Accurate estimation of energy requirements of young patients

Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary

OBJECTIVES

Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy.

METHODS

An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy.

RESULTS

The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy.

CONCLUSIONS

Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.

Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations

BACKGROUND

Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT.

METHODS

PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023.

RESULTS

On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points.

CONCLUSIONS

Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.

The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy in the world. Advances in treatment protocols have resulted in survival rates of >80% in most high-income countries (HIC); however, children and young people (CYP) with ALL continue to face significant nutrition-related challenges during treatment.

METHODS

This narrative review outlines the changing landscape of treatment and survivorship for CYP with ALL and the advances in nutrition knowledge that call for changes to clinical nutrition practice.

RESULTS

The incidence of ALL has remained stable in HIC; however, there have been significant advances in survival over the past 30 years. Overweight and obesity are increasingly prevalent in CYP with ALL at diagnosis, during treatment and in survivorship. Coupled with poor diet quality, high-energy and saturated fat intakes, altered eating behaviours and inactivity, this necessitates the need for a shift in nutrition intervention. Undernutrition remains a concern for CYP with high-risk treatment protocols where oral or enteral nutrition support remains a cornerstone of maintaining nutrition status.

CONCLUSIONS

With improved treatment protocols and high survival rates, a shift to focusing on diet quality, prevention of excessive weight gain and obesity during treatment and survivorship is necessary.

Association between goal nutrition and intubation in patients with bronchiolitis on noninvasive ventilation: A retrospective cohort study

BACKGROUND

Acute bronchiolitis causes many hospitalizations in children younger than 2 years. Early enteral nutrition is associated with improved outcomes in these patients. However, often nutrition is withheld when patients require noninvasive respiratory support because of the risk of aspiration worsening respiratory failure, possibly requiring intubation. We hypothesize that achieving goal energy intake is associated with a lower intubation rate in hospitalized children with bronchiolitis who require noninvasive ventilation.

METHODS

This retrospective cohort study examined the association between goal enteral nutrition (60% of dietary reference energy intake) and intubation rates. We grouped patients by severity of illness and compared intubation rates in those who met goal energy to those who did not. We use stratified analysis methods (for both level of respiratory support and feeding route) to evaluate progression to intubation.

RESULTS

Of the 272 patients, 215 met goal feeds. These groups had similar demographics, but the goal-feeds group started on higher respiratory support in the pediatric intensive care unit. We found that 4.65% of the patients who met goal feeds required intubation compared with 24.6% of patients who did not meet goal feeds (P < 0.0001), even after controlling for respiratory status at admission and time of feed initiation and feeding route.

CONCLUSION

We observed when adjusting for severity, feeding route, and respiratory support, achieving goal energy intake remained associated with a lower rate of intubation, without higher rates of aspiration. Confounding factors include practice variation and difference in severity of illness that objective scoring may have missed.

The accuracy of ten common resting metabolic rate prediction equations in men and women collegiate athletes

Predictive resting metabolic rate (RMR) equations are widely used to determine total daily energy expenditure (TDEE). However, it remains unclear whether these predictive RMR equations accurately predict TDEE in the athletic populations. The purpose of this study was to examine the accuracy of 10 commonly used RMR prediction equations (Cunningham, De Lorenzo, Freire, Harris-Benedict, Mifflin St. Jeor, Nelson, Owen, Tinsley, Watson, Schofield) in collegiate men and women athletes. One-hundred eighty-seven National Collegiate Athletic Association Division III men (n = 97) and women (n = 90) athletes were recruited to participate in one day of metabolic testing. RMR was measured using indirect calorimetry and body composition was analyzed using air displacement plethysmography. A repeated measures ANOVA with Bonferroni post hoc analyses was selected to determine mean differences between measured and predicted RMR. Linear regression analysis was used to assess the accuracy of each RMR prediction method (p<0.05). All prediction equations significantly underestimated RMR (p<0.001), although there was no difference between the De Lorenzo and Watson equations and measured RMR (p = 1.00) for women, only. In men, the Tinsley and Freire equations were the most agreeable formulas with the lowest root-mean-square prediction error value of 404 and 412 kcals, respectively. In women, the De Lorenzo and Watson equations were the most agreeable equations with the lowest root-mean-squared error value of 171 and 211 kcals, respectively. The results demonstrate that such RMR equations may underestimate actual energy requirements of athletes and thus, practitioners should interpret such values with caution.Highlights All prediction equations significantly underestimated RMR in men athletes.All prediction equations, except for the De Lorenzo and Watson equations, significantly underestimated RMR in women athletes.Although a significant underestimation of RMR in men athletes, the Freire and Tinsley equations were the most agreeable prediction equations.In women athletes, the De Lorenzo and Watson equations were the most agreeable prediction equations.

Resting energy expenditure in children and adolescents with cerebral palsy: accuracy of available prediction formulas and development of population-specific methods

Introduction

Energy requirements are difficult to estimate in children with cerebral palsy (CP). Resting energy expenditure (REE), necessary to implement personalized nutritional interventions, is most commonly estimated using prediction formulae since indirect calorimetry, the reference method, is not available in all nutrition units. The aims of the present study were: (1) to evaluate the accuracy of the most commonly used REE prediction formulae developed for healthy children, in children with CP; (2) to assess the accuracy of the REE population-specific formula for CP children proposed in our preliminary report; (3) to develop new population-specific methods.

Methods

REE was measured by indirect calorimetry in 100 children and adolescents with spastic quadriplegic cerebral palsy (SQCP) and estimated on the basis of predictive formulas selected by the clinicians [World Health Organization (WHO), Harris-Benedict, Schofield weight, Schofield weight & height, Oxford, Mifflin formulae and a population-specific formula for CP children developed in our preliminary report].

Results

100 children with SQCP (35 girls, 35%) classified as level V according to gross motor function classification system (GMFCS-V); 64% with oral nutrition, 29% total enteral nutrition (nasogastric tube feeding, percutaneous endoscopic gastrostomy, percutaneous endoscopic transgastric jejunostomy) and 7% mixed nutrition. The median (IQR) REE was 41.96 (17.5) kcal/kg/day.Statistical analysis highlighted a proportional bias between the indirect calorimetry and all considered predictive formulae for REE determination. By studying the relationship between the bias and the mean values of REE, specific conversion equations were obtained. With a pre-specified model having as predictors the variable weight and the variable Triceps Skinfold (TSF) and, as response the variable REE measured by indirect calorimetry, a predictive nomogram was developed to estimate the REE in this population of children.

Conclusions

We suggest using predictive formulae for healthy children with caution, and where possible carrying out indirect calorimetry to assess REE in children with CP. However, we propose a new tool which could be developed to become an additional help for assessment of REE in the clinical practice.Future objectives will be to obtain a larger sample size, in a multicenter perspective study, to build a specific predictive model for the REE of the studied population.

Development and validation of new predictive equations for resting energy expenditure in physically active boys

Measurement or estimation of resting energy expenditure (REE) should be the first step in determining energy demand in physically active boys. The purpose of this study was to develop and validate new equations for resting energy expenditure in male children and adolescents practicing soccer. The cross-sectional studywas carried out among 184 boys in the derivation group and 148 boys in the validation group (mean age 13.20 ± 2.16 years and 13.24 ± 1.75 years, respectively). The calorimeter and device for assessing body composition by bioelectrical impedance analysis (BIA) were used. Model of multiple regression showed that REE can be predicted in this population with Eq. (1) (with height and weight data) or Eq. (2) (with age, height, and fat free mass data). Predictive Eq. (1) had an average error of 51 ± 199 kcal and predictive Eq. (2) - 39 ± 193 kcal. Cohen's d coefficient was 0.2, which confirms the small difference. The bias was 4.7% and 3.9%, respectively. The accuracy was 61.2% in the population for predictive Eq. (1) and 66.2% for predictive Eq. (2). Therefore, the new equations developed and validated in this study are recommended for the estimation of REE in physically active boys, when the use of IC is not feasible or available.

Resting energy expenditure in adolescents with Down syndrome: a comparison of commonly used predictive equations

BACKGROUND

Adolescents with Down syndrome (DS) are two to three times more likely to be obese than their typically developing peers. When preventing or treating obesity, it is useful for clinicians to understand an individual's energy intake needs. Predictive resting energy expenditure (REE) equations are often recommended for general use in energy intake recommendations; however, these predictive equations have not been validated in youth with DS. The aim of this study was to compare the accuracy of seven commonly used predictive equations for estimating REE in adolescents who are typically developing to REE measured by indirect calorimetry in adolescents with DS.

METHODS

Adolescents with DS participated in a 90-min laboratory visit before 10:00 a.m. after a 12-h overnight fast and a 48-h abstention from aerobic exercise. REE was measured via indirect calorimetry, and estimated REE was derived using the Institute of Medicine, Molnar, Muller and World Health Organization equations. Mean differences between the measured and predicted REE for each equation were evaluated with equivalency testing, and P-values were adjusted for multiple comparisons using the Holm method.

RESULTS

Forty-six adolescents with DS (age: 15.5 ± 1.7 years, 47.8% female, 73.9% non-Hispanic White) completed the REE assessment. Average measured REE was 1459.5 ± 267.8 kcal/day, and the Institute of Medicine equations provided the most accurate prediction of REE with a 1.7 ± 11.2% (13.9 ± 170.3 kcal/day) overestimation. This prediction was not statistically different from the measured REE [P-value = 0.582; 95% confidence interval (CI): -64.5, 36.7], and the difference between the measured and predicted REE was statistically equivalent to zero (P-value = 0.024; 90% CI: -56.1, 28.3).

CONCLUSIONS

The results suggest that the Institute of Medicine equation may be useful in predicting REE in adolescents with DS. Future research should confirm these results in a larger sample and determine the utility of the Institute of Medicine equation for energy intake recommendations during a weight management intervention.

Evaluating the Dietary Intake of Children With Esophageal Atresia: A Prospective, Controlled, Observational Study

OBJECTIVES

Children with esophageal atresia (EA) often have feeding difficulties and dysphagia, which may compromise their nutritional status. This study aimed to compare dietary intake between children with EA and matched healthy controls (HC) and to investigate the relationship between dietary factors, growth, dysphagia, and feeding difficulties in the EA cohort.

METHODS

This cross-sectional cohort study recruited children with EA and HC aged 2-17 years from a tertiary pediatric hospital in Australia. Growth parameters were measured. Dietary intake was assessed using the validated Australian Child and Adolescent Eating Survey. Dysphagia and feeding difficulties were assessed using objective questionnaires.

