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Poh PF, Carey MC, Manning JC, Lee JH, Latour JM. Parental emotional, social and transitional health in the first 6 months after childhood critical illness: A longitudinal qualitative study. J Adv Nurs 2024. [PMID: 38922972 DOI: 10.1111/jan.16288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 12/07/2023] [Accepted: 06/06/2024] [Indexed: 06/28/2024]
Abstract
AIM To explore the experiences and support needs of parents in the first 6 months after paediatric critical care. DESIGN Longitudinal qualitative design. METHODS Sequential semi-structured qualitative interviews were conducted with a sample of 28 parents in succession at 1 month and at 6 months (n = 22) after their child's discharge from paediatric critical care using purposive sampling. Data were analysed using the adapted five-stage framework analysis. RESULTS Data were developed into eight synthesized themes, three domains and an overarching theme: Regaining Normalcy. Families of children requiring medical treatment at 6 months showed signs of adaption to daily care routines. The two domains were Parental Emotional Health and Parental Social Health. Parental Transitional Health, a third domain, was added to the Post Intensive Care Syndrome-paediatric framework. Parents were forward-looking and discussed emotional health, relating to current caregiving issues. Emotional attention was related to present challenges and concerns about current health and possible readmission to the hospital. In terms of Parental Social Health, families isolated themselves for infection control while remaining connected with families using chat applications. Parents were selective to whom they allowed access to their lives. The impact of parental transitional health was evident and emphasized the daily challenges associated with integration back to home life. Flexible work arrangements allowed working parents to support caregiving needs in the first 6 months after discharge. CONCLUSION In the first 6 months after paediatric critical illness, most families reported having moved past the experiences while having provoking memories of the admission period. Parents viewed the point of normalcy as child returned to school or when all medications were discontinued. Extension of transitional support can facilitate discharge experiences between paediatric critical care and normalcy. The findings highlight the importance of understanding the medium- and longer-term impact of paediatric critical care. IMPACT What problem did the study address? ○ Limited understanding of long-term parental experiences and support needs after PICU discharge. What were the main findings? ○ Most families regained normalcy when child returns to school or when medications were discontinued. Some families continued to show signs of adaptations at 6 months after PICU discharge. Where and on whom did the research have an impact? ○ The research has an impact on improving the understanding of long-term parental experiences and support needs after PICU discharge, informing clinical practice, guiding policy development and shaping parental support programs. REPORTING METHOD We reported this study using the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION Prior to confirming the interview guide, three parents of critically ill children actively participated by reviewing and providing feedback on its content. They provided suggestions to refine the wording and ensure clarity to enhance the participants' understanding. By including the perspectives of these parents, we aimed to improve the overall quality and relevance of the interview guide.
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Affiliation(s)
- Pei-Fen Poh
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Matthew C Carey
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | - Jan Hau Lee
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
- School of Nursing, Fudan University, Shanghai, China
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Zamberlan P, Mazzoni BP, Bonfim MAC, Vieira RR, Tumas R, Delgado AF. Body composition in pediatric patients. Nutr Clin Pract 2023; 38 Suppl 2:S84-S102. [PMID: 37721465 DOI: 10.1002/ncp.11061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/26/2023] [Accepted: 07/18/2023] [Indexed: 09/19/2023] Open
Abstract
Undernutrition is highly prevalent in children who are critically ill and is associated with increased morbidity and mortality, including a higher risk of infection due to transitory immunological disorders, inadequate wound healing, reduced gut function, longer dependency on mechanical ventilation, and longer hospital stays compared with eutrophic children who are critically ill. Nutrition care studies have proposed that early interventions targeting nutrition assessment can prevent or minimize the complications of undernutrition. Stress promotes an acute inflammatory response mediated by cytokines, resulting in increased basal metabolism and nitrogen excretion and leading to muscle loss and changes in body composition. Therefore, the inclusion of body composition assessment is important in the evaluation of these patients because, in addition to the nutrition aspect, body composition seems to predict clinical prognosis. Several techniques can be used to assess body composition, such as arm measurements, calf circumference, grip strength, bioelectrical impedance analysis, and imaging examinations, including computed tomography and dual-energy x-ray absorptiometry. This review of available evidence suggests that arm measurements seem to be well-established in assessing body composition in children who are critically ill, and that bioelectrical impedance analysis with phase angle, handgrip strength, calf circumference and ultrasound seem to be promising in this evaluation. However, further robust studies based on scientific evidence are necessary.
