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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 3 | Page : 110-115 |
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Impact of nutritional status of children admitted in PICU on mortality and morbidity: A prospective observational study
Moumita Samanta, Sanjay Das, Saikat Mahato, Akash Rai, Tapan K Sinhamahapatra
Department of Pediatric Medicine, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| Date of Submission | 17-Apr-2022 |
| Date of Decision | 29-Jul-2022 |
| Date of Acceptance | 06-Jun-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Akash Rai
Department of Pediatric Medicine, Nil Ratan Sircar Medical College and Hospital, 138 A.J.C. Bose Road, Kolkata 700014
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/DYPJ.DYPJ_32_22
Objectives: Anthropometry is a routine and simple procedure to assess the nutritional status of a child. We aimed to study the impact nutritional status has on the mortality and morbidity of children admitted in the pediatric intensive care unit (PICU) in a tertiary care hospital in Eastern India. Materials and Methods: We performed a prospective observational study to assess the relation between anthropometric measurements of children on admission in PICU and their outcomes in terms of mortality and morbidities (total stay in PICU, duration of mechanical ventilation, requirement of inotrope, delay in enteral nutrition, and total duration of enteral feeding). Results: Sixty children were included out of which 45 were under 5 years of age and 15 were more than 5 years of age. Children under 5 years with normal weight for age, weight for height, and mid-upper arm circumference had higher chances of survival. Similarly, in children >5 years of age, those with weight for age and body mass index for age in 25th–50th percentile had higher chances of survival. All these associations were statistically significant. On further analysis, these anthropometric measurements that affected mortality also influenced morbidities significantly. Conclusion: Children with inadequate nutritional status as assessed by anthropometry had statistically significant higher mortality and morbidity in the PICU. Thus nutritional status of a child on admission is an important factor to prognosticate the outcome of a child in PICU. Keywords: Anthropometry, malnutrition, morbidity, mortality
How to cite this article:
Samanta M, Das S, Mahato S, Rai A, Sinhamahapatra TK. Impact of nutritional status of children admitted in PICU on mortality and morbidity: A prospective observational study. D Y Patil J Health Sci 2022;10:110-5 |
How to cite this URL:
Samanta M, Das S, Mahato S, Rai A, Sinhamahapatra TK. Impact of nutritional status of children admitted in PICU on mortality and morbidity: A prospective observational study. D Y Patil J Health Sci [serial online] 2022 [cited 2023 Mar 23];10:110-5. Available from: http://www.dypatiljhs.com/text.asp?2022/10/3/110/370118 |
| What is Known | |  |
- Undernourished children are more prone to require PICU admission.
- Undernourished children have higher mortality in PICU.
| What is New | | |
- Undernourished children have higher mortality as well as higher morbidity.
- Anthropometry can be used to prognosticate PICU outcomes.
| Introduction | | |
The pediatric intensive care unit (PICU) concept was initially developed about 40 years ago with the first consensus conference on critical care admission held in 1983 by the National Institute of Health in the USA.[1],[2] The principle that emerged from this group continues to be relevant even today as it identifies patients who should be admitted to the PICU as those who have reversible medical conditions with a reasonable prospect of substantial recovery.[3],[4] As with any treatment, the decision to admit a patient to the PICU should be based on potential benefit.[5]
Accurate anthropometric measurements of weight and stature are required to calculate the correct dosage of medications and blood products, assess nutritional status, prescribe appropriate nutrient intake, and determine treatments and therapies.[6],[7] Additionally, these measurements are crucial for determining appropriate size of equipment, doses of emergency medications, and amount of energy for electrical defibrillation for treatment in cardiac arrests and similar emergencies.[8]
The accuracy of a patient’s weight before the current illness should be considered but should be interpreted with caution, particularly in children with altered fluid balance, malnutrition, or an underlying chronic illness.[6],[9] Measurement of stature (standing height or recumbent length) is necessary to calculate body mass index (BMI), ideal body weight, and body surface area, values that are often used for prescribing particular classes of medications and for calculating various therapies in critically ill patients.[6] Anthropometry has a long tradition of assessing nutritional and health status of the pediatric population as this is an inexpensive, non-invasive method. Moreover, anthropometric measurements are highly sensitive to the broad spectrum of nutritional statuses, whereas biochemical and clinical indicators are useful only at extremes of malnutrition.
Poor nutritional status is one of the major causes of mortality and morbidity of children in our country. Though multifactorial in origin, appropriate measures can alter the disease course in these children. Previous studies have shown that children admitted in the PICU had poorer nutritional status when compared with general population. Like malnourishment, obesity also adversely affects outcomes in children as studied by Srinivasan et al.,[10] in which they established that obesity is independently associated with worse odds of survival after in-hospital pediatric cardiopulmonary resuscitation. We carried out this study to assess the relation of nutritional status of children via anthropometric measurements admitted in the PICU with mortality and morbidity in terms of duration of mechanical ventilation, PICU stay, inotrope requirement, and enteral nutrition.
| Materials and Methods | | |
A prospective observational study was conducted at the PICU, Department of Paediatrics, Nil Ratan Sircar Medical College and Hospital (NRSMCH), Kolkata, India from May 2019 to May 2020. The study population included the patients admitted in the PICU unit during the said period, with no follow-up period. Purposive sampling was used to include pediatric patients between the age group of 1 month to 12 years, admitted in the PICU of NRSMCH. However, patients with age less than 1 month and above 12 years (according to the hospital protocols for admission in the PICU), post-operative patients, patients on follow-up found to be suffering from such infectious diseases requiring isolation, children suffering from any congenital syndrome, children on steroid use (more than 4 weeks prior to hospital admission), children suffering from any disease that causes fluid accumulation by edema or ascites and relative weight gain such as nephrotic syndrome and congestive heart failure, and patients who have left hospital against medical advices were excluded from the study.
All subjects of the study population were studied in a methodical manner in a predesigned structural proforma that included detailed history, general examination, vital signs, and anthropometry including height/length, body weight, BMI (for >5 years), and mid-upper arm circumference (MUAC) (6 months to 5 years).
After obtaining approval from the Institutional Ethics Committee, a written informed consent in local language was procured from parents prior to enrolment of children.
All the children admitted in the PICU, NRSMCH were subjected to a detailed physical examination and search for exclusion criteria and followed by anthropometry followed by their percentile measurement on admission [WHO charts (for children <5 years of age) and IAP charts (for >5 years of age) were used to determine the percentile] and mortality and morbidity in terms of their PICU stay, parenteral nutrition, delay of enteral nutrition, inotrope support, and duration of ventilation.
The weight of the children was measured at admission using a weighing machine—HSCO Baby Cum Adult Scale—model number BCA100 capacity 100 kg, accuracy 100 g. The children were also qualitatively divided into the following three categories: healthy (WFA above 3rd percentile), malnourished (WFA between 1st and 3rd percentile) and severely malnourished (WFA less than 1st percentile). The Figure 1 is a representation of the anthropometric measurements of the two groups.
The height of the children was measured at admission using a stadiometer—Prestige Stadiometer, measuring range 20–210 cm with 1 mm graduation (for height) for children more than 2 years of age and able to stand and non-stretchable measuring tape—Advancestore body measuring tape 150 cm length with 1 mm graduation (for length) for sick children not able to stand more than 2 years and an Infantometer for children less than 2 years. Based on the admission percentile qualitative interpretation was done in terms of normal [height for age (HFA) above 3rd percentile], stunted (HFA between 1st and 3rd percentile), and severely stunted (HFA less than 1st percentile).
The weight for height percentile for children <5 years of age was determined, and qualitative interpretation was done and categorized as healthy (>3rd percentile), moderate acute malnutrition (1st to 3rd percentile), and severe acute malnutrition (<1st percentile).
The MUAC for the non-dominant hand was measured for children >6 months to 5 years of age at admission, and percentiles were determined. Qualitative interpretation was done and classified as healthy (above 3rd percentile), malnourished (between 1st and 3rd percentile), and severely malnourished (less than 1st percentile).
BMI on admission was determined for children >5 years of age and percentiles were determined. However, qualitative interpretation could not be done as all the children above 5 years in the study were above 3rd percentile, and thus interpretation was done by grouping them in percentiles.
After anthropometric measurements and grouping the children, the correlation of the said parameters was done with mortality and morbidity in terms mentioned earlier. The sample size for the study was 60.
To calculate the sample size, the following formula (Daniel, 1999) was used, which is n = Z2p (1−p)/d2:
Z is the statistic for a level of confidence (for the level of confidence of 95%, which is conventional, Z-value is 1.96).
P is the expected prevalence or proportion (P is 0.04).
d is the precision (d is considered to be 0.05 to produce good precision and smaller error of estimate).
As in our PICU, prevalence of admission of children after discarding the patients who met the exclusion criteria was 4% in the last year, so P = 4%.
