1. NUTRITION SUPPORT IN THE PAEDIATRIC SURGICAL PATIENT
Dr. Mariama Mustapha
SHO III- Paediatrics and Child Health
Makerere University
Mwanamugimu Nutrition Unit, Mulago Hospital

2. Outline Introduction/Background
Conditions seen in MNU needing Surgical Interventions
Nutritional Rehabilitation in MNU
Role of the Paediatric Surgeons and Paediatricians
Conclusion

3. Introduction/Background
The WHO defines malnutrition as “the imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions”.
It is estimated that 34 million children under the age of 5 each year are affected by severe acute malnutrition (SAM).
UNICEF 2012
So just think about it in terms of the economic concepts of demand and supply..
SAM, a condition associated with significant increased risks of mortality and morbidity. Approximately 35% deaths in children under 5 are due to nutrition-related factors, 4.4% have been specifically attributable to severe wasting. Bachou et al, 2006 found a mortality of 24% among children admitted to Mwana mugimu nutrition unit, Mulago Hospital.

4. Background: Uganda DHS 2011
So just imagine what this means for our children in Ug.

5. Background
Work by Cooper and colleagues showed that 18% to 40% of paediatric surgical patients have malnutrition.
Paediatric surgical patients respond to surgical stress differently from older children or adults.
The metabolism of children is markedly affected by operative stress.
Herman R et al, 2011.
These rates are comparable to rates which have been reported in paediatric surgical pts ranging from 18-40%. But there is limited information worldwide and in Uganda about maln rates in these pts.
As well as anesthesia and other factors.
They can have increased energy expenditure.

6. Conditions seen in MNU needing Surgical Interventions
Cerebral Palsy
Congenital Heart Diseases
Massive Pleural Effusion/Empyema
Cleft Lip/Palate
Burns
Unfortunately, I do not have numbers or percentages of children we see in MNU requiring surgical interventions. These however include but are not limited to:
CP: Can suffer from oropharyngeal/esophageal dysphagia, as well as GI conds such as GERD, dysmotility, dumping syndrome, malrotation, diarrhoea, constipation. Pediatric surgeons are often responsible for providing nutritional access in some of these patients as well as for maintaining nutritional care before and after surgery, as well as correct som of their deformities.
CHDs: Infants have feeding difficulties due to dyspnea, increased fatigability, and secretion of anorexic hormones that limit the volume of feedings. (loss of lean body mass (cachexia). Cachexia is a state of catabolic/anabolic imbalance leading to weight loss and disordered homeostasis and involves inflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) and interleukins, as well as neurohormonal activation).
Massive pleural effusion/empyema: Secondary to infections common in malnourished children as a result of immune suppression.
Cleft Lip/Palate: with resultant feeding difficulties
Burns: Malnutrition occurs frequently among pediatric burn patients with delayed admissions, as open wounds rapidly stimulate muscle catabolism and systemic inflammation. Adequate surgical care, infection control, and nutrition are required for wound healing.

7. Conditions seen in MNU needing Surgical Interventions
Hydrocephalus
Pyloric Stenosis
Hirschsprung’s Disease
Oesophageal Stricture
Hydrocephalus: from whatever cause with feeding difficulties and vomiting 2o to raised ICP, infections etc
Pyloric stenosis: presenting with vomiting following feeding and hence severe dehydration with chronic malnutrition
HD and other causes of intestinal obstruction: presenting with vomiting and feeding difficulties
OS: 2o to ingestion of corrosive substances, presenting with subsequent feeding difficulties

