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

Inpatient Nutritional Considerations in Inflammatory Bowel Disease

PURPOSE OF REVIEW

This review aims to explain the causes, diagnosis, and treatment of malnutrition in hospitalized patients with inflammatory bowel disease (IBD), focusing on both adults and children.

RECENT FINDINGS

Malnutrition is common among IBD patients, affecting up to 85% of individuals, and is linked to higher rates of illness, death, and longer hospital stays. Recent studies highlight the importance of early detection using tools like the Subjective Global Assessment (SGA) and handgrip strength tests. Nutritional interventions-such as exclusive enteral nutrition (EEN) and parenteral nutrition (PN)-have proven effective in inducing remission and improving patient outcomes, especially in pediatric Crohn's disease. New evidence suggests that optimizing nutrition before and after surgery, as well as using immunonutrition, may reduce postoperative complications. Early identification and management of malnutrition in hospitalized IBD patients may be important for improving clinical outcomes. Using appropriate nutritional screening tools and creating personalized nutrition plans can help with recovery, decrease hospital stays, and improve quality of life. Further research is needed to develop standard protocols for nutritional assessment and treatment in this patient population.

Early Versus Late Enteral Nutrition in the Pediatric Critically-Ill Trauma Patient: A Retrospective Cohort Study

OBJECTIVES

To determine the effect of early (within 48 h of admission) enteral nutrition on length of stay (LOS) and number of ventilator days in the pediatric intensive care unit (PICU) and identify associated barriers to initiation of enteral nutrition.

METHODS

A retrospective cohort study at a level 1 pediatric trauma center with a tertiary care PICU including all patients <18 years of age admitted with traumatic injuries, classified into an early enteral nutrition group vs. late enteral nutrition (>48 h from admission). Primary outcomes of PICU and Hospital LOS and days on mechanical ventilation were compared between groups using multivariable negative binomial regression analysis to correct for confounding factors.

RESULTS

A total of 238 subjects were included in our study and then classified as either the early enteral nutrition (EEN) group (n = 116) or the late enteral nutrition (LEN) group (n = 122). Compared to the LEN group, the EEN group had a shorter PICU LOS (adjusted incidence rate ratio (aIRR) 1.26, 95 % CI 1.02-1.56, p = 0.030) and hospital LOS (aIRR 1.36, 95 % CI 1.10-1.69, p = 0.005), with no difference in number of days on mechanical ventilation.

CONCLUSIONS

Initiation of EEN after admission to the PICU is associated with decreased PICU and hospital LOS with no effect on mechanical ventilation days after controlling for severity of illness, opioid total daily dose, use of vasoactive medications, number of regions injured and number of surgical procedures performed.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE: 3

Impact of enteral nutrition initiated within 24 h of ECMO on nutritional status and inflammatory response in children

Objective

Malnutrition remains a significant issue in children undergoing ECMO. This study aimed to investigate the effects of initiating enteral nutrition (EN) within 24 h on the adequacy of nutrient intake, nutritional status, anabolic metabolism, and inflammatory markers in children receiving ECMO.

Methods

This was a prospective observational cohort study, including children receiving ECMO therapy at the Children's Hospital of Chongqing Medical University of China from April 2018 to August 2024. Patients were divided into early EN (EEN) and late EN (LEN) groups based on whether effective EN was initiated within 24 h after the start of ECMO. T-tests or Mann-Whitney U and Chi-square tests were used to compare the clinical characteristics, serum total protein (TP), nutritional intake, serum cholinesterase (CHE), and C-reactive protein (CRP) levels between the two groups. Linear mixed-effects models (LME) were applied to assess the effect of EEN on changes in CRP and CHE levels over time during ECMO.

Results

A total of 47 children were included in this study, with 24 patients (51.1%) successfully receiving EEN. The PRISM3 score was higher in the LEN group (P = 0.016). The majority of children in the EEN group had pneumonia or ARDS (P < 0.001). The average daily energy and protein intake, as well as their adequacy, was higher in the EEN group compared to the LEN group (P < 0.001), although the EEN group experienced more frequent interruptions in EN (P < 0.05). Serum TP levels in the EEN group were higher than those in the LEN group during the first 3 days of ECMO (P < 0.05). The median CHE levels were higher, and the median CRP levels were lower in the EEN group compared to the LEN group (P < 0.05). LME analysis showed a significant interaction effect between EEN and time on CRP and CHE levels (P < 0.001).

Conclusion

Successfully initiating EN within 24 h significantly improves the nutritional status of children receiving ECMO, promotes hepatic anabolic metabolism, and reduces inflammatory responses. This study provided new insights and data support for nutritional therapy strategies in children on ECMO.

The Japanese Critical Care Nutrition Guideline 2024

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

[Risk factors and development of a prediction model of enteral feeding intolerance in critically ill children]

OBJECTIVES

To explore the risk factors of feeding intolerance (FI) in critically ill children receiving enteral nutrition (EN) and to construct a prediction nomogram model for FI.

