NUTRITIONAL SUPPORT IN CRITICALLY ILL

PEDIATRIC PATIENT
 IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR
THE BABY
Breastfeeding provides the best nutrition and protection from illnesses of infants. For infants, breast milk is all that is needed for the first 6 months.
Breastmilk is the best and most economical food for baby.
Warning / Caution: Infant milk substitute is not the sole source of nourishment of an infant. Careful and hygienic preparation of infant milk substitute is
most essential for health. Lactose- free infant milk substitute should only be used in case of diarrehea due to Lactose intolerance. Lactose- free infant formula
should be withdrawn, if there is no improvement in symptoms of intolerance.
Continued use of infant milk substitute should not be recommended to avoid any difficulties in reverting to breastfeeding of infants after a period of feeding
by infant milk substitute. In the event recommending infant milk substitute in addition to breastmilk or its replacement during the first 6 months, keep the
costs in mind before recommending use of infant milk formula. Un-boiled water, un-boiled bottles or incorrect dilution can make a baby ill. Always advise to
follow instructions exactly.
Unnecessary introduction of partial bottle-feeding or other foods and drinks will have negative effect on breastfeeding.
Characteristics of breastmilk : Immediately after delivery, breastmilk is yellowish and sticky. The milk is called Colostrum, which is secreted during the
first-week of delivery. Colostrum is more nutritious than mature milk because it contains more proteins, more anti-infective properties, which are of great
importance for the infant’s defense against dangerous neo-natal infections. It also contains higher levels of Vitamin ‘A’.
Advantages of breastfeeding : (A) Breastfeeding is much cheaper than feeding an infant milk substitute as the cost of extra food needed by the mother is
negligible as compared to cost of feeding infant milk substitute; (B) Breastmilk is always available; (C) Breastmilk needs no utensils or water (which might
carry germs) or fuel for is preparation; (D) Mothers who breastfeed usually have longer periods of infertility after child birth than non-lactators.
Management of breastfeeding, as under:
I. Breastfeeding
A. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
B. Is successful when the infant suckles frequently and the mother wanting to breastfeed is confident in her ability to do so.
II.In order to promote and support breastfeeding the mother's natural desire to breastfeed should always be encouraged by giving, where needed,
practical advice and making sure that she has the support of her relatives.
iii. Adequate care for the breast and nipples should be taken during pregnancy.
iv. It is also necessary to put the infant to the breast as soon as possible after delivery.
v. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called
"rooming- in").
vi. Give the infant Colostrum as it is rich in many nutrients and its anti-infective factors protect the infants from infections during the few days of its birth.
vii. The practice of discarding Colostrum and giving sugar water, honey water, butter or other concoctions instead of Colostrum should be very strongly
discouraged.
viii. Let the infants suckle on demand.
ix. Every effort should be Abbott-For
made to breastfeed theprofessinoals
healthcare infants whenever
only they cry. 2
x. mother should keep her body and clothes and that of the infant always neat and clean.
 Contents

Demography of Adverse clinical Evidences for Take home

PICU outcomes with enteral nutrition in messages
hospitalization malnutrition ICU

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 Introduction
The provision of optimal nutrition support to critically ill infants and
children is essential for effective overall care, management, and outcomes

Obstacles often exist, which prevent timely and effective advancement of

both parenteral nutrition (PN) and enteral nutrition (EN) support to them

The prevalence of malnutrition has remained consistent within the

pediatric intensive care unit (PICU) over the past 30 years, with some
studies indicating that up to 65% of patients are malnourished on PICU
admission

Further deterioration of nutrition status commonly occurs during the

hospitalization because of the metabolic response to inflammation, injury,
stress, or surgery

JPEN J Parenter Enteral Nutr. 2009;33:260-276.

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Common Causes for Admission to PICU
■ Malnutrition, respiratory and diarrheal diseases are the most common
critical care illness in Indian children2

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Common diagnoses or conditions increasing
nutritional risk in PICU patients

■ On admission to the PICU,

infants and children often have
preexisting malnutrition and
premorbid nutrition related
conditions, which put them at
increased nutritional risk.