8. Summary of Nutritional Assessment and Classification
Nutritional assessment is a critical aspect of the initial evaluation of all surgical patients.
The objective portion of the assessment begins with the basic anthropometric measurements of height, weight, and head circumference. Measurements are placed on a standardized growth curve, such as that of the National Center for Health Statistics, from which the expected weight for height indexes can be calculated. Because length and head circumference are less affected than weight by excess fat or postoperative fluid fluctuations, length is an excellent indicator of long-term body growth. Acute changes in nutritional status have a more immediate effect on body weight, whereas chronic undernutrition results in a lag in both height and weight. These changes in growth are probably best expressed using a z score for weight-to-length ratio as well as weight, length, and head circumference for age. Once patients are over 2 years of age, weight-to-length ratio can best be reflected by a child’s body mass index (BMI), and expression of BMI as a z score can often add a useful perspective. Special growth charts are also available for monitoring the growth of children with special health care needs (eg, Down syndrome, Prader-Willi syndrome, myelomeningocele, achondroplasia, and cerebral palsy). Use of these
charts can give an important perspective as to where a child’s growth should lie.

9. Nutritional Rehabilitation: Outpatient Therapeutic Care (OTC)
Admission Criteria
Children with SAM who have appetite, are clinically well and alert and have oedema grade +/++
For MAM with HIV or TB
Transfers in
Relapse or readmission
Children in MNU with SAM can be managed as either inpatients or outpatients based on certain criteria.
Transfers in from inpatient care or the community
Special considerations

10. Nutritional Rehabilitation: OTC
Dietary Therapy
Ready-to-Use Therapeutic Food (RUTF):
Contains 500 kcal per 92g
Need calculated based on kcal/kg/day
Breastfeeding on demand.
Adequate safe drinking water while on RUTF.
RUTF is energy and nutrient dense pre-packed paste specially designed for the treatment of acute malnutrition. RUTF provides approximately 500 kcal per 92g and the ration given to a client is based on the need for an intake of between 175 to 200 kcal/kg/day and is calculated based on the weight of the client.
For children who are still breastfeeding, their mothers are counselled and supported to continue to breastfeed on demand while on treatment. Children are also given safe drinking water after feeding with RUTF in order to keep them hydrated.
1. Measles vaccination if not yet received & is between 9-59/12 at admission.
2. BS/MPs + antimalarials if +ve as per National guidelines
3. Oral antibiotics especially – Amoxyl
4. Iron & Folic acid from day 14 if there are signs of anaemia. Not given with SP(antifolate)
5. Mebendazole/albendazole at 2nd visit ie 1-2yrs-250mg/200mg; ˃2yrs – 500mg/ 400mg

11. Nutritional Rehabilitation: Inpatient Therapeutic Care (ITC)
Admission Criteria
Children with Severe Acute Malnutrition with:
Medical complications
Severe 0edema (+++)
Poor appetite
IMCI danger signs

12. Nutritional Rehabilitation: ITC
Dietary Therapy
F-75
F-100
RUTF
SDTM
Isomil
Components, when used, advs.
F-75: is the "starter" formula used during initial management of malnutrition in the stabilization phase. Contains 75 kcal and 0.9g of protein /100mls. Because at this initial stage, we don’t want to overwhelm the body’s systems leading to refeeding syndrome and its numerous complications.
Once children are stabilized, have appetite and reduced oedema and are therefore ready to move into the rehabilitation phase, they are transitioned from F-75 to RUTF over 2-3days ...or in some cases F-100 containing more calories and protein (100kcal and 2.9g protein in 100mls)
SDTM: Diluted (by 30%) F-100 used in the mx of infants <6months with SAM. But ofcoz feeding approaches in infants <6months with SAM prioritizes establishing or re-establishing effective exclusive BF by the mother sometimes using supplementary suckling techniques.
Isomil: Soy-based formula that is lactose free, used in children with lactose intolerance/malabsorption which can be secondary to lactase deficiency following injury to small bowel mucosa as a result of infectious gastroenteritis.
Isomil is a soy-based product which contains corn syrup solids and sucrose as carbohydrate sources. They are indicated to manage galactosemia and primary or secondary lactase deficiency. Shld not b used in patients with documented allergy or intolerance to milk protein.