RESULTS

Twenty-one children with EA were matched for age and sex with 21 HC. Compared to HC, children with EA had lower mean z scores for height-for-age, but mean weight-for-age and body mass index-for-age z scores were similar. Energy intake was similar between the groups. The diet of children with EA consisted of a higher proportion of fats and lower proportion of carbohydrates compared to matched HC. Dysphagia severity in children with EA positively correlated with proportion of energy from fats and saturated fats.

CONCLUSIONS

Children with EA have similar energy intake and growth parameters to HC, but their diet consists of a higher proportion of fats and lower proportion of carbohydrates compared to HC. Targeted dietary interventions and parental education are necessary.

Estimating nutritional needs in paediatric heart failure: beyond the equations

BACKGROUND

Nutrition optimisation is imperative in paediatric patients with heart failure. Energy needs can be assessed using indirect calorimetry.

METHODS

Presented are two cases of children with clinical heart failure who benefited from indirect calorimetry.

RESULTS

Using indirect calorimetry, it was determined both cases were hypermetabolic.

CONCLUSION

These cases demonstrate the impact of heart failure on metabolic rate and growth. Energy requirements were up to two times higher than estimations from predictive equations.

Resting Energy Expenditure and Related Factors in 6- to 9-Year-Old Southern African Children of Diverse Population Groups

Lower resting energy expenditure (REE) may partially explain the disproportionate prevalence of overweight/obesity among black African women. As no previous studies have investigated the REE of Southern African (South. Afr.) children, we aimed to determine, by sex and population group, the REE of 6- to 9-year-old urban school children. In a cross-sectional study with quota sampling, REE was measured with indirect calorimetry (IC). Confounders considered were: body composition (BC) (fat-free mass (FFM), FFM index, fat mass (FM), FM index), assessed using multifrequency bioelectrical impedance analysis, and physical activity (PA) measured with a pedometer. Multivariate regression was used to calculate REE adjusted for phenotypes (BC, z-scores of weight-for-age, height-for-age, body mass index-for-age) and PA. Sex and population differences in REE were determined with two-way ANOVA. Ninety-four healthy children (59.6% girls; 52.1% black) with similar socioeconomic status and PA opportunities participated. Despite BC variations, sex differences in REE were not significant (41 kcal/day; P = 0.375). The REE of black participants was lower than of white (146 kcal/day; P = 0.002). When adjusted for FFM and HFA z-score, the differences in REE declined but remained clinically meaningful at 91 kcal/day (P = 0.039) and 82 kcal/day (P = 0.108), respectively. We recommend the development of population-specific REE prediction equations for South. Afr. children.

The Diagnostic-Measurement Method-Resting Energy Expenditure Assessment of Polish Children Practicing Football

Establishing the amount of energy needed to cover the energy demand of children doing sport training and thus ensuring they achieve an even energy balance requires the resting energy expenditure (REE) to be estimated. One of the methods that measures REE is the indirect calorimetry method, which may be influenced by many factors, including body composition, gender, age, height or blood pressure. The aim of the study was to assess the correlation between the resting energy expenditure of children regularly playing football and selected factors that influence the REE in this group. The study was conducted among 219 children aged 9 to 17 using a calorimeter, a device used to assess body composition by the electrical bioimpedance method by means of segment analyzer and a blood pressure monitor. The results of REE obtained by indirect calorimetry were compared with the results calculated using the ready-to-use formula, the Harris Benedict formula. The results showed a significant correlation of girls’ resting energy expenditure with muscle mass and body height, while boys’ resting energy expenditure was correlated with muscle mass and body water content. The value of the REE was significantly higher (p ≤ 0.001) than the value of the basal metabolic rate calculated by means of Harris Benedict formula. The obtained results can be a worthwhile suggestion for specialists dealing with energy demand planning in children, especially among those who are physically active to achieve optimal sporting successes ensuring proper functioning of their body.

Resting Energy Expenditure of Physically Active Boys in Southeastern Poland-The Accuracy and Validity of Predictive Equations

Optimization of energy intake in the diet of young athletes is of primary importance. In addition to the energy expenditure associated with their body development, the demand resulting from intensive physical activity also increases. The aim of this study was to compare the accuracy of formulas commonly used for resting energy expenditure (REE) calculations with values obtained from measurements using indirect calorimetry among male children and adolescents practicing football. The study was conducted among 184 boys aged 9 to 17 using a calorimeter and a device for assessing body composition by means of electrical bioimpedance using a segment analyzer. The mean error ranged from −477 kcal/d by the Maffeis formula to −182 kcal/d for the Institute of Medicine of the National Academies (IMNA) formula. A statistically significant difference was found for all formulas in the calculated value in relation to the measured REE value (p < 0.0001). Most “ready-to-use” formulas underestimate REE, which can be a risk in determining the total energy demand in a group that requires more calories, especially when due to intensive growth and development and the expenditure associated with regular training and increased physical activity.

