Nutrition 29 (2013) 1094–1099

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Nutrition
journal homepage: www.nutritionjrnl.com

Review

Indirect calorimetry: A guide for optimizing nutritional support in the critically

ill child
Racheli Sion-Sarid M.D. a, Jonathan Cohen M.D. b, Zion Houri M.D. a, Pierre Singer M.D. b, *
a
Pediatric Intensive Care Unit, Wolfson Medical Center, Holon, Israel
b
Department of General Intensive Care, Rabin Medical Center, Campus Beilinson, Petah Tikva and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

a r t i c l e i n f o a b s t r a c t

Article history: The metabolic response of critically ill children is characterized by an increase in resting energy
Received 2 January 2013 expenditure and metabolism, and energy needs of the critically ill child are dynamic, changing
Accepted 12 March 2013 from a hypermetabolic to hypometabolic state through the continuum of the intensive care unit
(ICU) stay. It therefore appears essential to have a precise evaluation of energy needs in these
Keywords: patients in order to avoid underfeeding and overfeeding, loss of critical lean body mass, and
Indirect calorimetry
worsening of any existing nutrient deficiencies. However, there are no clear definitions regarding
Resting energy expenditure
either the exact requirements or the ideal method for determining metabolic needs. In clinical
Pediatric intensive care
practice, energy needs are determined either by using predictive equations or by actual
measurement using indirect calorimetry. Although many equations exist for predicting resting
energy expenditure, their accuracy is not clear. In addition, very few clinical trials have been
performed so that no firm evidence-based recommendations are available regarding optimal
nutritional management of critically ill children and infants. Most studies have come to the same
conclusion (i.e., current predictive equations do not accurately predict required energy needs in
the pediatric ICU population and predictive equations are unreliable compared with indirect
calorimetry). The recent American Society for Parenteral and Enteral Nutrition clinical guidelines
for nutrition support of the critically ill child suggest that indirect calorimetry measurements be
obtained when possible in pediatric patients with suspected metabolic alterations or malnutri-
tion, according to a list of criteria that may lead to metabolic instability, thus making standardized
predictive equations even less reliable. Although the standard use of indirect calorimetry is
limited due to equipment availability, staffing, and cost, the accuracy of the commercially available
devices continues to improve and the measurements have become more reliable and easier to
perform. In the absence of sufficient data, prospective controlled studies need to be conducted in
order to evaluate the benefit of tight calorie control achieved by accurately measuring the energy
needs of the critically ill child. Optimizing measuring techniques could make this more feasible
and decrease the need to rely on inaccurate equations while providing appropriate energy
requirements.
Ó 2013 Elsevier Inc. All rights reserved.

