PA-HCP-Role of Nutrition in Surgical PICU

Role of Nutrition
in
Surgical PICU
An educational initiative by
Abbott Nutrition
IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR THE
BABY
The content of this presentation is meant for the information

of Healthcare Professionals and Healthcare workers only.
Not intended for circulation.
IN-PDS-SD-DEC-2021-9066
2
IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR
THE BABY
Breastfeeding provides the best nutrition and protection from illnesses of infants. For infants, breast milk is all that is needed for the first 6 months. Breastmilk is the best and most
economical food for baby.
Warning / Caution: Infant milk substitute is not the sole source of nourishment of an infant. Careful and hygienic preparation of infant milk substitute is most essential for health.
Lactose- free infant milk substitute should only be used in case of diarrehea due to Lactose intolerance. Lactose- free infant formula should be withdrawn, if there is no
improvement in symptoms of intolerance.
Continued use of infant milk substitute should not be recommended to avoid any difficulties in reverting to breastfeeding of infants after a period of feeding by infant milk substitute.
In the event recommending infant milk substitute in addition to breastmilk or its replacement during the first 6 months, keep the costs in mind before recommending use of infant
milk formula. Un-boiled water, un-boiled bottles or incorrect dilution can make a baby ill. Always advise to follow instructions exactly.
Unnecessary introduction of partial bottle-feeding or other foods and drinks will have negative effect on breastfeeding.
Characteristics of breastmilk : Immediately after delivery, breastmilk is yellowish and sticky. The milk is called Colostrum, which is secreted during the first-week of delivery.
Colostrum is more nutritious than mature milk because it contains more proteins, more anti-infective properties, which are of great importance for the infant’s defense against
dangerous neo-natal infections. It also contains higher levels of Vitamin ‘A’.
Advantages of breastfeeding : (A) Breastfeeding is much cheaper than feeding an infant milk substitute as the cost of extra food needed by the mother is negligible as compared to
cost of feeding infant milk substitute; (B) Breastmilk is always available; (C) Breastmilk needs no utensils or water (which might carry germs) or fuel for is preparation; (D) Mothers
who breastfeed usually have longer periods of infertility after child birth than non-lactators.
Management of breastfeeding, as under:
I. Breastfeeding
A. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
B. Is successful when the infant suckles frequently and the mother wanting to breastfeed is confident in her ability to do so.
II.In order to promote and support breastfeeding the mother's natural desire to breastfeed should always be encouraged by giving, where needed,
practical advice and making sure that she has the support of her relatives.
iii. Adequate care for the breast and nipples should be taken during pregnancy.
iv. It is also necessary to put the infant to the breast as soon as possible after delivery.
v. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming- in").
vi. Give the infant Colostrum as it is rich in many nutrients and its anti-infective factors protect the infants from infections during the few days of its birth.
vii. The practice of discarding Colostrum and giving sugar water, honey water, butter or other concoctions instead of Colostrum should be very strongly discouraged.
viii. Let the infants suckle on demand.
ix. Every effort should be made to breastfeed the infants whenever they cry.
x. mother should keep her body and clothes and that of the infant always neat and clean.
3
Table of Contents
• Introduction
• Evaluation and Assessment
• Nutritional Support: Challenges
• Nutritional Approach
• Summary
Malnutrition is highly prevalent in hospitalized
children
• A study by Cooper et al showed that

18% to 40% of pediatric surgical
patients have malnutrition1
• Despite its high prevalence, malnutrition

remains a largely unrecognized issue by
healthcare workers2
1. Herman R, Btaiche I, Teitelaum DH. Nutrition Support in the Pediatric Surgical Patient. Surg Clin N Am. 2011;91:511-541
2. Durakbasa CU, Fettahoglu S, Bayar A, et al. The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients. Balkan Med J. 2014;31(4): 313-21..
Prevalence of Malnutrition: Clinical evidence
A prospective study included 494 pediatric surgical patients
Malnutrition was detected in 13.4% of patients
10.1% 1.4% 4.6%
Acute malnutrition (more Chronic

common in patients aged ≤ 5 malnutrition
years) Coexisting acute and
chronic malnutrition
Durakbasa CU, Fettahoglu S, Bayar A, et al. The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients. Balkan Med
J. 2014;31(4):313-21
Nutritional Impairment & Surgical outcome
Prolonged fast, disease, stress, or trauma lead to a
depletion of body stores, mainly protein reserves
These conditions decrease immunocompetence

