68 Questions
What is the suggested target energy intake in critically ill children by the end of the first week in the PICU?
At least two-thirds of the prescribed daily energy requirement
What is the limitation of currently available equations for estimating energy expenditure in critically ill children?
They fail to estimate energy expenditure within ±10% of MREE in a majority of critically ill children
What is the only available method to accurately determine energy requirements in critically ill children?
IC (indirect calorimetry)
What factors must be used selectively with caution when estimating energy expenditure using equations?
Stress factors
What is a sign of potential underfeeding in critically ill children?
Weight loss
Why are equations such as the Harris-Benedict and the RDAs not suitable for determining energy requirements in critically ill children?
They were developed for healthy adults and growing children, respectively
What is a recently developed simplified equation for estimating energy requirements in mechanically ventilated children?
VCO2-based equation
What is the advantage of using IC for measuring energy expenditure in critically ill children?
It is independent of nutrition status, initial diagnosis, or severity of the acute illness
What is a scenario where repeat measurements of MREE may be obtained in patients?
In patients with significant changes in clinical status
Why are innovative efforts needed to discover more accessible surrogates of MREE?
Because IC is not widely available clinically
What is the primary reason for prioritizing the evaluation of weight-for-age and BMI-for-age or weight-for-length z scores in PICU patients?
To identify malnourished patients and determine energy requirements
What is the recommended method for determining energy requirements in critically ill children?
Measuring energy expenditure through indirect calorimetry
What is the limitation of using published predictive equations to determine energy requirements in critically ill children?
They are not accurate and lead to overfeeding or underfeeding
What is the purpose of developing a validated nutrition screen for PICU patients?
To identify malnourished patients and facilitate early interventions
Why should the Harris-Benedict equations not be used to determine energy requirements in critically ill children?
They are not accurate and lead to overfeeding or underfeeding
What is the goal of determining energy requirements in critically ill children?
To guide prescription of the daily energy goal
What is the recommended approach when indirect calorimetry is not feasible for determining energy requirements in critically ill children?
Calculating energy expenditure using the Food Agriculture Organization / World Health Organization equations without added stress factors
What is the primary goal of examining the impact of malnutrition on clinical outcomes in the PICU population?
To improve nutrition care and patient outcomes
What is the minimum recommended protein intake for critically ill children?
1.5 g/kg/d
What is the association between higher energy intake and protein balance in critically ill children?
Positive correlation
What is the optimal protein delivery strategy in the PICU?
Provision of protein early in the course of critical illness
What is the recommended method to guide protein prescription in critically ill children?
Observational studies
What is the association between higher protein intake and 60-day mortality in children receiving mechanical ventilation?
Negative correlation
What is the primary outcome measured in randomized clinical trials of protein supplementation in critically ill children?
Nitrogen balance
What is the limitation of using RDA values to guide protein prescription in critically ill children?
RDA values were developed for healthy children
What is the optimal energy dose associated with improved clinical outcomes in critically ill children?
Unknown
What is the impact of route of nutrition delivery on the dose-outcome relationship in critically ill children?
Significant impact
What is the consequence of negative protein balance in critically ill children?
Loss of lean muscle mass
What is the minimum protein intake required to avoid cumulative protein deficits in critically ill children?
1.5 g/kg/d
What is the recommended protein intake for infants and young children admitted with bronchiolitis or other causes of respiratory failure requiring mechanical ventilation?
2.5-3 g/kg/d
What is the outcome of delivering >60% of prescribed enteral protein goal in critically ill children?
Decreased 60-day mortality
Why are RDA recommendations not suitable for guiding protein intake during critical illness?
They are based on healthy children's protein needs
What is the preferred mode of nutrient delivery to the critically ill child?
Enteral nutrition
What is a common barrier to enteral nutrition in the PICU?
All of the above
What is the recommended protein intake for obese patients in the PICU?
1.5 g/kg/d
Why is it challenging to determine protein requirements for obese patients in the PICU?
Due to the lack of reliable methods to monitor body composition
What is a limitation of current studies on protein intake in critically ill children?
Most studies have utilized the enteral route
What is a potential concern with protein intake >3g/kg/d in children >1 month old?
