Enteral and parenteral nutrition are important for critically ill children to prevent further deterioration. Enteral nutrition is preferred when possible due to gut trophic effects. Nutritional requirements vary based on factors like age, illness severity, and metabolic stress. Careful monitoring is needed to avoid overfeeding and associated complications while meeting caloric and protein goals tailored for each patient.

1. ENTERAL ANDENTERAL AND
PARENTERAL NUTRITIONPARENTERAL NUTRITION
IN CRITICALLY ILLIN CRITICALLY ILL
CHILDRENCHILDREN
Dr. Armaan SinghDr. Armaan Singh

2. LEARNING GOALSLEARNING GOALS
Impact of Critical Illness
Importance of Nutrition
Goals of nutritional support
Nutritional requirements
Enteral vs Parenteral
When and how to initiate and advance Nutrition
Monitoring

3. IMPACT OF CRITICAL ILLNESS-1IMPACT 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

4. IMPACT OF CRITICAL ILLNESS-2IMPACT OF CRITICAL ILLNESS-2
Increased energy expenditure
– Pain
– Anxiety
– Fever
– Muscular effort-WOB, shivering

5. RESPONSE TO INJURYRESPONSE TO INJURY

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

7. NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS
ACCP Consensus statement, 1997ACCP Consensus statement, 1997
Provide nutritional support appropriate
for the individual patient’s
– Medical condition
– Nutritional status
– Available routes for administration

8. NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS
Prevent/treat macro/micronutrient
deficiencies
Dose nutrients compatible with existing
metabolism
Avoid complications
Improve patient outcomes

9. ENTERALENTERAL
OROR
PARENTERALPARENTERAL

10. IMPACT OF STARVATION-1IMPACT OF STARVATION-1
Negative nitrogen balance, further wt loss
Morphological changes in the gut
– Mucosal thickness
– Cell proliferation
– Villus height
Functional changes
– Increased permeability
– Decreased absorption of amino acids

11. IMPACT OF STARVATION-2IMPACT OF STARVATION-2
Enzymatic/Hormonal changes
– Decreased sucrase and lactase
Impact on immunity
– Cellular: Decreased T cells, atrophied germinal
centers, mitogenic proliferation, differentiation,
Th cell function, altered homing
– Humoral: Complement, opsonins, Ig, secretory IgA
– (70-80% of all Ig produced is secretory IgA)
– Increased bacterial translocation

12. ENTERAL or PARENTERAL?ENTERAL or PARENTERAL?
Enteral Nutrition: Superior to Parenteral
– Trophic effects on intestinal villus
– Reduces bacterial translocation
– Supports Gut-associated Lymphoid Tissue
– Promotes secretory IgA secretion and function
– Lower cost
Parenteral Nutrition
– IV access
– Infectious risk

13. ENTERAL WITH PARENTERALENTERAL WITH PARENTERAL
IS THE COMBINATION BETTERIS THE COMBINATION BETTER
120 adult patients, (medical and surgical)
Combination vs enteral feeds alone
Prospective, randomized, double blind, controlled
RBP, pre albumin increased significantly D 0-7
No reduction in ICU morbidity
No reduction in ICU LOS/ vent, MSOF, dialysis
Reduced hospital stay (by 2 days)
Mortality at 90 days and 2 years was identical
Bauer et al, Intensive care med. 2000: 26, 893-900

14. A PRACTICAL APPROACH-1A PRACTICAL APPROACH-1
Nutritional assessment
– History-preexisting malnutrition, underlying
disease, recent wt loss (> 5% in 3 wks or >10%
in 3 months)
– Physical-anthropometrics, BMI, evidence of
wasting
– Labs-albumin (t ½ 18-21 d),
transferrin (t ½ 8 d), prealbumin (t ½ 2 d),
RBP (t ½ 0.5 d)

15. A PRACTICAL APPROACH-2A PRACTICAL APPROACH-2
Assessment of the present illness
Hypermetabolism-burns, sepsis, MSOF,
trauma
GI surgical procedures-prolonged NPO
End-organ failure (Hepatic/renal etc)
Metabolic Cart-facilitates assessment
of energy expenditure, Respiratory
Quotient

16. WHEN TO INITIATEWHEN TO INITIATE
ENTERAL NUTRITION:ENTERAL NUTRITION:
ASAP-usually within 24 hours in severe
trauma, burns and catabolic states
Contraindications to enteral nutrition:
– Nonfunctional gut, anatomic disruption, gut
ischemia
– Severe peritonitis
– Severe shock states

17. ROUTE OF FEEDINGROUTE OF FEEDING
Nasogastric
– Requires gastric motility/emptying
Transpyloric
– Effective in gastric atony/ colonic ileus
– Silicone/polyurethane tubing
– Positioning, Prokinetic agents/ fluoroscopic/ pH/
endoscopic guidance
Percutaneous/surgical placement
– PEG if > 4 weeks nutritional support anticipated
– Jejunostomy if GE reflux, gastroparesis, pancreatitis

18. POTENTIAL DRAWBACKSPOTENTIAL DRAWBACKS
OF ENTERAL FEEDSOF ENTERAL FEEDS
Gastric emptying impairments
Aspiration of gastric contents
Diarrhea
Sinusitis
Esophagitis /erosions
Displacement of feeding tube

19. NUTRITIONAL REQUIREMENTSNUTRITIONAL 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%

20. Resting Energy ExpenditureResting 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

21. Factors adding to REEFactors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree > 38ºC
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1
Sepsis 0.4
Growth 0.5

22. NUTRITIONAL REQUIREMENTSNUTRITIONAL 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

23. FORMULA COMPOSITIONFORMULA 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

24. FORMULA COMPOSITIONFORMULA 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

25. COMPOSITION-SPECIALCOMPOSITION-SPECIAL
FORMULASFORMULAS
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

26. IMMUNE MODULATIONIMMUNE MODULATION
Glutamine
Arginine
 Fatty acids (w-3)
Nucleotides
Vitamins and minerals
Pediatric burn patients: Arginine & w-3 fatty acid
supplements reduce infections, LOS
( Gottslisch: J Parenter. Ent. Nutr. 14: 225, 1990)

27. IMMUNE MODULATIONIMMUNE MODULATION
Glutamine+arginine+Branched chain AA
(Immunaid)
Arginine+omega-3 Fatty acids+RNA (Impact)
– EN started within 36 hrs
– Mortality, bacteremic episodes reduced
– More pronounced effect in APACHE II 10-15
Galban et al, CCM, 2000; 28: 3, (643-48)

28. IMMUNE MODULATIONIMMUNE MODULATION
MECHANISMS ARE UNCLEARMECHANISMS ARE UNCLEAR
Reduction of duration and magnitude of
inflammatory response
Will this disrupt the balance between pro
and anti-inflammatory processes??
Of the multiple ingredients in these special
formulas: which is “the” one
Beneficial effects seen in patients achieving
early EN

29. Conclusive studies, clear
indications
&
Cost-benefit analysis are
still needed
IMMUNE MODULATIONIMMUNE MODULATION

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

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

32. Fluid RequirementsFluid 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 calculations.

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

34. PN-suggested guidelines forPN-suggested guidelines for
Initiation and MaintenanceInitiation 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%

35. Resting Energy ExpenditureResting 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

36. Factors adding to REEFactors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree > 38ºC
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1
Sepsis 0.4
Growth 0.5

37. Suggested monitoring ProtocolSuggested monitoring Protocol
Weight Urine dip
for
glucose
Bedside
glucose
Labs
First week Daily Q shift Q shift Daily SMA-7, Ca,
Mg, Phos,
triglycerides
Q OD LFTs
Subsequently Daily Q shift Q shift SMA-7, Ca, Mg,
Phos 2x/wk
CBC, LFTs
weekly
Triglycerides
2x/wk

38. CalculationsCalculations
Dextrose
____g/100ml Dextrose × ____ml/day =
____grams/day
_____g/day ÷ (weight × 1.44) = _____mg/kg/min
_____g/kg/day × 3.4 kcal/g = _____ kcal/kg/day

39. CalculationsCalculations
Fat
 20 grams/100ml Fat × _____ml/day =
_____grams/day
_____g/kg/day × 9 kcal/g = _____
kcal/kg/day

40. CalculationsCalculations
grams Protein ÷ 6.25 = _____ Nitrogen
Non-protein calories ÷ Nitrogen =
Calorie:Nitrogen ratio

41. DANGERS OF OVERFEEDINGDANGERS OF OVERFEEDING
Secretory diarrhea (with EN)
Hyperglycemia, glycosuria, dehydration,
lipogenesis, fatty liver, liver dysfunction
Electrolyte abnormalities: PO4, K, Mg
Volume overload, CHF
 CO2production- ventilatory demand
 O2 consumption
Increased mortality (in adult studies)

42. MONITORINGMONITORING
Prevent OverfeedingPrevent Overfeeding
Carbohydrate: High RQ indicates CHO excess,
stool reducing substances
Protein: Nitrogen balance
Fat: triglyceride
Visceral protein monitoring
Electrolytes, vitamin levels
Caloric requirement assessment by metabolic cart

43. CONCLUSIONSCONCLUSIONS
Start nutrition early
Enteral route is preferred when available
Set goals for the individual patient
Dose nutrients compatible with existing
metabolism
Appropriate monitoring is essential
Avoid overfeeding