Crit Care Nurs Clin N Am 17 (2005) 385 393

Nutritional Assessment and Enteral Support of Critically Ill Children

Erwin Ista, RNT, Koen Joosten, MD, PhD
Department of Pediatrics, Erasmus MC - Sophia Childrens Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands

Critical illness has a major impact on the nutritional status of children. Nutritional assessment is required as an integral part of patient care; however, during an intensive care stay, attention is focused mostly on the primary medical problem and not on the childs nutritional status. When the child stays in the ICU for longer than 5 to 7 days, the chance of developing serious nutritional deficiencies increases significantly [1]. As early as 1980, researchers demonstrated protein-energy malnutrition in 15% to 20% of children who were admitted to the ICU [2]. A recent study showed a high prevalence (24%) of acute or chronic malnutrition in critically ill children who were admitted to a pediatric ICU (PICU) [3]. Therefore, nutritional support after initial nutritional assessment should be an essential aspect of the clinical management of patients in the PICU. The diversity in clinical presentation and the various age groups dictate a patient-tailored approach. Several common hospital practices have been identified that may cause the deterioration of nutritional status in admitted patients (Box 1). In general, the development of malnutrition during an ICU stay can be related to the disease, incomplete nutritional assessment or determination of the patients nutritional needs, or lack of adequate nutritional support. Widespread ignorance of the physiologic effects of different feeding routes and the composition of nutritional products results in the inappropriate use of routes of administration of enteral and par-

enteral feeds of uncertain composition or inadequate amounts. Critical care nurses play an important role in the feeding of critically ill children. Many procedures and caregiving interventions, such as placement of feeding tubes, registration of gastric retention, observation and care of the mouth, and administration of nutrition (enteral or parenteral), are within the nursing domain. This article discusses nutritional assessment techniques and enteral nutrition (EN) in critically ill children.

Nutritional assessment Definition Nutritional assessment can be defined as the interpretation of data concerning an individuals intake and use of nutrients to determine his or her health status. Data must be obtained by different means, and interpreted together to perform a comprehensive nutritional assessment. These data includes:
 General evaluation (including dietary and medi-

cal history and physical signs)

 Severity of illness assessment  Assessment of body composition  Laboratory studies (including the estimation of

energy requirements) Nutritional assessment is necessary to: (1) identify patients who have, or who are at risk for developing, protein-energy malnutrition; (2) establish the degree of malnutrition and the risk of developing malnu-

T Corresponding author. E-mail address: w.ista@erasmusmc.nl (E. Ista).

0899-5885/05/$ see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2005.07.011

ccnursing.theclinics.com

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Box 1. Common hospital practices that may result in deterioration of nutritional status Diffusion of responsibility for the nutritional care of patients Lack of interaction between medical, nursing, and dietetic staff Little emphasis on nutrition education in nursing and medical schools Limited availability of methods to assess nutritional status Failure to record patients height and weight Failure to observe and record patients dietary intake Frequent withholding of food because of diagnostic tests Delay in commencing nutritional support with prolonged use of glucose administration Adapted from Corish CA, Kennedy NP. Protein-energy undernutrition in hospital in-patients. Br J Nutr 2000;83(6):575 91; with permission.

physical examination [6]. On admission, a detailed history concerning nutrition can be performed by the nursing staff. It also is important to be alert for the development of malnutrition during admission. A study by Sermet-Gaudelus and colleagues [7] showed that 79% of hospitalized children lost weight (>2%) during admission. Using a pediatric nutritional risk score, they found that the patients degree of stress (Box 2), food intake, and pain were associated with weight loss. They developed a pediatric nutritional risk score that identifies three classes of risk (low, moderate, and high) and recommendations for nutritional interventions (Table 1). Anthropometry Classic anthropometry is a term that describes the measurement of body weight, body length, and head circumference. Additional anthropometric mea-

Box 2. Degree of stress Pathology Grade 1: mild stress factor Detection of health problem Bronchiolitis Gastroenteritis Minor surgery Other minor infection Grade 2: moderate stress factor Current surgery Chronic cardiopathy Chronic enteropathy Severe infection Cystic fibrosis Sickle cell disease Grade 3: severe stress factor Cardiac surgery Deterioration of chronic disease Major visceral surgery Hemopathy Severe depression Severe sepsis Adapted from Sermet-Gaudelus I, PoissonSalomon AS, Colomb V, et al. Simple pediatric nutritional risk score to identify children at risk of malnutrition. Am J Clin Nutr 2000;72(1):64 70; with permission.

trition related complications; and (3) evaluate the effect of nutritional support [4]. Accurate assessment of nutritional status in children is complex because of ongoing growth, changing energy needs, varying body composition, and disease [5]. In critically ill children this phenomenon is more complex because of weight shifts that are caused by third spacing of fluid; this can result in inaccurate anthropometric measurements and inaccurate assumptions of true weight [1]. Techniques General evaluation A full medical and dietary history is necessary for an extensive nutritional assessment. When the critically ill child has a history of chronic disease, the initial nutritional status at admission might be poor and the child may need extra attention. Physical signs of malnutrition usually do not appear until malnutrition had been prolonged and severe; however, the first impression of the child and subjective assessment of muscle and fat mass can help. Subjective global assessment is a clinical technique that assesses nutritional status based on features of the history and

picu nutritional assessment and enteral support Table 1 Pediatric nutritional risk score and recommendations for nutritional intervention Risk factors [coefficients] Pathology Mild (grade 1) [0] Mild (grade 1) [0] Mild (grade 1) [0] Moderate (grade 2) [1] Moderate (grade 2) [1] Moderate (grade 2) [1] Severe (grade 3) [3] Severe (grade 3) [3] Severe (grade 3) [3] Pain [1] Food intake <50% [1] None One Both None One Both None One Both Score 0 1 2 1 2 3 3 4 5 Nutritonal risk Low Moderate Moderate Moderate Moderate High High High High Nutritional intervention

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None Assess food intake and weight daily Refer to a dietitian Start oral nutritional support (NS) Measure ingested food precisely Refer to a nutrition team Consider enteral or parenteral NS

Adapted from Sermet-Gaudelus I, Poisson-Salomon AS, Colomb V, et al. Simple pediatric nutritional risk score to identify children at risk of malnutrition. Am J Clin Nutr 2000;72(1):64 70; with permission.

surements concern circumferences (mid upper arm, calf, abdominal), skin fold thickness, and lower leg length (knemometry). Weight Weight is the most important parameter for nutritional assessment of the critically ill child; therefore, it is a gold standard [1]. The assessment of weight in this group is not easy and changes in weight cannot be ascribed only to growth, because edema plays an important role. In our practice we propose assessing weight on admission and daily during the PICU stay (except in chronically ill children) [3,8]. Length Body length is difficult to measure and generally is of limited value as a nutritional assessment tool on the ICU, because changes in linear growth are hard to point out over a short period of admission. For newborn infants and children up to 24 months of age, the lower leg length measure is a promising method for measurement of short-term linear growth; it consists of a heel-to-knee measurement (knemometry) [9]. The tool is hand-held, can be used inside an incubator, and is less disruptive than making length measurements. Head circumference Head circumference is another important aspect of nutritional assessment in young children and should be included in the initial assessment and follow-up. In the PICU this parameter is used rarely; however, on admission it could signal a history of severe chronic malnutrition. Serial measurements in neonates can aid in detecting the development of malnutrition.

Body circumferences and skin fold thickness Measurements of body circumferences (mid upper arm, calf, abdominal) and skin fold thickness are anthropometric measurements that can provide information on fat mass and fat-free mass. Mid upper arm circumference (MUAC) is a measure of muscle, fat, and bone. It has been used as an index of malnutrition in rapid nutritional surveys when weight and length measurements were not feasible. We advocate measuring the MUAC in all children because it is simple to perform on admission and follow-up and it is an easy screening tool for malnutrition. Feasibility of anthropometry. One has to take into account that the feasibility to perform anthropometric measurements decreases with the severity of disease. The feasibility to perform anthropometric measurements routinely was investigated. For weight, 35% of ventilated children were weighed on admission; 84% of all children who were in the PICU for more than 48 hours were weighed [3,8]. This knowledge underlines the need for a patient-tailored approach in which measurements can be performed in the individual patient to detect malnutrition. Indirect calorimetry Measuring energy expenditure allows for a more accurate monitoring of the childs varying energy needs in the course of critical illness. Clinically, the measurement of energy expenditure by indirect calorimetry (IC) is applicable in critical care, and is more accurate than estimating individual energy expenditure from standard prediction equations. IC provides noninvasive, reliable, repeatable, and affordable measurements of actual energy expenditure (resting energy expenditure in nonventilated children and

