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Vega MRW, Cerminara D, Desloovere A, Paglialonga F, Renken-Terhaerdt J, Walle JV, Shaw V, Stabouli S, Anderson CE, Haffner D, Nelms CL, Polderman N, Qizalbash L, Tuokkola J, Warady BA, Shroff R, Greenbaum LA. Nutritional management of children with acute kidney injury-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2023; 38:3559-3580. [PMID: 36939914 PMCID: PMC10514117 DOI: 10.1007/s00467-023-05884-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/21/2023]
Abstract
The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
| | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - José Renken-Terhaerdt
- Wilhemina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Vanessa Shaw
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University, Hippokratio Hospital, Thessaloniki, Greece
| | | | - Dieter Haffner
- Hannover Medical School, Children's Hospital, Hannover, Germany
| | | | | | | | - Jetta Tuokkola
- New Children's Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Larry A Greenbaum
- Emory University, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
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Jotterand Chaparro C, Pabion C, Tume L, Mehta NM, Valla FV, Moullet C. Determining energy and protein needs in critically ill pediatric patients: A scoping review. Nutr Clin Pract 2023; 38 Suppl 2:S103-S124. [PMID: 37721467 DOI: 10.1002/ncp.11060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients. METHODS An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data. RESULTS A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated. CONCLUSION This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Céline Pabion
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Lyvonne Tume
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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BMI-z scores of boys with DMD already begin to increase before losing ambulation: a longitudinal exploration of BMI, corticosteroids and caloric intake. Neuromuscul Disord 2022; 32:236-244. [DOI: 10.1016/j.nmd.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 01/22/2023]
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Mtaweh H, Soto Aguero MJ, Campbell M, Allard JP, Pencharz P, Pullenayegum E, Parshuram CS. Systematic review of factors associated with energy expenditure in the critically ill. Clin Nutr ESPEN 2019; 33:111-124. [PMID: 31451246 DOI: 10.1016/j.clnesp.2019.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Indirect calorimetry is the reference standard for energy expenditure measurement. Predictive formulae that replace it are inaccurate. Our aim was to review the patient and clinical factors associated with energy expenditure in critically ill patients. METHODS We conducted a systematic review of the literature. Eligible studies were those reporting an evaluation of factors and energy expenditure. Energy expenditure and factor associations with p-values were extracted from each study, and each factor was classified as either significantly, indeterminantly, or not associated with energy expenditure. Regression coefficients were summarized as measures of central tendency and spread. Metanalysis was performed on correlations. RESULTS The search strategy yielded 8521 unique articles, 307 underwent full text review, and 103 articles were included. Most studies were in adults. There were 95 factors with 352 evaluations. Minute volume, weight, age, % body surface area burn, sedation, post burn day, and caloric intake were significantly associated with energy expenditure. Heart rate, fraction of inspired oxygen, respiratory rate, respiratory disease diagnosis, positive end expiratory pressure, intensive care unit days, C- reactive protein, and size were not associated with energy expenditure. Multiple factors (n = 37) were identified with an unclear relationship with energy expenditure and require further evaluation. CONCLUSIONS An important interval step in the development of accurate formulae for energy expenditure estimation is a better understanding of relationships between patient and clinical factors and energy expenditure. The review highlights the limitations of currently available data, and identifies important factors that are not included in current prediction formulae of the critically ill.
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Affiliation(s)
- Haifa Mtaweh
- Division of Critical Care, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto M5G 1X8, Canada; Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada.
| | - Maria Jose Soto Aguero
- Division of Critical Care, Hospital Nacional de Niños "Carlos Saenz Herrera", Calle 20, Avenida 0, Paseo Colón, San José, Costa Rica
| | - Marla Campbell
- Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, University of Toronto, 200 Elizabeth St, Toronto M5G 2C4, Canada
| | - Paul Pencharz
- Department of Paediatrics and Nutritional Sciences, University of Toronto, 1 King's College Circle, Toronto M5S 1A8, Canada
| | - Eleanor Pullenayegum
- Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada
| | - Christopher S Parshuram
- Division of Critical Care, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto M5G 1X8, Canada; Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada
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Jotterand Chaparro C, Moullet C, Taffé P, Laure Depeyre J, Perez MH, Longchamp D, Cotting J. Estimation of Resting Energy Expenditure Using Predictive Equations in Critically Ill Children: Results of a Systematic Review. JPEN J Parenter Enteral Nutr 2018; 42:976-986. [PMID: 29603276 DOI: 10.1002/jpen.1146] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/21/2017] [Accepted: 12/20/2017] [Indexed: 11/06/2022]
Abstract
Provision of adequate energy intake to critically ill children is associated with improved prognosis, but resting energy expenditure (REE) is rarely determined by indirect calorimetry (IC) due to practical constraints. Some studies have tested the validity of various predictive equations that are routinely used for this purpose, but no systematic evaluation has been made. Therefore, we performed a systematic review of the literature to assess predictive equations of REE in critically ill children. We systematically searched the literature for eligible studies, and then we extracted data and assigned a quality grade to each article according to guidelines of the Academy of Nutrition and Dietetics. Accuracy was defined as the percentage of predicted REE values to fall within ±10% or ±15% of the measured energy expenditure (MEE) values, computed based on individual participant data. Of the 993 identified studies, 22 studies testing 21 equations using 2326 IC measurements in 1102 children were included in this review. Only 6 equations were evaluated by at least 3 studies in critically ill children. No equation predicted REE within ±10% of MEE in >50% of observations. The Harris-Benedict equation overestimated REE in two-thirds of patients, whereas the Schofield equations and Talbot tables predicted REE within ±15% of MEE in approximately 50% of observations. In summary, the Schofield equations and Talbot tables were the least inaccurate of the predictive equations. We conclude that a new validated indirect calorimeter is urgently needed in the critically ill pediatric population.).
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Affiliation(s)
- Corinne Jotterand Chaparro
- Department of Nutrition and Dietetics, School of Health Professions, University of Applied Sciences Western Switzerland, Carouge, Geneva, Switzerland.,Pediatric Intensive Care Unit, Medico-Surgical Department of Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Clémence Moullet
- Department of Nutrition and Dietetics, School of Health Professions, University of Applied Sciences Western Switzerland, Carouge, Geneva, Switzerland
| | - Patrick Taffé
- Institute of Social and Preventive Medicine, Lausanne, Switzerland
| | - Jocelyne Laure Depeyre
- Department of Nutrition and Dietetics, School of Health Professions, University of Applied Sciences Western Switzerland, Carouge, Geneva, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Medico-Surgical Department of Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - David Longchamp
- Pediatric Intensive Care Unit, Medico-Surgical Department of Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jacques Cotting
- Pediatric Intensive Care Unit, Medico-Surgical Department of Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
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Westerterp KR. Doubly labelled water assessment of energy expenditure: principle, practice, and promise. Eur J Appl Physiol 2017; 117:1277-1285. [PMID: 28508113 PMCID: PMC5486561 DOI: 10.1007/s00421-017-3641-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/08/2017] [Indexed: 01/02/2023]
Abstract
The doubly labelled water method for the assessment of energy expenditure was first published in 1955, application in humans started in 1982, and it has become the gold standard for human energy requirement under daily living conditions. The method involves enriching the body water of a subject with heavy hydrogen (2H) and heavy oxygen (18O), and then determining the difference in washout kinetics between both isotopes, being a function of carbon dioxide production. In practice, subjects get a measured amount of doubly labelled water (2H 218 O) to increase background enrichment of body water for 18O of 2000 ppm with at least 180 ppm and background enrichment of body water for 2H of 150 ppm with 120 ppm. Subsequently, the difference between the apparent turnover rates of the hydrogen and oxygen of body water is assessed from blood-, saliva-, or urine samples, collected at the start and end of the observation interval of 1-3 weeks. Samples are analyzed for 18O and 2H with isotope ratio mass spectrometry. The doubly labelled water method is the indicated method to measure energy expenditure in any environment, especially with regard to activity energy expenditure, without interference with the behavior of the subjects. Applications include the assessment of energy requirement from total energy expenditure, validation of dietary assessment methods and validation of physical activity assessment methods with doubly labelled water measured energy expenditure as reference, and studies on body mass regulation with energy expenditure as a determinant of energy balance.
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Affiliation(s)
- Klaas R Westerterp
- Department of Human Biology, Maastricht University Medical Centre, PO Box 616, 6200 MD, Maastricht, The Netherlands.
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med 2017; 18:675-715. [PMID: 28691958 DOI: 10.1097/pcc.0000000000001134] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.