METHODS

A retrospective study was conducted to collect data from critically ill children admitted to the Pediatric Intensive Care Unit of Xiangya Hospital, Central South University, between January 2015 and October 2020. The children were randomly divided into a training set (346 cases) and a validation set (147 cases). The training set was further divided into a tolerance group (216 cases) and an intolerance group (130 cases). Multivariate logistic regression analysis was used to screen for risk factors for FI in critically ill children receiving EN. A nomogram was constructed using R language, which was then validated on the validation set. The model's discrimination, calibration, and clinical net benefit were evaluated using receiver operating characteristic curves, calibration curves, and decision curves.

RESULTS

Duration of bed rest, shock, gastrointestinal decompression, use of non-steroidal anti-inflammatory drugs, and combined parenteral nutrition were identified as independent risk factors for FI in critically ill children receiving EN (P<0.05). Based on these factors, a nomogram prediction model for FI in critically ill children receiving EN was developed. The area under the receiver operating characteristic curve for the training set and validation set was 0.934 (95%CI: 0.906-0.963) and 0.852 (95%CI: 0.787-0.917), respectively, indicating good discrimination of the model. The Hosmer-Lemeshow goodness-of-fit test showed that the model had a good fit (χ 2=12.559, P=0.128). Calibration curve and decision curve analyses suggested that the model has high predictive efficacy and clinical application value.

CONCLUSIONS

Duration of bed rest, shock, gastrointestinal decompression, use of non-steroidal anti-inflammatory drugs, and combined parenteral nutrition are independent risk factors for FI in critically ill children receiving EN. The nomogram model developed based on these factors exhibits high predictive efficacy and clinical application value.

On how to feed critically ill children in intensive care: A slowly shifting paradigm

Critically ill children requiring treatment in a pediatric intensive care unit (PICU) suffer from anorexia and/or feeding intolerance. The resulting macronutrient deficit associates with poor outcome. Until recently, this association formed the basis for initiating enteral or parenteral feeding early to improve outcome. The multicenter "Early-versus-Late-Parenteral-Nutrition-in-the-Pediatric-Intensive-Care-Unit" randomized controlled trial (PEPaNIC-RCT) addressed whether this association is causal. It showed that early supplementation of insufficient/contraindicated enteral nutrition with parenteral nutrition, as compared with accepting a macronutrient deficit throughout the first week in the PICU, did not improve outcome. On the contrary, it caused more infections and prolonged organ support and PICU stay, and adversely affected neurodevelopmental outcomes 2 and 4 years later. Harm was present in all subgroups and appeared explained by the macronutrient dose, more specifically the amino-acid dose, not lipid or glucose doses. These findings corroborated results from large-scale adult RCTs. Mechanisms of harm from early enhanced nutrition comprised suppressed cellular repair pathways like autophagy and ketogenesis, suppressed illness-induced alterations in thyroid hormone metabolism, more iatrogenic hyperglycemia, increased urea cycle activity through anabolic resistance, and induction of epigenetic modifications that mediate longer-term developmental impairments. These results came unexpected to many pediatric intensivists. Hence, the paradigm has only slowly begun to shift toward more restrictive macronutrient administration in the acute phase of critical illness. Benefits of early fasting responses have become clear, provided micronutrients are given to prevent deficiencies and refeeding syndrome. These insights open perspectives for studies investigating novel nutritional strategies to activate fasting-induced cellular repair while avoiding prolonged starvation.

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.

The Implementation of a Feeding Protocol in Patients With Noninvasive Ventilation Improves Enteral Nutrition: The NIVEN Study

PURPOSE

There is limited evidence to guide the treatment of enteral nutrition (EN) for children with bronchiolitis who receive biphasic positive airway pressure (BiPAP) support.

METHODS

This quality improvement project included patients with bronchiolitis who were supported by BiPAP ventilation. An algorithm to increase EN treatment in those patients was created by stakeholders. Two periods of time were compared: group 1 (January 2023 to August 2023) without nutrition implementation protocol vs group 2 (September 2023 to February 2024) after the protocol was implemented. EN was provided via nasogastric tubes. The project aim was to decrease the mean time to initiation of EN by 50% after the start of BiPAP. Secondary end points were time to reach target calories (100 kcal/kg/d), BiPAP total duration, and the proportion of patients with adverse effects.

RESULTS

For the 102 included patients (48 before and 54 after BiPAP ventilation), the median time to the start of EN decreased from 18 (8-26) hours to 6 (2-8) hours (P < 0.05) Median time to reach calorie goal decreased from 103 (85-120) hours to 48 hours (36-60) (P < 0.05). There were no differences in noninvasive ventilation mean duration. No episodes of aspiration or other adverse effects were documented.

CONCLUSIONS

The implementation of a standardized pathway for EN in patients with BiPAP was associated with faster initiation of EN and a shorter time to reaching caloric goals without any observed adverse events. Although our sample was small, the findings suggest that more aggressive enteral feeding should be considered in patients receiving noninvasive ventilation.

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.

Utility of mid-upper arm circumference in pediatric malnutrition: An Australasian Society of Parenteral and Enteral Nutrition consensus statement using the Delphi method

BACKGROUND

Mid-upper arm circumference (MUAC) is a simple anthropometric tool used to screen for childhood undernutrition in humanitarian settings or low-income and middle-income countries. However, there is conflicting evidence and a lack of consensus with regard to its diagnostic use in clinical settings or population groups beyond this context. In 2023, a project officer was appointed by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) to lead the development of a consensus review into the use of MUAC in the pediatric clinical setting.

