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Li X, Fan L, Pan X, Kwok CS. Enteral nutrition in children and adolescents who receive extracorporeal membrane oxygenation and its impact on complications and mortality: A systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2024; 48:406-420. [PMID: 38554128 DOI: 10.1002/jpen.2626] [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: 05/04/2023] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 04/01/2024]
Abstract
Enteral nutrition (EN) is one method of nutrition support for children and adolescents receiving extracorporeal membrane oxygenation (ECMO) therapy, and there are no guidelines for its use in this population. We conducted a systematic review to determine whether EN is effective and safe in children supported by ECMO. We searched the Cochrane Library database, MEDLINE, and Embase on Ovid in March 2023 to identify studies that evaluated children and adolescents who received ECMO and were treated with EN. Random effects meta-analysis was used to estimate the odds of mortality with EN compared with parenteral nutrition (PN). A total of 14 studies were included in this review with 1650 patients (796 received EN). The median duration of ECMO was 5-10 days, and the median EN initiation time ranged from 23 h to 7 days. The pooled results suggest no significant difference in mortality with EN compared with PN (odds ratio [OR] = 0.77; 95% CI, 0.56-1.05; I2 = 26%). Exclusion of the only study that reported an increase in mortality resulted in a borderline significant reduction in mortality with EN (OR = 0.71; 95% CI, 0.51-1.00; I2 = 26%). The predictors of EN were male sex, older age, heavier weight, greater height, cardiac diagnosis, longer duration of ECMO, and use of venovenous ECMO. Most studies suggest no correlation between EN and complications. EN use in children and adolescents who receive ECMO does not appear to be associated with increased mortality compared with PN and was safe in terms of intestinal complications and feeding intolerance.
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Affiliation(s)
- Xiuhong Li
- Department of Post-Qualifying Healthcare Practice, Birmingham City University, Birmingham, UK
- Shenzhen Children's Hospital, Cardiothoracic Surgery Department, Shenzhen, China
| | - Liping Fan
- Shenzhen Children's Hospital, Cardiothoracic Surgery Department, Shenzhen, China
| | - Xiaolan Pan
- Shenzhen Children's Hospital, Cardiothoracic Surgery Department, Shenzhen, China
| | - Chun Shing Kwok
- Department of Post-Qualifying Healthcare Practice, Birmingham City University, Birmingham, UK
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2
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Zivick E, Kilgallon K, Cheifetz IM. Challenges of Nutrition Support in Pediatric Patients Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:81-85. [PMID: 37788480 DOI: 10.1097/mat.0000000000002042] [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: 10/05/2023] Open
Abstract
Nutrition support in critically ill infants and children remains an integral part of providing optimal care for these patients. The pediatric patient requiring extracorporeal membrane oxygenation therapy faces specific challenges to the provision of suitable nutrition support. In this review, we aimed to summarize the existing literature around some of the more challenging aspects of delivering appropriate nutrition to children receiving extracorporeal membrane oxygenation.
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Affiliation(s)
- Elizabeth Zivick
- From the Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Kevin Kilgallon
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
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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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Tume LN, Beech G, Tse C, Nolan S, Brady A, Odutolu Y, Latten L. Association between enteral feeding and gastrointestinal complications in children receiving extracorporeal life support: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:729-735. [PMID: 37255500 DOI: 10.1002/jpen.2528] [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: 11/17/2022] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Extracorporeal life support is an accepted treatment modality for children with severe cardiac and/or respiratory dysfunction. However, after a period of inadequate gut perfusion, clinicians are often reluctant to initiate enteral nutrition. METHODS This was a retrospective cohort study in a single large pediatric intensive care unit in North West England over 5.5 years (2017-2022). RESULTS One hundred fifty-six children, who had a median age of 2 months (IQR, 0.3-15) and a mean weight-for-age z score of -1.50 (SD, 1.7), were included. Indications for extracorporeal life support were respiratory failure (31%), cardiac arrest (28%), low cardiac output state (27%), and inability to separate from cardiopulmonary bypass (12%). Most (75%) children were fed during extracorporeal life support, with a median time to initiate feeding of 24 h (IQR, 12.2-42.7). More gastrointestinal complications were associated with being enterally fed (86% vs 14%; P < 0.001), but complications were predominantly feed intolerance (46%), which was associated with receiving formula feeds rather than maternal (breast) milk (P < 0.001). Overall, the proportion of children's median energy targets achieved by 72 h was 38% (IQR, 10.7%-76%), but this varied by support indication. CONCLUSIONS Our findings suggest most children tolerated enteral feeding within 24 h after extracorporeal life support initiation, with only mild gastrointestinal complications.
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Affiliation(s)
- Lyvonne N Tume
- Edge Hill University, Ormskirk, UK
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Gail Beech
- St Helens and Knowsley Teaching Hospitals NHS Trust Lead Employer, Whiston Hospital, Prescot, Merseyside, UK
| | - Chi Tse
- St Helens and Knowsley Teaching Hospitals NHS Trust Lead Employer, Whiston Hospital, Prescot, Merseyside, UK
| | - Shirley Nolan
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Alison Brady
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Yetunde Odutolu
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Lynne Latten
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Vasopressors and Enteral Nutrition in the Survival Rate of Children During Extracorporeal Membrane Oxygenation. J Pediatr Gastroenterol Nutr 2022; 75:340-344. [PMID: 35641894 DOI: 10.1097/mpg.0000000000003496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Nutrition support is essential in improving outcome and survival in children on extra corporal membranous support (ECMO). We aim to evaluate the association between the timing of enteral nutrition (EN) initiation and its impact on outcome. METHODS We retrospectively reviewed the electronic health records of children (≤18 years) from November 2014 to November 2019 who were on veno-arterial ECMO for ≥48 hours. Abstracted data included demographics, ECMO indication and duration, timing of EN initiation, change in weight-for-age z score (WAZ), and survival rate. The vasoactive-inotropic score (VIS) was calculated to assess illness acuity. RESULTS We identified 76 children with median age (interquartile range [IQR]) of 0.3 years (0-2.6), 46 of which were infants (59%) who required ECMO for a median (IQR) of 10 days (6-22). Thirty-six (47%) survived to hospital discharge. EN was initiated in 55 (72%) of patients while on ECMO. EN initiation by day 3 of ECMO was positively associated with survival ( P = 0.0438). VIS at the time of EN initiation was lower in surviving infants ( P = 0.022). Children who achieved enteral autonomy were more likely to survive ( P = 0.0024). Survivors had greater WAZs at ECMO completion ( P = 0.0004). CONCLUSIONS Initiation of EN by day 3 of ECMO and at a lower VIS is associated with greater likelihood of survival.
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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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Harrington AW, Riebold J, Hernandez K, Staffa SJ, Meisner JW, Zurakowski D, Jennings R, Hamilton T, Zendejas B. Feeding and Growth Outcomes in Infants with Type C Esophageal Atresia Who Undergo Early Primary Repair. J Pediatr 2022; 241:77-82.e1. [PMID: 34687688 DOI: 10.1016/j.jpeds.2021.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To describe growth and feeding outcomes in patients with type C esophageal atresia who underwent early primary repair and to identify predictors for poor growth. STUDY DESIGN This single-center, retrospective, cohort study included all patients with type C esophageal atresia who underwent early primary repair from 2013 to 2019. Weight-for-age z score (WAZ) was calculated at birth, and every 6 months until 3 years postoperatively. Longitudinal median regression was used to evaluate WAZ over time. A multivariable logistic regression model explored predictors of growth outcomes. RESULTS Of 46 infants who met the inclusion criteria, 72% were term. The median age at repair was 1.5 days of life (IQR, 1-2 days of life) and the hospital length of stay was 20 days (IQR-14, 30 days). Two patients had esophageal leak (4.3%). The median WAZ at birth was below average (-0.72; IQR, -1.37 to -0.40), but improved to reach average by 3 years (-0.025; IQR, -0.85 to 0.97, P < .001). At discharge, 72% of patients were receiving full oral nutrition, which improved to 95% by 3 years. The only independent predictor of poor growth at 1 year (WAZ < -1 [33%]) was WAZ at discharge (P = .02). CONCLUSIONS Infants with esophageal atresia who undergo early primary repair are capable of achieving standard growth curves by 3 years of age. However, poor discharge WAZ score was predictive of poor WAZ score at 1 year. Efforts to identify at-risk patients and institute targeted inpatient and outpatient nutrition interventions are needed to improve their growth trajectory.