Putting all these values in the above equation, sample size (n) is
n = Z2p (1−p)/d2 = (1.96)2 ×0.04(1−0.96)/(0.05)2 =59.007 ≈ 60 patients.
| Results | | |
Out of the 60 children in the study, 45 being <5 years and 15 being >5 years with comparable sex ratio (male predominance) in both the groups and the majority (80%) belonged to Class I SES according to BG Prasad scale.[11] The most common cause of admission was respiratory distress/respiratory failure in both the groups [Table 1]. The mortality was significantly higher in children ≤ 5 years of age when compared with children >5 years of age (P = 0.01).
There exists a significant association between chances of survival of children ≤5 years and the following anthropometric measurements (P-value <0.05) [Figure 1]: qualitative interpretation of weight for age at admission in terms of healthy, underweight, and severe underweight; qualitative interpretation of weight for height at admission in terms of healthy, moderately acute malnutrition, severe acute malnutrition; qualitative interpretation of MUAC for age at admission in terms of healthy, malnourished, and severely malnourished [Table 2]. | Figure 1: Comparing the nutritional status of the two groups of patients (≤5 years and >5 years) in the study population
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 | Table 2: Correlation of the anthropometric parameters with the survival rate in the study population
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For children >5 years of age, no association exists between qualitative interpretation of both weight for age and BMI for age on admission and survival because in both parameters all the children were in the healthy range. Thus further analysis was done after dividing the said population into centiles and it was observed that the difference in the number of subjects in each group was statistically significant. Also there was a clear association between survival and weight for age on admission and BMI for age on admission in terms of centiles with highest survival seen in 25th–50th centile of both parameters [Table 2].
In our study, there is no significant relation of survival with HFA percentile (P = 0.786 in children up to 5 years, P = 0.933 in children above 5 years) or qualitative interpretation of height [Table 2].
Further analysis was done to check whether the anthropometric parameters that affect mortality also affect morbidity in the PICU.
In children under 5 years, weight for age (qualitative interpretation) had a significant association with duration of ventilation (0.00) and duration of enteral feeding (0.00). Further we found that if malnutrition was assessed in terms of MUAC (qualitative interpretation), there was a significant association with the total duration of enteral feeding and delay in initiation of enteral feeding (P-value <0.05) [Table 3]. | Table 3: Correlating the anthropometric parameters with the morbidities in PICU
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Similarly, in children >5 years of age, there was a significant association between weight for age in centile on admission and duration of ventilation and BMI centile on admission and duration of PICU stay, inotrope support, total duration of enteral feeding, and duration of ventilation (P-value <0.05).
| Discussion | | |
In our study, the mean age of the population of children up to 5 years group was 10.31 ± 15.3 months and that of above 5 years age group was 117.6 ± 19.4 months. Majority of the patients (65%) were infants, which is almost similar as observed by Jyothi and Ankireddy,[12] 54.16% of the patients being less than 1 year of age. Among the PICU-admitted cases in our hospital, 70% were males (68.9% up to 5 years and 80% above 5 years) and 30% were females (31.1% up to 5 years and 20% above 5 years), with boy: girl ratio being 2.3:1. Similar pattern was noted by Chakravarty et al. In another study on “Impact of malnutrition on pediatric risk of mortality score and outcome in pediatric intensive care unit" by Romi Nangalu et al.,[13] there was no difference in gender distribution or socio-economic status of patients regarding nutritional status.[14] Respiratory system involvement was the prime cause of admission for the study population (65%). Majority of the patients had impending respiratory failure (36.67%) while admitted to the PICU (42.2% in up to 5 years and 26.6% above 5 years). Chakravarty et al. also found that major indication for admission to the PICU was respiratory (30%), followed by neurological illnesses (25%) and infections (22%).[13]
In our study, we have found that there exists an association (P < 0.001) between survival and weight for age (assessed qualitatively) that is, for children up to 5 years of age, those with healthy weight had significantly higher chance of survival (P < 0.001). Prince et al.[15] studied 12,458 Caucasian children and found that weight for age at admission was an independent risk factor for mortality. On assessment of malnutrition in children <5 years both on the basis of qualitative interpretation of weight for height and MUAC, survival is less in the presence of malnutrition (P = 0.001). Ventura et al.[16] in a single-center prospective study in Southern Brazil conducted on 199 patients aged <15 years and PICU stay >48 h revealed that undernutrition on admission in critically ill children was a predictor of 60-day mortality.
For children >5 years of age, no association exists between qualitative interpretation of both weight for age and BMI for age on admission and survival because in both parameters all the children were in the healthy range. Thus further analysis was done after dividing the said population into centiles, and it was observed that the difference in the number of subjects in each group was statistically significant. Highest survival was seen in children in 25th–50th centile of weight for age and BMI for age (P = 0.00).
