Author:
Kai Knudsen
Updated:
5 September, 2025
Nutritional support for critically ill children in intensive care is a central component of comprehensive medical management and has implications for both short-term and long-term outcomes. Unlike adults, children are characterized by continuous growth and development, making their energy requirements more dynamic and their metabolic reserves limited. During critical illness, metabolism is further affected by inflammatory processes and pharmacological interventions, leading to alterations in energy expenditure, nutrient metabolism, and fluid balance.
Introduction
Evidence shows that both undernutrition and overnutrition are associated with adverse outcomes such as prolonged hospital stay, increased risk of infections, and impaired organ function. The challenge in pediatric intensive care is therefore to balance the need for adequate energy and protein intake against the risk of metabolic complications from excessive provision. This requires careful monitoring, individualized calculations, and an interdisciplinary approach involving physicians, nurses, and dietitians.
International guidelines, including those from ESPGHAN/ESPEN/ESPR/CSPEN (2018) and the Society of Critical Care Medicine (SCCM) in collaboration with the American Society for Parenteral and Enteral Nutrition (ASPEN) (2017), emphasize the importance of early enteral nutrition when possible, along with caution in providing excessive parenteral nutrition during the initial critical days. These recommendations highlight the need for evidence-based and individualized nutritional strategies for children in intensive care.
Key Recommendations
- Initiate enteral nutrition early, preferably within 24–48 hours, if the child’s clinical condition allows.
- Avoid overnutrition, particularly during the acute phase of critical illness.
- Parenteral nutrition should be avoided during the first days if adequate enteral feeding is feasible, but considered if enteral nutrition is not possible.
- Optimize protein intake to support growth and tissue repair, with gradual adjustment according to the course of illness.
- Regular monitoring of energy and nutritional status is essential to adjust therapy.
Fluid and Caloric Needs
- Full-term infant > one week old: 100-150 ml/kg/day (normally for PICU patients, stay on the lower range).
- One-year-old: approximately 100 ml/kg/day.
- 10 years old: approximately 50 ml/kg/day.
- Adjustments should be made based on the current condition. Postoperatively after major surgery, 2-3 ml/kg/h is recommended for the first day.
Normal Energy Requirements at Different Ages
- Premature – neonatal: 110-120 kcal/kg/day
- Full-term newborn – 1 month: 90-100 kcal/kg/day
- 1-7 months: 75-90 kcal/kg/day
- 7-12 months: 60-75 kcal/kg/day
- 12-18 months: 30-60 kcal/kg/day
Enteral Nutrition
- Enteral nutrition can be started immediately unless the surgeon objects.
- For smaller children, give 5 ml x 6 –8, and increase if gastric retention is reasonable.
- Addex-Na and Kajos can be added, preferably when reaching higher food amounts to avoid abdominal discomfort.
- Naloxone APL (10 µg/kg x 4 orally) is given enterally to all receiving opioid infusions (motility agents are generally not used).
Parenteral Nutrition
Initiation of Parenteral Nutrition
- It is somewhat unclear when it is optimal to start parenteral nutrition, likely not suitable in the first days for critically ill children.
- Recommended “if enteral energy intake is expected to be < 50% for > 2-5 days.”
- Three-chamber systems can be used in children > 2.5 kg (e.g., Numeta G16E). Energy content 1 kcal/ml. Not suitable in liver or kidney failure (use separate infusions in these cases).
- Until recently, separate infusions of Clinoleic, Vamin, and glucose were used.
- Larger children (teenagers) can receive Kabiven or similar in the same way as adults.
- All mixtures should be ramped up over three days. Monitor transaminases, bilirubin, and triglycerides in plasma.
Indications for PN
Parenteral nutrition is initiated when the child’s nutritional needs cannot be met with oral and/or enteral nutrition. Where possible, PN should be combined with enteral nutrition. Initiate PN if nutritional intake is less than 50% of the requirement for a period longer than indicated in Table 1 (rule of thumb). The exception is premature infants, where nutritional therapy is initiated immediately after birth.
Maximum period of time with nutritional intake less than 50% of energy needs before PN is started
| The child's age | Day |
|---|---|
| Prematurely born babies | Begins immediately after birth |
| Mature children | Can wait at most |
| < 1 month | 2 days |
| 1 month – 1 year | 3 days |
| > 1 year | 4-5 days |
For losses from the intestine (drain, stoma), pleura (drain), or central nervous system (CSF drainage), these losses should be replaced separately through isotonic infusion fluids and not within the prescribed PN volumes.
