BNF for Children 2011-2012

BNFC 2011–2012 9.5 Minerals 471dren over 6 years; the intake of electrolytes, vitaminsand minerals should be carefully assessed and modifiedto meet nutritional requirements. These feeds have ahigh osmolality when given at the recommended concentrationand therefore need gradual and careful introduction.Modular feeds. Modular feeds (see Specialised Formulasfor Specific Clinical Conditions, p. 768) are based onindividual protein, fat, carbohydrate, vitamin and mineralcomponents or modules which can be combined tomeet the specific needs of a child. Modular feeds areused when nutritionally complete specialised formulaare not tolerated, or if the fluid and nutrient requirementschange e.g. in gastro-intestinal, renal or liverdisease. The main advantage of modular feeds is theirflexibility; disadvantages include their complexity andpreparation difficulties. Modular feeds should not beused without the supervision of a paediatric dietician.Specialised formula. Highly specialised formulas aredesigned to meet the specific requirements in variousclinical conditions such as renal and liver diseases.When using these formulas, both the biochemical statusof the child and their growth parameters need to bemonitored.Feed thickeners Carob based thickeners (Appendix2, p. 777) may be used to thicken feeds for infants under1 year with significant gastro-oesophageal reflux.Breast-fed infants can be given the thickener mixed toa paste with water or breast-milk prior to feeds.Pre-thickened formula Milk-protein- or casein-dominantinfant formula, which contains small quantities ofpre-gelatinized starch, is recommended primarily forinfants with mild gastro-oesophageal reflux. Pre-thickenedformula is prepared in the same way as normalinfant formula and flows through a standard teat. Thefeeds do not thicken on standing but thicken in thestomach when exposed to acid pH.Starched based thickeners can be used to thickenliquids and feeds for children over 1 year of age withdysphagia.Dietary supplements for oral use (Appendix 2,p. 756) Three types of prescribable fortified dietarysupplements are available: fortified milk and non-milktasting (juice-style) drinks, and fortified milk-basedsemi-solid preparations. The recommended daily quantityis age-dependent. The following is a useful guide: 1–2 years, 200 kcal (840 kJ); 3–5 years, 400 kcal (1680 kJ);6–11 years, 600 kcal (2520 kJ); and over 12 years,800 kcal (3360 kJ). Supplements containing 1.5 kcal/mL are high in protein and should not be used forchildren under 3 years of age. Many supplements arehigh in sugar or maltodextrin; care should be taken toprevent prolonged contact with teeth. Ideally supplementsshould be administered after meals or at bedtimeso as not to affect appetite.Products for metabolic diseases There is a largerange of disease-specific infant formulas and aminoacid-based supplements available for use in childrenwith metabolic diseases (see under specific metabolicdiseases, Appendix 2, p. 781). Some of these formulasare nutritionally incomplete and supplementation withvitamins and other nutrients may be necessary. Many ofthe product names are similar; to prevent metaboliccomplications in children who cannot tolerate specificamino acids it is important to ensure the correct supplementis supplied.Preparations (Borderline substances) See Appendix2.9.5 Minerals9.5.1 Calcium and magnesium9.5.2 Phosphorus9.5.3 Fluoride9.5.4 ZincSee section 9.1.1 for iron salts.9.5.1 Calcium and magnesium9.5.1.1 Calcium supplements9.5.1.2 Hypercalcaemia and hypercalciuria9.5.1.3 Magnesium9.5.1.1 Calcium supplementsCalcium supplements are usually only required wheredietary calcium intake is deficient. This dietary requirementvaries with age and is relatively greater in childhood,pregnancy, and lactation, due to an increaseddemand. Hypocalcaemia may be caused by vitamin Ddeficiency (section 9.6.4), impaired metabolism, a failureof secretion (hypoparathyroidism), or resistance toparathyroid hormone (pseudohypoparathyroidism).Mild asymptomatic hypocalcaemia may be managedwith oral calcium supplements. Severe symptomatichypocalcaemia requires an intravenous infusion of calciumgluconate 10% over 5 to 10 minutes, repeating thedose if symptoms persist; in exceptional cases it may benecessary to maintain a continuous calcium infusionover a day or more. Calcium chloride injection is alsoavailable, but is more irritant; care should be taken toprevent extravasation.For the role of calcium gluconate in temporarily reducingthe toxic effects of hyperkalaemia, see p. 458.Persistent hypocalcaemia requires oral calcium supplementsand either a vitamin D analogue (alfacalcidol orcalcitriol) for hypoparathyroidism and pseudohypoparathyroidismor natural vitamin D (calciferol) if due tovitamin D deficiency (section 9.6.4). It is important tomonitor plasma and urinary calcium during long-termmaintenance therapy.Neonates Hypocalcaemia is common in the first fewdays of life, particularly following birth asphyxia orrespiratory distress. Late onset at 4–10 days after birthmay be secondary to vitamin D deficiency, hypoparathyroidismor hypomagnesaemia and may be associatedwith seizures.9 Nutrition and blood