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Zevallos MSC, Jara KSS, Ramírez CAC, Carreazo NY. Impact of Early Enteral Nutrition on the Hospital Stay of Pediatric Patients Undergoing Mechanical Ventilation. J Pediatr Intensive Care 2024; 13:147-154. [PMID: 38919690 PMCID: PMC11196157 DOI: 10.1055/s-0042-1744296] [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: 10/19/2021] [Accepted: 01/27/2022] [Indexed: 10/18/2022] Open
Abstract
Early initiation of enteral nutrition (EN) in pediatrics has been associated with improved clinical outcomes in critically ill pediatric patients. This research study aimed to measure the effect of early EN in intubated children on the length of stay (LOS) and days of mechanical ventilation (DMV). A retrospective cohort observational study was performed on patients admitted to the pediatric intensive care unit (PICU). We gathered the information from available medical records. Our exposure variable was EN, which can be classified as either early-onset (less than 72 hours following PICU admission) or late-onset (greater than or equal to 72 hours following PICU admission). The response variables were LOS defined as the period of time from either hospital or PICU admission to the time of hospital discharge and DMV defined as the length of time from endotracheal intubation to successful extubation. Late EN was associated with an increase in both hospital LOS consisting of 9.82 days and PICU LOS consisting of 5.89 days, and DMV consisting of 3.92 days compared with those patients receiving early EN. In addition, the disruption of EN was also associated with an increased hospital LOS consisting of 10.7 days. Patients in the PICU, undergoing mechanical ventilation, who received late EN have an increased risk of unfavorable outcomes consisting of prolonged hospital LOS, PICU-LOS, and DMV which may be further aggravated by any disruption of EN.
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Affiliation(s)
| | | | | | - Nilton Yhuri Carreazo
- School of Medicine, Universidad Peruana de Ciencias Aplicadas, Santiago de Surco, Peru
- Intensive Care Unit, Hospital de Emergencias Pediatricas, Lima, Peru
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2
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Winderlich J, Little B, Oberender F, Bollard T, Farrell T, Jenkins S, Landorf E, McCall A, Menzies J, O'Brien K, Rowe C, Sim K, van der Wilk M, Woodgate J, Paul E, Udy AA, Ridley EJ. Nutrition provision in Australian and New Zealand PICUs: A prospective observational cohort study (ePICUre). Nutrition 2024; 118:112261. [PMID: 37984244 DOI: 10.1016/j.nut.2023.112261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES The main aim of this study was to describe nutrition provision in Australian and New Zealand (ANZ) pediatric intensive care units (PICUs), including mode of nutrition and adequacy of enteral nutrition (EN) to PICU day 28. Secondary aims were to determine the proportion of children undergoing dietetics assessment, the average time to this intervention, and the methods for estimation of energy and protein requirements. METHODS This observational study was conducted in all ANZ tertiary-affiliated specialist PICUs. All children ≤18 y of age admitted to the PICU over a 2-wk period and remaining for ≥48 h were included. Data were collected on days 1 to 7, 14, 21, and 28 (unless discharged prior). Data points included oral intake, EN and parenteral nutrition support, estimated energy and protein adequacy, and dietetics assessment details. RESULTS We enrolled 141 children, of which 79 were boys (56%) and 84 were <2 y of age (60%). Thirty children (73%) received solely EN on day 7 with documented energy and protein targets for 22 (73%). Of these children, 14 (64%) received <75% of their estimated requirements. A dietetics assessment was provided to 80 children (57%), and was significantly higher in those remaining in the PICU beyond the median length of stay (41% in patients staying ≤4.6 d versus 72% in those staying >4.6 d; P < 0.001). CONCLUSIONS This prospective study of nutrition provision across ANZ PICUs identified important areas for improvement, particularly in EN adequacy and nutrition assessment. Further research to optimize nutrition provision in this setting is urgently needed.
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Affiliation(s)
- Jacinta Winderlich
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Nutrition and Dietetics, Monash Children's Hospital, Melbourne, Australia; Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia.
| | - Bridget Little
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Tessa Bollard
- Nutrition and Dietetics, Sydney Children's Hospital, Randwick, Australia
| | - Tamara Farrell
- Nutrition & Dietetics Department, Perth Children's Hospital, Perth, Australia
| | - Samantha Jenkins
- Nutrition and Dietetics, John Hunter Children's Hospital, New Lambton Heights, Australia
| | - Emma Landorf
- Nutrition Department, Women's & Children's Hospital, Adelaide, Australia
| | - Andrea McCall
- Nutrition Department, Women's & Children's Hospital, Adelaide, Australia
| | - Jessica Menzies
- Nutrition and Dietetics, Sydney Children's Hospital, Randwick, Australia
| | - Katie O'Brien
- Department of Nutrition & Food Services, The Royal Children's Hospital, Melbourne, Australia
| | - Carla Rowe
- Nutrition & Dietetics, The Children's Hospital at Westmead, Westmead, Australia
| | - Kirsten Sim
- Nutrition & Dietetics, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Jemma Woodgate
- Department of Dietetics & Foodservices, Queensland Children's Hospital, Brisbane, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Dietetics and Nutrition, Alfred Health, Melbourne, Australia
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3
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Tasker RC. Editor's Choice Articles for December. Pediatr Crit Care Med 2023; 24:983-986. [PMID: 38055000 DOI: 10.1097/pcc.0000000000003396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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4
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Haseeb M, Goiporia MH, Siddiqui MS, Sangle AL, Quadri SF, Ravali RL. Challenges Encountered in the Provision of Enteral Nutrition in Pediatric Intensive Care Unit: An Observational Study. Cureus 2023; 15:e49285. [PMID: 38143607 PMCID: PMC10747421 DOI: 10.7759/cureus.49285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Background Enteral nutrition (EN) represents the preferred modality for nutrient administration in critically ill patients. However, it is fraught with challenges such as delayed initiation and recurrent interruptions, which can significantly impact patient clinical outcomes. A substantial proportion of these interruptions can be mitigated. In the present investigation, our objective was to scrutinize the practice of EN in the Pediatric Intensive Care Unit (PICU). We sought to ascertain the frequency and underlying causes of EN interruptions and assess their ramifications for nutrient delivery. Study design We conducted an observational study within the PICU of Mahatma Gandhi Mission's (MGM) Medical College and Hospital, Aurangabad. The study encompassed children admitted to the PICU for a period exceeding 24 hours who were receiving enteral feeds. We documented the time of commencing EN from the point of PICU admission, instances of enteral feeding interruptions, the number and duration of each interruption episode, and the reasons behind these interruptions. Subsequently, we categorized the causes of feeding interruptions into avoidable and non-avoidable determinants. Results Out of the 100 patients enrolled in this study, only 34% presented with normal nutritional status upon admission. Sixty-five percent of patients had their nutritional support initiated within the first 48 hours of admission to the PICU. The median duration from PICU admission to the initiation of EN was 32.5 hours, with a median interruption duration per patient of 40.96 hours. Common causes of interruptions included radiological procedures, respiratory distress, altered sensorium, presence of gastric aspirates, and surgical procedures. Upon analysis, it was determined that a substantial majority, constituting 74%, of these interruptions were avoidable. Conclusions The primary challenges associated with EN in the PICU encompass delayed initiation of enteral feeds and frequent interruptions. Importantly, a significant proportion of these issues are avoidable.
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Affiliation(s)
- Mohammad Haseeb
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Mahafrin H Goiporia
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Mohd Saeed Siddiqui
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Avinash L Sangle
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Syed F Quadri
- Department of Public Health, John Snow, Inc. (JSI), Delhi, IND
| | - Ramula L Ravali
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
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5
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Fell DM, Bitetto EA, Skillman HE. Timing of enteral nutrition and parenteral nutrition in the PICU. Nutr Clin Pract 2023; 38 Suppl 2:S174-S212. [PMID: 37721466 DOI: 10.1002/ncp.11050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.
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Affiliation(s)
- Donna M Fell
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Emily A Bitetto
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
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6
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Irving SY, Berry KG, Morgan S, Seiple SM, Nagle ML, Stetzer M, Tabatabaei N, Murphy S, Srinivasan V, Mascarenhas M. Nutrition association with skin integrity and pressure injury in critically ill pediatric patients. Nutr Clin Pract 2023; 38 Suppl 2:S125-S138. [PMID: 37721464 DOI: 10.1002/ncp.11063] [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: 06/29/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Current research highlights the positive impact of nutrition therapy, particularly enteral nutrition, in critical illness. However, little attention is given to the impact of nutrition on skin integrity during critical illness. Skin integrity is at risk in critically ill children owing to necessary clinical therapies and challenges of providing nutrition therapy. METHODS We conducted a narrative literature review with three main thematic concepts to drive our literature search: the association of nutrition therapy with (1) skin integrity; (2) injury, wounds, and wound healing; and (3) differences of skin color. Using pertinent search and subject terms, PubMed, CINAHL, EMBASE, and SCOPUS databases were searched, yielding 316 articles. After removal of duplicates, articles were reviewed based on inclusion and exclusion criteria defined by the authors; only eight articles met the defined criteria to inform this review. RESULTS Large and important gaps exist in the current literature regarding an association between nutrition therapy, skin injury, and wound healing. Little to no attention was found for associations with skin color. The resulting narrative review addresses these topics and subtopics with additional references included that are independent of the original search strategy. CONCLUSIONS A dearth of evidence exists describing associations between nutrition and disruption of skin integrity in pediatric critical illness. Children with dark skin are at increased risk, as manifestation and identification of disruption to skin integrity may not be recognized. Research is needed to describe these associations and the impact of nutrition on skin integrity, including differences of skin color.
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Affiliation(s)
- Sharon Y Irving
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Department of Nursing and Clinical Care Services, Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Katarina G Berry
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sherry Morgan
- Holman Biotech Commons, Robert Wood Johnson Pavilion, Philadelphia, Pennsylvania, USA
| | - Stephanie M Seiple
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Monica L Nagle
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Stetzer
- Wound Ostomy and Vascular Access Services, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Neeka Tabatabaei
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara Murphy
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Vijay Srinivasan
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maria Mascarenhas
- Department of Clinical Nutrition, Division of Gastroenterology and Nutrition, Philadelphia, Pennsylvania, USA
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7
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Touré I, Maitre G, Boillat L, Chanez V, Natterer J, Ferry T, Longchamp D, Perez MH. Implementing a physician-driven feeding protocol is not sufficient to achieve adequate caloric and protein delivery in a paediatric intensive care unit: A retrospective cohort study. Clin Nutr ESPEN 2023; 55:384-391. [PMID: 37202072 DOI: 10.1016/j.clnesp.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND AIMS Daily caloric and protein intake is crucial for the management of critically ill children. The benefit of feeding protocols in improving daily nutritional intake in children remains controversial. This study aimed to assess whether the introduction of an enteral feeding protocol in a paediatric intensive care unit (PICU) improves daily caloric and protein delivery on day 5 after admission and the accuracy of the medical prescription. METHODS Children admitted to our PICU for a minimum of 5 days who received enteral feeding were included. Daily caloric and protein intake were recorded and retrospectively compared before and after the introduction of the feeding protocol. RESULTS Caloric and protein intake was similar before and after introduction of the feeding protocol. The prescribed caloric target was significantly lower than the theoretical target. The children who received less than 50% of the caloric and protein targets were significantly heavier and taller than those who received more than 50%; the patients who received more than 100% of the caloric and protein aims on day 5 after admission had a decreased PICU length of stay and decreased duration of invasive ventilation. CONCLUSION The introduction of a physician-driven feeding protocol was not associated with an increase in the daily caloric or protein intake in our cohort. Other methods of improving nutritional delivery and patient outcomes need to be explored.
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Affiliation(s)
- Ismael Touré
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Guillaume Maitre
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Laurence Boillat
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Vivianne Chanez
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Julia Natterer
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Thomas Ferry
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - David Longchamp
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Maria-Helena Perez
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
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8
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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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9
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Liauchonak S, Hamilton S, Franks JD, Callif C, Akhondi-Asl A, Ariagno K, Mehta NM, Martinez EE. Impact of implementing an evidence-based definition of enteral nutrition intolerance on nutrition delivery: A prospective, cross-sectional cohort study. Nutr Clin Pract 2023; 38:376-385. [PMID: 36541429 PMCID: PMC10023272 DOI: 10.1002/ncp.10941] [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: 06/30/2022] [Revised: 10/28/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) interruptions because of EN intolerance impede nutrient delivery. We aimed to examine whether revising the EN intolerance definition of an algorithm would decrease EN interruptions and improve nutrient delivery in critically ill children. METHODS We performed a cross-sectional cohort study including patients who were admitted to our intensive care unit (ICU) for >24 h and received EN. The EN intolerance definition in our nutrition algorithm was modified to include two symptoms of EN intolerance. We compared time to 60% EN adequacy (EN delivered/EN prescribed x 100) and EN interruptions before and after this intervention. RESULTS We included 150 eligible patients, 78 and 72 patients in the preimplementation and postimplementation cohorts, respectively. There were no significant differences in demographics and clinical characteristics. The preimplementation and postimplementation cohorts achieved 60% EN adequacy 4 (2-5) days and 3 (2-5) days after ICU admission, respectively (P = 0.59). The preimplementation cohort had a median of 1 (1-2) interruption per patient and the postimplementation cohort 2 (1-3; P = 0.08). The frequency of interruptions because of EN intolerance within the first 8 days of ICU admission was 17 in the preimplementation and 10 in the postimplementation cohorts. CONCLUSION Modifying the EN intolerance definition of a nutrition algorithm did not change the time to 60% EN adequacy or total number of EN interruptions in critically ill children. EN intolerance and interruptions continue to limit nutrient delivery. Research on the best definition for EN intolerance and its effect on nutrition outcomes is needed.
