Nutrition & FluidsNutrition & Fluids

Dr. D. BarryDr. D. Barry

1) Calories1) Calories

RequirementsRequirements GrowthGrowth Type of feedingType of feeding SupplementsSupplements

Calorie Requirements Calorie Requirements for Normal Growthfor Normal Growth

AgeAge Energy Energy (kcal/kg/day)(kcal/kg/day)

ProteinProtein

(g/kg/day)(g/kg/day)

0-6 months0-6 months 100 – 120 100 – 120 2.52.5

6-12 months6-12 months 90 – 10090 – 100 2.52.5

1-2 years1-2 years 80 – 9080 – 90 2.02.0

2-13 years2-13 years 1000 + 1000 +

100 x age (yrs)100 x age (yrs)1.51.5

Post-pubertalPost-pubertal 2000–2500 2000–2500 ♀ / ♀ / ♂♂

1.01.0

Neonatal Calorie RequirementsNeonatal Calorie Requirements

Normal Weight GainNormal Weight Gain

Neonates Neonates (Birth to 3 Months)(Birth to 3 Months)

Infants Infants (3 Months to 1 Year)(3 Months to 1 Year)

Children Children (2 Years until (2 Years until Puberty)Puberty)

~30 g/day. ~30 g/day. ~200g/wk~200g/wk Regain birth Regain birth weight by 10 to weight by 10 to 14 days of life.14 days of life.

~20 g/day~20 g/day ~150g/wk~150g/wk birth wt. birth wt. doubles by 4-5 doubles by 4-5 months & triples months & triples by one year.by one year.

2 kg/year 2 kg/year

The Diet/Feeding HistoryThe Diet/Feeding History What? What? How often? How often? How much? How much? How long to feed?How long to feed? Specific feeding concerns?Specific feeding concerns?

Lactose free? Soya? Etc. Lactose free? Soya? Etc. Any additions / supplements?Any additions / supplements? Previous feeds & why changed?Previous feeds & why changed? Growth?Growth?

Normal Feeding PatternsNormal Feeding Patterns

1)1) Neonate; Breast / Formula Neonate; Breast / Formula

2)2) 4-6/12; begin introduce solids 4-6/12; begin introduce solids Important developmental milestonesImportant developmental milestones

3)3) 6/12; follow-on formula / 6/12; follow-on formula / continue breast-feedingcontinue breast-feeding

4)4) 1 year; 3 meals +/- snacks 1 year; 3 meals +/- snacks Bottle; Cow’s Milk Bottle (not until > 1 Bottle; Cow’s Milk Bottle (not until > 1

year) year)

Breast milk vs. FormulaBreast milk vs. FormulaBreast milk Formula

Convenience Always available, premixed and warmed.

May require some preparation.

Hygiene Sterile Requires clean containers and water.

Immunology Maternal IgA N/A

Bonding Maternal-Infant bonding. Also may pump.

Can bond with any appropriate care giver.

Vitamins/Minerals

Bioavailable iron.Insufficient Vitamin D.

Iron usually added.Vitamin D added.

Fat ↑ fat (50%), + Omega-3 fatty acids

Less fat than formula

Protein Lactoferrin (E. coli protective iron-binding protein) nb NEC

Whey / Caesin Follow-on; Cow protein

Special FeedsSpecial Feeds

Lactose-free Lactose-free For For lactose intolerancelactose intolerance Profuse watery diarrhoea (eg post-Profuse watery diarrhoea (eg post-

gastro)gastro) Can give SoyaCan give Soya

Hydrolysed (pre-digested protein)Hydrolysed (pre-digested protein) For allergy/intolerence to For allergy/intolerence to Cow’s milkCow’s milk

ProteinProtein Soya not recommeded as X-reactivitySoya not recommeded as X-reactivity

Nutritional SupplementsNutritional Supplements

Vitamin KVitamin K: Prevents hemorrhagic : Prevents hemorrhagic disease of the newborn. Injected into disease of the newborn. Injected into all infants at birth.all infants at birth.

