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.

Continuous versus Intermittent Enteral Feeding in Critically Ill Children: A Systematic Review

Administration of enteral nutrition (EN) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) constitutes a major challenge due to the increased risk of complications, as well as the lack of well-trained healthcare professionals. EN is usually delivered via cyclic, continuous, or intermittent feeding; however, a number of potential barriers have been reported in the literature regarding different feeding regimens. The purpose of this review was to assess the effectiveness of continuous and intermittent bolus feeding on critically ill children. A systematic search was conducted in PubMed, Scopus Cochrane Central Register of Controlled Trials (CENTRAL) and a clinical trial registry up to September 2022, including randomized controlled trials (RCTs) published in the English language. Four studies met the inclusion criteria with a total population of 288 patients admitted to the PICU. Three studies were rated with a high risk of bias and one with some concerns. There was high heterogeneity between the studies in regard to the reporting of outcomes. Three studies measured the total time needed to reach prescribed caloric intake with conflicting results, while two studies evaluated the length of stay (LOS) in PICU with no difference between the two arms. One study assessed the time weaning from mechanical ventilation, favoring the bolus group. No data were provided for gastric residual volume (GRV), anthropometric measurements, and biochemical markers. Additional randomized trials with better methodology are needed to assess the efficacy of the two enteral feeding regimens in critically ill PICU patients.

Bolus Gastric Feeds Improve Nutritional Delivery to Mechanically Ventilated Pediatric Medical Patients: Results of the COntinuous vs BOlus (COBO2) Multi-Center Trial

BACKGROUND

Comparison of bolus (BGF) versus continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered.

METHODS

Multi-center, prospective, randomized comparative effectiveness trial conducted in seven Pediatric ICUs (PICUs). Eligibility criteria: 1 month - 12 years of age, intubated within 24 hours of PICU admission, expected duration of ventilation at least 48 hours, eligible to begin enteral nutrition within 48 hours.

EXCLUSION CRITERIA

acute or chronic gastrointestinal pathology, or acute surgery.

RESULTS

We enrolled 158 mechanically ventilated children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). The BGF group was slightly older than CGF, otherwise the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group that achieved goal feeds. Time to goal feeds was shorter in the BGF [Hazard Ratio 1.5 (CI 1.02-2.33); P = 0.0387]. Median percentage of target kilocalories [median kcal 0.78 vs 0.59; p = <.0001], and median percentage of protein delivered [median pro 0.77 vs 0.59; p = <.0001] was higher for BGF patients. There was no difference in serial oxygen saturation index between groups.

CONCLUSION

Our study demonstrated shorter time to achieve goal nutrition via BGF compared to CGF in mechanically ventilated pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations. This article is protected by copyright. All rights reserved.

Sarcopenia in critically ill children: A bedside assessment using point-of-care ultrasound and anthropometry

BACKGROUND & AIMS

Due to the lack of validated methods of muscle assessment, sarcopenia is not well described in critically ill children. The main objectives of this study were to assess muscle wasting using point-of-care ultrasound (POCUS) and anthropometry, as well as its association with nutrition delivery in PICU.

METHODS

This was a single-center, prospective cohort study, including consecutive children admitted to the PICU. Quadriceps femoris muscle thickness (QFMT) and anthropometrics measurements were performed at admission and then weekly until the 14th day of the PICU stay. The three moments of assessment were defined as T0 (baseline), T1 (7th day) and T2 (14th day). For analysis purposes, participants assessed only in T0 and T1 were defined as Subgroup 1, while those assessed in T0, T1 and T2 were defined as Subgroup 2. Actual total daily intake was determined by patient intake records until discharge or during the first 14 full days of PICU admission.

RESULTS

In all, 119 patients were included with a median age of 12.0 months (IQR 4.0-42.5). In Subgroup 1, QFMT significantly decreased between T0 and T1 (-12.93 ± 14.07 %; p < 0.001), and the same was observed in Subgroup 2 (-13.81 ± 13.05 %; p < 0.001). However, no differences in QFMT was observed between T1 and T2 (-2.06 ± 13.80 %; p = 0.936). Triceps skinfold thickness, mid-upper arm circumference, and upper arm muscle area presented a similar pattern of changes between periods in both groups. Decrease of QFMT at T1 was significantly correlated with the cumulative protein deficit in both subgroups, but not with the cumulative energy deficit.

