Journal of Pediatric Gastroenterology and Nutrition

41:S5–S11 Ó November 2005 ESPGHAN. Reprinted with permission.

2. Energy

METHODS need to be taken into account according to clinical

parameters:
Literature Search
1. Weight gain in regard to the target growth and
Medline search, Pub-Med search. required catch-up growth (see below).
Timeframe: publications from 1990–2003, in addition 2. Recommended intake of the different macronutrients
relevant publications from 1978 were considered. (see specific chapters on lipids, carbohydrates and
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Type of publications: original papers, meta-analyses, protein).

experts’ recommendations, overviews.
3. Tolerance to PN administration i.e. hyperglycaemia,
Key Words: Energy expenditure, total parenteral nutrition,
intensive care, critical care, prematurity, equations. hypertriglyceridaemia, liver enzyme abnormalities,
Language: English, French. cholestasis, tolerance of cyclic administration etc.
Key Words: Energy expenditure, resting energy expenditure,
diet induced thermogenesis.

Components of Energy Needs

ENERGY IN PAEDIATRIC PARENTERAL
NUTRITION (PN) Total energy needs of a healthy individual are the sum
of different components which can be divided into 4 main
Introduction sub-groups: Basal metabolic rate (BMR), diet induced
thermogenesis (DIT), physical activity (PA) and growth.
Energy supply should aim at covering the nutritional Energy needs may be affected by nutritional status, under-
needs of the patient (basal metabolic rate, physical lying diseases, energy intake, energy losses, age and
activity, growth and correction of pre-existing malnutri- gender. No effect of gender on different components of
tion) including the support of anabolic functions (1). daily energy expenditure was found in free-living prepu-
Excessive energy intake may result in hyperglycaemia, bertal children (4). On the other hand, Goran et al (1991)
increased fat deposition, fatty liver and other complica- found that fat free mass, gender and fat mass are important
tions (2). Underfeeding, on the other hand, may result in determinants of total energy expenditure (TEE) in
malnutrition, impaired immunologic responses and im- prepubertal children (5). During puberty and adolescence,
paired growth (3). In general, infants require more calories energy expenditure is affected by gender, body compo-
when fed enterally than when fed parenterally. Energy sition and season, but not by the stage of puberty (6).
supply can be divided into protein and non protein
(carbohydrate and lipid) calories (see specific chapters
on lipids, carbohydrates and amino acids). On a theoretical
basis, energy needs can be calculated based on non protein Basal Metabolic Rate
calories as protein needs are calculated only for new tissue
deposition, as well as for tissue renewal and not as an Basal metabolic rate (BMR) is the amount of energy
energy source. However, since the recommendations for needed for maintaining vital processes of the body not
energy needs in children usually include the protein including activity and food processing. It is measured in
contribution to energy expenditure, most of the statements a recumbent position, in a thermo-neutral environment
in this chapter will include proteins as well as carbohy- after 12 to 18 hours fast, just when the individual has
drates and lipids for assessment of energy needs. awakened before starting daily activities. In practice,
This chapter provides a short overview on energy, but resting energy expenditure (REE) is usually measured
is not a substitution for a Nutrition Textbook. Some instead of BMR. REE is similarly measured at rest in
theoretical issues in energy supply will be mentioned but a thermo-neutral environment, after 8–12 hours fast and
the intention is to provide a practical approach for not immediately after awakening. REE doesn’t differ by
clinical practice. In general, the total caloric require- more than 10% from BMR (7). Sleeping energy expen-
ments can either be estimated or directly measured. diture, a component of BMR was shown to be equal to
Measurement of energy expenditure is not routinely done REE 3 0.9 (8). BMR may be increased in conditions such
and different equations were suggested for estimating as inflammation, fever, chronic disease (i.e. cardiac, pul-
energy needs. These equations (see below) can serve only monary), or can decrease in response to low energy
as guidelines when commencing PN. Further aspects intake.

