Nutritional assessment and nutrition management of the children with tracheostomy
The global problem of the world, malnutrition leads to loss of lean body mass, growth and developmental delay, muscle weakness (e.g., decreased respiratory muscles’ and diaphgram strength), immune dysfunction (e.g., altered humoral and cellular immunity and increased bacterial adhesions in the lower respiratory tract, increased infections), delayed wound healing and prolong hospital stay 6-8. To prevent and improve malnutrition, the children with tracheostomy and HIMV should be evaluated for the nutritional status at hospital and after discharge regularly. The frequency of the visits is determined by the patients’ malnutrition degree, weight gain rate, presence of feeding intolerance or gastrointestinal symptoms. If the patients are stable, visits should be performed every 1 to 3 months for infants and every 3-6 months for older children1-3,6.
The nutritional assessment of children consists of a detailed dietary history, physical examination findings, anthropometric measurements and basic laboratory tests. During hospitalization and at every visit, patients’ detailed dietary intake (including water) and nutritional requirements should be determined. The deficiencies of vitamin and trace elements may reveal some pathological physical findings such as angular chelitis, keratitis, dermatitis, hair loss. Decubitus skin ulcers and poor peripheral circulation findings are the important physical examination findings related to undernutrition particularly in neurologically impaired patients. The anthropometric measurements should be recorded during hospitalization and should be routinely monitored in every visit. The length or height, body weight, head circumference measurements, weight for length and body mass index values should be evaluated due to age and gender of the patients and z-scores should be calculated. The growth charts and z-scores are very useful to monitor the growth of the children. The segmental measurements such as tibial and knee-heel length are useful in estimating height of the patients who cannot be measured due to severe contracture. In addition mid-upper arm circumference and triceps skin fold measurements are valuable in detecting acute malnutrition and also determining the effect of nutritional support on follow-up. Malnutrition definition generally based on the antropometric measurements. The severity of malnutrition is defined according to z-scores. Weight for age, weight for height, body mass index are mostly used indices to define malnutrition. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition (ASPEN) recommendations for definition moderate-severe acute malnutrion are given in Table 2. Also Academy of Nutrition and Dietetics/ASPEN defined inadequate nutrient intake as a risk factor for severe and moderate malnutrition, when nutrient intake is ≤25% and 26%-50% of estimated energy/protein requirement, respectively7,9-11.
Routine laboratory evaluation including hemoglobin levels, renal function tests, albumin, liver enzymes, fasting blood glucose should be performed. ESPGHAN recommended routine screening of vitamins (vitamin D, vitamin B12, folate, vitamin A, vitamin E), macrominerals (calcium, phosphate, magnesium), trace elements (zinc, iron), ferritin and parathormon in children with chronic conditions under high risk of malnutrition. The measurements should be performed in the absence of systemic inflammation because blood levels of vitamins and trace elements may be affected from systemic inflammation. In addition, a simultaneous measurement of acute phase reactans and albumin level is required 6,9,12.
The main purpose of nutritional support is to optimize growth and development. The nutritional requirement of every children changes due to own clinical condition and underlying disease. The patients who have undernutrition need higher energy requirements to catch-up growth.
Energy requirement of the children with neurological impairment (NI) differs due to the heterogeneity of clinical features. It depends on severity of the NI, muscle tone, physical activity level, mobility and presence of malnutrition. ESPGHAN recommended the use of dietary reference intake (DRI) standarts to estimate the energy need. But sometimes DRI may overestimate the energy needs of the children with NI. For instance total energy expenditure (TEE) / resting energy expenditure (REE) ratio is lower in quadriplegic cerebral palsy compared to children with normal activity (TEE/REE ratio is 1.1 and 1.5-1.6 respectively). Additionally the overestimation of energy need may result in obesity or being overweight. On the other hand the children with athetosis need more energy. At least in the beginning ‘The Schofield equation’ may be used to calculate basal metabolism rate (Table 3)13. On follow-up according to the weight gain velocity, activity and stress factors further dietary interventions can be made. In children with NI, recommended DRI for protein is same for healthy children. In case of decubitus ulcers or severely undernourished patients the protein intake may be increased to 2-2.4 g/kg/day6,9. The DRI values for energy and protein for healthy children are given in Table 414.
