PATRICIA ZAMBERLAN DOS SANTOS
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Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina
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- Lymphocyte count as a sign of immunoparalysis and its correlation with nutritional status in pediatric intensive care patients with sepsis: A pilot study(2016) MANZOLI, Talita Freitas; DELGADO, Artur Figueiredo; TROSTER, Eduardo Juan; CARVALHO, Werther Brunow de; ANTUNES, Ana Caroline Barreto; MARQUES, Desiree Mayara; ZAMBERLAN, PatriciaOBJECTIVES: Developing malnutrition during hospitalization is well recognized worldwide, and children are at a relatively higher risk for malnutrition than adults. Malnutrition can lead to immune dysfunction, which is associated with a higher mortality rate due to sepsis, the most frequent cause of death in pediatric intensive care units (PICUs). The aim of this study was to investigate whether malnourished patients are more likely to have relative or absolute lymphopenia and, consequently, worse prognoses. METHODS: We enrolled 14 consecutive patients with sepsis whose legal representatives provided written informed consent. Patients were classified as normal or malnourished based on anthropometric measurements. As an additional evaluation of nutritional status, serum albumin and zinc were measured on the 1 st and 7 th days of hospitalization. Lymphocyte count was also measured on the 1 st and 7 th days. Clinicaltrials. gov: NCT02698683. RESULTS: Malnutrition prevalence rates were 33.3% and 42.8% based on weight and height, respectively. Laboratory analyses revealed a reduction of serum albumin in 100% of patients and reduction of zinc in 93.3% of patients. A total of 35% of patients had fewer than 500 lymphocytes/mm(3) on their first day in the PICU. Lymphocyte counts and zinc concentrations significantly increased during hospitalization. CONCLUSIONS: Nutritional evaluations, including anthropometric measurements, were not correlated with lymphocyte counts. Lymphocyte counts concomitantly increased with zinc levels, suggesting that micronutrient supplementation benefits patients with sepsis.
- The Latin American and Spanish Survey on Nutrition in Pediatric Intensive Care (ELAN-CIP2)(2019) CAMPOS-MINO, Santiago; CID, Jesus Lopez-Herce; DELGADO, Artur Figueiredo; BENAVIDES, Eliana Munoz; COSS-BU, Jorge A.; VILLAVICENCIO, Pedro Mestre; IRAMAIN, Ricardo; VILLARUEL, Sayani Valdez; NIEVA, Ana; VARGAS, Ana; LOPEZ, Pilar Arias; FERNANDEZ, Analia; SILVESTRE, Andrea; BOTTA, Priscila; TORRES, Silvio Fabio; COSTA, Caroline Abud Drumond; GARCIA, Pedro Celiny Ramos; PIVA, Jefferson; CABEDO, Maria Thereza De Cordes; LUGLIO, Michele; ZAMBERLAN, Patricia; GUZMAN, Gustavo; LOBOGUERRERO, Fanny Garcia; FERNANDEZ, Mauricio; CASSALETT, Gabriel; PEREZ, German; MONTES, Miguel Ruz; VELASQUEZ, Rocio Porras; PEREZ, Victor; CASTRO, Santiago Ramirez; VILLAVICENCIO, Pedro Mestre; WEGNER, Adriana; ORDENES, Nadia; DESSAUER, Bettina Von; CORS, Carolina; GONZALES, Marcos; BENAVIDES, Eliana Munoz; QUIROZ, Miguel Angel Saavedra; PERALTA, Felipe Verscheure; ROQUE, Jorge; ROSICH, Patricia Del Rosario; CAMPOS-MINO, Santiago; MONTALVO, Erika; PESANTES, Xavier Paez; BARQUIN, Luis Augusto Moya; RIVAS, Ricardo Alfredo Mack; ROMAN, Carlos; ORTIZ, Cesar Antonio Ramos; MONSREAL, Miguel Ignacio Flores; VILLARUEL, Sayani Valdez; GONZALEZ, Sonia Vargas; JIMENEZ, Hassel Jimmy; BRACHO, Carlos; SAMUDIO, Lissa; PALPAN, Beatriz Atachagua; PALOMO, Patricia; ESCALANTE-KANASHIRO, Raffo; ARANA, Rosa; NUNEZ, Antonio Rodriguez; CID, Jesus Lopez-Herce; FERNANDEZ, Yolanda Lopez; MENCHACA, Amanda; LOPEZ, Claudia MadridObjective: To characterize the practices of nutritional support in Latin American and Spanish PICUs. Design: Survey with a questionnaire sent to Latin American Society of Pediatric Intensive Care members. Setting: PICUs of participant hospitals. Patients: Critically ill children between 1 month and 18 years old. Interventions: None. Measurements and Main Results: Forty-seven surveys from 17 countries were analyzed. Sixty-seven percent of PICUs were from university-affiliated hospitals, with a median of 380 admissions/yr. Sixty-eight percent and 48.9% had a nutritional support team and nutritional support protocol, respectively. Seventy-five percent completed nutritional evaluations, with 34.2% at admission. PICUs with high-volume admissions were likely to have a nutritional support team (p < 0.005), and university-affiliated hospitals showed a trend of having a nutritional support team (p = 0.056). Measured, estimated, and ideal weights were used in 75%, 14.6%, and 10.4%, respectively. Energy requirements were calculated using Holliday & Segar and Schofield equations in 90% of the PICUs; 