Malnutrition, nutritional indices, and early enteral feeding in critically ill children

Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy

OBJECTIVE

Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy.

METHODS

PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications.

RESULTS

Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65).

CONCLUSION

Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.

Personalized Nutrition in the Pediatric ICU: Steering the Shift from Acute Stress to Metabolic Recovery and Rehabilitation

BACKGROUND

Nutrition significantly impacts the outcomes of critically ill children in intensive care units (ICUs). Due to the evolving metabolic, neuroendocrine, and immunological disorders associated with severe illness or trauma, there are dynamically changing phases of energy needs requiring tailored macronutrient intake.

OBJECTIVES

This study aims to assess the changing dietary needs from the acute phase through recovery, provide recommendations for implementing evidence-based strategies to ensure adequate energy and nutrient provision in pediatric ICUs, and optimize patient outcomes.

METHODS

A comprehensive search of the MEDLINE-PubMed database was conducted, focusing on randomized controlled trials, meta-analyses, and systematic reviews related to the nutrition of critically ill children. The study highlights recent guidelines using the GRADE approach, supplemented by relevant adult studies, current clinical practices, challenges, gaps in knowledge, and future directions for research aimed at improving nutritional interventions.

RESULTS

Early personalized, incremental enteral feeding helps mitigate the negative energy balance during the acute phase, aids organ function restoration in the stabilization phase, and supports growth during the recovery phase and beyond. Conversely, early full nutritional support, high protein doses, or isolated micronutrient administration have not demonstrated benefits due to anabolic resistance in these patients. Moreover, early parenteral nutrition during the acute phase may suppress autophagy and lead to worse outcomes. Accurate assessment of nutritional status and monitoring of daily energy and protein needs are crucial.

CONCLUSIONS

Strong evidence supports the establishment of a dedicated nutritional team and the implementation of individualized nutritional protocols in the ICU to reduce morbidity and mortality in critically ill children.

Nutritional status and clinical outcomes of brain tumor surgery in pediatric intensive care unit: A prospective cohort study

BACKGROUND

To determine whether nutritional status affects mortality and length of stay in the pediatric intensive care unit (PICU) after brain tumor surgery.

METHODS

Subjects aged 2 months to 13 years with brain tumor surgery were included in the study. Z-scores of BMI for age, weight for age, and weight for length were calculated at admission. Undernutrition was defined as Z-score < -2. Nutritional intake was measured daily by a clinical nutritionist. Outcomes to be measured included duration of hospitalization and mortality. Regression analyses was used to investigate the relationship between nutritional variables and outcomes.

RESULTS

A total of 63 patients met the inclusion criteria. Undernutrition at admission was found in 33% of subjects based on Z-scores of BMI and weight for length. The mortality rate was 17.5%. Calorie and protein intake was <50% of the target in 50.7% and 42.8 % of children, respectively. Undernutrition by weight for age Z-score, BMI for age and weight for length Z-scores, and low protein intake increased mortality risk by 5, 5.9 and 4.7 times, respectively. The risk of shorter PICU-free days was independently 80% and 90% lower in those receiving <50% of protein and calorie requirements.

CONCLUSION

Undernutrition at admission is prevalent in children undergoing brain tumor surgery and is associated with a higher risk of mortality. Caloric and protein intake during hospitalization is generally low, leading to longer PICU stay.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Implementing a physician-driven feeding protocol is not sufficient to achieve adequate caloric and protein delivery in a paediatric intensive care unit: A retrospective cohort study

BACKGROUND AND AIMS

Daily caloric and protein intake is crucial for the management of critically ill children. The benefit of feeding protocols in improving daily nutritional intake in children remains controversial. This study aimed to assess whether the introduction of an enteral feeding protocol in a paediatric intensive care unit (PICU) improves daily caloric and protein delivery on day 5 after admission and the accuracy of the medical prescription.

METHODS

Children admitted to our PICU for a minimum of 5 days who received enteral feeding were included. Daily caloric and protein intake were recorded and retrospectively compared before and after the introduction of the feeding protocol.

RESULTS

Caloric and protein intake was similar before and after introduction of the feeding protocol. The prescribed caloric target was significantly lower than the theoretical target. The children who received less than 50% of the caloric and protein targets were significantly heavier and taller than those who received more than 50%; the patients who received more than 100% of the caloric and protein aims on day 5 after admission had a decreased PICU length of stay and decreased duration of invasive ventilation.

CONCLUSION

The introduction of a physician-driven feeding protocol was not associated with an increase in the daily caloric or protein intake in our cohort. Other methods of improving nutritional delivery and patient outcomes need to be explored.

Nutritional Support in Children Meeting the At-Risk for Pediatric Acute Respiratory Distress Syndrome Criteria

Pediatric acute respiratory distress syndrome (PARDS) is a prevalent condition in the PICU with a high morbidity and mortality, but effective preventative strategies are lacking.

OBJECTIVES

To examine associations between early enteral nutrition (EN) and PICU outcomes in a cohort of children meeting the 2015 Pediatric Acute Lung Injury Consensus Conference "at-risk" for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria.

DESIGN SETTING AND PARTICIPANTS

This was a single-center, electronic health record-based retrospective chart review. We included children less than or equal to 18 years-old admitted to our mixed medical-surgical PICU from January 2017 to December 2018 who met ARF-PARDS criteria within 48 hours of admission. Children were categorized as receiving "early" EN if feeds were initiated within 48 hours of admission. All others were categorized as "delayed" EN.

MAIN OUTCOMES AND MEASURES

Extracted data included demographics, illness characteristics including primary diagnosis and Pediatric Risk of Mortality (PRISM) III score, respiratory support and oxygenation indices, nutritional data, and PICU length of stay (LOS). The primary outcome of interest was subsequent diagnosis of PARDS.

RESULTS

Of 201 included children, 152 (75.6%) received early EN. The most common admission diagnoses were pneumonia, bronchiolitis, and influenza. Overall, 21.4% (n = 43) of children developed PARDS. Children receiving early EN had a subsequent diagnosis of PARDS less often then children receiving delayed EN (15.1% vs 40.8%; p < 0.001), an association that persisted after adjusting for patient demographics and illness characteristics, including PRISM III and diagnosis (adjusted odds ratio, 0.24; 95% CI, 0.10-0.58; p = 0.002). Early EN was also associated with a shorter PICU LOS in univariate analysis (2.2 d [interquartile range, 1.5-3.4 d] vs 4.2 d [2.7-8.9 d]; p < 0.001).

CONCLUSIONS AND RELEVANCE

In this single-center, retrospective cohort study, compared with children with ARF-PARDS who received late EN, those who received early EN demonstrated a reduced odds of subsequent diagnosis of PARDS, and an unadjusted reduction in PICU LOS when compared with delayed EN. Prospective studies should be designed to confirm these findings.

Nutritional Biomarkers as Predictors of Dysphonia Severity in Patients with Ischemic Stroke

Dysphonia and malnutrition are major problems in patients who have suffered an ischemic stroke. Tools to assess dysphonia severity include the dysphonia severity index (DSI) and maximum phonation time (MPT). This study aimed to investigate whether the nutritional biomarkers transferrin, albumin, and prealbumin could be predictors of dysphonia severity. A retrospective analysis was conducted between January 2018 and October 2022. A total of 180 patients who had suffered an ischemic stroke were included. Serum transferrin, albumin, and prealbumin levels were significantly correlated with DSI and MPT levels. In a multiple regression analysis, prealbumin and transferrin were significant predictors of DSI, whereas only prealbumin was a significant predictor of MPT. Serum transferrin, albumin, and prealbumin levels in patients who have suffered an ischemic stroke may correlate with dysphonia severity as assessed using DSI and MPT. These results may provide objective evidence that nutritional biomarkers affect dysphonia severity.

