Page 28 - 58peadiatric-surgery-speciality1-7_opt

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