Changes in global nutrition practices in critically ill children and the impact of emerging evidence: a secondary analysis of the Pediatric International Nutrition Studies (PINS), 2009-2018

BACKGROUND

The timeline of the three Pediatric International Nutrition Studies (PINS) coincided with the publication of 2 major guidelines for the timing of parenteral nutrition (PN) and recommended energy and protein delivery dose.

OBJECTIVE

The study's main objective was to describe changes in the nutrition delivery practice recorded in PINS 1 and 2 (conducted in 2009 and 2011, pre-exposure epoch) versus PINS 3 (conducted in 2018,post-exposure epoch), in relation to the published practice guidelines.

DESIGN

This study is a secondary analysis of data from a multi-center prospective cohort study.

PARTICIPANTS

/setting. Data from 3650 participants, aged 1 month to 18 years, admitted to 100 unique hospitals that participated in three PINS was used for this study.

MAIN OUTCOME MEASURES

The time in days from PICU admission to the initiation of PN and enteral nutrition (EN) delivery were the primary outcomes. Prescribed energy and protein goals were the secondary outcomes.

STATISTICAL ANALYSES PERFORMED

A frailty model with a random intercept per hospital with stratified baseline hazard function by region for the primary outcomes and a mixed-effects negative binomial regression with random intercept per hospital for the secondary outcomes.

RESULTS

The proportion of patients receiving EN (88.3% vs. 80.6%, p-value<0.001) was higher, and those receiving PN (20.6% vs. 28.8%, p-value<0.001) was lower in the PINS3 cohort compared to PINS1-2. In the PINS3 cohort, the odds of initiating PN during the 1st 10 days of PICU admission were lower, compared to the PINS1-2 cohort (HR=0.8, CI=[0.67-0.95], p-value=0.013); and prescribed energy goal was lower compared to the PINS1-2 cohort (IRR=0.918, CI=[0.874-0.965], p=0.001).

CONCLUSIONS

The likelihood of initiation of PN delivery significantly decreased in the first ten days post-admission in the PINS3 cohort compared to PINS1-2. Energy goal prescription in mechanically ventilated children significantly decreased in the post-guidelines epoch compared to the pre-guidelines epoch.

Stress Ulcer Prophylaxis Versus Placebo-A Blinded Pilot Randomized Controlled Trial to Evaluate the Safety of Two Strategies in Critically Ill Infants With Congenital Heart Disease

OBJECTIVES

The routine use of stress ulcer prophylaxis (SUP) in infants with congenital heart disease (CHD) in the cardiac ICU (CICU) is controversial. We aimed to conduct a pilot study to explore the feasibility of performing a subsequent larger trial to assess the safety and efficacy of withholding SUP in this population (NCT03667703).

DESIGN, SETTING, PATIENTS

Single-center, prospective, double-blinded, parallel group (SUP vs. placebo), pilot randomized controlled pilot trial (RCT) in infants with CHD admitted to the CICU and anticipated to require respiratory support for greater than 24 hours.

INTERVENTIONS

Patients were randomized 1:1 (stratified by age and admission type) to receive a histamine-2 receptor antagonist or placebo until respiratory support was discontinued, up to 14 days, or transfer from the CICU, if earlier.

MEASUREMENTS AND MAIN RESULTS

Feasibility was defined a priori by thresholds of screening rate, consent rate, timely drug allocation, and protocol adherence. The safety outcome was the rate of clinically significant upper gastrointestinal (UGI) bleeding. We screened 1,426 patients from February 2019 to March 2022; of 132 eligible patients, we gained informed consent in 70 (53%). Two patients did not require CICU admission after obtaining consent, and the remaining 68 patients were randomized to SUP (n = 34) or placebo (n = 34). Ten patients were withdrawn early, because of a change in eligibility (n = 3) or open-label SUP use (n = 7, 10%). Study procedures were completed in 58 patients (89% protocol adherence). All feasibility criteria were met. There were no clinically significant episodes of UGI bleeding during the pilot RCT. The percentage of patients with other nonserious adverse events did not differ between groups.

CONCLUSIONS

Withholding of SUP in infants with CHD admitted to the CICU was feasible. A larger multicenter RCT designed to confirm the safety of this intervention and its impact on incidence of UGI bleeding, gastrointestinal microbiome, and other clinical outcomes is warranted.

Long-Term Functional Outcomes at 1-Year After Hospital Discharge in Critically Ill Neonates With Congenital Diaphragmatic Hernia

OBJECTIVES

Congenital diaphragmatic hernia (CDH) is a birth defect associated with long-term morbidity. Our objective was to examine longitudinal change in Functional Status Scale (FSS) after hospital discharge in CDH survivors.

DESIGN

Single-center retrospective cohort study.

SETTING

Center for comprehensive CDH management at a quaternary, free-standing children's hospital.

PATIENTS

Infants with Bochdalek CDH were admitted to the ICU between January 2009 and December 2019 and survived until hospital discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred forty-two infants (58% male, mean birth weight 3.08 kg, 80% left-sided defects) met inclusion criteria. Relevant clinical data were extracted from the medical record to calculate FSS (primary outcome) at hospital discharge and three subsequent outpatient follow-up time points. The median (interquartile range [IQR]) FSS score at hospital discharge was 8.0 (7.0-9.0); 39 patients (27.5%) had at least moderate impairment (FSS ≥ 9). Median (IQR) FSS at 0- to 6-month (n = 141), 6- to 12-month (n = 141), and over 12-month (n = 140) follow-up visits were 7.0 (7.0-8.0), 7.0 (6.0-8.0), and 6.0 (6.0-7.0), respectively. Twenty-one patients (15%) had at least moderate impairment at over 12-month follow-up; median composite FSS scores in the over 12-month time point decreased by 2.0 points from hospital discharge. Median feeding domain scores improved by 1.0 (1.0-2.0), whereas other domain scores remained without impairment. Multivariable analysis demonstrated right-sided, C- or D-size defects, extracorporeal membrane oxygenation use, cardiopulmonary resuscitation, and chromosomal anomalies were associated with impairment.

CONCLUSIONS

The majority of CDH survivors at our center had mild functional status impairment (FSS ≤ 8) at discharge and 1-year follow-up; however, nearly 15% of patients had moderate impairment during this time period. The feeding domain had the highest level of functional impairment. We observed unchanged or improving functional status longitudinally over 1-year follow-up after hospital discharge. Longitudinal outcomes will guide interdisciplinary management strategies in CDH survivors.

Bio-impedance spectroscopy for total body water assessment in pediatric surgical patients: A single center pilot cohort study

BACKGROUND

Excess peri‑operative fluid administration is associated with higher morbidity and mortality. We aimed to examine the feasibility of bio-impedance spectroscopy (BIS) to record serial peri‑operative fluid volumes in the pediatric surgical population.

METHODS

Children who underwent major elective general surgery from March 2019 to March 2020 were included. Total body water (TBW) assessment by BIS was recorded prior to surgery and on subsequent post-operative days (POD). We recorded the duration, tolerance and completion of each BIS assessment. We used Spearman coefficient and Bland Altman analysis to examine correlation and agreement between fluid balance (FB) in ml/kg calculated from intake/output (IO) recording and measured by BIS.

RESULTS

20 (87%) of 23 consented patients, median age 2.5 (1-17) years and 13 (65%) male, completed pre-operative and post-operative measurements, and were included in the analysis. Median time required for BIS assessments was 10 (5-15) minutes, and there were no recorded side effects or intolerance. The correlation coefficient for fluid balance measurements on POD 1 between BIS and IO methods was 0.59 (p = 0.01); mean bias (limits) of agreement was 26 (111 to 163) mL/kg. The trend in TBW measured by BIS declined from POD 1-3, while the recorded FB increased.

CONCLUSION

Bedside BIS is feasible and well-tolerated. Despite moderate correlation between fluid balance assessment by BIS and IO on POD 1, the wide limits of agreement between values from these methods preclude their use interchangeably. The role of BIS in assessment of fluid status in the pediatric surgical population should be further examined.

LEVEL OF EVIDENCE

Level III.

Intermittent versus continuous enteral nutrition in critically ill children: A pre-planned secondary analysis of an international prospective cohort study

BACKGROUND & AIMS

Intermittent enteral nutrition (EN) may have physiologic benefits over continuous feeding in critical illness. We aimed to compare nutrition and infection outcomes in critically ill children receiving intermittent or continuous EN.

METHODS

International, multi-center prospective observational study of mechanically ventilated children, 1 month to 18 years of age, receiving EN. Percent energy or protein adequacy (energy or protein delivered/prescribed × 100) and acquired infection rates were compared between intermittent and continuous EN groups using adjusted-multivariable and 4:1 propensity-score matched (PSM) analyses. Sensitivity analyses were performed after excluding patients who crossed over between intermittent and continuous EN.

RESULTS

1375 eligible patients from 66 PICUs were included. Patients receiving continuous EN (N = 1093) had a higher prevalence of respiratory illness and obesity, and lower prevalence of neurologic illness and underweight status on admission, compared to those on intermittent EN (N = 282). Percent energy or protein adequacy, proportion of patients who achieved 60% of energy or protein adequacy in the first 7 days of admission, and rates of acquired infection were not different between the 2 groups in adjusted-multivariable and propensity score matching analyses (P > 0.05).

CONCLUSION

Intermittent versus continuous EN strategy is not associated with differences in energy or protein adequacy, or acquired infections, in mechanically ventilated, critically ill children. Until further evidence is available, an individualized feeding strategy rather than a universal approach may be appropriate.

Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children

BACKGROUND

Optimal nutrition in critically ill children involves a complex interplay between the doses, route, and timing of macronutrient delivery.

OBJECTIVES

We aimed to examine the association between the time to achieve delivery of 60% of the prescribed energy and protein targets and clinical outcomes in mechanically ventilated children.

METHODS

We conducted a prospective, observational cohort study of mechanically ventilated children admitted to pediatric intensive care units (PICUs) worldwide. Daily energy and protein delivery were recorded for up to 10 d in the PICU. We calculated "adequacy" as the percentage of the prescribed energy or protein goal delivered by enteral nutrition (EN), parenteral nutrition (PN), and total nutrition (EN + PN). Based on the days required to reach 60% energy or protein adequacy after PICU admission, we categorized patients into 3 groups: early (≤3 d), pragmatic (4 to 7 d), and late (more than 7 d). The primary outcome was 60-d all-cause mortality; secondary outcomes were the incidence of acquired infections and 28-d ventilator-free days (VFDs).

RESULTS

From 77 participating PICUs, 1844 patients, with a median age of 1.64 y (IQR, 0.47-7.05), were included; the 60-d mortality rate was 5.3% (n = 97). The average adequacies of delivery via EN + PN was 49% (IQR, 26-70) for energy and 66% (IQR, 44-89) for protein. In multivariable models adjusted for confounders, mortality was significantly lower in patients who achieved targets within 7 d, for energy (adjusted HR, 0.48; 95% CI: 0.28-0.82; P = 0.007) or protein (adjusted HR, 0.55; 95% CI: 0.33-0.94; P = 0.027) delivery. There were no clinically significant differences in infections or VFDs between groups.

CONCLUSIONS

Achieving 60% of energy or protein delivery targets within the first 7 d after PICU admission is associated with lower 60-d mortality in mechanically ventilated children, and is not associated with a greater incidence of infections or a reduction in VFDs compared to later achievement of targets. This trial was registered at clinicaltrials.gov as NCT03223038.

Stress ulcer prophylaxis versus placebo-a blinded randomized control trial to evaluate the safety of two strategies in critically ill infants with congenital heart disease (SUPPRESS-CHD)

BACKGROUND

Critically ill infants with congenital heart disease (CHD) are often prescribed stress ulcer prophylaxis (SUP) to prevent upper gastrointestinal bleeding, despite the low incidence of stress ulcers and limited data on the safety and efficacy of SUP in infants. Recently, SUP has been associated with an increased incidence of hospital-acquired infections, community-acquired pneumonia, and necrotizing enterocolitis. The objective of this pilot study is to investigate the feasibility of performing a randomized controlled trial to assess the safety and efficacy of withholding SUP in infants with congenital heart disease admitted to the cardiac intensive care unit.

METHODS

A single center, prospective, double-blinded, randomized placebo-controlled pilot feasibility trial will be performed in infants with CHD admitted to the cardiac intensive care unit and anticipated to require respiratory support for > 24 h. Patients will be randomized to receive a histamine-2 receptor antagonist (H2RA) or placebo until they are discontinued from respiratory support. Randomization will be performed within 2 strata defined by admission type (medical or surgical) and age (neonate, age < 30 days, or infant, 1 month to 1 year). Allocation will be a 1:1 ratio using permuted blocks to ensure balanced allocations across the two treatment groups within each stratum. The primary outcomes include feasibility of screening, consent, timely allocation of study drug, and protocol adherence. The primary safety outcome is the rate of clinically significant upper gastrointestinal bleeding. The secondary outcomes are the difference in the relative and absolute abundance of the gut microbiota and functional microbial profiles between the two study groups. We plan to enroll 100 patients in this pilot study.

DISCUSSION

Routine use of SUP to prevent upper gastrointestinal bleeding in infants is controversial due to a low incidence of bleeding events and concern for adverse effects. The role of SUP in infants with CHD has not been examined, and there is equipoise on the risks and benefits of withholding this therapy. In addition, this therapy has been discontinued in other neonatal populations due to the concern for hospital-acquired infections and necrotizing enterocolitis. Furthermore, exploring changes to the microbiome after exposure to SUP may highlight the mechanisms by which SUP impacts potential microbial dysbiosis of the gut and its association with hospital-acquired infections. Assessment of the feasibility of a trial of withholding SUP in critically ill infants with CHD will facilitate planning of a larger multicenter trial of safety and efficacy of SUP in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03667703. Registered 12 September 2018, https://clinicaltrials.gov/ct2/show/NCT03667703?term=SUPPRESS+CHD&draw=2&rank=1 . All WHO Trial Registration Data Set Criteria are met in this manuscript.

Feasibility of Enteral Protein Supplementation in Critically Ill Children

BACKGROUND

We describe the protein type and concentration in standard enteral nutrition (EN) formulas and the effect of protein supplementation on the osmolality of standard formulas. We also aimed to examine factors associated with optimal protein delivery in critically ill children.

METHODS

Protein content and other characteristics of pediatric EN formulas used worldwide were recorded. Factors associated with achievement of recommended protein delivery and tolerance of protein-supplemented formulas were recorded prospectively in a cohort of critically ill children. A range of protein supplement doses was added to 2 standard formulas and water, and the osmolality was recorded by cryoscopy in a bench experiment.

RESULTS

We reviewed 125 formulas used in a multicenter study including sites from >13 countries. A majority of the EN formulas (73.6%) were polymeric, with a nonprotein calorie/nitrogen ratio of 182 ± 66 and protein content of 3.53 ± 2.00 g/100 mL. In the cohort of critically ill children, 28.5% achieved protein intake goal within 4 days, with no intolerance. In addition to optimal protein prescription (P < 0.001), protein supplementation (P = 0.018) and early EN initiation (P = 0.006) were associated with significantly higher odds of achieving goal protein intake. Formulas supplemented with up to 8 g/100 mL polymeric protein had osmolality <450 mOsm/kg.

CONCLUSIONS

The protein content of current pediatric formulas may be inadequate to meet the needs of critically ill children. Protein supplementation of formulas allows early achievement of goal and is likely to be safe.).

Body Composition in Children with Chronic Illness: Accuracy of Bedside Assessment Techniques

OBJECTIVE

To evaluate the accuracy of estimated fat mass and fat-free mass from bedside methods compared with reference methods in children with chronic illnesses.

STUDY DESIGN

Fat mass and fat-free mass values were obtained by skinfold, bioelectrical impedance analysis (BIA), dual-energy x-ray absorptiometry (DXA), and deuterium dilution method in children with spinal muscular atrophy, intestinal failure, and post hematopoietic stem cell transplantation (HSCT). Spearman's correlation and agreement analyses were performed between (1) fat mass values estimated by skinfold equations and by DXA and (2) fat-free mass values estimated by BIA equations and by DXA and deuterium dilution methods. Limits of agreement between estimating and reference methods within ±20% were deemed clinically acceptable.

RESULTS

Fat mass and fat-free mass values from 90 measurements in 56 patients, 55% male, and median age of 11.6 years were analyzed. Correlation coefficients between the skinfold-estimated fat mass values and DXA were 0.93-0.94 and between BIA-estimated fat-free mass values and DXA were 0.92-0.97. Limits of agreement between estimated and DXA values of fat mass and fat-free mass were greater than ±20% for all equations. Correlation coefficients between estimated fat-free mass values and deuterium dilution method in 35 encounters were 0.87-0.91, and limits of agreement were greater than ±20%.

CONCLUSION

Estimated body composition values derived from skinfold and BIA may not be reliable in children with chronic illnesses. An accurate noninvasive method to estimate body composition in this cohort is desirable.

Importance of Dietary Sources of Iron in Infants and Toddlers: Lessons from the FITS Study

Iron deficiency (ID) affects 13.5% of 1–2 years old children in the US and may have a negative impact on neurodevelopment and behavior. Iron-fortified infant cereal is the primary non-heme iron source among infants aged 6–11.9 months. The objective of this study was to compare iron intakes of infant cereal users with non-users. Data from the Feeding Infants and Toddlers Study 2008 were used for this analysis. Based on a 24-h recall, children between the ages of 4–17.9 months were classified as ‘cereal users’ if they consumed any amount or type of infant cereal and ‘non-users’ if they did not. Infant cereal was the top source of dietary iron among infants aged 6–11.9 months. The majority of infants (74.6%) aged 6–8.9 months consumed infant cereal, but this declined to 51.5% between 9–11.9 months and 14.8% among 12–17.9 months old toddlers. Infant cereal users consumed significantly more iron than non-users across all age groups. Infants and toddlers who consume infant cereal have higher iron intakes compared to non-users. Given the high prevalence of ID, the appropriate use of infant cereals in a balanced diet should be encouraged to reduce the incidence of ID and ID anemia.

Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit

PURPOSE

Inadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU).

METHODS

In a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate.

RESULTS

Five hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score -0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery.

CONCLUSION

Enteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population.

LEVEL OF EVIDENCE

I.

TYPE OF STUDY

Prospective study.

Impact of Individualized Diet Intervention on Body Composition and Respiratory Variables in Children With Respiratory Insufficiency: A Pilot Intervention Study

OBJECTIVES

Diet modification may improve body composition and respiratory variables in children with respiratory insufficiency. Our objective was to examine the effect of an individualized diet intervention on changes in weight, lean body mass, minute ventilation, and volumetric CO2 production in children dependent on long-term mechanical ventilatory support.

DESIGN

Prospective, open-labeled interventional study.

SETTING

Study subjects' homes.

PATIENTS

Children, 1 month to 17 years old, dependent on at least 12 hr/d of transtracheal mechanical ventilatory support.

INTERVENTIONS

Twelve weeks of an individualized diet modified to deliver energy at 90-110% of measured energy expenditure and protein intake per age-based guidelines.

MEASUREMENTS AND MAIN RESULTS

During a multidisciplinary home visit, we obtained baseline values of height and weight, lean body mass percent by bioelectrical impedance analysis, actual energy and protein intake by food record, and measured energy expenditure by indirect calorimetry. An individualized diet was then prescribed to optimize energy and protein intake. After 12 weeks on this interventional diet, we evaluated changes in weight, height, lean body mass percent, minute ventilation, and volumetric CO2 production. Sixteen subjects, mean age 9.3 years (SD, 4.9), eight male, completed the study. For the diet intervention, a majority of subjects required a change in energy and protein prescription. The mean percentage of energy delivered as carbohydrate was significantly decreased, 51.7% at baseline versus 48.2% at follow-up, p = 0.009. Mean height and weight increased on the modified diet. Mean lean body mass percent increased from 58.3% to 61.8%. Minute ventilation was significantly lower (0.18 L/min/kg vs 0.15 L/min/kg; p = 0.04), and we observed a trend toward lower volumetric CO2 production (5.4 mL/min/kg vs 5.3 mL/min/kg; p = 0.06) after 12 weeks on the interventional diet.

CONCLUSIONS

Individualized diet modification is feasible and associated with a significant decrease in minute ventilation, a trend toward significant reduction in CO2 production, and improved body composition in children on long-term mechanical ventilation. Optimization of respiratory variables and lean body mass by diet modification may benefit children with respiratory insufficiency in the ICU.

Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study

BACKGROUND

The impact of protein intake on outcomes in pediatric critical illness is unclear.

OBJECTIVE

We examined the association between protein intake and 60-d mortality in mechanically ventilated children.

DESIGN

In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy.

RESULTS

We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery.

CONCLUSIONS

Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521.

Bone loss and vitamin D deficiency in children undergoing hematopoietic cell transplantation

BACKGROUND

Hematopoietic cell transplantation (HCT) may be detrimental to bone health and vitamin D status in children.

