●

●
●
●
●
●

● when
gastric emptying is not significantly
delayed, intact upper airway
protective reflexes, and no
gastro-oesophageal reflux
● Gastric route - via a percutaneous
gastrostomy tube.
● Jejunal route recommended during
mechanical ventilation, or when
upper airway protective reflexes
are impaired.
● Access to the GIT - Nasogastric tube

NGT measures about 80-90 cm. Long-term feeds - silk enteral tube are preferred. Sizes vary from 6-12 F. Have a wire or plastic stylet to
ease manipulation into the stomach. There is a conventional Ryle’s tube - more rigid and made of PVC.

NJT are longer and measure about 110 cm. Passed in the same manner as a nasogastric tube, and the stylet withdrawn. Once in the
stomach, the tube is secured with sufficient excess to permit spontaneous passage into the jejunum. Passage to the jejunum may be
hastened by administering IV metoclopramide 10-20 mg (?). If no entry to jejunum, it can be manipulated under fluoroscopy.

If prolonged enteral feeding is anticipated, a feeding gastrostomy should be considered.

 ● Nausea and/or vomiting is not uncommon.
● Regurgitation and aspiration of gastric contents
● Complications related to nasogastric tube insertion - perforation of the cribriform plate, nasopharyngeal and oesophageal perforation,
pneumomediastinitis, pneumo- and hydro-pneumothorax.
● Irritation caused by the tube can lead to rhinitis, sinusitis and oesophagitis.

The most frequent complication with tube feedings is diarrhoea.

Diarrhoea as a result of concurrent use of antibiotics, hypoalbuminaemia leading to intestinal oedema causing malabsorption and diarrhoea,
bacterial contamination, absence of fibre in the formulation, and certain drugs, e.g. sorbitol and hyperosmolar feeds.
 Solutions which are mildly hypertonic (600-900
mOsm/L) can be used through a peripheral vein. Fat
emulsions which are iso-osmolar, form the main
source of energy in peripheral parenteral nutrition. An
admixture of 5% glucose, lipid emulsions and amino
acid solutions can be used peripherally.

A central intravenous route is used when

hyperosmolar solutions with a high nutrient density
The parenteral route is used when the GI (25-50% glucose) are given. Central access is almost
exclusively via the subclavian or internal jugular
route is contraindicated.
approach percutaneously.

Important - a central line which is exclusively

dedicated to parenteral nutrition
•Daily •As needed
Body weight Nitrogen balance
Strict intake and output record Serum lipids
Electrolytes Zn, Cu, Fe
BUN, creatinine, glucose B12, folate

•Twice weekly
PT
SGOT, SGPT, ALP, bilirubin
Ca, P, Mg
Technical : These are associated with central venous catheterisation, e.g. pneumothorax, haemothorax, haematoma due to vascular injury, injury to
the brachial plexus, air and catheter embolism, cardiac tamponade, catheter malposition, haemomediastinum, venous thrombosis and thoracic duct
injury.

Metabolic: These can be prevented if vigilant monitoring is ensured.

a. Hyperglycaemia: Impaired utilisation of glucose may rapidly lead to hyperglycaemia. If an excess of calories is being given, consideration
should be given to reducing the glucose load. If the glucose load is considered excessive, IV infusion of insulin should be initiated, the dose
depends on blood sugar levels.
b. Hypoglycaemia: This is sometimes encountered after suddenly stopping TPN, and may be due to large quantities of circulating endogenous
insulin. It is advisable to infuse a 10% dextrose drip for about 24 hours after discontinuing TPN.
c. Hypokalaemia, hypocalcaemia, hypophosphataemia, hypochloraemia and hypomagnesaemia: Negative balances of these minerals can
occur rapidly, and repletion is indicated when serum levels indicate depletion.
d. Hyperkalaemia, hypercalcaemia, hyperphosphat-aemia, hyperchloraemia and hypermagnesaemia : These may sometimes be encountered
with excessive intake along with renal dysfunction.
e. Metabolic acidosis : Hyperchloraemic metabolic acidosis may occur during the metabolism of amino acids. The routine administration of
acetate (30 mEq) in place of corresponding chloride usually prevents this problem. If metabolic alkalosis is encountered, the acetate content
of the solution is reduced.
 F. Prerenal azotaemia : The administration of large nitrogen loads to dehydrated patients may result in azotaemia. Patients should be well
hydrated before initiating parenteral nutrition.

