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

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.

A Retrospective Analysis of Feeding Practices and Complications in Patients with Critical Bronchiolitis on Non-Invasive Respiratory Support

“…Pediatric studies have shown benefits of early nutrition, in both mechanically ventilated and non-invasively supported patients [ 16 , 28 ]. In fact, a recently published retrospective study in four European PICUs reached similar conclusions to ours, reporting safety and tolerance of early enteral nutrition in patients managed on NRS [ 20 ].…”

Enteral Feeding for Children on Bilevel Positive Pressure Ventilation for Status Asthmaticus

“…Several recent studies have highlighted the significance of early EN in the critically ill pediatric population including its role in shorter PICU and overall LOS. 11 14 15 16 There does not appear to be a consensus, however, on the definition and recommendation for early EN and has been stated in the past as anywhere from 24 to 48 hours. 8…”

“…There are a few studies detailing the benefits of early EN on infection prevention, clinical outcomes, and lower hospital charges in the general critically ill pediatric population. 11 12 However, there is limited data on the safety and feasibility of providing EN to patients admitted with SA receiving respiratory support via NPPV in the form of bilevel positive pressure ventilation (BIPAP). The need to determine feasibility of EN in children with SA on BIPAP is important, and differs from other respiratory failure cases needing the same, because children with SA on BIPAP recover faster and rarely progress to requiring invasive mechanical ventilation.…”

Barriers to Delivery of Enteral Nutrition in Pediatric Intensive Care: A World Survey

“…In a UK-wide survey of PICU physicians, nurses and dieticians (4), the top five barriers were: severe fluid restriction (60%), the child being 'too ill' to feed (17%), surgical post-operative orders (17%), nursing staff being slow in starting feeds (7%) and hemodynamic instability (7%). However, despite the paucity of randomized trial evidence to support enteral feeding during critical illness states, a substantial body of observational study evidence exists (16,17,18,19,20) indicating early EN is both feasible and improves clinical outcomes.…”