feeding the critically ill child -...

Lee Jan Hau, MBBS, MRCPCH, MCI

Children’s Intensive Care Unit

September 2018

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Feeding the

critically ill child

Khaw Sia (1913 – 1984)

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No disclosures

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Outline

• Is there a need to optimize enteral nutrition?

• Challenges in PICU nutritional practices

• Current evidence for best practices in PICU nutrition

• Concluding remarks

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Malnutrition in the PICU

• Malnutrition is common in critically ill children

• Associated with increased morbidity and mortality

• Adequate nutritional support is a fundamental component in management of critically ill children

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Mehta et al. JPEN J Parenter Enteral Nutrition 2009

Mueller et al. JPEN J Parenter Enteral Nutrition 2011

Metha et al. Crit Care Med 2012

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Metha et al. Crit Care Med 2012

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Metha et al. Am J Clin Nutr 2015

Impact of Protein Inadequacy

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Wong et al. JPEN 2016

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Wong et al. JPEN 2016

After adjusting for severity illness scores, oxygenation

index, presence of comorbidities, inadequate protein

intake was associated with mortality

The New Power Couple

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Protein + Energy

A minimum intake of 57 kcal/kg/day and 1.5 g protein/kg/day associated with positive protein balance

Bechard et al. J Peds 2012

• 74 children [median: 21 (4-35) months]

– 54 patients had surgical diagnoses

• 402 measurements of total urinary nitrogen and

resting energy expenditure

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Chaparro et al. Nutr Clin 2016

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Chaparro et al. Nutr Clin 2016

Nitrogen balance was achieved

with 1.5 (95% CI: 1.4 – 1.6)

g/kg/day

Energy balance was achieved

with 58 (95% CI: 53 – 63)

kcal/kg/day

Outline

• Is there a need to optimize enteral nutrition?

• Challenges in PICU nutritional practices

• Current evidence for best practices in PICU nutrition

• Future directions

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Heterogeneity in the PICU

• Patients

o Background nutrition status

• Case mix

o Type of cases

• Manpower

oNumber of doctors, nurses and dieticians

• Resources

o Equipment, assess to specialized formulas

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Leong et al. Ped Crit Care Med 2014

• 29/31 (93%) sites had dedicated intensive care unit dietician

• 10/31 (32%) units had guidelines/protocols for initiating and advancing enteral nutrition intake

• No consistent practice with regard to:

• Timing of initiation of enteral nutrition

• Use of motility agents

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Metha et al. Crit Care Med 2012

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• 35 centers from 18 countries

• Dedicated dietitian in 13 (37%) center

• 11 (31%) centers utilized feeding protocols

• Lack of consensus on when to start feeding

and when to use feeding adjuncts

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Kerklaan et al. Ped Crit Care Med 2016

• 156 PICUs from 52 countries

• 52% have nutrition protocols

• 57% have nutrition support teams

• < 15% have indirect calorimetry

• 60% aim to start enteral nutrition within 24 hours

of PICU admission

Challenges in Assessment of Caloric

Needs in the PICU

• Indirect Calorimetry • Gold standard • Not applicable in certain clinical situations:

• Leak • High oxygen requirement • High respiratory rate

• Equations

• Which ones do we use? • Stress factors • Risk of overfeeding

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Protein Homeostasis During Critical

Illness

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Coss-Bu et al. Nutr Clin Pract 2017

Protein Synthesis

Protein Catabolism

Challenges in Assessment of Protein

Homeostasis in the PICU

• Traditional markers are not robust • BMI, skin-fold thickness

• Body composition measurements

• Dual-energy x-ray absorptiometry, CT, MRI

• Serum biomarkers

• Albumin, pre-albumin, plasma amino acid

• Nitrogen balance

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Ong C et al. Clin Nutr 2014

Coss-Bu et al. Nutr Clin Pract 2017

Outline

• Is there a need to optimize enteral nutrition?

• Challenges in PICU nutritional practices

• Current evidence for best practices in PICU nutrition

• Concluding remarks

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Potential Solutions

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Patients

Manpower

Resources

Case Mix

Stratified

Approach

Protocols

Identify

Unique

Challenges

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Wong et al. J Parenter Enteral Nutrition 2014

PubMed 159

citations

Cochrane101

citations

CINAHL 189

citations

EMBASE 427

citations

854 non duplicate citations screened 742 citations excluded after

screening the title and abstract

112 citations retrieved 46 questionnaires/survey,

reviews, clinical guidelines, letters, commentaries or

teaching modules

9 studies included

21 did not utilise feeding protocols or did not report

outcomes of interest

36 studies involved exclusively adults or premature neonates

Improvement in

time of initiation

and achievement

of goal feeds

Reduction in

infective and

gastrointestinal

complications

Stratified Approach

• Congenital heart disease

• Extra-corporeal membrane oxygenation

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Congenital Heart Disease: Factors

Influencing Energy Expenditure

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Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015