CONCLUSION

Substantial muscle wasting occurs early in critically ill children and may be related to insufficient protein delivery. Anthropometric measurements are valuable in PICU and POCUS has the potential to play a major role in sarcopenia assessment during critical illnesses.

TRIAL REGISTRATION

Brazilian Clinical Trials registry, registration number: RBR-85YYGN.

Hypophosphatemia in critically ill pediatric patients receiving enteral and oral nutrition

BACKGROUND

Hypophosphatemia(HP) is related to several comorbidities in pediatric intensive care units (PICUs). This study aimed to evaluate the incidence of HP in severely ill pediatric patients receiving oral and/or enteral nutrition. The secondary objectives were to investigate the association between HP and the inflammatory state, PICU length of stay, severity, mortality, nutrition status, and protein, energy, calcium, vitamin D, and phosphate intake.

METHODS

A prospective, observational cohort study was conducted in a PICU of a quaternary hospital. Participants aged between 28 days and 14 years were included. Anthropometric and laboratory assessments were performed ≤72 h after PICU admission and repeated after 7 days for three consecutive times. Energy, protein, calcium, phosphate, and vitamin D intake per day of hospitalization were recorded individually. The Pediatric Index of Mortality 2 (PIM2) was used to determine each patient's severity score.

RESULTS

A total of 103 participants were included in the study. Hypophosphatemic events ranged from 27.2% to 37.5% among the assessments. HP was associated with high C-reactive protein levels (P = .012) and lower energy adequacy (P = .037). Serum phosphorus was inversely correlated (weak correlation) with PIM2 (P = .017).

CONCLUSION

HP is common in critically ill pediatric patients, even when they are not receiving parenteral nutrition. It is necessary to monitor serum phosphorus levels and consider the possibility of early replacement, especially in patients showing high levels of inflammation. In addition to inflammation itself, low energy intake and illness severity were related to HP.

Enteral Feeding of Children on Noninvasive Respiratory Support: A Four-Center European Study

OBJECTIVES

To explore enteral feeding practices and the achievement of energy targets in children on noninvasive respiratory support, in four European PICUs.

DESIGN

A four-center retrospective cohort study.

SETTING

Four PICUs: Bristol, United Kingdom; Lyon, France; Madrid, Spain; and Rotterdam, The Netherlands.

PATIENTS

Children in PICU who required acute noninvasive respiratory support in the first 7 days. The primary outcome was achievement of standardized kcal/goal.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 325 children were included (Bristol 104; Lyon 99; Madrid 72; and Rotterdam 50). The median (interquartile range) age and weight were 3 months (1-16 mo) and 5 kg (4-10 mo), respectively, with 66% admitted with respiratory failure. There were large between-center variations in practices. Overall, 190/325 (58.5%) received noninvasive respiratory support in order to prevent intubation and 41.5% after extubation. The main modes of noninvasive respiratory support used were high-flow nasal cannula 43.6%, bilevel positive airway pressure 33.2%, and continuous positive airway pressure 21.2%. Most children (77.8%) were fed gastrically (48.4% continuously) and the median time to the first feed after noninvasive respiratory support initiation was 4 hours (interquartile range, 1-9 hr). The median percentage of time a child was nil per oral while on noninvasive respiratory support was 4 hours (2-13 hr). Overall, children received a median of 56% (25-82%) of their energy goals compared with a standardized target of 0.85 of the recommended dietary allowance. Patients receiving step-up noninvasive respiratory support (p = < 0.001), those on bilevel positive airway pressure or continuous positive airway pressure (compared with high-flow nasal cannula) (p = < 0.001), and those on continuous feeds (p = < 0.001) achieved significantly more of their kcal goal. Gastrointestinal complications varied from 4.8-20%, with the most common reported being vomiting in 54/325 (16.6%), other complications occurred in 40/325 (12.3%) children, but pulmonary aspiration was rare 5/325 (1.5%).

