Feeding the critically ill infant and child By

Feeding the critically ill infant and child By : Shihaam Cader Principal Dietitian [HOD] Red Cross Children's Hospital By : Prof A Argent Head PICU Red Cross Children's Hospital By : Dr L Goddard GIT Consultant Red Cross Children's Hospital

Introduction • Nutrition is an essential part of the treatment and management of critically ill infants and children • Its benefits include maintaining vital body functions, reducing the effects of catabolism • And reducing morbidity, mortality and length of hospital stay Red Cross Childrens Hospital : Refresher Course Feb 2010

Introduction • Optimal nutrition is challenging task since, age, type of diagnosis, injury & individual metabolic response may vary between patients • Basic concepts of managing these patients needs to be highlighted for optimal nutrition therapy • Main areas are: • Early enteral feeding • Calories needed for critically ill • Ways to overcome barriers related to nutrition therapy Red Cross Childrens Hospital : Refresher Course Feb 2010

An approach to feeding the critically ill infant & child Red Cross Childrens Hospital : Refresher Course Feb 2010

Feed protocol • Studies have shown that feeding protocols may assist in achieving optimal nutritional care • Using standardized feeding protocol, will alleviate some of the barriers • Feeding protocol development should be multidisciplinary including dietitians, nursing, medical team Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 STEP 2 Nutritional assessment Early Enteral Nutrition ABCD approach Initiate within 24 hours STEP 3 Type & rate of feeding • Depends on age, nutritional needs, fluid restrictions, disease condition STEP 4 Route of feeding • Naso/oro-gastric feeding • Nasojejenal feeding STEP 6 STEP 5 Monitoring tolerance of feeding Managing the barriers to feeding • Input • Interruptions to feeding & calorie deficits • Output: vomiting, stools, NGA • GI disturbances: vomiting, stools, NGA • Other: abdominal distention • Fluid restrictions Total Parenteral Nutrition Only considered if all the above steps have failed and not able to achieve enteral nutrition by day 3 -5 of NPM Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 Nutritional assessment ABCD approach Red Cross Childrens Hospital : Refresher Course Feb 2010

Nutrition Assessment ABCD approach Anthropometry Weight, length, classifications, growth charts, NRS • Biochemistry/Special Investigations Electrolytes, CMP, hemoglobin, etc • FOG, Fecal elastase, alpha 1 antitrypsin, etc • Clinical Considerations Disease specific nutritional management • Dietary Assessment Diet history • Energy and protein requirements • Choosing appropriate feeds • Determining the route of feeding • Red Cross Childrens Hospital : Refresher Course Feb 2010

Anthropometry • Difficult to assess accurate growth parameters or trends in ICU setting • However basics still needs to be evaluated: • Weight • Height or length • Growth charts • Other measurements done when weight is not a true reflection eg. MUAC -not affected by edema

Growth charts used to classify patients, eg, wasting and stunting, acute or chronic malnutrition Growth trends Red Cross Childrens Hospital : Refresher Course Feb 2010

Biochemistry • Abnormal growth factors needs monitoring and restored • If they are abnormal, growth and development is not possible no matter how much calories are provided • Growth factors are: PHOSPHATE SODIUM CALCIUM MAGNESIUM POTASSIUM HEMOGLOBIN

Biochemistry • Albumin: Poor marker of nutrition & rather prognostic indicator • Most abundant plasma protein with MW of 65 k. Da, synthesized by liver • Half - life of 20 days • Many other causes for hypoalbuminemia: • Decreased synthesis or increase losses • Dilutional - fluid retention, edema • Increased catabolism of albumin - sepsis, acute phase response • Lactate: indicator of tissue perfusion • Prealbumin and CRP: • Prealbumin has a half-life of 24 -48 hours • Prealbumin + CRP are inversely related [ASPEN 2009] • Increase CRP + decrease Prealbumin = acute phase Nutrition 2009 (25)1004 -1005

Clinical assessment/diagnosis • Assessing the patients body for any signs of nutritional deficiencies, such as sparse hair, wasting, etc • Diagnosis plays a large part on the type of nutritional regime required, such as : Liver disease Renal disease Chronic lung disease Critically ill Metabolic disorders Cardiac disease Burns Severe malnutrition

Dietary assessment and management • Once the nutritional status and clinical diagnosis is determined, a dietary plan is prescribed for the medical team • Dietary plan includes: • Calories and protein required • Type of feed • Rate / volume of feed Enterally OR Parenterally • Route of feed Orally OR Nasogastric OR Nasojejenally OR Gastrostomy