METHODS

An AuSPEN appointed multidisciplinary group of informed clinicians used the Delphi method to critically appraise the evidence and develop a series of consensus statements. Delphi surveys were anonymous and distributed electronically. Members were asked to rate their level of agreement with each consensus statement using a 5-point Likert scale. A priori definition of consensus was established as ≥80% responses "agree" or "strongly agree."

RESULTS

Three Delphi rounds were required to reach consensus. A total of 18 consensus statements, including rationale, were developed across the topics 'assessment and diagnosis', 'screening and monitoring' and 'clinical settings'.

CONCLUSION

An evidence-based, region-specific consensus approach to the use of MUAC in pediatric malnutrition is a valuable tool for clinicians. MUAC is a straightforward, non-invasive and cost-effective tool, and may provide an advantage over traditional anthropometric tools in some clinical settings. There are limitations to the utility of MUAC and this consensus paper provides an empirical summary of advantages and limitations as they apply to the screening, assessment, diagnosis, and monitoring of pediatric malnutrition.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Development and internal validation of an artificial intelligence-assisted bowel sounds auscultation system to predict early enteral nutrition-associated diarrhoea in acute pancreatitis: a prospective observational study

Aims/Background An artificial intelligence-assisted prediction model for enteral nutrition-associated diarrhoea (ENAD) in acute pancreatitis (AP) was developed utilising data obtained from bowel sounds auscultation. This model underwent validation through a single-centre, prospective observational study. The primary objective of the model was to enhance clinical decision-making by providing a more precise assessment of ENAD risk. Methods The study enrolled patients with AP who underwent early enteral nutrition (EN). Real-time collection and analysis of bowel sounds were conducted using an artificial intelligence bowel sounds auscultation system. Univariate analysis, multicollinearity analysis, and logistic regression analysis were employed to identify risk factors associated with ENAD. The random forest algorithm was utilised to establish the prediction model, and partial dependence plots were generated to analyse the impact of risk factors on ENAD risk. Validation of the model was performed using the optimal model Bootstrap resampling method. Predictive performance was assessed using accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and an area under the receiver operating characteristic (ROC) curve. Results Among the 133 patients included in the study, the incidence of ENAD was 44.4%. Six risk factors were identified, and the model's accuracy was validated through Bootstrap iterations. The prediction accuracy of the model was 81.10%, with a sensitivity of 84.30% and a specificity of 77.80%. The positive predictive value was 82.60%, and the negative predictive value was 80.10%. The area under the ROC curve was 0.904 (95% confidence interval: 0.817-0.997). Conclusion The artificial intelligence bowel sounds auscultation system enhances the assessment of gastrointestinal function in AP patients undergoing EN and facilitates the construction of an ENAD predictive model. The model demonstrates good predictive efficacy, offering an objective basis for precise intervention timing in ENAD management.

[Clinical characteristics of children on prolonged mechanical ventilation due to different primary diseases]

OBJECTIVES

To investigate the differences in clinical characteristics among children on prolonged mechanical ventilation (PMV) due to different primary diseases.

METHODS

A retrospective analysis was performed on the clinical data of 59 pediatric patients requiring PMV from July 2017 to September 2022. According to the primary disease, they were divided into respiratory disease (RD) group, central nervous system (CNS) group, neuromuscular disease (NMD) group, and other disease group. The four groups were compared in terms of general information, treatment, and outcome.

RESULTS

There were significant differences among the four groups in age, body weight, Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score, Pediatric Risk of Mortality III (PRISM Ⅲ) score, analgesic and sedative treatment, nutrition supply, rehabilitation treatment, tracheotomy, successful ventilator weaning, and outcomes (P<0.05). Compared with the RD group, the CNS group and the other disease group had a significantly higher age and a significantly higher proportion of children receiving rehabilitation treatment, and the CNS group had a significantly higher proportion of children receiving tracheotomy (P<0.008). Compared with the other disease group, the CNS group and the NMD group had significantly lower PELOD-2 and PRISM III scores, and the CNS group had a significantly higher proportion of children with successful ventilator weaning and a significantly higher proportion of children who were improved and discharged (P<0.008).

CONCLUSIONS

There are differences in clinical characteristics among children receiving PMV due to different etiologies. Most children in the RD group have a younger age, and children in the CNS group have a relatively good prognosis.