In the patients with Duchenne muscular dystrophy (DMD), the Schofield equation considered as an accurate predictive equation and they should receive 100% of DRI for energy. The energy requirement should be specialized based on ambulation, physical activity and current weight of the patient. For instance, some reports suggested the estimated energy need is 80% of DRI in ambulatory DMD boys, and 70% of DRI in non-ambulatory boys with DMD. In the presence of weight loss, energy intake can be increased to 130%-150% of DRI in DMD boys. Similarly protein intake should meet the DRI for age15,16.
The accurate estimation of REE of the infants with spinal muscular atrophy (SMA) type 1 should be based on nutritional and ventilation status (spontaneous, non-invazive or invasive MV) of the patient. The tracheostomy and invazive MV leads to 50% of decrease in REE, but spontaneously breathing infants need more energy. The estimated amount of energy is recommended to be 9-11 kcal/cm/day by ‘The International Standarts of Care for SMA’ 17.
The patients with cystic fibrosis may have increased REE and increased nutrient loss due to pulmonary, pancreatic and hepatic involvement To maintain growth, development and pulmonary functions, daily energy and protein requirements should be 120-150% of DRI and 150%-200% of DRI16. The recommended daily energy intake for the infants with bronchopulmonary dysplasia (BPD) is 120-150 kcal/kg18. Luo J19 et al. reported a significant increase in weight and length z-scores of the infants with BPD and a decreased energy requirement within 4 weeks after tracheostomy placement.
The water intake is adjusted based on the healthy children’s daily requirements and can be calculated by Holliday Segar formula (Table 5)20. Daily water need is equal to daily caloric expenditure and approximately 100 ml/kg water for every 100 kcal/kg is needed in normal physiologic conditions. The water losses due to pathological conditions should be given separately15,20.
Enteral tube feeding is required when the patients can’t feed by oral route or oral intake is not sufficient for nutrition, hydration, growth and even medication intake. It may be performed through a nasogastric, nasojejunal, percutaneous endoscopic gastrostomy (PEG), or jejunal tube [PEG with a jejunal extension (PEG-J), percutaneous endoscopic jejunostomy (PEJ) or surgical jejunostomy]. When the patient need non-oral nutrition support more than 3-6 weeks, PEG is indicated21. There is no need to investigate the children for gastroesophageal reflux in the absence of related symptoms prior to PEG placement6,21. The long term MV requires a safe enteral feeding route. Goneidy A. et al22. suggested to insert a gastrostomy tube at time of tracheostomy formation in children receiving long term ventilation and have been already feeding with NG tube.
Percutaneous endoscopic gastrostomy placement should be performed under general anaesthesia by a trained staff. Aseptic cleaning (simple washing is sufficient) and sterile dry dressing of the wound site is recommended for one week. While site is healing, a clear discharge may be seen. The parents or caregivers should be trained for feeding tube and stoma care. They should be informed for possible complications such as tube removal, clogging. In daily care, infectious signs should be looked for the gastrostomy site. The parents or caregivers should be informed for the importance of nutrition. They should be trained for feeding techniques before discharge21,23.
Three hours after PEG placement, feeding can be started. Isoosmolar formulas are the best choice to start feeding. The first choice should be bolus feeding because it is more physiological. If the patient hasn’t tolerated the bolus feeding via NG tube previously, the alternative will be continuous feeding. The targeted energy intake is determined by assessing the nutritional status of the children. The feeding volume should be increased gradually both in bolus and continuous feeding because excessive feeding may cause abdominal distension, which may affect respiratory function. A stepwise increase of feeding is useful to monitor feeding intolerance or the other gastrointestinal complications21.
Enteral feeding formulas are chosen according to the patients age, underlying disease and tolerance. Breast milk, infant formulas, isocaloric and hypercaloric formulas may be used for enteral feeding. Formula may be changed depend on calorie requirements or volume restriction. Also feeding type or content of formula can be changed due to feeding intolerance in follow-up21. Adjusting a safe feeding regimen and optimal formula before discharge is essential for the patient with tracheostomy,