Pediatric Nutrition​- Inflammatory Bowel Disease Worksheet

Articles:

1. Nutrition Considerations in Pediatric Inflammatory Bowel Disease

Vol. 36 No. 3 Summer 2013
Building Block Newsletter, Academy of Dietetics and Nutrition
2. Crohn’s and Colitis Foundation of America (CCFA)
A Guide for Parents Handout
3. Crohn’s and Colitis Foundation of America
Diet, Nutrition, and IBD Handout (​www.ccfa.org/assets/pdfs/diet-nutrition-2013-1.pdf​)
4. Use of Enteral Nutrition for the Control of Intestinal Inflammation in Pediatric Crohn Disease
JPGN 2012;54(2)
(​http://www.naspghan.org/files/documents/pdfs/position-papers/Use_of_Enteral_Nutrition_for_the_C
ontrol_of.29%5B1%5D.pdf​)

17 yr. old male

ADMITTING DIAGNOSIS: Right upper quadrant pain
PAST MEDICAL HISTORY: Decreased po intake x 1 month secondary to pain and early satiety
6.3 kg wt lost in the past month
Depression
ANTHROPOMETRICS: WT- 50 kg (less than 3 %ile) HT- 170 cm (25 %ile)
LABS: 136 100 11
4.2 24 0.5 CRP- 12 Hgb-9.7 WBC- 22.75 k/uL Clotting factors elevated
Calprotectin, stool – 1401.3
I/O: 2250/2130 ml PO: 350 ml STOOLS: X 8 bloody
MEDS: Metronidazole, Unasyn, Prednisone
FINDINGS: Abdominal CT- Appendicitis with localized perforation
Loculated abscess in the R lower quadrant
Inflammation of terminal ileum and descending colon
Colonoscopy- Gross findings consistent with Crohn’s disease

The gastroenterologist recommends TPN for this patient

1. Why do you think this patient needs TPN?

Would need to use TPN because the perforation and abscess would prevent movement through the
gut.

2. Use the TPN information in the Pediatric Formulary card and the information on this patient to
practice doing a pediatric TPN calculation:
Step 1: Determine a fluid recommendation​- calculate the maintenance fluid needs
Fluid Recommendation: ___________2100_______ml/day
Step 2: Determine the desired protein intake​. Refer to the RDA table as a reference.
Protein Recommendation: _____45_____________gm/kg/day

2014

Step 3: Determine the desired lipid dose

Lipid Recommendation: _____50______________gm/kg/day

Step 4: Calculate the calorie needs​.

​Give 50% of the RDA for calories on Day 1
Calorie recommendation: _____45________kcal/kg/day ___2250_________ kcals/day

Step 5​: Total fluid ___2100______ml/day (Step 1)

Calculate ml of lipid: __50____gm/kg/day X 50 kg= _____X 5 (20% Intralipid- 1 gram of
lipid= 5 ml) = __250______ml lipid
_250____ ml lipid/day x 2 (calories /ml in 20% Intralipid) = __500___daily calories form lipid

Step 6:​ Total fluid __2100____ml/day – (minus) _250______ml lipid/day= _1850_____ ml/day
from dextrose and amino acid solution

Step 7​: Subtract daily lipid and protein calories from kcals/day (Step 4) __1570_____=kcal from
dextrose

Step 8: ​Convert calories from dextrose to grams of carbohydrate: __392____ grams of

carbohydrate

Step 9​: Set up an equation to determine the final concentration of dextrose (% dextrose) for the TPN
prescription
Grams of carbohydrate TPN volume (without lipids) x 100= __25______% dextrose

Step 10:​ To determine the % amino acid in the TPN prescription to Step 2
Protein recommendation ________gm/kg/day x 50 kg= ____45_____gm/day
Set up an equation to determine the final concentration of amino acids (% amino acid) for
the TPN prescription.
Grams of protein ÷ TPN volume (without lipids) X 100= ____2.4_____% amino acid

FINAL TPN PRESCRIPTION:​ 1850 ml ( _25_____% Dextrose, __2.4____% Amino Acid)

+ _250_____ ml 20% Intralipid
-----------------------------------------------------------------------------------------------------------------------------
 3. Refer to the lab values. State which values are abnormal.
CRP = H
WBC = H
Clotting factors elevated
HGB = L

4. Which of the lab values are potentially indicating presence of inflammation?

CRP is an indicator for inflammation

clotting factors are elevated

5. What criteria would you use for starting enteral/oral feeds in this patient?

Malnutrition: low PO for long than 1 month; greater than 10% weight loss; less than 25% of expected
weight gain.

6. If the patient is changed to enteral feedings, which enteral formula would you recommend and
why?

Nutren 250 ml carton

7. Which medication that the patient is receiving may affect his blood glucose?

Prednisone inhibits insulin production via inhibition of Gluc 3 in the cell.

8. What condition in his past medical history should the medical team have been concerned
about?

Weight loss in the past month

Depression can worsen IBD symptoms

9. Five different drug categories are commonly used in IBD and are mentioned in A Guide for
Parents Handout. State briefly the indication, the name of one medication in each category and
what is used for.
Aminosalicylates-
Sulfasalazine: can help with remission and mild symptoms of IBD
Corticosteroids-
Prednisone: suppress the immune response.
Immunomudulators-
Methotrexate: can be used to reduce the dependence on corticosteroids.
Antibiotics-
Metronidazole: use for infections during IBD.
Biologic therapies-
Inflaximab: antibody that binds to TNF. Reduces the number of fistulas.

10. List the rationale of the following diets in IBD. Refer to the CCFA Diet and Nutrition Handout.
Low Fiber-
Soluble fiber can help reduce diarrhea by slowing food through the GI tract.
Insoluble fiber can worsen IBD because can cause blockage or narrowing in the inflamed part of the
GI.
May need to avoid fiber because foods normally have a combination of both types of fiber.

Lactose restricted-
May occur because of a flare. Everyone is not consistently lactose intolerant with IBD, but may want
to avoid because of the many negative symptoms if lactose intolerant with IBD.

Low fat-
May cause steatorrhea and gas because of fat malabsorptions. Will want to avoid if IBD affects the
small intestine because that is where fat is absorbed.

11. The patient’s parents say that they have seen info on the internet about other diet restrictions
to treat/cure IBD. Where would you direct the family to learn about evidence based nutrition
information for IBD?
There is no cure for IBD. Can direct families to the CCFA Diet and Nutrition Handout.

12. List possible reasons to prescribe the following vitamins and minerals in children with IBD. Refer
to the Nutrition Considerations in Pediatric Inflammatory Bowel Disease article.
Folic Acid-
Some meds such as methotrexate block the absorption of folic acid and patient may have increased
needs.
B12-
absorbed in the ileum, an area of the small intestine that may be inflamed. A deficiency could mask
anemia.
Vitamin D-
Corticosteroid medications reduce bone mineral density increasing need for vitamin D. Lactose
intolerance can prevent the use of foods fortified with vitamin D, such as milk.
Iron-
Risk of GI bleed and ferritin can be falsely high. Look at total binding iron capacity.
Calcium-
Corticosteroid medications reduce bone mineral density increasing need for vitamin D. Lactose
intolerance can prevent the use of foods fortified with vitamin D, such as milk.