Peptide nutrient‐energy dense enteral feeding in critically ill infants: an observational study

Abstract

Background Enteral feeding is challenging in critically ill infants. Target intakes are often not achieved as a result of fluid restriction, procedural interruptions and perceived enteral feeding intolerance. In those infants perceived to have poor feeding tolerance, the use of a peptide nutrient‐energy dense enteral feed (PEF) may improve nutritional intake and minimise feeding interruptions as a result of gastrointestinal symptoms. The aim of this observational study was to characterise the use of a PEF amongst critically ill infants in two paediatric intensive care units (PICUs). Methods Records from critically ill infants aged <12 months admitted to two PICUs were retrospectively reviewed with a PICU length of stay (LOS) ≥ 7 days. Achievement of nutritional targets for the duration of PEF was reviewed. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters. Results In total, 53 infants were included, with a median age on admission of 2.6 months. Median admission weight was 3.9 kg in PICU‐1 and 4.7 kg in PICU‐2. Median (interquatile range) energy intake in PICU‐1 and PICU‐2 was 68 (47–92) and 90 (63–124) kcal kg−1, respectively, and median (interquatile range) protein intake 1.7 (1.1–2.4) g kg−1 and 2.5 (1.6–3.2) g kg−1, respectively. Feeding was withheld because of feeding intolerance in one infant (4%) on two occasions in PICU‐1 for 2.5 h and in two infants (7%) on two occasions in PICU‐2 for 19.5 h. Gastric residual mean (SD) volumes were 3.5 (5.4) mL kg−1 in PICU‐1 and 16.9 (15.6) mL kg−1 in PICU‐2. Conclusions Peptide nutrient‐energy dense feeding in infants admitted to the PICU is feasible, well tolerated and nutritional targets are met. However, with this study design, it is not possible to draw any conclusions regarding the benefit of PEF over standard PE feed in critically ill children and future work is required to clarify this further.

The use of extensively hydrolysed and amino acid feeds beyond cow’s milk allergy: a national survey

“…Gastrointestinal disorders including: gastroschisis, volvulus, pseudo‐obstruction, duodenal atresia, jejunal atresia, necrotising enterocolitis (NEC), intestinal failure – congenital or acquired including short bowel syndrome – defined as bowel length of <40 cm ( 20 )…”

Nutrition chez l'enfant : ce qui est important en réanimation pédiatrique

“…En cas de restriction hydrique majeure, ou de dénutrition préalable ou acquise en réanimation, une NE par des produits enrichis peut être envisagée. Quelques études semblent montrer qu'une nutrition enrichie permettrait de diminuer la dénutrition acquise au cours du séjour en réanimation [53,54].…”

Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

“… In the acute phase, energy intake provided to critically ill children should not exceed resting energy expenditure After the acute phase, energy intake provided to critically ill children should account for energy debt, physical activity, rehabilitation and growth Measuring resting energy expenditure using a validated indirect calorimeter should be considered to guide nutritional support or Schofield equations [ 24 ] are recommended to estimate resting energy expenditure For critically ill infants and children on enteral nutrition a minimum enteral protein intake of 1.5 g/kg/d can be considered to avoid negative protein balance Due to the gastrointestinal and atypical Kawasaki disease EN support may need to be continued for longer into the recovery phase until sufficient oral intake is consistently achieved to support physical and nutritional rehabilitation [ 18 ] An unknown is whether muscle mass loss may be more pronounced in children with severe disease and energy, protein deficits should be avoided The use of indirect calorimetry (IC) should be risk assessed with benefits of using it against Schofield equations [ 24 ], as limiting ventilator circuit disconnection will reduce virus aerosolization In critically ill children, do different feed formulas (polymeric vs. semi-elemental feed, standard vs. enriched formula) impact on clinical outcomes? Polymeric feeds should be considered as the first choice for EN in most critically ill children, unless there are contraindications Protein and energy-dense formulations may be considered to support achievement of nutritional requirements in fluid-restricted critically ill children Peptide-based formulations may be considered to improve tolerance and progression of enteral feeding in children for whom polymeric formulations are poorly tolerated or contra-indicated COVID 19 paediatric multisystem inflammatory syndrome may be associated with severe gastrointestinal symptoms, which may prevent early EN, or impact on its tolerance [ 16 ] In those where enteral feeding is possible a peptide based feed may be better tolerated [ 25 ] In critically ill children, does continuous feeding compared to intermittent bolus gastric feeding impact on outcomes? There is no evidence to suggest that either continuous or intermittent/bolus feeds are superior in delivering gastric feeds in critically ill children In children with gastrointestinal symptoms continuous feeds may be better tolerated with or without a two- 4 h feed break within 24 h day [ 25 ] In critically ill children, does gastric feeding compared to post-pyloric feeding impact on clinical outcomes?…”

“… Polymeric feeds should be considered as the first choice for EN in most critically ill children, unless there are contraindications Protein and energy-dense formulations may be considered to support achievement of nutritional requirements in fluid-restricted critically ill children Peptide-based formulations may be considered to improve tolerance and progression of enteral feeding in children for whom polymeric formulations are poorly tolerated or contra-indicated COVID 19 paediatric multisystem inflammatory syndrome may be associated with severe gastrointestinal symptoms, which may prevent early EN, or impact on its tolerance [ 16 ] In those where enteral feeding is possible a peptide based feed may be better tolerated [ 25 ] In critically ill children, does continuous feeding compared to intermittent bolus gastric feeding impact on outcomes? There is no evidence to suggest that either continuous or intermittent/bolus feeds are superior in delivering gastric feeds in critically ill children In children with gastrointestinal symptoms continuous feeds may be better tolerated with or without a two- 4 h feed break within 24 h day [ 25 ] In critically ill children, does gastric feeding compared to post-pyloric feeding impact on clinical outcomes? Gastric feeding is as safe as post pyloric feeding in the majority of critically ill children Gastric feeding is not inferior to post pyloric feeding in the most critically ill children Gastric feeding is recommended over post-pyloric feeding in children with severe sepsis/shock In an awake children e.g.…”

“…In children with gastrointestinal symptoms continuous feeds may be better tolerated with or without a two- 4 h feed break within 24 h day [ 25 ]…”