How can I calculate and design a 24‑hour nutrition feed chart for a critically ill child in the ICU, incorporating age, weight, height/length, and comorbidities such as sepsis, burns, or renal/hepatic dysfunction to determine caloric requirements, macronutrient distribution, fluid allowances, and monitoring parameters?

How to Create a 24-Hour Nutrition Feed Chart in the Pediatric ICU

Initial Assessment and Anthropometry (Within 24-48 Hours)

Measure and document weight, height/length, and calculate BMI-for-age z-scores (or weight-for-length z-scores for children <2 years) immediately upon PICU admission. 1 For children under 36 months, head circumference is mandatory. 1 Mid-upper arm circumference should also be recorded as part of the anthropometric panel. 2 Express all measurements as z-scores rather than percentiles for greater precision in identifying malnutrition or obesity, both of which increase mortality, infection risk, and duration of mechanical ventilation. 1

Energy Requirements Calculation

Acute Phase (First 24-72 Hours)

During the acute phase of critical illness, energy intake must not exceed resting energy expenditure (REE) to avoid overfeeding complications. 1

• Use the Schofield equation for weight (based on age and gender with accurate weight) to estimate REE without adding stress or activity factors. 1 The acute metabolic stress period typically lasts only 1-2 days in most critically ill children. 3
• Target energy delivery at or below measured/estimated REE during this phase. 1
• If indirect calorimetry is available, use it to measure REE after the acute phase for more precise energy targets. 1

Recovery/Stable Phase (After 72 Hours)

After the acute phase, increase energy intake to 1.3 times measured REE to account for energy debt, physical activity, rehabilitation, and growth. 1, 3

• Minimum intake of 57 kcal/kg/day is required to achieve a protein anabolic state. 3
• Energy requirements should account for catch-up growth in malnourished children. 1

Macronutrient Distribution

Protein/Amino Acid Requirements

Provide a minimum of 1.5 g/kg/day of protein enterally to avoid negative nitrogen balance, but there is insufficient evidence to support higher intakes (>1.5 g/kg/day) during the acute phase. 1, 3

• For enteral nutrition: Start at 1.5 g/kg/day and advance to maintain positive nitrogen balance. 1, 3
• For parenteral nutrition (if used): Term infants start at 1.5 g/kg/day, advancing to maximum 3.0 g/kg/day; preterm infants start at 1.5 g/kg/day on day 1, advancing to 2.5-3.5 g/kg/day from day 2. 3
• Ensure non-protein calories at minimum 30-40 kcal per 1g amino acids for proper protein utilization. 3

Lipid Requirements

Use composite lipid emulsions with or without fish oil as first-line choice when parenteral nutrition is indicated. 1, 3

Carbohydrate/Glucose Requirements

Parenteral glucose provision should prevent hypoglycemia (maintain blood glucose >70 mg/dL) without causing hyperglycemia. 1, 3

• Target glucose delivery rate: 10-12 mg/kg/min. 3
• For glucose solution, mix 60% dextrose 5% with 40% NaCl 0.9% at maintenance fluid rates. 3

Fluid Allowances

Provide maintenance fluid volumes of 100-150 mL/kg/day for term infants, up to 150-180 mL/kg/day if metabolic clearance is needed. 3

Route and Timing of Nutrition Delivery

Enteral Nutrition (Preferred Route)

Initiate enteral nutrition within 24 hours of PICU admission in all eligible children unless contraindicated. 1, 2

• Early EN (within 24-48 hours) is associated with shorter mechanical ventilation duration, lower nosocomial infection rates, and reduced mortality. 1, 2
• EN is feasible and safe in children receiving vasoactive medications, ECMO/ECLS support, and after cardiac surgery once hemodynamically stable. 1, 2
• Use gastric feeding as the default route; it is as safe as post-pyloric feeding in most critically ill children. 1 Reserve post-pyloric feeding only for children at high aspiration risk or requiring frequent procedural fasting. 1
• Advance feeds stepwise using a standardized feeding protocol to achieve two-thirds of nutrient goals by the end of the first week. 1, 2
• Do not routinely measure gastric residual volumes. 1

