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 Ws 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 bodys 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 Childrens

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

State of nutrition vs. LOS and Cost
18
16
14
12
10
8
6
4
2
0

$16,691
$14,118
$7,692

Normal

Borderline

Malnourished

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

Parameter Low Risk High Risk

Hosp. Days
7
13.5
Mech. Vent.
0
8.5
NPO days
3
8.5
Days on O2
4
20
P< 0.02

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

Ventilator
Patients:

Weaned Died

No Specific
Nutrition Plan

18

15

Focused
Nutrtional Care

13

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 Im
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
In your continuity clinic
Multidisciplinary team
Supplement , reassess, or reschedule

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

albumin

has nothing to do with

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

CRP

Prealbumin
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
Im 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
Group Early (75) Late (75)
p
VAP
49.3%
30.7%
.02
C diff
13.3%
4.0%
.042
ICU stay 13.6 14.2 9.8 7.4
.043
Mortality
20%
26.7%
.334

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 >96 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

1 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 TNF

> 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
Feed type # Patients Mortality

SMR

Enteral

167

25%

.71

Parenteral

26

54%

1.4

Parenteral
+ Trickle

24

38%

.9

Trophic feeds are stress ulcer and antibiotic prophylaxis

rolled into one
Marik, CCM(a), 2002

Trophic Feeds Vs. TPN

100
90
80
70
60
50
40
30
20
10
0

92.4
70.3

32.6
14.1

20.2

Assisted Vent

20.6

PN

36.1
24.8

Full Enteral

Hosp.
Discharge

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
1980s 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 1824 infusion
No immune problems when Triglycerides <700

Monitor Outcomes
Residuals
Age appropriate
weight gain
Diarrhea /
Constipation
Medication
Compatibility?
Emesis / Aspiration

Proper wound
healing
Fluid and
electrolyte balance
Euglycemia
Improved N2
balance and
Prealbumin

HOPE IS NOT A METHOD!

Who?

Is you, screening all your patients

Why? Theyll do worse if you dont
When? The sooner the better
What? Enteral better, even trophic
better than TPN alone
Where? PO>NG>NJ > IV