Nutrition in Surgical Pediatric Patients - 2

DOI: 10.1002/ncp.
10855
INVITED REVIEW
Nutrition
Nutrition considerations
considerations in pediatric
in pediatric surgical
surgical patients
patients
Debby S. Martins RD1 | Hannah G. Piper MD2
1
BC Children's Hospital, Vancouver,
British Columbia, Canada Abstract
2
Division of Pediatric Surgery, University Children who require surgical interventions are subject to physiologic stress,
of British Columbia/BC Children's necessitating a period of healing when nutrition needs may temporarily
Hospital, Vancouver, BC, Canada
change. Providing appropriate nutrition to children before and after surgery is
Correspondence an important part of minimizing surgical morbidity. There is a clear link
Hannah G. Piper, MD, Division of
between poor nutrition and surgical outcomes, therefore providing good
Pediatric Surgery, University of British
Columbia/BC Children's Hospital, reason for ensuring an appropriate nutrition plan is in place for children
4480 Oak Street, ACB K0 134, Vancouver, requiring surgery. This review will address recent research investigating
BC V6H 3V4, Canada.
nutrition considerations for pediatric surgical patients with a focus on
Email: hannah.piper@cw.bc.ca
practical tools to guide decision making in the preoperative, intraoperative,
For this and other NCP continuing and postoperative periods.
education articles, Please see https://aspen.
digitellinc.com/aspen/publications/13/view
KEYWORDS
nutrition assessment, pediatrics, surgery
INTRODUCTION included in the evaluation of whether a child is ready for

surgery and as part of the postoperative recovery plan.
Close to 4 million surgical procedures are performed on Although there are less data on how a child's nutrition
children in the United States each year, accounting for status should guide intraoperative decision making, there
~5% of the pediatric population.1 Because underlying are some practical points to consider. Additional
comorbidities and chronic disease tend to be less considerations for critically ill children will also be
common in children than in adults, most children do discussed.
well after their surgical interventions and return to their
preoperative level of functioning. However, complica-
tions and unforeseen setbacks do occur, and it is P RE O P E RA T I V E A S S E S SMENT:
important to consider interventions that could poten- WHEN TO INTERVENE
tially prevent adverse outcomes. The goal is to minimize
the impact of the surgery on quality of life. Although not It is well recognized that children have increased
always a primary consideration, nutrition health is nutrition requirements, compared with adults, to support
becoming well recognized as an important factor in both normal growth and development. It can, therefore, be
preparing for and recovering from surgery. Research challenging to meet these needs throughout the develop-
addressing issues such as the burden of malnutrition in mental stages, particularly in the setting of reduced
hospitalized children,2 the risks of prolonged fasting in intake or illness. Pediatric malnutrition is defined as an
preparation for surgery,3 and the association between imbalance between nutrient requirements and intake,
nutrition status and clinical outcomes4 has highlighted resulting in cumulative deficits of energy, protein, or
nutrition interventions that may benefit children micronutrients.5 Malnutrition in childhood can result in
undergoing surgery. Ideally, nutrition status should be permanent setbacks, including cognitive impairment,
© 2022 American Society for Parenteral and Enteral Nutrition.
510 | wileyonlinelibrary.com/journal/ncp Nutr. Clin. Pract. 2022;37:510–520.

