|Year : 2019 | Volume
| Issue : 3 | Page : 812-817
Nutrition in critically Ill pediatric patients: a systemic review
Ali M Elshafie1, Dalia M El-Lahony1, Zein A Omar1, Wael A Bahbah1, Hanem R M Ghetas2
1 Department of Pediatrics, Faculty of Medicine, Sers Al-Lyan Hospital, Sers Al-Lyan, Menoufia, Egypt
2 Department of Pediatrics, Sers Al-Lyan Hospital, Sers Al-Lyan, Menoufia, Egypt
|Date of Submission||15-Jan-2018|
|Date of Acceptance||06-Mar-2018|
|Date of Web Publication||17-Oct-2019|
Hanem R M Ghetas
Sers Al-Lyan Hospital, Menoufia 32717
Source of Support: None, Conflict of Interest: None
The study aimed to review the different types of nutrition in critically ill pediatric patients.
Medline databases (PubMed, Medscape, Science Direct, EMF-Portal, Google Scholar) and all materials available in the Internet from 2001 to 2014 were searched.
The initial search presented 150 articles of which 50 met the inclusion criteria. The articles studied the role of nutritional management in critically ill pediatric patients.
If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, adequate information provided, and assessment measures defined.
Comparisons were made by structured review with the results tabulated.
In total, 50 studies indicated that ICU patients who present with malnutrition or at a high probability of developing malnutrition during their hospital stay and those who are not expected to be on a full oral diet within 3 days should receive specialized enteral and/or parenteral nutritional support. Feeding should be started early within the first 24–48 h to facilitate diet tolerance and reduce the risk of intestinal barrier dysfunction and infections.
This review found that critically ill pediatric patients are at risk of malnutrition. Enteral nutrition is the preferred mode of nutrition and should be used whenever possible. Total parental nutrition is used only if the gastrointestinal tract is unable to meet the nutritional requirements for 1–3 days in infants and 4–5 days in children and adolescents.
Keywords: enteral nutrition, malnutrition, nutritional management, parenteral nutrition
|How to cite this article:|
Elshafie AM, El-Lahony DM, Omar ZA, Bahbah WA, Ghetas HR. Nutrition in critically Ill pediatric patients: a systemic review. Menoufia Med J 2019;32:812-7
|How to cite this URL:|
Elshafie AM, El-Lahony DM, Omar ZA, Bahbah WA, Ghetas HR. Nutrition in critically Ill pediatric patients: a systemic review. Menoufia Med J [serial online] 2019 [cited 2020 Apr 4];32:812-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/812/268814
| Introduction|| |
Critical illness is any disease process which causes physiological instability leading to disability or death within minutes or hours . Critically ill pediatric patients have complex nutritional needs and require intensive nutritional support. As part of the metabolic response to injury, resting energy expenditure may be raised, leading to extensive catabolism, hyperglycemia, progressive lean body mass loss, changes in serum trace element levels, fluid retention, and reduced synthesis of visceral proteins such as albumin. Contributing toPoorer ou tcome is the high prevalence of malnutrition (40%) in pediatric ICU patients, as reported by previous studies . Overall, the goal of feeding in pediatric ICU (PICU) patients is to provide nutrition support to those who need it, consistent with their medical condition, nutritional status, metabolic capability, and available route of administration . Enteral nutrition (EN) in critically ill patient with a functioning gastrointestin al (GI) tract should be the preferred mode of nutrition if tolerated to maintain physiologic and functional integrity of gut mucosa . Parenteral nutrition (PN) involves the infusion of mixture of amino acids, carbohydrates, and fat, as well as electrolytes and micronutrients. Sometimes PN is needed to supplement insufficient EN; total PN means that the infusion provides the patient's complete nutritional requirements . Transition from PN to EN should be done through appropriate minimal entera l feeds given in conjunction with PN wherever possible to prevent gut atrophy and encourage gut adaptation, as well as reduce the risk of PN . So, this present study aims to review the different types of nutrition in critically ill pediatric patients.
