A. Initial Management. Evaluate height, weight, weight-for-height, vital signs, and signs of dehydration. If patient is dehydrated or severely malnourished, hospital admission may be advisable. Goals of nutrition support must be delineated. Calculate child's energy needs. Can patient be enterally fed? If so, with what solids or formula products, and by which route?

B. Enteral Nutrition. Can be delivered by mouth; nasogastric, naso-duodenal, or nasojejunal tube; or gastric or jejunal tube.

1. Infant formulas (Table I-16). Typically provide 20 kcal/oz, mimicking breast milk. Most infants tolerate either cow's milk-based or soy-based formulas. There are hypoallergenic products in which the proteins have been broken down into peptides (Nutramigen, Pregestimil, Alimentum). Children with severe allergies may require products with free amino acids (Neocate, Elecare). Many specialized products for metabolic


Estimated Kcal Needs

Patient Considerations

REE x 1.0-1.1

Well-nourished child, or child who Is sedated on ventilator; ECMO;

minimal stress

REE x 1.3

Well-nourished child with decreased activity or minor surgery

REE x 1.5

Ambulatory child with mild-to-moderate stress; inactive child with

sepsis, cancer, trauma, or extensive surgery; minimally active child

with malnutrition and catch-up growth needs

REE x 1.7

Active child with catch-up growth requirement; active child with

severe stress

ECMO = extracorporeal membrane oxygenation.

ECMO = extracorporeal membrane oxygenation.





Medium-Chain Triglycerides

Enfamil Similac

Isomil ProSobee



Alimentum Pregestimil

Yes Yes

No No

No No

Whey Casein

Soy Soy

Amino acid hydrolysate (AAH) AAH AAH

No No

No No

Yes Yes diseases are also available. Children with fat malabsorption (cystic fibrosis or cholestatic liver disease) should be given formulas with a high percentage of fat as medium-chain triglycerides (Pregestimil, Alimentum).

2. Formulas for children older than 1 year. Primarily provide 30 kcal/oz; designed as a meal replacement and available as low-osmolality, low-lactose products. Hypoallergenic formulas contain either peptides or free amino acids. Many formulas have modified fat, protein, or carbohydrate content targeting special disease states. Properties such as the osmolality of the product will affect its tolerance and rate of delivery. Hypoallergenic products are often unpalatable and may require tube feeding. Generally the more specialized the product, the higher is the cost. C. Parenteral Nutrition Support. May be necessary if oral or enteral feeding is not feasible or tolerated.

1. Peripheral intravenous nutrition. Limited by osmolality of solution. In general, do not give > 10% dextrose solution with 2% amino acids. Higher concentrations cause frequent infiltration of IV fluid. Lipid solutions are well tolerated in peripheral IV lines and may significantly increase delivered kilocalories.

2. Central line parenteral nutrition. Should be written by a trained health care provider for safety and optimization of nutrient content. Complications include infection, hyperglycemia, and long-term issues such as hepatic steatosis and cirrhosis.

VI. Problem Case Diagnosis. The 1-year-old patient had celiac disease, diagnosed by serum antibody panel and duodenal biopsies. Growth failure after introduction to solid foods is a classic sign of either celiac disease or food allergy. Patient's growth improved with removal of the offending protein (gluten).

VII. Teaching Pearl: Question. Why can electrolyte imbalances occur when refeeding a severely malnourished child?

VIII. Teaching Pearl: Answer. Watch for refeeding syndrome when repleting a malnourished child. Severely malnourished children should be fed approximately 50% of estimated kilocalorie needs, and advanced slowly over several days with daily monitoring of serum electrolytes, especially potassium, phosphorus, calcium, and magnesium, to avoid cardiac instability.

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