and increase morbidity and mortality1
Severity of This risk is

nutritional increased during
impairment is surgery, when
strongly correlated stress response
with increased risk may accentuate
of subsequent catabolic
morbid events processes2
Pelizzo G, Calcaterra V, Acierno C, et al. Malnutrition and Associated Risk Factors Among Disabled Children. Special Considerations in the Pediatric Surgical “Fragile” Patients. Front Pediatr. 2019.
Early detection of malnutrition is Essential!
In pediatric 1. Preventing nutrition- a. Slowing of growth

surgical associated complications,
patients, such as: b. Increased susceptibility to
early various infections
detection of
malnutrition 2. Preventing prolonged
helps in:1 hospitalization
Maintaining adequate nutrition in pediatric surgical patients is

critical not only to
aid in healing but also to continue normal growth and development2
1. Durakbasa CU, Fettahoglu S, Bayar A, et al. The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients. Balkan Med J. 2014;31(4):313-21.
2. Herman R, Btaiche I, Teitelaum DH. Nutrition Support in the Pediatric Surgical Patient. Surg Clin N Am. 2011;91:511-541.
Evaluation and Assessment
• Measuring the resting energy expenditure in postoperative pediatric patient
• Assessing nitrogen balance; implications of nitrogen balance
• Laboratory tests for assessing nutrition
The “insult of operative trauma” initiates
stress response
• Energy, protein, lipid, and
glucose metabolism are altered in
postoperative period
• Changes in metabolism increase

the availability of substrates
required by essential organs and
regenerating and healing tissue
McHoney M, Eaten S, Pierro A. Metabolic Response to Surgery in Infants and Children. Eur J Pediatr Surg. 2009;19(05):275-285.
NBM before, during, and after
investigations and surgery
Perioperative nutritional status, especially the degree of fasting, influences
the metabolic response to surgery
Postoperative metabolic response is exaggerated by preoperative fasting
Limited fuel stores in

Prolonged fasting is children, who tolerate
Type of intraoperative
related to greater fasting poorly, may have
fluid administration can
degree of postoperative significant implications
also affect metabolism
insulin resistance for the metabolic
response to surgery
McHoney M, Eaten S, Pierro A. Metabolic Response to Surgery in Infants and Children. Eur J Pediatr Surg. 2009;19(05):275-285.
Measuring the resting energy expenditure in
postoperative pediatric patient
Nutritional assessment and

evaluation
Clinical history
Clinical examination
Anthropometry
Biochemical evaluation
Falcao MC, Tannuri U. Nutrition for the pediatric surgical patient: approach in the peri-operative period. Rev Hosp Clin. 2002;57(6):299-308.
Clinical examination may not always be
sufficient!
Although careful clinical

examination is important The depleted state cannot be
in determining a child’s reliably detected based on
nutritional status; parameters such as weight-to-
height ratio, MUAC, albumin
concentration, total protein
level, etc.
Estimation of metabolic rate and energy needs is the best method of assessing the
nutritional status
Herman R, Btaiche I, Teitelaum DH. Nutrition Support in the Pediatric Surgical Patient. Surg Clin N Am. 2011;91:511-541.
Indirect Calorimetry – A reliable method of
measuring energy expenditure
Energy expenditure, measured in

Involves measurement of CO2
cm3 of oxygen per minute, can
production and O2 consumption be converted to calories per hour
using a metabolic chart per day
All measurements are

These give an excellent way to
approximations of caloric needs
monitor pediatric patients,
for which a surgeon must further
particularly those in the surgical
adjust according to patient’s
PICU
clinical course
Biochemical measurements of nutritional status
• Includes plasma levels of albumin, transferrin, pre-
albumin, and retinol-binding protein
• Plasma protein concentrations are not specific and
may modified by many factors
• Of these, albumin plasma level is easily accessible and
is considered the classic biochemical marker to assess
malnutrition
• Other parameters are seldom used in clinical practice
as they are not easily accessible
• Urinary creatinine excretion is proportional to muscle
creatinine and to total muscle mass
• In the postoperative period, creatinine excretion is
altered and is not a valuable index
Assessing the nitrogen balance
Difference between nitrogen entering

and exiting the body
Indirect method of protein

conservation
A negative balance shows a catabolic

state in the critically ill patient
Nutritional Approach to the
Pediatric Surgical Patient
Nutritional therapy
If enteral feeding
Includes enteral Enteral feeding is is not indicated,
and/or parenteral parenteral
nutrition the 1st choice nutrition must be
utilized
In all cases, an individualized,

