Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

Abstract

This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and <18 years) expected to require a length of stay >2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

A review of feeding intolerance in critically ill children

“…We did not formally appraise the quality of these papers, as our aim was to describe the definition and use of the term feeding intolerance. A further 32 papers were review or discussion papers [n = 6] [2, 6,13,18,46,47], surveys [n = 5] [16,40,41,43,44], research papers which support this review but are not included in papers which defined feeding intolerance [n = 19] [3, 8, 11, 12, 14, 15, 17, 24, 25, 27, 30-32, 36, 38, 39, 42, 49], and guidelines [n = 2] [4,26] where feeding intolerance was mentioned or discussed.…”

“…Conversely, a more relaxed definition of feeding intolerance could also potentially lead to unsafe feeding practices. The latest ASPEN guidance [26] acknowledges feeding intolerance as a common barrier and only suggests the use of protocols that guide the detection and management of EN intolerance should be used; however, no guidance on how best to do this is made. The ESPGHAN nutrition committee 2010 position statement on practical approach of enteral nutrition in children (outside the PICU) highlighted diarrhea, nausea, vomiting, and regurgitations or aspirations as the major signs of enteral nutrition complications in children [4].…”

Indirect Calorimetry: History, Technology, and Application

“…This work showed that the expenditure of energy by organisms can be measured directly by direct calorimeters or estimated by measuring oxygen consumption (O 2 ): indirect calorimetry (4) (Figure 1). Indirect calorimetry is now considered the reference standard for measurement of energy expenditure in critically ill children (5). It is particularly recommended in children with nutritional deficits or derangements due to underlying disorders like cancers or acute diseases like sepsis or multiple trauma that are associated with large inaccuracies in estimation of energy needs, and those who fail attempts at liberation from mechanical ventilation (5–8).…”

“…All critically ill patients are susceptible to under and over nutrition, hence measurement of energy expenditure and the titration of intake based on the results is recommended (5). However, indirect calorimetry has suffered from limited spread that could be related to the high monetary cost to purchase and maintain the equipment, and the time cost to perform the measurement (58).…”

“…This has led nutritional societies to develop recommendations for certain patient populations where measurement of energy expenditure should be performed: (a) clinical conditions that significantly alter REE; (b) when patients fail to respond to presumed adequate nutrition support; and (c) in order to individualize the nutrition support in the ICU. More particular examples include patients with altered body composition, continued weight loss in face of “adequate” nutrition, persistent inflammatory state (for example severe burns, trauma, prolonged septic states), and difficulty in mechanical ventilation weaning (5, 58, 58–60). This recommendation aims to assist clinicians in prioritizing a scarce resource, however is inconsistent with the statements of both ASPEN and ESPEN that indirect calorimetry is the reference standard for energy expenditure measurement (5, 59).…”