Nutritional Intake in Children with Septic Shock: A Retrospective Single-Center Study

Nutritional practice in children with severe sepsis or septic shock remains poorly described. We aimed to describe nutrition received by children with severe sepsis or septic shock and explore the association of nutritional intake with clinical outcomes. This study was a retrospective study of children who required pediatric intensive care unit (PICU) admission from 2009 to 2016. Outcomes were mortality, ventilator-free days (VFDs), and PICU-free days (IFDs). A total of 74 patients with septic shock or severe sepsis were identified. Forty-one (55.4%) patients received enteral nutrition (EN) only, 6 (8.1%) patients received parental nutrition (PN) only, 15 (20.3%) patients received both EN and PN, and 12 (16.2%) patients received intravenous fluids alone. Eight of 74 (10.8%) and 4 of 74 (5.4%) had adequate energy and protein intake, respectively. Patients who received early EN had lower odds of 28-day mortality (adjusted hazard ratio [HR] = 0.09, 95% confidence interval [CI]: 0.02, 0.45, p  = 0.03) more 28-day VFDs (adjusted β-coefficient = 18.21 [95% CI: 11.11, 25.32], p  < 0.001), and IFDs (adjusted ß-coefficient = 16.71 [95% CI: 9.86, 23.56], p  < 0.001) than patients who did not receive EN. Late EN was also associated with lower odds of mortality, more VFDs, and IFDs compared with no EN (HR = 0.06, 95% CI: 0.02, 0.23; p  < 0.001; adjusted β coefficient = 15.66, 95% CI: 9.31, 22.02; p  < 0.001; and 12.34 [95% CI: 6.22, 18.46], p  < 0.001; respectively). Inadequate calories and protein were not associated with mortality. EN in children with septic shock or severe sepsis was associated with improved clinical outcomes. Future prospective studies are required to explore the impact of EN timing and optimal nutritional intake in these children.

Intravenous maintenance fluid therapy in acutely and critically ill children: state of the evidence

Intravenous maintenance fluid therapy (IV-MFT) is one of the most prescribed, yet one of the least studied, interventions in paediatric acute and critical care settings. IV-MFT is not typically treated in the same way as drugs with specific indications, contraindications, compositions, and associated adverse effects. In the last decade, societies in both paediatric and adult medicine have issued evidence-based practice guidelines for the use of intravenous fluids in clinical practice. The main objective of this Viewpoint is to summarise and compare the rationales on which these international expert guidelines were based and how these recommendations affect IV-MFT practices in paediatric acute and critical care. Although these guidelines recommend the use of isotonic fluids as a standard in IV-MFT, some discrepancies and uncertainties remain regarding the systematic use of balanced fluids, glucose and electrolyte requirements, and appropriate fluid volume. IV-MFT should be considered in the same way as any other prescription drug and none of the components of IV-MFT prescription should be overlooked (ie, choice of drug, dosing rate, duration of treatment, and de-escalation). Furthermore, most evidence that was used to inform the guidelines comes from high-income countries. Although some principles of IV-MFT are universal, the direct relevance to and feasibility of implementing the guidelines in low-income and middle-income countries is uncertain.

Variation in metabolic demand following severe pediatric traumatic brain injury: A case review

A traumatic brain injury (TBI) is one of the most common pediatric traumas among children in the United States. Appropriate nutrition support, including the initiation of early enteral nutrition, within the first 48 h after injury is crucial for children with a TBI. It is important that clinicians avoid both underfeeding and overfeeding, as both can lead to poor outcomes. However, the variable metabolic response to a TBI can make determining appropriate nutrition support difficult. Because of the dynamic metabolic demand, indirect calorimetry (IC) is recommended, instead of predictive equations, to measure energy requirements. Although IC is suggested and ideal, few hospitals have the technology available. This case review discusses the variable metabolic response, identified using IC, in a child with a severe TBI. The case report highlights the ability of the team to meet measured energy requirements early, even in the setting of fluid overload. It also highlights the presumed positive impact of early and appropriate nutrition provision on the patient's clinical and functional recovery. Further research is needed to investigate the metabolic response to TBIs in children and the impact optimal feedings based on the measured resting energy expenditure have on clinical, functional, and rehabilitation outcomes.

Challenges of Nutrition Support in Pediatric Patients Requiring Extracorporeal Membrane Oxygenation

Nutrition support in critically ill infants and children remains an integral part of providing optimal care for these patients. The pediatric patient requiring extracorporeal membrane oxygenation therapy faces specific challenges to the provision of suitable nutrition support. In this review, we aimed to summarize the existing literature around some of the more challenging aspects of delivering appropriate nutrition to children receiving extracorporeal membrane oxygenation.

Understanding nursing perspective towards barriers to the optimal delivery of enteral nutrition in intensive care settings

BACKGROUND

The management process of Enteral Nutrition (EN) typically involves the interaction between a team of health care practitioners. Nurses being the closest to the patients, have crucial responsibilities and play a major role in feeding delivery along with other medical treatments. This study was conducted to investigate the perception of the nurses working in adult and paediatric intensive care Units (ICUs) regarding the EN barriers and identify the factors that influenced their perception.

METHODS

The data in this cross-sectional study was collected via online survey between 15 October 2021 and January 2022. All nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The tool used for the data collection was adapted from Cahill et al. (2016) and then reviewed and modified by the researchers. The survey collected information about the demographics of the nurses, and it included 24 potential EN barriers where the participants were asked to rate their importance on a scale from 1 to 5. Descriptive statistics were performed to describe the variables, univariant analysis were performed to compare the perceptions of the nurses regarding the EN barriers based on their characteristics followed by stepwise linear regression analysis.

