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Winderlich J, Little B, Oberender F, Farrell T, Jenkins S, Landorf E, Menzies J, O'Brien K, Rowe C, Sim K, van der Wilk M, Woodgate J, Udy AA, Ridley EJ. Dietitian and nutrition-related practices and resources in Australian and New Zealand PICUs: A clinician survey. Aust Crit Care 2024; 37:490-494. [PMID: 37169654 DOI: 10.1016/j.aucc.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/19/2023] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Recommendations to facilitate evidence-based nutrition provision for critically ill children exist and indicate the importance of nutrition in this population. Despite these recommendations, it is currently unknown how well Australian and New Zealand (ANZ) paediatric intensive care units (PICUs) are equipped to provide nutrition care. OBJECTIVES The objectives of this project were to describe the dietitian and nutrition-related practices and resources in ANZ PICUs. METHODS A clinician survey was completed as a component of an observational study across nine ANZ PICUs in June 2021. The online survey comprised 31 questions. Data points included reporting on dietetics resourcing, local feeding-related guidelines and algorithms, nutrition screening and assessment practices, anthropometry practices, and indirect calorimetry (IC) device availability and local technical expertise. Data are presented as frequency (%), mean (standard deviation), or median (interquartile range). RESULTS Survey responses were received from all nine participating sites. Dietetics staffing per available PICU bed ranged from 0.01 to 0.07 full-time equivalent (median: 0.03 [interquartile range: 0.02-0.04]). Nutrition screening was established in three (33%) units, all of which used the Paediatric Nutrition Screening Tool. Dietitians consulted all appropriate patients (or where capacity allowed) in six (66%) units and on a request or referral basis only in three (33%) units. All units possessed a local feeding guideline or algorithm. An IC device was available in two (22%) PICUs and was used in one of these units. CONCLUSIONS This is the first study to describe the dietitian and nutrition-related practices and resources of ANZ PICUs. Areas for potential improvement include dietetics full-time equivalent, routine nutrition assessment, and access to IC.
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Affiliation(s)
- Jacinta Winderlich
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash, University, Melbourne, VIC, Australia; Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, VIC, Australia.
| | - Bridget Little
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Tamara Farrell
- Nutrition & Dietetics Department, Perth Children's Hospital, Perth, WA, Australia
| | - Samantha Jenkins
- Nutrition and Dietetics, John Hunter Children's Hospital, New Lambton Heights, NSW, Australia
| | - Emma Landorf
- Nutrition Department, Women's & Children's Hospital, Adelaide, SA, Australia; Nutrition Department, Alfred Health, Melbourne, VIC, Australia
| | - Jessica Menzies
- Nutrition and Dietetics, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Katie O'Brien
- Department of Nutrition & Food Services, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Carla Rowe
- Nutrition & Dietetics, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Kirsten Sim
- Nutrition & Dietetics, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Melanie van der Wilk
- Nutrition & Dietetics Department, Perth Children's Hospital, Perth, WA, Australia
| | - Jemma Woodgate
- Department of Dietetics & Foodservices, Children's Health Queensland Hospital, Brisbane, QLD, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash, University, Melbourne, VIC, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash, University, Melbourne, VIC, Australia; Nutrition Department, Alfred Health, Melbourne, VIC, Australia
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Winderlich J, Little B, Oberender F, Bollard T, Farrell T, Jenkins S, Landorf E, McCall A, Menzies J, O'Brien K, Rowe C, Sim K, van der Wilk M, Woodgate J, Paul E, Udy AA, Ridley EJ. Nutrition provision in Australian and New Zealand PICUs: A prospective observational cohort study (ePICUre). Nutrition 2024; 118:112261. [PMID: 37984244 DOI: 10.1016/j.nut.2023.112261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES The main aim of this study was to describe nutrition provision in Australian and New Zealand (ANZ) pediatric intensive care units (PICUs), including mode of nutrition and adequacy of enteral nutrition (EN) to PICU day 28. Secondary aims were to determine the proportion of children undergoing dietetics assessment, the average time to this intervention, and the methods for estimation of energy and protein requirements. METHODS This observational study was conducted in all ANZ tertiary-affiliated specialist PICUs. All children ≤18 y of age admitted to the PICU over a 2-wk period and remaining for ≥48 h were included. Data were collected on days 1 to 7, 14, 21, and 28 (unless discharged prior). Data points included oral intake, EN and parenteral nutrition support, estimated energy and protein adequacy, and dietetics assessment details. RESULTS We enrolled 141 children, of which 79 were boys (56%) and 84 were <2 y of age (60%). Thirty children (73%) received solely EN on day 7 with documented energy and protein targets for 22 (73%). Of these children, 14 (64%) received <75% of their estimated requirements. A dietetics assessment was provided to 80 children (57%), and was significantly higher in those remaining in the PICU beyond the median length of stay (41% in patients staying ≤4.6 d versus 72% in those staying >4.6 d; P < 0.001). CONCLUSIONS This prospective study of nutrition provision across ANZ PICUs identified important areas for improvement, particularly in EN adequacy and nutrition assessment. Further research to optimize nutrition provision in this setting is urgently needed.
