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Knebusch N, Hong-Zhu P, Mansour M, Daughtry JN, Fogarty TP, Stein F, Coss-Bu JA. An In-Depth Look at Nutrition Support and Adequacy for Critically Ill Children with Organ Dysfunction. CHILDREN (BASEL, SWITZERLAND) 2024; 11:709. [PMID: 38929288 PMCID: PMC11202264 DOI: 10.3390/children11060709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/30/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024]
Abstract
Patients admitted to a pediatric intensive care unit (PICU) need individualized nutrition support that is tailored to their particular disease severity, nutritional status, and therapeutic interventions. We aim to evaluate how calories and proteins are provided during the first seven days of hospitalization for children in critical condition with organ dysfunction (OD). A single-center retrospective cohort study of children aged 2-18 years, mechanically ventilated > 48 h, and admitted > 7 days to a PICU from 2016 to 2017 was carried out. Nutrition support included enteral and parenteral nutrition. We calculated scores for the Pediatric Sequential Organ Failure Assessment (pSOFA) on days 1 and 3 of admission, with OD defined as a score > 5. Of 4199 patient admissions, 164 children were included. The prevalence of OD for days 1 and 3 was 79.3% and 78.7%, respectively. On day 3, when pSOFA scores trended upward, decreased, or remained unchanged, median (IQR) caloric intake was 0 (0-15), 9.2 (0-25), and 22 (1-43) kcal/kg/day, respectively (p = 0.0032); when pSOFA scores trended upward, decreased, or remained unchanged, protein intake was 0 (0-0.64), 0.44 (0-1.25), and 0.66 (0.04-1.67) g/kg/day, respectively (p = 0.0023). Organ dysfunction was prevalent through the first 72 h of a PICU stay. When the pSOFA scores trended downward or remained unchanged, caloric and protein intakes were higher than those that trended upward.
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Affiliation(s)
- Nicole Knebusch
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Paola Hong-Zhu
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Marwa Mansour
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Jennifer N. Daughtry
- Department of Clinical Nutrition Services, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Thomas P. Fogarty
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Fernando Stein
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Jorge A. Coss-Bu
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
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Arabi YM, Al-Dorzi HM, Aldibaasi O, Sadat M, Jose J, Muharib D, Algethamy H, Al-Fares AA, Al-Hameed F, Mady A, Kharaba A, Al Bshabshe A, Maghrabi K, AlGhamdi K, Rasool G, AlGhamdi A, Almekhlafi GA, Chalabi J, AlHumedi HI, Sakkijha MH, Alamrey NK, Alaskar AS, Alhutail RH, Sifaoui K, Alqahtani R, Qureshi AS, Hejazi MM, Arishi H, AlQahtani S, Ghazi AM, Baaziz ST, Azhar AO, Alabbas SF, AlAqeely M, AlOrabi O, Al-Mutawa A, AlOtaibi M, Elghannam MF, Almaani M, Buabbas SF, Alfilfil WAM, Alshahrani MS, Starkopf J, Preiser JC, Perner A, AlMubarak JH, Hazem WM, Albrahim T, Al-Dawood A. Statistical analysis plan for the replacing protein via enteral nutrition in a stepwise approach in critically ill patients (REPLENISH) randomized clinical trial. Trials 2024; 25:296. [PMID: 38698442 PMCID: PMC11064302 DOI: 10.1186/s13063-024-08105-w] [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: 02/18/2023] [Accepted: 04/10/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND The optimal amount and timing of protein intake in critically ill patients are unknown. REPLENISH (Replacing Protein via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial evaluates whether supplemental enteral protein added to standard enteral nutrition to achieve a high amount of enteral protein given from ICU day five until ICU discharge or ICU day 90 as compared to no supplemental enteral protein to achieve a moderate amount of enteral protein would reduce all-cause 90-day mortality in adult critically ill mechanically ventilated patients. METHODS In this multicenter randomized trial, critically ill patients will be randomized to receive supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition to achieve a high amount of enteral protein (range of 2-2.4 g/kg/day) or no supplemental enteral protein to achieve a moderate amount of enteral protein (0.8-1.2 g/kg/day). The primary outcome is 90-day all-cause mortality; other outcomes include functional and health-related quality-of-life assessments at 90 days. The study sample size of 2502 patients will have 80% power to detect a 5% absolute risk reduction in 90-day mortality from 30 to 25%. Consistent with international guidelines, this statistical analysis plan specifies the methods for evaluating primary and secondary outcomes and subgroups. Applying this statistical analysis plan to the REPLENISH trial will facilitate unbiased analyses of clinical data. CONCLUSION Ethics approval was obtained from the institutional review board, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia (RC19/414/R). Approvals were also obtained from the institutional review boards of each participating institution. Our findings will be disseminated in an international peer-reviewed journal and presented at relevant conferences and meetings. TRIAL REGISTRATION ClinicalTrials.gov, NCT04475666 . Registered on July 17, 2020.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Omar Aldibaasi
- King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Jesna Jose
- King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Dina Muharib
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Haifa Algethamy
- Department of Anesthesia and Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdulrahman A Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Fahad Al-Hameed
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ahmed Mady
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
- Department of Anesthesiology and Surgical Intensive Care, Tanta University Hospitals, Tanta, Egypt
| | - Ayman Kharaba
- Pulmonary & Critical Care Departments, King Fahad Hospital, Critical Care Units- Madinah Region, Ministry of Health, Madinah, Saudi Arabia
| | - Ali Al Bshabshe
- Department of Critical Care Medicine, Aseer Central Hospital, King Khalid University, Abha, Saudi Arabia
| | - Khalid Maghrabi
- Internal Medicine, Critical Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid AlGhamdi
- Internal Medicine, Critical Care, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Ghulam Rasool
- Department of Anesthesiology and Surgical Intensive Care, Tanta University Hospitals, Tanta, Egypt
| | - Adnan AlGhamdi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ghaleb A Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Intensive Care Department, King Salman Bin Abdulaziz Medical City, Madinah, Saudi Arabia
| | - Jamal Chalabi
- Intensive Care Department, King Abdulaziz Medical City, King Abdullah International Medical Research Center, AlAhsa Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Haifaa Ibrahim AlHumedi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maram Hasan Sakkijha
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Norah Khalid Alamrey
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amjad Sami Alaskar
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rabeah Hamad Alhutail
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Kaouthar Sifaoui
- Pulmonary & Critical Care Departments, King Fahad Hospital, Critical Care Units- Madinah Region, Ministry of Health, Madinah, Saudi Arabia
| | - Rakan Alqahtani
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad S Qureshi
- Intensive Care Department, Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Madinah, Saudi Arabia
| | - Mohammed Moneer Hejazi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hatim Arishi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Samah AlQahtani
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Amro Mohamed Ghazi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saleh T Baaziz
- Department of Anesthesia and Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abeer Othman Azhar
- Department of Anesthesia and Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sara Fahad Alabbas
- Department of Anesthesia and Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mohammed AlAqeely
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ohoud AlOrabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Aliaa Al-Mutawa
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Maha AlOtaibi
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Madiha Fawazy Elghannam
- Internal Medicine, Critical Care, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohammed Almaani
- Adult Critical Care Services, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sarah Fadel Buabbas
- Department of Anesthesia, Critical Care and Pain Medicine, Jaber Al-Ahmed Al-Sabah Hospital, Kuwait City, Kuwait
| | | | - Mohammed S Alshahrani
- Department of Emergency and Critical Care, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Joel Starkopf
- Clinic of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Tartu, Estonia
| | | | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jumana Hani AlMubarak
- Department of Anesthesia, Critical Care and Pain Medicine, Jaber Al-Ahmed Al-Sabah Hospital, Kuwait City, Kuwait
| | - Wafa Mansoor Hazem
- Department of Intensive Care, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Talal Albrahim
- Department of Emergency and Critical Care, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Abdulaziz Al-Dawood
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, ICU, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Kirk AHP, Ong C, Wong JJM, Loh SW, Mok YH, Lee JH. Nutritional Intake in Children with Septic Shock: A Retrospective Single-Center Study. J Pediatr Intensive Care 2024; 13:18-24. [PMID: 38571981 PMCID: PMC10987225 DOI: 10.1055/s-0041-1736146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022] Open
Abstract
Nutritional practice in children with severe sepsis or septic shock remains poorly described. We aimed to describe nutrition received by children with severe sepsis or septic shock and explore the association of nutritional intake with clinical outcomes. This study was a retrospective study of children who required pediatric intensive care unit (PICU) admission from 2009 to 2016. Outcomes were mortality, ventilator-free days (VFDs), and PICU-free days (IFDs). A total of 74 patients with septic shock or severe sepsis were identified. Forty-one (55.4%) patients received enteral nutrition (EN) only, 6 (8.1%) patients received parental nutrition (PN) only, 15 (20.3%) patients received both EN and PN, and 12 (16.2%) patients received intravenous fluids alone. Eight of 74 (10.8%) and 4 of 74 (5.4%) had adequate energy and protein intake, respectively. Patients who received early EN had lower odds of 28-day mortality (adjusted hazard ratio [HR] = 0.09, 95% confidence interval [CI]: 0.02, 0.45, p = 0.03) more 28-day VFDs (adjusted β-coefficient = 18.21 [95% CI: 11.11, 25.32], p < 0.001), and IFDs (adjusted ß-coefficient = 16.71 [95% CI: 9.86, 23.56], p < 0.001) than patients who did not receive EN. Late EN was also associated with lower odds of mortality, more VFDs, and IFDs compared with no EN (HR = 0.06, 95% CI: 0.02, 0.23; p < 0.001; adjusted β coefficient = 15.66, 95% CI: 9.31, 22.02; p < 0.001; and 12.34 [95% CI: 6.22, 18.46], p < 0.001; respectively). Inadequate calories and protein were not associated with mortality. EN in children with septic shock or severe sepsis was associated with improved clinical outcomes. Future prospective studies are required to explore the impact of EN timing and optimal nutritional intake in these children.
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Affiliation(s)
- Angela H. P. Kirk
- Division of Nursing, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Judith J.-M. Wong
- Division of Medicine, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Sin Wee Loh
- Division of Medicine, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Division of Medicine, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Division of Medicine, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Campos-Miño S, Figueiredo-Delgado A, Zárate P, Zamberlan P, Muñoz-Benavides E, Coss-Bu JA. Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study. Pediatr Crit Care Med 2023; 24:1033-1042. [PMID: 37539965 DOI: 10.1097/pcc.0000000000003337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations. DESIGN The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding. SETTING Four-one PICUs in 13 LA countries. PATIENTS Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively. CONCLUSIONS The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.
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Affiliation(s)
| | - Artur Figueiredo-Delgado
- Pediatric Intensive Care Unit, Instituto da Criança do Hospital das Clínicas, Facultade de Medicina, Universidad de São Paulo, São Paulo, Brazil
| | - Patricia Zárate
- Pediatric Intensive Care Unit, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Patricia Zamberlan
- Pediatric Intensive Care Unit, Instituto da Criança do Hospital das Clínicas, Facultade de Medicina, Universidad de São Paulo, São Paulo, Brazil
| | | | - Jorge A Coss-Bu
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, and Texas Children´s Hospital, Houston, TX
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Jotterand Chaparro C, Pabion C, Tume L, Mehta NM, Valla FV, Moullet C. Determining energy and protein needs in critically ill pediatric patients: A scoping review. Nutr Clin Pract 2023; 38 Suppl 2:S103-S124. [PMID: 37721467 DOI: 10.1002/ncp.11060] [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: 03/27/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients. METHODS An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data. RESULTS A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated. CONCLUSION This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Céline Pabion
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Lyvonne Tume
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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Fernández Montes R, Urbano Villaescusa J, Carrillo Álvarez Á, Vivanco Allende A, Solana García MJ, Díaz Coto S, Rey Galán C, López-Herce Cid J. Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: a randomized controlled trial. An Pediatr (Barc) 2023:S2341-2879(23)00120-5. [PMID: 37344303 DOI: 10.1016/j.anpede.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/06/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. METHODS We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7 g/dL), protein-enriched diet (2.7 g/dL) and high protein-enriched diet (5.1 g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3-5 days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. RESULTS Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3-5 days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. CONCLUSION Enteral administration of higher amounts of protein improves serum protein levels in critically ill children. A protein intake of 2.2 g/kg/day is generally safe and well tolerated, whereas an intake of 3.4 g/kg/day may produce hyperuraemia in some patients.
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Affiliation(s)
- Reyes Fernández Montes
- Unidad de Cuidados Intensivos Pediátricos, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Javier Urbano Villaescusa
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Red de Salud Materno Infantil y del Desarrollo (REDSAMID), Instituto de Salud Carlos III, Madrid, Spain; Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Ángel Carrillo Álvarez
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Red de Salud Materno Infantil y del Desarrollo (REDSAMID), Instituto de Salud Carlos III, Madrid, Spain; Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Vivanco Allende
- Unidad de Cuidados Intensivos Pediátricos, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María José Solana García
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Red de Salud Materno Infantil y del Desarrollo (REDSAMID), Instituto de Salud Carlos III, Madrid, Spain
| | - Susana Díaz Coto
- Departamento de Estadística, Investigación Operativa y Didáctica de la Matemática, Facultad de Ciencias, Universidad de Oviedo, Oviedo, Spain
| | - Corsino Rey Galán
- Unidad de Cuidados Intensivos Pediátricos, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Spain; Red de Salud Materno Infantil y del Desarrollo (REDSAMID), Instituto de Salud Carlos III, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús López-Herce Cid
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Red de Salud Materno Infantil y del Desarrollo (REDSAMID), Instituto de Salud Carlos III, Madrid, Spain; Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
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Jotterand Chaparro C, Bertoni Maluf V, Moullet C, Kiszio B, Pugliese MT, Ramelet AS, Morice C, Valla FV, Tume LN. Effectiveness of high versus lower enteral protein intake, considering energy intake, on clinical outcomes in critically ill children: a systematic review protocol. JBI Evid Synth 2023:02174543-990000000-00155. [PMID: 37114868 DOI: 10.11124/jbies-22-00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVE The objective of this review is to evaluate the effectiveness of high versus lower enteral protein intake, considering energy intake, on clinical and nutritional outcomes in critically ill children hospitalized in the pediatric intensive care unit. INTRODUCTION Over and undernutrition increases the risk of morbidity and mortality in critically ill children. The impact of high versus lower enteral protein intake on clinical outcomes, considering energy intake, still needs to be investigated in children of different ages. INCLUSION CRITERIA This review will consider studies of critically ill children (aged between ≥ 37 wk' gestational age and < 18 y) admitted to the pediatric intensive care unit for a minimum of 48 hours and receiving enteral nutrition. Randomized controlled trials comparing high versus lower enteral protein intake, considering energy intake, will be eligible. Primary outcomes will include clinical and nutritional outcomes, such as length of stay in the pediatric intensive care unit and nitrogen balance. METHODS Using the JBI methodology for systematic reviews of effectiveness, we will search for randomized controlled trials published in English, French, Italian, Spanish, and German in electronic databases, including MEDLINE, CINAHL Complete, Embase, and the Cochrane Library, from database inception until the present. We will also search clinical trial registers and, if required, contact authors. Two independent reviewers will screen and select studies for inclusion, data extraction, and assessment of methodological quality. A third reviewer will be consulted if necessary. A statistical meta-analysis will be performed if feasible. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42022315325.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Valeria Bertoni Maluf
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Clémence Moullet
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Blanche Kiszio
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Marie-Thérèse Pugliese
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Anne-Sylvie Ramelet
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
- University Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Switzerland
- Lausanne University Hospital, Lausanne, Switzerland
| | - Claire Morice
- Pediatric Intensive Care Unit, Hôpital Universitaire Femme Mère Enfant, Hospices Civils de Lyon, France
- Pediatric Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Universitaire Femme Mère Enfant, Hospices Civils de Lyon, France
| | - Lyvonne N Tume
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
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8
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Fernández Montes R, Urbano Villaescusa J, Carrillo Álvarez Á, Vivanco Allende A, Solana García MJ, Díaz Coto S, Rey Galán C, López-Herce Cid J. Efecto de tres dietas enterales con diferente contenido en proteínas sobre el metabolismo proteico en lactantes críticamente enfermos: un ensayo clínico aleatorizado. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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9
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Bahramian B, Sarabi-Jamab M, Talebi S, Razavi SMA, Rezaie M. Designing blenderized tube feeding diets for children and investigating their physicochemical and microbial properties and Dietary Inflammatory Index. Nutr Clin Pract 2023; 38:360-375. [PMID: 35819346 DOI: 10.1002/ncp.10893] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/06/2022] [Accepted: 06/11/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Due to the benefits of blenderized tube feeding (BTF) diets, the interest in using them is increasing. This study aimed to design BTFs for children and investigate their physicochemical and microbial properties, as well as Dietary Inflammatory Index (DII). METHODS Five BTF diets were formulated mainly with fresh foods; their DII, physical (viscosity), and chemical (moisture, ash, protein, fat, energy, and micronutrients) characteristics were assessed. Also, the Hazard Analysis and Critical Control Points (HACCP) system was implemented for quality assurance of preparation, storage, and delivery of BTFs to patients in hospital. The microbial contamination (total count, Salmonella, Escherichia coli, Bacillus cereus, Listeria monocytogenes, coliforms, Staphylococcus aureus coagulase positive, mold, and yeast) was analyzed. RESULTS Energy and percentages of protein, fat, and carbohydrate in BTFs were in the range of 103-112 kcal/100 ml, 16%-22%, 28%-34%, and 48%-52%, respectively. The viscosity of the five developed BTFs was between 29 and 64 centipoises, which allows the formulas to flow without syringe pressure. The DII of all BTFs was between -0.73 and -2.24. Due to the implementation of HACCP, monitoring the production line of BTFs, and performance of corrective measures, no microbial contamination was observed by indicator pathogenic microorganisms. CONCLUSION A planned BTF diet can be an excellent selection for children using enteral nutrition with tube feeding especially when they are made from fresh and anti-inflammatory foods such as recipes prepared in this study.
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Affiliation(s)
- Behnam Bahramian
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahboobe Sarabi-Jamab
- Department of Food Biotechnology, Research Institute of Food Science and Technology, Mashhad, Iran
| | - Saeedeh Talebi
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mohammad Ali Razavi
- Department of Food Science and Technology, Food Engineering Division, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Mitra Rezaie
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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10
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Solana MJ, Manrique G, Slocker M, Fernández R, Gil R, Yun C, García M, Redondo S, Balaguer M, Rodríguez E, González-Posada A, Goñi C, Martín CM, Santiago C, Sánchez M, Miñambres M, López-Herce J. Early vs late enteral nutrition in pediatric intensive care unit: Barriers, benefits, and complications. Nutr Clin Pract 2023; 38:442-448. [PMID: 36268895 DOI: 10.1002/ncp.10922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 09/08/2022] [Accepted: 09/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to define the existing barriers for early enteral nutrition (EEN) in critically ill children and to analyze the differences in nutrient supply, complications, and outcomes between EEN and late EN (LEN). METHODS This is a secondary analysis of a multicenter observational, prospective study including critically ill children receiving EN. Variables analyzed included demographic and anthropometric features, caloric and nutrient supply, outcomes, and complications according to the EN onset. Patients were classified into two groups according to the start of EN: 24-EEN vs EN started after 24 h (24-LEN) and 48-EEN vs EN started after 48 h (48-LEN). RESULTS Sixty-eight children were enrolled; 22.1% received 24-EEN, and 67.6% received 48-EEN. EN was most frequently delayed in patients older than 12 months, in patients with cardiac disease, and in those requiring mechanical ventilation (MV). Children in the 24-EEN group had shorter duration of MV compared with those in the 24-LEN group (P = 0.04). The 48-EEN group received a higher caloric intake (P = 0.04), reached the caloric target earlier (P < 0.01), and had lower incidence of constipation (P = 0.01) than the 48-LEN group. There was a positive correlation between the time required to reach the maximum caloric intake and the length of pediatric intensive care stay (r = 0.46; P < 0.01). CONCLUSION EEN may improve nutrient delivery, reduce time on MV, and prevent constipation in critically ill children. No relevant differences between 24-EEN and 48-EEN were found. Cardiac disease, MV, and age older than 12 months were risk factors associated with LEN.
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Affiliation(s)
- María José Solana
- Gregorio Marañón University Hospital, Madrid, Spain.,Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.,Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Gema Manrique
- Gregorio Marañón University Hospital, Madrid, Spain.,Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.,Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - María Slocker
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.,Clínico Universitario de la Arrixaca, Murcia, Spain
| | | | - Raquel Gil
- H. Regional Universitario de Málaga, Málaga, Spain
| | - Cristina Yun
- H. Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | - Eva Rodríguez
- H. Nuestra Señora de la Candelaria, Santa Cruz, Spain
| | | | | | | | | | | | | | - Jesús López-Herce
- Gregorio Marañón University Hospital, Madrid, Spain.,Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.,Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain.,Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
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11
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Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S45-S60. [PMID: 36661435 DOI: 10.1097/pcc.0000000000003158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation). DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.
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12
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Lee AE, Munoz E, Al Dabbous T, Harris E, O'Callaghan M, Raman L. Extracorporeal Life Support Organization Guidelines for the Provision and Assessment of Nutritional Support in the Neonatal and Pediatric ECMO Patient. ASAIO J 2022; 68:875-880. [PMID: 35703144 DOI: 10.1097/mat.0000000000001767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
DISCLAIMER This guideline is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Amy E Lee
- From the Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Tala Al Dabbous
- Bayt Abdullah Children's Hospice, Al-Adan Hospital, NBK Children's Hospital, Kuwait City, Kuwait
| | | | - Maura O'Callaghan
- ECMO Service Team, Great Ormond Street Hospital, London, United Kingdom
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Joosten K, Verbruggen S. PN Administration in Critically Ill Children in Different Phases of the Stress Response. Nutrients 2022; 14:nu14091819. [PMID: 35565787 PMCID: PMC9104104 DOI: 10.3390/nu14091819] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 01/22/2023] Open
Abstract
Nutritional support is an important part of the treatment of critical ill children and the phase of disease has to be taken into account. The metabolic stress response during acute critical illness is characterized by severe catabolism. So far, there is no evidence that the acute catabolic state can be prevented with nutritional support. The Pediatric ’Early versus Late Parenteral Nutrition’ (PEPaNIC) trial showed that withholding supplemental parenteral nutrition (PN) during the first week in critically ill children, when enteral nutrition was not sufficient, prevented infections and shortened the stay in the pediatric intensive care unit (PICU) and the hospital. A follow-up performed 2 and 4 years later showed that withholding parenteral nutrition (PN) also improved several domains of the neurocognitive outcome of the children. Current international guidelines recommend considering withholding parenteral macronutrients during the first week of pediatric critical illness, while providing micronutrients. These guidelines also recommend upper and lower levels of intake of macronutrients and micronutrients if PN is administered.
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14
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Stoppe C, Wendt S, Mehta NM, Compher C, Preiser JC, Heyland DK, Kristof AS. Biomarkers in critical care nutrition. Crit Care 2020; 24:499. [PMID: 32787899 PMCID: PMC7425162 DOI: 10.1186/s13054-020-03208-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
The goal of nutrition support is to provide the substrates required to match the bioenergetic needs of the patient and promote the net synthesis of macromolecules required for the preservation of lean mass, organ function, and immunity. Contemporary observational studies have exposed the pervasive undernutrition of critically ill patients and its association with adverse clinical outcomes. The intuitive hypothesis is that optimization of nutrition delivery should improve ICU clinical outcomes. It is therefore surprising that multiple large randomized controlled trials have failed to demonstrate the clinical benefit of restoring or maximizing nutrient intake. This may be in part due to the absence of biological markers that identify patients who are most likely to benefit from nutrition interventions and that monitor the effects of nutrition support. Here, we discuss the need for practical risk stratification tools in critical care nutrition, a proposed rationale for targeted biomarker development, and potential approaches that can be adopted for biomarker identification and validation in the field.
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Affiliation(s)
- Christian Stoppe
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Sebastian Wendt
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania and Clinical Nutrition Support Service, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Jean-Charles Preiser
- Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, B-1070 Brussels, Belgium
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queen’s University, Angada 4, Kingston, ON K7L 2V7 Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston, ON K7L 2V7 Canada
| | - Arnold S. Kristof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, Faculty of Medicine, Departments of Medicine and Critical Care, Research Institute of the McGill University Health Centre, 1001 Décarie Blvd., EM3.2219, Montreal, QC H4A 3J1 Canada
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15
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Tsintoni A, Dimitriou G, Karatza AA. Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns. J Matern Fetal Neonatal Med 2020; 33:2487-2492. [PMID: 30608033 DOI: 10.1080/14767058.2018.1548602] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Congenital heart disease is one of the most of the groups of congenital anomalies with an incidence of about 1 per 100 live births. Almost one-third of these infants require some type of intervention, usually in the first year of life and increasingly often in the neonatal period. Innovative reparative and palliative surgical procedures and advanced medical support in the Neonatal Intensive Care Unit have significantly reduced the mortality related to congenital heart disease. Achieving survival is not the only target of clinicians for these patients. Appropriate growth, development, and improved quality of life are also very important. Growth failure is a very common problem of these children and nutritional support and management are a challenge for health care providers. Early intervention and identification of at-risk patients have the potential to decrease morbidity and mortality related to malnutrition.Aim/methods: The purpose of this article is to analyze the existing evidence and common concerns about perioperative and postdischarge nutritional management of neonates with congenital heart disease based on the special issues or complications that may arise. Furthermore, we reviewed the recent literature about current practices and proposed policies that could prevent malnutrition and improve the outcomes of neonates with congenital heart disease.Results/conclusion: A standardized institutional protocol and clear guidelines referring to feeding initiation, prompt estimation of caloric needs and provision of adequate and appropriate nutrient intake is likely to benefit these patients. Clear definitions for the nutritional approach in the setting of medical complications and close assessment of growth by pediatricians and specialized nutritionists are crucial for the long-term outlook and quality of life of these infants.
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Affiliation(s)
- Asimina Tsintoni
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Ageliki A Karatza
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
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16
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Protein intake deficiency in critically ill children with respiratory insufficiency: A call to action? Clin Nutr ESPEN 2020; 37:69-74. [DOI: 10.1016/j.clnesp.2020.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/05/2020] [Accepted: 03/20/2020] [Indexed: 11/21/2022]
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17
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Ng GYH, Ong C, Wong JJM, Teoh OH, Sultana R, Mok YH, Lee JH. Nutritional status, intake, and outcomes in critically ill children with bronchiolitis. Pediatr Pulmonol 2020; 55:1199-1206. [PMID: 32109353 DOI: 10.1002/ppul.24701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 02/14/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Optimal nutrition in children with severe bronchiolitis remains poorly described. We aimed to describe nutritional status and practices in children with severe bronchiolitis requiring admission to the pediatric intensive care unit (PICU), and explore their associations with outcomes. METHODS We conducted a retrospective study on patients with bronchiolitis requiring PICU stay from 2009 to 2014. Demographics, medical data, and baseline weight-for-length Z-scores (WLZ) were collected. In patients requiring more than 48 hours of PICU stay, nutritional intake data in the first 3 days of PICU stay were collected. Underfeeding and overfeeding were defined as the median energy intake of less than 80% and more than 120% of requirements, respectively. Protein adequacy was defined as intake of more than 1.5 g/kg/d. Primary and secondary outcomes of interest were the duration of PICU stay and mechanical ventilation (MV), respectively. RESULTS Seventy-four patients were included, with a median PICU stay of 4.9 days (interquartile range 2.0-8.2). Low WLZ at baseline was associated with longer duration of PICU stay (adjusted β: 4.33 [95% confidence interval [CI], 0.49-8.18]; P = .028) and MV days (adjusted β: 4.87 [95% CI, 1.56-8.18]; P = .008) compared to appropriate WLZ. In patients with ≥48 hours PICU stay, protein adequacy was significantly associated with greater PICU (adjusted β coefficient, 6.35 [95% CI, 1.66-11.0]; P = .009) and MV days (adjusted β coefficient, 5.22 [95% CI, 1.06-9.38]; P = .015). CONCLUSION Among bronchiolitis patients admitted to the PICU, low WLZ at admission was associated with a longer duration of PICU stay and MV. Protein adequacy was associated with longer PICU and MV days in children with ≥48 hours of PICU stay.
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Affiliation(s)
- Glenn Y H Ng
- Department of Pediatrics, General Paediatrics Service, KK Women's and Children's Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore.,Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Judith J M Wong
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Oon Hoe Teoh
- Department of Pediatrics, Respiratory Medicine Service, KK Women's and Children's Hospital, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Yee Hui Mok
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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18
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Tume LN, Valla FV, Joosten K, Jotterand Chaparro C, Latten L, Marino LV, Macleod I, Moullet C, Pathan N, Rooze S, van Rosmalen J, Verbruggen SCAT. Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations. Intensive Care Med 2020; 46:411-425. [PMID: 32077997 PMCID: PMC7067708 DOI: 10.1007/s00134-019-05922-5] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/28/2019] [Indexed: 01/09/2023]
Abstract
Background Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions. Electronic supplementary material The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health and Society, University of Salford, Manchester, M6 6PU, UK. .,Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L12 2AP, UK.
