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Enteral Nutrition - Pediatric - Inpatient [151]

Enteral Nutrition - Pediatric - Inpatient [151] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols

Delegation Protocol Number: 151

Delegation Protocol Title:
Enteral Nutrition - Pediatric - Inpatient

Delegation Protocol Applies To:
American Family Children’s Hospital (AFCH) Inpatients

Target Patient Population:
Pediatric patients admitted to any inpatient unit at AFCH who are receiving enteral nutrition
Pediatric patients admitted to the Burn Unit at University Hospital

Delegation Protocol Champions:
Diane Heatley, MD – Department of Surgery – Otolaryngology
Dan Sklansky, MD – Department of Pediatrics – Hospitalists

Delegation Protocol Reviewers:
Robin Crist, RD – Clinical Nutrition
Cassandra Kight, RD – Clinical Nutrition
Emily Wallace, RD – Clinical Nutrition

Responsible Department:
Clinical Nutrition

Purpose Statement:
The purpose of this delegation protocol is to delegate authority from the ordering provider to Registered
Dietitian Nutritionists to place orders for enteral nutrition (medications and vitamins) for pediatric patients.

Who May Carry Out This Delegation Protocol:
Registered Dietitian Nutritionists (RDN’s) who are trained in the use of this delegation protocol and meet
competency requirements defined by the Department of Clinical Nutrition. Recommended, but not required, is
the Certified Nutrition Support Clinician (CNSC) credential from the National Board of Nutrition Support
Certification, American Society for Parenteral and Enteral Nutrition

Guidelines for Implementation:
1. This delegation protocol is initiated when a provider orders “Consult Nutrition (Inpatient)” and indicates
in the order question “Initiate and Manage Tube Feedings”. The RDN will assess and document nutrition
needs. If an initial assessment has already been completed and documented the RD will
reassess/reconfirm needs. Based on this assessment, recommendations will include type of formula,
initiation rate, progression to goal rate, free water, if appropriate, and addition of any modulars,
vitamins, minerals, or fiber.
2. The RDN will complete orders for enteral nutrition (EN) using the tube feeding section of the diet order.
3. The RDN will monitor patient EN tolerance and evaluate appropriateness of advancing EN until goal rate
is reached. Monitoring will be completed daily while advancing with significant findings documented
with short progress notes in Health Link or communicated to primary team.
4. The RDN will continue to monitor patient once goal rate has been achieved. Identified issues with
gastrointestinal tolerance or metabolic abnormalities will be discussed with primary team.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:

5. The RDN may place orders for volume of water boluses or flushes as appropriate to meet maintenance
fluid needs using the Holliday-Segar method. If the patient’s fluid needs are restricted or greater than
maintenance, the RD will adjust volume after discussion with primary team.
6. The RDN may place orders for Oral/Enteral forms of vitamins and minerals as warranted by the patient’s
condition, laboratory values, or to correct any deficiencies inherent in the EN regimen.
7. The RDN may place orders for protein supplementation (e.g. Beneprotein, ProSource) with EN to meet
estimated protein needs of patient.
8. RDN may place an order for a fiber supplement such as Nutrisource Fiber/Benefiber (number of
packets/day not exceed Daily Reference Intake ) for age) for a patient who experiences diarrhea that is
not infectious, does not respond to adjustment of medications associated with diarrhea, or does not
respond to fiber-containing formula.
9. The RDN may place orders for anthropometric measurement.
10. When this delegation protocol is activated, the RDN will reassess at least weekly and document in the
progress note section of Health Link.

Order Mode: Protocol/Policy, Without Cosign

1. Corkins MR, ed. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2
Ed.The American Society for
Parenteral and Enteral Nutrition; 2015.
2. Academy of Nutrition and Dietetics Evidence Analysis Library. www.eatright.org
3. Academy of Nutrition and Dietetics Pediatric Nutrition Care Manual. Web-based application available within
U-Connect and Health Link.
4. ptoDate® (vitamin information). Accessed March 2016. Vitamin D: http://www.uptodate.com/contents/vitamin-
5. Kleinman RE & Greer FR, eds. Pediatric Nutrition, 7
ed: American Academy of Pediatrics; 2014.