Contemporary feeding practices in postoperative patients with Congenital Heart Disease

BACKGROUND

We aimed to assess the current nutritional practices in postoperative patients with Congenital Heart Disease.

METHODS

Cross-sectional electronic survey was sent to members of The Pediatric Cardiac Intensive Care Society.

MEASUREMENTS AND MAIN RESULTS

In Total, 52 members of the Pediatric Cardiac Intensive Care Society responded to the survey consisting of 14% paediatric intensivist, 53% paediatric cardiac intensivist, and 33% nurse/nurse practitioner with a median of 10 years of experience. There was an even distribution between intensivist (55%) and dietitian or nutritionist (45%) in nutrition management. Ninety-eight percent of respondents report that they would feed patients on inotropic or vasoactive support. Only 27% of respondents reported using indirect calorimetry in calculating resting energy expenditure which is the current gold standard. Academic hospitals compared to non-academic hospital were most likely to report feeding patients within 24 hours postoperative (p = 0.014). Having a feeding protocol was associated with feeding within 24 hours postoperative (p = 0.014) and associated with >50% goal intake by 48 hours postoperative (p = 0.025).

CONCLUSIONS

Substantial variation in feeding practice still exists despite the American Society for Parenteral and Enteral Nutrition guidelines from 2017. Report of institutional established feeding protocol was associated with increased early feeding and reaching goal feeds by 48 hours postoperative. Very few centres reported use of indirect calorimetry in postoperative paediatric cardiac intensive care patients and many respondents lacked knowledge about applications in this population. Additional work to determine optimal feeding pathways and assessment of caloric needs in this population is needed.

Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT

BACKGROUND & AIMS

Hypophosphatemia during critical illness has been associated with adverse outcome. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. We investigated the occurrence of early RFH, its association with clinical outcome, and the impact of early parenteral nutrition (PN) on the development of early RFH in pediatric critical illness.

METHODS

This is a secondary analysis of the PEPaNIC randomized controlled trial (N = 1440), which showed that withholding supplemental parenteral nutrition (PN) for 1 week (late-PN) in the pediatric intensive care unit (PICU) accelerated recovery and reduced new infections compared to early-PN (<24 h). Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. Early RFH was defined as serum/plasma phosphate <0.65 mmol/L and a drop of >0.16 mmol/L within 3 days of admission to the PICU. The association between baseline characteristics and early RFH, and the association of early RFH with clinical outcome were investigated using logistic and linear regression models, both uncorrected and corrected for possible confounders. To examine the impact of nutritional intake on phosphate concentrations, structural nested mean models with propensity score and censoring models were used.

RESULTS

A total of 1247 patients were eligible (618 early-PN, 629 late-PN). Early RFH occurred in 40 patients (3%) in total, significantly more in the early-PN group (n = 31, within-group occurrence 5%) than in the late-PN-group (n = 9, within-group occurrence 1%, p < 0.001). Patients who were older (OR 1.14 (95% CI 1.08; 1.21) per year added, p < 0.001) and who had a higher Pediatric Risk of Mortality (PIM3) score had a higher risk of developing early RFH (OR 1.36 (95% CI 1.15; 1.59) per unit added, p < 0.001), whereas patients in the late-PN group had a lower risk of early RFH (OR 0.24 (95% CI 0.10; 0.49), p < 0.001). Early RFH was significantly associated with a 56% longer PICU stay (p = 0.003) and 42% longer hospital stay (p = 0.007), but not with new infections (OR 2.01 (95% CI 0.90; 4.30), p = 0.08) or length of mechanical ventilatory support (OR 1.05 (95% CI -3.92; 6.03), p = 0.68), when adjusted for possible confounders. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c = -0.002 (95% CI -0.002; -0.001).

CONCLUSIONS

Early RFH occurred in 3% of critically ill children. Patients randomized to late-PN had a lower chance of developing early RFH, which may be explained by the more gradual build-up of nutrition. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH.

Nutrition in Pediatric Intensive Care: A Narrative Review

Nutrition support in pediatric intensive care is an integral part of a complex approach to treating critically ill children. Smaller energy reserves with higher metabolic demands (a higher basal metabolism rate) compared to adults makes children more vulnerable to starvation. The nutrition supportive therapy should be initiated immediately after intensive care admission and initial vital sign stabilization. In absence of contraindications (unresolving/decompensated shock, gut ischemia, critical gut stenosis, etc.), the preferred type of enteral nutrition is oral or via a gastric tube. In the acute phase of critical illness, due to gluconeogenesis and muscle breakdown with proteolysis, the need for high protein delivery should be emphasized. After patient condition stabilization, the acute phase with predominant catabolism converts to the anabolic phase and intensive rehabilitation, where high energy demands are the keystone of a positive outcome.

Nutritional Support for Pediatric Severe Traumatic Brain Injury

In critically ill children with severe traumatic brain injury (sTBI), nutrition may help facilitate optimal recovery. There is ongoing research regarding nutritional practices in the pediatric intensive care unit (PICU). These are focused on identifying a patient's most appropriate energy goal, the mode and timing of nutrient delivery that results in improved outcomes, as well as balancing these goals against inherent risks associated with nutrition therapy. Within the PICU population, children with sTBI experience complex physiologic derangements in the acute post-injury period that may alter metabolic demand, leading to nutritional needs that may differ from those in other critically ill patients. Currently, there are relatively few studies examining nutrition practices in PICU patients, and even fewer studies that focus on pediatric sTBI patients. Available data suggest that contemporary neurocritical care practices may largely blunt the expected hypermetabolic state after sTBI, and that early enteral nutrition may be associated with lower morbidity and mortality. In concordance with these data, the most recent guidelines for the management of pediatric sTBI released by the Brain Trauma Foundation recommend initiation of enteral nutrition within 72 h to improve outcome (Level 3 evidence). In this review, we will summarize available literature on nutrition therapy for children with sTBI and identify gaps for future research.

Incidence of Refeeding Syndrome in Critically Ill Children With Nutritional Support

INTRODUCTION

Early enteral nutrition is recommended for critically ill children, potentially exposing those who are undernourished to the risk of refeeding syndrome. However, data on its incidence is lacking, and the heterogeneity of diagnostic criteria and frequent electrolyte disorders in this population make its diagnosis complex. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) developed consensus recommendations for identifying patients at risk and with refeeding syndrome. These state that undernourished children are considered at risk of refeeding syndrome; those who develop one significant electrolyte disorder (decrease ≥ 10% in phosphorus, potassium, and/or magnesium) within the first five days of nutritional support, combined with a significant increase in energy intake, are considered to have refeeding syndrome. The aim of this study was to determine the incidence of refeeding syndrome according to the ASPEN definition in critically ill children on nutritional support.

MATERIALS AND METHODS

A secondary analysis of two prospective cohorts conducted in a tertiary pediatric intensive care unit in France was undertaken, and additional data were retrospectively collected. Children included were those (0-18 years) admitted to the pediatric intensive care unit with a minimum of one phosphorus, potassium, and/or magnesium assay and who received exclusive or supplemental nutritional support. Undernourished children (body mass index z-score < -2 standard deviations) were considered at risk of refeeding syndrome. The ASPEN critiera were used to identify those with probable refeeding syndrome.

RESULTS

A total of 1,261 children were included in the study, with 199 children (15.8%) classified as undernourished, who were at risk of refeeding syndrome. Of these, 93 children were identified as having probable refeeding syndrome, giving an overall incidence of 7.4%. The incidence rate among at-risk children was 46.7%. Most patients (58.1%) were classified as having severe refeeding syndrome.

CONCLUSION

Refeeding syndrome remains difficult to diagnose in critically ill children, due to frequent confounding factors impacting electrolyte plasma levels. These findings suggest that refeeding syndrome incidence may be high in undernourished children, and that refeeding syndromes can be severe. Further prospective studies using the ASPEN definition and risk criteria are required.

Nutritional screening tool for critically ill children: a systematic review

CONTEXT

Nutritional screening tools (NSTs) are used to identify patients who are at risk of nutritional status (NS) deterioration and associated clinical outcomes. Several NSTs have been developed for hospitalized children; however, none of these were specifically developed for Pediatric Intensive Care Unit (PICU) patients.

OBJECTIVE

A systematic review of studies describing the development, application, and validation of NSTs in hospitalized children was conducted to critically appraise their role in PICU patients.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, SciELO, LILACS, and Google Scholar were searched from inception to December 11, 2020.

DATA EXTRACTION

The review included 103 studies that applied NSTs at hospital admission. The NST characteristics collected included the aims, clinical setting, variables, and outcomes. The suitability of the NSTs in PICU patients was assessed based on a list of variables deemed relevant for this population.

DATA ANALYSIS

From 19 NSTs identified, 13 aimed to predict NS deterioration. Five NSTs were applied in PICU patients, but none was validated for this population. NSTs did not include clinical, NS, laboratory, or dietary variables that were deemed relevant for the PICU population.

CONCLUSION

None of the available NSTs were found to be suitable for critically ill children, so a new NST should be developed for this population. AQ6.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020167898.

Improving the rate of anthropometric measurements in the pediatric intensive care unit

BACKGROUND

Malnutrition occurs in approximately 25% of pediatric intensive care patients and correlates with increased length of stay, prolonged ventilation, and mortality. Anthropometric measurements should be obtained at admission and throughout hospitalization to evaluate nutrition status. We aimed to increase documentation, reporting, and discussion of anthropometric measurements, including height/length, weight, and occipital frontal circumference (OFC) within 24 hours of admission and weekly.

METHODS

A multifaceted process improvement model was implemented over 1 month. Interventions included education, recruiting nurse champions, process mapping, new equipment, and formal discussion of nutrition status during rounds. A proportions hypothesis test compared frequency of anthropometric measures obtained during each study phase: preintervention, postintervention, and sustainment.

RESULTS

In terms of admission metrics over respective study phases, the PICU had fluctuation in weights (91%, 98%, and 97%) and height (49%, 73%, and 71%) and increased rates in OFC (36%, 61%, and 65%). The cardiovascular intensive care unit (CVICU) had stable weights (100%, 100%, and 100%) and increased rates in height (87%, 94%, and 95%) and OFC (28%, 64%, and 86%), respectively. In terms of weekly metrics over study phases, the PICU had fluctuation in weights (91%, 89%, and 93%) and increased rates in heights (38%, 69%, and 76%) and OFC (45%, 76%, and 100%). The CVICU had increased rates in weights (98%, 100%, and 100%) and fluctuations in heights (50%, 83%, and 75%), and OFC (48%, 84%, and 75%).

CONCLUSIONS

Interventions increased rates of measurements. During the sustainment phase, there was regression in rates, although these remained above baseline. Additional interventions may increase compliance and foster change in unit culture.

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.

A comparative two-cohort study of pediatric patients with long term stay in ICUs

During the last decades, the number of patients with long stay admissions (LSA) in PICU has increased. The purpose of this study was to identify factors associated with PICU LSA, assessing healthcare resources use and changes in the profile of these patients. A retrospective, observational, single-center study was carried out. Characteristics of LSA were compared between two periods (2006–2010 and 2011–2015). During the earlier period there were 2,118 admissions (3.9% of them LSA), whereas during the second period, there were 1,763 (5.4% of them LSA) (p = 0.025). LSA accounted for 33.7% PICU stay days during the first period and 46.7% during the second (p < 0.001). Higher use of non-invasive ventilation (80.2% vs. 37.8%, p = 0.001) and high-flow oxygen therapy (68.8% vs. 37.8%, p = 0.005) was observed in the 2011–2015 cohort, whereas the use of arterial catheter (77.1% vs. 92.6%, p = 0.005), continuous infusion of adrenaline (55.2% vs. 75.9%, p = 0.004), and hemoderivative transfusion (74% vs. 89.2%, p = 0.010) was less frequent. In the 2006–2010 cohort, hospital-acquired infections were more common (95.2% vs. 68.8%, p < 0.001) and mortality was higher (26.8% vs. 13.8%, p = 0.026). The number of long-stay PICU admissions have increased entailing an intensive use of healthcare resources. These patients have a high risk for complications and mortality.

Nutritional status and nutrition support in critically ill children in Spain: Results of a multicentric study

OBJECTIVES

Critically ill children are often malnourished and require nutrition support (NS). Early enteral nutrition (EEN) seems to be safe in critically ill patients. However, there is a scarcity of data about the management of EEN in sick pediatric patients. The aim of this study was to analyze the nutritional status, NS characteristics, macronutrient supply, and associations between NS and outcomes in critically ill children in Spain.

METHODS

This was a multicentric, prospective, cross-sectional study involving critically ill children who received NS and with an expected length of stay (LOS) in the pediatric intensive care unit of ≥3 d. Anthropometric variables, characteristics of NS, EEN, nutrient supply, and complications were recorded.

RESULTS

We enrolled 86 children. Undernutrition and overweight were more prevalent in children ≤2 y of age than in older children (undernutrition: 40 versus 19%, respectively; overweight: 22.2 versus 14.3%, respectively). Being overweight was associated with a shorter PICU LOS (5.8 ± 2 versus 9.8 ± 6.5; P = 0.005). EN was the preferred method for nutrient delivery. EEN was administered to 58.1% of patients and was more common in children >2 y of age than in younger patients (73.1 versus 44.4%; P = 0.015). EEN was safe and was associated with a higher caloric intake (81.6 ± 35.3 versus 59.6 ± 36.6; P = 0.019). There was a negative correlation between mean time to EN initiation and maximum energy supply (r = -0.32; P = 0.07).

CONCLUSIONS

Malnutrition was prevalent among critically ill children in Spain. Being overweight was associated with a shorter PICU LOS. EEN was safe and was associated with a higher caloric intake; however, it is rarely used in PICUs in Spain.

Profile of Fluid Exposure and Recognition of Fluid Overload in Critically Ill Children

OBJECTIVES

Fluid overload is common in the PICU and has been associated with increased morbidity and mortality. It remains unclear whether fluid overload is a surrogate marker for severity of illness and need for increased support, an iatrogenic modifiable risk factor, or a sign of oliguria. The proportions of various fluid intake contributing to fluid overload and its recognition have not been adequately examined. We aimed to: 1) describe the types and amounts of fluid exposure in the PICU and 2) identify the clinicians' recognition of fluid overload.

