RESEARCH ARTICLE

Relationship Between Caloric Intake and

Length of Hospital Stay for Infants With
Bronchiolitis
abstract
OBJECTIVE: Poor oral intake is a common presenting symptom among
infants hospitalized with bronchiolitis. The prevalence, degree, and duration of
diminished caloric intake in these infants have not been studied. Our goal was
to determine the daily caloric intake among infants admitted with bronchiolitis
and to evaluate the relationship between early hospital caloric intake and length
of stay (LOS).
METHODS: We conducted a retrospective chart review of infants aged <1 year
admitted to Childrens Hospital of Wisconsin with bronchiolitis who were placed
in the bronchiolitis treatment protocol during the 20042005 season. Patient-,
disease-, respiratory-, and nutrition-specific data were abstracted.
RESULTS: A total of 273 patients with bronchiolitis were admitted between
November 1, 2004, and April 15, 2005; placed on the bronchiolitis protocol;
and included in the study. Median caloric intake was diminished on day 1 (53
kcal/kg per day) and day 2 (64 kcal/kg per day). Caloric intake was slower to
normalize in infants with progressively longer LOS, and a slower rate of increase
from day 1 to day 2 was significantly correlated with longer LOS (r = 0.18; P =
.002). Subgroup analysis revealed significant correlations between hospital day
2 caloric intake and LOS in formula-fed infants, breastfed infants, infants aged
<183 days, and infants aged 183 days.
CONCLUSIONS: Caloric intake was diminished in the early course of
hospitalization for infants who had bronchiolitis and slowest to normalize in
infants with the longest LOS. Interventions aimed at decreasing LOS among
infants admitted with bronchiolitis should consider the potential significance of
nutrition for severely affected infants with this condition.

AUTHORS
Michael C. Weisgerber, MD, MS,1,2
Patricia S. Lye, MD, MS,1,2 Melodee Nugent, MA,1,2
Shun-Hwa Li, PhD,1,2 Kari De Fouw, RD, 3
Rainer Gedeit, MD,1,2 Pippa Simpson, PhD,1,2
Marc H. Gorelick, MD, MSCE1,2
1

Department of Pediatrics, Medical College of

Wisconsin, Milwaukee, Wisconsin;
2
Childrens Research Institute, and
3
Childrens Hospital of Wisconsin, Milwaukee,
Wisconsin
KEY WORDS
bronchiolitis, caloric intake, length of stay,
nutrition
ABBREVIATIONS
CHW: Childrens Hospital of Wisconsin
IQR: interquartile range
LOS: length of stay
www.hospitalpediatrics.org
doi:10.1542/hpeds.2012-0032
Address correspondence to Michael C.
Weisgerber, MD, MS, Pediatrics, Medical
College of Wisconsin, Pediatric Hospital
Medicine, Suite C560, CHW Childrens
Corporate Center, PO Box 1997, Milwaukee,
WI 53201-1997. E-mail: mweisger@mcw.edu
HOSPITAL PEDIATRICS (ISSN Numbers: Print,
2154 - 1663; Online, 2154 - 1671).
Copyright 2013 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have
indicated they have no financial relationships
relevant to this article to disclose.
FUNDING: No external funding.

INTRODUCTION
Bronchiolitis is the most common reason for admission to the hospital among
infants aged <1 year.1 It causes substantial morbidity for patients as well as causing poorer health and increased stress for caretakers and families.2 The cost of
bronchiolitis is substantial: approximately $3800 dollars per admission and $500
million per year in the United States.3 Unfortunately, most of the commonly used
management modalities have not been effective in improving the clinical course
for infants who have bronchiolitis.4
Nutrition is an area of potential importance in the recovery of the infant with
bronchiolitis. Clinical signs and symptoms of bronchiolitis include tachypnea and
increased respiratory effort,4 which can increase oxygen consumption and energy
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HOSPITAL Pediatrics