43% used correction factors. Only three PICUs had indirect calorimetry. At day 3 of initiation of nutritional support, 57.3% of PICUs provided at least 50% of the calculated energy requirement, and 91.5% at day 5. Protein needs were estimated according to American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism/European Society for Paediatric Gastroenterology Hepatology and Nutrition guidelines in 55.3% and 40.4%, respectively. Enteral nutrition was the preferred feeding method, initiated in 97.7% at 48 hours. The feeding route was gastric (82.9%), by bolus (42.5%) or continuous (57.4%). Monitoring methods included gastric residual measurement in 55.3%. Enteral nutrition was discontinued in 82.8% when gastric residual was 50% of the volume. Prokinetics were used in 68%. More than half of PICUs used parenteral nutrition, with 95.8% of them within 72 hours. Parenteral nutrition was administered by central vein in 93.6%. Undernourished children received parenteral nutrition sooner, whether or not enteral nutrition intolerance was present. When enteral nutrition was not tolerated beyond 72 hours, parenteral nutrition was started in 57.4%. Parenteral nutrition was initiated when enteral nutrition delivered less than 50% in 97%. Conclusions: Nutritional practices are heterogeneous in Latin American PICUs, but the majority use nutritional support strategies consistent with international guidelines.
- Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study(2023) CAMPOS-MINO, Santiago; FIGUEIREDO-DELGADO, Artur; ZARATE, Patricia; ZAMBERLAN, Patricia; MUNOZ-BENAVIDES, Eliana; COSS-BU, Jorge A.OBJECTIVES: To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations. DESIGN: The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding. SETTING: Four-one PICUs in 13 LA countries. PATIENTS: Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively. CONCLUSIONS: The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.
- Can calf circumference be a viable option for nutritional assessment in the PICU?(2021) VIEIRA, Rafaela Rodrigues; CAMPOS, Marina Morgado Simoes de; ZAMBERLAN, Patricia; VIANI, KarinaBackground: Children admitted to paediatric intensive care units (PICUs) often need specialised nutri-tional intervention. Nutritional assessments provide specific data to support such interventions. Body composition measures, such as mid-upper arm circumference (MUAC), can complement nutritional assessment. However, MUAC has limitations. Calf circumference (CC) is an easy and common measure of muscle loss in the elderly; however, there are still very few studies on CC in children. Aims: To evaluate the viability of using CC for nutritional monitoring of children under intensive care, compared with MUAC and weight. Methods: Patients aged 2-10 years admitted to the PICU between December 2018 and August 2019 were included in the study. Two MUAC, CC, and weight measurements were performed: one in the first 24 h after PICU admission and another after 7 days. As there are no reference values for CC in children, this measure was used solely to observe the patient's individual progress. The nutritional status, both ac-cording to body mass index and MUAC, was used to characterise samples. Percentage changes in these measures were compared using the Wilcoxon signed-rank test for comparison between medians and Spearman's correlation test. Information from medical records regarding hospitalisation was also collected and analysed. Results: Thirty patients were included in the study. During hospitalisation week 1, CC decreased significantly (p = 0.001), whereas MUAC (p = 0.427) and weight (p = 0.315) did not change significantly. Percentage changes in CC and MUAC were statistically different (p = 0.0449), with a positive correlation between the changes in both measures (p = 0.0333; r = 0.3896); conversely, although the percentage changes in CC and weight significantly differed (p = 0.0066), no correlation was found between them (p = 0.9382; r = 0.0148). The percentage changes in MUAC and weight were not different (p = 0.1880) or correlated (p = 0.1691; r = 0.2577). No statistically significant relationship was found between per-centage changes in CC and clinical outcomes (length of stay, fasting time, and mechanical ventilation time). Conclusions: CC appears to be a viable measure for use in PICUs. Although positively correlated with MUAC, a measure proven useful in critically ill children, CC decreased significantly in the first week of intensive care, whereas MUAC remained unchanged, indicating that CC may show signs of depletion earlier than MUAC in these patients. Our study reinforces the importance of alternative measures for anthropometric assessment of critically ill children.