Introduction maintain normal basal physiological functioning. The REE is

Resting energy expenditure (REE) is defined as the amount of
calories required by the body at rest during a 24-h period and
represents 70% to 80% of the calories used by the body. It is the
resting metabolic rate that defines the energy released to
RS-S, PS, and ZH were involved in the research of the literature, drafting of the
manuscript, and final approval for the article; JC was involved in the drafting and
writing of the manuscript and final approval for the article.
* Corresponding author. Tel.: þ972-3-9376522; fax: þ972-3-9232333.
E-mail address: psinger@clalit.org.il (P. Singer).
0899-9007/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nut.2013.03.013
useful in optimizing and managing nutritional support. However,
ideal energy needs have not yet been formulated mainly due to
technical difficulties. The metabolic response of critically ill
children is characterized by an increase in REE and a precise
evaluation of energy needs in these patients would appear to be
essential in order to avoid underfeeding and overfeeding, as well
as to avoid loss of critical lean body mass and worsening of any
existing nutrient deficiencies [1]. Thus, overfeeding has been
associated with increased carbon dioxide production, respiratory
failure, hyperglycemia, and fat deposits in the liver, whereas
 R. Sion-Sarid et al. / Nutrition 29 (2013) 1094–1099
underfeeding may lead to malnutrition, muscle weakness, and
impaired immunity.
Many factors influence metabolic needs during acute illness.
Acute injury, burns, inflammation, surgery, or sepsis markedly
change the energy needs of the critically ill child. Additionally,
therapeutic interventions that are typical in the pediatric
intensive care unit (PICU) setting, such as mechanical ventila-
tion and the administration of vasoactive or sedative agents also
influence energy needs. It has been suggested that growth
ceases during the metabolic response to illness or injury in
children. Metabolism and energy needs of the critically ill child
seem to be dynamic, changing from a hypermetabolic to hypo-
metabolic state through the continuum of the PICU stay. In light
of these changes, determining the exact nutritional require-
ments for the critically ill child would appear to be essential
because adequate nutritional support and optimal nutritional
status have been shown to improve physiological stability and
outcome.
Validity of predicted versus measured REE
In clinical practice, energy needs are determined either by
using predictive equations (Table 1) or by actual measurement
using indirect calorimetry. Energy requirements of critically ill
infants and children are difficult to predict. In a prospective
study of 46 critically ill children, REE measured by indirect
calorimetry was not related to severity of illness, nutritional
status, or nitrogen balance [2]. Many equations exist for pre-
dicting REE, but their accuracy in estimating energy require-
ments for critically ill patients and children in particular, is not
clear. Most predictive equations are typically derived from
studies of healthy non- hospitalized individuals and few have
been validated in mechanically ventilated patients. Although
some studies have evaluated the accuracy of predictive versus
measured energy expenditure in critically ill children (Table 2),
they compared different sets of equations with the measured
energy expenditure and the population studied was different in
each of them. One of the problems with developing an accurate
predictive equation for critically ill children in the PICU is the
large heterogeneity regarding age, weight, muscle mass, level of
growth and maturity, diagnosis, and severity of illness. Ideally,
predictive equations should provide results within 10% of
measured energy expenditure [3]. Vasquez-Martinez et al per-
formed a prospective study of 43 ventilated critically ill children
during the first 6 h post-injury, in which they compared
measured energy expenditure by continuous indirect calorim-
etry with predictive energy expenditure calculated using the
Harris-Benedict, Caldwell-Kennedy, Schofield, Food and Agri-
culture Organization (FAO)/World Health Organization (WHO)/
United Nations University (UNU), Maffies, Fleisch, Kleiber,
Dreyer, and Hunter equations [4]. Most of the predictive equa-
tions overestimated measured energy expenditure, and mea-
sured energy expenditure and predictive energy equations
differed significantly except for the Fleisch and Caldwell-
Kennedy equations, which were found to be the best predic-
tors of energy expenditure. Bott and colleagues compared
measured versus predictive resting energy expenditure in 52
children with bronchopulmonary dysplasia (BPD) and in 30
healthy children, using four predictive equations, namely,
Schofield-W, Schofield-HW, Harris-Benedict and FAO equations
[5]. They concluded that the Harris-Benedict equation best
predicted REE in children with BPD while the Schoffield-W was
best in healthy children. Only minimal differences were found
between predictive equations and calorimetry and the authors
1095
Table 1
Standard equations used to predict energy expenditure in children
Harris-Benedict equation (kcal/d)
Boys: 66.4730 þ (5.0033  height) þ (13.7516  weight) 
(6.7550  age)
Girls: 655.0955 þ (1.8496  height) þ (9.5634  weight) 
(4.6756  age)
Schofield-W 3–10 y Girls: 22.5  weight þ 99
Boys: 22.7  weight þ 495
11–18 y Girls: 17.5  weight þ 651
Males: 12.5  weight þ 746
Schofield-HW 3–10 y Girls: 16.97  weight þ 1.618  height þ 371.2
Boys: 19.6  weight þ 1.033  height þ 414.9
11–18 y Girls: 8.365  weight þ 4.65  height þ 200
Boys: 16.25  weight þ 1.372  height þ 515.5
Schofield equations (kj/d) (1 kcal ¼ 4.186 kj)
< 3 y Boys: (0.0007  weight) þ (6.349  height)  2.584
Girls: (0.068  weight) þ (4.281  height)  1.730
3–10 y Boys: (0.082  weight) þ (0.545  height) þ 1.736
Girls: (0.071  weight) þ (0.677  height) þ 1.553
10–18 y Boys: (0.068  weight) þ (0.574  height) þ 2.157
Girls: (0.035  weight) þ (1.948  height) þ 0.837
White (kJ/d) 17  age [mo] þ (48  weight [kg]) þ (292  body
temp  C)  9677
FAO/WHO/UNU equations
< 3 y Boys: (kcal/d): (60.9  weight)  54
Girls: (kcal/d): (61  weight)  51
3–10 y old (1 kcal ¼ 4.186 kJ)
Boys: (kJ/g): (95  weight) þ 2071
Girls: (kJ/d): (94  weight) þ 2088
10–18 y Boys: (kcal/d): (16.6  weight) þ (77  height) þ 572
Girls (kcal/d): (7.4  weight) þ (482  height) þ 217
Maffeis equations (kJ/d) (1 kcal ¼ 4.186 kJ)
Boys: (28.6  weight) þ (23.6  height)  (69.1  age) þ 1287
Girls: (35.8  weight) þ (15.6  height)  (36.3  age) þ 1552
Fleisch equation (kcal/d)
Boys: 1–12 y: 24  BSA  (540.885  age)
13–19 y: 24  BSA  (42.5  [0.64  {age  13}])
Girls: 1–10 y: 24  BSA  (541.045  age)
11–19 y: 24  BSA  (42.5  [0.778  {age  11}])
Kleiber equations (kcal/d) PEE ¼ 70  weight0.75
Dreyer equation (kcal/d) Boys: weight1/2 /(0.1015  age0.1333)
Girls: weight1/2 /(0.1127  age0.1333)
Caldwell-Kennedy equation (kcal/d): 22 þ (31.05  weight) þ
(1.16  age)
Hunter equation (kcal/d) PEE ¼ 22  weight
BSA, body surface area; FAO/WHO/UNU, Food and Agriculture Organization/
World Health Organization/United Nations University; PEE, predictive energy
expenditure
concluded that predictive equations might be useful in the
management of children with BPD. In a study of 91 severely
burned children (> 40% body surface area), Suman and
colleagues compared the REE measured by indirect calorimetry
with predictive equations in this very hypermetabolic pop-
ulation [6]. Good agreement was obtained between the three
sets of equations used to calculate REE, namely, FAO/WHO/UNU,
Schofield-HW, and Harris-Benedict equations. However, the
predicted REEs were significantly lower than the measured
REEs. The authors concluded that indirect calorimetry should be
used to determine energy expenditure until more accurate
methods are developed for these critically ill patients. In
1096 R. Sion-Sarid et al. / Nutrition 29 (2013) 1094–1099