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NUTRITION IN CLINICAL PRACTICE | 511
developmental delays, and the inability to reach linear to administer, (2) be easily completed by healthcare
growth potential.6,7 Pediatric malnutrition may also professionals with no background in nutrition assess-
predispose children to chronic health conditions in ment, (3) not rely on the interpretation of anthropomet-
adulthood, such as cardiovascular disease, dyslipidemia, ric measures or growth standards, and (4) be validated in
hypertension, and glucose intolerance.8 Unfortunately, general pediatric hospital populations. A variety of
malnutrition in hospitalized children is prevalent, with malnutrition screening tools are currently validated in
as many as one in three Canadian children admitted pediatrics, but their use is not widespread.6 This may be
to a tertiary pediatric hospital being malnourished.9 partly due to difficulty in integrating some of the
Although the term “malnutrition” is most often used to validated tools into the electronic health record (EHR).
describe undernutrition, it is important to recognize that However, the Pediatric Nutrition Screening Tool (PNST),
obesity is also a form of malnutrition. Obesity can be the Screening Tool for Risk on Nutritional Status and
associated with nutrient deficiencies as well as with Growth (STRONGkids), and the new version of the
chronic inflammation and decreased muscle mass. Screening Tool for the Assessment of Malnutrition in
Obesity has also been identified as a risk factor for Pediatrics (STAMP) can be used in the EHR.11,17
adverse surgical outcomes and is associated with STRONGkids is a comprehensive screening tool that is
impaired wound healing, altered glucose utilization, based on four parameters—subjective clinical assess-
and an increased inflammatory response.10 The good ment, presence of high‐risk disease, nutrition intake and
news is that malnutrition is preventable and mostly losses, and weight loss or poor weight gain18—and has
reversible with early and appropriate intervention, been used successfully in pediatric surgical patients.11
making a strong argument for screening children for PNST is also based on four parameters—weight loss,
malnutrition prior to surgery when possible. poor weight gain, nutrition intake, and subjective clinical
assessment—and can be used to screen for both under-
weight and overweight.19 STAMP uses three parameters
Nutrition screening for screening—the presence of high‐risk disease,
recent nutrition intake, and anthropometrics20—and is
Screening for malnutrition in the pediatric population is currently the only screening tool supported by grade
the first step in identifying and addressing nutrition I evidence.11
needs. Appropriate screening tools can help identify Malnutrition screening should be considered in
children who are potentially at risk of malnutrition, hospitalized patients undergoing major surgery and in
allowing for early intervention with a goal of improving the outpatient setting during the preoperative assess-
patient outcomes.11 Ideally, all children undergoing ment, when surgery is scheduled in advance. For
surgery should be screened, given the simplicity of most children with a prolonged hospital stay after surgery,
screening tools. However, there are occasional instances rescreening may be necessary because of the ongoing risk
in which this may not be practical or feasible. Although of developing malnutrition.11,19 Validated presurgical
studies assessing the utility of malnutrition screening in screening tools in an outpatient setting are currently
the perioperative setting are limited in pediatrics, there not available; however, potential screening questions
are some data to support its use. In a recent study of may include the following:
children undergoing surgery for Crohn's disease, an
association was found between the severity of mal- • Is the child visibly underweight or overweight?
nutrition and the increased need for preoperative • Has the child recently had poor weight gain or
parenteral nutrition, preoperative sepsis, need for pre- unintentional weight loss?
operative blood transfusion, and increased length of • Does the child have an underlying condition affecting
stay.12 Another study found a relationship between both feeding or nutrition?
undernutrition and overnutrition detected preoperatively • Has the child's intake recently decreased?
and adverse postoperative outcomes.13 Additionally, • Is the child expected to undergo major surgery?
there are several studies that describe an association • Is the child expected to require a prolonged period of
with malnutrition and increased morbidity after surgery fasting (without enteral intake) after surgery?
in adult patients.14–16
There are several screening tools available for
pediatric patients intended to identify children who need Nutrition assessment
more extensive nutrition assessment. Key features of a
screening tool, as defined by the Canadian Malnutrition Pediatric patients who are identified to be at nutrition
Task Force, include that it should (1) be quick and easy risk after screening should undergo complete nutrition
512 | MARTINS AND PIPER
assessment by a registered dietitian or nutrition support
Chronic undernutrition
team to confirm the diagnosis of malnutrition. This
• Length‐for‐age/height‐
for‐age < −2 SD of the
WHO Child Growth
assessment is a systematic approach to collecting and
Standards median
summarizing a child's nutrition status and related
nutrition problems and helps inform an appropriate
nutrition plan.21
Abbreviations: BMI, body mass index; MUAC, mid‐upper arm circumference; SD, standard deviation (also referred to as z score); WFL, weight‐for‐length; WHO, World Health Organization.
Although several pediatric nutrition screening tools
are available, nutrition assessment tools are limited. The
Subjective Global Nutritional Assessment (SGNA) is
considered the gold standard for diagnosing pediatric
malnutrition because of its effectiveness at determining
• WFL/BMI < −3 SD of the WHO Child
• Weight‐for‐age < −2 SD of the WHO

