Pediatric Nutrition in Practice

274 Hulst  Joosten

infusion if the serum triglyceride level is >250
mg/dl (>2.9 mmol/l) in infants and >400 mg/dl
(>4.6 mmol/l) in children.

Burn Injury
In pediatric burn patients, several additional for-
mulas for determining energy needs have been
used, but they have been shown to either under-
estimate or overestimate energy expenditure [14,
15]. Therefore, measurement of energy expendi-
ture is highly recommended in this population. In
the absence of indirect calorimetry, the Schofield
prediction equation based on weight and height
[9] seems to be the best alternative for estimating
REE ( table 1 ).
Protein requirements are higher in burned
children than in normal children. In addition to
increased loss of protein across the burn wound,
there is a great demand for protein for wound
healing, host defense and gluconeogenesis as
amino acids become a primary source of energy.
Current recommendations for patients with
burns of more than 10% of the body surface area
are: 20% of the total kilocalories provided from
protein acids (children: 3 g/kg/day), 55–60%
from carbohydrates without exceeding 5 mg/kg/
min, and up to 30% from fats.

Nutritional Support

Indication and Goal
Nutritional support is important in the manage-
ment of the critically ill patient when oral food in-
take is inadequate or not possible. To determine
the risk for deterioration of the nutritional status
during admission, the use of a risk screening tool
(e.g. STRONG kids ) is advocated [16]. It is em-
ployed to minimize the loss of lean body mass and
support the synthesis of critical visceral proteins.

Timing of Nutritional Support
Nutritional support should be started within the
first 24 h of admission to the PICU for children

who are hemodynamically stable and have a func-

tioning gastrointestinal tract.

Route of Nutritional Support

Enteral nutrition (EN) via tube is the preferred

way of feeding the critically ill and burn patients.

EN reverses the loss of gastrointestinal mucosal

integrity, maintains intestinal blood flow, pre-

serves the IgA-dependent immunity and contrib-

utes to the maintenance of the host immune re-

sponse. Meta-analyses of clinical studies have re-

ported that EN as opposed to parenteral nutrition

(PN) is associated with a lower risk of infection

and also results in cost savings [17]. With trans-

pyloric feeding, it is possible to increase the deliv-

ery of EN, but it is unable to impede tracheal as-

piration of gastric fluids.

W hen EN is cont ra i nd icated or i nsu f f icient ly

tolerated, PN may be used to supplement or re-

place EN. Recently, in adults, a large random-

ized controlled study evaluated whether early

PN, to supplement EN if energy goals are not

met, was more beneficial than initiating supple-

mental PN after 1 week [18]. It appea red t hat late

initiation resulted in reduced morbidity as com-

pared with early initiation. No such compari-

sons have been done on children, but results

may differ for children because they have fewer

energy reserves and a shorter duration of acute

stress response.

Type of Formula

There are no studies available that support a clin-

ical advantage of oligomeric formulas over poly-

meric formulas for critically ill children. No evi-

dence is available yet on the use of immune-mod-

ulating formulas, e.g. formulas enriched with

glutamine, arginine or nucleotides, in the criti-

cally ill child. This can be considered with burn

injury and trauma patients.

Compliance

It is important to realize that large discrepan-

cies may arise between prescribed and deliv-

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