Janice Antino RD, MS, CSP

Review
Energy Expenditure
 Indirect Calorimetry
 Enteral Nutrition (EN)
 Parenteral Nutrition (PN


Increased metabolic stress
Meeting energy expenditure
Nutrient delivery
Pre-existing malnutrition

Goals





Minimize protein catabolism
Meet energy expenditure
Critical Illness + Poor Nutrition =




Prolonged ventilator dependence
Prolonged ICU stay
Increased susceptibility to infections
Increased mortality with mild/moderate
malnutrition







Hyperglycemia
Azotemia
High Triglycerides
Electrolyte imbalance
Immunosuppression
Hepatic steatosis
Failure to wean from mechanical ventilation






Decreased respiratory muscle strength
Failure to wean from mechanical ventilation
Impaired organ function
Immunosuppression
Poor wound healing
Low transport protein levels in the absence of
inflammation



Patients are fed below their REE (50-75%)
May benefit several populations of adult
critically ill patients
Not recommended for pediatrics

Resting Energy expenditure (REE): The amount
of calories required by the body at rest during a
24 hour period




Represents 70-80 % of the calories used
Defines the energy released to maintain normal basal
physiological functioning
Basal metabolic rate (BMR): The EE of a
recumbent child in a thermoneutral
environment after a 12-18 hour fast
Total energy expenditure : BMR, thermic effect
of food, thermoregulation, activity
Shulmman et al. 2002
Available methods to determine REE
 Predictive equations- estimates energy
expenditure
 Indirect calorimetry- measures gas exchange to
determine energy expenditure





Measures exchange of
oxygen and carbon
dioxide
Provides REE and
Respiratory
quotation(RQ)
Can be performed on
ventilated or non
ventilated patient’s
RQ: the ratio of carbon
dioxide to oxygen
consumed
Most accurate method for
determining energy needs
Age
RDA (kcal/kg)
Protein (2002, Dri’s)
0-6 months
108
1.5 AI
7-12 months
98
1.2
1-3 years
102
1.05
4-6 year
90
.95
7-10 yeas
70
.95
Males
11-14 years
15-18 years
Females
11-14 years
15-18 years
.85
55
45
.85
47
40
ASPEN Pediatric Core Curriculum 2010
Age
Male
Female
1-3 years
51.3-531
51.2-53
4-7 years
47.3-50.3
45.4-49.9
8-11 years
43.0-46.5
39.3-41.3
Raju. 2005
Condition
Stress factor
Mild starvation
.85-1.00
Postoperative state
1.0-1.05
Cancer
1.10-1.45
Sepsis/peritonitis
1.05-1.25
Multi trauma, burns
1.20-1.55
Raju 2005

Infants- intubated likely require > REE



Older children


0-3 months at least 80 kcal/kg
4-12 months at least 65 kcal/kg
May use WHO, Schofield, White equations
Activity and injury factors may not be needed

Burn patients require an activity/stress factor


2012, retrospective review, 240 patients
Critically ill patients had cumulative energy
and protein deficits in the first days

<90 % of energy requirements on 60 % of all patient
days and >110 % of energy requirements on 30 %
patient days
Both under and over feeding were prevalent, expect
in children younger than 2



Prospective clinical study
Measured REE in 37 children and compared to
predictive equations
Conclusion

Recommended dietary allowance and energy
expenditure predicted by stress related correction
factor-Grossly over estimate MEE
Briassoulis, 2000


Energy needs should be assessed throughout
the course of illness to determine energy
needs/ Estimates using available standard
equations are often unreliable
In a subgroup of patients with suspected
metabolic alterations or malnutrition, accurate
measurements of EE using indirect calorimetry
is desirable.
Criteria for using Targeted Indirect Calorimetry





Prospective cohort study -29 patients over 12
months
Examined the role of targeted indirect
calorimetry in detecting the adequacy of
energy intake and risk of energy imbalance
Measured REE from IC
Predicted EE from standard equationsSchofield, Harris-benedict
ASPEN criteria for Targeted IC
(Mehta et.al, 2011)
In Summary
 72% had an altered metabolism




High incidence of overfeeding
Standard equations overestimate the energy
requirements
Children < 1 year of age represented the large
majority of patients with hyper metabolism
Medical patients tended to be hypo metabolic

Nutritional support via placement through
the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first







