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Hilbrands J, Feuling MB, Szabo A, Teng BQ, Fabus N, Froh M, Heisler R, Lampone O, Smith A, Mikhailov TA, Goday PS. Nutrition Screening in the Pediatric Intensive Care Unit: Evaluation of an Electronic Medical Record-Based Tool. Nutrients 2023; 15:4591. [PMID: 37960244 PMCID: PMC10647546 DOI: 10.3390/nu15214591] [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: 07/24/2023] [Revised: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Hospitalized, critically ill children are at increased risk of developing malnutrition. While several pediatric nutrition screening tools exist, none have been validated in the pediatric intensive care units (PICU). The Children's Wisconsin Nutrition Screening Tool (CWNST) is a unique nutrition screening tool that includes the Pediatric Nutrition Screening Tool (PNST) and predictive elements from the electronic medical record and was found to be more sensitive than the PNST in acute care units. The aim of this study was to assess the performance of the tool in detecting possible malnutrition in critically ill children. The data analysis, including the results of the current nutrition screening, diagnosis, and nutrition status was performed on all patients admitted to PICUs at Children's Wisconsin in 2019. All 250 patients with ≥1 nutrition assessment by a dietitian were included. The screening elements that were predictive of malnutrition included parenteral nutrition, positive PNST, and BMI-for-age/weight-for-length z-score. The current screen had a sensitivity of 0.985, specificity of 0.06, positive predictive value (PPV) of 0.249, and negative predictive value of 0.929 compared to the PNST alone which had a sensitivity of 0.1, specificity of 0.981, PPV of 0.658, and NPV of 0.749. However, of the 250 included patients, 97.2% (243) had a positive nutrition screen. The CWNST can be easily applied through EMRs and predicts the nutrition risk in PICU patients but needs further improvement to improve specificity.
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Affiliation(s)
- Julia Hilbrands
- Clinical Nutrition, Children’s Wisconsin, Milwaukee, WI 53226, USA; (J.H.); (M.B.F.); (N.F.)
| | - Mary Beth Feuling
- Clinical Nutrition, Children’s Wisconsin, Milwaukee, WI 53226, USA; (J.H.); (M.B.F.); (N.F.)
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (A.S.)
| | - Bi Q. Teng
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (A.S.)
| | - Nicole Fabus
- Clinical Nutrition, Children’s Wisconsin, Milwaukee, WI 53226, USA; (J.H.); (M.B.F.); (N.F.)
| | - Melissa Froh
- Clinical Nutrition, Children’s Wisconsin, Milwaukee, WI 53226, USA; (J.H.); (M.B.F.); (N.F.)
| | - Rebecca Heisler
- Clinical Nutrition, Children’s Wisconsin, Milwaukee, WI 53226, USA; (J.H.); (M.B.F.); (N.F.)
| | - Olivia Lampone
- Clinical Nutrition, Children’s Wisconsin, Milwaukee, WI 53226, USA; (J.H.); (M.B.F.); (N.F.)
| | - Amber Smith
- Nutrition Services, University of California San Francisco Health, San Francisco, CA 94143, USA
| | | | - Praveen S. Goday
- Pediatric Gastroenterology, Nationwide Children’s Hospital, Columbus, OH 43205, USA
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2
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Pérez G, González E, Zamora L, Fernández SN, Sánchez A, Bellón JM, Santiago MJ, Solana MJ. Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation. J Pediatr Gastroenterol Nutr 2022; 74:110-115. [PMID: 34636794 PMCID: PMC8673839 DOI: 10.1097/mpg.0000000000003317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/06/2021] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To assess the safety of enteral nutrition (EN) in children on extracorporeal membrane oxygenation (ECMO). To describe nutritional status and the characteristics of the nutritional support in this population. METHODS A retrospective single-center analysis (2006-2016) including children <18 years on ECMO. Demographic data, nutritional status, characteristics of nutritional support, and development of gastrointestinal (GI) complications were recorded. RESULTS One hundred children, with a median age of 9.7 months (interquartile range [IQR] 3.9-63.1) were enrolled. Undernutrition was prevalent among children on ECMO (33.3%) mainly in patients <2 years (P = 0.042). Most patients (64%) received EN at some point during ECMO therapy. EN was administered in the first 48 hours after ECMO initiation (48HEN) to 60.3% of the children.Mortality rate in the Pediatric Intensive Care Unit was lower in patients who received EN as the initial artificial nutrition support (ANS) (37.7 vs 51%, P = 0.005) and in children on 48HEN (34% vs 50%, P = 0.04). In the logistic regression analysis, duration of ECMO support and low cardiac output indication were the only factors associated with mortality.Although most patients on ECMO (45%) developed digestive complications, they were mostly mild, being constipation the most prevalent. In the logistic regression analysis, EN was not associated with an increase in GI complications (P = 0.09). Only three patients developed intestinal ischemia (one without EN and two on EN). CONCLUSIONS Undernutrition is prevalent among children on ECMO, mainly in infants <2 years. EN is not associated with severe gastrointestinal complications or higher mortality in these children.
