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 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) Nutrition Goals for the PICU 1. 2. Minimize protein catabolism Meet energy requirement Mehta and Duggan (2009) 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) 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) 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) 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) 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) Limitations of IC Air leaks around ET tubes Chest tubes FiO2 >60% Receiving dialysis Comparison of MEE vs. cREE Briassoulis et al. (2000) DRI vs. REE Age DRI (kcal/kg) REE (kcal/kg) 0-3 mon 102 54 4-6 mon 7-12 mon 13-35 mon 3y 4y 5-6 y 7-8 y 82 80 82 85 70 65 60 54 51 56 57 47 47 47 Kcal Requirements: Intubated 0-12 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) 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) Kcal Requirements: Extubated Kcal goal = DRIs for age/gender Catch up growth may be necessary (DRI BMI x IBW) ÷ actual wt (kg) for age >85th%tile use IBW IBW: BMI for age @50th%tile (BMI @50th%tile x actual wt) ÷ actual BMI Protein Requirements Age 0-6mon 7-12mon 13-23mon 24mon-3y 4-13y 14-18y DRI (normal) 1.52g/kg/day 1.2 1.05 1.05 0.95 0.85 PICU 2-3g/kg/day 2-3 2-3 1.5-2 1.5-2 1.5 ***may require further increases in protein provision with burns, ECMO, bacterial sepsis Parenteral Nutrition PPN vs. TPN PPN Peripheral access <900 mOsm/L Max D12.5% Can go up to D15% with non-central PICC Usually requires increased fluid allowance ASPEN (2010) TPN Central access No osmolarity limitations Typical max dextrose usually D25% however can go up to D30% prn 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% Intralipid Essential Fatty Acids (EFA) Omega-6 source Concentrated source of kcal 2kcal/ml Parenteral Lipids Age Initiate Advance Maximum <1yr 1g/kg/day 1g/kg/day 3g/kg/day 1-10yr 1g/kg/day 1g/kg/day 2-3g/kg/day >10yr (adolescents) 1g/kg/day 1g/kg/day 1-2.5g/kg/day ***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) 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 (24% 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) Parenteral Amino Acids (AA) Neonatal AA (Trophamine 10%) Pediatric AA (Freamine 8.5%) 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 Used for >5kg Contains Phos ASPEN (2010) 0.1 mmol/gram AA Parenteral AA Guidelines Age Initiate Advance Maximum <1yr 1-2g/kg/day 1g/kg/day 4g/kg/day 1-10yr 1-2g/kg/day 1g/kg/day 1.5-3g/kg/day >10yr (adolescents) 1g/kg/day 1g/kg/day 0.8-2.5g/kg/day ***Goal aa correspond to ASPEN protein guidelines for critical illness mentioned earlier ***4kcal/g aa ASPEN (2010) 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) GIR/Dextrose Guidelines Age Initiate Advance Maximum <1yr ~6-9mg/kg/min 1-2mg/kg/min Goal: 1012mg/kg/min Max: 14mg/kg/min 1-10yr 1-2mg/kg/min >IVF GIR 1-2mg/kg/min Max: 810mg/kg/min >10yr (adolescents) 1-2mg/kg/min >IVF GIR 1-2mg/kg/min Max: 56mg/kg/min ASPEN (2010) PN Electrolyte Dosing Guidelines Electrolyte Preterm Neonates Infants/ Children Adolescents/ Children >50kg Na 2-5meq/kg 2-5meq/kg 1-2meq/kg K 2-4meq/kg 2-4meq/kg 1-2meq/kg Ca 2-4meq/kg 0.5-4meq/kg 10-20meq/day Phos 1-2mmol/kg 0.5-2mmol/kg 10-40mmol/day Mg 0.3-0.5meq/kg 0.3-0.5meq/kg 10-30meq/day Acetate As needed to maintain acid-base balance Chloride As needed to maintain acid-base balance ASPEN (2010) 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) 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 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 Enteral Nutrition 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 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 Infant Formulas 0-12 months of age Intact Protein Breastmilk (MBM) Enfamil Lipil Similac Advance Enfamil Gentlease (hydrolyzed casein & whey protein) GERD: Enfamil AR Renal: Similac PM 60-40 Chylothorax: Monogen (90% MCT) Soy Protein Enfamil ProSobee Similac Isomil Good Start Soy Lactose-Free Enfamil LactoFree Similac Sensitive Preterm Formula (24) Enfamil Premature Lipil Similac Special Care Preterm Discharge Formula (22) Enfamil EnfaCare Lipil Similac Neosure Peptide-Based Nutramigen Pregestimil (55% MCT) Alimentum (33% MCT) Elemental (100% free Amino Acids) Neocate (33% MCT) Elecare (33% MCT) Pediatric Formulas (1-10yr) Description CPOE name Product Specs Intact Protein (+/- Fiber) Pediatric Standard Nutren Jr 1kcal/ml; 30g protein per L Pediatric Standard with Fiber Nutren Jr with fiber 1kcal/ml; 30g protein per L Pediatric Blenderized Pediatric Compleat 1kcal/ml; 38g protein per L; omega 3 FA Pediatric High Calorie 1.5 with/without fiber Boost Kid Essentials 1.5 with/without fiber 1.5kcal/ml Fluid-restricted Pediatric Formulas (1-10yr) Description CPOE name Product Specs Peptide-based Pediatric SemiElemental (1) Peptamen Jr with prebio 1kcal/ml Pediatric SemiElemental (1.5) Peptamen Jr 1.5 1.5kcal/ml Pediatric Amino Acid-Based Elecare Jr 1kcal/ml (30kcal/oz) Elemental 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 References Agus, M., & Jaksic, T. 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American Journal of Clinical Nutrition, 88:340-7. 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.