Plan for 2-5 days to meet nutrition goal
Use isotonic feedings initially
Avoid making simultaneous changes in volume
and concentration
Advance cautiously in critically ill patients
Increase volume before concentration when
administering transpyloric feeds
Advance concentration before volume with gastric
feed
If feeding intolerance develops return to the
previously tolerated rate
ASPEN 1999



Trophic feeds: < 20 ml/kg/day
Continuous:
Initiate: 1 ml-2 ml/kg/hr
Advance: .5-1 ml/kg/ as tolerated- q 8-12 hrs
Bolus/Intermittent:
Begin at 25 % goal on first day
 Divide formula equally between 5-8 feedings
 Increase by 25 % as tolerated

ASPEN 1999

Fluid restriction


Longest duration off feeds
Gastrointestinal intolerance
Vomiting-most frequent
 Gastric residuals
 Diarrhea


Interruptions for procedures


shorter duration
50% patients achieved full EER by day 7
Roger et al 2003


Always use EN whenever possible
Use PN only when
Unable to meet nutritional requirements via the GI
tract
 Bowel dysfunction resulting in inability to tolerate
EN for

 1-3 days in infants
 4-5 days in children and adolescents
 7-10 days in adults







Very low birth weight infants(<1500 grams)
Inability to tolerate EN feeds
Small bowel obstruction
Radiation enteritis
Gastrointestinal fistula/high out put
Hemodynamic instability with high risk of
mesenteric ischemia( e.g ECMO, NEC in preterm
infants, shock, acute critical illness)
Conditions associated with intestinal failure-short
bowel syndrome, diarrhea with malabsorption,
intestine epithelial disorder-microvillus inclusion
disease
ASPEN. Pediatric nutrition support
core curriculum 2010

Peripheral Parental Nutrition (PPN)




Osmolality is limited to 900 mOsm/kg to minimize
risk of phlebitis and infiltration
Dextrose limited to 10 -12.5 %
Will require large volumes to supply adequate
nutrients
Central/Total Parental Nutrition (TPN)




Longer term needs, > 2 weeks
> 900 mOsm/kg
Meet nutrient requirements
Fluid restrictions
ASPEN. Pediatric nutrition support
core curriculum 2010



2-in-1
Dextrose and amino
acids
Lipids are provided
via a piggy back
infusions



3-in-1
Dextrose, amino acids
and lipids
Advantages



Convenience
Cost
Decreased risk of
microbial
contamination-fewer
manipulations to the
line
ASPEN. Nutrition Support Core
Curriculum 2007

Non-protein energy







Carbohydrate (dextrose)
Fat (lipid)
Protein (amino acids)
Electrolytes
Minerals, Vitamins, trace elements
Water
Miscellaneous: heparin, medications

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)
Age
Initiate
Advance
Maximum
< 1 year
6-9 mg
cho/kg/min
1-2 mg
cho/kg/min
Goal 10-12 mg cho/kg/min
Max: 14
1 – 10 years
1-2 mg
cho/kg/min
1-2 mg
cho/kg/min
8-10 mg cho/kg/min
> 10 years
1-2 mg
cho/kg/min
1-2 mg
cho/kg/min
5-6 mg cho/kg/min
ASPEN 2010

Functions:






Provides structure : muscle
Provides function: enzymes, transport protein
Increased Protein Needs: malnutrition, stress,
burns, enteric/urinary loss
Infants: need conditional amino acids like
histidine, taurine and cysteine because of
immature synthetic abilities
Protein should not serve as an energy source
Excess protein intake leads to hyperazotemia
Age
Gram/kg/day
Preterm
2.5-4.0 grams/kg
Term infant
2.2-3.5 grams/kg
Child
1.0-2.0 grams/kg
Adolescents
0.8-2.0 grams/kg
ASPEN 2010

Fat
20 % emulsion = 2 kcal/ml
 Soybean/safflower oil and emulsified egg yolk
phospholipid


Minimum of 1-2% of calories from combinations of
linoleic and linolenic acid to meet EFA needs- met
with .5-1.0 g/kg/d
Serum triene to tetraene ratio is reflective of EFA status
 Triene to tetraene ratio ratio >0.2 suggest deficiency