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Affiliation(s)
| | - Jane Riebold
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Kayla Hernandez
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jay W Meisner
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | | | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, MA
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Pérez G, González E, Zamora L, Fernández SN, Sánchez A, Bellón JM, Santiago MJ, Solana MJ. Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation. J Pediatr Gastroenterol Nutr 2022; 74:110-115. [PMID: 34636794 PMCID: PMC8673839 DOI: 10.1097/mpg.0000000000003317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/06/2021] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To assess the safety of enteral nutrition (EN) in children on extracorporeal membrane oxygenation (ECMO). To describe nutritional status and the characteristics of the nutritional support in this population. METHODS A retrospective single-center analysis (2006-2016) including children <18 years on ECMO. Demographic data, nutritional status, characteristics of nutritional support, and development of gastrointestinal (GI) complications were recorded. RESULTS One hundred children, with a median age of 9.7 months (interquartile range [IQR] 3.9-63.1) were enrolled. Undernutrition was prevalent among children on ECMO (33.3%) mainly in patients <2 years (P = 0.042). Most patients (64%) received EN at some point during ECMO therapy. EN was administered in the first 48 hours after ECMO initiation (48HEN) to 60.3% of the children.Mortality rate in the Pediatric Intensive Care Unit was lower in patients who received EN as the initial artificial nutrition support (ANS) (37.7 vs 51%, P = 0.005) and in children on 48HEN (34% vs 50%, P = 0.04). In the logistic regression analysis, duration of ECMO support and low cardiac output indication were the only factors associated with mortality.Although most patients on ECMO (45%) developed digestive complications, they were mostly mild, being constipation the most prevalent. In the logistic regression analysis, EN was not associated with an increase in GI complications (P = 0.09). Only three patients developed intestinal ischemia (one without EN and two on EN). CONCLUSIONS Undernutrition is prevalent among children on ECMO, mainly in infants <2 years. EN is not associated with severe gastrointestinal complications or higher mortality in these children.
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Affiliation(s)
- Gema Pérez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Gregorio Marañón Health Research Institute (IISGM)
| | - Elena González
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Laura Zamora
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Sarah N. Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Amelia Sánchez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | | | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
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Harrington AW, Riebold J, Hernandez K, Staffa SJ, Svetanoff WJ, Zurakowski D, Hamilton T, Jennings R, Mehta NM, Zendejas B. Nutrition delivery and growth outcomes in infants with long-gap esophageal atresia who undergo the Foker process. J Pediatr Surg 2021; 56:2133-2139. [PMID: 34366132 DOI: 10.1016/j.jpedsurg.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Predictors of growth outcomes in patients with long-gap esophageal atresia (LGEA) are not known. We examined nutrition and growth in-hospital and post-discharge in LGEA patients who underwent the Foker Process (FP). METHODS Single-center, retrospective cohort study of infants with LGEA undergoing primary (non-rescue) FP from 2014 to 2020. Weight-for-age z scores (WAZ, 0 = average), macronutrient prescription, anthropometry, and clinical variables were collected. Longitudinal median regression evaluated differences in WAZ over time. Multivariable median regression examined variables associated with change in WAZ at 1 year. RESULTS 45 patients met criteria, with median (IQR) age at repair of 4 (2, 5.8) months and WAZ of -0.96 (-1.55, -0.40). On admission, 11% were moderately (WAZ < -2) and 9% were severely (WAZ < -3) malnourished. Lower admission WAZ was significantly associated with improvement in WAZ at 1-year follow-up (p = 0.002); EA type (59% type A), esophageal leak (16%), median days paralyzed (13), ventilated (21), on parenteral nutrition (35), or to full enteral nutrition (35) were not associated with change in WAZ. Median WAZ remained stable while in-hospital, and patients maintained their growth curves through 3-year follow-up. CONCLUSION Throughout infancy, most primary FP LGEA patients have weight for age that is below average. Using targeted nutritional intervention, those who present with malnutrition can still achieve adequate growth despite prolonged and complicated hospital courses.
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Affiliation(s)
- Amanda W Harrington
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Jane Riebold
- Boston Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Boston, MA, United States
| | - Kayla Hernandez
- Boston Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Boston, MA, United States
| | - Steven J Staffa
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Wendy Jo Svetanoff
- Department of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States; Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Russell Jennings
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Nilesh M Mehta
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States.