Be careful of overfeeding in the

postoperative period

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Metha et al. Journal of Parenteral and Enteral Nutrition 2012

Post-operative

Fontan’s surgery

Congenital Heart Disease: Energy

Expenditure after CPB

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Metha et al. Journal of Parenteral and Enteral Nutrition 2012

Barriers and Strategies to Optimize Nutrition

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Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015

Nutrition in Pediatric ECMO

• Delivery of optimal nutrition in children with

ECMO remains a challenge

• Concerns

– Gut hemorrhage

– Gut ischemia (e.g., NEC)

• Very limited data in this aspect of ECMO

management

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• Describe EN practice in neonatal and pediatric ECMO

• Web-based survey

• 122/521 respondents from 96/187 institutions

• ~ 85% utilized EN during ECMO

• Top 4 factors considered in EN provision – Vasopressor requirement

– Underlying diagnosis

– Pharmacologic paralysis

– Mode of ECMO

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Desmarais et al. Journal of Pediatric Surgery 2015

Our Experience

• A review of all children (1 month – 18 years)

requiring ECMO between 2010 and 2016

• Data on enteral and parenteral energy and

protein intake in the first 7 days of ECMO were

collected

• Describe the association between nutritional

adequacy and mortality in children supported on

ECMO

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Patients’ Characteristics

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Variables Non-survivors (n=28) Survivors (n=23) p-value

Age at start of ECMO, years 1.33 (0.45 – 6.19) 5.82 (1.51 – 10.47) 0.051

Male gender, n (%) 15 (53.6) 9 (39.1) 0.304

Weight at start of ECMO, kg 8.0 (5.0 – 16.8) 20.0 (10.0 – 25.0) 0.062

Primary indication for ECMO, n (%)

0.216

Myocarditis 4 (14.3) 8 (34.8)

Complex heart disease – post-op 15 (53.6) 9 (39.1)

Sepsis/ARDS 7 (25.0) 6 (26.1)

Pulmonary hypertension 2 (7.1) 0 (0.0)

Veno-arterial ECMO, n (%) 25 (89.3) 18 (78.3) 0.281

Maximum number of inotropes/

vasopressor drugs required on ECMO 3 (2 – 5) 2 (1 – 3) 0.007

Vasopressor-inotropic score before start

of ECMO 20.0 (0.75 – 55.2) 14.0 (0 – 20.0) 0.155

ECMO duration, days 13.4 (7.0 – 19.5) 7.1 (4.7 – 8.7) 0.010

ICU LOS, days 19.3 (10.1 – 40.1) 15.2 (10.1 – 24.3) 0.642

Hospital LOS, days 22.5 (14.5 – 45.8) 29.0 (25.0 – 49.0) 0.125

Ong et al. Clinical Nutrition ESPEN 2018

Nutritional Adequacy

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Variables Non-survivors (n=28) Survivors (n=23) p value

Initiated EN in first 7d, n (%) 17 (60.7) 16 (69.6) 0.510

Time EN initiated after ECMO started, hours 49.6 (39.4 – 82.7) 36.8 (26.2 – 46.4) 0.028

Energy intake on ECMO, kcal/kg/d 23.2 (16.0 – 35.9) 23.9 (15.6 – 38.4) 0.719

Protein intake on ECMO, kcal/kg/d 0.80 (0.43 – 1.38) 0.80 (0.50 – 1.20) 0.798

Adequacy of total energy intake, % a 45.3 (23.1 – 59.3) 50.2 (35.8 – 70.5) 0.233

Adequacy of total protein intake, % a 43.0 (26.2 – 69.3) 50.6 (29.8 – 67.0) 0.705

Adequacy of EN energy intake, % a 0.5 (0 – 4.4) 11.8 (0 – 24.5) 0.034

Adequacy of PN energy intake, % a 44.2 (22.8 – 50.1) 37.6 (19.1 – 53.4) 0.596

Adequacy of EN protein intake, % a 0.1 (0 – 3.5) 6.3 (0 – 18.9) 0.065

Adequacy of PN protein intake, % a 40.7 (25.7 – 66.3) 40.6 (9.7 – 52.8) 0.495

Achieved 80% energy requirements by day 3, n (%) 5 (17.9) 8 (34.8) 0.168

Achieved 80% protein requirements by day 3, n (%) 6 (21.4) 4 (17.4) 1.000

a adequacy = total intake versus requirements over 7 days, expressed as a percentage

After adjusting for days on ECMO, maximum number

of drugs on ECMO and need for CRRT, we found a

significant association between EN energy adequacy

and mortality [adjusted OR: 0.93 (0.86 – 0.99)]

Ong et al. Clinical Nutrition ESPEN 2018

Conclusion

• We need to be mindful of caloric and protein provision in critically ill children

• Too much and too little can be bad

• Future studies are still needed to address the issue of the clinical impact of caloric intake and protein supplementation

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Chuah Thean Teng (1914 – 2008)

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Thank you lee.jan.hau@singhealth.com.sg