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