Factors associated with not meeting the recommendations for micronutrient intake in critically ill children.

OBJECTIVE: Children admitted to the intensive care unit (ICU) are at risk of not meeting their nutritional requirements. This study aimed to identify factors associated with failure to meet the dietary recommended intake (DRI) of zinc, selenium, cholecalciferol, and thiamine in critically ill children receiving enteral tube feeding during their stay in the ICU. METHODS: We analyzed prospectively 260 cases, corresponding to 206 patients who received enteral tube feeding for a minimum of 3 days up to 10 days during the first 10 d of ICU stay. Individual intake was compared to estimated average requirement (EAR) and adequate intake (AI) values during the first 10 d of ICU stay. The outcome variable was defined as not meeting the recommended intake of the micronutrients studied. Potential explanatory variables for the outcome were age <1 year, malnutrition (WHO), clinical severity scores, heart disease, severe sepsis or septic shock, use of alpha-adrenergic drugs, and renal replacement therapy (RRT). The effect of the explanatory variables on the outcome was analyzed by logistic regression analysis. RESULTS: The majority of patients did not meet the recommendations for micronutrients. After adjusting for covariates, age <1 year, malnutrition, heart disease, use of alpha-adrenergic drugs, and renal replacement therapy were associated with failure to meet the recommendations for at least one of the micronutrients studied. CONCLUSIONS: Factors associated with failure to meet the recommendations for micronutrient intake in children receiving enteral tube feeding during their ICU stay are linked to patients' low weight, restriction in fluid intake, and clinical severity of the disease.

Serum Albumin Is an Independent Predictor of Clinical Outcomes in Critically Ill Children.

OBJECTIVES: Serum albumin is a strong biomarker of disease severity and prognosis in adult patients. In contrast, its value as predictor of outcome in critically ill children has not been established. We aimed to determine whether admission hypoalbuminemia is associated with outcome in a general pediatric population of critically ill patients, taking into account the inflammatory response, disease severity, and nutritional status of the patient. DESIGN: Analysis of prospectively collected database. SETTING: PICU of a teaching hospital. PATIENTS: Two hundred seventy-one patients consecutively admitted. Neonates, patients with chronic liver or kidney disease, inborn errors of metabolism, those who received prior administration of albumin solution, and readmissions were excluded. MEASUREMENTS AND MAIN RESULTS: Outcome variables were 60-day mortality, probability of ICU discharge at 60 days, and ventilator-free days. Potential exposure variables for the outcome were sex, age, nutritional status, albumin, C-reactive protein and serum lactate at admission, and Pediatric Index of Mortality 2 score. Admission hypoalbuminemia was present in 64.2% of patients. After adjustment for confounding factors, only serum lactate, Pediatric Index of Mortality 2 score, and serum albumin were associated with higher mortality: the increase of 1.0 g/dL in serum albumin at admission resulted in a 73% reduction in the hazard of death (hazard ratio, 0.27; 95% CI, 0.14-0.51; p < 0.001). The increase of 1 g/dL in serum albumin was also independently associated with a 33% rise in the probability of ICU discharge (subhazard ratio, 1.33; 95% CI, 1.07-1.64; p = 0.008) and increased ventilator-free-days (odds ratio, 1.86; 95% CI, 0.56-3.16; p = 0.005). CONCLUSIONS: Hypoalbuminemia at admission to a PICU is associated with higher 60-day mortality, longer duration of mechanical ventilation, and lower probability of ICU discharge. These associations are independent of the magnitude of inflammatory response, clinical severity, and nutritional status.

Malnutrition may worsen the prognosis of critically ill children with hyperglycemia and hypoglycemia.

