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PEDIATRIC CRITICAL CARE
Janice Antino RD, MS, CSP
Objectives
Review Energy Expenditure Indirect Calorimetry Enteral Nutrition (EN) Parenteral Nutrition (PN
Challenges in the PICU
Increased metabolic stress Meeting energy expenditure Nutrient delivery Pre-existing malnutrition Goals
Minimize protein catabolism Meet energy expenditure
Why is Nutrition Important?
Critical Illness + Poor Nutrition = Prolonged ventilator dependence Prolonged ICU stay Increased susceptibility to infections Increased mortality with mild/moderate
malnutrition
Overfeeding
Hyperglycemia Azotemia High Triglycerides Electrolyte imbalance Immunosuppression Hepatic steatosis Failure to wean from mechanical
ventilation
Underfeeding
Decreased respiratory muscle strength Failure to wean from mechanical
ventilation Impaired organ function Immunosuppression Poor wound healing Low transport protein levels in the
absence of inflammation
Hypocaloric feeding
Patients are fed below their REE (50-75%) May benefit several populations of adult
critically ill patients Not recommended for pediatrics
Energy Expenditure (EE)
Resting Energy expenditure (REE): The amount of calories required by the body at rest during a 24 hour period Represents 70-80 % of the calories used Defines the energy released to maintain
normal basal physiological functioning Basal metabolic rate (BMR): The EE of a
recumbent child in a thermoneutral environment after a 12-18 hour fast
Total energy expenditure : BMR, thermic effect of food, thermoregulation, activity
Shulmman et al. 2002
Estimating Energy Needs of Critically Children
Available methods to determine REE Predictive equations- estimates energy
expenditure Indirect calorimetry- measures gas
exchange to determine energy expenditure
Indirect Calorimetry
Measures exchange of oxygen and carbon dioxide
Provides REE and Respiratory quotation(RQ)
Can be performed on ventilated or non ventilated patient’s
RQ: the ratio of carbon dioxide to oxygen consumed
Most accurate method for determining energy needs
ASPEN Pediatric Core Curriculum 2010
Recommended Dietary Reference Intake (RDA)
Age RDA (kcal/kg) Protein (2002, Dri’s)
0-6 months 108 1.5 AI
7-12 months 98 1.2
1-3 years 102 1.05
4-6 year 90 .95
7-10 yeas 70 .95
Males11-14 years15-18 years
5545
.85
Females11-14 years15-18 years
4740
.85
Standard equations for predicting energy requirements
Raju. 2005
Basal Metabolic Rate- Kcal/kg
Age Male Female
1-3 years 51.3-531 51.2-53
4-7 years 47.3-50.3 45.4-49.9
8-11 years 43.0-46.5 39.3-41.3
Raju 2005
Stress Factors
Condition Stress factor
Mild starvation .85-1.00
Postoperative state 1.0-1.05
Cancer 1.10-1.45
Sepsis/peritonitis 1.05-1.25
Multi trauma, burns 1.20-1.55
Energy Requirements
Infants- intubated likely require > REE 0-3 months at least 80 kcal/kg 4-12 months at least 65 kcal/kg
Older children May use WHO, Schofield, White equations
Activity and injury factors may not be needed Burn patients require an activity/stress factor
2012, retrospective review, 240 patients Critically ill patients had cumulative
energy and protein deficits in the first days- <90 % of energy requirements on 60 % of all
patient days and >110 % of energy requirements on 30 % patient days
Both under and over feeding were prevalent, expect in children younger than 2
Under Delivery of Energy and Protein
EE in critically Ill Children
Prospective clinical study Measured REE in 37 children and
compared to predictive equations Conclusion
Recommended dietary allowance and energy expenditure predicted by stress related correction factor-Grossly over estimate MEE
Briassoulis, 2000
ASPEN Criteria
Energy needs should be assessed throughout the course of illness to determine energy needs/ Estimates using available standard equations are often unreliable
In a subgroup of patients with suspected metabolic alterations or malnutrition, accurate measurements of EE using indirect calorimetry is desirable.
