Bronchopneumonia is the most common clinical manifestation of pneumonia in pediatric population and leading infectious cause of mortality in children under 5 years.1 Untreated pneumonia may progress to respiratory failure, septic shock and consequently death.2 Childhood pneumonia is the most common cause of pediatric sepsis.3 Sepsis, an infection initiated clinical syndrome, can progress to shock, multiple organ dysfunction syndrome and death.4
Malnutrition is common among critically ill children, especially in the developing world.5 In the ill child, malnutrition is usually of multifactorial origin. It is associated with an altered metabolism of certain substrates, increased or decreased metabolism, and reduced nutrient delivery. The presence of malnutrition prior to admission worsens the prognosis in the critically ill child. Furthermore, severe illness has marked repercussions on the nutritional status of these malnourished patients.6
Here we present a case of an infant with growth faltering due to severe bronchopneumonia and associated complications.
A 1-year and 20-day-old male child presented with chief complaint of severe bronchopneumonia complicated with sepsis.
Child was in respiratory failure, was ventilated and had cardiac arrest. He developed seizures and acute kidney injury. On admission, patient’s weight was 8 kg, height was 76 cm, head circumference was 45 cm and mid-upper arm circumference was 13 cm.
Chest X-ray, CBC, C-reactive protein, blood gas and serum electrolytes were ordered.
Chest X-ray showed bilateral haziness on the lung fields indicating pneumonia. Complete blood count showed normal haemoglobin levels (i.e. 11.3 g/dL) but an increase in white blood cell levels (19400 cells/mcL) suggesting severe infection. Platelet count was normal. Serum C-reactive protein levels (i.e. 2.4 mg/L) and packed cell volume (31.3%) were also within normal ranges.
On the basis of clinical investigations, primary diagnosis of severe bronchopneumonia with sepsis was made and since the child’s weight was less than 3rd percentiles on WHO growth chart, diagnosis of growth faltering was made.
Patient was admitted to pediatric intensive care unit (PICU). He remained there for 12 days and post PICU, was shifted to ward for further 11 days, making total of 23 days of hospitalization.
Child required mechanical ventilation with high frequency oscillation (HFO) in PICU immediately after admission. Total parenteral nutrition (TPN) was also started. As the condition improved after 12 days, child was taken off from ventilation.
After extubation child showed neurological deficit and was not feeding well. During hospital stay child lost almost 1.5 kg of weight. Therefore, energy and nutrient dense formula (ENDF) was started. ENDF was exclusively used as sole source of nutrition.
Child received ENDF feeds through nasogastric (NG) tube to meet high caloric demands. He was started on, 50 mL/2h initially and then shifted gradually, as the patient tolerated the formula, to 100 mL/2h for 24 hours.
Child showed weight gain of 400 gm over 10 days period making his weight 8.4 kg at the end of the 23 days. At discharge, his height was 76 cm, head circumference was 45 cm and mid-upper arm circumference was 13.5 cm. Patient’s recovery was good. He had no neurological deficits. He was active and stable.
Post-discharge, patient was continued on ENDF feeds. At follow up after 15 days from discharge, weight of the child further increased by 300 g to 8.7 kg, indicating that the patient tolerated formula well. Child showed acceptable weight gain and was thriving well.
Pneumonia causes substantial morbidity in children worldwide and leading cause of mortality in children in the developing world.2 The most important respiratory pathogen implicated in the severe and fatal cases of childhood pneumonia are Streptococcus pneumonia, Heaemophylus influenzae type B, respiratory syntical virus (RSV) and seasonal influenza virus.7 Severe pneumonia in children cause serious damage to the circulatory, respiratory, nervous and digestive systems of children. Moreover, severe pneumonia in children leads to growth failure and threatens the life of patients.8 Case fatality among children with sepsis ranges from 7.8–20%, depending on age, the presence of chronic comorbid conditions and the source of infection.4
Critically ill infants and children have an increased metabolic need, which predisposes them to nutritional deterioration during illness.9 Nutrition is an important component of patient management in the PICU.10 The provision of optimal nutrition support to critically ill infants and children is essential for effective overall care, management and outcomes.11
In the case presented here, we used ENDF in critically ill child who was suffering from bronchopneumonia and severe sepsis and was not thriving well. Since ENDF use here have shown convincing weight gain and desirable outcomes in patient, it can be inferred that ENDF can safely be administered using NG tube. In critically ill patients such as patients with bronchopneumonia, use of ENDF can be considered as one of the important measures.