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Mehta NM, Skillman HE, Irving SY, Coss-Bu JA, Vermilyea S, Farrington EA, McKeever L, Hall AM, Goday PS, Braunschweig C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr 2017; 41:706-742. [DOI: 10.1177/0148607117711387] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Heather E. Skillman
- Clinical Nutrition Department, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Sharon Y. Irving
- Division of Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Jorge A. Coss-Bu
- Section of Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah Vermilyea
- Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Anne Farrington
- Department of Pharmacy, Betty H. Cameron Women’s and Children’s Hospital, New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - Liam McKeever
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amber M. Hall
- Biostatistics, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Praveen S. Goday
- Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Carol Braunschweig
- Division of Epidemiology and Biostatistics, Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois, USA
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Loi M, Wang J, Ong C, Lee JH. Nutritional support of critically ill adults and children with acute respiratory distress syndrome: A clinical review. Clin Nutr ESPEN 2017. [DOI: 10.1016/j.clnesp.2017.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Conrad N, Karlik J, Lewandowski Holley A, Wilson AC, Koh J. A Narrative Review: Actigraphy as an Objective Assessment of Perioperative Sleep and Activity in Pediatric Patients. CHILDREN-BASEL 2017; 4:children4040026. [PMID: 28420221 PMCID: PMC5406685 DOI: 10.3390/children4040026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 12/27/2022]
Abstract
Sleep is an important component of pediatric health and is crucial for cognitive development. Actigraphy is a validated, objective tool to capture sleep and movement data that is increasingly being used in the perioperative context. The aim of this review is to present recent pediatric studies that utilized actigraphy in the perioperative period, highlight gaps in the literature, and provide recommendations for future research. A literature search was completed using OVID and PubMed databases and articles were selected for inclusion based on relevance to the topic. The literature search resulted in 13 papers that utilized actigraphic measures. Results of the review demonstrated that actigraphy has been used to identify predictors and risk factors for poor postoperative sleep, examine associations among perioperative pain and sleep patterns, and assess activity and energy expenditure in both inpatient and outpatient settings. We propose expansion of actigraphy research to include assessment of sleep via actigraphy to: predict functional recovery in pediatric populations, to study postoperative sleep in high-risk pediatric patients, to test the efficacy of perioperative interventions, and to assess outcomes in special populations for which self-report data on sleep and activity is difficult to obtain.
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Affiliation(s)
- Nicole Conrad
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University (OHSU), Portland, OR 97239, USA.
| | - Joelle Karlik
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University (OHSU), Portland, OR 97239, USA.
| | - Amy Lewandowski Holley
- Department of Pediatrics, Oregon Health and Science University (OHSU), Portland, OR 97329, USA.
| | - Anna C Wilson
- Department of Pediatrics, Oregon Health and Science University (OHSU), Portland, OR 97329, USA.
| | - Jeffrey Koh
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University (OHSU), Portland, OR 97239, USA.
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Jotterand Chaparro C, Laure Depeyre J, Longchamp D, Perez MH, Taffé P, Cotting J. How much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children? Clin Nutr 2015; 35:460-467. [PMID: 25912187 DOI: 10.1016/j.clnu.2015.03.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND & AIMS Protein and energy requirements in critically ill children are currently based on insufficient data. Moreover, longitudinal measurements of both total urinary nitrogen (TUN) and resting energy expenditure (REE) are lacking. The aim of this study was to investigate how much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children on the basis of daily measurements of TUN, REE and protein and energy intakes. Comparisons were made with the guidelines of the American Society for Parenteral and Enteral Nutrition and the Dietary Reference Intakes. METHODS Children with an expected duration of mechanical ventilation ≥72 h were prospectively recruited. TUN was measured by chemiluminescence, and REE was measured by indirect calorimetry. Generalised linear models for longitudinal data were used to study the relation between protein intake and nitrogen balance and to calculate the minimum intake of protein needed to achieve nitrogen equilibrium. A similar approach was used for energy. Results were compared to the recommended values. RESULTS Based on 402 measurements performed in 74 children (median age: 21 months), the mean TUN was high at 0.20 (95% CI: 0.20, 0.22) g/kg/d and the REE was 55 (95% CI: 54, 57) kcal/kg/d. Nitrogen and energy balances were achieved with 1.5 (95% CI: 1.4, 1.6) g/kg/d of protein and 58 (95% CI: 53, 63) kcal/kg/d for the entire group, but there were differences among children of different ages. Children required more protein and less energy than the Dietary Reference Intakes. CONCLUSIONS In critically ill children, TUN was elevated and REE was reduced during the entire period of mechanical ventilation. Minimum intakes of 1.5 g/kg/d of protein and 58 kcal/kg/d can equilibrate nitrogen and energy balances in children up to 4 years old. Older children require more protein.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Department of Nutrition and Dietetics, School of Health Professions, University of Applied Sciences Western Switzerland (HES-SO), Rue des Caroubiers 25, 1227 Carouge, Geneva, Switzerland.
