The prevalence of both acute and chronic malnutrition in the critically ill child continues to be documented.1 Vigilant nutrition screening to assess for malnutrition and the development of an appropriate nutrition prescription are important goals for nutrition support in the critically ill child.2 During critical illness, energy and macronutrient utilization is altered, resulting in glucose and lipid intolerance, as well as altered protein metabolism, making the design of appropriate nutrition support a challenge.3 Other barriers to nutrition delivery also commonly exist during critical illness, including fluid restrictions, interruptions in the advancement of nutrition support due to procedures, and the inability to obtain dedicated venous or enteral access.4
Compared to adults, critically ill neonates and children are at increased risk of loss of lean body mass due to their decreased energy stores and increased basal energy requirements, which can ultimately place them at risk for increased morbidity and mortality.5 A nutrition prescription consisting of a mixed substrate fuel system, including adequate protein, will not fully suppress the ensuing metabolic response, but can offset the catabolism and eventually lead to anabolism, ensuring continued growth and development.6
The field of parenteral nutrition (PN) dates only from the 1960s, when pioneering studies by Dudrick and others were described in patients with chronic gastrointestinal diseases, which set the stage in supporting the use of PN to address malnutrition in hospitalized patients.7 In this chapter, we will discuss the role of both primary and supportive PN in terms of delivering adequate nutrition to critically ill children. We will also discuss the importance of delivering a PN solution that will reduce the risk of morbidity and mortality. PN has considerably improved the survival of previously fatal pediatric conditions. Specialized enteral and PN solutions have made significant advancements and play an essential role in the overall management of critically ill children.8
INDICATIONS FOR PARENTERAL NUTRITION
Although current research supports enteral nutrition (EN) as the preferred mode of nutrition support, PN can be a judicious choice in terms of delivering adequate nutrition prescriptions when the function of the gastrointestinal tract is altered. Table 7-1 lists common clinical conditions that result in altered gastrointestinal function wherein PN use should be considered.8,9
Indications for PN8,9
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Indications for PN8,9
|Clinical Condition || |
|Surgical gastrointestinal disorders ||Gastroschisis, omphalocele, intestinal atresias, meconium ileus, Hirschsprung disease, diaphragmatic hernia, gastrointestinal fistula, postoperative ileus |
|Prematurity || |
|Short bowel syndrome || |
|Congenital heart disease ||Compromised blood supply to the mesentery |
|Intestinal disease ||Severe inflammatory bowel disease, chronic or secretory diarrhea, microvillus inclusion disease and tufting enteropathy |
|Motility disorders ||Intestinal pseudo-obstruction, total colonic Hirsch-sprung disease, mitochondrial and metabolic disorders |
|Bone marrow transplant ||Anorexia, mucositis, feeding intolerance related to side effects of therapy |
|Hypermetabolic states ||Trauma, burns, ...|
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