Pediatric Critical
Care Nutrition
Kristy Paley, MS, RD, LDN,
CNSC
Outline
PICU nutrition goals
 Energy expenditure/Kcal requirements
 Indirect Calorimetry
 Protein requirements
 Parenteral Nutrition Guidelines
 Enteral Nutrition Guidelines
 Infant and Child Formulas

PICU-associated malnutrition
Metabolic stress response
 Estimations of energy requirement
 Prescription and Delivery
 Preexisting deficiency/reduced somatic
stores

Mehta and Duggan (2009), Hulst et al. (2006), Rogers et al. (2003)
Nutrition Goals for the PICU
1.
2.
Minimize protein catabolism
Meet energy requirement
Mehta and Duggan (2009)
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

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)
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)
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)
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
Mehta et al. (2009)
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)
Limitations of IC
Air leaks around ET tubes
 Chest tubes
 FiO2 >60%
 Receiving dialysis

Comparison of MEE vs. cREE
Briassoulis et al. (2000)
DRI vs. REE
Age
DRI (kcal/kg)
REE (kcal/kg)
0-3 mon
102
54
4-6 mon
7-12 mon
13-35 mon
3y
4y
5-6 y
7-8 y
82
80
82
85
70
65
60
54
51
56
57
47
47
47
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)

Lloyd (1998)
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
Agus and Jaksic (2002), Hardy Framson et al. (2007)
Kcal Requirements: Extubated
Kcal goal = DRIs for age/gender
 Catch up growth may be necessary
 (DRI
 BMI
x IBW) ÷ actual wt (kg)
for age >85th%tile use IBW
 IBW:
BMI for age @50th%tile
 (BMI
@50th%tile x actual wt) ÷ actual BMI
Protein Requirements
Age
0-6mon
7-12mon
13-23mon
24mon-3y
4-13y
14-18y
DRI (normal)
1.52g/kg/day
1.2
1.05
1.05
0.95
0.85
PICU
2-3g/kg/day
2-3
2-3
1.5-2
1.5-2
1.5
***may require further increases in protein provision
with burns, ECMO, bacterial sepsis
Parenteral Nutrition
PPN vs. TPN

PPN

 Peripheral
access
 <900 mOsm/L
 Max D12.5%
 Can go up to D15%
with non-central PICC
 Usually requires
increased fluid
allowance
ASPEN (2010)
TPN
 Central
access
 No osmolarity
limitations
 Typical max dextrose
usually D25% however
can go up to D30%
prn
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% Intralipid
Essential Fatty Acids (EFA)
 Omega-6 source


Concentrated source of kcal
 2kcal/ml
Parenteral Lipids
Age
Initiate
Advance
Maximum
<1yr
1g/kg/day
1g/kg/day
3g/kg/day
1-10yr
1g/kg/day
1g/kg/day
2-3g/kg/day
>10yr
(adolescents)
1g/kg/day
1g/kg/day
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)
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 (24% 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)
Parenteral Amino Acids (AA)

Neonatal AA
(Trophamine 10%)

Pediatric AA
(Freamine 8.5%)

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

Used for >5kg
Contains Phos



ASPEN (2010)


0.1 mmol/gram AA
Parenteral AA Guidelines
Age
Initiate
Advance
Maximum
<1yr
1-2g/kg/day
1g/kg/day
4g/kg/day
1-10yr
1-2g/kg/day
1g/kg/day
1.5-3g/kg/day
>10yr
(adolescents)
1g/kg/day
1g/kg/day
0.8-2.5g/kg/day
***Goal aa correspond to ASPEN protein guidelines for critical
illness mentioned earlier
***4kcal/g aa
ASPEN (2010)
Parenteral Dextrose

