1. Pediatric Critical Care Nutrition
Kristy Paley, MS, RD, LDN, CNSC

2. Outline PICU nutrition goals Energy expenditure/Kcal requirements
Indirect Calorimetry
Protein requirements
Parenteral Nutrition Guidelines
Enteral Nutrition Guidelines
Infant and Child Formulas

3. PICU-associated malnutrition
Metabolic stress response
Estimations of energy requirement
Prescription and Delivery
Preexisting deficiency/reduced somatic stores
***talk about when RD sees pt; the royal children’s hospital in australia median of 37.7% of daily EER (n= 42); half pts achieved EER after median of 7d. (fluid restriction main issue)
Mehta and Duggan (2009), Hulst et al. (2006), Rogers et al. (2003)

4. Nutrition Goals for the PICU
Minimize protein catabolism
Meet energy requirement
Wt gain not the goal post-injury (CRP <2mg/dL = anabolism)
Mehta and Duggan (2009)

5. 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
Newborns undergoing major operations have a transient 20% increase in energy expenditure that returns to baseline within 12H without complications; 25-30% accounted for activity; talk about Hasbro Children’s Hospital, n = 44
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)

6. 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)

7. 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)

8. 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
Measures O2 consumption and CO2 production; based on the assumption that gas volumes and concentrations exchanged at the alveolar level reflect cellular metabolic activity
Mehta et al. (2009)

9. 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)

10. Limitations of IC Air leaks around ET tubes Chest tubes FiO2 >60%
Receiving dialysis

11. Comparison of MEE vs. cREE
Children’s hospital of Pittsburgh (37 pts, 77 measurements)
Briassoulis et al. (2000)

12. DRI vs. REE Age DRI (kcal/kg) REE (kcal/kg) 0-3 mon 102 54 4-6 mon 8280 51
13-35 mon 56
3 y 85 57
4 y 70 47
5-6 y 65
7-8 y 60

13. 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)
REE = basal met rate + diet-induced thermogenesis (heat generated by enteral substrates)
Lloyd (1998)

14. 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
Kcal used for growth in older children ~ <5%
Agus and Jaksic (2002), Hardy Framson et al. (2007)

15. Kcal Requirements: Extubated
Kcal goal = DRIs for age/gender
Catch up growth may be necessary
(DRI x IBW) ÷ actual wt (kg)
BMI for age >85th%tile use IBW
IBW: BMI for
x actual wt) ÷ actual BMI

16. Protein Requirements Age DRI (normal) PICU 0-6mon 1.52g/kg/day
1.2
2-3
13-23mon
1.05
24mon-3y
1.5-2
4-13y
0.95
14-18y
0.85
1.5
***may require further increases in protein provision with burns, ECMO, bacterial sepsis

17. Parenteral Nutrition

18. PPN vs. TPN PPN TPN Peripheral access <900 mOsm/L Max D12.5%
Can go up to D15% with non-central PICC
Usually requires increased fluid allowance
TPN
Central access
No osmolarity limitations
Typical max dextrose usually D25% however can go up to D30% prn
ASPEN (2010)

19. 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. 20% Intralipid Essential Fatty Acids (EFA) Omega-6 source
Concentrated source of kcal
2kcal/ml

21. Coss-Bu et al. (2001), ASPEN (2010)
Parenteral Lipids
Age
Initiate
Advance
Maximum
<1yr
1g/kg/day
3g/kg/day
1-10yr
2-3g/kg/day
>10yr (adolescents)
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)

22. 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 (2-4% 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)

23. Parenteral Amino Acids (AA)
Neonatal AA
(Trophamine 10%)
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
Pediatric AA
(Freamine 8.5%)
Used for >5kg
Contains Phos
0.1 mmol/gram AA
Replicates AA in breastmilk
ASPEN (2010)

24. Parenteral AA Guidelines
Age
Initiate
Advance
Maximum
<1yr
1-2g/kg/day
1g/kg/day
4g/kg/day
1-10yr
1.5-3g/kg/day
>10yr (adolescents)
g/kg/day
***Goal aa correspond to ASPEN protein guidelines for critical illness mentioned earlier
***4kcal/g aa
ASPEN (2010)

25. Parenteral Dextrose Glucose infusion rate (GIR) 3.4kcal/g dextrose
% dextrose x volume ÷ wt (kg) ÷ 1.44
Example: 15% 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)

26. GIR/Dextrose Guidelines
Age
Initiate
Advance
Maximum
<1yr
~6-9mg/kg/min
1-2mg/kg/min
Goal: 10-12mg/kg/min
Max: 14mg/kg/min
1-10yr
1-2mg/kg/min >IVF GIR
Max: 8-10mg/kg/min
>10yr (adolescents)
Max: 5-6mg/kg/min
ASPEN (2010)

27. PN Electrolyte Dosing Guidelines
Preterm
Neonates
Infants/
Children
Adolescents/
Children >50kg Na
2-5meq/kg
1-2meq/kg K
2-4meq/kg Ca
0.5-4meq/kg
10-20meq/day
Phos
1-2mmol/kg
0.5-2mmol/kg
10-40mmol/day Mg
meq/kg
10-30meq/day
Acetate
As needed to maintain acid-base balance
Chloride
Assuming normal organ function and losses
ASPEN (2010)