Treatment-related weight gain and metabolic complications in children with mental health disorders: potential role for lifestyle interventions

Over 1 million Canadian children are estimated to have a mental health disorder, which are commonly treated with medications, such as second-generation antipsychotics (SGAs). Estimates suggest that SGA prescriptions to children are increasing in Canada. Although these medications are important and lifesaving components of psychiatric treatment, they are not without side effects. For some children, SGA treatment is associated with adverse metabolic complications including rapid weight gain, dyslipidemia, elevated blood pressure, and risk for type 2 diabetes. It is not clear why these complications develop, but it is assumed that SGAs stimulate appetite and food intake, and reduce resting energy expenditure leading to weight gain and that the metabolic complications occur secondary to the weight gain. Understanding the mechanisms underlying these complications is key to being able to identify children at risk and prevent and optimize treatment. In this narrative review, we provide an overview of the literature pertaining to the weight gain and metabolic complications in children treated with SGAs, highlighting the scope of the problem and the current limited research on how diet and physical activity can be used to prevent or lessen the severity of the metabolic complications and improve the long-term health trajectories of SGA-treated children. Novelty: Children are increasingly being treated with second-generation antipsychotics for mental health disorders. Dietary and physical activity assessments are not commonly considered in clinical settings. Randomized controlled trials of lifestyle interventions are needed to determine the effectiveness of mitigating the cardiometabolic complications in second-generation antipsychotic-treated children.

Perioperative nutritional prehabilitation in malnourished children with congenital heart disease: A randomized controlled trial

OBJECTIVE

The poor preoperative nutritional state of children with congenital heart disease (CHD) is often exacerbated postoperatively. The aim of this study was to evaluate the effect of perioperative 1- versus 2-wk nutritional prehabilitation programs on growth and surgical outcomes in malnourished children with CHD.

METHODS

Forty malnourished infants scheduled for elective CHD surgery were randomized to receive either 1 or 2 wk of a nutritional prehabilitation program. Pre- and postoperative anthropometric parameters and feeding characteristics, feeding tolerance, duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS) and total hospital LOS were documented.

RESULTS

The 2-wk prehabilitation group showed higher weight-for-age z-score and body mass index than the 1-wk group both preoperatively postnutritional, and postoperatively with significantly higher weight gain postoperatively. The 2-wk prehabilitation group had a shorter duration of postoperative mechanical ventilation, ICU LOS, and total hospital LOS.

CONCLUSION

The 2-wk prehabilitation program was associated with better anthropometric measurements, shorter ICU LOS postoperatively, and shorter duration of hospitalization and mechanical ventilation. The preoperative nutritional status of children with CHD had a negative effect on ICU LOS and duration of mechanical ventilation.

Energy Expenditure in Mechanically Ventilated Korean Children: Single-Center Evaluation of a New Estimation Equation

OBJECTIVES

Accurate assessments of energy expenditure are vital for determining optimal nutritional support, especially in critically ill children. We evaluated current methods for energy expenditure prediction, in comparison with indirect calorimetry, and developed a new estimation equation for mechanically ventilated, critically ill Korean children.

DESIGN

Single-center retrospective study.

SETTING

Fourteen-bed pediatric medical ICU in a tertiary care children's hospital.

PATIENTS

Pediatric patients admitted to the PICU between October 2017 and September 2019 with a measured energy expenditure by indirect calorimetry.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total 95 pediatric patients (70 in derivation cohort for development of a new predictive equation and 25 in validation cohort) were included. Mean measured energy expenditure of group A was 66.20 ± 15.35 kcal/kg/d. All previously established predictive equations underestimated the predicted energy expenditure, compared with the measured energy expenditure, except the Food and Agriculture/World Health Organization/United Nations University equation. The Schofield-Height and Weight equation showed the best performance among the tested predictive equations for the entire cohort (least bias, -68.58 kcal/d; best percentage, 108.46% ± 33.60%) compared with the measured energy expenditure. It was also the best performing predictive equation in subgroup analysis by age, sex, nutritional status, and organ failure. Because some discrepancies remained between the measured energy expenditure and predicted energy expenditures, we developed a new estimation equation using multiple regression analysis and those variables significantly associated with our current measured energy expenditures: Energy expenditure = -321.264 + 72.152 × (body weight, kg)-1.396 × (body weight) + 5.668 × height (cm) + organ dysfunction* (*hematologic, 76.699; neurologic, -87.984). This new estimation equation showed the least bias and best percentage compared with previous predictive equations (least bias, 15.51 kcal/d; best percentage, 102.30% ± 28.10%).

CONCLUSIONS

There are significant disparities between measured and calculated energy expenditures. We developed a new estimation equation based on measured energy expenditure data that shows better performance in mechanically ventilated Korean children than other equations. This new estimation equation requires further prospective validation in pediatric series with a range in body habitus.

Development of new predictive equations for basal metabolic rate in Iranian healthy adults: negligible effect of sex

Some studies have reported inaccuracy of predicting basal metabolic rate (BMR) by using common equations for Asian people. Thus, this study was undertaken to develop new predictive equations for the Iranian community and also to compare their accuracy with the commonly used formulas. Anthropometric measures and thyroid function were evaluated for 267 healthy subjects (18-60 y). Indirect calorimetry (InCal) was performed only for those participants with normal thyroid function tests (n = 252). Comparison of predicted RMR (both kcal/d and kcal.kg.wt^-1.d^-1) using current predictive formulas and measured RMR revealed that Harris-Benedict and FAO/WHO/UNU significantly over-estimated and Mifflin-St. Jeor significantly under-estimated RMR as compared to InCal measurements. In stepwise regression analysis for developing new equations, the highest r² (=0.89) was from a model comprising sex, height and weight. However, further analyses revealed that unlike the subjects under 30 y, the association between age and the measured RMR in subjects 30 y and plus was negative (r = -0.241, p = 0.001). As a result, two separate equations were developed for these two age groups. Over 80 percent of variations were covered by the new equations. In conclusion, there were statistical significant under- and over-estimation of RMR using common predictive equations in our subjects. Using the new equations, the accuracy of the calculated RMR increased remarkably.