PROCEDURE

We conducted a prospective, multicenter cohort study to identify changes in bone health markers during the first 100 days after allogeneic HCT in 26 children. Bone mineral density (BMD), bone mineral content (BMC), and serum 25-hydroxyvitamin D (25OHD) concentrations were measured at baseline, 30 days, and 100 days after HCT.

RESULTS

Mean (SD) BMD and BMC Z-scores (-0.48 ± 1.09 and -0.98 ± 1.26, respectively) were normal at baseline. Repeated-measures analysis revealed significant declines in BMD and BMC Z-scores over the 100 day study period, when adjusted for age, sex, Tanner stage, lean mass, fat mass, resting energy expenditure, total energy intake, insulin sensitivity, serum phosphorus, and inpatient steroid intake. Adjusted mean (SE) 25OHD concentrations declined from 29.2 (3.1) ng/ml at baseline, to 17.7 (1.8) ng/ml at 100 days after HCT. Vitamin D deficiency (25OHD <20 ng/ml) was present in 50% of patients 100 days after HCT.

CONCLUSIONS

Significant bone loss and vitamin D deficiency occur in children in the first 100 days following allogeneic HCT. Strategies to diminish acute bone loss during HCT in children are needed.

Metabolic assessment and individualized nutrition in children dependent on mechanical ventilation at home

OBJECTIVE

To evaluate the nutritional and metabolic status and body composition of children on long-term mechanical ventilation using a home-based model.

STUDY DESIGN

Children on home mechanical ventilation, for at least 12 hours a day, were eligible. We performed anthropometry, bioelectrical impedance analysis (BIA), actual energy intake (AEI), and indirect calorimetry in the subject's home. Agreement between measured energy expenditure (MEE) from indirect calorimetry, and estimated energy expenditure by the Schofield equation and a novel volumetric carbon dioxide production-based equation was examined. Agreement between fat mass estimates from anthropometry and BIA was examined and compared with population norms.

RESULTS

We enrolled 20 children, 11 (55%) male; mean age 8.4 years (SD 4.8). Mean weight for age z-score was -0.26 (SD 1.48); 9/20 had z-scores <-1 or >+1. Thirteen were underfed (AEI:MEE <90%) or overfed (AEI:MEE >110%); 11 of 19 had protein intake that was less than recommended by guidelines. Fifteen subjects were hypo- or hypermetabolic. Mean (SD) fat mass % was 33.6% (8.6) by anthropometry, which was significantly greater than matched population norms (mean 23.0%, SD 6.1, P < .001). The estimated energy expenditure by a volumetric carbon dioxide production-based equation was in stronger agreement with the MEE than the Schofield equation (mean bias 0.06%, limits -15.98% to 16.16% vs mean bias -1.31%, limits -74.3% to 72%, respectively). BIA and anthropometric fat mass values were not in agreement.

CONCLUSION

A majority of children on home ventilation are characterized by malnutrition, altered metabolic status, and suboptimal macronutrient intake, in particular low protein intake. A multidisciplinary home-based model facilitates individualized energy and protein delivery and may improve outcomes in this cohort.

Carbon dioxide elimination and oxygen consumption in mechanically ventilated children

BACKGROUND

Accurate measurement of carbon dioxide elimination (V̇CO2 ) and oxygen consumption (V̇O2 ) at the bedside may help titrate nutritional and respiratory support in mechanically ventilated patients. Continuous V̇CO2 monitoring is now available with many ventilators. However, because normative data are sparsely available in the literature, we aimed to describe the range of V̇CO2 and V̇O2 values observed in mechanically ventilated children. We also aimed to examine the characteristics of V̇CO2 values that are associated with standard steady state (5-min period when V̇CO2 and V̇O2 variability are < 10%).

METHODS

Mechanically ventilated patients who underwent indirect calorimetry testing were eligible for inclusion, and subjects who achieved standard steady state were included. Normalized V̇CO2 and V̇O2 values (mL/kg/min) were modeled against subject height, and correlation coefficients were computed to quantify the goodness of fit. A steady-state definition using only V̇CO2 was developed (V̇CO2 variability of < 5% for a 5-min period) and tested against standard steady state using sensitivity and specificity.

RESULTS

Steady-state data from 87 indirect calorimetry tests (in 70 subjects) were included. For age groups < 0.5, 0.5-8, and > 8 y, the mean V̇CO2 values were 7.6, 5.8, and 3.5 mL/kg/min. Normalized V̇CO2 and V̇O2 values were inversely related to subject height and age. The relationships between normalized gas exchange values and height were demonstrated by the models: V̇CO2 = 115 × (height in cm)(-0.71) (R = 0.61, P < .001) and V̇O2 = 130 × (height in cm)(-0.72) (R = 0.61, P < .001). Steady-state V̇CO2 predicted standard steady state (sensitivity of 0.84, specificity of 1.0, P < .01).

CONCLUSIONS

V̇CO2 and V̇O2 measurements correlated with subject height and age. Smaller and younger subjects produced larger amounts of CO2 and consumed more O2 per unit of body weight. The use of a 5-min period when V̇CO2 varied by < 5% predicted standard steady state. Our observations may facilitate greater utility of V̇CO2 at the bedside in the pediatric ICU and thereby extend the benefits of metabolic monitoring to a larger group of patients.

Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study

BACKGROUND

Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs).

METHODS

Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis.

RESULTS

Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P < .001) and hours per EN interruption (-1.65; P = .001) and was not associated with the use of algorithms, promotility agents, or postpyloric feeding.

CONCLUSIONS

A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.

Influence of obesity on clinical outcomes in hospitalized children: a systematic review

IMPORTANCE

Obesity is prevalent among hospitalized children. Knowledge of the relationship between obesity and outcomes in hospitalized children will enhance nutrition assessment and provide opportunities for interventions.

OBJECTIVE

To systematically review the existing literature concerning the impact of obesity on clinical outcomes in hospitalized children.

EVIDENCE ACQUISITION

PubMed, Web of Science, and EMBASE databases were searched for studies of hospitalized children aged 2 to 18 years with identified obesity and at least 1 of the following clinical outcomes: all-cause mortality, incidence of infections, and length of hospital stay. Cohort and case-control studies were included. Cross-sectional studies, studies of healthy children, and those without defined criteria for classifying weight status were excluded. The Newcastle-Ottawa Scale was used to assess study quality.

RESULTS

Twenty-eight studies (26 retrospective; 24 cohort and 4 case-control) were included. Of the 21 studies that included mortality as an outcome, 10 reported a significant positive relationship between obesity and mortality. The incidence of infections was assessed in 8 of the 28 studies; 2 reported significantly more infections in obese compared with nonobese patients. Of the 11 studies that examined length of stay, 5 reported significantly longer lengths of hospital stay for obese children. Fifteen studies (53%) had a high quality score. Larger studies observed significant relationships between obesity and outcomes. Studies of critically ill, oncologic or stem cell transplant, and solid organ transplant patients showed a relationship between obesity and mortality.

CONCLUSIONS AND RELEVANCE

The available literature on the relationship between obesity and clinical outcomes is limited by subject heterogeneity, variations in criteria for defining obesity, and outcomes examined. Childhood obesity may be a risk factor for higher mortality in hospitalized children with critical illness, oncologic diagnoses, or transplants. Further examination of the relationship between obesity and clinical outcomes in this subgroup of hospitalized children is needed.

Systematic review of the influence of energy and protein intake on protein balance in critically ill children

OBJECTIVE

To examine the influence of protein and energy intakes on protein balance in children receiving mechanical ventilation in the pediatric intensive care unit.

STUDY DESIGN

We hypothesized that higher energy and protein intakes are correlated with positive protein balance. We performed a systematic literature search to identify studies reporting protein balance in children requiring mechanical ventilation. Factors contributing to protein balance, including protein and energy intake, age, illness severity, study design, and feeding routes, were analyzed using a qualitative approach.

RESULTS

Nine studies met the entry criteria and were included in the final analysis. Positive nitrogen balance was reported in 6 of the studies, with a wide range of associated energy and protein intakes. Measures of central tendency for daily energy and protein intakes were significantly correlated with positive protein balance. A minimum intake of 57 kcal/kg/day and 1.5 g protein/kg/day were required to achieve positive protein balance.

CONCLUSION

We found a correlation between higher energy and protein intakes and achievement of positive protein balance in children receiving mechanical ventilation in the pediatric intensive care unit. However, there is a paucity of interventional studies, and a variety of protocols have been used to determine nitrogen balance. Larger clinical trials with uniform methodology are needed to further examine the effect of energy and protein intake on protein balance, lean body mass, and clinical outcomes in children on mechanical ventilation.

Resting energy expenditure after Fontan surgery in children with single-ventricle heart defects

BACKGROUND

Data on resting energy expenditure (REE) and oxygen consumption (VO(2)) after pediatric cardiopulmonary bypass (CPB) will facilitate optimal nutrient prescription.

METHODS

The authors measured continuous REE and VO(2), using an in-line indirect calorimetery (IC) in 30 consecutive children with single-ventricle physiology immediately after Fontan surgery. REE during steady state at 8 hours after surgery was compared with standard equation-estimated energy expenditure (EEE). Patients were classified into 3 groups: hypermetabolic (measured REE [MREE]/EEE ratio >1.2), hypometabolic (MREE/EEE ratio <0.8), and normometabolic (MREE/EEE ratio 0.8-1.2). Demographic, anthropometric, and perioperative clinical characteristics were examined for their correlation with metabolic status.

RESULTS

In 26 of 30 patients with completed IC, mean REE at 8 hours after surgery was 57 ± 20 kcal/kg/d, and mean VO(2) was 110 ± 35 mL/min. Mean values of VO(2) and REE did not change within the first 24 hours after surgery. There was poor correlation between MREE at 8 hours and the EEE using the World Health Organization equation (r = 0.32, P = .11). Most patients (n = 19, 73%) were either normometabolic or hypometabolic. Lack of hypermetabolism was significantly associated with higher intraoperative serum lactate level and positive fluid balance compared with the rest of the group.

CONCLUSIONS

The authors report a low prevalence of hypermetabolism in children with single-ventricle defects after Fontan surgery. Measured REE had poor correlation with equation-estimated energy expenditure in a majority of the cohort. The absence of increased energy expenditure after CPB will influence energy prescription in this group.

Effect of titrated parenteral nutrition on body composition after allogeneic hematopoietic stem cell transplantation in children: a double-blind, randomized, multicenter trial

BACKGROUND

Children undergoing hematopoietic stem cell transplantation (HSCT) often require parenteral nutrition (PN) to optimize caloric intake. Standard approaches to nutritional supplementation provide 130-150% of estimated energy expenditure, but resting energy expenditure (REE) may be lower than expected after HSCT. Provision of PN exceeding energy needs may lead to overfeeding and associated complications.

OBJECTIVE

We conducted a blinded, randomized, controlled, multicenter trial in children undergoing HSCT to determine the effect on body composition of 2 different approaches of nutrition support: standard amounts of energy from PN (130-150% of REE) compared with PN titrated to match measured REE.

DESIGN

Twenty-six children undergoing HSCT were randomly assigned to standard or titrated PN. Energy intake was monitored until day 30 after HSCT. Body-composition and anthropometric measures were obtained through day 100. The primary outcome variable was percentage body fat (%BF) measured by dual energy X-ray absorptiometry.

RESULTS

The estimated change in %BF from baseline to day 30 was 1.2 ± 0.5% in the standard group and 0.1 ± 0.5% in the experimental group, but the overall time course of %BF did not differ significantly by treatment (P = 0.39 for time × treatment interaction). A profound loss of lean body mass (LBM) occurred in both groups during the intervention period and persisted through day 100.

CONCLUSIONS

Parenteral energy intake titrated to energy expenditure does not result in a lower accumulation of BF than does standard energy intake. Neither titrated nor standard PN regimens during HSCT preserve LBM. Alternative approaches to preserve LBM are needed. This trial is registered at clinicaltrials.gov as 00115258.

Is Energy Expenditure of Infants Predictable After Surgery?

Infants undergoing surgery have unique metabolic demands. The stress of an operation and recovery combined with expectations for growth and development imply elevations in energy expenditure beyond that of healthy, free-living infants. In contrast, surgery may trigger a diversion of energy utilization from tissue accumulation and growth toward the catabolic stress response and cytokine production. Predictive equations are commonly used in clinical settings to estimate basal or resting energy expenditure because measurement techniques such as indirect calorimetry may not be feasible or available. Investigations of measured energy expenditure in surgical infants have portrayed mixed results, however, and estimation equations may not consistently lead to accurate assessment of actual energy needs. Studies are limited in number and quality and often involve a heterogeneous, small population. Grouped outcomes may conceal the wide variability frequently observed in these studies. Measurement of energy expenditure is therefore preferable to the use of predictive equations to customize nutrition intervention for individual infants undergoing surgery.

A multi-center, randomized, controlled trial of parenteral nutrition titrated to resting energy expenditure in children undergoing hematopoietic stem cell transplantation ("PNTREE"): rationale and design

BACKGROUND

Children undergoing hematopoietic stem cell transplantation (HSCT) frequently require prolonged courses of parenteral nutrition (PN) as a consequence of gastrointestinal dysfunction related to preparative chemotherapy and radiation. PN has been associated with shorter engraftment time and decreased mortality during HSCT, however, it is also linked with complications, including infections, liver disease, and metabolic disturbances. Some of these complications may be a result of providing PN in excess of nutrient requirements. We previously described significant reductions in resting energy expenditure (REE), as measured by indirect calorimetry, over the course of HSCT. We also documented a decline in mid-arm muscle area, suggesting depletion of muscle mass, while triceps skinfold, a marker of fat stores, was unchanged. These results suggested the need for further study of energy expenditure, body composition and nutritional intake in this group of high risk patients.

DESIGN AND HYPOTHESIS

We hypothesize that changes in body composition affect REE during HSCT, and that standard nutritional support may lead to overfeeding. We are performing a randomized controlled trial of parenteral nutrition among children undergoing allogeneic HSCT. Subjects are randomized to receive PN designed to provide 100% of measured REE, or standard PN, i.e., 140% of estimated energy expenditure. The primary outcome variable is change in percent body fat. Secondary outcomes include glycemic control and frequency of infections, changes in REE and body composition.

CONCLUSION

This study will provide unique and comprehensive nutritional data and its results will guide nutritional therapy for children undergoing HSCT and possibly other catabolic patients.

Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry

INTRODUCTION

Failure to accurately estimate energy requirements may result in underfeeding or overfeeding. In this study, a dedicated multidisciplinary nutrition team measured energy expenditure in critically ill children.

METHODS

Steady-state indirect calorimetry was used to obtain measured resting energy expenditure, which was compared with equation-estimated energy expenditure and the total energy intake for each subject. The children's metabolic status was examined in relation to standard clinical characteristics.

RESULTS

Sixteen measurements were performed in 14 patients admitted to the multidisciplinary pediatric intensive care unit over a period of 12 months. Mean age of subjects in this cohort was 11.2 years (range 1.6 months to 32 years) and included 7 males and 7 postoperative patients. Altered metabolism was detected in 13 of 14 subjects and in 15 of 16 (94%) measurements. There was no correlation between the metabolic status of subjects and their clinical characteristics. Average daily energy balance was 200 kcal/d (range -518 to +859 kcal/d). Agreement between measured resting energy expenditure and equation-estimated energy expenditure was poor, with mean bias of 72.3 +/- 446 kcal/d (limits of agreement -801.9 to + 946.5 kcal/d).

CONCLUSIONS

A disparity was observed between equation-estimated energy expenditure, measured resting energy expenditure, and total energy intake, with a high incidence of underfeeding or overfeeding. A wide range of metabolic alterations were recorded, which could not be accurately predicted using standard clinical characteristics. Targeted indirect calorimetry on high-risk patients selected by a dedicated nutrition team may prevent cumulative excesses and deficits in energy balance.

Weekly measurements accurately represent trends in resting energy expenditure in children undergoing hematopoietic stem cell transplantation

BACKGROUND

Resting energy expenditure (REE) measurements are optimal for accurate assessment of energy requirements and precise provision of parenteral nutrients. We previously observed significant reduction in REE during a 4-week period in children undergoing hematopoietic stem cell transplantation (HSCT). The goal of this study was to determine if weekly REE measurements could accurately represent changes in REE in the peritransplant period compared with a more frequent standard of daily measurements.

METHODS

Data are presented from a previously described cohort of 37 children undergoing HSCT. We performed weekly indirect calorimetry on 25 patients; of those 25, we performed daily measurements on a convenience sample of 5 children. The time course of REE was analyzed in each sample by repeated measures regression.

RESULTS

The REE trend of the 20 weekly participants was similar to that of the 5 daily participants, reaching about 80% of predicted REE at 4 weeks posttransplant, with an average decline of 3.4% per week during 4 weeks.

CONCLUSION

The results suggest that weekly REE measurements accurately characterize REE changes 4 weeks after HSCT compared with daily measurements. Characterization of these trends using weekly measurements may help guide clinical and nutrition care of these patients.

Prognostic factors in the resumption of oral dietary intake after allogeneic hematopoietic stem cell transplantation (HSCT) in children

BACKGROUND

Parenteral nutrition (PN) is a common supportive care therapy in patients undergoing hematopoietic stem cell transplantation (HSCT). Inadequate oral dietary intake may necessitate prolonged courses of PN, which have been associated with metabolic, infectious, and hepatobiliary complications. The objective of this study was to identify demographic, clinical, and nutrition factors associated with the resumption of oral dietary intake following HSCT.

METHODS

This was an observational cohort study of 37 children undergoing allogeneic HSCT. Repeated-measures regression analysis was performed to identify factors associated with the resumption and macronutrient composition of oral nutrient intake after HSCT.

RESULTS

Mean oral dietary intake during the first 2 weeks after HSCT was <280 kcal/d. At all times, oral carbohydrate intake was high, ranging from 58% to 74% of oral energy. Age, time since transplant, degree of oral mucositis, and severity of graft-vs-host disease (GVHD) were all significantly correlated with the resumption of oral energy intake, as well as oral intake of carbohydrates. Oral protein and fat intake were also associated with elapsed time since HSCT, severity of mucositis, and GVHD. Factors not associated with oral dietary intake included gender, pre-HSCT nutrition status, diagnosis, type of donor, and infections.

CONCLUSIONS

Children undergoing HSCT exhibit a marked reduction in oral dietary intake and a preference for a diet high in carbohydrates. Careful attention should be directed to the oral dietary intake and nutrient requirements of children during HSCT, especially in younger patients and those who experience severe mucositis or GVHD.

Use of a fish oil-based lipid emulsion to treat essential fatty acid deficiency in a soy allergic patient receiving parenteral nutrition

The treatment of essential fatty acid deficiency (EFAD) in a 17-year-old male following allogeneic bone marrow transplantation is described. His transplant was complicated by gastrointestinal bleeding that precluded the use of enteral feedings. Due to a severe soy allergy, he could not tolerate any intravenous fat emulsions marketed in the US. After months of receiving fat-free parenteral nutrition and intermittent use of enteral feeds, he developed signs and symptoms consistent with EFAD, including a rash and an elevated plasma triene:tetraene ratio of 0.231 (0.013-0.05). After receiving FDA approval, a parenteral fish oil emulsion was administered to provide fat calories and sufficient alpha-linolenic and linoleic acid to correct his EFAD. Therapy was initiated at 0.2 g/kg/day and advanced to 0.67 g/kg/day, providing approximately 45 mg/kg/day of linoleic acid. After 10 days of therapy, his rash disappeared and his triene:tetraene ratio improved to 0.07. By day 17 the ratio normalized to 0.047. This suggests that using a fish oil emulsion with minimal linoleic acid may be safely used as the sole source of fat calories and may be an option to prevent or treat EFAD in subjects allergic to soy that require a parenteral source of fat.

A multiagent strategy to decrease regimen-related toxicity in children undergoing allogeneic hematopoietic stem cell transplantation

Regimen-related toxicity (RRT) is a frequent cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). In this pilot study, we examined the feasibility and potential efficacy of administering a fixed combination of agents as a novel approach to reducing RRT in children undergoing HSCT. Thirty-seven patients were treated with ursodeoxycholic acid, folinic acid, vitamin E, and parenteral nutrition titrated to measured energy expenditure in the peritransplantation period. Outcomes were compared with those in historical controls (n = 131). Compliance with oral ursodeoxycholic acid and vitamin E of at least 90% was achieved in a mean of 86% (95% confidence interval, 75%-97%) of patients. In the study group, we observed (1) reduced prevalence and severity of mucositis (P = .008 and.004, respectively); (2) less severe hepatic toxicity (P = .007); and (3) shorter time to engraftment (P = .02) compared with the control group. These benefits appeared most pronounced among high-risk patients. The administration of this regimen, including oral medications, is feasible during the peritransplantation period, and it is well tolerated. The decreased RRT observed in comparison to historical controls suggests that combination approaches deserve exploration as a means of reducing the morbidity of HSCT.