Malnutrition in critically ill children: from admission to 6 months after discharge

doi:10.1016/S0261-5614(03)00130-4

Clinical Nutrition

Volume 23, Issue 2, April 2004, Pages 223-232

https://doi.org/10.1016/S0261-5614(03)00130-4 Get rights and content

Abstract

Background & Aims: Little is known about the nutritional status of critically ill children during hospitalisation in and after discharge from an intensive care unit. We set up a prospective, observational study to evaluate the nutritional status of children in an intensive care unit from admission up to 6 months after discharge. A secondary aim was identifying patient characteristics that influence the course of the various anthropometric parameters.

Methods: The nutritional status of 293 children—104 preterm neonates, 96 term neonates and 93 older children—admitted to our multidisciplinary tertiary pediatric and neonatal intensive care unit was evaluated by anthropometry upon and during admission, at discharge and 6 weeks and 6 months following discharge.

Results: Upon admission, 24% of all children appeared to be undernourished. Preterm and term neonates, but not older children, showed a decline in nutritional status during admission. At 6 months after discharge almost all children showed complete recovery of nutritional status. Length of stay and history of disease were the parameters that most adversely affected the nutritional status of preterm and term neonates at discharge and during follow-up.

Conclusion: While malnutrition is a major problem in pediatric intensive care units, most children have good long-term outcome in terms of nutritional status after discharge.

Introduction

Critical illness has a major impact on the nutritional status of both children and adults. Studies conducted more than 20 years ago already demonstrated that 15–20% of children admitted to pediatric intensive care units were acutely or chronically malnourished.1., 2., 3., 4. Recent data on the prevalence of malnutrition in pediatric intensive care units are not available. It is not unimaginable, however, that this prevalence has changed, on account of improved intensive care technology, lowering of the age at which major surgery is performed and increased awareness of the significance of adequate nutritional support.

While follow-up studies concerning nutritional status in premature neonates are available,5., 6., 7. the nutritional status of critically ill children after discharge from an intensive care unit (ICU) has not been documented. The available follow-up studies focus on mortality and functional outcome,8., 9. rather than on nutritional status. Studies in specific subsets of patients, e.g. those with severe burns,10., 11. reveal impaired growth for up to 2 years.

The protein-energy malnutrition that may develop during ICU-stay is associated with an increase in morbidity and mortality,3., 12. whereas malnutrition in infancy is associated with poor growth and reduced or delayed mental and psychomotor development.5., 13., 14., 15. Recent studies in critically ill children showed a wide variation in individual energy expenditure.16., 17. This phenomenon would make them more vulnerable for energy malnutrition, seeing that a standard feeding protocol fails to take inter-individual differences into account. Moreover, individual assessment of a patient's nutritional status as guidance for nutritional support is not part of the routine procedures upon admission to a pediatric ICU. Because none of the available methods—including weight measurements, biochemical parameters, and dual-energy X-ray absorptiometry (DEXA)—is free from pitfalls, there is no single best test for nutritional assessment in ICU patients. Newly introduced non-invasive techniques, such as bioelectrical impedance analysis (BIA) and DEXA, have shown to be difficult in practice and very demanding, and most have not been validated for critically ill children, notably the very young.18., 19. Furthermore, in the acute setting hormonal and biochemical nutritional assessment parameters are predominantly useful as markers of disease severity and not of nutritional status per se.²⁰ This leaves anthropometry as the best tool currently available for assessing the nutritional status of a heterogeneous group of critically ill children, the more so because recent reference values are available for the different age groups and sexes.²¹

We conducted a prospective observational study to determine the nutritional status of a cohort of critically ill children by means of anthropometric parameters from admission to 6 months after discharge from a tertiary intensive care unit. Furthermore, we set out to identify risk factors for poor nutritional status at admission and during follow-up.

Section snippets

Materials and methods

Children admitted during the year 2001 to our level III multidisciplinary neonatal and pediatric\surgical intensive care unit (ICU) with an expected stay of at least 48 h were included in the study, provided written parental informed consent had been obtained. Exclusion criteria were withholding or withdrawing of treatment, inclusion into another nutritional intervention study, and treatment with Extra Corporeal Membrane Oxygenation (ECMO). Most patients on ECMO develop extreme generalised

Subjects

A total of 342 children were enrolled in the study. For various reasons 49 of them were not included in the analyses (Fig. 1). The characteristics and diagnoses of the remaining 293 children are shown in Table 1.

The first and second follow-up measurements actually took place after a mean (SD) of 6.3±1.8 and 26.6±3.3 weeks after discharge, respectively. We collected data of 268 (91%) children at first follow up and 260 (89%) children at second follow up.