Validity of predictive equations to estimate RMR in females with varying BMI

Estimation of RMR using prediction equations is the basis for calculating energy requirements. In the present study, RMR was predicted by Harris–Benedict, Schofield, Henry, Mifflin–St Jeor and Owen equations and measured by indirect calorimetry in 125 healthy adult women of varying BMI (17–44 kg/m²). Agreement between methods was assessed by Bland–Altman analyses and each equation was assessed for accuracy by calculating the percentage of individuals predicted within ± 10 % of measured RMR. Slopes and intercepts of bias as a function of average RMR (mean of predicted and measured RMR) were calculated by regression analyses. Predictors of equation bias were investigated using univariate and multivariate linear regression. At group level, bias (the difference between predicted and measured RMR) was not different from zero only for Mifflin–St Jeor (0 (sd 153) kcal/d (0 (sd 640) kJ/d)) and Henry (8 (sd 163) kcal/d (33 (sd 682) kJ/d)) equations. Mifflin–St Jeor and Henry equations were most accurate at the individual level and predicted RMR within 10 % of measured RMR in 71 and 66 % of participants, respectively. For all equations, limits of agreement were wide, slopes of bias were negative, and intercepts of bias were positive and significantly (P < 0⋅05) different from zero. Increasing age, height and BMI were associated with underestimation of RMR, but collectively these variables explained only 15 % of the variance in estimation bias. Overall accuracy of equations for prediction of RMR is low at the individual level, particularly in women with low and high RMR. The Mifflin–St Jeor equation was the most accurate for this dataset, but prediction errors were still observed in about one-third of participants.

Prediction of Resting Energy Expenditure in Children: May Artificial Neural Networks Improve Our Accuracy?

The inaccuracy of resting energy expenditure (REE) prediction formulae to calculate energy metabolism in children may lead to either under- or overestimated real caloric needs with clinical consequences. The aim of this paper was to apply artificial neural networks algorithms (ANNs) to REE prediction. We enrolled 561 healthy children (2-17 years). Nutritional status was classified according to World Health Organization (WHO) criteria, and 113 were obese. REE was measured using indirect calorimetry and estimated with WHO, Harris-Benedict, Schofield, and Oxford formulae. The ANNs considered specific anthropometric data to model REE. The mean absolute error (mean ± SD) of the prediction was 95.8 ± 80.8 and was strongly correlated with REE values (R² = 0.88). The performance of ANNs was higher in the subgroup of obese children (101 ± 91.8) with a lower grade of imprecision (5.4%). ANNs as a novel approach may give valuable information regarding energy requirements and weight management in children.

A Comparative Analysis of Equations to Estimate Patient Energy Requirements Following Cardiopulmonary Bypass for Correction of Congenital Heart Disease

Background

No consensus exists on the optimal method to estimate resting energy expenditure (REE) in critically ill children following cardiopulmonary bypass (CPB). This study assesses the accuracy of REE estimation equations in children with congenital heart disease following CPB and tests the feasibility of using allometric scaling as an alternative energy prediction equation.

Methods

A retrospective analysis of a pediatric cohort following CPB (n = 107; median age 5.2 months, median weight 5.65 kg) who underwent serial measures (median 5 measurements) of REE using indirect calorimetry for 72 hours following CPB. We estimated REE using common estimation methods (Dietary Reference Intake, Harris Benedict, Schofield, World Health Organization [WHO]) as well as novel allometric equations. We compared estimated with measured REE to determine accuracy of each equation using overall discrepancy, calculated as a time‐weighted average of the absolute deviation.

Results

All equations incorrectly estimated REE at all time points following CPB, with overestimation error predominating. WHO had the lowest discrepancy at 10.7 ± 8.4 kcal/kg/d. The allometric equation was inferior, with an overall discrepancy of 16.9 ± 10.4. There is a strong nonlinear relationship between body surface area and measured REE in this cohort, which is a key source of estimation error using linear equations.

Conclusion

In a cohort of pediatric patients with congenital heart disease following CPB, no currently utilized clinical estimation equation reliably estimated REE. Allometric scaling proved inferior in estimating REE in children following CPB. Indirect calorimetry remains the ideal method of determining REE after CPB until nonlinear methods can be derived due to overestimation using linear equations.

Growth failure in focal dermal hypoplasia

Focal dermal hypoplasia (FDH) is a rare genetic disorder caused by mutations in the PORCN gene located on the X chromosome. Short stature was previously noted to be a common finding in FDH, however the etiology of this is unclear. The present study sought to elucidate specific causes for short stature by assessing growth charts, determining bone ages and auxologic measurements, examining laboratory data for the common causes of growth failure, assessing dietary intake, and performing a growth hormone stimulation test. Sixteen patients with FDH between the ages of 3 and 18 years of age consented to the study. While 11 out of 16 patients had short stature based on height less than 2 standard deviations below mid-parental target height percentile and bone age not suggestive of likely catch-up growth, only four had a BMI less than the 5th percentile for age. Laboratory studies did not support a gastrointestinal, allergy or autoimmune cause of growth failure. Three patients had results suggestive of possible growth hormone deficiency. Although short stature is a common feature in FDH, our data suggests that severe undernutrition is not common in this group and that there may be underlying treatable causes for this short stature in some patients.

