Standardized Feeding Protocol Improves Delivery and Acceptance of Enteral Nutrition in Children Immediately After Liver Transplantation

Timing of enteral nutrition and parenteral nutrition in the PICU

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.

Early oral feeding following intestinal anastomosis surgery in infants: a multicenter real world study

Background

To prevent postoperative complications, delayed oral feeding (DOF) remains a common model of care following pediatric intestinal anastomosis surgery; however, early oral feeding (EOF) has been shown to be safe and effective in reducing the incidence of complications and fast recovery after pediatric surgery. Unfortunately, the evidence in support of EOF after intestinal anastomosis (IA) in infants is insufficient. Therefore, this study was primarily designed to evaluate the safety and efficacy of EOF. In addition, the current status of EOF application and associated factors that favor or deter EOF implementation were also assessed.

Methods

A total of 898 infants were divided into two groups (EOF group, n = 182; DOF group, n = 716), and the clinical characteristics were collected to identify the factors associated with EOF in infants. Complications and recovery were also compared to define the safety and efficacy after balancing the baseline data by propensity score matching (PSM) (EOF group, n = 179; DOF group, n = 319).

Results

The total EOF rate in infants with IA was 20.3%. Multivariate logistic regression revealed significant differences in the EOF rates based on IA site and weight at the time of surgery (OR = 0.652, 95% CI: 0.542-0.784, p < 0.001) and (OR = 1.188, 95% CI: 1.036-1.362, p = 0.013), respectively. The duration of total parenteral nutrition (TPN), parenteral nutrition (PN), and postoperative hospital stay were significantly shorter in the EOF group than the DOF group [2.0 (1.0, 2.0) d vs. 5.0 (3.0, 6.0) d; 6.0 (5.0, 8.0) d vs. 8.0 (6.0, 11.0) d; 10.0 (7.0, 14.0) d vs. 12.0 (9.0, 15.0) d, all p < 0.001]. The rates of abdominal distension and vomiting in the EOF group were significantly higher than the DOF group (17.9% vs. 7.2%, p < 0.001; 7.8% vs. 2.5%, p = 0.006); however, no differences were found in failure to initial OF, diarrhea, hematochezia, and anastomotic leakage between the two groups (p > 0.05).

Conclusion

The overall rate of EOF in infants following IA was low, and the sites of anastomosis and weight at surgery were two factors associated with EOF. Nevertheless, performing EOF in infants after IA was safe and effective, reduced PN usage, shortened the hospital stay, and did not increase the rate of severe complications.Clinical Trial Registration: ClinicalTrails.gov, identifier NCT04464057.