease, including biliary atresia, than healthy infants and children. Weight can be affected by ascites. Fat malabsorption may greatly increase energy needs.

PROTEIN: Infants/Toddlers: 2-3 gm protein/kg/day. Older children: 1.5-2 gm protein/kg/day. Protein may be restricted in hepatic encephalopathy. FLUIDS: Per medical team.

VITAMINS/MINERALS: Need to supplement Vitamins A, D, E, and K - AquADEK appropriate. Zinc and iron supplementation as needed. May need additional individual vitamin/mineral supplementation.

FEEDS: Infants - Breastfeeding but may need supplementation with concentrated formula. Pregestimil (preferred due to higher MCT content) or Alimentum concentrated to 26 kcal/oz plus 4 kcal/oz Solcarb to make 30 kcal/oz. MCT oil, 1-2 ml, 3-4 times/day may be provided. Children – High kcal intake with frequent meals and snacks. Oral supplements as indicated. Both infants and children may need tube feedings and/or TPN if unable to provide goal nutrition otherwise.

NICU PREMATURITY DEFINITIONS AND GROWTH CHARTS:

-Preterm: 36 6/7 weeks birth Gestational Age (GA) and below. -Term: 37 0/7 weeks birth GA and above.

-PMA (Post Menstrual Age) = Birth GA + Chronological Age. -PMA <50 weeks plot on Fenton Growth Chart.

-PMA 50 weeks or > plot on WHO Growth Chart and check box "Plot by Corrected Age". CALORIES:

-PMA <50 weeks: Enteral: 100-130 kcal/kg/day. Parenteral: 90-100 kcal/kg/day (with 3-4 gm amino acids/kg/day, and 3 gm IL/kg). -PMA 50 weeks or >: Kcal needs for corrected age.

PROTEIN:

-PMA <50 weeks: Enteral: 3.5-4 gm protein/kg/day. Parenteral: 3-4 gm amino acids/kg/day (with 90-100 kcal/kg/day and 3 gm IL/kg/day). -PMA 50 weeks or >: Protein needs for corrected age.

FLUIDS: Determined by medical team.

VITAMINS/MINERALS: Vitamin D and iron supplementation. After 2.5 kg can give 1 ml MV with iron daily to meet Vitamin D and iron needs. GROWTH GOALS:

-PMA <50 weeks: Use Preterm Growth Goals in Diet Manual.

-PMA 50 weeks or >: Use Growth Expectations in Diet Manual for appropriate corrected age.

-Catch-up growth goals not established for preterm infants. If weight-for-length <normal use clinical judgment to allow for appropriate catch-up growth. NUTRITION FOCUSED PHYSCICAL EXAM: Obtain MUAC if >50 weeks PMA.

LENGTH OF TIME ON PRETERM FOLLOW-UP FORMULA NEOSURE OR ENFACARE: - <30-32 weeks birth GA use until corrected age/PMA one year.

-30-34 weeks birth GA use until corrected age/PMA 6-9 months. -34-36 weeks birth GA use until corrected age/PMA 0-3 months.

PICU CALORIES:

-EER equation using sedentary Activity Factor if patient is extubated.

-EER x 80-100 appropriate initial goal with chronic respiratory failure requiring long term mechanical ventilation.

-WHO equation used to determine maintenance needs for most critically ill children. Infants, initial goal for weight maintenance is WHO x ~1.5 (~70-80 kcal/kg/day). Older children, WHO x 1-1.2 is usually appropriate. WHO x 1.2-1.5 may be needed in some older children – severe burn injury, severe trauma including closed head injury, septic shock, or unrepaired congenital cardiac defect.

PROTEIN: Birth to 2 years: 1.5-3 gm protein/kg/day. 2-13 years: 1.5-2.5 gm protein/kg/day. 13-18 years: 1.5-2 gm protein/kg/day. Protein may be restricted in renal failure if not on dialysis. Higher end of protein needs in burn or multi-trauma patients.

FLUIDS: Often determined by medical team. Maintenance fluids in mechanically ventilated patients are estimated at 80-100% of normal maintenance needs. If fluid restricted, all fluid intake is considered when determining fluid available for nutrition.

VITAMINS/MINERALS: Additional vitamins and minerals are not routinely prescribed in critically ill patients. Vitamin or mineral supplements may be recommended in patients with burn injury, malnourished patients, patients with significant wounds, or patients undergoing dialysis or CRRT. Refeeding Syndrome (Last update 2016. Margaret said no changes needed.) CALORIES:

-Obtain indirect calorimetry within the first 72 hours and weekly in patients considered at an escalated risk of refeeding syndrome. Utilize the measured resting energy expenditure (MREE) and respiratory quotient (RQ) to aid in determining energy recommendations.

-Restrict kcal intake to 50% of WHO equation or 50-100% of MREE for the first 24-72 hours. Advance to goal kcals in the next 4-5 days. Patients at escalated risk of refeeding syndrome should have kcal intake advanced to goal over 8-14 days.

-Do not advance kcal intake if electrolytes, phosphorus, or magnesium are unstable. PROTEIN: DRI for age plus increased needs as appropriate for catch-up growth. FLUIDS: Limit fluid to 80-100% normal maintenance fluid needs for first 24-72 hours. VITAMINS/MINERALS:

- <2 years of age: 1 ml/day liquid multivitamin with iron. May require additional supplementation of Vitamin B12, folate, and zinc. ->2 years of age: Daily pediatric multivitamin with mineral tablet.

-Daily MVI if receiving parenteral nutrition.

-Patients who are severely malnourished or have had rapid weight loss should also receive thiamin and selenium supplementation. All patients in the escalated risk category should receive thiamin and selenium.

Renal Inpatients (Last updated

2016)

CALORIES:

-EER for chronological age or weight age.

-If on dialysis use most recent estimated dry weight (EDW) if available.

-For other renal patients with fluid retention or anuric patients, use previous weight reported by family, or EDW determined by physician. PROTEIN:

-If has edema use EDW to calculate protein needs.

-Refer to Nutrition Assessment of Nephrology Inpatient Guidelines for protein needs for various ages and stages of renal disease. FLUIDS:

-Often determined by physician.

-Fluid restriction information can be found in RN Communication in “ORDERS” tab or in the diet order.

-Increased fluid needs are common among some conditions including kidney transplant, nephrogenic diabetes insipidus, and polyruric patients. VITAMINS/MINERALS:

- May be on individualized supplements for vitamins and minerals. Often receive supplements of sodium, phosphorus, potassium, calcium, Vitamin D, iron, zinc, copper, and water-soluble vitamins.

-Should receive DRI for vitamins and minerals from diet and/or supplements.

-With some exceptions, dialysis patients should not receive Vitamin A, Vitamin E, or Vitamin K supplementation.

Renal Inpatients (continued)

FORMULAS AND TUBE FEEDINGS: -Similac PM 60:40: Infant formula.

-Suplena: Adult formula that can be used for younger patients with fluid restriction. -Nepro: Adult formula high in protein used for adolescents with fluid restrictions.

-Calcilo XD – very low calcium and vitamin D-free formula used for some patients with extremely low calcium and vitamin D needs.

-Formula modulars often added to increase kcals and/or protein without increasing specific minerals – Renalcal, Solcarb, Beneprotein, Duocal,etc. -Tube feedings individualized. Fluid restricted patients may need formula concentrations of 30-60 kcal/oz. Patients with increased fluid needs may have formula concentrations <20 kcal/oz.

Short Bowel Syndrome

CALORIES:

-Enteral - EER x 1.2. Adjust for age-appropriate growth. May have increased needs due to malabsorption. -Parenteral: Start with EER. Adjust to achieve age-appropriate growth.

