Screening Infants and Children at Risk for Fractures Clinical Pathway — Inpatient

Nutritional Interventions

Adequate nutrition provisions are integral for growth and bone mineralization, particularly during the period of rapid growth that occurs during childhood
Critically ill children are at high risk of inadequate intake due to alterations or disruptions in nutrient delivery that may occur as a result of treatment plans or disease states such as:
- Alterations in intestinal absorption and mineral retention
- Disruptions in feeding delivery for procedures, feeding intolerance, or other medical needs
- Nutritional inadequacies of the products available for both parenteral and enteral nutrition
Therapeutic nutrition interventions are often necessary to optimize nutrient intake in this population

Intervention	Rationale/Additional Information
Place Nutrition Consult if RD Not Previously Involved in Care	Ensure adequate nutrition provisions of micronutrient intake from both formula fed and oral diets
Optimize PN Ca and Phosphorus Cysteine as needed	Consult with RD to adjust calcium and phosphorus in PN per lab values Ideal provisions for bone mineral accretion Ideal calcium to phosphorus ratio Compounding limits for calcium and phosphorus precipitation
Optimize enteral Ca and Phosphorus Intake	Adjust/add fortification as able Use preterm products for preterm infants when possible Add supplements when indicated
Ensure Adequate Vitamin D Intake Start at feeding initiation or cessation of PN	Include 25(OH) vitamin D content of feedings plus supplementation to achieve Adequate Intake (AI) < 12 mos 10 mcg (400 units)/dose daily or 20 mcg (800 units)/dose every other day ≥ 12 mos 15-20 mcg (600-800 units) daily
Optimize Diuretic and/or Steroid Regiment	Use mineral sparing agents when possible Stop or reduce medications with osteopathic effects as clinically able

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Screening Infants and Children at Risk for Fractures Clinical Pathway — Inpatient

Nutritional Interventions

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Screening Infants at Risk for Fractures — Nutritional Interventions — Clinical Pathway: Inpatient

Screening Infants and Children at Risk for Fractures Clinical Pathway — Inpatient

Nutritional Interventions