Measured versus predicted resting energy expenditure in infants: A need for reappraisal

doi:10.1016/S0022-3476(95)70494-9

The Journal of Pediatrics

Volume 126, Issue 1, January 1995, Pages 21-27

https://doi.org/10.1016/S0022-3476(95)70494-9 Get rights and content

Abstract

The reliability of commonly used predictive equations for estimating energy expenditure in infants in both health and disease was assessed by comparing resting energy expenditure (REE, measured by indirect calorimetry) in relation to weight, height, and body cell mass (by total body potassium analysis) with predictive equations (Harris-Benedict, Food and Agriculture Organization/ World Health Organization/United Nations University [FAO/WHO/UNU], Schofield weight-only, and Schofield weight-and-height equations) in 36 healthy infants (age 0.43 ± 0.27 years; 19 male) and in 9 infants with cystic fibrosis (age 0.41 ± 0.30 years; 4 male). Mean ± SD REE for healthy boys was 0.205 ± 0.019 MJ kg^-1 day^-1 and for healthy girls 0.217 ± 0.026 MJ kg^-1 day^-1. Infants with cystic fibrosis had a significantly higher REE (0.258 ± 0.034 vs 0.210 ± 0.024 MJ kg^-1 day^-1; p < 0.005). Compared with measured values, predicted REE values varied markedly among equations, overestimating REE in healthy infants (Harris-Benedict equation, 182% ± 63% [SD] of measured values; FAO/WHO/UNU equation, 104% ± 14%; Schofield weight-only equation, 107.5% ± 14%; and Schofield weight-and-height equation, 106% ± 11%) and underestimating REE in those with cystic fibrosis (84% to 88% for the FAO/WHO/UNU, Schofield weight-only, and Schofield weight-and-height equations) except the Harris-Benedict equation (152%). On regression analysis both weight and body cell mass were related significantly to REE (r² = 0.87 and r² = 0.61, respectively) for normal infants and (r² = 0.92 and r² = 0.94) for those with cystic fibrosis. Using a generalized linear model of variance, we saw a significant ( p < 0.001) variability among all REE measures. Thus we could rely on none of the predictive equations to give an accurate estimate of REE, and hence energy and fluid requirements, in individual infants. We suggest that when accurate estimates are needed, measurement of REE in individual infants should be attempted, especially in disease states, and that the continued use of current formulas should be reexamined. (J PEDIATR 1995;126:21-7)

Section snippets

Subjects

Thirty-six healthy infants (age 0.43 ± 0.27 years; 19 male) and nine infants with cystic fibrosis homozygous for the δF508 mutation (age 0.41 ± 0.30 years; 4 male) were studied. Sixteen of the healthy infants received more than 90% of their daily caloric intake as human milk, and neither the infants nor any of the breast-feeding mothers were taking medications, or had intercurrent infections or pyrexia. Infants were volunteered for this noninvasive study by their parents, and written informed

RESULTS

The age, weight, height, weight/height percentage, BCM represented by the TBK in grams, and the TBK expected for age and weight are represented in Table II. The CF group had a lower-than-expected BCM for age but also a lower BCM per unit of weight than normal infants, indicating altered body composition. The measured REE expressed in terms of weight and TBK are represented in Fig. 1, Fig. 2 for the healthy group (also divided into subsets of male, female, birth to 6 months of age, and 6 to 12

DISCUSSION

Estimation of nutritional and fluid requirements based on determination of energy expenditure by the use of predictive formulas is, on the basis of this study, prone to inaccuracy in individual infants, consistently overestimating energy and fluid requirements in healthy infants, and sometimes significantly underestimating them in disease states.

Schofield⁷ emphasised the wide coefficient of variation when these formulae are used to predict REE in healthy subjects, as opposed to group estimates