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total daily energy expenditure in ventilated children) and the respiratory quotient (RQ). RQ is a helpful parameter in nutritional assessment because it has been considered important in evaluating substrate use or nutritional support and in determining overfeeding and underfeeding [10,11]. Table 2 shows the RQ values related to the feeding status used in clinical practice. An RQ of greater than 1 indicates overfeeding, which most of the time is due to carbohydrate overfeeding; therefore, attention should be focused on the carbohydrate intake. In the critically ill child, quantification of energy expenditure also is important from the diagnostic standpoint because it allows the detection of hyper- or hypometabolic conditions that are related directly to the individual prognosis. The greatest advantage of using IC is to design a nutrition regimen that exactly meets the patients energy requirements and avoids the complications of overfeeding [12]. The IC in the ICU is valuable because not much other information is available for approximating the needs of the critically ill child [1]. IC to determine energy requirements is being used widely as a research tool. In most ICUs, limited space at the bedside, the cost of multiple metabolic carts, and the availability of trained staff to operate them limit its routine use. For the practical use of IC in critically ill children, accurate measurement requires the following conditions:
 Fraction of inspired oxygen of less than 0.60  Tube leakage of less than 10%. Tube leakage

be part of the admission procedure in the ICU. It has to be followed by an individual calculation of macro- and micronutrient needs. In addition, nutritional assessment should be repeated regularly to monitor changes in nutritional status, diagnoses, or conditions that might put the child at nutritional risk, and to monitor the efficacy of nutritional support. Fig. 1 shows a standard of nutritional assessment for the PICU population.

Nutritional support The most important element in nutritional support in the intensive care setting is to have a standard feeding protocol in which three issues should be considered:
 When to feed: indications for nutritional support  What to feed: composition of nutritional for-

mula and enteral feeding

 How to feed: how to administer EN

is determined by comparison of inspired and expired tidal volumes measured by the ventilator, assuming that there are no other leaks in the patient ventilator circuit. In one investigation, the feasibility of routine use of IC performed by the nursing staff was studied; it was possible in 70% to 80% of the eligible mechanically ventilated children [3,8]. Taken together, nutritional assessment is important in providing optimal care to critically ill children. A simple and integrated nutrition screening should

Application of such a protocol is the most important step in treating the malnourished patient in the ICU. The working group on nutrition and metabolism of the European Society of Intensive Care Medicine published a practical approach in 1998 for EN for adult patients in the ICU [13]. These recommendations consisted of the supply of macronutrients, micronutrients, and immunomodulating agents, and recommendations for feeding and organ dysfunction, feeding preparations, and conditioning and routes of feeding. Such a practical approach has not been published for critically ill children; however, the concept of this working group should be translated for the critically ill child. When to feed: indications for nutritional support For assessing the total nutritional status of a patient, several parameters have to be evaluated. Souba [14] stated that identification of the malnourished adult patient at risk is important because besides established indications for the use of nutritional support, there is a list of unproven indications that requires further study. There are accepted guidelines for the time to start additional nutritional support for the adult patient who has a severe illness; these consist of items, such as the duration of the catabolic state, days without nutrition, and the presence of malnutrition on admission [15]. Compared with adults, children have less physiologic reserves of fat and protein and increased energy

Table 2 Feeding status related to respiratory quotient Feeding status Underfeeding Adequate feeding Overfeeding Respiratory quotient < 0.85 0.85 1.0 > 1.0

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Initial nutritional screening in all children on admission (evaluation of nutritional risk) Weight (SDS) Length (SDS), if possible Head circumference (SDS) Primary diagnosis Illness severity score (PRISM, PIM, CRIB) Presence of comorbidities Surgery needed Expected duration of mechanical ventilation Expected length of ICU-stay