RESULTS

A total of 136 nurses working in adult and paediatric ICUs were included in this study. The results showed that the most important barriers as perceived by the nurses was "Frequent displacement of feeding tube, requiring reinsertion" [3.29 ± 1.28], "Delays in initiating motility agents in patients not tolerating enteral nutrition" [3.27 ± 1.24] and "Enteral formula not available on the unit". [3.27 ± 1.24]. Our results showed that the responses of the participants statistically varied based on their work settings, gender, region, and educational level for some items in the survey (P-value ≤ 0.05). In the regression analysis, gender was the only variable statistically influenced the total Likert rating scores of the participants (r = -0.213, p-value = 0.013).

CONCLUSION

This study identified several barriers that exist in the nursing practice of EN in critical care settings. There are distinct differences in the perception of the nurses to these barriers based on their characteristics. Understanding such differences is important for implementing future strategies for units that needed the most help in prioritizing EN delivery.

Validation of Indirect Calorimetry in Children Undergoing Single-Limb Non-Invasive Ventilation: A Proof of Concept, Cross-Over Study

BACKGROUND

The accurate assessment of resting energy expenditure (REE) is essential for personalized nutrition, particularly in critically ill children. Indirect calorimetry (IC) is the gold standard for measuring REE. This methodology is based on the measurement of oxygen consumption (VO2) and carbon dioxide production (VCO2). These parameters are integrated into the Weir equation to calculate REE. Additionally, IC facilitates the determination of the respiratory quotient (RQ), offering valuable insights into a patient's carbohydrate and lipid consumption. IC validation is limited to spontaneously breathing and mechanically ventilated patients, but it is not validated in patients undergoing non-invasive ventilation (NIV). This study investigates the application of IC during NIV-CPAP (continuous positive airway pressure) and NIV-PS (pressure support).

METHODS

This study was conducted in the Pediatric Intensive Care Unit of IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, between 2019 and 2021. Children < 6 years weaning from NIV were enrolled. IC was performed during spontaneous breathing (SB), NIV-CPAP, and NIV-PS in each patient. A Bland-Altman analysis was employed to compare REE, VO2, VCO2, and RQ measured by IC.

RESULTS

Fourteen patients (median age 7 (4; 18) months, median weight 7.7 (5.5; 9.7) kg) were enrolled. The REE, VO2, VCO2, and RQ did not differ significantly between the groups. The Limits of Agreement (LoA) and bias of REE indicated good agreement between SB and NIV-CPAP (LoA +28.2, -19.4 kcal/kg/day; bias +4.4 kcal/kg/day), and between SB and NIV-PS (LoA -22.2, +23.1 kcal/kg/day; bias 0.4 kcal/kg/day).

CONCLUSIONS

These preliminary findings support the accuracy of IC in children undergoing NIV. Further validation in a larger cohort is warranted.

Nutritional Needs of the Infant with Bronchopulmonary Dysplasia

Growth failure is a common problem in infants with established bronchopulmonary dysplasia (BPD). Suboptimal growth for infants with BPD is associated with unfavorable respiratory and neurodevelopmental outcomes; however, high-quality evidence to support best nutritional practices are limited for this vulnerable patient population. Consequently, there exists a wide variation in the provision of nutritional care and monitoring of growth for infants with BPD. Other neonatal populations at risk for growth failure, such as infants with congenital heart disease, have demonstrated improved growth outcomes with the creation and compliance of clinical protocols to guide nutritional management. Developing clinical protocols to guide nutritional management for infants with BPD may similarly improve long-term outcomes. Given the absence of high-quality trials to guide nutritional practice in infants with BPD, the best available evidence of systematic reviews and clinical recommendations can be applied to optimize growth and decrease variation in the care of these infants.

Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study

OBJECTIVES

To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations.

DESIGN

The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding.

SETTING

Four-one PICUs in 13 LA countries.

PATIENTS

Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively.

CONCLUSIONS

The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.

REstrictive versus StandarD FlUid Management in Mechanically Ventilated ChildrEn Admitted to PICU: study protocol for a pilot randomised controlled trial (REDUCE-1)

INTRODUCTION

Intravenous fluid therapy is the most common intervention in critically ill children. There is an increasing body of evidence questioning the safety of high-volume intravenous fluid administration in these patients. To date, the optimal fluid management strategy remains unclear. We aimed to test the feasibility of a pragmatic randomised controlled trial comparing a restrictive with a standard (liberal) fluid management strategy in critically ill children.

METHODS AND ANALYSIS

Multicentre, binational pilot, randomised, controlled, open-label, pragmatic trial. Patients <18 years admitted to paediatric intensive care unit and mechanically ventilated at the time of screening are eligible. Patients with tumour lysis syndrome, diabetic ketoacidosis or postorgan transplant are excluded.

INTERVENTIONS

1:1 random assignment of 154 individual patients into two groups-restrictive versus standard, liberal, fluid strategy-stratified by primary diagnosis (cardiac/non-cardiac). The intervention consists of a restrictive fluid bundle, including lower maintenance fluid allowance, limiting fluid boluses, reducing volumes of drug delivery and initiating diuretics or peritoneal dialysis earlier. The intervention is applied for 48 hours postrandomisation or until discharge (whichever is earlier).

ENDPOINTS

The number of patients recruited per month and proportion of recruited to eligible patients are feasibility endpoints. New-onset acute kidney injury and the incidence of clinically relevant central venous thrombosis are safety endpoints. Fluid balance at 48 hours after randomisation is the efficacy endpoint. Survival free of paediatric intensive care censored at 28 days is the clinical endpoint.