Energy • Gold standard of determining energy expenditure is with the use of indirect calorimeter • Predictive equations are used for practical reasons – but needs to be noted to either under or over estimate • Energy needs are lower during acute phase and increases when in the recovery phase • Overfeeding is found to be as detrimental as underfeeding • Excess CHO – lipogenesis, hyperglycemia, prolongs duration of mechanical ventilation & hospital stay Red Cross Childrens Hospital : Refresher Course Feb 2010

Protein • Adequate protein needed for lean body mass, wound healing • Those fed high protein [~2, 8 g/kg] had positive protein balance and lower protein oxidation compared to those fed 1. 7 g/kg • Infants need: • 7. 5 -12% of energy for protein • Childrens need: • 5 – 15% energy for protein Catch – up growth • 9% protein and adequate micronutrients required J Hum Nutr Diet 2007; 20: 329 Red Cross Childrens Hospital : Refresher Course Feb 2010

Additional nutrients. . . • Thamine – deficient in malnourished patient • Folate – anemia and antioxidant properties • Zinc • required for protein metabolism, wound healing, immune function, antioxidant properties • involved in many enzyme functions • Particularly given to malnourished patients, burns, diarrhea Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 STEP 2 Nutritional assessment Early Enteral Nutrition ABCD approach Initiate within 24 hours Red Cross Childrens Hospital : Refresher Course Feb 2010

Early enteral nutrition • Initiate enteral nutrition within 24 hours once hemodynamically stable • Feeding started after 72 hours has shown increase risk of gut permeability, bacterial translocation and increased inflammatory response • • • The initiation of Early enteral nutrition- unless: Patient is unstable requiring frequent resusc. or vasopressor manipulation Patient will be orally fed within next 24 hours Anticipated extubation or intubation in next 6 hours Patient is NPO for a procedure There is a contra indication for feeds Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 Nutritional assessment ABCD approach STEP 2 Early Enteral Nutrition Initiate within 24 hours STEP 3 Type & rate of feeding • Depends on age, nutritional needs, fluid restrictions, disease condition Red Cross Childrens Hospital : Refresher Course Feb 2010

Types and rate of feeding Rate of feeding • Enteral feeding is recommended to maintain gut integrity • Depending on age/size of infant and child, initiate starting rate • 50 -60% of maintenance volume for age • Goal of feeding to be achieved within 2 -3 days If the gut is working enteral feeding rate need NOT be cautiously introduced UNLESS there has been a surgical procedure or the patient is shocked Red Cross Childrens Hospital : Refresher Course Feb 2010

Types of feeds: Infants Breastfeeding • Complete with all the nutrients needed to ensure good growth. • Has growth factors suitable for bowel adaptation • Easily digested. • Protective factors against common infections. • Improves cognitive development • Safe and clean • and FREE. • Bonding Red Cross Childrens Hospital : Refresher Course Feb 2010

Types of feeds: Infants Expressed breastmilk • Should be included in the protocol • Moms should shown how to express and provided with cups or bottles needed to express into • Encouragement is needed and reassured that frequent times of expressing will increase their supply • Small amounts of EBM to placed into mouth for comfort Red Cross Childrens Hospital : Refresher Course Feb 2010

Alternative to breastfeeding Types of enteral nutrition [infants & children]: 1. Standard infant formula 2. Energy dense formula, 3. Soya based formula, 4. Hydrolysed formula [peptide based] 5. Amino acid based 6. Specialized products, eg, for management of chylothorax All these products needs to administered in safest way due to the risk of bacterial contamination. . . Red Cross Childrens Hospital : Refresher Course Feb 2010

Closed enteral feeding system • Recommended for institutions with patients who are critically ill , immuno-compromised • Increased risk of bacterial contamination of powdered milk products if not prepared and handled correctly • Benefits other than safety include: • Quality of product • No labour required – ready available Red Cross Childrens Hospital : Refresher Course Feb 2010

Types of enteral nutrition available Infant products [0 -1 year] 1. Standard infant formula • complete polymeric • 67 kcal/ml and 1. 5 g protein/100 ml 2. Energy dense formula, • complete feed • 1. 0 kcal/ml and 2. 6 g protein / 100 ml 3. Soya based formula, • complete lactose free, 67 kcal/ml and 1. 6 g protein / 100 ml 4. Hydrolysed formula [peptide based + LCT + MCT] 5. Amino acid based [+LCT] 6. Specialized products, eg, for management of chylothorax Red Cross Childrens Hospital : Refresher Course Feb 2010

