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Romano C, Lionetti P, Spagnuolo MI, Amarri S, Diamanti A, Verduci E, Lezo A, Simona G. Trends and challenges in home enteral feeding methods for children with gastrointestinal disorders: an expert review on bolus feeding delivery methods. Expert Rev Gastroenterol Hepatol 2024; 18:193-202. [PMID: 38030649 DOI: 10.1080/17474124.2023.2289530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/27/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION New evidence supports the benefits of bolus feeding for children receiving home enteral feeding (HEN). Current home methods of bolus feeding have certain limitations, particularly in mobile or restless patients. Therefore, innovative delivery methods have been introduced to provide more flexible methods of reducing feeding time and formula handling. AREAS COVERED This manuscript presents an expert review of the updates in HEN for children and the results of an online user experience questionnaire about an innovative new cap-based bolus feeding system. A literature bibliographic search was conducted on Medline via PubMed up to September 2023 to collect relevant studies. We presented recent evidence demonstrating a dramatic increase in HEN use among children requiring EN and its benefits on patients' nutritional status and quality of life. In addition, the article examined the clinical and social benefits of bolus feeding and current challenges in delivery methods. We described the benefits of the new system and its user experience. EXPERT OPINION The uses and indications for bolus feeding in HEN are increasing among children. However, there are still some unmet needs regarding traditional delivery methods. Innovative techniques can improve flexibility, reduce feeding time, and improve user experience and quality of life.
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Affiliation(s)
- Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Paolo Lionetti
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Department NEUROFARBA - University of Florence, Florence, Italy
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Sergio Amarri
- Pediatric Palliative Care, Fondazione Hospice MT. C. Seràgnoli, BO, Bentivoglio, Italy
| | - Antonella Diamanti
- Artificial Nutrition Unit Bambino Gesù, Children's Hospital, Rome, Italy
| | - Elvira Verduci
- Department of Pediatrics, Buzzi Children's Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Antonella Lezo
- Division of Clinical Nutrition, Regina Margherita Children's Hospital, Turin, Italy
| | - Gatti Simona
- Department of Pediatrics,Università Politecnica delle Marche, Italy
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Raina R, Suchan A, Soundararajan A, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Vitale VS, Crugnale AS, Keller GL, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE, Sethi SK. Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary. Nutrition 2024; 119:112272. [PMID: 38118382 DOI: 10.1016/j.nut.2023.112272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/04/2023] [Accepted: 10/21/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy. METHODS An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy. RESULTS The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy. CONCLUSIONS Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, Ohio, USA; Akron Children's Hospital, Akron, Ohio, USA.
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA; Children's Healthcare of Atlanta, Atlanta, Georgia, USA; ECU Health, Greenville, North Carolina, USA
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Weiwen V Shih
- Children's Hospital Colorado, University of Colorado, Section of Pediatric Nephrology, Aurora, Colorado, USA
| | - Arwa Nada
- Division of Pediatric Nephrology, Department of Pediatrics, Le Bonheur Children's Hospital and St. Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sharon Y Irving
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee, USA; Department of Medicine, University of Tennessee, Knoxville, Tennessee, USA
| | | | - Aylin S Crugnale
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, Ohio, USA
| | | | - Katarina G Berry
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E Bunchman
- Department of Pediatrics, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sidharth K Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta-The Medicity, Gurgaon, India
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Raina R, Suchan A, Sethi SK, Soundararajan A, Vitale VS, Keller GL, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Crugnale AS, Myneni A, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE. Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations. KIDNEY360 2024; 5:285-309. [PMID: 38112754 PMCID: PMC10914214 DOI: 10.34067/kid.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT. METHODS PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023. RESULTS On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points. CONCLUSIONS Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
- Akron Children's Hospital, Akron, Ohio
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, India
| | - Anvitha Soundararajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | | | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
- ECU Health, Greenville, North Carolina
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, United Kingdom
| | - Weiwen V. Shih
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Arwa Nada
- Department of Pediatrics, Division of Pediatric Nephrology, Le Bonheur Children's & St. Jude Children's Research Hospitals, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sharon Y. Irving
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee
- Department of Medicine, University of Tennessee at Knoxville, Knoxville, Tennessee
| | - Aylin S. Crugnale
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Archana Myneni
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Katarina G. Berry
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Jakub Zieg
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E. Bunchman
- Department of Pediatrics, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
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Veldscholte K, Hulst JM, Eveleens RD, de Jonge RC, de Koning BA, van den Berg SA, van der Wal R, Ruijter GJ, Rizopoulos D, Vanhorebeek I, Gunst J, Casaer M, Van den Berghe G, Joosten KF, Verbruggen SC. Gastrointestinal Biomarkers and Their Association with Feeding in the First Five Days of Pediatric Critical Illness. J Pediatr Gastroenterol Nutr 2023; 77:811-818. [PMID: 37728917 PMCID: PMC10642702 DOI: 10.1097/mpg.0000000000003950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/01/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Predicting the patients' tolerance to enteral nutrition (EN) would help clinicians optimize individual nutritional intake. This study investigated the course of several gastrointestinal (GI) biomarkers and their association with EN advancement (ENA) longitudinally during pediatric intensive care unit (PICU) admission. METHODS This is a secondary analysis of the Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit randomized controlled trial. EN was started early and increased gradually. The cholecystokinin (CCK), leptin, glucagon, intestinal fatty acid-binding protein 2 (I-FABP2), and citrulline plasma concentrations were measured upon PICU admission, day 3 and day 5. ENA was defined as kcal EN provided as % of predicted resting energy expenditure. The course of the biomarkers and ENA was examined in patients with samples on all time points using Friedman and Wilcoxon signed-rank tests. The association of ENA with the biomarkers was examined using a 2-part mixed-effects model with data of the complete population, adjusted for possible confounders. RESULTS For 172 patients, median age 8.6 years (first quartile; third quartile: 4.2; 13.4), samples were available, of which 55 had samples on all time points. The median ENA was 0 (0; 0) on admission, 14.5 (0.0; 43.8) on day 3, and 28.0 (7.6; 94.8) on day 5. During PICU stay, CCK and I-FABP2 concentrations decreased significantly, whereas glucagon concentrations increased significantly, and leptin and citrulline remained stable. None of the biomarkers was longitudinally associated with ENA. CONCLUSIONS Based on the current evidence, CCK, leptin, glucagon, I-FABP2, and citrulline appear to have no added value in predicting ENA in the first 5 days of pediatric critical illness.
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Affiliation(s)
- Karlien Veldscholte
- From the Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Jessie M. Hulst
- the Department of Pediatrics, University of Toronto, Toronto, Canada
- the Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- the Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Renate D. Eveleens
- the Department of Anesthesiology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | - Rogier C.J. de Jonge
- From the Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Barbara A.E. de Koning
- Pediatric Gastroenterology, Erasmus MC Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Sjoerd A.A. van den Berg
- the Department of Clinical Chemistry, Erasmus MC, Rotterdam, The Netherlands
- the Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Ronald van der Wal
- the Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Dimitris Rizopoulos
- the Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands
- the Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Ilse Vanhorebeek
- the Department of Anesthesiology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | - Jan Gunst
- the Department of Anesthesiology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | - Michaël Casaer
- the Department of Anesthesiology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | - Greet Van den Berghe
- the Department of Anesthesiology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | - Koen F.M. Joosten
- From the Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Sascha C.A.T. Verbruggen
- From the Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
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Haseeb M, Goiporia MH, Siddiqui MS, Sangle AL, Quadri SF, Ravali RL. Challenges Encountered in the Provision of Enteral Nutrition in Pediatric Intensive Care Unit: An Observational Study. Cureus 2023; 15:e49285. [PMID: 38143607 PMCID: PMC10747421 DOI: 10.7759/cureus.49285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Background Enteral nutrition (EN) represents the preferred modality for nutrient administration in critically ill patients. However, it is fraught with challenges such as delayed initiation and recurrent interruptions, which can significantly impact patient clinical outcomes. A substantial proportion of these interruptions can be mitigated. In the present investigation, our objective was to scrutinize the practice of EN in the Pediatric Intensive Care Unit (PICU). We sought to ascertain the frequency and underlying causes of EN interruptions and assess their ramifications for nutrient delivery. Study design We conducted an observational study within the PICU of Mahatma Gandhi Mission's (MGM) Medical College and Hospital, Aurangabad. The study encompassed children admitted to the PICU for a period exceeding 24 hours who were receiving enteral feeds. We documented the time of commencing EN from the point of PICU admission, instances of enteral feeding interruptions, the number and duration of each interruption episode, and the reasons behind these interruptions. Subsequently, we categorized the causes of feeding interruptions into avoidable and non-avoidable determinants. Results Out of the 100 patients enrolled in this study, only 34% presented with normal nutritional status upon admission. Sixty-five percent of patients had their nutritional support initiated within the first 48 hours of admission to the PICU. The median duration from PICU admission to the initiation of EN was 32.5 hours, with a median interruption duration per patient of 40.96 hours. Common causes of interruptions included radiological procedures, respiratory distress, altered sensorium, presence of gastric aspirates, and surgical procedures. Upon analysis, it was determined that a substantial majority, constituting 74%, of these interruptions were avoidable. Conclusions The primary challenges associated with EN in the PICU encompass delayed initiation of enteral feeds and frequent interruptions. Importantly, a significant proportion of these issues are avoidable.
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Affiliation(s)
- Mohammad Haseeb
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Mahafrin H Goiporia
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Mohd Saeed Siddiqui
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Avinash L Sangle
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
| | - Syed F Quadri
- Department of Public Health, John Snow, Inc. (JSI), Delhi, IND
| | - Ramula L Ravali
- Department of Pediatrics, Mahatma Gandhi Mission's (MGM) Medical College and Hospital, a Constituent Unit of MGM Institute of Health Sciences, Aurangabad, IND
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Fell DM, Bitetto EA, Skillman HE. Timing of enteral nutrition and parenteral nutrition in the PICU. Nutr Clin Pract 2023; 38 Suppl 2:S174-S212. [PMID: 37721466 DOI: 10.1002/ncp.11050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.
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Affiliation(s)
- Donna M Fell
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Emily A Bitetto
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
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Saleh NY, Aboelghar HM, Abdelaty NB, Garib MI, Mahmoud AA. Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial. Clin Exp Pediatr 2023; 66:403-411. [PMID: 37321580 PMCID: PMC10475857 DOI: 10.3345/cep.2023.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/27/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial. PURPOSE To identify the optimal timing of PN initiation in critically ill children. METHODS This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes. RESULTS Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018). CONCLUSION Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.
