Nutrition Interventions for Children with Special Health Care Needs

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Appendix N Modular Products Modular formulas or products are not nutritionally complete. They contain specific nutrients, which can be added to commercial or home-prepared formulas. Examples of modular products include the following: • Fats, used for additional energy; medium-chain triglycerides are fats that do not require bile acids and lipase for digestion and absorption. If the child can digest fats, a simple vegetable oil can be used. • Readily-digested carbohydrates used for additional energy • Protein and specific amino acid preparations to increase protein intake Careful monitoring of modulars is important to insure that all nutrient needs are being met and that the formula is tolerated with the additions. See Appendix S for examples of modular products. Specialized Formulas Specialized formulas are available for children with specific needs, such as prematurity, renal failure or inborn errors of metabolism. A physician or RD who is familiar with the products and their particular uses should select the formula. Additional formula thoughts The more viscous a formula, the slower it will flow through the tube. This may make it more difficult to gravity feed/bolus feed some formula, so parents may add water to “thin” the formula so it will flow faster. Another alternative would be to use an enteral pump for bolus feeds. Formula that is cold is also more viscous and may cause stomach distress. When instructing parents on formula use written recipes are very helpful along with making sure parents have appropriate measuring utensils. For example, a soup spoon does not equal a teaspoon. Have the parents demonstrate how they mix the formula. Often what is assumed is being delivered to the child is very different from what is actually given. Cleanliness is very important in preventing bacterial contamination and formula tolerance. Multiple episodes of diarrhea may be bacterial contamination and not viral illness or formula intolerance. Hang times for sterile formula are 8-12 hours with aseptic handling. If you are using powdered formula, the hang time is 4 hours. Please check with the formula company regarding hang time. The American Dietetic Association has published Infant Feeding Guidelines (11). 356 Nutrition Interventions for Children With Special Health Care Needs
Administration of Feeding Formula delivery will depend on tolerance, volume requirements/limits, safety, and the family’s home schedule. What works for a hospital setting may not fit into the child’s home, school, therapy, and/or daycare schedule. Compliance often relies on making enteral feeding simple for the family. Appendix N Children beginning tube feedings may be started on full strength isotonic formulas, given in small volumes (see recommended rate below). Hypertonic formulas should be started at half strength. Some children who have not had oral or tube feedings for a long period of time or have a history of formula intolerance (such as premature infants or children with short gut syndrome) may require half-strength formula initially, with gradual increases to full strength. In general, if a child needs diluted formula, it is best to increase volume to make sure the child meets fluid needs; then gradually increase concentration. Concentration and volume should not be increased at the same time. Frequent adjustments may be necessary as the child adjusts and as the family schedule changes. Suggested schedule to initiate enteral feedings (3,4): • Infants 10 ml/hour • Child 1-5 years 20 ml/hour • Child 5-10 years 30 ml/hour • Child >10 years 50 ml/hour Advance the delivery rate as tolerated to meet the goal for the child’s nutrition needs. Increase volume every 4-12 hours, monitoring carefully for tolerance. Tolerance is defined as absence of diarrhea, abdominal distension, vomiting or gagging. If a child is bolus fed, start feeds at 25% of goal volume increasing as tolerated. The physician may require that residuals be checked when a tube feeding is initiated or when formula or medications are changed. To check residuals, attach syringe to feeding tube and “pull back” stomach contents. If residuals are greater than 25-50% of previous bolus feeding or 2 times the hourly volume for continuous drip feeding, reduce the feeding to the previous volume and advance at a slower rate. Return residual contents to the stomach. Monitoring Monitoring home enteral for children varies greatly. Often enteral supplies and formula are delivered to the home, which may be the only contact between a child, Nutrition Interventions for Children With Special Health Care Needs 357
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Nutrition Interventions for Childre
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Kay Kopp, OTR/L Occupational Therap
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Appendices Appendix A Sample Screen
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ii Nutrition Interventions for Chil
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Population “Children with special
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vi Nutrition Interventions for Chil
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Chapter 1 - Nutrition Screening and
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Chapter 2 - Anthropometricss needs,
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Chapter 2 - Anthropometricss Statur
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Chapter 2 - Anthropometricss Techni
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Chapter 2 - Anthropometricss paraly