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Affiliation(s)
- Siarhei Liauchonak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Susan Hamilton
- Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Jennifer D. Franks
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Katelyn Ariagno
- Center for Nutrition, Department of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Center for Nutrition, Department of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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10
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Solana MJ, Slocker M, Martínez de Compañon Z, Olmedilla M, Miñambres M, Reyes S, Fernández R, Rodríguez E, Redondo S, Díaz L, Sánchez M, López-Herce J. Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children. Nutrients 2023; 15:nu15040855. [PMID: 36839213 PMCID: PMC9961435 DOI: 10.3390/nu15040855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.
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Affiliation(s)
- María José Solana
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Departamento de Salud Pública y Materno infantil, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
- Correspondence:
| | - María Slocker
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
| | | | | | - María Miñambres
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Susana Reyes
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Reyes Fernández
- Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Eva Rodríguez
- Hospital Universitario Nuestra Señora de la Candelaria, 38010 Tenerife, Spain
| | | | - Laura Díaz
- Complejo Hospitalario de Navarra, 31008 Pamplona, Spain
| | - María Sánchez
- Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Jesús López-Herce
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Continuous versus Intermittent Enteral Feeding in Critically Ill Children: A Systematic Review. Nutrients 2023; 15:nu15020288. [PMID: 36678158 PMCID: PMC9867148 DOI: 10.3390/nu15020288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Administration of enteral nutrition (EN) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) constitutes a major challenge due to the increased risk of complications, as well as the lack of well-trained healthcare professionals. EN is usually delivered via cyclic, continuous, or intermittent feeding; however, a number of potential barriers have been reported in the literature regarding different feeding regimens. The purpose of this review was to assess the effectiveness of continuous and intermittent bolus feeding on critically ill children. A systematic search was conducted in PubMed, Scopus Cochrane Central Register of Controlled Trials (CENTRAL) and a clinical trial registry up to September 2022, including randomized controlled trials (RCTs) published in the English language. Four studies met the inclusion criteria with a total population of 288 patients admitted to the PICU. Three studies were rated with a high risk of bias and one with some concerns. There was high heterogeneity between the studies in regard to the reporting of outcomes. Three studies measured the total time needed to reach prescribed caloric intake with conflicting results, while two studies evaluated the length of stay (LOS) in PICU with no difference between the two arms. One study assessed the time weaning from mechanical ventilation, favoring the bolus group. No data were provided for gastric residual volume (GRV), anthropometric measurements, and biochemical markers. Additional randomized trials with better methodology are needed to assess the efficacy of the two enteral feeding regimens in critically ill PICU patients.
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Zaher S. Barriers to Delivery of Enteral Nutrition in Intensive Care Settings in Saudi Arabia: A Comparative Study of the Perceptions of Health Care Providers Working in Adult and Paediatric ICUs. Risk Manag Healthc Policy 2022; 15:2357-2370. [PMID: 36544506 PMCID: PMC9762403 DOI: 10.2147/rmhp.s394035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Achieving optimal nutrition prescription is challenging in critically ill patients. Many factors can hinder the adequate delivery of enteral nutrition (EN) in intensive care units (ICUs). In this study, we aim to describe EN barriers and compare the perceptions of health care practitioners working in adult and paediatric ICUs regarding these barriers. Methods In this cross-sectional study, data were collected via online survey. All physicians, dietitians, and nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The survey contained 24 potential EN barriers and participants were asked to rate their importance on a scale from 1 to 5. A total Likert rating score of the 24 items was later calculated. Results We recruited 244 health care providers working in adult and paediatric ICUs. The most important perceived barriers were "Delay in physician ordering EN initiation" (3.33 ±1.32), and 'Waiting for dietitians to assess patients' (3.22 ±1.20). There was a statistical difference between the responses of health care providers based on their work settings for the following items; "Nurses failing to progress feeds according to feeding protocol" (p=0.006) and 'Feeding being held too far prior procedures or operating-room visits' (p=0.021). Profession significantly influenced the total Likert rating score of the 24 items (r=-0.234, p=0.001). Conclusion This study identified some barriers of EN delivery in ICUs and showed that participants' perceptions regarding these barriers were influenced by their roles. These findings shed light on the nutritional practices in Saudi hospitals and identify areas of improvement in EN practice and advancements in the field of critical care nutrition in the region.
