Metabolic, endocrine and nutritional aspects of critically ill children

Part 1 provides the aims of the studies (chapter 1) and a general overview and discussion of the current literature of metabolic, endocrine and nutritional aspects in critically ill children (chapter 2). In Part 2 the clinical use of an indirect calorimeter is tested and validated for use in critically ill mechanically ventilated children. In chapter 3 a new indirect calorimeter is tested in a laboratory setting using a ventilated lung model and a butane burner system to determine the accuracy of the calorimeter for use in young infants and children. The influence of low tidal volumes and low levels of oxygen consumption and carbon dioxide production with different levels of inspired oxygen concentrations is investigated. [n chapter 4 it is questioned how accurately total daily energy expenditure of mechanically ventilated pediatric patients can be estimated from measurement periods . of less than 24 hours. In addition, the influence of tube leakage on energy expenditure measurements is determined. In Part 3 the clinical use of the indirect calorimeter is tested in mechanically ventilated children. In chapter 5 using indirect calorimetry the following issues were studied: 1 What are the actual energy needs are for critically ill mechanically ventilated chi

The role of parenteral nutrition in paediatric critical care, and its consequences on recovery

The goal of nutritional support during critical illness is to provide the appropriate amount of nutrition accounting for the acute, stable and recovery phase in order to accelerate recovery and to improve short-term and long-term outcomes. Although the preferred route to provide nutritional support during paediatric critical illness is via enteral route, reaching target intakes is often difficult due to (perceived) feeding intolerance, fluid restriction, and interruptions around procedures. Because undernourishment in these children has been associated with impaired outcome, parenteral nutrition (PN) has therefore been viewed as an optimal alternative for reaching early and high nutritional targets. However, PN recommendations regarding timing, dose and composition varied widely and were based on studies using intermediate or surrogate endpoints and observational studies. It was not until the paediatric early versus late PN in critically ill children (PEPaNIC) randomized controlled trial (RCT) that the advice to reach high and early macronutrient goals via PN was challenged. The PEPaNIC study showed that omitting supplemental PN during the first week of paediatric intensive care unit (PICU) admission as compared with early initiation of PN (&lt;24 hours) reduced new acquired infections and accelerated recovery. The provision of amino acids in particular was negatively associated with short-term outcomes, probably explained by the suppression of the activation of autophagy. Autophagy is an evolutionary conserved intracellular degradation process and it is crucial for maintaining cellular integrity and function, which becomes even more important during acute stress. Results of the long-term PEPaNIC follow-up study showed that withholding early PN did not negatively affect anthropometrics and health status but improved neurocognitive and psychosocial development 2 and 4 years later. Current guidelines therefore advise to consider withholding parenteral macronutrients for the first week of PICU admission, while providing micronutrients. Although parenteral restriction during the first week of critical illness has been found beneficial, further research beyond the acute phase is warranted to determine the best role of PN in terms of optimal timing, dose and composition in order to improve short-term recovery and long-term developmental outcomes.</p

Association between nutritional status and subjective health status in chronically ill children attending special schools

Purpose: In hospitalized children with a chronic disease, malnutrition was associated with a lower subjective health status. In outpatient children with a chronic disease attending special schools, this association has never been studied. The aim of this study was to assess the association between nutritional status and subjective health status in chronically ill children attending special schools. Methods: Overall, 642 children, median age 9.8 years (IQR 7.7–11.5), 60 % male, 72 % Caucasian, were included in this prospective study in nine special schools for chronically ill children in the Netherlands. Overall malnutrition was assessed as: acute malnutrition (<−2 SDS for weight for height (WFH)) and chronic malnutrition (<−2 SDS for height for age). The malnutrition risk was assessed with the nutritional risk-screening tool STRONGkids. Subjective health status was assessed with EQ-5D. Results: Overall, 16 % of the children had overall malnutrition: 3 % acute and 13 % chronic malnutrition. Nurses reported ‘some/severe problems’ on the health status dimensions mobility (15 %), self-care (17 %), usual activities (19 %), pain/discomfort (22 %), and anxiety/depression (22 %) in chronically ill children. Their mean visual analogue scale score (VAS) was 73.0 (SD 11.1). Malnutrition, medication usage, and younger age explained 38 % of the variance of the VAS score. Conclusions: The presence of overall malnutrition in chronically ill children attending special schools was associated with lower subjective health status, especially in younger children and in those with chronic medication usage. Therefore, it is important to develop and use profile-screening tools to identify these children