The science of effective pediatric inpatient nutrition 2005
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The Science of Effective Pediatric Inpatient Nutrition 2005. Kevin M. Creamer M.D., FAAP Medical Director, PICU WRAMC Chief, Pediatric Nutrition Support Team. A hypothetical case .

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The Science of Effective Pediatric Inpatient Nutrition 2005

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The Science of Effective Pediatric Inpatient Nutrition 2005

Kevin M. Creamer M.D., FAAP

Medical Director, PICU WRAMC

Chief, Pediatric Nutrition Support Team


A hypothetical case

  • Starvin Marvin is a 2 y.o. who presents with a 2-3 week Hx of fevers, weight loss, pallor, decreased energy, appetite and activity

  • PE reveals Wt 13kg , down 1.5 kg, pallor, petechia,+ HSM

  • Labs reveal WBC 26 K with 50% blasts, anemia and thrombocytopenia


Hospital Course

  • Day 1 - NPO, IVFs, labs, Xrays

  • Day 2 – NPO for BM and LP, as well as Hickman

  • Day 3- Chemo, picky PO

  • Day 4-6 - continued poor PO, with emesis occasionally

  • Day 7-10 – emesis resolves, PO inadequate

  • Day 12 – pancytopenia, sepsis with GNR


Teaching points

  • Nutritionally-at-risk from the word GO

    • Debilitated Ortho spine patient

    • Recurrent bowel obstruction patient

  • No nutrition plan, No monitoring, No intervention

  • Hope is not a method

  • Could sepsis event been avoided??


Inpatient Nutrition Goals

  • Think about nutritional status on every patient

  • Outline the dynamic between illness, nutritional state and secondary morbidity

  • Recognize need to estimate/calculate goals calories in order to reach the goal

    • Individualized goals for time course, and disease process

  • Institute effective nutrition support with the help of Pediatric nutritionist


Acute Stress


The 5 W’s of Inpatient Nutrition

Why, Who, When, Where, What ?


Acute Stress

  • Major Surgery, Sepsis, Burns, Trauma

    • Result in massive outpouring of catechols, ACTH, GH, ADH, glucagon, somatomedins

      • Insulin inhibition, elevation of glucose and free fatty acids

    • ↑ Inflammatory Cytokines: TNF, IL 1, IL-6

      • PMN release and degranulation  Mucosal permeability

  • Stress hormones and mediators ↑ release of cAMP which down-regulate lymphoid immune activity


Acute Stress

  • NPO state starves gut mucosa

    • Gut mass  50% in 7 days of fasting

    • Gut contains 80% of body’s immune tissue

      • “GALT and MALT”

    • Intestinal sIgA ↓ in 5 days

    • ↑ Th1 pro-inflammatory lymphocytes

  • Major stress doubles protein turnover

    • Skeletal muscle cannibalized for fuel for enterocytes (glutamine)

Stechmiller JK, Am J Crit Care, 1997


Bacterial Translocation

  • Disruption of mucosal barrier

    • Ischemia-reperfusion during shock  risk of ulceration and  permeability

  • Bacterial translocation

    • Culture(-), found bacterial DNA in blood stream

  • Cytokine amplification in lymphatics and liver


Bacterial Translocation

  • Enteral nutrition can prevent translocation

    • Trophic feeds stimulate gut hormones and nourish mucosa, increase blood flow, re-energize tight junctions, improve brush border

    • Enteral vs. Parenteral feeds -  postop septic related complications

  • Enteral feeds stimulate Th2 lymphocytes which  PMN adhesion in lung

Deitch EA, Ann Surg, 1987, 1990;Border JR, AnnSurg, 1987; Carrico CJ, Arch Surg, 1986; Alverdy JC, Surgery, 1988; Moore J, JPEN, 1991,Kudsk,Am J Surg, 2002


WHY ?Is nutrition such a big deal?