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Affiliation(s)
- Patrícia Zamberlan
- Instituto da Criança e do Adolescente/Division of Nutrition, Support Team, Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
| | - Beatriz P Mazzoni
- Instituto da Criança e do Adolescente/Division of Nutrition, Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
| | - Maria A C Bonfim
- Instituto da Criança e do Adolescente/Division of Nutrition, Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
| | - Rafaela R Vieira
- Instituto da Criança e do Adolescente/Division of Nutrition, Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
| | - Rosana Tumas
- Instituto da Criança e do Adolescente/Nutrology Unit, Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
| | - Artur F Delgado
- Department of Pediatrics - Medical School, Universidade de São Paulo, São Paulo, Brazil
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Fell DM, Bitetto EA, Skillman HE. Timing of enteral nutrition and parenteral nutrition in the PICU. Nutr Clin Pract 2023; 38 Suppl 2:S174-S212. [PMID: 37721466 DOI: 10.1002/ncp.11050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.
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Affiliation(s)
- Donna M Fell
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Emily A Bitetto
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
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Touré I, Maitre G, Boillat L, Chanez V, Natterer J, Ferry T, Longchamp D, Perez MH. Implementing a physician-driven feeding protocol is not sufficient to achieve adequate caloric and protein delivery in a paediatric intensive care unit: A retrospective cohort study. Clin Nutr ESPEN 2023; 55:384-391. [PMID: 37202072 DOI: 10.1016/j.clnesp.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND AIMS Daily caloric and protein intake is crucial for the management of critically ill children. The benefit of feeding protocols in improving daily nutritional intake in children remains controversial. This study aimed to assess whether the introduction of an enteral feeding protocol in a paediatric intensive care unit (PICU) improves daily caloric and protein delivery on day 5 after admission and the accuracy of the medical prescription. METHODS Children admitted to our PICU for a minimum of 5 days who received enteral feeding were included. Daily caloric and protein intake were recorded and retrospectively compared before and after the introduction of the feeding protocol. RESULTS Caloric and protein intake was similar before and after introduction of the feeding protocol. The prescribed caloric target was significantly lower than the theoretical target. The children who received less than 50% of the caloric and protein targets were significantly heavier and taller than those who received more than 50%; the patients who received more than 100% of the caloric and protein aims on day 5 after admission had a decreased PICU length of stay and decreased duration of invasive ventilation. CONCLUSION The introduction of a physician-driven feeding protocol was not associated with an increase in the daily caloric or protein intake in our cohort. Other methods of improving nutritional delivery and patient outcomes need to be explored.
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Affiliation(s)
- Ismael Touré
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Guillaume Maitre
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Laurence Boillat
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Vivianne Chanez
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Julia Natterer
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Thomas Ferry
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - David Longchamp
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Maria-Helena Perez
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
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Jotterand Chaparro C, Bertoni Maluf V, Moullet C, Kiszio B, Pugliese MT, Ramelet AS, Morice C, Valla FV, Tume LN. Effectiveness of high versus lower enteral protein intake, considering energy intake, on clinical outcomes in critically ill children: a systematic review protocol. JBI Evid Synth 2023:02174543-990000000-00155. [PMID: 37114868 DOI: 10.11124/jbies-22-00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
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.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Valeria Bertoni Maluf
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Clémence Moullet
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Blanche Kiszio
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Marie-Thérèse Pugliese
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Anne-Sylvie Ramelet
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
- University Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Switzerland
- Lausanne University Hospital, Lausanne, Switzerland
| | - Claire Morice
- Pediatric Intensive Care Unit, Hôpital Universitaire Femme Mère Enfant, Hospices Civils de Lyon, France
- Pediatric Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Universitaire Femme Mère Enfant, Hospices Civils de Lyon, France
| | - Lyvonne N Tume
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
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Nutritional Support in Children Meeting the At-Risk for Pediatric Acute Respiratory Distress Syndrome Criteria. Crit Care Explor 2023; 5:e0856. [PMID: 36760816 PMCID: PMC9901991 DOI: 10.1097/cce.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pediatric acute respiratory distress syndrome (PARDS) is a prevalent condition in the PICU with a high morbidity and mortality, but effective preventative strategies are lacking. OBJECTIVES To examine associations between early enteral nutrition (EN) and PICU outcomes in a cohort of children meeting the 2015 Pediatric Acute Lung Injury Consensus Conference "at-risk" for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria. DESIGN SETTING AND PARTICIPANTS This was a single-center, electronic health record-based retrospective chart review. We included children less than or equal to 18 years-old admitted to our mixed medical-surgical PICU from January 2017 to December 2018 who met ARF-PARDS criteria within 48 hours of admission. Children were categorized as receiving "early" EN if feeds were initiated within 48 hours of admission. All others were categorized as "delayed" EN. MAIN OUTCOMES AND MEASURES Extracted data included demographics, illness characteristics including primary diagnosis and Pediatric Risk of Mortality (PRISM) III score, respiratory support and oxygenation indices, nutritional data, and PICU length of stay (LOS). The primary outcome of interest was subsequent diagnosis of PARDS. RESULTS Of 201 included children, 152 (75.6%) received early EN. The most common admission diagnoses were pneumonia, bronchiolitis, and influenza. Overall, 21.4% (n = 43) of children developed PARDS. Children receiving early EN had a subsequent diagnosis of PARDS less often then children receiving delayed EN (15.1% vs 40.8%; p < 0.001), an association that persisted after adjusting for patient demographics and illness characteristics, including PRISM III and diagnosis (adjusted odds ratio, 0.24; 95% CI, 0.10-0.58; p = 0.002). Early EN was also associated with a shorter PICU LOS in univariate analysis (2.2 d [interquartile range, 1.5-3.4 d] vs 4.2 d [2.7-8.9 d]; p < 0.001). CONCLUSIONS AND RELEVANCE In this single-center, retrospective cohort study, compared with children with ARF-PARDS who received late EN, those who received early EN demonstrated a reduced odds of subsequent diagnosis of PARDS, and an unadjusted reduction in PICU LOS when compared with delayed EN. Prospective studies should be designed to confirm these findings.
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Abstract
OBJECTIVES To identify nursing research priorities in pediatric critical care in Asia. DESIGN We conducted a modified three-round eDelphi survey with pediatric critical care nurses in Asia. The eDelphi technique has been extensively used within health research to achieve a common viewpoint from experts using questionnaires to gather research priorities. In round 1, participants were asked to list three to five research topics that they deemed important. These topics were thematically analyzed and categorized into a questionnaire. Participants rated the research topics in round 2 on a 6-point scale (1 = not important to 6 = extremely important). In round 3, the same questionnaire was used with addition of the calculated mean scores from round 2 for each topic. Research topics ranked among the top 10 were considered extremely important. SETTINGS Twenty-two PICUs in eight Asian countries. SUBJECTS Clinical nurses, managers, educators, and researchers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In round 1, 146 PICU nurses across eight countries provided 520 research topics. Topics from round 1 were categorized into seven domains with 52 research topics. Prioritized research topics included early recognition of patient deterioration (mean 5.58 ± 0.61), prevention of healthcare-associated infections (mean 5.47 ± 0.70), and interventions to reduce compassion fatigue (mean 5.45 ± 0.80). The top three research domains were end-of-life care (mean 5.34 ± 0.68), professionalism (mean 5.34 ± 0.69), and management of pain, sedation, and delirium (5.32 ± 0.72). CONCLUSIONS This first PICU nursing research prioritization exercise within Asia identified key nursing research themes that should be prioritized and provide a framework for future collaborative studies.
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Iping R, Hulst J, Joosten K. Research developments in pediatric intensive care nutrition: A research intelligence review. Clin Nutr ESPEN 2022; 50:1-7. [DOI: 10.1016/j.clnesp.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/30/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
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9
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Research Priorities for Pediatric Intensive Care Nutrition Within the United Kingdom: A National Institute of Health Research James Lind Alliance Priority Setting Partnership. Crit Care Explor 2022; 4:e0649. [PMID: 35265852 PMCID: PMC8901218 DOI: 10.1097/cce.0000000000000649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Walter S, DeLeon S, Walther JP, Sifers F, Garbe MC, Allen C. The nutritional impact of a feeding protocol for infants on high flow nasal cannula therapy. Nutr Clin Pract 2022; 37:935-944. [PMID: 35072294 DOI: 10.1002/ncp.10817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Clinicians may be reluctant to feed patients on high-flow nasal cannula (HFNC) therapy, despite studies suggesting it is beneficial and safe. We describe the implementation of a feeding protocol for patients with bronchiolitis on HFNC and determine its effect on nutrition goals. METHODS Prospective bedside data on enteral volume, feed interruptions, and aspiration events were collected on patients with bronchiolitis who were <24 months of age, treated with HFNC, and fed per a developed protocol. Exclusion criteria included history of prematurity <32 weeks, congenital heart disease, or positive-pressure ventilation before feeding. Length of intensive care unit and hospital stay was compared with both a concurrent cohort (CC) of patients not fed per the protocol and a retrospective cohort (RC) admitted prior to protocol creation. RESULTS Seventy-eight patients met the criteria for the prospective study arm: 24 patients were included in the CC, and 74 were included in the RC. Seventy-one percent of prospective patients received enteral nutrition (EN) on HFNC day 1 vs 42% of the CC. In the prospective cohort, feed interruption occurred in 23% of patients and was associated with higher flow rates; however, no aspiration events occurred. Patients fed per protocol were fed 8-10 h sooner and discharged 1 day earlier than those in the RC. CONCLUSION The use of a feeding protocol for patients with bronchiolitis on HFNC was safe and associated with shorter time to initiate EN and shorter length of hospital stay.
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Affiliation(s)
- Sarah Walter
- Department of Pediatrics, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Stephanie DeLeon
- Department of Pediatrics, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Jonathan P Walther
- Department of Pediatrics, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Felicia Sifers
- Department of Pediatrics, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA.,Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael Connor Garbe
- Department of Pediatrics, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Christine Allen
- Department of Pediatrics, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
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Mtaweh H, Martinez EE. Editorial: Gastrointestinal function and nutrition in pediatric critical care. Front Pediatr 2022; 10:1056544. [PMID: 36389356 PMCID: PMC9650102 DOI: 10.3389/fped.2022.1056544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Haifa Mtaweh
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Staff Physician, Department of Critical Care Medicine, SickKids, Toronto, ON, Canada
| | - Enid E Martinez
- Department of Anaesthesia, Harvard Medical School, Boston, MA, United States.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
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Brown AM, Irving SY, Pringle C, Allen C, Brown MF, Nett S, Singleton MN, Mikhailov TA, Madsen E, Srinivasan V, Anthony H, Forbes ML. Bolus Gastric Feeds Improve Nutritional Delivery to Mechanically Ventilated Pediatric Medical Patients: Results of the COntinuous vs BOlus (COBO2) Multi-Center Trial. JPEN J Parenter Enteral Nutr 2021; 46:1011-1021. [PMID: 34881440 DOI: 10.1002/jpen.2305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 09/28/2021] [Accepted: 11/05/2021] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Ann-Marie Brown
- Associate Clinical Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Nurse Scientist, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sharon Y Irving
- Associate Professor, Pediatric Nursing, Vice-Chair Department of Family & Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Charlene Pringle
- Pediatric Acute Care Nurse Practitioner, Division of Pediatric Critical Care Medicine, University of Florida, UFHealth Shands Children's Hospital, Gainesville, FL
| | - Christine Allen
- Associate Professor o Pediatrics, Division of Pediatric Critical Care, University of Oklahoma Health Sciences Center, The Children's Hospital at OU Health, Oklahoma City, OK
| | - Miraides F Brown
- Biostatistician, Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH
| | - Sholeen Nett
- Associate Professor, Division of Pediatric Critical Care, Dartmouth Hitchcock Medical Center, Lebanon, NH and Baystate Children's Hospital, Springfield, MA
| | - Marcy N Singleton
