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INTRODUCTION

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The provision of optimal nutrition may be challenging in developing countries due to a higher prevalence of malnutrition and scarcity of resources in the pediatric intensive care unit (PICU). Malnutrition affects nearly 50% of hospitalized children and 20% to 70% of critically ill children, more so in resource-limited countries.1 In a recent international multicenter cohort, over 30% of patients admitted to 31 PICUs had severe malnutrition on admission, with body mass index (BMI) Z-score >2 (13.2%) or <−2 (17.1%) on admission.2 Malnutrition was associated with greater length of ventilation, higher rate of complications, longer length of hospital stay and increased costs, and increased mortality.3,4 Furthermore, it is easy to underfeed critically ill children because of poor gut function, fasting for various surgical and nonsurgical procedures, and fluid constraints.5 Therefore, nutrition may deteriorate further in the hospital, and specifically in the PICU, with resultant poor outcomes, unless specific attention is paid to management of nutritional losses from drains, wound and skin losses, renal dysfunction, dialysis, etc. In the presence of preexisting malnutrition, children are much more susceptible to the deleterious effects of the protracted catabolic stress caused by critical illness. Compared to adults, children have significantly lower nutritional reserves and higher resting energy expenditure (REE) per unit body weight; the quantity of protein as a percentage of body weight, lipid stores, and carbohydrate reserves are reduced. The caloric and protein deficits accumulate quickly in critically ill children. While public health programs have focused on infant and child malnutrition in the general community, the deterioration of nutritional status in the hospital during critical illness is often neglected.

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IN-HOSPITAL MALNUTRITION

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Critically ill infants and children are susceptible to “in-hospital malnutrition.”6,7 In a recently completed study in our PICU, among critically ill children staying for 1 week, the proportion of undernourished children defined as weight-for-age Z-score <−2 was 54% in infants under 1 year and 27% in children 1 to 12 years. The number of undernourished children increased between admission and discharge to 70% in infants under 1 year and 53% in children 1 to 5 years of age. A trend toward recovery of anthropometric parameters was seen at 3 and 6 months post-hospitalization (Shrikant, Bhalla, and Singhi personal communication). Hypoalbuminemia was present in 21% (92 of 435) patients at admission, and 34% (151/435) by end of the first week of stay and in 37% (164/435) at the end of the second week. The hypoalbuminemic patients had prolonged PICU stay (13.8 vs. 6.7 days) and ventilator requirement (28.8% vs. 8.5%) (unpublished data). Hospital malnutrition has been associated with increased morbidity, mortality, hospital stay, and costs.8,9 However, hospital malnutrition is underrecognized. Its true incidence and impact, particularly in developing countries, may be much higher than presently estimated.10 Careful nutritional evaluation of children on admission is essential in order to identify those children who are already undernourished and hence at higher risk of further nutritional deterioration during their hospital stay.11

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NUTRITIONAL ASSESSMENT

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All children admitted to the PICU must undergo nutrition screening to identify those who are at risk of malnutrition. A formal nutrition assessment to obtain baseline data to estimate nutritional needs and to formulate a nutrition care plan is ...

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