Download Pediatric Nutrition: A Multidisciplinary Approach

The Science of Effective
Pediatric Inpatient
Nutrition 2005
Kevin M. Creamer M.D., FAAP
Medical Director, PICU WRAMC
Chief, Pediatric Nutrition Support Team
A hypothetical case
 Starvin
Marvin is a 2 y.o. who presents with
a 2-3 week Hx of fevers, weight loss, pallor,
decreased energy, appetite and activity
 PE reveals Wt 13kg , down 1.5 kg, pallor,
petechia,+ HSM
 Labs reveal WBC 26 K with 50% blasts,
anemia and thrombocytopenia
Hospital Course
 Day
1 - NPO, IVFs, labs, Xrays
 Day 2 – NPO for BM and LP, as well as
Hickman
 Day 3- Chemo, picky PO
 Day 4-6 - continued poor PO, with emesis
occasionally
 Day 7-10 – emesis resolves, PO inadequate
 Day 12 – pancytopenia, sepsis with GNR
Teaching points
Nutritionally-at-risk
from the word GO
• Debilitated Ortho spine patient
• Recurrent bowel obstruction patient
No
nutrition plan, No monitoring, No
intervention
Hope is not a method
Could sepsis event been avoided??
Inpatient Nutrition Goals
Think about nutritional status on every patient
Outline the dynamic between illness,
nutritional state and secondary morbidity
Recognize need to estimate/calculate goals
calories in order to reach the goal



•

Individualized goals for time course, and disease
process
Institute effective nutrition support with the
help of Pediatric nutritionist
Acute Stress
The 5 W’s of Inpatient Nutrition
Why, Who, When, Where, What ?
Acute Stress
 Major
Surgery, Sepsis, Burns, Trauma
• Result in massive outpouring of catechols,
ACTH, GH, ADH, glucagon, somatomedins
– Insulin inhibition, elevation of glucose and free fatty
acids
• ↑ Inflammatory Cytokines: TNF, IL 1, IL-6
– PMN release and degranulation  Mucosal permeability
hormones and mediators ↑ release of
cAMP which down-regulate lymphoid
immune activity
 Stress
Acute Stress
 NPO
state starves gut mucosa
• Gut mass  50% in 7 days of fasting
• Gut contains 80% of body’s immune tissue
– “GALT and MALT”
• Intestinal sIgA ↓ in 5 days
• ↑ Th1 pro-inflammatory lymphocytes
 Major
stress doubles protein turnover
• Skeletal muscle cannibalized for fuel for
enterocytes (glutamine)
Stechmiller JK, Am J Crit Care, 1997
Bacterial Translocation

Disruption of mucosal
barrier
• Ischemia-reperfusion during
shock  risk of ulceration
and  permeability