- Pediatric Acute Care Nurse Practitioner, Dartmouth Hitchcock Medical Center, Instructor in Pediatrics Geisel School of Medicine
| | - Theresa A Mikhailov
- Professor of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Pediatric Intensivist, Children's Wisconsin, Milwaukee, WI
| | - Erik Madsen
- Assistant Professor of Pediatrics, Division of Pediatric Critical Care, Saint Louis University School of Medicine, Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Vijay Srinivasan
- Assistant Professor of Anesthesiology, Critical Care and Pediatrics, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Attending Pediatric Intensivist, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heather Anthony
- Clinical Research Support Team Supervisor, GAMUT Program Coordinator, Clinical Research Nurse, Akron Children's Hospital, Akron, OH
| | - Michael L Forbes
- Professor of Pediatrics, Northeast Ohio Medical University, Associate Chair, Department of Pediatrics, Director, Hospital-Based Medical Practices, Director, Critical Care Research & Outcomes Analysis, Akron Children's Hospital, Akron, OH
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13
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Bechard LJ, Staffa SJ, Zurakowski D, Mehta NM. Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children. Am J Clin Nutr 2021; 114:1859-1867. [PMID: 34320161 DOI: 10.1093/ajcn/nqab244] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Optimal nutrition in critically ill children involves a complex interplay between the doses, route, and timing of macronutrient delivery. OBJECTIVES We aimed to examine the association between the time to achieve delivery of 60% of the prescribed energy and protein targets and clinical outcomes in mechanically ventilated children. METHODS We conducted a prospective, observational cohort study of mechanically ventilated children admitted to pediatric intensive care units (PICUs) worldwide. Daily energy and protein delivery were recorded for up to 10 d in the PICU. We calculated "adequacy" as the percentage of the prescribed energy or protein goal delivered by enteral nutrition (EN), parenteral nutrition (PN), and total nutrition (EN + PN). Based on the days required to reach 60% energy or protein adequacy after PICU admission, we categorized patients into 3 groups: early (≤3 d), pragmatic (4 to 7 d), and late (more than 7 d). The primary outcome was 60-d all-cause mortality; secondary outcomes were the incidence of acquired infections and 28-d ventilator-free days (VFDs). RESULTS From 77 participating PICUs, 1844 patients, with a median age of 1.64 y (IQR, 0.47-7.05), were included; the 60-d mortality rate was 5.3% (n = 97). The average adequacies of delivery via EN + PN was 49% (IQR, 26-70) for energy and 66% (IQR, 44-89) for protein. In multivariable models adjusted for confounders, mortality was significantly lower in patients who achieved targets within 7 d, for energy (adjusted HR, 0.48; 95% CI: 0.28-0.82; P = 0.007) or protein (adjusted HR, 0.55; 95% CI: 0.33-0.94; P = 0.027) delivery. There were no clinically significant differences in infections or VFDs between groups. CONCLUSIONS Achieving 60% of energy or protein delivery targets within the first 7 d after PICU admission is associated with lower 60-d mortality in mechanically ventilated children, and is not associated with a greater incidence of infections or a reduction in VFDs compared to later achievement of targets. This trial was registered at clinicaltrials.gov as NCT03223038.
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Affiliation(s)
- Lori J Bechard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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14
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Ventura JC, Silveira TT, Bechard L, McKeever L, Mehta NM, Moreno YMF. Nutritional screening tool for critically ill children: a systematic review. Nutr Rev 2021; 80:1392-1418. [PMID: 34679168 DOI: 10.1093/nutrit/nuab075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Nutritional screening tools (NSTs) are used to identify patients who are at risk of nutritional status (NS) deterioration and associated clinical outcomes. Several NSTs have been developed for hospitalized children; however, none of these were specifically developed for Pediatric Intensive Care Unit (PICU) patients. OBJECTIVE A systematic review of studies describing the development, application, and validation of NSTs in hospitalized children was conducted to critically appraise their role in PICU patients. DATA SOURCES PubMed, Embase, Web of Science, Scopus, SciELO, LILACS, and Google Scholar were searched from inception to December 11, 2020. DATA EXTRACTION The review included 103 studies that applied NSTs at hospital admission. The NST characteristics collected included the aims, clinical setting, variables, and outcomes. The suitability of the NSTs in PICU patients was assessed based on a list of variables deemed relevant for this population. DATA ANALYSIS From 19 NSTs identified, 13 aimed to predict NS deterioration. Five NSTs were applied in PICU patients, but none was validated for this population. NSTs did not include clinical, NS, laboratory, or dietary variables that were deemed relevant for the PICU population. CONCLUSION None of the available NSTs were found to be suitable for critically ill children, so a new NST should be developed for this population. AQ6. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42020167898.
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Affiliation(s)
- Julia C Ventura
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Taís T Silveira
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Lori Bechard
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Liam McKeever
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Nilesh M Mehta
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Yara M F Moreno
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
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15
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Becker PJ, Brunet-Wood MK. Pediatric malnutrition screening and assessment tools: Analyzing the gaps. Nutr Clin Pract 2021; 37:1088-1104. [PMID: 34664733 DOI: 10.1002/ncp.10793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Pediatric healthcare professionals know that children who are malnourished have worse clinical outcomes than do their well-nourished peers. The body of evidence in the literature on the topic of pediatric malnutrition (PMN) is growing and supports this conclusion. The goal of this article is to present the current state of practice related to PMN screening, the use of malnutrition risk screening (MNRS) tools, malnutrition assessment, and the use of malnutrition assessment tools. The purpose is also to discuss best practice for MNRS and assessment and to consider the gaps in practice where additional work is needed.
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Affiliation(s)
| | - M Kim Brunet-Wood
- Pediatric Working Group, Canadian Malnutrition Task Force, St Albert, Alberta, Canada
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16
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Pulido AV, Kellogg K, Hunt K, Davis C. Development of a clinical practice guideline for weaning and discontinuing parenteral nutrition in hospitalized children as part of a central line-associated bloodstream infection-focused quality improvement initiative. JPEN J Parenter Enteral Nutr 2021; 45:1653-1662. [PMID: 34350991 DOI: 10.1002/jpen.2247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Overprescribing of parenteral nutrition (PN) increases costs and risks to patients, including from central line-associated bloodstream infection (CLABSI). With CLABSI reduction in mind, our children's hospital began an iterative quality improvement effort to decrease PN utilization by first ensuring appropriate initiation and then defining and ensuring appropriate discontinuation. METHODS Education was launched along with audits to evaluate for appropriate PN indications. Next, a literature review was conducted to guide the development of an algorithm to appropriately wean and discontinue PN. Lastly, all PN discontinuations were audited for agreement with the new guideline. Retrospectively, monthly PN utilization index (orders per patient-day) was plotted on a statistical process control chart to assess change over time. The presence of PN as a risk factor for CLABSI events and the overall hospital CLABSI rate were trended. RESULTS Mean PN utilization index fell from 0.156 (July 2018 to January 2019) to 0.12 (February 2019 to August 2020) (P < .01). For 18 months, no PN utilization index reached the baseline lower control limit of 0.144, demonstrating special-cause variation and sustained change. PN as a risk factor for hospital CLABSI cases decreased from most prevalent (49% of cases) to fifth most prevalent (29%) as the CLABSI rate trended down. CONCLUSION Engaging frontline staff in the development of a clinical practice guideline and increased accountability to reduce potential patient harm led to a significant and sustained reduction in PN utilization, as well as decreased prevalence of PN as a risk factor in hospital CLABSI cases.
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Affiliation(s)
| | - Kim Kellogg
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathryn Hunt
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Cheryl Davis
- Seattle Children's Hospital, Seattle, Washington, USA
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17
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Abstract
PURPOSE OF REVIEW To review the current evidence evaluating early versus delayed commencement of parenteral nutrition in infants. RECENT FINDINGS Recent studies in very premature infants (<32 weeks gestation) have shown that early commencement of parenteral nutrition immediately after birth improves physical growth. However, there are concerns that early use of very high dose of amino-acids (>3.5 g/kg/day immediately after birth) may cause metabolic acidosis, elevated blood urea, slower head growth and refeeding-hypophosphatemia syndrome. A recent multicentre randomized controlled trial found that commencement of parenteral nutrition within 24-h of admission increases the risk of infections and prolongs the duration of ventilation and ICU stay in full-term neonates, older infants and children. The study also found that delaying to day 8 of admission increased the risk of hypoglycaemia. SUMMARY Benefits of commencing parenteral nutrition on the first day of life appear to outweigh risks in very premature infants; however, it is prudent to avoid early very high doses of amino acids (>3.5 g/kg/day) in the first few days of life. In moderate to late preterm infants, if enteral feeds are not tolerated by 72 h, it is reasonable to commence parenteral nutrition. In full-term and older infants, it is preferable to avoid parenteral nutrition within 24 h of admission and consider delaying by further few days. Diligent monitoring of blood glucose, serum phosphate and other parameters is essential while on parenteral nutrition.
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Affiliation(s)
- Kwi Moon
- Pharmacy Department, Perth Children's Hospital, Nedlands
- Medical School, The University of Western Australia, Perth
- Telethon Kids Institute
| | - Shripada C Rao
- Medical School, The University of Western Australia, Perth
- Department of Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
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18
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Successful Implementation of Nutritional Screening and Assessment in Infants With Congenital Heart Disease…Check! Now What? Pediatr Crit Care Med 2020; 21:600-601. [PMID: 32483030 DOI: 10.1097/pcc.0000000000002298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Gadhvi KR, Valla FV, Tume LN. Review of Outcomes Used in Nutrition Trials in Pediatric Critical Care. JPEN J Parenter Enteral Nutr 2020; 44:1210-1219. [PMID: 32010996 DOI: 10.1002/jpen.1765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Generating robust evidence within pediatric intensive care (PIC) can be challenging because of low patient numbers and patient heterogeneity. Systematic reviews may overcome small study biases but are limited by lack of standardization in outcome measures and their definition. Trials of nutrition interventions in PIC are increasing; thus, we wanted to examine the outcome measures being used in these trials. OBJECTIVE Our objective was to systematically describe outcome measures used when a nutrition intervention has been evaluated in a PIC randomized controlled trial. METHODS A systematic literature review of all studies involving a PIC trial of a nutrition intervention was undertaken from January 1, 1996, until February 20, 2018. RESULTS Twenty-nine trials met the criteria and were reviewed. They included a total of 3226 patients across all trials. Thirty-seven primary outcomes and 83 secondary outcomes were found. These were categorized into PIC-related outcomes (infection, intensive care dependency, organ dysfunction, and mortality) and nutrition outcomes (energy targets, nutrition parameters, and feeding tolerance). We found large variation in the outcome measures used. Outcome domains of energy targets, feeding tolerance, and infection were not adequately defined. CONCLUSIONS Considerable variation in the outcome measures chosen and their definitions exist within PIC nutrition trials. Optimal nutrition outcomes for PIC must be agreed upon and defined, specifically domains of nutrition efficiency, nutrition tolerance, and non-nutrition PIC outcomes. The next step is to conduct an international Delphi study to gain expert consensus and develop a core outcome set to be reported in future pediatric nutrition trials.
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Affiliation(s)
- Kunal R Gadhvi
- Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK
| | - Frédéric V Valla
- Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK.,Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, CarMEN INSERM UMR 1060, Lyon-Bron, France
| | - Lyvonne N Tume
- Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK
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20
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Brown AM, Madsen EC, Leonard CP, Leslie SL, Allen C, Srinivasan V, Irving SY. Continuous Versus Bolus Gastric Feeding in Children Receiving Mechanical Ventilation: A Systematic Review. Am J Crit Care 2020; 29:33-45. [PMID: 31968086 DOI: 10.4037/ajcc2020850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Nutrition guidelines recommend enteral nutrition in the form of gastric feedings for critically ill children and acknowledge a lack of evidence describing an optimal method for providing these feedings. OBJECTIVE To determine the state of the science regarding the efficacy of bolus (intermittent) or continuous gastric feedings to improve nutrition delivery in critically ill children receiving mechanical ventilation. METHODS Five hundred seventy-nine abstracts met the inclusion criteria and were screened by 2 reviewers according to prespecified criteria. Full-text reviews were performed on 28 articles; 11 studies were selected for detailed analysis. Because of the small number of eligible studies, broader searches were conducted. RESULTS Only 5 studies with a collective enrollment of fewer than 200 children closely addressed the specific research question. These 5 studies did not report any similarity in feeding regimens, nor did they report nutritional outcomes. Two of the articles described findings from the same study population. Although 4 of the 5 studies randomized children to bolus versus continuous feedings, only 3 studies described attainment of nutrient delivery goals in both the intervention and the control groups; the remaining study did not report this outcome. The heterogeneity in methodology and outcomes among the 5 studies did not allow for a meta-analysis. CONCLUSIONS The dearth of evidence regarding best practices and outcomes related to bolus versus continuous gastric feedings in critically ill children receiving mechanical ventilation requires additional rigorous investigation.
