the science of effective pediatric inpatient nutrition 2005 kevin m. creamer m.d., faap medical...
TRANSCRIPT
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
Stress hormones and mediators ↑ release of cAMP which down-regulate lymphoid immune activity
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 PEMHendricks, Arch Ped Adol Med, 1995
Nutrition and OutcomeState of nutrition vs. LOS and Cost
$7,692$14,118
$16,691
02468
1012141618
Normal Borderline Malnourished
Robinson G, JPEN, 1987
Nutrition and OutcomeLow 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
0
2468
101214161820
LOS Mortality (%)
PCMNo PCMPCM*No PCM*
Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, Rev Paul Med, 1995
Parameter Low Risk High Risk
Hosp. Days 7 13.5Mech. Vent. 0 8.5NPO days 3 8.5Days on O2 4 20
P< 0.02
Mezoff, Pediatrics, 1996
Nutrition Screen predictive of outcome in 25 RSV PICU admits
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 OutcomeVentilatorPatients:
Weaned Died
No SpecificNutrition Plan 18 15
FocusedNutrtional 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• Multidisciplinary team
• Supplement , reassess, or reschedule
In your continuity clinic
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
Prealbumin
CRP
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% .334Ibraham, JPEN, 2002
WHERE? In the gut do I put the food?
Oral vs.Tube feedingGastric 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 eventsLyons, 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 feedTrophic feeds
Enteral vs. ParenteralLipid 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
0
20
40
60
80
100
120
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age in Years
Ca
lori
es
p
er
Kilo
gra
m
Activity
Growth
BMR
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 weeksUehara, CCM,1999
1º Fever↑12%
Trophic Feeds Rats 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• 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 feedsFeed type # Patients Mortality SMR
Enteral 167 25% .71
Parenteral 26 54% 1.4
Parenteral+ Trickle
24 38% .9
Marik, CCM(a), 2002
Trophic feeds are stress ulcer and antibiotic prophylaxis rolled into one
Trophic Feeds Vs. TPN
14.120.2 20.6
32.624.8
36.1
70.3
92.4
0102030405060708090
100
Assisted Vent PN 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 18-
24° 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