- Increased nutrition risk at admission is associated with longer hospitalization in children and adolescents with COVID-19(2022) ZAMBERLAN, Patricia; CARLOTTI, Ana Paula de Carvalho Panzeri; VIANI, Karina Helena Canton; RODRIGUEZ, Isadora Souza; SIMAS, Josiane de Carvalho; SILVERIO, Ariadne Beatriz; VOLPON, Leila Costa; CARVALHO, Werther Brunow de; DELGADO, Artur FigueiredoBackground We investigated the association of nutritional risk and inflammatory marker level with length of stay (LOS) in children and adolescents hospitalized for COVID-19 infection in two pediatric teaching hospitals in a developing country. Methods This was a cross-sectional analytical retrospective study performed in two pediatric hospitals. We included the data from all children and adolescents who were hospitalized with a SARS-CoV-2 infection between March and December 2020. Demographic, anthropometric, clinical, and laboratory data were extracted from electronic medical records. Nutritional risk was assessed according to the STRONGkids tool within 24 hours of admission and was categorized into two levels: >= 4 (high risk) and <4 (moderate or low risk). Means or medians were compared between nutritional risk groups using the t test and Mann-Whitney U test, respectively. The association of nutritional risk and inflammatory markers with LOS was estimated using the Kaplan-Meier method and log-rank test. Cox proportional-hazard and linear regression models were performed, and adjusted for sex, age, and respiratory symptoms. Results From a total of 73 patients, 20 (27.4%) had a STRONGkids score >= 4 at admission, which was associated with a longer LOS even after adjusting (beta = 12.30; 1.74-22.9 95% CI; P = 0.023). The same association was observed between LOS and all laboratory markers except for D-dimer. Conclusion Among children and adolescents with COVID-19, a STRONGkids score >= 4 at admission, lower values of albumin, lymphocytes, and hemoglobin, and higher CRP values were associated with longer LOS.
- Bioelectrical Impedance Phase Angle and Morbidity and Mortality in Critically Ill Children(2019) ZAMBERLAN, Patricia; FEFERBAUM, Rubens; DORIA FILHO, Ulysses; CARVALHO, Werther Brunow de; DELGADO, Artur FigueiredoBackgroundNutrition markers may be useful for diagnosis and monitoring and, also, as additional indicators of estimating death risk. We tested the association of body composition indicators (mid-upper arm circumference and phase angle) with pediatric intensive care unit (PICU) length of stay and mortality in critically ill pediatric patients. MethodsData from children aged 2 months-18 years were collected, and bioelectrical impedance was performed to obtain phase angle. Severity was evaluated by scoring the Pediatric Index of Mortality. Descriptive statistics were reported for nominal variables. Receiver operating characteristic curve was used to analyze the association of phase angle with 30-day mortality and to find the best cutoff. Survival probabilities and PICU length of stay were estimated using the Kaplan-Meier method. ResultsWe evaluated 247 children with a median age of 4.8 years whose main cause of admission was sepsis. Survival curves showed higher survival in patients with phase angle >2.8 degrees compared with patients with phase angle 2.8 degrees (P<.0001). Kaplan-Meier time-to-event analysis showed that children with lower phase angle values were more likely to remain in the PICU (hazard ratio, 1.84; P=.003). Lower survival was also observed in patients who presented mid-upper arm circumference values 5th percentile (P<.03). ConclusionsMid-upper arm circumference and phase angle were associated with mortality and morbidity in critically ill children, suggesting that these parameters may be useful not only for nutrition diagnosis and monitoring, but also as an additional indicator in estimating prognosis.
- Nutritional risk and anthropometric evaluation in pediatric liver transplantation(2012) ZAMBERLAN, Patricia; LEONE, Claudio; TANNURI, Uenis; CARVALHO, Werther Brunow de; DELGADO, Artur FigueiredoOBJECTIVE: To analyze the nutritional status of pediatric patients after orthotopic liver transplantation and the relationship with short-term clinical outcome. METHOD: Anthropometric evaluations of 60 children and adolescents after orthotopic liver transplantation, during the first 24 hours in a tertiary pediatric intensive care unit. Nutritional status was determined from the Z score for the following indices: weight/age, height/age or length/age, weight/height or weight/length, body mass index/age, arm circumference/age and triceps skinfold/age. The severity of liver disease was evaluated using one of the two models which was adequated to the patients' age: 1. Pediatric End-stage Liver Disease, 2. Model for End-Stage Liver Disease. RESULTS: We found 50.0% undernutrition by height/age; 27.3% by weight/age; 11.1% by weight/height or weight/length; 10.0% by body mass index/age; 61.6% by arm circumference/age and 51.0% by triceps skinfold/age. There was no correlation between nutritional status and Pediatric End-stage Liver Disease or mortality. We found a negative correlation between arm circumference/age and length of hospitalization. CONCLUSION: Children with chronic liver diseases experience a significant degree of undernutrition, which makes nutritional support an important aspect of therapy. Despite the difficulties in assessment, anthropometric evaluation of the upper limbs is useful to evaluate nutritional status of children before or after liver transplantation.
- Nutrition Therapy in a Pediatric Intensive Care Unit: Indications, Monitoring, and Complications(2011) ZAMBERLAN, Patricia; DELGADO, Artur Figueiredo; LEONE, Claudio; FEFERBAUM, Rubens; OKAY, Thelma SuelyBackground: Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patient's risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). Methods: The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Crianca, Hospital das Clinicas, Universidade de Sao Paulo, Brazil. NT was established according to the protocol provided by the institution's NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. Results: NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a postpyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skinfold thickness decreased. Conclusions: The use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggests that NT probably helped patients maintain their nutrition status. (JPEN J Parenter Enteral Nutr. 2011;35:523-529)