Malnutrition Prevalence

Nutrition Status and Outcomes

Gut Bacterial Translocation


Malnutrition Prevalence

  • 15 to 50 % of hospitalized pediatric inpatients are malnourished on presentation (down from 35-65%)

    • 15 to 20 % of critically ill patients

    • 33% patients with congenital heart disease

    • 39% awaiting elective surgery

Parsons, AJCN,1980; Mize, Nutr Supt Ser, 1984; Merritt, Am J Clin Nutr, 1979, Huddleston KC, CC Clin of NA, 1993, Cameron, Arch Ped 1995, Cooper, J Ped Surg 1981


Malnutrition Snapshot

  • Inpatient population of Boston Children’s Hospital was surveyed Sept 24,1992

    • 268 children ages 0-18 years

  • Using Waterlow criteria:

    • 25% were acutely malnourished, 27% were chronically malnourished

  • Of 17 ICU patients, 4 (24%) were classified with severe PEM

Hendricks, Arch Ped Adol Med, 1995


Nutrition and Outcome

Robinson G, JPEN, 1987


Nutrition and Outcome

Low Prealbumin 95% specific, in 147 consecutive admissions

8 measures of malnutrition in 134 patients

50 cardiac surgery patients assessed

  • Low Prealbumin predictive post-op infectious complication

Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, Rev Paul Med, 1995


Nutrition Screen predictive of outcome in 25 RSV PICU admits

Mezoff, Pediatrics, 1996


Nutrition and Outcome

  • 60 PICU patients had nutrition status evaluated, with PSI, and TISS applied

  • Acute PEM associated (P<0.01) with  physiologic instability,  mortality and  quantity of care

  • Malnutrition can result in delayed wound healing, respiratory failure, increased potential for infection, death

Pollack MM, JPEN, 1985


Nutrition and Outcome

Bassili HR, JPEN,1980


Nutrition and Outcome

  • PICU Outcomes in 323 patients after Nutrition support team instituted

    • Use of Enteral nutrition (EN) in medical patients increased 25% to 67%

  • Mortality risk decreased 83% for those receiving EN >50% of LOS

    • EN independent predictor of survival in multiple regression analysis.

Gurgueira, JPEN, 2005


WHO ?Needs to know? Gets assessed?

ALL Physicians!

ALL Patients!


Nutrition Dichotomy

  • 79 FP residents

    • Nutrition Interest (72.2%) vs. Perceived Knowledge

      • Parenteral and enteral nutrition 34.2%, Infant nutrition 27.5 %, Nutrition assessment 17.7%

  • 3416 Primary Care physicians

    • < 40% practiced what they preached

Lasswell AB, J of Med Ed, 1984, Levine BS, Am J Clin Nut, 1993


Nutrition Practice: Uphill battle

  • Adult ICU group found their patients only received 52% of goal calories

    • Reasons included physician under ordering, frequent cessations, and slow advancement

  • Designed a protocol but only 58% went on it

Spain, JPEN, 1999


I wonder if I’m missing out on some critical piece of information


Nutrition Screen

  • Should be completed within 24 hours of admission

  • High risk surgical patients should be screened weeks to months ahead of planned surgery

    • Multidisciplinary team

    • Supplement , reassess, or reschedule

In your continuity clinic


Nutritionally-at-risk

  • Weight for age < 10th % tile

  • Weight for Height < 10th % tile

  • Acute weight loss > 5% over 1 month or >10% total

  • Birth weight < 2 SD below mean for gestational age

  • Increased metabolic requirements 2 chronic disease

  • Impaired ability to ingest or tolerate oral feeds

  • Weight % tile crossing 2 contour lines over time (FTT)


Prealbumin

  • Transthyretin has nothing to do with albumin

    • Small body pool and half life of 2 days makes prealbumin an reasonable monitor of visceral protein homeostasis

  • Drops during the first 3-5 days of stress it should rise thereafter

  • Daily rise of 1mg/dl indicates anabolism


Plasma Protein Stress Response

Fleck, A. Br J Clin Pract, 1988


Prealbumin as a predictor

  • Surgically stressed Infants

    • Prolonged ↑ CRP with ↓ Prealbumin had ↑ mortality

      • Strongest predictor POD#5 prealbumin depression

  • Prealbumin ideal nutrition screen for:

    • 50 children with solid tumors

      • before and during chemo

    • 86 Adult post-op patients requiring TPN

Chwals WJ, Surg Clin NA, 1992, Elhasid, Cancer, 1999, Erstad, Pharmaco, 1994


Prealbumin

  • Measure twice weekly

  • Once 65% of needs met expect levels to rise 1mg/dl a day

  • If weekly rise is less than 4mg/dl

    • check N2 balance and CRP to determine if cause is nutritional inadequacy or ongoing SIRS

Expert roundtable, 10th World Congress of Gastroenterolgy


WHEN?Should I start?