Resting energy expenditure in infants with congenital diaphragmatic hernia without respiratory support at time of neonatal hospital discharge

BACKGROUND

Infants with congenital diaphragmatic hernia (CDH) are at risk for growth failure because of inadequate caloric intake and high catabolic stress. There is limited data on resting energy expenditure (REE) in infants with CDH.

AIMS

To assess REE via indirect calorimetry (IC) in term infants with CDH who are no longer on respiratory support and nearing hospital discharge with advancing post-conceptional age and to assess measured-to-predicted REE using predictive equations.

METHODS

A prospective cohort study of term infants with CDH who were no longer on respiratory support and nearing hospital discharge was conducted to assess REE via IC and caloric intake. Baseline characteristics and hospital course data were collected. Three day average caloric intake around time of IC testing was calculated. Change in REE with advancing post-conceptional age and advancing post-natal age was assessed. The average measured-to-predicted REE was calculated for the cohort using predictive equations [22].

RESULTS

Eighteen infants with CDH underwent IC. REE in infants with CDH increased with advancing postconceptional age (r2 = 0.3, p < 0.02). The mean REE for the entire group was 53.2 +/- 10.9 kcal/kg/day while the mean caloric intake was 101.2 +/- 17.4 kcal/kg/day. The mean measured-to-predicted ratio for the cohort was in the normal metabolic range (1.10 +/- 0.17) with 50% of infants considered hypermetabolic and 11% of infants considered hypo-metabolic.

CONCLUSIONS

Infant survivors of CDH repair who are without respiratory support at time of neonatal hospital discharge have REE, as measured by indirect calorimetry, that increases with advancing post-conceptional age and that is within the normal metabolic range when compared to predictive equations.

LEVEL OF EVIDENCE

III.

Resting energy expenditure in children with cerebral palsy: Accuracy of available prediction formulae and development of a population-specific formula

BACKGROUND AND AIMS

Energy requirements are difficult to estimate in children with cerebral palsy (CP). Resting energy expenditure (REE), necessary for personalized nutritional intervention, is most commonly estimated using prediction formulae because the reference method, i.e. indirect calorimetry (IC), is not available in all Nutrition Units. The main aim of the present study was to evaluate the accuracy of the most commonly used REE prediction formulae in children with CP. The secondary aim was to develop a new population-specific formula for the estimation of REE in children with CP.

METHODS

REE was measured by IC in 54 children and adolescents with spastic quadriplegic cerebral palsy (SQCP) and estimated from the five most commonly used prediction formulae, i.e. the World Health Organization (WHO), Harris-Benedict, Schofield weight, Schofield weight & height, and Oxford formulae.

RESULTS

The mean (standard deviation, SD) difference between the estimated and measured REE was 64 (238) kcal/day for the WHO formula, 79 (226) kcal/day for the Schofield weight formula, 79 (223) kcal/day for the Schofield weight and height formula, 55 (226) kcal/day for the Oxford formula, 37 (224) kcal/day for the Harris-Benedict formula and 0 (213) kcal/day for the purposely developed population-specific formula. Owing to the large SD of the bias, none of these formulae can be reliably applied at the individual level to estimate REE.

CONCLUSIONS

The most commonly used REE prediction formulas are inaccurate at both the population and individual level in children with SQCP. A purposely developed population-specific formula, despite being accurate at the population level, does not perform better than the most commonly used REE formulae at the individual level.

Evaluating the predictive factors of resting energy expenditure and validating predictive equations for Chinese obese children

BACKGROUND

To study the predictive factors of resting energy expenditure (REE) and evaluate the accuracy of predicted equations with indirect calorimeter (IC) in Chinese school-age children, particularly for the obese population.

METHODS

Recruited children were from the department of child healthcare in Nanjing children's hospital during July 2014-September 2015. Anthropometric parameters and body composition were measured by bioelectrical impedance. Measured REE was assessed by IC. Predicted REE was estimated using ten published equations.

RESULTS

248 children aged 7-13 years were recruited, including 148 obese [body mass index standard deviation score (BMISDS) = 2.48 ± 0.91] and 100 non-obese (BMISDS = - 0.96 ± 1.08). The unit mass of REE (REE/kg) in obese group (29.06 ± 5.74) was lower than that in non-obese group (37.51 ± 6.56). The stepwise regression showed that age, BMISDS and fat-free mass (FFM) had a major impact on REE/kg as the regression equation: Y = 54.41 - 1.36 × X₁ - 2.25 × X₂ - 0.16 × X₃ (Y REE/kg, X₁ age, X₂ BMISDS, X₃ FFM; R = 0.633, R² = 0.401, P < 0.01). The accuracy of predicted REE in obese subjects was 62.16% by the new predictive equations.

CONCLUSIONS

The REE/kg in obese children was lower and closely correlated with age, BMISDS and FFM. It is necessary to validate the new predictive equation in a larger sample to estimate energy requirements, particularly for children with obesity.

Pediatric Burn Care: Unique Considerations in Management

Severe pediatric burns require a multidisciplinary team approach at a specialized pediatric burn center. Special attention must be paid to estimations of total body surface area, fluid resuscitation and metabolic demands, and adequate analgesia and sedation. Long-term effects involve scar management and psychosocial support to the child and their family. Compassionate comprehensive burn care is accomplished by a multidisciplinary team offering healing in the acute setting and preparing the child and family for long-term treatment and care.