SETTING

Noncardiac PICU in a quaternary care hospital.

PATIENTS

Pediatric patients admitted for more than 24 hours.

DESIGN

Prospective observational study over 28 days.

INTERVENTIONS

Data were collected on the amount and type of fluid exposure-resuscitative boluses, blood products, enteral intake, parenteral nutrition (total parenteral nutrition), or modifiable fluids (IV fluids and medications) indexed to the patients' admission body surface area on days 1 and 3. Charts of patients admitted for 3 days who developed 15% fluid overload were reviewed to assess clinicians' recognition of fluid overload.

MEASUREMENTS AND MAIN RESULTS

One hundred two patients were included. Day 1 median fluid exposure was 2,318 mL/m (1,831-3,037 mL/m; 1,646 mL/m [1,296-2,086 mL/m] modifiable fluids). Forty-seven patients (46%) received fluid boluses, and 16 (16%) received blood products. Day 3 median fluid exposure was 2,233 mL/m (1,904-2,556 mL/m; 750 mL/m [375-1,816 mL/m] modifiable fluids). Of the 54 patients, one patient (1.9%) received a fluid bolus and two (3.7%) received blood products. In our cohort, 47 of 54 (87%) had fluid exposure greater than 1,600 mL/m on day 3. Fluid overload was not recognized by the clinicians in 30% of the patients who developed more than 15% fluid overload.

CONCLUSIONS

Although resuscitation fluids contributed more to fluid exposure on day 1 compared with day 3, fluid exposure frequently exceeded maintenance requirements on day 3. Fluid overload was not always recognized by PICU practitioners. Further studies to correlate modifiable fluid exposure to fluid overload and explore modifiable practice improvement opportunities are needed.

A randomized controlled trial of high parenteral protein feeding in septic children: the role of tumor necrosis factor-alpha-308 polymorphism

BACKGROUND Septic children cause high protein degradation and inadequate nutritional intake would worsen the outcomes. In addition, there are conflicting results of association between tumor necrosis factor-α (TNFA)-308 polymorphism and poorer outcomes. This study was aimed to investigate the impact of high protein feeding in septic children and to examine the role of the TNFA-308 polymorphism in outcome of sepsis. METHODS In this randomized controlled trial, septic children were randomly assigned to receive either high protein feeding (amino acid of 4 g/kg of body weight [kgBW]/day) or standard nutrient (amino acid of 2 g/kgBW/day) for three days in the pediatric intensive care unit of four hospitals in Indonesia. The patient’s enrollment was done between April 2016 and May 2017. The primary outcome was the pediatric logistic organ dysfunction (PELOD) score. TNFA-308 polymorphism was investigated using restriction fragment length polymorphism method in both groups. PELOD score was analyzed as mean differences and gene polymorphism was analyzed with mortality in a subgroup. RESULTS There were 40 children in each group. PELOD score on day-1 (22.4 versus 20.5, p = 0.429), day-2 (20.5 versus 19.8, p = 0.815), and day-3 (18.8 versus 19.8, p = 0.772) were not lower in high protein feeding compared to standard feeding. TNFA-308 polymorphism had no role in mortality of both groups (high protein, p = 0.426; standard, p = 0.456). CONCLUSIONS From this study, researchers concluded that a high protein intervention did not significantly decrease the PELOD score, length of stay, and duration of ventilator use in both groups.

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.

Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations

Background

Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines.

Objective

To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children.

Design

The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds.

Results

The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions.

Conclusions

We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.

Gastrointestinal Issues in Critically Ill Children

Due to lack of uniform diagnostic criteria, gastrointestinal (GI) complications in critically ill occur with variable frequency,¹ and overall incidence of such complications seems to be less in children compared to adults. Major risk factors are use of catecholamines, sedatives, and muscle relaxants in patients with shock. GI dysmotility in critically ill patients is the main reason behind abdominal distension, increased gastric residual volume, and constipation. GI bleeding is described in about 10% of patients with critical illness with about 1.6% have clinically significant bleeding, particularly in patients with coagulopathy, respiratory failure, or PRISM scores >10.² In this review, the most common GI issues encountered in children will be discussed as mentioned earlier. In addition management of acute GI bleeding will also be discussed. How to cite this article: Khilnani P, Rawal N, Singha C. Gastrointestinal Issues in Critically Ill Children. Indian J Crit Care Med 2020;24(Suppl 4):S201-S204.

What do we know about optimal nutritional strategies in children with pediatric acute respiratory distress syndrome?

Nutrition in pediatric acute respiratory distress syndrome (PARDS) is an essential aspect of therapy, with potential to modify outcomes. The gut is slowly establishing its place as the motor of critical illness, and the 'gut-lung' axis has been shown to be in play in the systemic inflammatory response. Thus, utilizing the gut to modify outcomes in PARDS is an exciting prospect. PARDS is associated with high mortality in low- and middle-income countries (LMIC), where malnutrition is also prevalent and may worsen during hospital stay. Mortality may be higher in this subgroup of patients. At present, the gold standard to estimate resting energy expenditure (REE) in critically ill children is indirect calorimetry. However, it is a cumbersome and expensive procedure, as a result of which its routine practice is limited to very few units across the world. Therefore, predictive equations, which may under- or over-estimate REE, are relied upon to approximate calorie and protein needs of children with PARDS. Despite having target calorie and protein requirements, studies have found that a large proportion of critically ill children do not achieve these levels even at the end of a week in pediatric intensive care unit (PICU). The preferred mode of nutrition delivery is enteral, and if possible, early enteral nutrition (EEN). Immunonutrition has been a lucrative subject of research, and while there have been some strides, no therapy has yet conclusively demonstrated benefit in terms of mortality or reduced length of stay in PICU or the hospital. Probable immunonutrients in PARDS include omega-3 fatty acids, arginine, glutamine and vitamin D, though none are a part of any recommendations yet.

Nutritional Status Deterioration Occurs Frequently During Children's ICU Stay

OBJECTIVES

Malnutrition and faltering growth at PICU admission have been related to suboptimal outcomes. However, little is known about nutritional status deterioration during PICU stay, as critical illness is characterized by a profound and complex metabolism shift, which affects energy requirements and protein turnover. We aim to describe faltering growth occurrence during PICU stay.

DESIGN

Single-center prospective observational study.

SETTING

Twenty-three-bed general PICU, Lyon, France.

PATIENTS

All critically ill children 0-18 years old with length of stay longer than 5 days were included (September 2013-December 2015).

INTERVENTIONS

Weight and height/length were measured at admission, and weight was monitored during PICU stay, in order to calculate body mass index for age z score. Faltering growth was defined as body mass index z score decline over PICU stay. Children admitted during the first year of the study and who presented with faltering growth were followed after PICU discharge for 3 months.

MEASUREMENTS AND MAIN RESULTS

We analyzed 579 admissions. Of them, 10.2% presented a body mass index z score decline greater than 1 SD and 27.8% greater than 0.5. Admission severity risk scores and prolonged PICU stay accounted for 4% of the variability in nutritional status deterioration. Follow-up of post-PICU discharge nutritional status showed recovery within 3 months in most patients.

