Nutritional support to patients within the pediatric intensive setting

Micronutrient status during paediatric critical illness: A scoping review

BACKGROUND

No evidence based recommendations for micronutrient requirements during paediatric critical illness are available, other than those arising from recommended nutrient intakes (RNI) for healthy children and expert opinion.

OBJECTIVES

The objective of this review is to examine the available evidence from micronutrient status in critically ill children considering studies which describe 1) micronutrient levels, 2) associations between micronutrient levels and clinical outcome, and 3) impact on clinical outcome with micronutrient supplementation during PICU admission.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Any study which used a qualitative and quantitative design considering causes and consequences of micronutrient levels or micronutrient supplementation during paediatric critical illness.

SOURCES OF EVIDENCE

NICE Healthcare Databases Advanced Search website (https://hdas.nice.org.uk/) was used as a tool for multiple searches, with a content analysis and charting of data extracted.

RESULTS

711 records were identified, 35 were included in the review. Studies evaluated serum micronutrient status was determined on admission day in majority of patients. A content analysis identified (n = 49) initial codes, (n = 14) sub-categories and (n = 5) overarching themes during critical illness, which were identified as: i) low levels of micronutrients, ii) causes of aberrant micronutrient levels, iii) associations between micronutrients levels and outcome, iv) supplementation of micronutrients.

CONCLUSION

During critical illness, micronutrients should be provided in sufficient amounts to meet reference nutrient intakes for age. Although, there is insufficient data to recommend routine supplementations of micronutrients at higher doses during critical illness, the 'absence of evidence should not imply evidence of absence', and well designed prospective studies are urgently needed to elucidate paediatric micronutrient requirements during critical illness. The absence of reliable biomarkers make it challenging to determine whether low serum levels are reflective of a true deficiency or as a result redistribution, particularly during the acute phase of critical illness. As more children continue to survive a PICU admission, particularly those with complex diseases micronutrient supplementation research should also be inclusive of the recovery phase following critical illness.

Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed

BACKGROUND

Monitoring nutrition therapy is essential in the care of critically ill children, but the risk of nutrition failure seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutrition support.

MATERIALS AND METHODS

Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded and compared with the required energy intake (measured energy expenditure plus 10%); energy intake was classified as underfeeding (<90% of required energy intake), adequate feeding (90%-110%), or overfeeding (>110%). The reasons for interruptions to enteral and parenteral nutrition were recorded.

RESULTS

In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2%, 18.3%, and 60.5% of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children (median, 37.2 kcal/kg/d; range, 16.81-66.38 kcal/kg/d), but the variation within each child was small. Respiratory quotient had low sensitivity of 21% and 27% for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutrition support.

CONCLUSION

The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.

Impact of early enteral nutrition therapy on morbimortality reduction in a pediatric intensive care unit: a systematic review

OBJECTIVE

To assess the impact of early introduction of enteral nutrition therapy in reducing morbidity and mortality in pediatric intensive care unit.

METHODS

Search in the literature of the last 10 years, in English and the target population of individuals aged 1 month to 18 years admitted to pediatric intensive care units in the databases PubMed, Lilacs and Embase using the keywords: Critical Care, Nutritional Support and Nutrition Disorders or Malnutrition.

RESULTS

Despite advances in the quality of clinical care, the prevalence of malnutrition in hospitalized children remains unchanged in the last 20 years (15-30%) and has implications for the time of admission, course of illness and morbidity. Malnutrition is common and is often poorly recognized and therefore, untreated. Nutritional therapy is an essential part in the treatment of pediatric patients who have severely ill hypercatabolic state protein, which can be minimized with an effective nutritional treatment plan. In this study, we reviewed publications which have shown that there is still a paucity of randomized and controlled studies with good statistical treatment in relation to enteral nutritional therapy with outcomes related to morbidity and mortality. The current guidelines for nutritional therapy in these patients are largely based on expert opinion and data extrapolated from adult studies and studies in healthy children.

CONCLUSION

The scientific evidence on the use of enteral nutrition therapy in improving the development of critically ill pediatric patients is still scarce and further studies are needed focusing on it, and better guidelines must be formulated.