Pediatric Nutrition: Management of SBR, dehydration, & high ileostomy output -The influential role of a Clinical Dietitian

By Celina Chan

Dartmouth Hitchcock Medical Center- Lebanon

Founded 1893Teaching

HospitalOutpatient

visits: 645, 857Employees

6,724

Our Mission“We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.”

Dartmouth Hitchcock Medical Center- Lebanon Beds: 396 Mary Hitchcock

Memorial Hospital Geisel School of

Medicine at Dartmouth

Children’s Hospital at Dartmouth-Hitchcock (ChaD)

Norris Cotton Cancer Center

Clinical Dietitian Consults, diet

orders follow ups, NPO, etc

Diet Techs: Nissen, 2gNa, Puree, Braden, NPO, s/p CABG, etc.

Pts distributed at morning meeting according to specialty

20+ dietitians

Bump to RD level: -BMT

-All Pedi

-NPOx5

-Gestational

-HA1C 8 or higher

-BUN <2

-Renal

-CHO counting

-GI

-Tube feeds

-TPN

Outline

Pt introduction & historyDiagnosisAssessmentNutrition diagnosisIntervention (MNT)MonitoringEvaluation

Patient History-Baby JMale, Full term 38 wk Birth date: 8/25/14 --- d/c 10/9

(~6wk old)Readmitted 10/12 GastroschisisIleal AtresiaShort Bowel Resection (SBR)IleostomyDehydration

GastroschosisIntestines outside the body“vanishing” -resolved before birth

Pathogenesis & Etiology◦Abdominal wall birth defect◦CDC estimates 1,871 babies/yr ◦Abdominal wall does not form

correctly◦Intestines are outside the body (not

covered by sac). Typically to the right of the umbilical cord

◦Damage occurs from exposure to amniotic fluid (irritation, swelling, twisting, atreasia)

◦Potential for future difficulty feeding pt

Pathogenesis & Etiology cont…

◦Theories: Failure of differentiation of embryonic cells Rupture of amniotic membrane near umbilical

cord Abnormalities near umbilical cord Necrosis of cord leading to gut herniation Development failure at abdominal folds creating

improper closure

◦Many theories, but still unclear understanding of the disease

◦Risk factors: young mother, alcohol & tobacco, poor nutrition (or failure to take prenatal supplements)

Treatment Treatment

◦Surgery ◦“vanishing” – self resolves (surgery

still needed to close the abdominal wall)

◦Further complications requiring treatment may occur

Ileal AtresiaDistended loop of bowelNarrowing of the intestine

SBRSmall bowel

resectionTotal small bowel

length is 130cm- ligament of treitz to the ileocecal valve. Includes 12cm segment of terminal ileum proximal to ileocecal valve.

Ileostomy

Ileum brought up to the abdominal wall- stoma created.

Dehydration -watery stool, gassy, not taking bottle, no wet

diaper for 12 hrs, mottling, lethargy, crying, irritable, vomiting, diarrhea, decreased urine volume, pallor

Took in about 300-360mL formula at home. Parents unsure

Mom mixing wrong recipeCurrent Weight: 2.9 kg Weight at previous discharge: 3.34 kg Na: 125mmol/L (L)K: 6.8 mmol/L (H)CL: 93mmol/L (L)CO2: 10 mmol/L (L)

Nutrition ConsiderationsWeight Growth ChartElectrolytesI’s & O’s Ileostomy outputFood HistoryNeedsFormula

PES Decreased energy intake related

to inadequate oral consumption as evidenced by parent report of pts food refusal

Altered GI function related to SBR and ileostomy placement, as evidenced by increased ileostomy output of >2ml/kg/hr and a positive fecal fat test.

*this is the primary PES statement.

GoalsResolve dehydration— provide

appropriate formula and monitor intake

Stool output <50ml/kg/day or <2ml/kg/hr

Electrolytes & labs wnlWeight maintenance gain

(recommend caloric goal of 150kcal/kg)

*treated as a “functional” short gut pt

Current Diet order 10/17Gentlease 20kcal/oz ad lib Weight: 3.12 kgStool output last 24 hrs: 325ml

or, 104ml/kg/dayAvg intake: 550ml provided 372

kcal, 1.8 mEq Na/kg Na: 134mmol/l (L)K: 4.0 mmol/l

Recommendations 230ml Gentlease 20kcal/oz &

40ml Ceralyte 90 per bottle- give four bottles po ad lib

Provides: 524 kcal, 20.1 mEq Na

Ceralyte: oral rehydration Provides:◦Na 50-90mmol/L ◦K 20mmol/L

Follow up- 10/21230ml Gentlease 20kcal/oz &

40ml Ceralyte 90 per bottle- give four bottles po ad lib

Provides: 524 kcal, 20.1 mEq Na Previous weight: 3.12kg Current Weight: 3.17kg Na: 135mmol/L Stool output: 257mL =

3.3ml/kg/hr

Recommendations 10/21Switch from Gentlease to Elecare-

more elemental formula◦33%MCT, hypoallergenic

Please add Alk phos to labs Elecare provides 7.2mg zinc vs Gentlease 6.2mg If alk phos low- recommend 0.5-1mg/kg/day

elemental zinc for 14 days Intestinal losses can be up to 12 mg/L zinc

Recommend caloric goal of 150kcal/kgFollow serum Na, weights,

intake/output daily

Follow up 10/22Current Diet order: 230 ml Elecare

20kcal/oz & 40ml Ceralyte 90 per bottle daily po ad lib

Provides: 616kcal, 26.4 mEq Na

Weight: 3.17kg ~ avg week wt gain was 30g/wk)

Na: 138Stool output: 161ml = 2.1ml/kg/hr

(close to goal)Total intake: 512 kcal, 21.6meq Na

Follow up 10/23Weight: 3.2kgNa 139, K 3.7Intake past 24 hrs: 880 ml Elecare

20kcal/oz & 40ml Ceralyte 90Provided 590 kcal, 19.4mEqNa, 22.1 mEqK, Stool 123ml = 1.6ml/kg/hr (meets

goal!)

