Fluid and Nutritional imbalance in children and young people
- Children have a higher metabolism so they need more calories and fluid for growth
- The intestinal tract in children is larger per body weight compared to adults.
- Gastric acid secretion reaches adult levels by 10 years of age.
- Infants have a short oesophagus
- At three months pancreatic juice contains low levels of lipase
- Is an important part of a complete health appraisal
- Evaluates the balance between nutrient intake and expenditure
- Dietary intake, clinical examination, biochemical analysis
- Infancy- assess for time-frequency and volume
- There are numerous causes of dysphagia.
Reasons why children may not be able to meet their normal nutritional requirements.
- Impairment to the normal sucking chewing mechanism
- Refeeding syndrome
Growth and weight faltering
Non-organic causes are usually psychosocial
- Feeding problems and maternal stress and depression
- Lack of stimulation and undernutrition
- Fabricated or induced illness by cares.
- Disturbed attachment and bonding
- Anorexia and bulimia
- Inability feed
- Illness-induced anorexia
- Impaired nutrition absorption such as coeliac
Aetiologies of Fluid loss
- Diarrhoea, vomiting, haemorrhage, ostomy drainage, thermal injuries
- Diarrhoea is the most common cause of fluid loss in children followed by vomiting
- D and V is responsible for 9%of all hospital admission for children under the age of 5 years
Why do children need more water?
- High ratio of ECF to ICF
- High caloric expenditure due to high basal metabolic rate
- Large surface area due to leads to insensible water loss
- Daily water turnover 15% V 9% adults
- Immature homeostatic mechanism
Classification of dehydration
- Isotonic Dehydration: State in which the solute concertation is identical to that of the body fluids: Na between 130 and 145.
- Hypotonic dehydration: the solute concentration is below that of the normal body fluids.
- Hypertonic dehydration: The solute concertation is above that of the normal body fluids: Na >145.
Isotonic, hypertonic and hypotonic fluids
Isotonic: the same osmolarity as the serum= stays it is put and does not affect the size of the cells.
Hypertonic: higher osmolarity, fluid is pulled from the cells and the interstitial compartment into the blood vassals.
Hypotonic: lower osmolarity, fluid shifts out of the blood vassals and into the cells and into the cells and the interstitial spaces.
Types of Dehydration
Moderate dehydration 4-6%: Once their dehydration worsens, children may begin to feel tired, restless and irritable, which makes them difficult to drink water. Other signs and symptoms of mild to moderate dehydration include:
- Increased thirst
- A dry mouth and tongue
- Decreased urine output
- Minimal to no tears
- 3 to 6% weight loss (weight usually correlates to how dehydrated the child is)
- Normal increased heart rate and pulses, normal fast breathing and cool extremities
- Capillary refill greater than 2 seconds
- Sunken eyes and/fontanelle in baby)
Severe Dehydration 7-10%
- Increasing marked signs from the moderate group of signs
- Lethargic and unconscious
- Poor drinking and unable to drink
- A patched mouth and tongue
- Minimal or to no urine
- Greater than 9% weight loss
- Increased heart rate, weak pulses, deep breathing and cool and mottled extremities
- Capillary refill that is very prolonged or minimal
- Diminished skin turgor
- Deeply sunken eyes.
Priorities of management are to identify shock and treat it effectively and rapidly
Loss of electrolytes can seriously affect infants and children haemostatic systems
- Potassium affects the hearts
- Calcium affects nerve transmission
- Phosphorous affects muscle function
- Magnesium affects the metabolism of CHO
- Sodium regulates the fluid balance
- Acid-base balance considerations
Vomiting may be caused by:
- GI obstruction
- Pyloric stenosis, duodenal or ileal atresia
- Congenital malrotation, intussusception
- Hirschsprung disease
- Meconium oesophageal reflux
Urea and electrolytes
- PH and Bicarbonate
- PH monitoring and radiography study
- Presence of gastric peristalsis during feeding and presence of a pyloric tumour on palpation
- Bile-stained vomit- intestinal obstruction
- Urine for culture
ACUTE INFECTIOUS DIARRHOEA, CURRENT BEST PRACTICE
- Oral rehydration therapy – Moderate dehydration
- Intravenous Infusion therapy – Moderate dehydration, breast milk, solids
ANTIEMETICS, ANTIDIARRHOEA AGENTS AND ANTIBACTERIAL AGENTS. PREVENTION IS BETTER AND MORE COST EFFECTIVE
Fluid Replacement – Simple rules
- Replace blood with blood
- Replace plasma with colloids Resuscitate with colloids
- Replace ECF depletion with saline
- Rehydrate with dextrose
Nasogastric Tube feeding
- NGT will facilitate controlled feeding
- Prevents Iv cannulation
- Ensures accurate fluid input and output measurement
- Facilitates anti-emetic administration
Percutaneous Endoscopic Gastrotomy
- There are two types that are available: a gastrostomy tube and a tube or low-profile device
- The tube can stay in place for about three months, and the button for about six months to a one years
- Both are held in the stomach using a small balloon filled with water.
- A feeding adaptor may need to be attached to each feed depending on the type of equipment used
- Removed by deflating the balloon
- Sits at skin level
- Described as delay or difficulty in opening bowels, it is painful distressing and embarrassing
- The normal frequency of bowel motion varies from child to child, frequency alone is not a problem.
- Causes can be organic or non-organic
- Anatomic malformation: imperforate anus, anal stenosis, pelvic mass
- Metabolic and gastrointestinal: cystic fibrosis, diabetes mellitus, coeliac diseases and hypothyroidism
- Neuropathic: spinal cord problems and neurofibromatosis
- Intestinal nerve or muscle disorders: Hirschsprung’s disease, visceral myopathies
- Abnormalities of abdominal muscles: gastroschisis, Down’s syndrome
- Connective tissue disorders: systemic lupus erythematosus, scleroderma
- Drugs: opiates, phenobarbitone, anti-hypertensives, antidepressants
- Miscellaneous: lead poisoning, vitamin D overdose.
- Poor dietary management
- Developmental problems that affect toilet training
- Emotional abuse, depression and also inappropriate/punitive toilet training practices in the young child
- Familial tendencies and sedentary lifestyle