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LOS < 48 h

LOS > 48 h

No further assessment

Term neonates and older children with poor nutritional status at admission or at high risk* Anthropometry Weight HC (< 1 y) MUAC/CC KHL (< 2 y) TSF Energy requirements Indirect calorimetry Alternative: 0.5-1.0*RDA
Daily calculation of nutrient intake compared to prescribed intake (energy and protein)interruptions? Daily calculation of actual energy intake compared to estimated/measured EE deficits? Evaluation of RQ (2x/ wk): RQ > 1.0 decrease carbohydrate or energy intake; RQ < 0.85 increase intake Weekly calculation of cumulative energy and protein deficits in relation to growth/anthropometry

- twice a week - biweekly - adm, weekly - adm, weekly - adm, weekly

- ASAP after adm, 2x/ wk thereafter (to adjust intake)

Adjustment of intake

Fig. 1. Proposed standard of nutritional assessment in the pediatric ICU population. Adapted from Hulst JM. Nutritional assessment of critically ill children: the search for practical tools [masters thesis]. Rotterdam (The Netherlands): Erasmus University; 2004; with permission. Abbreviations: Adm, admission; ASAP, as soon as possible; CC, calf circumference; CRIB, Clinical Risk Index for Babies; EE, energy expenditure; HC, head circumference; LFA, length for age; KHL, knee-heel length; LOS, length of stay; MUAC, mild upper arm circumference; PIM, Pediatric Index of Mortality; PRISM, Pediatric Risk of Mortality; RQ, respiratory quotient; SDS, standard deviation score; TSF, triceps skin fold; WFA, Weight for age; WFL, Weight for length. * poor nutritional status: WFA-SDS or LFA-SDS or WFL-SDS <2; risk groups: prolonged expected ICU-stay, prolonged duration of mechanical ventilation, children undergoing surgery, children with underlying growth-affecting disease such as children with major congenital malformations, cardiac anomalies, cystic fibrosis, Inflammatory bowel disease, HIV-infection. y depending on age of child.

expenditure; therefore, children are at increased risk for malnutrition [16]. Furthermore, it seems appropriate to start nutritional support as soon as possible because children are in a state of growth, development, and organ maturation. What to feed: composition of nutritional formulas

use can be derived from adult studies and studies concerning primarily surgically treated newborn infants. Knowledge concerning energy expenditure can be derived from a few studies of mechanically ventilated children; however, some important conclusions can be drawn from these studies:
 There is a significant discrepancy between mea-

Current recommendations for nutritional support in critically ill pediatric patients are not based on randomized trials with feeding intervention studies. Knowledge concerning substrate intake and substrate

sured energy expenditure compared with calculated energy expenditure using predictive equations  The total daily energy requirements can be higher or lower than values of resting energy expendi-

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ture but in general the total daily energy requirements of the critically ill child will be lower than the total daily energy requirements for healthy children There is a considerable risk for overfeeding in the critically ill child for carbohydrate, fat and protein [11,17] There might be an individual maximum of oxidative capacity for carbohydrate, fat and protein Carbohydrate overfeeding can be determined by measuring the respiratory quotient; an RQ of more than 1.0 indicates overfeeding. Fat overfeeding can be determined by measuring plasma triglycerides levels or comparing fat intake with fat use. Protein needs can be determined by measuring urinary nitrogen excretion [11,18]. Protein retention can be increased by a balanced glucose/fat solution [19]. There might be an optimal nonprotein calorie: nitrogen ratio to enhance protein retention.