ETHICS AND DISSEMINATION

Ethics approval was gained from the Children's Health Queensland Human Research Ethics Committee (HREC/21/QCHQ/77514, date: 1 September 2021), and University of Zurich (2021-02447, date: 17 March 2023). The trial is registered with the Australia New Zealand Clinical Trials Registry (ACTRN12621001311842). Open-access publication in high impact peer-reviewed journals will be sought. Modern information dissemination strategies will also be used including social media to disseminate the outcomes of the study.

TRIAL REGISTRATION NUMBER

ACTRN12621001311842.

PROTOCOL VERSION/DATE

V5/23 May 2023.

Nutrition for critically ill children with congenital heart disease

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

Measuring Energy Requirements of Traumatic Brain Injury Patients in Pediatric Intensive Care With Indirect Calorimetry: A Comparison With Empiric Methods

OBJECTIVES

Energy requirements following moderate or severe pediatric traumatic brain injury (TBI) have not been fully elucidated. Indirect calorimetry (IC) is the gold standard for measuring resting energy expenditure (MREE) in PICU. However, technical complexity limits its use. We aimed to determine whether MREE differs from standard of care energy estimation and delivery in a cohort of pediatric patients following moderate to severe TBI during PICU admission.

DESIGN

Retrospective case series study.

SETTING

Single-center, 16-bed general PICU in Canada between May 2011 and January 2019.

PATIENTS

Children (0-18 yr) admitted to a PICU for moderate (Glasgow Coma Scale [GCS] 9-12) to severe TBI (GCS < 9) and had an IC study performed while mechanically ventilated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, 245 patients were admitted with the diagnosis of trauma with TBI. The study includes a convenience sample of 26 patients with severe ( n = 23) and moderate ( n = 3) TBI who underwent a total of 34 IC measurements. MREE varied considerably from 29% to 144% of predicted energy expenditure. Using Bland-Altman comparative analysis, neither Schofield nor World Health Organization predictive equations were in agreement with MREE. Only one measurement revealed that the patient was appropriately fed (energy provided in nutrition support was within 10% of MREE); 10 (38%) measurements revealed overfeeding and 15 (58%) underfeeding at the time of testing.

CONCLUSIONS

The present study adds to the small body of literature highlighting the limitations of predictive equations to evaluate energy requirements following moderate to severe pediatric TBI. IC, when feasible, should be used as the preferred method to orient PICU teams to feed such vulnerable patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Macronutrient and Micronutrient Intake in Children with Lung Disease

This review article aims to summarize the literature findings regarding the role of micronutrients in children with lung disease. The nutritional and respiratory statuses of critically ill children are interrelated, and malnutrition is commonly associated with respiratory failure. The most recent nutrition support guidelines for critically ill children have recommended an adequate macronutrient intake in the first week of admission due to its association with good outcomes. In children with lung disease, it is important not to exceed the proportion of carbohydrates in the diet to avoid increased carbon dioxide production and increased work of breathing, which potentially could delay the weaning of the ventilator. Indirect calorimetry can guide the process of estimating adequate caloric intake and adjusting the proportion of carbohydrates in the diet based on the results of the respiratory quotient. Micronutrients, including vitamins, trace elements, and others, have been shown to play a role in the structure and function of the immune system, antioxidant properties, and the production of antimicrobial proteins supporting the defense mechanisms against infections. Sufficient levels of micronutrients and adequate supplementation have been associated with better outcomes in children with lung diseases, including pneumonia, cystic fibrosis, asthma, bronchiolitis, and acute respiratory failure.

Biomarkers and Functional Assays of Epithelial Barrier Disruption and Gastrointestinal Dysmotility in Critical Illness-A Narrative Review

Enteral nutrition in critically ill children has been associated with improved clinical outcomes. Gastrointestinal dysfunction often impedes the timely initiation and advancement of enteral nutrition and can contribute to immune dysregulation and systemic inflammation. Therefore, assessing gastrointestinal function, at a cellular and functional level, is important to provide optimal enteral nutrition therapy and reduce the gastrointestinal tract's contribution to the inflammatory cascade of critical illness. In this narrative review, we present an overview of biomarker and functional assays for gastrointestinal dysfunction, including epithelial barrier disruption and gastrointestinal dysmotility, that have been considered for critically ill patients.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Catch-Up Growth in Infants and Young Children With Faltering Growth: Expert Opinion to Guide General Clinicians

Faltering growth (FG) is a problem regularly seen by clinicians in infants and young children (<2 years of age). It can occur due to non-disease-related and disease-related causes and is associated with a wide range of adverse outcomes, including shorter-term effects such as impaired immune responses and increased length of hospital stay, and longer-term consequences, including an impact on schooling and cognitive achievements, short stature, and socioeconomic outcomes. It is essential to detect FG, address underlying causes and support catch-up growth where this is indicated. However, anecdotal reports suggest misplaced fear of promoting accelerated (too rapid) growth may deter some clinicians from adequately addressing FG. An invited international group of experts in pediatric nutrition and growth reviewed the available evidence and guidelines on FG resulting from disease-related and non-disease-related effects on nutritional status in healthy term and small for gestational age infants and children up to the age of 2 years in low-, middle-, and high-income countries. Using a modified Delphi process, we developed practical consensus recommendations to provide clarity and practical recommendations for general clinicians on how FG should be defined in different young child populations at risk, how FG should be assessed and managed, and the role of catch-up growth after a period of FG. We also suggested areas where further research is needed to answer remaining questions on this important issue.

