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Saleh NY, Aboelghar HM, Abdelaty NB, Garib MI, Mahmoud AA. Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial. Clin Exp Pediatr 2023; 66:403-411. [PMID: 37321580 PMCID: PMC10475857 DOI: 10.3345/cep.2023.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/27/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
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.
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Affiliation(s)
- Nagwan Y. Saleh
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Hesham M. Aboelghar
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Nehad B. Abdelaty
- Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Mohamed I. Garib
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Asmaa A. Mahmoud
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
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Ghosh S, Balachandran R, Neema PK, Kottayil BP, Bhaskaran R, Sudhakar A, Krishna Kumar R. 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. World J Pediatr Congenit Heart Surg 2023; 14:300-306. [PMID: 36823964 DOI: 10.1177/21501351231154207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
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.
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Affiliation(s)
- Sreepurna Ghosh
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Rakhi Balachandran
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Praveen Kumar Neema
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Brijesh P Kottayil
- Department of Cardiovascular and Thoracic Surgery, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Abish Sudhakar
- Department of Pediatric Cardiology, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - R Krishna Kumar
- Department of Pediatric Cardiology, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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Zhu W, Chen P, Wang K, Xing X. The effect of transpyloric enteral nutrition on inflammatory response and prognosis for patients with Corona Virus Disease-19 in intensive care unit: A STROBE compliant study. Medicine (Baltimore) 2022; 101:e31294. [PMID: 36343035 PMCID: PMC9646609 DOI: 10.1097/md.0000000000031294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
To investigate the effect of transpyloric enteral nutrition (TEN) on NLRP1, inflammatory response and prognosis for patients with Corona Virus Disease-19 (COVID-19) in intensive care unit (ICU). The present prospective observational study included 29 cases of COVID-19 patients in ICU who admitted to our hospital during February 2020 to March 2020. All the patients were divided into gastrogavage groups (n = 16) and TEN group (n = 13) according to route of enteral nutrition. Serum levels of C-reactive protein (CRP), interleukin-1 β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and NLRP1 (NLR family pyrin domain containing 1) was detected by enzyme linked immunosorbent assay (ELISA). Serum levels of lymphocyte, albumin and hemoglobin was detected using an automatic biochemical analyzer. Patients' demographic and clinical characteristics were collected and analyzed. Kaplan-Meier (K-M) curve was conducted for survival analysis and receiver operating characteristic curve was used for the analysis of diagnostic value of biomarkers. All the patients were followed-up for 3 months. This study found that the survival group had higher rate of TEN therapies than the deceased. COVID-19 patients in ICU on TEN had lower APACHE II scores, frequency of feeding suspension and mortality, however, with higher content of albumin was found at 5th day. The incidence of nutritional intolerance including abdominal distension and gastric retention in patients on TEN was notably lower than those on gastrogavage. The serum levels of NLRP1, CRP, IL-1β, IL-6 and TNF-α decreased in a time-dependent manner, but patients on TEN had lower levels of NLRP1, CRP and IL-1β than patients on gastrogavage. A positive correlation was found among NLRP1 and inflammatory factors, and COVID-19 patients with lower NLRP1 had longer survival time. Serum NLRP1 also exhibited diagnostic value for the death of COVID-19 patients. TEN decreased inflammatory response and improved the prognosis for COVID-19 patients in ICU.
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Affiliation(s)
- Wei Zhu
- Intensive Care Unit, Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Hubei Province, China
| | - Ping Chen
- Intensive Care Unit, Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Hubei Province, China
| | - Ke Wang
- Intensive Care Unit, Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Hubei Province, China
| | - Xiaolei Xing
- Endocrine Department, Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Hubei Province, China
- * Correspondence: Xiaolei Xing, Endocrine Department, Tianyou Hospital Affiliated to Wuhan University of Science and Technology, No. 9, Tujialing, Wuchang District, Wuhan, Hubei Province 430064, China (e-mail: )
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4
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Pratt CA, Brown AGM, Dixit S, Farmer N, Natarajan A, Boyington J, Shi S, Lu Q, Cotton P. Perspectives: on Precision Nutrition Research in Heart, Lung, and Blood Diseases and Sleep Disorders. Adv Nutr 2022; 13:1402-1414. [PMID: 35561742 PMCID: PMC9526828 DOI: 10.1093/advances/nmac053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/20/2022] [Accepted: 05/06/2022] [Indexed: 01/28/2023] Open
Abstract
The release of the 2020-2030 Strategic Plan for NIH Nutrition Research (SPNR) and its emphasis on precision nutrition has provided an opportunity to identify future nutrition research that addresses individual variability in response to diet and nutrition across the life span-including those relevant to the Strategic Vision of the National Heart, Lung, and Blood Institute (NHLBI). The SPNR and the NHLBI's Strategic Vision were developed with extensive input from the extramural research community, and both have 4 overarching strategic goals within which are embedded several objectives for research. For the SPNR, these include 1) spur discovery science and normal biological functions (e.g., role of the microbiome in health and disease), 2) population science to understand individual differences (e.g., biomarkers including 'omics that predict disease status), 3) emerging scientific areas of investigation and their application (e.g., data science, artificial intelligence), and 4) cross-cutting themes (e.g., training the scientific workforce and minority health and health disparities). These strategic goals and objectives serve as blueprints for research and training. Nutrition remains important in the prevention and treatment of heart, lung, blood, and sleep (HLBS) disorders and diseases, and the NHLBI has played a pivotal role in supporting nutrition research. In this paper, we report important gaps in the scientific literature related to precision nutrition in HLBS diseases. Research opportunities that could stimulate precision nutrition and their alignment with the SPNR and the NHLBI Strategic Vision Objectives are provided. These opportunities include 1) exploring individual differences in response to varying dietary patterns and nutrients; 2) investigating genetic/epigenetic, biological (e.g., microbiome, biomarkers), social, psychosocial, and environmental underpinnings of individual variability in diet; 3) elucidating the role of circadian rhythm and chrononutrition; and 4) applying implementation science research methods in precision nutrition interventions relevant to HLBS diseases.
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Affiliation(s)
| | - Alison G M Brown
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Shilpy Dixit
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Nicole Farmer
- National Institutes of Health, Clinical Center, Bethesda, MD, USA
| | - Aruna Natarajan
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Josephine Boyington
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Scarlet Shi
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Qing Lu
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Paul Cotton
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
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5
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Dhochak N, Singh A, Malik R, Jat KR, Sankar J, Makharia G, Kabra SK, Lodha R. Acute gastrointestinal injury in critically ill children: Impact on clinical outcome. J Paediatr Child Health 2022; 58:649-654. [PMID: 34750905 DOI: 10.1111/jpc.15804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/26/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
AIM To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality. METHODS In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated. RESULTS Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality. CONCLUSIONS Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.
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Affiliation(s)
- Nitin Dhochak
- Departments of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Alka Singh
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Malik
- Pediatric Gastroenterology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kana R Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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6
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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7
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A Multi-Interventional Nutrition Program for Newborns with Congenital Heart Disease. J Pediatr 2021; 228:66-73.e2. [PMID: 32827527 DOI: 10.1016/j.jpeds.2020.08.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/21/2020] [Accepted: 08/14/2020] [Indexed: 12/25/2022]
Abstract
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.
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8
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Alsohime F, Assiry G, AlSalman M, Alabdulkareem W, Almuzini H, Alyahya M, Allhidan R, Al-Eyadhy A, Temsah MH, Al Sarkhy AA. Barriers to the delivery of enteral nutrition in pediatric intensive care units: A national survey. Int J Pediatr Adolesc Med 2020; 8:186-190. [PMID: 34350333 PMCID: PMC8319679 DOI: 10.1016/j.ijpam.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/24/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
Background and Aim According to previously reported studies in the literature, a significant number of patients do not receive enteral nutrition in pediatric intensive care unit (PICU) because of avoidable barriers. Optimal nutrition is a fundamental goal in PICU. This study aims to identify the barriers of enteral nutrition in PICU. Setting and Design A cross-sectional study of the results of a 25-item questionnaire-based survey distributed during the Annual International Critical Care Conference by the Saudi Critical Care Society. Methods and material A 7-point Likert-type scale was used to rank the participants’ responses, and the relative importance index (RII) approach was used to analyze the relative contribution of each indicator to its main theme. The factor and parallel analysis methods were used to assess the factorial and unidimensionality of the enteral feeding barriers scale. Results A total of 223 PICU healthcare workers from various intensive care settings responded to the survey. The top-three perceived barriers for commencing enteral feeding were due to the patient being hemodynamically unstable (M = 3.6 and SD = 1.70), delays and difficulties in obtaining small bowel access in patients not tolerating other types of enteral nutrition (M = 3.4 and SD = 1.52), or severe fluid restriction, particularly in postoperative cardiac surgery (M = 3.3 and SD = 1.59). The top perceived overall barriers to enteral feeding were the dietician-related issues (M = 3.3, SD = 1.32), barriers related to enteral feeding delivery (M = 3.16 and SD = 1.13), and medical practice-related (M = 3 and SD = 1.10) issues. The lowest reported overall barriers were the resource-related obstacles (M = 2.7 and SD = 1.26). Conclusion Being hemodynamically unstable and other dietician-related reasons were the top overall barriers in commencing enteral feeding.
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Affiliation(s)
- Fahad Alsohime
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ghadeer Assiry
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Wejdan Alabdulkareem
- Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hissah Almuzini
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Malak Alyahya
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reema Allhidan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Al Sarkhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Gastroenterology Unit, Pediatric Department, King Khalid University Medical City, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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9
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Elliott EM, Isserman RS, Stricker P, Yaddanapudi S, Subramanyam R. Fasting for anaesthesia: Less is more! Indian J Anaesth 2020; 64:87-89. [PMID: 32139924 PMCID: PMC7017675 DOI: 10.4103/ija.ija_936_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/08/2020] [Accepted: 01/13/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Elizabeth M Elliott
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, USA. E-mail:
| | - Rebecca S Isserman
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, USA. E-mail:
| | - Paul Stricker
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, USA. E-mail:
| | - Sandhya Yaddanapudi
- Department of Anesthesia and Critical Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Subramanyam
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, USA. E-mail:
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10
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Turner AD, Hamilton SM, Callif C, Ariagno KA, Arena AE, Mehta NM, Martinez EE. Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2020; 35:299-305. [PMID: 31990093 DOI: 10.1002/ncp.10452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. METHODS In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. RESULTS The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. CONCLUSION Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.
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Affiliation(s)
| | - Susan M Hamilton
- Department of Cardiovascular/Critical Care Nursing, Boston, Massachusetts, USA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anastasia E Arena
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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11
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The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019. J Pediatr Gastroenterol Nutr 2019; 69:239-258. [PMID: 31169666 DOI: 10.1097/mpg.0000000000002379] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety. METHODS A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors. RESULTS A total of 33 recommendations were voted on using the nominal voting technique. CONCLUSIONS JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.
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Brown AM, Fisher E, Forbes ML. Bolus vs Continuous Nasogastric Feeds in Mechanically Ventilated Pediatric Patients: A Pilot Study. JPEN J Parenter Enteral Nutr 2018; 43:750-758. [PMID: 30570162 DOI: 10.1002/jpen.1495] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/27/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Malnutrition increases the risk of mortality and morbidity in the pediatric intensive care unit (PICU). Barriers to adequate delivery of enteral nutrition (EN) include hemodynamic instability, feeding interruptions and intolerance, and lack of standardized feeding protocols. The most recent guidelines on nutrition support for the critically ill child describe a paucity of evidence around the best method to deliver EN. There is an untested clinical assumption that bolus gastric feeding (B-GF) in intubated patients is associated with aspiration events, lung injury, and associated morbidity compared with continuous gastric feeding (C-GF). This study compared the effectiveness and safety of C-GF vs B-GF in intubated pediatric patients. METHODS We enrolled randomized patients aged 1 month-12 years who were intubated within 24 hours and received EN starting within 48 hours of admission to a C-GF or B-GF group. Goal-directed EN volume and caloric density were increased every 3 and 12 hours, respectively, to target. Feeding interruptions and intolerance events were recorded. RESULTS Twenty-five subjects were enrolled (B-GF = 11; C-GF = 14). At 24 hours, B-GF was associated with higher energy and protein delivery (P < 0.007) and was associated with faster time to goal volume (median B-GF = 15 hours; C-GF = 29.5 hours). No aspiration events resulting in additional lung injury were noted for either group (P = 0.866). CONCLUSIONS B-GF was associated with superior delivery of EN with a comparable safety profile to C-GF. Further study is needed to compare both EN methods in other PICU populations.
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Affiliation(s)
- Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.,Pediatric Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA
| | - Elaine Fisher
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.,School of Nursing, College of Health Professions, The University of Akron, Akron, Ohio, USA
| | - Michael L Forbes
- Pediatric Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA
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Haney A, Burritt E, Babbitt CJ. The impact of early enteral nutrition on pediatric acute respiratory failure. Clin Nutr ESPEN 2018; 26:42-46. [PMID: 29908681 DOI: 10.1016/j.clnesp.2018.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/04/2018] [Accepted: 04/26/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS Children who are critically ill undergo metabolic stress and it is important that they receive adequate calories and protein in order to recover. Our objective was to investigate the impact of early enteral nutrition (EEN) on pediatric intensive care (PICU) patients with acute respiratory failure. METHODS A retrospective cohort study was performed on all patients admitted to a 20 bed PICU at a tertiary children's hospital over a 30 month period. Inclusion criteria were: intubation on admission or within 24 h of admission, ventilation over 48 h and enteral nutrition initiated on ventilatory support. Baseline patient characteristics and nutritional, ventilatory and overall outcome data were collected. Subgroup analysis was performed comparing those that received EEN (goal in 72 h) and those that did not. RESULTS Patients that received EEN had a shorter PICU and overall length of stay 8.7 vs 10.7 and 17.5 vs 22; p < 0.05 and received a higher percentage of goal Kcal and protein (71 vs 54, and 61 vs 51%, p < 0.002) in the PICU. After adjusting for age and severity of illness, EEN was still associated with decreased PICU and overall length of stay. More patients with feeding intolerance were on vasoactive agents (33 vs 9%, p = 0.02), but intolerance was not associated with use of motility agents or degree of respiratory failure. Feeds were interrupted in 19% of patients, most commonly for procedures. CONCLUSIONS In PICU patients with acute respiratory failure, EEN is associated with shorter PICU and overall length of stay and delivery of higher percentage of goal Kcal and protein by tube feeds. Feeds are commonly interrupted despite efforts to achieve EEN and patients receiving vasoactive agents have feeds held more commonly for perceived intolerance.
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Affiliation(s)
- Amanda Haney
- Department of Nutrition, Miller Children's Hospital, Long Beach CA 90806, USA
| | - Emily Burritt
- Department of Nutrition, Miller Children's Hospital, Long Beach CA 90806, USA
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Baǧci S, Keleş E, Girgin F, Yıldızdaş DR, Horoz ÖÖ, Yalındağ N, Tanyıldız M, Bayrakçi B, Kalkan G, Akyıldız BN, Köker A, Köroğlu T, Anıl AB, Zengin N, Dinleyici EÇ, Kıral E, Dursun O, Yavuz ST, Bartmann P, Müller A. Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey. J Paediatr Child Health 2018; 54:480-486. [PMID: 29278447 DOI: 10.1111/jpc.13810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 09/25/2017] [Accepted: 10/03/2017] [Indexed: 01/12/2023]
Abstract
AIM Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. METHODS We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). RESULTS Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. CONCLUSIONS There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children.
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Affiliation(s)
- Soyhan Baǧci
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Elif Keleş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Feyza Girgin
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Dinçer R Yıldızdaş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Özden Ö Horoz
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Nilüfer Yalındağ
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Murat Tanyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Benan Bayrakçi
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Gökhan Kalkan
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Başak N Akyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Erciyes, Kayseri, Turkey
| | - Alper Köker
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Tolga Köroğlu
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Ayşe B Anıl
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey.,Pediatric Intensive Care Unit, Department of Pediatrics, University of Izmir Katip Celebi, Izmir, Turkey
| | - Neslihan Zengin
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey
| | - Ener Ç Dinleyici
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Eylem Kıral
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Oğuz Dursun
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Akdeniz, Antalya, Turkey
| | | | - Peter Bartmann
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
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Cunningham CA, Gervais LB, Mazurak VC, Anand V, Garros D, Crick K, Larsen BMK. Adherence to a Nurse-Driven Feeding Protocol in a Pediatric Intensive Care Unit. JPEN J Parenter Enteral Nutr 2017; 42:327-334. [PMID: 28196328 DOI: 10.1177/0148607117692751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 01/14/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients admitted to pediatric intensive care units (PICUs) often experience prolonged periods without nutrition support, which may result in hospital-induced malnutrition and longer length of stay. Nurse-driven feeding protocols have been developed to prevent unnecessary interruptions or delays to nutrition support. The primary objective of this study was to identify compliance and reasons for noncompliance to a feeding protocol at a tertiary care hospital PICU in Canada. The secondary aim was to determine the mean time (hours) spent without any form of nutrition and to identify reasons for time spent without nutrition. MATERIALS AND METHODS This was a prospective cohort audit, consisting of 150 consecutive PICU admissions (January-February 2016). Exclusion criteria consisted of patient mortality within 48 hours (n = 1) and patients who were still admitted at the end of the data collection timeframe (n = 7). The remaining cohort consisted of 142 consecutive admissions. Data collection took place in real time and included patient demographics, diagnostic categories, time spent without nutrition, reasons for interruptions to nutrition support, and reasons for noncompliance to the protocol. Observations were obtained through paper and computer charts and conversing with clinicians. RESULTS There was a 95% compliance rate to the protocol and an average of 25.6 hours spent without nutrition per patient. The most prevalent reason for noncompliance was an avoidable delay to restart feeds before/after procedures or after surgery. CONCLUSIONS A nurse-driven feeding protocol may reduce time spent without nutrition. Future research is required to examine the relationship between adherence to feeding protocols and clinical outcomes.
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Affiliation(s)
- Carmen A Cunningham
- Division of Human Nutrition, Faculty of Agriculture, Life, and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay B Gervais
- Division of Human Nutrition, Faculty of Agriculture, Life, and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Vera C Mazurak
- Division of Human Nutrition, Faculty of Agriculture, Life, and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Vijay Anand
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Garros
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Katelynn Crick
- Department of Epidemiology, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Bodil M K Larsen
- Division of Human Nutrition, Faculty of Agriculture, Life, and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Nutrition Services, Alberta Health Services, Edmonton, Alberta, Canada
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Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries. Cardiol Young 2017; 27:S22-S30. [PMID: 29198259 DOI: 10.1017/s104795111700258x] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Poor growth with underweight for age, decreased length/height for age, and underweight-for-height are all relatively common in children with CHD. The underlying causes of this failure to thrive may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilisation of absorbed nutrition. These factors are particularly common and severe in low- and middle-income countries. Although nutrition should be carefully assessed in all patients, failure of growth is not a contraindication to surgical repair, and patients should receive surgical repair where indicated as soon as possible. Close attention should be paid to nutritional support - primarily enteral feeding, with particular use of breast milk in infancy - in the perioperative period and in the paediatric ICU. This nutritional support requires specific attention and allocation of resources, including appropriately skilled personnel. Thereafter, it is essential to monitor growth and development and to identify causes for failure to catch-up or grow appropriately.
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Zhang AM, Sun ZQ, Zhang LM. Mosapride combined with probiotics on gastrointestinal function and growth in premature infants. Exp Ther Med 2017; 13:2675-2680. [PMID: 28587329 PMCID: PMC5450587 DOI: 10.3892/etm.2017.4340] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/23/2016] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to investigate the effects of mosapride combined with probiotics on gastrointestinal function and growth and development in premature infants. A total of 240 premature infants treated at Weifang People's Hospital between June 2012 and May 2015 who matched our criteria were randomly divided into three groups of 80 cases each. Group A received routine treatment, group B received routine treatment combined with live B. subtilis and E. faecium granules with multivitamins (Medilac-Vita), and group C received routine treatment and Saccharomyces boulardii sachets (Bioflor). Mosapride was administered to patients in groups B and C to promote intestinal peristalsis. Gastrin and bilirubin levels, as well as jaundice fade time, were recorded. Growth and development condition (i.e., head circumference and weight), duration and incidence of feeding intolerance (FI), as well as other symptoms were also analyzed. By day 14, gastrin concentrations in groups B and C were significantly higher than those in group A (P<0.05). Serum bilirubin levels in groups B and C showed a progressive decline from day 7 to day 14, and jaundice duration in group A was significantly longer (P<0.05). Furthermore, at 2 weeks, the average weight growth rate and head circumference were significantly greater in groups B and C, weight loss recovery time was shorter, and EUGR incidence was lower (P<0.05). The incidence rate of gastric retention and FI were lower in groups B and C than group A (P<0.05), and neonatal hyperbilirubinemia, parenteral nutrition-associated cholestasis, necrotizing enterocolitis, and neonatal sepsis incidence was significantly lower in groups B and C (P<0.05). Mosapride combined with probiotics can effectively reduce FI incidence in premature infants, shorten enteral feeding time, promote the absorption of required nutrients, and promote the development and recovery of early physiological weight loss in preterm infants.
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Affiliation(s)
- Ai-Mei Zhang
- Department of Pediatrics, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Zhi-Qun Sun
- Department of Pediatrics, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Li-Ming Zhang
- Department of Pediatrics, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
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Goulet O, Jochum F, Koletzko B. Early or Late Parenteral Nutrition in Critically Ill Children: Practical Implications of the PEPaNIC Trial. ANNALS OF NUTRITION AND METABOLISM 2017; 70:34-38. [PMID: 28147359 DOI: 10.1159/000455336] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Olivier Goulet
- Hopital Necker Enfants Malade, Paris-Descartes University, Paris, France
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Abstract
BACKGROUND Patients in the neonatal intensive care unit are a vulnerable population with specific nutritional requirements, which include increased protein and caloric needs for adequate growth. Some infants cannot tolerate gastric feeds and need to have postpyloric feeds to grow. Placement of a postpyloric tube can be done by gastric insufflation. Gastric insufflation is a technique where air is inserted into the stomach as a nasogastric tube is advanced through the pylorus to the duodenum. There is research to support this technique in pediatrics, but scant evidence exists for placement of postpyloric tubes in the infant population. PURPOSE The aim of this quality improvement practice project was to determine whether the current practice for postpyloric tube placement by the bedside nurses in the neonatal intensive care unit is safe and effective. METHODS Data were prospectively collected on 38 infants requiring placement of 60 postpyloric tubes over an 8-week period. RESULTS The results indicate a success rate of 95.6% for tube placement when a subset of infants diagnosed with congenital diaphragmatic hernia (CDH) (n = 15) was excluded. Six (40%) of the 15 infants with CDH had postpyloric tubes placed successfully. Nursing years of experience did not affect successful postpyloric tube placement. IMPLICATIONS FOR PRACTICE The postpyloric tube placement policy was modified as a result of findings from this project. Placement of a postpyloric tube with one attempt by the bedside nurse was safe and effective in most preterm infants in our care excluding patients with CDH. The new policy reduced infants' exposure to radiation due to a decrease in the number of x-rays in comparison to interventional radiology placement. IMPLICATIONS FOR RESEARCH Further research should be done by units that primarily care for low birth-weight premature infants.
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Uhm JY, Lee H. Development and Implementation of a Feeding Protocol for Infants in a Pediatric Cardiac Intensive Care Unit. CHILD HEALTH NURSING RESEARCH 2016. [DOI: 10.4094/chnr.2016.22.4.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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A Nursing Survey on Nutritional Care Practices in French-Speaking Pediatric Intensive Care Units: NutriRéa-Ped 2014. J Pediatr Gastroenterol Nutr 2016; 62:174-9. [PMID: 26237373 DOI: 10.1097/mpg.0000000000000930] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Malnutrition in critically ill children contributes to morbidity and mortality. The French-speaking pediatric intensive care nutrition group (NutriSIP) aims to promote optimal nutrition through education and research. METHODS The NutriSIP-designed NutriRéa-Ped study included a cross-sectional survey. This 62-item survey was sent to the nursing teams of all of the French-speaking pediatric intensive care units (PICUs) to evaluate nurses' nutrition knowledge and practices. One nurse per PICU was asked to answer and describe the practices of their team. RESULTS Of 44 PICUs, 40 responded in Algeria, Belgium, Canada, France, Lebanon, Luxemburg, and Switzerland. The majority considered nutrition as a priority care but only 12 of the 40 (30%) had a nutrition support team, 26 of the 40 (65%) had written nutrition protocols, and 19 of 39 (49%) nursing teams felt confident with the nutrition goals. Nursing staff generally did not know how to determine nutritional requirements or to interpret malnutrition indices. They were also unaware of reduced preoperative fasting times and fast-track concepts. In 17 of 35 (49%) PICUs, the target start time for enteral feeding was within the first 24 hours; however, frequent interruptions occurred because of neuromuscular blockade, fasting for extubation or surgery, and high gastric residual volumes. Combined pediatric neonatal intensive care units were less likely to perform systematic nutritional assessment and to start enteral nutrition rapidly. CONCLUSIONS We found a large variation in nursing practices around nutrition, exacerbated by the lack of nutritional guidelines but also because of the inadequate nursing knowledge around nutritional factors. These findings encourage the NutriSIP to improve nutrition through focused education programs and research.
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Prakash V, Parameswaran N, Biswal N. Early versus late enteral feeding in critically ill children: a randomized controlled trial. Intensive Care Med 2015; 42:481-482. [PMID: 26679696 DOI: 10.1007/s00134-015-4176-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 01/08/2023]
Affiliation(s)
- V Prakash
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Pondicherry, 605006, India
| | - Narayanan Parameswaran
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Pondicherry, 605006, India
| | - Niranjan Biswal
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Pondicherry, 605006, India.
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Ang B, Han WM, Wong JJM, Lee AN, Chan YH, Lee JH. Impact of a nurse-led feeding protocol in a pediatric intensive care unit. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815610139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: To determine effectiveness of a nurse-led, volume-based feeding protocol in our pediatric intensive care unit (PICU), we evaluated patients’ nutrition adequacy pre- and post-protocol implementation. Methods: We conducted an observational study of patients admitted for more than three days in the PICU during pre- and post-feeding protocol periods. We recorded energy and protein intake and feed interruptions in patients started on enteral nutrition over the first seven days of admission. We excluded patients with septic shock requiring more than two inotropes, post-cardiac and post-gastrointestinal surgeries. To determine nutrition adequacy, actual energy and protein intakes were compared with calculated requirements, expressed as percentages. Results: We had a total of 40 patients (20 in the pre- and post-protocol groups, respectively) with median age of 9.4 (interquartile range (IQR) 2.8, 57) months. Median time to feed initiation was similar between groups (20.0 (IQR 17.0, 37.5) vs. 21.5 (IQR 10.5, 27.0) hours, p = 0.516). There was no difference in median energy (55 (IQR 12, 102) vs. 59 (IQR 25, 85) %, p = 0.645) and protein intake (53 (IQR 16, 124) vs. 73 (IQR 22, 137) %, p = 0.069) over the seven-day period between groups; the proportion of patients meeting their energy (10 vs. 35%, p = 0.127) and protein goal (15 vs. 30%, p = 0.451) by day three also did not differ significantly pre- and post-protocol implementation. The most common reasons for feed interruption were intubation/extubation and radiological procedures. Conclusion: Our current feeding protocol did not improve nutrient adequacy. The effectiveness of a more aggressive protocol in units where enteral nutrition is initiated within 24 hours should be investigated.