Table 2
Studies comparing predicted versus measured REE in critically ill children

First author Year Study population Equations compared Accuracy

Vasquez 2004 43 mechanically ventilated critically ill children Paired mean differences P value Paired mean differences* P-value
Martinez [4] 6 h postinjury Harris-Benedict 162.9  236.5; P ¼ 0.001
Caldwell-Kennedy 39.12  185.4; P NS
Schofield 96.74  186; P ¼ 0.01
FAO/WHO/UNU 82.7  200.8; P ¼ 0.038
Maffies 181.4  232.9; P < 0.0001
Fleisch 58.6  199.7; P NS
Kleiber 130.5  178.9; P ¼ 0.001
Dreyer 296.5  219; P < 0.0001
Hunter 317.7  180.5; P ¼ 0.001
Bott [5] 2006 52 children with BPD and 30 healthy children Mean difference pREE-mREE (kcal/d) Mean difference mREE-pREE (kcal/d)y
BPD Control BPD control
FAO/WHO/UNU 47.5 to 7.4
Harris-Benedict 15 to 33.3
Schofield-W 51.3 to 2.9
Schofield-HW 64.7 to 22.4
Suman [6] 2006 91 severely burned children Mean difference pREE-mREE (Kcal/day) Mean difference mREE-pREEz (kcal/day)
FAO/WHO/UNU 652  559
Schofield-HW 635  526
Harris-Benedict 640  555
Framson [3] 2007 44 children admitted to tertiary PICU Schofield White mREE similar to pREE 30% accuracyx
De Wit [8] 2010 21 mechanically ventilated children admitted Mean % difference mREE versus pREE Mean % difference mREE versus pREEjj
to PICU postsurgery for CHD Schofield 21.2
Schofieldþsf 18.39
WHO 23.39
White 36.45

BPD, bronchopulmonary dysplasia; CHD, congestive heart disease; FAO/WHO/UNU, Food and Agriculture Organization/World Health Organization/United Nations
University; REE, resting energy expenditure; mREE, measured REE; PICU, pediatric intensive care unit; pREE, predicted REE
* Paired t test; NS, not significant; means, the lowest difference.
y
Data of Bland Altman plot.
z
Data presented as means  SDdthe lower difference, the more accurate the test.
x
Predicted accurately in only 30% of measurements.
jj
Mean % difference of measured versus predicteddthe lower % difference, the more accurate the test.

