Risk Factors for Delayed Enteral Nutrition in Critically Ill Children

Late Nutrition and Negative Outcomes in a Brazilian Paediatric Intensive Care Unit: A Retrospective Cohort

AIM

To analyse the association between late initiation of enteral nutrition and negative outcomes in the Paediatric Intensive Care Unit (PICU) in Brazil.

METHOD

This was a retrospective cohort study with data from the medical records of children hospitalised between 2012 and 2017. The independent variable was late initiation of enteral nutrition (> 24 h after admission). The outcomes analysed included longer length of stay in the PICU and hospital, incidence of healthcare-related infections (HAIs), and death. Poisson regression models with robust variance were adjusted for potentially confounding variables by presenting relative risks (RR) and 95% confidence intervals (95% CI).

RESULTS

We analysed 840 hospitalizations: 311 (37.0%) with delayed initiation of nutrition, 252 (30.0%) with a diagnosis of HAIs, and 93 deaths (11.1%). After all adjustments, late initiation of enteral nutrition was associated with longer lengths of stay in the PICU (RR: 1.41; 95% CI: 1.01-1.30), hospital stay (RR: 1.22; 95% CI: 1.06-1.41), and higher HAI incidence (RR: 1.40; 95% CI: 1.14-1.73). The association with mortality was no longer significant after adjusting for the admission severity indicators.

CONCLUSION

The results indicate that late initiation of nutrition can lead to longer PICU and hospital stays and a higher incidence of HAIs.

Obstacles to meeting nutritional recommendations in a tertiary pediatric intensive care unit

OBJECTIVES

Optimal nutrition is associated with positive outcomes in critically ill children. In 2017, the Society of Critical Care Medicine (SCCM) and the American Society of Parenteral and Enteral Nutrition (ASPEN) updated guidelines for nutritional support for this population. However, implementation of these guidelines may be delayed due to clinical barriers. We aimed to assess our practice against the recommendations of the ASPEN guidelines, hypothesizing that caregiver bias and clinical factors may hinder their implementation in our pediatric intensive care unit (PICU).

METHODS

We focused on two ASPEN recommendations: (1) feeding within 48 h (48H) of admission and (2) meeting two thirds of estimated caloric requirements after seven calendar days. All children aged 1 month to 16 years admitted to our PICU from July 2017 to January 2020 were eligible. Using a retrospective chart review, nutritional and clinical data were collected at the time of admission, at 48H, and 7 calendar days after admission.

RESULTS

A total of 533 patients were included. After 48H of admission to the PICU, 402 out of 533 (75.4%) patients received feeding. The following factors were associated with not reaching nutritional goals at 48H: invasive ventilation support, inotropic and vasoactive support, and extracorporeal life support. After 7 days, 95 out of 118 (80.5%) received two thirds of caloric needs. At 7 days, the main obstacle to meeting caloric goals was invasive ventilation.

CONCLUSION

In a representative tertiary PICU, barriers to meeting ASPEN nutritional recommendations included hemodynamic instability or invasive ventilator support, especially within the first 48H of admission.

Enteral feeding in pediatric patients with bronchiolitis requiring non-invasive support via nasal interface

BACKGROUND AND OBJECTIVES

The benefits of enteral feeding in critically ill children have been well described, but the use of non-invasive respiratory support has been shown to delay initiation of feeds, in part due to safety concerns. We aimed to examine the association of enteral feeding by mouth and orogastric tube on clinically significant adverse events in children with bronchiolitis being treated with non-invasive respiratory support via nasal interfaces.

METHODS

A retrospective cohort study of patients 0-24 months of age between 2016 and 2022 in a quaternary care hospital pediatric intensive care unit with a diagnosis of bronchiolitis and treatment with non-invasive respiratory support via nasal interface. Standard comparative statistics and multivariable regression were used to determine the association between oral and nasogastric feeding and clinically significant outcomes such as new diagnosis of pneumonia and escalation in respiratory support, as well lengths of stay.

RESULTS

There were 407 patients 24 months or younger who were admitted with bronchiolitis and treated with non-invasive respiratory support. There was a 4.65 increased odds of developing a new pneumonia for patients who were fed nasogastrically versus orally. There were no differences in the development of pneumonia based on type of respiratory support, whether an escalation in respiratory support was needed, or based on the highest level of support received. Both pediatric intensive care unit and overall hospital lengths of stay were decreased in those who were orally fed.

CONCLUSIONS

Enteral feeding in children with bronchiolitis receiving non-invasive respiratory support appears to be safe and not associated with escalation in support or new diagnoses of pneumonia. Oral feeds were associated with decreased lengths of stay. Further work is needed to assess long term safety and ability to achieve adequate nutritional requirements.

IMPACT

Enteral feeding of children with bronchiolitis requiring non-invasive respiratory support via nasal interfaces did not have an effect on clinically significant adverse events Feeding by mouth led to decreased risk of pneumonia and shorter inpatient length of stay Future work is needed to study the ability to achieve nutrition goals when feeding by mouth on non-invasive support.

Changes in Global Nutrition Practices in Critically Ill Children and the Influence of Emerging Evidence: A Secondary Analysis of the Pediatric International Nutrition Studies, 2009-2018

BACKGROUND

The timeline of the 3 Pediatric International Nutrition Studies (PINS) coincided with the publication of 2 major guidelines for the timing of parenteral nutrition (PN) and recommended energy and protein delivery dose.

OBJECTIVE

The study's main objective was to describe changes in the nutrition delivery practice recorded in PINS1 and PINS2 (PINS1-2) (conducted in 2009 and 2011, preexposure epoch) vs PINS3 (conducted in 2018, postexposure epoch), in relation to the published practice guidelines.

DESIGN

This study is a secondary analysis of data from a multicenter prospective cohort study.

PARTICIPANTS/SETTING

Data from 3650 participants, aged 1 month to 18 years, admitted to 100 unique hospitals that participated in 3 PINS was used for this study.