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Affiliation(s)
- Gema Pérez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Gregorio Marañón Health Research Institute (IISGM)
| | - Elena González
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Laura Zamora
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Sarah N. Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Amelia Sánchez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | | | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
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Albadi MS, Bookari K. Is Undernutrition Associated With Deterioration of Outcomes in the Pediatric Intensive Care Unit (PICU): Systematic and Meta-Analysis Review. Front Pediatr 2022; 10:769401. [PMID: 35601420 PMCID: PMC9114497 DOI: 10.3389/fped.2022.769401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIM Undernutrition (UN) may negatively impact clinical outcomes for hospitalized patients. The relationship between UN status at pediatric intensive care unit (PICU) admission and clinical outcomes is still not well-reported. This systematic meta-analysis review evaluated the impact of UN at admission to PICU on clinical outcomes, including mortality incidence, length of stay (LOS), and the need for and length of time on mechanical ventilation (MV). METHODS A search was conducted using relevant and multi-medical databases from inception until January 2022. We considered studies that examined the link between UN at PICU admission and clinical outcomes in patients aged 18 years or younger. Pooled risk difference estimates for the PICU outcomes were calculated using a random-effects model. RESULT There were a total of 10,638 patients included in 17 observational studies; 8,044 (75.61%) and 2,594 (24.38%) patients, respectively, were normal-nourished (NN) and undernourished (UN). In comparison to NN patients, UN patients had a slightly higher risk of mortality (RD = 0.02, P = 0.05), MV usage (RD = 0.05, P = 0.02), and PICU LOS (RD = 0.07, P = 0.007). While the duration of MV was significantly longer in UN than in NN (RD = 0.13, P < 0.0001). Sensitivity analysis of UN classification cohorts with a z-score < -2 or in the 5%, patetints age up to 18 years, and mixed diagnose for PICU admission demonstrated a 6-fold increase in the probability of PICU LOS in UN patients compared to NN patients (RD = 0.06, 95% CI = 0.01, 0.12). UN patients have a higher risk of MV usage RD = 0.07, 95% CI = 0.00, 0.14) in studies involving cohorts with a mixed primary diagnosis for PICU admission. CONCLUSION In PICU, UN is linked to mortality incidence, longer PICU stay, MV usage, and duration on MV. The primary diagnosis for PICU admission may also influence clinical outcomes. Determining the prevalence of UN in hospitalized patients, as well as the subgroups of patients diagnosed at the time of admission, requires more research. This may help explain the relationship between nutritional status and clinical outcomes in PICU patients.
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Affiliation(s)
- Maram S Albadi
- Clinical Nutrition Department, Maternity and Children Hospital, Medina, Saudi Arabia.,Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia
| | - Khlood Bookari
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia
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4
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Mohialdeen Gubari MI, Hosseinzadeh-Attar MJ, Hosseini M, Mohialdeen FA, Othman H, Hama-ghareeb KA, Norouzy A. Nutritional Status in Intensive Care Unit: A Meta-Analysis and Systematic Review. Galen Med J 2021; 9:e1678. [PMID: 34466565 PMCID: PMC8344180 DOI: 10.31661/gmj.v9i0.1678] [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: 08/06/2019] [Revised: 08/12/2019] [Accepted: 09/05/2019] [Indexed: 11/16/2022] Open
Abstract
It is important to consider the nutritional status of patients in the intensive care unit (ICU) since it is a key element in the ability to overcome and survive critical illnesses and clinical outcomes. The aim of the present study was to provide a meta-analysis and systematic overview in determining the nutritional status of patients in ICU by examining other studies. All studies published during 2015-2019 on nutritional status in ICU were retrieved from Medline (via PubMed), Embase, Scopus, and Web of Science databases. Finally, 23 articles were included in the meta-analysis. Results obtained from these studies showed that the nutritional status of patients in ICU was inappropriate (the pooled proportion of malnutrition was 0.51 in the type of study stratified), in which many patients in this unit had different degrees of malnutrition (moderate-mild malnourished and severe malnutrition is 0.46 and 20%, respectively). According to the results of this study, the nutritional status of patients in ICU was unsatisfactory; hence, it is necessary to consider the nutritional status along with other therapeutic measures at the beginning of the patient's admission.