Table 2 shows the SD-scores of all

Discussion

This study aimed at evaluating how admission to a specialised intensive care unit affects children's nutritional status during hospitalisation and up to 6 months after discharge. It yielded some remarkable findings on the prevalence of malnutrition upon admission and follow-up, and on the risk factors as well. The novelty of this study lies in starting nutritional assessment measurements as early as in the acute phase of the critical illness. While several studies have been performed in small,

Acknowledgements

The authors thank the participating children and their parents. Our gratitude goes out to the nursing and medical staff of the Neonatal, Pediatric and Surgical Intensive care unit and the outpatient clinic of the Erasmus MC-Sophia Children's hospital, without whose support this study would not have been possible. We also thank Ko Hagoort (Erasmus MC, Rotterdam) for his careful editing.

References (42)

R.J Merritt et al.
Nutritional survey of hospitalized pediatric patients
Am J Clin Nutr
(1979)
D.W Hart et al.
Persistence of muscle catabolism after severe burn
Surgery
(2000)
P.S Klein et al.
Effects of starvation in infancy (pyloric stenosis) on subsequent learning abilities
J Pediatr
(1975)
M Winick
Malnutrition and brain development
J Pediatr
(1969)
H.N Lafeber
Nutritional assessment and measurement of body composition in preterm infants
Clin Perinatol
(1999)
M.P Fuhrman
The albumin-nutrition connectionseparating myth from fact
Nutrition
(2002)
A.R Frisancho
Triceps skin fold and upper arm muscle size norms for assessment of nutrition status
Am J Clin Nutr
(1974)
R Usher et al.
Intrauterine growth of live-born Caucasian infants at sea levelstandards obtained from measurements in 7 dimensions of infants born between 25 and 44 weeks of gestation
J Pediatr
(1969)
J.A Brunton et al.
Growth and body composition in infants with bronchopulmonary dysplasia up to 3 months corrected agea randomized trial of a high-energy nutrient-enriched formula fed after hospital discharge
J Pediatr
(1998)
J.B van Goudoever et al.
Short-term growth and substrate use in very-low-birth-weight infants fed formulas with different energy contents
Am J Clin Nutr
(2000)

R.J Andrassy et al.

Long-term nutritional assessment of patients with esophageal atresia and/or tracheoesophageal fistula

J Pediatr Surg

(1983)

J Edington et al.

Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group

Clin Nutr

(2000)

P Ravasco et al.

A critical approach to nutritional assessment in critically ill patients

Clin Nutr

(2002)

W Hendrikse et al.

Malnutrition in a children's hospital

Clin Nutr

(1997)

M.M Pollack et al.

Early nutritional depletion in critically ill children

Crit Care Med

(1981)

M.M Pollack et al.

Malnutrition in critically ill infants and children

J Parenter Enteral Nutr

(1982)

M.M Pollack et al.

Nutritional depletions in critically ill childrenassociations with physiologic instability and increased quantity of care

J Parenter Enteral Nutr

(1985)

A Lucas et al.

Randomised trial of early diet in preterm babies and later intelligence quotient

BMJ

(1998)

A Ruiz-Extremera et al.

Neurodevelopment of neonates in neonatal intensive care units and growth of surviving infants at age 2 years

Early Hum Dev

(2001)

W.H Kitchen et al.

Very low birth weight and growth to age 8 years. Iweight and height

Am J Dis Child

(1992)

W Butt et al.

Long-term outcome of children after intensive care

Crit Care Med

(1990)

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ORIGINAL ARTICLEMalnutrition in critically ill children: from admission to 6 months after discharge☆

Abstract

Introduction

Section snippets

Materials and methods

Subjects

Discussion

Acknowledgements

Am J Clin Nutr

Surgery

J Pediatr

J Pediatr

Clin Perinatol

Nutrition

Am J Clin Nutr

J Pediatr

J Pediatr

Am J Clin Nutr

J Pediatr Surg

Clin Nutr

Clin Nutr

Clin Nutr

Early nutritional depletion in critically ill children

Crit Care Med

Malnutrition in critically ill infants and children

J Parenter Enteral Nutr

Nutritional depletions in critically ill childrenassociations with physiologic instability and increased quantity of care

J Parenter Enteral Nutr

Randomised trial of early diet in preterm babies and later intelligence quotient

BMJ

Neurodevelopment of neonates in neonatal intensive care units and growth of surviving infants at age 2 years

Early Hum Dev

Very low birth weight and growth to age 8 years. Iweight and height

Am J Dis Child

Long-term outcome of children after intensive care

Crit Care Med

ORIGINAL ARTICLE
Malnutrition in critically ill children: from admission to 6 months after discharge☆