Feeding the critically ill child Khaw Sia (1913 1984) Lee Jan Hau, MBBS, MRCPCH, MCI Children s Intensive Care Unit September 2018 1
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3 No disclosures
Outline Is there a need to optimize enteral nutrition? Challenges in PICU nutritional practices Current evidence for best practices in PICU nutrition Concluding remarks 4
Malnutrition in the PICU Malnutrition is common in critically ill children Associated with increased morbidity and mortality Adequate nutritional support is a fundamental component in management of critically ill children Mehta et al. JPEN J Parenter Enteral Nutrition 2009 Mueller et al. JPEN J Parenter Enteral Nutrition 2011 Metha et al. Crit Care Med 2012 5
6 Metha et al. Crit Care Med 2012
Impact of Protein Inadequacy Metha et al. Am J Clin Nutr 2015 7
8 Wong et al. JPEN 2016
After adjusting for severity illness scores, oxygenation index, presence of comorbidities, inadequate protein intake was associated with mortality Wong et al. JPEN 2016 9
The New Power Couple Protein + Energy 10 A minimum intake of 57 kcal/kg/day and 1.5 g protein/kg/day associated with positive protein balance Bechard et al. J Peds 2012
74 children [median: 21 (4-35) months] 54 patients had surgical diagnoses 402 measurements of total urinary nitrogen and resting energy expenditure Chaparro et al. Nutr Clin 2016 11
Nitrogen balance was achieved with 1.5 (95% CI: 1.4 1.6) g/kg/day Energy balance was achieved with 58 (95% CI: 53 63) kcal/kg/day Chaparro et al. Nutr Clin 2016 12
Outline Is there a need to optimize enteral nutrition? Challenges in PICU nutritional practices Current evidence for best practices in PICU nutrition Future directions 13
Patients Heterogeneity in the PICU o Background nutrition status Case mix o Type of cases Manpower o Number of doctors, nurses and dieticians Resources o Equipment, assess to specialized formulas 14
Leong et al. Ped Crit Care Med 2014 15
29/31 (93%) sites had dedicated intensive care unit dietician 10/31 (32%) units had guidelines/protocols for initiating and advancing enteral nutrition intake No consistent practice with regard to: Timing of initiation of enteral nutrition Use of motility agents Metha et al. Crit Care Med 2012 16
35 centers from 18 countries Dedicated dietitian in 13 (37%) center 11 (31%) centers utilized feeding protocols Lack of consensus on when to start feeding and when to use feeding adjuncts 17
156 PICUs from 52 countries 52% have nutrition protocols 57% have nutrition support teams < 15% have indirect calorimetry 60% aim to start enteral nutrition within 24 hours of PICU admission Kerklaan et al. Ped Crit Care Med 2016 18
Challenges in Assessment of Caloric Needs in the PICU Indirect Calorimetry Gold standard Not applicable in certain clinical situations: Leak High oxygen requirement High respiratory rate Equations Which ones do we use? Stress factors Risk of overfeeding 19
Protein Homeostasis During Critical Illness Protein Synthesis Protein Catabolism Coss-Bu et al. Nutr Clin Pract 2017 20
Challenges in Assessment of Protein Homeostasis in the PICU Traditional markers are not robust BMI, skin-fold thickness Body composition measurements Dual-energy x-ray absorptiometry, CT, MRI Serum biomarkers Albumin, pre-albumin, plasma amino acid Nitrogen balance Ong C et al. Clin Nutr 2014 Coss-Bu et al. Nutr Clin Pract 2017 21
Outline Is there a need to optimize enteral nutrition? Challenges in PICU nutritional practices Current evidence for best practices in PICU nutrition Concluding remarks 22
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Potential Solutions Manpower Resources Protocols Identify Unique Challenges Patients Case Mix Stratified Approach 25
PubMed 159 citations Cochrane 101 citations EMBASE 427 citations CINAHL 189 citations Improvement in time of initiation and achievement of goal feeds Reduction in infective and gastrointestinal complications 854 non duplicate citations screened 112 citations retrieved 9 studies included 742 citations excluded after screening the title and abstract 46 questionnaires/survey, reviews, clinical guidelines, letters, commentaries or teaching modules 36 studies involved exclusively adults or premature neonates 21 did not utilise feeding protocols or did not report outcomes of interest 26 Wong et al. J Parenter Enteral Nutrition 2014