Early Enteral vs Standard timing


Enteral Contraindications

  • Intubation/extubation planned within 4°

  • Hemodynamic instability requiring escalation in therapy

  • Intestinal obstruction

  • Massive UGI bleed

  • Gut ischemia

  • I’m nervous about this kid


Early feeds vs. Standard

  • Adults with gut malignancies and neurotrauma has shorter LOS and fewer infections when fed early

  • 19 controlled studies (24° vs 3-5 days)

    • 16/19 studies showed improved outcome

    • Improved healing,  complications and LOS

    • Recommended for critically ill surgical pts

Braga, CCM, 2001 Grahm T, Neurosurgery, 1989 Taylor, CCM 1999 Heyland DK, CC Clin of NA, 1998 Zaloga. CCM 1999


Early feeds: Pediatrics

  • Tolerated pediatric burn patients

  • 42 ventilated children (76% on vasoactive meds)

    • Transpyloric feeding tubes placed at bedside

    • 74% of patients reached full feeds within 24 hrs, rest within 48 hrs

      • No complications

Chellis MJ, JPEN, 1996, Trocki, Burns, 1995


All is Not Rosy

  • All Mechanical Ventilated patients

  • Lots of exclusions

Ibraham, JPEN, 2002


WHERE? In the gut do I put the food?

Oral vs.Tube feeding

Gastric vs. Transpyloric feeds


Tube Feeding Considerations

  • Nutritionally-at-risk with inadequate oral intake for the past 3-5 days.

  • Meeting <50% estimated needs orally for previous 7-10 days.

    • Shorten to 3-5 days if traumatized or severely catabolic

  • Disease state preventing adequate P.O. intake for >5 days


Gastric vs. Transpyloric

  • No aspiration difference in 54 patients receiving gastric vs transpyloric radiolabeled feeds

  • 33 mechanicaly ventilated  Micro-aspiration 7.5 >> 3.9% in NJ fed patients

  • 80 adult trauma victims

    • Duodenally fed patients reached goal calories 34 vs. 44 hours with had less pneumonia 27% vs 42%*

  • 80 ventilated adults randomized

    • gastric feeds + E-mycin 200 mg q8 (55% / 74%)

    • Transpyloric feeds (44% / 67%)

Esparza, Intens C Med, 2001,Kortbeek, J Trauma, 1999, Heyland, CCM, 2001, Boivin, CCM, 2001


Transpyloric

  • 59 ventilated children randomized to receive continuous or interrupted transpyloric feeds during the day before and of extubation

    • Continuous group got >90% goal calories both day vs 73% and 46%

    • No aspiration events or difference in adverse events

Lyons, JPEN, 2002


Neuromuscular blockade and ECMO?

  • May decreased REE by 10-15 %

  • Primary Neurotransmitter in Gut is VIP not acetylcholine

    • Neuromuscular blockade work via AcH receptors

  • By what mechanism do neuromuscularly blocked patients become intolerant of enteral feeds?

    • Gastric atony 2° Benzodiazepines and narcotics

  • Enteral feeds for Pediatric ECMO patients is safe with trends toward improved survival

Pettignano, CCM, 1998


Enteral Pitfalls

  • 2 adult studies with 95 ICU pts, had 66%-78% of goal feeds prescribed, 52%- 71% delivered

    • Gastric Intolerance (Residuals #1)

      • BZD and Narcs effect stomach > intestine

    • Airway management

      • 22/26 PICU pts had feeds held for extubation that only 5 got

    • Diagnostic procedures

      • Some ventilated patients fed right up to OR

McClave SA, CCM, 1999,DeJonghe, CCM, 2001, Fry-Brower +McCunn, CCM(a), 2002,


WHAT?Amount of calories do I Feed Them?

How much to feed

Trophic feeds

Enteral vs. Parenteral

Lipid phobia


Caloric Goals?

  • Brazilian PICU reviewed 37 charts

  • Only 3 had an assessment done in 425 days

  • No Patient had caloric goals set

    • Only 29.7% met goals

    • 80.5 % fed Parenterally

Leite, Rev Assoc Med Bras, 1996


Steady State Energy Requirements


Energy Requirements

  • Calorie needs change during the course of the hospitalization.

    • Hemodynamically unstable?

    • Ventilated vs Extubated

  • Ebb phase (Hypometabolic): obligate (–) nitrogen balance during acute critical illness

    • No need for growth calories (BMR may suffice?)