CONCLUSIONS

Children on noninvasive respiratory support tolerated feeding well, with relatively few complications, but prospective trials are now required to determine the optimal timing and feeding method for these children.

Early Enteral Nutrition Is Associated With Improved Clinical Outcomes in Critically Ill Children: A Secondary Analysis of Nutrition Support in the Heart and Lung Failure-Pediatric Insulin Titration Trial

OBJECTIVES

The impact of early enteral nutrition on clinical outcomes in critically ill children has not been adequately described. We hypothesized that early enteral nutrition is associated with improved clinical outcomes in critically ill children.

DESIGN

Secondary analysis of the Heart and Lung Failure-Pediatric Insulin Titration randomized controlled trial.

SETTING

Thirty-five PICUs.

PATIENTS

Critically ill children with hyperglycemia requiring inotropic support and/or invasive mechanical ventilation who were enrolled for at least 48 hours with complete nutrition data.

INTERVENTIONS

Subjects received nutrition via guidelines that emphasized enteral nutrition and were classified into early enteral nutrition (enteral nutrition within 48 hr of study randomization) and no early enteral nutrition (enteral nutrition after 48 hr of study randomization, or no enteral nutrition at any time).

MEASUREMENTS AND MAIN RESULTS

Of 608 eligible subjects, 331 (54%) received early enteral nutrition. Both early enteral nutrition and no early enteral nutrition groups had similar daily caloric intake over the first 8 study days (median, 36 vs 36 kcal/kg/d; p = 0.93). After controlling for age, body mass index z scores, primary reason for ICU admission, severity of illness, and mean Vasopressor-Inotrope Score at the time of randomization, and adjusting for site, early enteral nutrition was associated with lower 90-day hospital mortality (8% vs 17%; p = 0.007), more ICU-free days (median, 20 vs 17 d; p = 0.02), more hospital-free days (median, 8 vs 0 d; p = 0.003), more ventilator-free days (median, 21 vs 19 d; p = 0.003), and less organ dysfunction (median maximum Pediatric Logistic Organ Dysfunction, 11 vs 12; p < 0.001).

CONCLUSIONS

In critically ill children with hyperglycemia requiring inotropic support and/or mechanical ventilation, early enteral nutrition was independently associated with better clinical outcomes.

Undernutrition at PICU Admission Is Predictor of 60-Day Mortality and PICU Length of Stay in Critically Ill Children

BACKGROUND

There are few studies that assess the role of different nutritional assessment variables at pediatric intensive care unit (PICU) admission in predicting clinical outcomes.

OBJECTIVE

To identify nutritional variables in the first 4 days of PICU stay that predict 60-day mortality and time to discharge alive from the PICU.

DESIGN

Single-center prospective study in Southern Brazil, conducted between July 2013 and February 2016. At PICU admission, children with z scores <-2 for body mass index (BMI)-for-age, mid-upper arm circumference (MUAC)-for-age, and triceps skinfold thickness (TSF)-for-age were considered as undernourished.

PARTICIPANTS/SETTING

There were 199 patients, aged <15 years, with PICU stay >48 hours.

MAIN OUTCOME MEASURES

Sixty-day mortality and time to discharge alive from the PICU.

STATISTICAL ANALYSIS PERFORMED

Cox regression model was applied to determine predictors of 60-day mortality and time to discharge alive from the PICU.

RESULTS

Median age was 23.1 months (interquartile range=3.9 to 89.1), and 63% were male, with 18% prevalence of undernutrition at admission by BMI-for-age. Median PICU stay was 7 days (interquartile range=4 to 12), and 60-day mortality was 12%. After adjusting for sex, age, Pediatric Index of Mortality 2, and presence of complex chronic conditions, undernutrition based on BMI-for-age (hazard ratio [HR]=3.75; 95% CI=1.41 to 9.95; P=0.008), MUAC-for-age (HR=7.62; 95% CI=2.42 to 23.97; P=0.001), and TSF-for-age (HR=4.01; 95% CI=1.14 to 14.15; P=0.031) was associated with higher risk of 60-day mortality. Based on MUAC-for-age with the same adjustment model, undernourished children had longer time to discharge alive from the PICU (HR=0.45; 95% CI=0.21 to 0.98; P=0.045).