| Patients and Methods|| |
We reviewed papers on the influence of different types of nutrition in critically ill pediatric patients from Medline databases, such PubMed, Medscape, and Science Direct, and materials available in the Internet. We used critically ill patients/different types of nutrition/nutritional management in critically ill pediatric patient/length of stay in PICU/mortality rate in PICU as search terms. In addition, we examined references from the specialist databases EMF-Portal (http://www.emf-portal.de), reference lists in relevant publications, and published reports about nutrition in critical illness. The search was performed in the electronic databases from 2001 to 2014.
All the studies were independently assessed for inclusion. They were included if they fulfilled the following criteria: published in English language, published in peer-reviewed journals, studied critically ill pediatric patients, studied different types of nutritional management in critically ill pediatric patients, length of stay in PICU, and mortality rate in PICU.
If a study had several publications on certain aspects, we used the latest publication giving the most relevant data.
If the studies did not fulfill the aforementioned criteria, they were excluded, such as nutrition management in noncritically ill patients, surveys about symptoms and health concerns without exposure assessment, report without peer-review, not within national research program, letters/comments/editorials/news, and studies not focused on exposure in noncritical illness and critical illness in adult patients.
The quality of all the studies was assessed. Important factors included study design, attainment of ethical approval, evidence of a power calculation, specified eligibility criteria, appropriate controls, adequate information, and specified assessment measures. It was expected that confounding factors would be reported and controlled for and appropriate data analysis made in addition to an explanation of missing data.
A structured systematic review was performed with the results tabulated.
| Results|| |
Study selection and characteristics
In total, 150 potentially relevant publications were identified, and 100 articles were excluded as they did not meet our inclusion criteria. Therefore, 50 studies were included in the review as they were deemed eligible by fulfilling the inclusion criteria. Most of the studies examined malnutrition and the role of different types of nutrition in critically ill pediatric patients.
Anthropometric changes during pediatric critical illness
Regarding anthropometric changes during pediatric critical illness, several studies are presented in [Table 1]. Two cohort studies , observed a correlation between energy deficit and deterioration in anthropometric parameters in a mixed population of critically ill children, and one cohort study  reported 65% prevalence of malnutrition on admission with increased mortality in this group. Another four retrospective cohort studies ,,, examined the performance of estimated energy needs in relation to measure resting energy expenditure in critically ill children.
Enteral nutrition in critically ill patient
Regarding enteral nutrition in critically ill patient, several studies presented in [Table 2] described nutritional support to critically ill patients. One literature review  defined enteral nutrition as a way of provision of nutrition into the gastrointestinal tract for the patients unable to otherwise meet nutrient requirements by oral route. There was another cohort study  that reported better tolerance in critically ill children receiving early (<24 h after PICU admission). than children feeding late (after 24 h) postpyloric nutrition. Another two RCTs , compared different route of EN feeding: one study  comparing gastric versus small bowel continuous tube feeds showed no significant difference, and the other study  comparing gastric EN administered either continuously or every 2 h showed tolerance to EN was similar. There were three cohort studies ,, that reported inability to achieve daily caloric goal in critically ill children, and the most common reasons for suboptimal enteral nutrient delivery are fluid restriction, interruption to EN, and EN intolerance owing to hemodynamic instability. Regarding the effect of immune-enhancing formula, there were eight trails ,,,,,,, comparing the role of immune-enhancing EN containing glutamine, arginine, omega-3 fatty acids, and antioxidants with standard age-appropriate formula; they did not show any clinically important outcomes. There were another four retrospective studies ,,, regarding presence of specialized nu trition support team in the PICU, and aggressive feeding protocols may enhance the overall delivery of nutrition with shorter time to achieve nutritional support and increase EN with decrease in the use of PN.