range from 1 g/kg/d to 4 g/kg/d in the severely ill child. A recommendation is to start with enteral or parenteral protein of 1 g/kg/d, and to increase the amount depending on the need and level of blood urea. Proteins that are administered with fresh frozen plasma should not be taken into account. Standard enteral formulas can be administered because there is no evidence to use protein diet formulas. Glucose requirements Enteral or parenteral glucose should be administered at 4 to 6 mg/kg/min, depending on the severity of disease and the tolerance of the patient. The method to evaluate carbohydrate overfeeding is measuring a respiratory quotient with IC or to determine serum hyperglycemia or glucosuria. Insulin therapy is started for hyperglycemia, depending on the duration and the diagnosis, according to the current guidelines of intensive insulin therapy in adults [20]. Fat requirements In general, the parenteral fat intake is less than the enteral fat intake because there is a maximum capacity to hydrolyze the administered parenteral fat emulsions. Furthermore, the absorption of enteral fat is 80% to 90%. When parenteral feeding, a low amount of fat0.5 g/kg/dis started in the acute phase of illness because of the risk of fat overloading. In general, a least 2% to 3% of calories should be linoleic acid to prevent fatty acid deficiency. The method to evaluate fat overload is to measure plasma triglycerides; fat intake should be adjusted depending on this level. The fat intake can be increased gradually to between 3 g/kg/d and 4 g/kg/d. When enteral feeding is supplied, fat in the amount of 1 g/kg/d to 1.5 g/kg/d should be given initially. This amount can be increased gradually to between 7 g/kg/d and 8 g/kg/d in small infants and to between 3 g/kg/d and 4 g/kg/d in older children.

Energy requirements The reference method to evaluate the energy need is IC. Some factors (eg, fever, injury, dialysis) cause an increase in energy expenditure, whereas other factors (eg, sedation or relaxation, decreased work of breathing, decreased loss of heat during mechanical ventilation) cause a decrease of energy expenditure. A pragmatic estimate of energy requirements is given in Table 3, based on a percentage of the recommended daily allowances of healthy children. For growth of the infant for each 1 gram growth, 4 kcal growth should be added. One should account for 10% to 15% loss of energy when enteral feeding is supplied. Protein requirements The method to evaluate the protein need is to calculate urinary nitrogen excretion. Protein need can

Table 3 Nutrition schedule of early enteral feeding protocol Amount of feeding Age 0 1 months 1 12 months 1 6 years 7 12 years >12 years
a

Type of feedinga Nutrilon / breast milk Infatrini / breast milk Nutrini multi fiber Tentrini multi fiber Nutrison multi fiber

Day 1 - half of RDA (kcal/kg/d) 50 47 100 46 35 42 25 30

Day 2 - total RDA (kcal/kg/d) 100 95 100 92 70 84 49 60

Nutricia, Zoetermeer, The Netherlands.

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How to feed: administration of enteral nutrition Although nutrition can be provided to critically ill children enterally or parenterally, the enteral route is preferred if there are no contraindications [21]. EN is the preferred method of nutritional support for pediatric patients when the gastrointestinal tract can by used. Advantages of EN are convenience, safety, and low cost. EN also is important in maintaining gastrointestinal mucosal integrity and immunologic function that may prevent bacterial translocation and multisystem organ failure in critically ill children [22]. Gastric and duodenal/jejunal feedings are the primary routes for EN administration in critically ill children. Gastric tubes usually are placed easily by bedside nurses with fewer complications. Nasoduodenal feeding tubes are recommended to reduce the risk of aspiration in the presence of delayed gastric emptying or reflux [22], and is a safe way when continuous enteral feeding of mechanically ventilated children is given. Many strategies have been developed to increase the success rate for placement of feeding tubes in the small bowel/duodenum. Spalding and colleagues [23] tested the effectiveness of gastric insufflation as an adjunct to the placement of feeding tubes in the small bowel compared with the standard insertion technique. The investigators assumed that gastric insufflation is a technique for bedside insertion of a transpyloric feeding tube. Determination of tube position was done by a radiographic method. Other studies demonstrated that the transpyloric placement of feeding tubes using pH sensing is successful, but specialized equipment is required [24,25]. Chellis and colleagues described their experience with bedside placement method using metoclopramide (0.1 mg/kg, intravenously). Transpyloric placement was confirmed by absence of blue dye in nasogastric secretions as well as by an abdominal radiograph [26]. In the PICU at Sophia Childrens Hospital, Rotterdam, The Netherlands, enteral feeding is given by a transpyloric route (duodenal feeding tube) in mechanically ventilated critically ill children. Transpyloric feeding was easy to establish within 24 hours after admission in most (44/46 [95%]) of the mechanically ventilated children of various ages and with various diseases [8] using a standard protocol. The protocol for inserting a transpyloric feeding tube is as described: A 6, 8, or 10 French enteral feeding tube of appropriate size for each patient is used. Before insertion, the length of tubing needed to reach the stomach and the fourth part of the duodenum is determined.