We can conclude from the case presented here that nutritional management is important for the management of growth faltering due to bronchopneumonia complicated with sepsis. ENDF can be successfully used to tackle growth faltering associated with sepsis.
References:-
Zec SL, Selmanovic K, Andrijic NL, Kadic A, Zecevic L, Zunic L. Evaluation of Drug Treatment of Bronchopneumonia at the Pediatric Clinic in Sarajevo. Med Arch. 2016 Jun;70(3): 177-81.
Wojsyk-Banaszak I, Bręborowicz A. Pneumonia in children. Chapter 6. In. Respiratory disease and infection - A new insight. Intech. 2013:317-71.
Randolph AG, McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014;Jan 1;5(1):179-89.
Farris RW, Weiss NS, Zimmerman JJ. Functional outcomes in pediatric severe sepsis: Functional Outcomes in Pediatric Severe Sepsis; Further Analysis of the RESOLVE Trial. Pediatr Crit Care Med. 2013 Nov;14(9):835-42.
Lee JH, Rogers E, Chor YK, Samransamruajkit R, Koh PL, Miqdady M, Al-Mehaidib AI, Pudjiadi A, Singhi S, Mehta NM. Optimal nutrition therapy in paediatric critical care in the Asia-Pacific and Middle East: a consensus. Asia Pac J Clin Nutr. 2016 Dec;25(4):676-696.
Prieto MB, Cid JL. Malnutrition in the critically ill child: the importance of enteral nutrition. Int J Environ Res Public Health. 2011 Nov;8(11):4353-66.
Grimwood K, Chang AB. Long-term effects of pneumonia in young children. Pneumonia. 2015 Oct 27;6:101-14.
Wang H, Zhao F, Liu W. Clinical treatment of severe pneumonia complicated with heart failure in children. Biomed Res. 2018 Apr 3;29(6):1270-74.
Mehta NM, Duggan CP. Nutritional deficiencies during critical illness. Pediatr Clin North Am. 2009 Oct ; 56(5): 1143–60.
Verger J. Nutrition in the pediatric population in the intensive care unit. Crit Care Nurs Clin North Am. 2014 Jun;26(2):199-215.
Abad-Jorge A. Nutrition management of the critically ill pediatric patient: minimizing barriers to optimal nutrition support. ICAN: Infant, Child, & Adolescent Nutrition. 2013 Aug;5(4):221-30.
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Important Notice:
The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.
*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.
Mothers should be explained the following advantages & nutritional superiority of breastfeeding:
- Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant's defence against dangerous neonatal infections. It also contains higher levels of, Vitamin 'A'.
- Breast miIk:
- Is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life).
- Has anti-infective properties that protect the infants from infection in the early months.
- Is always available.
- Needs no utensils or water (which might, carry germs) or fuel for its preparation.
- Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes.
- Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators.
Details of management of breast feeding, as under:
- Breast-feeding.
- Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
- Is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so.
- In order to promote and support breast-feeding the mother's natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives.
- Adequate care for the breast and nipples should be taken during pregnancy.
- It is also necessary to put the infant to the breast as soon as possible after delivery.
- Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming-in").
- Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth.
- The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged.
- Let the infants suckle on demand.
- Every effort should be made to breast-feed the infants whenever they cry.
- Mother should keep her body and clothes and that of the infant always neat and clean.
Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breast-milk, and reversing the decision not to breast-feed is difficult.
Always consult your Health-care Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer's instructions for use carefully - failure to follow the instructions may make your baby ill.