Enteral Protein Supplementation in Critically Ill Children: A Randomized Controlled Pilot and Feasibility Study

Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: a randomized controlled trial

INTRODUCTION

The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants.

METHODS

We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7 g/dL), protein-enriched diet (2.7 g/dL) and high protein-enriched diet (5.1 g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3-5 days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period.

RESULTS

Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3-5 days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group.

CONCLUSION

Enteral administration of higher amounts of protein improves serum protein levels in critically ill children. A protein intake of 2.2 g/kg/day is generally safe and well tolerated, whereas an intake of 3.4 g/kg/day may produce hyperuraemia in some patients.

Effectiveness of high versus lower enteral protein intake, considering energy intake, on clinical outcomes in critically ill children: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of high versus lower enteral protein intake, considering energy intake, on clinical and nutritional outcomes in critically ill children hospitalized in the pediatric intensive care unit.

INTRODUCTION

Over and undernutrition increases the risk of morbidity and mortality in critically ill children. The impact of high versus lower enteral protein intake on clinical outcomes, considering energy intake, still needs to be investigated in children of different ages.

INCLUSION CRITERIA

This review will consider studies of critically ill children (aged between ≥ 37 wk' gestational age and < 18 y) admitted to the pediatric intensive care unit for a minimum of 48 hours and receiving enteral nutrition. Randomized controlled trials comparing high versus lower enteral protein intake, considering energy intake, will be eligible. Primary outcomes will include clinical and nutritional outcomes, such as length of stay in the pediatric intensive care unit and nitrogen balance.

METHODS

Using the JBI methodology for systematic reviews of effectiveness, we will search for randomized controlled trials published in English, French, Italian, Spanish, and German in electronic databases, including MEDLINE, CINAHL Complete, Embase, and the Cochrane Library, from database inception until the present. We will also search clinical trial registers and, if required, contact authors. Two independent reviewers will screen and select studies for inclusion, data extraction, and assessment of methodological quality. A third reviewer will be consulted if necessary. A statistical meta-analysis will be performed if feasible.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022315325.

Bolus Gastric Feeds Improve Nutritional Delivery to Mechanically Ventilated Pediatric Medical Patients: Results of the COntinuous vs BOlus (COBO2) Multi-Center Trial

BACKGROUND

Comparison of bolus (BGF) versus continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered.

METHODS

Multi-center, prospective, randomized comparative effectiveness trial conducted in seven Pediatric ICUs (PICUs). Eligibility criteria: 1 month - 12 years of age, intubated within 24 hours of PICU admission, expected duration of ventilation at least 48 hours, eligible to begin enteral nutrition within 48 hours.

EXCLUSION CRITERIA

acute or chronic gastrointestinal pathology, or acute surgery.

RESULTS

We enrolled 158 mechanically ventilated children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). The BGF group was slightly older than CGF, otherwise the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group that achieved goal feeds. Time to goal feeds was shorter in the BGF [Hazard Ratio 1.5 (CI 1.02-2.33); P = 0.0387]. Median percentage of target kilocalories [median kcal 0.78 vs 0.59; p = <.0001], and median percentage of protein delivered [median pro 0.77 vs 0.59; p = <.0001] was higher for BGF patients. There was no difference in serial oxygen saturation index between groups.

CONCLUSION

Our study demonstrated shorter time to achieve goal nutrition via BGF compared to CGF in mechanically ventilated pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations. This article is protected by copyright. All rights reserved.

Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations

Background

Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines.

Objective

To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children.

Design

The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds.

Results

The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions.

Conclusions

We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.