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Affiliation(s)
- Nagwan Y. Saleh
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Hesham M. Aboelghar
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Nehad B. Abdelaty
- Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Mohamed I. Garib
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Asmaa A. Mahmoud
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
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Veldscholte K, Cramer ABG, de Jonge RCJ, Rizopoulos D, Joosten KFM, Verbruggen SCAT. Intermittent feeding with an overnight fast versus 24-h feeding in critically ill neonates, infants, and children: An open-label, single-centre, randomised controlled trial. Clin Nutr 2023; 42:1569-1580. [PMID: 37478810 DOI: 10.1016/j.clnu.2023.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND & AIMS Critically ill children are fed day and night, assuming this improves enteral tolerance and the probability of achieving nutritional goals. It was previously shown that a fasting response, reflected by increased ketosis, at least partly explained the beneficial outcome of delayed initiation of supplemental parenteral nutrition. This study aims to investigate whether an overnight fast increases ketosis and is feasible and safe in critically ill children. METHODS The Continuousversus Intermittent Nutrition in Paediatric Intensive Care (ContInNuPIC) study is a randomised controlled trial in a tertiary referral Paediatric Intensive Care Unit (PICU) in the Netherlands. Critically ill children (term newborn-18 years) with an expected PICU stay ≥48 h, dependent on artificial nutrition, were eligible. Participants were randomly assigned (1:1, stratified for age group) to intermittent feeding, with interruption of feedings during an age-dependent overnight period of eight to 12 h, or to continuous feeding, with the administration of feedings day and night. In both groups, similar daily caloric targets were pursued. For children younger than one year, mandatory minor glucose infusions were provided during fasting. The primary outcome was the feasibility, defined as two conditions (1): a significant difference in the patients' highest daily ketone (3-β-hydroxybutyrate, BHB) levels during each overnight period, and (2): non-inferiority regarding daily caloric intake, examined using a two-part mixed-effects model with a predefined non-inferiority margin of 33%, in an intention-to-treat analysis. The study is registered in the Netherlands Trial Register (NL7877). RESULTS Between May 19, 2020, and July 13, 2022, 140 critically ill children, median (first quartile; third quartile) age 0.3 (0.1; 2.7) years, were randomised to intermittent (n = 67) or continuous feeding (n = 73). In the intermittent feeding group, BHB levels were significantly higher (median 0.4 (0.2; 1.0) vs. 0.3 (0.1; 0.7) mmol/L, p < 0.001). The ratio of total caloric intake in the intermittent feeding group to the intake in the continuous feeding group was not consistently significantly more than 0.67, thus not proving non-inferiority. No severe, resistant hypoglycaemic events, nor severe gastrointestinal complications related to the intervention occurred, and feeding intolerance did not occur more often in the intermittent than in the continuous feeding group. CONCLUSION Compared with day and night feeding, intermittent feeding with an overnight fast and mandatory glucose infusion for children younger than one year marginally increased ketosis and did not lead to more hypoglycaemic incidents in critically ill children. Because non-inferiority regarding daily caloric intake was not proven, the feasibility of an overnight fast could not be shown in the current study. However, as feeding intolerance did not increase during the condensed feeding periods, the nutritional intake was probably limited by the prescription of nutrition and interruptions. More research is needed to determine the optimal level and duration of clinically relevant ketosis and the best method to achieve this.
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Affiliation(s)
- Karlien Veldscholte
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnout B G Cramer
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rogier C J de Jonge
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sascha C A T Verbruggen
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
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Misirlioglu M, Yildizdas D, Ekinci F, Ozgur Horoz O, Tumgor G, Yontem A, Talay MN, Kangin M, Tufan E, Kesici S, Yener N, Kinik Kaya HE, Havan M, Tunc A, Akçay N, Sevketoglu E, Durak F, Ozel Dogruoz A, Ozcan S, Perk O, Duyu M, Boyraz M, Uysal Yazici M, Ozturk Z, Çeleğen M, Bukulmez A, Kacmaz E, Cagri Dinleyici E, Dursun O, Koker A, Bayraktar S, Talip Petmezci M, Nabaliyeva A, Agin H, Hepduman P, Akkuzu E, Kendirli T, Ozen H, Topal S, Ödek Ç, Ozkale M, Ozkale Y, Atay G, Erdoğan S, Konca C, Yapici G, Arslan G, Besci T, Yilmaz R, Gumus M, Oto A, Dalkiran T, Mercan M, Çoban Y, Ipek S, Gungor S, Arslankoylu AE, Alakaya M, Sari F, Yucel A, Yazar A. Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey. Front Pediatr 2023; 11:1179721. [PMID: 37601138 PMCID: PMC10436004 DOI: 10.3389/fped.2023.1179721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/29/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Malnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies. Material and Method In this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined. Results Of the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024). Conclusion Timely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score.
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Affiliation(s)
- Merve Misirlioglu
- Department of Pediatric Intensive Care, Faculty of Medicine, Mersin University, Mersin, Türkiye
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Faruk Ekinci
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Ozden Ozgur Horoz
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Ahmet Yontem
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Mehmet Nur Talay
- Department of Pediatrics, Health Sciences University, Gazi Yasargil Training and Research Hospital, Diyarbakir, Türkiye
| | - Murat Kangin
- Department of Pediatric Intensive Care, Faculty of Medicine, Medipol University, Istanbul, Türkiye
| | - Erennur Tufan
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Selman Kesici
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Nazik Yener
- Department of Pediatric Intensive Care, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Türkiye
| | - Hatice Elif Kinik Kaya
- Department of Pediatric Intensive Care, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Türkiye
| | - Merve Havan
- Department of Pediatric Intensive Care, Mersin City Training and Research Hospital, Mersin, Türkiye
| | - Ali Tunc
- Department of Pediatrics, Mersin City Training and Research Hospital, Mersin, Türkiye
| | - Nihal Akçay
- Department of Pediatric Intensive Care, University of Health Sciences Bakirkoy, Dr. Sadi Konuk Training and Research Hospital, İstanbul, Türkiye
| | - Esra Sevketoglu
- Department of Pediatric Intensive Care, University of Health Sciences Bakirkoy, Dr. Sadi Konuk Training and Research Hospital, İstanbul, Türkiye
| | - Fatih Durak
- Department of Pediatric Intensive Care, İzmir Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Aysenur Ozel Dogruoz
- Department of Pediatric Intensive Care, İzmir Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Serhan Ozcan
- Department of Pediatric Intensive Care, Ankara City Hospital, Ankara, Türkiye
| | - Oktay Perk
- Department of Pediatric Intensive Care, Ankara City Hospital, Ankara, Türkiye
| | - Muhterem Duyu
- Department of Pediatric Intensive Care, Medeniyet University, Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Türkiye
| | - Merve Boyraz
- Department of Pediatric Intensive Care, Medeniyet University, Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Türkiye
| | - Mutlu Uysal Yazici
- Department of Pediatric Intensive Care, Health Sciences University Ankara, Dr. Sami Ulus Obstetrics Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Zeynelabidin Ozturk
- Department of Pediatric Intensive Care, Health Sciences University Ankara, Dr. Sami Ulus Obstetrics Child Health and Diseases Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Çeleğen
- Department of Pediatric Intensive Care, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyonkarahisar, Türkiye
| | - Aysegul Bukulmez
- Department of Pediatric Gastroenterology, Faculty of Medicine, Hepatology and Nutrition, Afyonkarahisar Health Sciences University, Afyonkarahisar, Türkiye
| | - Ebru Kacmaz
- Department of Pediatric Intensive Care, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Türkiye
| | - Ener Cagri Dinleyici
- Department of Pediatric Intensive Care, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Türkiye
| | - Oguz Dursun
- Department of Pediatric Intensive Care, Faculty of Medicine, Akdeniz University, Antalya, Türkiye
| | - Alper Koker
- Department of Pediatric Intensive Care, Faculty of Medicine, Akdeniz University, Antalya, Türkiye
| | - Suleyman Bayraktar
- Department of Pediatric Intensive Care, Sultangazi Haseki Training and Research Hospital, Istanbul, Türkiye
| | - Mey Talip Petmezci
- Department of Pediatric Intensive Care, Prof. Dr. Cemil Tascıoglu City Hospital, Istanbul, Türkiye
| | - Aygul Nabaliyeva
- Department of Pediatric Intensive Care, Prof. Dr. Cemil Tascıoglu City Hospital, Istanbul, Türkiye
| | - Hasan Agin
- Department of Pediatric Intensive Care, University of Health Sciences Izmir, Dr. Behcet Uz Child Diseases and Surgery Training and Research Hospital, Izmir, Türkiye
| | - Pinar Hepduman
- Department of Pediatric Intensive Care, University of Health Sciences Izmir, Dr. Behcet Uz Child Diseases and Surgery Training and Research Hospital, Izmir, Türkiye
| | - Emine Akkuzu
- Department of Pediatric Intensive Care, Isparta City Hospital, Isparta, Türkiye
| | - Tanil Kendirli
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Türkiye
| | - Hasan Ozen
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Türkiye
| | - Sevgi Topal
- Department of Pediatric Intensive Care, Erzurum Regional Training and Research Hospital, ErzurumTürkiye
| | - Çağlar Ödek
- Department of Pediatric Intensive Care, Faculty of Medicine, Uludag University, Bursa, Türkiye
| | - Murat Ozkale
- Department of Pediatric Intensive Care, Faculty of Medicine, Baskent University, Adana Dr Turgut Noyan Teaching and Medical Research Center, Adana, Türkiye
| | - Yasemin Ozkale
- Department of Pediatric Intensive Care, Faculty of Medicine, Baskent University, Adana Dr Turgut Noyan Teaching and Medical Research Center, Adana, Türkiye
| | - Gürkan Atay
- Department of Pediatric Intensive Care, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Seher Erdoğan
- Department of Pediatric Intensive Care, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Capan Konca
- Department of Pediatric Intensive Care, Adiyaman Training and Research Hospital, Adiyaman, Türkiye
| | - Guler Yapici
- Department of Pediatric Intensive Care, Adiyaman Training and Research Hospital, Adiyaman, Türkiye
| | - Gazi Arslan
- Department of Pediatric Intensive Care, Faculty of Medicine, Dokuz Eylul University, Izmir, Türkiye
| | - Tolga Besci
- Department of Pediatric Intensive Care, Faculty of Medicine, Dokuz Eylul University, Izmir, Türkiye
| | - Resul Yilmaz
- Department of Pediatric Intensive Care, Faculty of Medicine, Selcuk University, Konya, Türkiye
| | - Meltem Gumus
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Selcuk University, Konya, Türkiye
| | - Arzu Oto
- Department of Pediatric Intensive Care, University of Health Sciences Bursa High Specialization Hospital, Bursa, Türkiye
| | - Tahir Dalkiran
- Department of Pediatric Intensive Care, Necip Fazil City Hospital, Kahramanmaras, Türkiye
| | - Mehmet Mercan
- Department of Pediatrics, Necip Fazil City Hospital, Kahramanmaras, Türkiye
| | - Yasemin Çoban
- Department of Pediatric Intensive Care, Faculty of Medicine, Mugla University, Mugla, Türkiye
| | - Sevcan Ipek
- Department of Pediatric Intensive Care, Faculty of Medicine, Sutcu Imam University, Kahramanmaras, Türkiye
| | - Sukru Gungor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Sutcu Imam University, Kahramanmaras, Türkiye
| | - Ali Ertug Arslankoylu
- Department of Pediatric Intensive Care, Faculty of Medicine, Mersin University, Mersin, Türkiye
| | - Mehmet Alakaya
- Department of Pediatric Intensive Care, Faculty of Medicine, Mersin University, Mersin, Türkiye
| | - Ferhat Sari
- Department of Pediatric Intensive Care, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Türkiye
| | - Aylin Yucel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Necmettin Erbakan University Meram, Konya, Türkiye
| | - Abdullah Yazar
- Department of Pediatric Intensive Care, Faculty of Medicine, Necmettin Erbakan University Meram, Konya, Türkiye
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Vergara C, Del Pozo P, Niklitschek J, Le Roy C. Nutritional support in the critical ill patient: Requirements, prescription and adherence. An Pediatr (Barc) 2023; 99:94-101. [PMID: 37537114 DOI: 10.1016/j.anpede.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 05/22/2023] [Indexed: 08/05/2023] Open
Abstract
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.
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Affiliation(s)
- Camila Vergara
- Departamento de Gastroenterología y Nutrición Pediátrica, División de Pediatría, Escuela de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paulina Del Pozo
- Unidad Académica de Cuidados Intensivos Pediátricos, Departamento de Pediatría, División de Pediatría, Escuela de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jessie Niklitschek
- Departamento de Gastroenterología y Nutrición Pediátrica, División de Pediatría, Escuela de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catalina Le Roy
- Departamento de Gastroenterología y Nutrición Pediátrica, División de Pediatría, Escuela de Medicina Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de Pediatría y Cirugía Infantil, Campus Centro, Facultad de Medicina, Universidad de Chile, Santiago, Chile.
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11
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Sierra-Colomina M, Yehia NA, Mahmood F, Parshuram C, Mtaweh H. A Retrospective Study of Complications of Enteral Feeding in Critically Ill Children on Noninvasive Ventilation. Nutrients 2023; 15:2817. [PMID: 37375722 DOI: 10.3390/nu15122817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
The utilization of noninvasive ventilation (NIV) in pediatric intensive care units (PICUs), to support children with respiratory failure and avoid endotracheal intubation, has increased. Current guidelines recommend initiating enteral nutrition (EN) within the first 24-48 h post admission. This practice remains variable among PICUs due to perceptions of a lack of safety data and the potential increase in respiratory and gastric complications. The objective of this retrospective study was to evaluate the association between EN and development of extraintestinal complications in children 0-18 years of age on NIV for acute respiratory failure. Of 332 patients supported with NIV, 249 (75%) were enterally fed within the first 48 h of admission. Respiratory complications occurred in 132 (40%) of the total cohort and predominantly in non-enterally fed patients (60/83, 72% vs. 72/249, 29%; p < 0.01), and they occurred earlier during ICU admission (0 vs. 2 days; p < 0.01). The majority of complications were changes in the fraction of inspired oxygen (220/290, 76%). In the multivariate evaluation, children on bilevel positive airway pressure (BiPAP) (23/132, 17% vs. 96/200, 48%; odds ratio [OR] = 5.3; p < 0.01), receiving a higher fraction of inspired oxygen (FiO2) (0.42 vs. 0.35; OR = 6; p = 0.03), and with lower oxygen saturation (SpO2) (91% vs. 97%; OR = 0.8; p < 0.01) were more likely to develop a complication. Time to discharge from the intensive care unit (ICU) was longer for patients with complications (11 vs. 3 days; OR = 1.12; p < 0.01). The large majority of patients requiring NIV can be enterally fed without an increase in respiratory complications after an initial period of ICU stabilization.
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Affiliation(s)
| | - Nagam Anna Yehia
- Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Farhan Mahmood
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Christopher Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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12
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Touré I, Maitre G, Boillat L, Chanez V, Natterer J, Ferry T, Longchamp D, Perez MH. Implementing a physician-driven feeding protocol is not sufficient to achieve adequate caloric and protein delivery in a paediatric intensive care unit: A retrospective cohort study. Clin Nutr ESPEN 2023; 55:384-391. [PMID: 37202072 DOI: 10.1016/j.clnesp.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND AIMS Daily caloric and protein intake is crucial for the management of critically ill children. The benefit of feeding protocols in improving daily nutritional intake in children remains controversial. This study aimed to assess whether the introduction of an enteral feeding protocol in a paediatric intensive care unit (PICU) improves daily caloric and protein delivery on day 5 after admission and the accuracy of the medical prescription. METHODS Children admitted to our PICU for a minimum of 5 days who received enteral feeding were included. Daily caloric and protein intake were recorded and retrospectively compared before and after the introduction of the feeding protocol. RESULTS Caloric and protein intake was similar before and after introduction of the feeding protocol. The prescribed caloric target was significantly lower than the theoretical target. The children who received less than 50% of the caloric and protein targets were significantly heavier and taller than those who received more than 50%; the patients who received more than 100% of the caloric and protein aims on day 5 after admission had a decreased PICU length of stay and decreased duration of invasive ventilation. CONCLUSION The introduction of a physician-driven feeding protocol was not associated with an increase in the daily caloric or protein intake in our cohort. Other methods of improving nutritional delivery and patient outcomes need to be explored.
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Affiliation(s)
- Ismael Touré
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Guillaume Maitre
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Laurence Boillat
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Vivianne Chanez
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Julia Natterer
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Thomas Ferry
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - David Longchamp
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
| | - Maria-Helena Perez
- Paediatric Intensive Care Unit, Service of Paediatrics, Women-Mother-Children Department, Lausanne University and Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
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13
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Liauchonak S, Hamilton S, Franks JD, Callif C, Akhondi-Asl A, Ariagno K, Mehta NM, Martinez EE. Impact of implementing an evidence-based definition of enteral nutrition intolerance on nutrition delivery: A prospective, cross-sectional cohort study. Nutr Clin Pract 2023; 38:376-385. [PMID: 36541429 PMCID: PMC10023272 DOI: 10.1002/ncp.10941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/28/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) interruptions because of EN intolerance impede nutrient delivery. We aimed to examine whether revising the EN intolerance definition of an algorithm would decrease EN interruptions and improve nutrient delivery in critically ill children. METHODS We performed a cross-sectional cohort study including patients who were admitted to our intensive care unit (ICU) for >24 h and received EN. The EN intolerance definition in our nutrition algorithm was modified to include two symptoms of EN intolerance. We compared time to 60% EN adequacy (EN delivered/EN prescribed x 100) and EN interruptions before and after this intervention. RESULTS We included 150 eligible patients, 78 and 72 patients in the preimplementation and postimplementation cohorts, respectively. There were no significant differences in demographics and clinical characteristics. The preimplementation and postimplementation cohorts achieved 60% EN adequacy 4 (2-5) days and 3 (2-5) days after ICU admission, respectively (P = 0.59). The preimplementation cohort had a median of 1 (1-2) interruption per patient and the postimplementation cohort 2 (1-3; P = 0.08). The frequency of interruptions because of EN intolerance within the first 8 days of ICU admission was 17 in the preimplementation and 10 in the postimplementation cohorts. CONCLUSION Modifying the EN intolerance definition of a nutrition algorithm did not change the time to 60% EN adequacy or total number of EN interruptions in critically ill children. EN intolerance and interruptions continue to limit nutrient delivery. Research on the best definition for EN intolerance and its effect on nutrition outcomes is needed.
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Affiliation(s)
- Siarhei Liauchonak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Susan Hamilton
- Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Jennifer D. Franks
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Katelyn Ariagno
- Center for Nutrition, Department of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Center for Nutrition, Department of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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14
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Solana MJ, Slocker M, Martínez de Compañon Z, Olmedilla M, Miñambres M, Reyes S, Fernández R, Rodríguez E, Redondo S, Díaz L, Sánchez M, López-Herce J. Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children. Nutrients 2023; 15:nu15040855. [PMID: 36839213 PMCID: PMC9961435 DOI: 10.3390/nu15040855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.
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Affiliation(s)
- María José Solana
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Departamento de Salud Pública y Materno infantil, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
- Correspondence:
| | - María Slocker
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
| | | | | | - María Miñambres
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Susana Reyes
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Reyes Fernández
- Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Eva Rodríguez
- Hospital Universitario Nuestra Señora de la Candelaria, 38010 Tenerife, Spain
| | | | - Laura Díaz
- Complejo Hospitalario de Navarra, 31008 Pamplona, Spain
| | - María Sánchez
- Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Jesús López-Herce
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
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15
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Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S45-S60. [PMID: 36661435 DOI: 10.1097/pcc.0000000000003158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation). DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.
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16
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Kappel SS, Maastrup R, Sangild PT, Jakobsen KT, Christensen VB, Aunsholt L. Nurses' and Physicians' Rationale Behind Clinical Performance and Interpretation of Routine Prefeed Gastric Aspiration in Preterm Infants: A Cross-sectional Study. J Perinat Neonatal Nurs 2023; 37:77-83. [PMID: 36548337 DOI: 10.1097/jpn.0000000000000618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This study aims at understanding the rationale behind performing prefeed gastric aspirations in preterm infants, how nurses and physicians interpret the gastric aspiration and variations between them, and illuminating potential barriers for omitting routine prefeed aspiration. Nurses and physicians from all Danish neonatal intensive care units completed a questionnaire. Of 682 participants, the majority (94%) indicated that they routinely performed prefeed aspiration, primarily to check the feeding tube placement (nurses: 88%, physicians: 46%). Nurses feared necrotizing enterocolitis when observing a large gastric residual (GR) volume (31%) and green-stained GR (63%). Fewer nurses relative to physicians had "no worries" related to large volumes (15% vs 34%) or green-stained GR (14% vs 24%, both P < .01). More nurses than physicians intended to pause enteral feeding when observing green-stained GR (31% vs 16%, P < .01) and more nurses were concerned of completely omitting routine gastric aspirations (90% vs 46%, P < .05). The rationale behind the clinical use of GR volume and color as markers of necrotizing enterocolitis and feeding intolerance differs markedly between nurses and physicians in Denmark. If routine prefeed gastric aspiration should be omitted, special focus on information about early signs of necrotizing enterocolitis and methods to check tube placement is needed.
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Affiliation(s)
- Susanne Soendergaard Kappel
- Departments of Neonatology (MScN Kappel and Drs Maastrup, Sangild, and Aunsholt) and Pediatrics and Adolescent Medicine (Dr Christensen), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhagen, Denmark (MScN Kappel and Drs Sangild and Aunsholt); Department of Pediatrics, Odense University Hospital, Odense, Denmark (Dr Sangild); and The Think Tank DEA, Copenhagen, Denmark (Dr Jakobsen)
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17
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Baldini L, Librandi K, D’Eusebio C, Lezo A. Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood. Nutrients 2022; 14:nu14194055. [PMID: 36235705 PMCID: PMC9572747 DOI: 10.3390/nu14194055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.
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Affiliation(s)
- Letizia Baldini
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Pediatria Specialistica, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
- Correspondence:
| | - Katia Librandi
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Chiara D’Eusebio
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
| | - Antonella Lezo
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
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18
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Gysi S, Doulberis M, Légeret C, Köhler H. The Role of the Pediatric Yorkhill Malnutrition Score (PYMS), Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Malnutrition Prediction of Hospitalized Children. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091378. [PMID: 36138687 PMCID: PMC9497887 DOI: 10.3390/children9091378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022]
Abstract
Malnutrition in hospitalized children represents a significant burden with occasionally detrimental consequences. In this retrospective analysis of pediatric patients aged one to 16 years old, who were hospitalized in the children’s cantonal hospital of Aarau, Switzerland, we investigated the utilization of PYMS (Pediatric Yorkhill Malnutrition Score) as a routine screening tool for malnutrition in pediatric inpatients. Additionally, we explored the correlation between PYMS and NLR (neutrophil−lymphocyte ratio) and PLR (platelet−lymphocyte ratio), which are two novel biomarkers. Various parameters were analyzed from the medical records of the patients. Most of the sample (n = 211, 77.3%) was characterized by a low PYMS of 0−1 point. Greater NLR and PLR values were significantly associated with greater PYMS (p = 0.030 and p = 0.004, respectively). ROC (receiver operating characteristic curves) analysis revealed that PLR had a significant predictive ability for having PYMS > 1 (AUC = 0.59; 95% CI: 0.51−0.68; p = 0.024). The optimal cut-off was 151 with sensitivity of 51.6% (95% CI: 38.6−64.5%) and specificity of 67.3% (95% CI: 60.5−73.6%). Furthermore, 37% of the children (n = 101) yielded a PLR over 151. Our results support a promising value of PLR as a predictive marker for moderate to severe malnutrition in hospitalized children.
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Affiliation(s)
- Spyridoula Gysi
- Children’s Hospital of Aarau, 5001 Aarau, Switzerland
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
- Correspondence: ; Tel.: +41-76-226-2027
| | - Michael Doulberis
- Division of Gastroenterology and Hepatology, Medical University Department, Cantonal Hospital of Aarau, 5001 Aarau, Switzerland
- Department of Gastroenterology and Hepatology, University of Zurich, 8091 Zurich, Switzerland
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, 54652 Thessaloniki, Macedonia, Greece
| | - Corinne Légeret
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
- University Children’s Hospital Basel, 4056 Basel, Switzerland
| | - Henrik Köhler
- Children’s Hospital of Aarau, 5001 Aarau, Switzerland
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
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Lee AE, Munoz E, Al Dabbous T, Harris E, O'Callaghan M, Raman L. Extracorporeal Life Support Organization Guidelines for the Provision and Assessment of Nutritional Support in the Neonatal and Pediatric ECMO Patient. ASAIO J 2022; 68:875-880. [PMID: 35703144 DOI: 10.1097/mat.0000000000001767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Amy E Lee
- From the Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Tala Al Dabbous
- Bayt Abdullah Children's Hospice, Al-Adan Hospital, NBK Children's Hospital, Kuwait City, Kuwait
| | | | - Maura O'Callaghan
- ECMO Service Team, Great Ormond Street Hospital, London, United Kingdom
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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20
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Impact of Nutrition Support Team in Achieving Target Calories in Children Admitted in Pediatric Intensive Care Unit. J Pediatr Gastroenterol Nutr 2022; 74:830-836. [PMID: 35258507 DOI: 10.1097/mpg.0000000000003438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
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.
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21
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Elliott E, Shoykhet M, Bell MJ, Wai K. Nutritional Support for Pediatric Severe Traumatic Brain Injury. Front Pediatr 2022; 10:904654. [PMID: 35656382 PMCID: PMC9152222 DOI: 10.3389/fped.2022.904654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Elizabeth Elliott
- Critical Care Medicine, Children's National Hospital, Washington, DC, United States
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22
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Achievement of Nutritional Goals after a Pediatric Intensive Care Unit Nutrition Support Guideline Implementation. Clin Nutr ESPEN 2022; 50:277-282. [DOI: 10.1016/j.clnesp.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 11/22/2022]
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23
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Zevallos MSC, Jara KSS, Ramírez CAC, Carreazo NY. Impact of Early Enteral Nutrition on the Hospital Stay of Pediatric Patients Undergoing Mechanical Ventilation. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1744296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractEarly initiation of enteral nutrition (EN) in pediatrics has been associated with improved clinical outcomes in critically ill pediatric patients. This research study aimed to measure the effect of early EN in intubated children on the length of stay (LOS) and days of mechanical ventilation (DMV). A retrospective cohort observational study was performed on patients admitted to the pediatric intensive care unit (PICU). We gathered the information from available medical records. Our exposure variable was EN, which can be classified as either early-onset (less than 72 hours following PICU admission) or late-onset (greater than or equal to 72 hours following PICU admission). The response variables were LOS defined as the period of time from either hospital or PICU admission to the time of hospital discharge and DMV defined as the length of time from endotracheal intubation to successful extubation. Late EN was associated with an increase in both hospital LOS consisting of 9.82 days and PICU LOS consisting of 5.89 days, and DMV consisting of 3.92 days compared with those patients receiving early EN. In addition, the disruption of EN was also associated with an increased hospital LOS consisting of 10.7 days. Patients in the PICU, undergoing mechanical ventilation, who received late EN have an increased risk of unfavorable outcomes consisting of prolonged hospital LOS, PICU-LOS, and DMV which may be further aggravated by any disruption of EN.
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Affiliation(s)
| | | | | | - Nilton Yhuri Carreazo
- School of Medicine, Universidad Peruana de Ciencias Aplicadas, Santiago de Surco, Peru
- Intensive Care Unit, Hospital de Emergencias Pediatricas, Lima, Peru
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24
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Typpo KV, Irving SY, Prince JM, Pathan N, Brown AM. Gastrointestinal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S53-S58. [PMID: 34970680 PMCID: PMC9662164 DOI: 10.1542/peds.2021-052888h] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 02/02/2023] Open
Abstract
CONTEXT Prior criteria to define pediatric multiple organ dysfunction syndrome (MODS) did not include gastrointestinal dysfunction. OBJECTIVES Our objective was to evaluate current evidence and to develop consensus criteria for gastrointestinal dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and EMBASE were conducted from January 1992 to January 2020, using medical subject heading terms and text words to define gastrointestinal dysfunction, pediatric critical illness, and outcomes. STUDY SELECTION Studies were included if they evaluated critically ill children with gastrointestinal dysfunction, performance characteristics of assessment/scoring tools to screen for gastrointestinal dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, case series with sample size ≤10, and non-English language studies with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS The systematic review supports the following criteria for severe gastrointestinal dysfunction: 1a) bowel perforation, 1b) pneumatosis intestinalis, or 1c) bowel ischemia, present on plain abdominal radiograph, computed tomography (CT) scan, magnetic resonance imaging (MRI), or gross surgical inspection, or 2) rectal sloughing of gut mucosa. LIMITATIONS The validity of the consensus criteria for gastrointestinal dysfunction are limited by the quantity and quality of current evidence. CONCLUSIONS Understanding the role of gastrointestinal dysfunction in the pathophysiology and outcomes of MODS is important in pediatric critical illness.
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Affiliation(s)
- Katri V. Typpo
- Department of Pediatrics and the Steele Children’s Research Center, University of Arizona College of Medicine, Tucson, AZ
| | - Sharon Y. Irving
- Associate Professor, Department of Family and Community Health, University of Pennsylvania School of Nursing
| | - Jose M. Prince
- Associate Professor of Surgery and Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, University Lecturer in Paediatrics, University of Cambridge, Clinical Research Associate, Kings College, Cambridge
| | - Ann-Marie Brown
- Associate Clinical Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA,Nurse Scientist, Children’s Healthcare of Atlanta, Atlanta, GA
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Nabialek T, Tume LN, Cercueil E, Morice C, Bouvet L, Baudin F, Valla FV. Planned Peri-Extubation Fasting in Critically Ill Children: An International Survey of Practice. Front Pediatr 2022; 10:905058. [PMID: 35633966 PMCID: PMC9132478 DOI: 10.3389/fped.2022.905058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them. MATERIALS AND METHODS A cross sectional electronic survey was disseminated via the European Pediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation. RESULTS We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice: 46 (38%) and 26 (21%) of PICUs withheld oral and gastric/jejunal nutrition more than 5 h, respectively, and 45 (37%) started oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children [78 (64%)] or reducing fasting times [57 (47%)] respectively. DISCUSSION This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it.
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Affiliation(s)
- Tomasz Nabialek
- Pediatric Intensive Care, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Eloise Cercueil
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Claire Morice
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Lionel Bouvet
- Department of Anesthesiology and Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Florent Baudin
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Frederic V Valla
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
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Powell MBF, Rajapreyar P, Yan K, Sirinit J, Mikhailov TA. Nutritional practices & outcomes in patients with pediatric acute respiratory distress syndrome. JPEN J Parenter Enteral Nutr 2021; 46:1290-1297. [PMID: 34961948 PMCID: PMC9546013 DOI: 10.1002/jpen.2320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pediatric acute respiratory distress syndrome (PARDS) remains a significant cause of morbidity and mortality. Evidence suggests enteral nutrition (EN) may be protective in critically ill children. This study was designed to determine if an association exists between early enteral nutrition (EEN) and PARDS outcomes. METHODS Retrospective cohort study comparing intubated patients with PARDS who received EEN and those who did not. We included intubated patients with PARDS aged 2 weeks to 18 years who could receive full nutrition enterally prior to their disease and excluded patients with cyanotic heart disease. Disease severity captured with oxygenation index (OI), oxygen saturation index (OSI), and pediatric logistic organ dysfunction (PELOD-2) scores. EEN defined as having received at least 25% of calculated caloric goal enterally within the first 48 hours of PARDS diagnosis. We compared PICU mortality, PICU length of stay (LOS), and 28-day ventilator-free days between EEN and non-EEN groups. RESULTS We included 151 patients. Adjusted for age, OI, and OSI, the EEN group had a lower PICU mortality rate (aOR=0.071, 95% CI 0.009-0.542, p=0.011), higher likelihood of PICU discharge (aRR=1.79, 95% CI 1.25-2.55, p=0.001) and was more likely to have at least one ventilator-free day (aOR=3.96, 95% CI 1.28-12.22, p=0.017). Adjusted for age and PELOD-2, a statistically significant association between the EEN group and lower PICU mortality (p=0.033), shorter PICU LOS (p<0.001), and more ventilator-free days (p=0.037) persisted. CONCLUSIONS Our study found EEN was associated with superior mortality rates, PICU LOS, and ventilator-free days in patients with PARDS. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Matthew B F Powell
- Medical College of Wisconsin, Milwaukee, WI, USA.,Children's Wisconsin, Milwaukee, WI, USA
| | | | - Ke Yan
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Theresa A Mikhailov
- Medical College of Wisconsin, Milwaukee, WI, USA.,Children's Wisconsin, Milwaukee, WI, USA
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27
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Brown AM, Irving SY, Pringle C, Allen C, Brown MF, Nett S, Singleton MN, Mikhailov TA, Madsen E, Srinivasan V, Anthony H, Forbes ML. Bolus Gastric Feeds Improve Nutritional Delivery to Mechanically Ventilated Pediatric Medical Patients: Results of the COntinuous vs BOlus (COBO2) Multi-Center Trial. JPEN J Parenter Enteral Nutr 2021; 46:1011-1021. [PMID: 34881440 DOI: 10.1002/jpen.2305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 09/28/2021] [Accepted: 11/05/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Comparison of bolus (BGF) versus continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered. METHODS Multi-center, prospective, randomized comparative effectiveness trial conducted in seven Pediatric ICUs (PICUs). Eligibility criteria: 1 month - 12 years of age, intubated within 24 hours of PICU admission, expected duration of ventilation at least 48 hours, eligible to begin enteral nutrition within 48 hours. EXCLUSION CRITERIA acute or chronic gastrointestinal pathology, or acute surgery. RESULTS We enrolled 158 mechanically ventilated children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). The BGF group was slightly older than CGF, otherwise the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group that achieved goal feeds. Time to goal feeds was shorter in the BGF [Hazard Ratio 1.5 (CI 1.02-2.33); P = 0.0387]. Median percentage of target kilocalories [median kcal 0.78 vs 0.59; p = <.0001], and median percentage of protein delivered [median pro 0.77 vs 0.59; p = <.0001] was higher for BGF patients. There was no difference in serial oxygen saturation index between groups. CONCLUSION Our study demonstrated shorter time to achieve goal nutrition via BGF compared to CGF in mechanically ventilated pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ann-Marie Brown
- Associate Clinical Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Nurse Scientist, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sharon Y Irving
- Associate Professor, Pediatric Nursing, Vice-Chair Department of Family & Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Charlene Pringle
- Pediatric Acute Care Nurse Practitioner, Division of Pediatric Critical Care Medicine, University of Florida, UFHealth Shands Children's Hospital, Gainesville, FL
| | - Christine Allen
- Associate Professor o Pediatrics, Division of Pediatric Critical Care, University of Oklahoma Health Sciences Center, The Children's Hospital at OU Health, Oklahoma City, OK
| | - Miraides F Brown
- Biostatistician, Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH
| | - Sholeen Nett
- Associate Professor, Division of Pediatric Critical Care, Dartmouth Hitchcock Medical Center, Lebanon, NH and Baystate Children's Hospital, Springfield, MA
| | - Marcy N Singleton
- Pediatric Acute Care Nurse Practitioner, Dartmouth Hitchcock Medical Center, Instructor in Pediatrics Geisel School of Medicine
| | - Theresa A Mikhailov
- Professor of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Pediatric Intensivist, Children's Wisconsin, Milwaukee, WI
| | - Erik Madsen
- Assistant Professor of Pediatrics, Division of Pediatric Critical Care, Saint Louis University School of Medicine, Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Vijay Srinivasan
- Assistant Professor of Anesthesiology, Critical Care and Pediatrics, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Attending Pediatric Intensivist, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heather Anthony
- Clinical Research Support Team Supervisor, GAMUT Program Coordinator, Clinical Research Nurse, Akron Children's Hospital, Akron, OH
| | - Michael L Forbes
- Professor of Pediatrics, Northeast Ohio Medical University, Associate Chair, Department of Pediatrics, Director, Hospital-Based Medical Practices, Director, Critical Care Research & Outcomes Analysis, Akron Children's Hospital, Akron, OH
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28
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Martinez EE, Dang H, Franks J, Callif CG, Tasker RC, Madden K, Mehta NM. Association Between Anticholinergic Drug Burden and Adequacy of Enteral Nutrition in Critically Ill, Mechanically Ventilated Pediatric Patients. Pediatr Crit Care Med 2021; 22:1083-1087. [PMID: 34560773 DOI: 10.1097/pcc.0000000000002840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Enteral nutrition delivery is limited by intolerance and interruptions in critically ill children. Anticholinergic properties of frequently administered medications may contribute to altered gastric motility and enteral nutrition intolerance in this population. We examined the association between the anticholinergic burden of administered medications using the Anticholinergic Drug Scale and adequacy of enteral nutrition delivery. DESIGN Secondary analysis of data from a previously characterized PICU cohort. SETTING Multidisciplinary PICU in a quaternary academic medical center. PATIENTS Younger than or equal to 18 years, on mechanical ventilation and received enteral nutrition within the first 3 days of PICU admission. MEASUREMENTS AND MAIN RESULTS Daily Anticholinergic Drug Scale score, demographic data, and clinical data were obtained from the primary study. Percent enteral energy adequacy ([kcal delivered ÷ kcal prescribed] × 100) during the first 3 days of PICU admission was calculated. Forty-two patients received enteral nutrition, with median age (interquartile range) 5 years (1.09-12.54 yr), and 62% were male. Median Anticholinergic Drug Scale score was inversely correlated with energy adequacy, with a median 9% decline in energy adequacy per 1-point increase in Anticholinergic Drug Scale score (coefficient, -9.3; 95% CI, -13.43 to -5.27; R2 = 0.35; p < 0.0001). Median hours of enteral nutrition interruptions directly correlated with Anticholinergic Drug Scale score (coefficient, 1.5; 95% CI, 0.531-2.54; R2 = 0.19; p = 0.004). Severity score was greater in patients with less than or equal to 25% enteral energy adequacy and directly correlated with median Anticholinergic Drug Scale score. CONCLUSIONS Anticholinergic burden from medications administered in the PICU is a potentially modifiable factor for suboptimal enteral nutrition delivery.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jennifer Franks
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Charles G Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Nutrition, Boston Children's Hospital, Boston, MA
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29
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Novel role of zonulin in the pathophysiology of gastro-duodenal transit: a clinical and translational study. Sci Rep 2021; 11:22462. [PMID: 34789790 PMCID: PMC8599512 DOI: 10.1038/s41598-021-01879-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/25/2021] [Indexed: 12/29/2022] Open
Abstract
We examined the relationship between zonulin and gastric motility in critical care patients and a translational mouse model of systemic inflammation. Gastric motility and haptoglobin (HP) 2 isoform quantification, proxy for zonulin, were examined in patients. Inflammation was triggered by lipopolysaccharide (LPS) injection in C57Bl/6 zonulin transgenic mouse (Ztm) and wildtype (WT) mice as controls, and gastro-duodenal transit was examined by fluorescein-isothiocyanate, 6 and 12 h after LPS-injection. Serum cytokines and zonulin protein levels, and zonulin gastric-duodenal mRNA expression were examined. Eight of 20 patients [14 years, IQR (12.25, 18)] developed gastric dysmotility and were HP2 isoform-producing. HP2 correlated with gastric dysmotility (r = − 0.51, CI − 0.81 to 0.003, p = 0.048). LPS injection induced a time-dependent increase in IL-6 and KC-Gro levels in all mice (p < 0.0001). Gastric dysmotility was reduced similarly in Ztm and WT mice in a time-dependent manner. Ztm had 16% faster duodenal motility than WT mice 6H post-LPS, p = 0.01. Zonulin mRNA expression by delta cycle threshold (dCT) was higher in the stomach (9.7, SD 1.4) than the duodenum (13.9, SD 1.4) 6H post-LPS, p = 0.04. Serum zonulin protein levels were higher in LPS-injected mice compared to vehicle-injected animals in a time-dependent manner. Zonulin correlated with gastric dysmotility in patients. A mouse model had time-dependent gastro-duodenal dysmotility after LPS-injection that paralleled zonulin mRNA expression and protein levels.
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30
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Shine AM, Foyle L, Gentles E, Ward F, McMahon CJ. Growth and Nutritional Intake of Infants with Univentricular Circulation. J Pediatr 2021; 237:79-86.e2. [PMID: 34171362 DOI: 10.1016/j.jpeds.2021.06.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the nutritional status and early nutritional intake of infants with univentricular congenital heart disease. STUDY DESIGN The included infants underwent a Norwood procedure or hybrid intervention (stage 1) within the first 6 weeks of life, between January 2014 and January 2019, at Children's Health Ireland at Crumlin. Demographic, anthropometric, nutritional intake, and morbidity data were collected. RESULTS Data were collected on 90 infants and 1886 neonatal admission days. There was a significant drop in mean weight-for-age z-score (WAZ) between measurements at birth, -0.01 and on discharge post stage 1 surgery -1.45 (P < .01). On hospital discharge (median hospital stay, 25 days) 32% of infants had a WAZ <-2 and 11% had a WAZ <-3. Pre-stage 1, 26% received trophic feeds and 39% received parenteral nutrition. Basal metabolic requirements and target caloric intake (120 kcal/kg) were met on 56% and 13% of admission days, respectively. Infants referred to a dietitian had a shorter time to any form of nutrition support, enteral feeds, and target caloric intake (P < .001, P = .016, and P = .048, respectively). At stage 3 (Fontan) surgery, 15% of infants were classified as stunted (length-for-age z-score [LAZ] <-2). CONCLUSIONS The greatest decline in nutritional status occurs in the neonatal period, followed by significant growth stunting by the time of the Fontan procedure. Early involvement of dietitians is critical in the care of this nutritionally fragile group. With the currently low rate of preoperative nutritional support, there may be opportunities to improve intake at this critical stage.
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Affiliation(s)
- Anne Marie Shine
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland.
| | - Leah Foyle
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Emma Gentles
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Fiona Ward
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology and Cardiothoracic Surgery, Children's Health Ireland at Crumlin, Dublin, Ireland
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31
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Miserachs M, Kean P, Tuira L, Al Nasser Y, De Angelis M, Van Roestel K, Ghanekar A, Cattral M, Mouzaki M, Ng VL, Mtaweh H, Avitzur Y. Standardized Feeding Protocol Improves Delivery and Acceptance of Enteral Nutrition in Children Immediately After Liver Transplantation. Liver Transpl 2021; 27:1443-1453. [PMID: 34018670 DOI: 10.1002/lt.26102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/10/2021] [Accepted: 04/24/2021] [Indexed: 12/13/2022]
Abstract
Delivery of adequate nutrition after liver transplantation (LT) surgery is an important goal of postoperative care. Existing guidelines recommend early enteral nutrition after abdominal surgery and in the child who is critically ill but data on nutritional interventions after LT in children are sparse. We evaluated the impact of a standardized postoperative feeding protocol on enteral nutrition delivery in children after LT. Data from 49 children (ages 0-18 years) who received a LT prior to feeding protocol implementation were compared with data for 32 children undergoing LT after protocol implementation. The 2 groups did not differ with respect to baseline demographic data. After protocol implementation, enteral nutrition was started earlier (2 versus 3 days after transplant; P = 0.005) and advanced faster when a feeding tube was used (4 versus 8 days; P = 0.03). Protocol implementation was also associated with reduced parenteral nutrition use rates (47% versus 75%; P = 0.01). No adverse events occurred after protocol implementation. Hospital length of stay and readmission rates were not different between the 2 groups. In conclusion, implementation of a postoperative nutrition protocol in children after LT led to optimized nutrient delivery and reduced variability of care.
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Affiliation(s)
- Mar Miserachs
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Obstetrics and Gynaecology and Preventative Medicine, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Penni Kean
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lori Tuira
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yasser Al Nasser
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maria De Angelis
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada
| | - Krista Van Roestel
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Ontario, Canada
| | - Mark Cattral
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Ontario, Canada
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vicky Lee Ng
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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32
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Opeyemi OM, Rogers MB, Firek BA, Janesko-Feldman K, Vagni V, Mullett SJ, Wendell SG, Nelson BP, New LA, Mariño E, Kochanek PM, Bayır H, Clark RS, Morowitz MJ, Simon DW. Sustained Dysbiosis and Decreased Fecal Short-Chain Fatty Acids after Traumatic Brain Injury and Impact on Neurologic Outcome. J Neurotrauma 2021; 38:2610-2621. [PMID: 33957773 PMCID: PMC8403202 DOI: 10.1089/neu.2020.7506] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Traumatic brain injury (TBI) alters microbial populations present in the gut, which may impact healing and tissue recovery. However, the duration and impact of these changes on outcome from TBI are unknown. Short-chain fatty acids (SCFAs), produced by bacterial fermentation of dietary fiber, are important signaling molecules in the microbiota gut-brain axis. We hypothesized that TBI would lead to a sustained reduction in SCFA producing bacteria, fecal SCFAs concentration, and administration of soluble SCFAs would improve functional outcome after TBI. Adult mice (n = 10) had the controlled cortical impact (CCI) model of TBI performed (6 m/sec, 2-mm depth, 50-msec dwell). Stool samples were collected serially until 28 days after CCI and analyzed for SCFA concentration by high-performance liquid chromatography-mass spectrometry/mass spectrometry and microbiome analyzed by 16S gene sequencing. In a separate experiment, mice (n = 10/group) were randomized 2 weeks before CCI to standard drinking water or water supplemented with the SCFAs acetate (67.5 mM), propionate (25.9 mM), and butyrate (40 mM). Morris water maze performance was assessed on post-injury Days 14-19. Alpha diversity remained stable until 72 h, at which point a decline in diversity was observed without recovery out to 28 days. The taxonomic composition of post-TBI fecal samples demonstrated depletion of bacteria from Lachnospiraceae, Ruminococcaceae, and Bacteroidaceae families, and enrichment of bacteria from the Verrucomicrobiaceae family. Analysis from paired fecal samples revealed a reduction in total SCFAs at 24 h and 28 days after TBI. Acetate, the most abundant SCFA detected in the fecal samples, was reduced at 7 days and 28 days after TBI. SCFA administration improved spatial learning after TBI versus standard drinking water. In conclusion, TBI is associated with reduced richness and diversity of commensal microbiota in the gut and a reduction in SCFAs detected in stool. Supplementation of soluble SCFAs improves spatial learning after TBI.
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Affiliation(s)
| | - Matthew B. Rogers
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian A. Firek
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vincent Vagni
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven J. Mullett
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stacy G. Wendell
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brittany P. Nelson
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee Ann New
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eliana Mariño
- Department of Biochemistry, Monash University, Melbourne, Victoria, Australia
| | - Patrick M. Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Children's Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hülya Bayır
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Children's Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Children's Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J. Morowitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Microbiome and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dennis W. Simon
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- UPMC Children's Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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33
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Hawk H, Valdivia H. Bedside Methods for Transpyloric Feeding Tube Insertion in Hospitalized Children: A Systematic Review of Randomized and non-Randomized Trials. J Pediatr Nurs 2021; 60:238-246. [PMID: 34304053 DOI: 10.1016/j.pedn.2021.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/18/2022]
Abstract
PROBLEM Enteral nutrition is a critical component of therapy for many hospitalized children. Some children, especially those with critical illness, require post-pyloric enteral nutrition, but placement of post-pyloric feeding tubes poses challenges, necessitating costly fluoroscopy procedures and delaying initiation of enteral nutrition. There is no established standard method for pediatric transpyloric tube placement at the bedside. ELIGIBILITY CRITERIA We searched for trials that assessed the efficacy of methods for transpyloric tube placement at the bedside. Studies that evaluated gastric insufflation, prokinetic agents, pH guided devices, and electromagnetic devices with an objective of bedside transpyloric tube placement in children ages one month to 18 years were included. RESULTS After each author independently reviewed the search results, we agreed on fourteen articles for inclusion, consisting of six randomized controlled trials, five quasi-experimental studies, and three cohort studies. Intervention protocols varied, both within and between studies, with most trials incorporating more than one variable in the intervention. CONCLUSIONS The heterogeneity of the research does not provide clear direction about best practices. All interventions demonstrated some efficacy, with the exception of erythromycin. Gastric insufflation, the most prevalent intervention studied, is safe and at least moderately effective. The research demonstrates the positive impact of a small, trained team of personnel for the insertion of a transpyloric tube. IMPLICATIONS High quality studies with clear protocols evaluating a single variable are needed in order to establish a bedside transpyloric tube placement protocol. We recommend studies on the efficacy of a dedicated team for this procedure.
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Affiliation(s)
- Heather Hawk
- Oregon Health and Science University, School of Nursing, OR, United States of America.
| | - Hector Valdivia
- Seattle Children's Hospital, Pediatric Intensive Care Unit & Clinical Effectiveness, WA, United States of America.
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34
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Veldscholte K, Cramer ABG, Joosten KFM, Verbruggen SCAT. Intermittent fasting in paediatric critical illness: The properties and potential beneficial effects of an overnight fast in the PICU. Clin Nutr 2021; 40:5122-5132. [PMID: 34461586 DOI: 10.1016/j.clnu.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022]
Abstract
Although evidence for the superiority of continuous feeding over intermittent feeding is lacking, in most paediatric intensive care units (PICU) artificial feeding is administered continuously for 24 h per day. Until now, studies in PICU on intermittent feeding have primarily focused on surrogate endpoints such as nutritional intake and gastro-intestinal complaints and none have studied the effects of an extended fasting period. Intermittent fasting has been proven to have many health benefits in both animal and human studies. The observed beneficial effects are based on multiple metabolic and endocrine changes that are presumed crucial in critical illness as well. One key element is the transition to ketone body metabolism, which, among others, contributes to the stimulation of several cellular pathways involved in stress resistance (neuro)plasticity and mitochondrial biogenesis, and might help preserve brain function. Secondly, the fasting state stimulates the activation of autophagy, a process that is crucial for cellular function and integrity. Of the different intermittent fasting strategies investigated, time-restricted feeding with a daily extended fasting period appears most feasible in the PICU. Moreover, planning the fasting period overnight could help maintain the circadian rhythm. Although not investigated, such an overnight intermittent fasting strategy might improve the metabolic profile, feeding tolerance and perhaps even have beneficial effects on tissue repair, reperfusion injury, muscle weakness, and the immune response. Future studies should investigate practical implications in critically ill children and the optimal duration of the fasting periods, which might be affected by the severity of illness and by age.
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Affiliation(s)
- Karlien Veldscholte
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnout B G Cramer
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands.
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35
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Kelley J, Sullivan E, Norris M, Sullivan S, Parietti J, Kellogg K, Scott AI. Carnitine deficiency among hospitalized pediatric patients: A retrospective study of critically ill patients receiving extracorporeal membrane oxygenation therapy. JPEN J Parenter Enteral Nutr 2021; 45:1663-1672. [PMID: 34415080 PMCID: PMC9293107 DOI: 10.1002/jpen.2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background The metabolic demands associated with critical illness place patients at risk for nutrition deficits. Carnitine is a small molecule essential for fatty acid oxidation and gluconeogenesis. Secondary carnitine deficiency can have clinically significant complications and has been observed anecdotally in patients receiving extracorporeal membrane oxygenation (ECMO) therapy at our institution. Guidelines for monitoring and supplementing carnitine are lacking. This retrospective study determined whether critically ill pediatric patients receiving ECMO have an increased risk of carnitine deficiency. Methods Acylcarnitine analysis was performed on residual specimens from patients who received ECMO therapy. The control data were a convenience sample gathered by chart review of patients who had been tested for carnitine during a hospitalization. Results Acylcarnitines were measured in 217 non‐ECMO patients and 81 ECMO patients. Carnitine deficiency, based on age‐specific reference ranges, was observed in 41% of ECMO cases compared with 21% of non‐ECMO cases. Multivariable analysis of age‐matched patients identified that the odds of carnitine deficiency were significantly lower among patients on the floor compared with ECMO patients (odds ratio, 0.21; 95% CI, 0.10–0.44). Age‐specific frequency of qualitative carnitine deficiency ranged from 15% (patients >5 years old) to 56% (patients 1 week to 1 month old) in ECMO patients and 15% (patients >5 years old) to 34% (patients 1–5 years old) in non‐ECMO patients. Conclusion In this study, ECMO patients were carnitine deficient more frequently compared with other inpatients, with the highest rates of deficiency among ECMO patients between 1 week and 1 month old.
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Affiliation(s)
- Jenna Kelley
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin Sullivan
- Biostatistics, Epidemiology, and Analytics for Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Marie Norris
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Sullivan
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jennifer Parietti
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly Kellogg
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Anna I Scott
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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36
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Jacobs A, Güiza F, Verlinden I, Dulfer K, Garcia Guerra G, Joosten K, Verbruggen SC, Vanhorebeek I, Van den Berghe G. Differential DNA methylation by early versus late parenteral nutrition in the PICU: a biological basis for its impact on emotional and behavioral problems documented 4 years later. Clin Epigenetics 2021; 13:146. [PMID: 34315515 PMCID: PMC8314560 DOI: 10.1186/s13148-021-01124-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background The PEPaNIC multicenter randomized controlled trial (RCT) has shown that early administration of supplemental parenteral nutrition (early-PN) as compared with withholding PN for 1 week (late-PN) induced long-term internalizing, externalizing and total emotional/behavioral problems in critically ill children, as observed 4 years later. Early-PN was further shown to alter the methylation status of 37 CpG-sites in leukocyte DNA between admission and discharge from the pediatric intensive care unit (PICU). In a preplanned subanalysis of the PEPaNIC trial, we now investigated whether the altered methylation of these CpG-sites could statistically explain the negative impact of early-PN on emotion/behavior documented 4 years after PICU admission. Results The combination of DNA methylation data and data on behavior 4 years after PICU admission was available for 403 of the 1440 patients (aged 0–17 years at PICU admission) who were included in the PEPaNIC RCT (192 early-PN and 211 late-PN patients). Mediation analyses with use of bootstrapped multivariable non-linear regression analyses adjusted for baseline risk factors revealed that the adverse alterations by early-PN in methylation of the 37 CpG-sites together statistically explained its harmful impact on internalizing, externalizing and total emotional/behavioral problems. When adding the methylation status of the 37 CpG-sites to the models, the explanatory power improved with a 1.710 to 1.851-fold increase, and the impact of the altered methylation status of the CpG-sites explained the impact of the randomization to early-PN versus late-PN. Conclusions Abnormal DNA methylation induced by the early use of PN in the PICU provides a biological basis for its long-term harmful effect on emotion/behavior of critically ill children 4 years after PICU admission. Trial Registration ClinicalTrials.gov NCT01536275, registered February 17, 2012, https://clinicaltrials.gov/ct2/show/NCT01536275. Supplementary Information The online version contains supplementary material available at 10.1186/s13148-021-01124-3.
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Affiliation(s)
- An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ines Verlinden
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Karolijn Dulfer
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - Koen Joosten
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sascha C Verbruggen
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Sundar VV, Sehu Allavudin SF, Easaw MEPM. Factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit. Clin Nutr ESPEN 2021; 43:353-359. [PMID: 34024540 DOI: 10.1016/j.clnesp.2021.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/27/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND & AIMS Inadequate nutrition delivery in critically ill children has shown associated with poor clinical outcomes. Therefore, identifying barriers to deliver adequate nutrition is vital. The aim of this study was to identify factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit (PICU). METHODS This single-centre prospective study, involved children aged from birth to 3 years old, admitted to PICU longer than 72 hours. They received either enteral nutrition (EN) or combination of EN and partial parenteral nutrition (PPN). Clinical and nutrition delivery characteristics were recorded from admission until transferred out of PICU. Multiple regression analysis at significant level p < 0.05 were used to identify independent risk factors for lower protein and energy intake. RESULTS One hundred and thirty-nine patients were included in this study with median age 6.5 (1.8-20.6) months and median PICU length of stay of 6 (4-7) days. The median energy and protein adequacy were 83.2% and 46.7%, respectively. In multivariable analysis, children who underwent surgery (AOR 0.97; 95% CI 0.27-0.75; p = 0.041), with fluid restriction (AOR 0.97; 95% CI 0.25-0.73; p = 0.041), longer length of PICU stay (AOR 0.35; 95% CI 0.18-0.64; p = 0.001) and longer feeding interruptions (AOR 3.57; 95% CI 1.39-9.15; p = 0.008) were more likely to have lower energy intake. Children at risk of malnutrition (weight-for-age Z score of < -2 SD) (AOR 2.54; 95% CI 1.12 to 5.77; p = 0.026) and longer duration of mechanical ventilation (AOR 0.73; 95% CI 0.53 to 0.98; p = 0.041) were more likely to have lower protein intake. CONCLUSION This study highlighted the factors influencing adequate protein and energy delivery in critically ill children with heart disease in PICU. Strategies to improve the nutrition delivery in this group of patients should be outlined and implemented by the dietitians along with multidisciplinary team.
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Affiliation(s)
- Vatana V Sundar
- Dietetics and Food Services, National Heart Institute, 145, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia.
| | | | - Mary Easaw P M Easaw
- Dietetics and Food Services, National Heart Institute, 145, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia.
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Yinusa G, Scammell J, Murphy J, Ford G, Baron S. Multidisciplinary Provision of Food and Nutritional Care to Hospitalized Adult In-Patients: A Scoping Review. J Multidiscip Healthc 2021; 14:459-491. [PMID: 33654405 PMCID: PMC7910096 DOI: 10.2147/jmdh.s255256] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Multidisciplinary approaches to nutritional care are increasingly emphasized and recommended. However, there is little evidence of how different disciplines work together collaboratively to deliver optimum quality care to adult in-patients. This scoping review aimed to describe the existing literature on multidisciplinary collaboration to identify the various disciplines involved and the features that influence collaborative working in implementing multidisciplinary food and nutritional care with adult in-patients. METHODS Multiple databases were searched, including MEDLINE Complete, Embase, CINAHL Complete, HMIC, and Scopus, from their inception to December 2019. Data were retrieved from eligible studies. A narrative description of findings is reported with respect to the disciplines involved, the aspects of nutritional care explored, and the collaborative processes categorized using the input, process, and outcome framework. RESULTS Thirty-one studies with heterogeneous study designs met the eligibility criteria. Studies were undertaken in six countries. Findings show a wide diversity of multidisciplinary collaborations in various aspects of nutritional care in all studies. Multidisciplinary nutritional care provision was facilitated by several processes, including training and development, communication and information sharing, and clinical leadership and management support. Outcomes were reported at the patient, team, and organizational levels. CONCLUSION This review reveals the significance of the interrelationship between different disciplines and their complementary contributions towards the delivery of optimal food and nutritional care. Key aspects include the involvement of different disciplines, the clarification of roles and multidisciplinary interrelationships, communication, information sharing, clinical leadership, and management support, all of which facilitated collaborative working. Our review uncovered that these features can significantly influence multidisciplinary working. This review is the first to present literature concerning the attributes that affect collaborative working. Further research is recommended specifically around multidisciplinary nutritional care processes and conditions that allow for better collaborative working.
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Affiliation(s)
- Gladys Yinusa
- Department of Nursing Science, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Janet Scammell
- Department of Nursing Science, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Jane Murphy
- Ageing and Dementia Research Centre, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Gráinne Ford
- Dietetic Department, The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Dorset, UK
| | - Sue Baron
- Department of Nursing Science, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
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Ariagno K, Bechard L, Quinn N, Rudie C, Finnan E, Arena A, Sun T, Hale J, Duggan CP, Mehta NM. Timing of parenteral nutrition is associated with adequacy of nutrient delivery and anthropometry in critically ill children: A single-center study. JPEN J Parenter Enteral Nutr 2021; 46:190-196. [PMID: 33605456 DOI: 10.1002/jpen.2079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The optimal timing of supplemental parenteral nutrition (PN) use in the pediatric intensive care unit (ICU) is unclear. We aimed to describe patterns of PN use in the ICU and the association between the timing of PN initiation and macronutrient delivery and anthropometry. METHODS We enrolled patients (aged <18 years) with an ICU stay >3 days were started on PN in the ICU. Initiation within 48 hours of admission was deemed as early, and duration <5 days was deemed as short. We used multivariable analysis to examine the association between PN timing and macronutrient delivery adequacy (percentage of the prescribed target that was actually delivered) and weight-for-age z-score (WAZ) over hospital stay. RESULTS Ninety-five patients were included. Median (interquartile range [IQR]) time to initiate PN was 4 (1, 6) days, and in 33%, PN was initiated early. Median (IQR) PN duration was 8 (5, 14) days, and in 16.8%, duration was short. Median (IQR) adequacies for total energy and protein delivery were 55% (40, 74) and 72% (44, 81) in the early PN group compared with 29% (3, 50) and 31% (4, 47), respectively, in the late PN group (P < .001). The late PN group had a 0.50-unit greater decline in mean WAZ compared with the early PN group (95% CI, 0.11-0.89; P = .012). CONCLUSION Late PN initiation was associated with significantly lower adequacy of macronutrient delivery and greater decline in WAZ in critically ill children. The relationship between PN timing patient outcomes must be further examined.
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Affiliation(s)
- Katelyn Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lori Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nicolle Quinn
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Coral Rudie
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Emily Finnan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anastasia Arena
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tina Sun
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jaqueline Hale
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher P Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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40
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Knight DE, Larmour K, Wellman P, Mulvey N, Hopkins J, Tibby SM. Prospective evaluation of a novel enteral feeding guideline based on individual gastric emptying times: an improvement project in a pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2021; 45:1720-1728. [PMID: 33475176 DOI: 10.1002/jpen.2077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND On a 20-bed, mixed cardiac and general, UK pediatric intensive care unit (PICU), we aimed to determine if a physiologically based enteral feeding guideline for critically ill children, using feed frequency tailored to individual gastric emptying times, resulted in earlier establishment of full feeds (when 100% of fluid allowance (FA) available to be given as intravenous maintenance fluid or feed, defined as free FA [FFA], is given as enteral nutrition [EN]) and an increase in FFA given as EN. METHODS Four prospective audits (totaling 331 patients and 19,771 hours) were conducted at 1 year before guideline introduction and 1, 5, and 10 years after. Patient feeding data were collected from admission until day 4 or discharge, including reasons why feed was withheld. RESULTS The median time from admission to establishing full feeds decreased from 18 to 10 hours preguideline and postguideline and was sustained over 10 years. After adjustment for 5 confounders, this represented a reduction in the geometric mean time to full feeds of 30% (2009), 29% (2013), and 48% (2019) compared with 2007 (all P < .01). Nil-per-oral (NPO) hours were categorized as due to modifiable and nonmodifiable factors. Preguideline and postguideline NPO hours from modifiable factors decreased from 21 (2007) to 10 (2009) per 100 audit hours, which was sustained across 10 years (all P < .01). Conversely, NPO hours from nonmodifiable factors ranged from 27 to 36 per 100 audit hours throughout the audits, with no consistent trend over time. Similar inconsistency was shown in the proportion of FFA given as EN: 48% (2007), 71% (2009), 51% (2013), and 64% (2019). Continuous nasogastric and hourly bolus feeds decreased over time; they comprised 66% of feeds in 2007 but only 4%-11% in subsequent periods, being replaced with more 2-6 hour bolus, on-demand, or continuous nasojejunal feeds. CONCLUSION The guideline was associated with sustained reduction in the time to establishing full feeds and NPO hours due to modifiable factors and more or no less FFA being given as EN.
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Affiliation(s)
- Dawn E Knight
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Kelly Larmour
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Paul Wellman
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Nicki Mulvey
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Julia Hopkins
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Shane M Tibby
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
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Alsohime F, Assiry G, AlSalman M, Alabdulkareem W, Almuzini H, Alyahya M, Allhidan R, Al-Eyadhy A, Temsah MH, Al Sarkhy AA. Barriers to the delivery of enteral nutrition in pediatric intensive care units: A national survey. Int J Pediatr Adolesc Med 2020; 8:186-190. [PMID: 34350333 PMCID: PMC8319679 DOI: 10.1016/j.ijpam.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/24/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
Background and Aim According to previously reported studies in the literature, a significant number of patients do not receive enteral nutrition in pediatric intensive care unit (PICU) because of avoidable barriers. Optimal nutrition is a fundamental goal in PICU. This study aims to identify the barriers of enteral nutrition in PICU. Setting and Design A cross-sectional study of the results of a 25-item questionnaire-based survey distributed during the Annual International Critical Care Conference by the Saudi Critical Care Society. Methods and material A 7-point Likert-type scale was used to rank the participants’ responses, and the relative importance index (RII) approach was used to analyze the relative contribution of each indicator to its main theme. The factor and parallel analysis methods were used to assess the factorial and unidimensionality of the enteral feeding barriers scale. Results A total of 223 PICU healthcare workers from various intensive care settings responded to the survey. The top-three perceived barriers for commencing enteral feeding were due to the patient being hemodynamically unstable (M = 3.6 and SD = 1.70), delays and difficulties in obtaining small bowel access in patients not tolerating other types of enteral nutrition (M = 3.4 and SD = 1.52), or severe fluid restriction, particularly in postoperative cardiac surgery (M = 3.3 and SD = 1.59). The top perceived overall barriers to enteral feeding were the dietician-related issues (M = 3.3, SD = 1.32), barriers related to enteral feeding delivery (M = 3.16 and SD = 1.13), and medical practice-related (M = 3 and SD = 1.10) issues. The lowest reported overall barriers were the resource-related obstacles (M = 2.7 and SD = 1.26). Conclusion Being hemodynamically unstable and other dietician-related reasons were the top overall barriers in commencing enteral feeding.
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Affiliation(s)
- Fahad Alsohime
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ghadeer Assiry
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Wejdan Alabdulkareem
- Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hissah Almuzini
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Malak Alyahya
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reema Allhidan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Al Sarkhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Gastroenterology Unit, Pediatric Department, King Khalid University Medical City, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Nutritional status and nutrition support in critically ill children in Spain: Results of a multicentric study. Nutrition 2020; 84:110993. [PMID: 33109454 DOI: 10.1016/j.nut.2020.110993] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/10/2020] [Accepted: 08/15/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Critically ill children are often malnourished and require nutrition support (NS). Early enteral nutrition (EEN) seems to be safe in critically ill patients. However, there is a scarcity of data about the management of EEN in sick pediatric patients. The aim of this study was to analyze the nutritional status, NS characteristics, macronutrient supply, and associations between NS and outcomes in critically ill children in Spain. METHODS This was a multicentric, prospective, cross-sectional study involving critically ill children who received NS and with an expected length of stay (LOS) in the pediatric intensive care unit of ≥3 d. Anthropometric variables, characteristics of NS, EEN, nutrient supply, and complications were recorded. RESULTS We enrolled 86 children. Undernutrition and overweight were more prevalent in children ≤2 y of age than in older children (undernutrition: 40 versus 19%, respectively; overweight: 22.2 versus 14.3%, respectively). Being overweight was associated with a shorter PICU LOS (5.8 ± 2 versus 9.8 ± 6.5; P = 0.005). EN was the preferred method for nutrient delivery. EEN was administered to 58.1% of patients and was more common in children >2 y of age than in younger patients (73.1 versus 44.4%; P = 0.015). EEN was safe and was associated with a higher caloric intake (81.6 ± 35.3 versus 59.6 ± 36.6; P = 0.019). There was a negative correlation between mean time to EN initiation and maximum energy supply (r = -0.32; P = 0.07). CONCLUSIONS Malnutrition was prevalent among critically ill children in Spain. Being overweight was associated with a shorter PICU LOS. EEN was safe and was associated with a higher caloric intake; however, it is rarely used in PICUs in Spain.
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Abstract
OBJECTIVES To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians, and physicians) in delivering enteral nutrition to critically ill children across the world. DESIGN Cross-sectional international online survey adapted for use in pediatric settings. SETTING PICUs across the world. SUBJECTS PICU nurses, physicians, and dietitians. INTERVENTIONS The 20-item adult intensive care "Barriers to delivery of enteral nutrition" survey was modified for pediatric settings, tested, and translated into 10 languages. The survey was distributed online to pediatric intensive care nurses, physicians, and dieticians via professional networks in March 2019 to June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of enteral nutrition in their PICUs with a 7-point Likert scale from 0 "not at all a barrier" to 6 "an extreme amount." MEASUREMENT AND MAIN RESULTS Nine-hundred twenty pediatric intensive care professionals responded from 57 countries; 477 of 920 nurses (52%), 407 of 920 physicians (44%), and 36 of 920 dieticians (4%). Sixty-two percent had more than 5 years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were as follows: 1) enteral feeds being withheld in advance of procedures or operating department visits, 2) none or not enough dietitian coverage on weekends or evenings, and 3) not enough time dedicated to education and training on how to optimally feed patients. CONCLUSIONS This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses, and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focused nutrition education for all PICU professional groups.
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Protein intake deficiency in critically ill children with respiratory insufficiency: A call to action? Clin Nutr ESPEN 2020; 37:69-74. [DOI: 10.1016/j.clnesp.2020.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/05/2020] [Accepted: 03/20/2020] [Indexed: 11/21/2022]
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Early Enteral Nutrition Is Associated With Improved Clinical Outcomes in Critically Ill Children: A Secondary Analysis of Nutrition Support in the Heart and Lung Failure-Pediatric Insulin Titration Trial. Pediatr Crit Care Med 2020; 21:213-221. [PMID: 31577692 PMCID: PMC7060827 DOI: 10.1097/pcc.0000000000002135] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The impact of early enteral nutrition on clinical outcomes in critically ill children has not been adequately described. We hypothesized that early enteral nutrition is associated with improved clinical outcomes in critically ill children. DESIGN Secondary analysis of the Heart and Lung Failure-Pediatric Insulin Titration randomized controlled trial. SETTING Thirty-five PICUs. PATIENTS Critically ill children with hyperglycemia requiring inotropic support and/or invasive mechanical ventilation who were enrolled for at least 48 hours with complete nutrition data. INTERVENTIONS Subjects received nutrition via guidelines that emphasized enteral nutrition and were classified into early enteral nutrition (enteral nutrition within 48 hr of study randomization) and no early enteral nutrition (enteral nutrition after 48 hr of study randomization, or no enteral nutrition at any time). MEASUREMENTS AND MAIN RESULTS Of 608 eligible subjects, 331 (54%) received early enteral nutrition. Both early enteral nutrition and no early enteral nutrition groups had similar daily caloric intake over the first 8 study days (median, 36 vs 36 kcal/kg/d; p = 0.93). After controlling for age, body mass index z scores, primary reason for ICU admission, severity of illness, and mean Vasopressor-Inotrope Score at the time of randomization, and adjusting for site, early enteral nutrition was associated with lower 90-day hospital mortality (8% vs 17%; p = 0.007), more ICU-free days (median, 20 vs 17 d; p = 0.02), more hospital-free days (median, 8 vs 0 d; p = 0.003), more ventilator-free days (median, 21 vs 19 d; p = 0.003), and less organ dysfunction (median maximum Pediatric Logistic Organ Dysfunction, 11 vs 12; p < 0.001). CONCLUSIONS In critically ill children with hyperglycemia requiring inotropic support and/or mechanical ventilation, early enteral nutrition was independently associated with better clinical outcomes.
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Eveleens R, Joosten K, de Koning B, Hulst J, Verbruggen S. Definitions, predictors and outcomes of feeding intolerance in critically ill children: A systematic review. Clin Nutr 2020; 39:685-693. [DOI: 10.1016/j.clnu.2019.03.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/20/2019] [Accepted: 03/17/2019] [Indexed: 01/18/2023]
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Gadhvi KR, Valla FV, Tume LN. Review of Outcomes Used in Nutrition Trials in Pediatric Critical Care. JPEN J Parenter Enteral Nutr 2020; 44:1210-1219. [PMID: 32010996 DOI: 10.1002/jpen.1765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Generating robust evidence within pediatric intensive care (PIC) can be challenging because of low patient numbers and patient heterogeneity. Systematic reviews may overcome small study biases but are limited by lack of standardization in outcome measures and their definition. Trials of nutrition interventions in PIC are increasing; thus, we wanted to examine the outcome measures being used in these trials. OBJECTIVE Our objective was to systematically describe outcome measures used when a nutrition intervention has been evaluated in a PIC randomized controlled trial. METHODS A systematic literature review of all studies involving a PIC trial of a nutrition intervention was undertaken from January 1, 1996, until February 20, 2018. RESULTS Twenty-nine trials met the criteria and were reviewed. They included a total of 3226 patients across all trials. Thirty-seven primary outcomes and 83 secondary outcomes were found. These were categorized into PIC-related outcomes (infection, intensive care dependency, organ dysfunction, and mortality) and nutrition outcomes (energy targets, nutrition parameters, and feeding tolerance). We found large variation in the outcome measures used. Outcome domains of energy targets, feeding tolerance, and infection were not adequately defined. CONCLUSIONS Considerable variation in the outcome measures chosen and their definitions exist within PIC nutrition trials. Optimal nutrition outcomes for PIC must be agreed upon and defined, specifically domains of nutrition efficiency, nutrition tolerance, and non-nutrition PIC outcomes. The next step is to conduct an international Delphi study to gain expert consensus and develop a core outcome set to be reported in future pediatric nutrition trials.
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Affiliation(s)
- Kunal R Gadhvi
- Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK
| | - Frédéric V Valla
- Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK.,Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, CarMEN INSERM UMR 1060, Lyon-Bron, France
| | - Lyvonne N Tume
- Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK
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Turner AD, Hamilton SM, Callif C, Ariagno KA, Arena AE, Mehta NM, Martinez EE. Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2020; 35:299-305. [PMID: 31990093 DOI: 10.1002/ncp.10452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. METHODS In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. RESULTS The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. CONCLUSION Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.
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Affiliation(s)
| | - Susan M Hamilton
- Department of Cardiovascular/Critical Care Nursing, Boston, Massachusetts, USA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anastasia E Arena
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Iyer R, Bansal A. What do we know about optimal nutritional strategies in children with pediatric acute respiratory distress syndrome? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:510. [PMID: 31728363 DOI: 10.21037/atm.2019.08.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Rajalakshmi Iyer
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Lee SW, Loh SW, Ong C, Lee JH. Pertinent clinical outcomes in pediatric survivors of pediatric acute respiratory distress syndrome (PARDS): a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:513. [PMID: 31728366 DOI: 10.21037/atm.2019.09.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The objectives of this review are to describe the limitations of commonly used clinical outcomes [e.g., mortality, ventilation parameters, need for extracorporeal membrane oxygenation (ECMO), pediatric intensive care unit (PICU) and hospital length of stay (LOS)] in pediatric acute respiratory distress syndrome (PARDS) studies; and to explore other pertinent clinical outcomes that pediatric critical care practitioners should consider in future clinical practice and research studies. These include long-term pulmonary function, risk of pulmonary hypertension (PHT), nutrition status and growth, PICU-acquired weakness, neurological outcomes and neurocognitive development, functional status, health-related quality of life (HRQOL)], health-care costs, caregiver and family stress. PubMed was searched using the following keywords or medical subject headings (MESH): "acute lung injury (ALI)", "acute respiratory distress syndrome (ARDS)", "pediatric acute respiratory distress syndrome (PARDS)", "acute hypoxemia respiratory failure", "outcomes", "pediatric intensive care unit (PICU)", "lung function", "pulmonary hypertension", "growth", "nutrition', "steroid", "PICU-acquired weakness", "functional status scale", "neurocognitive", "psychology", "health-care expenditure", and "HRQOL". The concept of contemporary measure outcomes was adapted from adult ARDS long-term outcome studies. Articles were initially searched from existing PARDS articles pool. If the relevant measure outcomes were not found, where appropriate, we considered studies from non-ARDS patients within the PICU in whom these outcomes were studied. Long-term outcomes in survivors of PARDS were not follow-up in majority of pediatric studies regardless of whether the new or old definitions of ARDS in children were used. Relevant studies were scarce, and the number of participants was small. As such, available studies were not able to provide conclusive answers to most of our clinical queries. There remains a paucity of data on contemporary clinical outcomes in PARDS studies. In addition to the current commonly used outcomes, clinical researchers and investigators should consider examining these contemporary outcome measures in PARDS studies in the future.
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Affiliation(s)
- Siew Wah Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore.,Pediatric Intensive Care Unit, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Sin Wee Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore.,Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
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