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Affiliation(s)
- Jacinta Winderlich
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Nutrition and Dietetics, Monash Children's Hospital, Melbourne, Australia; Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia.
| | - Bridget Little
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Tessa Bollard
- Nutrition and Dietetics, Sydney Children's Hospital, Randwick, Australia
| | - Tamara Farrell
- Nutrition & Dietetics Department, Perth Children's Hospital, Perth, Australia
| | - Samantha Jenkins
- Nutrition and Dietetics, John Hunter Children's Hospital, New Lambton Heights, Australia
| | - Emma Landorf
- Nutrition Department, Women's & Children's Hospital, Adelaide, Australia
| | - Andrea McCall
- Nutrition Department, Women's & Children's Hospital, Adelaide, Australia
| | - Jessica Menzies
- Nutrition and Dietetics, Sydney Children's Hospital, Randwick, Australia
| | - Katie O'Brien
- Department of Nutrition & Food Services, The Royal Children's Hospital, Melbourne, Australia
| | - Carla Rowe
- Nutrition & Dietetics, The Children's Hospital at Westmead, Westmead, Australia
| | - Kirsten Sim
- Nutrition & Dietetics, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Jemma Woodgate
- Department of Dietetics & Foodservices, Queensland Children's Hospital, Brisbane, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Dietetics and Nutrition, Alfred Health, Melbourne, Australia
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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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4
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The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position on the Role of the Registered Dietitian Nutritionist in the Care of the Pediatric Patient With Chronic Gastrointestinal Diseases. J Pediatr Gastroenterol Nutr 2023; 76:390-399. [PMID: 36580920 DOI: 10.1097/mpg.0000000000003695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The optimization of nutrition is essential for the growth and development of all children, including those with gastrointestinal (GI) conditions that can variably affect nutrient intake, absorption, or metabolism. Registered Dietitian Nutritionists (RDNs) are essential partners in delivering high quality care for pediatric GI disorders, but limited evidence is available to support the role of the RDN in the care of these patients. This position paper outlines the evidence supporting the role of the RDN in the management of chronic pediatric GI issues in both inpatient and outpatient settings. Gaps in the literature, opportunities for future research, and barriers to RDN access are discussed.
