Pediatric Nutrition in Practice

Intensive Care 273

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dominates. Thus, critically ill children typically
manifest a net negative protein balance, which
may clinically be noted by weight loss and skeletal
muscle wasting which may have deleterious ef-
fects on outcome. An increased protein intake
cannot reverse protein breakdown but can im-
prove nitrogen balance by enhancing protein syn-
thesis. There is a close interrelationship between
protein and energy metabolism. A lack of energy
supply will enhance an already increased protein
catabolism during critical illness. However, an in-
crease in the energy supply will not promote ni-
trogen retention unless the protein supply is ad-
equate, and, conversely, an increased protein sup-
ply will be useless if energy is limited. The current
guidelines on parenteral amino acid intake are
shown in table  2 [10]. For enteral feeding, the
same intake can be followed.

Carbohydrates
Energy requirements of the body, and especially
the brain, depend on glucose as the major fuel.
Plasma glucose levels are the resultant of a bal-
ance between exogenous glucose intake and en-
dogenous glucose production (glycogenolysis
and gluconeogenesis) on the one hand and glu-
cose utilization (oxidation or storage as glycogen
and triglycerides) on the other. Initial screening
for hypo- and hyperglycemia should be per-
formed on all critically ill children. Both low and
high blood glucose levels as well as variability in
glucose levels worsen outcome and should be
treated. Hyperglycemia with high plasma insulin

concentrations is the result of insulin insensitivity

that occurs during stress. Both insulin resistance

and (relative) β-cell dysfunction play a role in the

occurrence of hyperglycemia in critically ill chil-

dren [11].

For children <30 kg, a glucose intake of 4–6

mg/kg/min is recommended, whereas for chil-

dren >30 kg this is 2–4 mg/kg/min. In case of hy-

perglycemia, glucose intake can be decreased, but

it is recommended to start insulin therapy in an

early phase [1 2]. Large randomized outcome

studies of a tight glucose regimen with insulin

therapy in the critically ill pediatric population

are limited; so far one study showed an improved

outcome, using tight glycemic control in a mixed

PICU population [13].

L i p i d s

Lipid metabolism is generally accelerated by ill-

ness and physiologic stress, and lipids are a prime

source of energy. Infusion of lipid emulsions al-

lows a high energy supply, facilitates the preven-

tion of high glucose infusion rates and is indis-

pensable for the supply of essential fatty acids.

Lipid intake should usually provide 25–40% of

nonprotein calories in fully parenterally fed pa-

tients ( table 2 ). A minimum linoleic acid intake of

0.1 g/kg/day should be administered to infants

and older children in order to prevent essential

fatty acid deficiency. The dosage of fat should not

exceed the capacity for lipid clearance, and should

be adapted if marked hyperlipidemia occurs. It is

recommended to decrease or stop parenteral lipid

Age Total energy

expenditure in

health, kcal

REE, kcal Parenteral

amino acid,

g/kg/day

Parenteral

lipid,

g/kg/day

0 – 2 months 100 50 1.5 – 3.0 3 – 5

3 – 12 months 100 50 1.0 – 2.5 3 – 4

1 – 6 years 90 45 1.0 – 2.0 2 – 3

7 – 12 years 70 35 1.0 – 2.0 2 – 3

>12 years 50 25 1.0 – 2.0 2 – 3

Ta b l e 2. Current nutritional recom-
mendations for critically ill children
[10]

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