Paediatrics: Nutritional support

Nutritional support

Nutritional support can be either enteral or parenteral. Enteral nutrition, when possible, is preferred as it is cheaper, technically less demanding, more physiological, and associated with fewer complications.

•   Involve a paediatric dietitian to assess nutritional status, requirements, and support.

•   Beware of ‘refeeding syndrome’ (potentially fatal respiratory and cardiac failure induced by electrolyte disturbance following overzealous nutritional therapy in severe malnutrition) and be prepared to use PN in severe cases.

Indications

•   Severely ill patients, e.g. ill preterm infants.

•   Nutritional supplementation is required, e.g. FTT, cystic fibrosis.

•   Swallowing difficulty, e.g. severe cerebral palsy.

•   Metabolic diseases, e.g. phenylketonuria.

•   Gastrointestinal failure, e.g. malabsorption, short bowel syndrome.

•   Other primary disease state, e.g. chronic renal failure.

Oral supplementation 

Includes high energy milks, mineral/vitamin supplementation.

Specialized foods 

Huge range of specialized milk and feeds exist for many different conditions, (modular elemental diets for IBD, hypoaller-genic milk for milk protein allergy).

Enteral tube feeding

·  Can be orogastric, NG, nasojejunal, and gastrostomy.

·  Liquid feeds are given as boluses or continuously, e.g. overnight.

•   Indications: swallowing problems (e.g. severe cerebral palsy, prematurity), cardiorespiratory compromise, GORD, anorexia, generalized debilitation, e.g. trauma.

•   Feeds: standard polymeric diets (e.g. ready to feed nutritionally complete whole protein products); elemental diets and semi-elemental diets requiring little or no digestion; or disease-specific formulations.

•   Gastrostomy reduces orofacial complications/discomfort, but complications include: Gastric leakage; localized skin infection or

•   inflammation; GI perforation/trauma/haemorrhage.

Trophic feeding

•   Synonyms: minimal enteral feeding, gut priming.

•   Indications: during PN in newborn infants, particularly if preterm.

•   Rationale: prolongation of enteral starvation leads to loss of normal GI structure and function despite PN-induced anabolic body state. Small milk volumes appear to prevent this. Also promotes GI development in newborn infants.

•   Typically 0.5–1mL/kg/h milk is fed within 2–3 days of birth.

•   Evidence of beneficial effects (in newborns) includes: fewer episodes of sepsis; fewer days of PN; improved growth; improved gut function.