Fluid and Nutrition Needs
The child’s energy requirements determine the amount of PN prescribed. PN solutions are energy-dense, and a prescription based on fluid needs results in excessive intake of energy and nutrients. If the patient requires additional fluid, it is prescribed in the form of another infusion solution. Ensure there is no dehydration, acid/base imbalance, electrolyte disturbance, or impact on renal or liver function before starting PN. Dehydration, acid/base, or electrolyte disturbances should be corrected before initiating PN treatment. If the child has significantly impaired renal or liver function, PN may need to be modified (e.g., reduction in protein or fat amounts). This should be discussed with a gastroenterology consultant.
Energy requirements are affected by nutritional status and disease state. In critically ill children with metabolic stress (sepsis, intensive care), energy needs are reduced to about 50-70% of normal. According to the latest research, it is not advantageous to initiate PN treatment within the first days in critically ill children in intensive care 3.
The child's total protein needs
Protein requirement per kg of body weight
| Age group | Gram/kg body weight/day |
|---|---|
| Children born before w.37 and during the neonatal period | 1,5 - 4,0 |
| Full-term infants | 1,5 - 3,0 |
| 2 months – 3 years | 1,0 - 2,5 |
| 3-18 years | 1,0 - 2,0 |
Normal energy requirement in children per kg/body weight by age
| Age (years) | Kcal/kg/day |
|---|---|
| Premature - neonatal: | 120-110 kcal/kg/day |
| Full-term newborn - 1 year: | 100-90 kcal/kg/day |
| 1-7 years: | 90-75 kcal/kg/day |
| 7-12 years: | 75-60 kcal/kg/day |
| 12-18 years | 60-30 kcal/kg/day |
Parenteral nutrition for children according to weight and age
The child's total energy needs in ml per kg. The energy content is approximately 1 kCal/ml
| Age (years) | Kcal/kg body weight/day | ml/body weight/day |
|---|---|---|
| Full-term newborns-1 | 100-90 | 100-90 |
| 1 to 7 years | 90-75 | 90-75 |
| 7 to 12 years | 75-60 | 75-60 |
| 12 to 18 years | 60-30 | 60-30 |
The child's total fluid needs
Fluid requirements per kg of body weight (Holliday-Segar)
| Weight (kg) | Quantity per day |
|---|---|
| Children born before w.37 and during the neonatal period | See PM for patients at Neonatal |
| < 5 kg | 150 ml/kg |
| 5 -10 kg | 100 ml/kg |
| 11 - 20 kg | 1000 ml + 50 ml for every kg over 10 kg |
| > 20 | 1500 ml + 20 ml for every kg over 20 kg |
Vitamins and minerals should be included in full amounts from day 1 when starting PN (for dosage see Table 5). In products ordered from APL, these are already added, but in standardized three-chamber bags, they need to be added. The supplements used in combination are Soluvit, Vitalipid, and Peditrace/Addaven.
Dosage of vitamins and trace elements per day
| Age | Younger than 11 years | Older than 11 years | ||
|---|---|---|---|---|
| Weight | < 10 kg | 10-15 kg | > 15 kg | |
| Soluvit® | 1 ml/kg | 10 ml | 10 ml | 10 ml |
| Vitalipid infant® | 10 ml | 10 ml | 10 ml | |
| Vitalipid adult® | 10 ml | |||
| Peditrace® | 1 ml/kg | 1 ml/kg | ||
| Addaven® | 0,1 ml/kg (max 10 ml) | 0,1 ml/kg (max 10 ml) | ||
Part of a Bag
A patient who is 2 months old and weighs 4 kg is prescribed 400 ml Numeta G16E® (= 412 kCal). The bag size is 500 ml, so only 80% of the bag is given to the patient. To meet the daily requirement of vitamins and minerals, the supplements need to be adjusted.
Multiple Bags
If more than one three-chamber bag is given during the same day, vitamin supplements should be added to the first bag.
Ramping Up PN
Ramping up parenteral nutrition is based on the child’s condition. During the ramp-up, the remaining amount of fluid needed to meet fluid requirements should be given separately. Below is a suggestion for ramping up PN. Day 1 33%, Day 2 67%, Day 3 100%. The prescribed amount should be given over as much of the day as possible; full amounts should not be given in less than 16 hours/day. The recommended infusion time is 20 hours. PPN can be given in a shorter time, but the infusion rate must not exceed the maximum infusion rate according to the product summary, which is 5.5 ml/kg/hour.
Determine the child’s total energy needs, see below. Consider the patient’s condition to determine energy needs. Since the energy content is about 1 kcal/ml, it can easily be converted to volume, see below.
The child's total energy needs
| Age (years) | Kcal/kg body weight/day | ml/kg/day |
|---|---|---|
| 1 - 7 years | 90-75 | 90-75 |
| 7 - 12 years | 75-60 | 75-60 |
| 12 - 18 years | 60-30 | 60-30 |
The development of elevated liver values during PN treatment usually signals ongoing inflammation, steatosis (accumulation of fat in liver cells), and/or impaired bile flow (cholestasis) in the liver. Be particularly vigilant for the development of cholestasis (i.e., conjugated bilirubin > 20 micromol/L), but even mild elevations in other liver values lasting more than a few days are reasons to contact a gastroenterologist for discussion on appropriate management and consideration of the need for investigation of any other underlying causes. If this assessment concludes that the cause of liver impact is PN-related, adjustments to the amount and type of fat in the PN solution may be necessary, often in combination with adjustments in glucose and protein amounts. This type of liver impact seen during relatively short-term use of PN is usually benign and reversible.
The most serious form of liver disease seen during PN treatment is that which affects intestinal failure patients on long-term PN. This condition is called Intestinal Failure Associated Liver Disease, IFALD (previously also known as parenteral nutrition-associated liver disease/cholestasis, PNALD/PNAC) and refers to a progressive liver disease seen in these patients. The diagnosis is clinical, and requires, in addition to intestinal failure and long-term PN, the presence of cholestasis (conjugated bilirubin > 20 micromol/L). The etiology is multifactorial, but the risk of developing IFALD can be reduced, among other things, by using an optimally composed PN solution, especially concerning fat. Modified fat composition (fish oil-based fat emulsion) in PN is also the basis for treating already developed IFALD.
Complications under treatment with TPN
| Complication to TPN | Cause | Proposed action |
|---|---|---|
| Infection in central entrance | Bacterial contamination of entrance | Antibiotic treatment Consider changing the entrance Taurolock® can be used to prevent infections |
| Hyperglycemia | High glucose supply For fast delivery Diabetes | Reduce the feed rate If necessary, give insulin |
| Nausea | For fast delivery Too high energy level Dehydration | Exclude reasons other than PN Lower energy level and speed Provide solution with lower osmolality Ev. antiemetics |
| Tachycardia Fever Rapid weight gain | Refeeding syndrome Fat overload syndrome Kidney failure Infection | Lower energy level and speed Weight control 1 time / day Temp controls Check electrolytes (phosphate, magnesium and potassium drops, in refeeding syndrome) Sepsis investigation, infection tests Coagulation tests in Fat overload syndrome |
| Rising liver values | Cholestasis Liver steatosis Hypertriglyceridemia Chronic inflammation | Change fat emulsion (for example Omegaven®) Stimulate the gut with enteral nutrition Reduce fat content and speed Put possibly. in Ursofalk® Consider antibiotic treatment |
| Rising urea | Impaired renal function Too high nitrogen supply Too low energy supply | Investigation of kidneys / urinary tract Reduce nitrogen supply Increase energy supply |
| Hypertriglyceridemia | Incorrect sampling Too high fat supply Liver failure | Recheck of S-TG Discuss ev. fat reduction with gastroconsultation |
References
- Mehta, N. M., Skillman, H. E., Irving, S. Y., Coss-Bu, J. A., Vermilyea, S., Farrington, E. A., … & Goday, P. S. (2017). Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Journal of Parenteral and Enteral Nutrition, 41(5), 706–742.
- Koletzko, B., Goulet, O., Hunt, J., Krohn, K., & Shamir, R. (2018). Guidelines on paediatric parenteral nutrition of the ESPGHAN/ESPEN/ESPR/CSPEN, special issue. Journal of Pediatric Gastroenterology and Nutrition, 66(1), 142–180.
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