ICAN: Infant, Child, & Adolescent Nutrition;5(4):221-30

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 Epidemiology of Protein-Energy Malnutrition
in Critically Ill Children Admitted to PICU

PEM % in
Clinical study2 critically ill
One in every five admitted to PICU
children admitted
to PICU has acute Pollack et al.,1981 16–20%
or chronic Hulst et al., 2006 24%
malnutrition1 Delgado et al.,
53%
2008

Protein-energy malnutrition (PEM) is a major concern in children admitted

to PICU as it is associated with increased morbidity and mortality3
PEM: Protein-energy malnutrition

1. Mehta NM et al. Pediatr Clin North Am. 2009;56(5):1143–60.

2. Hulst J, et al. Clin Nutr. 2004;23(2):223–32.
3. Abbott-For
Meyer, et al.Clinical Pediatric healthcare
Dietitics.John Wiley andprofessinoals
Sons,2014,pp66only 7
 Risk Factors for Malnutrition in
PICU

Underlying disease
condition and duration
of pre-PICU illness

Increased energy
demands during
critical illness and
poor provision of
adequate nutrition

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 Impact of Malnutrition on Infection Rates and
LOS in Critically Ill Children Admitted to
PICU

Sepsis incidence and length of hospital stay in well-nourished and malnourished

patients
Non-malnourished Severely malnourished
Sepsis incidence 34% 36%
Period of hospitalization at the ICU 5 days 8 days

Increased medical cost

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Delgado AF, et al. Clinics. 2008;63(3):357–62. healthcare professinoals only 9
 Correlation between Malnutrition, LOS and
Mortality Rates in Critically Ill Children
Admitted to PICU

Comparison of outcome variables in non-malnourished and severely

malnourished children admitted to PICU

Non- Severely
Variable malnourished malnourished p-Value
N=142 (%) N=132 (%)
Mortality 52 (36.6) 58 (43.9) 0.27
Number of children mechanically 99 (69.7) 107 (81.0) 0.06
ventilated
PICU stay (days) 48 (33.8) 69 (52.3) 0.008
>7 days (n=141)
Ventilation (days)
>7 days (n=118) 38 (38.4) 61 (57) 0.028

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Bagri NK et al. Indian J Pediatr. 2015;82(7):601–605. 10
 Metabolic Stress Response to Critical Illness
Pathways of metabolic response to stress1

Ketones Tissue repair

Fuel for brain Wound healing

Loss of lean Acute inflammatory Proteins

Lipolysis
body mass
Fatty acids
Trauma
Protein synthesis
Sepsis Critical Muscle Amino
illness
break down acids
Gluconeogenesis
Burn
Urea
Surgery
Glycolysis  Glucose Fuel for brain RBC,
 Utilization and kidneys

Hyperglycemia

Owing to changes in gastrointestinal tract during critical illness, underfeeding develops in

critically ill patients resulting in inadequate nutrition2

1.Mehta NM et al. Pediatr Clin North Am. 2009;56(5):1143–60.

2.Karnad DR et al. Medicine Update 2012; 22:711.
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 When to provide nutrition
supplementation?
Insufficient oral intake Wasting and stunting
• Intake Inability to meet >60% to 80% of • Weight loss or no weight gain for a period of
individual requirements for >10 days >3 mo in a child older than 2 years of age
• In children older than 1 y, nutrition support • Change in weight for age over 2 growth
should be initiated within 5 days, and in a channels on the growth charts
child younger than 1 y within 3 days of the
anticipated lack of oral intake • Triceps skinfolds consistently <5 th percentile
for age
• Total feeding time in a disabled child >4 to 6
h/day • Fall in height velocity >0.3 SD/y
• Decrease in height velocity >2 cm/y from
the preceding year during early/mid-puberty

JPGN Volume 51, Number 1, July 2010

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 Goals for Nutrition Support

Identify patients with

Nutritional screening -
preexisting
within 24-48 hours of
malnutrition or those
admission
nutritionally at risk

Develop a nutrition
care plan within 24 to
72 hours of admission
to the PICU

Abbott-For healthcare professinoals only ICAN: Infant, Child, & Adolescent Nutrition;5(4):221-30
13
 ASPEN nutrition support guidelines for critically
ill pediatric patients include the following:

Nutrition screening of admitted PICU patients to

identify those with existing malnutrition
Nutritional
guidelines Nutritional assessment with development of a
nutrition care plan for those children with
for PICU premorbid conditions

patients Use of EN for critically ill children with a

functioning GI tract

Identification and prevention of avoidable

interruptions to EN
JPEN J Parenter Enteral Nutr. 2009;33:260-276.

