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picture1_Enteral Nutrition Pdf 134826 | 20180050 Nutricia Infographic Aw Hr Final


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File: Enteral Nutrition Pdf 134826 | 20180050 Nutricia Infographic Aw Hr Final
conclusion how to manage gastroenterological and nutritional evaluation and management should be enteral tube feeding is recommended in cases of nutritional problems in children with performed by a mdt unsafe ...

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                                                                           CONCLUSION                                                                                                    How to Manage Gastroenterological and  
                  •	Nutritional	evaluation	and	management	should be	 •	Enteral	tube	feeding	is	recommended	in	cases	of	                                                                  Nutritional Problems in Children with  
                     performed	by	a	MDT                                                        unsafe	or	inefficient	oral	feeding,	preferably	before	                                    Neurological Impairment
                  •	Accurate	nutritional	assessments	should	be	carried	                        the development	of	undernutrition
                     out to monitor nutritional status                                      •	Follow-up	anthropometry	is	important	and	                                                  A short guide based on the 2017 European Society for Paediatric Gastroenterology, 
                  • Oral feeding is the preferred option in children                           micronutrient	markers	should	be	checked	annually                                          Hepatology and Nutrition (ESPGHAN) Consensus Guidelines
                     with	NI	if	it	is	nutritionally	sufficient,	safe,	stress- •	Parents	and/or	caregivers	should	be	involved	in	
                     free and feeding time is not prolonged                                    decision	making,	especially	around	gastrostomy	                                           THE NEED FOR THE ESPGHAN CONSENSUS 
                                                                                               feeding
                                                                                                                                                                                         Children with neurological impairment (NI) frequently have feeding and swallowing problems which can 
                                                                                                                                                                                         be associated with undernutrition, growth failure, micro-nutrient deficiencies, osteopenia, and nutritional 
                                            Multidisciplinary nutritional assessment of the neurologically impaired child:                                                               comorbidities.
                                            •  weight, length, triceps skinfold                                                                                                          Prior to this ESPGHAN consensus, there was a lack of systematic approach to the care of children with NI.
                                            •  dietary history (e.g., meal duration)
                                            •  evaluation of oral motor function                                                                                                           ASSESSING NUTRITIONAL STATUS 
                                                                                                                                                                                         A multidisciplinary team (MDT) is recommended to perform nutritional evaluation and management. An ideal MDT 
                                Adequate nutrition                                                                          Inadequate nutrition                                         includes a physician, dietitian, nurse, speech therapist, physical therapist, psychologist, and occupational therapist.
                                                                                                                        Safe                    Unsafe                                   HOW TO ASSESS NUTRITIONAL STATUS
                            Safe                   Unsafe*                                                                                                                               Routine nutritional assessments by MDT
                                                                                                                  Optimize intake
                  Systematic re-evaluation            Ensure consistency, 
                   (yearly or on indication)              positioning                                          Inadequate nutrition
                                                                                                                                                                                               Weight and height                    Knee height or tibial                Measurement of fat mass                  Anthropometry should  
                                                                                                                                                                                          measurements should not                      length should be                     by skinfold thickness                be checked at least every  
                                                                                                                    Tube feeding                                                               be solely relied on                measured to assess linear                  should be a routine                           6 months
                                                             Unsafe                                             (supplementary vs.                                                                                                   growth when height                       component of the 
                                                                                                                     exclusive)                                                                                                      cannot be measured                    nutritional assessment 
                                                                                                                       GORD                                                              Laboratory assessments
                                                                                                                                                                                         • Assess micronutrient status (e.g., vitamin D, iron status, calcium, phosphorus) as part of nutritional assessment
                                                                                                           No                         Yes                                                • Micronutrients should be checked annually
                                                                                 Gastrostomy                       Controlled                    Not controlled                          HOW TO IDENTIFY UNDERNUTRITION
                                                                                                                    (PPI, diet)                     (PPI, diet)                          Undernutrition should be assessed based on the interpretation of anthropometric data.
                                                                                                                                                                                         Standard growth charts are not helpful as growth patterns vary from the general pediatric population. 
                                                                                                                           •  Gastrostomy with fundoplication                            Cerebral palsy specific growth charts may not be recommended to identify undernutrition.
                                                                                                                           • Jejunostomy
               FIGURE 1. *Unsafe swallow is defined as occurring in a child who has both a history of aspiration pneumonia (antibiotics                                                     RED FLAG WARNING SIGNS TO IDENTIFY UNDERNUTRITION:
               or hospital admission for chest infection) and objective evidence of aspiration or penetration on contrast video fluoroscopy. 
               GORD: gastroesophageal reflux; PPI: proton pump inhibitor.                                                                                                                   • Physical signs of undernutrition such as decubitus skin problems and poor peripheral circulation
                                                                                                                                                                                            • Weight for age z score <-2
                                                                                                                                                                                            • Triceps skinfold thickness <10th centile for age and sex
               Reference                                                                                                                                       Disclaimer                   • Mid-upper arm fat or muscle area <10th percentile
               Romano C et al. European Society for Paediatric Gastroenterology, Hepatology   This guide has been reproduced for Healthcare professional use only from the ESPGHAN          • Faltering weight and/or failure to thrive
               and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and      Consensus Guidelines for the Evaluation and Treatment of Gastrointestinal and 