MAIN OUTCOME MEASURES

The time in days from pediatric intensive care unit admission to the initiation of PN and enteral nutrition delivery were the primary outcomes. Prescribed energy and protein goals were the secondary outcomes.

STATISTICAL ANALYSES PERFORMED

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

RESULTS

The proportion of patients receiving enteral nutrition (88.3% vs 80.6%; P < .001) was higher, and those receiving PN (20.6% vs 28.8%; P < .001) was lower in the PINS3 cohort compared with PINS1-2. In the PINS3 cohort, the odds of initiating PN during the first 10 days of pediatric intensive care unit admission were lower, compared with the PINS1-2 cohort (hazard ratio 0.8, 95% CI 0.67 to 0.95; P = .013); and prescribed energy goal was lower compared with the PINS1-2 cohort (incident rate ratio 0.918, 95% CI 0.874 to 0.965; P = .001).

CONCLUSIONS

The likelihood of initiation of PN delivery significantly decreased during the first 10 days after admission in the PINS3 cohort compared with PINS1-2. Energy goal prescription in children receiving mechanical ventilation significantly decreased in the postguidelines epoch compared with the preguidelines epoch.

Measurements of enteral feeding intolerance in critically ill children: a scoping review

Objective

To examine the measurements on enteral feeding intolerance (EFI) in critically ill children.

Methods

The Joanna Briggs Institute methods for conducting a scoping review were followed. Articles published since 2004 which assessed EFI in critically ill children were identified. A full search strategy was executed in seven English databases (MEDLINE, EMBASE, PubMed, Web of Science, Cochrane Central Register of Controlled Trials, JBI EBP, CINAHL) and four Chinese databases (CNKI, VIP, Wanfang, Sinomed). Two reviewers screened records according to our inclusion and exclusion criteria, and conducted a full-text review of selected articles. The reference lists of all studied selected were screened for additional sources. Relevant data was extracted using a researcher-developed tool.

Results

Of the 627 articles identified, 32 were included in this scoping review. Most articles focused on the measurement of high gastric residual volume (n = 22), followed by diarrhea (n = 20), and vomiting (n = 9). Most of the studies were of observational-analytic design (13/32) and experimental design (8/32).

Conclusion

This scoping review addressed the complexity and diversity of EFI measurements. Given the importance of adequacy of enteral nutrient intake, we highlighted the necessary to develop individual measurements of EFI, taking the age of children and disease condition into consideration. Further studies can also investigate accurate and objective physiological measurements of EFI to advance EN and improve outcomes in critically ill children.

Factors Influencing Feeding Decisions in Children With Bronchiolitis on High-Flow Nasal Cannula

BACKGROUND AND OBJECTIVES

High-flow nasal cannula (HFNC) is used in up to 50% of children admitted with bronchiolitis. Consensus recommendations for feeding these children have not been established, and there is variability in practice. We sought to identify factors influencing feeding decisions for general care patients admitted with bronchiolitis on HFNC from a national sample of interdisciplinary care team members.

METHODS

In this qualitative study, we conducted semi-structured virtual interviews with care team members involved in making feeding decisions at 10 US hospitals from June 2022 to March 2023. Eligible participants included 1 nurse, respiratory therapist, speech language pathologist, and physician from each site. Interviews were audio-recorded, transcribed, and conducted until reaching sufficiency. Three researchers analyzed transcript data using content analysis guided by the Systems Engineering Initiative for Patient Safety 2.0 model.

RESULTS

We interviewed 29 participants, including 19 nurses, respiratory therapists, and speech language pathologists and 10 physicians. Participants identified 11 factors influencing feeding decisions related to hospital work systems and processes outlined in the Systems Engineering Initiative for Patient Safety model, including people (child and parent characteristics, care team experience), tools and technology (guideline, protocol, ordersets), organization (institutional culture, education), environment (time of day, care location), task (interventions to optimize feeding), and process (clinical assessment, feeding trial, communication).

CONCLUSIONS

Our findings suggest that feeding decisions are driven by factors related to the child, care team experience, institutional tools, and culture. These key factors may inform local improvement efforts to decrease variation in feeding children with bronchiolitis requiring HFNC.

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.

Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey

INTRODUCTION

Malnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies.

MATERIAL AND METHOD

In this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined.

RESULTS

Of the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024).

CONCLUSION

Timely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score.

A Retrospective Study of Complications of Enteral Feeding in Critically Ill Children on Noninvasive Ventilation

The utilization of noninvasive ventilation (NIV) in pediatric intensive care units (PICUs), to support children with respiratory failure and avoid endotracheal intubation, has increased. Current guidelines recommend initiating enteral nutrition (EN) within the first 24-48 h post admission. This practice remains variable among PICUs due to perceptions of a lack of safety data and the potential increase in respiratory and gastric complications. The objective of this retrospective study was to evaluate the association between EN and development of extraintestinal complications in children 0-18 years of age on NIV for acute respiratory failure. Of 332 patients supported with NIV, 249 (75%) were enterally fed within the first 48 h of admission. Respiratory complications occurred in 132 (40%) of the total cohort and predominantly in non-enterally fed patients (60/83, 72% vs. 72/249, 29%; p < 0.01), and they occurred earlier during ICU admission (0 vs. 2 days; p < 0.01). The majority of complications were changes in the fraction of inspired oxygen (220/290, 76%). In the multivariate evaluation, children on bilevel positive airway pressure (BiPAP) (23/132, 17% vs. 96/200, 48%; odds ratio [OR] = 5.3; p < 0.01), receiving a higher fraction of inspired oxygen (FiO₂) (0.42 vs. 0.35; OR = 6; p = 0.03), and with lower oxygen saturation (SpO₂) (91% vs. 97%; OR = 0.8; p < 0.01) were more likely to develop a complication. Time to discharge from the intensive care unit (ICU) was longer for patients with complications (11 vs. 3 days; OR = 1.12; p < 0.01). The large majority of patients requiring NIV can be enterally fed without an increase in respiratory complications after an initial period of ICU stabilization.

Gastric feeding intolerance in critically ill patients during sustained pharmacologic neuromuscular blockade

BACKGROUND

The purpose of this study was to assess gastric feeding intolerance for critically ill patients who received sustained neuromuscular blocker (NMB) pharmacotherapy.

METHODS

Adult patients (>17 years of age) admitted to the trauma intensive care unit who received continuous intravenous NMB pharmacotherapy (rocuronium, cisatracurium, vecuronium, or pancuronium) for ≥48 h during continuous intragastric enteral nutrition (EN) were retrospectively evaluated. Gastric feeding intolerance was defined by initiation of a prokinetic agent (metoclopramide, erythromycin, or both) for an elevated gastric residual volume (GRV) >300 ml and with distention of the abdomen by physical examination, observation of regurgitation or emesis, temporary discontinuation of EN with low intermittent gastric suctioning, or initiation of parenteral nutrition (PN). Patients were evaluated for gastric feeding intolerance for the first 3 days of combined EN and NMB pharmacotherapy. A P value < 0.05 was considered statistically significant.

RESULTS

Ten patients of the 47 patients (21%) were intolerant to EN during NMB pharmacotherapy. No statistically or clinically relevant differences in patient characteristics were found between patients who tolerated EN vs those who experienced gastric feeding intolerance, except for a higher median maximum GRV of 125 ml (28, 200) vs 300 (250, 400) ml, respectively (P < 0.001). Five patients responded to prokinetic therapy and five required PN.

CONCLUSION

Most patients tolerated intragastric EN during sustained NMB pharmacotherapy. Presence of NMB pharmacotherapy is not an absolute contraindication for EN.

Early vs late enteral nutrition in pediatric intensive care unit: Barriers, benefits, and complications

BACKGROUND

This study aimed to define the existing barriers for early enteral nutrition (EEN) in critically ill children and to analyze the differences in nutrient supply, complications, and outcomes between EEN and late EN (LEN).

METHODS

This is a secondary analysis of a multicenter observational, prospective study including critically ill children receiving EN. Variables analyzed included demographic and anthropometric features, caloric and nutrient supply, outcomes, and complications according to the EN onset. Patients were classified into two groups according to the start of EN: 24-EEN vs EN started after 24 h (24-LEN) and 48-EEN vs EN started after 48 h (48-LEN).

RESULTS

Sixty-eight children were enrolled; 22.1% received 24-EEN, and 67.6% received 48-EEN. EN was most frequently delayed in patients older than 12 months, in patients with cardiac disease, and in those requiring mechanical ventilation (MV). Children in the 24-EEN group had shorter duration of MV compared with those in the 24-LEN group (P = 0.04). The 48-EEN group received a higher caloric intake (P = 0.04), reached the caloric target earlier (P < 0.01), and had lower incidence of constipation (P = 0.01) than the 48-LEN group. There was a positive correlation between the time required to reach the maximum caloric intake and the length of pediatric intensive care stay (r = 0.46; P < 0.01).

CONCLUSION

EEN may improve nutrient delivery, reduce time on MV, and prevent constipation in critically ill children. No relevant differences between 24-EEN and 48-EEN were found. Cardiac disease, MV, and age older than 12 months were risk factors associated with LEN.

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children

Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.

Oral Feeding on High-Flow Nasal Cannula in Children Hospitalized With Bronchiolitis

OBJECTIVE

Oral feeding by children with bronchiolitis on high-flow nasal cannula (HFNC) is questioned, resulting in high practice variability. Our objective was to determine the incidence of aspiration pneumonia and adverse feeding events in otherwise healthy children with bronchiolitis on HFNC who fed orally from admission.

METHODS

We conducted a single-center, retrospective chart review, in a tertiary children's hospital, of 876 children who were <24 months old, admitted for bronchiolitis, and treated with HFNC in the pediatric ward from March 2017 to May 2020. Primary outcomes included the incidence of aspiration pneumonia and adverse feeding events. Secondary outcomes included escalation of care, frequency and duration of nil per os status, length of stay, and 7-day readmission.

RESULTS

Most patients (77.2%) met inclusion criteria and were fed orally within 2 hours of admission. The average maximum HFNC flow rate was 8 L/min (1 L/kg/min); the average maximum respiratory rate was 62 ± 10. Adverse feeding events occurred in 11 patients (1.6%), of which 3 had a concern for possible microaspiration. None were diagnosed with or treated for aspiration pneumonia. Few patients (8.1%) were made nil per os while on HFNC but returned to oral feeding by discharge.

CONCLUSION

Among those with bronchiolitis on HFNC who received oral nutrition on admission, there were few incidences of adverse feeding events and no diagnoses of aspiration pneumonia, suggesting that oral feeding while on HFNC can be well-tolerated in similar populations. However, this study was limited by its single-center retrospective design, and future prospective studies are needed.

Impact of Nutrition Support Team in Achieving Target Calories in Children Admitted in Pediatric Intensive Care Unit

OBJECTIVE

To determine the impact of nutrition support team (NST) on achieving an early target caloric goal in mechanically ventilated children admitted in pediatric intensive care unit (PICU).

METHODS

An early enteral nutrition protocol (EENP) was implemented by NST to ensure early and adequate nutrition provision to PICU patients. All children (1 month- 18 years) that were admitted in PICU for >2days and received mechanical ventilation, with no contraindications to enteral feed, were included and data was compared with those of pre-intervention. The adequacy of energy intake was defined as 70% achievement of target energy intake on the third day of admission. Chi-square/t-test was used to determine the difference between different variables pre and post intervention.

