Pediatric Critical Care Nutrition

Kristy Paley, MS, RD, LDN, CNSC

Outline

PICU nutrition goals Energy expenditure/Kcal requirements Indirect Calorimetry Protein requirements Parenteral Nutrition Guidelines Enteral Nutrition Guidelines Infant and Child Formulas

Mehta and Duggan (2009), Hulst et al. (2006), Rogers et al. (2003)

PICU-associated malnutrition

Metabolic stress response Estimations of energy requirement Prescription and Delivery Preexisting deficiency/reduced somatic

stores

Mehta and Duggan (2009)

Nutrition Goals for the PICU

1. Minimize protein catabolism

2. Meet energy requirement

Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus and Jaksic (2002)

Energy Expenditure

Pediatric patients may not exhibit significant hypermetabolism post-injury

Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure

Agus and Jaksic (2002)

Energy Provision

Increased risk of overfeeding with intubation/sedationIncreased risk of overfeeding with intubation/sedation Impair liver function by Impair liver function by inducing steatosis/cholestasisinducing steatosis/cholestasis Increase risk of infectionIncrease risk of infection HyperglycemiaHyperglycemia Prolonged mechanical Prolonged mechanical ventilationventilation Increased PICU LOSIncreased PICU LOS

No benefit to the maintenance of lean body mass (LBM)

Hardy et al. (2002), Vazquez Martinez et al. (2004), Fung (2000), Sy et al. (2008), Briassoulis et al. (2000), Verhoeven et al. (1998)

Energy Requirements

Standard equations to predict energy needs unreliable

Indirect calorimetry is the gold standard to accurately predict REE

Unable to use IC for

all PICU patients

Mehta et al. (2009)

Suggested Candidates for Indirect Calorimetry (IC)• Underweight (BMI < 5th percentile for age)

or overweight (BMI > 95th percentile for age) *(EN or PN support)

• Failure to wean, or need to escalate respiratory support*

• Need for muscle relaxants or mechanical ventilation for > 7 days

Mehta et al. (2009)

Suggested Candidates for IC

• Neurologic trauma*• Children with thermal injury*• Children suspected to be severely

hypermetabolic or hypometabolic • Any patient with ICU LOS > 4 weeks

Limitations of IC

Air leaks around ET tubes Chest tubes FiO2 >60% Receiving dialysis

Briassoulis et al. (2000)

Comparison of MEE vs. cREE

DRI vs. REE

Age DRI (kcal/kg) REE (kcal/kg)

0-3 mon 102 54

4-6 mon 82 54

7-12 mon 80 51

13-35 mon 82 56

3 y 85 57

4 y 70 47

5-6 y 65 47

7-8 y 60 47

Lloyd (1998)

Kcal Requirements: Intubated0-12 months May require > REE

Activity not significant % of kcalKcal used predominately for growth

Consensus is to provide >REE for infants 0-Consensus is to provide >REE for infants 0-12 months despite intubation/sedation 12 months despite intubation/sedation (~75-80% of the DRI for age)(~75-80% of the DRI for age)

0-3 mon (~80kcal/kg)0-3 mon (~80kcal/kg) 4-12 mon (~65kcal/kg)4-12 mon (~65kcal/kg)

Agus and Jaksic (2002), Hardy Framson et al. (2007)

Kcal Requirements: Intubated> 12 months Kcal goal = REE

WHO, Schofield, White equations 3y: ~60kcal/kg 4-8y: ~50kcal/kg

Activity and injury factors not routinely Activity and injury factors not routinely usedused(exception): REE x 1.2 for intubated burn pts

Kcal Requirements: Extubated

Kcal goal = DRIs for age/gender Catch up growth may be necessary

(DRI x IBW) ÷ actual wt (kg) BMI for age >85th%tile use IBW

IBW: BMI for age @50th%tile (BMI @50th%tile x actual wt) ÷ actual BMI

Protein RequirementsAge DRI (normal) PICU

0-6mon 1.52g/kg/day 2-3g/kg/day

7-12mon 1.2 2-3

13-23mon 1.05 2-3

24mon-3y 1.05 1.5-2

4-13y 0.95 1.5-2

14-18y 0.85 1.5

***may require further increases in protein provision with burns, ECMO, bacterial sepsis

Parenteral Nutrition

PPN vs. TPN

PPN Peripheral access <900 mOsm/L Max D12.5% Can go up to D15%

with non-central PICC Usually requires

increased fluid allowance

TPN Central access No osmolarity

limitations Typical max dextrose

usually D25% however can go up to D30% prn

ASPEN (2010)

Fung (2000)

Parenteral Nutrition Kcal

Goal kcal dictate macronutrient goals Extubated: provide ~10% < DRIs due to

lack of thermogenesis Intubated: REE or ~80% DRI (dependent

on pt’s age) usually appropriate

20% Intralipid

Essential Fatty Acids (EFA) Omega-6 source

Concentrated source of kcal2kcal/ml

Coss-Bu et al. (2001), ASPEN (2010)