CONCLUSIONS

Nutritional deterioration is frequent and often intense in critically ill children with length of stay greater than 5 days. Future research should focus on how targeted nutritional therapies can minimize PICU faltering growth and improve post-PICU rehabilitation.

Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients

Background: insufficient feeding is frequent in the intensive care unit (ICU), which results in poor outcomes. Little is known about the nutrition pattern of patients requiring prolonged ICU stays. The aims of our study are to describe the demographic, metabolic, and nutritional specificities of chronically critically ill (CCI) patients defined by an ICU stay >2 weeks, and to identify an early risk factor. Methods: analysis of consecutive patients prospectively admitted to the CCI program, with the following variables: demographic characteristics, Nutrition Risk Screening (NRS-2002) score, total daily energy from nutritional and non-nutritional sources, protein and glucose intakes, all arterial blood glucose values, length of ICU and hospital stay, and outcome (ICU and 90-day survival). Two phases were considered for the analysis: the first 10 days, and the next 20 days of the ICU stay. Statistics: parametric and non-parametric tests. Results: 150 patients, aged 60 ± 15 years were prospectively included. Median (Q1, Q3) length of ICU stay was 31 (26, 46) days. The mortality was 18% at ICU discharge and 35.3% at 90 days. Non-survivors were older (p = 0.024), tended to have a higher SAPSII score (p = 0.072), with a significantly higher NRS score (p = 0.033). Enteral nutrition predominated, while combined feeding was minimally used. All patients received energy and protein below the ICU’s protocol recommendation. The proportion of days with fasting was 10.8%, being significantly higher in non-survivors (2 versus 3 days; p = 0.038). Higher protein delivery was associated with an increase in prealbumin over time (r² = 0.19, p = 0.027). Conclusions: High NRS scores may identify patients at highest risk of poor outcome when exposed to underfeeding. Further studies are required to evaluate a nutrition strategy for patients with high NRS, addressing combined parenteral nutrition and protein delivery.

Nutritional Laboratory Markers in Malnutrition

Serum visceral proteins such as albumin and prealbumin have traditionally been used as markers of the nutritional status of patients. Prealbumin is nowadays often preferred over albumin due to its shorter half live, reflecting more rapid changes of the nutritional state. However, recent focus has been on an appropriate nutrition-focused physical examination and on the patient's history for diagnosing malnutrition, and the role of inflammation as a risk factor for malnutrition has been more and more recognized. Inflammatory signals are potent inhibitors of visceral protein synthesis, and the use of these proteins as biomarkers of the nutritional status has been debated since they are strongly influenced by inflammation and less so by protein energy stores. The current consensus is that laboratory markers could be used as a complement to a thorough physical examination. Other markers of the nutritional status such as urinary creatinine or 3-methylhistidine as indicators of muscle protein breakdown have not found widespread use. Serum IGF-1 is less influenced by inflammation and falls during malnutrition. However, its concentration changes are not sufficiently specific to be useful clinically as a marker of malnutrition, and serum IGF-1 has less been used in clinical trials. Nevertheless, biomarkers of malnutrition such as prealbumin may be of interest as easily measurable predictors of the prognosis for surgical outcomes and of mortality in severe illnesses.

NUTRI-REAPED study: nutritional assessment of French critically ill children and nutrition practice survey in French-speaking pediatric intensive care units

BACKGROUND

Impaired nutritional status is adversely associated with suboptimal outcomes in critically ill children. Undernutrition at pediatric intensive care unit (PICU) admission ranges from 15 to 65%. A lack of knowledge of the nutritional status of children in French PICUs prevents us from specifically targeting education. This study aims to describe the nutritional status of children in French PICUs and to assess nutritional practices and physicians' knowledge of nutrition, in order to focus NutriSIP (the French-speaking PICU nutrition group) future education programs. A prospective observational multicenter point prevalence study was conducted in French PICUs, recruiting all children admitted over three different weeks. Anthropometric measurements were taken (weight, height/length, mid-upper arm, and head circumferences), in order to calculate nutritional indices. Nutritional status was defined according to WHO Body Mass Index z-score and dynamic assessment based on growth faltering detection. Concurrently, PICU physicians and PICU nurses from seven French-speaking countries completed a survey to ascertain knowledge about local nutritional care practices and overall nutrition knowledge. PICU physicians' responses were compared to PICU nurses' responses (previously published).

RESULTS

Four hundred and thirty-two children were included in the observational study from 27 French PICUs. Undernutrition was diagnosed in 18.5% of them, young age and underlying chronic condition being the two independent risk factors. Faltering growth was diagnosed in 4.8% and overweight in 7.4%. Subjective nutritional assessment was not accurate. Thirty-eight French-speaking PICUs completed the survey. These showed nutritional practices frequently did not comply with international guidelines, especially regarding nutritional goals, and the reasons for withholding enteral nutrition. Comparison between physicians' and nurses' responses to the survey showed large discrepancies.

CONCLUSION

Undernutrition is frequent at admission in French PICUs. Nutritional status should be assessed using a holistic approach, because of the potential impact on outcome. French-speaking PICU healthcare professionals need further nutrition education, in order to improve nutritional practices to comply with international recommendations. This study will serve as a baseline to focus NutriSIP teaching programs in the future.

The Association of Nutrition Status Expressed as Body Mass Index z Score With Outcomes in Children With Severe Sepsis: A Secondary Analysis From the Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study

OBJECTIVES

The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the association of nutrition status (expressed as body mass index z score) with outcomes in pediatric severe sepsis.

DESIGN

Secondary analysis of the Sepsis Prevalence, Outcomes, and Therapies study. Patient characteristics, ICU interventions, and outcomes were compared across nutrition status categories (expressed as age- and sex-adjusted body mass index z scores using World Health Organization standards). Multivariable regression models were developed to determine adjusted differences in all-cause ICU mortality and ICU length of stay by nutrition status.

SETTING

One-hundred twenty-eight PICUs across 26 countries.

PATIENTS

Children less than 18 years with severe sepsis enrolled in the Sepsis Prevalence, Outcomes, and Therapies study (n = 567).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Nutrition status data were available for 417 patients. Severe undernutrition was seen in Europe (25%), Asia (20%), South Africa (17%), and South America (10%), with severe overnutrition seen in Australia/New Zealand (17%) and North America (14%). Severe undernutrition was independently associated with all-cause ICU mortality (adjusted odds ratio, 3.0; 95% CI, 1.2-7.7; p = 0.02), whereas severe overnutrition in survivors was independently associated with longer ICU length of stay (1.6 d; p = 0.01).

CONCLUSIONS

There is considerable variation in nutrition status for children with severe sepsis treated across this selected network of PICUs from different geographic regions. Severe undernutrition was independently associated with higher all-cause ICU mortality in children with severe sepsis. Severe overnutrition was independently associated with greater ICU length of stay in childhood survivors of severe sepsis.

The impact of early enteral nutrition on pediatric acute respiratory failure

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.

The science and art of pediatric critical care nutrition

PURPOSE OF REVIEW

Nutritional status and nutrient delivery during critical illness impact clinical outcomes. We have reviewed recent studies that may guide best practices regarding nutrition therapy in critically ill children.