Types of enteral nutrition available Pediatric products [1 -10 year] 1. Standard infant formula • complete polymeric, usually with soluble fibre • 1. 0 kcal/ml and 2. 8 - 3 g protein/100 ml 2. Energy dense formula, • complete feed • 1. 5 kcal/ml and 3. 8 g protein / 100 ml 3. Hydrolysed formula [peptide based + LCT + MCT] 5. Amino acid based [+LCT] 6. Specialized products, eg, for management of chylothorax Note: ALL pediatric products are lactose free Red Cross Childrens Hospital : Refresher Course Feb 2010

Concentration of feeds. . . 1. Feed Supplementation can be requested when the calories cannot be achieved because of fluid restrictions • However maximum concentrations should not be exceeded, i. e: • Carbohydrate concentrations [g/100 ml] • < 6 mths: 10 -12% • 6 -12 mths: 12 - 15% • 1 -2 yrs: 15 – 20% • children: 20 – 30% • Fat concentrations [g/100 ml] • Infants: 5 – 6 % • Children: 7% Note: No supplementation is recommended if there is diarrhea or any malabsorption Red Cross Childrens Hospital : Refresher Course Feb 2010

Concentration of feeds. . . Type of feed supplementation • CHO • glucose polymer – lesser osmotic effect than mono – or disaccharides • Added in increments of 1% • Fat • LCT – lower osmotic effect and source of EFAs • MCT – only for fat malabsorption • higher osmotic effect and can cause abdominal cramps Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 STEP 2 Nutritional assessment Early Enteral Nutrition ABCD approach Initiate within 24 hours STEP 3 Type & rate of feeding • Depends on age, nutritional needs, fluid restrictions, disease condition STEP 4 Route of feeding • Naso/oro-gastric feeding • Nasojejenal feeding Red Cross Childrens Hospital : Refresher Course Feb 2010

Route of feeding Gastric feeding • More physiological - Well tolerated , safe and easily placed • However, due to GIT complications, small bowel feeding can be considered Small bowel feeding [jejenum] • Tolerated in most patients in the ICU • But not easy to site & requires AXR to ensure accurate placement • Also likely to be dislodged and blocked • However, maintains adequate feeds by allowing less NPM periods prior to any procedure, such as, surgery or extubation Recommendations are to initiate gastric feeding first with transition to jejenal feeding if the gastric route is not tolerated Red Cross Childrens Hospital : Refresher Course Feb 2010

Route of feeding Remember when using nasojejenal feeding: • CAUTION: Use in preterms/neonates • And cyanotic heart disease patients should not be given NJT feeds due to risk of NEC [JPGN 2007] • No bolus feeding can be administered • No water solutions is advised via NJT [JPEN 2004; 28; 27] Nutrition; 2007: 23; 16 -22 Red Cross Childrens Hospital : Refresher Course Feb 2010

Route of feeding Pro’s & Cons to both – Often remains preference of unit Bolus – More physiological – However, ICU is not a normal environment! – Difficulties with monitoring tolerance – Requires additional nursing time Continuous – Less time consuming – Easier to monitor – May delay gastric emptying [adult ICU] – May reduce gall bladder contraction Absence of consensus – Adequate delivery of nutrients should be main goal – This should not be hampered by route Shaw & Lawson 2007 3 rd Ed Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 STEP 2 Nutritional assessment Early Enteral Nutrition ABCD approach Initiate within 24 hours STEP 3 Type & rate of feeding • Depends on age, nutritional needs, fluid restrictions, disease condition STEP 4 Route of feeding • Naso/oro-gastric feeding • Nasojejenal feeding STEP 5 Monitoring tolerance of feeding • Input • Output: vomiting, stools, NGA • Other: abdominal distention Red Cross Childrens Hospital : Refresher Course Feb 2010

Monitoring the tolerance of feeding Common complications are: 1. Vomiting • • • Prokinetic – erythromycin low dose 2 – 10 mg/kg 6 hourly NJT Reflux - consider omeprazole 2. High gastric aspirates • No actual reference values – except for any amount of greater than 50% of volume administered in the previous 4 hours [Curr Opin Clin Nutr Met ab Care 2009] 3. Diarrhea • Sepsis – related, antibiotic use • If persists – investigate stool MC+S, reducing sub, Fecal omolar gap 4. Constipation 5. Refeeding syndrome Red Cross Childrens Hospital : Refresher Course Feb 2010

Enteral Feeding protocol STEP 1 STEP 2 Nutritional assessment Early Enteral Nutrition ABCD approach Initiate within 24 hours STEP 3 Type & rate of feeding • Depends on age, nutritional needs, fluid restrictions, disease condition STEP 5 STEP 4 Route of feeding • Naso/oro-gastric feeding • Nasojejenal feeding STEP 6 Monitoring tolerance of feeding Managing the barriers to feeding • Input • Interruptions to feeding & calorie deficits • Output: vomiting, stools, NGA • GI disturbances: vomiting, stools, NGA • Other: abdominal distention • Fluid restrictions Red Cross Childrens Hospital : Refresher Course Feb 2010

Managing the barriers to feeding Main barriers to optimum feeding: 1. Fluid restrictions • Common for infants/ children restricted to 40 – 60 ml/kg/day • Most common in cardiac infant and those with severe pneumonia • Prioritizing the use of fluid for nutrition • Using energy dense formula 2. Feed interruptions • Interruption of feeds – procedures/ trial extubation • Feeds - often re-started at a graded rate – takes days to get back to full volume • Using NJT feeds may assist in reducing time periods of NPM if patient is expected to have many procedures done in ICU, eg burns Red Cross Childrens Hospital : Refresher Course Feb 2010

Optimise calories and reduce calorie deficits • • Assessment of nutrition needs – Daily assessment of actual nutrition intake vs. required – Calculation of cumulative energy deficit Enteral formula with high energy density – < 1 yr 1 kcal/ml – > 1 yr 1. 5 kcal/ml – Bolus flushes with MCT/LCT & CHO powder – Do not exceed recommendations and concentration of feeds • Note: not to exceed protein levels i. e – Infants 4 g/kg – Children 3 g/kg Curr Op Clin Nutr Met Care. 2006; 9: 297 -303 Red Cross Childrens Hospital : Refresher Course Feb 2010

Immunonutrition Adult studies: • Glutamine – fuel for enterocytes • Arginine – cautioned in use of septic-critically ill • Omega-3 s – anti-inflammatory / antioxidant properties – Acute respiratory distress syndrome [ARDS] Pediatrics: • Limited evidence does NOT support the use of these products in PICU yet • May have detrimental effects ASPEN 2009 Nutrition 2005; 21: 799 - 807 Red Cross Childrens Hospital : Refresher Course Feb 2010

When enteral nutrition fails… Total parenteral is only considered for the following reasons: 1. Unable to feed enterally due to abdominal surgery and/or loss of gut function 2. If enteral nutrition is not tolerated, i. e. • Ongoing losses through, NGAs, chylothorax, malabsorption • Not able to meet all calorie needs orally or NPM for 3 days TPN needs close monitoring for all complications, namely: sepsis, liver dysfunction Red Cross Childrens Hospital : Refresher Course Feb 2010

Conclusion • Nutrition is integral part of management • Early enteral nutrition needs to be initiated 24 hrs • Energy needs are reduced in acute phase & then increases in the recovery phase • Enteral nutrition is well tolerated and choice of types and routes of delivery can improve the tolerance of feeding • Main barriers of feeding are challenging • But with the help of standardized feeding protocol and a multidisciplinary team, these challenges can be effectively managed Red Cross Childrens Hospital : Refresher Course Feb 2010

Thank you! Acknowledgements: L Marino [certain slides] Prof Argent and Dr Goddard

References 1. Nutrition support to pediatrics within the pediatric intensive setting. Pediatr Anesthesia 2009; 19: 300 -312 2. Strategies to manage GI symptoms: Complications of EN JPEN 2009; 33: 21 3. ASPEN Clinical guidelines: Nutrition support of critically ill child. JPEN 2009; 33: 260 4. The impact of enteral feeding protocols on nutritional support in critically ill children. JHum Nutr. Diet 2009; 22: 428 -436 5. Nutrition therapy in critically ill infants and children. JPEN 2008; 32: 52 6. GI compliations in critically ill: whar differs between adults and children. Curr Opin. Clin Nutr Metab Care. 2009; 12: 180 -185 7. Critically ill infants benefit from early administration of and energy-enriched formula. Clinical Nutrition 2009; 28: 249 -255