Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient

Based on observational studies, malnutrition, including obesity, is associated with adverse clinical outcomes, including longer periods of ventilation, higher risk of hospital-acquired infection, longer PICU and hospital stay, and increased mortality. We recommend that patients in the PICU undergo detailed nutrition assessment within 48 h of admission. Furthermore, as patients are at risk of nutrition deterioration during hospitalization, which can adversely affect clinical outcomes, we suggest that the nutrition status of patients be reevaluated at least weekly throughout hospitalization. (S - Strong, VL - Very Low)

On the basis of observational studies and expert consensus, we recommend that weight and height/length be measured on admission to the PICU and that z scores for body mass index for age (weight for length <2 y) or weight for age (if accurate height is not available) be used to screen for patients at extremes of these values. In children <36 mo old, head circumference must be documented. Validated screening methods for the PICU population to identify patients at risk of malnutrition must be developed. Screening methods might allow limited resources to be directed to high-risk patients who are most likely to benefit from early nutrition assessment and interventions. (S - Strong, VL - Very Low)

On the basis of observational cohort studies, we suggest that measured energy expenditure by IC be used to determine energy requirements and guide prescription of the daily energy goal. (W - Weak, L - Low)

If IC measurement of resting energy expenditure is not feasible, we suggest that the Schofield or Food Agriculture Organization / World Health Organization / United Nations University equations may be used without the addition of stress factors to estimate energy expenditure. Multiple cohort studies have demonstrated that most published predictive equations are inaccurate and lead to unintended overfeeding or underfeeding. The Harris-Benedict equations and the RDAs, which are suggested by the dietary reference intakes, should not be used to determine energy requirements in critically ill children. (W - Weak, VL - Very Low)

On the basis of observational cohort studies, we suggest achieving delivery of at least two-thirds of the prescribed daily energy requirement by the end of the first week in the PICU. Cumulative energy deficits during the first week of critical illness may be associated with poor clinical and nutrition outcomes. On the basis of expert consensus, we suggest attentiveness to individualized energy requirements, timely initiation and attainment of energy targets, and energy balance to prevent unintended cumulative caloric deficit or excesses. (W - Weak, L - Low)

On the basis of evidence from RCTs and as supported by observational cohort studies, we recommend a minimum protein intake of 1.5 g/kg/d. Protein intake higher than this threshold has been shown to prevent cumulative negative protein balance in RCTs. In critically ill infants and young children, the optimal protein intake required to attain a positive protein balance may be much higher than this minimum threshold. Negative protein balance may result in loss of lean muscle mass, which has been associated with poor outcomes in critically ill patients. Based on a large observational study, higher protein intake may be associated with lower 60-d mortality in mechanically ventilated children. (S - Strong, M - Moderate)

On the basis of results of randomized trials, we suggest provision of protein early in the course of critical illness to attain protein delivery goals and promote positive nitrogen balance. Delivery of a higher proportion of the protein goal has been associated with positive clinical outcomes in observational studies. (W - Weak, M - Moderate)

The optimal protein dose associated with improved clinical outcomes is not known. We do not recommend the use of RDA values to guide protein prescription in critically ill children. These values were developed for healthy children and often underestimate the protein needs during critical illness. (S - Strong, M - Moderate)

On the basis of observational studies, we recommend EN as the preferred mode of nutrient delivery to the critically ill child. Observational studies support the feasibility of EN, which can be safely delivered to critically ill children with medical and surgical diagnoses and to those receiving vasoactive medications. Common barriers to EN in the PICU include delayed initiation, interruptions due to perceived intolerance, and prolonged fasting around procedures. On the basis of observational studies, we suggest that interruptions to EN be minimized in an effort to achieve nutrient delivery goals by the enteral route. (S - Strong, L - Low)

Although the optimal dose of macronutrients is unclear, some amount of nutrient delivered as EN has been beneficial for gastrointestinal mucosal integrity and motility. Based on large cohort studies, early initiation of EN (within 24–48 h of PICU admission) and achievement of up to two-thirds of the nutrient goal in the first week of critical illness have been associated with improved clinical outcomes. (W - Weak, L - Low)

On the basis of observational studies, we suggest the use of a stepwise algorithmic approach to advance EN in children admitted to the PICU. The stepwise algorithm must include bedside support to guide the detection and management of EN intolerance and the optimal rate of increase in EN delivery. (W - Weak, L - Low)

On the basis of observational studies, we suggest a nutrition support team, including a dedicated dietitian, be available on the PICU team, to facilitate timely nutrition assessment, and optimal nutrient delivery and adjustment to the patients. (W - Weak, L - Low)

Existing data are insufficient to make universal recommendations regarding the optimal site to deliver EN to critically ill children. On the basis of observational studies, we suggest that the gastric route be the preferred site for EN in patients in the PICU. The postpyloric or small intestinal site for EN may be used in patients unable to tolerate gastric feeding or those at high risk for aspiration. Existing data are insufficient to make recommendations regarding the use of continuous vs intermittent gastric feeding. (W - Weak, L - Low)

On the basis of expert opinion, we suggest that EN be initiated in all critically ill children, unless it is contraindicated. Given observational studies, we suggest early initiation of EN, within the first 24–48 h after admission to the PICU, in eligible patients. We suggest the use of institutional EN guidelines and stepwise algorithms that include criteria for eligibility for EN, timing of initiation, and rate of increase, as well as a guide to detecting and managing EN intolerance. (W - Weak, L - Low)

On the basis of a single RCT, we do not recommend the initiation of PN within 24 h of PICU admission. (S - Strong, M - Moderate)

For children tolerating EN, we suggest stepwise advancement of nutrient delivery via the enteral route and delaying commencement of PN. Based on current evidence, the role of supplemental PN to reach a specific goal for energy delivery is not known. The time when PN should be initiated to supplement insufficient EN is also unknown. The threshold for and timing of PN initiation should be individualized. Based on a single RCT, supplemental PN should be delayed until 1 wk after PICU admission for patients with normal baseline nutrition state and low risk of nutrition deterioration. On the basis of expert consensus, we suggest PN supplementation for children who are unable to receive any EN during the first week in the PICU. For patients who are severely malnourished or at risk of nutrition deterioration, PN may be supplemented in the first week if they are unable to advance past low volumes of EN. (W - Weak, L - Low)

On the basis of available evidence, we do not recommend the use of immunonutrition in critically ill children. (S - Strong, M - Moderate)