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Affiliation(s)
- Bixia Ang
- Department of Nutrition and Dietetics, KK Women’s and Children’s Hospital, Singapore
| | - Wee Meng Han
- Department of Nutrition and Dietetics, KK Women’s and Children’s Hospital, Singapore
| | - Judith Ju-Ming Wong
- Department of Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Ang Noi Lee
- Division of Nursing, KK Women’s and Children’s Hospital, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
- Office of Clinical Sciences, Duke-NUS Graduate School of Medicine, Singapore
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Brown AM, Carpenter D, Keller G, Morgan S, Irving SY. Enteral Nutrition in the PICU: Current Status and Ongoing Challenges. J Pediatr Intensive Care 2015; 4:111-120. [PMID: 31110860 DOI: 10.1055/s-0035-1559806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.
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Affiliation(s)
- Ann-Marie Brown
- School of Nursing, The University of Akron, Akron, Ohio, United States.,Division of Critical Care, Akron Children's Hospital, Akron, Ohio, United States
| | - Debbie Carpenter
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Gerri Keller
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Sherry Morgan
- Biomedical Library, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sharon Y Irving
- Department of Nursing, Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,School of Nursing, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Abstract
PURPOSE OF REVIEW The focus of postoperative care in the pediatric patient with congenital heart disease has become a reduction in length of stay and morbidity. This review will discuss strategies to achieve this goal and recent studies to support current practices. RECENT FINDINGS Most agree that prolongation of the length of stay following a cardiac surgery contributes to morbidity. Postoperative feeding difficulty, hyperglycemia, acute kidney injury, fluid overload, and prolonged intubation contribute significantly to length of stay. SUMMARY Postoperative care of the neonate and child following a cardiac surgery remains challenging with limited data to drive our practices. Patients remain at risk for significant morbidity, and future studies should focus on recognizing predictors of morbidity, prevention, and treatment.
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Askegard-Giesmann JR, Kenney BD. Controversies in nutritional support for critically ill children. Semin Pediatr Surg 2015; 24:20-4. [PMID: 25639806 DOI: 10.1053/j.sempedsurg.2014.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nutritional support for critically ill infants and children is of paramount importance and can greatly affect the outcome of these patients. The energy requirement of children is unique to their size, gestational age, and physiologic stress, and the treatment algorithms developed in adult intensive care units cannot easily be applied to pediatric patients. This article reviews some of the ongoing controversial topics of fluid, electrolyte, and nutritional support for critically ill pediatric patients focusing on glycemic control and dysnatremia. The use of enteral and parenteral nutrition as well as parenteral nutritional-associated cholestasis will also be discussed.
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Affiliation(s)
- Johanna R Askegard-Giesmann
- Division of Pediatric Surgery, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr, Room 2500, Indianapolis, Indiana 46202.
| | - Brian D Kenney
- Division of Pediatric Surgery, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
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A Canadian survey of perceived barriers to initiation and continuation of enteral feeding in PICUs. Pediatr Crit Care Med 2014; 15:e49-55. [PMID: 24196008 DOI: 10.1097/pcc.0000000000000016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Clinicians believe nutrition support is important; however, delivery of enteral nutrition may be delayed or interrupted due to a lack of guidelines or perceived contraindications to administration. The aim of this national survey was to examine the knowledge and perceived barriers among clinicians which prevent enteral nutrition administration to PICU patients. DESIGN The survey consisted of 23 questions (19 primary and four branching). The survey was validated using a semistructured pilot test by three pediatric critical care intensivists and two pediatric critical care registered dietitians external to the study team. SETTING The survey was electronically distributed to clinicians in all PICUs across Canada. POPULATION One hundred sixty-two PICU clinicians, including 96 staff intensivists, eight clinical assistants, 36 fellows, and 22 registered dietitians from PICUs across Canada. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The survey was administered from January to March 2013. The response rate was 50% (55 staff intensivists, two clinical assistants, nine fellows, and 15 registered dietitians). There was high variability among clinicians regarding reasons to delay the onset of enteral nutrition or interrupt enteral nutrition administration. High variability (> 70% agreement and < 10% disagreement or vice versa) was found for some reasons to delay or interrupt enteral nutrition, including lactates (rising or > 2 or > 4 mmol/L), high gastric residual volumes, CT/MRI scans, and hypoplastic left heart syndrome. Sixty-eight percent of PICU clinicians reported no written feeding protocol to be in place. CONCLUSIONS Overall, there is high variability among clinicians regarding acceptable procedural and clinical barriers to enteral nutrition administration; this may be improved by a standardized feeding protocol. Therefore, further research must be conducted to provide clinicians with evidence to support their practices for enteral nutrition administration.
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Keehn A, O'Brien C, Mazurak V, Brunet-Wood K, Joffe A, de Caen A, Larsen B. Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2013; 39:211-7. [PMID: 24285250 DOI: 10.1177/0148607113513800] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nutrition support is often delayed or interrupted. The aim of this study is to identify reasons for and quantify time spent without nutrition in a mixed medical-surgical-cardiac pediatric intensive care unit (PICU). METHODS Data were prospectively collected to describe the patient cohort (anthropometrics and diagnostic category) and nutrition practices (time to nutrition initiation; frequency, duration, and causes of interruptions; and overall caloric intake). Descriptive statistics were used; comparisons of groups were performed using an independent t test and P < .05 as significance. RESULTS The mean (standard deviation) time to nutrition initiation was 22.8 (16.6) hours following admission; 35% of patients were initiated after >24 hours. Nutrition was interrupted 1.2 (2.0) times per patient. Time spent without nutrition due to interruptions was 11.6 (23.0) hours, up to 102 hours. Patients spent 42.4% (28.2%) of their median (range) PICU admission of 2.9 days (0.25-39 days) without any form of nutrition. Patients aged 0-6 months had a significantly higher mean number and duration of interruptions (P = .001 and P < .001, respectively) compared with children >6 months. Interruptions due to surgery and planned extubation lasted significantly longer than all other interruptions (P < .001 and P = .001, respectively). Pediatric Risk of Mortality (PRISM) III scores were not correlated with percentage of length of stay spent without nutrition (r = 0.137). CONCLUSIONS Prolonged time to nutrition initiation and interruptions in delivery caused pediatric patients to spend a high proportion of admission without nutrition support, preventing most from meeting energy requirements. Further research addressing specific patient outcomes is required to define optimal initiation times and appropriate procedural-specific fasting times.
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Affiliation(s)
- Alysha Keehn
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Vera Mazurak
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Ari Joffe
- University of Alberta, Edmonton, Alberta, Canada Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Allan de Caen
- University of Alberta, Edmonton, Alberta, Canada Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Bodil Larsen
- Stollery Children's Hospital, Edmonton, Alberta, Canada Alberta Health Services, Edmonton, Alberta, Canada
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Abstract
Respiratory syncytial virus is a highly infectious virus that commonly causes bronchiolitis and leads to high morbidity and a low, but important, incidence of mortality. Supportive therapy is the foundation of management. Hydration/nutrition and respiratory support are important evidence-based interventions. For children with severe disease, continuous positive airway pressure or mechanical ventilation may be necessary. Ribavirin may be used for treatment of patients with severe disease. Palivizumab provides important ongoing immunoprophylaxis during epidemic months for high-risk infants. Caregiver education and incorporating an explanation of all therapies and anticipatory guidance, including strategies for reducing the risk of infection, are vital.
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Wong JJM, Ong C, Han WM, Lee JH. Protocol-driven enteral nutrition in critically ill children: a systematic review. JPEN J Parenter Enteral Nutr 2013; 38:29-39. [PMID: 24072738 DOI: 10.1177/0148607113502811] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Enteral nutrition (EN) protocols are thought to improve clinical outcomes in the pediatric intensive care unit (PICU); however, critical evaluation of their efficacy is limited. We conducted a systematic review with the aim of assessing the effect of EN protocols on important clinical outcomes in these children. We searched MEDLINE, Cochrane Database for Reviews, Embase, and CINAHL using predetermined keywords and MESH terms. We included randomized controlled trials (RCTs) and observational studies that involved EN protocols in children admitted to the PICU for >24 hours. We included studies that reported at least 1 of our outcomes of interest. Studies that exclusively studied premature neonates or adults were excluded. Primary outcomes were PICU or hospital mortality, PICU or hospital length of stay (LOS), duration of mechanical ventilation, gastrointestinal (GI) complications, and infective complications. Secondary outcomes were time to initiate feeds and time to achieve goal feeds. In total, we included 9 studies (total 1564 children) in our systematic review (1 RCT, 4 before-and-after studies, 1 single-arm cohort study, 1 prospective descriptive study, and 2 audits). There is low-level evidence that the use of EN protocols is associated with a reduction in GI and infective complications and improved timeliness of feed initiation and achievement of goal feeds. Current medical literature does not have compelling data on the effects of an EN protocol on clinical outcomes among critically ill children. Future clinical trials should look into using standardized interventions and outcome measures to strengthen the existing evidence.
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Affiliation(s)
- Judith Ju-Ming Wong
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
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Abstract
Provision of optimal nutritional support to children in the pediatric intensive care unit (PICU) is important for optimizing nutritional management, yet challenging because of a variety of factors. Previous nutritional status, degree of malnutrition, and variability in disease states differ significantly among PICU patients. Although there are numerous benefits for enteral nutrition (EN) in critically ill children, obstacles exist within the PICU that prevent the initiation and delivery of appropriate EN and parenteral nutritional (PN) support. Evidence-based nutrition care guidelines have been established to promote optimal nutrition support practice in PICU patients, including identification of those at greatest nutritional risk, initiating EN or PN in a timely manner, and providing EN as the preferred nutrition support modality for children with a functioning gastrointestinal tract. Strategies can be implemented to minimize avoidable delays or interruptions to the optimal delivery of PN and EN, including establishing nutrition support guidelines to promote consistency in practice, promoting clear and consistent communication among the PICU team via direct communication, unit rounds, and the medical record. The education of frontline PICU staff by trained professionals such as pediatric registered dietitians board certified in pediatric nutrition or nutrition support practice can also help promote improved nutritional support practice and outcomes. Specific strategies to optimize nutritional support and EN initiation and delivery at the author’s institution are also presented.