requirements.5 Despite having higher

energy requirements, many infants
admitted with bronchiolitis fall short
of their normal requirements. One
study reported 82% of infants admitted with bronchiolitis had poor feeding
before admission and 26% of infants
had inadequate feeding, extending the
length of stay (LOS) beyond the resolution of their oxygen requirement.6
Our previous research has shown that
the caloric intake of infants hospitalized with bronchiolitis was significantly lower on hospital day 2 in those
who had a prolonged LOS >5 days
compared with those with a shorter
LOS.7 Poor nutrition may slow recovery
from respiratory illness because of the
adverse effects on respiratory muscle
strength and host immune function.8
Conversely, good nutrition has positive effects for ill patients. Premature
infants who had respiratory distress
syndrome with early enteral feedings
regained their birth weight faster,
spent fewer days on a ventilator, and
spent fewer days in the hospital compared with those with delayed enteral
feedings.9 Patients with bronchiolitis
in the ICU receiving adequate proteinenergy had better-preserved anabolism and nitrogen balance.10,11
This research suggests the potential
importance of nutrition as a therapeutic modality in the management
of bronchiolitis, particularly in the
most severely affected infants. The
scope of the problem of poor nutrition in infants admitted with bronchiolitis, however, is not well understood.
Although we found 1 study noting the
prevalence of poor feeding before
admission,6 detailed information concerning the magnitude of decreased
caloric intake, rate of change, and
its relation to length of recovery and
hospital stay has not been described

AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS

previously. Accurate information concerning the natural variation in caloric

intake, including rate of change during
the hospital course, is an important
first step in the process of exploring
the potential of nutritional interventions as a modality aimed at improving the recovery of infants hospitalized
with bronchiolitis.
Our objectives were as follows: (1)
characterize the daily caloric intake
and rate of change in infants admitted with bronchiolitis with varying
LOS; and (2) evaluate the relationship
between early hospital caloric intake
(days 1 and 2) and LOS. We hypothesized that infants with the most diminished early caloric intake would take
the longest time to return to normal
and have the longest LOS.

METHODS
Study Population and Setting

We conducted a retrospective cohort

study during a single bronchiolitis
season to identify factors predictive of
increased morbidity and a prolonged
LOS, and these data have been published previously.7 The current study
is a more detailed analysis of the
nutrition-specific data whereas the
previous article focused on factors
predictive of prolonged LOS.
Childrens Hospital of Wisconsin (CHW)
is a 294-bed tertiary care academic
center. The charts of all infants discharged from CHW who met all of the
following criteria were reviewed: (1)
age <365 days; (2) admitted between
November 1, 2004, and April 15, 2005;
(3) discharge diagnosis of bronchiolitis
according to the International Classification of Diseases, Ninth Revision
discharge codes 466.11 (acute bronchiolitis due to respiratory syncytial

virus) or 466.19 (acute bronchiolitis

due to other infectious organisms); and
(4) placement on the CHW bronchiolitis treatment protocol. Only patients
placed on this treatment protocol were
studied because these infants have
a consistent model of care modeled
after American Academy of Pediatrics
guidelines.4 Inclusion in the protocol
requires a physician making a clinical
diagnosis of bronchiolitis and ordering the protocol. Protocol monitoring
and therapeutic decisions are guided
by clinical respiratory scores, which
influence decisions on whether to initiate or continue therapies such as
bronchodilators or positive expiratory
pressure treatments. Typically, 70% of
infants admitted to CHW with bronchiolitis are placed on this protocol. The
other 30% are composed of patients
whose diagnoses are less certain,
whose conditions are medically complex and involve other comorbidities,
who have other preexisting respiratory problems in which the clinical
scores would be confounded and not
be able to be used for appropriate
management, or who have admitting
physicians who choose not to order
the protocol.
Infants with events or surgeries that
occurred during the admission not
related to bronchiolitis and affecting
LOS were excluded. An example of
this would include gastrostomy tube
placement during admission. Infants
admitted to the ICU were included if
placed in the bronchiolitis treatment
protocol.