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 ESPGHAN Recommended Indications for Enteral and
Parenteral Feeds in Critically Ill Children

■ Enteral nutrition1
– Inadequate oral intake (tumors, trauma, mechanical ventilation etc.)
– Disorders of digestion or absorption (cystic fibrosis, short bowel
syndrome, inflammatory bowel disease etc.)
– Disorders of gastrointestinal motility (chronic pseudo-obstruction)
– Increased nutritional requirements (chronic renal disease, burns)
■ Parenteral nutrition2
– Chronic intestinal failure
– Severe malnutrition and growth failure
– Disorders in which the child is unable to tolerate nasogastric or
orogastric feeds

1.
1. Braegger
Braegger C,
C, et
et al.
al. JJ Pediatr
Pediatr Gastroenterol
Gastroenterol Nutr.
Nutr. 2010;51(1):110–22.
2010;51(1):110–22.
2.
2. Koletzko
Koletzko B,
B, et
et al.
al. JJ Pediatr
Pediatr Gastroenterol
Gastroenterol Nutr.
Nutr. 2005;41
2005;41 Suppl
Suppl 2:S1–87.
2:S1–87.

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 What to Feed?
ESPGHAN Recommended Pediatric Enteral
Nutrition Formulations

■ Enteral feeds
– Polymeric feeds: Cow’s-milk protein-based feeds
– Low-molecular formulas: Feeds with oligopeptides derived from protein
hydrolysates
– High-fat feeds: Provide more than 40% of energy content as lipids
– Disease-specific enteral formulations: Feeds specific to certain diseases

Iso-osmolar (300–350 mOsm/kg) enteral feed is considered preferable because feeds with
high osmolality (e.g. low-molecular diets) may induce diarrhoea in some patients with
intestinal pathology

Braegger C, Decsi T, Dias JA et al.. Abbott-For healthcare

J Pediatr Gastroenterol professinoals
Nutr. only
2010;51(1):110–22. 16
 How to Feed?
ESPGHAN-Recommended Sites for Administration
of Enteral and Parenteral Nutrition

Peripherally inserted central catheters

Gastric feeding is preferred to Post
and tunnelled central venous catheters
pyloric feeding as it allows for secure
should preferably be used to provide
positioning of the gastric tubes and is
central venous access in children
more physiological
receiving prolonged PN

1. Braegger C, et al. J Pediatr Gastroenterol Nutr. 2010;51(1):110–22.

2. Koletzko B, et al. J Pediatr GastroenterolAbbott-For healthcare
Nutr. 2005;41 Suppl 2:S1–87. professinoals only 17
 How Much to Feed?
ESPGHAN Recommendations for Intake of EN and PN in
Critically Ill Children

• Standard polymeric feeds based on cow’s-milk protein with fibre

and age-adapted for energy and nutrient content are
recommended, as they are suitable for most pediatric patients
Enteral • An energy density of approximately 1 kcal/mL feed is
Nutrition1 recommended. It meets the full nutrient requirements and also
supplies sufficient fluid intake

• Energy requirement: 75–90 kilocalories/kg body weight/day

• Amino acid intake: up to 3g/kg per day
Parenteral
• Parenteral lipid intake: 2–3g/kg per day(0.08–0.13 g/kg per hour)
Nutrition2
• Glucose intake: should be limited to 5mg/kg per
min(7.2g/kg/day)
• Parenteral fluid intake: should be 80–100ml/kg body weight/day

1. Braegger C, et al. J Pediatr Gastroenterol Nutr. 2010;51(1):110–22.

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2. Koletzko B, et al. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S1–87.
18
 How Long to Feed?
ESPGHAN Recommendations for Weaning from PN,
in Critically Ill Children

Weaning

Enteral
Parenteral feeding
feeding

Reduction in amount of PN may be attempted as soon as

the child is stabilised (intestinal loss from vomiting and
diarrhea reduces) and optimal nutritional state is reached

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Koletzko B, et al. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S1–87.
19
 ESPGHAN Recommendations for
Monitoring Parameters for Children
on EN and PN

Enteral nutrition1 Parenteral

Regular review of nutritional status Growth andnutrition
body composition2 in children
including intake, weight, height, on long-term PN
biochemical indices, general clinical Daily intake and output of fluids
state, gastrointestinal function, tube Daily monitoring of electrolytes
integrity, and tube-related complications Routine monitoring of triglycerides levels
Trace elements and vitamin status should Monitoring of serum concentrations of
be monitored trace elements and minerals
Monitoring for refeeding syndrome
(electrolytes, metabolic, nutrition
parameters)
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1. Braegger C, et al. J Pediatr Gastroenterol Nutr. 2010;51(1):110–22.
2. Koletzko B, et al. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S1–87.
20
 Blenderized
Factors of Blenderized Commercial
concern tube feeds enteral feeds
Feeds vs
Commercial
Nutritional
Does not meet
Meets nutrient Enteral Feeds
nutrient
content standards ■ Blenderized tube
standards
feedings contain
Poor tube flow Good tube flow ■ common foodstuffs
Osmolality due to high due to iso-
such as milk, eggs,
osmolality osmolality
meat, soft fruits,
Bacterial Chances are ■ and vegetables
Chances are high
contamination low which are pureed in
a blender or mixer

