Energy imbalance and the risk of overfeeding in critically ill children

Respiratory quotient as an early predictor of length of stay after cardiac surgery: A prospective observational study

BACKGROUND AND OBJECTIVES

This study aimed to investigate the respiratory quotient (RQ) levels and its trend in the early postoperative period of patients with heart disease. Additionally, we explored factors influencing RQ and evaluated the predictive capabilities of RQ and lactic acid for various outcomes.

METHODS AND STUDY DESIGN

In this prospective observational study, participants included were heart disease patients aged 18-80 years who underwent elective open-heart surgery and were subsequently admitted to the cardiothoracic surgery ICU post-operation. Indirect calorimetry (IC) measurements were conducted on patients dur-ing the first three days after surgery to assess their RQ levels. Clinical data, including personal information, postoperative characteristics, and duration of surgery, were documented based on the patient's medical history.

RESULTS

In this study, 135 patients, of whom 57.04% were male, underwent a total of 247 IC measurements following cardiac surgery. On the first, second, and third days of admission to the ICU, the RQ values were 0.77±0.09, 0.80±0.07, and 0.78±0.05, respectively. The ROC curve analysis showed that on the first day of admission to the ICU, RQ was a better predictor of prolonged mechanical ventilation, LOS in ICU, and LOS in hospital compared to lactate level. However, on the second day of ICU admission, neither RQ nor lactate level could predict longer durations of mechanical ventilation, LOS in ICU, and LOS in hospital.

CONCLUSIONS

RQ may serve as a potential predictor for LOS in patients after cardiac surgery.

Quantity of Caloric Support After Pediatric Severe Traumatic Brain Injury: Description of Associated Outcomes in a Single Retrospective Center Cohort, 2010-2022

OBJECTIVES

To examine the relationship between adequacy of caloric nutritional support during the first week after severe traumatic brain injury (TBI) and outcome.

DESIGN

Single-center retrospective cohort, 2010-2022.

SETTING

Tertiary care children's hospital with a level 1 trauma center.

PATIENTS

Children younger than 18 years with PICU stay greater than 7 days for management of TBI, who had severe TBI, defined as Glasgow Coma Scale (GCS) score less than or equal to 8 at initial presentation and/or placement of an intracranial pressure monitor or external ventricular drain, and/or decompressive hemicraniectomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 93 patients were identified (median age 46 mo; 53% male; median GCS 5; hospital mortality 4%). Caloric goal was assigned by a dietician and the proportion of prescribed calories delivered to each patient over the first 7 days of PICU admission were analyzed. At the end of the first 7 days post-injury, overall median (interquartile range [IQR]) caloric and protein adequacies were 42% (IQR, 28-62%) and 48% (IQR, 29-61%), respectively. We failed to identify an association between adequacy of caloric support and greater odds of higher Functional Status Scale (FSS) score or higher Glasgow Outcome Scale Extended for Pediatrics score at discharge. However, at outpatient follow-up, prior adequacy of PICU caloric support was associated with greater odds of worse FSS (multiplicative increase per 10% increase in calories [MI], 1.10; 95% CI, 1.03-1.18; p = 0.002) and worse GOS E-Peds (MI, 1.16; 95% CI, 1.08-1.27; p < 0.001) at outpatient follow-up.

CONCLUSIONS

In pediatric patients with severe TBI, there is an association between delivery of a greater proportion of their goal calories during the first 7 days after injury and greater odds of worse outcome at outpatient follow-up.

Nutritional Intensive Support in a Pediatric Patient With Severe Traumatic Brain Injury: A Case Report

Estimating the nutritional requirements for pediatric patients requires a comprehensive approach with various factors including age, gender, body mass index, and physical activity level, due to the significant growth and developmental changes observed in this population. This complexity renders the use of a simplistic generalization or a standard formula impractical. A number of methodologies have been established to calculate nutritional needs for the pediatric population. However, the application of these methodologies is challenging due to the variability in the aforementioned factors. Determining nutritional requirements for pediatric patients with underlying medical conditions is complicate, influenced by variables such as the nature of the illness, treatment modalities, and the patient's overall condition. Nutritional support in severely traumatically brain-injured pediatric patients is directly correlated with prognosis and growth outcomes. Therefore, this case study aims to validate existing methodologies for estimating nutritional requirements in pediatric patients with severe traumatic brain injury and to provide primary data for the development of effective nutritional support strategies. A case of a 5-year-old male patient admitted to the intensive care unit due to severe traumatic brain injury is examined. Future case studies and ongoing research are imperative to ensure the safe and effective nutritional support of pediatric patients with severe traumatic brain injury.

An In-Depth Look at Nutrition Support and Adequacy for Critically Ill Children with Organ Dysfunction

Patients admitted to a pediatric intensive care unit (PICU) need individualized nutrition support that is tailored to their particular disease severity, nutritional status, and therapeutic interventions. We aim to evaluate how calories and proteins are provided during the first seven days of hospitalization for children in critical condition with organ dysfunction (OD). A single-center retrospective cohort study of children aged 2-18 years, mechanically ventilated > 48 h, and admitted > 7 days to a PICU from 2016 to 2017 was carried out. Nutrition support included enteral and parenteral nutrition. We calculated scores for the Pediatric Sequential Organ Failure Assessment (pSOFA) on days 1 and 3 of admission, with OD defined as a score > 5. Of 4199 patient admissions, 164 children were included. The prevalence of OD for days 1 and 3 was 79.3% and 78.7%, respectively. On day 3, when pSOFA scores trended upward, decreased, or remained unchanged, median (IQR) caloric intake was 0 (0-15), 9.2 (0-25), and 22 (1-43) kcal/kg/day, respectively (p = 0.0032); when pSOFA scores trended upward, decreased, or remained unchanged, protein intake was 0 (0-0.64), 0.44 (0-1.25), and 0.66 (0.04-1.67) g/kg/day, respectively (p = 0.0023). Organ dysfunction was prevalent through the first 72 h of a PICU stay. When the pSOFA scores trended downward or remained unchanged, caloric and protein intakes were higher than those that trended upward.

Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

BACKGROUND

In the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI.

METHODS

During the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized.

RESULTS

Two consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-"omics" in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments.

CONCLUSIONS

Neonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.

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.

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.

Nutritional support in the critical ill patient: Requirements, prescription and adherence

INTRODUCTION

In critically ill patients, nutritional support is a challenge in terms of both estimating their requirements and ensuring adherence to the prescribed treatment.

OBJECTIVE

To assess the association between requirements, prescription and adherence to energy and protein supplementation based on the phase of disease in critically ill patients.

SAMPLE AND METHODS

We conducted a prospective, observational and analytical study in patients aged 0-18 years admitted to the paediatric intensive or intermediate care unit in 2020-2021. We collected data on demographic and anthropometric characteristics and the phase of disease (acute phase [AP] vs. non-acute phase [nAP]), in addition to prescribing (P) (indication of nutritional support), basal metabolic rate (BMR, Schofield equation), adherence to nutritional support (A) and protein requirements (R), and calculated the following ratios: P/BMR, P/R, A/BMR, A/R, and A/P.

RESULTS

The sample included 131 participants with a median age of 16 (4.5) months, of who 128 (97.7%) had comorbidities and 13 (9.9%) were in the AP. Comparing the phases of disease (AP vs. nAP), the median values for energy supplementation were P/BMR, 0.5 (IQR, 0.1-1.4) vs. 1.3 (IQR, 0.9-1.8) (P = 0.0054); A/BMR, 0.4 (IQR, 0-0.6) vs. 1.2 (IQR, 0.8-1.7) (P = 0.0005); A/P, 0.7 (IQR, 0-0.9) vs. 1 (IQR, 0.8-1) (P = 0.002), and for protein were P/R, 0.7 (IQR, 0-1.1) vs. 1.2 (0.9-1.6) (P = 0.0009); A/R 0.3 (IQR, 0-0.6) vs. 1.1 (IQR, 0.8-1.5) (P = 0.0002); A/P 0.7 (IQR, 0-1) vs. 1(IQR, 0.8-1) (P = 0.002). We found AP/nAP ratios greater than 110% for energy in the P/BMR (4 patients [30.8%]/72 patients [61%]; P = 0.007), A/BMR (3 [23%]/63 [53.4%]; P = 0.009) and A/P (1 [7%]/3 [2.5%]; P = 0.007). As for protein, more than 1.5 g/kg/day was prescribed in 3 patients (23.1%) in the AP and 71 (60.1%) in the nAP. We found adherence to the prescribed intake in 2 (15.4%) patients in the AP and 66 (56%) in the nAP. We found a correlation coefficient of 0.6 between the energy P/R and the protein P/R. Prescribed support was discontinued in 7 patients (53.8%) in the AP and 31 (26.3%) in the nAP (P = 0.002).

CONCLUSIONS

The proportion of adherence to prescribed nutritional support was high in patients in the nAP of the disease. Overfeeding was frequent, more so in the nAP. We identified difficulties in adhering to prescribed support, chief of which was the discontinuation of feeding.

Feeding medium-chain fatty acid-rich formula causes liver steatosis and alters hepatic metabolism in neonatal pigs

Medium-chain fatty acids (MCFA) and long-chain fatty acids (LCFAs) are often added to enhance the caloric value of infant formulas. Evidence suggests that MCFAs promote growth and are preferred over LCFAs due to greater digestibility and ease of absorption. Our hypothesis was that MCFA supplementation would enhance neonatal pig growth to a greater extent than LCFAs. Neonatal pigs (n = 4) were fed a low-energy control (CONT) or two isocaloric high-energy formulas containing fat either from LCFAs, or MCFAs for 20 days. Pigs fed the LCFAs had greater body weight compared with CONT- and MCFA-fed pigs (P < 0.05). In addition, pigs fed the LCFAs and MCFAs had more body fat than those in the CONT group. Liver and kidney weights as a percentage of body weight were greater (P ≤ 0.05) for pigs fed the MCFAs than those fed the CONT formula, and in those fed LCFAs, liver and kidney weights as a percentage of body weight were intermediate (P ≤ 0.05). Pigs in the CONT and LCFA groups had less liver fat (12%) compared with those in the MCFA (26%) group (P ≤ 0.05). Isolated hepatocytes from these pigs were incubated in media containing [13C]tracers of alanine, glucose, glutamate, and propionate. Our data suggest alanine contribution to pyruvate is less in hepatocytes from LCFA and MCFA pigs than those in the CONT group (P < 0.05). These data suggest that a formula rich in MCFAs caused steatosis compared with an isocaloric LCFA formula. In addition, MCFA feeding can alter hepatocyte metabolism and increase total body fat without increasing lean deposition.NEW & NOTEWORTHY Our data suggest that feeding high-energy MCFA formula resulted in hepatic steatosis compared with isoenergetic LCFA or low-energy formulas. Steatosis coincided with greater laurate, myristate, and palmitate accumulation, suggesting elongation of dietary laurate. Data also suggest that hepatocytes metabolized alanine and glucose to pyruvate, but neither entered the tricarboxylic acid (TCA) cycle. In addition, the contribution of alanine and glucose was greater for the low-energy formulas compared with the high-energy formulas.

Measuring the Resting Energy Expenditure in Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study

Both overfeeding and underfeeding critically ill children are problematic. This prospective pilot study evaluated the resting energy expenditure in infants and children requiring extracorporeal membrane oxygenation (ECMO) support. An indirect calorimeter was used to measure oxygen consumption (VO 2 ) and carbon dioxide production (VCO 2 ) from the mechanical ventilator. Blood gases were used to determine VO 2 and VCO 2 from the ECMO circuit. Values from the mechanical ventilator and ECMO circuit were added, and the resting energy expenditure (REE) (Kcal/kg/day) was calculated. Measurements were obtained > 24 hours after ECMO support was initiated (day 2 of ECMO), 1 day before ECMO discontinuation or transfer, and 1 day after decannulation. Data were compared with the predicted energy expenditure. Seven patients aged 3 months to 13 years were included. The REE varied greatly both above and below predicted values, from 26 to 154 KCal/kg/day on day 2 of ECMO support. In patients with septic shock, the REE was > 300% above the predicted value on day 2 of ECMO. Before ECMO discontinuation, two of six (33%) children continued to have a REE > 110% of predicted. Three patients had measurements after decannulation, all with a REE < 90% of predicted. REE measurements can be obtained by indirect calorimetry in children receiving ECMO support. ECMO may not provide metabolic rest for all children as a wide variation in REE was observed. For optimal care, individual testing should be considered to match calories provided with the metabolic demand.

External Validation of Equations to Estimate Resting Energy Expenditure in Critically Ill Children and Adolescents with and without Malnutrition: A Cross-Sectional Study

We evaluated the validity of sixteen predictive energy expenditure equations for resting energy expenditure estimation (eREE) against measured resting energy expenditure using indirect calorimetry (REEIC) in 153 critically ill children. Predictive equations were included based on weight, height, sex, and age. The agreement between eREE and REEIC was analyzed using the Bland−Altman method. Precision was defined by the 95% limits of the agreement; differences > ±10% from REEIC were considered clinically unacceptable. The reliability was assessed by the intraclass correlation coefficient (Cronbach’s alpha). The influence of anthropometric, nutritional, and clinical variables on REEIC was also assessed. Thirty (19.6%) of the 153 enrolled patients were malnourished (19.6%), and fifty-four were overweight (10.5%) or obese (24.8%). All patients received sedation and analgesia. Mortality was 3.9%. The calculated eREE either underestimated (median 606, IQR 512; 784 kcal/day) or overestimated (1126.6, 929; 1340 kcal/day) REEIC compared with indirect calorimetry (928.3, 651; 1239 kcal/day). These differences resulted in significant biases of −342 to 592 kcal (95% limits of agreement (precision)−1107 to 1380 kcal/day) and high coefficients of variation (up to 1242%). Although predicted equations exhibited moderate reliability, the clinically acceptable ±10% accuracy rate ranged from only 6.5% to a maximum of 24.2%, with the inaccuracy varying from −31% to +71.5% of the measured patient’s energy needs. REEIC (p = 0.017) and eREE (p < 0.001) were higher in the underweight compared to overweight and obese patients. Apart from a younger age, malnutrition, clinical characteristics, temperature, vasoactive drugs, neuromuscular blockade, and energy intake did not affect REEIC and thereby predictive equations’ accuracy. Commonly used predictive equations for calculating energy needs are inaccurate for individual patients, either underestimating or overestimating REEIC compared with indirect calorimetry. Altogether these findings underscore the urgency for measuring REEIC in clinical situations where accurate knowledge of energy needs is vital.

Extracorporeal Life Support Organization Guidelines for the Provision and Assessment of Nutritional Support in the Neonatal and Pediatric ECMO Patient

DISCLAIMER

This guideline is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

Nutritional Support for Pediatric Severe Traumatic Brain Injury

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

The Effect of Various, Everyday Practices on Glucose Levels in Critically Ill Children

BACKGROUND

To evaluate the effect of various, everyday intensive care unit (ICU) practices on glucose levels in critically ill pediatric patients with the use of a continuous glucose monitoring system.

METHODS

Seventeen sensors were placed in 16 pediatric patients (8 male). All therapeutic and diagnostic interventions were recorded and 15 minutes later, a flash glucose measurement was obtained by swiping the sensor with a reader. Glucose difference was calculated as the glucose value 15 minutes after the intervention minus the mean daily glucose value for each individual patient. Additionally, the consciousness status of the patient (awake or sedated) was recorded.

RESULTS

Two hundred and five painful skin interventions were recorded. The mean difference of glucose values was higher by 1.84 ± 14.76 mg/dL (95% CI: -0.19 to 3.87 mg/dL, P = .076). However, when patients were categorized regarding their consciousness level, mean glucose difference was significantly higher in awake state than in sedated patients (4.76 ± 28.07 vs -2.21 ± 15.77 mg/dL, P < .001). Six hundred forty-nine interventions involving the respiratory system were recorded. Glucose difference during washings proved to be significantly higher than the ones during simple suctions (4.74 ± 14.18 mg/dL vs 0.32 ± 18.22 mg/dL, P = .016). Finally, glucose difference in awake patients was higher by 3.66 ± 13.91 mg/dL compared to glucose difference of -2.25 ± 21.07 mg/dL obtained during respiratory intervention in sedated patients.

CONCLUSIONS

Diagnostic and therapeutic procedures in the ICU, especially when performed in an awake state, exacerbate the stress and lead to a significant rise in glucose levels.

A methodological and clinical approach to measured energy expenditure in the critically ill pediatric patient

The metabolic response to injury and stress is characterized initially by a decreased energy expenditure (Ebb phase) followed by an increased metabolic expenditure (Flow phase). Indirect calorimetry is a methodology utilized to measure energy expenditure and substrate utilization by measuring gas exchange in exhaled air and urinary nitrogen. The use of indirect calorimetry in critically ill patients requires precise equipment to obtain accurate measurements. The most recent guidelines suggested that measured energy expenditure by indirect calorimetry be used to determine energy requirements. This article reviews the methodological and clinical use of indirect calorimetry in critically ill pediatric patients.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical Case Reports on the acceptability and tolerance of a High-Energy whey peptide-based Pediatric oral nutritional supplement in children aged over 12 months

The nutritional management of the complex needs of children with impaired gastrointestinal function can be challenging, using a high-energy pediatric whey-based peptide formula in clinical practice demonstrates its role in managing symptoms.

Which is the best route to achieve nutritional goals in pediatric ECMO patients?

OBJECTIVES

Estimating caloric intake and choosing route of administration are fundamental in the nutritional support of patients being supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to review the nutritional intervention carried out in a pediatric cohort in a third-level hospital.

METHODS

This was a prospective descriptive study. Age, sex, underlying pathology, Pediatric Risk of Mortality score, ECMO indication, type of care, duration of ECMO support, and prognosis were collected. Type of nutritional support, route of administration, kcal/kg achieved, estimated energy requirements, and percentage of caloric objective (%CO) reached on days 3 and 5 after cannulation were recorded.

RESULTS

Twenty-four venoarterial ECMO runs in 23 patients over a period of 2 y were recorded. Of the 23 patients, 15 were <1 y of age. The underlying pathology in 56.5% was cardiac disease. Three groups were identified: parenteral nutrition (group 0, n = 7), enteral nutrition (group 1, n = 8), and mixed nutrition (group 2, n = 7). The median of the %CO was 33.34 (0-84) on day 3 and 87.75% (78.4-100) on day 5 of ECMO, respectively for group 0; 75.5 (42.25-98.5) and 85% (24.4-107.7) in group 1 and 68.7 (44.4-82.2) and 91.2% (35.5-92) in group 2 (P > 0.05). Children <12 mo of age and cardiac patients represented 85.71% and 71.43% of total patients in group 0. Among the eight episodes of exclusive enteral nutrition, no complications were identified.

CONCLUSION

Enteral nutrition appears to be safe in the setting of hemodynamic stability and absence of contraindications and is equivalent to other nutritional interventions in terms of compliance with estimated energy requirements.

Nutritional Therapy in Children With Spinal Muscular Atrophy in the Era of Nusinersen

OBJECTIVES

Spinal muscular atrophy (SMA) is a genetic motor neuron disorder characterized by progressive muscle atrophy. Our aims were to evaluate the impact of nutritional intervention and nusinersen therapy on the nutritional status of SMA patients.

STUDY DESIGN

This prospective study included all children and young adults (<24 years of age) with SMA who attended our multidisciplinary SMA clinic, during January 2017-July 2019. We documented demographic, clinical, anthropometric, and nutritional data at baseline and follow-up. A nutritional intervention was implemented according to standards of the 2018 Consensus Statement of SMA Management.

RESULTS

The cohort included 51 SMA patients with a median age of 7.2 (interquartile range 2.1-15.3) years. Among them, 24 (47%) were SMA type 1, 16 (31.4%) SMA type 2, and 11 (21.6%) SMA type 3 patients. At baseline, 28 (54.9%) patients presented with malnutrition, 20 (71.4%) of whom with severe malnutrition. A decline in the frequency of severe malnutrition of SMA type 1 patients was observed at follow-up. The body mass index of patients who started nusinersen therapy after the nutritional intervention increased significantly compared with patients that started nusinersen therapy before the nutritional intervention (P = 0.042). There was also a significant increase in total energy and protein consumption in the former group (P = 0.043).

CONCLUSIONS

Malnutrition is frequent among children with SMA, and the nutritional status of patients that started nusinersen therapy after implementation of a nutritional intervention underwent a more significant improvement. The importance of combining adequate nutritional management with disease-modifying treatment is highlighted.

Metabolism and energy prescription in critically III children

Optimal nutrition therapy can positively influence clinical outcomes in critically ill children. Accurate assessment of nutritional status, metabolic state, macronutrient requirements and substrate utilization allows accurate prescription of nutrition in this population. In response to stress and injury, the body undergoes adaptive physiologic changes leading to dysregulation of the inflammatory response and hyperactivation of the inflammatory cascade. This results in a global catabolic state with modification in oxygen consumption and macronutrient metabolism. A comprehensive understanding of the metabolic response is essential when prescribing nutritional interventions aimed to offset the burden of this adaptive stress response in the critically ill. In this narrative review we aim to provide a comprehensive review of the physiologic basis, recent literature and some emerging concepts related to energy expenditure and the practical aspects of energy delivery in the critically ill child. Based on the unique metabolic characteristics of the critically ill child, we aim to provide a pragmatic approach to providing nutrition therapy.

Overfeeding and obesity in young children with positive pressure ventilation via tracheostomy following cardiac surgery

OBJECTIVES

Infants with CHD requiring positive pressure ventilation via tracheostomy are especially vulnerable to malnutrition following cardiac surgery. Current post-operative feeding recommendations may overestimate the caloric needs.

DESIGN

We retrospectively studied infants requiring tracheostomy after cardiac surgery. Anthropometric and nutritional data were collected, including caloric goals, weight-for-age z score, length-for-age z score, and weight-for-length z score. Changes in anthropometrics over time were compared to ascertain the impact of nutritional interventions. Data were shown as mean ± standard deviation.

RESULTS

Nineteen infants with CHD required tracheostomy at 160 ± 109 days (7-364 days), 13 had reparative surgery, and 6 had palliative surgery for single ventricle. The indications for tracheostomy consisted of airway abnormality/obstruction (n = 13), chronic respiratory failure (n = 7), and/or vocal cord paresis (n = 2). Initial maintenance nutritional target was set at 100-130 cal/kg per day. Fourteen patients (73.7%) became obese (maximum weight-for-length z score: 2.59 ± 0.47) under tracheostomy and gastrostomy feeding, whereas five patients did not (weight-for-length z score: 0.2 ± 0.83). Eight obese patients (weight-for-length z score: 2.44 ± 0.85) showed effective reduction of obesity within 6 months (weight-for-length z score: 0.10 ± 0.20; p < 0.05 compared with pre-adjustment) after appropriate feeding adjustment (40-90 cal/kg per day). Overall mortality was high (31.6%) in this population.

CONCLUSION

Standard nutritional management resulted in overfeeding and obesity in young children with CHD requiring positive pressure ventilation via tracheostomy. Optimal nutritional management in this high-risk population requires close individualised management by multidisciplinary teams.

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

Children who sustain moderate to large surface area burns present in a hypermetabolic state with increased caloric and protein requirements. A policy was implemented at our institution in 2017 to initiate enteral nutrition (EN) in pediatric burn patients within 4 hours of admission. The authors hypothesize that early EN (initiated within 4 hours of admission) is more beneficial than late EN (initiated ≥ 4 hours from admission) for pediatric burn patients and is associated with decreased rates of pneumonia, increased calorie and protein intake, fewer feeding complications, a shorter Intensive Care Unit (ICU) length of stay (LOS), and a reduced hospital LOS. Children who sustained a total body surface area (TBSA) burn injury ≥ 10% between 2011 and 2018 were identified in a prospectively maintained burn registry at Children's Hospital Colorado. Patients were stratified into two groups for comparison: early EN and late EN. The authors identified 132 pediatric burn patients who met inclusion criteria, and most (60%) were male. Approximately half (48%) of the study patients were in the early EN group. The early EN group had lower rates of underfeeding during the first week (P = .014) and shorter ICU LOS (P = .025). Achieving and sustaining adequate nutrition in pediatric burn patients with moderate to large surface area burn injuries are critical to recovery. Early EN in pediatric burn patients is associated with decreased underfeeding and reduced ICU LOS. The authors recommend protocols to institute feeding for patients with burns ≥ 10% TBSA within 4 hours of admission at all pediatric burn centers.

Nutritional survey in critically ill children: a single center study in China

BACKGROUND

The incidence of malnutrition in children, who were admitted to the pediatric intensive care unit (PICU), has kept high level over the past 30 years. In addition, nutrition status of critically ill children deteriorates further during the changing of their conditions and may have a negative effect on patients' outcomes. This study aimed to determine the nutritional status of critically ill children and to survey current nutrition practices and support in PICU.

METHODS

In this prospective observational study, 360 critically ill children stayed in the PICU not less than 3 days from Feb. to Nov. in 2017 were enrolled. Each patient underwent nutrition assessment. Nutritional status was determined using Z-scores of length/height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ), body mass index-for-age (BAZ), based on the World Health Organization child growth standards. We also observed the patients' intake of calories and protein during the first 10 days after admission.

RESULTS

Three hundred and sixty were enrolled in the study. One hundred and eighty-six patients (51.67%) were malnourished at PICU admission, above 50% and 56.45% (105/186) of malnourished patients had severe malnutrition. Except fasting in case of clinical instability in 5.3% (19/360), nutrition was provided in the form of oral feeding in 26.6% (96/360), enteral nutrition (EN) in 56.1% (202/360), parenteral nutrition (PN) in 6.4% (23/360) and mixed support (EN + PN) in 5.6% (20/360). Totally 384 times interruption of feeding happened in the process of EN, and 1.9 times feeding interruption happened to each patient. Twenty-seven point two percent of these patients had more than three times feeding interruption. The severe malnutrition group had significantly greater length of ICU stay and higher mechanical ventilation support rate (P=0.007, P=0.029). Total 44 (44/360, 12.22%) patients died in the study, and the malnutrition was not statistically different between survivor group and death group (P=0.379). More than 85% of the patients had lower daily nutritional intake compared with prescribed goals. Sixty-eight point three percent of the patients received the required calories during EN with median time of 2 [2-4] days. Only 32.7% of patients underwent EN received estimated protein requirements.

CONCLUSIONS

These results showed that malnutrition was common among children admitted to PICU. Furthermore, nutrition delivery was generally inadequate in critically ill children, and nutritional status was getting worsening during PICU.

A Comparative Analysis of Equations to Estimate Patient Energy Requirements Following Cardiopulmonary Bypass for Correction of Congenital Heart Disease

BACKGROUND

No consensus exists on the optimal method to estimate resting energy expenditure (REE) in critically ill children following cardiopulmonary bypass (CPB). This study assesses the accuracy of REE estimation equations in children with congenital heart disease following CPB and tests the feasibility of using allometric scaling as an alternative energy prediction equation.

METHODS

A retrospective analysis of a pediatric cohort following CPB (n = 107; median age 5.2 months, median weight 5.65 kg) who underwent serial measures (median 5 measurements) of REE using indirect calorimetry for 72 hours following CPB. We estimated REE using common estimation methods (Dietary Reference Intake, Harris Benedict, Schofield, World Health Organization [WHO]) as well as novel allometric equations. We compared estimated with measured REE to determine accuracy of each equation using overall discrepancy, calculated as a time-weighted average of the absolute deviation.

RESULTS

All equations incorrectly estimated REE at all time points following CPB, with overestimation error predominating. WHO had the lowest discrepancy at 10.7 ± 8.4 kcal/kg/d. The allometric equation was inferior, with an overall discrepancy of 16.9 ± 10.4. There is a strong nonlinear relationship between body surface area and measured REE in this cohort, which is a key source of estimation error using linear equations.

CONCLUSION

In a cohort of pediatric patients with congenital heart disease following CPB, no currently utilized clinical estimation equation reliably estimated REE. Allometric scaling proved inferior in estimating REE in children following CPB. Indirect calorimetry remains the ideal method of determining REE after CPB until nonlinear methods can be derived due to overestimation using linear equations.

Use of an Electronic Feeds Calorie Calculator in the Pediatric Intensive Care Unit

Supplemental Digital Content is available in the text.

Strategies to improve nutritional management are associated with better outcomes in pediatric intensive care units. We implemented a calorie-based protocol that integrated an electronic feeds calculator and stepwise feeds increment algorithm.

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

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

Feeding modality is a barrier to adequate protein provision in children receiving continuous renal replacement therapy (CRRT)

BACKGROUND

Critically ill children have a high prevalence of malnutrition. Children with acute kidney injury experience high rates of protein debt. Previous research has indicated that protein provision is positively associated with survival.

METHODS

This was a prospective observational study of all patients receiving CRRT for greater than 48 h at our tertiary care institution. Patients with inborn errors of metabolism were excluded. Data collection included energy, protein, and fluid volume intakes, anthropometrics, feeding modality, and route of nutrition intake.

RESULTS

Forty-one patients 9 ± 6.8 years of age, 66% male, received CRRT over a 10-month time period. CRRT treatment was 17.3 ± 25 days. Forty-one percent were malnourished via anthropometric criteria at CRRT start. Median protein delivery was 2 g/kg/day (IQR 1.4-2.5). Fifty-one percent received a combination of parenteral nutrition (PN) and enteral/oral feedings (EN), 34% received only PN, and 12% received only EN. Percentage of time meeting protein goals by modality was 27.6%, 34.6%, and 65.3% for those patients receiving solely EN, PN, and EN + PN combination, respectively. When weaned to only EN support from combination PN + EN, the average percentage of time protein goals were met decreased to 20.5% (p < 0.01).

CONCLUSIONS

Without PN, patients on enteral/oral nutrition support fail to meet appropriate protein prescription. Transition of parenteral to enteral feeds was identified as a period of nutritional risk in children receiving CRRT.

Energy Balance in Critically Ill Children With Severe Sepsis Using Indirect Calorimetry: A Prospective Cohort Study

OBJECTIVES

Energy needs in critically ill children are dynamic and variable. Data on energy balance in children with severe sepsis using indirect calorimetry (IC) is lacking. Thus, we planned to study the energy needs and balance of this cohort.

METHODS

Prospective observational study conducted in ventilated children aged 5 to 12 years, admitted in pediatric intensive care unit with severe sepsis from May 2016 to June 2017. Measured resting energy expenditure (mREE) was measured with IC (Quark RMR, COSMED) till 7 days or pediatric intensive care unit discharge. Predicted energy expenditure (pREE) was estimated using Schofield, Harris and Benedict, and FAO/WHO/UNU equations. Primary outcome was to study the daily energy balance. Secondary outcome was to determine nitrogen balance and agreement of mREE with pREE.

RESULTS

Forty children (24 boys) with median age of 7 (5.2, 10) years were enrolled. All received enteral nutrition; 35 (87.5%) received inotropic support. Median ventilation-free days were 19 days and 4 children died (10%). A total of 176 IC measurements were obtained with an average of 4 per patient. The mean mREE was 51 ± 17 kcal/kg and mean respiratory quotient was 0.77 ± 0.07. There was persistent negative energy balance from days 1 to 7 and negative nitrogen balance from days 1 to 5. There was poor agreement of pREE with mREE using Bland Altman plots. None of severity of illness scores (PRISM III, daily Sequential Organ Function Assessment, daily Vasoactive Inotropic Score) showed correlation with mREE.

CONCLUSIONS

Persistent negative energy and nitrogen balance exist during acute phase of severe sepsis. Predictive equations are inaccurate compared with IC as the criterion standard.

Association between enteral macronutrient delivery and inflammatory response in critically ill children

BACKGROUND AND AIMS

An important goal of nutrition support in paediatric critical illness is minimising catabolism. While focussing on providing full energy requirements, macronutrient balance is often neglected. Studies suggest that there is interplay between nutrition and inflammation. We aimed to assess the amount of enteral macronutrients delivered compared to estimated requirements, and the association between delivered macronutrients and systemic inflammation in critically ill children.

METHOD

We prospectively evaluated energy and macronutrient intake in critically ill children who required at least 72 h of mechanical ventilation. Data on enteral energy and macronutrient intake was collected and expressed as a percentage of the estimated requirements. Circulating levels of inflammatory cytokines were measured by ELISA and association assessed with delivery of macronutrients from the previous 24 h.

RESULTS

A total of 87 children (0-16 years) were included in this study. By day 3 the median (IQR) intake of energy, fat, carbohydrate (CHO) and protein were 75% (50-103), 85% (43-120), 63% (42-102) and 45% (23-65) respectively. We have also shown that delivery of enteral fat and protein was associated with elevation in the levels of tumour necrosis factor alpha (TNF-α) and interleukin-6 (IL-6).

CONCLUSION

The inflammatory response in critically ill children is influenced by the amount of enteral fat and protein delivered. Our data suggests that within the feed delivered, fat is often higher than protein and CHO. It is crucial to take into account the proportion of macronutrients required and not only aim to achieve the energy goal.

Overfeeding-associated hyperglycemia and injury-response homeostasis in critically ill neonates

BACKGROUND

Injury severity induces a proportionate acute metabolic stress response, associated with increased risk of hyperglycemia. We hypothesized that excess caloric delivery (overfeeding) during high stress states would increase hyperglycemia and disrupt response homeostasis.

METHODS

Gestational age, daily weight, total daily caloric intake, serum C-reactive protein (CRP), prealbumin, and blood glucose concentrations in all acutely-injured premature NICU infants requiring TPN over the past 3years were reviewed. Injury severity was based on CRP and patients were divided into high (CRP ≥50mg/L) versus low (CRP <50mg/L) stress groups. Glycemic variability was used to measure disruption of homeostasis.

RESULTS

Overall sample included N=563 patient days (37 patients; 42 episodes). High stress group pre-albumin levels negatively correlated with CRP levels (R=-0.62, p<0.005). A test of equal variance demonstrated significantly increased high stress glycemic variability (Ha:ratio>1, Pr(F>f)=0.0353). When high stress patients were separated into high caloric intake (≥70kg/kcal/day) versus low caloric intake (<70kg/kcal/day), maximum serum glucose levels were significantly higher with overfeeding (230.33±55.81 vs. 135.71±37.97mg/dL, p<0.004).

CONCLUSION

Higher injury severity induces increased disruption of response homeostasis in critically ill neonates. TPN-associated overfeeding worsens injury-related hyperglycemia in more severely injured infants.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level II.

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.

Estimation of Resting Energy Expenditure Using Predictive Equations in Critically Ill Children: Results of a Systematic Review

Provision of adequate energy intake to critically ill children is associated with improved prognosis, but resting energy expenditure (REE) is rarely determined by indirect calorimetry (IC) due to practical constraints. Some studies have tested the validity of various predictive equations that are routinely used for this purpose, but no systematic evaluation has been made. Therefore, we performed a systematic review of the literature to assess predictive equations of REE in critically ill children. We systematically searched the literature for eligible studies, and then we extracted data and assigned a quality grade to each article according to guidelines of the Academy of Nutrition and Dietetics. Accuracy was defined as the percentage of predicted REE values to fall within ±10% or ±15% of the measured energy expenditure (MEE) values, computed based on individual participant data. Of the 993 identified studies, 22 studies testing 21 equations using 2326 IC measurements in 1102 children were included in this review. Only 6 equations were evaluated by at least 3 studies in critically ill children. No equation predicted REE within ±10% of MEE in >50% of observations. The Harris-Benedict equation overestimated REE in two-thirds of patients, whereas the Schofield equations and Talbot tables predicted REE within ±15% of MEE in approximately 50% of observations. In summary, the Schofield equations and Talbot tables were the least inaccurate of the predictive equations. We conclude that a new validated indirect calorimeter is urgently needed in the critically ill pediatric population.).

Comprehensive nutritional and metabolic assessment in patients with spinal muscular atrophy: Opportunity for an individualized approach

Optimal nutrition support is recommended for patients with spinal muscular atrophy (SMA). In a prospective study, we performed comprehensive nutritional assessments with the aim to guide best nutritional strategies for patients with SMA types II and III. We recorded a) anthropometry; b) macro- and micronutrient intakes; c) measured resting energy expenditure by indirect calorimetry; and d) body composition including dual X-ray absorptiometry. We enrolled a cohort of 21 patients aged 3 to 36 years of which 13 were female; 19 had SMA type II and 2 had SMA type III. The body mass index z-score ranged from -3 to 2.4. Forty-five percent of the cohort was either underfed or overfed, based on the difference between actual energy intake and measured resting energy expenditure. Vitamin D, E, K, folate and calcium intakes were low in a majority of the cohort. Forty-five percent of the cohort was either hypometabolic or hypermetabolic. Fat mass index (kg/m²) was significantly higher and lean body mass index (kg/m²) was significantly lower in the study cohort compared to population normalized values. Bone mineral density was low in 13 of 17 patients. In summary, we have described the prevalence of malnutrition, suboptimal feeding and alterations in body composition in children with SMA. A comprehensive nutritional assessment could guide individualized nutrition therapy in this vulnerable population.

Can energy intake alter clinical and hospital outcomes in PICU?

BACKGROUND & AIMS

Energy is essential for the treatment and recovery of children admitted to Pediatric Intensive Care Units (PICU). There are significant immediate and long-term health consequences of both under- and over-feeding in this population. Energy requirements of critically ill children vary depending on age, nutritional status, sepsis, fever, pharmacotherapy, and duration and stage of critical illness. This study aimed to determine the incidence of over- and under-feeding and to compare hospital outcomes between these feeding categories. Secondary outcomes were collected to describe the association between feeding categories and biochemistries (serum lactate, triglycerides, C-reactive protein).

METHODS

An ethics approved retrospective study of children admitted to PICU was performed. All intubated patients admitted to PICU (2008-2013) were included, except those in which an IC test was not feasible. Data collection included demographics, the primary outcome variable reported as under feeding (<90%MREE), appropriate (MREE ±10%) or overfeeding (>110% MREE) determined through comparison of measured resting energy expenditure (MREE) using indirect calorimetry (IC) to actual energy intake based on predicted basal metabolic rate (PBMR) and clinical outcomes mechanical ventilation and PICU length of stay (LOS). Data were analysed with descriptive methods, ANOVA and linear regression models.

RESULTS

A total of 139 patients aged 10 (range 0.03-204) months were included. Sixty (43%) were female and 77 (55%) were admitted after a surgical procedure. A total of 210 IC tests were conducted showing a statistically significant difference between MREE measurements and PBMR (p = 0.019). Of the 210 measurements, only 26 measures (12.4%) demonstrated appropriate feeding, while 72 (34.3) were underfed and 112 (53.3%) were overfed. Children who were overfed had significantly longer PICU LOS (median 45.5, IQR 47.8 days) compared to those children in the appropriately fed (median 21.0, IQR 54.5 days), and underfed groups (median 16.5, IQR 21.3 days). There was a mean difference between the over and under feeding category and ventilation days after adjusting for age and PRISM score (p = 0.026), suggesting decreased mechanical ventilation days for underfed. Children who were underfed had significantly higher CRP (median 75.5, IQR 152.8 mg/L) compared to those children in the appropriately fed (median 57.8, IQR 90.9 mg/L) and overfed groups (median 22.4, IQR 56.2 mg/L).

CONCLUSIONS

This retrospective study confirms that estimations of energy expenditure in critically ill children are inaccurate leading to unintended under and overfeeding. Importantly under feeding seems to be associated with fewer mechanical ventilation days and PICU LOS. Further research is required to elucidate the role of optimal nutrition in altering clinical variables in this population.

Underweight Status Is an Independent Predictor of In-Hospital Mortality in Pediatric Patients on Extracorporeal Membrane Oxygenation

BACKGROUND

Malnutrition is associated with an increased risk of mortality in patients admitted to the intensive care unit. Children requiring extracorporeal membrane oxygenation (ECMO) support represent an extremely ill subset of this population. There is a lack of data on the impact of nutrition state on survival in this cohort. We examined the association between being underweight and in-hospital mortality among children supported with ECMO.

MATERIALS AND METHODS

This article reports on an observational retrospective cohort study performed among neonatal and pediatric patients supported with ECMO in a tertiary children's hospital from May 1996 through June 2013. Nutrition status on intensive care unit admission was defined with z scores on weight for length and body mass index.

RESULTS

Patients (N = 491) had a median age of 31 days (interquartile range, 2-771): 24.4% were underweight, and 8.9% were obese. During ECMO support, 88.3% received total parenteral nutrition, and 30.3% received enteral nutrition. Median maximum energy intake while receiving ECMO was 82 kcal/kg/d (interquartile range, 54.7-105). Multiple logistic regression showed that underweight status was associated with increased predicted odds of in-hospital mortality when compared with normal weight (odds ratio: 1.99, 95% confidence interval: 1.21-3.25, P = .006). Other factors associated with increased odds of mortality included extracorporeal cardiopulmonary resuscitation and the need for continuous renal replacement therapy.

CONCLUSION

Underweight status was an independent predictor for in-hospital mortality in our cohort of pediatric ECMO patients. Prospective studies evaluating the impact of metabolic state of children on ECMO should further define this relationship.

Nutrition Support and Tight Glucose Control in Critically Ill Children: Food for Thought!

Numerous studies have examined the strategy of tight glucose control (TGC) with intensive insulin therapy (IIT) to improve clinical outcomes in critically ill adults and children. Although early studies of TGC with IIT demonstrated improved outcomes at the cost of elevated hypoglycemia rates, subsequent studies in both adults and children have not demonstrated any benefit from such a strategy. Differences in patient populations, variable glycemic targets, and glucose control protocols, inconsistency in attaining these targets, heterogeneous intermittent sampling, and measurement techniques, and variable expertise in protocol implementation are possible reasons for the contrasting results from these studies. Notably, differences in modes of nutrition support may have also contributed to these disparate results. In particular, combined use of early parenteral nutrition (PN) and a strategy of TGC with IIT may be associated with improved outcomes, while combined use of enteral nutrition (EN) and a strategy of TGC with IIT may be associated with equivocal or worse outcomes. This article critically examines published clinical trials that have employed a strategy of TGC with IIT in critically ill children to highlight the role of EN vs. PN in influencing clinical outcomes including efficacy of TGC, and adverse effects such as occurrence of hypoglycemia and hospital acquired infections. The perspective afforded by this article should help practitioners consider the potential importance of mode of nutrition support in impacting key clinical outcomes if they should choose to employ a strategy of TGC with IIT in critically ill children with hyperglycemia.

Preventing Underfeeding and Overfeeding: A Clinician's Guide to the Acquisition and Implementation of Indirect Calorimetry

BACKGROUND

In critically ill patients, indirect calorimetry (IC) is the gold standard to determine energy needs, as the use of predictive equations can result in underfeeding or overfeeding. The aim of this quality improvement (QI) initiative was to describe the rationale for and implementation of a process to target energy provision according to IC measurements in a tertiary academic medical center pediatric intensive care unit (PICU).

MATERIALS AND METHODS

To justify the purchase of an indirect calorimeter for clinical use, a needs assessment was conducted, followed by a training and implementation period. PICU patients were selected for IC according to published guidelines. Measured energy expenditure was compared with predicted energy expenditure and the provided energy prescription. The dietitians assessed IC results and adjusted energy prescriptions, if indicated.

RESULTS

Thirty-five total tests were completed with 24 patients. Sixty-nine percent of measurements resulted in energy delivery adjustments. Fifteen (47%) energy prescriptions decreased by a mean of 27% ± 11%, and 7 (22%) increased by a mean of 17% ± 15%. Staff and patient/guardians accommodated the use of IC, and PICU dietitian recommendations for IC tests and to adjust nutrition regimens were universally implemented.

CONCLUSIONS

Data to support the procurement of IC are vital to promote best practice to measure energy expenditure. Critically ill pediatric patients exhibit metabolic alterations that cannot be predicted by standard equations. Our QI initiative demonstrated the implementation and application of IC in the critically ill population and the ability to target energy provision to prevent energy imbalances.

Morbidity and mortality among "big" babies who develop necrotizing enterocolitis: A prospective multicenter cohort analysis

BACKGROUND

Necrotizing enterocolitis (NEC) is classically a disease of prematurity, with less reported regarding morbidity and mortality of this disease among other infants.

METHODS

Data were prospectively collected from 2009 to 2015 at 252 Vermont Oxford Network member centers on neonates with birth weight>2500g admitted to a participating NICU within 28days of birth.

RESULTS

Of 1629 neonates with NEC, gestational age was 37 (36, 39) weeks, and 45% had major congenital anomalies, most commonly gastrointestinal defects (20%), congenital heart defects (18%), and chromosomal anomalies (7%). For the 23% of infants who had surgery for NEC, mortality and length of stay were 23% and 63 (36, 94) days versus 8% and 34 (22, 61) days in medical NEC. Independent predictors of mortality were congenital heart defects (p<0.0001), chromosomal abnormalities (p<0.05), other congenital malformations (p<0.001), surgical NEC (p<0.0001), and sepsis (p<0.05). All of these in addition to gastrointestinal defects were independent predictors of increased length of stay. Nutritional morbidity at discharge included 6% receiving no enteral feeds and 27% who were <10th percentile weight-for-age.

CONCLUSIONS

Major congenital anomalies are present in nearly half of >2500g birth weight infants diagnosed with necrotizing enterocolitis. Morbidity and mortality increase with sepsis, surgical disease, and congenital anomalies.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

Level II.

The Metabolic Response to Stress and Infection in Critically Ill Children: The Opportunity of an Individualized Approach

The metabolic response to stress and infection is closely related to the corresponding requirements of energy and nutrients. On a general level, the response is driven by a complex endocrine network and related to the nature and severity of the insult. On an individual level, the effects of nutritional interventions are highly variable and a possible source of complications. This narrative review aims to discuss the metabolic changes in critically-ill children and the potential of developing personalized nutritional interventions. Through a literature search strategy, we have investigated the importance of blood glucose levels, the nutritional aspects of the different phases of acute stress response, and the reliability of the available tools to assess the energy expenditure. The dynamics of metabolism during stressful events reveal the difficult balance between risk of hypo- or hyperglycemia and under- or overfeeding. Within this context, individualized and accurate measurement of energy expenditure may help in defining the metabolic needs of patients. Given the variability of the metabolic response in critical conditions, randomized clinical studies in ill children are needed to evaluate the effect of individualized nutritional intervention on health outcomes.

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.

Timing of the initiation of parenteral nutrition in critically ill children

PURPOSE OF REVIEW

To review the current literature evaluating clinical outcomes of early and delayed parenteral nutrition initiation among critically ill children.

RECENT FINDINGS

Nutritional management remains an important aspect of care among the critically ill, with enteral nutrition generally preferred. However, inability to advance enteral feeds to caloric goals and contraindications to enteral nutrition often leads to reliance on parenteral nutrition. The timing of parenteral nutrition initiation is varied among critically ill children, and derives from an assessment of nutritional status, energy requirements, and physiologic differences between adults and children, including higher nutrient needs and lower body reserves. A recent randomized control study among critically ill children suggests improved clinical outcomes with avoiding initiation of parenteral nutrition on day 1 of admission to the pediatric ICU.

SUMMARY

Although there is no consensus on the optimal timing of parenteral nutrition initiation among critically ill children, recent literature does not support the immediate initiation of parenteral nutrition on pediatric ICU admission. A common theme in the reviewed literature highlights the importance of accurate assessment of nutritional status and energy expenditure in deciding when to initiate parenteral nutrition. As with all medical interventions, the initiation of parenteral nutrition should be considered in light of the known benefits of judiciously provided nutritional support with the known risks of artificial, parenteral feeding.

Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies

OBJECTIVE

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

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS/SETTING

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

INTERVENTION

Implementation of NS Guidelines.

MAIN OUTCOME MEASURES

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

STATISTICAL ANALYSIS PERFORMED

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

RESULTS

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

CONCLUSIONS

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