Nutrition for critically ill children and neonates requiring dialysis: Application of clinical practice recommendations

Approximately 30% of all children and neonates admitted to the intensive care unit (ICU) experience acute kidney injury (AKI). Children with AKI are largely poorly fed and experience high rates of malnutrition. Nutrition prescription and provision are exceptionally challenging for critically ill neonates, infants, and children with AKI given the dynamic nature of AKI and its respective treatment modalities. Managing the nutrition prescription of critically ill neonates, infants, and children with AKI requires nutrition support clinicians to have a high-level understanding of the various treatment modalities for AKI, which can affect the patient's protein, fluid, electrolyte, and mineral needs. Accurate and timely nutrition assessment in critically ill neonates and children with AKI can be flawed owing to difficulty obtaining accurate anthropometric parameters. Recently, the Pediatric Renal Nutrition Taskforce introduced clinical practice recommendations for the nutrition management of children with AKI. In this review, we will discuss the practical implications of these recent guidelines and work to bridge the knowledge and practice gaps for pediatric and neonatal nutrition support clinicians providing nutrition therapy for patients with AKI in the ICU. We also appraise special nutrition-related considerations for neonates with AKI given newer available renal replacement treatment modalities.

Nutrition for critically ill children with congenital heart disease

Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.

Body composition in pediatric patients

Undernutrition is highly prevalent in children who are critically ill and is associated with increased morbidity and mortality, including a higher risk of infection due to transitory immunological disorders, inadequate wound healing, reduced gut function, longer dependency on mechanical ventilation, and longer hospital stays compared with eutrophic children who are critically ill. Nutrition care studies have proposed that early interventions targeting nutrition assessment can prevent or minimize the complications of undernutrition. Stress promotes an acute inflammatory response mediated by cytokines, resulting in increased basal metabolism and nitrogen excretion and leading to muscle loss and changes in body composition. Therefore, the inclusion of body composition assessment is important in the evaluation of these patients because, in addition to the nutrition aspect, body composition seems to predict clinical prognosis. Several techniques can be used to assess body composition, such as arm measurements, calf circumference, grip strength, bioelectrical impedance analysis, and imaging examinations, including computed tomography and dual-energy x-ray absorptiometry. This review of available evidence suggests that arm measurements seem to be well-established in assessing body composition in children who are critically ill, and that bioelectrical impedance analysis with phase angle, handgrip strength, calf circumference and ultrasound seem to be promising in this evaluation. However, further robust studies based on scientific evidence are necessary.

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.

Nutrition association with skin integrity and pressure injury in critically ill pediatric patients

BACKGROUND

Current research highlights the positive impact of nutrition therapy, particularly enteral nutrition, in critical illness. However, little attention is given to the impact of nutrition on skin integrity during critical illness. Skin integrity is at risk in critically ill children owing to necessary clinical therapies and challenges of providing nutrition therapy.

METHODS

We conducted a narrative literature review with three main thematic concepts to drive our literature search: the association of nutrition therapy with (1) skin integrity; (2) injury, wounds, and wound healing; and (3) differences of skin color. Using pertinent search and subject terms, PubMed, CINAHL, EMBASE, and SCOPUS databases were searched, yielding 316 articles. After removal of duplicates, articles were reviewed based on inclusion and exclusion criteria defined by the authors; only eight articles met the defined criteria to inform this review.

RESULTS

Large and important gaps exist in the current literature regarding an association between nutrition therapy, skin injury, and wound healing. Little to no attention was found for associations with skin color. The resulting narrative review addresses these topics and subtopics with additional references included that are independent of the original search strategy.

CONCLUSIONS

A dearth of evidence exists describing associations between nutrition and disruption of skin integrity in pediatric critical illness. Children with dark skin are at increased risk, as manifestation and identification of disruption to skin integrity may not be recognized. Research is needed to describe these associations and the impact of nutrition on skin integrity, including differences of skin color.

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

INTRODUCTION

In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients.

METHODS

An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data.

RESULTS

A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated.

CONCLUSION

This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter.

Measuring growth in critically ill neonates and children

Critical illness increases the risk of malnutrition in both infants and children. Malnutrition risk is multifactorial and includes premorbid factors as well as changes in nutrient metabolism and energy demands during critical illness. Inadequate nutrition has been linked to poor health outcomes and prolonged length of stay in the intensive care unit, demonstrating the importance of both recognizing and addressing malnutrition in this population. Assessing growth and identifying malnutrition requires methodical measurement of growth and a collaborative, multimodal approach to nutrition assessment. Among the nutrition assessment and growth evaluation tools, neonatal, preterm, pediatric, and disease-specific growth charts remain an important component of growth assessment and should be used along with a nutrition-focused physical examination. Routine measurement promotes the identification of potential growth delays that may require interventions. Indirect calorimetry adds an additional layer of detail for a complete picture of each infant or child's unique nutrition status and progress. Quality improvement research on a national level is urgently needed to assess the adequacy and availability of resources in neonatal and pediatric critical care units and to further the development of standard clinical outcome measures for nutrition assessment and intervention in the critically ill neonate and child.

Select micronutrients for the preterm neonate

If premature neonates are not provided with adequate nutrition, they will quickly become deficient because of increased requirements and a lack of nutrient stores to achieve adequate growth. The provision of many of the recommended micronutrients for pediatric and adult patients is challenging in premature neonates because of the limited data surrounding the true needs of premature neonates and the difficulty in assessing adequate serum levels of these nutrients in this patient population. Parenteral and enteral nutrition shortages further complicate providing adequate micronutrients to premature neonates. This review will discuss select micronutrients and their importance to the preterm neonate, with special emphasis on micronutrients with limited evidence and more challenging supplementation and repletion strategies.