Pediatric Nutrition in Practice

272 Hulst  Joosten

Nutritional Requirements

Nutritional requirements for critically ill children
range widely with altered metabolic states deter-
mined by the children’s age and nutritional sta-
tus. Metabolic responses may greatly vary as well,
depending on the nature of the injury and the
variability in the individual response to the same
type of injury. Both a hypometabolic and a hyper-
metabolic response may occur [7]. Especially in
children with burn injury there is an exaggerated
catabolic response and they also show exudation
of nutrients through the damaged skin. These fac-
tors together result in very high requirements for
energy, protein and other nutrients in this catego-
ry of patients [8].

Energy
In practice, daily energy demands of critically ill
children should be calculated individually based
on one of the following methods:
(1) Measurement of resting energy expendi-
ture (REE) by indirect calorimetry in venti-
lated and nonventilated children
(2) Estimation of REE by predictive equations
based on weight (and height), age and sex

(3) Estimation using dietary reference intakes

for healthy children matched for age and sex

The preferred method is measuring the REE.

The measured REE is the minimum amount of

energy needed. Several factors commonly pres-

ent in the ICU population might affect measured

REE and must be taken into account when inter-

preting the outcome; fever, for example, can in-

crease energy expenditure, while sedatives, anes-

thesia and muscle relaxants may decrease it in

some patients. The Schofield equation [9] is a use-

ful alternative for estimating REE and is shown

in table 1.

In the recovery phase, additional factors

should be taken into account to calculate energy

needs, such as activity, illness, growth and ab-

sorption coefficient in case of enteral feeding. In

general, infants require 10–20% more calories

when fed enterally than when fed parenterally,

whereas the differences are smaller in children

(close to 10%), primarily because of more effec-

tive enteral absorption with older age.

P r o t e i n s

Both protein synthesis and protein breakdown

are intensified in critical illness, but the latter pre-

Ta b l e 1. Schofield equations for estimating REE from weight and from weight and height in kcal/day^1 [9]

Age, years Boys Girls

0 – 3 60.9 × weight – 54 61.0 × weight – 51

0.167 × weight + 1,516.7 × height – 617.6 16.2 × weight + 1,022.7 × height – 413.5

3 – 10 22.7 × weight + 495 22.5 × weight + 499

19.6 × weight + 130.2 × height + 414.9 17.0 × weight + 161.7 × height + 371.2

10 – 18 17.5 × weight + 651 12.2 × weight + 746
16.2 × weight + 137.1 × height + 515.5 8.4 × weight + 465.4 × height + 200.0

In order to calculate total energy needs, additional factors must be taken into account: (a) illness factor of critically ill
children – 1.2 – 1.6 with PICU patients, 1.4 with burn patients, 1.3 – 1.5 with trauma patients; (b) activity factor of criti-
cally ill children – 1.0 – 1.1; (c) growth factor of critically ill children – 1.0 in the acute phase; in reconvalescent phase,
1.3 if age <4 months, 1.1 if age 4 – 12 months, and 1.02 – 1.04 for older children.

(^1) 1 kcal = 4,186 kJ; weight in kilograms, height in meters.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 271–277
DOI: 10.1159/000360351