Data Collected

Five trained abstractors (3 were study

authors) abstracted information from
patient records (including written charts
and electronic data sources). Variables
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abstracted from patient charts included

the following: demographic data; clinical respiratory status data; comorbidity data; and nutritional data including
weight, height, Waterlow classification
(percentage of ideal body weight) and
calculated daily caloric intake. After
data entry, a statistician informed the
primary author of missing data and
statistical outliers. These findings were
double-checked for accuracy. Selected
charts were reviewed for accuracy by
the primary reviewer in the training process of new abstractors to ensure that a
standardized procedure was used.

It was assumed that the majority of

caloric intake was from formula or
breast milk. Intravenous fluids were
not included. Calories from solid food
intake were not included because flow
sheet data include qualitative but not
quantitative descriptions of solid food
intake, and these data are insufficient
to produce a caloric estimate.
The caloric intake obtained via active
breastfeeding was estimated by using
an equation created by an institutional
expert panel after careful literature
review. The estimate equation involved
a low, medium, and high estimate of
calories likely obtained per feeding (Table 1). The high estimate was
equivalent to the volume of calories
per feeding to meet age-appropriate
norms.12,13 The low estimate assumed
that the infant had no intake (zero
calories). The medium estimate was
mid-way between the low and high
estimates. The 3 estimates allowed
for a crude sensitivity analysis for the
possible variable contributions from
breastfeeding, which were added
to measurable caloric intake. For all
baseline analyses, the medium estimate of the breastfeeding contribution to caloric intake was used. For the
primary outcome, sensitivity analyses
were run using the low, medium, and
high estimates. The primary outcome
was correlation between caloric intake

Caloric intake was defined as the number of kilocalories consumed or estimated on a given hospital day and
expressed in kilocalories per kilogram
per day (kcal/kg per day). A hospital day
was defined according to nursing flow
sheets from 6 AM to 5:59 AM the following day. Total kilocalories for any infant
were determined by summing the
measurable calories from formula or
expressed breast milk with an estimate of
calories obtained from sessions of active
breastfeeding (Table 1). If the infant was
in the hospital <24 hours (typically on
the day of admission or discharge), the
caloric intake was extrapolated to a
24-hour day and expressed as kcal/kg
per day by dividing the measured intake
by the number of hours they were in the
hospital multiplied by 24.

on hospital day 2 and LOS, defined as

the number of hours from the time a
subject arrived in the hospital unit to
the time of last nursing documentation at time of discharge. Hospital day
2 was chosen rather than hospital day
1 because it was the first complete
day of caloric intake information. For
many patients admitted at night, hospital day 1 only comprised a few hours.
In addition, many outcomes from our
previous work demonstrated stronger
associations with day 2 variables; thus,
day 2 caloric intake was chosen for our
primary outcome.7
When accounting for baseline malnutrition status, the Waterlow classification was chosen as an expression of
chronic malnutrition status by using
the percentage of ideal body weight:
class 1, >90% (normal); class 2, 81% to
90% (mild malnutrition); class 3, 71%
to 80% (moderate malnutrition); and
class 4, <70% (severe malnutrition).14

Analysis and Sample

Standard descriptive statistics were

used for describing daily caloric
intake on hospital days 1 through 5
for infants of varying LOS. Because
age and caloric intake were likely to
be nonnormally distributed, median
and interquartile range (IQRs) were
used.

TABLE 1 Estimates for Kilocalories Obtained per Session of Breastfeeding

Age

030 d
3190 d
91180 d
181270 d
271360 d

Recommended Daily
Allowance
(kcal/kg/day)20

Typical No. of
Feedings
per Day13

Calories Likely Obtained

From Breastfeeding,
(kcal/kg/day)13,21

High
Estimate,a
(kcal/kg/Feeding)

Medium
estimateb
(kcal/kg/feeding)

Low
Estimatec
(kcal/kg/feeding)

108
108
108
98
98

8
6
5
4
3

108
108
108
82
53

13.5
18
21.6
20.5
16.6

6.8
9
10.8
10.2
8.4

0
0
0
0
0

Well-child estimate.
Half of well-child estimate.
c
No significant intake.
b

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HOSPITAL Pediatrics

Correlation between day 2 caloric

intake and LOS was calculated. To
identify a modest correlation by using
the Pearson correlation coefficient
between caloric intake and LOS (correlation coefficient of 0.2), a sample
of 287 subjects was needed. Power
was chosen to achieve 90%, and a
lower level of significance of P < .01
was used to account for multiple comparisons. Stratified subgroup analyses
were performed for these outcomes
to identify potential confounding and
effect modification from breastfeeding
status, age, and preexisting chronic
malnutrition.
This study was approved by the CHW
institutional review board, and the
requirement for informed consent was
waived.

