Recently at our hospital nutrition support colloquium, there was an update on eating disorders and optimal management.
This lecture and slides are available at the Pediatric Nutritionist Website: Eating Disorders Nutrition Support Lecture
2015 N2U Syllabus & Presentations
Growth Failure, Macro- and Micronutrients, and Biliary Atresia James Heubi (Syllabus pg 62 –68)
Case in Point: AK is a 5-month-old Hispanic male with biliary atresia s/p hepatoportoenterostomy at age 6 weeks who was seen in clinic with a 2 month history of poor nutritional intake (full details on syllabus pg 62).
- Increasing caloric density 24 cal with MCT-containing formula, then up to 30 cal (avoid monotherapy with portagen due to EFA deficiency); if not effective, then nocturnal tube feedings (NG/NJ) are likely to be needed. Parenteral supplementation –not being used at Cincinnati in pretransplant patients.
- Ascites, when present, limits fluid volume intakes. Aldactone (often at about 3 mg/kg/day) can be helpful; check to make sure urine sodium indicates some natriuresis.
- Fat soluble vitamin supplementation/micronutrient supplementation (when needed). Check levels at about 3 months of age. If Vitamin D (25-OH) is greater than 20 (in pediatrics), this is probably reasonable in this population. With Alagille/hyperlipidemic patients, need to correct vitamin E for cholesterol (or total lipid) (Sokol RJ, Heubi JE, et al. NEJM 1984; 310: 1209-12).
- For biliary atresia, direct bilirubin >2 indicates need for fat soluble monitoring; in other cholestatic conditions (eg. Alagille, PFIC), don’t rely on direct bilirubin as fat soluble deficiency can develop with lower direct bilirubins.
- Vitamin D supplementation: 1000 units/kg/day Drisdol D3 (expensive). D3 preferred but D2 usually OK. Monitor levels and increase dosing if needed. Check monthly until adequate level. Alternatives: Bio-D-Mulsion Forte (D3) http://www.bioticsresearch.com/node/1570, Nature’s Blend Ultra Strength (D3). http://www.nationalvitamin.com
- Vitamin E supplementation: Liqui-E (w TPGS) or Nutr-E-sol 15-25 IU/kg/day. Alternative: Aqua-E
- Vitamin A supplementation/monitoring: AquaADEKs is reasonable supplement. Harder to monitor vitamin A levels.
- If failed Kasai, likely headed to transplantation fairly quickly.
Kwashiokor –Rob Shulman (Syllabus pgs 21-33)
Case in point: 15 mo –Fed a diet of coconut and rice milks managed by pediatrician and chiropractor. (This can occur with BRAT diets as well.)
- Terminology: from language spoken in a region of Ghana. Term developed to describe the sickness a baby gets when the new baby comes. This is a result of child who gets displaced from breastfeeding as the result of a sibling being born. Willaims CD. Lancet 1935; 226: 1151-52. Original description
- Etiology: protein deficiency, protein quality, infection (‘pushes them over the edge’)
- Microbiome in Kwashiokor References: Tilg et al. Nature Rev. 2013;10:261-262. Smith et al. Science. 2013;339:548-554. Initial study showed discrepant microbiome in identical twins with and without Kwashiokor. Followup study by placing stool (from Kwashiokor and from healthy children) in mice. Stool from twin with Kwashiokor resulted in mice malnutrition (Garrett W. NEJM 2013; 368: 1746-47). (Related blogs:Gut microbiomes of Malawian twin pairs discordant for … and Microbiome and the risk of Kwashiokor | gutsandgrowth )
Feeding plan/ Prevention of Refeeding Syndrome:
- Check labs –including protime, zinc, phosphorus, potassium, magnesium
- Oral feedings with standard formulas/diet (usually). Limit feeding volumes initially for 1st week Kwashiokor (page 37 in syllabus) –about ½ full caloric intake (consider ½ strength formula).
- ‘Advancing diet slowly is not needed with other forms of malnutrition.’
- Give multivitamin. In 3rd world, it is recommended to add additional vitamin A (200,000 units once).
- Hold off on iron (even in multivitamin) until improved for a few weeks.
- Albumin infusions are not recommended àassociated with worse outcomes
- Refeeding syndrome is an iatrogenic disease! This is associated with Kwashiokor and not with other malnutrition diseases.
- Add Kphos to feedings (eg Neutraphos, NeutraphosK). Usually drop in phosphorus drop most likely in first 48 hours –monitor carefully in first few days and again during increments in feeding.
- In 3rd World countries, addition of antibiotics (amoxicillin or cefdinir for 7 d) to therapeutic regimens for uncomplicated severe acute malnutrition associated with a significant improvement in recovery and mortality rates. In U.S. this translates to low threshold for using antibiotics but not required in every case.
Disclaimer: This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.
These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Subway Mosaic Art (Chicago)
Refeeding syndrome (RFS) is defined as the potentially fatal shifts in fluid and electrolytes that may occur in malnourished patients who are abruptly refed either enterally or parenterally. The biochemical hallmark is hypophosphatemia. Other changes can include hypokalemia, hypomagnesemia, and thiamin deficiency. RFS can worsen the prognosis of children with celiac crisis as well (JPGN 2012; 54: 522-5).
A chart review from Lucknow, India from Jan-Dec 2010, identified 5 cases of RFS among 35 celiac patients. All were severely malnourished. All had anemia, hypoalbuminemia, hypophosphatemia, hypokalemia, and hypomagnesemia. All improved with initial caloric restriction followed by gradual escalation of caloric intake along with electrolyte supplementation.
This article shows that a variety of causes of malnutrition can lead to refeeding syndrome. Considering refeeding syndrome in any severely malnourished child may help improve the prognosis by altering the nutritional management.
- Nutr Clin Pract 2012; 27: 34-40. Reviewed refeeding syndrome publications since 2000. Hypophosphatemia occurred in 96% of cases (26 of 27).
- Crit Care Med 2010; 14: R172-R178. Refeeding syndrome with anorexia.
- Nutrition 2010; 26: 156-67. Review of refeeding syndrome treatment.
- Nutr Clin Pract 2008; 23: 166-71. Death due to refeeding syndrome.
- JPEN 1990: 14.1; 90-97. Refeeding syndrome review.
- Crit Care Med 1990; 18: 1030-1033. Review.