NICUPeds Case Study Christine Malia Cabral and Yasuko

NICU/Peds Case Study Christine Malia Cabral and Yasuko Kato

Learning Objectives �Identify nutritional concerns in infants with cleft palate. �Utilize growth charts for nutritional assessment of a peds pt. �Calculate calorie/protein requirements to support catch-up weight gain.

Learning Objectives (cont) �Calculate calories and protein provided by an infant formula recipe. �Describe nutritional interventions for a peds pt with a FTT diagnoses. �Identify community resources available for peds patients and their families.

Baby Girl K � 8 mo girl; born 9/28/2013 at 39 3/7 (term) �Measurements at birth ◦ Wt: 2. 84 kg (AGA) ◦ Length: 46. 7 cm (SGA) ◦ Head Circumference: 34. 4 cm (AGA)

WHO weight-for-age

WHO length-for-age

WHO head circumference

WHO weight-for-length

Diagnoses �Pierre Robin Sequence �Bilateral cleft palate �Dysphagia, aspiration �GERD

NICU Clinical Course � 27 -day stay �G-Tube placed 10/18/13 �Discharge Feeding Plan: Similac Advance, 4 bolus feedings during the day (60 ml @ 0900, 1200, 1500, 1800) and an overnight continuous feeding @ 30 ml/hr from 2000 -0600.

Pierre Robin Sequence • Congenital condition of facial anomalies • Micrognathia: Smaller than normal lower jaw • Glossoptosis: Downward displacement/retraction of tongue, may obstruct airway • Most have a Cleft Palate Complications: Breathing problems, Ear infections, and Reduced hearing, feeding problems

Cleft palate The roof of the mouth does not join together completely during pregnancy Surgical repair often occurs between 9 – 18 months Complications: Ear infections, Hearing impairment, Speech problems, Dental problems, and Feeding difficulties

Nutritional Implications � Difficulty creating the necessary suction to pull milk from the bottle or breast. � Increased feeding duration. � Possibility for “nasal regurgitation” (milk coming out of the infant’s nose during a feeding) � Missing/extra/malformed/displaced teeth and cavities � Poor growth and weight gain

Social History �Ethnicity: Hawaiian, Chinese, Japanese, Portuguese, American Indian, German � 19 y/o mother, not married �No siblings �Lives with mother & father, paternal grandparents, and paternal aunt. �Parents do not have their own means of transportation �Parents are both unemployed

Feeding Plan Changes (outpatient) � 10/28/13 Changed 20 cal → 24 cal ◦ d/t suboptimal weight gain � 11/18/13 Changed Similac Advance → Similac Total Comfort ◦ ↑whey protein ◦ ↑gastric emptying ◦ ↓reflux

Outpatient RD note 4/21/14

Outpatient Course � No show for nutrition re-assessment appointment on 4/24. � Peds RD made multiple attempts to contact parents with no response/call back. � Weights: 04/09/14 4. 905 kg 04/21/14 4. 763 kg � Pediatrician left message on 4/26 requesting weight check within 1 week, admit for FTT if insufficient weight gain. � Weight check on 4/29, pediatrician recommended direct admission for FTT.

Admit to MOA 4/29 �Admission Dx: Failure to Thrive ◦ Admission weight: 4. 82 kg ◦ Admission length: 59 cm �Diet Order: 95 ml of Similac Total Comfort 24 cal/oz formula, 7 x/d, over 45 min. ◦ Feeds are at 600, 900, 1200, 1500, 1800, 2100 and 2400 • 100% whey, partially hydrolyzed proteins • Suitable for infants with lactose sensitivity • Contains prebiotics to help promote digestive health • Available on WIC program

Interview with parents ◦ Parents admit to staying up late (until 3 or 4 am) and missing 6 am feeding. ◦ Unable to recall correct recipe and feeding plan. ◦ Requested adjusted feeding plan—want continuous feed overnight in addition to bolus feedings during the day. Don’t want 6 am feeding. ◦ Baby K is on the WIC program (later conversation w/ WIC RD reveals parents have not received formula from them since late 2013).

Weight-for-age WHO Girls 0 -2 years ↑

Length-for-age WHO Girls 0 -2 years ↑

Head Circumference-for-age WHO Girls 0 -2 Years ↑

Weight-for-length WHO Girls 0 -2 years ↑

Interpretation of Growth Charts �Weight loss of 80 g over the past 3 weeks (4/9 -4/29) ◦ Any weight loss for peds patient is not good �Length age of 3 months and weight age of 2 months �Wt-for-age <3 rd%, but length-for-age also <3 rd% �Wt-for-length ~3 rd% indicates undernutrition!