The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents

Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

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

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

OBJECTIVES

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

DESIGN SETTING AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Clinical Phenotypes of Malnutrition in Young Children: Differential Nutritional Correction

This review article summarizes current data on malnutrition etiology and pathogenesis in infants. Topical requirements for revealing this condition, its diagnosis and severity assessment via centile metrics are presented. The characteristics of the most common clinical phenotypes of postnatal growth insufficiency in infants (premature infants with different degree of maturation, including patients with bronchopulmonary dysplasia) are described. Differential approaches for malnutrition nutritional correction in these children are presented. The final section of the article describes special nutritional needs for children with congenital heart defects in terms of hemodynamic disorders nature and severity. Modern nutritional strategies for preparation of these patients to surgery and for their postoperative period are presented. The use of high-calorie/high-protein product for malnutrition correction in the most vulnerable patients with described in this review phenotypes is worth noticing.

Nutritional follow-up in children after discharge: Organisation in a tertiary care centre

BACKGROUND

To improve the standard of care for patients with a nutritional intervention we aim to evaluate how nutritional follow-up (FU) is organized at discharge and after 6 months.

METHODS

From November 16, 2020 until December 20, 2020 we retrospectively included patients admitted >1 day to the general ward of a tertiary hospital. Medical charts were reviewed for demographics, anthropometric measurements and nutritional interventions (e.g. tube, parenteral nutrition). Involved health care provider (HCP), dietician and speech and language therapist (SLT) was scored. Nutritional care FU was categorised as in a primary, secondary or tertiary care setting.

RESULTS

We included 206 (52.4% male) patients, median length of stay (LOS) of 4 [3 - 8] days. Pre-hospitalisation 58 (28.2%) patients had a nutritional intervention compared to 74 (35.9%) patients at discharge. In total 80 (38.8%) patients received nutritional care FU by a total of 114 HCP, approximately half (53.5%) were dieticians. FU was mostly conducted by a dietician in the tertiary care (78.7%) and by an SLT in the primary care (54.5%). For 15 (20.3%) patients the discharge letter included complete reports of nutritional interventions. At 6 months FU 26.6% of the children still had a nutritional intervention. Mean weight SDS increased significantly between discharge from the hospital and 6 months FU.

CONCLUSION

A considerable amount of paediatric patients received a nutritional intervention pre- and post-hospitalisation. Nutritional care is organised around a multitude of different HCP, however not in all cases multidisciplinary. Nutritional care was scarcely reported correctly in the discharge letter. This article is protected by copyright. All rights reserved.

Vasopressors and Enteral Nutrition in the Survival Rate of Children During Extracorporeal Membrane Oxygenation

OBJECTIVES

Nutrition support is essential in improving outcome and survival in children on extra corporal membranous support (ECMO). We aim to evaluate the association between the timing of enteral nutrition (EN) initiation and its impact on outcome.

METHODS

We retrospectively reviewed the electronic health records of children (≤18 years) from November 2014 to November 2019 who were on veno-arterial ECMO for ≥48 hours. Abstracted data included demographics, ECMO indication and duration, timing of EN initiation, change in weight-for-age z score (WAZ), and survival rate. The vasoactive-inotropic score (VIS) was calculated to assess illness acuity.

RESULTS

We identified 76 children with median age (interquartile range [IQR]) of 0.3 years (0-2.6), 46 of which were infants (59%) who required ECMO for a median (IQR) of 10 days (6-22). Thirty-six (47%) survived to hospital discharge. EN was initiated in 55 (72%) of patients while on ECMO. EN initiation by day 3 of ECMO was positively associated with survival ( P = 0.0438). VIS at the time of EN initiation was lower in surviving infants ( P = 0.022). Children who achieved enteral autonomy were more likely to survive ( P = 0.0024). Survivors had greater WAZs at ECMO completion ( P = 0.0004).

CONCLUSIONS

Initiation of EN by day 3 of ECMO and at a lower VIS is associated with greater likelihood of survival.

Decreasing Time to Full Enteral Feeds in Hospitalized Children With Medical Complexity Experiencing Feeding Intolerance

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) with gastrostomy and jejunostomy tubes are commonly hospitalized with feeding intolerance, or the inability to achieve target enteral intake combined with symptoms consistent with gastrointestinal dysfunction. Challenges resuming feeds may prolong length of stay (LOS). Our objective was to decrease median time to reach goal feeds from 3.5 days to 2.5 days in hospitalized CMC with feeding intolerance.

METHODS

A multidisciplinary team conducted this single-center quality improvement project. Key drivers included: standardized approach to feeding intolerance, parental buy-in and shared understanding of parental goals, timely formula delivery, and provider knowledge. Plan-do-study-act cycles included development of a feeding algorithm, provider education, near-real-time reminders and feedback. A run chart tracked the effect of interventions on median time to goal enteral feeds and median LOS.