    • Watch out for overfeeding

      • Steatosis, Hyperglycemia, Hypertriglyceridemia


Therapeutic window

  • 187 critically ill adults >96º in ICU

    • Tertiles of % ACCP recommended caloric intake

  • Patients receiving 33-65% goal Vs. <33% (18kcal/kg)

    • OR survival 1.22, discharge without sepsis 1.2, without vent 1.8

    • Patients > 65% goal OR 0.82, 0.75, 0.69

  • Sickest patients (SAPS>50)

    • Did worse when they received >33% goal

Krishnan, Chest, 2003


Energy Requirements

  • Flow phase (Hypermetabolic)

    • As the child improves and becomes anabolic, calorie needs for growth and activity must be included

  • Underestimating needs can increase risk for infection, poor wound healing, poor growth, and overall poor outcome


Energy Requirements

  • 12 Septic and 12 Traumatized patients

    • Total energy expenditure and REE measured for 2 separate 5-day periods

    • TEE Sepsis 25kcal/kg >>> 47kcal/kg

    • TEE Trauma 31kcal/kg >>> 59kcal/kg

  • Second week TEE: indirect calorimetry X1.8

  • TEE remained elevated for weeks

Uehara, CCM,1999


1º Fever

↑12%


Trophic Feeds

  • Rats fed 15% calories enterally had  permeability and bacterial translocation

  • 10 post-op infants fed trophically (21cal/kg/d) had improved Staph killing vs TPN alone

    • 37% vs. 52% vs. 65% (Controls)

      • Related to production of TNFα

  • > 6kcal/kg (>25% ACCP cal goals) in 138 adult MICU patients reduced BSI (relative hazard 0.24)

Omura, Ann Surg, 2000, Okada, J Ped Surg, Robinson,CCM, 2004


Trophic feeds

Trophic feeds are stress ulcer and antibiotic prophylaxis rolled into one

Marik, CCM(a), 2002


Trophic Feeds Vs. TPN

McClure RJ, Arch Dis child , 2000


Enteral Feeds vs. TPN

  • Enteral feeds in Critically ill population

    • improve wound healing,  mucosal permeability

  • > 10 studies show enteral feeds are safe, feasible and cheaper than TPN

  • Meta analysis adult ICU patients Enteral feeds vs. TPN RR infection 0.66

Schroeder D, JPEN, 1991, Hadfield R, Am J Resp Crit Care Med, 1995 Robert Dimand, UC Davis, Peds CC Update 2002, Gramlich, Nutrition, 2004


TPN vs. Hope

  • Meta Analysis 26 studies (210 reviewed)

    • 2211 patients

    • Trend toward reduced complications in TPN patients (risk ratio 0.84)

  • 4 studies used TPN > 3 weeks

    • Mortality in TPN pts was 6.8% vs. 12.4%

  • Meta Analysis 11 studies

    • Parenteral nutrition vs. delayed enteral improved mortality

    • Increased infectious risk (OR 1.65 CI1.1-2,5) in PN vs. all enteral

Heyland DK, JAMA, 1999, Simpson, Int Care Med, 2005, Doig, CCM(A) 2005


Parenteral Considerations

  • Nutritionally-at-risk patient with non-functional gut.

  • Adequate nutritional status on admission but non-functioning gut 3-5 days after admission

“The major advance in TPN since the

1980’s is that it is not used as much”


Lipid Phobia?

  • When infants given TPN without lipids

    • CHO only TPN resulted in  amino acid oxidation, proteolysis, CO2 production and  lipogenesis

  • Lipid requirements

    • Essential fatty acid (0.5gm/kg/d), Promote Nitrogen sparing, Increased lipid clearance during stress

  • Balanced approach to fulfilling energy requirements

Bresson, Am J Clin Nut 1991,Tilden, AJDC, 1989, Schears, Crit Care Clin, 1997


Lipids

  • Original 10% lipid compounds

    • Intravenous fat emulsions contain 50-60% linoleic acid a precursor to arachidonic acid

    • May disturb balance between thromboxane and prostacyclin production

  • Modern 20% emulsion cause less Trig 

    • Neonates clear better, less phospholipids

    • No problems with oxygenation when given as 18-24° infusion

    • No immune problems when Triglycerides <700


  • Residuals

    Age appropriate weight gain

    Diarrhea / Constipation

    Medication Compatibility?

    Emesis / Aspiration

    Proper wound healing

    Fluid and electrolyte balance

    Euglycemia

    Improved N2 balance and Prealbumin

    Monitor Outcomes


    HOPE IS NOT A METHOD!

    • Who? Is you, screening all your patients

    • Why? They’ll do worse if you don’t

    • When? The sooner the better

    • What? Enteral better, even trophic better than TPN alone

    • Where? PO>NG>NJ > IV


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