| | - Jocelyne Laure Depeyre
- Department of Nutrition and Dietetics, School of Health Professions, University of Applied Sciences Western Switzerland (HES-SO), Rue des Caroubiers 25, 1227 Carouge, Geneva, Switzerland.
| | - David Longchamp
- Paediatric Intensive Care Unit, Medico-Surgical Department of Paediatrics, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Marie-Hélène Perez
- Paediatric Intensive Care Unit, Medico-Surgical Department of Paediatrics, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Patrick Taffé
- Institute for Social and Preventive Medicine (IUMSP), Biopôle 2, Route de la Corniche 10, 1010 Lausanne, Switzerland.
| | - Jacques Cotting
- Paediatric Intensive Care Unit, Medico-Surgical Department of Paediatrics, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
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12
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Mehta NM, Smallwood CD, Graham RJ. Current applications of metabolic monitoring in the pediatric intensive care unit. Nutr Clin Pract 2014; 29:338-47. [PMID: 24699395 DOI: 10.1177/0884533614526259] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Delivery of adequate nutrients during illness to counteract the metabolic stress response and facilitate healing and tissue repair is an important goal in the care of critically ill children. With recent advances in technology, accurate minute-to-minute gas exchange and energy expenditure measurements are now available in intensive care units. The bedside availability of these devices may allow a titrated approach to energy delivery for patients, ushering in a new era of individualized nutrition therapy. Basic concepts, available monitoring devices, indications, pitfalls, and bedside application of metabolic monitoring are discussed in this article.
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Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anaesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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13
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de Betue CTI, van Steenselen WN, Hulst JM, Olieman JF, Augustus M, Mohd Din SH, Verbruggen SCAT, Tibboel D, Joosten KFM. Achieving energy goals at day 4 after admission in critically ill children; predictive for outcome? Clin Nutr 2014; 34:115-22. [PMID: 24576820 DOI: 10.1016/j.clnu.2014.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 01/28/2014] [Indexed: 12/07/2022]
Abstract
BACKGROUND & AIMS Adequate nutritional intake is essential during pediatric intensive care admission. We investigated whether achievement of energy intake goals at day 4 after admission and route of nutrition were associated with improved outcome. METHODS Observational study using prospectively acquired data. Patients receiving enteral and/or parenteral nutrition were included. The energy intake target range at day 4 after admission was 90-110% of resting energy expenditure +10%. Acute malnutrition was defined as weight-for-age <-2 SD. Clinical outcome measures were length of stay, days on ventilator, duration of antibiotics and number of new infections. Data as median (min-max). RESULTS Of 325 subjects (age 0.14 (0.0-18.0) year), 19% were acutely malnourished upon admission. Median 86% of energy goals were administered via the enteral route. With enteral energy intake, 7% of patients were fed within the target range, 50% were fed below and 43% were fed above the target range. In a subgroup (n = 223) the acutely malnourished proportion at discharge (26%) was not significantly different from that upon admission (22%). Whether the energy intake was below, within or above the target range did not affect changes in clinical outcome, nor did the route of nutrition. CONCLUSIONS Acute malnutrition was highly prevalent upon admission and at discharge. With our nutritional protocol we achieved high rates of (enteral) energy intake. A high percentage of our population received enteral energy above the target energy range. However, there was no association between the amount of energy intake or route of nutrition and clinical outcome.
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Affiliation(s)
- C T I de Betue
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - W N van Steenselen
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J M Hulst
- Department of Pediatric Gastroenterology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J F Olieman
- Department of Dietetics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M Augustus
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - S H Mohd Din
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
| | - S C A T Verbruggen
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - D Tibboel
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K F M Joosten
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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Abstract
The ideal set of variables for nutritional monitoring that may correlate with patient outcomes has not been identified. This is particularly difficult in the PICU patient because many of the standard modes of nutritional monitoring, although well described and available, are fraught with difficulties. Thus, repeated anthropometric and laboratory markers must be jointly analyzed but individually interpreted according to disease and metabolic changes, in order to modify and monitor the nutritional treatment. In addition, isotope techniques are neither clinically feasible nor compatible with the multiple measurements needed to follow progression. On the other hand, indirect alternatives exist but may have pitfalls, of which the clinician must be aware. Risks exist for both overfeeding and underfeeding of PICU patients so that an accurate monitoring of energy expenditure, using targeted indirect calorimetry, is necessary to avoid either extreme. This is very important, since the monitoring of the nutritional status of the critically ill child serves as a guide to early and effective nutritional intervention.