13. Preoperative Nutrition
In malnourished adults, provision of enteral feedings
preoperatively for 2 to 3 weeks may reduce:
Postop wound infections
Anastomotic leakage
Hepatic and renal failure
Length of hospital stay
Data for PN support are less clear!
Herman R et al, 2011
Enteral nutrition (EN) includes oral nutritional supplementation and tube feedings. EN should be the primary source of nutrients if the gastrointestinal tract is functional. Even when full feedings are not tolerated enterally, the provision of small volumes of trophic feedings may prevent further deterioration of intestinal function. Children receiving gastric feedings tolerate a higher osmolarity and volume than those being fed into the small bowel. Furthermore, gastric acid may benefit digestion, has a bactericidal effect, and is associated with less-frequent gastrointestinal complications. For patients requiring feedings for more than 8 weeks, a more permanent feeding access (eg, gastrostomy tube) should be considered.
PN: A metaanalysis demonstrated little benefit and possibly an increase in complications in mildly or moderately malnourished patients. Hence, if necessary, shld b used only in patients with severe malnutrition.
106 The most significant benefit has been documented in severely malnourished patients who have developed fewer noninfectious complications if receiving perioperative PN (PN presurgery for 7 to 15 days and postsurgery for 3 days).107 PN patients were noted, however, to have increased infection rates, which could not totally be explained by the use of central venous catheters. This suggests that the use of PN may predispose patients to increased infectious complications.
Thus, unless there are clear indications of severe malnutrition, a delay in operative management to provide preoperative PN is not indicated.3 An extrapolation of these findings to neonatal patients is difficult because of their limited nutritional stores.