| | - Frederic V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, CarMEN INSERM UMR, 1060 Hospices Civils de Lyon, Lyon-Bron, France
| | - Koen Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Lynne Latten
- Nutrition and Dietetics, Alder Hey Children's Hospital Liverpool, Liverpool, UK
| | - Luise V Marino
- Department of Dietetics/Speech and Language Therapy, NIHR Biomedical Research Centre Southampton, University Hospital Southampton, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Isobel Macleod
- Pediatric Intensive Care Unit, Royal Hospital for Children, Glasgow, UK
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nazima Pathan
- Department of Pediatrics, University of Cambridge, Hills Road, Cambridge, UK
| | - Shancy Rooze
- Pediatric Intensive Care Unit, Queen Fabiola Children's University Hospital, Brussels, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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19
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Goday PS, Kuhn EM, Mikhailov TA. Early Parenteral Nutrition in Critically Ill Children Not Receiving Early Enteral Nutrition Is Associated With Significantly Higher Mortality. JPEN J Parenter Enteral Nutr 2019; 44:1096-1103. [DOI: 10.1002/jpen.1731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 09/24/2019] [Accepted: 10/05/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Praveen S. Goday
- Division of Pediatric Gastroenterology and NutritionMedical College of Wisconsin Milwaukee Wisconsin USA
| | - Evelyn M. Kuhn
- Children's Hospital of Wisconsin Milwaukee Wisconsin USA
| | - Theresa A. Mikhailov
- Division of Pediatric Critical CareMedical College of Wisconsin Milwaukee Wisconsin USA
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20
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Fernández R, Urbano J, Carrillo Á, Vivanco A, Solana MJ, Rey C, López-Herce J. Comparison of the effect of three different protein content enteral diets on serum levels of proteins, nitrogen balance, and energy expenditure in critically ill infants: study protocol for a randomized controlled trial. Trials 2019; 20:585. [PMID: 31604481 PMCID: PMC6787979 DOI: 10.1186/s13063-019-3686-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/28/2019] [Indexed: 11/22/2022] Open
Abstract
Background Nutritional support is essential in the care of critically ill children since malnutrition in this population is associated with increased morbidity and mortality. Injury in patients admitted to pediatric intensive care units (PICU) results in a catabolic state and augmented protein breakdown, leading to a negative protein balance. Current recommendations about protein prescription in the PICU are fundamentally based on expert opinions, and the minimum threshold is 1.5 g/kg per day of protein, although protein needs could be higher in certain subgroups of patients. The main objectives of the present study are to examine whether the administration of a protein-enriched infant formula increases the serum levels of total proteins, albumin, prealbumin, transferrin, and retinol and improves nitrogen balance and to analyze the effect of the high-protein diet on energy expenditure. A secondary objective is to register possible secondary effects of the protein-enriched diet. Methods A multicenter prospective randomized controlled trial (RCT) will be performed in three hospitals. Patients meeting inclusion criteria will be randomly allocated to one of three enteral feeding formulae with different protein contents. Blood and urine test, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry will be performed at the beginning of the nutrition regimen and at 24 h, 72 h and 5–7 days after initiation. The sample size for this trial is estimated to be 90 participants (about 30 participants in each group). The data analysis will be by intention to treat. Discussion This RCT will provide new data about the amount of protein needed to improve levels of serum protein and nitrogen balance, a surrogate of protein balance, in critically ill infants receiving enteral nutrition. Trial registration ClinicalTrials.gov identifier: NCT03901742. Registered April 1, 2019 – Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13063-019-3686-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Reyes Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Javier Urbano
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain. .,Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain. .,Universidad Complutense de Madrid, Madrid, Spain.
| | - Ángel Carrillo
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain.,Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Vivanco
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María José Solana
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain.,Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Corsino Rey
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain.,Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain.,Universidad de Oviedo, Oviedo, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain.,Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain
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21
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van Puffelen E, Jacobs A, Verdoorn CJM, Joosten KFM, van den Berghe G, Ista E, Verbruggen SCAT. International survey of De-implementation of initiating parenteral nutrition early in Paediatric intensive care units. BMC Health Serv Res 2019; 19:379. [PMID: 31196076 PMCID: PMC6567488 DOI: 10.1186/s12913-019-4223-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/06/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Initiating parenteral nutrition (PN) within 24 h in critically ill children is inferior to withholding PN during the first week, as was found in the PEPaNIC study. The aims of this study were to investigate de-implementation of early initiation of PN at PICUs worldwide, and to identify factors influencing de-implementation. METHODS A cross-sectional online survey was conducted (May - October 2017), consisting of 41 questions addressing current PN practices, the degree of de-implementation, and factors affecting de-implementation. RESULTS We analysed 81 responses from 39 countries. Of these 81 respondents, 53 (65%) were aware of the findings of the PEPaNIC study, and 43 (53%) have read the article. In these 43 PICUs, PN was completely withheld during the first week in 10 PICUs, of which 5 already withheld PN (12%), and 5 de-implemented early initiation of PN (12%). Partial de-implementation was reported by 17 (40%) and no de-implementation by 16 (37%). Higher de-implementation rates were observed when the interpreted level of evidence and grade of recommendation of PEPaNIC was high. Predominant reasons for retaining early initiation of PN were concerns on withholding amino acids, the safety in undernourished children and neonates, and the long-term consequences. Furthermore, the respondents were waiting for updated guidelines. CONCLUSIONS One year after the publication of the PEPaNIC trial, only two-thirds of the respondents was aware of the study results. Within this group, early initiation of PN was de-implemented completely in 12% of the PICUs, while 40% asserted partial de-implementation. Increasing the awareness, addressing the intervention-specific questions and more frequently revising international guidelines might help to accelerate de-implementation of ineffective, unproven or harmful healthcare.
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Affiliation(s)
- Esther van Puffelen
- Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children’s Hospital, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - An Jacobs
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Charlotte J. M. Verdoorn
- Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children’s Hospital, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Koen F. M. Joosten
- Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children’s Hospital, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Greet van den Berghe
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Erwin Ista
- Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children’s Hospital, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Internal Medicine, Nursing Science, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sascha C. A. T. Verbruggen
- Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children’s Hospital, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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22
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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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23
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Ingelse SA, Geukers VG, Dijsselhof ME, Lemson J, Bem RA, van Woensel JB. Less Is More?-A Feasibility Study of Fluid Strategy in Critically Ill Children With Acute Respiratory Tract Infection. Front Pediatr 2019; 7:496. [PMID: 31921715 PMCID: PMC6915071 DOI: 10.3389/fped.2019.00496] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/15/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Fluid overload is common in critically ill children and is associated with adverse outcome. Therefore, restricting fluid intake may be beneficial. This study aims to study the feasibility of a randomized controlled trial (RCT) comparing a conservative to a standard, more liberal, strategy of fluid management in mechanically ventilated pediatric patients with acute respiratory tract infection (ARTI). Methods: This is a feasibility study in a single, tertiary referral pediatric intensive care unit (PICU). Twenty-three children receiving mechanical ventilation for ARTI, without ongoing hemodynamic support, admitted to the PICU of the Emma Children's Hospital/Amsterdam UMC between 2016 and 2018 were included. Patients were randomized to a conservative (<70% of normal intake) or standard (>85% of normal intake) fluid strategy, which was kept throughout the period of mechanical ventilation. Results: Primary endpoints were adherence to fluid strategy and safety parameters such as calorie and protein intake. Secondary outcomes were cumulative fluid intake (CFI) and cumulative fluid balance (CFB) on day 3. In the conservative group, in 75% of the mechanical ventilation days patients achieved their target fluid intake. Median [25th-75th percentiles] calorie intake over all mechanical ventilation days was 67.9 [51.5-74.0] kcal/kg/day in the conservative vs. 67.2 [58.0-75.2] kcal/kg/day in the standard group (p = 0.878). Protein intake was 1.6 [1.3-1.8] gr protein/kg in the conservative and 1.5 [1.2-1.7] gr protein/kg in the standard group (p = 0.598). No adverse effects on hemodynamics or electrolyte imbalances were noted. Mean (±SD) CFI on day 3 was 262.3 (±58.9) ml/kg in the conservative group vs. 360.5 (±52.6) ml/kg in the standard fluid group (p < 0.001), which did not result in a lower CFB. Conclusions: A conservative fluid strategy in mechanically ventilated children with ARTI seems feasible, without limiting metabolic needs. However, in our study a conservative fluid strategy surprisingly did not reduce the degree of fluid overload. This study aids the design and sample size calculation of a future larger multicenter RCT, in which we need to redefine the target fluid strategy, possibly by even further fluid restriction and early initiation of active diuresis. Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT02989051.
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Affiliation(s)
- Sarah A Ingelse
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Vincent G Geukers
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Monique E Dijsselhof
- Department of Dietetics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Job B van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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24
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Jonckheer J, Vergaelen K, Spapen H, Malbrain MLNG, De Waele E. Modification of Nutrition Therapy During Continuous Renal Replacement Therapy in Critically Ill Pediatric Patients: A Narrative Review and Recommendations. Nutr Clin Pract 2018; 34:37-47. [PMID: 30570180 PMCID: PMC7379206 DOI: 10.1002/ncp.10231] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction Nutrition is an important part of treatment in critically ill children. Clinical guidelines for nutrition adaptations during continuous renal replacement therapy (CRRT) are lacking. We collected and evaluated current knowledge on this topic and provide recommendations. Methods Questions were produced to guide the literature search in the PubMed database. Results Evidence is scarce and extrapolation from adult data was often required. CRRT has a direct and substantial impact on metabolism. Indirect calorimetry is the preferred method to assess resting energy expenditure (REE). Moderate underestimation of REE is common but not clinically relevant. Formula‐based calculation of REE is inaccurate and not validated in critically ill children on CRRT. The nutrition impact of nonintentional calories delivered as citrate, lactate, and glucose during CRRT must be considered. Quantifying nitrogen balance is not feasible during CRRT. Protein delivery should be increased by 25% to compensate for losses in the effluent. Fats are not removed by CRRT and should not be adapted during CRRT. Electrolyte disturbances are frequently present and should be treated accordingly. Vitamins B1, B6, B9, and C are lost in the effluent and should be adapted to the effluent dose. Trace elements, with the exception of selenium, are not cleared in relevant quantities. Manganese accumulation is of concern because of potential neurotoxicity. Conclusion Current recommendations regarding nutrition support in pediatric CRRT must be extrapolated from adult studies. Recommendations are provided, based on the weak level of evidence. Additional research on this topic is warranted.