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Optimizing nutrition therapy to enhance mobility in critically ill patients. Crit Care Nurs Q 2013; 36:28-36. [PMID: 23221439 DOI: 10.1097/cnq.0b013e31827507d7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Critically ill patients are at high risk of malnutrition and lean body mass loss. Screening for malnutrition and performing detailed assessment of energy needs should be routine for patients admitted to intensive care units. Providing adequate calorie and protein provisions can attenuate muscle loss in many at-risk patients. Enteral nutrition is associated with decreased risks of morbidity and infections and is therefore preferred to parenteral nutrition in hemodynamically stable patients with favorable anatomy. Judicious use of steroids and paralytics in combination with adequate glucose control may decrease the risk of developing critical illness polyneuromyopathy. There is growing evidence for the potential immune-enhancing benefits of many micronutrients and vitamins in the critically ill, but more research is needed to determine which nutrients are most effective in which disease processes and what dosing regimens are safe and effective. Elderly, obese, and very young patients pose unique challenges for nutrition therapy and early mobility programs. Pairing early mobility programs with optimal nutrition therapy can help reduce morbidity, limit muscle loss, and speed recovery in intensive care unit patients.
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Plasqui G, Bonomi AG, Westerterp KR. Daily physical activity assessment with accelerometers: new insights and validation studies. Obes Rev 2013; 14:451-62. [PMID: 23398786 DOI: 10.1111/obr.12021] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 12/21/2012] [Accepted: 01/07/2013] [Indexed: 11/29/2022]
Abstract
The field of application of accelerometry is diverse and ever expanding. Because by definition all physical activities lead to energy expenditure, the doubly labelled water (DLW) method as gold standard to assess total energy expenditure over longer periods of time is the method of choice to validate accelerometers in their ability to assess daily physical activities. The aim of this paper was to provide a systematic overview of all recent (2007-2011) accelerometer validation studies using DLW as the reference. The PubMed Central database was searched using the following keywords: doubly or double labelled or labeled water in combination with accelerometer, accelerometry, motion sensor, or activity monitor. Limits were set to include articles from 2007 to 2011, as earlier publications were covered in a previous review. In total, 38 articles were identified, of which 25 were selected to contain sufficient new data. Eighteen different accelerometers were validated. There was a large variability in accelerometer output and their validity to assess daily physical activity. Activity type recognition has great potential to improve the assessment of physical activity-related health outcomes. So far, there is little evidence that adding other physiological measures such as heart rate significantly improves the estimation of energy expenditure.
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Affiliation(s)
- G Plasqui
- Human Biology Department, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands.
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Botrán M, López-Herce J, Mencía S, Urbano J, Solana MJ, García A. Enteral nutrition in the critically ill child: comparison of standard and protein-enriched diets. J Pediatr 2011; 159:27-32.e1. [PMID: 21429514 DOI: 10.1016/j.jpeds.2011.02.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 01/10/2011] [Accepted: 02/01/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare a standard diet and a protein-enriched diet in critically ill children. STUDY DESIGN In this prospective randomized controlled trial in critically ill children, all patients received enteral nutrition exclusively and were randomly assigned to a standard diet or a protein-enriched diet (1.1 g protein/100 mL of feeding formula). Blood and urine tests, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry were performed before the beginning of the nutrition regimen and at 24 hours, 72 hours, and 5 days after initiation. Demographic data and pediatric mortality risk scores were recorded. RESULTS Fifty-one children were randomized, and 41 completed the study. Of these, 21 patients received standard formula and 20 received a protein-enriched formula. There were no between-group differences in terms age, sex, diagnosis, or mortality risk scores. There was a greater positive trend in levels of prealbumin, transferrin, retinol-binding protein, and total protein in the protein-enriched diet group. These differences were significant only for retinol-binding protein. The positive nitrogen balance trend was also higher in the protein-enriched diet group; however, this difference did not reach statistical significance. No adverse effects or hyperproteinemia were detected in the protein-enriched diet group. CONCLUSIONS The standard diet provides insufficient protein delivery to critically ill children. Enteral protein supplementation is safe and can improve some biochemical parameters of protein metabolism.
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Affiliation(s)
- Marta Botrán
- Pediatric Intensive Care Department, General Hospital of Gregorio Marañón University, Madrid, Spain
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Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children. Br J Nutr 2011; 105:731-7. [PMID: 21272396 DOI: 10.1017/s0007114510004162] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.
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Specialized refeeding treatment for anorexia nervosa patients suffering from extreme undernutrition. Clin Nutr 2010; 29:627-32. [DOI: 10.1016/j.clnu.2010.03.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 03/16/2010] [Accepted: 03/17/2010] [Indexed: 01/15/2023]
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