Red Cross Childrens Hospital : Refresher Course Feb 2010 Feeding the critically ill infant and child...

Red Cross Childrens Hospital : Refresher Course Feb 2010

Feeding the critically ill infant and child

By : Shihaam CaderPrincipal Dietitian [HOD]Red Cross Children's Hospital

By : Prof A Argent Head PICURed Cross Children's Hospital

By : Dr L GoddardGIT ConsultantRed 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


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


An approach to feeding the

critically ill infant & child


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 multi-disciplinary including dietitians, nursing, medical team


Enteral Feeding protocolSTEP 1

Nutritional assessment

ABCD approach

STEP 5

Monitoring tolerance of feeding•Input

•Output: vomiting, stools, NGA

•Other: abdominal distention

STEP 2

Early Enteral Nutrition

Initiate within 24 hoursSTEP 4

Route of feeding•Naso/oro-gastric feeding•Nasojejenal feeding

STEP 3

Type & rate of feeding•Depends on age, nutritional needs, fluid restrictions, disease condition

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

STEP 6

Managing the barriers to feeding•Interruptions to feeding & calorie deficits

•GI disturbances: vomiting, stools, NGA

•Fluid restrictions


Enteral Feeding protocol

STEP 1


ABCD approach


Nutrition Assessment

ABCD approach

Anthropometry•Weight, length, classifications, growth charts, NRS

Biochemistry/Special Investigations•Electrolytes, CMP, hemoglobin, etc•FOG,Fecal elastase, alpha1 antitrypsin, etc

Clinical Considerations•Disease specific nutritional management

Dietary Assessment • Diet history•Energy and protein requirements•Choosing appropriate feeds•Determining the route of feeding


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 trends

Growth charts used to classify patients, eg, wasting and stunting, acute or chronic malnutrition


• 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:

SODIUM

MAGNESIUMPOTASSIUM

PHOSPHATE

CALCIUM

HEMOGLOBIN

Biochemistry


•Albumin: Poor marker of nutrition & rather prognostic indicator

• Most abundant plasma protein with MW of 65 kDa, 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

• Increase CRP + decrease Prealbumin = acute phase

Biochemistry

Nutrition 2009 (25)1004-1005

[ASPEN 2009]


• 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

Cardiac diseaseChronic lung disease

Critically ill Burns

Severe malnutritionMetabolic disorders

Clinical assessment/diagnosis


•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

• Route of feedEnterally OR Parenterally

Orally OR Nasogastric OR Nasojejenally OR Gastrostomy

Dietary assessment and management


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


Protein

• Adequate protein needed for lean body mass, wound healing

• Those fed high protein [~2,8g/kg] had positive protein balance and lower protein oxidation compared to those fed 1.7g/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 requiredJ Hum Nutr Diet 2007;20:329


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



STEP 1


ABCD approach

STEP 2


Initiate within 24 hours


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



STEP 1


ABCD approach

STEP 2



Type & rate of feeding

•Depends on age, nutritional needs, fluid restrictions, disease condition


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


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

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

Types of feeds: Infants


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...


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


Types of enteral nutrition available


• complete polymeric

•67kcal/ml and 1.5g protein/100ml


• complete feed

•1.0kcal/ml and 2.6g protein / 100ml

3. Soya based formula,

• complete lactose free, 67kcal/ml and 1.6g protein / 100ml

4. Hydrolysed formula [peptide based + LCT + MCT]

5. Amino acid based [+LCT]


Infant products [0-1 year]


Types of enteral nutrition available


• complete polymeric, usually with soluble fibre

•1.0kcal/ml and 2.8 - 3g protein/100ml


• complete feed

•1.5kcal/ml and 3.8g protein / 100ml

3. Hydrolysed formula [peptide based + LCT + MCT]

5. Amino acid based [+LCT]


Pediatric products [1-10 year]

Note: ALL pediatric products are lactose free


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/100ml]

• < 6 mths: 10 -12%

• 6-12 mths: 12- 15%

• 1-2 yrs: 15 – 20%

• children: 20 – 30%

•Fat concentrations [g/100ml]

• Infants: 5 – 6 %

• Children: 7%Note: No supplementation is recommended if there is diarrhea or any malabsorption


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




ABCD approach

STEP 2




STEP 3




Route of feeding

Recommendations are to initiate gastric feeding first with transition to jejenal feeding if the gastric route is not tolerated

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


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

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 3rd Ed

Route of feeding




ABCD approach

STEP 5




STEP 2




STEP 3




Monitoring the tolerance of feeding

Common complications are:

1. Vomiting• Prokinetic – erythromycin low dose 2 – 10mg/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




ABCD approach

STEP 5




STEP 2




STEP 3



STEP 6

Managing the barriers to feeding•Interruptions to feeding & calorie deficits

•GI disturbances: vomiting, stools, NGA

•Fluid restrictions


Managing the barriers to feedingMain barriers to optimum feeding:

1.Fluid restrictions• Common for infants/ children restricted to 40 –

60ml/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


• 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 1kcal/ml– > 1 yr 1.5kcal/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 4g/kg– Children 3g/kg

Curr Op Clin Nutr Met Care. 2006; 9: 297-303

Optimise calories and reduce calorie deficits


Adult studies:• Glutamine

– fuel for enterocytes• Arginine

– cautioned in use of septic-critically ill• Omega-3s

– 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 2009Nutrition 2005; 21: 799 - 807

Immunonutrition


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


Conclusion

• Nutrition is integral part of management

• Early enteral nutrition needs to be initiated 24hrs

• 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


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 NutrDiet 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 OpinClin 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

Date post:	13-Jan-2016
Category:	Documents
Upload:	gary-melton
View:	217 times
Download:	0 times

Red Cross Childrens Hospital : Refresher Course Feb 2010 Feeding the critically ill infant and child...

Documents