CONCLUSIONS

Undernutrition at PICU admission based on different anthropometric variables was predictive of 60-day mortality and longer time to discharge alive from the PICU.

Impact of energy deficit during hospitalization and biomarkers at admission on clinical outcomes in critically ill children: A longitudinal study

BACKGROUND & AIMS

To evaluate the impact of energy deficit during hospitalization and the biomarkers albumin and C-reactive protein (CRP) on the clinical outcomes length of stay (LOS) and duration of mechanical ventilation (DMV) in children and adolescents admitted to the pediatric intensive care unit (PICU) of a private hospital in Rio de Janeiro.

METHODS

A longitudinal, retrospective study was conducted of the medical records of patients admitted to the PICU from May 2016 to June 2017 who received enteral nutrition (EN) for 72 h or longer. The cut-off points for serum albumin and CRP were set at ≥3.5 and <2.0, respectively. The energy balance was calculated as the difference between the energy prescribed and the energy received by the patient. The comparison of continuous variables related to LOS and DMV was assessed using Student's t-test and the Mann-Whitney test. The significance value was set at p < 0.05.

RESULTS

Ninety-three patients were selected, with a median age of 32 (±39.49) months. The mean serum albumin and CRP levels were 4.04 (±0.59) and 4.67 (±7.40), respectively. In linear regression models adjusted for length of stay, reduced albumin, increased CRP, and negative energy balance were positively associated. In the models adjusted to DMV, the values for reduced albumin and increased CRP were significant.

CONCLUSION

A significant association was found between serum albumin and CRP at admission and the outcomes under investigation, LOS and DMV. Energy deficit was also associated with LOS.

Peptide nutrient-energy dense enteral feeding in critically ill infants: an observational study

BACKGROUND

Enteral feeding is challenging in critically ill infants. Target intakes are often not achieved as a result of fluid restriction, procedural interruptions and perceived enteral feeding intolerance. In those infants perceived to have poor feeding tolerance, the use of a peptide nutrient-energy dense enteral feed (PEF) may improve nutritional intake and minimise feeding interruptions as a result of gastrointestinal symptoms. The aim of this observational study was to characterise the use of a PEF amongst critically ill infants in two paediatric intensive care units (PICUs).

METHODS

Records from critically ill infants aged <12 months admitted to two PICUs were retrospectively reviewed with a PICU length of stay (LOS) ≥ 7 days. Achievement of nutritional targets for the duration of PEF was reviewed. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters.

RESULTS

In total, 53 infants were included, with a median age on admission of 2.6 months. Median admission weight was 3.9 kg in PICU-1 and 4.7 kg in PICU-2. Median (interquatile range) energy intake in PICU-1 and PICU-2 was 68 (47-92) and 90 (63-124) kcal kg^-1 , respectively, and median (interquatile range) protein intake 1.7 (1.1-2.4) g kg^-1 and 2.5 (1.6-3.2) g kg^-1 , respectively. Feeding was withheld because of feeding intolerance in one infant (4%) on two occasions in PICU-1 for 2.5 h and in two infants (7%) on two occasions in PICU-2 for 19.5 h. Gastric residual mean (SD) volumes were 3.5 (5.4) mL kg^-1 in PICU-1 and 16.9 (15.6) mL kg^-1 in PICU-2.

CONCLUSIONS

Peptide nutrient-energy dense feeding in infants admitted to the PICU is feasible, well tolerated and nutritional targets are met. However, with this study design, it is not possible to draw any conclusions regarding the benefit of PEF over standard PE feed in critically ill children and future work is required to clarify this further.

Bolus vs Continuous Nasogastric Feeds in Mechanically Ventilated Pediatric Patients: A Pilot Study

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.

[Research advances in nutritional support for critically ill children]

Most critically ill children are in a state of serious stress and tend to develop malnutrition, which may reduce the body's ability to fight against diseases and repair damaged tissues and thus aggravate their conditions. Reasonable and effective nutritional support for critically ill children can improve their nutritional status and prognosis, and so it is necessary to offer nutritional support for critically ill children. This article reviews the research on nutritional support for critically ill children and the current status of clinical application. It also introduces the main methods for nutritional support, including enteral nutrition and parenteral nutrition, and elaborates on the new methods for nutritional support, such as early enteral nutrition, enteral immunonutrition, and supplementary parenteral nutrition, in order to provide a reference for nutritional support for critically ill children.