Criteria for using Targeted Indirect Calorimetry
Energy Imbalance and Risk of Overfeeding in Critically Ill
Children Prospective cohort study -29 patients
over 12 months Examined the role of targeted indirect
calorimetry in detecting the adequacy of energy intake and risk of energy imbalance
Measured REE from IC Predicted EE from standard equations-
Schofield, Harris-benedict ASPEN criteria for Targeted IC
(Mehta et.al, 2011)
Energy Imbalance and risk of overfeeding in critically ill children
Energy Imbalance and risk of overfeeding in critically ill children
In Summary 72% had an altered metabolism
High incidence of overfeeding Standard equations overestimate the
energy requirements Children < 1 year of age represented the
large majority of patients with hyper metabolism
Medical patients tended to be hypo metabolic
Enteral Nutrition (EN)
Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)—Tube feedings—Must have functioning GI tract—IF THE GUT WORKS, USE IT!—Exhaust all oral diet methods first
Criteria for Enteral Nutrition
ASPEN 1999
Initiating EN
Plan for 2-5 days to meet nutrition goal Use isotonic feedings initially Avoid making simultaneous changes in
volume and concentration Advance cautiously in critically ill patients Increase volume before concentration when
administering transpyloric feeds Advance concentration before volume with
gastric feed If feeding intolerance develops return to the
previously tolerated rate
ASPEN 1999
Initiating and Advancing EN
Trophic feeds: < 20 ml/kg/day Continuous:
Initiate: 1 ml-2 ml/kg/hrAdvance: .5-1 ml/kg/ as tolerated- q 8-12
hrs Bolus/Intermittent:
Begin at 25 % goal on first day Divide formula equally between 5-8
feedings Increase by 25 % as tolerated
Roger et al 2003
Barriers to Adequate Nutrition in Critically ill Children
Fluid restriction Longest duration off feeds
Gastrointestinal intolerance Vomiting-most frequent Gastric residuals Diarrhea
Interruptions for procedures shorter duration
50% patients achieved full EER by day 7
Parental Nutrition-Indications
Always use EN whenever possible Use PN only when
Unable to meet nutritional requirements via the GI tract
Bowel dysfunction resulting in inability to tolerate EN for 1-3 days in infants 4-5 days in children and adolescents 7-10 days in adults
ASPEN. Pediatric nutrition support core curriculum 2010
Parental Nutrition-Indications
Very low birth weight infants(<1500 grams) Inability to tolerate EN feeds Small bowel obstruction Radiation enteritis Gastrointestinal fistula/high out put Hemodynamic instability with high risk of
mesenteric ischemia( e.g ECMO, NEC in preterm infants, shock, acute critical illness)
Conditions associated with intestinal failure-short bowel syndrome, diarrhea with malabsorption, intestine epithelial disorder-microvillus inclusion disease
ASPEN. Pediatric nutrition support core curriculum 2010
Route of Administration
Peripheral Parental Nutrition (PPN) Osmolality is limited to 900 mOsm/kg to
minimize risk of phlebitis and infiltration Dextrose limited to 10 -12.5 % Will require large volumes to supply adequate
nutrients Central/Total Parental Nutrition (TPN)
Longer term needs, > 2 weeks > 900 mOsm/kg Meet nutrient requirements Fluid restrictions
ASPEN. Nutrition Support Core Curriculum 2007
Parental Nutrition Administration
2-in-1 Dextrose and
amino acids Lipids are provided
via a piggy back infusions
3-in-1 Dextrose, amino
acids and lipids Advantages
Convenience Cost Decreased risk of
microbial contamination-fewer manipulations to the line
Components of PN
Non-protein energy Carbohydrate (dextrose) Fat (lipid)
Protein (amino acids) Electrolytes Minerals, Vitamins, trace elements Water Miscellaneous: heparin, medications
Glucose
Glucose infusion rate (GIR) % dextrose x volume ÷ wt (kg) ÷ 1.44 Example: 15% dextrose @ 20ml/H (480ml
total volume) for 5kg patient: 0.15 x 480 ÷ 5 ÷ 1.44 = GIR 10
3.4kcal/g dextrose Net fat synthesis may lead to hepatic
steatosis; would not exceed GIR >12.5mg/kg/min in term infants (maximum glucose oxidation rate)
ASPEN 2010
Glucose Infusion Rates
Age Initiate Advance Maximum
< 1 year 6-9 mg cho/kg/min
1-2 mg cho/kg/min
Goal 10-12 mg cho/kg/minMax: 14
1 – 10 years 1-2 mg cho/kg/min
1-2 mg cho/kg/min
8-10 mg cho/kg/min
> 10 years 1-2 mg cho/kg/min
1-2 mg cho/kg/min
5-6 mg cho/kg/min
Protein-Amino Acids
Functions: Provides structure : muscle Provides function: enzymes, transport protein
Increased Protein Needs: malnutrition, stress, burns, enteric/urinary loss
Infants: need conditional amino acids like histidine, taurine and cysteine because of immature synthetic abilities
Protein should not serve as an energy source Excess protein intake leads to hyperazotemia
ASPEN 2010
Protein Requirements
Age Gram/kg/day
Preterm 2.5-4.0 grams/kg
Term infant 2.2-3.5 grams/kg
Child 1.0-2.0 grams/kg
Adolescents 0.8-2.0 grams/kg
APEN 2010
Fat-lipid
Fat 20 % emulsion = 2 kcal/ml Soybean/safflower oil and emulsified egg yolk
phospholipid Minimum of 1-2% of calories from combinations
of linoleic and linolenic acid to meet EFA needs- met with .5-1.0 g/kg/d Serum triene to tetraene ratio is reflective of EFA
status Triene to tetraene ratio ratio >0.2 suggest deficiency
Monitor Triglyceride to assess tolerance 300-400 mg/dl are tolerated
ASPEN 2010
Dose for lipids
Age Starting dose Maximum dose
Neonate/infant 1 gram/kg/day 3 gram/kg/day
Children 1 gram/kg/day 2 gram/kg/day
Adolescent/adult 0.5grams/kg/day 1 gram/kg/day
Parental Fat Emulsions
Gura et al 2008
Parenteral Nutrition Complications
Infectious complications- Central line associated blood stream infections
Mechanical Metabolic
Hyper/hypoglycemia Essential fatty acid deficiency Azotemia- increased BUN may occur as a
result of intolerance to the protein load Fluid/electrolyte complications/refeeding
syndrome Parenteral Nutrition Associated Liver Disease
Parenteral Nutrition Associated Liver Disease( PNALD)
Three types of hepatobiliary disorders Steatosis:
can occur 2 weeks after pn started, elevated serum aminotransferase levels
Treat: decrease total energy intake, appropriate fat intake
Appears to be related to over feeding Cholestasis : Direct bilirubin >2 mg/dl
Treat: decrease fat and/or change composition of fat
Gallbladder sludge/stones: gall bladder stasis may lead to BG stones/cholecystisis
Kumpf, 2006
Treatment PNALD
Provide maximal tolerated EN Provide a cyclical PN as soon as possible Prevent over feeding Consider restricting lipids to 1 gm/kg/day
Consider fish oil based lipids
Guru, et al 2008Kumpf 2006
Guru et al. 2008
Omegaven
10% fish oil fat emulsion Docosahexaenoic acid (DHA) Eicosapentaenoic acid (EPA) Anti inflammatory properties Used to treat/prevent PNALD
Omegaven in TPN related Liver Disease at StonyBrook Medicine Compassionate use to treat infants and
children who PNALD Goal: Reverse cholestasis, prevent liver
disease Patient selection
Two consecutive direct bilirubin levels 2 mg/dl for tpn dependent children
Other causes liver disease ruled out Must have utilized standard accepted therapies
