Prep 2012 Pediatrics

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Peds Prep questions 2012
   2012 PREP SA ON CD-ROM Copyright © 2012 American Academy of Pediatrics Question 1 You are caring for a 2-month-old infant who has hypoplastic left heart syndrome. He weighed 2,800 g at term birth. The baby has undergone the first stage of the multistage corrective surgical procedure. His medications include digoxin and furosemide to ameliorate congestive heart failure. He visited his cardiologist last week, where his weight was 3,250 g, and no changes in medication dosages were recommended. At the time of his office visit today, his parents report that the baby is taking 60 mL of a 24 kcal/30 mL cow milk protein-based formula every 4 hours, but he seems to tire easily. He spits up formula once or twice after each feeding. His weight today is 3,300 g. Of the following, the MOST appropriate recommendation for feeding this infant is A. an every-2-hours feeding schedule B. an amino acid-based formula C. formula thickened with rice cereal D. medium-chain triglyceride supplements E. nasogastric feedings   2012 PREP SA ON CD-ROM Copyright © 2012 American Academy of Pediatrics Critique 1 Preferred Response: E Disturbances in growth and weight gain are common in infants who have congenital heart disease and congestive heart failure (CHF). Clearly, the most effective preventive measure for such nutritional complications is total surgical correction of the cardiac lesion. When that option is not feasible, adjunctive therapy must be directed at providing sufficient energy intake to assure a relatively normal growth rate, including incremental calorie supplementation to respond to increased metabolic demand and to achieve catch-up growth, if necessary. Studies have indicated that infants who have CHF and growth failure require 140 to 150 kcal/kg per day to achieve these objectives. The weight gain for the infant described in the vignette has been poor (about 7 g/day in the past week), and his total daily energy intake is approximately 250 kcal/day or less than 80 kcal/kg per day. The most effective method of dietary management to achieve the targeted intake needed is nasogastric feedings. Although various formulas (including amino acid-based preparations) and energy supplementation (rice cereal, medium-chain triglycerides, glucose polymers) may be used, evidence suggests that the necessary energy intake goal cannot be achieved with oral feedings, either alone or in combination with nighttime enteral nutrition. More frequent feedings will not aid in achieving the goal. Energy requirements are highly variable in healthy children and are influenced by basal metabolism, growth rate, physical activity, sex, body size, and developmental stage. Numerous methodologies have been proposed to determine total energy requirements for infants, children, and adolescents. Several recently developed equations for estimating energy needs from birth through adolescence are offered by Glassman and Kleinman (see references). However, these guidelines do not account for special situations in which energy needs may increase because of a chronic illness, such as cystic fibrosis, or decrease because of reduced activity, such as for the child who has cerebral palsy and severe motor impairment. As demonstrated by this infant, energy requirements may vary widely from established norms, not only because of increased energy expenditure related to CHF, but also because of the need to achieve catch-up growth in infants who have long-standing undernutrition for the malnourished child. Estimates of energy intake necessary to achieve catch-up growth alone may be calculated as follows, using the National Center for Health Statistics weight for height data: kcal/kg/day = RDA for weight age (kcal/kg) x target weight for height actual weight where the weight age represents the age at which the child’s current weight would be at the 50th percentile and the target weight for height is the median weight for the patient’s height. In many cases, catch-up growth alone demands an energy intake totaling 120% to 125% of the age-related recommended daily allowance (RDA). Increased needs related to clinical disease states must be added to this estimate. Enteral nutrition may be defined as the provision of liquid nutrition that involves complex, partially hydrolyzed, or elemental diets, generally via a nasally or percutaneously placed feeding tube. Enteral feedings are an essential component of care for patients who are unable to satisfy their nutritional requirements through regular oral feedings and may be warranted under the following clinical conditions: ã  Increased energy expenditure (“hypermetabolism”) ã  Oral-motor dysfunction ã  Esophageal and gastric dysmotility ã  Compromised intestinal function (maldigestion, malabsorption) ã  Neurologic impairment  As shown in Item C1, enteral feedings are employed in a wide variety of clinical disease states to achieve targeted nutrient intake. For conditions in which oral feedings cannot maintain nutritional adequacy, enteral alimentation should be considered as either supportive or primary therapy for patients retaining either partial or complete gastrointestinal function. American Board of Pediatrics Content Specification(s):   !  Know the caloric requirements for infants, children, and adolescents !  Understand the indications for providing enteral nutritional support   2012 PREP SA ON CD-ROM Copyright © 2012 American Academy of Pediatrics Suggested Reading:  Glassman MS, Woolf PK, Schwarz SM. Nutritional considerations in children with congenital heart disease . In: Baker SB, Baker RD, Davis A, eds. Pediatric Enteral Nutrition . New York, NY: Chapman & Hall; 1994: 340-350 Kleinman RE. Cardiac disease. In: Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American  Academy of Pediatrics; 2009:981-1000 Leitch CA. Growth, nutrition and energy expenditure in pediatric heart failure. Progr Pediatr Cardiol.  2000;11:195-202. DOI: 10.1016/S1058-9813(00)00050-3. Abstract available at: Schwarz SM, Gewitz MH, See CC, et al. Enteral nutrition in infants with congenital heart disease and growth failure. Pediatrics.  1990;86:368-373. Available at: Schwarz SM. Feeding disorders in children with developmental disabilities. Infants & Young Children.  2003;16:317-330. Abstract available at: Serrano M-S, Mannick EM. Consultation with the specialist: enteral nutrition. Pedatr Rev. 2003;24:417-423. DOI: 10.1542/pir.24-12-417. Available at:   2012 PREP SA ON CD-ROM Copyright © 2011 American Academy of Pediatrics Critique 1 Item C1 . Conditions in Which Enteral Feedings May Be Indicated !  Prematurity !  Congestive heart failure !  Chronic pulmonary disease !  Cystic fibrosis !  Short bowel syndrome !  Inflammatory bowel disease !  Dysphagia !  Gastroesophageal reflux !  Protracted diarrhea of infancy !  Burn injury !  Severe head trauma !  Cancer !  Cerebral palsy !  Renal disease !  Chronic liver disease !  Inadequate spontaneous oral intake  Adapted from Kleinman RE, ed. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009
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