● G. Hepatic complications : An elevation in transaminases, alkaline phosphatase and bilirubin with evidence of hepatic fatty infiltration may be
seen. This kind of presentation is usually due to excessive caloric intake, especially glucose. A cholestatic presentation with elevation of
bilirubin and alkaline phosphatase can be due to excess fat emulsions or due to lack of essential fatty acids. In long-term parenteral nutrition,
fatty infiltration and even cirrhosis has been reported. Prolonged parenteral nutrition can sometimes lead to acalculus cholecystitis.

Sepsis is a constant threat to patients on TPN. It can be best prevented by measures which include aseptic insertion technique, meticulous
hand-washing before handling solution or central line connections, strict dressing protocol and examination of insertion sites for sepsis. In long-term
parenteral nutrition tunneling of the catheter reduces the incidence of sepsis. If a catheter infection is suspected, it should be removed and the tip
sent for culture.
The real single indication for home parenteral nutrition is the short gut syndrome from any cause. The venous catheter is usually a Hickman/Broviac
catheter which is tunneled subcutaneously into the subclavian or internal jugular vein. The patient generally infuses the contents of the TPN bag
nocturnally. During the day, the catheter is filled with heparinised saline to prevent catheter occlusion.
 Malnutrition is a persistent problem in hospitals and intensive care units
(ICUs) worldwide.

Critically ill patients quickly develop malnutrition, or pre-existing malnutrition is

aggravated - inflammatory response, metabolic stress and bed rest which
cause catabolism

+ complications of increased morbidity due to infection, multi-organ

dysfunction (MOD) and prolonged hospitalisation.

Malnutrition remains undiagnosed in 70% of hospitalised patients

According to the Universal Declaration of Human Rights

(UDHR) Article 25(1), “everyone has the right to a standard of
living adequate for the health and well-being of himself and of
his family, including food…”. • In emergency contexts, it is
important to reaffirm the fundamental right of everyone to
have access to adequate and safe food.
T
➔
➔
➔

REE (kcal/day) = [(3.9 x VO2 ) + (1.1 x VCO2 ) - 61] x 1440

BEE– In kilocalories/day
Weight - In kilograms
Height - In inches
Age – In years
 Recommendations on Feeding in Infants and Young Children

● Early initiation of breastfeeding within 1 hour of birth;

● Exclusive breastfeeding for the first 6 months of life; and
● Introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding
up to 2 years of age or beyond.

However, many infants and children do not receive optimal feeding. For example, only about 36% of infants aged 0–6 months
worldwide were exclusively breastfed over the period of 2007-2014.

Recommendations have been refined to also address the needs for infants born to HIV-infected mothers. Antiretroviral drugs now allow
these children to exclusively breastfeed until they are 6 months old and continue breastfeeding until at least 12 months of age with a
significantly reduced risk of HIV transmission.
● Exclusive breastfeeding for 6 months has many benefits for the infant and mother.
● Breast-milk is also an important source of energy and nutrients in children aged 6–23 months. It can provide half or more of a
child’s energy needs between the ages of 6 and 12 months, and one third of energy needs between 12 and 24 months.
● Breast-milk is also a critical source of energy and nutrients during illness, and reduces mortality among children who are
malnourished.
● Children and adolescents who were breastfed as babies are less likely to be overweight or obese.
● Additionally, they perform better on intelligence tests and have higher school attendance.
● Breastfeeding is associated with higher income in adult life.
● Improving child development and reducing health costs results in economic gains for individual families as well as at the
national level.
● Longer durations of breastfeeding also contribute to the health and well-being of mothers: it reduces the risk of ovarian and
breast cancer and helps space pregnancies–exclusive breastfeeding of babies under 6 months has a hormonal effect which often
induces a lack of menstruation. This is a natural (though not fail-safe) method of birth control known as the Lactation
Amenorrhoea Method.
Mothers and families need to be supported for their children to be optimally breastfed.