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Affiliation(s)
- Ann-Marie Brown
- Ann-Marie Brown is an assistant clinical professor at Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, and a nurse practitioner in pediatric intensive care at Akron Children’s Hospital, Akron, Ohio
| | - Erik C. Madsen
- Erik C. Madsen is an assistant professor of pediatrics at Saint Louis University and a pediatric intensivist at Cardinal Glennon Children’s Hospital, St Louis, Missouri
| | - Charlene P. Leonard
- Charlene P Leonard is a nurse practitioner in pediatric critical care medicine, University of Florida and UFHealth Shands Children’s Hospital, Gainesville, Florida
| | - Sharon L. Leslie
- Sharon L. Leslie is a nursing informationist at Woodruff Health Sciences Center Library, Emory University
| | - Christine Allen
- Christine Allen is associate professor of pediatrics at the Children’s Hospital of Oklahoma/University of Oklahoma, Oklahoma City, Oklahoma
| | - Vijay Srinivasan
- Vijay Srinivasan is an assistant professor of anesthesiology, critical care, and pediatrics at Perelman School of Medicine at the University of Pennsylvania and a pediatric intensivist in the Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sharon Y. Irving
- Sharon Y. Irving is an assistant professor of pediatric nursing at the University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, and a nurse practitioner in pediatric intensive and progressive care at Children’s Hospital of Philadelphia
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21
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Marino LV, Eveleens RD, Morton K, Verbruggen SCAT, Joosten KFM. Peptide nutrient-energy dense enteral feeding in critically ill infants: an observational study. J Hum Nutr Diet 2019; 32:400-408. [PMID: 30848864 DOI: 10.1111/jhn.12645] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Enteral feeding is challenging in critically ill infants. Target intakes are often not achieved as a result of fluid restriction, procedural interruptions and perceived enteral feeding intolerance. In those infants perceived to have poor feeding tolerance, the use of a peptide nutrient-energy dense enteral feed (PEF) may improve nutritional intake and minimise feeding interruptions as a result of gastrointestinal symptoms. The aim of this observational study was to characterise the use of a PEF amongst critically ill infants in two paediatric intensive care units (PICUs). METHODS Records from critically ill infants aged <12 months admitted to two PICUs were retrospectively reviewed with a PICU length of stay (LOS) ≥ 7 days. Achievement of nutritional targets for the duration of PEF was reviewed. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters. RESULTS In total, 53 infants were included, with a median age on admission of 2.6 months. Median admission weight was 3.9 kg in PICU-1 and 4.7 kg in PICU-2. Median (interquatile range) energy intake in PICU-1 and PICU-2 was 68 (47-92) and 90 (63-124) kcal kg-1 , respectively, and median (interquatile range) protein intake 1.7 (1.1-2.4) g kg-1 and 2.5 (1.6-3.2) g kg-1 , respectively. Feeding was withheld because of feeding intolerance in one infant (4%) on two occasions in PICU-1 for 2.5 h and in two infants (7%) on two occasions in PICU-2 for 19.5 h. Gastric residual mean (SD) volumes were 3.5 (5.4) mL kg-1 in PICU-1 and 16.9 (15.6) mL kg-1 in PICU-2. CONCLUSIONS Peptide nutrient-energy dense feeding in infants admitted to the PICU is feasible, well tolerated and nutritional targets are met. However, with this study design, it is not possible to draw any conclusions regarding the benefit of PEF over standard PE feed in critically ill children and future work is required to clarify this further.
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Affiliation(s)
- L V Marino
- Department of Dietetics and Speech & Language Therapy, University of Southampton, Southampton, UK.,NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK.,Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - R D Eveleens
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K Morton
- Faculty of Health Sciences, University of Southampton, Southampton, UK.,Paediatric Intensive Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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