Vitamin B12Vitamin B12: Only necessary for : Only necessary for exclusively breastfed babies of exclusively breastfed babies of vegan mothers.vegan mothers.

IronIron Vitamin D Vitamin D

Nutritional Supplements: Nutritional Supplements: Vitamin DVitamin D

Required to prevent ricketsRequired to prevent rickets Supplemented in all standard infant Supplemented in all standard infant

formulasformulas Not found in adequate supplies in Not found in adequate supplies in

breast milkbreast milk Consider supplementation in Consider supplementation in

exclusively breastfed infants with low exclusively breastfed infants with low sun exposure sun exposure

Nutritional Supplements: IronNutritional Supplements: Iron Prevent Iron-def. Anemia.Prevent Iron-def. Anemia. Supplemented in all standard infant Supplemented in all standard infant

formulas. (Beware the low-iron formulas. (Beware the low-iron brands!)brands!)

Good supply in breast milk – also Good supply in breast milk – also more bioavailable.more bioavailable.

NOT adequate amounts in cow’s milkNOT adequate amounts in cow’s milk

Introduction of Solid FoodsIntroduction of Solid Foods Normal, healthy infants do not require Normal, healthy infants do not require

any nutrition besides breast milk or any nutrition besides breast milk or formula until 4-6 months.formula until 4-6 months.Why not earlier?Why not earlier?

Head control lackingHead control lacking Calories sufficientCalories sufficient

Why not later?Why not later? Oral motor skills important early in Oral motor skills important early in

developmentdevelopment Protein/Iron/Zinc needs increaseProtein/Iron/Zinc needs increase Total caloric need increasesTotal caloric need increases

Introduction of Solid FoodsIntroduction of Solid Foods Weaning to solids begins with mineral Weaning to solids begins with mineral

fortified cereals (iron and zinc) and fortified cereals (iron and zinc) and advances to other foods.advances to other foods. Start with single grain cereals (rice, oatmeal, Start with single grain cereals (rice, oatmeal,

barley).barley). When starting new foods (pureed fruits, When starting new foods (pureed fruits,

vegetables or meats) offer single items vegetables or meats) offer single items sequentially to identify any food allergiessequentially to identify any food allergies

Avoid peanuts, eggs, fish or other Avoid peanuts, eggs, fish or other common allergenic foodscommon allergenic foods

Avoid Honey < 2 years; risk botulismAvoid Honey < 2 years; risk botulism

Why No Cow’s Milk Before Why No Cow’s Milk Before One Year of Age?One Year of Age?

1.1. Iron Deficiency AnemiaIron Deficiency Anemia• Low iron content of cow’s milkLow iron content of cow’s milk• Replaces other iron sources in the toddler’s Replaces other iron sources in the toddler’s

dietdiet• Possible allergic colitis – GI blood lossPossible allergic colitis – GI blood loss

2.2. Allergic PotentialAllergic Potential• Immune system less robust, higher risk of Immune system less robust, higher risk of

cow’s milk protein allergy and eczema before 1 cow’s milk protein allergy and eczema before 1 yearyear

The Child with a The Child with a Chronic DiseaseChronic Disease

Higher metabolic needs:Higher metabolic needs: Cerebral Palsy with SpasticityCerebral Palsy with Spasticity Congenital Heart DiseaseCongenital Heart Disease

Lower metabolic needs:Lower metabolic needs: HypotoniaHypotonia

Special diets:Special diets: Cystic FibrosisCystic Fibrosis Celiac Celiac DiabetesDiabetes PKUPKU

General Advise ParentsGeneral Advise Parents

< 1 food treat / week< 1 food treat / week Low-fat milk after age 2Low-fat milk after age 2 Healthy balanced diet better than Healthy balanced diet better than

supplementssupplements ExerciseExercise

2) Fluids2) Fluids

PhysiologyPhysiology RequirementsRequirements DehydrationDehydration CalculationsCalculations Methods of Methods of

ReplacementReplacement ElectrolytesElectrolytes Types of IVTypes of IV

Fluids; Basic PhysiologyFluids; Basic Physiology

Human Body is 60% WaterHuman Body is 60% Water 40% protein, minerals, fat & 40% protein, minerals, fat &

carbohydrate (little) carbohydrate (little) Term Infant 75% waterTerm Infant 75% water Premature Baby 80% waterPremature Baby 80% water