S5
S6 GUIDELINES ON PAEDIATRIC PARENTERAL NUTRITION

TABLE 2.1. Equations for calculating REE and BMR (kcal/day) in infants
from 0–3 years*
Source Gender Equation
WHO male REE = 60.9 3 Wt 2 54
female REE = 61 3 Wt 2 51
Schofield (W) male BMR = 59.48 3 Wt 2 30.33
female BMR = 58.29 3 Wt 2 31.05
Schofield (WH) male BMR = 0.167 3 Wt + 1517.4 3 Ht 2 617.6
female BMR = 16.25 3 Wt + 1023.2 3 Ht 2 413.5
Harris-Benedict male REE = 66.47 + 13.75 3 Wt + 5.0 3 Ht 2 6.76 3 age
female REE = 655.10 + 9.56 3 Wt + 1.85 3 Ht 2 4.68 3 age

*Wt = body weight in kilograms; Ht = Length in meters.

Diet Induced Thermogenesis on during adolescence imposes extra caloric needs

as compared to adults. The energy needed to maintain
Diet induced thermogenesis (DIT) reflects the amount accelerated growth represents 30–35% of the energy
of energy needed for food digestion, absorption and part requirements in term neonates and is greater in preterm
of synthesis and can, therefore, be affected by the route of infants. Energy cost for 1gr of tissue deposition ranges
substrate administration (oral, enteral or parenteral). DIT between 4.9 kcal/g in premature infants and 6.4 kcal/g in
usually accounts for about 10% of daily energy needs. In adults recovering from anorexia nervosa (14). In patients
orally fed healthy adult subjects the time of food con- fed parenterally over longer periods of time, growth and
sumption may affect DIT (9). During PN, DIT and the body composition should be assessed on a regular basis,
respiratory quotient are affected by the mode of PN and caloric intake adapted to allow normal growth.
administration (continuously vs. cyclic) (10–12).
Activity Catch-Up Growth
Activity is the amount of energy spent for daily move- Children recovering from malnutrition need extra
ments and physical activity. In older children, activity calories to correct their growth deficits (weight, height).
accounts for a large proportion of total energy expendi- In such cases energy needs may be calculated based on
ture. TEE of a hospitalized child lying in bed, on the the 50th percentile of weight and height for the actual
other hand, is reduced. In contrast to most adults the age, rather than the present weight. This difference will
activity of children on home parenteral nutrition, who provide extra calories (above daily needs) to achieve
can attend school, is not reduced (13). catch-up growth. Alternatively, calculation may be based
To account for energy needs related to activity, differ- on the actual weight multiplied by 1.2–1.5, or even by 1.5
ent metabolic constants were suggested for multiplica- to 2 times in severe cases of failure to thrive, to provide
tion of BMR (i.e. EE = BMR 3 constant). In patients on the extra calories needed for catch up growth. Further
PN the more applicable constants are: 3 1.0 for sleep- caloric needs should be adjusted according to weight and
ing, 3 1.2 for lying awake and for sitting quietly, and 3 height gain.
1.4–1.5 for standing quietly or sitting activities (14).
Generally 1.1 or 1.2 are the constants used for patients.
Special Considerations
Growth
Energy needs are affected by the underlying disease
The rapid changes in organ maturation and the higher and current nutritional status and should be met accord-
growth velocity during the first 2 years of life and later ingly (1). Some diseases have been shown to increase or

TABLE 2.2. Equations for calculating REE and BMR (kcal/day) in children
from 3–10 years*
Source Gender Equation
WHO male REE = 22.7 3 Wt + 495
female REE = 22.4 3 Wt + 499
Schofield (W) male BMR = 22.7 3 Wt + 505
female BMR = 20.3 3 Wt + 486
Schofield-(WH) male BMR = 19.6 3 Wt + 130.3 3 Ht + 414.9
female BMR = 16.97 3 Wt + 161.8 3 Ht + 371.2
Harris-Benedict male REE = 66.47 + 13.75 3 Wt + 5.0 3 Ht 2 6.76 3 age
female REE = 655.10 + 9.56 3 Wt + 1.85 3 Ht 2 4.68 3 age

