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Pediatric Critical Care Nutrition

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.

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Pediatric Critical Care Nutrition

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  1. Pediatric Critical Care Nutrition Kristy Paley, MS, RD, LDN, CNSC

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

  3. PICU-associated malnutrition • Metabolic stress response • Estimations of energy requirement • Prescription and Delivery • Preexisting deficiency/reduced somatic stores Mehta and Duggan (2009), Hulst et al. (2006), Rogers et al. (2003)

  4. Nutrition Goals for the PICU • Minimize protein catabolism • Meet energy requirement Mehta and Duggan (2009)

  5. 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 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)

  6. Energy Provision • Increased risk of overfeeding with intubation/sedation • Impair liver function by inducing steatosis/cholestasis • Increase risk of infection • Hyperglycemia • Prolonged mechanical ventilation • Increased PICU LOS • No benefit to the maintenance of lean body mass (LBM) Agus and Jaksic (2002)

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

  8. 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)

  9. 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 Mehta et al. (2009)

  10. Limitations of IC Air leaks around ET tubes Chest tubes FiO2 >60% Receiving dialysis

  11. Comparison of MEE vs. cREE Briassoulis et al. (2000)

  12. DRI vs. REE

  13. Kcal Requirements: Intubated0-12 months • May require > REE • Activity not significant % of kcal • Kcal used predominately for growth • Consensus is to provide >REE for infants 0-12 months despite intubation/sedation • (~75-80% of the DRI for age) • 0-3 mon (~80kcal/kg) • 4-12 mon (~65kcal/kg) Lloyd (1998)

  14. 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 used • (exception): REE x 1.2 for intubated burn pts Agus and Jaksic (2002), Hardy Framson et al. (2007)

  15. 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

  16. Protein Requirements • ***may require further increases in protein provision with burns, ECMO, bacterial sepsis

  17. Parenteral Nutrition

  18. 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 PPN vs. TPN ASPEN (2010)

  19. 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 Fung (2000)

  20. 20% Intralipid • Essential Fatty Acids (EFA) • Omega-6 source • Concentrated source of kcal • 2kcal/ml

  21. Parenteral Lipids ***goals dependent on total kcal goals ***do not exceed 60% kcal via lipid (ketosis) ***maximum lipid clearance 0.15g/kg/H Coss-Bu et al. (2001), ASPEN (2010)

  22. 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 Marcason (2007), ASPEN (2010)

  23. 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 Amino Acids (AA) ASPEN (2010)

  24. Parenteral AA Guidelines ***Goal aa correspond to ASPEN protein guidelines for critical illness mentioned earlier ***4kcal/g aa ASPEN (2010)

  25. 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)

  26. GIR/Dextrose Guidelines ASPEN (2010)

  27. PN Electrolyte Dosing Guidelines ASPEN (2010)

  28. 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)

  29. 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

  30. 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

  31. Enteral Nutrition

  32. Enteral Nutrition • Whenever possible, feed the gut • GALT/reduce risk for bacterial translocation • Trophic feeds: ≤20ml/kg/day • Continuous feeds • Initiate @~1ml/kg/H • Advance by 0.5-1ml/kg Q4-6H

  33. 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 increment • Use infant formulas to concentrate MBM in term AGA pts, not HMF

  34. Pediatric Formulas (1-10yr)

  35. Pediatric Formulas (1-10yr)

  36. Other Formula Considerations • ≥10yr: can use adult formula • Standard Isotonic with Fiber: Nutren 1.0 with Fiber • Standard Isotonic: Nutren 1.0 • High 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

  37. 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.

  38. 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.

  39. 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.

  40. 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.

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