75% 75% 60% by 12 months old 60% by 12 months old

Body Composition In Children Body Composition In Children

% of total body weight% of total body weight

Total Body Water60%

Intra- cellular Fluid40%

Interstitial Fluid15%

(ECF)

Plasma5%

(ECF)

Blood volumeBlood volume

Blood volume is 8% - 10% of body weightBlood volume is 8% - 10% of body weight

2 kg newborn has 200mls of blood2 kg newborn has 200mls of blood

600g premature baby has 60mls of blood600g premature baby has 60mls of blood

10kg child has 800 10kg child has 800 1000mls of blood1000mls of blood

PhysiologyPhysiology

Children (particularly Infants) are sensitive Children (particularly Infants) are sensitive to changes in TBWto changes in TBW

Young infants have poor urine Young infants have poor urine concentrating ability therefore get concentrating ability therefore get dehydrated faster dehydrated faster

Volume of TBW can be altered by Volume of TBW can be altered by dehydration, anaemia, Heart Failure, abn dehydration, anaemia, Heart Failure, abn osmolality, hypoalbuminaemia etc.osmolality, hypoalbuminaemia etc.

More vulnerable to electrolyte imbalancesMore vulnerable to electrolyte imbalances

When Do You Need to Consider When Do You Need to Consider Administering Fluids?Administering Fluids?

NPO (eg. Pre-op, intra-op)NPO (eg. Pre-op, intra-op) Intake insufficient to replace ongoing Intake insufficient to replace ongoing

losses losses (eg. Ileostomy / severe diarrhoea / DI / (eg. Ileostomy / severe diarrhoea / DI / salt-losing crises etc.)salt-losing crises etc.)

Dehydration; mild / mod / severeDehydration; mild / mod / severe ↓ ↓ intake;intake; systemic illness / resp dx in infant systemic illness / resp dx in infant ↑ ↑ losses;losses; vomiting / diarrhoea (eg. G/E), vomiting / diarrhoea (eg. G/E),

insensible losses, shock (DD of causes)insensible losses, shock (DD of causes)

IV vs. PO fluidsIV vs. PO fluids

If tolerating PO – can give PO (or NG)If tolerating PO – can give PO (or NG) ORS / dioralyte / Water etc. ORS / dioralyte / Water etc.

Indications IVIndications IV Not tolerating adequate oral intake (eg. GE)Not tolerating adequate oral intake (eg. GE) Mod – Severe DehydrationMod – Severe Dehydration NPO (? Pre-op)NPO (? Pre-op) Burns / Post Operative / DKA etcBurns / Post Operative / DKA etc Correcting Significant Electrolyte Correcting Significant Electrolyte

abnormalitiesabnormalities

Oral FluidsOral Fluids

Oral fluids are much more Oral fluids are much more Physiological than IV FluidsPhysiological than IV Fluids

Most cases of gastroenteritis can be Most cases of gastroenteritis can be treated with Oral Fluidstreated with Oral Fluids

Depending on Clinical history, Depending on Clinical history, examination and severity of examination and severity of dehydrationdehydration

Can use PO + IV concurrentlyCan use PO + IV concurrently

IV FluidsIV Fluids

Maintenance Maintenance (calculated per weight)(calculated per weight)

Maintenance + Deficit Maintenance + Deficit (if dehydrated; as % of TBW est)(if dehydrated; as % of TBW est)

Maintenance + Replacement Maintenance + Replacement (if ongoing losses; diarrhoea / ileostomy (if ongoing losses; diarrhoea / ileostomy

etc)etc)

Check U&E for electrolyte imbalancesCheck U&E for electrolyte imbalances

Calculating Fluid RequirementsCalculating Fluid Requirements Obtain Obtain weight;weight; weigh the child or estimate weigh the child or estimate Assess Assess Hydration statusHydration status (as % TBW) (as % TBW) Assess/measure ongoing Assess/measure ongoing losseslosses Consider cause of dehydration/losses & treatConsider cause of dehydration/losses & treat

