To Feed or Not To Feed; the EBM Question!

12/10/1434

The Critically Ill Child Hani Temsah, MD Pediatric Intensivist KKUH KSU

To Feed or Not To Feed; the EBM Question!

Goals: • Impact of Critical Illness on Nutritional requirements • Why this topic? • Goals of nutritional support in PICU • Enteral Nutrition: When, What & How? • Barriers to Optimal Nutrition • Overfeeding

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Impact of Critical Illness • Physiologic stress response : Catabolic phase: • increased caloric needs, urinary nitrogen losses • inadequate intake  wasting of endogenous protein

Impact of Critical Illness • Increased energy expenditure – Pain – Anxiety – Fever

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The Importance Of Nutrition CRITICAL ILLNESS + POOR NUTRITION =>

• • • •

Prolonged ventilator dependency Prolonged ICU stay Increase susceptibility to HAI Increased mortality with malnutrition

Why this Topic? • Data showing that more than half of all ICU patients worldwide are significantly underfed based on the energy they are prescribed to receive for the first two weeks of ICU care Cahill et al, Crit Care Med 2010

• Multifactorial issues => Multidisplenary Approach is needed!

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Common or Rare? • • • •

international prospective cohort study 31 PICUs in academic hospitals in 8 countries. 500 patients 30% of patients had severe malnutrition on admission • Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Mehta et al, Crit Care Med. 2012

Not Good News: Energy

Protein

Prescribed goals

64 kcals/kg

1.7 g/kg

Daily nutritional intake

38 %

43 %

•Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. •Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p = .008)

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Good News: • A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p = .002) • Feeding protocol : lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p = .008), and this association was independent of the amount of energy or protein intake. Mehta et al, Crit Care Med. 2012

May be unrecognized • 1077 PICU patients. • 53% of patients were classified with moderate or severe malnutrition. • Malnutrition in children remains largely unrecognized by healthcare workers on admission. Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit

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Even less Protein! • In 240 PICU patients: • Only 75% of estimated energy and 40% of protein requirements were met in the first 8 days of PICU stay. These data demonstrate a high prevalence of critically ill children who are not meeting their recommended levels of protein and energy. Kyle et al, J Acad Nutr Diet. 2012

Causes of Inadequate Nutrition in PICU • Difficulty in estimating nutritional needs of the individual child. • Under-prescription • Inadequate delivery of nutrients: – fluid volume restriction – procedural interruptions or cessation because of gastrointestinal intolerance or mechanical problems Causes and consequences of inadequate substrate supply to pediatric ICU patients. Hulst et al, Curr Opin Clin Nutr Metab Care. 2006

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Nutritional assessment • As routine nutritional assessment is lacking in many PICUs, the ability to monitor the adequacy of nutritional support is poor. Causes and consequences of inadequate substrate supply to pediatric ICU patients. Hulst et al, Curr Opin Clin Nutr Metab Care. 2006

Barriers to adequate nutrition: More in Cardiac pts • Patients in the PICU received a median of 37.7% (range, 0.2-130.2%) of their EERs. • The cardiac group achieved significantly lower energy intakes than did the non-cardiac group (P = 0.02). • Main barrier was fluid volume restriction. • Others: Interruption of feeding for procedures and feeding intolerance Rogers et al, Nutrition. 2003

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The targets of nutritional support in critically ill children are: • Preventing protein catabolism • Preventing under and over feeding • Achieving normal growth

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Determining Calorie and Protein Needs in PICU • Do not use the standard RDA tables initially to calculate energy requirements. • Estimate basal energy needs (BEE) • Determine Stress Factor

Total Calories = BEE X Stress Factor • Estimate patient's protein requirements

Total Protein = Protein RDAs X Stress Factor

Stress Factors Clinical Condition

Stress Factor

Maintenance without Stress

1.0 - 1.2

Fever

12% per degree > 37 C

Routine/elective surgery, minor sepsis

1.1 - 1.3

Cardiac failure

1.25 - 1.5

Major surgery

1.2 - 1.4

Sepsis

1.4 - 1.5

Catch-up Growth

1.5 - 2.0

Trauma or head injury

1.5 - 1.7

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Resting Energy Expenditure Age

RDA (Kcal/Kg)

REE (Kcal/Kg)

0-6 months

108

55

7-12 months

98

55

1-3 years

102

57

4-6 years

90

48

7-10 years

70

40

11-14 years (M/F)

55/47

32/28

15-18 years (M/F)

45/40

27/25

Total Calories = BEE X Stress Factor

Protein Requirement (RDA) Age

Protein (gm/kg)

0-6 months

2.2

7-12 months

1.6

1-3 years

1.2

4-6 years

1.1

7-10 years

1.0

11-18 years (M/F)

1.0/0.8

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Special PICU Population Cerebral Palsy ( age 5-11)

Mild to moderate activity : 13.9 kcal/cm Sever physical restrictions: 11.1 kcal/cm Sever restricted activity : 10 kcal/cm 60% to 70% of RDA

Down syndrome ( 5-12y)

Boys: 16.1 kcal/cm Girls: 14.3 kcal/cm

Prader-Willi Syndrome ( for all children and adolescents)

10-11 kcal/cm for maintenance 8.5 kcal/cm for wt loss

Spina Bifida ( over 8 years of age and minimally active)

9-11kcal/cm for maintenance 7 kcal/cm for wt loss 50% of RDA for age after infancy

When to Feed? • When To Initiate Enteral Nutrition ? • ASAP: Whenever possible, feed the gut! • usually within 24 hours in severe trauma, burns and catabolic states • Contraindications To Enteral Nutrition: Nonfunctional gut, anatomic disruption, gut ischemia, Severe peritonitis, Severe shock

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Early Feeding Preserves Patients! • Within 72 hours of hospitalization. • 80% received EN – 5% needed postpyloric tube.

• TPN in 10% • EN + PN in 10% • The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. • No statistically significant change in most anthropometric indicators Zamberlan et al, JPEN J Parenter Enteral Nutr. 2011

Initiation Of Feed • Trophic feeds: ≤20ml/kg/day

 Continuous feeds

 May Initiate @ 1ml/kg/H  Advance by 0.5-1ml/kg Q4-6H

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Protein-Energy Enriched Formula

• Infants with respiratory failure due to RSVbronchiolitis • received a protein-energy enriched formula (PE formula, n=8) • or a standard formula (S formula, n=10) during 5 days after admission. • Nutrient intakes were higher in PE fed infants and met RDA by day 3-5 whilst in S fed infants RDA was met on day 5 only. Nutritional effects of early administration of a protein and energy enriched formula in critically ill infants; a randomized controlled trial

More is more! • Cumulative nitrogen balance and energy balances were higher in PE infants compared to S infants (cNB: 866 ± 113 vs.296 ± 71 mg/kg; cEB: 151 ± 31 and 26 ± 17 kcal/kg, both p 25% of the total body surface area were randomized to either enteral nutrition within 24 hours or after at least 48 hours. • No statistically significant differences were observed for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels. • The trial was assessed as of low methodological quality (based on the Jadad scale) with an unclear risk of bias.

Cochrane Database Syst Rev. 2009 • Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.

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Take Home Message • Early assessment of Nutritional requirements in PICU, with early enteral feeding • Feeding Protocols help! • Have dieticians in your PICU Team • Avoid extremes! (Underfeeding or Overfeeding)

Welcome to Special Appetizers!

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