By Sara O’Brien, MS, RDN
Working with pediatric patents, most providers focus on linear growth and weight gain as a sign of appropriate nutrition status. However, some pediatric patient populations cannot be compared to healthy developing children. Chronically ill and neurologically impaired children have special nutritional needs that may include a reduced calorie formula to meet protein and micronutrient requirements without contributing to excessive weight gain.
Special considerations for an extra special patient population
Neurologically impaired children suffer from a combination of both malnutrition and overnutrition.1 Neither the daily references intakes (DRI) nor recommended dietary allowance (RDA) set forth by the National Institute of Health apply to this population. Many of these patients have disease states or severe contractures that restrict and inhibit linear growth.
Tube fed chronically ill pediatric patients are at risk for overfeeding due to their inability to communicate feelings of hunger and satiety.1 These children are often wheelchair-bound and dependent on caregivers and medical professionals for transfers and care.1 Therefore, increasing caloric provision and weight gain do not result in lean body mass gains but rather, excessive fat mass.1 This makes it harder for these children to be cared for and puts both the caregiver and patient at risk for injuries during transfers or care.
It is recommended that wheelchair-bound children remain less than the 25%ile weight-for-length, while a weight-for-length less than the 10%ile is appropriate for a bedridden child.1 In comparison, growth rates for healthy developing children should be around the 50%ile weight-for-length.1
Estimating energy needs
While there are multiple equations to determine energy needs for pediatric patients, the best way to determine energy needs is by monitoring weight gain in response to dietary therapy, in combination with clinical judgment.1 As health care providers, there is an ethical dilemma in this patient population to try and provide adequate nutrition without growth restriction or excessive weight gain. A reasonable strategy is to keep caloric provision low to prevent excessive weight gain, while providing 100% of the DRI for protein and micronutrients to support lean tissue production and promote slow, controlled weight gain.
Choosing the appropriate formula
While a 1 kcal/ml or a 1.5 kcal/ml pediatric formula is considered the standard, reduced calorie formulas are available. Current formulas on the market include Abbott’s PediaSure® Reduced Calorie (0.63 kcals/ml) or Nestle’s Compleat® Pediatric Reduced Calorie (0.6 kcals/ml). Both of these formulas provide approximately 40% less calories per ounce than standard pediatric formulas. However, they are able to supply 100% of the requirements for protein and micronutrients in a volume of 1,000 to 1,500 ml. Therefore, protein modulars or a multivitamin are not needed to meet their protein and micronutrient needs. The only downside of utilizing a reduced calorie formula is that a higher total volume may be required to meet the patient’s energy requirements.
More information is needed to determine what constitutes “normal” growth for this patient population. For professionals working with these pediatric patients, it is very important to advocate for more research to be done in this arena. For now, however, dietitians are essential to meeting the unique nutritional needs of these pediatric patients.
Sara O’Brien, MS, RDN, is the Clinical Nutrition Manager for Blythedale Children’s Hospital a specialty pediatric rehabilitation center and long term care facility. She completed a combined bachelor’s degree and dietetic internship at the University of Connecticut and a Masters Degree in Dietetics at the University of Rhode Island. Sara is a specialist in pediatric nutrition and believes in an individualized patient-focused approach to nutrition.
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Nutrition in neurologically impaired children. Paediatr Child Health. 2009;14(6):395-401.