This document discusses nutrition in critically ill children. It begins by defining nutritional support and critical illness. It then discusses that malnutrition is common in critically ill children and can worsen during ICU admission if not addressed. Several barriers to adequate nutritional intake in the ICU are outlined, including fluid restrictions and gastrointestinal intolerance. The document provides guidelines for assessing nutritional status, determining caloric and protein needs, and considering enteral versus parenteral nutrition. It stresses the importance of nutrition to prevent complications and support recovery in critically ill children.

1. Nutrition in Critically ill Child

2. 2
By the end of this lecture, students will be able
to understand:
• The importance of nutrition in the first year
of life
• How calorie intake in infants is different
from that of an adult
• The gradual transition in diet intake in the
first year of life, and the differences
between breast and bottle feeding
• The concepts related to the assessment of
nutritional intake in infancy
• The transition between infancy and
childhood and how that affects nutritional
intake

3. • Nutritional support in the critically ill child has not been well
investigated and is a controversial topic in paediatric critical
care medicine. There are no clear guidelines for the optimal
timing and forms of nutritional support in these children.
3

4. • Nutritional support as the provision of energy in the form of
glucose, protein, or lipid to provide calories and substrate for
metabolism.
• Some would define metabolic support as provision of these
calories at basal metabolic rate, without any intention of
supporting anabolic activities such as growth or activities of
daily living. Accordingly, metabolic support is a form of
nutritional support. For the purposes of this review, we defined
critical illness as any illness requiring admission to a pediatric
intensive care unit
4

5. introduction
• Malnutrition is common on admission to PICU
• Nutrition may deteriorate within the picu unless specific
attention is paid to the issues
• There is very little quality data available on the optimal nutrition
of critically ill children
• There is a need to set and achieve nutritional goals in the PICU
Nutrition must be assessed in context

6. who is the critically ill patient?
pre-term infant
kwashiorkior
abdominal injury
post cardiac surgery chronic ventilation
others…..

8. nutrition – why worry?
problems are common
• acute PEM in 19%, chronic PEM in 18% of PICU admissions
Pollack et al JPEN 1982
• 16.7% of PICU admissions depleted of protein and 31% of fat stores
• survivors had higher prealbumin levels
Briassoulis et al Nutrition 2001
• 12 of 43 patients had normal nutritional status
Vazquez Martinez et al PCCM 2004
• 53% of admissions had moderate or severe malnutrition(adolescents and children)
• Delgado et al, Clinics, 2008
malnutrition is common in critically ill children

9. nutrition – why worry?
problems may get worse
• Group of infants and children studied from admission
to 6 months after discharge
• 24% malnourished on admission, and a decline in nutritional status
occurred during the admission
• majority showed good long term outcome
Hulst J et al Clin Nutr 2004

10. what limits how much you get
in?
• 42 children in tertiary PICU
• received mean of 37.7% of EER (cardiac patients had lower intake)
• barriers
• fluid restriction (66.7%)
• GIT intolerance (57.1%)
• procedures (61.0%)
• surgical (42.9%)
• extubation (33.3%)
Rogers et al, Nutrition, 2003
• 55 critically ill children
• aged 8.2 +/- 11.4 months
• delivered vs required energy <90% in 55.7% days.
• low prescription main reason for not achieving energy goal in the first 5
days
de Olivera Iglesias et al, Clin Prac Nutr, 2007
what to do when feeds interrupted?
increase feed rate to compensate?
gradually increase from baseline?
? benefits of transpyloric feeds

11. how to measure nutritional
status?
• anthropometry technically difficult
• frequently not done
• most biochemical markers associated with acute phase
reaction
• trends may be useful
• indirect calorimetry
• technically challenging
• time consuming
• monitoring of intake

12. Metabolic stress response
Mehta & Duggan, Pediatric Clinics of North America, 2009

13. IMPACT OF CRITICAL ILLNESS-1
• Physiologic stress response : Catabolic phase
• increased caloric needs, urinary nitrogen losses
• inadequate intake wasting of endogenous protein
stores, gluconeogenesis
• mass reduction of muscle-protein breakdown

14. IMPACT OF CRITICAL ILLNESS-2
• Increased energy expenditure
• Pain
• Anxiety
• Fever
• Muscular effort- shivering

15. WHY IS NUTRITION IMPORTANT
CRITICAL ILLNESS + POOR NUTRITION =
• Prolonged ventilator dependency
• Prolonged ICU stay
• Heightened susceptibility to nosocomial infections
• Increased mortality with mild/moderate or severe
malnutrition

16. Risk Factors for Malnutrition in the Critically
Ill Child
• The incidence of malnutrition is higher in children
under two years of age
• a prolonged hospital stay,
• child require mechanical ventilation.
• Children with congenital heart disease and extensive
burn injuries are also at increased risk of malnutrition
16

17. • An additional factor is that critically ill children frequently
receive an insufficient calorie and protein delivery because
enteral or parenteral nutrition cannot be initiated due to
gastrointestinal intolerance or the need to restrict fluid
intake, initiation is delayed, or there are interruptions in
enteral nutrition in order to administer medication or to
perform interventions requiring sedation.
17