adequate diet is obligatory to decrease
the occurrence of overfeeding and its
undesirable consequences
Special Problems in
the Nutritional
Support of Pediatric
Surgical Patients
Pediatric patients respond differently to
surgical stress than adults
• Metabolism of children is markedly
affected by operative stress
• Induction of anesthesia has profound
effects on metabolism
• Protein turnover and catabolism are
not affected by major operative
procedures
• In pediatric surgical patients, PN is
associated with increased production
of oxygen-free radicals, which may
lead to suppression of the immune
status
Meeting the Nutrient
Requirements
Meeting the nutritional requirements
Water
• Water content of pediatric patients
is higher than that of adults
• Water requirement is related to
caloric consumption
• In general, calorie requirements are
matched to the amount of fluid
needs
Protein
• Protein requirement is based on
combined needs of growth and
maintenance
• Average protein intake should comprise
appr. 15% of total calories
• Protein requirements are based on age,
nutritional status, stress level, severity,
and type of injury
Meeting the nutritional requirements
Carbohydrates
• Major source of EN and PN routes

• Short periods of fasting can lead to hypoglycemic state
Fat
• Lipids are an excellent source of energy and essential fatty acids
• 2% to 4% of dietary energy should come from essential fatty acids
• If full delivery of lipids is not done, essential fatty acid deficiency should be
monitored at least once a month
Minerals, trace elements, and vitamins
• Vitamins are essential components or
cofactors of various metabolic reactions
• Trace elements comprise less than
0.01% of the total body weight in
humans
• Zinc deficiency commonly occurs in
patients with SBS, thermal burns,
peritoneal dialysis, IBD, and other
causes of diarrhea
• Copper deficiency has been reported in
patients receiving PN formulas that are
not supplemented with copper
• Selenium levels dramatically decline
after as few as 6 weeks of PN
ESPNIC recommendations for nutritional support of
pediatric surgical patient
Early EN is recommended in
children after cardiac surgery
Post-pyloric feeding can be

considered for critically ill
children at high risk of
aspiration or requiring frequent
fasting for surgery or procedures
Routes for Providing
Nutritional Therapies
Enteral nutrition
• Includes ONS and tube feedings
• Should be the primary source of nutrients if GI tract is functional
• When full feedings are not tolerated enterally, providing small volumes of trophic
feedings may prevent further deterioration of intestinal function 1
How quickly should EN be started and
advanced?
• Multiple published guidelines support the provision of early EN in patients
who are unable to maintain adequate oral intake in the first week of
admission to an ICU2
• Children in a good state of health before surgery/trauma can sustain 5-7 days
without significant energy intake provided that adequate nutritional support
is initiated thereafter1
2. Kenney BD, Piper H, Relles D, et al. Nutrition [internet]. Pediatric Surgery NaT. American Pediatric Surgical Association. 2020 [cited 2021 July 12]. Available from:
https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829018/all/Nutrition
How quickly should EN be started and advanced?
• Multiple published guidelines support the provision of early EN in patients who are unable to
maintain adequate oral intake in the first week of admission to an ICU 1
• Children in a good state of health before surgery/trauma can sustain 5-7 days without
significant energy intake provided that adequate nutritional support is initiated thereafter 2
How often is EN effective in meeting the caloric goals of critically ill children?
• Several studies have demonstrated that in septic or critically-ill ICU patients,

only 25-50% met nutritional goals
• Unmet nutritional needs are often due to interrupted feeding schedules (relating
to NPO status for procedures), fluid restrictions, and feeding intolerance1
1. Kenney BD, Piper H, Relles D, et al. Nutrition [internet]. Pediatric Surgery NaT. American Pediatric Surgical Association. 2020 [cited 2021 July 12]. Available from:
https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829018/all/Nutrition
ONS can help mitigate the impact of
malnutrition
Studies in children with

Similar improvements in
cystic fibrosis concluded
nutrition status and
ONS improves health that ONS led to
disease control were
outcomes in improved nutrition
also noted in children
hospitalized children status with positive
with Crohn’s disease
benefits on clinical
who received ONS
outcomes
Lakdawalla DN, Mascarenhas M, Jena AB, Vanderpuye-Orgle J, LaVallee C, Linthicum MT, Snider JT. Impact of oral nutrition supplements on hospital outcomes in pediatric patients. JPEN J Parenter Enteral Nutr. 2014 Nov;38(2 Suppl):42S-9S.
Parenteral nutrition
Indications and initiation
• Ideal in children who are unable to tolerate enteral feedings