The impact of being underweight on pediatric outcomes may have biologic plausibility. Underweight could be a symptom of an underlying disease or a reason for admission that relates to mortality risk. Underweight children may also have impaired immune function that could limit their defense against exposure to infections common in hospitals. Furthermore, critically ill children are at risk of further nutritional deterioration during their illness course due to disease or barriers to nutrient delivery in the PICU.
On analyzing the impact of nutritional status on morbidity in the PICU, we found an association between ventilation duration in days and weight for age (qualitative interpretation) in children up to 5 years of age. Malnourished children (as indicated by weight for age on admission) had a higher chance of prolong ventilation for >7 days (P < 0.001). Romi Nangalu et al. observed that children with normal nutrition needed ventilation for significantly less number of days, nearly half needing for <3 days, and ventilation was significantly prolonged in the malnourished group in spite of the almost similar disease profile needing ventilation.[14] A prospective observational study to analyze the nutritional status of 174 critically ill children receiving continuous renal replacement therapy by Castillo et al.[17] found that malnutrition was a risk factor for length of ICU stay and also related with length of ventilation more than 5 days. In children, above 5 years of age, we found that children with 25th–50th percentile of weight for age had a shorter need for ventilation <7 days (P = 0.001). Also children with BMI between 25th and 50th percentile required ventilation <7 days (P = 0.001). A study on impact of malnutrition on the outcome of 332 critically ill children by Bagri et al.[18] between 1 month and 15 years of age finds that children who were severely malnourished had significantly prolonged ICU stay (>7 days) as well as duration of mechanical ventilation (>7 days).
We found that there was a significant delay (P < 0.001) in the initiation of enteral nutrition >7 days in healthy weight for age children (P = 0.00). In those with underweight and severely underweight, steps were taken to initiate feed as soon as possible. When MUAC is taken, a similar finding of delay in feeding was found in children with the absence of malnutrition (P < 0.05). It was also found that children >5 years of age with BMI between 50th and 90th percentile had lesser need of total duration enteral nutrition (less than 7 days) (P = 0.002). This could be explained by the fact that nutritional rehabilitation takes equal priority if not more over controlling the disease process in underweight children; however, in children with healthy weight, nutritional rehabilitation was probably not the primary concern for a pediatric intensivist. However, irrespective of the initial nutritional status of the patient, initiation of enteral nutrition should be prompted as soon as possible as per the Surviving Sepsis Guidelines 2021.[19] A study on “Early enteral nutrition is associated with lower mortality in critically ill children” which included patients aged 1 month to 18 years by Mikhailov et al.[20] has shown that early enteral nutrition in critically ill children is associated with a significantly lower mortality rate during their PICU admission. There exists an association between qualitative interpretation of weight on admission and total duration of enteral nutrition. From the study, it is clear that severely underweight children had received >14 days of enteral nutrition. Thus children with severe underweight needed prolong enteral nutrition before getting transferred from the PICU. We also found that children with less MUAC needed prolonged enteral nutrition (P < 0.001) before being transferred from the PICU.
In the age group >5 years, children (BMI between 25th and 50th percentile) had a shorter total PICU stay duration, that is, <7 days (P = 0.001) and lesser inotrope requirement as well (P = 0.001). The shorter PICU stay could be explained by the fact that post-extubation children in the mentioned percentile range of BMI could be discharged early as nutritional rehabilitation was not a concern in these children. A study on impact of malnutrition on the outcome of 332 critically ill children by Bagri et al.[18] between 1 month and 15 years of age finds that more children who were severely malnourished had significantly prolonged ICU stay (>7 days) as well as duration of mechanical ventilation (>7 days).
Limitation
This is a small-scale single center study in a tertiary care hospital. The population is not truly representative of the existing social demographics as it is a tertiary care referral center. Follow-up for long-term survival and anthropometric assessments were not included in our study. Also in the population of children above 5 years, we had no children in the underweight or obese category, so a bigger sample size is required to validate the role of BMI as an indicator of survival and morbidity in the PICU in this age group.
