Nutrition Support in Critically Ill Children: Underdelivery of Energy and Protein Compared with Current Recommendations

Published:October 12, 2012DOI:


      Critically ill children are at high risk for developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. This study's aims were to examine current nutrition practices and the adequacy of nutrition support in the pediatric intensive care unit (PICU). This retrospective chart review included 240 PICU patients admitted to PICU for longer than 48 hours and documented all intravenous (IV), parenteral, and enteral energy and protein for the first 8 days. Basal metabolic rate and protein requirements were estimated by Schofield equation and the American Society for Parenteral and Enteral Nutrition Clinical Guidelines, respectively. Moderate/severe acute malnutrition was defined as weight for age greater than −2 z scores, and moderate/severe chronic malnutrition (growth stunting) was defined as height for age greater than −2 z scores, using 2000 Centers for Disease Control and Prevention growth charts. During the first 8 days of PICU stay, the actual energy intake for all patient-days was an average of 75.7%±56.7% of basal metabolic rate and was significantly lower than basal metabolic rate (P<0.001); the actual protein intake for all patient-days met an average of 40.4%±44.2% of protein requirements and was significantly lower than the American Society for Parenteral and Enteral Nutrition guidelines (P<0.001). Delivery of energy and protein were inadequate on 60% and 85% of patient-days, respectively. Only 75% of estimated energy and 40% of protein requirements were met in the first 8 days of PICU stay. These data demonstrate a high prevalence of critically ill children who are not meeting their recommended levels of protein and energy. In order to avoid undernutrition of these children, providers must conduct ongoing assessment of protein and energy intake compared with protein and energy requirements.


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        • Mehta N.M.
        • Duggan C.P.
        Nutritional deficiencies during critical illness.
        Pediatr Clin North Am. 2009; 56: 1143-1160
        • Coss-Bu J.A.
        • Klish W.J.
        • Walding D.
        • et al.
        Energy metabolism, nitrogen balance, and substrate utilization in critically ill children.
        Am J Clin Nutr. 2001; 74: 664-669
        • Delgado A.F.
        • Okay T.S.
        • Leone C.
        • et al.
        Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit.
        Clinics (Sao Paulo). 2008; 63: 357-362
        • Waterlow J.C.
        Classification and definition of protein-calorie malnutrition.
        Br Med J. 1972; 3: 566-569
        • Pawellek I.
        • Dokoupil K.
        • Koletzko B.
        Prevalence of malnutrition in paediatric hospital patients.
        Clin Nutr. 2008; 27: 72-76
        • Hendricks K.M.
        • Duggan C.
        • Gallagher L.
        • et al.
        Malnutrition in hospitalized pediatric patients.
        Arch Pediatr Adolesc Med. 1995; 149: 1118-1122
        • Pollack M.M.
        • Wiley J.S.
        • Holbrook P.R.
        Early nutritional depletions in critically ill children.
        Crit Care Med. 1981; 9: 580-583
        • Hals J.
        • Ek J.
        • Svalastog A.G.
        • et al.
        Studies on nutrition in severely neurologically disabled children in an institution.
        Acta Paediatr. 1996; 85: 1469-1475
        • Hulst J.M.
        • van Goudoever J.B.
        • Zimmermann L.J.
        • et al.
        The effect of cumulative energy and protein deficiency on anthropometric parameters in a pediatric ICU population.
        Clin Nutr. 2004; 23: 1381-1389
        • Briassoulis G.
        • Zavras N.
        • Hatzis T.
        Malnutrition, nutritional indices, and early enteral feeding in critically ill children.
        Nutrition. 2001; 17: 548-557
        • Lambe C.
        • Hubert P.
        • Jouvet P.
        • et al.
        A nutritional support team in the pediatric intensive care unit: Changes and factors impeding appropriate nutrition.
        Clin Nutr. 2007; 26: 355-363
        • Frankenfield D.C.
        • Smith Jr, J.S.
        • Cooney R.N.
        • et al.
        Relative association of fever and injury with hypermetabolism in critically ill patients.
        Injury. 1997; 28: 617-621
        • Briassoulis G.
        • Tsorva A.
        • Zavras N.
        • et al.
        Influence of an aggressive early enteral nutrition protocol on nitrogen balance in critically ill children.
        J Nutr Biochem. 2002; 13: 560
        • Chwals W.J.
        Overfeeding the critically ill child: Fact or fantasy?.
        New Horizons. 1994; 2: 147-155
        • Pollack M.M.
        • Ruttimann U.E.
        • Wiley J.S.
        Nutritional depletions in critically ill children: Associations with physiologic instability and increased quantity of care.
        JPEN J Parenter Enteral Nutr. 1985; 9: 309-313
        • Alberda C.
        • Gramlich L.
        • Jones N.
        • et al.
        The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observational study.
        Intensive Care Med. 2009; 35: 1728-1737
        • Dvir D.
        • Cohen J.
        • Singer P.
        Computerized energy balance and complications in critically ill patients: An observational study.
        Clin Nutr. 2006; 25: 37-44
        • Villet S.
        • Chiolero R.L.
        • Bollmann M.D.
        • et al.
        Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.
        Clin Nutr. 2005; 24: 502-509
        • Arabi Y.M.
        • Haddad S.H.
        • Tamim H.M.
        • et al.
        Near-target caloric intake in critically ill medical-surgical patients is associated with adverse outcomes.
        JPEN J Parenter Enteral Nutr. 2010; 34: 280-288
        • Schofield W.N.
        Predicting basal metabolic rate, new standards and review of previous work.
        Hum Nutr Clin Nutr. 1985; 39c: 5-41
        • Mehta N.M.
        • Compher C.
        • A.S.P.E.N.
        Clinical Guidelines: Nutrition support of the critically ill child.
        JPEN J Parenter Enteral Nutr. 2009; 33: 260-276
        • Kuczmarski R.J.
        • Ogden C.L.
        • Guo S.S.
        • et al.
        2000 CDC Growth Charts for the United States: Methods and development.
        Vital Health Stat 11. 2002; : 1-190
        • De León A.L.
        • Romero-Gutiérrez G.
        • Valenzuela C.A.
        • Gonzáles-Bravo F.E.
        Simplified PRISM III score and outcome in the pediatric intensive care unit.
        Pediatr Int. 2005; 47: 80-83
        • Pollack M.M.
        • Patel K.M.
        • Ruttimann U.E.
        PRISM III: An updated Pediatric Risk of Mortality score.
        Crit Care Med. 1996; 24: 743-752
        • Leteurtre S.
        • Duhamel A.
        • Grandbastien B.
        • et al.
        Paediatric logistic organ dysfunction (PELOD) score.
        Lancet. 2006; 367 (author reply 900-902): 897
        • Leteurtre S.
        • Martinot A.
        • Duhamel A.
        • et al.
        Validation of the paediatric logistic organ dysfunction (PELOD) score: Prospective, observational, multicentre study.
        Lancet. 2006; 362: 192-197
        • Mehta N.M.
        • McAleer D.
        • Hamilton S.
        • et al.
        Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit.
        JPEN J Parenter Enteral Nutr. 2010; 34: 38-45
        • Taylor R.M.
        • Preedy V.R.
        • Baker A.J.
        • et al.
        Nutritional support in critically ill children.
        Clin Nutr. 2003; 22: 365-369
        • Biolo G.
        Can we increase protein synthesis by anabolic factors?.
        Am J Kidney Dis. 2001; 37: 115-118
        • Botran M.
        • Lopez-Herce J.
        • Mencia S.
        • et al.
        Enteral nutrition in the critically ill child: Comparison of standard and protein-enriched diets.
        J Pediatr. 2011; 159 (e1): 27-32
        • Martin C.M.
        • Doig G.S.
        • Heyland D.K.
        • et al.
        Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT).
        CMAJ. 2004; 170: 197-204
        • de Oliveira Iglesias S.B.
        • Leite H.P.
        • Santana e Meneses J.F.
        • et al.
        Enteral nutrition in critically ill children: Are prescription and delivery according to their energy requirements?.
        Nutr Clin Pract. 2007; 22: 233-239
        • Hulst J.
        • Joosten K.
        • Zimmermann L.
        • et al.
        Malnutrition in critically ill children: From admission to 6 months after discharge.
        Clin Nutr. 2004; 23: 223-232
        • Mowe M.
        • Bosaeus I.
        • Rasmussen H.H.
        • et al.
        Insufficient nutritional knowledge among health care workers?.
        Clin Nutr. 2008; 27: 196-202
        • Takala J.
        Nutrition and body composition in multiple organ failure.
        Nutrition. 1995; 11: 769-770
        • Petrillo-Albarano T.
        • Pettignano R.
        • Asfaw M.
        • et al.
        Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit.
        Pediatr Crit Care Med. 2006; 7: 340-344
        • Meyer R.
        • Harrison S.
        • Sargent S.
        • et al.
        The impact of enteral feeding protocols on nutritional support in critically ill children.
        J Hum Nutr Diet. 2009; 22: 428-436
        • Soguel L.
        • Revelly J.P.
        • Schaller M.D.
        • et al.
        Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: The intensive care unit dietitian can make the difference.
        Crit Care Med. 2012; 40: 412-419
        • Badjatia N.
        • Fernandez L.
        • Schlossberg M.J.
        • et al.
        Relationship between energy balance and complications after subarachnoid hemorrhage.
        JPEN J Parenter Enteral Nutr. 2010; 34: 64-69


      U. G. Kyle is an instructor, Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston.


      N. Jaimon is a research nurse, Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston.


      J. A. Coss-Bu is associate professor and associate director of research, Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston.