Patrícia Zamberlan

Nutrition Therapy in a Pediatric Intensive Care Unit Indications, Monitoring, and Complications

BACKGROUND Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patients risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). METHODS The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo, Brazil. NT was established according to the protocol provided by the institutions NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. RESULTS NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a postpyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skinfold thickness decreased. CONCLUSIONS The use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggests that NT probably helped patients maintain their nutrition status.

Challenges of nutritional assessment in pediatric ICU.

Purpose of reviewThe nutritional assessment of children in the pediatric ICU is unique in view of the metabolic changes of the underlying disease. This review addresses the use and limitations of anthropometry and laboratorial and body composition markers in the diagnosis of the nutritional status of such patients. Recent findingsThe presence of inflammatory activity leads to body composition changes (lean mass reduction) and undernutrition. Nutritional assessment in pediatric ICU must prioritize anthropometric and laboratory markers that can differentiate body composition to detect specific macronutrient and micronutrient deficiencies and assessment of the inflammatory activity. SummaryNutritional assessment is one of the main aspects of the pediatric intensive care patient and is the most important tool to avoid hospital undernutrition. There is currently no gold standard for nutritional assessment in the pediatric ICU. The results of anthropometric and laboratory markers must be jointly analyzed, but individually interpreted according to disease and metabolic changes, in order to reach a correct diagnosis of the nutritional status and to plan and monitor the nutritional treatment.

Changes in lipid metabolism in pediatric patients with severe sepsis and septic shock

OBJECTIVES Limited knowledge exists regarding the lipid profiles of critically ill pediatric patients with systemic inflammatory response syndrome. The aim of this study was to evaluate the relationship between the intensity of the inflammatory response and changes in the lipid profiles of critically ill pediatric patients admitted to a pediatric intensive care unit (PICU) with severe sepsis/septic shock. METHODS This was a prospective and observational study at a 15-bed PICU at a public university hospital. We analyzed the lipid profiles of 40 patients with severe sepsis/septic shock admitted to the PICU on the first and seventh days of hospitalization. C-reactive protein was used as a marker for systemic inflammation. Forty-two pediatric patients seen in the emergency department and without systemic inflammatory response syndrome were used to provide control values. RESULTS On day 1 of admission to the PICU, the patients had significantly lower levels of total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) as well as higher concentrations of triacylglycerols compared with the control group. There was a significant increase in the TC, HDL, LDL, and apolipoprotein levels from day 1 to day 7 of the study. CONCLUSIONS During severe sepsis/septic shock, we found lower serum levels of lipoproteins and apolipoproteins, and these were negatively correlated with C-reactive protein. As the inflammatory response improved, the levels of TC, HDL, LDL, and apolipoproteins increased, suggesting a direct relationship between changes in the lipid profiles and inflammation.

Lymphocyte count as a sign of immunoparalysis and its correlation with nutritional status in pediatric intensive care patients with sepsis: A pilot study

OBJECTIVES: Developing malnutrition during hospitalization is well recognized worldwide, and children are at a relatively higher risk for malnutrition than adults. Malnutrition can lead to immune dysfunction, which is associated with a higher mortality rate due to sepsis, the most frequent cause of death in pediatric intensive care units (PICUs). The aim of this study was to investigate whether malnourished patients are more likely to have relative or absolute lymphopenia and, consequently, worse prognoses. METHODS: We enrolled 14 consecutive patients with sepsis whose legal representatives provided written informed consent. Patients were classified as normal or malnourished based on anthropometric measurements. As an additional evaluation of nutritional status, serum albumin and zinc were measured on the 1st and 7th days of hospitalization. Lymphocyte count was also measured on the 1st and 7th days. Clinicaltrials.gov: NCT02698683. RESULTS: Malnutrition prevalence rates were 33.3% and 42.8% based on weight and height, respectively. Laboratory analyses revealed a reduction of serum albumin in 100% of patients and reduction of zinc in 93.3% of patients. A total of 35% of patients had fewer than 500 lymphocytes/mm3 on their first day in the PICU. Lymphocyte counts and zinc concentrations significantly increased during hospitalization. CONCLUSIONS: Nutritional evaluations, including anthropometric measurements, were not correlated with lymphocyte counts. Lymphocyte counts concomitantly increased with zinc levels, suggesting that micronutrient supplementation benefits patients with sepsis.

