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The Science of Effective Pediatric Inpatient Nutrition 2005

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 .

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The Science of Effective Pediatric Inpatient Nutrition 2005

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  1. The Science of Effective Pediatric Inpatient Nutrition 2005 Kevin M. Creamer M.D., FAAP Medical Director, PICU WRAMC Chief, Pediatric Nutrition Support Team

  2. 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

  3. 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

  4. 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??

  5. 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

  6. Acute Stress

  7. The 5 W’s of Inpatient Nutrition Why, Who, When, Where, What ?

  8. 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

  9. 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

  10. 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

  11. 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

  12. WHY ?Is nutrition such a big deal? Malnutrition Prevalence Nutrition Status and Outcomes Gut Bacterial Translocation

  13. 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

  14. 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 PEM Hendricks, Arch Ped Adol Med, 1995

  15. Nutrition and Outcome Robinson G, JPEN, 1987

  16. Nutrition and Outcome Low 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 Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, Rev Paul Med, 1995

  17. Nutrition Screen predictive of outcome in 25 RSV PICU admits Mezoff, Pediatrics, 1996

  18. 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

  19. Nutrition and Outcome Bassili HR, JPEN,1980

  20. 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

  21. WHO ?Needs to know? Gets assessed? ALL Physicians! ALL Patients!

  22. 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

  23. 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

  24. I wonder if I’m missing out on some critical piece of information

  25. 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

  26. 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)

  27. 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

  28. Plasma Protein Stress Response Fleck, A. Br J Clin Pract, 1988

  29. 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

  30. 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

  31. WHEN?Should I start? Early Enteral vs Standard timing

  32. 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

  33. 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

  34. 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

  35. All is Not Rosy • All Mechanical Ventilated patients • Lots of exclusions Ibraham, JPEN, 2002

  36. WHERE? In the gut do I put the food? Oral vs.Tube feeding Gastric vs. Transpyloric feeds

  37. 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

  38. 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

  39. 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 events Lyons, JPEN, 2002

  40. 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

  41. 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,

  42. WHAT?Amount of calories do I Feed Them? How much to feed Trophic feeds Enteral vs. Parenteral Lipid phobia

  43. 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

  44. Steady State Energy Requirements

  45. 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

  46. 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

  47. 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

  48. 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 weeks Uehara, CCM,1999

  49. 1º Fever ↑12%

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