Growth Velocity Standards Appropriate growth = between 5 th and 85 th percentile � Baby K’s wt decreased 80 g in 3 weeks (6 – 7 mo) � → http: //www. who. int/childgrowth/standards/w_velocity/en/

Growth Velocity Standards � Appropriate growth = between 5 th and 85 th percentile � Baby K’s wt increased 419 g in 3 month (4 – 7 mo) → http: //www. who. int/childgrowth/standards/w_velocity/en/

Nutrition Diagnoses � Inadequate protein-energy intake related to routinely missed feedings and suspected incorrect mixing of formula as evidenced by wt loss of 80 g over the past three weeks, weight for length <3 rd%.

Weight-for-length WHO Girls 0 -2 years Weight: 4. 82 kg Length: 59 cm What is BG K’s Ideal Weight?

Calculating Nutrition Goals to support catch-up growth ◦ Ideal wt – 5. 8 kg ◦ Actual wt – 4. 82 kg • Catch up calories = EER* x Ideal wt (kg) Actual wt (kg) *EER = (89 x actual wt(kg) – 100) + 22 • Catch up protein = DRI for age (g/kg/day) x Ideal wt (kg) Table 1. 10 Texas Children’s Hospital Reference Guide

Calculating Nutrition Goals (cont) �Fluid Needs �Holiday-Segar Method (from Texas Children’s) �Ideal Weight: 5. 8 kg Texas Childrens Hospital Reference Guide, p 27

And the answers are… �Estimated Calorie needs: 422 kcal �Estimated Protein needs: 7 grams �Estimated Fluid needs: 580 m. L

Modified Nutrition Goals Diet Order PTA Energy 422 kcal 530 kcal Protein 7 grams 12 grams �Calorie increased beyond nutrition goal d/t inadequate wt gain

Nutrition Interventions �Change in feeding plan to meet parents’ schedule and capability Similac Total Comfort 24 cal ◦ 4 bolus feedings of 105 ml (900, 1200, 1500, 1800) ◦ Overnight drip feeding @ 25 ml/hr (21000600) �Add 4 oz of formula to bag at 9 pm �At 1 am, add another 4 oz of formula to bag

How to calculate cal and pro �Total 516 cal ◦ Calculate total daily volume in ounces � 4 bolus feedings of 105 m. L + Overnight drip feeding 225 m. L � 105 m. L x 4 + 225 m. L = 645 m. L � 645 m. L ÷ 30 ml = 21. 5 oz ◦ Calculate total cal � 21. 5 oz x 24 cal/oz = 516 cal/day �Protein 12 grams ◦ 2. 32 grams protein per 100 cal ◦ 5. 16 x 2. 32 = 11. 9 ≈ 12 grams

Nutrition Interventions (cont) �Continue to educate parents about the recipe ◦ Provide bottles with lines ◦ Simplifying the recipe ◦ Demonstrate mixing recipe

Simplified Recipe �Similac Total Comfort (24 cal) ◦ For mixing bolus feeds � 3 level scoops (8. 9 g/scoop) + 5 oz water ◦ For mixing overnight drip feeding � 6 level scoops (8. 9 g/scoop) + 10 oz water �Store the remaining formula in a closed container in the refrigerator for next feeding

Social Component �Collaborate with Social Worker and CCC about discharge disposition �Continue to work with community agencies ◦ H-KISS (Early Intervention Services) �Public Health RN, ST, PT, and OT (2 x/month) ◦ WIC

Monitoring/Evaluation � Inpatient ◦ Monitor weight gain (use growth charts, avg growth velocity table from Texas Children’s book) ◦ Monitor tolerance to new feeding plan ◦ Follow-up and provide additional education to parents as needed.