RESULTS
A total of 273 (79% of all bronchiolitis admissions) infants met inclusion
criteria and their data reviewed. One
patient was excluded because of gastrostomy tube placement during the
admission. Two patients had missing
data for caloric intake on days 1 and 2.
Twenty-three patients did not have
length obtained, and therefore their
Waterlow classification could not be
determined.
Baseline and selected characteristics
of infants admitted with bronchiolitis
are described in Table 2. The majority
of subjects (77%) were term infants,
were <6 months old (63%), and were
formula fed (16% being breastfed
some or all of the time).
Median caloric intake for infants of
varying LOS for the first 5 days of the
hospitalization using the medium estimate (estimate of caloric intake for
breastfed infants) is described in Table 3

AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 2 Characteristics of Infants Admitted With Bronchiolitis

Characteristic
Age in days
Gestation in weeks
Race
White
Other
Male gender
Respiratory support at birth
Chronic respiratory disease
Breastfed, some or all of the time
Waterlow percentile
Moderate or severe malnutrition
Days of decreased oral intake before admission
Received intravenous fluids
Day 1 caloric intake (kcal/kg/day)
Day 2 caloric intake, low estimate (kcal/kg/day)
Day 2 caloric intake, medium estimate (kcal/kg/day)
Day 2 caloric intake, high estimate (kcal/kg/day)

and depicted in Fig 1. The 270 patients

with complete caloric intake data were
included in this analysis. We noted a
trend between change in caloric intake
from day 1 to day 2 in which it seemed
that shorter LOS stay groups were
faster to improve their caloric intake.
However, there was substantial variation in the range of caloric intake as
noted by a wide IQR in caloric intake
among the LOS groups. There was a
modest inverse correlation (r = 0.18;
P = .002) between change in caloric
intake (day 2 day 1 kcal/kg per day)
and LOS (hours) (lower caloric intake
was associated with longer LOS).
There was a modest inverse correlation between the caloric intake of

Median (IQR) or N (%)

272
271
272

137 (62226)
40 (3740)
131 (48)
141 (52)
146 (54)
34 (13)
29 (11)
43 (16)
99 (92108)
10 (4)
1 (0 2)
106 (40)
53 (2381)
57 (3279)
64 (4486)
67 (4498)

272
272
272
272
249
249
217
266
270
270
270
270

formula-fedonly infants and LOS (r =

0.28; P < .001) (Table 4). These
formula-fed infants had their entire
caloric intake measured without the
use of estimate equations for contributions from breastfeeding. When the
caloric intake of all infants was evaluated (including the use of breastfeeding caloric estimates for those who
had breastfed), there was a modest
significant inverse correlation between
caloric intake on day 2 and LOS in all
infants by using the low, medium, and
high estimates for the contribution of
breastfeeding.
Stratified subgroup analysis of day
2 caloric intake and correlation with
LOS was performed in the following

TABLE 3 Median and IQR Caloric Intake for Infants (N = 270) With Varying LOS
LOS Hours

Caloric Intake (kcal/kg/day; IQR) Consumed on First 5 Hospital Daysa

Day 1

Day 2

Day 3

Day 4

Day 5

024
2548

43
72

65 (42100)
53 (3682)

80 (52105)
75 (5494)

78 (45110)

4972

58

43 (1874)

61 (4178)

64 (4893)

66 (41104)

7396

43

53 (080)

63 (4181)

72 (5081)

74 (6297)

97120

21

53 (2975)

37 (1567)

50 (3479)

66 (5775)

78 (60112)
80 (5299)

>120

33

58 (2977)

54 (3269)

56 (3479)

59 (3885)

66 (46-93)

Quantifiable caloric intake (kcal/kg/day) plus estimated calories from breastfeeding sessions by using
medium estimate described in Table 1.