Parenteral Nutrition Timing

Consider withholding parenteral nutrition for up to one week in critically ill term neonates and children (regardless of nutritional status) while providing micronutrients, as this reduces infections, ventilator days, and PICU length of stay. 1, 3, 2

• Provide glucose, electrolytes, and micronutrients from day 1. 3
• Essential intravenous minerals, trace elements, and vitamins must be added from day 1. 3

Feed Formula Selection

Use polymeric feeds as first-choice for most critically ill children. 1

• Consider protein and energy-dense formulations in fluid-restricted children to meet nutritional requirements. 1
• Peptide-based formulations may be used if polymeric feeds are poorly tolerated or contraindicated. 1

Comorbidity-Specific Adjustments

Sepsis

• Septic children have 20% increased REE during days 1-3 and 40% increased REE during recovery compared to acute phase. 1
• Monitor triglycerides frequently in septic infants receiving parenteral lipids. 3

Burns

• Burn patients experience hypermetabolic response proportional to burn size and severity. 4
• Energy requirements increase significantly; use indirect calorimetry when available to guide targets. 1

Renal Dysfunction

• Adjust protein intake based on degree of renal impairment and whether renal replacement therapy is used. 5
• Monitor electrolytes closely and adjust fluid volumes accordingly. 3

Hepatic Dysfunction

• Hepatic dysfunction carries the highest mortality among organ dysfunctions in severe sepsis. 5
• Use composite lipid emulsions cautiously and monitor liver function tests. 1, 3

Monitoring Parameters

Glucose Monitoring

Monitor blood glucose every 2-4 hours initially using a blood gas analyzer. 3

• Maintain blood glucose >70 mg/dL to suppress protein catabolism. 3
• Avoid hyperglycemia, which is common especially in sick extremely low birth weight infants. 1

Biochemical Monitoring

• Monitor triglycerides frequently, especially in septic infants. 3
• Monitor electrolytes based on serum levels and adjust additions accordingly. 3
• Track liver function tests if hepatic dysfunction is present. 5

Growth Monitoring

Re-evaluate nutritional status at least weekly throughout PICU stay, as hospitalized children are at risk of rapid nutritional deterioration. 1, 2

• Repeat anthropometric measurements regularly during admission. 1, 2
• Track weight and length after the acute phase. 3
• Muscle wasting occurs quickly in critically ill children and requires continuous assessment. 2

Critical Pitfalls to Avoid

• Do not overfeed during the acute phase—energy intake exceeding REE is associated with poor outcomes. 1
• Do not delay EN initiation due to hemodynamic instability once vasoactive support or ECLS is stabilized. 1, 2
• Do not use adult screening tools (NRS-2002, MUST, MNA) in pediatric patients. 2
• Do not routinely use prokinetic agents—insufficient evidence supports their use for improving gastric emptying or feed tolerance. 1
• Do not add stress or activity factors to Schofield equation estimates during acute illness. 1
• Minimize interruptions to EN to achieve nutrient delivery goals; common barriers include perceived intolerance and prolonged fasting around procedures. 1

Practical 24-Hour Feed Chart Template

Document the following elements:

1. Patient identifiers: Age, weight (kg), height/length (cm), BMI z-score, diagnosis, comorbidities
2. Calculated REE (Schofield equation): _____ kcal/day
3. Target energy: Acute phase = REE; Recovery phase = 1.3 × REE = _____ kcal/day
4. Target protein: 1.5 g/kg/day = _____ g/day
5. Target fluid: 100-150 mL/kg/day = _____ mL/day
6. Route: Enteral (gastric/post-pyloric) or Parenteral (if EN contraindicated or delayed)
7. Feed type: Polymeric/peptide-based/energy-dense formula
8. Hourly rate: Total daily volume ÷ 24 hours = _____ mL/hr
9. Advancement schedule: Stepwise increases per institutional protocol to reach goal by day 3-7
10. Monitoring schedule: Glucose q2-4h initially, electrolytes daily, triglycerides 2-3×/week, weight daily, anthropometrics weekly