Protein intake and requirements in children and adolescents undergoing Hematopoietic Stem Cell Transplant (HSCT): An international benchmarking survey and a scoping review

BACKGROUND & AIMS

For children and adolescents undergoing hematopoietic stem cell transplant (HSCT), adequate protein and energy intake is essential to mitigate malnutrition risk. However, little is known about optimal requirements, including adequate dietary protein intake in this population. We conducted an international benchmarking survey and a scoping review to explore current practices in determining protein requirements (PR) and examine existing evidence for PR and dietary protein intake in pediatric HSCT.

METHODS

Twelve pediatric oncology centers were surveyed to elicit current practices in determining PR in pediatric HSCT. A scoping review then collected sources of evidence from six databases (MEDLINE, Embase, CINAHL, PubMed, Cochrane Library and Web of Science) and grey literature (Google Scholar).

RESULTS

Survey data revealed variable practices in determining PR for pediatric HSCT patients. Four centers (44%) used the American Society for Parenteral and Enteral Nutrition (ASPEN) Nutrition Support in Pediatric Critically Ill Patient Guidelines 2009 and four (44%) used local guidelines or their national nutrient reference values (NRV). The scoping review included nineteen studies. The review highlighted a broad range of PR used in this population, ranging from 0.8 to 3.0 g/kg/d. Practices regarding the documentation and frequency of collecting protein intake data varied. Only five studies reported estimated protein requirement (EPR) status and just two studies met EPR. No clinical guidelines on PR in pediatric HSCT were identified.

CONCLUSIONS

Given the existing gap in evidence, the optimal amount of protein required for children and adolescents undergoing HSCT remains unknown. To establish specific, evidence-based PR guidelines, comprehensive research is needed. Future investigations should prioritize evaluating current clinical practices, assessing the gap between actual protein intake and EPR, and understanding the relationship between protein intake, protein status, and the impact on treatment outcomes. Addressing these research priorities is crucial for bridging the current evidence gap, thereby enabling the development of enhanced and personalized nutritional support for children and adolescents undergoing HSCT.

Nutrition Provision in Children with Heart Disease on Extracorporeal Membrane Oxygenation (ECMO)

Nutrition provision for children with heart disease supported with extracorporeal membrane oxygenation (ECMO) involves nuanced decision making. We examined nutrition provision while on ECMO in the CICU and the relationship between energy and protein adequacy and end organ function as assessed by pediatric sequential organ failure assessment (pSOFA) scores in children with heart disease supported with ECMO. Children (≤ 21 years-old) with congenital or acquired heart disease who received ECMO in the cardiac intensive care unit were included. There were 259 ECMO runs in 252 patients over an 8-year study period (2013-2020). Median energy delivery and adequacy were 26.1 [8.4, 45.9] kcal/kg/day and 58.3 [19.8, 94.6]%, respectively. Median protein delivery and adequacy were 0.98 [0.36, 1.64] g/kg/day and 35.7 [13.4, 60.3]%, respectively. pSOFA increased by a median of four points during the ECMO run. Change in pSOFA score was not associated with energy or protein adequacy (p = 0.46 and p = 0.72, respectively). Higher energy and protein adequacy-from parenteral nutrition-correlated with increased hospital-acquired infections (HAIs, p = 0.031 and p = 0.003, respectively). Achieving nutritional adequacy was dependent on the use of parenteral nutrition. Similar clinical outcomes with regard to end organ function but with an increased incidence of HAIs suggests the need to explore the role of optimal enteral nutrition delivery on ECMO.

Procedures for a Transpyloric Feeding Tube Inserted Into Newborns and Infants: A Systematic Review

BACKGROUND

Enteral feeding by a transpyloric tube in critically ill infants is indicated when there is a failure in gastric feeding. However, there is a wide variability regarding the insertion technique.

PURPOSE

To perform a systematic review of the methods for inserting a transpyloric feeding tube in newborns and infants.

DATA SOURCES

Nine databases, without date or language restrictions, accessed in September 2021.

STUDY SELECTION

A systematic review of experimental and nonexperimental studies, according to the "Patient/problem; Intervention; Comparison; Outcome" strategy and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The clinical question was about the measurement and insertion techniques, as well as the success rates of properly placing a transpyloric tube in newborns and infants.

DATA EXTRACTION

Two authors (N.M.Q. and J.F.S.) analyzed 6 observational descriptive prospective studies, all of them published in peer-reviewed indexed medical journals and one in the official journal of the National Association of Neonatal Nurses.

RESULTS

The success rate varied between 70% and 100%. There was an important variability in the type of tube, measurement method, and insertion techniques. It was found that the most common strategies to achieve proper positioning were glabella-calcaneal measurements, gastric air insufflation, and right lateral decubitus.

IMPLICATIONS FOR PRACTICE

A transpyloric catheter insertion protocol needs to be established in each neonatal unit, according to the literature findings.

IMPLICATIONS FOR RESEARCH

Randomized controlled studies that evaluate the gastric air insufflation technique and other adjuvant measures could elucidate the knowledge gap concerning the correct positioning of transpyloric tubing in newborns and infants.

The malnutrition screening tool STRONGKIDS performed better than other screening tools for children hospitalised in Egypt

AIM

To compare the accuracy of three different screening tools, namely, the Paediatric Yorkhill Malnutrition Score (PYMS), Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP), and Screening Tool for Risk on Nutritional Status and Growth (STRONGKIDS), in assessing malnutrition risk in hospitalised children.

METHODS

A cross-sectional study was conducted on 300 children aged 6 months to 15 years at Alexandria University Children's Hospital, Egypt. The sensitivity and specificity of each tool were calculated to detect acute and chronic malnutrition, and an agreement test was conducted between the nutritional screening tools. The patients were classified into different nutritional risk groups, and their classification was compared with anthropometric measures and clinical variables, such as the length of hospital stay (LOS).

RESULTS

The prevalence of stunting and wasting on admission was found to be 3% and 6.6%, respectively. Children categorised as high-risk on admission had a longer LOS than those at low risk. The agreement test between the STAMP score and STRONGKIDS score on admission showed the most significant agreement, and STRONGKIDS had the best accuracy in detecting acute and chronic malnutrition.

CONCLUSION

The comparison of the three screening tools revealed that STRONGKIDS exhibited the best accuracy in detecting acute and chronic malnutrition.

Dietitian and nutrition-related practices and resources in Australian and New Zealand PICUs: A clinician survey

BACKGROUND

Recommendations to facilitate evidence-based nutrition provision for critically ill children exist and indicate the importance of nutrition in this population. Despite these recommendations, it is currently unknown how well Australian and New Zealand (ANZ) paediatric intensive care units (PICUs) are equipped to provide nutrition care.

OBJECTIVES

The objectives of this project were to describe the dietitian and nutrition-related practices and resources in ANZ PICUs.

METHODS

A clinician survey was completed as a component of an observational study across nine ANZ PICUs in June 2021. The online survey comprised 31 questions. Data points included reporting on dietetics resourcing, local feeding-related guidelines and algorithms, nutrition screening and assessment practices, anthropometry practices, and indirect calorimetry (IC) device availability and local technical expertise. Data are presented as frequency (%), mean (standard deviation), or median (interquartile range).

RESULTS

Survey responses were received from all nine participating sites. Dietetics staffing per available PICU bed ranged from 0.01 to 0.07 full-time equivalent (median: 0.03 [interquartile range: 0.02-0.04]). Nutrition screening was established in three (33%) units, all of which used the Paediatric Nutrition Screening Tool. Dietitians consulted all appropriate patients (or where capacity allowed) in six (66%) units and on a request or referral basis only in three (33%) units. All units possessed a local feeding guideline or algorithm. An IC device was available in two (22%) PICUs and was used in one of these units.

CONCLUSIONS

This is the first study to describe the dietitian and nutrition-related practices and resources of ANZ PICUs. Areas for potential improvement include dietetics full-time equivalent, routine nutrition assessment, and access to IC.

A Quality Initiative to Prioritize Enteral Feeding in Bronchiolitis

Introduction

Recent studies have identified enteral feeding as a safe alternative to intravenous fluid hydration for inpatients with bronchiolitis receiving respiratory support. Specifically, it can improve vital signs, shorten time on high-flow nasal cannula, and is associated with reduced length of stay. We aimed to increase the percentage of patients receiving enteral feeding on admission with mild-to-moderate bronchiolitis, including those on high-flow nasal cannula, from 83% to 95% within 6 months.

Methods

A multidisciplinary quality improvement team identified key drivers preventing enteral feeding as lack of standardization, perception of aspiration risk, and lack of familiarity with feeding orders. PDSA cycles focused on developing and implementing a bronchiolitis clinical practice pathway with an embedded guideline and order set as decision support to prioritize enteral feeding. Additionally, educational sessions were provided for trainees and attendings who were impacted by this pathway.

Results

Following interventions, initiation of enteral feeding increased (83%-96%). Additionally, intravenous line placement decreased (37%-12%) with a mirrored increase in nasogastric tube placement (4%-21%). This was associated with a shorter overall length of stay and no increased transfer rate to intensive care.

Conclusions

Using quality improvement methodology to standardize enteral feeding and hydration increased the initiation rate of enteral feeding in patients admitted with bronchiolitis. These changes were seen immediately after the implementation of the clinical pathway and sustained throughout the bronchiolitis season.

Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary

OBJECTIVES

Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy.

METHODS

An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy.

RESULTS

The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy.

CONCLUSIONS

Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.

Nutritional Intake in Children with Septic Shock: A Retrospective Single-Center Study

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.

Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations

BACKGROUND

Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT.

METHODS

PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023.

RESULTS

On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points.

CONCLUSIONS

Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.

An Overview of Parenteral Nutrition from Birth to Adolescence Based on a Composite Fish Oil Containing Lipid Emulsion and a Pediatric Amino Acid Solution

Intestinal failure (IF) is characterized by a critical reduction in functional gut mass below the minimum needed for optimal growth in children. It requires parenteral nutrition (PN) and home-PN (HPN), which is challenging in terms of meeting nutritional needs according to age, growth velocity, clinical situation, and rapid changes in fluid and electrolyte requirements. Due to these complex requirements, age-adapted multi-chamber bags (MCBs) are important additions to the nutrition armamentarium. The launch of composite fish oil (FO)-containing intravenous lipid emulsions (ILEs) heralded the development of MCBs containing these ILEs in combination with a crystalline amino acid solution adapted for pediatric use. The safety and efficacy of lipid and amino acid components in this context have been widely documented in numerous published studies. This narrative manuscript includes a review of the articles published in PudMed, Embase, and Google Scholar up to June 2023 for the age groups of term infants to children and adolescents. Preterm infants with their highly specific demands are not included. It aims to offer an overview of the clinical experience regarding the use of a composite FO-based ILE and a developed specific amino acid solution.

Assisted Enteral Feeding of Exotic Companion Animals

Malnutrition is a known concern during hospitalization for humans, dogs, and cats. The same nutrition principals to reduce the risk of malnutrition can be applied to exotic companion animal patients. However, it's important to understand that many nutritional requirements are ill defined for specific species and prudent clinical judgment is required.

Nutritional and clinical factors associated with acute kidney injury development in critically ill children

BACKGROUND

Acute kidney injury (AKI) is common in the pediatric intensive care unit (ICU) and is associated with poorer clinical outcomes. There is scarce data to support an association between nutritional status and nutrient delivery in critically ill pediatric patients. Therefore, the present study aimed to identify the nutritional and clinical factors associated with the development of AKI during pediatric ICU stay.

METHODS

This prospective study included critically ill pediatric patients aged < 15 years who were admitted to the medical and surgical pediatric ICU. Clinical, laboratory, nutritional status, nutritional therapy parameters, and AKI data were recorded. Adjusted logistic regression was applied and expressed as odds ratio (OR) and 95% confidence interval (95%CI). P-value < 0.05 was considered significant.

RESULTS

We enrolled 108 patients with a median age of 9 months (interquartile range/IQR 2.4-62.5), and 43.5% developed AKI. Sepsis/septic shock (OR 8.00; 95% CI 2.06-32.51, p = 0.003), higher severity of illness (OR 1.89; 95% CI 1.24-2.90, p = 0.003), hypoalbuminemia (OR 4.11; 95% CI 1.61-10.46, p = 0.006), edema (OR 3.42, 95% CI 1.10-10.67, p = 0.034), fluid overload (OR 3.52, 95% CI 1.56-7.96, p = 0.003), need for mechanical ventilation (OR 3.62, 95% CI 1.45-9.04, p = 0.006) and adequate protein intake (OR 0.79, 95% CI 0.63-1.00, p = 0.048) were associated with development of AKI.

CONCLUSIONS

Hypoalbuminemia, need for mechanical ventilation, fluid overload, severity of illness, sepsis/septic shock, and edema were risk factors for AKI in pediatric ICU. Furthermore, adequate protein intake is associated with AKI during pediatric ICU stay, making it important to implement nutritional assessment and nutritional therapy protocols for critically ill pediatric patients.

Timing of enteral nutrition and parenteral nutrition in the PICU

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.

Determining energy and protein needs in critically ill pediatric patients: A scoping review

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.

Macronutrient and Micronutrient Intake in Children with Lung Disease

This review article aims to summarize the literature findings regarding the role of micronutrients in children with lung disease. The nutritional and respiratory statuses of critically ill children are interrelated, and malnutrition is commonly associated with respiratory failure. The most recent nutrition support guidelines for critically ill children have recommended an adequate macronutrient intake in the first week of admission due to its association with good outcomes. In children with lung disease, it is important not to exceed the proportion of carbohydrates in the diet to avoid increased carbon dioxide production and increased work of breathing, which potentially could delay the weaning of the ventilator. Indirect calorimetry can guide the process of estimating adequate caloric intake and adjusting the proportion of carbohydrates in the diet based on the results of the respiratory quotient. Micronutrients, including vitamins, trace elements, and others, have been shown to play a role in the structure and function of the immune system, antioxidant properties, and the production of antimicrobial proteins supporting the defense mechanisms against infections. Sufficient levels of micronutrients and adequate supplementation have been associated with better outcomes in children with lung diseases, including pneumonia, cystic fibrosis, asthma, bronchiolitis, and acute respiratory failure.

Cumulative Dose of Prostaglandin E1 Determines Gastrointestinal Adverse Effects in Term and Near-Term Neonates Awaiting Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the association between treatment characteristics of prostaglandin E1 including initiation time and duration, maximal and cumulative doses, and adverse effects.

DESIGN

A retrospective cohort study in which medical records of neonates with duct-dependent lesions were studied for treatment parameters and adverse effects. Multivariable logistic regression model was applied for testing the effect PGE1 variables on outcomes.

MAIN OUTCOME MEASURES

The primary outcomes of this study were association of adverse effects of PGE1 treatment with maximal dose, cumulative dose, and treatment duration. The secondary outcomes included safety of feeding in infants treated with PGE1.

RESULTS

Eighty-two infants with duct-dependent lesions receiving PGE1 were included. Several infants who received early PGE1 treatment required ventilation support. Feeds were ceased more often as the cumulative dose and duration of PGE1 treatment increased. Gastrointestinal adverse effects were significantly associated with the cumulative dose of PGE1 and treatment duration. Apneas, hyperthermia, and tachycardia were associated with maximal dose. Our data did not demonstrate a difference in the incidence of NEC associated with characteristics of PGE1 treatment.

CONCLUSION

Cumulative PGE1 dose is associated with gastrointestinal adverse effects in neonates. Lower doses should be considered in neonates expecting prolonged PGE1 treatment.

Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial

BACKGROUND

The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial.

PURPOSE

To identify the optimal timing of PN initiation in critically ill children.

METHODS

This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes.

RESULTS

Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018).

CONCLUSION

Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.

Nutritional management of postoperative chylothorax in children with CHD

INTRODUCTION

Chylothorax after congenital cardiac surgery is associated with increased risk of malnutrition. Nutritional management following chylothorax diagnosis varies across sites and patient populations, and a standardised approach has not been disseminated. The aim of this review article is to provide contemporary recommendations related to nutritional management of chylothorax to minimise risk of malnutrition.

METHODS

The management guidelines were developed by consensus across four dietitians, one nurse practitioner, and two physicians with a cumulative 52 years of experience caring for children with CHD. A PubMed database search for relevant literature included the terms chylothorax, paediatric, postoperative, CHD, chylothorax management, growth failure, and malnutrition.

RESULTS

Fat-modified diets and nil per os therapies for all paediatric patients (<18 years of age) following cardiac surgery are highlighted in this review. Specific emphasis on strategies for treatment, duration of therapies, optimisation of nutrition including nutrition-focused lab monitoring, and supplementation strategies are provided.

CONCLUSIONS

Our deliverable is a clinically useful guide for the nutritional management of chylothorax following paediatric cardiac surgery.

Analysis of the prevalence and risk factors of pressure injuries in the hospitalized pediatric population: A retrospective study

BACKGROUND

Pressure injury (PI) is an essential indicator of the quality of nursing care and affects hospitalized newborns and children. However, studies on the prevalence of PI and associated risk factors in children are limited.

AIMS

This study aimed to analyze the prevalence of PI and risk factors affecting the development of PI in the hospitalized pediatric population.

METHODS

This was a descriptive, retrospective study. Data were obtained via electronic medical records of 6350 pediatric patients admitted to a university hospital between January 2019 and April 2022. Ethics committee approval was obtained. Patient medical records and data associated with PI and medical treatment were collected through the 'Information Form,' 'Braden Scale,' 'Braden Q Scale,' 'Pressure Ulcer Staging Form,' and 'Pediatric Nutrition Risk Score (PNRS).' Data were analyzed using descriptive statistics, correlation analysis, Mann-Whitney U test, Kruskal Wallis test, and Multilinear Regression analysis.

RESULTS

More patients (66.2%) were males, and 49.2% of the children were 0-12 months old. 2368 out of 6350 pediatric patients were treated in the PICU. It was determined that a total of 143 PI occurred in 59 patients from PICU. The PI prevalence was 2.25% for all patients and 6.04% for PICU patients. Twenty-one percent of the patients had medical device-related PI (MDRPIs), 35.7% of PI occurred in the occiput, 13.3% in the coccyx/sacrum, and 67.1% of PI was Deep Tissue Injury. In the multiple regression model, children's albumin level, hemoglobin level, PNRS scores, Body Mass Index, and length of hospital stay significantly affected BRADEN scores. They were explained 30.3% of their scores of Braden.

CONCLUSION

Despite the limitations of the retrospective study, the prevalence of PI in the pediatric population in this study was lower than that reported in previous studies, but the prevalence of MDRPIs was higher. Based on the study results, it is recommended to implement preventive interventions for MDRPIs and plan prospective studies.

Nutrition in congenital heart disease: consensus document

INTRODUCTION

The prevalence of malnutrition among infants with congenital heart disease (CHD) is high. Early nutritional assessment and intervention contribute significantly to its treatment and improve outcomes. Our objective was to develop a consensus document for the nutritional assessment and management of infants with CHD.

MATERIAL AND METHODS

We employed a modified Delphi technique. Based on the literature and clinical experience, a scientific committee prepared a list of statements that addressed the referral to paediatric nutrition units (PNUs), assessment, and nutritional management of infants with CHD. Specialists in paediatric cardiology and paediatric gastroenterology and nutrition evaluated the questionnaire in 2 rounds.

RESULTS

Thirty-two specialists participated. After two evaluation rounds, a consensus was reached for 150 out of 185 items (81%). Cardiac pathologies associated with a low and high nutritional risk and associated cardiac or extracardiac factors that carry a high nutritional risk were identified. The committee developed recommendations for assessment and follow-up by nutrition units and for the calculation of nutritional requirements, the type of nutrition and the route of administration. Particular attention was devoted to the need for intensive nutrition therapy in the preoperative period, the follow-up by the PNU during the postoperative period of patients who required preoperative nutritional care, and reassessment by the cardiologist in the case nutrition goals are not achieved.

CONCLUSIONS

These recommendations can be helpful for the early detection and referral of vulnerable patients, their evaluation and nutritional management and improving the prognosis of their CHD.

A review and guide to nutritional care of the infant with established bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) remains the most common long-term morbidity of premature birth, and the incidence of BPD is not declining despite medical advancements. Infants with BPD are at high risk for postnatal growth failure and are often treated with therapies that suppress growth. Additionally, these infants may display excess weight gain relative to linear growth. Optimal growth and nutrition are needed to promote lung growth and repair, improve long-term pulmonary function, and improve neurodevelopmental outcomes. Linear growth in particular has been associated with favorable outcomes yet can be difficult to achieve in these patients. While there has been a significant clinical and research focus regarding BPD prevention and early preterm nutrition, there is a lack of literature regarding nutritional care of the infant with established BPD. There is even less information regarding how nutritional needs change as BPD evolves from an acute to chronic disease. This article reviews the current literature regarding nutritional challenges, enteral nutrition management, and monitoring for patients with established BPD. Additionally, this article provides a practical framework for interdisciplinary nutritional care based on our clinical experience at the Comprehensive Center for Bronchopulmonary Dysplasia.

Impact of Type of Enteral Feeds on Early Postoperative Outcomes After Congenital Heart Surgery in Neonates and Young Infants: A Single Center Experience in a Limited Resource Environment

Background: Breast milk is known to prevent infections and is recommended for enteral feeding of infants after congenital heart surgery (CHS). During the Covid-19 pandemic, expressed breast milk (EBM) was not always available; hence, feeding after CHS was maintained with EBM or infant formula (IF) or both; we evaluated the impact of enteral feed type on early postoperative outcomes after CHS. Methods: In a prospective observational study, consecutive neonates and infants <4 months undergoing CHS were divided into EBM, IF, or EBM+IF groups; incidences of postoperative infections, ventilation duration, intensive care unit (ICU) stay, and mortality were studied. Results: Among 270 patients; 90 (33.3%) received EBM, 89 (32.9%) received IF, and 91 (33.7%) received EBM+IF. IF group had more neonates (78.7%[IF] vs 42.2%[EBM] and 52.7%[EBM+IF], P < 0.001) and greater surgical complexity. Postoperative infections were 9 (10.0%) in EBM; 23 (25.8%) in IF; and 14 (15.4%) in EBM+IF (P = .016). IF group (OR 2.58 [1.05-6.38], P = .040), absence of preoperative feeding (OR 6.97 [1.06-45.97], P = .040), and increase in cardiopulmonary bypass time (OR 1.005 [1.001-1.010], P = .027) were associated with postoperative infection. Ventilation duration in hours was 26 (18-47.5) in EBM; 47 (28-54.5) in IF; and 40 (17.5-67) in EBM+IF (P = .004). ICU stay in days was 4 (3-7) in EBM; 6 (5-9) in IF; and 5 (3-9) in EBM+IF (P = .001). Mortality did not differ (P = .556). Conclusion: IF group had a greater proportion of neonates with higher surgical complexity. Patients who received EBM after CHS had fewer postoperative infections and better postoperative outcomes compared to those receiving IF or EBM+IF.

Malnutrition screening and treatment in pediatric oncology: a scoping review

BACKGROUND

Malnutrition and cachexia during pediatric cancer treatment worsen toxicity and quality-of-life. Clinical practice varies with lack of standard malnutrition definition and nutrition interventions. This scoping review highlights available malnutrition screening and intervention data in childhood cancer and the need for standardizing assessment and treatment.

METHODS

Ovid Medline, CINAHL, and Cochrane Library were searched for studies containing malnutrition as the primary outcome with anthropometric, radiographic, or biochemical measurements. Secondary outcomes included validated nutritional assessment or screening tools. Two authors reviewed full manuscripts for inclusion. Narrative analysis was chosen over statistical analysis due to study heterogeneity.

RESULTS

The search yielded 234 articles and 17 articles identified from reference searching. Nine met inclusion criteria with six nutritional intervention studies (examining appetite stimulants, nutrition supplementation, and proactive feeding tubes) and three nutritional screening studies (algorithms or nutrition support teams) each with variable measures and outcomes. Both laboratory evaluations (albumin, prealbumin, total protein) and body measurement (weight loss, mid-upper arm circumference) were used. Studies demonstrated improved weight, without difference between formula or appetite stimulant used. Screening studies yielded mixed results on preventing weight loss, weight gain, and survival.

CONCLUSION

Our review demonstrated a paucity of evidence for malnutrition screening and intervention in pediatric cancer treatment. While a variety of malnutrition outcomes, interventions, and screening tools exist, nutritional interventions increased weight and decreased complications. Screening tools decreased malnutrition risk and may improve weight gain. Potential age- and disease-specific nutritional benefits and toxicities also exist, further highlighting the benefit of standardizing malnutrition definitions, screening, and interventions.

The Effects of Swallowing Disorders and Oral Malformations on Nutritional Status in Children with Cerebral Palsy

Nutrition plays an important role both from a nutrition and a socio-psychological point of view; this part seems to be even more crucial in cerebral palsy where undernutrition is responsible for an increase in morbidity and mortality. The objective of this study was to evaluate the effects of swallowing disorders and oral malformations on the nutritional status of children with cerebral palsy. We evaluated 65 patients aged 2 to 17 years using a cross-sectional, descriptive and observational approach. All patients had a definite diagnosis of cerebral palsy. The measurement of anthropometric variables (weight, height, Body Mass Index (BMI) and circumferences) was performed according to recognized techniques and measurements. The Z-score was also calculated using the World Health Organization (WHO) references. The 5-level Gross Motor Function Classification System was used, providing a standardized classification of motor disability patterns for children with cerebral palsy. The population had a median age of 9.25 (4.50−16.00) and was about 53% female. Furthermore, 75% of the patients had a height inferior to 158 cm. The results of our study show that 42 (64.6%) had false routes, 17 (26.2%) had oral-facial malformations and 51 (78.5%) did not have lip prehensions during meals. The results also show that growth retardation is closely related to gross motor function with p = 0.01, as well as all nutritional indices (Z-score weight for age, Z-score height for age and Z-score BMI for age) are affected by swallowing disorders and oral malformations, with statistically significant values < 0.05. In conclusion, a preventive and curative management specific to this population of children with cerebral palsy must be implemented with an interdisciplinary concertation.

Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD

OBJECTIVE

A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap.

METHODS

Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. "Consensus" was defined as ≥ 80% of responses as "agree" or "strongly agree" to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not.

RESULTS

The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for "low" and "high" volume patients, and timing and duration of fat-modified diet. All recommendations achieved "consensus" (agreement >80%) by the workgroup (range 81-100%). Ex vivo simulations demonstrated good understanding by developers (range 94-100%) and non-developers (73%-100%).

CONCLUSIONS

The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.

Use of parenteral nutrition in term and late preterm infants: an Australian and New Zealand survey

There is limited information regarding the use of parenteral nutrition (PN) in term and late preterm infants. We conducted a survey to study the current clinical practices within Australia and New Zealand (ANZ). A fifteen-question online survey was distributed to 232 neonatologists and fifty-five paediatric intensivists across ANZ between September and November 2019. At least one neonatologist from twenty-seven out of thirty tertiary neonatal intensive care units responded (90 %). Responses were received from sixty-nine neonatologists (30 %) and seven paediatric intensivists (13 %). The overall response rate was 26 % (76/287). Thirty-three percent (25/76) commenced PN within 24 h of admission, 27 % (20/75) between 24 and 48 h, 24 % (18/75) between 48 and 72 h, 9 % (7/75) between 72 and 96 h and 4 % (3/75) between 96 h and 7 days. None of the respondents commenced PN after 7 d of admission. Sixty-one percent (46/75) aimed for 1·5-3 g/kg per d of parenteral amino acids, whereas 27 % (20/75) aimed for 2-3 g/kg per d. Renal failure (59 %; 38/64) and high plasma urea (44 %; 28/64) were the major indications for withholding/decreasing the amino acid intake. Eighty-three percent (63/76) aimed for a dose of 2·5g-3·5 g/kg per d of parenteral lipids; about 9 % (7/76) targeted a dose of 1-2·5 g/kg per d and 4 % (3/76) for > 3·5 g/kg per d. Thirty-two percent (24/74) reported that they would withhold/decrease the dose of parenteral lipids in infants with sepsis. The variations in clinicians' practices with respect to the use of PN in term and late preterm infants highlight the need for high-quality research in this population.

Nutritional Management of Short Bowel Syndrome

Short bowel syndrome (SBS) of infancy is a cause of prolonged morbidity with intolerance to enteral feeding, specialized nutritional needs, and partial/total dependence on parenteral nutrition. These infants can benefit from individualized nutritional strategies to support and enhance the process of intestinal adaptation. Early introduction of enteral feeds during the period of intestinal adaptation is crucial, even though the enteral feedings may need to be supplemented with an effective, safe, and nutritionally adequate parenteral nutritional regimen. Newer generation intravenous lipid emulsions can be effective in preventing and treating intestinal failure-associated liver disease. Prevention of infection(s), pharmaceutical interventions to enhance bowel motility and prevent/mitigate bacteria overgrowth, and specialized multidisciplinary care to minimize the injury to other organs such as the liver, kidneys, and the brain can assist in nutritional rehabilitation and lower the morbidity in SBS.

Impact of Nutrition Support Team in Achieving Target Calories in Children Admitted in Pediatric Intensive Care Unit

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.

Current Strategies to Optimize Nutrition and Growth in Newborns and Infants with Congenital Heart Disease: A Narrative Review

(1) Objective: This review aims to identify the clinical and practical barriers to optimizing nutrition in newborn infants with congenital heart disease (CHD) and to describe updated evidence-based recommendations for clinical and nutritional management of these patients in a narrative review. (2) Research Methods and Procedures: We conducted a search of the relevant literature published from 2000 to December 2021. (3) Results: CHD patients undergo several nutritional challenges related to the underlying cardiac disease anomaly, the potential increased risk of NEC, and delayed enteral feeding, resulting in inadequate energy intake and sub-optimal growth, increased morbidity and mortality. (4) Conclusions: To optimize nutrition and growth in newborn infants with CHD, standardized protocols should be implemented. Regular nutritional and growth assessment with a multi-disciplinary team is essential. We propose a decisional algorithm that may represent a potentially useful tool to guide clinicians to optimize growth and nutrition.

The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children

BACKGROUND

In critically ill children with acute kidney injury (AKI), continuous kidney replacement therapy (CKRT) enables nutrition provision. The magnitude of amino acid loss during continuous venovenous hemodiafiltration (CVVHDF) is unknown and needs accurate quantification. We investigated the mass removal and clearance of amino acids in pediatric CVVHDF.

METHODS

This is a prospective observational cohort study of patients receiving CVVHDF from August 2014 to January 2016 in the pediatric intensive care unit (PICU) of a tertiary children's hospital.

RESULTS

Fifteen patients (40% male, median age 2.0 (IQR 0.7, 8.0) years) were enrolled. Median PICU and hospital lengths of stay were 20 (9, 59) and 36 (22, 132) days, respectively. Overall survival to discharge was 66.7%. Median daily protein prescription was 2.00 (1.25, 2.80) g/kg/day. Median daily amino acid mass removal was 299.0 (174.9, 452.0) mg/kg body weight, and median daily amino acid mass clearance was 18.2 (13.5, 27.9) ml/min/m², resulting in a median 14.6 (8.3, 26.7) % protein loss. The rate of amino acid loss increased with increasing dialysis dose and blood flow rate.

CONCLUSION

CVVHDF prescription and related amino acid loss impact nutrition provision, with 14.6% of the prescribed protein removed. Current recommendations for protein provision for children requiring CVVHDF should be adjusted to compensate for circuit-related loss. A higher resolution version of the Graphical abstract is available as Supplementary information.

A methodological and clinical approach to measured energy expenditure in the critically ill pediatric patient

The metabolic response to injury and stress is characterized initially by a decreased energy expenditure (Ebb phase) followed by an increased metabolic expenditure (Flow phase). Indirect calorimetry is a methodology utilized to measure energy expenditure and substrate utilization by measuring gas exchange in exhaled air and urinary nitrogen. The use of indirect calorimetry in critically ill patients requires precise equipment to obtain accurate measurements. The most recent guidelines suggested that measured energy expenditure by indirect calorimetry be used to determine energy requirements. This article reviews the methodological and clinical use of indirect calorimetry in critically ill pediatric patients.

Nutrition delivery and growth outcomes in infants with long-gap esophageal atresia who undergo the Foker process

BACKGROUND

Predictors of growth outcomes in patients with long-gap esophageal atresia (LGEA) are not known. We examined nutrition and growth in-hospital and post-discharge in LGEA patients who underwent the Foker Process (FP).

METHODS

Single-center, retrospective cohort study of infants with LGEA undergoing primary (non-rescue) FP from 2014 to 2020. Weight-for-age z scores (WAZ, 0 = average), macronutrient prescription, anthropometry, and clinical variables were collected. Longitudinal median regression evaluated differences in WAZ over time. Multivariable median regression examined variables associated with change in WAZ at 1 year.

RESULTS

45 patients met criteria, with median (IQR) age at repair of 4 (2, 5.8) months and WAZ of -0.96 (-1.55, -0.40). On admission, 11% were moderately (WAZ < -2) and 9% were severely (WAZ < -3) malnourished. Lower admission WAZ was significantly associated with improvement in WAZ at 1-year follow-up (p = 0.002); EA type (59% type A), esophageal leak (16%), median days paralyzed (13), ventilated (21), on parenteral nutrition (35), or to full enteral nutrition (35) were not associated with change in WAZ. Median WAZ remained stable while in-hospital, and patients maintained their growth curves through 3-year follow-up.

CONCLUSION

Throughout infancy, most primary FP LGEA patients have weight for age that is below average. Using targeted nutritional intervention, those who present with malnutrition can still achieve adequate growth despite prolonged and complicated hospital courses.

Features Associated With Weight Loss and Growth Stunting for Young Children During Cancer Therapy

Features associated with malnutrition are poorly elucidated in pediatric cancer care. We aimed to better understand characteristics associated with weight-for-height (WHZ) and height-for-age (HAZ) changes for infants and young children during cancer treatment. This retrospective study included 434 patients diagnosed <3 years old from 2007 to 2015 at a large pediatric cancer center. Patients starting treatment outside our center, those with relapsed or secondary malignancies, or with inaccurate information were excluded. Abstracted weights and heights for a 24-month period after treatment initiation were converted to sex-specific and age-specific z scores. Although not statistically different at baseline, patients with hematologic malignancies gained weight over time, while other tumor types did not. Higher treatment intensity and younger age at diagnosis increased odds of clinically significant weight loss. Older children had higher HAZ at diagnosis and HAZ also significantly decreased over time for all examined risk factors, which is distinctly different from patterns in WHZ over time. In conclusion, WHZ and HAZ are affected differently by cancer treatment in infants and young children. We identify key risk factors for weight loss and growth stunting which will be necessary to develop prospective trials to examine anthropometric, biochemical, and patient recorded outcomes around nutrition.

Study protocol for a two-center test of a nurse-implemented chronotherapeutic restoring bundle in critically ill children: RESTORE Resilience (R2)

Often, pediatric intensive care environments are not conducive to healing the sick. Critically ill children experience disruptions in their circadian rhythms, which can contribute to delayed recovery and poor outcomes. We aim to test the hypothesis that children managed via RESTORE Resilience (R2), a nurse-implemented chronotherapeutic bundle, will experience restorative circadian rhythms compared to children receiving usual care. In this two-phased, prospective cohort study, two separate pediatric intensive care units in the United Sates will enroll a total of 20 baseline subjects followed by 40 intervention subjects, 6 months to less than 18 years of age, requiring invasive mechanical ventilation. During the intervention phase, we will implement the R2 bundle, which includes: (1) a focused effort to replicate the child's pre-hospitalization daily routine, (2) cycled day-night lighting and sound modulation, (3) minimal yet effective sedation (RESTORE), (4) nighttime fasting with bolus enteral daytime feedings, (5) early progressive mobility (PICU Up!), (6) continuity in nursing care, and (7) parent diaries. Our primary outcome is circadian activity ratio post-extubation. We hypothesize that children receiving R2 will experience restored circadian rhythms as evidenced by decreased nighttime activity while in the PICU. Our exploratory outcomes include salivary melatonin levels; electroencephalogram (EEG) slow-wave activity; R2 feasibility, adherence, and system barriers; levels of patient comfort; exposure to sedative medications; time to physiological stability; and parent perception of being well cared for. This paper describes the design, rationale, and implementation of R2.

CLINICALTRIALSGOV IDENTIFIER

NCT04695392.

Bedside Methods for Transpyloric Feeding Tube Insertion in Hospitalized Children: A Systematic Review of Randomized and non-Randomized Trials

PROBLEM

Enteral nutrition is a critical component of therapy for many hospitalized children. Some children, especially those with critical illness, require post-pyloric enteral nutrition, but placement of post-pyloric feeding tubes poses challenges, necessitating costly fluoroscopy procedures and delaying initiation of enteral nutrition. There is no established standard method for pediatric transpyloric tube placement at the bedside.

ELIGIBILITY CRITERIA

We searched for trials that assessed the efficacy of methods for transpyloric tube placement at the bedside. Studies that evaluated gastric insufflation, prokinetic agents, pH guided devices, and electromagnetic devices with an objective of bedside transpyloric tube placement in children ages one month to 18 years were included.

RESULTS

After each author independently reviewed the search results, we agreed on fourteen articles for inclusion, consisting of six randomized controlled trials, five quasi-experimental studies, and three cohort studies. Intervention protocols varied, both within and between studies, with most trials incorporating more than one variable in the intervention.

CONCLUSIONS

The heterogeneity of the research does not provide clear direction about best practices. All interventions demonstrated some efficacy, with the exception of erythromycin. Gastric insufflation, the most prevalent intervention studied, is safe and at least moderately effective. The research demonstrates the positive impact of a small, trained team of personnel for the insertion of a transpyloric tube.

IMPLICATIONS

High quality studies with clear protocols evaluating a single variable are needed in order to establish a bedside transpyloric tube placement protocol. We recommend studies on the efficacy of a dedicated team for this procedure.

Nutrition in Pediatric Extracorporeal Membrane Oxygenation: A Narrative Review

Extracorporeal membrane oxygenation (ECMO) support is increasingly utilized in quaternary pediatric intensive care units. Metabolic derangements and altered nutritional requirements are common in critically ill children supported on ECMO. However, there remains no consensus on the optimal approach to the prescription of nutrition in these patients. This narrative review aims to summarize the current medical literature on various aspects of nutrition support in pediatric patients on ECMO. These include: (1) nutritional adequacy, (2) pros and cons of feeding on ECMO, (3) enteral vs. parenteral nutrition, and (4) proposed recommendations and future directions for research in this area.

Nutrition Considerations in Neonatal Extracorporeal Life Support

Extracorporeal life support (ECLS) is a life-saving therapy, but neonates who require ECLS have unique nutritional needs and require aggressive, early nutritional support. These critically ill neonates are at increased risk for long-term feeding difficulties, malnutrition, and growth failure with associated increased morbidity and mortality. Unfortunately, few studies specific to this population exist. Clinical guidelines published by the American Society for Parenteral and Enteral Nutrition are specific to this population and available to aid clinicians in appropriate nutrition regimens, but studies to date suggest that nutrition provision varies greatly from center to center and often is inadequate. Though enteral feedings are becoming more common, aggressive parenteral nutrition is still needed to ensure nutrition goals are met, including the goal of increased protein provision. Long-term complications, including the need for tube feedings and growth failure, are common in neonatal ECLS survivors, particularly those with congenital diaphragmatic hernia. Oral aversion with poor feeding and growth failure must be anticipated and recognized early if present. The nutritional implications associated with the development of acute kidney injury, fluid overload, or the use of continuous renal replacement therapy must be recognized. In this state-of-the-art review, we examine aspects of nutrition for neonates receiving ECLS including nutritional requirements, nutrition provision, current practices, long-term outcomes, and special population considerations.

Sample Preparation for High-Throughput Urine Proteomics Using 96-Well Polyvinylidene Fluoride (PVDF) Membranes

Proteomics analysis of urine samples allows for studying the impact of system perturbation. However, meaningful proteomics-based biomarker discovery projects often require the analysis of large patient cohorts with hundreds of samples to describe the biological variability. Thus, robust high-throughput sample processing methods are a prerequisite for clinical proteomics pipelines that minimize experimental bias due to individual sample processing methods. Herein we describe a high-throughput method for parallel 96-well plate-based processing of urine samples for subsequent LC/MS-based proteomic analyses. Protein digestion and subsequent sample processing steps are efficiently performed in 96-well polyvinylidene fluoride (PVDF) membrane plate allowing for the use of vacuum manifolds for rapid liquid transfer, and multichannel pipettes and/or liquid handing robots. In this chapter we make available a detailed step-by-step protocol for our 'MStern blotting' sample processing strategy applied to patient urine samples followed by mass spectrometry-based proteomics analysis. Subsequently, we provide an example application using minimal volume of urine samples (e.g. 150 μL) collected from children pre and post thoracotomy to identify the predominant sites of protein catabolism and aid in the design of therapies to ameliorate protein catabolism and breakdown during critical illness. Furthermore, we demonstrate how the systemic state is reflected in the urine as an easily obtainable, stable, and safe biofluid.

Factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit

BACKGROUND & AIMS

Inadequate nutrition delivery in critically ill children has shown associated with poor clinical outcomes. Therefore, identifying barriers to deliver adequate nutrition is vital. The aim of this study was to identify factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit (PICU).

METHODS

This single-centre prospective study, involved children aged from birth to 3 years old, admitted to PICU longer than 72 hours. They received either enteral nutrition (EN) or combination of EN and partial parenteral nutrition (PPN). Clinical and nutrition delivery characteristics were recorded from admission until transferred out of PICU. Multiple regression analysis at significant level p < 0.05 were used to identify independent risk factors for lower protein and energy intake.

RESULTS

One hundred and thirty-nine patients were included in this study with median age 6.5 (1.8-20.6) months and median PICU length of stay of 6 (4-7) days. The median energy and protein adequacy were 83.2% and 46.7%, respectively. In multivariable analysis, children who underwent surgery (AOR 0.97; 95% CI 0.27-0.75; p = 0.041), with fluid restriction (AOR 0.97; 95% CI 0.25-0.73; p = 0.041), longer length of PICU stay (AOR 0.35; 95% CI 0.18-0.64; p = 0.001) and longer feeding interruptions (AOR 3.57; 95% CI 1.39-9.15; p = 0.008) were more likely to have lower energy intake. Children at risk of malnutrition (weight-for-age Z score of < -2 SD) (AOR 2.54; 95% CI 1.12 to 5.77; p = 0.026) and longer duration of mechanical ventilation (AOR 0.73; 95% CI 0.53 to 0.98; p = 0.041) were more likely to have lower protein intake.

CONCLUSION

This study highlighted the factors influencing adequate protein and energy delivery in critically ill children with heart disease in PICU. Strategies to improve the nutrition delivery in this group of patients should be outlined and implemented by the dietitians along with multidisciplinary team.

The effects of implementation of a stepwise algorithmic protocol for nutrition care process in gastro-intestinal surgical children in Pediatric Intensive Care Unit (PICU)

INTRODUCTION

Malnutrition is known as one of the major health problems among critically ill children; optimum nutrition support is considered as a therapeutic strategy to improve clinical outcomes and minimize the length of Pediatric Intensive Care Unit (PICU) staying as well as its costs. Implementation of an algorithmic protocol can result in the upgrade of the quality of nutrition support system in PICU.

METHOD

In this study, we developed a stepwise algorithmic nutrition care protocol for PICU patients in two phases as follows: a critical review of past literature and an expert discussion panel. The final structured protocol includes three following steps for the nutrition care process: 1) Initial nutrition screening and assessment, 2) Nutritional intervention and 3) Nutritional monitoring. Pre and post-implementation audits were carried out in a 23 bed medical/surgical PICU in a children's hospital affiliated to Mashhad University of Medical Sciences over two 4-week periods to evaluate the impact of the algorithm implementation. The post-implementation audit was performed by passing 12 weeks from the protocol implementation. Critically ill children aged between 1month and 10 years, and PICU length of stay>24 h who were in post gastrointestinal surgery state, were enrolled.

RESULTS

Totally, 34 eligible critically ill gastrointestinal surgical children in post-implementation audit were compared with 30 patients with similar eligibility criteria in the pre-implementation audit. Notably, there were no significant differences in gender, median age, length of PICU stay, and mechanical ventilation requirement in the two audits. The comparison of our pre and post-implementation audits showed a significant increase in the proportion of energy delivery goal achievement following performing our intervention (56.7%, and 85.3%, for pre and post-implementation audits, respectively; p-value = 0.01).Additionally, time of achieving energy and protein goals were significantly decreased (5.5 vs. 3 days; p-value = 0.008 and 4 vs 3 days; p-value = 0.002, for energy and protein delivery goal achievements, respectively).

CONCLUSION

The implementation of the algorithm have significantly improved the adequacy ratio of energy delivery and also decreased the time to achieve the goal in energy and protein intake among critically ill children in post-gastrointestinal state. In this regard, further prospective studies are needed for continuing the evaluation of the algorithm implementation outcomes in critically ill children with different surgical and internal underlying diseases.

Skeletal Muscle Changes, Function, and Health-Related Quality of Life in Survivors of Pediatric Critical Illness

OBJECTIVES

To describe functional and skeletal muscle changes observed during pediatric critical illness and recovery and their association with health-related quality of life.

DESIGN

Prospective cohort study.

SETTING

Single multidisciplinary PICU.

PATIENTS

Children with greater than or equal to 1 organ dysfunction, expected PICU stay greater than or equal to 48 hours, expected survival to discharge, and without progressive neuromuscular disease or malignancies were followed from admission to approximately 6.7 months postdischarge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional status was measured using the Functional Status Scale score and Pediatric Evaluation of Disability Inventory-Computer Adaptive Test. Patient and parental health-related quality of life were measured using the Pediatric Quality of Life Inventory and Short Form-36 questionnaires, respectively. Quadriceps muscle size, echogenicity, and fat thickness were measured using ultrasonography during PICU stay, at hospital discharge, and follow-up. Factors affecting change in muscle were explored. Associations between functional, muscle, and health-related quality of life changes were compared using regression analysis. Seventy-three survivors were recruited, of which 44 completed follow-ups. Functional impairment persisted in four of 44 (9.1%) at 6.7 months (interquartile range, 6-7.7 mo) after discharge. Muscle size decreased during PICU stay and was associated with inadequate energy intake (adjusted β, 0.15; 95% CI, 0.02-0.28; p = 0.030). No change in echogenicity or fat thickness was observed. Muscle growth postdischarge correlated with mobility function scores (adjusted β, 0.05; 95% CI, 0.01-0.09; p = 0.046). Improvements in mobility scores were associated with improved physical health-related quality of life at follow-up (adjusted β, 1.02; 95% CI, 0.23-1.81; p = 0.013). Child physical health-related quality of life at hospital discharge was associated with parental physical health-related quality of life (adjusted β, 0.09; 95% CI, 0.01-0.17; p = 0.027).

CONCLUSIONS

Muscle decreased in critically ill children, which was associated with energy inadequacy and impaired muscle growth postdischarge. Muscle changes correlated with change in mobility, which was associated with child health-related quality of life. Mobility, child health-related quality of life, and parental health-related quality of life appeared to be interlinked.

Cardiac critical care of the post-operative congenital heart disease patient

Cardiac critical care has become an increasingly complex subspecialty, involving multiple subspecialists to support patients with congenital heart disease. This requires understanding of their physiology and the impact of medical interventions. The purpose of this article is to provide a concise review of the current strategies utilized by cardiac intensivists to optimize outcomes for this vulnerable patient population, with the goal of broadening the knowledge of other members of the multi-disciplinary team.

Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice

Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.

Supplementation of vitamins, trace elements and electrolytes in the PEPaNIC Randomised Controlled Trial: Composition and preparation of the prescription

BACKGROUND AND AIMS

Following the results of the paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial, the new ESPGHAN/ESPEN/ESPR/CSPEN and ESPNIC guidelines recommend to consider withholding parenteral macronutrients for 1 week, while providing micronutrients, in critically ill children if enteral nutrition is insufficient. Critically ill children are suspected to be vulnerable to micronutrient deficiencies due to inadequate enteral nutrition, increased body's demands and excessive losses. Hitherto, micronutrient requirements in PICU are estimated based on recommended daily intakes for healthy children and expert opinion. We aimed to provide an overview of the current practice of micronutrient administration and practical considerations in the three participating centres of the PEPaNIC study, and compare these therapies with the recommendations in the new ESPGHAN/ESPEN/ESPR/CSPEN guidelines.

METHODS

We describe the current composition and preparation of the prescribed parenteral micronutrients (consisting of vitamins, trace elements and electrolytes) in the three centres (Leuven, Rotterdam and Edmonton) that participated in the PEPaNIC RCT, and compare this per micronutrient with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines recommendations.

RESULTS

The three centres use a different micronutrient supplementation protocol during the first week of critical illness in children, with substantial differences regarding the amounts administered. Leuven administers commercial vitamins, trace elements and electrolytes in separate infusions both in 4 h. Rotterdam provides commercial vitamins and trace elements simultaneously via 8-h infusion and electrolytes continuously over 24 h. Lastly, Edmonton administers commercial vitamins and institutionally prepared trace elements solutions in 1 h and electrolytes on demand. Comparison with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines yields in differences between the recommendations and the administered amounts, which are most substantial for vitamins.

CONCLUSION

The practice of intravenous micronutrient administration differs substantially between the three PEPaNIC centres and in comparison with the current guideline recommendations. This deviation is at least partially explained by the inability to provide all recommended amounts with the currently available commercial products and by the lack of strong evidence supporting these recommendations.

A Multi-Interventional Nutrition Program for Newborns with Congenital Heart Disease

OBJECTIVE

To evaluate how outcomes changed in newborns undergoing surgery for congenital heart disease after implementation of a standardized preoperative and postoperative nutrition program.

STUDY DESIGN

We performed a single-center cohort study of newborns who underwent cardiac surgery between September 2008 and July 2015. We evaluated growth and feeding outcomes in the 2 years of preprogram time (phase 0), in the 2 years after initiation of a postoperative feeding algorithm (phase 1), and in the 2 years following introduction of a preoperative feeding program (phase 2) using traditional statistics and quality improvement methods.

RESULTS

The study included 570 newborns with congenital heart disease. Weight-for-age z-score change from birth to hospital discharge significantly improved from phase 0 (-1.02 [IQR, -1.45 to -0.63]) to phase 1 (-0.83 [IQR, -1.25 to -0.54]; P = .006), with this improvement maintained in phase 2 (-0.89 [IQR, -1.30 to -0.56]; P = .017 across phases). Gastrostomy tube use decreased significantly (25% in phase 0 vs 12% and 14% in phases 1 and 2; P < .001) and preoperative enteral feeding increased significantly (47% and 46% in phases 0 and 1 vs 76% in phase 2; P < .001) without increases in necrotizing enterocolitis, hospital stay, or mortality.

CONCLUSIONS

Introduction of a multi-interventional nutrition program was associated with improved weight gain, fewer gastrostomy tubes at hospital discharge, and increased preoperative enteral feeding without increases in necrotizing enterocolitis, hospital stay, or mortality.

The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations

GENERAL PURPOSE

To review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline with further discussion of nutrition for pressure injury management in the context of the recommendations.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Distinguish nutrition and malnutrition, especially as they relate to the development and healing of pressure injuries.2. Differentiate the tools and techniques that help clinicians assess nutrition status as well as the causes of pressure injuries in specific populations.3. Identify interventions for improving nutrition status and promoting pressure injury healing.

ABSTRACT

Macro- and micronutrients are required by each organ system in specific amounts to promote the growth, development, maintenance, and repair of body tissues. Specifically, nutrition plays an important role in the prevention and treatment of pressure injuries. The purpose of this manuscript is to review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Nutrition for pressure injury management is discussed in the context of the recommendations.

Impact of Computer Calculation Program on Quality of Individualized Parenteral Nutrition and Selected Clinical Parameters of Extremely Low-Birth-Weight Infants

BACKGROUND

The aim of the study was to assess the effects of computerized provider order entry (CPOE) for parenteral nutrition (PN) on selected clinical parameters of extremely low-birth-weight (ELBW) neonates in a tertiary neonatal intensive care unit.

METHODS

This study was a retrospective data analysis of preterm infants born over a 1-year period before and after introduction of CPOE. PN composition during the first 2 weeks of life, change in weight, head circumference and body length z-scores were assessed. Duration of PN and selected neonatal complications were compared. Logistic regression was used to adjust for confounding variables (sex, birth weight, and birth-gestational age).

RESULTS

Ninety-four patients in 2 equal groups were analyzed. Birth weight (median 810 vs 825 g) and gestational age (27 vs 27 weeks) were comparable. After adjustment for confounding variables, on the first and seventh day of life, significantly more energy (P < .001), protein (P < .001), lipid (P < .03), and carbohydrate (P < .02) were administered in the CPOE group than in the manually calculated (MC) prescriptions group. The CPOE group had lower weight loss (P < .001), a significant improvement in linear growth, and faster regain of birth weight (P < .01) compared with the MC group.

CONCLUSION

The CPOE positively influences the quality of PN in ELBW infants. It also significantly reduced initial weight loss, time to regain birth weight, and linear growth. It may also have beneficial effects on selected clinical outcomes, which requires further study.