Stratified Approach Congenital heart disease Extra-corporeal membrane oxygenation 27
Congenital Heart Disease: Factors Influencing Energy Expenditure 28 Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015
Be careful of overfeeding in the postoperative period Post-operative Fontan s surgery Metha et al. Journal of Parenteral and Enteral Nutrition 2012 29
Congenital Heart Disease: Energy Expenditure after CPB Metha et al. Journal of Parenteral and Enteral Nutrition 2012 30
Barriers and Strategies to Optimize Nutrition 31 Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015
Nutrition in Pediatric ECMO Delivery of optimal nutrition in children with ECMO remains a challenge Concerns Gut hemorrhage Gut ischemia (e.g., NEC) Very limited data in this aspect of ECMO management 32
33 Describe EN practice in neonatal and pediatric ECMO Web-based survey 122/521 respondents from 96/187 institutions ~ 85% utilized EN during ECMO Top 4 factors considered in EN provision Vasopressor requirement Underlying diagnosis Pharmacologic paralysis Mode of ECMO Desmarais et al. Journal of Pediatric Surgery 2015
Our Experience A review of all children (1 month 18 years) requiring ECMO between 2010 and 2016 Data on enteral and parenteral energy and protein intake in the first 7 days of ECMO were collected Describe the association between nutritional adequacy and mortality in children supported on ECMO 34
Patients Characteristics Variables Non-survivors (n=28) Survivors (n=23) p-value Age at start of ECMO, years 1.33 (0.45 6.19) 5.82 (1.51 10.47) 0.051 Male gender, n (%) 15 (53.6) 9 (39.1) 0.304 Weight at start of ECMO, kg 8.0 (5.0 16.8) 20.0 (10.0 25.0) 0.062 Primary indication for ECMO, n (%) Myocarditis 4 (14.3) 8 (34.8) Complex heart disease post-op 15 (53.6) 9 (39.1) Sepsis/ARDS 7 (25.0) 6 (26.1) 0.216 Pulmonary hypertension 2 (7.1) 0 (0.0) Veno-arterial ECMO, n (%) 25 (89.3) 18 (78.3) 0.281 Maximum number of inotropes/ vasopressor drugs required on ECMO 3 (2 5) 2 (1 3) 0.007 Vasopressor-inotropic score before start of ECMO 20.0 (0.75 55.2) 14.0 (0 20.0) 0.155 ECMO duration, days 13.4 (7.0 19.5) 7.1 (4.7 8.7) 0.010 ICU LOS, days 19.3 (10.1 40.1) 15.2 (10.1 24.3) 0.642 Hospital LOS, days 22.5 (14.5 45.8) 29.0 (25.0 49.0) 0.125 35 Ong et al. Clinical Nutrition ESPEN 2018
Nutritional Adequacy Variables Non-survivors (n=28) Survivors (n=23) p value Initiated EN in first 7d, n (%) 17 (60.7) 16 (69.6) 0.510 Time EN initiated after ECMO started, hours 49.6 (39.4 82.7) 36.8 (26.2 46.4) 0.028 Energy intake on ECMO, kcal/kg/d 23.2 (16.0 35.9) 23.9 (15.6 38.4) 0.719 Protein intake on ECMO, kcal/kg/d 0.80 (0.43 1.38) 0.80 (0.50 1.20) 0.798 After adjusting for days on ECMO, maximum number of drugs on ECMO and need for CRRT, we found a significant association between EN energy adequacy and mortality [adjusted OR: 0.93 (0.86 0.99)] Adequacy of total energy intake, % a 45.3 (23.1 59.3) 50.2 (35.8 70.5) 0.233 Adequacy of total protein intake, % a 43.0 (26.2 69.3) 50.6 (29.8 67.0) 0.705 Adequacy of EN energy intake, % a 0.5 (0 4.4) 11.8 (0 24.5) 0.034 Adequacy of PN energy intake, % a 44.2 (22.8 50.1) 37.6 (19.1 53.4) 0.596 Adequacy of EN protein intake, % a 0.1 (0 3.5) 6.3 (0 18.9) 0.065 Adequacy of PN protein intake, % a 40.7 (25.7 66.3) 40.6 (9.7 52.8) 0.495 Achieved 80% energy requirements by day 3, n (%) 5 (17.9) 8 (34.8) 0.168 Achieved 80% protein requirements by day 3, n (%) 6 (21.4) 4 (17.4) 1.000 a adequacy = total intake versus requirements over 7 days, expressed as a percentage Ong et al. Clinical Nutrition ESPEN 2018 36
Conclusion We need to be mindful of caloric and protein provision in critically ill children Too much and too little can be bad Future studies are still needed to address the issue of the clinical impact of caloric intake and protein supplementation Chuah Thean Teng (1914 2008) 37
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Thank you lee.jan.hau@singhealth.com.sg