RESULTS

Total 180 patients (99 and 81 in pre- and post-intervention group, respectively) were included. Overall, 115 (63.9%) received adequate calories (70%) on third day of admission. Of which 69 (85.2%) were from post intervention (P  < 0.001; odds ratio [OR] 6.6, 95% confidence interval [CI] 3.195-13.73). Moreover, NST intervention also promoted adequate protein intake in 62 (76.5%) children compared to 37 (37.4%) in pre-intervention group (P < 0.001, OR 5.468, 95% CI 2.838- 10.534). The median (interquartile range) length of PiCU stay in pre-NST group was 6 (4-9) days and in NST supported group was 4 (3-4) days (OR 0.580, CI 0.473-0.712, P < 0.001). Age, severity of illness, multiorgan dysfunction syndrome, sepsis, need of organ support had no effect in achievement of caloric target in both the groups (P > 0.05).

CONCLUSION

Introduction of EENP with NST helped in the achievement of better and quicker target caloric intake.

The nutritional impact of a feeding protocol for infants on high flow nasal cannula therapy

BACKGROUND

Clinicians may be reluctant to feed patients on high-flow nasal cannula (HFNC) therapy, despite studies suggesting it is beneficial and safe. We describe the implementation of a feeding protocol for patients with bronchiolitis on HFNC and determine its effect on nutrition goals.

METHODS

Prospective bedside data on enteral volume, feed interruptions, and aspiration events were collected on patients with bronchiolitis who were <24 months of age, treated with HFNC, and fed per a developed protocol. Exclusion criteria included history of prematurity <32 weeks, congenital heart disease, or positive-pressure ventilation before feeding. Length of intensive care unit and hospital stay was compared with both a concurrent cohort (CC) of patients not fed per the protocol and a retrospective cohort (RC) admitted prior to protocol creation.

RESULTS

Seventy-eight patients met the criteria for the prospective study arm: 24 patients were included in the CC, and 74 were included in the RC. Seventy-one percent of prospective patients received enteral nutrition (EN) on HFNC day 1 vs 42% of the CC. In the prospective cohort, feed interruption occurred in 23% of patients and was associated with higher flow rates; however, no aspiration events occurred. Patients fed per protocol were fed 8-10 h sooner and discharged 1 day earlier than those in the RC.

CONCLUSION

The use of a feeding protocol for patients with bronchiolitis on HFNC was safe and associated with shorter time to initiate EN and shorter length of hospital stay.

Planned Peri-Extubation Fasting in Critically Ill Children: An International Survey of Practice

INTRODUCTION

Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them.

MATERIALS AND METHODS

A cross sectional electronic survey was disseminated via the European Pediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation.

RESULTS

We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice: 46 (38%) and 26 (21%) of PICUs withheld oral and gastric/jejunal nutrition more than 5 h, respectively, and 45 (37%) started oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children [78 (64%)] or reducing fasting times [57 (47%)] respectively.

DISCUSSION

This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it.

Enteral Feeding for Children on Bilevel Positive Pressure Ventilation for Status Asthmaticus

A retrospective data analysis was conducted to evaluate enteral nutrition practices for children admitted with status asthmaticus in a single-center pediatric intensive care unit. Of 406 charts, 315 were analyzed (63% male); 135 on bilevel positive airway pressure ventilation (BIPAP) and 180 on simple mask. Overall median age and weight were 6.0 (interquartile range [IQR]: 6.0) years and 24.8 (IQR: 20.8) kg, respectively. All children studied were on full feeds while still on BIPAP and simple mask; 99.3 and 100% were fed per oral, respectively. Median time to initiation of feeds and full feeds was longer in the BIPAP group, 11.0 (IQR: 20) and 23.0 hours (IQR: 26), versus simple mask group, 4.3 (IQR: 7) and 12.0 hours (IQR: 15), p  = 0.001. The results remained similar after adjusting for gender, weight, clinical asthma score at admission, use of adjunct therapy, and duration of continuous albuterol. By 24 hours, 81.5% of patients on BIPAP and 96.6% on simple mask were started on feeds. Compared with simple mask, patients on BIPAP were sicker with median asthma score at admission of 4 (IQR: 2) versus 3 (IQR: 2) on simple mask, requiring more adjunct therapy (80.0 vs. 43.9%), and a longer median length of therapy of 41.0 (IQR: 41) versus 20.0 hours (IQR: 29), respectively, p  = 0.001. There were no complications such as aspiration pneumonia, and none required invasive mechanical ventilation in either group. Enteral nutrition was effectively and safely initiated and continued for children admitted with status asthmaticus, including those on noninvasive bilevel ventilation therapy.

A Retrospective Analysis of Feeding Practices and Complications in Patients with Critical Bronchiolitis on Non-Invasive Respiratory Support

Limited data exist regarding feeding pediatric patients managed on non-invasive respiratory support (NRS) modes that augment oxygenation and ventilation in the setting of acute respiratory failure. We conducted a retrospective cohort study to explore the safety of feeding patients managed on NRS with acute respiratory failure secondary to bronchiolitis. Children up to two years old with critical bronchiolitis managed on continuous positive airway pressure, bilevel positive airway pressure, or RAM cannula were included. Of the 178 eligible patients, 64 were reportedly nil per os (NPO), while 114 received enteral nutrition (EN). Overall equivalent in severity of illness, younger patients populated the EN group, while the NPO group experienced a higher incidence of intubation. Duration of stay in the pediatric intensive care unit and non-invasive respiratory support were shorter in the NPO group, though intubation eliminated the former difference. Within the EN group, ninety percent had feeds initiated within 48 h and 94% reached full feeds within 7 days of NRS initiation, with an 8% complication and <1% aspiration rate. Reported complications did not result in escalation of respiratory support. Notably, a significant improvement in heart rate and respiratory rate was noted after feeds initiation. Taken together, our study supports the practice of early enteral nutrition in patients with critical bronchiolitis requiring NRS.

Factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit

BACKGROUND & AIMS

Inadequate nutrition delivery in critically ill children has shown associated with poor clinical outcomes. Therefore, identifying barriers to deliver adequate nutrition is vital. The aim of this study was to identify factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit (PICU).