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Chapter 2 - Anthropometricss time a
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Chapter 2 - Anthropometricss measur
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Chapter 2 - Anthropometricss Mild m
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Chapter 2 - Anthropometricss 9. Re-
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Chapter 2 - Anthropometricss 5. Per
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Chapter 2 - Anthropometrics Table 2
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Chapter 2 - Anthropometricss Refere
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Chapter 2 - Anthropometricss 26. Kr
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Chapter 3 - Physical Activity for C
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Chapter 4 - Breastfeeding recommend
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Chapter 4 - Breastfeeding Table 4-1
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Chapter 4 - Breastfeeding Assessmen
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Chapter 4 - Breastfeeding 58 Nutrit
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Chapter 5 - Medication-Nutrient Int
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Chapter 6 - Nutrition Interventions
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Chapter 8 - Oral-Motor Feeding Prob
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Chapter 9 - Behavior Issues Related
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Chapter 10 - Enteral Feeding Other
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Chapter 10 - Enteral Feeding Table
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Chapter 10 - Enteral Feeding Table
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Chapter 10 - Enteral Feeding Refere
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Chapter 11 - Community Monitoring o
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Chapter 12 - Accommodating Special
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Chapter 13 - Nutrition Intervention
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Chapter 22 - Ketogenic Diet for Sei
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Appendix A Please list any other nu
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Appendix A Baby formula What kind o
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Appendix B Manufacturer Description
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Appendix C 282 Nutrition Interventi
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Appendix D 284 Nutrition Interventi
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Appendix E 292 Nutrition Interventi
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Appendix E Table 3: Parent-Specific
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Appendix F Percentiles of Upper Arm
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Appendix F 302 Nutrition Interventi
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Appendix G 304 Nutrition Interventi
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Page 328 and 329: Appendix H 312 Nutrition Interventi
Page 336 and 337: Appendix I 320 Nutrition Interventi
Page 344 and 345: Appendix J 328 Nutrition Interventi
Page 352 and 353: Appendix K 336 Nutrition Interventi
Page 354 and 355: Appendix K 338 Nutrition Interventi
Page 356 and 357: Appendix L 340 Nutrition Interventi
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Page 362 and 363: Appendix N Gastrostomy Tube Feeding
Page 364 and 365: Appendix N activities. When feeding
Page 366 and 367: Appendix N Feeding Sets/Extensions
Page 368 and 369: Appendix N Fluid and Electrolytes W
Page 370 and 371: Appendix N osmolality of full-stren
Page 374 and 375: Appendix N his family, and the home
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Page 386 and 387: Appendix O Some conditions increase
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Page 392 and 393: Appendix P Diet Prescription for Me
Page 394 and 395: Appendix Q Goals Considerations for
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Page 400 and 401: Appendix R References 1. Ekvall SW
Page 402 and 403: Appendix S Table S-1: Infant Formul
Page 404 and 405: Appendix S Comments Osmolality (mOs
Page 406 and 407: Appendix S Table S-2: Pediatric For
Page 408 and 409: Appendix S Table S-3: Modular Produ
Page 410 and 411: Appendix S Comments Energy (kcal) P
Page 412 and 413: Appendix S Contact Information Abbo
Page 414 and 415: Appendix T Powdered Formulas Accura
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Page 420 and 421: Appendix U Nutrition Strategies for
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Appendix U ADA Pocket Guide to Nutr
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Glossary Autism Spectrum Disorders
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Glossary Early intervention service
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Glossary Length (recumbent length)
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Glossary Stadiometer moveable headb
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Index specialist 98 target 108 Bink
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Index elemental formula 348 elimina
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Index I ICF. See International Clas
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Index risk indicators 4 screening 1
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Index suppositories 72, 77 Surmonti
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Nutrition Interventions for Children with Special Health Care Needs

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