RECENT FINDINGS

Malnutrition is prevalent in the pediatric ICU population, and is associated with worse outcomes. Nutrition support teams, dedicated dietitians, and educational programs facilitate surveillance for existing malnutrition and nutrition risk, but specific tools for the pediatric ICU population are lacking. Estimation of macronutrient requirements is often inaccurate; novel strategies to accurately determine energy expenditure are being explored. Indirect calorimetry remains the reference method for measuring energy expenditure. Enteral nutrition is the preferred route for nutrition in patients with a functioning gut. Early enteral nutrition and delivery of adequate macronutrients, particularly protein, have been associated with improved clinical outcomes. Delivery of enteral nutrition is often interrupted because of fasting around procedures and perceived intolerance. Objective measures for detection and management of intolerance to nutrient intake are required. In low-risk patients who are able to tolerate enteral nutrition, supplemental parenteral nutrition may be delayed during the first week of critical illness.

SUMMARY

Systematic research and consensus-based practices are expected to promote optimal nutritional practices in critically ill children with the potential to improve clinical outcomes.

Faltering growth in the critically ill child: prevalence, risk factors, and impaired outcome

Low body mass index (BMI) z score is commonly used to define undernutrition, but faltering growth allows for a complementary dynamic assessment of nutritional status. We studied the prevalence of undernutrition and faltering growth at admission in the pediatric intensive care (PICU) setting and their impacts on outcome. All (685) consecutive children (aged 0 to 18 years old) admitted in a single-center PICU over a 1-year period were prospectively enrolled. Nutritional status assessment was based on anthropometric measurements performed at admission and collected from medical files. Undernutrition was considered when z score BMI for age was < - 2SD. Faltering growth was considered when the weight for age curve presented a deceleration of > - 1 z score in the previous 3 months. Undernutrition was diagnosed in 13% of children enrolled, and faltering growth in 13.7% mostly in children with a normal BMI. Faltering growth was significantly associated with a history of underlying chronic disease, and independently with extended length of PICU stay in a multivariate analysis.

CONCLUSION

Assessment of nutritional status in critically ill children should include both undernutrition and faltering growth. This study highlights that faltering growth is independently associated with suboptimal outcome in PICU. What is Known: • Malnutrition, defined according to BMI-for-age z score, is correlated with poor outcome in the critically ill child. • In this setting, nutritional assessment should consist not only of a static assessment based on BMI-for-age z score but also of a dynamic assessment to identify recent faltering growth. What is New: • Critically ill children frequently present with faltering growth at admission. • Faltering growth is a newly identified independent associated factor of suboptimal outcome in this setting (extended length of stay).

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES

Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months.

METHODS

We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration.

RESULTS

Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis.

CONCLUSIONS

We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU

OBJECTIVE

To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.

DESIGN

Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.

SETTING

Ninety PICUs from 16 countries with eight or more beds.

PATIENTS

Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.

MEASUREMENTS AND MAIN RESULTS

Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p < 0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p < 0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p < 0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p < 0.001) fewer ventilator-free days than normal weight and overweight, respectively.

CONCLUSIONS

Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

Effects of a Gastric Feeding Protocol on Efficiency of Enteral Nutrition in Critically Ill Infants and Children

Objective: Enteral nutrition (EN) has well-established benefits in critically ill children. Optimally, full nutritional support should be achieved expeditiously. The authors hypothesized that a protocolized continuous gastric EN (GEN) approach would decrease time to goal feeding rate and calories (TTG). Design: 96 patients were enrolled, divided equally into control (pre) and treatment (post) groups. Patients were monitored every 4 hours for 5 signs of feeding intolerance. Significance was defined as P < .05. Setting: 23-bed multidisciplinary pediatric intensive care unit (PICU). Subjects: PICU patients <18 years of age in whom GEN was to be started were eligible. Exclusion criteria included patients receiving total parental nutrition, <24 hours postoperative, had transpyloric feeding, had previous fundoplication, had preexisting gastrointestinal disease or chronic regimen. Interventions: The authors instituted a protocolized, weight-based approach to GEN and collected outcomes and tolerance data on both the control and treatment groups. Measurements and Main Results: There was no difference in TTG between the control and treatment groups. However, for patients less than 10 kg (74/96 patients), TTG was 15 hours faster in the treatment group compared with the control (56.85 ± 22.71, 70.44 ± 32.45 hours, respectively). Conclusions: The authors investigated the value of a GEN protocol in improving efficiency to goal nutrition in critically ill children. While no difference was found overall, in the subgroup analysis (77%) a significant improvement in TTG was found in infants <10 kg. Further investigation is needed to define impact on patient outcomes, such as length of stay, weight gain, and ICU morbidities.

Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies

OBJECTIVE

To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by relevant literature.

CONCLUSIONS

Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.

Implementation of Nutrition Support Guidelines May Affect Energy and Protein Intake in the Pediatric Intensive Care Unit

BACKGROUND

Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality.

OBJECTIVE

The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU).

DESIGN

This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively.

PARTICIPANTS/SETTING

Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation).

INTERVENTION

Implementation of NS Guidelines.

MAIN OUTCOME MEASURES

Changes in actual energy and protein intake in the post- compared with the pre-Implementation period.

STATISTICAL ANALYSIS PERFORMED

Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score.

RESULTS

After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (P<0.05). For the 8-day period, statistically or clinically significant improvements occurred in the cumulative protein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively.

CONCLUSIONS

The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a positive effect on improving NS in critically ill children.

Reducing variation in feeding newborns with congenital heart disease

OBJECTIVE

Enteral feeding is associated with decreased infection rates, decreased mechanical ventilation, decreased hospital length of stay, and improved wound healing. Enteral feeding difficulties are common in congenital heart disease. Our objective was to develop experience-based newborn feeding guidelines for the initiation and advancement of enteral feeding in the cardiothoracic intensive care unit.

DESIGN

This is a retrospective analysis of a quality improvement project.

SETTING

This quality improvement project was performed in a cardiothoracic intensive care unit.

PATIENTS

Newborns admitted to the cardiothoracic intensive care unit for cardiac surgery from January 2011 to May 2015 were retrospectively reviewed.

INTERVENTION

Newborn feeding guidelines for the initiation and advancement of enteral feeding were implemented in January 2012.

OUTCOME MEASURES

Guideline compliance and clinical variables before and after guideline implementation were reviewed.

RESULTS

Compliance with the guidelines increased from 83% in 2012 to 100% in the first two quarters of 2015. Preguidelines (January 2011-December 2011): 45 newborns underwent cardiac surgery; 8 deaths prior to discharge; 1 patient discharged from NICU, therefore, N = 36. Postguidelines (January 2012-May 2015): 131 newborns with 12 deaths, 12 admitted from home, 8 in the NICU, 3 on the floor preop, and 3 back transferred, therefore, N = 93. No difference in feeding preop (post 75% vs pre 69%; P = .5) or full po feeds at discharge (post 78% vs pre 89%; P = .2). Mesenteric ischemia was not statistically different postguidelines (post 6% vs pre 14%; P = .14). Length of hospital stay decreased postguidelines (post 27 + 17 d vs pre 34 + 42 d; P < .001).

CONCLUSIONS

Implementation of experience-based newborn feeding guidelines for initiation and advancement of enteral feeding in the cardiothoracic intensive care unit was successful in reducing practice variation supported by increasing guideline compliance. Percentage of patient's full oral feeding at discharge did not change. Length of hospital stay was reduced although cannot be fully attributed to feeding guideline implementation.

Protein Feeding in Pediatric Acute Kidney Injury Is Not Associated With a Delay in Renal Recovery

OBJECTIVE

Critically ill children with acute kidney injury (AKI) are at high risk of underfeeding. Newer guidelines for nutrition support recommend higher protein intake. Therefore, the study evaluated the effects of protein feeding on the resolution of AKI and compared energy and protein intake in patients with and without AKI after implementation of Nutrition Support guidelines.

DESIGN

Retrospective study.

SUBJECTS

Five hundred twenty critically ill children from October 2012 to June 2013 and October to December 2013.

MAIN OUTCOME MEASURE

Energy and protein intake in patients with no AKI, resolved, or persistent AKI. Energy and protein intake was documented for days 1-8 of Pediatric Intensive Care Unit stay and in the postimplementation versus preimplementation period of nutrition support guidelines. AKI was defined by modified pRIFLE. Persistent AKI was defined as patients who did not resolve their AKI during the study period.

RESULTS

A higher percentage of patients with resolved and persistent AKI met ≥ 80% of protein needs versus no AKI. After adjustment for Pediatric Risk of Mortality Score, the odds ratio for protein intake of ≥ 80% compared to <80% of estimated protein needs was not significant, which suggests that higher protein intake was not associated with nonresolution of AKI. There were significant improvements in the cumulative protein gap in patients with no AKI in the postimplementation (-1.0 [-1.7 to -0.6] g/kg/day) compared to preimplementation period (-1.3 [-1.7 to -0.9] g/kg/day, P = .001) and persistent AKI in the postimplementation (-0.8 [-1.4 to -0.1] g/kg/day) compared to preimplementation (-1.3 [-1.7 to -0.9] g/kg/day, P = .03).

CONCLUSIONS

Higher protein intake was not associated with a delay in renal recovery in patients with AKI after adjustment for severity of illness. Protein intake was improved in critically ill children with no AKI, resolved, and persistent AKI after implementation of Nutrition Support Guidelines, but underfeeding persisted in these patients.

Does Persistent Inflammatory Catabolic Syndrome Exist in Critically Ill Neonates?

BACKGROUND

Persistent inflammatory catabolic syndrome (PICS) has not been described in the infant population. This study proposes a definition of PICS in critically ill infants.

METHODS

A published adult criterion of PICS was modified using anthropometric and biochemical reference ranges for infants. A prospective chart review of admissions to a tertiary surgical neonatal intensive care unit (NICU) was performed over 65 days. Demographic, anthropometric, biochemical, and other clinical variables such as length of stay and medication use were collected daily throughout admission. Infants were categorized as having or not having PICS.

RESULTS

Twenty percent of admitted infants (n = 15) developed PICS using the proposed criteria. Infants with PICS were more likely to be classified as failure to thrive (53%), meeting only 75% of their anticipated weight gain. Significantly more infants with PICS had undergone surgery (100%; P = .01), received inotropic medication (40%; P = .05), and had longer NICU and total hospital length of stay ( P < .001 and P < .001). Infants with PICS had higher peak glucose levels (11.8 ± 7.3 mmol/L) and elevated urea concentrations (7.9 ± 4.6 mmol/L).

CONCLUSIONS

PICS does exist in a critically ill neonatal population and may be identified using the definition proposed in this study. Infants with PICS displayed metabolic dysregulation, impaired expected growth velocity, and longer length of stay despite no differences in severity scores or diagnosis between the groups. Validation of this work is required, and research into timely identification of infants with PICS is needed to inform whether these infants would benefit from earlier and novel nutrition intervention.

Use of Indirect Calorimetry to Detect Overfeeding in Critically Ill Children: Finding the Appropriate Definition

OBJECTIVES

Overfeeding during critical illness is associated with adverse effects such as metabolic disturbances and increased risk of infection. Because of the lack of sound studies with clinical endpoints, overfeeding is arbitrarily defined as the ratio caloric intake/measured resting energy expenditure (mREE) or alternatively as a comparison of measured respiratory quotient (RQ) to the predicted RQ based on the macronutrient intake (RQmacr). We aimed to compare definitions of overfeeding in critically ill mechanically ventilated children based on mREE, RQ, and caloric intake to find an appropriate definition.

METHODS

Indirect calorimetry measurements were performed in 78 mechanically ventilated children, median age 6.3 months. Enteral and/or parenteral nutrition was provided according to the local guidelines. Definitions used to indicate overfeeding were the ratio caloric intake/mREE of >110% and >120% and by the measured RQ > RQmacr + 0.05.

RESULTS

The proportion of patients identified as overfed varied widely depending on the definition used, ranging from 22% (RQ > RQmacr + 0.05), to 40% and 50% (caloric intake/mREE of >120% and >110%, respectively). Linear regression analysis showed that all patients would be identified as overfed with the definition RQ > RQmacr + 0.05 when the ratio caloric intake/mREE exceeded 165%. Caloric intake was higher in children with a standard deviation-score weight for age <-2.

CONCLUSIONS

The proportion of mechanically ventilated patients identified as overfed ranged widely depending on the definition applied. These currently used definitions fail to take into account several relevant factors affecting metabolism during critical illness and are therefore not generally applicable to the pediatric intensive care unit population.

Results of a Feeding Protocol in Patients Undergoing the Hybrid Procedure

Neonates with single-ventricle physiology are at increased risk of developing gastrointestinal morbidities. Feeding protocols in this patient population have been shown to decrease feeding complications after the Norwood procedure, but no data exist to determine the effectiveness of a feeding protocol in patients undergoing the hybrid procedure. Goal of this study was to examine the impact of a standardized feeding protocol on the incidence of overall postoperative gastrointestinal morbidity after the hybrid procedure. Retrospective chart review was performed on neonates undergoing the hybrid procedure. Neonates were divided into two groups, pre-feeding protocol (pre-FP), which encompassed the years 2002-2008, and post-feeding protocol (post-FP), which encompassed the years 2011-2014. Preoperative, operative, and postoperative data were collected. T test or Fisher's exact test was used for analysis. p < 0.05 was considered significant. Seventy-three neonates were in the pre-FP and 52 neonates were in the post-FP. There were no significant differences between the pre-FP and the post-FP in cardiac diagnosis (62 HLHS, 11 other vs. 39 HLHS, 13 other, respectively). Pre-FP underwent hybrid procedure later than the post-FP (9.1 ± 5.8 vs. 5.7 ± 3.4 days, respectively, p < 0.01) and achieved full enteral feeds earlier than the post-FP (3.2 + 2.9 vs. 7.8 + 3.9 days, respectively, p < 0.01). The incidence of necrotizing enterocolitis was higher in the pre-FP versus post-FP [11.0 % (8/65) vs. 5.8 % (3/49), respectively, p = 0.36]. Though not significant, the incidence of necrotizing enterocolitis decreased by almost 50 % after initiating a feeding protocol in patients undergoing the hybrid procedure. This is consistent with previous studies showing beneficial results of a feeding protocol in this complex patient population.

Nutritional support for critically ill children

BACKGROUND

Nutritional support in the critically ill child has not been well investigated and is a controversial topic within paediatric intensive care. There are no clear guidelines as to the best form or timing of nutrition in critically ill infants and children. This is an update of a review that was originally published in 2009. .