METHODS

This single-centre prospective study, involved children aged from birth to 3 years old, admitted to PICU longer than 72 hours. They received either enteral nutrition (EN) or combination of EN and partial parenteral nutrition (PPN). Clinical and nutrition delivery characteristics were recorded from admission until transferred out of PICU. Multiple regression analysis at significant level p < 0.05 were used to identify independent risk factors for lower protein and energy intake.

RESULTS

One hundred and thirty-nine patients were included in this study with median age 6.5 (1.8-20.6) months and median PICU length of stay of 6 (4-7) days. The median energy and protein adequacy were 83.2% and 46.7%, respectively. In multivariable analysis, children who underwent surgery (AOR 0.97; 95% CI 0.27-0.75; p = 0.041), with fluid restriction (AOR 0.97; 95% CI 0.25-0.73; p = 0.041), longer length of PICU stay (AOR 0.35; 95% CI 0.18-0.64; p = 0.001) and longer feeding interruptions (AOR 3.57; 95% CI 1.39-9.15; p = 0.008) were more likely to have lower energy intake. Children at risk of malnutrition (weight-for-age Z score of < -2 SD) (AOR 2.54; 95% CI 1.12 to 5.77; p = 0.026) and longer duration of mechanical ventilation (AOR 0.73; 95% CI 0.53 to 0.98; p = 0.041) were more likely to have lower protein intake.

CONCLUSION

This study highlighted the factors influencing adequate protein and energy delivery in critically ill children with heart disease in PICU. Strategies to improve the nutrition delivery in this group of patients should be outlined and implemented by the dietitians along with multidisciplinary team.

SCRATCH Trial: An Initiative to Reduce Excess Use of High-Flow Nasal Cannula

OBJECTIVES

We aimed to reduce unnecessary use of high-flow nasal cannula (HFNC) at lower flow rates through the implementation of a standard daily trial off HFNC at a medium-sized academic center.

METHODS

We used an interprofessional quality improvement collaboration to develop and implement interventions to reduce HFNC waste in children aged 1 month to 24 months with bronchiolitis who were admitted to the inpatient ward or ICU. Key interventions included development and implementation of the Simple Cannula/Room Air Trial for Children (SCRATCH Trial), a standard trial off HFNC for eligible infants. Process measures were selected as metrics of use of the newly developed trial. The primary outcome measure was hours of treatment with ≤8 L per minute (LPM) of HFNC. Additional outcome measures included total hours of treatment with HFNC and length of stay.

RESULTS

A total of 271 patients were included in this study, 131 in the preimplementation group and 140 in the postimplementation group. The mean hours of treatment below our a priori determined waste line (≤8 LPM of HFNC) decreased from 36.3 to 16.8 hours after SCRATCH Trial implementation, and mean length of stay decreased from 4.1 to 3.0 days.

CONCLUSIONS

The SCRATCH Trial was successfully implemented across hospital units, with a significant reduction in hours on ≤8 LPM of flow. Rapid discontinuation of HFNC appears feasible and may be associated with a shorter length of stay.

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.

Enteral Nutrition Improves Vital Signs in Children With Bronchiolitis on Noninvasive Ventilation

OBJECTIVES

In children hospitalized for bronchiolitis, enteral nutrition (EN) practices during noninvasive ventilation (NIV) vary widely. We sought to assess the potential impact of EN by observing changes in physiometric indices (heart rate [HR] and respiratory rate [RR]) before and after EN initiation.

METHODS

We performed a retrospective cohort study in children <2 years of age hospitalized for bronchiolitis receiving NIV from 2017 to 2019 in a quaternary ICU. The primary outcome was patient HR and RR before and after EN initiation. Descriptive data included demographics, anthropometrics, comorbidities, NIV parameters, EN characteristics, and general hospital outcomes. Analyses included paired comparative and descriptive statistics.

RESULTS

Of the 124 children studied, 85 (69%) were permitted EN at a median of 12 (interquartile range [IQR]: 7 to 29) hours. The route was oral (76.5%), nasogastric (15.3%), or postpyloric (8.2%) and was predominantly started during high-flow nasal cannula (71%) at flow rates of 1 (IQR: 0.7 to 1.4) L/kg per minute. After EN initiation, reductions in the median RR (percentage change: -11 [IQR: -23 to 3]; P < .01) and HR (percentage change: -5 [IQR: -12 to 1]; P < .01) were noted. Those permitted EN were younger (5 [IQR: 2 to 11] vs 11 [IQR: 3 to 17] months; P < .01) and more likely to have bronchopulmonary dysplasia (19% vs 5%; P = .04). Malnutrition rates, comorbidities, admission timing, flow rates, length of stay, and NIV duration did not differ for those provided or not provided EN. No aspiration events were observed.

CONCLUSIONS

Reductions between pre- and postprandial RR after EN initiation among children hospitalized for bronchiolitis on NIV were observed without clinically significant aspiration. These findings support existing data that suggest that EN is safe during NIV and may lessen distress in some patients.

Management of Enteral Nutrition in the Pediatric Intensive Care Unit: Prokinetic Effects of Amoxicillin/Clavulanate in Real Life Conditions

PURPOSE

Malnutrition is a common feature in critically ill children. Enteral nutrition (EN) is the main strategy to nutritionally support critical ill children, but its use can be hindered by the development of intolerance. The study aimed to assess the effectiveness and safety of amoxicillin/clavulanate (A/C) to treat EN intolerance.

METHODS

We retrospectively evaluated patients admitted to the pediatric intensive care unit from October 2018 to October 2019. We conducted a case-control study: in the first 6 months (October 2018-April 2019) we implemented the nutritional protocol of our Institution with no drug, whereas in the second half (May 2019-October 2019) we employed A/C for 1 week at a dose of 10 mg/kg twice daily.

RESULTS

Twelve cases were compared with 12 controls. At the final evaluation, enteral intake was significantly higher than that at baseline in the cases (from 2.1±3.7 to 66.1±27.4% of requirement, p=0.0001 by Wilcoxon matched-pairs signed rank test) but not in the controls (from 0.2±0.8 to 6.0±14.1% of the requirement, p=NS). Final gastric residual volume at the end of the observation was significantly lower in the cases than in the controls (p=0.0398). The drug was well tolerated as shown by the similar safety outcomes in both cases and controls.

CONCLUSION

Malnutrition exposes critically ill children to several complications that affect the severity of disease course, length of stay, and mortality; all may be prevented by early EN. The development of intolerance to EN could be addressed with the use of A/C. Future prospective clinical trials are needed to confirm these conclusions.

Barriers to Delivery of Enteral Nutrition in Pediatric Intensive Care: A World Survey

OBJECTIVES

To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians, and physicians) in delivering enteral nutrition to critically ill children across the world.

DESIGN

Cross-sectional international online survey adapted for use in pediatric settings.

SETTING

PICUs across the world.

SUBJECTS

PICU nurses, physicians, and dietitians.

INTERVENTIONS

The 20-item adult intensive care "Barriers to delivery of enteral nutrition" survey was modified for pediatric settings, tested, and translated into 10 languages. The survey was distributed online to pediatric intensive care nurses, physicians, and dieticians via professional networks in March 2019 to June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of enteral nutrition in their PICUs with a 7-point Likert scale from 0 "not at all a barrier" to 6 "an extreme amount."

MEASUREMENT AND MAIN RESULTS

Nine-hundred twenty pediatric intensive care professionals responded from 57 countries; 477 of 920 nurses (52%), 407 of 920 physicians (44%), and 36 of 920 dieticians (4%). Sixty-two percent had more than 5 years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were as follows: 1) enteral feeds being withheld in advance of procedures or operating department visits, 2) none or not enough dietitian coverage on weekends or evenings, and 3) not enough time dedicated to education and training on how to optimally feed patients.

CONCLUSIONS

This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses, and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focused nutrition education for all PICU professional groups.

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.

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.

Feeding during High-Flow Nasal Cannula for Bronchiolitis: Associations with Time to Discharge

BACKGROUND

High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events.

METHODS

This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission.

RESULTS

Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups.

LIMITATIONS

Assessment of feeding exposure did not account for quantity and duration.

DISCUSSION

Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enteral Nutrition Initiation in Children Admitted to Pediatric Intensive Care Units After Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of death and long-term disability among injured children. Early feeding has been shown to improve outcomes in adults, with some similar evidence in children with severe TBI. We aimed to examine the current practice of initiation of enteral nutrition in children with TBI and to evaluate the risk factors associated with delayed initiation of enteral nutrition.

METHODS

This retrospective, multicenter study used the Pediatric Trauma Assessment and Management Database including all children with head trauma discharged from five pediatric intensive care units (PICU) at pediatric trauma centers between January 1, 2013 and December 31, 2013. We compared demographics, injury and procedure data, time to initiation of nutrition, and injury and illness severity scores between patients who received enteral nutrition early (≤ 48 h) and late (> 48 h). Fisher's exact and Mann-Whitney U tests compared discrete and continuous variables. Univariate and multivariable analyses evaluated variables associated with delayed initiation of feeding. Outcomes of interest included mortality, complications, ventilator days, hospital and ICU length of stay, and functional status at ICU discharge.

RESULTS

In the 416 patients in the study, the overall mortality was 2.6%. The majority of patients (83%; range 69-88% between five sites, p = 0.0008) received enteral nutrition within 48 h of PICU admission. Lower Glasgow Coma Scale scores and higher Injury Severity Score (ISS) were independently associated with delayed initiation of enteral nutrition. Delayed enteral nutrition was independently associated with worse functional status at PICU discharge (p = 0.02) but was not associated with mortality or increased length of stay.

CONCLUSIONS

Children with severe TBI and higher ISS were more likely to have delayed initiation of enteral nutrition. Delayed enteral nutrition was an independent risk factor for worse functional status at ICU discharge for the entire cohort, but not for the severe TBI group.

Quality Improvement Bedside Rounding Audits Enhance Protein Provision for Pediatric Patients Receiving Continuous Renal Replacement Therapy

OBJECTIVES

Describe quality improvement process improvements in protein delivery of continuous renal replacement therapy initiation.

DESIGN

Prospective study.

SETTING

PICU and cardiovascular ICU within a quaternary care children's hospital.

PATIENTS

PICU and cardiovascular ICU patients receiving continuous renal replacement therapy for greater than 48 hours. Inborn errors of metabolism were excluded.

INTERVENTIONS

Plan-Do-Study-Act cycles were initiated. Cycle 1 developed interdisciplinary quality improvement group continuously monitoring nutrition care with thrice weekly bedside safety rounds and protein prescriptions within nephrologist's notes. Cycle 2 included education to intensivists. Cycle 3 initiated monthly quality improvement meetings reviewing nutritional care goals.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was percentage of time patients met protein goals in the first 5 days of continuous renal replacement therapy. Secondary outcome was percentage of time patients met protein goals for duration of continuous renal replacement therapy. Cohort (n = 55) mean age was 8.1 years (SD ± 6.8), 62% male, and 31% malnutrition at baseline. Percent of time meeting protein goals by day 5 was 22%, 33%, and 71% and percent of time meeting protein goals throughout was 35%, 39%, and 75% of groups 1, 2, and 3, respectively. Significant improvement occurred after Plan-Do-Study-Act 3 (group 2 vs group 3; p < 0.01) for primary and secondary outcomes.

CONCLUSIONS

Implementation of an interprofessional quality improvement team significantly decreased number of continuous renal replacement therapy days with unmet protein goals and improved protein delivery.

Weight improvement with the use of protein and energy enriched nutritional formula in infants with a prolonged PICU stay

BACKGROUND

Reaching an optimal nutritional intake is challenging in critically ill infants. One possible way to minimise nutritional deficits is the use of protein and energy-enriched (PE)-formulas. We aimed to describe weight achievement and gastrointestinal symptoms in infants admitted to the paediatric intensive care unit (PICU) while receiving PE-formula for a prolonged period.

METHODS

Records from infants admitted to a multidisciplinary PICU and using PE-formula were analysed retrospectively. Infants were eligible if they received PE-formula daily for at least 2 weeks. Weight achievement was determined as the difference between weight-for-age (WFA) Z-scores at the start and end of PE-formula use. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters.

RESULTS

Seventy infants with a median [interquartile range (IQR)] age of 76 (30-182) days were eligible. The PICU duration was 50 (35-83) days during which they received PE-formula for 30 (21-54) days. Predominant admission diagnoses were post-cardiac surgery, respiratory and cardiac diagnosis. A significant mean (SD) WFA Z-score increase of 0.48 (1.10) (P < 0.001) and a median (IQR) weight gain of 5.80 (3.28-9.04) g kg^-1 day^-1 was observed. Multivariate regression showed that a lower WFA Z-score at start was associated with a higher WFA Z-score increase during PE-formula use (β -0.35 (95% confidence interval =  -0.50 to -0.19); P < 0.001). The maximum 24-h gastric residual volume was 8.1 mL (IQR = 2.2-14.3) for each 1 kg in bodyweight. Three (4%) infants were treated for diarrhoea and three infants were treated for vomiting.

CONCLUSIONS

The majority of infants with a prolonged PICU stay showed weight improvement when using PE-formula. PE-formula was well tolerated because gastrointestinal symptoms only occurred in few infants.

Prealbumin and Retinol Binding Proteins Are Not Usable for Nutrition Follow-Up in Pediatric Intensive Care Units

PURPOSE

Feeding children is a problem in pediatric intensive care units (PICU) and it is difficult to know the correct amount. The purpose of this study is to evaluate if prealbumin or retinol binding proteins (RBP) are effective relative to daily enteral nutrition, without being affected by severity of diseases or infections and can be used to follow up nutritional amount.

METHODS

This is a prospective observational study that includes 81 patients admitted to PICU in Akdeniz University with estimated duration >72 hours, age between 1 month and 8 years. Daily calorie and protein intake were calculated and prealbumin, RBP and C-reactive protein (CRP) levels were measured on the first, third, fifth and seventh mornings.

RESULTS

We find moderate correlation between daily calorie intake and prealbumin levels (r=0.432, p<0.001), RBP levels and daily protein intake (r=0.330, p<0.001). When we investigated the relationship between changes of prealbumin, RBP, CRP, calorie and protein intake during intensive care stay, we found that increase of Prealbumin and RBP levels are explained by decrease of CRP levels (r=-0.546 and -0.645, p<0.001) and not with increase of nourishment.

CONCLUSION

Even adjusted for PRISM3, age and CRP, prealbumin and RBP are correlated with last 24 hours' diet. However, it is not convenient to use as a follow up biomarker because increase of their levels is related with decrease of CRP levels.

Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children

BACKGROUND

This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain.

METHODS

A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study.

RESULTS

The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN.

CONCLUSION

Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.

Accuracy of Administrative Codes for Distinguishing Positive Pressure Ventilation From High-Flow Nasal Cannula

OBJECTIVES

Noninvasive positive pressure ventilation (NIPPV) is increasingly used in critically ill pediatric patients, despite limited data on safety and efficacy. Administrative data may be a good resource for observational studies. Therefore, we sought to assess the performance of the International Classification of Diseases, Ninth Revision procedure code for NIPPV.

METHODS

Patients admitted to the PICU requiring NIPPV or heated high-flow nasal cannula (HHFNC) over the 11-month study period were identified from the Virtual PICU System database. The gold standard was manual review of the electronic health record to verify the use of NIPPV or HHFNC among the cohort. The presence or absence of a NIPPV procedure code was determined by using administrative data. Test characteristics with 95% confidence intervals (CIs) were generated, comparing administrative data with the gold standard.

RESULTS

Among the cohort (n = 562), the majority were younger than 5 years, and the most common primary diagnosis was bronchiolitis. Most (82%) required NIPPV, whereas 18% required only HHFNC. The NIPPV code had a sensitivity of 91.1% (95% CI: 88.2%-93.6%) and a specificity of 57.6% (95% CI: 47.2%-67.5%), with a positive likelihood ratio of 2.15 (95% CI: 1.70-2.71) and negative likelihood ratio of 0.15 (95% CI: 0.11-0.22).

CONCLUSIONS

Among our critically ill pediatric cohort, NIPPV procedure codes had high sensitivity but only moderate specificity. On the basis of our study results, there is a risk of misclassification, specifically failure to identify children who require NIPPV, when using administrative data to study the use of NIPPV in this population.

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.

Enteral Nutrition Practices in Critically Ill Children Requiring Noninvasive Positive Pressure Ventilation

OBJECTIVES

Evaluate the practice of providing enteral nutrition in critically ill children requiring noninvasive positive pressure ventilation.

DESIGN

Retrospective cohort study.

SETTING

PICU within a quaternary care children's hospital.

PATIENTS

PICU patients older than 30 days requiring noninvasive positive pressure ventilation for greater than or equal to 24 hours from August 2014 to June 2015. Invasive mechanical ventilation prior to noninvasive positive pressure ventilation and inability to receive enteral nutrition at baseline were additional exclusionary criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was enteral nutrition initiation within 24 hours of admission. Secondary outcomes included time to goal enteral nutrition rate, adequacy of nutrition, adverse events (pneumonia not present at admission, intubation after enteral nutrition initiation, feeding tube misplacement), and lengths of noninvasive positive pressure ventilation and PICU stay. Among those included (n = 562), the median age was 2 years (interquartile range, 39 d to 6.8 yr), 54% had at least one chronic condition, and 43% had malnutrition at baseline. The most common primary diagnosis was bronchiolitis/viral pneumonia. The median length of time on noninvasive positive pressure ventilation was 2 days (interquartile range, 2.0-4.0). Most (83%) required continuous positive airway pressure or bi-level support during their PICU course. Sixty-four percent started enteral nutrition within 24 hours, with 72% achieving goal enteral nutrition rate within 72 hours. Forty-nine percent and 44% received an adequate cumulative calorie and protein intake, respectively, during their PICU admission. Oral feeding was the most common delivery method. On multivariable analysis, use of bi-level noninvasive positive pressure ventilation (odds ratio, 0.40; 95% CI, 0.25-0.63) and continuous dexmedetomidine (odds ratio, 0.59; 95% CI, 0.35-0.97) were independently associated with decreased likelihood of early enteral nutrition. Twelve percent of patients had at least one adverse event.

CONCLUSIONS

A majority of patients requiring noninvasive positive pressure ventilation received enteral nutrition within 24 hours. However, less than half achieved caloric and protein goals during their PICU admission. Further investigation is warranted to determine the safety and effectiveness of early enteral nutrition in this population.

Oral Nutrition in Children With Bronchiolitis on High-Flow Nasal Cannula Is Well Tolerated

OBJECTIVES

To determine the incidence of aspiration-related respiratory failure and nutrition interruptions in children with bronchiolitis on high-flow nasal cannula (HFNC) receiving enteral nutrition.

METHODS

We performed a single-center, prospective, observational cohort study within a 313-bed tertiary medical center from January through December 2015. We included term children 1 month to 2 years of age without comorbid bacterial pneumonia or chronic medical conditions who were diagnosed with bronchiolitis while receiving HFNC and enteral nutrition. Primary outcomes were incidence of aspiration-related respiratory failure and nutrition interruptions. Secondary outcomes were duration of HFNC therapy, length of stay, and nutrition characteristics.

RESULTS

Of the 344 children admitted with bronchiolitis, 132 met the inclusion criteria. Ninety-seven percent received enteral nutrition by mouth and 3% by nasogastric tube. HFNC flow rates at the time of nutrition initiation ranged between 4 and 13 L per minute (0.3-1.9 L/kg per minute) and respiratory rates from 18 to 69 breaths per minute. One (0.8%) subject had aspiration-related respiratory failure and 12 (9.1%) experienced nutrition interruptions. Children with interruptions in nutrition had a longer length of stay by 2.5 days (P < .01) and received an additional day of HFNC therapy (P < .01). By discharge, 55 (42%) children achieved all nutritional goals: caloric, volume, and protein. Children admitted overnight had an increased incidence of delay to nutrition initiation (30% vs 11%; P < .01).

CONCLUSIONS

We observed a low incidence of aspiration-related respiratory failure in term children with bronchiolitis on HFNC receiving enteral nutrition. Oral nutrition was tolerated across a range of HFNC flow and respiratory rates, suggesting the practice of withholding nutrition in this population is unsupported.

Modified B-ultrasound method for measurement of antral section only to assess gastric function and guide enteral nutrition in critically ill patients

AIM

To establish a modified B-ultrasound method of measuring the antral section only to assess gastric motility in healthy people, and evaluate its application in guiding enteral nutrition (EN) in critically ill patients.

METHODS

First, 30 healthy volunteers were selected. The modified B-ultrasound method and the traditional B-ultrasound method were applied to assess gastric function. The correlation of indices of gastric function between the two groups was analyzed statistically. In addition, 64 critically ill patients were selected, and the modified B-ultrasound method and the gastric juice withdrawal method were applied to guide the implementation of EN. Daily caloric value, the time required to achieve complete EN, ICU stay, hospitalization time, and serum prealbumin and albumin levels were recorded and compared between the two groups. Kaplan-Meier survival curve was used to compare the complications of EN between the two groups.

RESULTS

In healthy subjects, there was a good correlation among gastric emptying time, antral contraction frequency and antral motility index between the two groups (r = 0.57, 0.61 and 0.54, respectively). The study on critically ill patients also revealed that a better effect of EN was achieved in the modified B-ultrasound method group, in which patients had shorter ICU stay and hospitalization time and higher levels of serum prealbumin and albumin. The Kaplan-Meier survival analysis revealed that the improved B-ultrasound method was associated with significantly fewer EN complications (P = 0.031).

CONCLUSION

The modified B-ultrasound method can provide a good real-time assessment of gastric function and has a better effect than the traditional method in guiding EN in critically ill patients.

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.

Gastric Emptying in Critically Ill Children

BACKGROUND

Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. We examined the correlation between (a) bedside EN intolerance assessments, including gastric residual volume (GRV); (b) delayed GE; and (c) delayed EN advancement.

MATERIALS AND METHODS

We prospectively enrolled patients ≥1 year of age, eligible for gastric EN and without contraindications to acetaminophen. Gastric emptying was determined by the acetaminophen absorption test, specifically the area under the curve at 60 minutes (AUC₆₀). Slow EN advancement was defined as delivery of <50% of the prescribed EN 48 hours after study initiation. EN intolerance assessments (GRV, abdominal distension, emesis, loose stools, abdominal discomfort) were recorded.

RESULTS

We enrolled 20 patients, median 11 years (4.4-15.5), 50% male. Sixteen (80%) patients had delayed GE (AUC₆₀ <600 mcg·min/mL) and 7 (35%) had slow EN advancement. Median GRV (mL/kg) for patients with delayed vs normal GE was 0.43 (0.113-2.188) vs 0.89 (0.06-1.91), P = .9635. Patients with slow vs rapid EN advancement had median GRV (mL/kg) of 1.02 mL/kg (0.20-3.20) vs 0.27 mL/kg (0.06-1.62), P = .3114, and frequency of altered EN intolerance assessments of 3/7 (42.9%) vs 5/13 (38.5%), P = 1. Median AUC₆₀ for patients with slow vs rapid EN advancement was 91.74 mcg·min/mL (53.52-143.1) vs 449.5 mcg·min/mL (173.2-786.5), P = .0012.

CONCLUSIONS

A majority of our study cohort had delayed GE. Bedside EN intolerance assessments, particularly GRV, did not predict delayed GE or rate of EN advancement. Delayed gastric emptying predicted slow EN advancement. Novel tests for delayed GE and EN intolerance are needed.