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CHAPTER 6

                                 Nutritional Support



                                                      Afua A.J. Hesse
                                                       Jane P. Balint





                            Introduction                       Table 6.1: Caloric recommendations for children.
        Nutritional support is indicated in paediatric surgical patients for a variety   Age  Caloric recommendations
        of reasons. Invariably, it is indicated for patients who, for one reason or
        another,  are  unable  to  get  enough  calories  to  meet  the  requirements  for   2–3 years  1000–1400 calories
        daily function and to maintain lean body mass. Preoperatively, most of our   4–8 years  1400–1600 calories
        patients in Ghana are frankly malnourished or very close to this, which
        has implications for postoperative outcomes, resulting in varying degrees   9–13 years  girls: 1600–2000 calories
                                                                           boys: 1800–2200 calories
        of poor wound healing. A 2006 World Bank report on nutrition suggests
        that 24% of children in Africa are underweight and 35% are stunted.  This   14–18 years  girls: 2000 calories
                                                       1
                                                                           boys: 2200–2400 calories
        situation puts those children who then go on to develop problems requiring
        surgery at a distinct disadvantage in relation to their peers in developed
        countries. Surgical site infections of varying degrees or wound dehiscence   Table 6.2: Protein requirements.
        are common manifestations of this poor nutrition.       Age                    Protein requirement
           Patients  undergoing  surgery  who  are  at  risk  for  long  periods  of
        ileus postoperatively will require careful planning for nutritional support.   Low birth weight neonate  3.5–4 gm/kg per day
        Patients with high metabolic requirements postoperatively will also require   Infant  2.5 gm/kg per day
        nutritional support. If surgery is elective, it is better to improve on nutritional
        status preoperatively. This is the best opportunity to maximise postoperative   2- to 13-year-old child  1.5–2 gm/kg per day
        outcomes. If surgery is emergent, then supplemental nutrition should be   Adolescents   1–1.5 gm/kg per day
        offered as soon as possible following surgery. Oral and enteral feeding is
        always preferred, offering fewer complications than parenteral nutrition. In
        our environment, and for most centres, full parenteral nutrition is not always   Table 6.3: Trace minerals requirements.
        available, and other options must be explored.          Trace mineral   Recommended requirements
                     Nutritional Support Needs                  Zinc            100 μg/kg*
        Preoperatively, oral and enteral feeding are the best ways to provide needed   Copper  20 μg/kg
        calories.  The  advantages  of  oral  and  enteral  feeding  include  promoting   Chromium  0.14–0.2 μg/kg
        the natural flora of the intestine, maintaining the integrity of the intestinal   Manganese  2-10 μg/kg
                                                      2
        mucosa, and preventing the translocation of bacteria from the gut.  These
        feedings can promote immune function. If the intestinal tract is functional, a   *There may be increased needs with diarrhoea or losses via an ostomy.
        large amount of calories can be given by the oral or enteral route. Evidence   Source: Adapted from Skipper A. Dietitian’s Handbook of Enteral and Parenteral Nutrition, 2nd
                                                               ed. Aspen Publishers, 1998, Pp 80–108.
        shows that adequate nutrition can be provided, even to patients with short
        gut who have only 2 feet of viable bowel, in the absence of parenteral nutri-
        tion, by overnight tube feeding with a slow infusion, which also serves to   Table 6.4: Fluid guidelines.
                                   3,4
        correct fluid and electrolyte imbalance.  In addition to resulting in fewer   Weight of patient  Basic amount  Additions
        complications, enteral feeding is also lower in cost than parenteral feeding. 5  <10 kg  100 ml/kg per 24 hours
           Generally, in the first year of life, caloric requirements are estimated
        at 90–150 kcal/kg, gradually decreasing to 40–60 kcal/kg by adolescence.   11–20 kg  1,000ml  50 ml/kg for each kg >10
           The Institute of Medicine (IOM) recommendations for children in the                    kg per 24 hours
        United States are shown in Table 6.1. There are no comparative figures   21–40 kg  1,500ml  20 ml for each kg >20 kg
        currently available for African children.                                                 per 24 hours
           If  parenteral  nutrition  is  necessary,  the  general  guidelines  for  the   >40 kg  1,500ml/m2 per 24 hours
        distribution  of  calories  (although  these  are  fairly  broad)  are  specifically:   Source: Adapted from Kerner JA. ,  Manual of Pediatric Nutrition. John Wiley & Sons, 1983.
        not more than 50% of the calories as fat (usually 20–40%), 40–60% of the
        calories as carbohydrate (specifically dextrose), and 10–20% of the calories
        as protein. Protein requirements vary by age, as seen in Table 6.2.  Pathophysiology of Malnutrition
                                                           6
           The daily trace metals requirements for children are given in Table 6.3.    Paediatric  surgical  patients  who  require  nutritional  support  include
        In addition, selenium at 2 μg/kg per day and vitamins should be added   those who normally would fall within the 50th centile on their weight
        to the parenteral nutrition. Fluid and electrolyte needs will vary with the   charts but who, for one reason or another, have not been able to feed
        patient’s underlying condition and losses, and will need to be monitored for   orally  for  more  than  5  days;  those  who,  as  a  result  of  their  surgical
        adequacy of supplementation. Routine fluid requirements in children are   problems, have a poor absorptive capacity; those who have high nutri-
        given in Table 6.4.                                    ent losses, such as would occur with small bowel enterostomies and
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