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Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Kingdom of Saudi Arabia,National Nutrition Committee (NNC), Saudi Food and Drug Authority (Saudi FDA), Riyadh, Saudi Arabia,Correspondence: Sara Zaher, Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Kingdom of Saudi Arabia, Email ;
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Martinez EE, Bechard LJ, Brown AM, Coss-Bu JA, Kudchadkar SR, Mikhailov TA, Srinivasan V, Staffa SJ, Verbruggen SSCAT, Zurakowski D, Mehta NM. Intermittent versus continuous enteral nutrition in critically ill children: A pre-planned secondary analysis of an international prospective cohort study. Clin Nutr 2022; 41:2621-2627. [PMID: 36306567 PMCID: PMC9722589 DOI: 10.1016/j.clnu.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/14/2022] [Accepted: 09/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Intermittent enteral nutrition (EN) may have physiologic benefits over continuous feeding in critical illness. We aimed to compare nutrition and infection outcomes in critically ill children receiving intermittent or continuous EN. METHODS International, multi-center prospective observational study of mechanically ventilated children, 1 month to 18 years of age, receiving EN. Percent energy or protein adequacy (energy or protein delivered/prescribed × 100) and acquired infection rates were compared between intermittent and continuous EN groups using adjusted-multivariable and 4:1 propensity-score matched (PSM) analyses. Sensitivity analyses were performed after excluding patients who crossed over between intermittent and continuous EN. RESULTS 1375 eligible patients from 66 PICUs were included. Patients receiving continuous EN (N = 1093) had a higher prevalence of respiratory illness and obesity, and lower prevalence of neurologic illness and underweight status on admission, compared to those on intermittent EN (N = 282). Percent energy or protein adequacy, proportion of patients who achieved 60% of energy or protein adequacy in the first 7 days of admission, and rates of acquired infection were not different between the 2 groups in adjusted-multivariable and propensity score matching analyses (P > 0.05). CONCLUSION Intermittent versus continuous EN strategy is not associated with differences in energy or protein adequacy, or acquired infections, in mechanically ventilated, critically ill children. Until further evidence is available, an individualized feeding strategy rather than a universal approach may be appropriate.
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Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lori J Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Jorge A Coss-Bu
- Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Austin, TX, USA
| | - Sapna R Kudchadkar
- Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theresa A Mikhailov
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Vijay Srinivasan
- Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven J Staffa
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA
| | - S Sascha C A T Verbruggen
- Pediatric Intensive Care Unit, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, NL, USA
| | - David Zurakowski
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
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Ndirangu-Mugo E, Barros LM, Mutwiri BD, Shumba CS, Waweru B, Siika WW. Current State of Critical Care Nursing Worldwide: Current Training, Roles, Barriers, and Facilitators. Crit Care Clin 2022; 38:657-693. [PMID: 36162904 DOI: 10.1016/j.ccc.2022.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This review provides insights on the current state of roles and responsibilities, on-the-job training, barriers, and facilitators of critical care nursing (CCN) practice. Some of the established roles and training of CCN were providing care for acutely ill patients, delivering expert and specialist care, working as a part of a multidisciplinary team, monitoring, and initiating timely treatment, and providing psychosocial support and advanced system treatment, especially in high-income countries. In low-resource settings, critical care nurses work as health care assistants, technical or ancillary staff, and clinical educators; manage medications; care for mechanically ventilated patients; and provide care to deteriorating patients.
