Why Delay? Early Enteral Nutrition in Pediatric Burn Patients Improves Outcomes

Impact of early enteral nutrition in critically ill children: A systematic review and meta-analysis

BACKGROUND

This study aims to evaluate the impact of early enteral nutrition (EEN) compared with late enteral nutrition on clinical outcomes in critically ill children.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched until December 2024. The primary outcome was all-cause mortality, with secondary outcomes including duration of mechanical ventilation and length of stay in the pediatric intensive care unit (PICU) and hospital. The meta-analysis used a random-effects model with inverse variance weighting.

RESULTS

Twenty-one studies (10,006 children) were included. Definitions of EEN varied across studies, ranging from 24 to 72 h. EEN was associated with decreased mortality in both randomized controlled trials (RCTs) (odds ratio [OR] = 0.64; 95% CI, 0.43-0.96; P = 0.03) and observational studies (OR = 0.38; 95% CI, 0.23-0.62; P < 0.001). A sensitivity analysis was conducted by combining studies with similar EEN definitions. EEN initiated within 24 h of PICU admission was not significantly associated with mortality (OR = 0.72; 95% CI, 0.43-1.20; P = 0.21). However, EEN within 48 h was significantly associated with reduced mortality (OR = 0.37; 95% CI, 0.25-0.56; P < 0.001). The certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) from RCTs was evaluated as low, whereas that from observational studies was evaluated as very low.

CONCLUSION

The evidence from this study suggests that EEN benefits critically ill children by reducing mortality and shortening hospital stays. However, the high risk of bias and very low certainty of the evidence highlight the need for further research.

Metabolic and Hormonal Changes in Pediatric Burn Patients: Mechanisms, Evidence, and Care Strategies

BACKGROUND

Burn injuries constitute a significant global health challenge, especially in pediatric populations, where they are a leading cause of morbidity and mortality. Pediatric burns require particular attention due to their unique pathophysiology, long-term consequences on growth and development, and psychological impacts.

METHODS

We propose a comprehensive review of recent advancements in understanding the key aspects of hormonal and metabolic changes in burned children, aiming to guide therapeutic interventions, improve outcomes, and reduce the global burden of these injuries.

RESULTS

Effective management of the physiological stress response in pediatric burn patients necessitates a multidisciplinary approach integrating medical, nutritional, and rehabilitative strategies. Timely nutritional support and individualized plans preserve muscle mass, promote wound healing, and reduce complications and organ dysfunction risk. Advances in pharmacological interventions, such as beta-blockers, anabolic agents, and hormonal treatment, offer promising pathways to improve recovery and mitigate long-term complications. Early mobilization and physiotherapy are essential for preventing complications of prolonged immobility, including muscle wasting, joint contractures, and functional decline; their effectiveness is closely tied to advancements in minimally invasive procedures, regenerative medicine, and reconstructive techniques, particularly for pediatric patients.

CONCLUSIONS

While current strategies have significantly improved survival and outcomes for pediatric burn patients, ongoing research is critical to refine these new care strategies.

Nutritional interventions in patients with burn injury: an umbrella review of systematic reviews and meta-analyses of randomised clinical trials

Multiple reviews have examined the impact of nutritional interventions in patients with burn injuries; however, discrepancies among results cast doubt about their validity. We implemented this review to assess the impact of various nutritional interventions in adult patients with burn injuries. We conducted a thorough search of PubMed, Scopus and Web of Science databases until 1 August 2024, to identify relevant meta-analyses of intervention trials, examining the impact of nutritional interventions on burn patients. We adopted the random-effect models to determine the pooled effect sizes while employing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to examine evidence certainty. Thirty-three original intervention trials from eleven meta-analyses were entered in our review. Early enteral nutrition could substantially reduce overall mortality (relative risk (RR): 0·36, 95 % CI: 0·19, 0·68, GRADE = moderate certainty), hospital stay (mean difference (MD): -15·3, 95 % CI: -20·4, -10·2, GRADE = moderate certainty) and sepsis risk (RR: 0·23, 95 % CI: 0·11, 0·45, GRADE = moderate certainty). Glutamine showed a notable decrease in the length of hospital stay (MD: -6·23, 95 % CI: -9·53, -2·94, GRADE = low certainty). However, other nutritional interventions, including combined immunonutrition, branched-chain amino acids, fish oil, ornithine α-ketoglutarate and trace elements, did not significantly affect the assessed clinical outcomes. Early enteral nutrition might impose a beneficial effect on mortality, hospital stay length and incidence of sepsis with moderate evidence. Lower length of hospital stay was also seen in burn patients supplemented with glutamine, although the evidence was weak.

Critical Care of the Pediatric Burn Patient

Life-saving pediatric burn care is often initiated in hospitals that are not designated as a pediatric burn center. Therefore, familiarity with critical care of pediatric burn patients is crucial for physicians working in all healthcare settings equipped to care for children. Management of airway, mechanical ventilation, preservation of ideal circulatory status, and establishment of vascular access in pediatric burn patients requires many unique considerations. This article aims to summarize important principles of critical care of children with significant burn injuries for review by physicians and surgeons working in hospitals designated as a pediatric burn center and those that stabilize these patients prior to referral.

