NICU/ Peds Case Study

1. NICU/Peds Case Study Christine Malia Cabral and Yasuko Kato

2. 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.

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

4. Baby Girl K • 8mo 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)

5. WHO weight-for-age

6. WHO length-for-age

7. WHO head circumference

8. WHO weight-for-length

9. Diagnoses • Pierre Robin Sequence • Bilateral cleft palate • Dysphagia, aspiration • GERD

10. 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.

11. 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

12. 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

13. 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

14. 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

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

16. Outpatient RD note 4/21/14

17. 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.

18. 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/ozformula, 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

19. 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).

20. Weight-for-ageWHO Girls 0-2 years ↑

21. Length-for-ageWHO Girls 0-2 years ↑

22. Head Circumference-for-ageWHO Girls 0-2 Years ↑

23. Weight-for-lengthWHO Girls 0-2 years ↑

24. Interpretation of Growth Charts • Weight loss of 80g 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 <3rd%, but length-for-age also <3rd% • Wt-for-length ~3rd% indicates under-nutrition!

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

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

27. 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 <3rd%.

28. Weight-for-lengthWHO Girls 0-2 years • Weight: 4.82 kg • Length: 59 cm • What is BG K’s Ideal Weight?

29. Calculating Nutrition Goals 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

30. Calculating Nutrition Goals (cont) • Fluid Needs • Holiday-Segar Method (from Texas Children’s) • Ideal Weight: 5.8 kg Texas Childrens Hospital Reference Guide, p27

31. And the answers are… • Estimated Calorie needs: 422 kcal • Estimated Protein needs: 7 grams • Estimated Fluid needs: 580 mL

32. Modified Nutrition Goals • Calorie increased beyond nutrition goal d/t inadequate wt gain

33. 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 (2100-0600) • Add 4 oz of formula to bag at 9 pm • At 1 am, add another 4 oz of formula to bag

34. How to calculate cal and pro • Total 516 cal • Calculate total daily volume in ounces • 4 bolus feedings of 105mL + Overnight drip feeding 225mL • 105mL x 4 + 225mL = 645mL • 645mL ÷ 30ml = 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

35. Nutrition Interventions (cont) • Continue to educate parents about the recipe • Provide bottles with lines • Simplifying the recipe • Demonstrate mixing recipe

36. Simplified Recipe • Similac Total Comfort (24 cal) • For mixing bolus feeds • 3 level scoops (8.9g/scoop) + 5 oz water • For mixing overnight drip feeding • 6 level scoops (8.9g/scoop) + 10 oz water • Store the remaining formula in a closed container in the refrigerator for next feeding

37. 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 (2x/month) • WIC

38. 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.

39. 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

40. 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

41. 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 (p21-22) • Fluid (p27) • Catch-up Energy and Protein (p26) • Shared “R” drive

42. 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

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

44. Objectives Wt: 4.98 kg (up 1160 g in 50 days) Length: 58.0 cm

45. 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

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

47. 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

48. 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, p27

49. Answers • Energy: 520 kcal • Protein: 7.6 g/d (1.52 g/kg) • Fluid: 500 mL

50. Current feeding plan • How much energydo the current feeds provide? • Similac Total Comfort 20 cal (0.68cal/mL) • Feeding schedule: every 2-3 hours • 4 oz 6x/day (1oz = 30mL)