Regarding PN in critical illness, several studies presented in [Table 3] described parental nutrition. One literature review  defined PN as the feeding of the patients intravenously by passing over the usual process of eating and digestion. In a randomized study  involving 300 patients undergoing major surgery, the patients received continuous total parental nutrition or exclusively glucose (250–300 g/day) intravenous administration for 14 days. Those on parental nutrition had 10 times less mortality than those on glucose. Regarding the benefits of PN, four meta-analysis studies ,,, demonstrated the benefits of PN during PICU admission. An unblended study  showed intravenous fish oil supplementation had favorable effects on survival, infection rate, and length of stay, and another four studies ,,, described that administration of PN supplemented with fish oil-enriched lipid emulsion showed no significant difference in term of mortality. Six trails, one post-hoc analysis and five RCTs ,,,,,, investigated the effect of different dose and composition of PN in critically ill children treated in PICU. Of these six studies, four studies investigated infant after cardiac surgery and two included children with sepsis or after other major surgery or burns, respectively.
| Discussion|| |
Clinical instability and poor nutritional status in critically ill children have been reported as barrier to providing optimal nutrition . Prevalence of malnutrition (15–65%) on admission is related to increased mortality in this group, and on follow-up, a significant portion of these children had further deterioration in nutrition status . Stress or activity correction factors have been traditionally factored into basal energy requirement estimates to adjust for the nature of illness, of its severity, and the activity level of hospitalized patients . Patients at high risk for metabolic alterations such as underweight patient (BMI<fifth percentile for age), patients in need for muscle relaxants for more than 7 days, patients having neurologic trauma such as traumatic, hypoxic, and/or ischemic with evidence of dysautonomia, oncologic diagnoses including children with stem cell or bone marrow transplant, children with thermal injury, children requiring mechanical ventilator support for more than 7 days, and children suspected to be severely hypermetabolic, such as status epilepticus, hyperthermia, systemic inflammatory response syndrome, and dysautonomia storms, or hypometabolic, such as hypothermia, hypothyroidism, phenobarbital, or midazolam coma . Nutrition management includes both EN and PN. For critically ill children with a functioning GI tract, the enteral route is preferable to PN. EN is physiologic and has been shown to be more cost effective without the added risk of nosocomial infection inherent with PN . Critically ill children receiving early feeding (<24 h after PICU admission) reported better tolerance than children feeding late (after 24 h) postpyloric nutrition . GI symptoms are the most common complication of EN including aspiration, diarrhea, constipation, vomiting, and abdominal distention. These may be minimized by selection of the appropriate enteral formula and mode of delivery, gradual introduction of the feed with monitoring of residual gastric volumes . About total PN is provision of nutrition for metabolic requirements and growth through the parenteral route . The indications for PN in children are similar to the indications in adults, that is, if the GI tract cannot be used as a route of administration for nutrition, parenteral nutrition may be indicated. One big difference versus adults is that due to fewer body stores and a higher caloric daily requirement, children are started on hyperalimentation sooner than adults . Catheter-related sepsis is one of the most serious complications. Incidence of catheter-related sepsis is ~5%, and it is documented that any fever in the absence of an obvious focus of infection must be attributed to catheter-related sepsis until proved otherwise. Added that the use of antacids and third-generation cephalosporins and a delay in enteral feeding are encourage bacterial colonization  lipid-related complications including lipid intolerance, increased free bilirubin concentrations, impaired pul monary function, or increased risk for developing chronic lung disease and interference with immune and platelet function . The most serious and significant life-threatening complication nowadays continues to be parenteral nutrition-associated cholestasis. During total parental nutrition infusion, a minimal amount of enteral feeds should be given to patients whenever possible and increased gradually while decreasing total PN. Aba-Sinden and Bollinger  recommended that parental nutrition may be stopped when the infant is tolerating at least 100 cm 3/kg/day of enteral feedings or is receiving up to 25 cm 3/kg/day of total parental nutrition .