a prospective observational study, Hardy et al [7] examined
whether a similar hypermetabolic response to that observed in
adults exists in children and compared a newly derived
predictive equation specific for the PICU (i.e., the White equa-
tion) with measured REE and with the age appropriate
Schofield-predictive equation [8]. They concluded that currently
available predictive equations cannot substitute for indirect
calorimetry measurement of energy expenditure in guiding
nutritional support in PICUs. The White equation was accurate in
only 30% of measurements [8]. In another prospective study,
predictive equations including the Schofield equation, the White
equation, and the WHO equation were compared with indirect
calorimetry in mechanically ventilated children who underwent
surgery for congenital heart disease [9]. They also compared REE
with the Schofield equation using a stress correction factor,
which is widely used to estimate energy expenditure in critically
ill children. They found poor a correlation between measured
REE and predicted energy requirements with none of the
predictive equations predicting requirements within 10% of
the REE. The Schofield equation with added stress factor had the
lowest percentage difference [9].
In general, most of these studies came to the same
conclusion: Current predictive equations do not accurately
predict required energy needs in the PICU population and need
to be reevaluated in the context of the variability of the
metabolic state in various conditions such as surgery, cardio-
pulmonary bypass, and postoperative organ dysfunction.
Additionally, the dynamic alterations in energy metabolism
that characterize critical illness can only accurately be assessed
with repeated indirect calorimetry, which remains the gold
standard.
Measuring energy expenditure by indirect calorimetry
REE can be measured indirectly with a metabolic cart, using
the analysis of expired gases to derive the volume of air that
passes through the lungs, the amount of oxygen extracted from it
(VO2) and the amount of carbon dioxide that is expelled into the
atmosphere (VCO2) as a byproduct of metabolism. This technique
has become the most commonly used to measure the rate of
energy production and substrate oxidation in critically ill
patients, both in clinical practice and in research studies. The
accuracy of the commercially available devices continues to
improve and the measurements have become more reliable and
easier to perform. All indirect calorimeters (IC) monitors use
inspired and expired gas volumes and concentrations to calcu-
late VO2 and VCO2. Metabolic monitors are now available as
portable bedside modules enabling the accurate estimation of
patient metabolic demands and most can measure VO2 with an
accuracy of more than 95%. The closed-circuit ICs that are used
most frequently collect expired air via a face mask or canopy or
directly from the ventilator’s exit port. The inspired air source is
room air or oxygen from inside the calorimeter. Open-circuit ICs
are those in which inspired gas source is room air or from the
ventilator [10].
The principle of IC is derived from the fact that the human
body burns available sources of fuel using oxygen while
producing CO2. In this model, all the oxygen that is consumed is
completely used and the CO2 that is expired is derived
from complete oxidation of fuels. The formulae used to calcu-
late REE are shown below. The equations are based on
the classic work of Weir, first published in 1949 and later
modified [11].
 R. Sion-Sarid et al. / Nutrition 29 (2013) 1094–1099
Formulae for deriving REE from IC:
VCO2 ¼ Q  FeCO2
RQ ¼ ½1  FiO2 =½ðFiO2  FeO2 Þ=FeCO2   FiO2
ðHaldane transformationÞ
VO2 ¼ VCO2 =RQ
Q ¼ total flow
FeO2 ¼ mixed expired O2 concentration
FeCO2 ¼ mixed expired CO2 concentration
RQ ¼ respiratory quotient
REE ¼ 3:91 VO2 þ 1:1 VCO2  3:34 NM
Or
REE ¼ VO2  4:838
 1:44ðfor patients without respiratory failureÞ
NM ¼ urinary nitrogen secretion:
The process of IC measurements
FiO2 is measured through the inspiratory limb of the venti-
lator circuit. The expired gas from the ventilator passes into
a mixer chamber where FeO2 and FeCO2 are analyzed. The
expired gas is then mixed with a flow of room air, large enough to
ensure constant flow. The new FeCO2 is recalculated and CO2
production calculated using the formulae described. The RQ is
calculated using the Haldane transformation and the O2 is then
calculated. The output is given as values of CO2 and O2 in mL/min,
whereas the RQ is given as a pure number.
Limitations of IC
Accurate assessment of REE and RQ may not be possible in
situations preventing complete collection of expired gases.
Examples include air leaks from the ventilator circuit and around
endotracheal tubes or through chest drains while CO2 removal
across hemodialysis membranes is also not taken into account by
IC. High settings on conventional ventilation, including FiO2