Bacterial translocation
• Culture(-), found bacterial
DNA in blood stream

Cytokine amplification
in lymphatics and liver
Bacterial Translocation
 Enteral
nutrition can prevent translocation
• Trophic feeds stimulate gut hormones and nourish
mucosa, increase blood flow, re-energize tight
junctions, improve brush border
• Enteral vs. Parenteral feeds -  postop septic related
complications
 Enteral
feeds stimulate Th2 lymphocytes which
 PMN adhesion in lung
Deitch EA, Ann Surg, 1987, 1990;Border JR, AnnSurg, 1987; Carrico CJ, Arch Surg,
1986; Alverdy JC, Surgery, 1988; Moore J, JPEN, 1991,Kudsk,Am J Surg, 2002
WHY ?
Is nutrition such a big deal?
Malnutrition Prevalence
Nutrition Status and Outcomes
Gut Bacterial Translocation
Malnutrition Prevalence
15
to 50 % of hospitalized pediatric
inpatients are malnourished on
presentation (down from 35-65%)
• 15 to 20 % of critically ill patients
• 33% patients with congenital heart disease
• 39% awaiting elective surgery
Parsons, AJCN,1980; Mize, Nutr Supt Ser, 1984; Merritt, Am J Clin Nutr, 1979, Huddleston
KC, CC Clin of NA, 1993, Cameron, Arch Ped 1995, Cooper, J Ped Surg 1981
Malnutrition Snapshot
 Inpatient
population of Boston Children’s
Hospital was surveyed Sept 24,1992
• 268 children ages 0-18 years
 Using
Waterlow criteria:
• 25% were acutely malnourished, 27% were
chronically malnourished
 Of
17 ICU patients, 4 (24%) were classified
with severe PEM
Hendricks, Arch Ped Adol Med, 1995
Nutrition and Outcome
State of nutrition vs. LOS and Cost
18
16
14
12
10
8
6
4
2
0
$16,691
$14,118
$7,692
Normal
Borderline
Malnourished
Robinson G, JPEN, 1987
Nutrition and Outcome
Low Prealbumin 95%
specific, in 147
consecutive admissions
8 measures of malnutrition
in 134 patients
50 cardiac surgery patients
assessed
• Low Prealbumin
predictive post-op
infectious complication
20
18
16
14
12
10
8
6
4
2
0
PCM
No PCM
PCM*
No PCM*
LOS
Mortality (%)
Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, Rev Paul Med, 1995
Parameter Low Risk High Risk
Hosp. Days
7
13.5
Mech. Vent.
0
8.5
NPO days
3
8.5
Days on O2
4
20
P< 0.02
Nutrition Screen predictive of outcome
in 25 RSV PICU admits
Mezoff, Pediatrics, 1996
Nutrition and Outcome
 60
PICU patients had nutrition status
evaluated, with PSI, and TISS applied
 Acute PEM associated (P<0.01) with 
physiologic instability,  mortality and 
quantity of care
 Malnutrition can result in delayed wound
healing, respiratory failure, increased
potential for infection, death
Pollack MM, JPEN, 1985
Nutrition and Outcome
Ventilator
Patients:
Weaned Died
No Specific
Nutrition Plan
18
15
Focused
Nutrtional Care
13
1
Bassili HR, JPEN,1980
Nutrition and Outcome
PICU
Outcomes in 323 patients after
Nutrition support team instituted
• Use of Enteral nutrition (EN) in medical
patients increased 25% to 67%
Mortality
risk decreased 83% for those
receiving EN >50% of LOS
• EN independent predictor of survival in
multiple regression analysis.
Gurgueira, JPEN, 2005
WHO ?
Needs to know?
Gets assessed?
ALL Physicians!
ALL Patients!
Nutrition Dichotomy
79
FP residents
• Nutrition Interest (72.2%) vs. Perceived
Knowledge
– Parenteral and enteral nutrition 34.2%, Infant
nutrition 27.5 %, Nutrition assessment 17.7%

3416 Primary Care physicians
• < 40% practiced what they preached
Lasswell AB, J of Med Ed, 1984, Levine BS, Am J Clin Nut, 1993
Nutrition Practice: Uphill battle
Adult
ICU group found their patients only
received 52% of goal calories
• Reasons included physician under ordering,
frequent cessations, and slow advancement
Designed
a protocol but only 58% went
on it
Spain, JPEN, 1999
I wonder if I’m
missing out on
some critical
piece of
information
Nutrition Screen
Should
be completed within 24 hours of
admission
High risk surgical patients should be
screened weeks to months ahead of
planned surgery
In your continuity clinic
• Multidisciplinary team
• Supplement , reassess, or reschedule
Nutritionally-at-risk
Weight for age < 10th % tile
 Weight for Height < 10th % tile
 Acute weight loss > 5% over 1 month or >10% total
 Birth weight < 2 SD below mean for gestational age
 Increased metabolic requirements 2 chronic disease
 Impaired ability to ingest or tolerate oral feeds
 Weight % tile crossing 2 contour lines over time
(FTT)

Prealbumin
Transthyretin
has nothing to do with
albumin
• Small body pool and half life of 2 days
makes prealbumin an reasonable monitor of
visceral protein homeostasis
Drops
during the first 3-5 days of stress
it should rise thereafter
 Daily rise of 1mg/dl indicates anabolism
Plasma Protein Stress Response
CRP
Prealbumin
Fleck, A. Br J Clin Pract, 1988
Prealbumin as a predictor
 Surgically
stressed Infants
• Prolonged ↑ CRP with ↓ Prealbumin had ↑
mortality
– Strongest predictor POD#5 prealbumin depression
 Prealbumin
ideal nutrition screen for:
• 50 children with solid tumors
– before and during chemo
• 86 Adult post-op patients requiring TPN
Chwals WJ, Surg Clin NA, 1992, Elhasid, Cancer, 1999, Erstad, Pharmaco, 1994
Prealbumin
Measure
twice weekly
Once 65% of needs met expect levels
to rise 1mg/dl a day
 If weekly rise is less than 4mg/dl
• check N2 balance and CRP to determine
if cause is nutritional inadequacy or
ongoing SIRS
Expert roundtable, 10th World
Congress of Gastroenterolgy
WHEN?
Should I start?
Early Enteral vs Standard timing
Enteral Contraindications
Intubation/extubation planned within 4°
 Hemodynamic instability requiring
escalation in therapy
 Intestinal obstruction
 Massive UGI bleed
 Gut ischemia
 I’m nervous about this kid