Glucose infusion rate (GIR)
dextrose x volume ÷ wt (kg) ÷ 1.44
 Example: 15% dextrose @ 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)
GIR/Dextrose Guidelines
Age
Initiate
Advance
Maximum
<1yr
~6-9mg/kg/min
1-2mg/kg/min
Goal: 1012mg/kg/min
Max: 14mg/kg/min
1-10yr
1-2mg/kg/min
>IVF GIR
1-2mg/kg/min
Max: 810mg/kg/min
>10yr
(adolescents)
1-2mg/kg/min
>IVF GIR
1-2mg/kg/min
Max: 56mg/kg/min
ASPEN (2010)
PN Electrolyte Dosing Guidelines
Electrolyte
Preterm
Neonates
Infants/
Children
Adolescents/
Children >50kg
Na
2-5meq/kg
2-5meq/kg
1-2meq/kg
K
2-4meq/kg
2-4meq/kg
1-2meq/kg
Ca
2-4meq/kg
0.5-4meq/kg
10-20meq/day
Phos
1-2mmol/kg
0.5-2mmol/kg
10-40mmol/day
Mg
0.3-0.5meq/kg
0.3-0.5meq/kg
10-30meq/day
Acetate
As needed to maintain acid-base balance
Chloride
As needed to maintain acid-base balance
ASPEN (2010)
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)
Btaiche and Khalidi (2002), Kaufman (2002)
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
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

Enteral Nutrition
Enteral Nutrition
 Whenever possible, feed the gut
 GALT/reduce risk for bacterial translocation
 Trophic feeds: ≤20ml/kg/day
 Continuous feeds
 Initiate @~1ml/kg/H
 Advance by 0.5-1ml/kg Q4-6H
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
Infant Formulas
0-12 months of age
Intact Protein
Breastmilk (MBM)
Enfamil Lipil
Similac Advance
Enfamil Gentlease (hydrolyzed casein & whey protein)
GERD: Enfamil AR
Renal: Similac PM 60-40
Chylothorax: Monogen (90% MCT)
Soy Protein
Enfamil ProSobee
Similac Isomil
Good Start Soy
Lactose-Free
Enfamil LactoFree
Similac Sensitive
Preterm Formula (24)
Enfamil Premature Lipil
Similac Special Care
Preterm Discharge Formula (22)
Enfamil EnfaCare Lipil
Similac Neosure
Peptide-Based
Nutramigen
Pregestimil (55% MCT)
Alimentum (33% MCT)
Elemental
(100% free Amino Acids)
Neocate (33% MCT)
Elecare (33% MCT)
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
1kcal/ml; 30g
protein per L
Pediatric
Blenderized
Pediatric
Compleat
1kcal/ml; 38g
protein per L;
omega 3 FA
Pediatric High
Calorie 1.5
with/without fiber
Boost Kid
Essentials 1.5
with/without fiber
1.5kcal/ml
Fluid-restricted
Pediatric Formulas (1-10yr)
Description
CPOE name
Product
Specs
Peptide-based
Pediatric SemiElemental (1)
Peptamen Jr with
prebio
1kcal/ml
Pediatric SemiElemental (1.5)
Peptamen Jr 1.5
1.5kcal/ml
Pediatric Amino
Acid-Based
Elecare Jr
1kcal/ml
(30kcal/oz)
Elemental
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
References






Agus, M., & Jaksic, T. (2002). Nutritional support of the critically ill child.
Current Opinion in Pediatrics, 14, 470-81.
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), 1166-72.
Btaiche, I.F. & Khalidi, N. (2002). Parenteral Nutrition-associated liver
complications in children, 22(2): 188-211.
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: 664-9.
Fung, E.B. (2000). Estimating energy expenditure in critically ill adults and
children. AACN Advanced Critical Care, 11(4): 480-97.
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, 182-9.
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, 264-7.
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, 9:297-303.
Kaufman, S.S. (2002). Prevention of parenteral nutrition-associated liver
disease in children. Pediatric Transplantation, 6: 37-42.
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), 988-93.
References






Llyod, D.A. (1998). Energy requirements of surgical newborn infants
receiving parenteral nutrition. Nutrition, 14(1): 101-104.
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), 260-76.
Mehta, N., & Duggan, C. (2009). Nutritional deficiencies during critical
illness. Pediatric Clinics of North America, 56, 1143-1160.
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.
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), 19-27.
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, 464-8.