Calculate Calculate MAINTENANCEMAINTENANCE Calculate Calculate DEFICIT DEFICIT ie rehydration requiredie rehydration required Calculate Calculate REPLACEMENTS REPLACEMENTS Add up total & administer over 24 hours min. Add up total & administer over 24 hours min. Choose fluid type; ie ? Sugars ? electrolytesChoose fluid type; ie ? Sugars ? electrolytes

Estimating weightEstimating weight

Full term; 3.5kg average (2.5 - 4.5kg)Full term; 3.5kg average (2.5 - 4.5kg) By 1 year; 10 kgBy 1 year; 10 kg 1-10 years; 1-10 years;

Wt = 2 (age + 4)Wt = 2 (age + 4) [APLS guidelines][APLS guidelines]

Eg. 5 year old; est. wt = (5 + 4) x 2 = Eg. 5 year old; est. wt = (5 + 4) x 2 = 18kg18kg

Calculating Maintenance IV Fluid Calculating Maintenance IV Fluid RequirementsRequirements

0- 10 Kg; 0- 10 Kg; 100mls/Kg/day100mls/Kg/day

11 – 20 Kg; 11 – 20 Kg; (1000mls for 1(1000mls for 1stst 10kg as above) 10kg as above)

+ + 50mls/Kg/day50mls/Kg/day (for each kg (for each kg >10kg)>10kg)

> 20 Kg; > 20 Kg; (1500mls for 1(1500mls for 1stst 20kg as above) 20kg as above)

+ + 20mls/Kg/day20mls/Kg/day (for each kg >20kg)(for each kg >20kg)

E.g. 23 Kg child 1000 + 500 + 60 E.g. 23 Kg child 1000 + 500 + 60 = 1560mls/day = 1560mls/day = = 65mls / hour65mls / hour

Q.Q. Calculate maintenance for 16kg child Calculate maintenance for 16kg child

(20/12 old)…(20/12 old)…

Calculate maintenance for 38kg child Calculate maintenance for 38kg child

(11 year old)…(11 year old)…

Fluid DeficitFluid Deficit

Who has a fluid deficit;Who has a fluid deficit;

Dehydration eg Gastroenteritis / Dehydration eg Gastroenteritis / ↓ intake↓ intake BurnsBurns Post Operative Post Operative DKA DKA

Some conditions show intravascular depletion with Some conditions show intravascular depletion with oedema eg. Hypoalbuminaemia etc. oedema eg. Hypoalbuminaemia etc.

Assessing Hydration StatusAssessing Hydration StatusSignSign Mild Mild

(<5%)*(<5%)*Mod Mod (5-10%)*(5-10%)*

Severe Severe (>10%)*(>10%)*

thirstthirst ++ ++++ too too sicklysickly

Mucus Mucus membmemb

N - mildN - mild drydry Very dry Very dry

eyes/ eyes/ fontanellefontanelle

NormalNormal sunkensunken Very sunk, Very sunk, drydry

Skin Skin turgorturgor

NormalNormal reducedreduced Grey , Grey , sicksick

Output Output ¶¶ Normal Normal ↓ ↓ wet nappywet nappy OliguricOliguric

CVSCVS StableStable StableStable ↑ ↑ HR, HR, ↓BP↓BP

* % of total body weight¶; normal output; 1-2 ml / kg / hour

Emergency FluidsEmergency Fluids

IV Bolus; 10 – 20 ml / kg IV Bolus; 10 – 20 ml / kg Normal SalineNormal Saline For Mod – Severe deyhydrationFor Mod – Severe deyhydration In shock – can repeat ++In shock – can repeat ++ Resus managementResus management This is NOT rehydration fluids!This is NOT rehydration fluids!