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients

INTRODUCTION

Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States.

METHODS

We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap.

RESULTS

We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different.

CONCLUSIONS

Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

Timing of enteral nutrition and parenteral nutrition in the PICU

The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.

Safety and benefits of intraoperative enteral nutrition in critically ill pediatric burn patients: A systematic review and pooled analysis

Burn injuries significantly increase a patient's metabolic demand. Adequate nutrition is essential as an adjunct to recovery and reducing morbidity and mortality. In contrast to adults, this is especially important for pediatric patients who have limited reserves and are in a period of growth. Burn patients often require multiple anesthetic procedures that are accompanied by standard perioperative fasting periods that result in substantial nutritional interruptions. Continuous intraoperative feeding has been proposed as a solution, but there is no current consensus on its role and safety, particularly in the pediatric population. Thus, the goal of this study was to examine the safety and benefits of intraoperative nutrition in critically-ill pediatric burn injured patients. A systematic review of MEDLINE, PubMed, Scopus, and Web of Science was conducted using the following terms: feeding or enteral or nutrition or fasting and adolescent or youth or pediatric or child or teen and burn or thermal injury or fire. The primary outcome was incidence of aspiration. Secondary outcomes included patient nutritional status (caloric deficit and weight), wound healing, days spent in the intensive care unit, ventilator days, pneumonia, number of surgeries, length of hospital stay, and mortality. Pooled analyses of binary outcomes were computed. Four studies consisting of 496 patients, met inclusion criteria. All studies were level IV evidence, but had high methodological quality. The median burn total body surface area (TBSA) was 43.8% (IQR 33.4-58.8%), with a median of 30% of patients having an inhalational injury. Patients underwent a median of 4.2 surgeries (IQR 1.8-7.4). Intraoperative feeding was conducted through nasoduodenal tubes. There were no aspiration events. Pooled analysis demonstrated that there were no differences in rates of aspiration, pneumonia, or wound infection (p>0.05) between patients who were intraoperatively fed and those who were not. Those fed intraoperatively had significantly more surgeries, ventilator days, longer hospital stays, but lower mortality (p<0.05). There was large heterogeneity in nutritional assessment methods. Intraoperatively fed patients had an average gain of 144.4 kcal/kg,1.7 days of exclusive enteral nutrition (vs. loss of -119.1 kcal/kg and -1.4 days), and a cumulative positive caloric balance of +2673kcal ±2147 (vs. loss of -7899kcal ±3123) compared to those with interrupted feeding. Continuous intraoperative duodenal feeding during burn surgery appears to be safe in the pediatric burn population, with no reported episodes of aspiration. Uninterrupted feeding was also associated with weight maintenance and reduced caloric deficit. It may also have a survival benefit, as continuously fed patients needed more surgeries and intensive/hospital care, but had decreased mortality.

Global trends in pediatric burn injuries and care capacity from the World Health Organization Global Burn Registry

BACKGROUND

Burn injuries are a major cause of death and disability globally. The World Health Organization (WHO) launched the Global Burn Registry (GBR) to improve understanding of burn injuries worldwide, identify prevention targets, and benchmark acute care. We aimed to describe the epidemiology, risk factors, and outcomes of children with burns to demonstrate the GBR's utility and inform needs for pediatric burn prevention and treatment.

METHODS

We performed descriptive analyses of children age ≤ 18 years in the WHO GBR. We also described facility-level capacity. Data were extracted in September of 2021.

RESULTS

There were 8,640 pediatric and adult entries from 20 countries. Of these, 3,649 (42%) were children (0-18 years old) from predominantly middle-income countries. The mean age was 5.3 years and 60% were boys. Children aged 1-5 years comprised 62% (n = 2,279) of the cohort and mainly presented with scald burns (80%), followed by flame burns (14%). Children >5 years (n = 1,219) more frequently sustained flame burns (52%) followed by scald burns (29%). More than half of pediatric patients (52%) sustained a major burn (≥15% total body surface area) and 48% received surgery for wound closure during the index hospitalization. Older children had more severe injuries and required more surgery. Despite the frequency of severe injuries, critical care capacity was reported as "limited" for 23% of pediatric patients.

CONCLUSIONS

Children represent a large proportion of people with burn injuries globally and often sustain major injuries that require critical and surgical intervention. However, critical care capacity is limited at contributing centers and should be a priority for healthcare system development to avert preventable death and disability. This analysis demonstrates that the GBR has the potential to highlight key epidemiological characteristics and hospital capacity for pediatric burn patients. To improve global burn care, addressing barriers to GBR participation in low- and low-middle-income countries would allow for greater representation from a diversity of countries, regions, and burn care facilities.