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Risk of Weight Loss in Adult Patients and the Effect of Staffing Registered Dietitians in Kaifukuki (Convalescent) Rehabilitation Wards: A Retrospective Analysis of a Nationwide Survey. Healthcare (Basel) 2021; 9:healthcare9060753. [PMID: 34207324 PMCID: PMC8235006 DOI: 10.3390/healthcare9060753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/02/2021] [Accepted: 06/15/2021] [Indexed: 01/26/2023] Open
Abstract
There is scarce evidence regarding the risk of weight loss and the effect of having registered dietitians (RDs) on staff in rehabilitation wards on weight loss. We aimed to examine the effects of RDs in Kaifukuki (convalescent) rehabilitation wards (KRWs) on the prevention of weight loss in adult patients. Data from 2-year nationwide annual surveys on KRWs in Japan were retrospectively analysed. Weight loss was defined as loss of ≥5% weight during the KRW stay. Risk of weight loss in class 1 KRWs (obligated to provide nutrition care) was compared with that in class 2–6 KRWs (not obligated). Risk of weight loss in class 2–6 KRWs with RDs was compared to those without. Overall, 17.7% of 39,417 patients lost weight. Class 1 KRWs showed a lower risk of weight loss than class 2–6 KRWs (17.3% vs. 18.5%, p = 0.003). KRWs with RDs showed a significantly lower incidence of weight loss than those without RDs (16.1% vs. 18.8%, p = 0.015). Class 1 KRWs and exclusively staffed RDs were independently associated with lower odds of weight loss (odds ratio = 0.915 and 0.810, respectively). Approximately 18% of KRW patients lost weight, and having RDs on staff can lower the risk of weight loss.
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Mujlli G, Aldisi D, Aljuraiban GS, Abulmeaty MMA. Impact of Nutrition Care Process Documentation in Obese Children and Adolescents with Metabolic Syndrome and/or Non-Alcoholic Fatty Liver Disease. Healthcare (Basel) 2021; 9:healthcare9020188. [PMID: 33572340 PMCID: PMC7916099 DOI: 10.3390/healthcare9020188] [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] [Received: 12/06/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 11/16/2022] Open
Abstract
This study evaluated the Nutrition Care Process documentation used by dietitians for obese pediatric patients diagnosed with metabolic syndrome (MetS) and/or non-alcoholic fatty liver disease (NAFLD) and its impact on the achievement of nutritional goals. This retrospective cohort study utilized data retrieved from three tertiary care hospitals in Riyadh. A total of 142 obese pediatric patients aged 8–18 years diagnosed with NAFLD and/or MetS were evaluated. Data on weight, height, blood pressure (BP), lipid profile, and liver enzymes were collected. A validated audit was used to assess the documentation quality. Twenty-seven (46.6%) dietitian notes received a high score, 21 (36.2%) received a medium score, and 10 (17.2%) received a low score. There was no significant effect of dietitian audit scores on nutritional outcomes, however, the change in body mass index from 6 to 12 months follow-up period was inversely correlated with the audit score (r = −0.761, p = 0.007), and alkaline phosphatase was inversely correlated with the audit score (r = −0.819, p = 0.013). In conclusion, there was a clear variation in the quality of dietitians’ documentation and the impact of documentation scores on nutritional outcomes.
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Affiliation(s)
- Gadah Mujlli
- Clinical Nutrition Program, Community Health Department, King Saud University, Riyadh 11362, Saudi Arabia; (G.M.); (D.A.); (G.S.A.)
- Education, Simulation and Skills Development Center, Princess Nourah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
| | - Dara Aldisi
- Clinical Nutrition Program, Community Health Department, King Saud University, Riyadh 11362, Saudi Arabia; (G.M.); (D.A.); (G.S.A.)
| | - Ghadeer S. Aljuraiban
- Clinical Nutrition Program, Community Health Department, King Saud University, Riyadh 11362, Saudi Arabia; (G.M.); (D.A.); (G.S.A.)
| | - Mahmoud M. A. Abulmeaty
- Clinical Nutrition Program, Community Health Department, King Saud University, Riyadh 11362, Saudi Arabia; (G.M.); (D.A.); (G.S.A.)