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10
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Hofheinz SB, Núñez-Ramos R, Germán-Díaz M, Melgares LO, Arroba CMA, López-Fernández E, Moreno-Villares JM. Which is the best route to achieve nutritional goals in pediatric ECMO patients? Nutrition 2021; 93:111497. [PMID: 34689035 DOI: 10.1016/j.nut.2021.111497] [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: 01/25/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Estimating caloric intake and choosing route of administration are fundamental in the nutritional support of patients being supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to review the nutritional intervention carried out in a pediatric cohort in a third-level hospital. METHODS This was a prospective descriptive study. Age, sex, underlying pathology, Pediatric Risk of Mortality score, ECMO indication, type of care, duration of ECMO support, and prognosis were collected. Type of nutritional support, route of administration, kcal/kg achieved, estimated energy requirements, and percentage of caloric objective (%CO) reached on days 3 and 5 after cannulation were recorded. RESULTS Twenty-four venoarterial ECMO runs in 23 patients over a period of 2 y were recorded. Of the 23 patients, 15 were <1 y of age. The underlying pathology in 56.5% was cardiac disease. Three groups were identified: parenteral nutrition (group 0, n = 7), enteral nutrition (group 1, n = 8), and mixed nutrition (group 2, n = 7). The median of the %CO was 33.34 (0-84) on day 3 and 87.75% (78.4-100) on day 5 of ECMO, respectively for group 0; 75.5 (42.25-98.5) and 85% (24.4-107.7) in group 1 and 68.7 (44.4-82.2) and 91.2% (35.5-92) in group 2 (P > 0.05). Children <12 mo of age and cardiac patients represented 85.71% and 71.43% of total patients in group 0. Among the eight episodes of exclusive enteral nutrition, no complications were identified. CONCLUSION Enteral nutrition appears to be safe in the setting of hemodynamic stability and absence of contraindications and is equivalent to other nutritional interventions in terms of compliance with estimated energy requirements.
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Affiliation(s)
- Sylvia Belda Hofheinz
- Pediatric Intensive Care Department, University Hospital October 12, Madrid, Spain; School of Medicine, Department of Public and Maternal - Child Health, Complutense University of Madrid, Madrid, Spain
| | - Raquel Núñez-Ramos
- Pediatric Gastroenterology, Hepatology and Nutrition Unit. University Hospital October 12, Madrid, Spain.
| | - Marta Germán-Díaz
- Pediatric Gastroenterology, Hepatology and Nutrition Unit. University Hospital October 12, Madrid, Spain
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11
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Toh TSW, Ong C, Mok YH, Mallory P, Cheifetz IM, Lee JH. Nutrition in Pediatric Extracorporeal Membrane Oxygenation: A Narrative Review. Front Nutr 2021; 8:666464. [PMID: 34409059 PMCID: PMC8365758 DOI: 10.3389/fnut.2021.666464] [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] [Received: 02/10/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) support is increasingly utilized in quaternary pediatric intensive care units. Metabolic derangements and altered nutritional requirements are common in critically ill children supported on ECMO. However, there remains no consensus on the optimal approach to the prescription of nutrition in these patients. This narrative review aims to summarize the current medical literature on various aspects of nutrition support in pediatric patients on ECMO. These include: (1) nutritional adequacy, (2) pros and cons of feeding on ECMO, (3) enteral vs. parenteral nutrition, and (4) proposed recommendations and future directions for research in this area.
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Affiliation(s)
- Theresa S W Toh
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Palen Mallory
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ira M Cheifetz
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
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12
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Murphy HJ, Selewski DT. Nutrition Considerations in Neonatal Extracorporeal Life Support. Neoreviews 2021; 22:e382-e391. [PMID: 34074643 DOI: 10.1542/neo.22-6-e382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Extracorporeal life support (ECLS) is a life-saving therapy, but neonates who require ECLS have unique nutritional needs and require aggressive, early nutritional support. These critically ill neonates are at increased risk for long-term feeding difficulties, malnutrition, and growth failure with associated increased morbidity and mortality. Unfortunately, few studies specific to this population exist. Clinical guidelines published by the American Society for Parenteral and Enteral Nutrition are specific to this population and available to aid clinicians in appropriate nutrition regimens, but studies to date suggest that nutrition provision varies greatly from center to center and often is inadequate. Though enteral feedings are becoming more common, aggressive parenteral nutrition is still needed to ensure nutrition goals are met, including the goal of increased protein provision. Long-term complications, including the need for tube feedings and growth failure, are common in neonatal ECLS survivors, particularly those with congenital diaphragmatic hernia. Oral aversion with poor feeding and growth failure must be anticipated and recognized early if present. The nutritional implications associated with the development of acute kidney injury, fluid overload, or the use of continuous renal replacement therapy must be recognized. In this state-of-the-art review, we examine aspects of nutrition for neonates receiving ECLS including nutritional requirements, nutrition provision, current practices, long-term outcomes, and special population considerations.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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13
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Abstract
The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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14
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Ohman K, Zhu H, Maizlin I, Williams RF, Guner YS, Russell RT, Harting MT, Vogel AM, Starr JP, Johnson D, Ramirez R, Manning L. A Multicenter Study of Nutritional Adequacy in Neonatal and Pediatric Extracorporeal Life Support. J Surg Res 2020; 249:67-73. [DOI: 10.1016/j.jss.2019.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 09/16/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
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15
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Nutrition in children with continuous renal replacement therapy. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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16
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Santiago Lozano MJ, Alonso Álvarez C, Álvarez Heidbüchel C, Fernández Lafever S, Solana García MJ, López-Herce Cid J. [Nutrition in children with continuous renal replacement therapy]. An Pediatr (Barc) 2019; 92:208-214. [PMID: 31734157 DOI: 10.1016/j.anpedi.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/18/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). MATERIAL AND METHODS A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. RESULTS A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. CONCLUSIONS A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped.