Increased blood urea nitrogen
What is the preferred modality to provide nutrition support to adults and children?
Enteral route
What is the association between early initiation of EN and clinical outcomes in critically ill children?
Improved clinical outcomes
What is the challenge in initiating and maintaining EN in critically ill children?
Perceived barriers to EN
What is the significance of delivering more than two-thirds of the energy goal and more than 60% of the protein goal through EN?
Lower 60-day mortality
What is the recommended approach to advancing EN in critically ill children?
Stepwise algorithmic approach
What is the role of a multidisciplinary nutrition support team in optimizing nutrition therapy?
Facilitating timely nutrition assessment and optimal nutrient delivery
What is the limitation of the current practice of providing EN to critically ill children?
Variable practice
What is the benefit of providing one-fourth of the goal calories enterally over the first 48 hours of admission?
Reduced PICU mortality
What is the association between enteral delivery of adequate calories and protein and ICU mortality?
Reduced ICU mortality
What is the future direction for studying the feasibility of EN in critically ill children?
Evaluating the impact on well-defined outcomes
What is the primary goal of using a stepwise protocol/algorithm in EN delivery?
To optimize nutrient delivery without increasing the risk of other complications
What is the outcome of using an EN algorithm in several studies?
Decreased time to initiation of EN, increased EN delivery, and decreased reliance on PN
What is the role of a dedicated dietitian in the PICU?
To support sound nutrition practices, such as timely assessment and documentation of nutrition status
What is the significance of the presence of a dedicated dietitian in the PICU?
It is a predictor of adequate enteral protein intake
What is the future direction in EN algorithms?
To clarify the evidence to inform stepwise decision making in EN algorithms
What is the limitation of measuring GRV as a marker of delayed gastric emptying?
It is not correlated with delayed gastric emptying
What is the outcome of using a stepwise algorithmic approach in EN delivery?
Rapid advancement of EN and achievement of nutrient delivery goals
What is the importance of a multidisciplinary nutrition team in the ICU?
It is important for guiding the timely initiation and management of nutrition support
What is the purpose of developing a seamless transition of nutrition care plan?
To ensure sound nutrition practices as patients move across the continuum of pediatric ward to the ICU and back
What is the future direction in measuring GRV?
To challenge the practice of measuring GRV as a marker of EN intolerance
What is the recommended route for delivering EN to critically ill children, unless there are perceived or demonstrated risks of aspiration?
Gastric route
What is the recommended timing for initiating EN in critically ill children, unless it is contra-indicated?
Within the first 24-48 hours after admission to the PICU
What is the suggested benefit of using postpyloric feeding tubes in critically ill children?
Improved nutrient delivery
What is a limitation of using postpyloric feeding tubes in critically ill children?
Higher cost
What is the suggested benefit of using gastric feeding in critically ill children?
Physiologic and preferred route
What is the recommended approach to EN delivery in critically ill children, according to the content?
Use of institutional EN guidelines and stepwise algorithms
What is the suggested benefit of early EN initiation in critically ill children?
Survival benefit
What is a common risk factor associated with delayed EN in critically ill children?
All of the above
What is the suggested direction for future research in EN delivery in critically ill children?
All of the above
What is the quality of evidence supporting the recommendations for EN delivery in critically ill children?
Low
Study Notes
Importance of Anthropometric Measurements in PICU
- Routine evaluation of weight-for-age and BMI-for-age or weight-for-length z scores is crucial in the PICU.
- Documentation of anthropometric measurements at admission is considered the standard of care in most tertiary centers.
Energy Requirements in Critically Ill Children
- Measured energy expenditure by indirect calorimetry (IC) is recommended to determine energy requirements and guide prescription of the daily energy goal.
- If IC is not feasible, the Schofield or WHO equations can be used to estimate energy expenditure, without adding stress factors.
- The Harris-Benedict equations and RDAs (recommended daily allowances) should not be used to determine energy requirements in critically ill children.
- The target energy intake is to achieve at least two-thirds of the prescribed daily energy requirement by the end of the first week in the PICU.
Protein Requirements in Critically Ill Children
- A minimum protein intake of 1.5 g/kg/d is recommended to prevent cumulative negative protein balance.