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 GUIDELINES ON PAEDIATRIC PARENTERAL NUTRITION S7

TABLE 2.3. Equations for calculating REE and BMR (kcal/day) in children from 10–18 years*
Source Gender Equation
WHO male REE = 12.2 3 Wt + 746
female REE = 17.5 3 Wt + 651
Schofield (W) male BMR = 13.4 3 Wt + 693
female BMR = 17.7 3 Wt + 659
Schofield (WH) male BMR = 16.25 3 Wt + 137.2 3 Ht + 515.5
female BMR = 8.365 3 Wt + 465 3 Ht + 200
Harris-Benedict male REE = 66.47 + 13.75 3 Wt + 5.0 3 Ht 2 6.76 3 age
female REE = 655.10 + 9.56 3 Wt + 1.85 3 Ht 2 4.68 3 age

decrease energy needs, and some of these situations are Calculating Daily Energy Needs
discussed below.
Different equations have been developed to calculate
REE, BMR and TEE. These predicting equations were
ESTIMATING ENERGY NEEDS based on various studies that took place during the first
80 years of the 20th century. Of these, the WHO
Energy needs can be either measured or calculated equations (WHO 1985), (Schofield (1985) and Harris
based on acceptable equations. The best way to assess Benedict (1919) equations are mostly used (14,23,24)
energy needs in children is to measure total energy (Tables 2.1–2.3). The main predictor for each component
expenditure or alternatively REE (15). Previous estimation of energy expenditure is body weight (25) while height
of energy needs were based mainly on body size (i.e. also accounts for some of the variability in energy needs.
weight, height, body surface area) (16), but it has been Apart from special considerations which will be dis-
suggested that prediction of energy needs should be based cussed below, in most cases there is little need to provide
on fat free mass, to account for differences in body com- more than 110–120% of energy expenditure to most of
position (17) or even on organ tissue mass basis (18). the hospitalized patients (7). This is not the case in pa-
Daily energy requirements are usually estimated by add- tients on home parenteral nutrition where a recent study
ing the increased energy expenditure associated with activ- measuring total daily energy expenditure under free-
ity, stress, disease state, injury and growth to the calculated conditions in stable subjects did not find any difference
basal metabolic rate of healthy children (14). The differ- from healthy controls (13).
ences in actual energy needs versus calculated needs based Some studies have recently suggested that the above
on general equations arise from the special status of currently used equations provide an inadequate esti-
the patient, i.e.: reduced physical activity during illness, mation of REE in different age groups. Duro et al found
energy losses from ostomies, malabsorption, diarrhoea, that the 3 above equations (WHO, Schofield-W and
underlying disease or inflammation, infection, impaired Schofield-WH) underestimate REE in healthy infants ,3
body composition (decreased lean body mass due to year old (25). Thompson et al measured healthy infants
increased catabolism) and different energy routes of (0.43 6 0.27 years) and found that all the equations
supplementation (oral, enteral feeding, continuous vs. overestimated REE. The worst estimation in this age
intermittent feeding and PN). In addition, the total energy group was obtained by using the H-B equations ((26)
expenditure of a child who is hospitalized and lying in bed (LOE 211)). These equations are specifically inade-
is reduced. quate in children with altered growth and body com-
As most of the children in need of PN suffer from one position (27). In cases like failure to thrive, the Schofield
or more of the above, the estimated energy needs based -WH was found to be the best predicting equation (28).
on current equations may be incorrect. When the WHO equation was used for estimating energy
needs in healthy subjects of 2–12 years of age, the
equation overestimated the measure of REE by
Measuring Energy Needs 105 6 12% (27). Overestimation by the H-B equations
was also found in adult subjects (29). In another study
Different techniques are available for short and long-
term measurement of energy expenditure: TABLE 2.4. Parenteral energy needs
BMR and REE can be studied by an open circuit
indirect calorimetry. Age (yr) Kilocalories/kg body weight per day
Total energy expenditure (TEE) can be estimated by Pre-term 110–120
stable isotope techniques (2H18
2 O Doubly labelled water) 0–1 90–100
and bicarbonate (13C) (19) as well as by heart rate 1–7 75–90
7–12 60–75
monitoring (20,21). Physical activity can be estimated by 12–18 30–60
activity monitoring (22).

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S8 GUIDELINES ON PAEDIATRIC PARENTERAL NUTRITION

which compared predicted to actual measurements in energy balance (energy intake-energy expenditure) of
7.8–16.6 years healthy controls, the Schofield -WH approximately 25 kcal/kg per day represents a reasonable
equation showed the best agreement with actual measure- goal for these small premature infants. Thus, on
ment (30). In a study of 199 subjects aged 5–16 years a theoretical basis sick children with high energy
both the Schofield WHO and were comparable to the expenditure (85 kcal/kg per day) would require at least
measured resting values, with the Schofield equations 85 1 25 = 110 kcal/kg per day to grow. Moreover, using
providing the best estimates (31). In various illnesses and the same doubly labelled water technique, it has been
related malnutrition, these prediction equations were not shown that ELBW infants may require even more energy
accurately estimating actual REE requirements ((27) (LOE intake at 3 to 5 weeks of age, when their measured EE
211)). Of the four equations the Schofield equation ranges between 86–94 kcal/kg per day (39).
using both weight and height measurements was the best
at predicting REE. Nevertheless, all of these equations Intensive Care Unit (ICU)
have been established in normal children and should
be used with caution in sick children treated with PN. In critically ill ventilated children, within-day varia-
Average daily parenteral energy intakes per kg body- tions in energy expenditure measurements are uncom-
weight considered adequate for a major proportion of mon and a single 30-minute energy measurement can be
patients are shown in Table 4. an acceptable guide. Between-day variation on the other
hand can, however, be large (40). Several studies did not
observe hyper-metabolism in critically ill children and
Recommendation most of the recent data suggest that the predicting equa-
 Reasonable values for energy expenditure can be tions overestimate or nearly estimate the actual REE.
derived from formulae, e.g. Schofield. However, Moreover, some studies found that measured EE was
in individual patients measurement of REE may lower than predicted and was associated with a higher
be useful. REE may be measured rather than cal- mortality risk (41). Using stress factors added to the
culated to estimate caloric needs due to a different predicted equations grossly overestimated the energy
individual variability and over or underestimation expenditure (42). It was suggested, therefore, to use
by the predicting equations. GOR D only predicting equations without ‘‘stress factors’’
when calculating energy needs (42–44). In a study that
found increased REE, the measurement was done
Special Considerations alongside PN administration and was 20% higher than
the predicted by the Talbot’s tables (45). Similar results
Premature Infants were obtained for the H-B equations with a stress factor
of 1.3 (46). The catabolic process in critically ill
Early nutrition support is advocated in extremely low subjects inhibits growth, thus reducing energy require-
birth weight and very low birth weight infants because of ments on one hand, while increasing basal energy
limited nutritional stores (32). A recent randomized con- expenditure on the other (47).
trolled study compared the effect of PN on the first day of A combined measurement of energy expenditure along
life as compared to PN started in the first few days and with nitrogen balance or RQ may help in tailoring the
being advanced more slowly. Better growth was found right formulation (48).
with early PN (33). Energy intake affects nitrogen balance; White et al recently suggested a new formula for
minimal energy requirements are met with 50–60 kcal/kg estimating energy expenditure in ICU patients with
per day, but 100–120 kcal/kg/d facilitate maximal protein a close correlation between predicted and measured EE
accretion (34). A newborn infant receiving PN needs (R2 = 0.867) (44):
fewer calories (90–100 kcal/kg per day) than a newborn
fed enterally because there is no energy lost in the stools EE ðkcal=dÞ ¼ [(17 3 age in months)
and there is less thermogenesis (35).
þ (48 3 weight in kg)
In premature infants after surgery, one study of post
surgical sick premature neonates did not find an increase þ (292 3 body temperature in °CÞ
in energy expenditure (36). However, in extremely low 2 9677
3 0:239
birth weight infants (ELBW), using doubly labelled
water technique to measure energy expenditure, Carr et al This group has found that EE increased with time
found that ELBW (,1000 g birth-weight) with minimal relative to the injury insult, which emphasizes the
respiratory disease but requiring mechanical ventilation importance of serial measurements of EE in these
appear to have significantly increased rates of energy ex- patients. The changes were ascribed to the ‘‘ebb’’ and
penditure (85 kcal/kg per day) in early postnatal life (37). ‘‘flow’’ phases of the metabolic stress process. Resump-
Since foetal life energy accretion is approx. 24 kcal/kg tion of anabolic (growth) metabolism may also contrib-
per day between 24–48 weeks of gestation (38), an ute significantly to this phenomenon (47).

J Pediatr Gastroenterol Nutr, Vol. 41, Suppl. 2, November 2005

 GUIDELINES ON PAEDIATRIC PARENTERAL NUTRITION S9

Post-Operative with beta-blockers was found to reverse catabolism and

attenuate hypermetabolism in children with burns (60).
Most of the studies indicate that major operations such
as abdominal surgery are not accompanied by increased
EE (49). REE peaks 2–4 hours after surgery and returns Recommendations
to baseline levels by 12–24 hours (50). The increase in  Reasonable parenteral energy supply can be
postoperative REE is directly related to the severity of
estimated from calculated resting energy expen-
the operation and is greater in premature babies and in
diture multiplied by a factor reflecting additional
infants .48 hours of age. Because the increase in REE is
needs including physical activity, and from
of short duration and involves temporary metabolic
monitoring weight change. GOR D. Therefore,
changes there is no necessity to increase the energy
parenterally fed patients should be regularly
intake of infants who have an uncomplicated operation
weighed, usually on a daily basis during acute
(35). Pierro et al developed an equation for predicting
disease phases and in unstable patients. GOR D
basal energy requirements of stable surgical infants of  For calculating REE, WHO and especially Scho-
less than 12 months (51).
field (WH) equations should be used for children
REE ðcal=minÞ ¼ 74:436 less than 10 years of age. For children aged 10
years and older, Harris Benedict, WHO and
þ (34.661 3 weight in kg) Schofield equations can be used. GOR B
þ (0.496 3 rate in beats/min)  Measurement of resting energy expenditure by
indirect calorimetry, and estimation of total
þ (0.178 3 in days)
energy expenditure from heart rate monitoring,
might be used in selected patients to provide
additional information. However, their general
Statement use is not recommended because of lack of data
 There is no support for increased energy needs on outcome. GOR D
after uncomplicated surgery. LOE 2++  Energy intake should be adapted in patients with
disease states that increase resting energy expen-
diture, such as pulmonary (e.g. cystic fibrosis) and
cardiac (e.g. some congenital heart disease)
Head Injury
disorders. GOR B
REE is significantly increased after head injury  In most parenterally fed hospital patients energy
(52,53). Energy expenditure varied markedly between needs are met by 100–120% of resting energy
and within children (mean 97% of predicted, range 60– expenditure. GOR D
137%) and was significantly lower in the children with  Patients who are underweight and need to regain
poor outcome (52). Neuromuscular blockade (54) and weight may need 130 to 150% of REE. GOR D
hypothermia (55) reduce it to the predicted values.  Energy intake should not be increased after
uncomplicated surgery. GOR B
 Total parenteral energy needs (including protein)
Burn Injury of stable patients may be roughly estimated using
Table 2.4. GOR D
Recent studies suggest that previous studies over-
estimated energy needs (56). Goran et al (1991) com-
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