baseline nutrition status. It is an abbreviated but
Child Growth Standards median

comprehensive nutrition assessment tool and can be
Severe acute undernutrition
• Presence of nutrition edema
• Presence of nutrition edema

administered at the bedside by a dietitian or other trained
Growth Standards median

professional. The SGNA has been validated to identify
the presence and degree of malnutrition in pediatric
patients, including preoperative surgical patients.22 It is
• MUAC ≤ 115 mm
based on the subjective assessment of seven parameters
of a nutrition‐focused medical assessment (presence of
stunting, presence of wasting, unintentional changes in
weight, adequacy of dietary intake, gastrointestinal
symptoms, functional capacity, and metabolic stress of
disease) and three parameters of a nutrition‐focused
physical examination (loss of subcutaneous fat, muscle
wasting, and presence of edema). Validation studies have −2 SD of the WHO Child Growth
• MUAC between 115 and 124 mm

Moderate acute undernutrition
• WFL/BMI between the −3 and
shown it to be related to outcome measures such as

infection rates, length of stay, and readmission rates.23
However, the SGNA is relatively complex and requires
significant time and technical skills from the assessor,
Standards median
which may be a limitation to its use in an already

overburdened healthcare system. The SGNA scores triage
World Health Organization (https://www.who.int/publications/i/item/9789241506328).

patients into well nourished, moderately malnourished,
or severely malnourished.
Diagnostic parameters for acute and chronic malnutrition
As part of a complete nutrition assessment, measures

of body composition can be helpful. In the pediatric
population, this most commonly includes weight, length
or height, mid‐upper arm circumference, and triceps
−1 SD of the WHO Child Growth
skinfolds. When measured and plotted accurately on a

• WFL/BMI between the −2 and
growth chart, one‐time measurements may be used to

screen for nutrition risk, using the diagnostic parameters
Mild acute malnutrition
or risk of malnutrition
typically used for acute and chronic malnutrition

(Table 1). However, they do not provide adequate
Standards median
information to assess a child's growth and may,

therefore, be misleading. When available, a series of
two or more measurements over time are more informa-
tive of the child's growth trajectory and allow for a more
accurate assessment.
In addition to the variables measured in nutrition
assessment tools, plasma protein levels, such as
6–59 monthsa
albumin and prealbumin, were previously considered

