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Energy metabolism, nitrogen balance, and substrate utilization in critically ill children^1,2,3

From the sections of Critical Care, Gastroenterology and Nutrition, and the Department of Pediatrics, Baylor College of Medicine, Houston, and the US Department of Agriculture, Agricultural Research Service Children's Nutrition Research Center, Houston.

Background: Critically ill patients are characterized by a hypermetabolic state, a catabolic response, higher nutritional needs, and a decreased capacity for utilization of parenteral substrate.

Objective: We sought to analyze the relation between a patient's metabolic state and their nutritional intake, substrate utilization, and nitrogen balance (NB) in mechanically ventilated, critically ill children receiving parenteral nutrition.

Design: This was a cross-sectional study in which resting energy expenditure (REE) and NB were measured and substrate utilization and the metabolic index (MI) ratio (REE/expected energy requirements) were calculated.

Results: Thirty-three children (mean age: 5 y) participated. Their average REE was 0.23 ± 0.10 MJ•kg^-1•d^-1 and their average MI was 1.2 ± 0.5. Mean energy intake, protein intake, and NB were 0.25 ± 0.14 MJ•kg^-1•d^-1, 2.1 ± 1 g•kg^-1•d^-1, and -89 ± 166 mg•kg^-1•d^-1, respectively. Patients with an MI >1.1 (n = 19) had a higher fat oxidation than did patients with an MI <1.1 (n = 14; P < 0.05). Patients with lipogenesis (n = 13) had a higher carbohydrate intake than did patients without lipogenesis (n = 20; P < 0.05). Patients with a positive NB (n = 12) had a higher protein intake than did patients with a negative NB (n = 21; P < 0.001) and lower protein oxidation (P < 0.01).

Conclusions: Critically ill children are hypermetabolic and in negative NB. In this population, fat is used preferentially for oxidation and carbohydrate is utilized poorly. A high carbohydrate intake was associated with lipogenesis and less fat oxidation, a negative NB was associated with high oxidation rates for protein, and a high protein intake was associated with a positive NB.

Key Words: Energy expenditure • nitrogen balance • substrate oxidation • pediatrics • mechanical ventilation • critically ill patients

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