Body composition in pediatric patients.

Undernutrition is highly prevalent in children who are critically ill and is associated with increased morbidity and mortality, including a higher risk of infection due to transitory immunological disorders, inadequate wound healing, reduced gut function, longer dependency on mechanical ventilation, and longer hospital stays compared with eutrophic children who are critically ill. Nutrition care studies have proposed that early interventions targeting nutrition assessment can prevent or minimize the complications of undernutrition. Stress promotes an acute inflammatory response mediated by cytokines, resulting in increased basal metabolism and nitrogen excretion and leading to muscle loss and changes in body composition. Therefore, the inclusion of body composition assessment is important in the evaluation of these patients because, in addition to the nutrition aspect, body composition seems to predict clinical prognosis. Several techniques can be used to assess body composition, such as arm measurements, calf circumference, grip strength, bioelectrical impedance analysis, and imaging examinations, including computed tomography and dual-energy x-ray absorptiometry. This review of available evidence suggests that arm measurements seem to be well-established in assessing body composition in children who are critically ill, and that bioelectrical impedance analysis with phase angle, handgrip strength, calf circumference and ultrasound seem to be promising in this evaluation. However, further robust studies based on scientific evidence are necessary.

Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study.

OBJECTIVES: To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations. DESIGN: The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding. SETTING: Four-one PICUs in 13 LA countries. PATIENTS: Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively. CONCLUSIONS: The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.

Increased nutrition risk at admission is associated with longer hospitalization in children and adolescents with COVID-19.

BACKGROUND: We investigated the association of nutritional risk and inflammatory marker level with length of stay (LOS) in children and adolescents hospitalized for COVID-19 infection in two pediatric teaching hospitals in a developing country. METHODS: This was a cross-sectional analytical retrospective study performed in two pediatric hospitals. We included the data from all children and adolescents who were hospitalized with a SARS-CoV-2 infection between March and December 2020. Demographic, anthropometric, clinical, and laboratory data were extracted from electronic medical records. Nutritional risk was assessed according to the STRONGkids tool within 24 hours of admission and was categorized into two levels: ≥4 (high risk) and <4 (moderate or low risk). Means or medians were compared between nutritional risk groups using the t test and Mann-Whitney U test, respectively. The association of nutritional risk and inflammatory markers with LOS was estimated using the Kaplan-Meier method and log-rank test. Cox proportional-hazard and linear regression models were performed, and adjusted for sex, age, and respiratory symptoms. RESULTS: From a total of 73 patients, 20 (27.4%) had a STRONGkids score ≥4 at admission, which was associated with a longer LOS even after adjusting (ß = 12.30; 1.74-22.9 95% CI; P = 0.023). The same association was observed between LOS and all laboratory markers except for D-dimer. CONCLUSION: Among children and adolescents with COVID-19, a STRONGkids score ≥4 at admission, lower values of albumin, lymphocytes, and hemoglobin, and higher CRP values were associated with longer LOS.

Metabolic and nutritional repercussions of liver disease on children: how to minimize them? / Repercussões metabólicas e nutricionais da doença hepática em crianças: como minimizá-las?

ABSTRACT Objective: To describe the metabolic and nutritional repercussions of chronic liver disease (CLD), proposing strategies that optimize nutritional therapy in the pre- and post-liver transplantation (LT) period, in order to promote favorable clinical outcomes and adequate growth and development, respectively. Data sources: Bibliographic search in the PubMed, Lilacs and SciELO databases of the last 12 years, in English and Portuguese; target population: children from early childhood to adolescence; keywords in Portuguese and their correlates in English: "Liver Transplant," "Biliary Atresia," "Nutrition Therapy," "Nutritional Status," and "Child"; in addition to Boolean logics "and" and "or," and the manual search of articles. Data synthesis: Malnutrition in children with CLD is a very common condition and an important risk factor for morbidity and mortality. There is an increase in energy and protein demand, as well as difficulties in the absorption of carbohydrates, lipids and micronutrients such as fat-soluble vitamins and some minerals. An increase in the supply of energy, carbohydrates and proteins and micronutrients, especially fat-soluble vitamins, iron, zinc and calcium, is suggested, except in cases of hepatic encephalopathy (this restriction is indicated for a short period). Conclusions: Based on metabolic changes and anthropometric and body composition monitoring, a treatment plan should be developed, following the nutritional recommendations available, in order to minimize the negative impact of malnutrition on clinical outcomes during and after LT.

RESUMO Objetivo: Revisar de forma descritiva as repercussões metabólicas e nutricionais da doença hepática crônica, propondo estratégias que aperfeiçoem a terapia nutricional nos períodos pré e pós transplante hepático (TxH), para promover desfechos clínicos favoráveis e crescimento e desenvolvimento adequados, respectivamente. Fontes de dados: Pesquisa bibliográfica nas bases de dados PubMed, Lilacs e SciELO dos últimos 30 anos em língua inglesa e portuguesa; população-alvo: crianças da primeira infância até a adolescência; palavras-chave em português e seus correlatos em inglês: "transplante de fígado", "atresia biliar," "terapia nutricional", "estado nutricional" e "criança"; além das lógicas booleanas and e or e da busca manual de artigos. Síntese dos dados: A subnutrição em crianças com doença hepática crônica é uma condição muito comum e um importante fator de risco para a morbimortalidade. Ocorre aumento das demandas de energia e proteínas, bem como dificuldades na absorção de carboidratos, lipídeos e de micronutrientes como vitaminas lipossolúveis e alguns minerais. Sugere-se incremento no aporte de energia, carboidratos, proteínas e micronutrientes, sobretudo de vitaminas lipossolúveis, ferro, zinco e cálcio, exceto em casos de encefalopatia hepática (a restrição é indicada por um curto período). Conclusões: Com base nas alterações metabólicas, no monitoramento antropométrico e na composição corporal, um plano terapêutico deve ser elaborado, seguindo as recomendações nutricionais disponíveis, com o objetivo de minimizar o impacto negativo da subnutrição nos desfechos clínicos durante e após o transplante hepático.

Can calf circumference be a viable option for nutritional assessment in the PICU?

BACKGROUND: Children admitted to paediatric intensive care units (PICUs) often need specialised nutritional intervention. Nutritional assessments provide specific data to support such interventions. Body composition measures, such as mid-upper arm circumference (MUAC), can complement nutritional assessment. However, MUAC has limitations. Calf circumference (CC) is an easy and common measure of muscle loss in the elderly; however, there are still very few studies on CC in children. AIMS: To evaluate the viability of using CC for nutritional monitoring of children under intensive care, compared with MUAC and weight. METHODS: Patients aged 2-10 years admitted to the PICU between December 2018 and August 2019 were included in the study. Two MUAC, CC, and weight measurements were performed: one in the first 24 h after PICU admission and another after 7 days. As there are no reference values for CC in children, this measure was used solely to observe the patient's individual progress. The nutritional status, both according to body mass index and MUAC, was used to characterise samples. Percentage changes in these measures were compared using the Wilcoxon signed-rank test for comparison between medians and Spearman's correlation test. Information from medical records regarding hospitalisation was also collected and analysed. RESULTS: Thirty patients were included in the study. During hospitalisation week 1, CC decreased significantly (p = 0.001), whereas MUAC (p = 0.427) and weight (p = 0.315) did not change significantly. Percentage changes in CC and MUAC were statistically different (p = 0.0449), with a positive correlation between the changes in both measures (p = 0.0333; r = 0.3896); conversely, although the percentage changes in CC and weight significantly differed (p = 0.0066), no correlation was found between them (p = 0.9382; r = 0.0148). The percentage changes in MUAC and weight were not different (p = 0.1880) or correlated (p = 0.1691; r = 0.2577). No statistically significant relationship was found between percentage changes in CC and clinical outcomes (length of stay, fasting time, and mechanical ventilation time). CONCLUSIONS: CC appears to be a viable measure for use in PICUs. Although positively correlated with MUAC, a measure proven useful in critically ill children, CC decreased significantly in the first week of intensive care, whereas MUAC remained unchanged, indicating that CC may show signs of depletion earlier than MUAC in these patients. Our study reinforces the importance of alternative measures for anthropometric assessment of critically ill children.

METABOLIC AND NUTRITIONAL REPERCUSSIONS OF LIVER DISEASE ON CHILDREN: HOW TO MINIMIZE THEM?