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Affiliation(s)
| | - Mohammad Javad Hosseinzadeh-Attar
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetic, Tehran University of Medical Sciences, Tehran, Iran
- Centre of Research Excellence in Translating, Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Mostafa Hosseini
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Fadhil Ahmed Mohialdeen
- Community Health Department, Technical College of Health, Sulaimani Polytechnic University, Sulaimani, Iraq
| | - Haval Othman
- General Shar Teaching Hospital, ICU Unit, Sulaimani, Iraq
| | | | - Abdolreza Norouzy
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetic, Tehran University of Medical Sciences, Tehran, Iran
- Correspondence to: Dr. Abdolreza Norouzy, Department of Clinical Nutrition, School of Nutritional Sciences and Dietetic, Tehran University of Medical Sciences, Tehran, Iran Telephone Number: 09153145073 Email Address:
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5
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Clinical conditions and complications associated with parenteral nutrition use in critically ill patients admitted to an intensive care unit of a general hospital. NUTR HOSP 2021; 37:645-653. [PMID: 32686437 DOI: 10.20960/nh.03004] [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: 11/02/2022] Open
Abstract
Introduction Objective: the aim of this study was to evaluate the clinical conditions, the existing complications, and the drug prescription profile of patients who received parenteral nutrition in the intensive care unit. Material and methods: this retrospective, analytical cohort study was carried out among individuals admitted to a public general hospital ICU. For data collection, the electronic medical records for the entire period of inpatient treatment were analyzed. Results: in total, 213 individuals who had received parenteral nutrition for a period greater than 48 hours were included in the study. Most participants were male and mean age was < 60 years; death occurred in 75 % of patients, and abdominal surgery was the main indication for parenteral nutrition. Hyperglycemia was the most common complication. The Mann-Whitney test showed that the individuals who died were using a higher number of medications. The increased use of medications correlated with use of PN and led to an increase in hospital length of stay and death rate (p-value < 0.001). There was a higher proportion of deaths among patients using standard parenteral nutrition solutions (76.9 %) as compared to the period when patients started receiving custom-made parenteral nutrition solutions (71.7 %). However, there was no statistical evidence of the association between type of nutrition and the outcome of death (p-value = 0.395). Conclusions: custom-made parenteral nutrition may result in benefits for the patients, such as a decrease in the number of medications used. The relationship between type of nutrition and the outcome of death did not prove to be statistically significant.
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6
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Tuokkola J, Heikkilä A, Junttila K, Orell H. Prevalence of malnutrition risk and acute malnutrition in pediatric population in a tertiary hospital and their burden on healthcare. Nutr Clin Pract 2021; 36:1270-1275. [PMID: 33955581 DOI: 10.1002/ncp.10656] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malnutrition is related to an increased rate of complications and prolonged hospital stays. Malnutrition risk screening is recommended for all hospital inpatients, but its applicability as part of routine care is not well known. METHODS The prevalence of malnutrition risk, measured by the Screening Tool for Risk of Impaired Nutritional Status and Growth (STRONGkids), and acute malnutrition were studied 1 day per year in all pediatric inpatient and day wards in 2015 and 2016 and in inpatients and outpatients in 2017 at a university hospital. Nurses carried out the STRONGkids screening and measured the weight and height of each child, recording the information in the hospital database, where it was subsequently extracted along with data on the child's diagnoses, procedures, and the length and costs of hospital stay. RESULTS In all, 696/1217 patients (57.2%) were screened. Of inpatients and outpatients, 37/398 (9.3%) and 3/298 (1.0%), respectively, were classified as being at high risk of malnutrition. The corresponding figures for those who were acutely malnourished were 18/260 (6.9%) and 11/264 (4.2%). High risk of malnutrition increased the costs and length of hospital stay (P < .05). Dietetic input was involved during hospital stay in 12/37 (32.4%), 32/173 (18.5%), and 13/188 (6.9%) of inpatients at high, moderate, and low risk, respectively (P < .001). Nutrition risk screening did not detect all patients classified as acutely malnourished. CONCLUSION Hospitals need to ensure proper application of nutrition screening, develop a protocol for the care of children at nutrition risk, and monitor the use of this protocol.