above 0.6 or high-applied positive end-expiratory pressure
(PPEP) levels also may result in inaccurate measurements of REE.
Connecting the IC to ventilators with large bias flow, especially
when the ventilator is set in the flow-triggered mode, is a special
problem if the IC is unable to separate the inspired and expired
gases related to the bias flow. Other technical issues such as
correct calibration, equipment malfunction, extreme circuit-flow
rates, and methodologic problems such as the appropriate length
of measurement, are all of great importance to ensure valid
results. The operators should actively look for instabilities or
pitfalls that may influence the results.
Timing and duration of IC measurements
There is no consensus regarding the optimal timing or dura-
tion of IC measurements but several studies have addressed this
question in adult ICU settings. No major differences in REE were
1097
found when comparing prolonged measurements (24 h) to
a much shorter duration (30 min) [12]. The ideal time for short-
duration measurements was found to be around noon. Longer
periods of measurements have been recommended for meta-
bolically unstable patients. In metabolically stable patients
a 5-min steady-state test may give precise estimation of the 24-h
REE. Some have suggested the need for repeated measurements,
as the metabolic course of critically ill patients is dynamic and
changes through hospitalization [13]. Recently, a prospective
study examined factors associated with successful IC testing
using the standard 5-min protocol in mechanically ventilated
children [14]. The study examined the agreement between the
REE obtained using the standard 5-min protocol and two
abbreviated 4-min and 3-min protocols as well as the Schofield
prediction equation. REE during a shortened period was opti-
mally correlated with 24-h REE measurements only if steady-
state criteria were met, that is, when minute-to-minute VO2
and VCO2 varied by not more than 10% consecutively for 5 min.
However, some patients may fail to achieve a steady state by
these criteria and a reliable measurement of REE may not be
obtained. Indeed, the number of patients who were able to reach
steady state was nearly doubled when using the 3-min protocol.
The authors concluded that the abbreviated protocols allowed
REE measurements to be obtained in most patients with
reasonable accuracy and may decrease the need to rely on
inaccurate equations when assessing energy expenditure in
children who fail IC testing by standard steady-state criteria.
Although many nutritional experts favor the view that IC
measurements should be used for all critically ill patients, no
study has yet proven that IC should be adopted as a standard
component of patient care. Recently, the concept of “tight calorie
control” has been advocated in critically ill adults, with the
understanding that both underestimation and overestimation of
daily energy expenditure may result in adverse outcomes.
A prospective observational study performed on 243 consecutive
patients in a mixed medical-surgical ICU found that optimal
nutritional therapy improved both ICU and hospital survival, but
only in women [15]. All patients in this study received enteral
nutrition from day 1, using the Harris-Benedict equation plus
a stress factor of 1.2. Screening was performed on days 3 to 5 of
ICU stay and mechanically ventilated patients with an expected
stay of a further 5 d or more were enrolled. IC was performed as
part of routine care. IC dictated caloric goals and total energy
expenditure was calculated as 1.2 times that measured by IC. The
target calorie supply was more than 90% of the estimated total
energy expenditure. Nutrition was guided by the results of IC
measurements and patients were provided at least 1.2 g protein/
kg daily based on preadmission body weight. The investigators
concluded that the achievement of an energy goals was impor-
tant and affected mortality, but emphasized that achieving
protein goals was as important as achieving energy goals.
Recently, TICACOS (Tight Calorie Control Study), a prospective,
randomized controlled, pilot study in 112 mechanically venti-
lated patients, showed that patients receiving tight control of
energy balance through the provision of energy guided by indi-
rect calorimetry and using enteral and parenteral nutrition, had
a higher intake of calories and protein, whereas the control
group (targeted at 25 kcal/kg) had a negative cumulative energy
balance [16]. More importantly, hospital mortality decreased in
the intervention group. However, hospital length of stay and the
total complication rate increased. An accompanying editorial
suggested that the use of indirect calorimetry should be
recommended to individualize nutrition, and that follow-up be
extended beyond the doors of the hospital [17].
1098 R. Sion-Sarid et al. / Nutrition 29 (2013) 1094–1099