5
Age group
0–20 years
TABLE 1
nutrition biomarkers and were widely used to evaluate

nutrition risk for postoperative complications. It is now
well recognized that albumin and prealbumin are
a
negative acute‐phase reactants. Their concentration • If a child screens positive, follow up with a more
decreases with inflammation and physiologic stress, thorough nutrition assessment.
regardless of nutrition status. Although they remain • For children who are severely malnourished (z score <
independent risk factors for complications, they are −2 SD), provide a nutrition plan to target 10% body
not reliable markers of nutrition status and should not weight increase prior to surgery, if possible.
be used as such.24–26
OPERATIVE CONSIDERATIONS:
Nutrition intervention WHEN TO CHANGE COURSE
When malnutrition is confirmed, consideration should Situations do arise when surgery cannot be delayed
be given to optimizing nutrition intake prior to surgery. regardless of nutrition status. However, it is recognized
This is a somewhat controversial topic, as the feasibility that when operating on a significantly malnourished
and duration of therapy must be weighed against the child, there is an increased likelihood of postoperative
urgency of the surgical intervention. When nutrition complications. Previous studies have shown that stunting
rehabilitation before surgery is indicated and feasible, (low height‐for‐age), often a marker of chronic under-
several options can be considered. This may include nutrition, was associated with postoperative complica-
nutrition education, diet modifications, oral supplemen- tions, whereas wasting (low weight‐for‐age), typically a
tation, enteral or parenteral nutrition support, and marker of acute undernutrition, was not.13,31 Addition-
nutrition‐focused medical therapy. However, this ally, another study found that adults who were at high
must be done with sufficient time and intensity to risk of malnutrition, based on preoperative screening,
provide benefit. Routine nutrition supplementation is were almost 3 times as likely to develop complications
unnecessary and provides no benefit for children who are and 12 times as likely to die.32 Similarly, in a study of
well nourished. When surgery can be safely delayed, children in Zimbabwe undergoing both elective and
enteral nutrition should be given to children found to be emergency surgery, 50% of undernourished children had
severely malnourished until a 10% increase in body a postoperative complication compared with 12% of those
weight and a z score >−2 SD is achieved.27 Children with adequately nourished. Undernourished children were
mild to moderate malnutrition may benefit from receiv- also four times as likely to have a surgical site infection
ing at least 10–14 days of enteral nutrition prior to compared with adequately nourished children.4 Under-
surgery to improve nitrogen balance and help with nutrition may even disadvantage children undergoing
wound healing. If enteral nutrition is not possible, relatively minor surgery. An older study looking at
parenteral nutrition should be used.28 Parenteral nutri- recurrence after inguinal hernia repair in children
tion supplementation is associated with reduced post- identified poor nutrition as a risk factor.33
operative complications in children with Crohn's disease There are several theories explaining the increased
and infants with congenital heart disease.29,30 The goals risk for wound‐related and tissue healing complications
of preoperative nutrition support are to avoid starvation for malnourished children. The most common rationale
to minimize negative protein balance; maintain muscle, is that the body's natural stress response to surgery
immune, and cognitive functions; and ultimately en- results in macronutrients being distributed from skeletal
hance recovery and return to baseline function. In muscle and fat for wound repair and immune response.34
situations in which the urgency of the surgical interven- If skeletal muscle mass is already compromised because
tion outweighs the ability to provide preoperative of malnutrition and wasting, there may not be sufficient
nutrition support, the focus should then be on post- reserve to support effective postoperative healing, result-
operative nutrition rehabilitation. ing in wound breakdown and surgical complications.
It can, therefore, be difficult to decide the best
surgical approach for severely malnourished children.
Practical recommendations For example, should a stoma be considered instead of an
intestinal anastomosis? Should wounds be repaired using
• Find a screening tool that is easy to administer and a different technique? There is a paucity of data to guide
readily available (STRONGkids, PNST, and STAMP are these decisions in children. In the adult literature, there
good examples). is some evidence to suggest that malnutrition35 and
• Use the screening tool routinely, especially for recent weight loss36 are risk factors, specifically for
children undergoing complex or major surgery with intestinal anastomotic leak and reoperation in patients
an expected inpatient stay. requiring colorectal surgery. However, currently there
are insufficient data to support a change in surgical nutrition beyond caloric and micronutrient provision are
technique when operating on malnourished children in now well recognized, including preservation of intestinal
an emergency setting. Typically, these decisions are integrity and minimization of bacterial translocation and
made on a case‐by‐case basis depending on the child's inflammation; therefore, reducing time spent fasting in
