Overview• Difference in energy expenditure between a critically ill
child and healthy child• Gastrointestinal tract and absorption• Fat, protein, carbohydrate absorption• Glucose from the gut to maintaining blood glucose• The role of insulin and glucagon• The stress response and glucose metabolism• Starvation and/or stress and glucose levels• Route of Feeding• Impact of Nutritional Support on Glucose levels
The critically Ill child versus the healthy child
Active
Growth
Ventilated and fed artificially
Diagnosis and disease severity
Not active
No growthSpontaneous breathing and eating food
Parental consent obtainedThermoneutral environment
Environmental factors
The Gastrointestinal Tract and Absorption
Alcohol/medication
Most nutrients:
Protein, CHO, Fat
H2O, Na, Vit K
The Role of Insulin and GlucagonInsulin and glucagon work synergistically to keep blood glucose
concentration normal
Category Starvation StressProt Catabolism + +++
CarbohydrateGlycogenolysis + +++Gluconeogenesis + +++
LipidsLipolysis +++ +++/+++
Ketosis +++ ++
MetabolismEnergy Exp - / - / Serum Alb Change slow
Physiological Impact of Starvation +/- Stress
Route of Feeding
• Nasogastric– Continuous– boluses
• Nasojejunal– Continuous
• Parenteral– Cyclical– Continuous
When and what route
• First 24 hours NBM
Enteral Nutrition
Parenteral Nutrition
• Attempt gastric feeding
• Ensure maintenance: saline dextrose/ dextrose
24-48 hours NBM
Enteral Parenteral
• Insert NJ if possible
• Change feed
• 10% Dextrose (drugs, IV)
5 % (24 hours) 10% (24hours) PN (24 hours)
200 kcal 400 kcal 590 kcal
Eg: 10kg child on 100% fluid
> 72 Hours NBM
Parenteral Nutrition
Enteral Nutrition
•>2 days (neonates) PN indicated
•> 4 days(infants and young children) PN indicated
•>7 days in older children and teenagers
Nutritional Support and Glucose Control
• Route of feeding• Feeding break/ no feeding break?• Bolus/ Continuous Feeding• Parenteral Nutrition
– Central line: much higher glucose– Peripheral line: max 12.5%
• Type of feed, especially additions– Maxijul/ Duocal
• Medication mixed with dextrose