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,