Dietetic Intern: Lusi M. Martin Rotation: Pediatrics

1

Children’s Hospital (Knoxville, TN) Spring 2010

Enteral Feeding Case Study 1: CK is a 2 week old term female that you have been consulted to see. Her weight is 2.5 kilograms. Her birth weight was 3.3 kilograms. Mom reports that CK was initially fed Similac with Iron for 4 days and changed due to fussiness and loose stools. Her formula progression has been: Nutramigen for 2 days, Pregestimil for 1 day, and she is now on Alimentum. Mom reports that she drinks her bottles quickly and “never seems to be full.” Her typical formula intake per day is 18 ounces. Following each bottle, CK has a bowel movement, which is loose and seedy. Mom reports that her stools now look like they have blood in them. Her intake has decreased over the last 3 days to 8 ounces per day. CK’s pediatrician admitted her to the hospital for dehydration and further evaluation. 1. Plot her birth weight and present weight. What are her energy and protein needs for catch-up to 3.8 kilograms?

IBW 3.8 kg

Birth weight 25th -50th percentile

Current weight < 3rd percentile

Catch up Growth(kcal/kg/d) 108kcal/kg x 3.8kg 2.5kg

= 164kcal/kg

Protein Requirement(g/kg/d) 2.2g/kg x 3.8kg 2.5kg

= 3.3g/kg

2. Why do you think CK now has blood in her stools? Blood in CK’s stool indicates a protein allergy. 3. What would be an appropriate formula choice for CK? Elecare (elemental formula). Easy to absorb and since there is a protein allergy, the formula is amino-acid based and will be appropriate for CK. 4. How much formula does she need to meet her energy needs? Current wt X Catch up Growth Energy Requir: 410kcals Elecare= 20kcals/fl oz.

410kcals/20 fl.oz = 20.5 ~ 21 oz

CK has changed to her new formula. The bloody stools have not been present since the change. She is not drinking her formula well. Her weight gain is slow and in a discussion with the pediatrician, you both decide to initiate 24-hour continuous drip feedings. 1. What is the goal rate to provide 100% of her catch-up needs in 24-hours? 410kcal/20fl oz.= 21 oz X 30ml/oz=630ml/24hrs= 26ml/hr 2. How would you initiate and advance her drip feedings? Initiate 1-2 ml/kg/hr Advance 1-2 ml/kg/hr until goal is met 3. CK is tolerating her formula without difficulty. She is unable to tolerate a rate above 18mL/hour. What should you do? Increase calorie in formula as follows: 410kcals/14.4oz = ~28kcals/oz 18 x 24= 432ml 30 = 14.4oz x 28kcal/oz = 410kcal Since CK has been on a 20kcal formula, initiate at 22-24kcal and increase as tolerated to goal of 28kcal/oz.