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of the hospitalization. It also confirmed

there is a correlation between LOS
and both lower early hospital caloric
intake and slower rate of improvement
in caloric intake.

FIGURE 1 Median daily caloric intake in infants who had varying LOS.

strata: infants aged <183 days versus

those aged 183 days, any breastfeeding versus none, and no/mild chronic
malnutrition versus moderate/severe
chronic malnutrition. All subgroups had
significant mild correlations between
day 2 caloric intake and LOS (Table 4).
The only subgroup comparison with
a significant difference in day 2 caloric
intake was in infants 183 days old
who had significantly lower median
caloric intake than infants <183 days
old.

DISCUSSION
To the best of our knowledge, this
study is the first to report detailed
information about the daily caloric
intake of a large cohort of infants
admitted to the hospital with bronchiolitis. We report the daily caloric
intake of the first 5 days of admission
for 6 different LOS groups (Fig 1). This
study confirmed our hypothesis that
low caloric intake is common for many
infants who have bronchiolitis and for
some is persistent through many days

TABLE 4 Analysis of Median Day 2 Caloric Intake and Correlation With LOS in All Infants
and Subgroups by Using the Medium Estimate
Variable
All infants, low estimate
All infants, medium estimate
All infants, high estimate
Age <183 d
Age 183 d
Nonbreastfed
Any breastfeeding
None/mild malnutrition
Moderate/severe malnutrition

Median (IQR)

Correlation (r)

272
270
270
172
98
228
42
237
10

59 (3582)
66 (4790)
69 (4899)
72 (5194)
54 (3869)
63 (4385)
72 (4290)
64 (4486)
82 (54103)

NA
NA
NA
.001a

0.18
0.31
0.24
0.30
0.36
0.28
0.46
0.32
0.44

.003*
<.001*
<.001*
<.001*
<.001*
<.001*
.002*
<.001*
.200

.799
.232

Caloric intake (kcal/kg/day) correlated by using low, medium, and high estimates of contributions
of breastfeeding in various subgroups (eg, age, breastfeeding status, malnutrition status). NA, not
available.
* Statistically significant with P < .01.

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Previous research has shown that

many infants with bronchiolitis have
poor feeding before admission.6 An
important part of our work was to
evaluate the spectrum of poor caloric
intake extending into the hospitalization as well. Descriptive statistics
revealed that the median caloric intake
of infants on day 1 of the admission
was 49% of their caloric needs. It
was fairly similar in groups of infants
of varying LOS, ranging from 39% to
60% of their needs assuming the normal state, although we would expect
with increased respiratory rate and
effort, that their actual energy expenditure would be higher. By day 2 of the
admission, median intake was similar
(53% of needs); however, there was
increased separation of the median
caloric intake among infants of varying LOS. The rate of change in caloric
intake from day 1 to day 2 modestly
correlated with LOS. The shortest LOS
groups had rapid increases in caloric
intake toward 70 to 80 kcal/kg per day
by the day of discharge, whereas progressively longer LOS groups reached
this level of caloric intake more slowly.
In the longest LOS group, caloric
intake remained diminished even 5
days into the admission. In addition,
infants had diminished oral intake at
home for an average of 1 day before
admission. In our previous study, we
found that infants with LOS >5 days
had diminished oral intake for 3 days
before admission.7 Although this study
cannot determine the effect of up to
8 days with a growing calorie deficit
between consumption and expenditure, we speculate a deficit of this

