nutrition in sick children
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Dr Bedangshu Saikia
Registrar, Pediatrics and Neonatology
St Stephens Hospital, New Delhi, India
bedangshu@gmail.com
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
Nutritional assessment
Anthropometry
○ Mid upper arm circumference
○ Triceps skin fold thickness
○ Weight
○ Length / height
○ BMI
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++
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
Thibault &Pichard, Medical Clinics of North America, 2010
What happens if
EN is used alone in the early course ?
Thibault &Pichard, Medical Clinics of North America, 2010
EN alone causes an energy debt
Thibault &Pichard, Medical Clinics of North America, 2010
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
Thibault &Pichard, Medical Clinics of North America, 2010
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
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