18. Importance of Nutrition in the Critically Ill
Child
• to enable growth and development.
• the critically ill child uses nutrients principally to defend the
body against disease.
18

19. What Calorie Delivery Does the Critically Ill
Child Require
• The critically ill child typically has a lower energy expenditure
than the healthy child due to the reduced motor activity and
work of breathing, in addition to the sedation, relaxation, and
hypothermia; however these patients have different
requirements for certain nutrients .
• Only a small percentage of children, those with persistent
high fever, trauma, major burns, or prolonged admission to
the PICU, have an increased metabolic rate.
19

20. Underfeeding and overfeeding
during critical illness
• Overfeeding has important adverse effects during critical
illness
• Excess carbohydrate intake can increase carbon dioxide
production and impede ventilator weaning
• Excess protein does not prevent catabolism and can even
increase catabolism of body protein
• High calorific intake can increase fat deposition, including
in the liver
20

21. Nutritional assessment
⚫History
○ Preexisting malnutrition
○ Underlying disease
○ Recent weight loss
⚫>5% in 3 wks or
⚫>10% in 3 months

22. Nutritional assessment
⚫Anthropometry
○ Mid upper arm circumference
○ Triceps skin fold thickness
○ Weight
○ Length / height
○ BMI

23. Nutritional assessment
⚫ Biochemical assessment
○ Measure – visceral protein pool, acute phase protein pool,
nitrogen balance, REE
○ Albumin (t ½ 14-20 d)
⚫ Reliability questionable
○ Transferrin (t ½ 8 d), prealbumin (t ½ 2 d), retinol
binding protein (t ½ 0.5 d)
○ C – reactive protein
○ Micronutrient deficiency: variable
⚫ Enzymes, cofactors (Se, Zn, Fe, Mn), glutathione, vitamins
(A,B,C,D,E,K), electrolyte, Ca++, HCO3, PO4, Mg++

24. Assessment of the present illness
⚫Hypermetabolism
○ Burns,
○ Sepsis,
○ MSOF,
○ Trauma
⚫GI surgical procedures-prolonged NPO
⚫End-organ failure (Hepatic/renal etc)

25. NUTRITIONAL REQUIREMENTS
• 25-30 non protein Kcal/kg/d adult males
• 20-25 non protein Kcal/kg/d adult females
• Children: BMR 37-55 Kcal/kg/d (50% of EE)
+ Activity + growth
• Factors increasing EE
• Fever 12%
• Burns upto 100%
• Sepsis 40-50 %
• Major surgery 20-30%

26. Resting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 – 1 55
1 – 3 57
4 –6 48
7 –10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25

27. NUTRITIONAL REQUIREMENTS
• Initial protein intake 1.2-1.5 gram/kg/d
• Micronutrients-added if feeds are small in volume or
patient has excessive losses
• Tailor individually, 24-30 cal/oz formula
• Usually continuous feeds are tolerated better
• Add for catch up growth upon recovery
• Adequate calories = adequate growth

28. FORMULA COMPOSITION
• Carbohydrates: 60-70% of non protein calories
• Polysaccharides/disaccharides/monosaccharides
• Glucose polymers better absorbed
• Lipids: 30-40% of non protein calories
• Source of EFA
• Concentrated calories-but poorer absorption
• MCT direct portal absorption-better

29. FORMULA COMPOSITION
• Proteins
• -polymeric (pancreatic enzymes required) or peptides
• Small peptides from whey protein hydrolysis
absorbed better than free AA
• Fibers
• Insoluble-reduce diarrhea, slower transit-better
glycemic control
• Degraded to SCFA-trophic to colon

30. COMPOSITION-SPECIAL FORMULAS
• Pulmonary: High fat( 50%), Low CHO
• Hepatic: High BCAA, low aromatic AA, <0.5 gm/kg/d
protein in encephalopathy
• Renal: Low protein, calorically dense, low PO4 , K,
Mg
GFR >25: 0.6-0.7 g/kg/d
GFR <25: 0.3 g/kg/d
• Immune-enhancing

31. • Maintains nutritional status
• Prevents catabolism
• Provides resistance to infection
• Potential effect on immune
modulation
ENTERAL NUTRITION IN
CRITICAL ILLNESS:

32. PARENTERAL NUTRITION (PN)
The PN formulation is based on:
• Fluid Requirements
• Energy Requirements
• Vitamins
• Trace elements
• Other additives-Heparin, H2 blocker etc

33. Fluid Requirements
Fluid requirements = maintenance + repair of
dehydration + replacement of ongoing losses.
• Maintenance Fluid Requirements
1 - 10 kg = 100 ml/kg/day
10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg
20 kg = 1500 ml + 20ml for each kg > 20 kg
• PN generally should be used for the maintenance
needs.
• Deficit and replacement of losses should be
provided separately.
• Remember to consider medications, flushes, drips,
pressures lines and other IV fluids in your