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Affiliation(s)
- Joop Jonckheer
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium
| | - Klaar Vergaelen
- Pediatric Intensive Care Unit, University Hospital Brussels, Brussels, Belgium
| | - Herbert Spapen
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium
| | - Manu L N G Malbrain
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium.,Pediatric Intensive Care Unit, University Hospital Brussels, Brussels, Belgium
| | - Elisabeth De Waele
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium.,Department of Nutrition, University Hospital Brussels, Brussels, Belgium
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25
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Joosten K, Embleton N, Yan W, Senterre T, Braegger C, Bronsky J, Cai W, Campoy C, Carnielli V, Darmaun D, Decsi T, Domellöf M, Embleton N, Fewtrell M, Fidler Mis N, Franz A, Goulet O, Hartman C, Hill S, Hojsak I, Iacobelli S, Jochum F, Joosten K, Kolaček S, Koletzko B, Ksiazyk J, Lapillonne A, Lohner S, Mesotten D, Mihályi K, Mihatsch WA, Mimouni F, Mølgaard C, Moltu SJ, Nomayo A, Picaud JC, Prell C, Puntis J, Riskin A, Saenz De Pipaon M, Senterre T, Shamir R, Simchowitz V, Szitanyi P, Tabbers MM, Van Den Akker CH, Van Goudoever JB, Van Kempen A, Verbruggen S, Wu J, Yan W. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Energy. Clin Nutr 2018; 37:2309-2314. [DOI: 10.1016/j.clnu.2018.06.944] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 01/06/2023]
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26
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Arabi YM, Al-Dorzi HM, Mehta S, Tamim HM, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakkijha MH, Sadat M, Afesh L, Kumar A, Bagshaw SM, Aldawood AS. Association of protein intake with the outcomes of critically ill patients: a post hoc analysis of the PermiT trial. Am J Clin Nutr 2018; 108:988-996. [PMID: 30475959 DOI: 10.1093/ajcn/nqy189] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/26/2018] [Indexed: 12/12/2022] Open
Abstract
Background The optimal amount of protein intake in critically ill patients is uncertain. Objective In this post hoc analysis of the PermiT (Permissive Underfeeding vs. Target Enteral Feeding in Adult Critically Ill Patients) trial, we tested the hypothesis that higher total protein intake was associated with lower 90-d mortality and improved protein biomarkers in critically ill patients. Design In this post hoc analysis of the PermiT trial, we included patients who received enteral feeding for ≥3 consecutive days. Using the median protein intake of the cohort as a cutoff, patients were categorized into 2 groups: a higher-protein group (>0.80 g · kg-1 · d-1) and a lower-protein group (≤0.80 g · kg-1 · d-1). We developed a propensity score for receiving higher protein. Primary outcome was 90-d mortality. We also compared serial values of prealbumin, transferrin, 24-h urinary nitrogen, and 24-h nitrogen balance on days 1, 7, and 14. Results Among the 729 patients included in this analysis, the average protein intake was 0.8 ± 0.3 g · kg-1 · d-1 [1.0 ± 0.2 g · kg-1 · d-1 in the higher-protein group (n = 365) and 0.6 ± 0.2 g · kg-1 · d-1 in the lower-protein group (n = 364); P < 0.0001]. There was no difference in 90-d mortality between the 2 groups [88/364 (24.2%) compared with 94/363 (25.9%), propensity score-adjusted OR: 0.80; 95% CI: 0.56, 1.16; P = 0.24]. Higher protein intake was associated with an increase in 24-h urea nitrogen excretion compared with lower protein intake, but without a significant change in prealbumin, transferrin, or 24-h nitrogen balance. Conclusions In the PermiT trial, a moderate difference in protein intake was not associated with lower mortality. Higher protein intake was associated with increased nitrogen excretion in the urine without a corresponding change in prealbumin, transferrin, or nitrogen balance. Protein intake needs to be tested in adequately powered randomized controlled trials targeting larger differences in protein intake in high-risk populations.
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Affiliation(s)
- Y M Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - H M Al-Dorzi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - S Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - H M Tamim
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.,Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - S H Haddad
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - G Jones
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - L McIntyre
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - O Solaiman
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - M H Sakkijha
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - M Sadat
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - L Afesh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - A Kumar
- Health Sciences Center, Manitoba, Canada
| | - S M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - A S Aldawood
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
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27
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Tekgüç H, Özel D, Sanaldi H, Akbaş H, Dursun O. Prealbumin and Retinol Binding Proteins Are Not Usable for Nutrition Follow-Up in Pediatric Intensive Care Units. Pediatr Gastroenterol Hepatol Nutr 2018; 21:321-328. [PMID: 30345246 PMCID: PMC6182478 DOI: 10.5223/pghn.2018.21.4.321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 02/07/2018] [Accepted: 03/14/2018] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Feeding children is a problem in pediatric intensive care units (PICU) and it is difficult to know the correct amount. The purpose of this study is to evaluate if prealbumin or retinol binding proteins (RBP) are effective relative to daily enteral nutrition, without being affected by severity of diseases or infections and can be used to follow up nutritional amount. METHODS This is a prospective observational study that includes 81 patients admitted to PICU in Akdeniz University with estimated duration >72 hours, age between 1 month and 8 years. Daily calorie and protein intake were calculated and prealbumin, RBP and C-reactive protein (CRP) levels were measured on the first, third, fifth and seventh mornings. RESULTS We find moderate correlation between daily calorie intake and prealbumin levels (r=0.432, p<0.001), RBP levels and daily protein intake (r=0.330, p<0.001). When we investigated the relationship between changes of prealbumin, RBP, CRP, calorie and protein intake during intensive care stay, we found that increase of Prealbumin and RBP levels are explained by decrease of CRP levels (r=-0.546 and -0.645, p<0.001) and not with increase of nourishment. CONCLUSION Even adjusted for PRISM3, age and CRP, prealbumin and RBP are correlated with last 24 hours' diet. However, it is not convenient to use as a follow up biomarker because increase of their levels is related with decrease of CRP levels.
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Affiliation(s)
- Hakan Tekgüç
- Pediatric Intensive Care Unit, Koru Hastanesi, Antalya, Turkey
| | - Deniz Özel
- Biostatistics and Medical Informatics, Akdeniz University School of Medicine, Antalya, Turkey
| | - Huriye Sanaldi
- Nutrition and Dietician Department, Akdeniz University School of Medicine, Antalya, Turkey
| | - Halide Akbaş
- Clinical Biochemistry Department, Akdeniz University School of Medicine, Antalya, Turkey
| | - Oğuz Dursun
- Pediatric Intensive Care Unit, Akdeniz University School of Medicine, Antalya, Turkey
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28
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van Puffelen E, Hulst JM, Vanhorebeek I, Dulfer K, Van den Berghe G, Verbruggen SCAT, Joosten KFM. Outcomes of Delaying Parenteral Nutrition for 1 Week vs Initiation Within 24 Hours Among Undernourished Children in Pediatric Intensive Care: A Subanalysis of the PEPaNIC Randomized Clinical Trial. JAMA Netw Open 2018; 1:e182668. [PMID: 30646158 PMCID: PMC6324499 DOI: 10.1001/jamanetworkopen.2018.2668] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Undernourishment has been associated with poor outcomes of critical illness in children. The effects of withholding parenteral nutrition (PN) for 1 week in undernourished critically ill children are unknown. OBJECTIVE To assess the outcome effects of withholding PN for 1 week in undernourished critically ill children. DESIGN, SETTING, AND PARTICIPANTS This is a subanalysis of the randomized clinical trial Pediatric Early vs Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC; N = 1440), which focused on the subgroup of pediatric intensive care unit (PICU) patients identified as undernourished on admission. Children included in the PEPaNIC trial were enrolled between June 18, 2012, and July 27, 2015. Undernourishment was defined as weight-for-age z score less than -2 in children younger than 1 year, and body mass index-for-age z score less than -2 in children 1 year or older. Data analysis was conducted from August 3, 2017, to July 6, 2018. INTERVENTIONS Patients were randomized to initiation of supplemental PN within 24 hours (early PN) or after 1 week (late PN) when enteral nutrition was insufficient. MAIN OUTCOMES AND MEASURES Primary end points were risk of new infections acquired in the PICU and time to live PICU discharge, assessed via multivariable logistic regression and Cox proportional hazard analyses, adjusted for risk factors. RESULTS A total of 289 of 1440 children (20.1%), term newborn to age 17 years, were identified as undernourished, of whom 150 of 717 patients (20.9%) were in the late PN group and 139 of 723 patients (19.2%) were in the early PN group. On admission, characteristics were similar among the treatment groups. Mean (SD) weight z scores were -3.33 (1.18) in the late PN group and -3.21 (1.09) in the early PN group. Compared with well-nourished PICU patients, undernourishment on admission was associated with lower likelihood of an earlier live PICU discharge (adjusted hazard ratio, 0.86; 95% CI, 0.75-0.99; P = .03). Among undernourished PICU patients, late PN reduced the risk of new infections by 11.0% (adjusted odds ratio, 0.39; 95% CI, 0.19-0.78; P = .01), and shortened the duration of PICU stay by a median of 2 days (earlier live PICU discharge: adjusted hazard ratio, 1.37; 95% CI, 1.06-1.75; P = .01). The safety outcomes mortality, incidence of hypoglycemia during the first week, and incidence of weight deterioration during PICU stay were similar between the treatment groups. CONCLUSIONS AND RELEVANCE In undernourished critically ill children, withholding PN for 1 week was clinically superior to early PN. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01536275.
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Affiliation(s)
- Esther van Puffelen
- Department of Pediatrics and Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jessie M. Hulst
- Division of Pediatric Gastroenterology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University Hospitals Katholieke Universiteit Leuven, Leuven, Belgium
| | - Karolijn Dulfer
- Department of Pediatrics and Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University Hospitals Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sascha C. A. T. Verbruggen
- Department of Pediatrics and Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Koen F. M. Joosten
- Department of Pediatrics and Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Zhang J, Cui Y, Ma, MD Z, Luo Y, Chen X, Li J. Energy and Protein Requirements in Children Undergoing Cardiopulmonary Bypass Surgery: Current Problems and Future Direction. JPEN J Parenter Enteral Nutr 2018; 43:54-62. [PMID: 30070710 DOI: 10.1002/jpen.1314] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/16/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Jian Zhang
- Clinical Physiology Research Laboratory Capital Institute of Pediatrics Beijing China
| | - Yan‐Qin Cui
- Cardiac Intensive Care Unit Guangzhou Women and Children's Medical Center Guangdong Province China
| | - Ze‐Ming Ma, MD
- Department of Cardiac Surgery Children's Hospital affiliated to Capital Institute of Pediatrics Beijing China
| | - Yi Luo
- Department of Cardiac Surgery Children's Hospital affiliated to Capital Institute of Pediatrics Beijing China
| | - Xin‐Xin Chen
- Department of Cardiac Surgery Guangzhou Women and Children's Medical Center Guangdong Province China
| | - Jia Li
- Clinical Physiology Research Laboratory Capital Institute of Pediatrics Beijing China
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Hauschild DB, Oliveira LDA, Farias MS, Barbosa E, Bresolin NL, Mehta NM, Moreno YMF. Enteral Protein Supplementation in Critically Ill Children: A Randomized Controlled Pilot and Feasibility Study. JPEN J Parenter Enteral Nutr 2018; 43:281-289. [PMID: 29959852 DOI: 10.1002/jpen.1416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/04/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Loss of muscle mass in critically ill children can negatively impact outcomes. The aims of this study were to conduct a pilot randomized control trial (RCT) to examine the difference in protein delivery and nitrogen balance in critically ill children with enteral protein supplementation vs controls. We also aimed to assess the feasibility, safety, and tolerance of the pilot trial. METHODS This is a 3-arm RCT in critically ill children eligible for enteral nutrition (EN) therapy. Patients were randomized to 1 of the 3 groups: (1) control (routine EN), (2) polymeric protein module added to EN to reach protein goal by day 4, or (3) oligomeric protein supplementation. Demographics, clinical characteristics, nutrition status, and daily nutrition intake variables were recorded. Protein delivery, nitrogen balance, feasibility variables, and rate of adverse events were the outcomes. RESULTS After screening 286 consecutive patients admitted to the pediatric intensive care unit over 11 months, we enrolled and randomized 25 patients. Twenty-two patients (88% of the enrolled) completed the study procedures. Significantly higher protein prescription and actual protein intake within the first 5 days was achieved in the intervention groups, compared with the control group. Nitrogen balance was obtained in 15 patients. There was no significant difference between the groups for the rate of adverse effects and clinical outcomes. CONCLUSION In our pilot trial, protein supplementation was safe and well tolerated. Our preliminary results suggest that a larger RCT is potentially feasible, with some modifications of the entry criteria. Trial enrollment was low, likely due to restrictive entry criteria.
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Affiliation(s)
- Daniela B Hauschild
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Luna D A Oliveira
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Mirelle S Farias
- Nutrition, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Eliana Barbosa
- Nutrition, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Nilzete L Bresolin
- Pediatric Intensive Care Unit, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Yara M F Moreno
- Department of Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
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van Puffelen E, Vanhorebeek I, Joosten KFM, Wouters PJ, Van den Berghe G, Verbruggen SCAT. Early versus late parenteral nutrition in critically ill, term neonates: a preplanned secondary subgroup analysis of the PEPaNIC multicentre, randomised controlled trial. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:505-515. [PMID: 30169323 DOI: 10.1016/s2352-4642(18)30131-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/05/2018] [Accepted: 04/06/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous randomised studies showed that withholding parenteral nutrition for 1 week of critical illness was superior to early initiation (<24-48 h) of parenteral nutrition in children and adults. However, neonates are considered more susceptible to macronutrient deficits. We investigated the effect of withholding parenteral nutrition for 1 week in critically ill, term neonates. METHODS We previously did a randomised, controlled study (PEPaNIC) of children aged up to 17 years admitted to paediatric intensive-care units (ICUs) in three hospitals in Belgium, Canada, and the Netherlands randomly assigned (1:1) to either standard care of parenteral nutrition initiated early within 24 h of admission to an ICU or late parenteral nutrition (where supplemental parenteral nutrition was withheld for 1 week after admission to the ICU). In this preplanned, secondary subanalysis of PEPaNIC, we looked at data from critically ill, term neonate participants (gestational age ≥37 weeks) aged up to 28 days (studied in overlapping age groups of ≤4 weeks, ≤1 week, and <1 day-ie, age at admission). In both the early parenteral nutrition and late parenteral nutrition groups, enteral nutrition was initiated as soon as possible and increased according to local protocols. Outcome assessors and investigators not directly involved in the paediatric ICU were not informed of treatment allocation. The primary endpoints were incidence of new infections and duration of paediatric ICU dependency (quantified as the number of days in the paediatric ICU and likelihood of earlier live discharge from the ICU), analysed based on intention to treat. Multivariable analyses were adjusted for the following risk factors: centre, Paediatric Logistic Organ Dysfunction score, Paediatric Index of Mortality 2 score, diagnosis group, and weight-for-age Z scores on admission. Secondary safety outcomes were mortality (at 90 days, during the intervention, in the paediatric ICU, and in the hospital) and hypoglycaemic incidents during the intervention. All patients in the respective groups were included in the safety analysis. FINDINGS Between June 18, 2012, and July 27, 2015, we included 209 participants in this substudy, 145 of whom were aged up to and including 1 week and 45 aged younger than 1 day. In neonates aged up to and including 4 weeks, late parenteral nutrition increased the likelihood of earlier live discharge from the paediatric ICU compared with early parenteral nutrition (adjusted hazard ratio [HR] 1·61, 95% CI 1·19-2·20; p=0·0021) but did not affect the risk of infection. The risk of infection in neonates aged up to and including 1 week and younger than 1 day was lower with late parenteral nutrition than with early parenteral nutrition (adjusted odds ratios [OR] 0·36, 95% CI 0·15-0·83, p=0·017; and 0·10, 0·01-0·64, p=0·015, respectively). For neonates aged up to and including 1 week, the likelihood of an earlier live discharge from the ICU was higher with late parenteral nutrition (adjusted HR 1·69, 95% CI 1·16-2·46; p=0·0063). For neonates younger than 1 day, adjusted HR was 1·95 (95% CI 0·93-4·12; p=0·078). Mortality at all studied timepoints was similar between the groups for all ages; however, in neonates aged up to and including 4 weeks and aged up to and including 1 week, the risk of hypoglycaemia was higher with late parenteral nutrition (23% vs 14%; adjusted OR 3·05, 95% CI 1·27-7·35, p=0·013; and 24% vs 14%; 3·57, 1·23-10·45, p=0·019, respectively. INTERPRETATION In critically ill, term neonates, withholding parenteral nutrition for 1 week was clinically superior to standard care of initiating parenteral nutrition within 24 h for short-term outcomes. However, withholding parenteral nutrition for 1 week significantly increased the risk of developing hypoglycaemia, which necessitates long-term follow-up of these children before late parenteral nutrition can be confidently recommended for this vulnerable patient group. FUNDING Flemish Agency for Innovation through Science and Technology, Methusalem-Programme Flemish Government, European Research Council, Fonds NutsOhra, Stichting Agis-Zorginnovatie, and the Sophia Research-Foundation.
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Affiliation(s)
- Esther van Puffelen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Pieter J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, Netherlands.
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Abstract
PURPOSE OF REVIEW Nutritional status and nutrient delivery during critical illness impact clinical outcomes. We have reviewed recent studies that may guide best practices regarding nutrition therapy in critically ill children. RECENT FINDINGS Malnutrition is prevalent in the pediatric ICU population, and is associated with worse outcomes. Nutrition support teams, dedicated dietitians, and educational programs facilitate surveillance for existing malnutrition and nutrition risk, but specific tools for the pediatric ICU population are lacking. Estimation of macronutrient requirements is often inaccurate; novel strategies to accurately determine energy expenditure are being explored. Indirect calorimetry remains the reference method for measuring energy expenditure. Enteral nutrition is the preferred route for nutrition in patients with a functioning gut. Early enteral nutrition and delivery of adequate macronutrients, particularly protein, have been associated with improved clinical outcomes. Delivery of enteral nutrition is often interrupted because of fasting around procedures and perceived intolerance. Objective measures for detection and management of intolerance to nutrient intake are required. In low-risk patients who are able to tolerate enteral nutrition, supplemental parenteral nutrition may be delayed during the first week of critical illness. SUMMARY Systematic research and consensus-based practices are expected to promote optimal nutritional practices in critically ill children with the potential to improve clinical outcomes.
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Fullerton BS, Sparks EA, Khan FA, Fisher JG, Anzaldi R, Scoville MR, Yu YM, Wagner DA, Jaksic T, Mehta NM. Whole Body Protein Turnover and Net Protein Balance After Pediatric Thoracic Surgery: A Noninvasive Single-Dose 15 N Glycine Stable Isotope Protocol With End-Product Enrichment. JPEN J Parenter Enteral Nutr 2018; 42:361-370. [PMID: 29443397 DOI: 10.1177/0148607116678831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/20/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND We used the 15 N glycine urinary end-product enrichment technique to quantify whole body protein turnover following thoracic surgery. MATERIALS AND METHODS A single dose of 15 N glycine (2 mg/kg) was administered orally on postoperative day 1 to children (1-18 years) following thoracic surgery. 15 N enrichment of ammonia and urea was measured in mixed urine after 12 and 24 hours, respectively, and protein synthesis, breakdown, and net balance determined. Nitrogen balance (dietary intake minus urinary excretion) was calculated. Urinary 3-methylhistidine:creatinine ratio was measured as a marker of skeletal muscle protein breakdown. RESULTS We enrolled 19 subjects-median (interquartile range): age, 13.8 years (12.2-15.1); weight, 49.2 kg (38.4-60.8)-who underwent thoracotomy (n = 12) or thoracoscopic (n = 7) surgery. Protein synthesis and breakdown by 15 N enrichment were 7.1 (5.5-9) and 7.1 (5.6-9) g·kg-1 ·d-1 with ammonia (12 hours) as the end product, and 5.8 (3.8-6.7) and 6.7 (4.5-7.6) with urea (24 hours), respectively. Net protein balance by the 15 N glycine and urinary urea nitrogen methods were -0.34 (-0.47, -0.3) and -0.48 (-0.65, -0.28) g·kg-1 ·d-1 , respectively (rs = 0.828, P < .001). Postoperative change in 3-methylhistidine:creatinine ratio did not correlate significantly with protein breakdown or balance. CONCLUSION The single-dose oral administration of 15 N glycine stable isotope with measurement of urinary end-product enrichment is a feasible and noninvasive method to investigate whole body protein turnover in children. After major surgery, children manifest increased protein turnover and net negative balance due to increased protein breakdown.
