Nutrition in Critically ill Children

ESPEN/ SCCM 2016 guidelines were helpful for dogmalysis on many topics related to nutrition in critically ill adults. Soon after this nutrition support guidelines in critically ill children were published in 2017.

For the first time American Society of Parenteral and Enteral Nutrition ( ESPEN) and the Society of Critical Care Medicine (SCCM), combinedly released the BEST PRACRICES FOR NUTRITION IN CRITICALLY ILL CHILDREN 2017 (> 1 month and < 18 years)

# Myths in critical care nutrition, find the links below to dispell all of them

Literature revieved

16 randomized controlled trials
37 cohort studies
Used to answer eight preidentified questions for eight practice areas

Guidelines Limitations

Based general consensus among a group of professionals
Literature used has variation in study design, small sample size, patient heterogeneity, variability in disease severity, lack of information on baseline nutritional status
No high quality statistical data available for analysis

#1 A. Impact of nutritional status on outcomes in critically ill children

Quality of evidence: very low
Grade of recommendation recommendation: strong

Answer:

Malnutrition, including obesity, is associated with adverse clinical outcomes including

longer periods of ventilation,
higher risk of hospital-acquired infection,
longer PICU and hospital stay, and
increased mortality.

Detailed nutritional assessment within 48 hr of admission.
Reevaluate at least weekly throughout hospitalization.

#1 B. Best practices to screen and identify patients with malnutrition or at risk in the PICU

Quality of evidence: very low
Grade of recommendation: strong

Recommendation:

weight and height/length to be measured on admission to the PICU, and z scores for BMI for age, weight-for-length in < 2 yr, or weight-for-age if accurate, height is not available, be
used to screen for nutrition status,

In children under 36 mo old, head circumference must be documented.

Additional Points
BMI z scores may be useful to screen for patients at risk of poor outcomes in the PICU

#2 A. Recommended energy requirement for critically ill children

Quality of evidence: low
Grade of recommendation: weak

Indirect calorimetry (IC) to be used to determine energy expenditure (REE) and guide prescription of
the daily energy requirements

#2 B. Determination of energy requirement in the absence of indirect calorimetry

Quality of evidence: very low
Grade of recommendation: weak

If IC measurement is not available,
Use the Schofield or Food Agriculture Organization/World Health Organization/United Nations
University equations “without” the addition of stress factors to estimate energy
expenditure.

Recommends Against
Use of the Harris-Benedict equations and the RDAs to determine energy requirements in critically ill children.

What is Harris-Benedict equations

BMR is the amount of calories burnt during inactive / sleep prtiod. It can be calculated from height, weight, age and gender.

The Harris Benedict Equation uses BMI and calculate the total energy expenditure (TEE) for the given activity by using activity factor

For example

Sedentary or light activity

TEE = BMR x 1.53

Active or moderately activeTEE = BMR x 1.76

Vigorously active
BMR x 2.25

#2C. Target energy intake in critically ill children

Quality of evidence: low

Two thirds of the prescribed daily energy requirement by the end of the first week in the PICU.
Individualized energy requirements, initiate timely and attained of energy targets

#3A. Minimum recommended protein requirement for critically ill children

Quality of evidence: moderate
Grade of recommendation: strong

Minimum protein intake of 1.5 g/kg/d.

Higher than this threshold shown to prevent cumulative negative protein balance in RCTs.
The optimal protein intake required to attain a positive protein balance may be higher than this minimum threshold in sick chidlren

Negative protein balance may result in loss of lean muscle mass, which has been associated with poor outcomes in critically ill patients.

Higher protein intake may be associated with lower 60-d mortality in mechanically ventilated children. (Observational study )

#3B. Optimal protein delivery strategy in the PICU

Quality of evidence: moderate
Grade of recommendation: weak

Provide protein early in the course of critical illness to attain protein delivery goals and promote positive nitrogen balance. (RCTs)

Delivery of a higher proportion of the protein goal has been associated with positive clinical
outcomes in observational studies.

#3C. Protein delivery goals in PICU

Quality of evidence: moderate
Grade of recommendation: strong

The optimal protein dose associated with improved clinical outcomes is not known.

RDA values were developed for healthy children and often underestimate the protein needs
during critical illness.

#4A. Feasible of enteral nutrition in critically ill children

Quality of evidence: low
Grade of recommendation: strong

EN is the preferred mode in critically ill child with both medical and surgical diagnoses, and in
those receiving vasoactive medications.

Common barriers to EN in the PICU include delayed initiation, interruptions due to perceived intolerance, and prolonged fasting around procedures.