34. Energy Requirements
Total Daily Energy Requirements (kcal/day) = Resting Energy
Expenditure (REE) + REE  (Total Factors)
Factors = Maintenance + Activity + Fever + Simple Trauma +
Multiple Injuries + Burns + Growth

35. PN-suggested guidelines for Initiation and
Maintenance
Substrate Initiation Advance
ment
Goals Comments
Dextrose 10% 2-5%/day 25% Increase as tolerated.
Consider insulin if
hyperglycemic
Amino
acids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Maintain
calorie:nitrogen ratio
at approximately
200:1
20%
Lipids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Only use 20%

36. Resting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 – 1 55
1 – 3 57
4 –6 48
7 –10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25

37. NUTRITION SUPPORT IN THE INTENSIVE
CARE UNIT.
Nutrition unless there is a major gut condition which will delay
commencement of enteral nutrition
• Nasogastric feeding should begin within 24 h, but if intolerance
develops, promotility drugs (erythromycin or metoclopramide)
or small bowel feeding should be attempted before resorting to
supplementary parenteral nutrition

38. Enteral Nutrition
• Use EN in patients who can be fed
via the enteral route
• Avoid additional parenteral
nutrition in patients who tolerate
EN and can be fed approximately
to the target values
• There is no significant difference
in the efficacy of jejunal versus
Grade A
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lnutrition in intensive care:

39. • Small bowel feeding tubes
– are more expensive
– appear to block more commonly
– are not uncommonly
inadvertently removed
– can be difficult to place, delay in
EN
Nguyen N, et al. World J Gastroenterol 2006;
12:4383–4388

40. 0% 2% 4% 6% 8% 10% 12% 14%
GIT complications
Duodenal
perforation
NEC
GIT bleeding
Diarrhea
Abdominal
distension / GR
Lopez-Herce J, et al. Eur J Clin Nutr. 2007 Feb 28
Gastrointestinal complications in
critically ill children with
transpyloric enteral nutrition

41. ROUTESOFNUTRITIONSUPPORTGUIDELINE
Contraindication to
EN? (see blue
box)
Hypermetabolic&/
or malnourished:
EN
contraindicated
>7-10 days?
Able to meet needs
via oral route?
Oral diet.
No PN;
reassess q 24-
48 hrs re EN.
PN; reassess q
24 - 48 hrs re
EN.
EN
Contraindication
to gastric EN?
(see purple box)
GastricEN. PostpyloricEN.
Planned
abdominal
surgery?
Intraoperativepostpyloricfeedingtube.
Short term: nasoduodenaltube.
Longterm: feedingjejunostomy.
Short term: manual (seepinkbox),
endoscopic,orfluoroscopicnasoduodenal
feeding tube.
Long term: endoscopic or
fluoroscopic
gastrojejunostomy.
Absolute contraindications:
Mechanical bowel obstruction
Bowel ischemia
Relative contraindications:
Hemodynamic instability Small
bowel ileus
Small bowel fistulae Bowel
anastomosis
Contraindication to gastric
EN:
1)Gastric residual volumes >
threshold maximum (250 ml)
despite prokinetics agents.
2)Chronic/acute
gastroesophageal reflux.
3)High risk pulmonary aspiration
(i.e. required to be cared for in
prone or supine position).
Yes
No
Yes
Yes No
No
Yes
No
No
Yes
Developed by J. Greenwood, RD,
(Vancouver General Hospital) in
collaboration with the CCCCPGC
(1/1/07).
www.criticalcarenutrition.com
Nasoduodenal Feeding Tubes Manual Placement Techniques:
Kalliafas S, et al. Erythromycin facilitates postpyloric placement of
nasoduodenal feeding tubes in intensive care unit patients: randomized,
double-blinded, placebo-controlled trial. JPEN 20:385-388,1996.
Nicholas CD, et al. Simple bedside placement of nasal-enteral feeding
tubes: a case series. Nutr Clin Pract 16:165-168, 2001.
Salasidis R, et al. Air insufflation technique of enteral tube insertion: a
randomized, controlled trial. Crit Care Med 26:1036-1039,1998.
Ugo PJ, et al. Bedside postpyloric placement of weighted feeding tubes.
Nutr Clin Pract 7:284-287,1992.
Zaloga G. Bedside method for placing small bowel feeding tubes in
critically ill patients. Chest 100:1643-1646,1991.

42. Type of nutritional support delivered
Taylor: Pediatr Crit Care Med, Volume 4(2) April 2003.176-180
Enteral &
Parenteral
9%
Non
e
15%
Parenteral
21%
Enteral
55%

43. Intolerance in adult ICUs
• Lower cut-off values (150–250 mL) have often
been criticized because they can result in
premature cessation of feeds and significant
underfeeding
• When protocols using 200 mL or 400 mL to
define intolerance were compared, there was
no difference in the frequency of regurgitation
or aspiration
Lin & Van Citters, 1997, McClave et al., 2005