Monitor Triglyceride to assess tolerance

300-400 mg/dl are tolerated
APEN 2010
Age
Starting dose
Maximum dose
Neonate/infant
1 gram/kg/day
3 gram/kg/day
Children
1 gram/kg/day
2 gram/kg/day
Adolescent/adult
0.5grams/kg/day
1 gram/kg/day
ASPEN 2010
Gura et al 2008



Infectious complications- Central line
associated blood stream infections
Mechanical
Metabolic





Hyper/hypoglycemia
Essential fatty acid deficiency
Azotemia- increased BUN may occur as a result of
intolerance to the protein load
Fluid/electrolyte complications/refeeding syndrome
Parenteral Nutrition Associated Liver Disease
Three types of hepatobiliary disorders
 Steatosis:




Cholestasis : Direct bilirubin >2 mg/dl


can occur 2 weeks after pn started, elevated serum
aminotransferase levels
Treat: decrease total energy intake, appropriate fat
intake
Appears to be related to over feeding
Treat: decrease fat and/or change composition of fat
Gallbladder sludge/stones: gall bladder stasis
may lead to BG stones/cholecystisis
Kumpf, 2006




Provide maximal tolerated EN
Provide a cyclical PN as soon as possible
Prevent over feeding
Consider restricting lipids to 1 gm/kg/day

Consider fish oil based lipids
Guru, et al 2008
Kumpf 2006





10% fish oil fat emulsion
Docosahexaenoic acid (DHA)
Eicosapentaenoic acid (EPA)
Anti inflammatory properties
Used to treat/prevent PNALD
Guru et al. 2008



Compassionate use to treat infants and
children who PNALD
Goal: Reverse cholestasis, prevent liver disease
Patient selection



Two consecutive direct bilirubin levels 2 mg/dl for
tpn dependent children
Other causes liver disease ruled out
Must have utilized standard accepted therapies
 Removal copper and manganese
 Trial enteral feeds
 Use of ursodiol

Definition


Risk factors


Chronic malnutrition, anorexia nervosa, pt’s not fed 7-11
days with evidence of stress and depletion
Clinical


The metabolic and physiological shifts of fluid,
electrolytes and minerals that occur as a result of
aggressive nutrition support
Low serum phosphorus, magnesium, potassium levels,
acute respiratory and circulatory collapse
Treatment

Initiate and advance slow 25-50 % energy needs and
increase by 10 -20 % daily
ASPEN 2010




Use caution when estimating energy needs
using predictive equations
Indirect calorimetry is considered the gold
standard method to measure EE
Use EN when ever possible
PN can be lifesaving when tolerance to enteral
nutrition is limited







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
The ASPEN Nutrition Support Core Curriculum
: A Case-based Approach: the Adult Patient. American Society
for Parenteral and Enteral Nutrition, 2007.
The ASPEN Pediatric Nutrition Support Core Curriculum. American Society for Parenteral and
Enteral Nutrition, 2010
Briassoulis, G., Venkataraman, S., & Thompson, A. E. (2000). Energy expenditure in critically ill children.
Critical care medicine, 28(4), 1166-1172.
Gura, K. M., Lee, S., Valim, C., Zhou, J., Kim, S., Modi, B. P., ... & Puder, M. (2008). Safety and
efficacy of a fish-oil–based fat emulsion in the treatment of parenteral nutrition–associated
liver disease. Pediatrics, 121(3), e678-e686.
Kumpf, V. J. (2006). Parenteral nutrition-associated liver disease in adult and pediatric patients.
Nutrition in clinical practice, 21(3), 279-290.
MCHIR, L., & David, A. (1998). Energy requirements of surgical newborn infants receiving parenteral
nutrition. Nutrition, 14(1), 101-104.
Mehta, N. M., Bechard, L. J., Dolan, M., Ariagno, K., Jiang, H., & Duggan, C. (2011). Energy imbalance
and the risk of overfeeding in critically ill children*. Pediatric Critical Care Medicine, 12(4), 398-405.
Mehta, N. M., & Compher, C. (2009). ASPEN Clinical Guidelines: nutrition support of the critically ill child.
Journal of Parenteral and Enteral Nutrition, 33(3), 260-276.
Mehta, Nilesh M., et al. "Cumulative energy imbalance in the pediatric intensive care unit: role
of targeted indirect calorimetry." Journal of Parenteral and Enteral Nutrition 33.3 (2009): 336-344.
Kyle G. Ursla. MS, RD, Rd/LD., Jaimon Nancy RN., Coss-Bu A Jorge, MD. Nutrition Support in
Critically ill Children Under delivery of energy and Protein compared with Current
Recommendation. Journal of the Academy of Nutrition and Dietetics, 112 (12)2012
Shulman, R. J., & Phillips, S. (2003). Parenteral nutrition in infants and children. Journal of pediatric
gastroenterology and nutrition, 36(5), 587-607.





The ASPEN Nutrition Support Core Curriculum: A Case-based Approach: the Adult Patient. American Society for
Parenteral and Enteral Nutrition, 2007.
The ASPEN Pediatric Nutrition Support Core Curriculum. American Society for Parenteral and Enteral
Nutrition, 2010
de Souza Menezes, F., Leite, H. P., & Koch Nogueira, P. C. (2012). Malnutrition as an independent predictor of
clinical outcome in critically ill children. Nutrition, 28(3), 267-270.
Raju col ums, Choudhary, Sanjay., Harjai, MM., Nutritional Support in the critically ill child. MJAFI 2005; 61:
45-50
Hardy, C. M., Dwyer, J., Snelling, L. K., Dallal, G. E., & Adelson, J. W. (2002). Pitfalls in predicting resting
energy requirements in critically ill children: a comparison of predictive methods to indirect calorimetry.
Nutrition in clinical practice, 17(3), 182-189.
Janice Antino RD, MS, CSP



Recommended for the first 6 months of life
Lower risk for otitis media, lower respiratory
infections and diarrhea
Supplement –



Vitamin D 400 i.u units starting in the first few days
of life
Iron 1 mg/kg starting at 4 months age, until iron
containing complementary foods have been
introduced
Fortified Breast milk-premature infants, cardiac
or GI surgery






Weight gain- 4-7 ounce per week after the 4 th
day of life
Minimum of 6 wet diapers (after 3-5 days)
Minimum of 3-4 stool daily during first few
week
Minimum 8-12 feeding ( 15-20 minutes)
Alert, healthy appearance
No food or drink other than breast milk


Infant formula act passed in 1980 with
amendments in 1986
Established minimum levels of 29 nutrients
and maximum of 9 (protein, fat, Vit A, Vit D,
Fe, iodine, Na, K, and chloride)


Human milk is the gold standard for infant
formula compositions
Cow’s milk became the major substitute for
human milk changes in substrates were
necessary




Protein: alter casein whey ration from 80:20
Electrolytes: decrease concentration
Fat: cow’s milk fat is not well absorbed, add
vegetable oil
Increase iron content

Similac Special Care or Enfamil Premature –
considered pre discharge formulas



24 kcal/oz, milk protein based, higher
concentrations of protein, calcium and phosphorus,
used until discharged
Neosure or Enfacare – considered post discharge
formulas
22 kcal/oz, milk protein based, used until 9 months
corrected age






Standard –cow’s milk based
Soy based
Extensively hydrolyzed protein
Free amino acid
Metabolic
Categorized by:


Protein composition : cow-milk, soy protein, protein
hydrolysate or amino acid based
Consumer group: Term infant, premature or
metabolic/special needs

Indications: healthy term infants
Enfamil Newborn or infant Similac advance, Store
brands
 Enfamil gentelease and Similac sensitive
 Enfamil AR or Similac for Spit up




Contradictions: Galactosemia and lactose
intolerance, milk protein allergy, metabolic
disorders
Nutrients are expressed as “per 100 kcal”
Standard concentration is 20 kcal/oz
Composition
CHO: Lactose (42% calories)
Protein: Altered casein: whey to 60:40 with
dominant whey protein B-lactoglobin (9-12%
calories)
Fat: Combination of vegetable oils (40-50 %
calories)

Available in:


Ready-to-use, concentrated liquid or powder
Different methods of preparation
 powder 1scoop/2 oz water = 20 kcal/oz
 13 oz can of concentrate/13 oz water = 20 kcal/oz


Docosahexaenoic acid (DHA)
Arachidonic acid (ARA)
Long chain polyunsaturated fatty acids
 Derived from linoleic and linoleic acids
 Structural Components of cell membranes in the
brain and retina
 Studies have shown enhanced cognitive
development and visual acuity in premature infants





Nucleotides: Non-protein nitrogenous compound,
found in high concentration in breast milk
Prebiotics: non digestible food ingredient that benefits
the host by selectively stimulating the favorable
growth or activity of one or more probiotic bacteria
Probiotics: An oral food supplement that contains a
sufficient # viable microorganisms to alter the micro
flora of the host with potential health benefits
Benefits




Enhances immune system
Promotes Gastrointestinal development
Decrease diarrhea
Improved antibody response after vaccines-Hib, diphtheria and
polio
ENFAMIL NEWBORN –FIRST
3 MONTHS


AAP recommends 400
i.u Vitamin D with in
the first few days of life
Breast milk : Vitamin D
content : <25-78 i.u/L


Suggest 1ml Di-vi-sol
daily
Formula fed:

400 i.u Vitamin D in 27 oz
of formula


Indications: Vegetarian, lactose intolerance,
galactosemia, IgE –associated allergy to milk
protein
Condradictions: Premature infants < 1800 gms,
renal disease, Fructose intolerance (has
sucrose), prevention of colic or allergy, cow
milk protein induced entercolitis or
enteropathy





Supplemented with L-methionine and taurine
to improve it’s biologic value
Nucleotides are not added
Supplemented with zinc and iron
Aluminum concentrations of 600-1.300 ng/ml
compared to 4-65 ng/ml in human milk
Contains isoflavones with estrogenic activity




Proteins are casein or whey
Treated with heat and enzymatically
hydrolyzed.
Results in free amino acids and peptide of
varying length
Contain varying amounts of Medium chain
Triglycerides


Indications: Disorders associated with
compromised enteric digestion-Short bowel
syndrome, food protein allergy, pancreatic
insufficiency, biliary atresia
Contraindications: Severe food
allergy/intolerance
Formula
CHO
Fat
Protein
Nutramigen
Corn syrup
solids, corn
starch
Sucrose,
tapioca starch
Corn syrup
solids,
dextrose
LCF, No MCT
Hydrolyzed
casein
33 % MCT
Hydrolyzed
casein
Hydrolyzed
casein
Alimentum
Pregestermil
55 % MCT





Protein source are free amino acids
Considered non-immunogenic
Only available in powder
Indications: Severe and multiple food allergies
Caution: contains soy oil





Renal impairment
Protein content same as standard, whey:casein
ration is 60:40
Mineral content same as human milk
Slightly less NA and K than standard formula
Low Iron
Fat malabsorption
 Usually associated with chylous ascites,
chylothorax
 MCT oil- 85% fat content
 Not for long term use, may need essential fatty
acid supplementation
 Formulas: Enfaport, Portagen, Monogen






To provide increased macronutrients
For patients who can not tolerate high volumes
necessary to meet needs
Usually increase by 2-4 kcal/oz increments
Can be concentrated to 24 or 27 kcal/oz (see
hand out for mixing instructions)
Addition of modulars after 26-28 kcal/oz
Older than one year can concentrate greater
than 30 kcal/oz



Fluid vs. calorie needs
Micronutrient adequacy
Renal solute load




The sum of solutes filtered by the kidney
Solutes include amino acids urea, electrolytes
When the solute load is above is above the handling
capacity of the kidney can result in dehydration and
osmotic diuresis
Hypernatremia, metabolic acidosis, elevated BUN

Fat


CHO


Polycose, rice cereal
Protein


Microlipid, MCT, Vegetable oil
Beneprotein, Prostat, Juven
Other

Duocal, powder infant formula, fiber


Vitamin K provided at birth
Vitamin D: 400 i.u daily



Standard Term formula requires 32 ounces
Enfamil newborn requires 27 ounces
Flouride-begin at 6 months .25 mg/day if
water supple 0.3ppm – 1 ml poly-vi-flor


Standard dilution 1 kcal/1ml = 30 kcal/oz
 Ready to feed or powder
 For children 1-10 years
Concentrated pediatric formulas available
 30-40 kg may use adult formulas
 Decrease fluid, concentrated formula
 Increase protein needs

Pediasure or Nutren jr




Elemental: Pediasure peptide, Peptamin jr



1.0 to 1.5 kcal/ml
Milk protein base
Used orally or tube feeding
1.0, 1.5 kcal/ml
Speciatly formulas: Vivonex, Elecare Jr,
Tolerax, Modulen
Pediasure side kicks

20 kcal/oz-lower calorie