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Affiliation(s)
- Ana Abad-Jorge
- Department of Nutrition Services, University of Virginia Health System, Charlottesville, Virginia
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Abdul Manaf Z, Kassim N, Hamzaid NH, Razali NH. Delivery of enteral nutrition for critically ill children. Nutr Diet 2013. [DOI: 10.1111/1747-0080.12007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Zahara Abdul Manaf
- Dietetic Programme; School of Healthcare Sciences; Faculty of Health Sciences; National University of Malaysia; Malaysia
| | - Norasimah Kassim
- Dietetics and Food Services Department; Hospital Kuala Lumpur; Kuala Lumpur; Malaysia
| | - Nur Hana Hamzaid
- Dietetic Programme; School of Healthcare Sciences; Faculty of Health Sciences; National University of Malaysia; Malaysia
| | - Nurul Huda Razali
- Dietetic Programme; School of Healthcare Sciences; Faculty of Health Sciences; National University of Malaysia; Malaysia
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Abstract
The aim of the present study was to describe the present knowledge of healthcare professionals and the practices surrounding enteral feeding in the UK and Irish paediatric intensive care unit (PICU) and propose recommendations for practice and research. A cross-sectional (thirty-four item) survey was sent to all PICU listed in the Paediatric Intensive Care Audit Network (PICANET) database (http://www.picanet.org.uk) in November 2010. The overall PICU response rate was 90 % (27/30 PICU; 108 individual responses in total). The overall breakdown of the professional groups was 59 % nursing staff (most were children's nurses), 27 % medical staff, 13 % dietitians and 1 % physician assistants. Most units (96 %) had some written guidance (although brief and generic) on enteral nutrition (EN); 85 % of staff, across all professional groups (P= 0.672), thought that guidelines helped to improve energy delivery in the PICU. Factors contributing to reduced energy delivery included: fluid-restrictive policies (60 %), the child just being 'too ill' to feed (17 %), surgical post-operative orders (16 %), nursing staff being too slow in starting feeds (7 %), frequent procedures requiring fasting (7 %) and haemodynamic instability (7 %). What constituted an 'acceptable' level of gastric residual volume (GRV) varied markedly across respondents, but GRV featured prominently in the decision to both stop EN and to determine feed tolerance and was similar for all professional groups. There was considerable variation across respondents about which procedures required fasting and the duration of this fasting. The present survey has highlighted the variability of the present enteral feeding practices across the UK and Ireland, particularly with regard to the use of GRV and fasting for procedures. The present study highlights a number of recommendations for both practice and research.
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Abstract
PURPOSE OF REVIEW Adequate enteral nutrition and growth are vital to recovery and survival of infants following palliation for univentricular hearts. This group of patients experiences frequent feeding complications that may impede adequate delivery of enteral nutrition. This review presents the most recent data related to feeding practices, growth patterns and outcomes. It also explores management strategies for delivering enteral nutrition safely and effectively to this high-risk group of infants. RECENT FINDINGS Infants following palliation for single ventricle physiology have persistent growth failure until at least 14 months of life. Greater daily caloric intake attenuates this growth failure. Persistent growth failure is associated with increased mortality following cardiac surgery. Management of enteral nutrition varies widely both pre and postoperatively. Data suggest that standardizing feeding practices improves delivery of enteral nutrition and decreases feeding complications. Evidence-based international feeding guidelines do not exist. SUMMARY Delivery of adequate nutrition in infants with single ventricle physiology is essential to improve outcomes but is often difficult to achieve. Evidence-based feeding guideline development is crucial to improve outcomes in this group of patients.
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Khlevner J, Antino J, Panesar R, Chawla A. Establishing early enteral nutrition with the use of self-advancing postpyloric feeding tube in critically ill children. JPEN J Parenter Enteral Nutr 2012; 36:750-2. [PMID: 22492399 DOI: 10.1177/0148607112442548] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Early nutrition support is an integral part of the care of critically ill children. Early enteral nutrition (EN) improves nitrogen balance and prevents bacterial translocation and gut mucosal atrophy. Adequate EN is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes without endoscopic intervention or use of anesthesia can range from 30%-80%. The authors report on their experience with a 14Fr polyurethane self-advancing jejunal feeding tube in a pediatric population. These tubes have been used in the adult population with success, but to the authors' knowledge, there have been no reports of its use in the pediatric age group. CASE SERIES The authors present 7 critically ill patients 8-19 years old, admitted to the pediatric intensive care unit, in whom prolonged recovery, inability to tolerate gastric feeds, and dependence on ventilator were predicted at the outset. The jejunal feeding tube was successfully placed on first attempt at the bedside in all 7 patients within the first 24 hours without the use of a promotility agent or endoscopic intervention. Nutrition goal achieved within 48 hours of feeding tube placement was reported for each patient. This case series demonstrates that children fed via the small bowel reached their nutrition goal earlier and did not require parenteral nutrition. CONCLUSION The self-advancing jejunal feeding tube can be used effectively to establish early EN in critically ill children.
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Affiliation(s)
- Julie Khlevner
- Stony Brook Long Island Children's Hospital, Stony Brook, New York, USA.
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Gupta P, Tobias JD, Goyal S, Kuperstock JE, Hashmi SF, Shin J, Hartnick CJ, Noviski N. Perioperative care following complex laryngotracheal reconstruction in infants and children. Saudi J Anaesth 2011; 4:186-96. [PMID: 21189858 PMCID: PMC2980667 DOI: 10.4103/1658-354x.71577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tume L, Latten L, Darbyshire A. An evaluation of enteral feeding practices in critically ill children. Nurs Crit Care 2011; 15:291-9. [PMID: 21040260 DOI: 10.1111/j.1478-5153.2010.00420.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Establishing and sustaining enteral feeding in critically ill children is challenging and has met with many problems. AIMS AND OBJECTIVES The aim of this study was to investigate (a) how actual calorie intake compared with estimated caloric requirements and (b) whether feeding guideline adherence resulted in improved nutritional intake. DESIGN AND METHODS A prospective observational study was undertaken over 1 month in a tertiary referral paediatric intensive care unit (PICU) in the northwest of England. RESULTS Forty-seven children were studied, with a wide range of diagnoses in a 1-month period. Only 47% of the children had enteral feeds started within our 6 h post-admission target. Over half (55%) of the children received less than half of their estimated calorie requirements, but if feeding guidelines were followed, this resulted in a significantly higher (p = 0.004) delivery of the child's estimated requirements. CONCLUSIONS This study found that many children are not receiving adequate nutrition in PICU and that the use of feeding guidelines significantly improves calorie delivery in PICU patients. RELEVANCE TO CLINICAL PRACTICE This paper highlights the dearth of research related to enteral feeding in critically ill children. We found that the use of feeding guidelines improved calorie delivery and so units should be encouraged to develop their own guidelines based on the best evidence available.
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Affiliation(s)
- Lyvonne Tume
- PICU, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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