Will the Use of Anthropometric Measurements Solely to Assess Nutritional Status in Picu Suffice

To the Editor: Undernutrition is highly prevalent in critically ill children throughout the world. Several studies performed in Brazil and in developing countries demonstrated that this condition can affect 50% of children and adolescents during hospitalization and it is associated with increased morbidity and mortality, including: a higher risk of infections due to transitory immunologic disorder, inadequate wound-healing, reduced gut function, longer dependency on mechanical ventilation, and lengthier hospital stays (1). Although undernutrition has been reported to prolong hospital stays thus increasing the risk of infection and mortality in patients in PICU, the appropriateness of these assertions is waned due to the diagnostic methods (2, 3). In a recent issue of Critical Care Medicine, Bechard et al (4) in a multicenter study with a large population showed that undernutrition at admission evaluated by anthropometry was associated with higher risk of mortality and fewer ventilator-free days. Body mass index (BMI) was used by the authors to evaluate the nutritional status in a study conducted in a tertiary level PICU (utilizing a smaller population sample) by means of anthropometric methods, and it was demonstrated that BMI does not seem to be a good discriminator of nutritional status of children (3). Despite the importance of anthropometry we reckon, it is a part of overall nutritional assessment, but it is difficult to interpret because the measurements may be influenced by factors caused by disease or trauma, (e.g., fluid retention and swelling) and by the quality of measurements with large inter and intraobserver variability. In this way, we think that the estimation of measurements should be avoided, and if Bechard et al (4) had used median instead of mean for the majority of data, the results may have been different. Taking into account the importance of collecting accurate measurements, Valla et al (5) proposed a targeted nutritional assessment teaching program that enhanced staff knowledge and nutritional practices including techniques of measurements. Therefore, we have wondering in PICU whether anthropometry, despite its limitations, is as efficient as other evaluation methods such as the assessment of body composition by bioelectrical impedance and arm measurements, increasingly used in PICU. In view of these aspects, nutritionrelated serum biomarkers have been used to predict clinical outcomes, although a recent systematic review of nutritional indicators in critically ill adults concluded that markers with good specificity are rare (6). Furthermore, the absence of nutritional condition monitoring and insufficient nutritional support during hospitalization can also be associated to negative clinical outcomes in PICU. In the study by Bechard et al (4), a detailed description of the nutritional evaluation routine as well as a followup during in PICU to assess this influence in outcomes of The authors reply:

Pediatric ICU and Nutritional Assessments

Nutrient Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Amino Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Minerals and Trace Elements . . . . . . . . . . . . . . . . . . . . . . . . 336

Use of a symbiotic supplement in a child with short bowel Syndrome: a case report

UNLABELLED The short bowel syndrome (SBS) is due to loss of bowel after surgery. Characterized by generalized nutrients malabsorption, its signs and symptoms include electrolyte imbalance, deficiency of vitamins, minerals and nutrients that can lead to death. Parenteral and enteral nutrition have a key role in its treatment. OBJECTIVE To describe the clinical course of a patient with SBS during continuous use of enteral nutrition supplemented with symbiotic. CASE REPORT A seven-year-old male underwent an emergency laparotomy at 18 months old with a massive bowel resection, remaining about 20 cm of the small intestine and the entire colon. He was dependent of exclusive parenteral nutrition for over a year, leading to the occurrence of numerous infectious complications. Due to complications caused by prolonged use of central venous access, was unable to continue to receive the parenteral nutrition. Enteral nutrition by a nasogastric tube and supplemental symbiotic was the nutritional therapy option for him. The assessment of the volume of losses by the colostomy was measured daily. RESULTS There was a significant reduction of losses by colostomy, especially in the first days after introduction of the enteral nutrition plus symbiotic supplementation, as well as significant decrease in gas production. CONCLUSION Despite the lack of evidence for a formal recommendation on the use of symbiotic for SBS patients, its use in the nutritional therapy of this patient resulted in reduced electrolyte loss electrolyte and consequent improvement of his clinical and nutritional condition.

Nasojejunal versus nasogastric nutritional support: ending a debate.

Critical Care Medicine www.ccmjournal.org e17 analysis of only those patients receiving antipseudomonal βlactams further supports our conclusion. Although fluoroquinolones may offer advantages over macrolides in specific clinical situations, our data support that the β-lactam plus macrolide combination is superior to the β-lactam plus fluoroquinolone combination in the setting of empiric therapy for severe community-acquired pneumonia. The mechanism behind the improved outcomes remains to be elucidated, but our findings are in line with several previous studies, which found macrolide combination therapy to improve outcomes over both fluoroquinolone monotherapy and combination therapy (2–5). Ultimately, our hypothesis driven study further reaffirms the need for well-designed randomized clinical trials. Dr. Anzueto consulted for GlaxoSmithKline, Dey Pharma, Pfizer, BI, Bayer-Shering Pharma, and Astra Zeneca (not related); and received payments for lectures from GlaxoSmithKline, Dey Pharma, Pfizer, BI, Bayer-Schering Pharma, and Astra Zeneca. Dr. Restrepo received a grant from the National Heart, Blood and Lung Institute (time partially protected by the Award Number K23HL096054) and the National Institutes of Health (NIH); and consulted for the data safety monitoring board Theravance and Trius. Dr. Pugh received grant support from the NIH. Mr. Wilson received a grant from the National Institute of Nursing Research-MSTAR Program. Dr. Mortensen received a grant from the NIH.