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Affiliation(s)
- Brenna S Fullerton
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eric A Sparks
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Faraz A Khan
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy G Fisher
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rocco Anzaldi
- Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael R Scoville
- Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Yong-Ming Yu
- Department of Surgery, Shriner Burns Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Tom Jaksic
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Division of Critical Care, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Arabi YM, Aldawood AS, Al-Dorzi HM, Tamim HM, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakkijha MH, Sadat M, Mundekkadan S, Kumar A, Bagshaw SM, Mehta S. Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial. Am J Respir Crit Care Med 2017; 195:652-662. [PMID: 27589411 DOI: 10.1164/rccm.201605-1012oc] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE The optimal nutritional strategy for critically ill adults at high nutritional risk is unclear. OBJECTIVES To examine the effect of permissive underfeeding with full protein intake compared with standard feeding on 90-day mortality in patients with different baseline nutritional risk. METHODS This is a post hoc analysis of the PermiT (Permissive Underfeeding versus Target Enteral Feeding in Adult Critically Ill Patients) trial. MEASUREMENTS AND MAIN RESULTS Nutritional risk was categorized by the modified Nutrition Risk in Critically Ill score, with high nutritional risk defined as a score of 5-9 and low nutritional risk as a score of 0-4. Additional analyses were performed by categorizing patients by body mass index, prealbumin, transferrin, phosphate, urinary urea nitrogen, and nitrogen balance. Based on the Nutrition Risk in Critically Ill score, 378 of 894 (42.3%) patients were categorized as high nutritional risk and 516 of 894 (57.7%) as low nutritional risk. There was no association between feeding strategy and mortality in the two categories; adjusted odds ratio (aOR) of 0.84 (95% confidence interval [CI], 0.56-1.27) for high nutritional risk and 1.01 (95% CI, 0.64-1.61) for low nutritional risk (interaction P = 0.53). Findings were similar in analyses using other definitions, with the exception of prealbumin. The association of permissive underfeeding versus standard feeding and 90-day mortality differed when patients were categorized by baseline prealbumin level (≤0.10 g/L: aOR, 0.57 [95% CI, 0.31-1.05]; >0.10 and ≤0.15 g/L: aOR, 0.79 [95% CI, 0.42-1.48]; >0.15 g/L: aOR, 1.55 [95% CI, 0.80, 3.01]; interaction P = 0.009). CONCLUSIONS Among patients with high and low nutritional risk, permissive underfeeding with full protein intake was associated with similar outcomes as standard feeding.
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Affiliation(s)
- Yaseen M Arabi
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulaziz S Aldawood
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hani M Tamim
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,2 Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samir H Haddad
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Gwynne Jones
- 3 Division of Critical Care Medicine, Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lauralyn McIntyre
- 3 Division of Critical Care Medicine, Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Othman Solaiman
- 4 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maram H Sakkijha
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Shihab Mundekkadan
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Anand Kumar
- 5 Section of Critical Care Medicine, Health Sciences Centre, University of Manitoba, Manitoba, Canada
| | - Sean M Bagshaw
- 6 Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sangeeta Mehta
- 7 Interdepartmental Division of Critical Care Medicine, Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada; and.,8 Mount Sinai Hospital, Toronto, Canada
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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: 116] [Impact Index Per Article: 16.6] [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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Ong C, Lee JH. Protein provision in the critically ill child: is less more? THE LANCET RESPIRATORY MEDICINE 2017; 5:458-459. [PMID: 28522350 DOI: 10.1016/s2213-2600(17)30175-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 04/28/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore 229899.
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore; Duke-NUS School of Medicine, Singapore
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Hauschild DB, Ventura JC, Mehta NM, Moreno YMF. Impact of the structure and dose of protein intake on clinical and metabolic outcomes in critically ill children: A systematic review. Nutrition 2017; 41:97-106. [PMID: 28760436 DOI: 10.1016/j.nut.2017.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/10/2017] [Accepted: 04/24/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The aim of this study was to describe the effects of structure/type and total amount of protein intake on protein balance and clinical outcomes in critically ill children. METHODS We conducted a systematic review of relevant literature on Embase, PubMed/Medline, Web of Science, Scopus, and Latin American and Caribbean Health Sciences. A partial gray literature search was undertaken and the reference lists of the selected articles were searched manually. Observational and clinical trials that evaluated the total protein intake, structure of the protein source, or both, in critically ill children were included. Nitrogen balance and clinical outcomes (mortality, length of stay, and duration of mechanical ventilation) were the main outcomes of interest. RESULTS We found 18 eligible studies, of which 17 assessed the quantity and one described protein structure in relation to the outcomes. In all, 2118 pediatric critically ill patients <18 y of age were included. The total daily protein intake ranged from 0.67 to 4.7 g/kg. Average daily total protein intake >1.1 g/kg, especially >1.5 g/kg, was associated with positive protein balance and lower mortality. CONCLUSION In critically ill children, total daily protein intake >1.1 g/kg was associated with positive effects on clinical outcomes and protein balance. The existing data are not sufficient for determining the optimal structure of protein delivered by enteral route in critically ill children.
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Affiliation(s)
- Daniela B Hauschild
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Julia C Ventura
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Yara M F Moreno
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil.
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Hurt RT, McClave SA, Martindale RG, Ochoa Gautier JB, Coss-Bu JA, Dickerson RN, Heyland DK, Hoffer LJ, Moore FA, Morris CR, Paddon-Jones D, Patel JJ, Phillips SM, Rugeles SJ, Sarav, MD M, Weijs PJM, Wernerman J, Hamilton-Reeves J, McClain CJ, Taylor B. Summary Points and Consensus Recommendations From the International Protein Summit. Nutr Clin Pract 2017; 32:142S-151S. [DOI: 10.1177/0884533617693610] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Ryan T. Hurt
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Stephen A. McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Robert G. Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Juan B. Ochoa Gautier
- Nestlé HealthCare Nutrition, Inc, Florham Park, New Jersey, USA, and the Department of Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Jorge A. Coss-Bu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Roland N. Dickerson
- Department of Clinical Pharmacology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - L. John Hoffer
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Claudia R. Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Douglas Paddon-Jones
- School of Health Professions, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jayshil J. Patel
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stuart M. Phillips
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Saúl J. Rugeles
- Department of Surgery, Pontificia Universidad Javeriana Medical School, Hospital Universitario San Ignacio, Bogota, Colombia
| | - Menaka Sarav, MD
- Department of Medicine, Northshore University Health System, Evanston, Illinois, USA
| | - Peter J. M. Weijs
- Department of Medicine, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Jan Wernerman
- Department of Clinical Science, Karolinska University, Stockholm, Sweden
| | - Jill Hamilton-Reeves
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Craig J. McClain
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Beth Taylor
- Department of Food and Nutrition, Barnes-Jewish Hospital, St Louis, Missouri, USA
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Coss-Bu JA, Hamilton-Reeves J, Patel JJ, Morris CR, Hurt RT. Protein Requirements of the Critically Ill Pediatric Patient. Nutr Clin Pract 2017; 32:128S-141S. [PMID: 28388381 DOI: 10.1177/0884533617693592] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This article includes a review of protein needs in children during health and illness, as well as a detailed discussion of protein metabolism, including nitrogen balance during critical illness, and assessment and prescription/delivery of protein to critically ill children. The determination of protein requirements in children has been difficult and challenging. The protein needs in healthy children should be based on the amount needed to ensure adequate growth during infancy and childhood. Compared with adults, children require a continuous supply of nutrients to maintain growth. The protein requirement is expressed in average requirements and dietary reference intake, which represents values that cover the needs of 97.5% of the population. Critically ill children have an increased protein turnover due to an increase in whole-body protein synthesis and breakdown with protein degradation leading to loss of lean body mass (LBM) and development of growth failure, malnutrition, and worse clinical outcomes. The results of protein balance studies in critically ill children indicate higher protein needs, with infants and younger children requiring higher intakes per body weight compared with older children. Monitoring the side effects of increased protein intake should be performed. Recent studies found a survival benefit in critically ill children who received a higher percentage of prescribed energy and protein goal by the enteral route. Future randomized studies should evaluate the effect of protein dosing in different age groups on patient outcomes, including LBM, muscle structure and function, duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality.
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Affiliation(s)
- Jorge A Coss-Bu
- 1 Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,2 Texas Children's Hospital, Houston, Texas, USA
| | - Jill Hamilton-Reeves
- 3 Department of Dietetics & Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jayshil J Patel
- 4 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claudia R Morris
- 5 Department of Pediatrics, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ryan T Hurt
- 6 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Use of Indirect Calorimetry to Detect Overfeeding in Critically Ill Children: Finding the Appropriate Definition. J Pediatr Gastroenterol Nutr 2016; 63:445-50. [PMID: 26998927 DOI: 10.1097/mpg.0000000000001197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Overfeeding during critical illness is associated with adverse effects such as metabolic disturbances and increased risk of infection. Because of the lack of sound studies with clinical endpoints, overfeeding is arbitrarily defined as the ratio caloric intake/measured resting energy expenditure (mREE) or alternatively as a comparison of measured respiratory quotient (RQ) to the predicted RQ based on the macronutrient intake (RQmacr). We aimed to compare definitions of overfeeding in critically ill mechanically ventilated children based on mREE, RQ, and caloric intake to find an appropriate definition. METHODS Indirect calorimetry measurements were performed in 78 mechanically ventilated children, median age 6.3 months. Enteral and/or parenteral nutrition was provided according to the local guidelines. Definitions used to indicate overfeeding were the ratio caloric intake/mREE of >110% and >120% and by the measured RQ > RQmacr + 0.05. RESULTS The proportion of patients identified as overfed varied widely depending on the definition used, ranging from 22% (RQ > RQmacr + 0.05), to 40% and 50% (caloric intake/mREE of >120% and >110%, respectively). Linear regression analysis showed that all patients would be identified as overfed with the definition RQ > RQmacr + 0.05 when the ratio caloric intake/mREE exceeded 165%. Caloric intake was higher in children with a standard deviation-score weight for age <-2. CONCLUSIONS The proportion of mechanically ventilated patients identified as overfed ranged widely depending on the definition applied. These currently used definitions fail to take into account several relevant factors affecting metabolism during critical illness and are therefore not generally applicable to the pediatric intensive care unit population.