OBJECTIVE: To describe the metabolic and nutritional repercussions of chronic liver disease (CLD), proposing strategies that optimize nutritional therapy in the pre- and post-liver transplantation (LT) period, in order to promote favorable clinical outcomes and adequate growth and development, respectively. DATA SOURCES: Bibliographic search in the PubMed, Lilacs and SciELO databases of the last 12 years, in English and Portuguese; target population: children from early childhood to adolescence; keywords in Portuguese and their correlates in English: "Liver Transplant," "Biliary Atresia," "Nutrition Therapy," "Nutritional Status," and "Child"; in addition to Boolean logics "and" and "or," and the manual search of articles. DATA SYNTHESIS: Malnutrition in children with CLD is a very common condition and an important risk factor for morbidity and mortality. There is an increase in energy and protein demand, as well as difficulties in the absorption of carbohydrates, lipids and micronutrients such as fat-soluble vitamins and some minerals. An increase in the supply of energy, carbohydrates and proteins and micronutrients, especially fat-soluble vitamins, iron, zinc and calcium, is suggested, except in cases of hepatic encephalopathy (this restriction is indicated for a short period). CONCLUSIONS: Based on metabolic changes and anthropometric and body composition monitoring, a treatment plan should be developed, following the nutritional recommendations available, in order to minimize the negative impact of malnutrition on clinical outcomes during and after LT.

Bioelectrical Impedance Phase Angle and Morbidity and Mortality in Critically Ill Children.

BACKGROUND: Nutrition markers may be useful for diagnosis and monitoring and, also, as additional indicators of estimating death risk. We tested the association of body composition indicators (mid-upper arm circumference and phase angle) with pediatric intensive care unit (PICU) length of stay and mortality in critically ill pediatric patients. METHODS: Data from children aged 2 months-18 years were collected, and bioelectrical impedance was performed to obtain phase angle. Severity was evaluated by scoring the Pediatric Index of Mortality. Descriptive statistics were reported for nominal variables. Receiver operating characteristic curve was used to analyze the association of phase angle with 30-day mortality and to find the best cutoff. Survival probabilities and PICU length of stay were estimated using the Kaplan-Meier method. RESULTS: We evaluated 247 children with a median age of 4.8 years whose main cause of admission was sepsis. Survival curves showed higher survival in patients with phase angle >2.8° compared with patients with phase angle ≤2.8° (P < .0001). Kaplan-Meier time-to-event analysis showed that children with lower phase angle values were more likely to remain in the PICU (hazard ratio, 1.84; P = .003). Lower survival was also observed in patients who presented mid-upper arm circumference values ≤5th percentile (P < .03). CONCLUSIONS: Mid-upper arm circumference and phase angle were associated with mortality and morbidity in critically ill children, suggesting that these parameters may be useful not only for nutrition diagnosis and monitoring, but also as an additional indicator in estimating prognosis.

Changes in lipid metabolism in pediatric patients with severe sepsis and septic shock.

OBJECTIVES: Limited knowledge exists regarding the lipid profiles of critically ill pediatric patients with systemic inflammatory response syndrome. The aim of this study was to evaluate the relationship between the intensity of the inflammatory response and changes in the lipid profiles of critically ill pediatric patients admitted to a pediatric intensive care unit (PICU) with severe sepsis/septic shock. METHODS: This was a prospective and observational study at a 15-bed PICU at a public university hospital. We analyzed the lipid profiles of 40 patients with severe sepsis/septic shock admitted to the PICU on the first and seventh days of hospitalization. C-reactive protein was used as a marker for systemic inflammation. Forty-two pediatric patients seen in the emergency department and without systemic inflammatory response syndrome were used to provide control values. RESULTS: On day 1 of admission to the PICU, the patients had significantly lower levels of total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) as well as higher concentrations of triacylglycerols compared with the control group. There was a significant increase in the TC, HDL, LDL, and apolipoprotein levels from day 1 to day 7 of the study. CONCLUSIONS: During severe sepsis/septic shock, we found lower serum levels of lipoproteins and apolipoproteins, and these were negatively correlated with C-reactive protein. As the inflammatory response improved, the levels of TC, HDL, LDL, and apolipoproteins increased, suggesting a direct relationship between changes in the lipid profiles and inflammation.

Lymphocyte count as a sign of immunoparalysis and its correlation with nutritional status in pediatric intensive care patients with sepsis: A pilot study.

