ORIGINAL ARTICLEThe effect of cumulative energy and protein deficiency on anthropometric parameters in a pediatric ICU population
Introduction
It is generally acknowledged that nutritional support is essential in the care for children with (chronic) disease since inadequate feeding may increase morbidity and mortality and negatively affect body composition and growth.1., 2. There are, however, limited prospective data available describing non-selected groups of children admitted to a pediatric intensive care unit (ICU). Protein-energy malnutrition has been found to occur in 15–20% of critically ill children.3., 4., 5., 6. Lacking endogenous stores of protein and fat and having higher baseline requirements, neonates and children under the age of 2 are particularly susceptible to loss of lean body mass and its related morbidity.7
In critically ill children sustained catabolism may lead to severe protein-energy malnutrition. Although in this situation both protein synthesis and protein breakdown are intensified, the latter predominates. Thus, critically ill children manifest a net negative protein balance, which may clinically be noted by weight loss, negative nitrogen balance and skeletal muscle wasting. Supplementation of amino acids, has shown to improve protein balance by increasing protein synthesis in preterm infants.8., 9. Providing adequate dietary protein may, therefore, be a very important nutritional intervention in critically ill children.
Nutritional regimens for energy and protein at an ICU are frequently based on recommended intakes for healthy children (RDA). Complying with these reference values is controversial, however, in the first stage of acute illness when energy needs might be lower or higher than RDA and protein needs might be higher.10., 11. A more precise, individual estimation of energy requirements can be obtained by measuring an infant's actual energy expenditure.
Once nutritional support is started, its adequacy may be assessed by parameters of nutritional status, such as anthropometric measurements. Studies in preterm infants showed a significant accumulation of nutrient deficits in the first few weeks of postnatal life resulting in severe growth retardation.12., 13., 14. Cumulative nutritional deficits have not yet been investigated in other age groups admitted to an ICU, except in critically ill infants with lower respiratory tract infections, though without paying attention to impact on growth or changes in body composition.15
The first aim of our study was to prospectively assess daily and cumulative energy and protein intakes of a cohort of critically ill children during their first 14 days in the ICU, and to compare these intakes to the RDA. The second purpose was to examine relationships between accumulated energy and protein intake and changes in anthropometric parameters.
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Subjects
Children admitted during the year 2001 to our level III multidisciplinary neonatal and pediatric/surgical 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 withdrawal of treatment, inclusion into another nutritional study, or treatment with extra corporeal membrane oxygenation (ECMO). The institutional review board of Erasmus MC approved the study protocol.
The patients were
Results
A total of 342 children were enrolled in the study, of which 81 children were not included in the analyses for various reasons (Fig. 1). The characteristics and diagnoses of the remaining 261 children are shown in Table 1. Frequencies of routes of nutritional supply changed during the ICU-stay. Overall, 59% of the children on day 1 received parenteral feeding exclusively (21% only glucose solution), a proportion which gradually decreased to 10% on day 14. Administration of enteral feeding (full
Discussion
This observational study shows that under the current feeding regimen, and using the RDA as the value for optimal energy and protein intake, an unselected group of children admitted to the ICU suffers from considerable cumulative energy and protein deficits.
The cumulative deficits in energy and protein intake relative to RDA were related to decreases in anthropometric variables between admission and discharge/day 14 after admission. This relationship underscores the inadequacy of nutritional
Acknowledgements
The authors thank the participating children and their parents. We also thank Ada van den Bos, Annelies Bos, Marianne Maliepaard, Marjan Mourik and Ineke van Vliet for their great help with data collection and inclusion of patients. Furthermore, our gratitude goes out to the nursing and medical staff of the Neonatal, Pediatric and Surgical Intensive care unit of the Erasmus MC-Sophia Children's hospital, for their support. We also thank Ko Hagoort (Erasmus MC, Rotterdam) for his careful editing.
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