Nutrition in sick children

Dr Bedangshu Saikia

Registrar, Pediatrics and Neonatology

St Stephens Hospital, New Delhi, India

[email protected]

Metabolic stress response

Mehta & Duggan, Pediatric Clinics of North America, 2009

Nutritional assessment

History

○ Preexisting malnutrition

○ Underlying disease

○ Recent weight loss

> 5% in 3 wks or

>10% in 3 months


Anthropometry

○ Mid upper arm circumference

○ Triceps skin fold thickness

○ Weight

○ Length / height

○ BMI


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++

Assessment of the present illness

Hypermetabolism

○ Burns,

○ Sepsis,

○ MSOF,

○ Trauma

GI surgical procedures-prolonged NPO

End-organ failure (Hepatic/renal etc)

Resting energy expenditure

equations

Clinical nutrition highlights •

2007

Harris-Benedict Equations (calories/day):

Male: (66.5 + 13.8 X weight) + (5.0 X height) - (6.8 X age)

Female: (665.1 + 9.6 X weight) + (1.8 X height) - (4.7 X age)

[weight in kilograms, height in centimeters, age in years]

Overestimate by 6% to15% the actual energy expenditure measurements done by indirect calorimetry

Resting energy expenditure

equations

Resting energy expenditure (REE)

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

Normal nutritional requirements

BMR / REE

[37-55 Kcal/kg/d (50% of EE)]

+

Maintenance

+

Activity

+

Growth

Total energy expenditure

in kcal/kg/day

Energy Requirements in sick child

REE

+

REE (Total Factors)

Factors:

Maintenance + Activity + Growth + Fever + Simple Trauma + Multiple Injuries + Burns + Surgery

Total energy expenditure

in kcal/kg/day

Factors Multiplication factor

Maintenance 0.2

Activity 0.1 - 0.25

Growth 0.5

Fever 0.13/per degree > 38ºC

Simple Trauma 0.2

Multiple Injuries 0.4

Burns 0.5-1

Sepsis 0.4 – 0.5

Major surgery 0.2 – 0.3

How reliable are these equations ?

Inaccurate in critical illness

May underestimate or overestimate the true

energy requirement

Often results in underfeeding or overfeeding

Indirect calorimetry

Volume of O2 consumed, VO2

(ml/min):

Cardiac output x (CaO2 –

CvO2) [Fick Equation]

CaO2 is the arterial oxygen

content

CvO2 is the venous oxygen

content.

(CaO2 – CvO2) is

the arteriovenous o2 difference

Volume of CO2 produced,

VCO2 (ml/min):

VE (FECO2- FICO2)

VE = Volume of air expired in

mL/min

FECO2 = Fraction of CO2 in

expired air

FICO2 = Fraction of CO2 in

inspired air

REE

= [3.9 (VO2) + 1.1 (VCO2)] 1.44

[Abbreviated Weir Equation]

Respiratory

quotient (RQ)

= VCO2/VO2

VO2 = oxygen uptake (ml/min)

VCO2 = carbon dioxide output (ml/min)

The respiratory quotient (RQ)

RQ is a measure of substrate use and in individual patients has a low

specificity

RQ <0.85 is s/o underfeeding [low sensitivity, 63%; high specificity,

89%; and high negative predictive value,90%]

RQ >1.0 is s/o overfeeding [poor sensitivity, 21%; high specificity, 97%;

and a high positive predictive value , 93%]

Pre – requisite for IC Important considerations or conditions to improve the

REE measurement: Individual should rest for at least 30 minutes in bed or a

recliner before the test, should not be asleep.

No food for at least 2 hours before the test.

Maintain quiet surroundings and normal temperature. The individual should not move arms or legs during the test.

Normal room temperature should be maintained, avoid drafts or any condition that might result in shivering.

Medications taken should be noted, such as stimulants ordepressants.

Steady state should be achieved, which would be identifiedclinically by the following:5 minute period when average minute VO2 and VCO2changes by less than 10% and the average RQ changesby less than 5%.

Stable interpretable measurements should be obtained in a 15 to 20 minute test.

Pre – requisite for IC Additional considerations for hospitalized

individuals: If the individual is on specialized nutrition support

(enteral or parenteral nutrition) continuous 24-hour infusion does not need to be stopped.

The nutrients infused should be constant for at least 12 hours.

If feedings are intermittent or cyclic, the feeding should be held for at least 2 hours. Document the product and the rate the individual is receiving.

Discontinue any supplemental sources of oxygen

If the individual is on a ventilator, the settings should remain constant for at least 1-1/2 hours before the test.

No recent chest therapy or physical procedures.

Renal failure patients requiring hemodialysis shouldnot be tested during dialysis therapy.