OBJECTIVES:: Developing malnutrition during hospitalization is well recognized worldwide, and children are at a relatively higher risk for malnutrition than adults. Malnutrition can lead to immune dysfunction, which is associated with a higher mortality rate due to sepsis, the most frequent cause of death in pediatric intensive care units (PICUs). The aim of this study was to investigate whether malnourished patients are more likely to have relative or absolute lymphopenia and, consequently, worse prognoses. METHODS:: We enrolled 14 consecutive patients with sepsis whose legal representatives provided written informed consent. Patients were classified as normal or malnourished based on anthropometric measurements. As an additional evaluation of nutritional status, serum albumin and zinc were measured on the 1st and 7th days of hospitalization. Lymphocyte count was also measured on the 1st and 7th days. Clinicaltrials.gov: NCT02698683. RESULTS:: Malnutrition prevalence rates were 33.3% and 42.8% based on weight and height, respectively. Laboratory analyses revealed a reduction of serum albumin in 100% of patients and reduction of zinc in 93.3% of patients. A total of 35% of patients had fewer than 500 lymphocytes/mm3 on their first day in the PICU. Lymphocyte counts and zinc concentrations significantly increased during hospitalization. CONCLUSIONS:: Nutritional evaluations, including anthropometric measurements, were not correlated with lymphocyte counts. Lymphocyte counts concomitantly increased with zinc levels, suggesting that micronutrient supplementation benefits patients with sepsis.

Lymphocyte count as a sign of immunoparalysis and its correlation with nutritional status in pediatric intensive care patients with sepsis: A pilot study

OBJECTIVES: Developing malnutrition during hospitalization is well recognized worldwide, and children are at a relatively higher risk for malnutrition than adults. Malnutrition can lead to immune dysfunction, which is associated with a higher mortality rate due to sepsis, the most frequent cause of death in pediatric intensive care units (PICUs). The aim of this study was to investigate whether malnourished patients are more likely to have relative or absolute lymphopenia and, consequently, worse prognoses. METHODS: We enrolled 14 consecutive patients with sepsis whose legal representatives provided written informed consent. Patients were classified as normal or malnourished based on anthropometric measurements. As an additional evaluation of nutritional status, serum albumin and zinc were measured on the 1st and 7th days of hospitalization. Lymphocyte count was also measured on the 1st and 7th days. Clinicaltrials.gov: NCT02698683. RESULTS: Malnutrition prevalence rates were 33.3% and 42.8% based on weight and height, respectively. Laboratory analyses revealed a reduction of serum albumin in 100% of patients and reduction of zinc in 93.3% of patients. A total of 35% of patients had fewer than 500 lymphocytes/mm3 on their first day in the PICU. Lymphocyte counts and zinc concentrations significantly increased during hospitalization. CONCLUSIONS: Nutritional evaluations, including anthropometric measurements, were not correlated with lymphocyte counts. Lymphocyte counts concomitantly increased with zinc levels, suggesting that micronutrient supplementation benefits patients with sepsis.

Use of a symbiotic supplement in a child with short bowel Syndrome; a case report.

UNLABELLED: The short bowel syndrome (SBS) is due to loss of bowel after surgery. Characterized by generalized nutrients malabsorption, its signs and symptoms include electrolyte imbalance, deficiency of vitamins, minerals and nutrients that can lead to death. Parenteral and enteral nutrition have a key role in its treatment. OBJECTIVE: To describe the clinical course of a patient with SBS during continuous use of enteral nutrition supplemented with symbiotic. CASE REPORT: A seven-year-old male underwent an emergency laparotomy at 18 months old with a massive bowel resection, remaining about 20 cm of the small intestine and the entire colon. He was dependent of exclusive parenteral nutrition for over a year, leading to the occurrence of numerous infectious complications. Due to complications caused by prolonged use of central venous access, was unable to continue to receive the parenteral nutrition. Enteral nutrition by a nasogastric tube and supplemental symbiotic was the nutritional therapy option for him. The assessment of the volume of losses by the colostomy was measured daily. RESULTS: There was a significant reduction of losses by colostomy, especially in the first days after introduction of the enteral nutrition plus symbiotic supplementation, as well as significant decrease in gas production. CONCLUSION: Despite the lack of evidence for a formal recommendation on the use of symbiotic for SBS patients, its use in the nutritional therapy of this patient resulted in reduced electrolyte loss electrolyte and consequent improvement of his clinical and nutritional condition.

