Feeding and Impact on Glucose Control

Rosan MeyerPaediatric Dietitian

Dec 2007

Overview• Difference in energy expenditure between a critically ill

child and healthy child• Gastrointestinal tract and absorption• Fat, protein, carbohydrate absorption• Glucose from the gut to maintaining blood glucose• The role of insulin and glucagon• The stress response and glucose metabolism• Starvation and/or stress and glucose levels• Route of Feeding• Impact of Nutritional Support on Glucose levels

The critically Ill child versus the healthy child

Active

Growth

Ventilated and fed artificially

Diagnosis and disease severity

Not active

No growthSpontaneous breathing and eating food

Parental consent obtainedThermoneutral environment

Environmental factors

The Gastrointestinal Tract and Absorption

Alcohol/medication

Most nutrients:

Protein, CHO, Fat

H2O, Na, Vit K

Absorption of Nutrients

Glucose Absorption

The Role of Insulin and GlucagonInsulin and glucagon work synergistically to keep blood glucose

concentration normal

What about Glucose Metabolism in the Critically Ill Child

The RESULT !!!!

GLUCOSE

↓GLUCOSE USE!

↑ GLUCOSE SYNTHESIS

Other Factors that Impact on Glucose Levels

SIZE MATTERS!!!!

Stages of Starvation

Start Feeding!

Nurse !!

Category Starvation StressProt Catabolism + +++

CarbohydrateGlycogenolysis + +++Gluconeogenesis + +++

LipidsLipolysis +++ +++/+++

Ketosis +++ ++

MetabolismEnergy Exp - / - / Serum Alb Change slow

Physiological Impact of Starvation +/- Stress

Route of Feeding

• Nasogastric– Continuous– boluses

• Nasojejunal– Continuous

• Parenteral– Cyclical– Continuous

When and what route

• First 24 hours NBM

Enteral Nutrition

Parenteral Nutrition

• Attempt gastric feeding

• Ensure maintenance: saline dextrose/ dextrose

24-48 hours NBM

Enteral Parenteral

• Insert NJ if possible

• Change feed

• 10% Dextrose (drugs, IV)

5 % (24 hours) 10% (24hours) PN (24 hours)

200 kcal 400 kcal 590 kcal

Eg: 10kg child on 100% fluid

> 72 Hours NBM

Parenteral Nutrition

Enteral Nutrition

•>2 days (neonates) PN indicated

•> 4 days(infants and young children) PN indicated

•>7 days in older children and teenagers

Nutritional Support and Glucose Control

• Route of feeding• Feeding break/ no feeding break?• Bolus/ Continuous Feeding• Parenteral Nutrition

– Central line: much higher glucose– Peripheral line: max 12.5%

• Type of feed, especially additions– Maxijul/ Duocal

• Medication mixed with dextrose

Summary

• Glucose metabolism is dependant on insulin and glucagon

• Hormone levels affected by the stress response

• Starvation can make it worse

• Feeding can affect (improve) glucose levels