Nutrition in critical illness is very

important

CRITICAL ILLNESS + POOR NUTRITION

Prolonged ICU stay

Prolonged ventilator dependency

Increased susceptibility to nosocomial infections

Multi system dysfunction

Increased mortality

Nutrition: overall goals

ACCP consensus statement,

1997 Provide nutritional support appropriate for the individual

patient’s

Medical condition

Nutritional status

Available routes for administration

Prevent/treat macro/micronutrient deficiencies

Dose nutrients compatible with existing metabolism

Avoid complications

Improve patient outcome

What guidelines say ?

Thibault &Pichard, Medical Clinics of North America, 2010


What happens if

EN is used alone in the early course ?


EN alone causes an energy debt


Enteral with parenteral :

is the combination better ?

120 adult medical and surgical patients

Combination vs enteral feeds alone

Prospective, double blinded, RCT

RBP, pre albumin increased significantly D 0-7

Reduced hospital stay (by 2 days)

No reduction in ICU morbidity

No reduction in ICU LOS/ ventilatory requirement, MSOF,

dialysis

Mortality at 90 days and 2 years was identical

Bauer et al, Intensive care med, 2000

Advantages of the combination


Impact of no – enteral nutrition

Negative nitrogen balance

Morphological changes in

the gut

Mucosal thickness

Cell proliferation

Villus atrophy

Functional changes

Increased permeability

Decreased absorption

of amino acids

Enzymatic/Hormonal changes

Decreased sucrase/lactase

Impact on immunity

Cellular: Decreased T cells,

atrophied germinal centers,

Humoral: Decreased

complement, opsonins, Ig,

reduced secretory IgA

Increased bacterial

translocation

Probably enteral nutrition is better as it is more

physiological

Frequently associated with insufficient coverage of

energy requirements, correlated with a worsened

clinical outcome.

All-in-one PN - no significant negative effect on

mortality and infectious morbidity in ICU patients

Initiation of EN

When: as soon as

possible

Usually within 24 hours

in all cases

Small volume trophic

feeds is a good choice

Contraindications

Absolute

○ Occlusive intestinal stenosis

○ Pseudo-obstruction with complete food

intolerance,

○ Clinically or endoscopically severe colitis

Others: allow the intestine to "rest"

○ Digestive fistulae with a high flow

○ Inflammatory bowel disease (Crohn's

disease, irradiated bowel disease)

○ Severe peritonitis

○ Severe shock states, gut ischemia

Routes of EN

• Requires good gastric motility

• Requires good gastric emptyingNasogastric

• Effective in gastric atony/ ileus

• Silicone/polyurethane tubing

• Positioning: fluoroscopic/ pH monitoring / endoscopic guidance

Transpyloric

• PEG if > 4 weeks nutritional support anticipated

• Jejunostomy - GER, gastroparesis, pancreatitis

Percutaneous

or

Surgical placement

POTENTIAL DRAWBACKS

OF ENTERAL FEEDS

Gastric emptying impairments

Aspiration of gastric contents

Diarrhea

Sinusitis

Esophagitis /erosions

Displacement of feeding tube

Methods of EN

Bolus feeding

• More chances of aspiration

Intermittent feeding

• Given as 2ml/kg 4 – 6 hrly

• Each time for 20 – 45 mins

Continuous drip feeding

• Least potential for aspiration, bloating, diarrhea

• Chances of bacterial overgrowth

Different enteral formulasType of formula Contents Amount Nutrition Value/ 100ml

Elemental Protinex powder 50 gm Calories 110 kcal

Glucose 100 gm Proteins 2.6 gm

Refined oil 30 gm Carbs 19.5 gm

Water To make 1000 cc Fats 3 gm

Polymeric (Milk based)(Suji kheer)

Milk 500 gm Calories 150 kcal

Sugar 50 gm Proteins 4 gm

Suji 20 gm Carbs 4 gm

Oil 20 gm Fats 7.5 gm

Polymeric (Lactose free)

Rice 50 gm Calories 66 gm

Sugar 45 gm Proteins 3 gm

Oil 30 gm Carbs 8.4 gm

Water To make 1000 cc Fats 3.7 gm

PGIMER, Chandigarh

Enteral formulas in SSH

Immune modulationGlutamine

Arginine

Fatty acids (w-3)

Nucleotides

Vitamins and minerals

Pediatric burn patients: Arginine & w-3 fatty acid supplements reduce

infections, LOS

Mortality, bacteremic episodes reduce

More pronounced effect in APACHE II

(J Parenter. Ent. Nutr.,1990; CCM, 2000)

Children older than 10 years

can be fed adult formulas

Enteral formulas

Complications of EN Mechanical Gastrointestinal Metabolic

Tube blockage Diarrhea Hyperglycemia

Pulmonary

aspiration

Abdominal

distension

Dehydration

Poor or shifted tube

position

Nausea and

vomiting

Hypokalemia

Accidental tube

withdrawl

Intestinal

obstipation

Hyperkalemia

Hypernatremia

Hypophosphatemia

Hypercapnia

Tolerance

Nutrition and metabolic

Daily weight

SE, osmolality, acid base balance, RBS, Mg, Ca, Po,

urine, LFT

Mechanical

Tube patency and position

Irrigation

Monitoring in EN

Goals PN Clinical nutrition highlights • 2007

Maximal preservation of major organ system function

during the acute phase of illness

Minimization of the catabolic response

Prompt restoration of the pre - morbid nutritional state

without producing treatment related complications

Goals PN Ann Med Interne (Paris) 2000 Dec

Nutritional support

Must be complete

Must be conducted according to a rigorous written protocol

specific for each indication

Avoid iatrogenic and metabolic risks

Enhance the efficacy of the nutritional support

Avoid inappropriate prescriptions, notably for

parenteral administration

These allows a better risk/benefit ratio evaluated with nutritional standards

Indication : PN Ann Med Interne (Paris) 2000 Dec

Absolute

Occlusive intestinal stenosis

Pseudo-obstruction with complete food intolerance,

Clinically or endoscopically severe colitis

Others: allow the intestine to "rest"

digestive fistulae with a high flow

inflammatory bowel disease (Crohn's disease, irradiated

bowel diseasenutrition )

Complementary:

Poorly tolerated quantitatively insufficient oral or enteral

nutrition

Study at SGRH -2007 related to

PN Results:

80 delegates

Already using PN - 20

Reasons for not using PN(n=60)

○ Fear of sepsis – 48(80%)

○ Non availability of CV access- 42 (70%)

○ Very expensive – 39(65%)

○ Non availability of PN fluids( lipids) – 30(50%)

○ Complications of PN – 38(63%)

○ Difficult to calculate – 24 (40%)

○ No laminar flow – 21(35%)

○ Don’t have ELBW Babies in unit -21 (35%)

Types of PN:

Peripheral (<3 weeks)

Central (>3 weeks)

Lipid, amino – acids and dextrose: infused through

separate IV sets which are attached to the IV

cannula through a 3 – way stop cock

Suggested parenteral solution:

Nutrients Volume (ml/kg/day) Amount (kg/day)

Aminoven (10%) 25 2.5 gm

Intralipid (10%) 10 – 30 0.5 – 3 gm

Glucose (50%) 10

KCl (15%) 1 2 – 3 meq

MgSO4 (50%) 0.04 20 mg

Calcium gluconate (5%) 3.5 1.5 meq

NaCl (25%) 6 3 meq

Trace metals 1 Zn, Cu, Mn, Se, Cr, I

MVI 1

Glucose 10% to make 120ml

Vit K – 1 mg, Vit B12 – 50 ugm, Folic acid – 1 mg: weekly supplementation

PGIMER, Chandigarh

Laminar flow system

Serum electrolytes

Blood urea

Serum lactate

Serum ammonia

Serum proteins

Arterial blood gas

Blood glucose

Serum triglycerides and

Nitrogen balance

Laboratory Monitoring

Complications of PN Mechanical Septic Metabolic

Pneumothorax, Exogenous

[ Extraluminal

and

Intraluminal ]

Hypo/ Hyperglycemia

HemothoraxHyperlipidemia/ Increased AA

Dyselectrolytemia

Hematoma

Tracheal puncture Endogenous Hypophosphatemia

Catheter blockage Hypocalcemia / Hypercalcemia

Catheter migration Hypomagnesemia

Venous thrombosis Trace element deficiency

Cholestasis

Overfeeding syndrome

Occurs when TPN intake exceeds need, resulting in increased fat synthesis

Fatty infiltration of the liver, hyperglycemia, hypertriglyceridemia, increased

metabolic rate, and electrolyte disturbances

Increases in oxygen uptake, CO2 production, and CO2 retention may be seen in

children with pulmonary or cardiac insufficiency.

Hypermetabolic and malnourished patients are more susceptible to these

respiratory problems

Another potential complication, an increase in infectious complications, as

hyperglycemia represents a risk factor for infection

To avoid overfeeding, nutritional status must be assessed and monitored to

achieve a balanced supply of nutrient needs

Overfeeding syndrome

Conclusion

Deeper knowledge of the physiopathology of

metabolic stress, the application of new

concepts in nutrition and metabolism and the

deployment of multidisciplinary nutritional

therapy teams within the hospital setting can

bring about improvements in the quality of

nutritional intervention

Health & Medicine

Nutrition in sick children