condition at the time of surgery and other clinical factors the perioperative period has become a priority.37 Even
(presence of infection, hypothermia, coagulopathy, etc). relatively brief periods of fasting have been associated
However, prolonged hospital stay and longer recovery with gut‐associated lymphoid tissue cell loss and gut
times can be expected for malnourished children. atrophy in animal models38 and alterations in glucose
If possible, assessing a child's nutrition status prior to control and tissue glycosylation.39 This has prompted
surgery and discussing potential risks factors with other protocols across several surgical disciplines in adults to
care providers, including registered dietitians and nutri- include a high‐carbohydrate beverage to be ingested 2 h
tion support teams, can be helpful in guiding operative before surgery.40,41 Although there are less data to
decision making. Identifying potential barriers to proper support this practice in children, it does appear safe
nutrition in the postoperative period, including food and potentially beneficial as long as the drink does not
security and feeding difficulties, may help identify contain protein.42
solutions to improve postoperative recovery. Similarly, the traditional pathway of waiting until a
child has return of bowel function postoperatively prior
to allowing enteral feeding has been challenged, and in
Practical recommendations many cases early enteral nutrition seems beneficial.
Improved outcomes, including reduced time to full
• Assess a child's nutrition status and potential barriers feeding and length of stay, have been reported.43,44
to adequate nutrition prior to surgery. However, it is important to keep in mind that studies
• If surgery is emergent/urgent in the setting of severe have considerable variability in the type of surgery and,
malnutrition, discuss with caregivers that there is therefore, the expected ileus (gastrostomy tube place-
increased risk for complications and prolonged length ment vs intestinal anastomosis) and in their definition of
of stay. enteral feeding (clear fluids vs regular diet). However, a
• For children who are severely malnourished with recent randomized trial in neonates undergoing intesti-
recent weight loss, consider alterations to the surgical nal anastomosis found that early feeding within 48 h of
plan to minimize wound healing complications. surgery did not increase morbidity, including surgical
complications or gastrointestinal symptoms. Although
there was no significant difference in time to full feeds or
POSTOPERATIVE M ANAGEMENT: length of hospital stay between early and late feeding
WHEN AND H OW TO FEED groups, the study did demonstrate the safety of initiating
early feeding.45 A meta‐analysis of recent studies looking
Enhanced recovery protocols after surgery at the same concluded that early enteral feeding within
the first 48 h of bowel anastomosis resulted in early
Initiatives to minimize invasive monitoring and reduce discharge from the hospital and fewer surgical site
barriers to getting back to a preoperative lifestyle in infections and septic episodes.46,47 The majority of
adults undergoing gastrointestinal surgery have become studies included in the meta‐analysis defined early
common in the past decade. These same initiatives, feeding as oral fluids, followed by solid food as tolerated.
enhanced recovery after surgery (ERAS), are now being The most sensible approach is likely to allow the patient
implemented in the pediatric population, and nutrition is to guide intake, relying on factors such as abdominal
a key consideration including both preoperative and distension, nausea or vomiting, and signs of hunger to
postoperative interventions. Ideally, ERAS protocols are decide when to start feeds as opposed to waiting on a
implemented with a team approach to include the bowel movement or other more downstream indicators.
expertise of nurses, anesthesiologists, surgeons, dieti- For children undergoing surgical procedures that do not
tians, and other allied health professionals. This ensures involve the gastrointestinal tract, the decision to start
that all aspects of enhanced recovery are appropriately enteral feeds without delay postoperatively is more
addressed. However, even if this resource is not straightforward. This even includes infants undergoing
immediately available, the nutrition aspects of an congenital heart surgery.48 Recently, the ERAS Society
enhanced recovery plan can be beneficial. Preoperatively, published consensus guidelines for perioperative care in
the focus has been on reducing the time spent fasting and neonatal intestinal surgery, recommending starting
encouraging adequate hydration. The benefits of enteral enteral feeds within 24 to 48 h after surgery when
possible and using human milk as the first choice for parent's own expressed human milk should be used
nutrition.49 preferentially for most infants as soon as enteral
nutrition is initiated, and efforts should be made to
support lactation in parents who choose to breastfeed or
Feeding protocols chestfeed. Although pasteurization decreases the
immune benefits of human milk, many nutrition
In addition to initiating enteral nutrition early, there has components are only minimally altered or decreased.
been an emphasis in recent years on standardizing the Therefore, when parent's own milk is not available, not
approach to feeding based on the best available evidence. recommended, or limited in volume despite lactation
The idea is to minimize errors and improve outcomes. support, pasteurized donor human milk from a regulated
Feeding protocols have been used in pediatric nutrition, milk bank remains a desirable alternative for sick and
particularly for neonates and children who are in the hospitalized infants.55,56 When human milk is not an
intensive care unit after complex surgery. In neonates option, infants whose condition does not affect the
undergoing cardiac surgery, the use of a postoperative gastrointestinal tract should receive a standard infant
feeding protocol resulted in earlier feeding and reaching formula. In infants whose condition does affect the
goal feeds more quickly without increased complica- gastrointestinal tract, the choice of formula when human
tions.50 Similarly, another recent study in infants under- milk is not an option is controversial. Those who have no
going cardiac surgery found that by implementing a history of intestinal damage can receive a standard infant
feeding pathway, there were improvements in weight‐ formula, but may tolerate a partially hydrolyzed, whey‐
for‐age z scores when compared with those who were not based standard formula better. Extensively hydrolyzed
on the pathway.51 Feeding protocols have also been and amino acid–based formulas continue to be a
studied in infants with gastroschisis after abdominal wall common choice for infants who have a history of
closure. A recent meta‐analysis found that although intestinal damage to optimize absorption in the presence
standardized feeding did not reduce time receiving of a compromised mucosal barrier. However, studies
parenteral nutrition, it did result in earlier feeding, have not clearly shown a benefit over standard formu-
reduced complications, and reduced mortality.52 Inter- las.54 Amino acid–based formulas may be better tolerated
estingly, the specific details of the protocol are quite in infants with compromised motility; however, they can
variable among studies, and it seems that benefits are be expensive and difficult to obtain. Therefore, trialing
often realized just by having standardized the approach, alternative formulas in a stepwise fashion before decid-
which can simplify things for providers and families, ing on the best option and ensuring availability prior to
allowing for more consistent delivery of enteral nutrition. discharge are essential.
Another consideration in the pediatric population
specifically is whether carnitine supplementation is of
Choice of nutrition benefit. Carnitine is an essential amino acid that plays an
important role in the transfer of fatty acids into the
When it comes to choosing the most appropriate enteral mitochondria and in their beta oxidation, with subse-
diet for children after surgery, there are a number of quent energy release. Although considered nonessential
potential factors to consider. For healthy children who in adults, carnitine is conditionally essential in children.
are able to resume their preoperative diet, national Acquired deficiency is most commonly seen in preterm
guidelines for a balanced diet are recommended (such as or low‐birth‐weight infants, when receiving prolonged
the United States Department of Agriculture: MyPlate carnitine‐free parenteral nutrition, in the setting of
Healthy Eating or Health Canada's Food Guide for sepsis, or in severely malnourished infants and children.
Healthy Eating). If enteral formula is required to Deficiency inhibits fatty acid oxidation and may present
supplement an oral diet or fully support dietary needs, as hypertriglyceridemia, decreased tolerance to lipid
a standard polymeric formula is appropriate for most emulsions, and decreased weight gain or failure to
patients.53 Although amino acid‐based formulas have thrive. The benefits of carnitine supplementation in
historically been used in children with short‐bowel pediatric nutrition are poorly understood, but several
syndrome, studies have not clearly shown a benefit over studies have found that carnitine supplementation
standard formulas.54 through either the enteral or parenteral routes improved
For infants and neonates, human milk is typically the nutrition markers and increased nitrogen balance and
best choice. Human milk is rich in immunological and weight gain.57,58 There is currently insufficient evidence
growth factors, which support the immune system and to support the routine supplementation of pediatric
have a direct trophic effect on the intestinal mucosa. The surgical patients. However, in view of the potential
benefits and relatively low risk, consideration can be hyperglycemia.59 However, the duration of the metabolic
given to supplementing carnitine in malnourished changes after surgery can be quite variable depending on
postoperative patients or those who are expected to other factors affecting metabolism. In newborns, major
require prolonged parenteral nutrition. abdominal surgery causes only a brief increase in REE,
lasting less than a day.60 Additionally, infants and
children tend to divert protein and energy away from
Practical recommendations growth to allow for tissue repair and healing, which
minimizes the increase in REE.61
• Keep preoperative fasting to a minimum, focusing on When it is available, indirect calorimetry (IC) should
maintaining appropriate hydration and carbohydrate be used to estimate caloric needs, whereas oxygen
intake. consumption and carbon dioxide production are used
• Initiate feeds as soon as possible postoperatively when to estimate REE.62 IC is particularly useful in patients
a child is exhibiting signs of hunger. with an altered REE or when nutrition goals are not
• Consider developing feeding protocols for populations reached despite seemingly sufficient nutrition support.
with similar postoperative recovery needs. IC is the gold standard to measure REE but may not
• If enteral formula is required, start with a standard always be available in resource‐limited settings. In
polymeric composition. addition, it must be performed when the child is quiet,
awake, and calm. When IC is not available or not
possible, a predictive equation, such as the Schofield
NUTRITION F OR CHILDREN equation, can be used, with the addition of stress factors
R E Q U I R I N G CR I T I C A L CA R E if needed.27,63 However, these equations tend to be much
AFTER SURGERY less accurate and may lead to unintended overfeeding or
underfeeding.
As it becomes well recognized that adequate nutrition Postoperative caloric needs, particularly in critically ill
intake is essential for optimal recovery after major children, have often been overestimated, as energy needs
surgery, efforts are now focused on what and how much sometimes decrease because energy is shunted away from
to feed. This requires special consideration in children growth.55 Both underfeeding and overfeeding can be
recovering from major surgery who require multiple days problematic for critically ill children. Macronutrient defi-
in the hospital. Nutrition requirements in the immediate ciencies can result in increased risk of infection, prolonged
postoperative period can be difficult to estimate and may mechanical ventilation, and sustained muscle weakness, and
depend on many factors, such as other medical condi- overfeeding can result in liver injury and increased risk of
tions and mobility. In a critical care setting, this may also infection.64 Protein requirements may be increased in the
include the need for mechanical ventilation, external postoperative period because of catabolism and, in already
heat support, sedation, and neuromuscular blockers. In malnourished children, because of decreased reserves.
pediatrics, this is further complicated by the need to Protein is a key nutrient in wound healing and should,
prevent overfeeding while still providing sufficient therefore, be optimized without delay. In critically ill infants
nutrition to support a limited increase in resting energy and children receiving enteral nutrition, current recommen-
expenditure (REE) and the inflammatory response. It is dations are to try to provide at least 65% of energy
also important to avert catabolism and provide sufficient requirements, including 1.5 g/kg/day of protein within the
substrate for growth.27 Despite the challenges, estimating first week of hospitalization.65 If the surgical wound is not
nutrition requirements is important. healing as expected, consideration can be given to increasing
Much of the research on postoperative nutrition protein to 120%–125% of estimated requirements.27
requirements has been done in critically ill pediatric As in other pediatric populations, starting enteral feeds
populations, including those with congenital cardiac early is beneficial for those requiring critical care,
disease. Although there are some limitations in applying including children on ventilatory and/or vasoactive
these data more broadly, this information can help guide support.66 Despite known benefits, there are often barriers
those caring for postoperative pediatric patients. Gener- to the delivery of sufficient enteral nutrition. This includes
ally, during critical illness and significant stress, there is perceived feed intolerance and frequent fasting require-
an increase in muscle breakdown and as a result, an ments for diagnostic tests or procedures. Although there is
increase in circulating free amino acids. These are used insufficient evidence to make strong recommendations,
to synthesize acute inflammatory proteins and help with the Society of Critical Care Medicine recommends
tissue repair. This can also be accompanied by increased initiating or continuing enteral feeds as long as vasoactive
fatty acid oxidation and gluconeogenesis resulting in support is not escalating and foregoing checking gastric
residuals routinely, as this may impede enteral feeding recent study looking at undernourished children with
without just cause.67 Postpyloric or jejunal feeding is also weight‐for‐age or body mass index z scores <−2 SD in the
an option if gastric feeding has failed. As mentioned intensive care unit, those who started receiving parenteral
previously, the development of enteral feeding protocols nutrition early (day 1) vs late (after 1 week) had a higher
can be helpful in a critical care setting, allowing for more incidence of infection and a longer intensive care unit
consistent delivery of enteral nutrition and advancement stay.68 It is recommended to initiate parenteral nutrition
to goal enteral intake.50 The use of parenteral nutrition when full nutrition support cannot be given enterally
when enteral feeding is suboptimal is important, but the within 2 to 3 days in infants, 5 to 7 days in children, and 7
timing of when to initiate this is more controversial. In a to 10 days in adolescents.55
F I G U R E 1 Nutrition pathway for pediatric surgical patients. ERAS, enhanced recovery after surgery; GI, gastrointestinal;
NST, nutrition support team; PNST, Pediatric Nutrition Screening Tool; RD, registered dietitian; SGNA, Subjective Global Nutritional
Assessment; STAMP, Screening Tool for the Assessment of Malnutrition in Pediatrics; STRONGkids, Screening Tool for Risk
on Nutritional Status and Growth.
P r a c t i c a l re c o m m e n d a t i o n s 5. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric

malnutrition: a paradigm shift toward etiology‐related defini-
• When available, use IC to determine energy require- tions. JPEN J Parenter Enteral Nutr. 2013;37(4):460‐481.
6. Carter LE, Shoyele G, Southon S, et al. Screening for pediatric
ments. Otherwise, estimate energy requirements using
malnutrition at hospital admission: which screening tool is
predictive equations for REE with stress factors.
best? Nutr Clin Pract. 2020;35(5):951‐958.
• Optimize protein intake and increase to 120%–125% of 7. Murray RD, Kerr KW, Brunton C, Williams JA, DeWitt T,
expected requirements if surgical wounds are not healing Wulf KL. A first step towards eliminating malnutrition:
as expected. a proposal for universal nutrition screening in pediatric
• Delay the start of parenteral nutrition postoperatively practice. Nutr Diet Suppl. 2021;13:17‐24.
for 7 days in older children who cannot tolerate full 8. Grey K, Gonzales GB, Abera M, et al. Severe malnutrition or
famine exposure in childhood and cardiometabolic non‐
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11. Becker PJ, Gunnell Bellini S, Wong Vega M, et al. Validity
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Children undergoing major surgery should have nutrition 288‐318.e2.
screening followed by assessment and intervention if needed. 12. Ladd MR, Garcia AV, Leeds IL, et al. Malnutrition increases the
Postoperatively, the focus is on initiating enteral nutrition risk of 30‐day complications after surgery in pediatric patients
early and estimating caloric needs as accurately as possible with Crohn disease. J Pediatr Surg. 2018;53(11):2336‐2345.
(Figure 1). 13. Alshehri A, Afshar K, Bedford J, Hintz G, Skarsgard ED. The
relationship between preoperative nutritional state and
adverse outcome following abdominal and thoracic surgery
AUTHOR CONTRIBUTIONS in children: results from the NSQIP database. J Pediatr Surg.
Hannah G. Piper and Debby S. Martins contributed to the 2018;53(5):1046‐1051.
conception and design of the research and interpretation 14. Ozkalkanli MY, Ozkalkanli DT, Katircioglu K, Savaci S.
of the data. Both authors drafted the manuscript, Comparison of tools for nutrition assessment and screening
critically revised the manuscript, and agree to be fully for predicting the development of complications in orthopedic
accountable for the integrity and accuracy of the work. surgery. Nutr Clin Pract. 2009;24(2):274‐280.
15. Williams DGA, Molinger J, Wischmeyer PE. The mal-
All authors read and approved the final manuscript.
nourished surgery patient: a silent epidemic in perioperative
outcomes? Curr Opin Anaesthesiol. 2019;32(3):405‐411.
C O N F LI C T S OF IN T E R E ST 16. Matthews LS, Wootton SA, Davies SJ, Levett DZH. Screening,
The authors declare no conflicts of interest. assessment and management of perioperative malnutrition: a
survey of UK practice. Perioper Med (Lond). 2021;10(1):30.
ORCID 17. Reed M, Mullaney K, Ruhmann C, et al. Screening Tool for
Hannah G. Piper http://orcid.org/0000-0002-8379-2271 the Assessment of Malnutrition in Pediatrics (STAMP) in the
electronic health record: a validation study. Nutr Clin Pract.
2020;35(6):1087‐1093.
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Nutrition in Surgical Pediatric Patients - 2

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DOI: 10.1002/ncp.

Debby S. Martins RD1 | Hannah G. Piper MD2

INTRODUCTION included in the evaluation of whether a child is ready for

© 2022 American Society for Parenteral and Enteral Nutrition.

510 | wileyonlinelibrary.com/journal/ncp Nutr. Clin. Pract. 2022;37:510–520.

assessment by a registered dietitian or nutrition support

• WFL/BMI < −3 SD of the WHO Child

• Weight‐for‐age < −2 SD of the WHO

Child Growth Standards median

Severe acute undernutrition

• Presence of nutrition edema

• Presence of nutrition edema

Growth Standards median

• MUAC between 115 and 124 mm

shown it to be related to outcome measures such as

which may be a limitation to its use in an already

World Health Organization (https://www.who.int/publications/i/item/9789241506328).

As part of a complete nutrition assessment, measures

skinfolds. When measured and plotted accurately on a

growth chart, one‐time measurements may be used to

typically used for acute and chronic malnutrition

information to assess a child's growth and may,

albumin and prealbumin, were previously considered

nutrition biomarkers and were widely used to evaluate

P r a c t i c a l re c o m m e n d a t i o n s 5. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric

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