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