Early minimal enteral supplementation in severely burned children receiving parenteral nutrition

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

Protein Requirements of the Critically Ill Pediatric Patient

This article includes a review of protein needs in children during health and illness, as well as a detailed discussion of protein metabolism, including nitrogen balance during critical illness, and assessment and prescription/delivery of protein to critically ill children. The determination of protein requirements in children has been difficult and challenging. The protein needs in healthy children should be based on the amount needed to ensure adequate growth during infancy and childhood. Compared with adults, children require a continuous supply of nutrients to maintain growth. The protein requirement is expressed in average requirements and dietary reference intake, which represents values that cover the needs of 97.5% of the population. Critically ill children have an increased protein turnover due to an increase in whole-body protein synthesis and breakdown with protein degradation leading to loss of lean body mass (LBM) and development of growth failure, malnutrition, and worse clinical outcomes. The results of protein balance studies in critically ill children indicate higher protein needs, with infants and younger children requiring higher intakes per body weight compared with older children. Monitoring the side effects of increased protein intake should be performed. Recent studies found a survival benefit in critically ill children who received a higher percentage of prescribed energy and protein goal by the enteral route. Future randomized studies should evaluate the effect of protein dosing in different age groups on patient outcomes, including LBM, muscle structure and function, duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality.