Unpredictable combination of metabolic and feeding patterns in malnourished critically ill children: the malnutrition–energy assessment question

Abstract

Dear Editor, Advances in paediatric critical care have resulted in the increased survival of chronically ill patients. In many units, such patients represent [50 % of the workload and are often malnourished [1]. Prediction of energy expenditure (PEE) equations are simple alternatives to the gold standard of assessing resting energy expenditure (REE) by indirect calorimetry (IC). However, recent work has suggested that PEE equations fail to adequately predict REE. New paediatric intensive care unit (PICU)-oriented equations have been found to be no better than well-established tools, such as the Schofield-HW equation [2]. We have compared PICU-specialized and commonly used PEE equations with REE using a new modular metabolic monitor (E-COVX) in well-nourished and malnourished critically ill children. The E-COVX compact metabolic module has the advantage of not being influenced by uneventful open endotracheal suctioning [3]. It is suitable for repeated 30-min measurements in well-sedated mechanically ventilated children with stable respiratory patterns in a variety of ventilation modes [4]. We hypothesized that IC using the E-COVX would show that energy expenditure is unpredictable in malnourished children and that replacing REE with any PEE equation, including the new PICU-oriented equations, might not be applicable for estimating energy expenditure in patients suffering from malnutrition during a critical illness. The Ethics Committee of the Institutional Review Board approved this study, and parents or guardians of the children gave informed, written consent.Mechanically ventilated critically ill children, consecutively admitted to the PICU of the University Hospital, Heraklion, Crete, were enrolled in the study. Thirty consecutive 1-min gas exchange measurements (VO 2 and VCO 2 ) were taken and the respiratory quotient (RQ) and REE were calculated for each patient (results were blinded from the attending physician). The nutritional status was evaluated for the presence of proteinenergy malnutrition as defined by Waterlow [5]. The PEE was estimated and basal metabolic rate (PBMR) was predicted using the common Harris-Benedict, Schofield-HW, Seashore, Fleisch, CaldwellKennedy and Henrys formulas, as well as equations specifically developed for the PICU by White and by Meyer [2]. Patients were classified as hypermetabolic, normometabolic and hypometabolic when the REE was [110, 90-110 and \90 % of the Schofield-PBMR, respectively, and as overfed, adequately fed and underfed when the caloric intake was [110, 80-110 and \80 % of the REE, respectively.Forty-four patients (28 boys, 16 girls) were studied (total measurements 1,320). Four patients were admitted after an elective procedure; the remaining patients were admitted as a result of an acute illness or injury. Twelve (27.3 %) patients presented severe (4) or moderate (8) malnutrition. All patients survived.The REE did not differ between patients according to a body temperature of \37.1°C (1,068 ± 460 kcal/ day) or C37.1°C (824 ± 217 kcal/ day) or with a Ramsey s...

Caloric Requirements of Patients With Brain Impairment and Cerebral Palsy Who Are Dependent on Chronic Ventilation

“…Consequently, the loss of muscle mass in our patients probably contributed to their extremely low REE. Similar results were observed by Briassoulis et al 16 in malnourished children whose REE was lower than that calculated through the Schofield-HW equation (0.0001), the White equation (0.02), and the Meyer equation (0.04). In the malnutrition group, energy intake was higher than REE.…”

“…Similar results were observed by Briassoulis et al 16 in malnourished children whose REE was lower than that calculated through the Schofield‐HW equation (0.0001), the White equation (0.02), and the Meyer equation (0.04). In the malnutrition group, energy intake was higher than REE 16 . With a double‐labeled water stable isotope method, it has been shown that the observed reduction in total energy requirements in chronically ventilated pediatric patients was due to a reduction in lean body mass and an increase in fat 17 …”

“…In the malnutrition group, energy intake was higher than REE. 16 With a double-labeled water stable isotope method, it has been shown that the observed reduction in total energy requirements in chronically ventilated pediatric patients was due to a reduction in lean body mass and an increase in fat. 17 Gastrostomy has also been found to decrease energy expenditure.…”

Bioelectrical Impedance Phase Angle and Morbidity and Mortality in Critically Ill Children

“…Undernutrition is common among critically ill children because they have lower nutrition stores compared with critically ill adults and, thus, are likely to be at higher risk of malnutrition. Timely and accurate nutrition assessment and prescription often is necessary to optimize clinical care for these children …”

Systemic Inflammation Increases Energy Expenditure Following Pediatric Cardiopulmonary Bypass

“…Unfortunately, routine nutritional assessment was not completed on subjects prior to surgery and therefore could not be accounted for in this cohort. Age-related differences in the prevalence of undernutrition may therefore have contributed for the observed effects of age on REE (41). The management of subjects remained at the discretion of the treating team.…”