When Stable; When Stable;

Maintenance + Deficit + ReplacementsMaintenance + Deficit + Replacements

Calculate for 24 hour period minimumCalculate for 24 hour period minimum

Calculating Rehydration FluidsCalculating Rehydration Fluids

Clinical assessment % TBW Clinical assessment % TBW 5% 5% (50ml/kg)(50ml/kg) of 23kg of 23kg (23000g)(23000g) child = 1150ml child = 1150ml 10% 10% (100ml/kg)(100ml/kg) of 23kg child = 2300ml of 23kg child = 2300ml

Replace over 24-72 hours Replace over 24-72 hours Check U&ECheck U&E Add to Maintenance Add to Maintenance (1560ml/day if 15kg child)(1560ml/day if 15kg child)

If over 48 hours; 1560 + 1560 = 3120mlIf over 48 hours; 1560 + 1560 = 3120ml + 2300ml (mod./ 10% dehydrated) + 2300ml (mod./ 10% dehydrated) = 5420ml over 48 hours = 113ml/hr x 48 hrs= 5420ml over 48 hours = 113ml/hr x 48 hrs

Which fluid to use?Which fluid to use?

Urine OutputUrine Output

Normal output 1-2ml/kg/hr minimumNormal output 1-2ml/kg/hr minimum CatheterisedCatheterised Weigh wet nappies (reliable indicator Weigh wet nappies (reliable indicator

if uncontaminated)if uncontaminated) Input/output chart, +/- daily weightsInput/output chart, +/- daily weights If reduced output – assess hydration If reduced output – assess hydration

status; clinical signs & vitals status; clinical signs & vitals ? Dehydrated ? Overloaded? Dehydrated ? Overloaded palpate bladder ? Full ? obstructionpalpate bladder ? Full ? obstruction

Q.Q. 2 year old 2 year old Poor intake Poor intake Dry MM, Eyes & Dry MM, Eyes &

fontanelle sunkenfontanelle sunken No wet nappy all No wet nappy all

day day HR 180 bts/minHR 180 bts/min Extremities coolExtremities cool

What’s est. weight?What’s est. weight? What’s % What’s %

dehydration?dehydration? Immediate Immediate

management?management? Fluid Replacement?Fluid Replacement?

IV Fluids; choicesIV Fluids; choices

ColloidsColloids Larger insoluble Larger insoluble

moleculesmolecules bloodblood a colloid a colloid AlbuminAlbumin (4.5%, 20%)(4.5%, 20%)

gelatingelatin (Gelofusine), (Gelofusine), Remain Remain intravascularintravascular for for

between 1 and 4 hours between 1 and 4 hours depending on the solution depending on the solution usedused

Treatment shock / ongoing Treatment shock / ongoing intravascular depletionintravascular depletion

CrystalloidsCrystalloids Aqueous Aqueous solutionssolutions of of

mineral salts or other mineral salts or other water-soluble water-soluble molecules.molecules.

Often close to the Often close to the concentration in the concentration in the blood (blood (isotonicisotonic)) normal normal salinesaline, 0.9%NaCl, 0.9%NaCl Hartman’s SolutionHartman’s Solution Ringer's lactateRinger's lactate (isotonic (isotonic

solution often used for solution often used for large-volume fluid large-volume fluid replacement)replacement)

IV Fluids; which to choose?IV Fluids; which to choose?

Colloids if intravascular depletions / Colloids if intravascular depletions / shock shock

Crystalloids for Maintenance fluids & Crystalloids for Maintenance fluids & Rehydrating deficits as discussed Rehydrating deficits as discussed aboveabove

Hypotonic / Isotonic / Hypertonic?Hypotonic / Isotonic / Hypertonic? Electrolyte conc; Na / KElectrolyte conc; Na / K Sugar content; dextrose ? 2.5% / 5%Sugar content; dextrose ? 2.5% / 5%

Maintenance IV Fluid Maintenance IV Fluid RequirementsRequirements

Neonates; 5 – 10% dextroseNeonates; 5 – 10% dextrose cannot tolerate fasting cannot tolerate fasting Hypoglycaemic if no sugar sourceHypoglycaemic if no sugar source

Infants <10kg; 2.5% Dex + 0.9% Infants <10kg; 2.5% Dex + 0.9% NaClNaCl

> 10 kg; Hartman’s / O.9% NaCl> 10 kg; Hartman’s / O.9% NaCl

U & EU & E

Na (135 – 145); Na (135 – 145); [requirement; 2–3 mmol/Kg/day][requirement; 2–3 mmol/Kg/day]

