Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation

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.

Enteral Nutrition During Extracorporeal Membrane Oxygenation in the Neonatal and Pediatric Populations: A Literature Review

“…No randomized clinical trials were identified in this literature search. Studies did not always specify where the samples were obtained, but seven studies specified the PICU (2, 8, 13, 18, 19, 21, 22). Five studies were conducted in The Netherlands (12, 17, 19, 20, 24), four studies in the United States (9, 13, 18, 23), two studies in Spain (2, 21), one study in Singapore (8), one study in China (25), and one study in Thailand (22).…”

“…In the five studies that listed sex, both males and females were represented evenly (8, 9, 13, 17, 23, 24). Neonatal pulmonary and cardiac diseases were the greatest underlying diagnoses requiring ECMO (2, 8, 9, 12, 17–25). Four studies evaluated patients who only received EN (9, 12, 13, 20).…”

“…Four studies evaluated patients who only received EN (9, 12, 13, 20). Ten studies evaluated groups of patients who received EN along with those who received a combination of EN and PN (2, 8, 17–17, 21–25).…”

“…Underutilization referred to studies where there was delayed initiation of enteral feeds (> 48 hr post-ICU admission) or those that did not reach caloric goals. Many studies did not report the rate of those who reached full EN (2, 8, 9, 12, 13, 17, 22, 25). In the studies that presented adequate caloric goals, an average of 22% of patients achieved the caloric goals over a 1- to 5-day period (18–21, 23, 24).…”

“…Since 2009, there has been a 24% increase in children needing ECMO (1). While increased mortality is associated with the prolonged duration of ECMO, providing nutrition through the gastrointestinal tract, known as enteral nutrition (EN), is associated with reduced rates of morbidity and mortality (2). Furthermore, EN should be considered when managing a patient on ECMO (2).…”