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Affiliation(s)
- Jetta Tuokkola
- New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anniina Heikkilä
- HUS Group Administration, Nursing, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kristiina Junttila
- HUS Nursing Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Helena Orell
- Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Deja E, Roper L, Tume LN, Dorling J, Gale C, Arch B, Latten L, Pathan N, Eccleson H, Hickey H, Preston J, Beissel A, Andrzejewska I, Valla FV, Woolfall K. Can they stomach it? Parent and practitioner acceptability of a trial comparing gastric residual volume measurement versus no gastric residual volume in UK NNU and PICUs: a feasibility study. Pilot Feasibility Stud 2021; 7:49. [PMID: 33593416 PMCID: PMC7885383 DOI: 10.1186/s40814-021-00784-5] [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: 05/20/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Routine measurement of gastric residual volume (GRV) to guide feeding in neonatal and paediatric intensive care is widespread. However, this practice is not evidence based and may cause harm. As part of a feasibility study, we explored parent and practitioner views on the acceptability of a trial comparing GRV measurement or no GRV measurement. METHODS A mixed-methods study involving interviews and focus groups with practitioners and interviews with parents with experience of tube feeding in neonatal and/or paediatric intensive care. A voting system recorded closed question responses during practitioner data collection, enabling the collection of quantitative and qualitative data. Data were analysed using thematic analysis and descriptive statistics. RESULTS We interviewed 31 parents and nine practitioners and ran five practitioner focus groups (n=42). Participants described how the research question was logical, and the intervention would not be invasive and potential benefits of not withholding the child's feeds. However, both groups held concerns about the potential risk of not measuring GRV, including delayed diagnosis of infection and gut problems, increased risk of vomiting into lungs and causing discomfort or pain. Parent's views on GRV measurement and consent decision making were influenced by their views on the importance of feeding in the ICU, their child's prognosis and associated comorbidities or complications. CONCLUSIONS The majority of parents and practitioners viewed the proposed trial as acceptable. Potential concerns and preferences were identified that will need careful consideration to inform the development of the proposed trial protocol and staff training.
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Affiliation(s)
- Elizabeth Deja
- Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - Louise Roper
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Lyvonne N Tume
- School of Health & Society, University of Salford, Manchester, M6 6PU, UK
| | - Jon Dorling
- Division of Pediatrics and Neonatal-Perinatal Medicine, Dalhousie University, Halifax, Canada
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital campus, London, UK
| | - Barbara Arch
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool Institute of Child Health Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - Lynne Latten
- Department of Dietetics, Alder Hey Children's Hospital, Liverpool, UK
| | - Nazima Pathan
- Paediatric Intensive Care, University of Cambridge, Addenbrooke's Hospital Cambridge, Campbridge, UK
| | - Helen Eccleson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool Institute of Child Health Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - Helen Hickey
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool Institute of Child Health Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - Jenny Preston
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anne Beissel
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | | | - Frédéric V Valla
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK.,Pediatric Intensive Care Unit, CarMEN INSERM UMR 1060 Equipe INFOLIP, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | - Kerry Woolfall
- Institute of Population Health, University of Liverpool, Liverpool, UK
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Dokal K, Asmar N, Shergill-Bonner R, Mutalib M. Nutrition Evaluation Screening Tool: An Easy to Use Screening Tool for Hospitalised Children. Pediatr Gastroenterol Hepatol Nutr 2021; 24:90-99. [PMID: 33505898 PMCID: PMC7813567 DOI: 10.5223/pghn.2021.24.1.90] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/25/2020] [Accepted: 08/17/2020] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Nutrition screening is vital to ensure patients are appropriately managed in hospital. In paediatrics there is currently no universally accepted nutrition screening tool. The Nutrition Evaluation Screening Tool (NEST) was developed as an easy to use and practical screening tool for hospitalised children. We aim to evaluate compliance of the NEST and assess agreement of the NEST with the already validated nutrition screening tools, Screening Tool for Risk on Nutritional Status and Growth (STRONGkids), Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) and the Subjective Global Nutritional Assessment (SGNA) tool. METHODS Retrospective review of 102 patient episodes at the Evelina London Children's Hospital. Electronic records were used to assess NEST compliance and to complete the nutrition tools for each patient episode. Cohen's kappa was used to determine the level of agreement between each nutrition tool. RESULTS There was moderate agreement between the NEST and the two screening tools, STRONGkids (κ=0.472) and STAMP (κ=0.416) for patients on initial screening at admission. 87.2% of patient episodes were NEST compliant within 24 hours of admission to hospital. CONCLUSION The moderate agreement between these two already validated screening tools enhances the NEST's validity as a paediatric screening tool. The NEST had the strongest correlation with the SGNA tool compared to other screening tools. The NEST is user friendly screening tool for hospitalised children.
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Affiliation(s)
- Kitt Dokal
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Nadia Asmar
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Rita Shergill-Bonner
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
| | - Mohamed Mutalib
- Faculty of Life Science and Medicine, King's College London, London, UK.,Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
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Alsohime F, Assiry G, AlSalman M, Alabdulkareem W, Almuzini H, Alyahya M, Allhidan R, Al-Eyadhy A, Temsah MH, Al Sarkhy AA. Barriers to the delivery of enteral nutrition in pediatric intensive care units: A national survey. Int J Pediatr Adolesc Med 2020; 8:186-190. [PMID: 34350333 PMCID: PMC8319679 DOI: 10.1016/j.ijpam.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/24/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
Background and Aim According to previously reported studies in the literature, a significant number of patients do not receive enteral nutrition in pediatric intensive care unit (PICU) because of avoidable barriers. Optimal nutrition is a fundamental goal in PICU. This study aims to identify the barriers of enteral nutrition in PICU. Setting and Design A cross-sectional study of the results of a 25-item questionnaire-based survey distributed during the Annual International Critical Care Conference by the Saudi Critical Care Society. Methods and material A 7-point Likert-type scale was used to rank the participants’ responses, and the relative importance index (RII) approach was used to analyze the relative contribution of each indicator to its main theme. The factor and parallel analysis methods were used to assess the factorial and unidimensionality of the enteral feeding barriers scale. Results A total of 223 PICU healthcare workers from various intensive care settings responded to the survey. The top-three perceived barriers for commencing enteral feeding were due to the patient being hemodynamically unstable (M = 3.6 and SD = 1.70), delays and difficulties in obtaining small bowel access in patients not tolerating other types of enteral nutrition (M = 3.4 and SD = 1.52), or severe fluid restriction, particularly in postoperative cardiac surgery (M = 3.3 and SD = 1.59). The top perceived overall barriers to enteral feeding were the dietician-related issues (M = 3.3, SD = 1.32), barriers related to enteral feeding delivery (M = 3.16 and SD = 1.13), and medical practice-related (M = 3 and SD = 1.10) issues. The lowest reported overall barriers were the resource-related obstacles (M = 2.7 and SD = 1.26). Conclusion Being hemodynamically unstable and other dietician-related reasons were the top overall barriers in commencing enteral feeding.
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Affiliation(s)
- Fahad Alsohime
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ghadeer Assiry
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Wejdan Alabdulkareem
- Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hissah Almuzini
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Malak Alyahya
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reema Allhidan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Al Sarkhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Gastroenterology Unit, Pediatric Department, King Khalid University Medical City, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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10
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Nutrition in children with continuous renal replacement therapy. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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11
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Feng S, Cheng L, Lu H, Shen N. Nutritional Status and Clinical Outcomes in Children with Cancer on Admission to Intensive Care Units. Nutr Cancer 2020; 73:83-88. [PMID: 32188289 DOI: 10.1080/01635581.2020.1742361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Malnutrition is prevalent among pediatric oncology patients admitted to the pediatric intensive care unit (PICU), which leads to unfavorable clinical outcomes. This was a secondary data analysis of the nutrition data of 160 pediatric oncology patients admitted to the PICU. Cox's regression (adjusted for sex, age, and pediatric critical illness score) and Chi-square were used to examine the association between nutritional status and outcomes. Most of the patients were diagnosed with leukemia and admitted to PICU for medical reasons. The prevalence of malnutrition was 11.3% according to weight-for-age z-score, 16.3% according to height-for-age z-score, 21.3% according to body mass index-for-age z-score, 14.4% according to weight-for-height z-score, 34.4% according to mid-upper arm circumference-for-age z-score. Anthropometrical parameters that predicted the duration of mechanical ventilation were weight-for-age (hazard ratio [HR], 2.727; 95% confidence interval [CI], 1.729-4.302); height-for-age (HR, 1.969; 95% CI, 1.440-2.693); weight-for-height (HR, 2.645; 95% CI, 1.575-4.441); and upper arm muscle area-for-age (HR, 2.098; 95% CI, 1.430-3.077). Length of PICU stay was predicted by weight-for-age (HR, 1.207; 95% CI, 1.014-1.436). Malnutrition is prevalent among pediatric oncology patients admitted to the PICU, which lead to unfavorable clinical outcomes. Comprehensive nutritional status assessment should be performed for these children.
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Affiliation(s)
- Sheng Feng
- Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Cheng
- School of Nursing, Fudan University, Shanghai, China
| | - Hua Lu
- Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Nanping Shen
- Hemotology & Oncology, Nursing Department, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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12
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Santiago Lozano MJ, Alonso Álvarez C, Álvarez Heidbüchel C, Fernández Lafever S, Solana García MJ, López-Herce Cid J. [Nutrition in children with continuous renal replacement therapy]. An Pediatr (Barc) 2019; 92:208-214. [PMID: 31734157 DOI: 10.1016/j.anpedi.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/18/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). MATERIAL AND METHODS A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. RESULTS A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. CONCLUSIONS A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped.
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Affiliation(s)
- Maria José Santiago Lozano
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España.
| | - Cristina Alonso Álvarez
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Caterina Álvarez Heidbüchel
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Sarah Fernández Lafever
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Maria José Solana García
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Jesús López-Herce Cid
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
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13
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Energy Balance in Critically Ill Children With Severe Sepsis Using Indirect Calorimetry: A Prospective Cohort Study. J Pediatr Gastroenterol Nutr 2019; 68:868-873. [PMID: 30889134 DOI: 10.1097/mpg.0000000000002314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Energy needs in critically ill children are dynamic and variable. Data on energy balance in children with severe sepsis using indirect calorimetry (IC) is lacking. Thus, we planned to study the energy needs and balance of this cohort. METHODS Prospective observational study conducted in ventilated children aged 5 to 12 years, admitted in pediatric intensive care unit with severe sepsis from May 2016 to June 2017. Measured resting energy expenditure (mREE) was measured with IC (Quark RMR, COSMED) till 7 days or pediatric intensive care unit discharge. Predicted energy expenditure (pREE) was estimated using Schofield, Harris and Benedict, and FAO/WHO/UNU equations. Primary outcome was to study the daily energy balance. Secondary outcome was to determine nitrogen balance and agreement of mREE with pREE. RESULTS Forty children (24 boys) with median age of 7 (5.2, 10) years were enrolled. All received enteral nutrition; 35 (87.5%) received inotropic support. Median ventilation-free days were 19 days and 4 children died (10%). A total of 176 IC measurements were obtained with an average of 4 per patient. The mean mREE was 51 ± 17 kcal/kg and mean respiratory quotient was 0.77 ± 0.07. There was persistent negative energy balance from days 1 to 7 and negative nitrogen balance from days 1 to 5. There was poor agreement of pREE with mREE using Bland Altman plots. None of severity of illness scores (PRISM III, daily Sequential Organ Function Assessment, daily Vasoactive Inotropic Score) showed correlation with mREE. CONCLUSIONS Persistent negative energy and nitrogen balance exist during acute phase of severe sepsis. Predictive equations are inaccurate compared with IC as the criterion standard.
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14
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Ong SH, Chee WSS, Lapchmanan LM, Ong SN, Lua ZC, Yeo JXN. Validation of the Subjective Global Nutrition Assessment (SGNA) and Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) to Identify Malnutrition in Hospitalized Malaysian Children. J Trop Pediatr 2019. [PMID: 29514329 DOI: 10.1093/tropej/fmy009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early detection of malnutrition in hospitalized children helps reduce length of hospital stay and morbidity. A validated nutrition tool is essential to correctly identify children at risk of malnutrition or who are already malnourished. This study compared the use of the Subjective Global Nutrition Assessment (SGNA, nutrition assessment tool) and Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP, nutrition screening tool) with objective nutritional parameters to identify malnutrition in hospitalized children. METHODS A cross-sectional study was carried out in two general paediatric wards in a public hospital. SGNA and STAMP were performed on 82 children (52 boys and 30 girls) of age 1-7 years. The scores from both methods were compared against Academy of Nutrition and Dietetics/American Society of Parental and Enteral Nutrition Consensus Statement for identification of paediatric malnutrition. The objective measurements include anthropometry (weight, height and mid-arm circumference), dietary intake and biochemical markers (C-reactive protein, total lymphocytes and serum albumin). Kappa agreement between methods, sensitivity, specificity and cross-classification were computed. RESULTS SGNA and STAMP identified 45% and 79% of the children to be at risk of malnutrition, respectively. Using a compendium of objective parameters, 46% of the children were confirmed to be malnourished. The agreement between SGNA and objective measurements (k = 0.337) was stronger than between STAMP and objective measurements (k = 0.052) in evaluating the nutritional status of hospitalized children. SGNA also has a 4-fold higher specificity (70.45%) than STAMP (18.18%) in detecting children who are malnourished. CONCLUSION SGNA is a valid nutrition assessment tool in diagnosing malnutrition status among hospitalized children in Malaysia. The discrepancy in specificity values between the two methods explains the distinguished roles between SGNA and STAMP. The use of STAMP will have to be followed up with a more valid tool such as SGNA to verify the actual nutrition status of the paediatric population.
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Affiliation(s)
- Shu Hwa Ong
- Department of Nutrition and Dietetics, School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Winnie Siew Swee Chee
- Department of Nutrition and Dietetics, School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | | | - Shan Ni Ong
- Department of Nutrition and Dietetics, School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Zhi Chin Lua
- Department of Nutrition and Dietetics, School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Jowynna Xia-Ni Yeo
- Department of Nutrition and Dietetics, School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
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15
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Costa CAD, Garcia PCR, Cabral DD, Tonial CT, Bruno F, Enloft PR, Velozo KDS. Reducing malnutrition in critically ill pediatric patients. Rev Bras Ter Intensiva 2018; 30:160-165. [PMID: 29995080 PMCID: PMC6031423 DOI: 10.5935/0103-507x.20180034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/12/2018] [Indexed: 12/02/2022] Open
Abstract
Objective To compare the prevalence of malnutrition during two time periods in a
pediatric intensive care unit. Methods This was a retrospective cross-sectional study of patients admitted to the
pediatric intensive care unit of a university hospital during two one-year
periods with an interval of four years between them. Nutritional evaluation
was conducted based on weight and height measured at admission. The body
mass index-for-age was the parameter chosen to evaluate nutritional status,
as classified according to the World Health Organization, according to age
group. Results The total sample size was 881 (406 in the contemporary sample and 475 in the
historical sample). There was a significant reduction in malnutrition in the
contemporary sample (p = 0.03). Malnourishment in patients in the historical
sample was significantly associated with mortality and length of stay, while
malnourishment in patients in the contemporary sample was not associated
with worse outcomes. Conclusion There was a significant reduction in malnutrition among patients in the same
pediatric intensive care unit when comparing the two time periods. Our
findings of a change in nutritional profile in critically ill patients
corroborate the nutritional status data of children and adolescents
worldwide.
