NUTRITIONAL SUPPORT

IN PEDIATRIC
CRITICALLY ILL PATIENTS
 CRITICALLY ILL
HEALTHY CHILD
CHILD

ORAL ENTERAL/
PARENTERAL

NORMAL
METABOLISM HYPER
METABOLISM

MINIMIZED
GROWTH
CATABOLISM
NORMAL METABOLISM

HIGH INSULIN/
LOW INSULIN/
LOW GLUCAGON
HIGH GLUCAGON

ABSORPTIVE POSTABSORPTIV STARVATION

STATE E STATE

MEAL – 6 HOURS 6 – 12 HOURS > 12 HOURS

 ABSORPTIVE STATE (HIGH INSULIN)
OTAK: INSULIN INDEPENDET

INTESTINE

LIVER MUSCLE
Glycogen synthesis Glycogen synthesis
Glycolisis Glycolisis
Lipogenesis Lipogenesis
Prot. visceral synthesis Prot. skeletal synthesis

ADIPOSE TISSUE
Lipogenesis
Glycolysis
 POSTABSORPTIVE STATE
OTAK: INSULIN INDEPENDET

LIVER MUSCLE
Glycogenolysis Glycogenolysis
Gluconeogenesis INSULIN ↓ Proteolysis
GLUCAGON ↑

ADIPOSE TISSUE
Lipolysis
 METABOLISM IN STRESS & INJURY

Insulin resistance

LIVER MUSCLE
Glycogenolysis Stress Hormone
Cortisol, glucagon, Glycogenolysis
Gluconeogenesis
nor/epinephrine Lipolysis
Decreased prot.
Proteolysis
visceral synthesis
CRP synthesis

ADIPOSE TISSUE
Lipolysis
 STRESS RESPONSE

ANABOLIC SUPRESSION
INCREASED CATABOLIC
INSULIN RESISTANCE

HYPERGLYCEMIC
without having to rely upon external support

BRAIN, IMMUNE SYSTEM, VITAL CELL.

NUTRITIONAL ASSESSMENT

MEDICAL HISTORY
CLINICAL EXAMINATION
ANTHROPOMETRIC
BIOCHEMICAL

NUTRITIONAL STATUS
METABOLIC CONDITION
GASTROINTESTINAL FUNCTION
 ANTHROPOMETRIC

WEIGHT; HEIGHT
SKINFOLD THICKNESS
ARM CIRCUMFERENCE

FOR NUTRITIONAL STATUS,

BUT NOT ACCURATE IF EDEMA

DO NOT GIVE INFORMATION ABOUT

METABOLIC CONDITION
 BIOCHEMICAL MARKERS

PLASMA PROTEIN IS THE MOST USEFUL

ALBUMIN
LONG HALF LIFE , HIGH PROGNOSTIC VALUE
NORMAL: > 3,5 G/DL
MILD: 2,8 – 3,5 G/DL
MODERATE: 2,1 – 2,7 G/DL
SEVERE: < 2,1 G/DL
PREALBUMIN AND RETINOL BINDING PROTEIN

SHORT HALF LIFE, GOOD FOR NUTRITIONAL

STATUS AND INTERVENTION EFFICACY

PER-ALB RBP
NORMAL 20-40 MG/DL 3-6 MG/DL
MILD 10-15 MG/DL
MODERATE 5-10 MG/DL
SEVERE < 5 MG/DL
TRANSFERRIN
HALF LIF 8-9 DAYS
NORMAL : 225 – 400 MG/DL
MILD : 150-200 MG/DL
MODERATE : 100 – 150 MG/DL
SEVERE : < 100 MG/DL

C-REACTIVE PROTEIN

NORMAL: NOT DETECTABLE (< 1 MG/DL)

INCREASE IN STRESS CONDITION.
IF LEVEL DECREASE
PROT. VISCERAL COULD BE USED FOR
EVALUATE NUTRITIONAL EFFICACY
 NUTRITIONAL REQUIREMENT

DIFFERENT NUTRITIONAL REQUIREMENT IN

NORMAL METABOLISM AND HYPERMETABOLISM

DO NOT USING THE STANDARD RDA

OVERFEEDING:
HYPERGLYCEMIA, HYPERTRIGLYCERIDE, AZOTEMIA

UNDERFEEDING:
INCREASE CATABOLISM,
MULTIORGAN FAILURE AND DEATH

BALANCED CARBOHYDRATE-FAT-PROTEIN
START LOW, GO SLOW
ENERGY REQUIREMENT

Age BMR Activity Growth Total BMR/total

Vlbw 47 15 67 130 36%

<1 55 15 40 110 50%
1 55 35 20 110 50%
2 55 45 5 100 50%
5 47 38 2 87 54%
10 37 38 2 77 48%

Condition Increase in EE (%)

Fever 12% per ºC*
Cardiac failure 15-25
Major surgery 20-30
Burns up to 100
Severe sepsis 40-50
* for core body temperatures > 37ºC
PROTEIN
Age Dosage
VLBW 2,25 gm/kg/day
0-12 months 2,5 gm/kg/day
1 – 8 years 1,5 – 2 gm/kg/day
8 – 15 years 1 – 1,5 gm/kg/day

CARBOHYDRATE: 50-60%
PARENTERAL: GLUCOSE 10-25 GM/KG/DAY

LIPID
Age Dosage
0-12 months 4 – 5 gm/kg/day
1 – 10 years 3 – 4 gm/kg/day
≥ 11 years 2 – 3 gm/kg/day
 NUTRITIONAL THERAPY

ENTERAL VS PARENTERAL

USE PARENTERAL ONLY IF UNABLE TO

TOLERATE ENTERAL FEEDINGS

GIVING TROPHIC FEEDING IN PARENTERAL

 ENTERAL FEEDING
OROGASTRIC, NASOGASTRIC,

TRANSPYLORIC: RISK ASPIRATION

SOME MEDICATION IMPAIR GASTRIC MOTILITY, BUT
SMALL INTESTINE MOTILITY AND ABSORTIVE
FUNCTION REMAIN INTACT

GASTROSTOMY: LONGTERM ENTERAL FEEDING

INTERMITTENT BOLUS FEEDING OR

CONTINUOUS INFUSION DELIVERY

START WITH LOW RATE OF AN ISOTONIC FORMULA

 INDICATION
UNABLE TO SAFELY CONSUME
ADEQUATE ORAL NUTRITION
MAY BE USED TO PROVIDE ALL OR PART
OF REQUIREMENT

SELECTION PRODUCT
0-12 MONTHS: INFANT FORMULA
1-10 YEARS: PEDIATRIC FORMULA
≥ 11 YEARS ADULT PRODUCT
Clinical condition Suggested formula

Prematurity Preterm formula

Full-term Standard formula
Casein/lactoalbumin 60:40
Casein
Lactose intolerance Soy formula
Lactose-free
Sucrose-free
Casein sensibility Soy formula
Partial hydrolysate protein
Organ dysfunction or failure Low electrolytes
Low osmolarity
Steatorreia Low MCT
Ileal dissection
Lymphatic anomalies
Soy sensibility Hypoallergenic formula
Absorption deficiency MCT addition
Digestion deficiency Lactose-free
Intraluminal transport deficiency Sucrose-free
Severe malnutrition Partial/total hydrolysate
High energy
MINIMAL ENTERAL NUTRITION (TROPHIC FEEDING)
a volume less than or equal to 10 mL/kg per day of choice diet

Beneficial Effects of Minimal Enteral Intake

No increase in incidence of necrotizing
enterocolitis
Less cholestatic jaundice
Less osteopenia
Increased glucose tolerance
Increased weight gain
Earlier tolerance of full enteral intake
Increased gut hormones
Prevention of gut atrophy
MONITORING

Routine assessment of gastrointestinal, metabolic, mechanical,

and growth parameters

Tolerance of enteral feedings is assessed by vomiting,

abdominal distension, diarrhea

Checking for residual formula, greater than two times the feeding rate
are typically a sign of intolerance

Decreasing the rate by half for a few hours, rechecking residuals,

and slowly advancing

If this is unsuccessful, changing to transpyloric feeding may be beneficial

Right lateral decubitus positioning and/or administration of a

hypermotility agent such as metoclopramide to enhance gastric emptying

Ensuring correct placement of the feeding tube is also necessary.

PARENTERAL NUTRITION
Primary therapy, adjunctive therapy, or the sole source of
nutritive support
For full nutritional support - conjunction with trophic feeds

Peripheral Vein Versus Central Venous Access

Depending on the dextrose concentration and osmolarity of the
solution

Maximum dextrose concentration for peripheral PN solution is

12.5% dextrose

The maximum osmolarity should not exceed 900 mOsm/L

MONITORING
HIGH RISK OF COMPLICATION

The first 3 to 5 days: serum electrolytes, glucose, calcium,

phosphorus, magnesium, blood urea nitrogen, and creatinine are
measured daily

Hepatic studies including serum triglycerides are checked at least

two to three times each week.

Patients with hepatic or renal insufficiency may require more

frequent monitoring of laboratory values

Urine monitoring: gives immediate information on glucose and

protein tolerance and the patient’s overall fluid balance.
 CONCLUSION
Critically ill children have unique and complex needs

The acute hypermetabolic response represents a catabolic state and

postpone the anabolic metabolism.

Be careful with underfeeding and overfeeding

Nutrition support must be start with low amount of nutrition,

increase slowly, and we must pay great attention to the sign of
metabolic complication

Use of the gut is the primary route for delivery of nutrients

Parenteral with trophic feeding

The provision of nutrition to the critically ill child requires attentive

monitoring and assessment.