OBJECTIVES: To determine whether hyperglycemia and hypoglycemia are associated with higher mortality, longer length of intensive care unit (ICU) stay, and fewer ventilator-free days in critically ill children while taking into account the clinical severity and nutrition status. PATIENTS AND METHODS: A prospective observational cohort study was conducted on 221 children admitted to the ICU. Blood glucose levels were analyzed in the first 72 hours. Potential exposure variables for adverse prognosis included hyperglycemia (blood glucose >150 mg/dL), hypoglycemia (blood glucose ≤60 mg/dL), age <1 year, sex, nutrition status, the revised Pediatric Index of Mortality (PIM 2), and the Pediatric Logistic Organ Dysfunction (PELOD). RESULTS: Of the patients, 47.1% were malnourished. Controlling for nutrition status, both hyperglycemia and hypoglycemia increased the risk of mortality in the malnourished patients compared with the well-nourished ones. Adjusting for clinical severity, the odds ratio of mortality was higher in malnourished patients with hyperglycemia (odds ratio [OR], 3.98; 95% confidence interval [CI], 1.14-13.94; P = .03), whereas no significant associations were detected in the well-nourished patients. After controlling for nutrition status, hypoglycemia was associated with longer length of ICU stay (OR, 6.5; 95% CI, 1.30-32.57; P < .01) and fewer ventilator-free days (OR, 4.11; 95% CI, 1.26-13.40; P < .01) only in the malnourished group of patients. CONCLUSIONS: Compared with the well nourished, malnourished patients with hyperglycemia are at a greater risk of mortality, independent of clinical severity. Hypoglycemia was shown to be associated with mortality, longer length of ICU stay, and fewer ventilator-free days only in malnourished patients.

Hypophosphatemia-induced seizure in a child with diabetic ketoacidosis.

We report an unusual case of hypophosphatemia-related seizure in a child with diabetic ketoacidosis (DKA). A 1-year-old type 1 diabetic boy with hyperglycemia, ketoacidosis, and dehydration was admitted to the pediatric intensive care unit. After having received fluid replacement using isotonic solution with added potassium and continuous intravenous insulin administration according to the protocol for DKA, the patient was conscious, awake, and fed with breast milk. After 20 hours of pediatric intensive care unit stay, he presented 2 tonic-clonic seizures followed by apnea. One hour later, he had cardiorespiratory arrest, requiring cardiovascular support and mechanical ventilation. Serum phosphorus concentration was 1.0 mg/dL, and severe hypophosphatemia was diagnosed. Subsequent to intravenous phosphate replacement, he showed improved neurological and hemodynamic statuses. No other cause of cerebral complication was found. He had no neurologic lesions and was discharged. Although hypophosphatemia is a common complication of DKA treatment, phosphate supplementation has not been routinely recommended in the treatment of DKA. Early recognition and treatment of severe hypophosphatemia in the treatment of DKA are important to reduce the risk of neurological complications.

Enteral nutrition in critically ill children: are prescription and delivery according to their energy requirements?

BACKGROUND: The purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support. METHODS: In a prospective cohort study, we evaluated 55 critically ill children aged 8.2 +/- 11.4 months (0-162.3 months), who were fed for > or =2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity. RESULTS: The ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 > or =15%, gastrointestinal complications, dialysis, and use of alpha-adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal. CONCLUSIONS: The prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.

Bedside transpyloric tube placement in the pediatric intensive care unit: a modified insufflation air technique.

OBJECTIVE: To test air insufflation as an adjunct to placement of enteral feeding tubes and the effectiveness of using a smaller insufflation volume in pediatric patients. DESIGN AND SETTING: A randomized, controlled study in a pediatric intensive care unit in two tertiary hospitals. PATIENTS: A total of 78 children with indication for transpyloric tube feeding were studied. INTERVENTIONS: An unweighted feeding tube was placed into the stomach through the nares; a 20-ml syringe was used to insufflate 10 ml/kg air into the stomach. The tube was advanced an estimated distance into the pylorus or beyond. The control group received the same procedure except for air insufflation. Resident physicians performed all procedures. Abdominal radiography was performed 3 h later. RESULTS: Of 38 tubes in the study group 33 (86.8%) were successfully placed in a single attempt, compared to 18 of 40 tubes (45%) in the control group. Compared with the technique of using 20 ml/kg air for insufflation, no statistically significant difference was observed. No significant complication was observed. CONCLUSIONS: The gastric insufflation technique required no expensive equipment, minimal training, and consistently allowed transpyloric passage of feeding tubes. The use of 10 ml/kg air may significantly improve the rate of success without increasing risks.