Collateral Documents/Tools:
UW Health Enteral Nutrition – Pediatric – Inpatient/Ambulatory Clinical Practice Guideline

Approved By:
UWHC Nutrition Committee: May 2011, *June 2014; *November 2016
UWHC Medical Board: May 2011, *August 2014, *January 2017

Effective Date: January 2017
Scheduled for Review: January 2020
2016 – Pulled from combined adult protocol
* expedited review approval process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:

Oral/Enteral Vitamin/Mineral Repletion for Pediatric Patients on Enteral Nutrition

Vitamin Pediatric Dose, Route,
Clinical Condition
Recommended Daily Allowance
(RDA): Oral/Enteral: Infant: 400
units/day. Children and
Adolescents: 600 units/day (IOM
Vitamin D deficiency,
prevention: (Wagner 2008):
Oral/Enteral: Breast-fed infants
(fully or partially): Oral/Enteral:
400 units/day beginning in the
first few days of life. Continue
supplementation until infant is
weaned to ≥1,000 mL/day or 1
qt/day of vitamin D-fortified
formula or whole milk (after 12
months of age)
Formula-fed infants ingesting
<1,000 mL of vitamin D-fortified
formula: Oral/Enteral: 400
units/day. Infants ingesting >500
mL formula: Oral/Enteral: 200
Children and Adolescents
without adequate intake:
Oral/Enteral: 600 units/day to
meet the RDA.
Vitamin D deficiency,
treatment: Oral/Enteral: Note: In
addition to calcium and
phosphorus supplementation
(Holick 2011; Golden 2014):
Infants: Oral/Enteral: 1,000 (mild
to moderate deficiency) to 2,000
units daily to achieve a serum
25(OH)D level within normal
limits; followed by a
maintenance dose of 400 to
1,000 units daily.
• To meet RDA for infants receiving human
milk or infant formulas, children and
adolescents with inadequate intake or
exposure to sun, those with dark skin
pigmentation, or those with dietary fat
• Documented Vitamin D deficiency
• Continuation of Vitamin D supplementation
patient received at home for underlying
medical condition (e.g. osteopenia)

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:

Children and Adolescents:
Oral/Enteral: 2,000 units daily to
achieve serum 25(OH)D level
within normal range; followed by
a maintenance dose of 600 to
1,000 units daily.
If treating a deficiency, measure
25(OH)D level at 3-month
intervals until normal
concentrations have been
Cystic Fibrosis specific
multivitamin (drops,
chewables, softgels) and
Vitamin D
Consult Pulmonology Service for
dosing of multivitamins for
children with CF. The dose is
specific to the age of the patient
and the brand of the vitamin.

Vitamin D supplementation for
children with CF. Consult with
Pulmonary Team.
• Cystic Fibrosis (CF)

Iron Infants: Breastfed term infants
beginning at 4 months until
consuming appropriate iron-
containing complementary
foods: 1 mg/kg/day

For infants and children with
proven or suspected iron-
deficiency anemia (IDA), Up-to-
date® suggests Oral/Enteral
supplementation with 3 to
6 mg/kg/day of elemental iron,
depending on the severity of

• Premature infants need 2 to 4 mg/kg/day
• Infants born at term have sufficient stores
until 4-6 months of age
• Full-term, formula-fed infants do not need
additional iron
• Screening recommended beginning 12
months of age
Multivitamin +/-
(drops, chewables,
Infants: Polyvitamin drops +/-
iron, 1mL
Toddlers 2-3 yrs: ½ tablet or 1
• Recommended EN regimen fails to provide
100% of Reference Daily Intake (RDI) for
one or more vitamins
• Increased needs (burns, wound healing)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:

gummy) gummy
Children 4 yrs and older: 1 tablet
or 2 gummies

• Medications which interfere with
metabolism of one or more vitamins (e.g.
phenytoin, phenobarbital, sulfasalazine).

Renal Multivitamin Need and dosing is patient
specific. Consult Pediatric
Nephrology Team.
• Inadequate EN and RRT
Selenium Dosing to be determined
individually for each patient in
coordination with primary
• Long-term parenteral nutrition without
source of selenium (e.g. shortages)
• HIV disease progression
• Bariatric surgery or severe gastrointestinal
Thiamine Severe deficiency should be
initially addressed with IV
Children: 10-50 mg/dose
Oral/Enterally every day for 2
weeks, then 5-10 mg/dose
Oral/Enterally daily for 1 month
• Suspected thiamine deficiency due to
severely restricted diet (anorexia, food
• Alcohol abuse in a child or adolescent
Zinc Dosing to be determined
individually for each patient in
coordination with primary
• Malnutrition
• Severe or persistent diarrhea
• Malabsorption syndromes including celiac
disease, cystic fibrosis, and short bowel
• Inflammatory bowel disease (Crohn’s,
ulcerative colitis)
• Sickle cell anemia

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: