Epidemiology of Interruptions to Nutrition Support in Critically Ill Children in the Pediatric Intensive Care Unit

Keehn, Alysha; O’Brien, Christina; Mazurak, Vera C.; Brunet‐Wood, Kim; Joffe, Ari R.; Caen, Allan de; Larsen, Bodil

doi:10.1177/0148607113513800

Cited by 51 publications

(61 citation statements)

References 27 publications

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“…EN interruptions have been described in both pediatric and adult critically ill patients (6). A significant proportion of these interruptions may be avoidable (6,23). A variety of strategies have been used to avoid unintended EN interruptions in the intensive care unit, including the use of the postpyloric route, stepwise algorithms, and volume-based feeding (24)(25)(26).…”

Section: Discussionmentioning

confidence: 99%

Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study

Mehta

Bechard

Zurakowski

et al. 2015

The American Journal of Clinical Nutrition

184

153

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Background: The impact of protein intake on outcomes in pediatric critical illness is unclear. Objective: We examined the association between protein intake and 60-d mortality in mechanically ventilated children. Design: In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for $48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay #10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. Results: We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean 6 SD prescribed energy and protein goals were 69 6 28 kcal/kg per day and 1.9 6 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 6 35% and 37 6 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P , 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake ,20%, intake $60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. Conclusions: Delivery of .60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521.

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Section: Discussionmentioning

confidence: 99%

Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study

Mehta

Bechard

Zurakowski

et al. 2015

The American Journal of Clinical Nutrition

184

153

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“…Rogers et al reported that fluid restriction was a major factor limiting nutrient intake in pediatric cardiac patients 3 . Fasting prior to procedures, failure to reinstitute timely nutrient intake after procedures, and mechanical issues with feeding tubes have all been identified as other major contributing factors to EN interruptions 3,5,6,16 . These interruptions to EN may result in a nutrient deprivation for a high proportion of the illness course.…”

Section: Discussionmentioning

confidence: 99%

A Stepwise Enteral Nutrition Algorithm for Critically Ill Children Helps Achieve Nutrient Delivery Goals*

Hamilton¹,

McAleer²,

Ariagno³

et al. 2014

Pediatric Critical Care Medicine

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Objective To evaluate the impact of implementing an enteral nutrition (EN) algorithm on achieving optimal EN delivery in the Pediatric Intensive Care Unit (PICU). Design Prospective pre/post implementation audit of EN practices. Setting One 29-bed medical/surgical PICU in a free standing, university affiliated children’s hospital. Patients Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of > 24 hours who received EN. Interventions Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing and maintaining EN in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, EN interruptions, parenteral nutrition (PN) use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and post-intervention cohorts. Time to achieving energy goal was analyzed using Kaplan Meier statistical analysis. Measurements and Main Results Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the pre-implementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating EN, or use of post-pyloric feeding between the 2 cohorts. We recorded a significant decrease in the number of avoidable episodes of EN interruption (3 vs. 51, p0.0001) and the incidence and duration of PN dependence in patients with avoidable EN interruptions in the post-intervention cohort. Median time to reach energy goal decreased from 4 days to 1 (p<0.0001), with a higher proportion of patients reaching this goal (99% vs. 61%, p = 0.01). Conclusions The implementation of an EN algorithm significantly improved EN delivery and decreased reliance on PN in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

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“…Early EN, though variably defined by investigators, promotes the achievement of energy and protein nutrition goals and is associated with improved survival in children in the PICU (9-12). In a multicenter retrospective study of 5105 critically ill children, 40% of them had EN delayed beyond 48 hours after admission to the PICU.…”

Section: Introductionmentioning

confidence: 99%

“…Little is known about obstacles to the initiation of EN although it is probable that they would be similar to those associated with the inability to achieve nutritional goals. Since many of the obstacles to achieving nutritional goals may be modifiable, it is possible that barriers to initiation of EN may be modifiable as well (12, 16, 18). The aim of this study was to determine the factors associated with delayed EN in critically ill children.…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Delayed Enteral Nutrition in Critically Ill Children*

Canarie

Barry

Carroll

et al. 2015

Pediatric Critical Care Medicine

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Objective Delayed enteral nutrition (EN), defined as EN started ≥ 48 hours after admission to the pediatric intensive care unit (PICU) is associated with an inability to achieve full EN and worse outcomes in critically ill children. We reviewed nutritional practices in 6 medical-surgical PICUs and determined risk factors associated with delayed EN in critically ill children. Design Retrospective cross-sectional study using medical records as source of data Setting Six medical-surgical PICUs in northeastern United States Patients Children < 21 years old admitted to the PICU for ≥ 72 hours excluding those awaiting or recovering from abdominal surgery. Measurements/Main Results A total of 444 children with a median age of 4.0 years were included in the study. EN was started at a median time of 20 hours after admission to the PICU. There was no significant difference in time to start EN among the PICUs. Of those included, 88 (19.8%) children had delayed EN. Risk factors associated with delayed EN were: non-invasive (odds ratio [OR]: 3.37; 95% CI: 1.69-6.72) and invasive positive pressure ventilation (OR: 2.06; 95% CI: 1.15-3.69), severity of illness, (OR for every 0.1 increase in Pediatric Index of Mortality 2 score: 1.39; 95% CI: 1.14-1.71) as well as procedures (OR 3.33; 95% CI: 1.67-6.64) and; gastrointestinal disturbances (OR: 2.05; 95% CI: 1.14-3.68) within 48 hours after admission to the PICU. Delayed EN was associated with failure to reach full EN while in the PICU (OR 4.09; 95% CI: 1.97-8.53). Nutrition consults were obtained in less than half of the cases and none of the PICUs employed tools to assure the adequacy of energy and protein nutrition. Conclusions Institutions in this study initiated EN for a high percentage of patients by 48 hours of admission. Non-invasive positive pressure ventilation was most strongly associated with delay EN. A better understanding of these risk factors and assessments of nutritional requirements should be explored in future prospective studies.

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Epidemiology of Interruptions to Nutrition Support in Critically Ill Children in the Pediatric Intensive Care Unit

Cited by 51 publications

References 27 publications

Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study

Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study

A Stepwise Enteral Nutrition Algorithm for Critically Ill Children Helps Achieve Nutrient Delivery Goals*

Risk Factors for Delayed Enteral Nutrition in Critically Ill Children*

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