               Nutritional Complications in Children with Neurological Impairment. Journal of   Nutritional Complications in Children with Neurological Impairment. The development 
               Pediatric Gastroenterology and Nutrition 2017; 65: 242–264                                               was supported by Nutricia Advanced Medical Nutrition.
             NUTRITIONAL REQUIREMENTS                                                                                                       DIETETIC MANAGEMENT AND MONITORING
                                                                                                                                          WHICH TYPE OF DIET?
                                Requirements                                               How to assess requirements
                                                                                                                                            1st choice:                                             Consider switching to enteral tube 
                                • Energy requirements are diffi cult to defi ne in           • Energy needs can be                                                                                    feeding if:
                                  children with NI                                           estimated using Dietary                        • Oral feeding is preferred in all children when it 
                                • Energy requirements must be individualised to take         Reference Intake (DRI) for                       is nutritionally suffi cient, safe, stress-free, and  • Severe OPD (dysphagia, unsafe swallow) has 
                                  into account mobility, muscle tone, activity level,        basal energy expenditure for                     feeding time is not prolonged                           associated repeated pulmonary aspirations, 
                                  altered metabolism, and growth                             normally developing children                   • Follow-up period of 1–3 months when trialling           pneumonias, dehydration, and/or life-threatening 
                                • Immobile patients dependent on a wheelchair                                                                 oral feeding, but more frequently in infants            events
                 Energy                                                                                                                       and severely malnourished patients
                                  require only 60–70% of the energy of typically                                                                                                                    • Total oral feeding time exceeds 3 hours per day 
                                  developing children                                                                                                                                               • Where inadequate oral intake manifests as insuffi cient 
                                • Children with NI who can walk or have athetosis                                                                                                                     weight gain or a decrease in height velocity
                                  have higher energy requirements
                                • Problems with protein intake may arise when calorie      • Dietary reference intakes                    • Ethical consideration:
                                  needs are low                                              (DRIs) can be used, as                         Parents and/or caregivers should always be involved in decision making including about gastrostomy feeding
                                • Only use supplementary protein in specifi c clinical       protein requirements are 
                 Protein          situations, such as decubitus ulcers, or in children       similar to healthy children                  ENTERAL FEEDING – WHICH TYPE OF ENTERAL PRODUCT?
                                  with low energy requirements                                                                             Children <1 year old:                       Human milk, standard infant milk formula or nutrient dense formula 
                                • High risk of dehydration caused by inability to          • Monitor hydration                                                                         (1.0 kcal/mL) if clinically indicated
                                  communicate thirst, drooling or unsafe swallowing          status closely                                Children >1 year old:                       Standard (1.0 kcal/mL) polymeric age-appropriate 
                  Fluid         • Excessive salivary secretion is a clinical symptom of                                                                                                formula including fi ber
                                  children with NI                                                                                         Children with increased energy              High-energy density formula (1.5 kcal/mL) containing fi ber. 
                                • Micronutrient defi ciency is common, particularly         • DRI for micronutrients in                     requirements or poor volume tolerance:      Must monitor hydration carefully
                                  where nutritional supplements are not being received       typically developing children                 Children with low energy needs:             Low-fat, low-calorie (0.75 kcal/mL), high fi ber and 
                                • Children who are tube-fed may develop nutritional          can be used to estimate the                                                               micronutrient-replete formula
             Micronutrients       defi ciencies as nutritional formulas provide adequate      appropriate micronutrient 
                                  micronutrients only when suffi cient volumes are            intake for children with NI                   Children with GORD or                       Whey-based formula
                                  consumed                                                 • Vitamin D supplements                         gagging and retching:
                                                                                             may be required
                                                                                                                                                 CAUTION: There are nutritional adequacy and safety concerns around pureed food for enteral tube feeding
             GASTROINTESTINAL  ISSUES
                                                                                                                                                                                      BOLUS OR CONTINUOUS?
                                                                                                                                                                                      Consider using a combination of nocturnal 
           OROPHARYNGEAL DYSFUNCTION                                                GASTROESOPHAGEAL REFLUX                                                                           continuous feeds with day time bolus 
           (OPD) >90% PREVALENCE                                                    DISEASE (GORD) 70% INCIDENCE                                                                      feeds in children with high-caloric needs 
           • Feeding history taken from early infancy                               • Consider modifying enteral nutrition                                                            or poor tolerance to volume
             and direct visual assessment of feeding                                  (thickening of liquid enteral formulas) 
             by appropriately trained professionals                                   and the use of whey-based formulas as 
             is recommended                                                           options for the management of GORD
           • Consider OPD in all patients even with 
             no obvious clinical signs or symptoms
           • OPD is a risk factor for undernutrition                                CONSTIPATION                                                    WHICH TYPE OF TUBE?
           • Growth and nutritional status should                                   • Consider increasing fl uid and fi ber                         Consider using a gastrostomy to provide intragastric access for
             be monitored regularly                                                   intake in addition to other therapeutic                       long-term tube feeding
                                                                                      options for constipation                                      Consider using jejunal feeding in cases of aspiration due to GORD, 
                                                                                                                                                    refractory vomiting, retching and bloating
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...Conclusion how to manage gastroenterological and nutritional evaluation management should be enteral tube feeding is recommended in cases of problems children with performed by a mdt unsafe or inefficient oral preferably before neurological impairment accurate assessments carried the development undernutrition out monitor status follow up anthropometry important short guide based on european society for paediatric gastroenterology preferred option micronutrient markers checked annually hepatology nutrition espghan consensus guidelines ni if it nutritionally sufficient safe stress parents caregivers involved free time not prolonged decision making especially around gastrostomy need frequently have swallowing which can associated growth failure micro nutrient deficiencies osteopenia multidisciplinary assessment neurologically impaired child comorbidities weight length triceps skinfold prior this there was lack systematic approach care dietary history e g meal duration motor function asse...

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