Early feeds vs. Standard
Adults
with gut malignancies and
neurotrauma has shorter LOS and fewer
infections when fed early
19 controlled studies (24° vs 3-5 days)
• 16/19 studies showed improved outcome
• Improved healing,  complications and LOS
• Recommended for critically ill surgical pts
Braga, CCM, 2001 Grahm T, Neurosurgery, 1989 Taylor, CCM 1999 Heyland
DK, CC Clin of NA, 1998 Zaloga. CCM 1999
Early feeds: Pediatrics
 Tolerated
pediatric burn patients
 42 ventilated children (76% on vasoactive
meds)
• Transpyloric feeding tubes placed at bedside
• 74% of patients reached full feeds within 24
hrs, rest within 48 hrs
– No complications
Chellis MJ, JPEN, 1996, Trocki, Burns, 1995
All is Not Rosy
 All
Mechanical Ventilated patients
 Lots of exclusions
Group Early (75) Late (75)
p
VAP
49.3%
30.7%
.02
C diff
13.3%
4.0%
.042
ICU stay 13.6± 14.2 9.8 ± 7.4
.043
Mortality
20%
26.7%
.334
Ibraham, JPEN, 2002
WHERE?
In the gut do I put the food?
Oral vs.Tube feeding
Gastric vs. Transpyloric feeds
Tube Feeding Considerations
Nutritionally-at-risk with inadequate
oral intake for the past 3-5 days.
 Meeting <50% estimated needs orally
for previous 7-10 days.

• Shorten to 3-5 days if traumatized or
severely catabolic
Disease
state preventing adequate P.O.
intake for >5 days
Gastric vs. Transpyloric
 No
aspiration difference in 54 patients receiving
gastric vs transpyloric radiolabeled feeds
 33 mechanicaly ventilated  Micro-aspiration
7.5 >> 3.9% in NJ fed patients
 80 adult trauma victims
• Duodenally fed patients reached goal calories 34 vs.
44 hours with had less pneumonia 27% vs 42%*
 80
ventilated adults randomized
• gastric feeds + E-mycin 200 mg q8 (55% / 74%)
• Transpyloric feeds (44% / 67%)
Esparza, Intens C Med, 2001,Kortbeek, J Trauma, 1999, Heyland, CCM, 2001, Boivin, CCM, 2001
Transpyloric
59
ventilated children randomized to
receive continuous or interrupted
transpyloric feeds during the day
before and of extubation
• Continuous group got >90% goal calories
both day vs 73% and 46%
• No aspiration events or difference in
adverse events
Lyons, JPEN, 2002
Neuromuscular blockade and ECMO?
 May
decreased REE by 10-15 %
 Primary Neurotransmitter in Gut is VIP not
acetylcholine
• Neuromuscular blockade work via AcH receptors
 By
what mechanism do neuromuscularly
blocked patients become intolerant of enteral
feeds?
• Gastric atony 2° Benzodiazepines and narcotics
 Enteral
feeds for Pediatric ECMO patients is
safe with trends toward improved survival
Pettignano, CCM, 1998
Enteral Pitfalls
2
adult studies with 95 ICU pts, had 66%-78% of
goal feeds prescribed, 52%- 71% delivered
• Gastric Intolerance (Residuals #1)
– BZD and Narcs effect stomach > intestine
• Airway management
– 22/26 PICU pts had feeds held for extubation that only 5 got
• Diagnostic procedures
– Some ventilated patients fed right up to OR
McClave SA, CCM, 1999,DeJonghe, CCM,
2001, Fry-Brower +McCunn, CCM(a), 2002,
WHAT?
Amount of calories do I Feed
Them?
How much to feed
Trophic feeds
Enteral vs. Parenteral
Lipid phobia
Caloric Goals?
Brazilian
PICU reviewed 37 charts
Only 3 had an assessment done in 425
days
No Patient had caloric goals set
• Only 29.7% met goals
• 80.5 % fed Parenterally
Leite, Rev Assoc Med Bras, 1996
Steady State Energy Requirements
120
Calories per Kilogram
100
Activity
Growth
BMR
80
60
40
20
0
0
1
2
3
4
5
6
7 8 9 10 11 12 13 14 15 16
Age in Years
Energy Requirements
 Calorie
needs change during the course of the
hospitalization.
• Hemodynamically unstable?
• Ventilated vs Extubated
 Ebb
phase (Hypometabolic): obligate (–)
nitrogen balance during acute critical illness
• No need for growth calories (BMR may suffice?)
• Watch out for overfeeding
– Steatosis, Hyperglycemia, Hypertriglyceridemia
Therapeutic window
 187
critically ill adults >96º in ICU
• Tertiles of % ACCP recommended caloric intake
 Patients
receiving 33-65% goal Vs. <33%
(18kcal/kg)
• OR survival 1.22, discharge without sepsis 1.2,
without vent 1.8
• Patients > 65% goal OR 0.82, 0.75, 0.69
 Sickest
patients (SAPS>50)
• Did worse when they received >33% goal
Krishnan, Chest, 2003
Energy Requirements

Flow phase (Hypermetabolic)
• As the child improves and becomes
anabolic, calorie needs for growth and
activity must be included
Underestimating
needs can increase
risk for infection, poor wound healing,
poor growth, and overall poor outcome
Energy Requirements
12
Septic and 12 Traumatized patients
• Total energy expenditure and REE
measured for 2 separate 5-day periods
• TEE Sepsis 25kcal/kg >>> 47kcal/kg
• TEE Trauma 31kcal/kg >>> 59kcal/kg
Second
week TEE: indirect calorimetry
X1.8
TEE remained elevated for weeks
Uehara, CCM,1999
1º Fever
↑12%
Trophic Feeds
fed 15% calories enterally had 
permeability and bacterial translocation
 10 post-op infants fed trophically (21cal/kg/d)
had improved Staph killing vs TPN alone
 Rats
• 37% vs. 52% vs. 65% (Controls)
– Related to production of TNFα
>
6kcal/kg (>25% ACCP cal goals) in 138
adult MICU patients reduced BSI (relative
hazard 0.24)
Omura, Ann Surg, 2000, Okada, J Ped Surg, Robinson,CCM, 2004
Trophic feeds
Feed type # Patients Mortality
SMR
Enteral
167
25%
.71
Parenteral
26
54%
1.4
Parenteral
+ Trickle
24
38%
.9
Trophic feeds are stress ulcer and antibiotic prophylaxis
rolled into one
Marik, CCM(a), 2002
Trophic Feeds Vs. TPN
100
90
80
70
60
50
40
30
20
10
0
92.4
70.3
36.1
32.6
14.1
20.2
Assisted Vent
20.6
PN
24.8
Full Enteral
Hosp.
Discharge
McClure RJ, Arch Dis child , 2000
Enteral Feeds vs. TPN
Enteral
feeds in Critically ill population
• improve wound healing,  mucosal
permeability
>
10 studies show enteral feeds are safe,
feasible and cheaper than TPN
Meta analysis adult ICU patients Enteral
feeds vs. TPN RR infection 0.66
Schroeder D, JPEN, 1991, Hadfield R, Am J Resp Crit Care Med, 1995 Robert Dimand, UC
Davis, Peds CC Update 2002, Gramlich, Nutrition, 2004
TPN vs. Hope
 Meta Analysis
26 studies (210 reviewed)
• 2211 patients
• Trend toward reduced complications in TPN
patients (risk ratio 0.84)
4
studies used TPN > 3 weeks
• Mortality in TPN pts was 6.8% vs. 12.4%
 Meta Analysis
11 studies
• Parenteral nutrition vs. delayed enteral improved
mortality
• Increased infectious risk (OR 1.65 CI1.1-2,5) in
PN vs. all enteral
Heyland DK, JAMA, 1999, Simpson, Int Care Med, 2005, Doig, CCM(A) 2005
Parenteral Considerations
Nutritionally-at-risk
patient with non-
functional gut.
Adequate nutritional status on
admission but non-functioning gut 3-5
days after admission
“The major advance in TPN since the
1980’s is that it is not used as much”
Lipid Phobia?
 When
infants given TPN without lipids
• CHO only TPN resulted in  amino acid oxidation,
proteolysis, CO2 production and  lipogenesis
 Lipid
requirements
• Essential fatty acid (0.5gm/kg/d), Promote
Nitrogen sparing, Increased lipid clearance during
stress
 Balanced
approach to fulfilling energy
requirements
Bresson, Am J Clin Nut 1991,Tilden,
AJDC, 1989, Schears, Crit Care Clin, 1997
Lipids
 Original
10% lipid compounds
– Intravenous fat emulsions contain 50-60% linoleic acid
a precursor to arachidonic acid
– May disturb balance between thromboxane and
prostacyclin production
 Modern
20% emulsion cause less Trig 
• Neonates clear better, less phospholipids
• No problems with oxygenation when given as 1824° infusion
• No immune problems when Triglycerides <700
Monitor Outcomes
 Residuals
 Age
appropriate
weight gain
 Diarrhea /
Constipation
 Medication
Compatibility?
 Emesis / Aspiration
 Proper
wound
healing
 Fluid and
electrolyte balance
 Euglycemia
 Improved N2
balance and
Prealbumin
HOPE IS NOT A METHOD!
Who?
Is you, screening all your patients
Why? They’ll do worse if you don’t
When? The sooner the better
What? Enteral better, even trophic
better than TPN alone
Where? PO>NG>NJ > IV