● Adoption of policies such as the International Labour Organization’s "Maternity Protection Convention 183" and "Recommendation No.
191", which complements "Convention No. 183" by suggesting a longer duration of leave and higher benefits;
● Adoption of the "International Code of Marketing of Breast-milk Substitutes" and subsequent relevant World Health Assembly resolutions;
● Implementation of the "Ten Steps to Successful Breastfeeding" specified in the Baby-Friendly Hospital Initiative, including:
○ skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life;
○ breastfeeding on demand (that is, as often as the child wants, day and night);
○ rooming-in (allowing mothers and infants to remain together 24 hours a day);
○ not giving babies additional food or drink, even water, unless medically necessary;
● Provision of supportive health services with infant and young child feeding counselling during all contacts with caregivers and young
children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization; and
● Community support, including mother support groups and community-based health promotion and education activities.

Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of exclusive and continued breastfeeding can be
improved over the course of a few years.
Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and
complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If
complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s normal growth
cycle may be distorted. Guiding principles for appropriate complementary feeding are:

● Continue frequent, on-demand breastfeeding until 2 years of age or beyond;

● Practice responsive feeding (for example, feed infants directly and assist older children. Feed slowly and patiently, encourage
them to eat but do not force them, talk to the child and maintain eye contact);
● Practice good hygiene and proper food handling;
● Start at 6 months with small amounts of food and increase gradually as the child gets older;
● Gradually increase food consistency and variety;
● Increase the number of times that the child is fed: 2–3 meals per day for infants 6–8 months of age and 3–4 meals per day for
infants 9–23 months of age, with 1–2 additional snacks as required;
● Use fortified complementary foods or vitamin-mineral supplements as needed; and
● During illness, increase fluid intake including more breastfeeding, and offer soft, favorite foods.
Families and children in difficult circumstances require special attention and practical support. Wherever possible, mothers and babies
should remain together and get the support they need to exercise the most appropriate feeding option available. Breastfeeding remains
the preferred mode of infant feeding in almost all difficult situations, for instance:

● low-birth-weight or premature infants;

● mothers living with HIV in settings where mortality due to diarrhoea, pneumonia and malnutrition remain prevalent;
● adolescent mothers;
● infants and young children who are malnourished; and
● Families suffering the consequences of complex emergencies.

COVID?!
Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant ways to improve infant survival rates.
While HIV can pass from a mother to her child during pregnancy, labour or delivery, and also through breast-milk, the evidence on HIV
and infant feeding shows that giving antiretroviral treatment (ART) to mothers living with HIV significantly reduces the risk of
transmission through breastfeeding and also improves her health.

WHO now recommends that all people living with HIV, including pregnant women and lactating mothers living with HIV, take ART for
life from when they first learn their infection status.

Mothers living in settings where morbidity and mortality due to diarrhoea, pneumonia and malnutrition are prevalent and national health
authorities endorse breastfeeding should exclusively breastfeed their babies for 6 months, then introduce appropriate complementary
foods and continue breastfeeding up to at least the child’s first birthday.
Drug Nutrient affected Overall effect Prevention
Age in months EER (kcal/day)
0-3 {89 x weight (kg)} + 75 Age WHO Equation (kcal/day)
4-6 {89 x weight (kg)} – 44 0-3 Male: (60.9 x weight (kg))
7-12 {89 x weight (kg)} – 78 – 54
13-36 {89 x weight (kg)} - 80 Female: (61 x weight (kg))
– 51
3-10 Male: (22.7 x weight (kg))
+ 495
Female: (22.5 x weight
(kg)) + 499
Age DRI for Protein

0-6 months 1.52 g/kg/d*

6-12 months 1.2 g/kg/d
12-36 months 1.05 g/kg/d
4-13 years 0.95 g/kg/d
14-18 years 0.85 g/kg/d
>18 years 0.8 g/kg/d
AGE PROTEIN
NEEDS
0-2 years 2-3 g/kg/d
2-13 years 1.5-2 g/kg/d
13-18 years 1.5 g/kg/d
Weight (kg) =Fluid Needs

1 – 10 kg =100 ml/kg

11 – 20 kg =1000 ml + 50 ml/kg for each kg above 10kg

Above 20 kg =1500 ml + 20 ml/kg for each kg above 20kg

Weight
Thank You
for listening