Objective To examine the role of targeted indirect calorimetry in detecting the adequacy of energy intake and the risk of cumulative energy imbalance in a subgroup of critically ill children suspected to have alterations in resting energy expenditure. We examined the accuracy of standard equations used for estimating resting energy expenditure in relation to measured resting energy expenditure in relation to measured resting energy expenditure and cumulative energy balance over 1 week in this cohort. Design A prospective cohort study. Setting Pediatric intensive care unit in a tertiary academic center. Interventions A subgroup of critically ill children in the pediatric intensive care unit was selected using a set of criteria for targeted indirect calorimetry. Measurements Measured resting energy expenditure from indirect calorimetry and estimated resting energy expenditure from standard equations were obtained. The metabolic state of each patient was assigned as hypermetabolic (measured resting energy expenditure/estimated resting energy expenditure >110%), hypometabolic (measured resting energy expenditure/estimated resting energy expenditure <90%), or normal (measured resting energy expenditure/estimated resting energy expenditure = 90– 110%). Clinical variables associated with metabolic state and factors influencing the adequacy of energy intake were examined. Main Results Children identified by criteria for targeted indirect calorimetry, had a median length of stay of 44 days, a high incidence (72%) of metabolic instability and alterations in resting energy expenditure with a predominance of hypometabolism in those admitted to the medical service. Physicians failed to accurately predict the true metabolic state in a majority (62%) of patients. Standard equations overestimated the energy expenditure and a high incidence of overfeeding (83%) with cumulative energy excess of up to 8000 kcal/week was observed, especially in children <1 yr of age. We did not find a correlation between energy balance and respiratory quotient (RQ) in our study. Conclusions We detected a high incidence of overfeeding in a subgroup of critically ill children using targeted indirect calorimetry The predominance of hypometabolism, failure of physicians to correctly predict metabolic state, use of stress factors, and inaccuracy of standard equations all contributed to overfeeding in this cohort. Critically ill children, especially those with a longer stay in the PICU, are at a risk of unintended overfeeding with cumulative energy excess.

Objective To evaluate the impact of implementing an enteral nutrition (EN) algorithm on achieving optimal EN delivery in the Pediatric Intensive Care Unit (PICU). Design Prospective pre/post implementation audit of EN practices. Setting One 29-bed medical/surgical PICU in a free standing, university affiliated children’s hospital. Patients Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of > 24 hours who received EN. Interventions Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing and maintaining EN in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, EN interruptions, parenteral nutrition (PN) use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and post-intervention cohorts. Time to achieving energy goal was analyzed using Kaplan Meier statistical analysis. Measurements and Main Results Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the pre-implementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating EN, or use of post-pyloric feeding between the 2 cohorts. We recorded a significant decrease in the number of avoidable episodes of EN interruption (3 vs. 51, p0.0001) and the incidence and duration of PN dependence in patients with avoidable EN interruptions in the post-intervention cohort. Median time to reach energy goal decreased from 4 days to 1 (p<0.0001), with a higher proportion of patients reaching this goal (99% vs. 61%, p = 0.01). Conclusions The implementation of an EN algorithm significantly improved EN delivery and decreased reliance on PN in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

A majority of our study cohort had delayed GE. Bedside EN intolerance assessments, particularly GRV, did not predict delayed GE or rate of EN advancement. Delayed gastric emptying predicted slow EN advancement. Novel tests for delayed GE and EN intolerance are needed.

Restricted dietary intake is common among children with behavioral issues. Here we report a case of a severely autistic child who presented initially with limp but who soon developed cough, tachypnea, hypoxia, and tachycardia. An echocardiogram revealed evidence of pulmonary hypertension (PH) with severely dilated right ventricle and elevated right-sided pressures. The etiology of his PH was unclear but further laboratory evaluation demonstrated severe nutritional deficiencies, in particular an undetectable ascorbic acid (vitamin C) level as well as deficient levels of thiamine (vitamin B 1 ), pyridoxine (vitamin B 6 ), cobalamin (vitamin B 12 ), and vitamin D. Repletion of these vitamins was associated with resolution of his PH and his musculoskeletal complaints. We report this case and a review of the relevant literature as a clinical lesson to expand the differential diagnosis of limp in children who may be difficult to assess as well as to report on an unusual association between severe vitamin deficiencies and PH.