Removal copper and manganese Trial enteral feeds Use of ursodiol
ASPEN 2010
Refeeding Syndrome
Definition The metabolic and physiological shifts of fluid,
electrolytes and minerals that occur as a result of aggressive nutrition support
Risk factors Chronic malnutrition, anorexia nervosa, pt’s not fed 7-
11 days with evidence of stress and depletion Clinical
Low serum phosphorus, magnesium, potassium levels, acute respiratory and circulatory collapse
Treatment Initiate and advance slow 25-50 % energy needs and
increase by 10 -20 % daily
Summary
Use caution when estimating energy needs using predictive equations
Indirect calorimetry is considered the gold standard method to measure EE
Use EN when ever possible PN can be lifesaving when tolerance to
enteral nutrition is limited
References The ASPEN Nutrition Support Core Curriculum: A Case-based Approach: the Adult Patient. American
Society for Parenteral and Enteral Nutrition, 2007. The ASPEN Pediatric Nutrition Support Core Curriculum. American Society for Parenteral and Enteral
Nutrition, 2010 Briassoulis, G., Venkataraman, S., & Thompson, A. E. (2000). Energy expenditure in critically ill children.
Critical care medicine, 28(4), 1166-1172. Gura, K. M., Lee, S., Valim, C., Zhou, J., Kim, S., Modi, B. P., ... & Puder, M. (2008). Safety and
efficacy of a fish-oil–based fat emulsion in the treatment of parenteral nutrition–associated liver disease. Pediatrics, 121(3), e678-e686.
Kumpf, V. J. (2006). Parenteral nutrition-associated liver disease in adult and pediatric patients. Nutrition in clinical practice, 21(3), 279-290.
MCHIR, L., & David, A. (1998). Energy requirements of surgical newborn infants receiving parenteral nutrition. Nutrition, 14(1), 101-104.
Mehta, N. M., Bechard, L. J., Dolan, M., Ariagno, K., Jiang, H., & Duggan, C. (2011). Energy imbalance and the risk of overfeeding in critically ill children*. Pediatric Critical Care Medicine, 12(4), 398-405.
Mehta, N. M., & Compher, C. (2009). ASPEN Clinical Guidelines: nutrition support of the critically ill child. Journal of Parenteral and Enteral Nutrition, 33(3), 260-276.
Mehta, Nilesh M., et al. "Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry." Journal of Parenteral and Enteral Nutrition 33.3 (2009): 336-344.
Kyle G. Ursla. MS, RD, Rd/LD., Jaimon Nancy RN., Coss-Bu A Jorge, MD. Nutrition Support in Critically ill Children Under delivery of energy and Protein compared with Current Recommendation. Journal of the Academy of Nutrition and Dietetics, 112 (12)2012
Shulman, R. J., & Phillips, S. (2003). Parenteral nutrition in infants and children. Journal of pediatric gastroenterology and nutrition, 36(5), 587-607.
References
The ASPEN Nutrition Support Core Curriculum: A Case-based Approach: the Adult Patient. American Society for Parenteral and Enteral Nutrition, 2007.
The ASPEN Pediatric Nutrition Support Core Curriculum. American Society for Parenteral and Enteral Nutrition, 2010
de Souza Menezes, F., Leite, H. P., & Koch Nogueira, P. C. (2012). Malnutrition as an independent predictor of clinical outcome in critically ill children. Nutrition, 28(3), 267-270.
Raju col ums, Choudhary, Sanjay., Harjai, MM., Nutritional Support in the critically ill child. MJAFI 2005; 61: 45-50
Hardy, C. M., Dwyer, J., Snelling, L. K., Dallal, G. E., & Adelson, J. W. (2002). Pitfalls in predicting resting energy requirements in critically ill children: a comparison of predictive methods to indirect calorimetry. Nutrition in clinical practice, 17(3), 182-189.
INFANT FEEDINGJanice Antino RD, MS, CSP
Breastfeeding Recommended for the first 6 months of life Lower risk for otitis media, lower
respiratory infections and diarrhea Supplement –
Vitamin D 400 i.u units starting in the first few days of life
Iron 1 mg/kg starting at 4 months age, until iron containing complementary foods have been introduced
Fortified Breast milk-premature infants, cardiac or GI surgery
Adequate breastmilk provision
Weight gain- 4-7 ounce per week after the 4 th day of life
Minimum of 6 wet diapers (after 3-5 days)
Minimum of 3-4 stool daily during first few week
Minimum 8-12 feeding ( 15-20 minutes) Alert, healthy appearance No food or drink other than breast milk
The Infant Formula Act
Infant formula act passed in 1980 with amendments in 1986
Established minimum levels of 29 nutrients and maximum of 9 (protein, fat, Vit A, Vit D, Fe, iodine, Na, K, and chloride)
Infant formulas
Human milk is the gold standard for infant formula compositions
Cow’s milk became the major substitute for human milk changes in substrates were necessary Protein: alter casein whey ration from 80:20 Electrolytes: decrease concentration Fat: cow’s milk fat is not well absorbed, add
vegetable oil Increase iron content
Preterm Infant formula
Similac Special Care or Enfamil Premature – considered pre discharge formulas 24 kcal/oz, milk protein based, higher
concentrations of protein, calcium and phosphorus, used until discharged
Neosure or Enfacare – considered post discharge formulas
22 kcal/oz, milk protein based, used until 9 months corrected age
Term Infant Formulas
Standard –cow’s milk based Soy based Extensively hydrolyzed protein Free amino acid Metabolic Categorized by:
Protein composition : cow-milk, soy protein, protein hydrolysate or amino acid based
Consumer group: Term infant, premature or metabolic/special needs
Standard Infant Formula
Indications: healthy term infants Enfamil Newborn or infant Similac advance,
Store brands Enfamil gentelease and Similac sensitive Enfamil AR or Similac for Spit up
Contradictions: Galactosemia and lactose intolerance, milk protein allergy, metabolic disorders
Nutrients are expressed as “per 100 kcal” Standard concentration is 20 kcal/oz
Standard Infant Formula
CompositionCHO: Lactose (42% calories)
Protein: Altered casein: whey to 60:40 with dominant whey protein B-lactoglobin (9-12%
calories)Fat: Combination of vegetable oils (40-50 %
calories)
Standard Infant Formula
Available in: Ready-to-use, concentrated liquid or powder Different methods of preparation
powder 1scoop/2 oz water = 20 kcal/oz 13 oz can of concentrate/13 oz water = 20
kcal/oz
DHA/ARA
Docosahexaenoic acid (DHA) Arachidonic acid (ARA)
Long chain polyunsaturated fatty acids Derived from linoleic and linoleic acids Structural Components of cell membranes in
the brain and retina Studies have shown enhanced cognitive
development and visual acuity in premature infants
Immune modulating agents
Nucleotides: Non-protein nitrogenous compound, found in high concentration in breast milk
Prebiotics: non digestible food ingredient that benefits the host by selectively stimulating the favorable growth or activity of one or more probiotic bacteria
Probiotics: An oral food supplement that contains a sufficient # viable microorganisms to alter the micro flora of the host with potential health benefits
Benefits Enhances immune system Promotes Gastrointestinal development Decrease diarrhea Improved antibody response after vaccines-Hib, diphtheria
and polio
Vitamin D
ENFAMIL NEWBORN –FIRST 3 MONTHS
AAP recommends 400 i.u Vitamin D with in the first few days of life
Breast milk : Vitamin D content : <25-78 i.u/L Suggest 1ml Di-vi-sol
daily Formula fed:
400 i.u Vitamin D in 27 oz of formula
Soy FormulaProsobee, Isomil, Gerber good start soy
Indications: Vegetarian, lactose intolerance, galactosemia, IgE –associated allergy to milk protein
Condradictions: Premature infants < 1800 gms, renal disease, Fructose intolerance (has sucrose), prevention of colic or allergy, cow milk protein induced entercolitis or enteropathy
Soy Formula
Supplemented with L-methionine and taurine to improve it’s biologic value
Nucleotides are not added Supplemented with zinc and iron Aluminum concentrations of 600-1.300
ng/ml compared to 4-65 ng/ml in human milk
Contains isoflavones with estrogenic activity
Protein Hydrolysate FormulasAlimentum, Nutramigen, Pregestermil
Proteins are casein or whey Treated with heat and enzymatically
hydrolyzed. Results in free amino acids and peptide of
varying length Contain varying amounts of Medium
chain Triglycerides
Protein Hydrolysate Formulas
Indications: Disorders associated with compromised enteric digestion-Short bowel syndrome, food protein allergy, pancreatic insufficiency, biliary atresia
Contraindications: Severe food allergy/intolerance
Protein Hydrolyzed
Formula CHO Fat Protein
Nutramigen Corn syrup solids, corn starch
LCF, No MCT Hydrolyzed casein
Alimentum Sucrose, tapioca starch
33 % MCT Hydrolyzed casein
Pregestermil
Corn syrup solids, dextrose
55 % MCT Hydrolyzed casein
Free Amino Acid FormulasElecare, Neocate, Puramino
Protein source are free amino acids Considered non-immunogenic Only available in powder Indications: Severe and multiple food
allergies Caution: contains soy oil
PM 60/40
Renal impairment Protein content same as standard,
whey:casein ration is 60:40 Mineral content same as human milk Slightly less NA and K than standard
formula Low Iron
Enfaport, Portagen, Monogen
Fat malabsorption Usually associated with chylous ascites,
chylothorax MCT oil- 85% fat content Not for long term use, may need essential
fatty acid supplementation Formulas: Enfaport, Portagen, Monogen
Concentrating formula
To provide increased macronutrients For patients who can not tolerate high
volumes necessary to meet needs Usually increase by 2-4 kcal/oz
increments Can be concentrated to 24 or 27 kcal/oz
(see hand out for mixing instructions) Addition of modulars after 26-28 kcal/oz Older than one year can concentrate
greater than 30 kcal/oz
Issues to Consider
Fluid vs. calorie needs Micronutrient adequacy Renal solute load
The sum of solutes filtered by the kidney Solutes include amino acids urea, electrolytes When the solute load is above is above the
handling capacity of the kidney can result in dehydration and osmotic diuresis
Hypernatremia, metabolic acidosis, elevated BUN
Modulars
Fat Microlipid, MCT, Vegetable oil
CHO Polycose, rice cereal
Protein Beneprotein, Prostat, Juven
Other Duocal, powder infant formula, fiber
Multivitamin and mineral supplementation
Vitamin K provided at birth Vitamin D: 400 i.u daily
Standard Term formula requires 32 ounces Enfamil newborn requires 27 ounces
Flouride-begin at 6 months .25 mg/day if water supple 0.3ppm – 1 ml poly-vi-flor
Pediatric Formulas
Standard dilution 1 kcal/1ml = 30 kcal/oz Ready to feed or powder For children 1-10 years
Concentrated pediatric formulas available 30-40 kg may use adult formulas Decrease fluid, concentrated formula
Increase protein needs
Pediatric Formulas
Pediasure or Nutren jr 1.0 to 1.5 kcal/ml Milk protein base Used orally or tube feeding
Elemental: Pediasure peptide, Peptamin jr 1.0, 1.5 kcal/ml
Speciatly formulas: Vivonex, Elecare Jr, Tolerax, Modulen
Pediasure side kicks 20 kcal/oz-lower calorie
Recommended