Feeding of the critically

ill child.
Dr Waceke Nganga Kombe
Paediatric Gastroenterologist,
Aga Khan University Hospital
 Outline
• Who is the critically ill child
• Effects of malnutrition in the critically ill child
• Nutritional requirements
• Route of nutrient delivery
• Immunonutrition
• Summary
• Questions
 Who is the critically ill child?
• Child requiring intensive care nursing and management would be described
as a critically ill child.
• Most research articles use admission to PICU. A few include admission to
PHDU as well.
• Include burns patients and trauma patients
Effects of malnutrition in critically ill child
Malnutrition as an independent predictor of clinical outcome in critically
ill children

De Souza Menezes F, Leite HP, Koch Nogueira PC.

Nutrition 2012;28:267–70.
 Malnutrition as an independent predictor of clinical
outcome in critically ill children

Findings
• 175 patients (45.5%) were malnourished on admission.
• Sixteen patients of the malnourished group (9.14%) and 25 patients (11.9%) of the non-
malnourished group died.
• Malnutrition was associated with greater length of mechanical ventilation and length of ICU stay,
but not with mortality on univariate analysis.
• Malnutrition was associated with greater length of ventilation on the multiple logistic regression
model (OR 1.76, 95%; CI 1.08-2.88; P = 0.024).
 Weight-for-age distribution and case-mix adjusted
outcomes of 14,307 paediatric intensive care
admissions
Nicholas J. Prince Katherine L. Brown Teumzghi F. Mebrahtu Roger C. Parslow Mark J. Peters
Intensive Care Med (2014) 40:1132–1139 DOI 10.1007/s00134-014-3381-x

• Main findings
• Out of 12,458 admissions, mean weight-for age was 1.04 SD below the UK reference
population mean (p<0.0001).
• Based on 942 deaths, risk-adjusted mortality was lowest in those with mild-to-
moderately raised weight-for-age (SDS 0.5–2.5) and highest in children with extreme
under- or overweight (SDS< -3.5 and SDS> +3.5)
 Nutritional requirements
• It is a major challenge defining the nutritional requirements of a patients
who is critically ill.
• It is difficult to take some anthropometric measurements eg height
• The metabolic response to stress, injury, surgery or inflammation cannot be accurately
predicted.
• Burns patients have an exaggerated catabolic response. So do trauma patients, especially
head injury.
 Energy requirements
• Should be individually calculated based on one of the following methods
1. Measurement of energy expenditure by indirect calorimetry
2. Estimation of resting energy expenditure by predictive equations based on weight, age
and sex
3. Estimation using dietary reference intakes for healthy children matched for age and
sex.
 Energy requirements
• One of the formulas used to estimate energy requirements is the Schofield
formula.
• It takes into account the
• Age
• Sex
• Illness factor
• Activity factor
• Growth factor
 Factors influencing energy expenditure in
critically ill children
Increase in energy expenditure Decrease in energy expenditure
• Sepsis
• Mechanical ventilation
• Surgery
• Activity • Temperature controlled environment
• Fever
• Drugs- sedatives, analgesics, β blockers
• Weaning from mechanical ventilation
• Drugs- ionotropes, cathcholamines • Progression of sepsis to septic shock
• Pain
• Anxiety
 Energy requirements

Age group Kcal/kg/day

Premature infants 120-150
Neonates 100-120
1-12 months 90-100
1-6years 75-100
7-12years 60-75
13-18years 30-60
 Energy requirements.
• Estimating energy expenditure needs based on standard equations has been
shown to be inaccurate and can significantly underestimate or overestimate
the resting energy expenditure in critically ill children.
 Protein requirements
• Both protein synthesis and protein breakdown are intensified in critical
illness, but the latter predominates.
• The progressive breakdown of muscle mass from critical organs results in
loss of diaphragmatic and intercostal muscle and to the loss of cardiac
muscle.
• Excessive protein administration ( 4-6gm/kg/day) has been associated with
toxicities and adverse effects such as azotemia, metabolic acidosis, and
neurodevelopmental abnormalities.
 Protein requirements
• A significant feature of the metabolic stress response is that the provision of
dietary glucose does not halt gluconeogenesis. Consequently, the catabolism
of muscle protein to produce glucose continues unabated, and attempts to
provide large carbohydrate intake in critically ill patients have been
abandoned.
 Protein requirements
Age Group Protein (gm/kg/day)
Premature infants 2.5-3.0
Infants (0-1year) 2.0-2.5
Children( 2-13 years) 1.5-2.0
Adolescents/Adults 1.0-1.5
 Carbohydrate requirements
• Glucose is the primary energy used by the brain, erythrocyte and renal
medulla and is useful in the repair of injured tissue.
• There is a debate around tight glycemic control
• On one hand, it was shown to decrease mortality
• On the other hand, frequent cases of hypoglycemia, with conflicting results.
 Fat requirements
• Lipid turnover is generally accelerated by critical illness, surgery and trauma.
• Critically ill children have a higher rate of fat oxidation. Fatty acids are the
prime source of energy in metabolically stressed children.
• These children are susceptible to essential fatty acid deficiency if
administered a fat-free diet.
• Should therefore receive linoleic and linolenic acid at concentrations of 4.5%
and 0.5% of total calories, respectively.
 Nutrient delivery
• Nutritional support should be started within the first 24 hours from
admission to the ICU in children who are hemodynamically stable and have a
functioning gastrointestinal tract.
• Enteral nutrition via tube feeding is the preferred method of feeding the
critically ill patient.
• It reverses the loss of gastrointestinal mucosal integrity
• maintains intestinal blood flow,
• preserves Ig A dependent immunity
 Nutrient delivery
• Total or additional parenteral nutrition is recommended when EN cannot
meet the nutritional requirements.
• Post pyloric tube placement Vs gastric tube placement. Post pyloric feeding
may be considered in children at high risk of aspiration or those who have
failed a trial of gastric feeding.
 Immunomodulation
• There is no evidence as yet on the use of immune-modulating formulas, eg
formulas enriched with glutamine, arginine, ω 3 fatty acids or nucleotides in
the critically ill child. Can be considered in burns injury and trauma patients.
 summary
• Children who are critically ill are at a risk of malnutrition while in PICU
• Malnutrition as an independent predictor of clinical outcome in critically ill children
• Nutritional requirements need to be individually assessed for each child admitted to
the PICU
• Provide adequate protein, glucose and lipids.
• Enteral route is the preferred feeding route.
THANK YOU.