Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU*

Abstract

Objective To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the pediatric intensive care unit (PICU). Design Data from 2 multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by BMI Z-score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator free days (VFD), using multivariate analysis. Setting 90 PICUs from 16 countries with 8 beds. Patients Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more that 48 hours Measurements and Main Results Data from 1622 eligible patients, 54.8% male and mean (SD) age 4.5 (5.1) years, were analysed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on BMI Z-score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (OR 1.53, P<0.001) children. The odds of hospital-acquired infections were higher in underweight (OR 1.88, P=0.008) and obese (OR 1.64, P<0.001) children. Hazard ratios for hospital discharge were lower among underweight (HR 0.71, P<0.001) and obese (HR 0.82, P=0.04) children. Underweight was associated with 1.3 (P=0.001) and 1.6 (P<0.001) fewer VFD, compared to normal weight and overweight, respectively. Conclusions Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

Impact of Obesity on Outcomes in Critically Ill Children

“…This finding corroborates our decision to exclude the underweight patients, who have multiple independent risk factors for a worse prognosis, from this study. In addition, Bechard et al 26 reported that although obese patients had a higher rate of hospital-acquired infections, there was no difference in mortality risk or length of mechanical ventilation in the overweight or obese group compared with normal-weight patients, which is a finding similar to the results of this study. Finally, Ward et al 13 looked at the impact of obesity on the outcomes in pediatric patients with acute respiratory distress syndrome (ARDS).…”

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

“…Admission z scores based on weight for age and BMI for age (or weight for length for children <2 years) in relation to population reference standards have been used to classify patients as undernourished or obese. Admission BMI z scores predicted mortality in a large multicenter cohort of children receiving mechanical ventilation 4 . Due to the consistent associations with LOS, duration of mechanical ventilation, and mortality, BMI z scores may be useful to screen for patients at risk of poor outcomes in the PICU 17 .…”

“…Since the first pediatric critical care nutrition guidelines (ASPEN) published in 2009, there has been a substantial increase in research and publications related to this subject. The impact of nutrition status and nutrient delivery during critical illness has been demonstrated on clinical outcomes such as mortality, infectious complications, and LOS 4 – 10 . Thus, careful planning and monitoring of nutrient delivery at the bedside is attempted in most intensive care units (ICUs).…”

“…Malnutrition is prevalent in children admitted to the PICU 6 , 7 , 14 , 15 . Although variables used to define malnutrition are inconsistent across reports, underweight and overweight status have both been associated with worse morbidity and mortality 4 – 6 , 10 . More recently, guidelines to define pediatric malnutrition have become available to facilitate early identification of individuals at risk 16 .…”

Protein Requirements of the Critically Ill Pediatric Patient

“…A multicenter cohort study reported BMI and outcomes in 1622 mechanically ventilated children; underweight and obesity were associated with a higher risk of hospital‐acquired infections and a lower likelihood of hospital discharge. In addition, underweight children had a higher risk of mortality and fewer ventilator‐free days 71 …”