Comparison of Resting Energy Expenditure Assessment in Pediatric Oncology Patients

BACKGROUND

Evaluation of energy requirements is an important part of the nutrition assessment of pediatric oncology patients. Adequate provision of energy in this population is of extreme importance because of the prevalence of malnutrition and its effect on growth, development, quality of life, morbidity, and mortality. Numerous methods are used in clinical practice for estimating the resting energy expenditures (REE), specifically indirect calorimetry and predictive equations. A relatively new instrument used to assess REE is the hand-held indirect calorimeter. The purpose of this quality improvement project was to compare the accuracy of REE measurements taken by a hand-held indirect calorimeter and predictive equations to that of a standard indirect calorimeter metabolic cart.

METHODS

Patients receiving therapy for pediatric cancer, aged 7-18 years, and having a weight ≥15 kg and scheduled for a REE nutrition assessment were eligible. Sequentially, the patient's REE was assessed with the cart and the hand-held indirect calorimeter along with the predictive equation calculation.

RESULTS

Post hoc pairwise comparisons revealed that all 3 methods were significantly different from one another (P < .0001). When compared with the cart, the portable hand-held calorimeter was found to underestimate REE by 11.9%, whereas predictive equations overestimated REE by 12.4%.

CONCLUSION

Our quality improvement project suggests that the hand-held indirect calorimeter underestimated REE, and predictive equations overestimated REE in pediatric oncology nutrition assessment. Therefore, we recommend that these limitations in assessment be considered when assessing REE using a hand-held indirect calorimeter or predictive equations.

21st century toolkit for optimizing population health through precision nutrition

Scientific, technological, and economic progress over the last 100 years all but eradicated problems of widespread food shortage and nutrient deficiency in developed nations. But now society is faced with a new set of nutrition problems related to energy imbalance and metabolic disease, which require new kinds of solutions. Recent developments in the area of new analytical tools enable us to systematically study large quantities of detailed and multidimensional metabolic and health data, providing the opportunity to address current nutrition problems through an approach called Precision Nutrition. This approach integrates different kinds of "big data" to expand our understanding of the complexity and diversity of human metabolism in response to diet. With these tools, we can more fully elucidate each individual's unique phenotype, or the current state of health, as determined by the interactions among biology, environment, and behavior. The tools of precision nutrition include genomics, metabolomics, microbiomics, phenotyping, high-throughput analytical chemistry techniques, longitudinal tracking with body sensors, informatics, data science, and sophisticated educational and behavioral interventions. These tools are enabling the development of more personalized and predictive dietary guidance and interventions that have the potential to transform how the public makes food choices and greatly improve population health.

Nutritional management in the critically ill child with acute kidney injury: a review

Acute kidney injury (AKI) in critically ill children is frequently a component of the multiple organ failure syndrome. It occurs within the framework of the severe catabolic phase determined by critical illness and is intensified by metabolic derangements. Nutritional support is a must for these children to improve outcomes. Meeting the special nutritional needs of these children often requires nutritional supplementation by either the enteral or the parenteral route. Since critically ill children with AKI comprise a heterogeneous group of subjects with varying nutrient needs, nutritional requirements should be frequently reassessed, individualized and carefully integrated with renal replacement therapy. This article is a state-of-the-art review of nutrition in critically ill children with AKI.

Accuracy of Prediction Formulae for the Assessment of Resting Energy Expenditure in Hospitalized Children

BACKGROUND AND AIM

The resting energy expenditure (REE) of ill children is commonly estimated from prediction formulae developed in healthy children. The aim of the present study was to evaluate the accuracy of commonly employed REE prediction formulae versus indirect calorimetry in hospitalized children.

METHODS

We performed a cross-sectional study of 236 infants, children, and adolescents consecutively admitted to the Intermediate Care, Nephrology, Intensive Care, Emergency, and Cystic Fibrosis Units of the De Marchi Pediatric Hospital (Milan, Italy) between September 2013 and March 2015. REE was measured by indirect calorimetry and estimated using the World Health Organization (WHO), Harris-Benedict, Schofield, and Oxford formulae.

RESULTS

The mean (standard deviation) difference between the estimated and measured REE was: -1 (234) kcal/day for the WHO formula; 82 (286) kcal/day for the Harris-Benedict formula; 2 (215) kcal/day for the Schofield-weight formula; -2 (214) kcal/day for the Schofield-weight and height formula; and -5 (221) kcal/day for the Oxford formula. Even though the WHO, Schofield, and Oxford formulae gave accurate estimates of REE at the population level (small mean bias), all the formulae were not accurate enough to be employed at the individual level (large SD of bias).

CONCLUSIONS

The WHO, Harris-Benedict, Schofield, and Oxford formulae should not be used to estimate REE in hospitalized children.

Resting Energy Expenditure of Children and Adolescents With Nonalcoholic Fatty Liver Disease

BACKGROUND

The mainstay of treatment for pediatric nonalcoholic fatty liver disease (NAFLD) is lifestyle modification, which includes dietary changes that lead to slow but sustained weight loss or weight stabilization in growing children. Accurate estimation of energy requirements is necessary to achieve this goal. The objective of this study was to assess the accuracy of the most commonly used equations in predicting the resting energy expenditure (REE) of children with NAFLD.

METHODS

This was a retrospective study performed in a single institution. The predictive accuracy of various equations was assessed by comparing their estimates against the measured REE obtained with indirect calorimetry. Accuracy was defined as an estimate within 10% of measured REE.