Parenteral Lipids

***goals dependent on total kcal goals

***do not exceed 60% kcal via lipid (ketosis)

***maximum lipid clearance 0.15g/kg/H

Age Initiate Advance Maximum

<1yr 1g/kg/day 1g/kg/day 3g/kg/day

1-10yr 1g/kg/day 1g/kg/day 2-3g/kg/day

>10yr (adolescents)

1g/kg/day 1g/kg/day 1-2.5g/kg/day

Marcason (2007), ASPEN (2010)

Essential Fatty Acid Deficiency

Can occur within “days to weeks” although clinical S/S may not been detected for months

Triene:tetaene ratio ≥ 0.4 Prevented by providing 0.5g/kg/day of lipid (2-

4% of total kcal) Symptoms of EFAD:

Alopecia, scaly dermatitis, increased capillary fragility, poor wound healing, increased platelet aggregation, increased susceptibility to infection, fatty liver, and growth retardation in infants and children

ASPEN (2010)

Parenteral Amino Acids (AA) Neonatal AA

(Trophamine 10%) AA attempt to mimic breastmilk Cysteine added to lower pH =

more Ca and Phos to TPN More fluid-restricted than pediatric

standard AA solution Used for <5kg

Pediatric AA

(Freamine 8.5%) Used for >5kg Contains Phos

0.1 mmol/gram AA

Parenteral AA Guidelines

Age Initiate Advance Maximum

<1yr 1-2g/kg/day 1g/kg/day 4g/kg/day

1-10yr 1-2g/kg/day 1g/kg/day 1.5-3g/kg/day

>10yr (adolescents)

1g/kg/day 1g/kg/day 0.8-2.5g/kg/day

***Goal aa correspond to ASPEN protein guidelines for critical illness mentioned earlier ***4kcal/g aa

ASPEN (2010)

Parenteral Dextrose

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)

GIR/Dextrose Guidelines

Age Initiate Advance Maximum

<1yr ~6-9mg/kg/min 1-2mg/kg/min Goal: 10-12mg/kg/minMax: 14mg/kg/min

1-10yr 1-2mg/kg/min >IVF GIR

1-2mg/kg/min Max: 8-10mg/kg/min

>10yr (adolescents)

1-2mg/kg/min >IVF GIR

1-2mg/kg/min Max: 5-6mg/kg/min

ASPEN (2010)

ASPEN (2010)

PN Electrolyte Dosing Guidelines

Electrolyte Preterm

Neonates

Infants/

Children

Adolescents/

Children >50kg

Na 2-5meq/kg 2-5meq/kg 1-2meq/kg

K 2-4meq/kg 2-4meq/kg 1-2meq/kg

Ca 2-4meq/kg 0.5-4meq/kg 10-20meq/day

Phos 1-2mmol/kg 0.5-2mmol/kg 10-40mmol/day

Mg 0.3-0.5meq/kg 0.3-0.5meq/kg 10-30meq/day

Acetate As needed to maintain acid-base balance

Chloride As needed to maintain acid-base balance

PNALD

PNALD Avoid macronutrient overfeeding in general Decrease lipids GIR ≤ 12.5mg/kg/min Cholestatic trace elements

Decreased Cu; no Mn

Cycle TPN as able Initiate EN asap (even trophic feeds)

Btaiche and Khalidi (2002), Kaufman (2002)

Other PN considerations

Cysteine: conditionally essential aa Decreases pH of TPN; increases solubility of

Ca and Phos Carnitine

Synthesis and storage suboptimal at birth 10mg/kg/day if anticipate exclusive PN for 2-4

weeks; can increase to 20mg/kg/day prn

Other PN considerations

Current trace elements contain no Se Parenteral requirement: 2mcg/kg/day Se deficiency

Cardiac and skeletal myopathy Risk factor for BPD Hypothyroidism Weakened immune system

Enteral Nutrition

Enteral Nutrition

Whenever possible, feed the gutGALT/reduce risk for bacterial translocation

Trophic feeds: ≤20ml/kg/day

Continuous feeds Initiate @~1ml/kg/H

Advance by 0.5-1ml/kg Q4-6H

Infant Formulas

Term formulas: standard concentration 20kcal/oz

Preterm formulas: 24kcal/oz Preterm transitional formulas: 22kcal/oz Can increase up to 30kcal/oz

Increase concentration by 2kcal/oz incrementUse infant formulas to concentrate MBM in term

AGA pts, not HMF

I nfant Formulas 0-12 months of age

Lactose- Free Enf amil LactoFree Similac Sensitive

Soy Protein Enf amil ProSobee

Similac I somil Good Start Soy

Preterm Formula (24) Enf amil Premature Lipil

Similac Special Care

Preterm Discharge Formula (22) Enf amil Enf aCare Lipil

Similac Neosure

Peptide- Based Nutramigen

Pregestimil (55% MCT) Alimentum (33% MCT)

Elemental (100% f ree Amino Acids)

Neocate (33% MCT) Elecare (33% MCT)

I ntact Protein Breastmilk (MBM)

Enf amil Lipil Similac Advance

Enf amil Gentlease (hydrolyzed casein & whey protein) GERD: Enf amil AR

Renal: Similac PM 60-40 Chylothorax: Monogen (90% MCT)