Sullivan MM, et al. Asia Pac J Clin Nutr. 2004;13(4):385–91. 21

 EN is more physiological than PN, maintains the physiologic and
functional integrity of the GI mucosa by nourishing the gut first,
and thus prevents or decreases the risk for bacterial translocation

Benefits of More cost-effective than PN

enteral
Associated with both decreased risk of infectious complications
nutrition in and length of stay, as compared with patients nutritionally
supported with PN
critically ill
patients Management of fluid and electrolyte balance is often easier when
using EN

EN may promote anti-inflammatory effects by decreasing

cytokine production such as tumor necrosis factor and IL-6

JPEN J Parenter Enteral Nutr. 2003;27:355-373 EN- Enteral nutrition

Intensive Care Med. 2005;31:12-23
JPEN J Parenter Enteral Nutr. 2005;24(4 suppl):S134-S140. PN-Parenteral nutrition
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EVIDENCES ON BENEFITS
OF NUTRITIONAL
INTERVENTION

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Nutritional Practices and Clinical Outcomes in
Critically Ill Children

Improved enteral
energy intake is
associated with
significant reduction
in morbidity and
mortality

Mean daily cumulative energy intake (as percentage of prescribed goal) by PICU days

Mehta NM, et al. Crit Care Med. 2012;40(7):2204–11.

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 Correlation Between Early Enteral
Nutrition and Mortality Rates in
Critically Ill Children
Effect of increased proportion of EN at 96 hours on mortality
Patient group based on % of en Died, Survived, Unadjusted OR Adjusteda OR
goal received by 96 hours n (%) n (%) (95% CI)b (95% CI)b
Did not receive EN by % hours 162(7.83) 1907 (92.17) – –
Received <25% of EN goal for
54 (6.26) 809 (93.74) 0.79 (0.57–1.08) 0.64 (0.45–0.91)
96 hours
Received 25%-100% of EN goal
38(2.71) 1363 (97.29) 0.33 (0.23–0.47) 0.34 (0.23–0.50)
for 96 hours
Received > 100% of EN goal for
19(2.46) 753 (97.54) 0.30 (0.18–0.48) 0.37(0.21–0.63)
96 hours
Total 273 (5.35) 4832 (94.65)
Cl: confidcncc interval; EN:enteral nutrition; OR: odds ratio.
a
Adjusted for propensity score. Pediatric Index of Mortality-2 score, age. and center. b Comparison
to "did not receive EN by 96 hours.”

Early enteral nutrition is strongly associated with lower mortality in critically ill children admitted
to PICU with a length of stay of ≥96 hours

Mikhailov TA , et al. JPEN J Parenter Enteral Nutr. 2014;38(4):459–66

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 Impact of Enteral Feeding Protocols on
Nutritional Practices in Critically Ill Children

Benefits of
introduction of
enteral feeding
protocol

Implementation of
feeding protocols is
associated with
improved nutrition
practices in critically ill
children admitted to
PICU

26
Meyer R et al. J Hum Nutr Diet. 2009;22(5):428–36.
 Role of Enteral Nutrition Algorithm on
Nutritional Practices

1.0
Proportion of patients reaching energy goal

0.8 Implementation of enteral

nutrition algorithm in
0.6 PICU aids in reducing
avoidable EN
0.4
interruptions, improves EN
delivery and decreases the
0.2
Pre-intervention cohort
dependence on parenteral
Post-intervention cohort
nutrition in critically ill
0.0
children.
1 2 3 4 5 6 7 8 9 10 11 12

Days from PICU admission

Kaplan Meier plot showing the proportion of patients in the PICU achieving
energy goal in relation to days since admission.

27
Hamilton S et al.Pediatr Crit Care Med. 2014;15(7):583–9.
 Protein-energy malnutrition (PEM) is a major concern in
children admitted to PICU and is associated with
increased morbidity and mortality

During metabolic response to stress, increased muscle

Key take protein degradation, increased carbohydrate and fatty

aways… acid turnover occurs

Clinical data suggests that early enteral nutrition is

strongly associated with lower mortality in critically ill
children admitted to PICU with prolonged LOS

Enteral route is preferred in patients admitted to PICU

with functional gastrointestinal tract

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