HOSPITAL Pediatrics

magnitude might slow recovery. Our

findings correlating low caloric intake
with longer LOS aligns with findings
in our previous research, which identified very low caloric intake (<23.5
kcal/kg per day) on day 2 of the hospitalization as 1 of 5 factors predictive of
a prolonged LOS in a recursive partitioning model.
In addition to examining groups of
varying LOS, we examined subgroups
based on type of feeding, age, and
the presence of malnutrition. Caloric
intake in these subgroups has not been
previously reported and is important
in gaining a complete understanding
of caloric intake among infants hospitalized with bronchiolitis. Infants who
were strictly formula-fed had a significant modest correlation between
caloric intake and LOS. This was an
important group because it encompassed the majority of infants in our
study, and these infants had caloric
intake that was entirely measured
without the need for breastfeeding
estimates. Infants who were breastfed had similar correlations between
caloric intake and LOS. We found
a significantly lower day 2 caloric
intake among infants aged 183 days
(6 months) compared with those aged
<183 days. One possibility for this
finding is an underestimation of calories because of unquantified calories from solid foods in older infants.
These 2 age groups, however, had
similar correlations between caloric
intake and LOS. Patients with moderate to severe malnutrition had caloric
intake more strongly correlated with
LOS. However, with only 10 of these
patients in our study, this correlation was underpowered and did not
reach statistical significance. This
trend does suggest that early caloric
intake may be even more important

AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS

in malnourished patients who have

bronchiolitis.
This study has several limitations. First,
it was a retrospective study of a single
bronchiolitis season at a single institution. It is possible results would differ
during a different season or at another
institution. Second, the authors also
served as data abstractors and could
have been biased because they
were not blinded. Third, intake from
breastfeeding was estimated by using
a nonvalidated measure because no
validated measure exists. In addition,
because the minority of infants were
breastfed, it is possible we could have
missed a differential effect of breastfeeding on caloric intake or relationship with LOS. Fourth, solid food
intake was not quantified and is therefore absent from caloric estimates.
For infants <183 days old, this would
unlikely affect the results. For older
infants, it could have led to an underestimation of caloric intake. Fifth, this
study did not evaluate the contribution of intravenous fluids as a provider
of calories or modifier of oral intake.
However, the proportion of infants
receiving intravenous fluids was similar in both short and prolonged stay
groups, and intravenous fluids provide
very few calories. Sixth, this study evaluated nutrition by measuring only 1
aspect (caloric intake). There are other
specific nutrients such as fatty acids,
vitamins, and various nutrients that
may have an impact on recovery from
bronchiolitis that could not be evaluated in our study.1519 Seventh, because
adequate caloric intake is part of the
discharge criteria at our institution as
well as many others, it is logical that
low caloric intake will contribute to a
prolonged stay merely based on the
fact that it is 1 of the discharge criteria. Eighth, our sample size was slightly

less than thought to be needed in our

power calculations (272 vs 288); therefore, it is possible some outcomes fell
short of significance because they
were underpowered. Ninth, because
not all infants with bronchiolitis were
placed in the bronchiolitis protocol,
a systematic bias could have been
introduced, and it is important to note
these results may not generalize to
highly medically complex infants with
bronchiolitis who were underrepresented in the bronchiolitis protocol.
Finally, it is important to recognize this
study cannot differentiate whether
lower caloric intake itself had an independent role in prolonging recovery
in bronchiolitis or whether it merely
served as a proxy for severity of illness. We suspect that severity of illness is the predominant factor, which
causes diminished caloric intake in
infants admitted with bronchiolitis.
For many infants, this is a short-lived
problem unlikely to contribute to morbidity. However, for the most severely
affected infants with many days of
diminished caloric intake, we suspect
poor nutritional intake may become
an additional source of morbidity and
slow recovery.
This study lays the groundwork needed
for further exploration of the potential
benefit of nutritional interventions for
infants hospitalized with bronchiolitis.
There is a group of infants with bronchiolitis and prolonged LOS who have
poor caloric intake readily identifiable
early in their hospitalization. With few
effective interventions known to reduce
morbidity in bronchiolitis, the impact of
nutrition ought to be considered.

CONCLUSIONS
Caloric intake is often diminished in
infants admitted with bronchiolitis.
It seems to normalize more slowly
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in infants with progressively longer LOS. As early as hospital day 2,

it was significantly lower in infants
with a prolonged LOS and inversely
and modestly correlated with LOS.
These findings suggest that efforts to
improve nutrition early in the course of
bronchiolitis are worthy of additional
study, particularly in the most severely
affected patients in whom diminished
caloric intake remains prolonged and
theoretically could prolong recovery.

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