- Obesity Management and Research Unit, Medical Physiology Department, Zagazig University, Zagazig 44519, Egypt
- Correspondence: ; Tel.: +96-65-4815-5983
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Nishioka S, Kokura Y, Okamoto T, Takayama M, Miyai I. Assignment of Registered Dietitians and Other Healthcare Professionals Positively Affects Weight Change of Underweight Patients in Convalescent (Kaifukuki) Rehabilitation Wards: A Secondary Analysis of a Nationwide Survey. J Nutr Sci Vitaminol (Tokyo) 2020; 65:435-442. [PMID: 31666481 DOI: 10.3177/jnsv.65.435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study aimed to verify the relationship between assignment of professional registered dietitians (RDs) and other healthcare professionals and body weight or functional outcome in underweight patients. This was a secondary analysis of the nation-wide survey data from Kaifukuki (convalescent) rehabilitation wards (KRWs). Data of patients aged ≥20 y with disabilities and body mass index (BMI) <18.5 kg/m2 and who were discharged from 1,099 KRWs were analyzed. The primary outcome was BMI at discharge. Secondary outcomes were Functional Independence Measure (FIM) at discharge and returning to home. Patients were divided into two groups: those in KRWs with ≥1 or <1 dedicated RD per ward (KRW/RD+ and KRW/RD-, respectively). Of 5,843 eligible participants (female, 63%; median age, 82 y; hip/vertebral/knee fracture, 47%; stroke, 34%; disuse syndrome secondary to acute illness, 11%; others, 8%), 1,288 and 4,555 were from the KRW/RD+ and KRW/RD- groups, respectively. At discharge, KRW/RD+ patients had higher FIM (93 vs. 90) and BMI (17.1 vs. 17.0 kg/m2) than did KRW/RD- patients. Multivariable analysis showed that assignment of dedicated RDs (B=0.213, 95% confidence interval [CI], 0.036-0.389), number of nurses (B=0.023, 95% CI, 0.003-0.043), and daily rehabilitation dose were significantly associated with changes in body weight. Furthermore, these factors positively affected BMI at discharge. Number of nurses and rehabilitation dose correlated with FIM, but assignment of RDs did not correlate with FIM. In conclusion, assignment of RDs, nurses, and sufficient rehabilitation dose may contribute to BMI gain. Nurses and daily rehabilitation dose may positively affect functional recovery.
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Affiliation(s)
- Shinta Nishioka
- Nutrition Committee, Kaifukuki Rehabilitation Ward Association.,Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital
| | - Yoji Kokura
- Nutrition Committee, Kaifukuki Rehabilitation Ward Association.,Department of Clinical Nutrition, Keiju Medical Center
| | - Takatsugu Okamoto
- Annual Survey Committee, Kaifukuki Rehabilitation Ward Association.,Nishi-Hiroshima Rehabilitation Hospital
| | - Masako Takayama
- Nutrition Committee, Kaifukuki Rehabilitation Ward Association.,Department of Nutrition, Kumamoto Kinoh Hospital
| | - Ichiro Miyai
- Annual Survey Committee, Kaifukuki Rehabilitation Ward Association.,Morinomiya Hospital
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Sng QW, Ong C, Ang SLL, Kirk AHP, Lee JH. Use of an Electronic Feeds Calorie Calculator in the Pediatric Intensive Care Unit. Pediatr Qual Saf 2020; 5:e249. [PMID: 32766483 PMCID: PMC7056286 DOI: 10.1097/pq9.0000000000000249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 12/03/2019] [Indexed: 12/13/2022] Open
Abstract
Supplemental Digital Content is available in the text. Strategies to improve nutritional management are associated with better outcomes in pediatric intensive care units. We implemented a calorie-based protocol that integrated an electronic feeds calculator and stepwise feeds increment algorithm.
