Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

There are reports of children COVID-19 or COVID-19 like symptoms with hyperinflammatory multisystem syndrome, ARDS, gastrointestinal and atypical Kawasaki disease presenting to PICU worldwide temporally associated with COVID-19, for which there are important nutrition support considerations. As a result, the European Society of Pediatric and Neonatal Intensive Care – Metabolism, Endocrine and Nutrition group (ESPNIC-MEN) and paediatric nutritionists working in PICUs are being consulted regarding nutrition management of critically ill children with COVID-19 or COVID-19 like symptoms. Therefore, the aim of this short report is to provide a summary of nutrition support recommendations for critically ill children with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 and surviving sepsis recommendations from February 2020.

Clinical Outcomes in Critically Ill Children With Excess Weight: A Retrospective Cohort Study

BACKGROUND

Because of its high prevalence and negative impact on quality of life and longevity, overweight in childhood and adolescence is a major public health concern. The objective of the present study was to determine whether excess weight is associated with clinical outcomes in critically ill children and adolescents admitted to the pediatric intensive care unit (PICU).

METHOD

This retrospective cohort study was performed with children and adolescents admitted to a PICU over 3 years. Nutrition status was classified based on the body mass index z-score for age, following World Health Organization (WHO) criteria. The following outcomes were assessed: mortality, need for mechanical ventilation, length of admission, and multiple organ dysfunction syndrome.

RESULTS

Of 1468 patients admitted during the study period, 1407 were included in the study: 956 (68.0%) had adequate weight, 228 (16.2%) were overweight, and 223 (15.8%) were underweight. Associations were detected between most variables and all nutrition categories (underweight, adequate weight, and overweight). In the descriptive analysis, mortality was more prevalent in nutrition status extremes (extremely underweight or overweight). An independent association between nutrition status and mortality was not detected in any category.

CONCLUSION

Nutrition status was not independently associated with poor outcomes. However, overweight should be considered a potential risk factor for adverse clinical outcomes in PICU admissions.

Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit

BACKGROUND

Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort.

METHODS

We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery.

RESULTS

Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3.

CONCLUSIONS

The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.

Optimal nutrition in the paediatric ICU

PURPOSE OF REVIEW

This article describes the current best available evidence on optimal nutrition in the paediatric intensive care based on different levels of outcome, which can be divided in surrogate and hard clinical outcome parameters.

RECENT FINDINGS

Undernutrition is associated with increased morbidity and mortality, whereas in specific cohorts of critically ill children, such as those with burn injury, obesity is associated with more complications, longer length of stay, and decreased likelihood of survival. There is a relation with adequacy of delivery of enteral nutrition and the amount of protein on length of hospital stay, neurological status, and mortality. Studies relating organ function, other than skin healing after thermal injury, with the nutritional status are scarce. There is also a scarcity of data concerning long-term follow-up and health economics.

SUMMARY

Until now, there are no randomized controlled trials which have investigated a causal relation between different feeding regimens on the nutritional status and short and long-term outcome. As a result current optimal nutritional strategies are based on small trials with surrogate outcome parameters. Prospective randomized studies are needed with nutritional and/or metabolic interventions to come to an optimal feeding strategy for critically ill children.