- Higher protein intake may be associated with improved clinical outcomes, including lower 60-day mortality.
- Protein intake should be delivered early in the course of critical illness to attain protein delivery goals and promote positive nitrogen balance.
- The optimal protein dose associated with improved clinical outcomes is not known, and the use of RDA values to guide protein prescription is not recommended.
Enteral Nutrition (EN) in Critically Ill Children
- EN is the preferred mode of nutrient delivery in critically ill children.
- Interruptions to EN should be minimized to achieve nutrient delivery goals by the enteral route.
- Early initiation of EN (within 24-48 hours of PICU admission) and achievement of up to two-thirds of the nutrient goal in the first week of critical illness have been associated with improved clinical outcomes.
- The presence of a multidisciplinary nutrition support team, including a dedicated dietitian, is essential for optimizing nutrition therapy in the PICU.
Advancing EN in the PICU Population
- A stepwise algorithmic approach is recommended to advance EN in children admitted to the PICU.
- The stepwise algorithm should include bedside support to guide the detection and management of EN intolerance and the optimal rate of increase in EN delivery.
Future Directions
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Future studies are needed to examine the optimal energy dose and protein intake associated with improved clinical outcomes in critically ill children.
-
The impact of the route of nutrition delivery and specific protein sources on outcomes should be further examined.
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Higher-quality randomized study designs are needed to evaluate the benefits of providing adequate EN with predefined energy and protein goals.### Seamless Transition of Nutrition Care Plan
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Developing a seamless transition of nutrition care plan is crucial as patients move across the continuum of pediatric ward to the ICU and back.
-
Future studies must clarify the evidence to inform stepwise decision making in the EN algorithms.
EN Algorithms
- The EN algorithms include:
- Selection of gastric versus postpyloric tube feeding
- Clear and practical definitions of feeding intolerance (e.g., reflux, vomiting, constipation, diarrhea, and malabsorption)
- The role of adjuncts such as prokinetic, antiemetic, antidiarrheal, acid suppressive, and laxative medications
Gastric Residual Volume (GRV)
- The practice of measuring GRV as a marker of EN intolerance in the PICU population must be challenged.
- Future studies are needed to examine the role of GRV and the optimal threshold to guide EN delivery.
Optimal Site for EN Delivery
- There is no universal recommendation for the optimal site to deliver EN to critically ill children.
- The gastric route is suggested as the preferred site for EN in patients in the PICU, unless they are unable to tolerate gastric feeding or are at high risk for aspiration.
- The postpyloric or small intestinal site for EN may be used for patients who cannot tolerate gastric feeding.
Timing of EN Initiation
- EN should be initiated in all critically ill children, unless it is contraindicated.
- Early initiation of EN, within the first 24–48 hours after admission to the PICU, is suggested in eligible patients.
- Institutional EN guidelines and stepwise algorithms should be used to guide EN initiation and advancement.
Rationale for Gastric Feeding
- Gastric feeding is physiologic and is the preferred EN route for critically ill children, unless they have perceived or demonstrated risks of aspiration.
- Small intestinal (postpyloric) feeding has not been shown to reduce aspiration when compared with gastric feeding.
Postpyloric Feeding
- Postpyloric feeding requires the placement of a feeding tube past the pylorus, which can be accomplished by several methods but requires time and expertise and incurs higher costs.
- Mechanical problems with postpyloric tubes can lead to frequent EN interruptions and failure to achieve delivery of goal nutrients.
Continuous vs. Intermittent Gastric Feeding
- There is no difference in EN tolerance between continuous and intermittent gastric feeding.
- Both modalities can be used to deliver EN to critically ill children.
Early EN and Survival Benefit
- Early EN, defined as delivery of one-quarter of cumulative goal enteral energy over the first 48 hours, has been associated with a survival benefit in critically ill children.
- Delayed EN initiation is associated with positive-pressure invasive and noninvasive ventilation, procedures, and gastrointestinal disturbances.
This quiz covers the importance of prioritizing anthropometric measurements, such as weight-for-age and BMI-for-age, in Pediatric Intensive Care Units (PICUs). It also discusses the need for a validated nutrition screen to identify malnourished patients.
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