title: Challenges to nutrition therapy in the pediatric critically ill obese patient.
abstract: BACKGROUND
  Obesity has been associated with poor clinical outcomes in critically ill children. The optimal approach to nutrition therapy in this vulnerable cohort is unclear.
  
  
  METHODS
  We report the nutrition management of 2 obese patients admitted to a pediatric intensive care unit (PICU). We focus on their nutrition assessment, energy requirements, and macronutrient delivery.
  
  
  RESULTS
  Case 1 describes a 19-year-old male, body mass index (BMI) 52.4 kg/m(2), who was admitted after emergent orthopedic surgery. Case 2 describes a 13-year-old male, BMI 31.5 kg/m(2), who was admitted with respiratory distress. Average PICU length of stay was 2 months. Nutrition assessments, including weight and height, were obtained early and regularly. Skinfold measurements were challenging. Estimated energy expenditure by predictive equations was significantly higher compared with measured resting energy expenditure (MREE) by indirect calorimetry in both cases. The Mifflin St-Jeor equation (in case 1) overestimated MREE by 681 kcal/d; the Schofield equation (in case 2) overestimated MREE by 662 kcal/d. Both patients had barriers to enteral nutrition and prolonged periods of time when they received no enteral nutrition, requiring parenteral nutrition for 28% and 75% of their PICU stay, respectively. Average daily protein delivered was 0.8 g/kg and 1 g/kg, below adult recommended protein intake for obese patients and pediatric recommendations for age.
  
  
  CONCLUSIONS
  These cases were notable for (1) challenges to anthropometric assessments, (2) inaccurate estimates of energy requirements, (3) suboptimal enteral nutrition delivery, (4) need for supplemental parenteral nutrition, and (5) suboptimal protein intake. Research is needed to determine the best approach to nutrition therapy in this cohort.
authors: Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts enid.martinez@childrens.harvard.edu.
authors: Enid E
authors: EE
authors: Martinez
authors: Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts.
authors: Katelyn
authors: K
authors: Ariagno
authors: Universidad Francisco Marroquin, Guatemala City, Guatemala.
authors: Aldis
authors: A
authors: Arriola
authors: Universidad Francisco Marroquin, Guatemala City, Guatemala.
authors: Kattina
authors: K
authors: Lara
authors: Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts.
authors: Nilesh M
authors: NM
authors: Mehta
mesh_terms: D000293:Adolescent; D015992:Body Mass Index; D001835:Body Weight; D002153:Calorimetry, Indirect; D016638:Critical Illness / Q000628:therapy*; D004044:Dietary Proteins / Q000008:administration & dosage; D002149:Energy Intake; D004734:Energy Metabolism; D004750:Enteral Nutrition; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008297:Male; D015596:Nutrition Assessment; D009751:Nutritional Requirements; D010288:Parenteral Nutrition; D063766:Pediatric Obesity / Q000178:diet therapy*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D004044:Dietary Proteins
keywords: calorimetry; critical care; intensive care; nutrition assessment; nutritional support; obesity; pediatrics