14. Postoperative Nutrition
When used, postop nutrition should be started early using a combination of PN and EN until the GIT fully recovers.
In the postop period, there are higher infection rates in patients on PN.
Postop PN should be restricted to:
Infants who do not tolerate enteral feedings.
Older children who probably cannot tolerate EN for at least 5 to 7 days.
Herman R et al, 2011
Use of aggressive postoperative nutritional support is even more controversial.
Bullet 1: In critically ill adult patients, early EN within 24 to 48 hours of admission to an ICU has been shown to reduce infectious complications.108,109 Gastrointestinal complications and feeding intolerance, however, can be a considerable limitation to the adequate delivery of enteral nutrition..These data suggest that...
The gastrointestinal tract generally tolerates feedings well once the postoperative ileus has resolved, but it is not without complications. Not uncommonly, critically ill children sustain a loss of a significant portion of the absorptive function, often due to a lactase deficiency. Symptoms are generally manifested by cramping, diarrhea, or emesis. Symptoms often improve with the initiation of a lactose-free diet. In critically ill children, frequent interruptions of enteral feeding for procedures, feeding intolerances, fluid restriction, or gastrointestinal dysmotility result in suboptimal EN delivery.41,42 The gastrointestinal tract generally tolerates increased volume more readily than increased osmolarity. Rapid-bolus nasogastric feedings may lead to a high incidence of reflux, which can be associated with aspiration, a major known risk of enteral feedings. Complications can be decreased with the use of a slow, continuous infusion or preferably with jejunal feedings, a now controversial method.43 Use of small bowel feeding has been shown to improve energy and nutrition delivery in children.44 In stable patients, continuous infusion through a nasogastric tube is associated with no higher incidence of aspiration than is infusion through a nasoduodenal tube, even in those with delayed gastric emptying.45 When a patient’s clinical condition allows, raising the backrest or the head of the bed to 30 to 45 during continuous feeding also decreases the risk of aspiration. Assessment of adequate absorption can be performed most readily by the testing of the stool for the absorption of carbohydrates, by measuring stool pH, and by detecting for reducing substances.
Neonates, particularly those with ostomies, may have high stool output, which is associated with excessive losses of zinc, magnesium, sodium, bicarbonate, and potassium.124 These losses must be monitored. Total body sodium depletion has been shown to be associated with FTT, despite the administration of adequate amounts of calories.125 A simple way to detect such a deficit is to measure a spot urine sodium. A urine sodium of less than 10 mEq/L may indicate total body sodium depletion and supplementation (sodium chloride or sodium bicarbonate, as indicated) should be given on a daily basis.126 Stool or ostomy volume should be 45 mL/kg per day, and a major obstacle to advancing feeds may be high stool output. The cause of this high output may include infections, malabsorption, or rapid transit as well as bile acid irritation of the colonic epithelium.
Bullet 2: PN is ideal for maintaining nutrition in infants and children who are unable to tolerate enteral feedings. Clinical conditions in children likely requiring PN include gastrointestinal disorders (short bowel syndrome, malabsorption, intractable diarrhea, bowel obstruction, protracted vomiting, inflammatory bowel disease, and enterocutaneous fistulas), congenital anomalies (gastroschisis, bowel atresia, volvulus, and meconium ileus), radiation therapy to the gastrointestinal tract, chemotherapy resulting in gastrointestinal dysfunction, and severe respiratory distress syndrome in premature infants.
Very-low-birth-weight infants are generally intolerant of enteral feeding and require PN during the first 24 hours after birth. Signs of starvation may be seen in underfed premature infants in as few as 1 to 2 days.
The effect of PN on postoperative healing has been negligible.. Meta-analysis studies show that there is an adverse effect to postoperative PN.106
Complications of PN can be metabolic(hyperglcaemia, hypog, hypertri, metabolic acidosis, metabolic bone disease), respiratory, hepatobiliary(cholestasis, steatosis, and cholelithiasis), and infectious(catheter-realted infections with sepsis).
Bullet 3: Critically ill infants: Energy and nutrient deficiencies occur rapidly in a pediatric ICU, and this highlights the need for aggressive nutritional support. (High lipid infusion may also have benefit in neonates and results in achieving significantly higher energy delivery, and a reduction in need for insulin therapy; other potential benefits include a reduced rate of retinopathy of prematurity and NEC.115 A 3-fold reduction in NEC can also be seen in neonates receiving human milk.116 This somewhat aggressive nutritional support must be balanced with recent data that suggest physicians overestimate energy needs in critically ill children and support more accurate measurements of these needs, including the use of indirect calorimetry.117 Recent
data have supported the use of tight glucose control in an ICU setting, which has been shown to improve short-term outcomes.99 Such support must be performed carefully, because up to 25% of children developed hypoglycemia. Recent guidelines should be used when caring for this complex group of children)
In well-nourished adolescents, this period of time can be increased to 7 to 10 days.
Nutritional care of critically ill or septic postoperative patients represents a much greater challenge than the general pediatric surgical patient. Almost one-third of an infant’s energy needs is provided to support growth (30 to 35 kcal/kg/d). Because a cessation of growth occurs during periods of sepsis and critical illness, a marked decrease in energy needs may ensue. In a study of critically ill postoperative infants, the mean measured basal energy expenditure was only 43 kcal/kg per day.17 Results are extraordinarily variable, however, further emphasizing the utility of performing indirect calorimetry.
But note that PNsolution should be not be used to manage acute fluid and electrolyte losses!!

15. How Can We Work Together?
Role of the Paediatric Surgeons?
Identify patients needing nutritional interventions
Consult/Refer
Role of the Paediatricians?
Identify patients needing surgical interventions
So the very good question we must now ask ourselves is how can we work together as Paediatricians and Paediatric Surgeons, to provide adequate nutritional support to our patients?
On the part of the paed surgeons, there is need to...
We need to come up with an efficient system of working together for the good of our patients...who are only just children!

16. Conclusion
Maintaining adequate nutrition of paediatric surgical patients is critical.
Close follow-up is critical to maintain a child on target for growth objectives.
Paediatric Surgeons and Paediatricians need to work together to provide optimal nutrition support to paediatric surgical patients.
Nutrition in paed surgical pts critical: Not only to aid in healing, but also to continue normal growth and development.
It is also very critical to follow them up closely to make sure they are on target.
Finally, we all need to work together to provide optimal nutrition support to these children, as well as follow up their growth and development...

17. THANK YOU!!