Recommendations D/c Ceralyte…try with pectin Start with 0.6ml pectin/120ml

Elecare can increase to 1.2ml/120ml if stool still has not thickened

Follow up 10/24Diet order: Infant feeding formula Ad-

lib: Elecare 20kcal/oz & 0.6ml pectin/120ml Elecare

Took in 470ml Elecare This provides 517 kcal, 12.52 meq Na

10/23 10/24

Weight 3.2kg 3.13kg

Na (mmol/L) 139 138

K (mmol/L) 3.7 4.2

Stool output 1.6ml/kg/hr 2.7ml/kg/hr

Follow up 10/27 Current diet order: Elecare

20kcal/oz + PectinOstomy output: 4.2ml/kg/hr Meeting goal with feeds

10/24 10/27

Weight 3.13kg 3.36kg

Ileostomy output

2.7ml/kg/hr 4.2ml/kg/hr

Na (mmol/L) 138 136

K (mmol/L) 4.2 5

Follow ups….Elecare + Ceralyte Positive for fecal fatMedications added: flagyl,

immodium, AquAdek

10/27 10/30 10/31

Weight 3.36kg 3.33kg 3.43kg

Recommendations Ceralyte not available at WIC and

is typically not covered by insurance. ◦Consider: Homemade cereal base

sol’n◦Recipe: 1/2c baby rice cereal, ½ tsp

table salt, 2c watergCHO/ml mEq

Na/mlmEq K/ml

Ceralyte 0.04 0.09 0.02

Homemade cereal sol’n

0.05 0.11 0.005

Plans Reinfuse stool into distal mucus

fistula so that it goes into colon

D/C Elecare 20kcal/oz ad lib + Rice Cereal

SolnWt: 3.7kgAvg daily intake: 168kcal/kg/dayDiet is meeting needs for growth

based on growth. Stool output has also decreased

Stool infusion going well-Refeeding stool with goal of whole bag TID about 30mL max over 15 min (per GI team)

“Mushy” in diaper Provided mixing as well as stool

reinfusion education to parents.

SummaryGentlease Gentlease + Ceralyte

Elecare + Ceralyte Elecare + Pectin Elecare + Rice Sol’n (to mimic ceralyte)

Flagyl, aquadek

Final Thoughts Initiation of Elecare Pectin? Complicated situation:

◦more than one solution: “many right answers, obvious wrong answers”

◦Team effort (Pedi MDs, Dietitians, GI team, pedi, etc)

References Pediatric Nutrition Care Manual Hendricks, KM, Duggan, C. Chp 36- Short Bowel Syndrome.

In Manual of pediatric nutrition. Hamilton, Ontario: BC Decker; 2005: 718-735.

https://www.childrenshospital.org/~/media/Centers%20and%20Services/Programs/A_E/Center%20for%20Advanced%20Intestinal%20Rehabilitation/Hendricks%20Ch%2036.ashx Mattei, P. Fundamentals of pediatric surgery. New York: Springer;

2011. Weaver LT, Austin S, Cole TJ. Small intestinal length: a factor

essential for gut adaptation. Gut 1991;32(11):1321-1323. Leonberg, BL. ADA pocket guide to pediatric nutrition assessment.

Chicago: American Dietetic Association; 2008. Groh-Wargo, S, Thompson, M, Cox, JH. ADA pocket guide to neonatal

nutrition. Chicago, IL: American Dietetic Association; 2009. Wong, KKY, Lan, LCL, Lin, SCL, Chan, AWS, Tam, PKH. Mucous Fistula

Refeeding in Premature Neonates With Enterostomies. Journal of Pediatric Gastroenterology and Nutrition. 2004;39(1):43-45. doi:10.1097/00005176-200407000-00009.

http://www.cdc.gov/ncbddd/birthdefects/Gastroschisis.html

References (photos) http://acareotc.caraudio.netdna-cdn.com/media/catalog/product/cache/1/ima

ge/500x500/9df78eab33525d08d6e5fb8d27136e95/4/0/404925.Jpg http://www.convatec.com/media/12324/ileostomy-copy.jpg http://www.columbusfetalmedicine.org/images/gastroschisis-1.png http://img.medscape.com/pi/emed/ckb/radiology/336139-409746-10248tn.jp

g https://www.luriechildrens.org/en-us/care-services/conditions-treatments/feta

l-intestinal-atresia/PublishingImages/LowAtresia_sm_new.gif http://fce-study.netdna-ssl.com/2/images/upload-flashcards/60/80/54/560805

4_m.jpg http://www.uofmchildrenshospital.org/fv/groups/public/documents/images/95

145.jpg http://static.abbottnutrition.com/cms-prod/abbottnutrition.com/img/06-07-20

11-01-16-05_EleCare_Infant.jpg http://g-ecx.images-amazon.com/images/G/01/hpc/detail-page/c26-B0026RH

UO4-1-l.jpg http://www.jocosarblog.org/.a/6a0105364e2a0e970b01157193be95970b-pi http://c4.diapers.com/images/products/p/ns/ns-688_1z.jpg http://www.chadkids.org/images/DHMC_location.jpg http://www.brplusa.com/images/projects/healthcare/dhmc_aerial_fs.jpg