Use of a symbiotic supplement in a child with short bowel Syndrome; a case report / Uso de suplemento simbiótico en un niño con síndrome del intestino corto; caso clínico

The short bowel syndrome (SBS) is due to loss of bowel after surgery. Characterized by generalized nutrients malabsorption, its signs and symptoms include electrolyte imbalance, deficiency of vitamins, minerals and nutrients that can lead to death. Parenteral and enteral nutrition have a key role in its treatment. Objective: To describe the clinical course of a patient with SBS during continuous use of enteral nutrition supplemented with symbiotic. Case report: A seven-year-old male underwent an emergency laparotomy at 18 months old with a massive bowel resection, remaining about 20 cm of the small intestine and the entire colon. He was dependent of exclusive parenteral nutrition for over a year, leading to the occurrence of numerous infectious complications. Due to complications caused by prolonged use of central venous access, was unable to continue to receive the parenteral nutrition. Enteral nutrition by a nasogastric tube and supplemental symbiotic was the nutritional therapy option for him. The assessment of the volume of losses by the colostomy was measured daily. Results: There was a significant reduction of losses bycolostomy, especially in the first days after introduction of the enteral nutrition plus symbiotic supplementation, as well as significant decrease in gas production. Conclusion: Despite the lack of evidence for a formal recommendation on the use of symbiotic for SBS patients, its use in the nutritional therapy of this patient resulted in reduced electrolyte loss electrolyte and consequent improvement of his clinical and nutritional condition (AU)

El síndrome del intestino corto (SIC) se debe a una pérdida intestinal tras cirugía. Caracterizado por una mal absorción generalizada de nutrientes, sus signos y síntomas incluyen el desequilibrio electrolítico y la deficiencia de vitaminas, minerales y nutrientes que pueden acarrearla muerte. La nutrición parenteral y enteral tiene un papel clave en su tratamiento. Objetivo: Describir el curso clínico de un paciente con SIC durante el uso continuo de nutrición enteral suplementada con un simbiótico. Caso clínico: Un chico de siete años fue sometido a una laparotomía urgente a los 18 meses de edad con una resección intestinal masiva, quedando sólo 20 cm de intestino delgado y el colon al completo. Dependió de nutrición parenteral exclusiva durante más de un año, lo que le produjo numerosas complicaciones infecciosas. Debido a las complicaciones causadas por el uso prolongado de un acceso venoso central, no pudo continuar recibiendo la nutrición parenteral. La opción terapéutica para él fue la nutrición enteral a través de una sonda nasogástrica y un suplemento simbiótico. Se evaluaron a diario las pérdidas de volumen a través de la colostomía. Resultados: Hubo una reducción significativa de las pérdidas por la colostomía, especialmente en los primeros días de la introducción de la nutrición enteral y la suplementación simbiótica, así como un descenso significativo de la producción de gas. Conclusión: A pesar de la falta de evidencia de una recomendación formal para el uso de simbiótico en pacientes con SIC, su empleo en la terapia nutricional de este paciente produjo una reducción de la pérdida de electrolitos y la consiguiente mejoría de su situación clínica y nutricional (AU)

Nutritional risk and anthropometric evaluation in pediatric liver transplantation

OBJECTIVE: To analyze the nutritional status of pediatric patients after orthotopic liver transplantation and the relationship with short-term clinical outcome. METHOD: Anthropometric evaluations of 60 children and adolescents after orthotopic liver transplantation, during the first 24 hours in a tertiary pediatric intensive care unit. Nutritional status was determined from the Z score for the following indices: weight/age height/age or length/age, weight/height or weight/length, body mass index/age, arm circumference/age and triceps skinfold/age. The severity of liver disease was evaluated using one of the two models which was adequated to the patients' age: 1. Pediatric End-stage Liver Disease, 2. Model for End-Stage Liver Disease. RESULTS: We found 50.0% undernutrition by height/age; 27.3% by weight/age; 11.1% by weight/height or weight/ length; 10.0% by body mass index/age; 61.6% by arm circumference/age and 51.0% by triceps skinfold/age. There was no correlation between nutritional status and Pediatric End-stage Liver Disease or mortality. We found a negative correlation between arm circumference/age and length of hospitalization. CONCLUSION: Children with chronic liver diseases experience a significant degree of undernutrition, which makes nutritional support an important aspect of therapy. Despite the difficulties in assessment, anthropometric evaluation of the upper limbs is useful to evaluate nutritional status of children before or after liver transplantation.