• Includes conditions like GI disorders (SBS, malabsorption, IBD, etc.),
congenital anomalies (gastroschisis, bowel atresia, etc.), radiation therapy to
the GI tract, chemotherapy resulting in GI dysfunction
• Children generally do not require PN unless periods of starvation extend
beyond 7-10 days
• Initiation of PN should begin with 25 to 30 kcal/kg/d, with advancement over
several days to reach goal calories
PN is associated with various metabolic, respiratory, hepatobiliary, and
infectious complications
Peripherally administered PN vs centrally
administered PN
Peripheral PN Central PN
• Can be administered to any patient • Placement of central lines may lead
who needs transient to iatrogenic injury
supplementation for EN due to a
• Once in place, the line itself can be
brief period of starvation
an entry or nidus for infection
• Must be diluted to avoid osmotic leading to bacteremia, fungemia, or
injury to the vein sepsis
• Primary benefit is avoidance of the
placement of a central venous catheter
Kenney BD, Piper H, Relles D, et al. Nutrition [internet]. Pediatric Surgery NaT. American Pediatric Surgical Association. 2020 [cited 2021 July 12]. Available from: https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829018/all/Nutrition
Preoperative and
postoperative nutrition
Indications for preoperative nutrition
• Clinical evidence suggests that PN is may predispose patients to
increased infectious complications, especially those who are mildly
to moderately malnourished
• Severely malnourished patients, however, may benefit from PN
• Thus, unless there are clear indications of severe malnutrition, a
delay in operative management to provide preoperative PN is not
indicated
Indications for postoperative nutrition
• Postoperative nutrition should be started early using a combination of EN
and PN until the GI tract fully recovers
• A controlled study showed that postoperative PN had a positive effect on
nitrogen balance and IGF-1 levels; however, no clinical benefit was noted
• In the postoperative period, there are higher infection rates in patients on
PN
• Postoperative PN should be restricted to infants who do not tolerate even a
short period of starvation or older children who cannot tolerate EN for at
least 5 to 7 days
Nutritional care of critically ill patients is more
challenging than general pediatric surgical patients
• Critically ill children manifest poor enteral feeding, anorexia, and
often a paralytic ileus
• Insulin resistance results in hyperglycemia and hypertriglyceridemia
• Energy needs of postoperative critically ill patients are often
overestimated
• Almost 1/3rd of an infant’s energy needs is provided to support growth
• Because a cessation of growth occurs during periods of sepsis and
critical illness, a marked decrease in energy needs may ensue
Energy and nutrient deficiencies occur rapidly
in a PICU
• The rapid decline in energy and nutrients highlights the need for
aggressive nutritional support
• High lipid infusion may help in achieving significantly higher energy
delivery, and a reduction in need for insulin therapy
• A per recent data, use of tight glucose control in an ICU setting has
been shown to improve short-term outcomes
• However, care should be taken as this method is associated with the
risk of hypoglycemia
Advantages of EN over PN
Nutritional benefit
• Early initiation of feeds is associated with mitigation of metabolic stress response
Non-nutritional benefit
• Gastrointestinal – maintenance of gut mucosal integrity, prevention of bacterial
translocation, avoidance of gut mucosal atrophy
• Immune response – modulation of key regulatory cells that enhance systemic
immunity, promotion of anti-inflammatory over pro-inflammatory responses,
maintenance of mucosa-associated lymph tissue
• Metabolic – attenuated metabolic stress response, enhanced nitrogen balance, reduced
muscle and tissue loss, reduced incidence of hyperglycemia, improved insulin
sensitivity
Enteral Nutrition Algorithm – Pediatric Surgery
American Pediatric Surgical Association. 2020
1. Select route 2. Identify goal 3. Select 4. Identify advancement plan

formula
A. Clear: If? Ability to protect airway

Oral feeds Bolus Full Resume previously
B. ½ strength formula: If NPO >2wk,
Alert, intubated, feeds calories established feeding
malnourished, at risk for gut
strong cough and gag schedule as tolerated
ischemia [advance to full strength
(FS) formula after 24 h]
C. FS formula
D. Regular or specialty diet
Unless contraindicated*, begin enteral nutrition support within 24 h of admission to the

surgical PICU
*Contraindications include potential endotracheal intubation/extubation within 4 hours; hemodynamically unstable requiring escalation of therapy; postoperative ileus, upper
gastrointestinal bleeding, at risk for NEC/intestinal ischemia, intestinal obstruction, post-allogenic bone marrow transplant who have graft vs. host disease or post-bone marrow
transplant patients prior to gut recontamination and in patients whom care is being redirected.
Full A. Clear: If? Ability to A. To start:
calories protect airway Calculate ½ the volume of FS feeds
B. ½ strength formula: If needed to meet caloric requirements
NPO >2wk, and divide by the number of feedings
Nasogastric/GT malnourished, at risk per day. Usually, 8 if <6 months and 6
feeds Bolus for gut ischemia if >6 months. If volume intolerant, try
Oral route feeds (advance to FS after small volume more frequent bolus or
inaccessible, strong 24 h) continuous feeds.
cough and gag C. FS formula B. To advance:
D. Regular or specialty Increase each feeding by 25% as
diet tolerated.
Trophic A. Clear: If? Ability to 5–20 mL/kg/d
feeds protect airway divided doses (smaller volume in larger
(advance to FS after patients)
24 h)
B. FS formula
surgical PICU
A. ½ strength formula: If NPO >2 A. To start:

Nasojejunal/JT Full wk, malnourished, at risk for gut 1–2 mL/kg/h (or 0.5
feeds calories ischemia (advance to FS formula mL/kg/h if at risk for gut
High risk for after 24 h) ischemia)
aspiration B. FS formula B. To advance:
(depressed gag Continuou <1 year: 1–5 mL/h q3–4h
reflex, delayed s feeds >1 year: 5–20 mL/h q4h
gastric
emptying, GE 5–20 mL/kg/d
reflux, Trophi FS (smaller volume in larger
bronchospasm) c feeds formula patients)

surgical PICU
Parenteral Nutrition Algorithm - Pediatric Surgery
I. Assess fluid and ~100 mL/kg/day (adjust for age of child)
caloric needs:
Start: 4 to 6 mg/kg/min Formula for Dextrose Infusion Rate:
II. Carbohydrates: Advance: 1 to 2 mg/kg/min mg/kg/min = 0.69 x dextrose%* x 24 x rate (mL/hr)
Goal: 12 mg/kg/min; 45% of total calories body weight (kg)
Start: 0.5 to 1 g/kg/day Formula for Proteins and Lipids:

III. Protein: Advance: 0.5 to 1 g/kg/day g/kg/day = (conc.)* x 0.24 x rate (mL/hr)
Goal: 2.5 to 3 g/kg/day; 15% of total calories body weight (kg)
Start: 0.5 to 1 g/kg/day

IV. Lipids: Advance: 0.5 to 1 g/kg/day
Goal: 3 g/kg/day; 40% of total calories
Vitamins; Trace Elements; Electrolytes; Minerals

• Evaluate lab values: Adjust additives Formula:
V. Additives: • Add extra sodium, acetate, Mg and Zn with increased stool Precipitation factor
output
• Adjust chloride/acetate ratio based on acid/base status
• Adjust calcium/phosphate ratio based on ppt. factor
VI. Check 80–105 Kcal/kg/day Formula:
Nutritional Goal: Calories delivered = 24 x rate (mL/hr) x Kcal/mL
(Kcal/kg/day) body weight (kg)
Summary
• Although highly prevalent, malnutrition in surgical PICU remains largely
unrecognized
• Early detection and management of malnutrition is essential to help in healing and
to promote growth and development
• Care needs to be taken to avoid overfeeding and its associated adverse
consequences
• Clinical examination alone may not be a reliable method to assess the nutritional
status
• Nutritional therapy includes enteral and parenteral routes; enteral route is the
preferred choice

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Role of Nutrition

The content of this presentation is meant for the information

Not intended for circulation.

• A study by Cooper et al showed that

• Despite its high prevalence, malnutrition

Malnutrition was detected in 13.4% of patients

10.1% 1.4% 4.6%

Acute malnutrition (more Chronic

These conditions decrease immunocompetence

Severity of This risk is

In pediatric 1. Preventing nutrition- a. Slowing of growth

Maintaining adequate nutrition in pediatric surgical patients is

• Changes in metabolism increase

Postoperative metabolic response is exaggerated by preoperative fasting

Limited fuel stores in

Nutritional assessment and

Although careful clinical

Energy expenditure, measured in

All measurements are

Difference between nitrogen entering

Indirect method of protein

A negative balance shows a catabolic

In all cases, an individualized,

• Major source of EN and PN routes

Post-pyloric feeding can be

• Several studies have demonstrated that in septic or critically-ill ICU patients,

Studies in children with

• Ideal in children who are unable to tolerate enteral feedings

1. Select route 2. Identify goal 3. Select 4. Identify advancement plan

A. Clear: If? Ability to protect airway

Unless contraindicated*, begin enteral nutrition support within 24 h of admission to the

A. ½ strength formula: If NPO >2 A. To start:

Unless contraindicated*, begin enteral nutrition support within 24 h of admission to the

Start: 0.5 to 1 g/kg/day Formula for Proteins and Lipids:

Start: 0.5 to 1 g/kg/day

Vitamins; Trace Elements; Electrolytes; Minerals

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