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Affiliation(s)
- Caroline Abud Drumond Costa
- Programa de Pós-Graduação em Pediatria e Saúde da Criança, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Pedro Celiny Ramos Garcia
- Programa de Pós-Graduação em Pediatria e Saúde da Criança, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva Pediátrica, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Daiane Drescher Cabral
- Programa de Pós-Graduação em Pediatria e Saúde da Criança, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cristian Tedesco Tonial
- Programa de Pós-Graduação em Pediatria e Saúde da Criança, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva Pediátrica, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Francisco Bruno
- Unidade de Terapia Intensiva Pediátrica, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Paulo Roberto Enloft
- Unidade de Terapia Intensiva Pediátrica, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
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16
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Pereira PMDL, Neves FS, Bastos MG, Cândido APC. Adductor Pollicis Muscle Thickness for nutritional assessment: a systematic review. Rev Bras Enferm 2018; 71:3093-3102. [PMID: 30517416 DOI: 10.1590/0034-7167-2017-0913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 05/19/2018] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE The aim of this study is to systematically review the scientific findings about the efficacy of the measure of the Adductor Pollicis Muscle Thickness for nutritional assessment of individuals in various clinical conditions. METHOD Systematic review study performed according to the methodology Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS 13 original articles published between 2004 and 2016 were included. The measure was associated/correlated to parameters of nutritional status (such as weight, body mass index and Global Subjective Assessment) and muscle mass markers (such as circumference brachial muscle circumference, brachial muscle area, calf circumference, and muscle mass). All these correlations were weak or moderate. CONCLUSION The measurement can be used in different populations, being able to estimate nutritional status and muscle mass. However, it is suggested that it be used in a complementary way to the nutritional evaluation, not constituting a single diagnostic/monitoring parameter.
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Affiliation(s)
| | - Felipe Silva Neves
- Universidade Federal de Juiz de Fora. Juiz de Fora, Minas Gerais, Brazil
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17
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Tume LN, Bickerdike A, Latten L, Davies S, Lefèvre MH, Nicolas GW, Valla FV. Routine gastric residual volume measurement and energy target achievement in the PICU: a comparison study. Eur J Pediatr 2017; 176:1637-1644. [PMID: 28921175 PMCID: PMC5682857 DOI: 10.1007/s00431-017-3015-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 01/04/2023]
Abstract
Critically ill children frequently fail to achieve adequate energy intake, and some care practices, such as the measurement of gastric residual volume (GRV), may contribute to this problem. We compared outcomes in two similar European Paediatric Intensive Care Units (PICUs): one which routinely measures GRV (PICU-GRV) to one unit that does not (PICU-noGRV). An observational pilot comparison study was undertaken. Eighty-seven children were included in the study, 42 (PICU-GRV) and 45 (PICU-noGRV). There were no significant differences in the percentage of energy targets achieved in the first 4 days of PICU admission although PICU-noGRV showed more consistent delivery of median (and IQR) energy targets and less under and over feeding for PICU-GRV and PICU-noGRV: day 1 37 (14-72) vs 44 (0-100), day 2 97 (53-126) vs 100 (100-100), day 3 84 (45-112) vs 100 (100-100) and day 4 101 (63-124) vs 100 (100-100). The incidence of vomiting was higher in PICU-GRV. No necrotising enterocolitis was confirmed in either unit, and ventilator-acquired pneumonia rates were not significantly different (7.01 vs 12 5.31 per 1000 ventilator days; p = 0.70) between PICU-GRV and PICU-noGRV units. CONCLUSIONS The practice of routine gastric residual measurement did not significantly impair energy targets in the first 4 days of PICU admission. However, not measuring GRV did not increase vomiting, ventilator-acquired pneumonia or necrotising enterocolitis, which is the main reason clinicians cite for measuring GRV. What is known: • The practice of routinely measuring gastric residual volume is widespread in critical care units • This practice is increasingly being questioned in critically ill patients, both as a practice that increases • The likelihood of delivering inadequate enteral nutrition amounts and as a tool to assess feeding tolerance What is new: • Not routinely measuring gastric residual volume did not increase adverse events of ventilator acquired pneumonia, necrotising enterocolitis or vomiting. • In the first 4 days of PICU stay, energy target achievement was not significantly different, but the rates of under and over feeding were higher in the routine GRV measurement unit.
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Affiliation(s)
- Lyvonne N. Tume
- Faculty of Health and Applied Sciences, University of West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD UK
| | - Anna Bickerdike
- School of Medicine, University of Liverpool, MBChB Office, Cedar House, Ashton Street, Liverpool, L69 3GE UK
| | - Lynne Latten
- Department of Dietetics, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Simon Davies
- Department of Anaesthesia, Royal Oldham Hospital, Rochdale Road, Manchester, OL1 2JH UK
| | - Madeleine H. Lefèvre
- University of Lyon Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100 Lyon-, Villeurbanne, France
| | - Gaëlle W. Nicolas
- University of Lyon Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100 Lyon-, Villeurbanne, France
| | - Frédéric V. Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500 Lyon-, Bron, France
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