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The indirect calorimetry in very low birth weight preterm infants: An easier and reliable procedure
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Citation Excerpt :
Ensuring proper growth through the administration of adequate energy and protein intake is essential to prevent medium- and long-term complications associated with extrauterine growth retardation [2,7–9]. Often, the resting energy expenditures (REEs) are derived from the application of predictive formulae, as described by Schofield [10] in the1980s, but some evidence supports performing an actual analysis of energy expenditure rather than using prediction formulae [11–17]. There are different methods to measure energy expenditure such as direct calorimetry, indirect calorimetry, and doubly labeled water.
Preterm infants are at increased risk of developing extrauterine growth restriction, which is associated with worse health outcomes. The energy needs are not well known, as the measurement of resting energy expenditure (REE) using indirect calorimetry has critical issues when applied to infants. One of the main issues is the time required to obtain reliable data owing to the difficulty in keeping infants quiet during the entire examination. Thus, the aim of this study was to define the minimum duration of calorimetry to obtain reliable data.
The volume of oxygen consumption (VO₂) and the volume of carbon dioxide production (VCO₂) were recorded for a mean duration of 90 consecutive minutes. REE was calculated using a neonatal prototype calculator. We extracted data regarding VO₂, VCO₂, and REE at 10(T1), 20(T2), 30(T3), 40(T4), and 50(T5) minutes of steady state and compared these data to those of entire steady state period.
Twenty-six very low birth weight preterm infants were evaluated at 36.58 ± 0.99 wk corrected age. Infants were appropriate for gestational age and clinically stable without comorbidities. There were no significant differences between mean VO₂ and REE at T1 (8.26 ± 1.45 mL/kg to 57.80 ± 10.51 kcal/kg), T2 (8.15 ± 1.41 mL/kg to 56.87 ± 10.05 kcal/kg), T3 (8.04 ± 1.41 mL/kg to 56.32 ± 9.73 kcal/kg), T4 (8.05 ± 1.41 mL/kg to 56.07 ± 10.28 kcal/kg), and T5 (8.06 ± 1.55 mL/kg to 57.17 ± 11.62 kcal/kg), respectively, compared to steady state (8.13 ± 1.33 mL/kg to 56.77 ± 9.34 kcal/kg). The median values of VCO₂ were significantly different only when T1 data were compared with other time slots (7.02 ± 1.02 mL/kg at steady state; 7.26 ± 1.23 mL/kg at T1; 7.13 ± 1.20 mL/kg at T2; 7.02 ± 1.19 mL/kg at T3; 6.85 ± 1.16 mL/kg at T4; 6.91 ± 1.24 mL/kg at T5).
Twenty consecutive minutes in steady state condition are sufficient to obtain reliable data on REE in stable, very low birth weight infants.
Simple and accurate assessment of energy expenditure in ventilated paediatric intensive care patients
2004, Clinical Nutrition
Aims: To assess validity and reliability of energy expenditure measurements with a short Douglas bag protocol compared to the standard metabolic monitor in a paediatric intensive care setting.
Methods: 51 paired measurements were performed in 14 ventilated patients (age 0–18 years) with sepsis, trauma or following major surgery. Measured data were compared mutually and compared to Schofield equations using Bland–Altman analysis.
Results: Comparing Douglas bag (3.21±1.43 MJ/day) and metabolic monitor (3.15±1.49 MJ/day) we found bias in energy expenditure of −0.06 (equal to −2%, NS) with limits of agreement of −0.5 to 0.4 MJ/day (equal to −16% to +13%). Intra-measurement variability (coefficient of variation) was within 10% for both methods. Both the metabolic monitor and Douglas bag showed significant bias compared to Schofield equations (3.39±1.64 MJ/day) of −7% (P<0.01) and −5% (P<0.05), respectively, with wide limits of agreement: metabolic monitor vs. Schofield: −37% to +22%, Douglas bag vs. Schofield: −37% to +26%.
Conclusions: The Douglas bag method compared favourably to the metabolic monitor where Schofield equations failed to predict individual energy expenditure. Considering its low cost, this renders the short and simple Douglas bag method a robust measure and a routinely applicable instrument for tailored nutritional assessment in critically ill children.
Nutrition in patients with cystic fibrosis: A European Consensus
2002, Journal of Cystic Fibrosis
This document is the result of an European Consensus conference which took place in Artimino, Tuscany, Italy, in March 2001 involving 33 experts on nutrition in patients with cystic fibrosis, organised by the European Cystic Fibrosis Society, and sponsored by Axcan-Scandipharm, Baxter, Dr Falk Pharma, Fresenius, Nutricia, SHS International, Solvay Pharmaceuticals (major sponsor). The purpose of the conference was to develop a consensus document on nutrition in patients with cystic fibrosis based on current evidence.
Energy metabolism in infants with cystic fibrosis
2002, Journal of Pediatrics
Citation Excerpt :
