Assessment of hydration
- Heart rate (bpm)
o Newborn – 3 months: 85 - 205
o 3 months – 2 years: 100 - 190
o 2 years to 10 years: 60 - 140
o >10 years: 60 - 100
- Weight
o Infant scale age
o Standing scale age >2 year
o Helpful to document which scale was used for consistency
- Physical exam findings (sunken eyes, dry mucous membranes, decreased skin turgor)
- Urine color (dark, amber, clear, precipitate, blood)
- Urine specific gravity
o normal 1.003-1.030
o Neonates normal 1.003
- Urine osmolarity
o Normal 300-900
- BUN
- Uric acid
- Hemoglobin
- Fractional excretion of sodium – caution when using in children and neonates. Also must be considered w/ context considered in HPN patients!!!
o = (100 X NaUrineXCreatinineUrine)/(NaPlasmaXCreatinineUrine)
o
o >2%: Acute tubular necrotis or other kidney damage
o Intermediate either
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Schedule and decisions should be customized according to best clinical judgement.
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Test
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Reason
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Frequency
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Abdominal ultrasound
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Steatotosis, portal hypertension, liver masses, nephrocalcinosis
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Yearly
|
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Alpha-fetoprotein
|
Risk of liver tumor
|
Yearly with cirrhosis
|
|
Transient elastography
|
Liver fibrosis, steatosis
|
Yearly (limited evidence)
|
|
Chest X-ray
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Central line tip location
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Yearly before age 2
Every 2 years after age 2
|
|
DXA
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Bone density
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Every 1-2 years after age 5
|
|
Bone age
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Skeletal maturity
|
Every 1-2 years with short stature
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|
HPN laboratory monitoring
|
Tolerance of PN additives
|
Every 1-3 months
|
|
HPN outpatient visits
|
Health & nutrition promotion
|
Every 1-3 months
|
|
Vaccines including varicella
|
Prevention of communicable diseases
|
Standard schedule
|
|
Primary care visits
|
General health promotion
|
Standard schedule
|
|
Dental visits
|
Dental health promotion
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Every 6 months starting at age 1, antibiotic prophylaxis not needed in general
|
|
Blood pressure measurements
|
Health promotion
|
Measurement at every visit
|
Cazals-Hatem D, Billiauws L, Rautou PE, Bondjemah V, Poté N, Corcos O, Paradis V, Joly F. Ultra-short bowel is an independent risk factor for liver fibrosis in adults with home parenteral nutrition. Liver Int. 2018 Jan;38(1):174-182. doi:10.1111/liv.13545. Epub 2017 Sep 2. PubMed PMID: 28792647.
Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017. www.aap.org/periodicityschedule.
Flynn JT, Kaelber DC, Baker-Smith CM, et al; SUBCOMMITTEE ON SCREENING AND
MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017; 140(3):e20171904. Pediatrics. 2017 Dec;140(6). pii: e20173035. doi: 10.1542/peds.2017-3035. PubMed PMID: 29192011.
Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for Infection. Pediatr Dent. 2016 Oct;38(6):328-333. PubMed PMID: 27931473.
Kumaraguru N, Mantegazza C, Köglmeier J. A survey of oral and dental health in children on home parenteral nutrition. Eur J Paediatr Dent. 2016 Mar;17(1):57-9. PubMed PMID: 26949241.
Hukkinen M, Kivisaari R, Lohi J, Heikkilä P, Mutanen A, Merras-Salmio L,
Pakarinen MP. Transient elastography and aspartate aminotransferase to platelet ratio predict liver injury in paediatric intestinal failure. Liver Int. 2016 Mar;36(3):361-9. doi: 10.1111/liv.12887. Epub 2015 Jun 25. PubMed PMID: 26058319.
Lee AM, Gabe SM, Nightingale JM, Burke M. Intestinal failure and home
parenteral nutrition: implications for oral health and dental care. Clin Nutr. 2013 Feb;32(1):77-82. doi: 10.1016/j.clnu.2012.05.018. Epub 2012 Jun 23. PubMed PMID: 22727546.
Lee AM, Gabe SM, Nightingale JM, Burke M. Oral health, dental prophylaxis and
catheter related bloodstream infections in home parenteral nutrition patients: results of a UK survey and cohort study. Br Dent J. 2012 Jan 27;212(2):E4. doi: 10.1038/sj.bdj.2012.50. PubMed PMID: 22281655.
Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Pract. 2007 Jun;22(3):340-50. Review. PubMed PMID: 17507734.
Van Gossum A, Pironi L, Messing B, Moreno C, Colecchia A, D'Errico A, Demetter P, De Gos F, Cazals-Halem D, Joly F. Transient Elastography (FibroScan) Is Not Correlated With Liver Fibrosis but With Cholestasis in Patients With Long-Term Home Parenteral Nutrition. JPEN J Parenter Enteral Nutr. 2015 Aug;39(6):719-24. doi: 10.1177/0148607114538057. Epub 2014 Jun 9. PubMed PMID: 24913657.
Immunizations
- In general, HPN patients should be encouraged to receive all childhood vaccines.
-
Many children on HPN have co-morbidities that require careful consideration (bone marrow transplant patients, IBD patients on immunosuppressive medications). Therefore, it is important to collaborate with other providers in providing advice regarding vaccinations.
Parents are often apprehensive about giving vaccines, because they understandably fear that a fever will result in automatic admission and IV antibiotics (disruption in their life). It is worthwhile discussing risks/benefits. It may also be worthwhile prescribing an anti-pyretic for short-term use in light of benefits of vaccination.