Monitoring/Evaluation (cont) After Discharge �Continue follow-up with Cleft Clinic �Continue follow-up with peds outpatient RD �Follow-up with home health/community agencies and pediatrician for updates

General Tips for Pediatric patients �Refer to Growth charts �Nutrition goals change with growth/ development �Refer to Texas Children’s Hospital Reference Guide for assessment �Involve caregivers as much as possible �Consider socioeconomic status and capabilities of caregivers �Know government programs available for pediatric population

Resources in peds �Growth chart in Health Connect �Growth velocity standards ◦ http: //www. who. int/childgrowth/standards/w_velocity/en/ �Texas Children’s Hospital Reference Guide ◦ EER and Protein (p 21 -22) ◦ Fluid (p 27) ◦ Catch-up Energy and Protein (p 26) �Shared “R” drive

Practice 1: S. G. �S. G. is a 3 month female with cleft of soft palate. PMHx includes bilateral pna, hypoxia and FTT, admitted when she was 23 days old. �PO via Haberman feeder (a special nipple for cleft palate) �Supplement: ◦ 0. 5 ml(7. 5 mg) iron and trivisol

Family’s concerns �BM is hard, and S. G. has a hard time pushing it out

Objectives Wt: 4. 98 kg (up 1160 g in 50 days) Length: 58. 0 cm

Interpretation of growth �Growth chart in Health Connect ◦ Is her growth curve following the reference line? ◦ % of current measurements �Wt �Length �Wt-for-length �Growth velocity standards ◦ Average wt gain ____g/day

Answers �Wt: �Length: �Wt-for-length: above 10 th% approaching to 25 th% �Average wt gain: 23 g/day

Calculating Nutrition Goals with new measurement �EER = (89 x wt(kg) – 100) +175 ◦ Wt: 4. 98 kg �Protein = “DRI g/kg/day” x wt Table 1. 10 Texas Children’s Hospital Reference Guide

Calculating Nutrition Goals with new measurement (cont) �Fluid Needs �Holliday-Segar Method (from Texas Children’s Hospital Reference Guide) �Weight: 4. 98 kg Texas Children’s Hospital Reference Guide, p 27

Answers �Energy: 520 kcal �Protein: 7. 6 g/d (1. 52 g/kg) �Fluid: 500 m. L

Current feeding plan �How much energy do the current feeds provide? ◦ Similac Total Comfort 20 cal (0. 68 cal/m. L) ◦ Feeding schedule: every 2 -3 hours � 4 oz 6 x/day (1 oz = 30 m. L)

Current feeding plan (cont) �How much protein and fluid do the current feeds provide? ◦ Protein � 20 cal: 0. 0157 gram protein/m. L ◦ Fluid �ml/kg/d

Answers �Energy: 490 �Protein: 11 �Fluid: cal g 145 m. L/kg/d

Revising the feeding plan Are these intakes appropriate? What changes to the current feeding plan would you recommend? How would you address a concern about BM?

Practice 2: M. A. �M. A. is a 4 1/2 month female with multiple congenital anomalies and complex medical hx including diaphragmatic hernia s/p repair, rectovaginal fistula, imperforate anus, cleft of hard and soft palete �G-tube placed d/t aspiration

Family’s concerns �M. A. seems be hungry with current feeding plan �Family would like to decrease the length of daytime feeds

Objectives Wt: 5. 455 kg (up 740 g in 35 days) Length: 60. 7 cm

Interpretation of growth �Growth chart in Health Connect ◦ Is her growth curve following the reference line? ◦ % of current measurements �Wt �Length �Wt-for-length �Growth velocity standards ◦ Average wt gain ____g/day

Answers �Wt: Above 5 th% �Length: Above 10 th% �Wt-for-length: Above 10 th% �Average wt gain: 21 g/day

Calculating Nutrition Goals with new measurement �EER = (89 x wt(kg) – 100) +56 ◦ Wt: 5. 455 kg �Protein = “DRI g/kg/day” x wt Table 1. 10 Texas Children’s Hospital Reference Guide

Calculating Nutrition Goals with new measurement (cont) �Fluid Needs �Holiday-Segar Method (from Texas Children’s Hospital Reference Guide) �Weight: 5. 46 kg Texas Childrens Hospital Reference Guide, p 27

Answers �Energy: 440 kcal �Protein: 8. 3 g/d (1. 52 g/kg) �Fluid: 550 m. L

Current feeding plan �How much energy do the current feeds provide? �M. A. is exclusively on G-tube feeding of Good Start Soothe 22 cal (0. 74 cal/m. L) ◦ Daytime feeds � 75 ml x 5 feeds during day ◦ Overnight drip feed � 270 ml

Current feeding plan (cont) �How much protein and fluid do the current feeds provide? ◦ Protein � 22 cal: 0. 0163 gram protein/m. L ◦ Fluid �ml/kg/d

Answers �Energy: 477 cal �Protein: 10. 5 g �Fluid: 118 m. L/kg/d

Revising the feeding plan Are these intakes appropriate? What changes to the current feeding plan would you recommend? How would you address a concern about satiety?