RESULTS

There were 225 patient encounters. The most common cooccurring diagnoses were viral gastroenteritis, upper respiratory infections, and urinary tract infections. Median time to goal enteral feeds for CMC fed via gastrostomy or gastrojejunostomy tubes decreased from 3.5 days to 2.5 days within 6 months and was sustained for 1 year. This change coincided with implementation of a feeding intolerance management algorithm and provider education. There was no change in LOS.

CONCLUSIONS

Implementation of a standardized feeding intolerance algorithm for hospitalized CMC was associated with decreasing time to goal enteral feeds. Future work will include incorporating the algorithm into electronic health record order sets and spread of the algorithm to other services who care for CMC.

Nutrition in Pediatric Intensive Care: A Narrative Review

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

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.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.

Prevalence and Time Course of Thiamine Deficiency in Critically Ill Children: A Multicenter, Prospective Cohort Study in Turkey

OBJECTIVES

To determine the prevalence and time course of thiamine deficiency (TD) in PICU patients.

DESIGN

Multicenter, prospective, cohort study between May 2019 and November 2019.

SETTING

Three university-based tertiary care, mixed medical-surgical PICUs in Ankara, Turkey.

PATIENTS

PICU patients 1 month to 18 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We studied 476 patients and grouped them by TD status on days 1 and 3 of the PICU admission. There might be a risk of unintended bias since we excluded 386 patients because of the absence of consent, inadequate blood samples, loss of identifier information, and recent vitamin supplementation. On day 1, TD was present in 53 of 476 patients (11.1%) and median (minimum-maximum) thiamine levels were 65.5 ng/mL (5-431 ng/mL). On day 3, TD was present in 27 of 199 patients (13.6%) with repeated measurement. The median (minimum-maximum) thiamine levels were 63 ng/mL (13-357 ng/mL). The time course of TD from day 1 to day 3 in these 199 patients was as follows. In 21 of 199 patients (10.6%) with TD on day 1, 11 of 21 (52%) continued to have TD on day 3 and the other 10 of 21 patients (48%) improved to no longer having TD. In 178 of 199 patients (89.4%) without TD on day 1, 16 of 178 (9%) went on to develop TD by day 3, and the other 162 of 178 (91%) continued to have normal thiamine status.

CONCLUSIONS

In the PICU population in three centers in Turkey, the prevalence of TD in the sample of patients was 11.1%. In those TD patients who had serial studies, we also identified that by day 3 some continued to be TD, and some patients improved to normal thiamine status. Of concern, however, is the population who develop TD over the course of PICU stay.

Current Strategies to Optimize Nutrition and Growth in Newborns and Infants with Congenital Heart Disease: A Narrative Review

(1) Objective: This review aims to identify the clinical and practical barriers to optimizing nutrition in newborn infants with congenital heart disease (CHD) and to describe updated evidence-based recommendations for clinical and nutritional management of these patients in a narrative review. (2) Research Methods and Procedures: We conducted a search of the relevant literature published from 2000 to December 2021. (3) Results: CHD patients undergo several nutritional challenges related to the underlying cardiac disease anomaly, the potential increased risk of NEC, and delayed enteral feeding, resulting in inadequate energy intake and sub-optimal growth, increased morbidity and mortality. (4) Conclusions: To optimize nutrition and growth in newborn infants with CHD, standardized protocols should be implemented. Regular nutritional and growth assessment with a multi-disciplinary team is essential. We propose a decisional algorithm that may represent a potentially useful tool to guide clinicians to optimize growth and nutrition.

Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation

OBJECTIVES

To assess the safety of enteral nutrition (EN) in children on extracorporeal membrane oxygenation (ECMO). To describe nutritional status and the characteristics of the nutritional support in this population.

METHODS

A retrospective single-center analysis (2006-2016) including children <18 years on ECMO. Demographic data, nutritional status, characteristics of nutritional support, and development of gastrointestinal (GI) complications were recorded.

RESULTS

One hundred children, with a median age of 9.7 months (interquartile range [IQR] 3.9-63.1) were enrolled. Undernutrition was prevalent among children on ECMO (33.3%) mainly in patients <2 years (P = 0.042). Most patients (64%) received EN at some point during ECMO therapy. EN was administered in the first 48 hours after ECMO initiation (48HEN) to 60.3% of the children.Mortality rate in the Pediatric Intensive Care Unit was lower in patients who received EN as the initial artificial nutrition support (ANS) (37.7 vs 51%, P = 0.005) and in children on 48HEN (34% vs 50%, P = 0.04). In the logistic regression analysis, duration of ECMO support and low cardiac output indication were the only factors associated with mortality.Although most patients on ECMO (45%) developed digestive complications, they were mostly mild, being constipation the most prevalent. In the logistic regression analysis, EN was not associated with an increase in GI complications (P = 0.09). Only three patients developed intestinal ischemia (one without EN and two on EN).

CONCLUSIONS

Undernutrition is prevalent among children on ECMO, mainly in infants <2 years. EN is not associated with severe gastrointestinal complications or higher mortality in these children.