Interruptions to EN to be minimized in an effort to achieve nutrient delivery goals.

#4B. Benefits of EN in sick children

Quality of evidence: low
Grade of recommendation: weak

Some amount of nutrient delivered as EN has been beneficial for gastrointestinal mucosal integrity and motility.

Early initiation of EN (within 24–48 hr of PICU admission) and achievement of up to two thirds of the nutrient goal in the first week of critical illness have been associated with improved clinical outcomes. (Large cohort studies)

#5A. Best method for advancing EN in the PICU population?

Quality of evidence: low
Grade of recommendation:weak

Use of a stepwise algorithmic approach to advance EN in children admitted to the PICU. The stepwise algorithm must include bedside support to guide the detection and management of EN intolerance and the optimal rate of increase in EN delivery.

#5B. Role of a nutrition support team or a dedicated dietitian in optimizing nutrition

Quality of evidence: low
Grade of recommendation: weak

Nutrition support team, including a dedicated dietitian suggested as a pert of PICU team, to facilitate timely nutritional assessment, and optimal nutrient delivery.

#6A. Best site for EN delivery - gastric or small bowel

Quality of evidence: low
Grade of recommendation: weak

Preferred route is gastric
The post pyloric route may be used in patients unable to tolerate gastric feeding or those at
high risk for aspiration.
Insufficient data to make recommendations regarding the use of continuous vs intermittent gastric feeding.

#6B. When to initiate enteral nutrition

Quality of evidence: low
Grade of recommendation recommendation: weak

EN to be initiated in all critically ill children, unless contraindicated.
Early initiation of EN, within the first 24–48 hr after admission to the PICU, in eligible patients.

#7A. What is the indication for and optimal timing of PN in critically ill children?

Quality of evidence: moderate
Grade of recommendation : strong

No recommendation to initiate of PN within 24 hr of PICU admission. (single RCT)

#7B. Role of PN as a supplement to inadequate EN

Quality of evidence: low
Grade of recommendation recommendation: weak

Stepwise advancement of nutrient delivery via the enteral route and delaying commencement of PN. The role of supplemental PN to reach a specific goal for energy delivery is not known.
The time when PN should be initiated to supplement insufficient EN is also unknown.

Based on a single RCT, supplemental PN should be delayed until 1 wk after PICU admission in
patients with normal baseline nutritional state and low risk of nutritional deterioration.

PN supplementation in children who are unable to receive any EN during the first week in the PICU.

In patients who are severely malnourished or at risk of nutritional deterioration, PN may be supplemented in the first week if they are unable to advance volumes of EN.

#8. What is the role of immunonutrition in critically ill children?

Quality of evidence: moderate
Grade of recommendation recommendation: strong

Not recommended

SHORT SUMMARY

Nutritional assessment within 48 hr of admission, r-eevaluate weekly
Use z scores for BMI , weight-for-length, weight-for-age, HC for assesment
Use Indirect caloriemtry
Dont use Harris-Benedict equations, RDAs as guide to requirements
Initiate enteral nutrition within 24 to 48 hours unless contraindicated
Atleast 2/3rd of calories by the end of 1st week unless contraindicated
Minimum protein intake of 1.5 g/kg/d.
Prefer enteral nutrition over parenteral
No difference in in gastric vs post-pyloric feeds
No immuno-nutrition

Myths in ICU nutrition (Paul E. Marik)

MYTH NO. 1: STARVATION OR UNDERNUTRITION IS “OKAY”
MYTH NO. 2: PARENTERAL NUTRITION IS SAFE
MYTH NO. 3: EN CONTRAINDICATED WITH VASOPRESSORS
MYTH NO. 4: EARLY EN IS NOT IMPORTANT IN PATIENTS RECEIVING MECHANICAL VENTILATION
MYTH NO. 5: EN IS CONTRAINDICATED WITH HIGH GASTRIC RESIDUAL VOLUME
MYTH NO. 6: POSTPYLORIC FEEDING REDUCES THE RISK OF ASPIRATION
MYTH NO. 7: EN IS CONTRAINDICATED IN PATIENTS WITHOUT BOWEL SOUND AND/OR A POSTOPERATIVE ILEUS
MYTH NO. 8: EN IS CONTRAINDICATED FOLLOWING GI SURGERY
MYTH NO. 9: EN IS CONTRAINDICATED IN PATIENTS WITH AN OPEN ABDOMEN
MYTH NO. 10: EN IS CONTRAINDICATED IN PATIENTS WITH PANCREATITIS