The tube is placed in the stomach and the position is confirmed by injection of air with auscultation. Children are positioned right side down. Before the feeding tube is advanced to the predetermined length, ice water is inserted to stimulate pyloric opening. The amount of ice water is related to the age of the patient (Table 4). The position of a transpyloric feeding tube is determined by the use of a pH stick; if the pH is between 7.0 and 8.0 it can be concluded that the feeding tube is located transpyloric. If this method is not successful after two attempts with ice water, erythromycin (10 mg/kg) is administrated intravenously for 30 minutes. Directly after infusion of erythromycin, a new attempt is executed. The use of erythromycin can be helpful in stimulating pyloric opening. The bedside placement of pH-guided transpyloric small bowel feeding tubes can be done by nurses. In addition, it is a low cost method for determining the location of the feeding tube tip. Both of these are considered advantages of this particular method. If it is not possible to feed transpyloricly, continuous gastric feeding will be started and gastric motility agents (eg, motilium) will be added; however, it is not possible to give all patients EN. Gastric retention, diarrhea, and abdominal distention can limit the use of enteral feeding. If possible, the enteral route of feeding should be used, even with small amounts, unless it is absolutely contraindicated (eg, bowel obstruction, intractable diarrhea).

Early enteral nutrition Zaloga and Roberts [27] reviewed the results of early EN in animal and human adult studies. Animal studies showed that early EN improved gut blood flow and gut mass, diminished the invasiveness of gut bacteria, protected the liver and prevented injury during shock, improved protein synthesis and the rate of wound healing, and increased survival after critical illness. More importantly, prospective, randomized trials in humans have indicated that early EN improved outcome during critical illness.
Table 4 Amount of ice water Age child 0 6 months 6 12 months > 1 year Ice water 5 ml 10 ml 1 ml/kg

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Studies in premature and low birth-weight infants found that the lack of enteral feeding may result in an absence of the natural stimulus for growth of the intestinal mucosa, as well as diminished production of intestinal mucins, which acts as a barrier to bacterial translocation [28]. Further proof of the efficacy and safety of early enteral feeds was given in the form of case reports and case series of burn patients [29,30]. Chellis and colleagues performed a study in 42 critically ill children to evaluate the feasibility and safety of early enteral feedings. All patients were able to achieve caloric goals within 48 hours of beginning enteral feedings, and there were no documented complications, such as aspiration or abdominal distention [31]. A more recent retrospective study in 95 critically ill children showed that it was possible to start EN within 24 hours after admission in most children [32]. A limitation of both of these studies was the use of retrospective chart review for data collection. A recent prospective analysis examined the use of an early enteral feeding protocol in critically ill children who were hemodynamically stable and who had not undergone abdominal surgery. The aim of the enteral feeding protocol was to feed critically ill children within 2 days after admission according to the total recommended daily energy intake (RDA) for healthy children. The type and amount of enteral feeding were based on the age category and weight of the child (see Table 3). On day 1 of admission, enteral feeding is started at 50% of the total RDA and increased to 100% of RDA on day 2. With this protocol, on day 1 and day 2, 90% and 89%, respectively, of the children received the type of feeding according to the protocol. In 10% and 11% of the cases, respectively, the caregivers deviated from the standard because of nutrition intolerance and logistical problems. Concerning the amount of the enteral feeding, on day 1 and day 2, 84% and 78% of the children, respectively, received the amount according to the protocol [8]. Despite the enthusiasm about enteral feeding, it is not possible to give all critically ill children the maximum required amount of enteral feeding according to RDA. Barriers for the adequacy of nutritional support in critically ill children are restriction of fluid intake, clinical interventions (extubation), administration of medications, gastrointestinal intolerance, and mechanical complications with the enteral feeding tube [32 34]. Enteral feeding in critically all children should be started as soon as possible. If critically ill children are hemodynamically stabilizedeven if high doses of inotropics are necessarysmall amounts of en-

teral feeding can be started. Because critically ill children suffer from gastric dysmotility and emptying difficulties, transpyloric tube feeding is the preferred route. Total parenteral feeding is indicated when the gastric intestinal tract is nonfunctional, when it is impossible to obtain enteral access, or when EN alone is not able to meet the childs energy requirements.

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