May be hyponatraemic (<130) or May be hyponatraemic (<130) or hypernatraemic (>150) with dehyrationhypernatraemic (>150) with dehyration

Choose replacement fluid & speed of Choose replacement fluid & speed of replacement accordinglyreplacement accordingly

K (3.5 – 5.0); K (3.5 – 5.0); [requirement; [requirement; 1–2 mmol/Kg/day]1–2 mmol/Kg/day]

Often hypokalaemic if vomiting / diarrhoeaOften hypokalaemic if vomiting / diarrhoea Add to IV fluids eg. 10mmol/1L IV fluidsAdd to IV fluids eg. 10mmol/1L IV fluids Seldom need to be added if any PO intakeSeldom need to be added if any PO intake

Hypernatraemic DehydrationHypernatraemic DehydrationSodium > 150Sodium > 150

Too Much Salt or Not enough WaterToo Much Salt or Not enough Water Intra- cellular loss greatestIntra- cellular loss greatest

Use 0.45% NaCl, Use 0.45% NaCl, Correction MUST BE SLOW; 48-72 hoursCorrection MUST BE SLOW; 48-72 hours

If Sodium falls too rapidly, it leads to re-If Sodium falls too rapidly, it leads to re-expansion of intra-cellular space too quickly expansion of intra-cellular space too quickly Odema------ Particularly of Brain cells Odema------ Particularly of Brain cells

Hyponatraemic DehydrationHyponatraemic Dehydration Sodium < 130 Sodium < 130

Sodium losses exceed water lossesSodium losses exceed water losses Fluid goes from extra Fluid goes from extra intracellular intracellular

odema odema Can cause convulsionsCan cause convulsions Use 0.9% NaClUse 0.9% NaCl Ideally replace slowly, but if seizing, Ideally replace slowly, but if seizing,

may have to do over 24hours (very may have to do over 24hours (very careful monitoring) careful monitoring)

IV fluids complicationsIV fluids complications

IV fluids are a medicationIV fluids are a medication Must be prescribed by Doctors (ie. YOU!!!)Must be prescribed by Doctors (ie. YOU!!!) Side-effects;Side-effects; Electrolyte imbalances Electrolyte imbalances Potentially letal if wrong fluid or durationPotentially letal if wrong fluid or duration

Eg cerebral oedema if correct hypernatraemic Eg cerebral oedema if correct hypernatraemic dehydration too quicklydehydration too quickly

Eg. Fatal arrhythmias with K replacementEg. Fatal arrhythmias with K replacement OverloadOverload

OverloadOverload

Oedema; sacral, scrotum, periorbital, Oedema; sacral, scrotum, periorbital,

(+/- ankle)(+/- ankle) CVS; ↑ JVP, ↑ BP, tachycardicCVS; ↑ JVP, ↑ BP, tachycardic Heart failure, Pulmonary Oedema, Heart failure, Pulmonary Oedema,

hepatomegaly, asciteshepatomegaly, ascites ↑ ↑ weightweight

Summary; FluidsSummary; Fluids

Know how to assess HydrationKnow how to assess Hydration Know to calculate maintenance & Know to calculate maintenance &

deficitdeficit Know to consider electrolytes; Know to consider electrolytes;

Na, K & Dex when administering IV +/- Na, K & Dex when administering IV +/- otherother

Know complications of IV fluidsKnow complications of IV fluids PO is best if possiblePO is best if possible

Final Q.Final Q. 4 yr old boy4 yr old boy Vomiting & Diarrhoea Vomiting & Diarrhoea

x 2/7x 2/7 Not tolerating Not tolerating

anything today; anything today; vomiting!vomiting!

Wet nappiesWet nappies Dry tongue, lipsDry tongue, lips Normal skin turgorNormal skin turgor Miserable but alertMiserable but alert HR 100 bpm, BP 90/60HR 100 bpm, BP 90/60

What do you do?What do you do?