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Affiliation(s)
- Qian Wen Sng
- Division of Nursing, KK Women's and Children's Hospital, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore
| | - Su Ling Linda Ang
- Division of Nursing, KK Women's and Children's Hospital, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | | | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
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Wong Vega M, Beer S, Juarez M, Srivaths PR. Malnutrition Risk in Hospitalized Children: A Descriptive Study of Malnutrition-Related Characteristics and Development of a Pilot Pediatric Risk-Assessment Tool. Nutr Clin Pract 2018; 34:406-413. [PMID: 30294809 DOI: 10.1002/ncp.10200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Underrecognition of pediatric malnutrition may affect nutrition interventions and outcomes. Pediatric malnutrition uses more specific etiology-based criteria but lacks clarity in implementation guidelines. Study goals were to identify malnutrition and risk among hospitalized patients, characterize malnutrition risk factors, and assess reliability of criteria against outcome measures. MATERIALS AND METHODS All children 44 weeks postmenstrual age-18 years, admitted for 48 hours during a 16-day period, were included (n = 528). Trained dietitians assessed patients in physical assessments (PA), growth, energy intake, increased nutrient losses (IL), altered absorption of nutrients (AA), hypermetabolism and inflammation, laboratory information, micronutrient deficiency, and functional status. Outcome data assessed were length of stay (LOS), intensive care unit (ICU) LOS, ventilation days, nutrition support, and dietitian intervention. RESULTS Malnutrition prevalence upon admission was 19.7%. Weight/length or BMI/age z-score (ZS) had no effect on LOS. AA and IL upon admission were independently associated with malnutrition (both, P<.01). Wasting and hypermetabolism were independently associated with longer LOS (P<.01). Other factors associated with longer LOS included IL and inflammation (P < .05). Those with hypermetabolism had significant ZS improvements if followed by a dietitian (P < .05). Wasting via PA was the only factor associated with longer ICU LOS (P < .05). CONCLUSIONS Identification of risk factors (wasting, hypermetabolism, AA, IL) beyond anthropometrics to define malnutrition and risk is important in prioritizing care in a tertiary pediatric facility. Of great significance is the ability of dietitian-based PA to predict LOS and need for intervention.
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Affiliation(s)
- Molly Wong Vega
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Beer
- Gastroenterology, Hepatology and Nutrition Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Marisa Juarez
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children. World J Pediatr 2018; 14:419-428. [PMID: 30155618 DOI: 10.1007/s12519-018-0175-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain. METHODS A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study. RESULTS The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN. CONCLUSION Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.
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Carvalho-Salemi J, Salemi JL, Wong-Vega MR, Spooner KK, Juarez MD, Beer SS, Canada NL. Malnutrition among Hospitalized Children in the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between 2002 and 2011. J Acad Nutr Diet 2018; 118:40-51.e7. [DOI: 10.1016/j.jand.2017.02.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/16/2017] [Indexed: 01/13/2023]
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12
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med 2017; 18:675-715. [PMID: 28691958 DOI: 10.1097/pcc.0000000000001134] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.
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Mehta NM, Skillman HE, Irving SY, Coss-Bu JA, Vermilyea S, Farrington EA, McKeever L, Hall AM, Goday PS, Braunschweig C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr 2017; 41:706-742. [DOI: 10.1177/0148607117711387] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Heather E. Skillman
- Clinical Nutrition Department, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Sharon Y. Irving
- Division of Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Jorge A. Coss-Bu
- Section of Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah Vermilyea
- Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Anne Farrington
- Department of Pharmacy, Betty H. Cameron Women’s and Children’s Hospital, New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - Liam McKeever
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amber M. Hall
- Biostatistics, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Praveen S. Goday
- Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Carol Braunschweig
- Division of Epidemiology and Biostatistics, Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois, USA
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Boullata JI, Carrera AL, Harvey L, Escuro AA, Hudson L, Mays A, McGinnis C, Wessel JJ, Bajpai S, Beebe ML, Kinn TJ, Klang MG, Lord L, Martin K, Pompeii-Wolfe C, Sullivan J, Wood A, Malone A, Guenter P. ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]. JPEN J Parenter Enteral Nutr 2016; 41:15-103. [PMID: 27815525 DOI: 10.1177/0148607116673053] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.
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Affiliation(s)
- Joseph I Boullata
- 1 Clinical Nutrition Support Services, Hospital of the University of Pennsylvania and Department of Nutrition, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Lillian Harvey
- 3 Northshore University Hospital, Manhasset, New York, and Hofstra University NorthWell School of Medicine, Garden City, New York, USA
| | - Arlene A Escuro
- 4 Digestive Disease Institute Cleveland Clinic Cleveland, Ohio, USA
| | - Lauren Hudson
- 5 Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew Mays
- 6 Baptist Health Systems and University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Carol McGinnis
- 7 Sanford University of South Dakota Medical Center, Sioux Falls, South Dakota, USA
| | | | - Sarita Bajpai
- 9 Indiana University Health, Indianapolis, Indiana, USA
| | | | - Tamara J Kinn
- 11 Loyola University Medical Center, Maywood, Illinois, USA
| | - Mark G Klang
- 12 Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Linda Lord
- 13 University of Rochester Medical Center, Rochester, New York, USA
| | - Karen Martin
- 14 University of Texas Center for Health Sciences at San Antonio, San Antonio, Texas, USA
| | - Cecelia Pompeii-Wolfe
- 15 University of Chicago, Medicine Comer Children's Hospital, Chicago, Illinois, USA
| | | | - Abby Wood
- 17 Baylor University Medical Center, Dallas, Texas, USA
| | - Ainsley Malone
- 18 American Society for Enteral and Parenteral Nutrition, Silver Spring, Maryland, USA
| | - Peggi Guenter
- 18 American Society for Enteral and Parenteral Nutrition, Silver Spring, Maryland, USA
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15
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Getting Basic Nutrition Right in the PICU*. Crit Care Med 2016; 44:1615-6. [DOI: 10.1097/ccm.0000000000001770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Skillman HE, Zebuhr CA. Optimal Nutrition for Acute Rehabilitation in the PICU. J Pediatr Intensive Care 2015; 4:194-203. [PMID: 31110872 DOI: 10.1055/s-0035-1563546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/12/2015] [Indexed: 01/15/2023] Open
Abstract
Achieving optimal nutrition for a child who is receiving acute rehabilitation in the pediatric intensive care unit requires an individualized approach. Nutrition screening and assessment is necessary to identify children at high risk for complications who require targeted interventions. Early enteral nutrition can improve outcomes, and is thus preferred over parenteral nutrition in the absence of gastrointestinal contraindications. Measurement of caloric requirements with indirect calorimetry is essential to accurately prescribe nutrition support, while monitoring body composition can determine efficacy of nutrition therapies employed. The complex care of critically ill children receiving acute rehabilitation is composed of treatments that compete with delivery of prescribed nutrition. Repeated feeding interruptions can lead to nutrition deficits and prolonged recovery. Nutrition bundles that incorporate evidenced-based nutrition algorithms, methods to overcome nutrition barriers, and nutrition monitoring parameters can direct and optimize nutrition care for critically ill children in need of acute rehabilitation.
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Affiliation(s)
- Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Carleen A Zebuhr
- Section of Critical Care, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, United States
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17
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Brown AM, Carpenter D, Keller G, Morgan S, Irving SY. Enteral Nutrition in the PICU: Current Status and Ongoing Challenges. J Pediatr Intensive Care 2015; 4:111-120. [PMID: 31110860 DOI: 10.1055/s-0035-1559806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.
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Affiliation(s)
- Ann-Marie Brown
- School of Nursing, The University of Akron, Akron, Ohio, United States.,Division of Critical Care, Akron Children's Hospital, Akron, Ohio, United States
| | - Debbie Carpenter
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Gerri Keller
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Sherry Morgan
- Biomedical Library, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sharon Y Irving
- Department of Nursing, Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,School of Nursing, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
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18
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Mehta NM, Bechard LJ, Zurakowski D, Duggan CP, Heyland DK. Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study. Am J Clin Nutr 2015; 102:199-206. [PMID: 25971721 PMCID: PMC4480666 DOI: 10.3945/ajcn.114.104893] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/15/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The impact of protein intake on outcomes in pediatric critical illness is unclear. OBJECTIVE We examined the association between protein intake and 60-d mortality in mechanically ventilated children. DESIGN In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. RESULTS We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. CONCLUSIONS Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521.
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Affiliation(s)
- Nilesh M Mehta
- Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, and Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | - Lori J Bechard
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | - David Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, and Harvard Medical School, Boston, MA; and Kingston General Hospital, Kingston, Canada
| | - Christopher P Duggan
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
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