PROTEIN: DRI X 1.2-1.5. May need more if po/enterally fed due to malabsorption. FLUIDS:

-Infants: 125-150% maintenance. Adjust as needed to maintain hydration. -1+ years old: Usually 125% of maintenance. Adjust as needed for hydration. ENTERAL NUTRITION - TUBE FEEDINGS:

-Infants:May tolerate amino acid formulas better. Continuous feeds recommended since bolus feeds poorly tolerated. -Toddlers/children: Transition as able to hydrolyzed protein or polymeric formula.

ENTERAL NUTRITION – ORAL INTAKE

-Small, frequent, meals. Start oral intake at developmentally appropriate age to avoid oral aversion. Limit concentrated sweets, limit fruits, avoid fruit juices. -Without a colon: Usually do not benefit from fiber or MCT oil. 40-50% CHO kcals. 30-40% Fat kcals. 20-30% protein kcals.

-With some colon: Usually benefit from complex carbohydrates, fiber (water-soluble pectin or hydrolyzed guar gum), and MCT oil. Solid Organ

Pre-Transplants

CALORIES:

-Based on growth trends or EER. Weight gain if malnutrition is present. Weight loss if overweight/obese.

-Ventilated or Ventricular Assist Device (Berlin Heart) patients may have lower energy requirements compared to the EER.

-Peritoneal dialysis patients may have lower energy requirements compared to the EER related to dextrose kcal absorption from dialysis fluid.

-Biliary atresia and cholestasis patients may have increased energy requirements compared to the EER. Provide 120-200 kcal/kg/day for infants and 130-160% EER/IBW for older children.

PROTEIN:

-Heart: Use PICU Nutrition Guidelines.

-Liver: 2.5-3 gm protein/kg/day for biliary atresia and cholestasis patients. 0.5-1.5 gm protein/kg/day patients with hepatic encephalopathy.

-Kidney: Adequate protein per stage of chronic kidney disease. Refer to “Recommended Dietary Protein Intake in Children with CKD Stage 4-5 and Dialysis” table on page 3 of “Solid Organ Transplant Assessment During all Phases of Transplant Guidelines” in the Nutrition Care Manual.

FLUIDS: Determined by physician.

MICRONUTRIENT NEEDS: Assess for nutrition deficiencies via nutrition focused physical exam, lab values, etc. Review medication list for supplements and include these in assessment of intake.

Solid Organ Post-Transplants

(Acute)

-NUTRITION NEEDS:

-Use “PICU Nutrition Guidelines” in the Nutrition Care Manual for acute post-transplant needs.

-Consider nutrition modifications: May have elevated serum glucose, possible formula change at time of transplant, and route of nutrition (po vs tube feeding).

Solid Organ Post-Transplants

(Chronic Inpatient)

NUTRITION NEEDS: Refer to previous outpatient RD assessment as guide.

CALORIES: Start with age-appropriate equation. Adjust requirement to patient’s growth trends. PROTEIN: Start with age-appropriate DRI. Adjust requirement to patient’s growth trends. FLUIDS:

-Heart: Maintenance fluids per Holliday-Segar equation.

-Kidney: Increased fluid requirements to maintain perfusion of kidney, often 1-1.5x maintenance fluids per Holliday-Segar equation. This fluid goal is determined by the medical team and will be in most recent outpatient RD note.

-Liver: Maintenance fluid requirements per Holliday-Segar equation.

MICRONUTRIENT NEEDS: Start with age-appropriate DRI. Assess for nutrient deficiencies via nutrition focused physical exam, lab values, etc. Review medication list for supplements and include these in assessment of intake.

FORMULAS: Refer to page 8 of “Solid Organ Transplant Nutrition Assessment during All Phases of Transplant” in Nutrition Care Manual. Transplants

Bone Marrow

CALORIES: 1.2-1.5 x REE based on nutrition status. May need 1.75 x REE if malnourished. PROTEIN: 2x DRI.

FLUIDS: Maintenance or per medical team. May be fluid restricted. DIET ORDER: Immunosuppressed.

NUTRITION SUPPORT: As indicated by nutrition assessment. DISCHARGE EDUCATION: “Nutrition after Transplant” handout.

DJB

3/4/2020