Interpretation
Children admitted to the PICU are at a high risk of mortality and morbidity owing to various factors such as invasive procedures, sepsis, chronic conditions, and barriers in nutrition. As such, the initial nutritional status of the child assessed carefully at admission via anthropometry helps to prognosticate the survival of the child and also helps to predict the morbidity during the PICU stay which is what this study aimed to establish. It was seen that children with better nutritional status had higher chances of survival with lesser morbidities when compared with children with below par nutritional status as per age. It is very important to emphasize that nutritional deterioration occurs in critically ill pediatric patients, and only a sequential evaluation, considering simple variables (mainly anthropometrical measurements), permits an early detection of failure of growth and, hopefully, prevents it, even in previously well-nourished children. The use of protocols and educational programs is essential to promote the best practices.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Pediatric Intensive Care and Pediatric Emergency. History of picu. Bangalore, India: St. John’s Medical College and Hospital.  |
| 2. | Department of Pediatrics. History of PICU. University of Utah, Salt Lake City, Utah, USA. |
| 3. | Pediatric Critical Care Medicine. Patient Care Policies. SUNY Downstate Medical Center, Brooklyn, New York. |
| 4. | Distinguished Professor of Emergency Medicine and Pediatrics; Handbook of Critical Care. SUNY Downstate Medical Center, Brooklyn, NY. |
| 5. | Policies of picu. Acute and Critical Care Consultant, Kamineni Super Speciality Hospital, Hyderabad, India. |
| 6. | Bloomfield R, Steel E, MacLennan G, Noble DW Accuracy of weight and height estimation in an intensive care unit: Implications for clinical practice and research. Crit Care Med 2006;34: 2153-7. |
| 7. | Maskin LP, Attie S, Setten M, Rodriguez PO, Bonelli I, Stryjewski ME, et al. Accuracy of weight and height estimation in an intensive care unit. Anaesth Intensive Care 2010;38:930-4. |
| 8. | Krieser D, Nguyen K, Kerr D, Jolley D, Clooney M, Kelly AM Parental weight estimation of their child’s weight is more accurate than other weight estimation methods for determining children’s weight in an emergency department? Emerg Med J 2007;24:756-9. |
| 9. | Orellana RA, Kyle UG, Coss Bu JA Nutritional assessment and feeding in the ICU. In: Stockwell, JA, Preissig, CM, editors. Comprehensive Critical Care: Pediatric. Mount Prospect, IL: Society of Critical Care Medicine; 2012. p. 931-48. |
| 10. | Srinivasan V, Nadkarni VM, Helfaer MA, Carey SM, Berg RA; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Childhood obesity and survival after in-hospital pediatric cardiopulmonary resuscitation. Pediatrics 2010;125:e481-8. |
| 11. | Prasad BG Social classification of Indian families. J Indian Med Assoc 1961;37:250-1. |
| 12. | Yothi AK, Ankireddy K A study on clinical profile and outcome of patients in PICU (paediatric intensive care unit) at tertiary care unit. Int J Contemp Pediatr 2019;6:75760. |
| 13. | Chakravarty A, Mohapatra J, Garg R, Kumar S Outcome analysis of a newly setup pediatric intensive care unit in a teaching hospital of northern India. Int J Contemp Pediatr 2019;6:2147. |
| 14. | Nangalu R, Pooni PA, Bhargav S, Bains HS Impact of malnutrition on pediatric risk of mortality score and outcome in pediatric intensive care unit. Indian J Crit Care Med 2016;20:385-90. |
| 15. | Prince NJ, Brown KL, Mebrahtu TF, Parslow RC, Peters MJ Weight-for-age distribution and case-mix adjusted outcomes of 14,307 paediatric intensive care admissions. Intensive Care Med 2014;40:1132-9. |
| 16. | Ventura JC, Hauschild DB, Barbosa E, Bresolin NL, Kawai K, Mehta NM, et al. Undernutrition at PICU admission is predictor of 60-day mortality and PICU length of stay in critically ill children. J Acad Nutr Diet 2020;120:219-29. |
| 17. | Castillo A, Santiago MJ, López-Herce J, Montoro S, López J, Bustinza A, et al. Nutritional status and clinical outcome of children on continuous renal replacement therapy: A prospective observational study. BMC Nephrol 2012;13:125. |
| 18. | Bagri NK, Jose B, Shah SK, Bhutia TD, Kabra SK, Lodha R. Impact of malnutrition on the outcome of critically ill children. Indian J Pediatr 2015;82. |
| 19. | Surviving Sepsis Campaign International Guidelines. Pediatrics 2020;145:e20200629. |
| 20. | Mikhailov TA, Kuhn EM, Manzi J, Christensen M, Collins M, Brown AM, et al. Early enteral nutrition is associated with lower mortality in critically ill children. Jpn J Parenter Enteral Nutr 2014;38:459-66. |
[Figure 1]
[Table 1], [Table 2], [Table 3]
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