Enteral Protein Supplementation in Critically Ill Children: A Randomized Controlled Pilot and Feasibility Study

BACKGROUND

Loss of muscle mass in critically ill children can negatively impact outcomes. The aims of this study were to conduct a pilot randomized control trial (RCT) to examine the difference in protein delivery and nitrogen balance in critically ill children with enteral protein supplementation vs controls. We also aimed to assess the feasibility, safety, and tolerance of the pilot trial.

METHODS

This is a 3-arm RCT in critically ill children eligible for enteral nutrition (EN) therapy. Patients were randomized to 1 of the 3 groups: (1) control (routine EN), (2) polymeric protein module added to EN to reach protein goal by day 4, or (3) oligomeric protein supplementation. Demographics, clinical characteristics, nutrition status, and daily nutrition intake variables were recorded. Protein delivery, nitrogen balance, feasibility variables, and rate of adverse events were the outcomes.

RESULTS

After screening 286 consecutive patients admitted to the pediatric intensive care unit over 11 months, we enrolled and randomized 25 patients. Twenty-two patients (88% of the enrolled) completed the study procedures. Significantly higher protein prescription and actual protein intake within the first 5 days was achieved in the intervention groups, compared with the control group. Nitrogen balance was obtained in 15 patients. There was no significant difference between the groups for the rate of adverse effects and clinical outcomes.

CONCLUSION

In our pilot trial, protein supplementation was safe and well tolerated. Our preliminary results suggest that a larger RCT is potentially feasible, with some modifications of the entry criteria. Trial enrollment was low, likely due to restrictive entry criteria.

Nutritional practices and adequacy in children supported on extracorporeal membrane oxygenation

BACKGROUND AND AIMS

Use of extracorporeal membrane oxygenation (ECMO) in children is increasing. Yet, little is known about optimal nutritional practices in these children. We aim to describe the nutritional adequacy, factors associated with enteral nutrition, and the association between nutritional adequacy and mortality in children supported on ECMO.

METHODS

We conducted a retrospective review of all children (1 month-18 years) requiring ECMO between 2010 and 2016. Data on enteral and parenteral energy and protein intake in the first 7 days of ECMO were collected. Adequacy of nutrition intake was defined as total intake vs. total requirements, expressed as a percentage.

RESULTS

51 patients were included, of which 43 (84.3%) were supported on veno-arterial ECMO. Median ECMO duration was 8.6 days [interquartile range (IQR) 6.1-16.2]. Overall energy and protein adequacy across the first 7 days of ECMO were 48.3% (IQR 28.0-67.4) and 44.8% (IQR 26.9-67.0) respectively. Parenteral nutrition provided majority of calories [median 88.0% (IQR 62.9-100)] and protein [median 91.0% (IQR 62.3-100)] intake. Enteral nutrition (EN) was initiated in 33 (64.7%) patients. Time to EN initiation, vasoactive-inotropic score just before ECMO initiation, veno-arterial ECMO mode and continuous renal replacement therapy in the first week of ECMO were factors associated with EN energy adequacy. Hospital mortality rate was 55% (28/51). Compared to survivors, non-survivors had lower adequacy of EN energy intake [0.5% (IQR 0-4.4) vs. 11.8% (IQR 0-24.5), p = 0.034]. After correcting for ECMO duration, need for continuous renal replacement therapy and number of vasoactive drugs required on ECMO, greater EN energy adequacy remained associated with lower risk of mortality [adjusted odds ratio 0.93 (95% confidence interval: 0.86-0.99), p = 0.048].

CONCLUSIONS

Nutritional adequacy, especially that of EN, remains low in children supported on ECMO. EN energy adequacy was found to be associated with lower mortality. Further studies on nutritional adequacy in pediatric ECMO, as well as strategies to optimize EN in these children, are warranted.