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Affiliation(s)
- Eunice Ndirangu-Mugo
- School of Nursing and Midwifery, Aga Khan University, P O Box 39340-00623, Nairobi, Kenya.
| | - Lia M Barros
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Campus Box 356522, Seattle 98195-6522, Washington
| | - Benard D Mutwiri
- School of Nursing and Midwifery, Aga Khan University, P O Box 39340-00623, Nairobi, Kenya
| | - Constance S Shumba
- School of Nursing and Midwifery, Aga Khan University, P O Box 39340-00623, Nairobi, Kenya
| | - Beth Waweru
- School of Nursing and Midwifery, Aga Khan University, P O Box 39340-00623, Nairobi, Kenya
| | - Wangari Waweru Siika
- Department of Anaesthesia, Aga Khan University Hospital, P.O Box 39340-00623, Nairobi, Kenya
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Challenges and advances in nutrition for the critically ill child. Curr Opin Crit Care 2022; 28:401-408. [DOI: 10.1097/mcc.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Impact of Nutrition Support Team in Achieving Target Calories in Children Admitted in Pediatric Intensive Care Unit. J Pediatr Gastroenterol Nutr 2022; 74:830-836. [PMID: 35258507 DOI: 10.1097/mpg.0000000000003438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To determine the impact of nutrition support team (NST) on achieving an early target caloric goal in mechanically ventilated children admitted in pediatric intensive care unit (PICU). METHODS An early enteral nutrition protocol (EENP) was implemented by NST to ensure early and adequate nutrition provision to PICU patients. All children (1 month- 18 years) that were admitted in PICU for >2days and received mechanical ventilation, with no contraindications to enteral feed, were included and data was compared with those of pre-intervention. The adequacy of energy intake was defined as 70% achievement of target energy intake on the third day of admission. Chi-square/t-test was used to determine the difference between different variables pre and post intervention. RESULTS Total 180 patients (99 and 81 in pre- and post-intervention group, respectively) were included. Overall, 115 (63.9%) received adequate calories (70%) on third day of admission. Of which 69 (85.2%) were from post intervention (P < 0.001; odds ratio [OR] 6.6, 95% confidence interval [CI] 3.195-13.73). Moreover, NST intervention also promoted adequate protein intake in 62 (76.5%) children compared to 37 (37.4%) in pre-intervention group (P < 0.001, OR 5.468, 95% CI 2.838- 10.534). The median (interquartile range) length of PiCU stay in pre-NST group was 6 (4-9) days and in NST supported group was 4 (3-4) days (OR 0.580, CI 0.473-0.712, P < 0.001). Age, severity of illness, multiorgan dysfunction syndrome, sepsis, need of organ support had no effect in achievement of caloric target in both the groups (P > 0.05). CONCLUSION Introduction of EENP with NST helped in the achievement of better and quicker target caloric intake.
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Fan L, Lee JH. Enteral feeding and the microbiome in critically ill children: a narrative review. Transl Pediatr 2021; 10:2778-2791. [PMID: 34765500 PMCID: PMC8578772 DOI: 10.21037/tp-20-349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/09/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE This narrative review summarizes our current knowledge on the interplay between enteral nutrition (EN) and gut microbiota in critically ill children, using examples from two commonly encountered diagnoses in the pediatric intensive care unit (PICU): severe sepsis and acute respiratory distress syndrome (ARDS). This review will also highlight potential areas of therapeutic interventions that should be explored in future studies. BACKGROUND Critically ill children display extreme dysbiosis in their gut microbiome. Factors within the PICU that are often associated with dysbiosis include the use of broad-spectrum antibiotics, proton-pump inhibitors (PPIs), intravenous morphine, and fasting. Dysbiosis can potentially lead to adverse clinical outcomes (e.g., nosocomial infection, and prolonged hospitalization). EN may modulate dysbiosis. The gut microbiota is involved in the breaking down of macronutrients, mainly carbohydrates and proteins. Fermentation of undigestible carbohydrate (e.g., inulin and oligosaccharides), and amino acids by large intestine microbiota produces short chain fatty acids (SCFAs). SCFAs serve as the main fuel source for enterocytes and help to maintain healthy gut lining. Changes to selected components of macronutrients can result in alterations in gut microbiome and have potentially beneficial effects in patients in the PICU. METHODS A comprehensive search of the MEDLINE, Cochrane Library and Google Scholar databases was conducted using appropriate MESH terms and keywords. In this narrative review, we provide a summary of current knowledge on effect of EN on gut microbiota in pediatric studies, but also describes animal- and lab-based, as well as adult studies where relevant. CONCLUSIONS The gut microbiome can be altered by dietary modifications and common PICU practices and treatment. Although there are strong associations in restoring eubiosis and improvement in clinical outcomes, proving causality remains challenging. Further microbiome research is needed to provide mechanistic insights into the impact of the ever changing gut microbiome. In the future, new microbiota targeted therapies could potentially be the treatment of challenging PICU conditions and restore homeostasis in these children.
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Affiliation(s)
- Lijia Fan
- Division of Paediatric Critical Care, Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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