Table 3
ASPEN criteria for the use of IC measurements [18]

Children at high risk for metabolic alterations who are suggested as candidates for targeted measurement of REE in the PICU.
Underweight (BMI < 5th percentile for age), at risk for overweight (BMI > 85th percentile for age) or overweight (BMI > 95th percentile for age)
 Children with > 10% weight gain or loss during ICU stay
 Failure to consistently meet prescribed caloric goals
 Failure to wean, or need to escalate respiratory support
 Need for muscle relaxants for > 7 d
 Neurologic trauma (traumatic, hypoxic and/or ischemic) with evidence of dysautonomia
 Oncologic diagnoses (including children with stem cell or bone marrow transplant)
 Children with thermal injury
 Children requiring mechanical ventilator support for > 7 d
 Children suspected to be severely hypermetabolic (status epilepticus, hyperthermia, systemic inflammatory response syndrome, dysautonomic
storms, etc.) or hypometabolic (hypothermia, hypothyroidism, pentobarbital or midazolam coma, etc.)
 Any patient with ICU LOS > 4 wk may benefit from IC to assess adequacy of nutrient intake.

ASPEN, American Society for Parenteral and Enteral Nutrition; BMI, body mass index; IC, indirect calorimetric; ICU, intensive care unit; LOS, length of stay;
PICU, pediatric intensive care unit; REE, resting energy expenditure

At present, there are limited data regarding the use of indirect
calorimetry in children. Indeed there are many challenges
associated with its use, including the use of specialized equip-
ment, technical support, high settings on conventional ventila-
tion, including high FiO2 or high PEEP, use of high-frequency
oscillating ventilation (HFOV) or extracorporeal membrane
oxygenation (ECMO) support, and the presence of chest tubes
with air leak. Finally, it may be difficult to obtain a steady state
during the IC measurement due to the presence of fever, feeding
regimens, uncontrolled movements, degree of sedation, and
environmental noise.
The standard use of IC is limited due to equipment avail-
ability, staffing and cost. The recent American Society for
Parenteral and Enteral Nutrition (ASPEN) clinical guidelines for
nutrition support of the critically ill child (Table 3) suggested that
IC measurements should be obtained when possible in pediatric
patients with suspected metabolic alterations or malnutrition,
according to a list of criteria that may lead to metabolic insta-
bility thus making standardized equations even less reliable [18].
A recent prospective chart review attempted to determine
how many PICU patients would be candidates for IC measure-
ments during their first week of stay, based on the current ASPEN
recommendations [19]. The review hypothesized that > 50% of
patients admitted to the PICU would meet these criteria and
benefit from IC measurements. This prospective chart review
included 150 consecutive patients admitted to PICU during
a 7-wk period. Underweight, overweight, and obesity were
defined as 5th, 85th to 95th, and > 95th percentiles, respectively
(Centers for Disease Control and Prevention values). The nutri-
tion intake data were collected prospectively each morning for
the previous 24 h for the duration of the PICU stay or for 7 d,
whichever was longer. All intravenous, parenteral, and enteral
nutrition sources were recorded. A registered dietitian calculated
energy and protein intake for each day. Energy needs were
estimated by the Schofield prediction equation. Protein needs
were estimated according to ASPEN guidelines. Patients were
classified to be at high risk for metabolic alterations according to
ASPEN criteria (previously mentioned) and patients meeting
these criteria were suggested as candidates for IC measurements.
The review found that IC was indicated in 72% of patients, with
the most frequent indications for IC being overweight/obesity
(32.4%), hypermetabolism (26.4%), not meeting nutrition goals
(13.7%), and mechanical ventilation (11.5%). Patients with
neurologic/seizure and respiratory disorders were responsible
for 66% of the suggested indications for IC. The review concluded
that in addition to the ASPEN criteria, further prioritization for IC
measurements should be given to patients ages < 2 y who are at
risk for developing nutrition deficiencies given their high basal
metabolic rate, weight (underweight or overweight) or PICU
length of stay (> 5 d). Restrictions may be necessary when
resources limit the availability of IC use.
Conclusions
The role of optimizing nutritional management in order to
improve the outcomes of critically ill children and infants has not
been adequately studied in terms of clinical trials. As a result,
there are no firm evidence-based recommendations concerning
optimal nutritional management in the PICU. There is growing
evidence from adult ICU studies for the need to measure energy
expenditure accurately in order to track the dynamic energy
needs of the critically ill, instead of prescribing for nutritional
needs according to static predictive equations. In children, only
a few studies have examined the validity of predictive equations
versus indirect calorimetry and all concluded that the equations
were less reliable. Recently, questioning whether indirect calo-
rimetry is a necessity or a luxury in a PICU led to the conclusion
that more than 72% of patients would derive benefit from the
measurement. However, prospective controlled studies need to
be performed in order to examine the necessity for tight calorie
control by way of measuring energy needs in critically ill chil-
dren. Optimizing the IC protocol and measuring technique could
possibly make this more feasible and decrease the need to rely
on inaccurate equations when assessing energy expenditure in
children.
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