Pediatric Formulas (1-10yr)

Description CPOE name Product Specs

Intact Protein (+/- Fiber)

Pediatric Standard

Nutren Jr 1kcal/ml; 30g protein per L

Pediatric Standard with Fiber

Nutren Jr with fiber

1kcal/ml; 30g protein per L

Pediatric Blenderized

Pediatric Compleat

1kcal/ml; 38g protein per L; omega 3 FA

Fluid-restricted Pediatric High Calorie 1.5 with/without fiber

Boost Kid Essentials 1.5 with/without fiber

1.5kcal/ml

Pediatric Formulas (1-10yr)

Description CPOE name Product Specs

Peptide-based Pediatric Semi-Elemental (1)

Peptamen Jr with prebio

1kcal/ml

Pediatric Semi-Elemental (1.5)

Peptamen Jr 1.5 1.5kcal/ml

Elemental Pediatric Amino Acid-Based

Elecare Jr 1kcal/ml(30kcal/oz)

Other Formula Considerations

≥10yr: can use adult formulaStandard Isotonic with Fiber: Nutren 1.0 with FiberStandard Isotonic: Nutren 1.0High Calorie 1.5: Nutren 1.5 (fluid restricted)

***Children >10yr w/ MRCP or with malnutrition may still require pediatric product due to wt age <10yrs

References

Agus, M., & Jaksic, T. (2002). Nutritional support of the critically ill child. Current Opinion in Pediatrics, 14, 470-81.

American Society for Parenteral and Enteral Nutrition. (2010). The A.S.P.E.N. pediatric nutrition support core curriculum.

Briassoulis, G., Venkataraman, S., & Thompson, A. (2000). Energy expenditure in critically ill children. Critical Care Medicine, 28(4), 1166-72.

Btaiche, I.F. & Khalidi, N. (2002). Parenteral Nutrition-associated liver complications in children, 22(2): 188-211.

Coss-Bu, J., Klish, W.J., Walding, D., Stein, F., O’Brien Smith, E., Jefferson, L.S. (2001). Energy metabolism, nitrogen balance, and substrate utilization in critically ill children. American Journal of Clinical Nutrition, 74: 664-9.

Fung, E.B. (2000). Estimating energy expenditure in critically ill adults and children. AACN Advanced Critical Care, 11(4): 480-97.

References

Hardy, C., Dwyer, J., Snelling, L., Dallal, G., Adelson, J. (2002). Pitfalls in predicting resting energy requirements in critically ill children: a comparison of predictive methods to indirect calorimetry. Nutrition in Clinical Practice, 17, 182-9.

Hardy Framson, C., LeLeiko, N., Dallal, G., Roubenoff, R., Snelling, L., & Dwyer, J. (2007). Energy expenditure in critically ill children. Pediatric Critical Care Medicine, 8, 264-7.

Hulst, J.M., Joosten, K.F., Tibboel, D., van Goudoever, J.B. (2006). Causes and consequences of inadequate substrate supply to pediatric ICU patients. Current Opinion in Clinical Nutrition and Metabolic Care, 9:297-303.

Kaufman, S.S. (2002). Prevention of parenteral nutrition-associated liver disease in children. Pediatric Transplantation, 6: 37-42.

Letton, R., Chwals, W., Jamie, A., & Charles, B. (1995). Early postoperative alterations in infant energy use increase the risk of overfeeding. Journal of Pediatric Surgery, 30(7), 988-93.

References

Llyod, D.A. (1998). Energy requirements of surgical newborn infants receiving parenteral nutrition. Nutrition, 14(1): 101-104.

Marcason, W. (2007). Can cutaneous application of vegetable oil prevent an essential fatty acid deficiency? Journal of the American Dietetic Association, 107(7): 1262.

Mehta, N., Compher, C., & ASPEN board of directors. (2009). A.S.P.E.N. clinical guidelines: nutrition support of the critically ill child. Journal of Parenteral and Enteral Nutrition, 33(3), 260-76.

Mehta, N., & Duggan, C. (2009). Nutritional deficiencies during critical illness. Pediatric Clinics of North America, 56, 1143-1160.

Rogers, E.J., Gilbertson, H.R., Heine, R.G., Henning, R. (2003). Barriers to adequate nutrition in critically ill children. Nutrition, 19:865-8.

Sy, J., Gourishankar, A., Gordon, W.E., Griffin, D., Zurakowski, D., Roth, R.M., Coss-Bu, J., Jefferson, L., Heird, W., Castillo, L. (2008). Bicarbonate kinetics and predicted energy expenditure in critically ill children. American Journal of Clinical Nutrition, 88:340-7.

References

Vasquez Martinez, J., Martinez-Romillo, P., Sebastian, J., & Tarrio, F. (2004). Predicted versus measured energy expenditure by continuous, online indirect calorimetry in ventilated, critically ill children during the early postinjury period. Pediatric Critical Care Medicine, 5(1), 19-27.

Verhoeven, J., Hazelzet, J., Van der Voort, E., & Joosten, K. (1998). Comparison of measured and predicted energy expenditure in mechanically ventilated children. Intensive Care Medicine, 24, 464-8.