Chapter 8

### Key Points

1. Although optimal growth of the neonate can be insured with a caloric intake from 100 to 150 kcal/kg/D, during acute metabolic stress (injury) states, characterized by increased C-reactive protein and decreased prealbumin serum concentrations, daily energy repletion should be based on either measured energy expenditure values or basal metabolic rate.

2. The metabolic rate increases 10% to 13% per degree centigrade elevation and 7.2% per degree Fahrenheit elevation.

3. The nutritional caloric regimen for the metabolic impact of acute injury in infants does not require the replacement of calories allotted for growth.

4. Glycemic control during the resuscitative and stabilization phase of acute illness may provide a favorable impact on patient morbidity and mortality.

5. Indirect calorimetry is a useful energy assessment tool. During critical illness, changes in daily energy repletion are dependent on the magnitude and duration of the acute metabolic stress response, but do not include energy required for growth, insensible losses, or activity.

6. Both enteral and parenteral nutrition are effective in reducing the hypermetabolic response to injury as well as reducing protein catabolism.

### Overview

Optimal nutritional therapy is an essential requirement in the postoperative care of pediatric surgical patients, especially infants and children in the intensive care setting. Growth velocity during early infancy is higher than at any other time during childhood and is exceeded only by intrauterine growth rates. Daily energy needs range from 100 kcal/kg/day in term infants to 150 kcal/kg/day in very premature babies. Although these energy needs decrease in older children, growth and activity requirements still exceed those of normal adults. In the surgical population, particularly in critically ill patients, metabolic status is significantly altered. Perioperative acute tissue injury markedly reduces these energy needs, due to the injury-related induction of catabolic metabolism (which inhibits growth), sedation (which inhibits activity), and environmental temperature control (which reduces insensible heat loss). In concert, these factors result in a substantial decrease in energy needs, especially in the mechanically ventilated child. To account for these alterations in energy metabolism, caloric amounts equal to measured energy expenditure (MEE) values or basal energy requirements should be provided to prevent overfeeding (ie, the provision of calories and/or nutritional substrates in excess of the energy required to maintain the metabolic homeostasis). Overfeeding can create or prolong the requirement for mechanical ventilation (increased ventilatory workload), impair liver function (induced hepatic steatosis and cholestasis), and increase injury-induced hyperglycemia (increased risk of infection). Nutritional assessment of critically ill pediatric patients can be quantitatively accomplished by measuring the visceral protein pool (ie, serum C-reactive protein [CRP]), the acute-phase protein pool (ie, serum prealbumin), and energy expenditure. Serum prealbumin levels decrease and CRP levels increase with a magnitude and duration proportional to injury severity, and the values return to normal as the acute injury response resolves. Serum CRP concentrations have been shown to correlate well with MEE; however, predictive equations for energy expenditure are inaccurate. A substantial percent of preterm infants are dependent on total ...

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