Pediatric Nutrition in Practice

Intensive Care 275

3

ered, or prescribed and required, nutrients due
to inadequate delivery or poor compliance [19].
The main reasons for inadequate delivery are
interruptions to EN due to gastrointestinal dys-
function (e.g. vomiting, nausea, retention and

diarrhea) or fasting in anticipation of diagnos-

tic or surgical procedures, delayed EN initia-

tion, fluid restriction, patients on vasoactive

drugs, and general reluctance to address nutri-

tion delivery.

Initial assessment of critically ill children

on admission to the ICU

No

Yes

Start EN within 24 h after admission

according to REE or prediction equation or

<1 year

1–6 years

7–12 years

>1 2 y e a r s

During admission:

1 Adjust energy intake according to measurement of energy expenditure and RQ;

when RQ >1, decrease glucose intake; when RQ <0.80, increase energy intake

2 Daily assess differences between prescribed and delivered nutrients and actively try to prevent these

deficits

3 Weekly actual nutritional assessment and nutritional risk assessment (e.g. STRONGkids)

Start PN

Start glucose infusion

<30 kg: 4–6 mg/kg/min

>30 kg: 2–4 mg/kg/min

Inadequate amounts of EN reached

No

Recovery phase – increase EN: 2 × MEE

(if indirect calorimetry is performed) or

Consider additional PN in order to meet

requirements

Try to increase EN in the following days and

try to reach complete EN

Yes

Reconsider starting EN daily

Hemodynamic instability or

contraindication for EN*

Nutritional status: weight, length, MUAC

Risk assessment: e.g. STRONGkids [16]

Primary diagnosis

Illness severity

Measurement of energy expenditure

50 kcal/kg

45 kcal/kg

35 kcal/kg

25 kcal/kg

<1 year

1–6 years

7–12 years

>1 2 y e a r s

100 kcal/kg

90 kcal/kg

70 kcal/kg

50 kcal/kg

Fig. 1. Nutritional strategy in pediatric intensive care patients. MUAC = Mid-upper-arm circumfer-

ence; MEE = measured energy expenditure; RQ = respiratory quotient. * Contraindications for EN:

serious gastrointestinal difficulties; congenital anomalies of the gastrointestinal tract; surgery to

the gastrointestinal system; short bowel disease; hemodynamic instability; asphyxia.

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