Fluid and Nutritional Imbalance in Children

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

Nutritional assessments

  • 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
  • Dyspnoea
  • Neuromuscular
  • Anorexia
  • Absorption
  • Pharmacological
  • 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

Organic causes

  • Inability feed
  • Malabsorption
  • 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:

  • Overfeeding
  • GI obstruction
  • Pyloric stenosis, duodenal or ileal atresia
  • Congenital malrotation, intussusception
  • Hirschsprung disease
  • Meconium oesophageal reflux
  • Pertussis

Key Investigations

Urea and electrolytes

  • Chloride
  • PH and Bicarbonate
  • Toxicology
  • 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

Constipation

  • 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

Organic causes

  • 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.

Non-organic causes

  • 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

Sources

Hassinger, A., & Valentine, S. (2018). 341: Intravenous Fluid Management By Pediatric Intensivists. Critical Care Medicine46(1), 153.
Medeiros, D. N. M., Ferranti, J. F., Delgado, A. F., & de Carvalho, W. B. (2015). Colloids for the initial management of severe sepsis and septic shock in pediatric patients: a systematic review. Pediatric emergency care31(11), e11-e16.
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