RESULTS

Fifty-six children (70% male; 52% white and 36% Asian) with a median age of 13 years were included. The median measured REE was 1829 kcal/d. Of the equations studied, the Schofield had the smallest average bias (-32 kcal/d; confidence interval, -121 to 56). The Schofield and Molnar equations were the most accurate, providing REE estimates within 10% of measured in 59% of cases. The remaining equations had lower and variable predictive accuracy. The use of adjusted body weight in predictive equations did not improve the predictive accuracy.

CONCLUSION

In a cohort of children and adolescents with NAFLD, the Schofield and Molnar equations performed best in predicting energy expenditure. However, predictive equations were often inaccurate, suggesting that clinicians should interpret their results with caution and consider using indirect calorimetry when available.

Nutritional Intake, Energy Expenditure, and Growth of Infants Following Congenital Diaphragmatic Hernia Repair

BACKGROUND/OBJECTIVES

The pathophysiology of failure to thrive in congenital diaphragmatic hernia (CDH) has not been fully elucidated, and the nutritional care of these infants is hindered by paucity of data on the optimal calorie requirements for growth. The primary objective of this study was to investigate the energy intake required for infants with CDH to grow optimally at the time of first hospital discharge. The secondary objectives were to assess their measured resting energy expenditure in infancy, and their long-term growth outcomes.

METHODS

Nutritional intake, anthropometrics, indirect calorimetry results, and respiratory status of infants with CDH from 2011 to 2014 were collected retrospectively. Data on confounders (gastroesophageal reflux disease and feeding intolerance, respiratory rate and pulmonary hypertension) were also collected. Analyses were performed using Stata (College Station, TX).

RESULTS

Of the 72 infants diagnosed with CDH during that period of time, 43 met the inclusion criteria. A caloric intake of 125.0 ± 20 kcal · kg · day was required to meet discharge weight gain criteria (25-35 g · kg · day). In a subset of 17 patients, measured resting energy expenditure was higher than predicted resting energy expenditure (58.0 ± 18 vs 46.6 ± 3 kcal · kg · day, P < 0.05), and 59% of infants were hypermetabolic (measured resting energy expenditure >110% of predicted resting energy expenditure) in early infancy. Failure to thrive prevalence at discharge was 16.2% compared to 3.6% and 4.2% at 12- and 24-months of age, respectively (P = 0.03; P = 0.005, respectively).

CONCLUSIONS

Optimal weight gain can be achieved with higher than predicted calorie provision. Most infants with CDH are hypermetabolic. Despite this, failure to thrive prevalence can improve during the first year of life.

Can Vco2-Based Estimates of Resting Energy Expenditure Replace the Need for Indirect Calorimetry in Critically Ill Children?

BACKGROUND

Optimal energy provision, guided by measured resting energy expenditure (REE), is fundamental in the care of critically ill children. REE should be determined by indirect calorimetry (IC), which has limited availability. Recently, a novel equation was developed for estimating REE derived from carbon dioxide production (Vco₂). The aim of this study was to validate the accuracy of this equation in a population of critically ill children following cardiopulmonary bypass (CPB).

METHODS

This is an ancillary study to a larger trial of children undergoing CPB. Respiratory mass spectrometry was used measure oxygen consumption (Vo₂) and Vco₂. REE was then calculated according to the established Weir equation (REE_W) and the modified, Vco₂-based equation (REE_CO2). The agreement between the 2 measurements was assessed using Bland-Altman plots and mixed-model regressions accounting for repeated measures.

RESULTS

Data from 104 patients, which included 575 paired measurements, were included. The agreement between REE_W and REE_CO2 was biased during the 72-hour observation period post CPB, with a mean percentage error between measurements of 11% (±7%). The most important determinant of the bias with the Vco₂-based equation was the respiratory quotient (RQ). The percentage error between REE_W and REE_CO2 dropped to 4.4% (±2.4%) in those with an RQ between 0.8 and 1. The within-subject variability for RQ in this cohort was wide (11%).

CONCLUSIONS

IC remains the most accurate method to determine the REE of critically ill patients. Widespread availability of Vco₂ data renders Vco₂-based approaches to measurement of REE attractive; however, further research is needed to ensure that REE is estimated accurately.

Long-term nutritional morbidity for congenital diaphragmatic hernia survivors: Failure to thrive extends well into childhood and adolescence

BACKGROUND

Failure to thrive (FTT) is well documented among congenital diaphragmatic hernia (CDH) survivors ≤3years of age, but its etiology, severity, and persistence beyond this age require further elucidation.

METHODS

We conducted a single-center, retrospective study assessing anthropometrics, measured energy expenditure, and feeding tube (FT) use of 5-17 year olds in our multidisciplinary CDH clinic since January 2001. We stratified clinic visits based on age A: 5.0-6.9, B: 7.0-9.9, C: 10.0-14.9, and D: 15-17.9years.

RESULTS

One hundred sixteen patients with 376 outpatient visits were reviewed. Anthropometric z-scores were below zero and did not vary across age cohorts. FTT and growth stunting each occurred in 14% of clinic visits. FTs inserted during infancy occurred in 25% of patients, and 60% remained by age 7years. In cohort A, those with FTs were lighter and shorter than those without (p<0.05) but had similar BMIs. FTT incidence was higher in the FT group (p=0.020), but FTs were present in only 30% of those with FTT. Indirect calorimetry revealed increased energy expenditure in 58% of patients.

CONCLUSIONS

Failure to thrive continues in long-term CDH survivors, FTs may not improve incidence of FTT. Increased energy expenditure may play a role.