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Affiliation(s)
- Maria José Santiago Lozano
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España.
| | - Cristina Alonso Álvarez
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Caterina Álvarez Heidbüchel
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Sarah Fernández Lafever
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Maria José Solana García
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Jesús López-Herce Cid
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
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17
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De Waele E, Jonckheer J, Pen JJ, Demol J, Staessens K, Puis L, La Meir M, Honoré PM, L. N. G. Malbrain M, Spapen HD. Energy expenditure of patients on ECMO: A prospective pilot study. Acta Anaesthesiol Scand 2019; 63:360-364. [PMID: 30397903 DOI: 10.1111/aas.13287] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/13/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND An optimal nutritional approach sustained by convenient monitoring of metabolic status and reliable assessment of energy expenditure (EE) may improve the outcome of critically ill patients on extracorporeal membrane oxygenation (ECMO). We previously demonstrated the feasibility of indirect calorimetry (IC)-the standard of care technique to determine caloric targets-in patients undergoing ECMO. This study aims to compare measured with calculated EE during ECMO treatment. We additionally provide median EE values for use in settings where IC is not available. METHODS IC was performed in seven stable ECMO patients. Gas exchange was analyzed at the ventilator, and ECMO side and values were introduced in a modified Weir formula to calculate resting EE. Results were compared with EE calculated with the Harris-Benedict equation and with the 25 kcal/kg/day ESPEN recommendation. RESULTS Total median oxygen consumption rate was 196 (Q1-Q3 158-331) mL/min, and total median carbon dioxide production was 150 (Q1-Q3 104-203) mL/min. Clinically relevant differences between calculated and measured EE were observed in all patients. The median EE was 1334 (Q1-Q3 1134-2119) kcal/24 hours or 18 (Q1-Q3 15-27) kcal/kg/day. CONCLUSION Compared with measured EE, calculation of EE both over- and underestimated caloric needs during ECMO treatment. Despite a median EE of 21 kcal/kg/day, large variability in metabolic rate was found and demands further investigation.
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Affiliation(s)
- Elisabeth De Waele
- Intensive Care Unit, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
- Department of Nutrition, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Joop Jonckheer
- Intensive Care Unit, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Joeri J. Pen
- Department of Nutrition, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
- Diabetes Clinic, Department of Internal Medicine, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Joy Demol
- Intensive Care Unit, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
- Department of Nutrition, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Kurt Staessens
- Department of cardiac surgery, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Luc Puis
- Department of cardiac surgery, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Mark La Meir
- Department of cardiac surgery, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Patrick M. Honoré
- Intensive Care Unit, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Manu L. N. G. Malbrain
- Intensive Care Unit, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
- Faculty of Medicine and Pharmacy; Vrije Universiteit Brussel (VUB); Brussels Belgium
| | - Herbert D. Spapen
- Intensive Care Unit, UZ Brussel; Vrije Universiteit Brussel (VUB); Brussels Belgium
- Faculty of Medicine and Pharmacy; Vrije Universiteit Brussel (VUB); Brussels Belgium
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18
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Farr BJ, Rice-Townsend SE, Mehta NM. Nutrition Support During Pediatric Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2018; 33:747-753. [PMID: 30325533 DOI: 10.1002/ncp.10212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Providing adequate nutrition to critically ill pediatric patients is essential and positively impacts outcomes. Critically ill infants and children receiving extracorporeal membrane oxygenation (ECMO) therapy are nutritionally vulnerable, yet there are challenges to reliable assessment of nutrition requirements and to the delivery of optimal nutrition in this cohort. In this review of the relevant literature, we present the current evidence and guidelines for the optimal prescription and delivery of nutrition for pediatric patients receiving ECMO. We also discuss nutrient delivery considerations in ECMO survivors and identify areas where further study is needed.
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Affiliation(s)
- Bethany J Farr
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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