OBJECTIVES

The objective of this review was to assess the impact of enteral and parenteral nutrition given in the first week of illness on clinically important outcomes in critically ill children. There were two primary hypotheses:1. the mortality rate of critically ill children fed enterally or parenterally is different to that of children who are given no nutrition;2. the mortality rate of critically ill children fed enterally is different to that of children fed parenterally.We planned to conduct subgroup analyses, pending available data, to examine whether the treatment effect was altered by:a. age (infants less than one year versus children greater than or equal to one year old);b. type of patient (medical, where purpose of admission to intensive care unit (ICU) is for medical illness (without surgical intervention immediately prior to admission), versus surgical, where purpose of admission to ICU is for postoperative care or care after trauma).We also proposed the following secondary hypotheses (a priori), pending other clinical trials becoming available, to examine nutrition more distinctly:3. the mortality rate is different in children who are given enteral nutrition alone versus enteral and parenteral combined;4. the mortality rate is different in children who are given both enteral feeds and parenteral nutrition versus no nutrition.

SEARCH METHODS

In this updated review we searched: the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2); Ovid MEDLINE (1966 to February 2016); Ovid EMBASE (1988 to February 2016); OVID Evidence-Based Medicine Reviews; ISI Web of Science - Science Citation Index Expanded (1965 to February 2016); WebSPIRS Biological Abstracts (1969 to February 2016); and WebSPIRS CAB Abstracts (1972 to February 2016). We also searched trial registries, reviewed reference lists of all potentially relevant studies, handsearched relevant conference proceedings, and contacted experts in the area and manufacturers of enteral and parenteral nutrition products. We did not limit the search by language or publication status.

SELECTION CRITERIA

We included studies if they were randomized controlled trials; involved paediatric patients, aged one day to 18 years of age, who were cared for in a paediatric intensive care unit setting (PICU) and had received nutrition within the first seven days of admission; and reported data for at least one of the pre-specified outcomes (30-day or PICU mortality; length of stay in PICU or hospital; number of ventilator days; and morbid complications, such as nosocomial infections). We excluded studies if they only reported nutritional outcomes, quality of life assessments, or economic implications. Furthermore, we did not address other areas of paediatric nutrition, such as immunonutrition and different routes of delivering enteral nutrition, in this review.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the searches, applied the inclusion criteria, and performed 'Risk of bias' assessments. We resolved discrepancies through discussion and consensus. One author extracted data and a second checked data for accuracy and completeness. We graded the evidence based on the following domains: study limitations, consistency of effect, imprecision, indirectness, and publication bias.

MAIN RESULTS

We identified only one trial as relevant. Seventy-seven children in intensive care with burns involving more than 25% of the total body surface area were randomized to either enteral nutrition within 24 hours or after at least 48 hours. No statistically significant differences were observed for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels. We assessed the trial as having unclear risk of bias. We consider the quality of the evidence to be very low due to there being only one small trial. In the most recent search update we identified a protocol for a relevant randomized controlled trial examining the impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients; no results have been published.

AUTHORS' CONCLUSIONS

There was only one randomized trial relevant to the review question. Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.

Nutritional status as a predictor of duration of mechanical ventilation in critically ill children

OBJECTIVES

Critically ill children admitted to the pediatric intensive care unit (PICU) often are malnourished. The aim of this study was to determine the role of nutritional status on admission as a predictor of the duration of mechanical ventilation in critically ill children.

METHODS

This was a single-center, prospective cohort study, including consecutive children (ages 1 mo to 15 y) admitted to a PICU. Demographic characteristics, clinical characteristics, and nutritional status were recorded and patients were followed up until hospital discharge. Nutritional status was evaluated by anthropometric parameters and malnutrition was considered if the Z-scores for the parameters were ≤-2. Adjusted Cox's regression analysis was used to determine the association between nutritional status and duration of mechanical ventilation.

RESULTS

In all, 72 patients were included. The prevalence of malnutrition was 41.2%, according to height-for-age Z-score, 18.6% according to weight-for-height Z-score, and 22.1% according body mass index-for-age Z-score. Anthropometrical parameters that predicted the duration of mechanical ventilation were weight-for-age (hazard ratio [HR], 2.73; 95% confidence interval [CI], 1.44-5.18); height-for-age (HR, 2.49; 95% CI, 1.44-4.28); and upper arm muscle area-for-age (HR, 5.22; 95% CI, 1.19-22.76).

CONCLUSION

Malnutrition, based on a variety of anthropometric variables, was associated with the duration of mechanical ventilation in this cohort of critically ill children. Assessment of nutritional status by anthropometry should be performed on admission to the PICU to allow targeted nutritional rehabilitation for the subset of children with existing malnutrition.

Worldwide Survey of Nutritional Practices in PICUs

OBJECTIVE

To assess current nutritional practices in critically ill children worldwide.

DESIGN

A two-part online, international survey. The first part, "the survey", was composed of 59 questions regarding nutritional strategies and protocols (July-November 2013). The second part surveyed the "point prevalence" of nutritional data of patients present in a subgroup of the responding PICUs (May-September 2014).

SETTING

Members of the World Federation of Pediatric Intensive and Critical Care Societies were asked to complete the survey.

SUBJECTS

Pediatric critical care providers.

INTERVENTIONS

Survey.

MEASUREMENTS AND MAIN RESULTS

We analyzed 189 responses from 156 PICUs in 52 countries (survey). We received nutritional data on 295 patients from 41 of these 156 responding PICUs in 27 countries (point prevalence). According to the "survey", nutritional protocols and support teams were available in 52% and 57% of the PICUs, respectively. Various equations were in use to estimate energy requirements; only in 14% of PICUs, indirect calorimetry was used. Nutritional targets for macronutrients, corrected for age/weight, varied widely. Enteral nutrition would be started early (within 24 hr of admission) in 60% of PICUs, preferably by the gastric route (88%). In patients intolerant to enteral nutrition, parenteral nutrition would be started within 48 hours in 55% of PICUs. Overall, in 72% of PICUs supplemental parenteral nutrition would be used if enteral nutrition failed to meet at least 50% of energy delivery goal. Several differences between the intended (survey) and the actual (point prevalence) nutritional practices were found in the responding PICUs, predominantly overestimating the ability to adequately feed patients.

CONCLUSION

Nutritional practices vary widely between PICUs worldwide. There are significant differences in macronutrient goals, estimating energy requirements, timing of nutrient delivery, and threshold for supplemental parenteral nutrition. Uniform consensus-based nutrition practices, preferably guided by evidence, are desirable in the PICU.

Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome

Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.

Protein-energy malnutrition: a risk factor for various ailments

The wheel of industrialization that spun throughout the last century resulted in urbanization coupled with modifications in lifestyles and dietary habits. However, the communities living in developing economies are facing many problems related to their diet and health. Amongst, the prevalence of nutritional problems especially protein-energy malnutrition (PEM) and micronutrients deficiencies are the rising issues. Moreover, the immunity or susceptibility to infect-parasitic diseases is also directly linked with the nutritional status of the host. Likewise, disease-related malnutrition that includes an inflammatory component is commonly observed in clinical practice thus affecting the quality of life. The PEM is treatable but early detection is a key for its appropriate management. However, controlling the menace of PEM requires an aggressive partnership between the physician and the dietitian. This review mainly attempts to describe the pathophysiology, prevalence and consequences of PEM and aims to highlight the importance of this clinical syndrome and the recent growth in our understanding of the processes behind its development. Some management strategies/remedies to overcome PEM are also the limelight of the article. In the nutshell, early recognition, prompt management, and robust follow up are critical for best outcomes in preventing and treating PEM.