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Moreno YMF, Hauschild DB, Barbosa E, Bresolin NL, Mehta NM. Problems With Optimal Energy and Protein Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2016; 31:673-80. [DOI: 10.1177/0884533616639125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Yara M. F. Moreno
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Daniela B. Hauschild
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Eliana Barbosa
- Joana de Gusmão Children’s Hospital, Florianópolis, Brazil
| | | | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Wu W, Zhong M, Zhu DM, Song JQ, Huang JF, Wang Q, Tan LJ. Effect of Early Full-Calorie Nutrition Support Following Esophagectomy: A Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2016; 41:1146-1154. [PMID: 27208039 DOI: 10.1177/0148607116651509] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Wei Wu
- Intensive Care Unit, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
| | - Ming Zhong
- Intensive Care Unit, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
| | - Du-ming Zhu
- Intensive Care Unit, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
| | - Jie-qiong Song
- Intensive Care Unit, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
| | - Jun-feng Huang
- Intensive Care Unit, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
| | - Qun Wang
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
| | - Li-jie Tan
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Shanghai Fudan University School of Medicine, Shanghai, China
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Wong JJM, Cheifetz IM, Ong C, Nakao M, Lee JH. Nutrition Support for Children Undergoing Congenital Heart Surgeries: A Narrative Review. World J Pediatr Congenit Heart Surg 2016; 6:443-54. [PMID: 26180163 DOI: 10.1177/2150135115576929] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative period where improvements in nutrition status will likely impact surgical outcomes.
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Affiliation(s)
- Judith J M Wong
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Ira M Cheifetz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore
| | - Masakazu Nakao
- Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore Office of Clinical Sciences, Duke-NUS Graduate School of Medicine, Singapore
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Wong JJM, Han WM, Sultana R, Loh TF, Lee JH. Nutrition Delivery Affects Outcomes in Pediatric Acute Respiratory Distress Syndrome. JPEN J Parenter Enteral Nutr 2016; 41:1007-1013. [PMID: 26962064 DOI: 10.1177/0148607116637937] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Malnutrition is prevalent in critically ill children. We aim to describe nutrition received by children with acute respiratory distress syndrome (ARDS) and to determine whether provision of adequate nutrition is associated with improved clinical outcomes. MATERIALS AND METHODS We studied characteristics and outcomes of 2 groups of patients: (1) those who received adequate calories (defined as ≥80% of predicted resting energy expenditure) and (2) those who received adequate protein (defined as ≥1.5g/kg/d of protein). Outcomes of interest were mortality, ventilator-free days (VFDs), intensive care unit (ICU)-free days, multiorgan dysfunction, and need for extracorporeal membrane oxygenation. Categorical variables were analyzed using the Fisher exact test, and continuous variables were analyzed using the Mann-Whitney U test. Univariate and multivariate logistic regression models were used to identify associated risk factors related to these outcomes of interest. RESULTS In total, 107 patients with ARDS were identified. There was a reduction in ICU mortality in patients who received adequate calories (34.6% vs 60.5%, P = .025) and adequate protein (14.3% vs 60.2%, P = .002) compared with those that did not. Patients with adequate protein intake also had more VFDs (median [interquartile range], 12 [3.0-19.0] vs 0 [0.0-14.8] days; P = .005). After adjusting for severity of illness, adequate protein remained significantly associated with decreased mortality (adjusted odds ratio [95% confidence interval], 0.09 [0.01-0.94]; P = .044). CONCLUSION Our study demonstrated that adequate nutrition delivery in children with ARDS was associated with improved clinical outcomes. Protein delivery may have potentially more impact than overall caloric delivery.
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Affiliation(s)
| | - Wee Meng Han
- 2 Department of Department of Nutrition & Dietetics, KK Women's and Children's Hospital, Singapore
| | - Rehena Sultana
- 3 Centre for Quantitative Medicine, Duke-NUS Medical School, The Academia, 169856, Singapore
| | - Tsee Foong Loh
- 4 Children's Intensive Care Unit, Department of Pediatric Subspecialities, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- 4 Children's Intensive Care Unit, Department of Pediatric Subspecialities, KK Women's and Children's Hospital, Singapore.,5 Office of Clinical Sciences, Duke-NUS School of Medicine, The Academia, 169856, Singapore
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Abstract
PURPOSE OF REVIEW Muscle wasting is dramatic in critically ill patients and related to worsened outcome. The question is whether this can be prevented or reduced by adequate protein feeding. Recommendations for protein requirements are different between different societies, because of limited and weak evidence. Most studies, on which these recommendations are based, use nitrogen balance as primary outcome. However, nitrogen balance to estimate protein needs over short periods, is not reliable. RECENT FINDINGS Studies using tracer methodology to assess the effects of feeding on whole-body protein synthesis, breakdown and balance, show that both adult and pediatric critically ill patients can utilize parenterally and enterally given proteins or amino acids to build body protein, and that the extra amino acids are not oxidized. SUMMARY Recent studies show a positive correlation between protein intake and protein balance, with many patients reaching a positive protein balance. However, many questions remain. Especially whether adult patients should have a constant positive protein balance, whether the route of administration affects utilization, which proteins are synthesized and whether these are beneficial, is more protein better and what is the upper limit, and whether a positive protein balance affects clinical outcome?
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Affiliation(s)
- Felix Liebau
- Department of Anesthesiology and Intensive Care, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW This article describes the current best available evidence on optimal nutrition in the paediatric intensive care based on different levels of outcome, which can be divided in surrogate and hard clinical outcome parameters. RECENT FINDINGS Undernutrition is associated with increased morbidity and mortality, whereas in specific cohorts of critically ill children, such as those with burn injury, obesity is associated with more complications, longer length of stay, and decreased likelihood of survival. There is a relation with adequacy of delivery of enteral nutrition and the amount of protein on length of hospital stay, neurological status, and mortality. Studies relating organ function, other than skin healing after thermal injury, with the nutritional status are scarce. There is also a scarcity of data concerning long-term follow-up and health economics. SUMMARY Until now, there are no randomized controlled trials which have investigated a causal relation between different feeding regimens on the nutritional status and short and long-term outcome. As a result current optimal nutritional strategies are based on small trials with surrogate outcome parameters. Prospective randomized studies are needed with nutritional and/or metabolic interventions to come to an optimal feeding strategy for critically ill children.
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Affiliation(s)
- Koen Joosten
- ErasmusMC-Sophia Children's Hospital, Department of Paediatric Intensive Care, Dr Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
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Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
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Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
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49
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Abstract
OBJECTIVE Delayed enteral nutrition, defined as enteral nutrition started 48 hours or more after admission to the PICU, is associated with an inability to achieve full enteral nutrition and worse outcomes in critically ill children. We reviewed nutritional practices in six medical-surgical PICUs and determined risk factors associated with delayed enteral nutrition in critically ill children. DESIGN Retrospective cross-sectional study using medical records as source of data. SETTING Six medical-surgical PICUs in northeastern United States. PATIENTS Children less than 21 years old admitted to the PICU for 72 hours or more excluding those awaiting or recovering from abdominal surgery. MEASUREMENTS AND MAIN RESULTS A total of 444 children with a median age of 4.0 years were included in the study. Enteral nutrition was started at a median time of 20 hours after admission to the PICU. There was no significant difference in time to start enteral nutrition among the PICUs. Of those included, 88 children (19.8%) had delayed enteral nutrition. Risk factors associated with delayed enteral nutrition were noninvasive (odds ratio, 3.37; 95% CI, 1.69-6.72) and invasive positive-pressure ventilation (odds ratio, 2.06; 95% CI, 1.15-3.69), severity of illness (odds ratio for every 0.1 increase in pediatric index of mortality 2 score, 1.39; 95% CI, 1.14-1.71), procedures (odds ratio, 3.33; 95% CI, 1.67-6.64), and gastrointestinal disturbances (odds ratio, 2.05; 95% CI, 1.14-3.68) within 48 hours after admission to the PICU. Delayed enteral nutrition was associated with failure to reach full enteral nutrition while in the PICU (odds ratio, 4.09; 95% CI, 1.97-8.53). Nutrition consults were obtained in less than half of the cases, and none of the PICUs used tools to assure the adequacy of energy and protein nutrition. CONCLUSIONS Institutions in this study initiated enteral nutrition for a high percentage of patients by 48 hours of admission. Noninvasive positive-pressure ventilation was most strongly associated with delay enteral nutrition. A better understanding of these risk factors and assessments of nutritional requirements should be explored in future prospective studies.
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Abstract
Nutrition is an essential component of patient management in the pediatric intensive care unit (PICU). Poor nutrition status accompanies many childhood chronic illnesses. A thorough assessment of the critically ill child is required to inform the plan for nutrition support. Accurate and clinically relevant nutritional assessment, including growth measurements, provides important guidance. Indirect calorimetry provides the most accurate measurement of resting energy expenditure, but is too often unavailable in the PICU. To prevent inappropriate caloric intake, reassessment of the child's nutrition status is imperative. Enteral nutrition is the recommended route of intake. Human milk is preferred for infants.
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Affiliation(s)
- Judy Verger
- Pediatric Acute Care Nurse Practitioner Program, Critical Care Department, School of Nursing, Children's Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA; Pediatric Clinical Nurse Specialist Program, Critical Care Department, School of Nursing, Children's Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA; Neonatal Clinical Nurse Specialist Program, Critical Care Department, School of Nursing, Children's Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA.
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