These data suggest that there is no abnormality in the proportion of extracellular water in subjects with CF with mild lung disease, allowing energy expenditure to be expressed in terms of FFM. The failure of established predictive equations to accurately estimate BMR for both healthy and newly diagnosed infants with CF in this study is consistent with previous observations.30 Consistent with an earlier report,1 TEE was not elevated in subjects with CF. Similarly, the MEI and the ratios of its components were not significantly different between CF and control infants.
Objective: To determine whether a defect in energy metabolism exists in infants with cystic fibrosis (CF). Design: Unselected, newly-diagnosed subjects with CF (n = 46) and 24 healthy infants aged <20 weeks had measurements of resting energy expenditure (REE), total energy expenditure (TEE) (n = 25), and body composition. Metabolizable energy intake (MEI) was calculated. Genotype, energy intake, and pancreatic status was determined in all subjects with CF, and 24 underwent bronchial lavage. Results: At diagnosis, infants with CF detected by newborn screening had significant anthropometric deficits (mean [SD] z-weight = 0.5 [1.0], z-length = 0.7 [1.3]) associated with pancreatic insufficiency. Their REE, TEE, or MEI (absolute measurements, per unit body weight or fat-free mass) were not increased. No relationship between REE, TEE, or MEI and ΔF₅₀₈ genotype, and no proportional differences in individual components of MEI between subjects with CF and controls, or between subjects with CF who were homozygotes or compound heterozygotes for ΔF₅₀₈ were observed. REE and TEE were not correlated with bronchial infection or inflammation. Conclusion: Growth impairment during the first weeks of life in infants with CF is associated with pancreatic insufficiency. However, there is no evidence for a defect of energy metabolism related to ΔF₅₀₈, and in infants with CF, minimal lung disease is unaccompanied by increased energy expenditure. (J Pediatr 2002;140:527-33)
Energy expenditure and the body cell mass in cystic fibrosis
2001, Nutrition
Poor nutritional status in patients with cystic fibrosis (CF) is associated with severe lung disease, and possible causative factors include inadequate intake, malabsorption, and increased energy requirements. Body cell mass (which can be quantified by measurement of total body potassium) provides an ideal standard for measurements of energy expenditure. The aim of this study was to compare resting energy expenditure (REE) in patients with CF with both predicted values and age-matched healthy children and to determine whether REE was related to either nutritional status or pulmonary function. REE was measured by indirect calorimetry and body cell mass by scanning with total body potassium in 30 patients with CF (12 male, mean age = 13.07 ± 0.55 y) and 18 healthy children (six male, mean age = 12.56 ± 1.25 y). Nutritional status was expressed as a percentage of predicted total body potassium. Lung function was measured in the CF group by spirometry and expressed as the percentage of predicted forced expiratory volume in 1 s. Mean REE was significantly increased in the patients with CF compared with healthy children (119.3 ± 3.1% predicted versus 103.6 ± 5% predicted, P < 0.001) and, using multiple regression techniques, REE for total body potassium was significantly increased in patients with CF (P = 0.0001). There was no relation between REE and nutritional status or pulmonary disease status in the CF group. In conclusion, REE is increased in children and adolescents with CF but is not directly related to nutritional status or pulmonary disease.
An overview of nutritional issues for the adult with cystic fibrosis
2000, Nutrition

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^☆: From the Department of Child Health, Children's Nutrition Research Center, Royal Children's Hospital, and the Queensland Institute of Medical Research, Brisbane, Australia.

^☆☆: Reprint requests: R.W. Shepherd, MD, FRACP, Department of Child Health, Royal Children's Hospital, Brisbane, Queensland 4029, Australia.

^★: 0022-3476/95/$3.00 + 0 9/20/59481

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Measured versus predicted resting energy expenditure in infants: A need for reappraisal☆,☆☆,★

Abstract

Section snippets

Subjects

RESULTS

DISCUSSION

Lancet

J PEDIATR

J PEDIATR

J P EDIATR

Lancet

Lancet

J PEDIATR

Versammlung deutsch Naturfarscher u Aezte in München

Basal metabolism of girls: physiological background and application of standards

Am J Dis Child

Studies of the energy of metabolism of normal individuals: a standard for basal metabolism with nomogram for clinical application

Am J Physiol

A biometric study of basal metabolism in man

Energy and protein requirements: report of a joint FAO/WHO/UNU expert consultation

Predicting basal metabolic rate, new standards and review of previous work

Hum Nutr Clin Nutr

Basal metabolism in children.

The maintenance need for water in parenteral fluid therapy

Paediatrics