Early vs late enteral nutrition in pediatric intensive care unit: Barriers, benefits, and complications

Abstract

Background: This study aimed to define the existing barriers for early enteral nutrition (EEN) in critically ill children and to analyze the differences in nutrient supply, complications, and outcomes between EEN and late EN (LEN). Methods: This is a secondary analysis of a multicenter observational, prospective study including critically ill children receiving EN. Variables analyzed included demographic and anthropometric features, caloric and nutrient supply, outcomes, and complications according to the EN onset. Patients were classified into two groups according to the start of EN: 24-EEN vs EN started after 24 h (24-LEN) and . Results: Sixty-eight children were enrolled; 22.1% received 24-EEN, and 67.6% received 48-EEN. EN was most frequently delayed in patients older than 12 months, in patients with cardiac disease, and in those requiring mechanical ventilation (MV). Children in the 24-EEN group had shorter duration of MV compared with those in the 24-LEN group (P = 0.04). The 48-EEN group received a higher caloric intake (P = 0.04), reached the caloric target earlier (P < 0.01), and had lower incidence of constipation (P = 0.01) than the 48-LEN group. There was a positive correlation between the time required to reach the maximum caloric intake and the length of pediatric intensive care stay (r = 0.46; P < 0.01).

Timing of enteral nutrition and parenteral nutrition in the PICU

“…Early initiation of EN may result in quicker achievement of higher energy intakes during pediatric critical illness. In an additional secondary analysis of a multicenter observational study including 68 infants and children from 12 PICUs in Spain, EN started within 48 h vs after 48 h was associated with significantly higher energy intake and faster attainment of maximum energy provision, 8 guided by the Schofield equation. 19 With EN initiated in 24 h compared with after 24 h, a significantly shorter duration of mechanical ventilation was revealed, although severity of illness was significantly and positively correlated with the timing of EN initiation.…”

“…Despite uncommon reports of adverse events, early EN in 24–48 h from admission or injury is safe and tolerable for the majority of children with critical illness. Early EN improves gastrointestinal tolerance in some patients, with reports of decreased constipation 8 and reduced abdominal distension 17 . Results of these observational studies are confounded by the inability to control for all variables impacting study outcomes, and more randomized controlled trials are needed to determine safety, tolerance, and efficacy of early vs delayed EN.…”

“…Providing early vs delayed EN is significantly associated with reduced mortality, 7,10,12,15 less organ dysfunction, 10 reduced ventilator requirement, 7,8,10 decreased length of stay in the intensive care unit 7,13 and hospital, 13 cost savings, 14 and attainment of energy and protein intake goals. 8,13 Conversely, late EN initiation >48 h after admission was significantly associated with pulmonary infections in a prospective observational study of 350 infants and children with critical illness in whom the majority were admitted following surgery for congenital heart disease. 18 In addition, a retrospective multicenter study of 416 children with traumatic brain injury demonstrated significant associations between delayed initiation of EN of >48 h and lower Glasgow Coma Scale scores, higher Injury Severity Score, and worse functional status at discharge.…”

“…Intubation/extubation 58,[63][64][65] Procedures/surgery/imaging 24,58,[63][64][65][66][67][68] Hemodynamic/respiratory/medical instability 58,63,64,66,67 Gastrointestinal intolerance 24,58,63,65,67,68 Enteral access/feeding tube issues 63,65,66 Fluid restriction 63,67,68 Illness severity 8,24 Invasive mechanical ventilation 8,24 Noninvasive positive pressure ventilation 24 Opioid requirement 8 Medication administration 58 Upper gastrointestinal bleeding 67 Red blood cell transfusion 58 Hyperglycemia 63 Lack of enteral nutrition guideline 64 Lack of dietitian presence 66 Provider knowledge deficit 66 Transfers between units 63 Fluid restriction 63,67,68 Hyperglycemia …”

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children

“…EEN has also been associated with a reduction in mortality, length of hospital stays and weight loss when compared to DEN [ 13 ]. A recent multicenter study in critically ill children also found that early enteral nutrition could be helpful in improving nutrient delivery, reducing time on mechanical ventilation and preventing constipation in sick children [ 14 ]; however, the presence of cardiac disease, mechanical ventilation and an age of over 12 months were risk factors associated with DEN. International guidelines recommend early enteral nutrition in critically ill children with hemodynamic support, extracorporeal life support and other situations once the child has been resuscitated [ 6 , 15 ], but enteral nutrition is often delayed due to gastrointestinal intolerance or the need to restrict fluid intake, making critically ill children prone to receiving insufficient calorie and protein intake [ 16 ].…”