Nutrition for the Pediatric Surgical

Patient
 Objectives

• Provide framework for defining appropriate

nutrition for the pediatric patient especially
in the postoperative period

• Highlight importance of assessing the

nutritional status of the postoperative child

• Discuss nutritional requirements and

nutritional therapy
 The Basics

• Nutrition essential for maintenance of

physiologic homeostasis and growth

• Nutrient requirements during childhood are

different than those of adults
– Pediatric need for growth and development
– Rapid changes occur in association with maturation of
organ systems
 The Basics

• Hypermetabolic state
– Causes include prolonged fast, acute illness, stress, or
trauma
– Leads to depletion of body stores, mainly protein reserves
– Can decrease immunocompetence and increase morbidity
and mortality
– Children in particular have limited nutritional reserves
and are quickly depleted

• Our role as providers:

– Be aware of these limits
– Constantly monitor the nutritional status of our patients
– Ensure that nutritional support is provided when necessary
 A Case Example

• A 7 yr old with h/o myelomeningocele is

being admitted after posterior spinal fusion
to correct her neuromuscular scoliosis.
She is less than 3rd percentile for height
and weight at her age, she is wheelchair
bound and she is also a picky eater.
Consider this patient as we think about
assessing nutrition and developing a
nutrition plan for post-operative patients.
 Nutrition Requirements for Surgical Patients

With the exception of those with major burns

and trauma, pediatric surgical patients do
not require more than the normal
recommended amounts of energy and
protein
 Nutrition Requirements

Infants Children Adolescents

2-12 yr

Cal/kg/day 80-100 60-80 30-40

Protein 1.2-1.8 1 0.8
gram/kg/day
 The Problem
• Healthy children need appropriate
nourishment for optimal growth

• Surgical patients need nourishment for

optimal wound healing

• Daily nutritional needs of healthy children

are best met by a balanced oral diet but this
may not be possible in post surgical patients
 Surgical Patient Populations at Increased Risk

• Neonates (especially those born prematurely)

• Patients receiving chemotherapy
• Patients with major trauma and/or burn
injuries
• Patients with IBD
• Patients with chronic renal failure
• Patients with chronic neurological disorders
• Patients with fever and/or sepsis
 Nutritional Status in the Postop Period

• Important points to consider:

– Disease process that necessitates surgical intervention will
influence decisions about nutritional approach

– Surgery provokes an increase in stress response parameters

– Acute stress response is catabolic and involves the

mobilization of substrates (protein, fat, and carbohydrates)

– Response is variable and depends on:

• Age
• Degree of organ maturity
• Underlying nutritional status
• Severity of the inciting event/ insult
ASSESSMENT OF
NUTRITIONAL STATUS
 Nutritional Assessment
• Goal: Identification of specific nutrition abnormalities
and determination of severity of malnutrition

• No one parameter can determine a patient’s nutritional

status hence must use a comprehensive approach

• Clinical assessment should include:

– Nutritional intake
– Disease process and its catabolic effect
– Current physical state of malnutrition and weight loss
– Functional status of the central nervous system
 Nutritional Assessment
• Critical components
– Growth assessment and measurement of weight,
length, head circumference
– Medical, developmental, social history
– Nutritional intake history
– History of food allergies
– Laboratory evaluation of biochemical and metabolic
changes
– Review of nutrition-focused physical examination
findings
– Educational needs and potential barriers to learning
 Nutritional Assessment: History and Physical Findings

• Presence or absence of:

– Anorexia, nausea, and vomiting
– Chronic or recent weight loss

• Evidence of malnutrition on physical exam:

– Hair loss
– Skin breakdown
– Peripheral edema
– Muscle wasting
 Markers To Assess Nutrition

• Albumin
– Classic marker to assess nutritional state
– Levels altered by
• disturbances in hepatic synthesis
• distribution in plasma space
• protein loss from vasculature
• alterations in hydration status
– Long half life (20 days) hence not a good reflection of
acute changes
– Low albumin associated with increased morbidity and
mortality rates in hospitalized children
 Markers To Assess Nutrition

• Transferrin
– Half life of ~8 days

– Body pool of transferrin smaller than albumin

• better indicator of protein depletion

– Levels affected by
• iron deficiency
• liver failure
• some antimicrobials
• fluid shifts post op
 Markers To Assess Nutrition

• Prealbumin binding protein

• Earliest laboratory indicator of nutritional status
• Preferred marker for malnutrition; correlates with patient
outcomes in a wide variety of clinical conditions
– Transport protein for thyroxine
– Short half life of 2 days, small distribution pool
– Also has large amounts of the amino acid tryptophan;
better reflects visceral protein status
 Nutritional Assessment: Does It Make A Difference?

• Undernutrition is a predictor of poor

surgical outcomes
• Studies suggest that early recognition of
protein malnutrition and initiation of
nutritional therapy can shorten the length
of hospital stays and improve patient
outcomes
 Postop Nutritional Delivery Systems

• Enteral: “If the gut works, use it”

– Ideal, allows preservation of normal intestinal function
and structure
• Maintenance of intestinal mucosal integrity and
local immunity
– Stimulation of enteric digestive enzyme synthesis
– Prevents bacterial translocation (acid is bactericidal)
– Maintains normal absorptive processes
– Cost effective
– Few infectious complications
– Multiple options for feeding routes
 Formulas
• Classified as standard, elemental or specialized
• Many available with varying amounts of protein, fat,
and carbohydrates
• Variety allows selection of an appropriate formula
for the individual patient based on:
– Formula composition
– Underlying diagnosis
– Physiology of the GI tract
• Formulas range in energy content from 0.67 cal/mL
(equal to human milk) to around 1 cal/mL
• All provide adequate protein for healing and growth
 Enteric Nutritional Support
• Complications
– Transesophageal tubes: can cause GER, which can,
in turn, lead to esophagitis, esophageal strictures,
and/or aspiration pneumonia
• Conditions that may limit enteral nutrition
– Post op ileus
– Significant loss of absorptive function
• Usually due to lactase deficiency
• Strategies for success
– Consider lactose free diet
– Slow advancement of formula concentration
– Continuous then bolus; reduction of reflux, vomiting,
aspiration
 Total Parenteral Nutrition (TPN)
–Supplies needed energy to limit the breakdown of body
fat and protein
• Prevents depletion of skeletal muscle by providing sufficient
protein to maintain the circulating amino acid pool and to
aid in tissue repair

–Indications for TPN initiation:

• Non functioning GI tract for an extended period of time (eg,
mechanical obstruction, paralytic ileus, malabsorption)
– Enteral feeds are not enough to meet nutritional demands or
intolerance of enteral feeds
– Prolonged starvation beyond 7-10 days
– Those with inadequate intestinal length
 Total Parenteral Nutrition (TPN)
• Monitoring
– Ins and Outs
– Weight measurements
– Weekly measurement of BUN, creatinine, electrolytes, triglyceride, calcium,
magnesium, and phosphate levels
– Liver function and hemoglobin, albumin, iron, and zinc levels should be periodically
checked

• Complications
– Catheter related – Infection, thrombosis
– Arrhythmia
– Pulmonary embolism
– Hyperglycemia/ Hypoglycemia
– Metabolic acidosis
– Hypertriglyceridemia
– Electrolyte disturbance
– Cholestasis
– Fatty liver
 Key Points
• Children in general have low nutritional reserves;
important to remember especially in the postoperative
population
• Stress response from surgical intervention leads to
increased catabolism and potential for increased protein
loss
• Nutritional assessment encompasses a thorough history,
physical exam and laboratory interpretation
• If the gut works, use it!
• TPN may be an option especially in children with
suboptimal nutrition over 7 days
• Use your dieticians as a resource…they are awesome
 Questions for Review

• What historical, physical and laboratory

findings should be included in a nutritional
assessment?
• List 3 groups of pediatric surgical patients
at high risk for poor post-op nutrition.
 Further Discussion

• The mother of a patient who is s/p spinal

fusion would prefer IV nutrition because
she is concerned her son will not tolerate
an NG tube. What important points would
you discuss with mom regarding your
reason for preferring enteral feeding?
 References
Falcão MC, Tannuri U. Nutrition for the pediatric surgical patient: approach in the peri-operative period. Rev Hosp Clin
Fac Med Sao Paulo. Nov-Dec 2002;57(6):299-308.

Herman R, Btaiche I, Teitelbaum DH. Nutrition support in the pediatric surgical patient. Surg Clin North Am. Jun
2011;91(3):511-41.

Mears E. Outcomes of continuous process improvement of a nutritional care program incorporating serum prealbumin
measurements. Nutrition. 1996;12:479–84.

Powell-Tuck J. Perioperative nutritional support: does it reduce hospital complications or shorten convalescence?. Gut.
Jun 2000;46(6):749-50.

Wesson, D. Nutrition in the Pediatric Surgical Patient.

http://emedicine.medscape.com/article/938975-overview#aw2aab6b3 Accessed 2/22/15