28. Btaiche and Khalidi (2002), Kaufman (2002)
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)
IL: build up of excess phytosterols therby increasing the lithogenesis of bile; omega-6 FA pro-inflammatory
Cu and Mn are excreted in bile
Trophic feeds to stimulate Cholecystokinin
Btaiche and Khalidi (2002), Kaufman (2002)

29. 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
Adults synthesize cysteine from methionine

30. 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
(Se deficiency does not usually cause illness by itself but can make the body more susceptible to illnesses caused by other nutritional, biochemical or infectious stresses) Se is a cofactor in glutathione (tripeptide, antioxidant), iodine, and thyroid metabolism. Increased oxidative injury (se is an antioxidant), altered thyroid hormone metabolism. In HIV pediatric pts, Se deficiency has shown to be a predictor of more rapid disease progression and mortality

31. Enteral Nutrition

32. Enteral Nutrition Whenever possible, feed the gut
GALT/reduce risk for bacterial translocation
Trophic feeds: ≤20ml/kg/day
Continuous feeds
Advance by 0.5-1ml/kg Q4-6H

33. 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

35. 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
Pediatric Blenderized
Pediatric Compleat
1kcal/ml; 38g protein per L; omega 3 FA
Fluid-restricted
Pediatric High Calorie 1.5 with/without fiber
Boost Kid Essentials 1.5 with/without fiber
1.5kcal/ml

36. Pediatric Formulas (1-10yr)
Description
CPOE name
Product
Specs
Peptide-based
Pediatric Semi-Elemental (1)
Peptamen Jr with prebio
1kcal/ml
Pediatric Semi-Elemental (1.5)
Peptamen Jr 1.5
1.5kcal/ml
Elemental
Pediatric Amino Acid-Based
Elecare Jr
(30kcal/oz)

37. 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

38. References
Agus, M., & Jaksic, T. (2002). Nutritional support of the critically ill child. Current Opinion in Pediatrics, 14,
American Society for Parenteral and Enteral Nutrition. (2010). The A.S.P.E.N. pediatric nutrition support core curriculum.
Briassoulis, G., Venkataraman, S., & Thompson, A. (2000). Energy expenditure in critically ill children. Critical Care Medicine, 28(4),
Btaiche, I.F. & Khalidi, N. (2002). Parenteral Nutrition-associated liver complications in children, 22(2):
Coss-Bu, J., Klish, W.J., Walding, D., Stein, F., O’Brien Smith, E., Jefferson, L.S. (2001). Energy metabolism, nitrogen balance, and substrate utilization in critically ill children. American Journal of Clinical Nutrition, 74:
Fung, E.B. (2000). Estimating energy expenditure in critically ill adults and children. AACN Advanced Critical Care, 11(4):

39. References
Hardy, C., Dwyer, J., Snelling, L., Dallal, G., Adelson, J. (2002). Pitfalls in predicting resting energy requirements in critically ill children: a comparison of predictive methods to indirect calorimetry. Nutrition in Clinical Practice, 17,
Hardy Framson, C., LeLeiko, N., Dallal, G., Roubenoff, R., Snelling, L., & Dwyer, J. (2007). Energy expenditure in critically ill children. Pediatric Critical Care Medicine, 8,
Hulst, J.M., Joosten, K.F., Tibboel, D., van Goudoever, J.B. (2006). Causes and consequences of inadequate substrate supply to pediatric ICU patients. Current Opinion in Clinical Nutrition and Metabolic Care, 9:
Kaufman, S.S. (2002). Prevention of parenteral nutrition-associated liver disease in children. Pediatric Transplantation, 6:
Letton, R., Chwals, W., Jamie, A., & Charles, B. (1995). Early postoperative alterations in infant energy use increase the risk of overfeeding. Journal of Pediatric Surgery, 30(7),

40. References
Llyod, D.A. (1998). Energy requirements of surgical newborn infants receiving parenteral nutrition. Nutrition, 14(1):
Marcason, W. (2007). Can cutaneous application of vegetable oil prevent an essential fatty acid deficiency? Journal of the American Dietetic Association, 107(7): 1262.
Mehta, N., Compher, C., & ASPEN board of directors. (2009). A.S.P.E.N. clinical guidelines: nutrition support of the critically ill child. Journal of Parenteral and Enteral Nutrition, 33(3),
Mehta, N., & Duggan, C. (2009). Nutritional deficiencies during critical illness. Pediatric Clinics of North America, 56,
Rogers, E.J., Gilbertson, H.R., Heine, R.G., Henning, R. (2003). Barriers to adequate nutrition in critically ill children. Nutrition, 19:865-8.
Sy, J., Gourishankar, A., Gordon, W.E., Griffin, D., Zurakowski, D., Roth, R.M., Coss-Bu, J., Jefferson, L., Heird, W., Castillo, L. (2008). Bicarbonate kinetics and predicted energy expenditure in critically ill children. American Journal of Clinical Nutrition, 88:340-7.

41. 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),
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,