| Conclusion|| |
EN should be used whenever possible. Total PN is used only if the GI tract is unable to meet the nutritional requirements for 1–3 days in infants and 4–5 days in children and adolescents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al
. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365
McClave S, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al
. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr 2009; 33
Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011; 15
Mikhailov TA, Kuhn EM, Manzi J, Christensen B, Maureen C, Brown A, et al
. Early enteral nutrition is associated with lower mortality in critically ill children. J Parenter Enteral Nutr 2014; 38
Singer P, Berger M, Van den Berghe G, Biolo G, Calder P, Forbes A, et al
. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr 2009; 28
Miller M, Vaidya R, Rastogi D, Bhutada A, Rastogi S. From parenteral to enteral nutrition: a nutrition-based approach for evaluating postnatal growth failure in preterm infants. J Parenter Enteral Nutr 2014; 38
Hulst J, Joosten K, Zimmermann L. Malnutrition in critically ill children: from admission to 6 months after discharge. Clin Nutr 2004; 23
Hulst JM, Goudoever JB, Zimmermann LJ, Tibboel D, Joosten KF. The role of initial monitoring of routine biochemical nutritional markers in critically ill children. J Nutr Biochem 2006; 17
Leite HP, Isatugo MK, Sawaki L, Fisberg M. Anthropometric nutritional assessment of critically ill hospitalized children. Rev Paul Med 1993; 111
De Klerk G, Hop WC, Hoog M, Joosten KF. Serial measurements of energy expenditure in critically ill children: useful in optimizing nutritional therapy? Intensive Care Med 2002; 28
White MS, Shepherd RW, McEniery JA. Energy expenditure measurements in ventilated critically ill children: within- and between day variability. J Parenter Enteral Nutr 1999; 23
White MS, Shepherd RW, McEniery JA. Energy expenditure in 100 ventilated, critically ill children: improving the accuracy of predictive equations. Crit Care Med 2000; 28
Derumeaux-Burel H, Meyer M, Morin L, Boirie Y. Prediction of resting energy expenditure in a large population of obese children. Am J Clin Nutr 2004; 80
Axelrod D, Kazmerski K, Iyer K. Pediatric enteral nutrition. J Parenter Enteral Nutr 2006; 30
Sanchez C, Lopez-Herce J, Carrillo A, Mencia S, Vigil D. Early transpyloric enteral nutrition in critically ill children. Nutrition 2007; 23
Meert KL, Daphtary KM, Metheny NA. Gastric vs small-bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest 2004; 126
Horn D, Chaboyer W. Gastric feeding in critically ill children: a randomized controlled trial. Am J Crit Care 2003; 12
De Oliveira SB, Leite HP, Meneses JF, De Carvalho WB. Enteral nutrition in critically ill children: are prescription and delivery according to their energy requirements? Nutr Clin Pract 2007; 22
Rogers EJ, Gilbertson HR, Heine RG, Henning R. Barriers to adequate nutrition in critically ill children. Nutrition 2003; 19
Taylor RM, Preedy VR, Baker AJ, Grimble G. Nutritional support in critically ill children. Clin Nutr 2003; 22
Barbosa E, Moreira EA, Goes JE, Faintuch J. Pilot study with a glutamine-supplemented enteral formula in critically ill infants. Rev Hosp Clin Fac Med Sao Paulo 1999; 54
Briassoulis G, Filippou O, Hatzi E, Papassotiriou I, Hatzis T. Early enteral administration of immune nutrition in critically ill children: results of a blinded randomized controlled clinical trial. Nutrition 2005; 21
Alberda C, Gramlich L, Field C, McCargar L, Meddings J, Madsen K Effects of probiotic therapy in critically ill patients: a randomized, double-blind, placebo-controlled study. Gastroenterology 2005; 2
Albers MJ, Steyerberg EW, Hazebroek FW, Mourik M, Borsboom GJ. Glutamine supplementation of parenteral nutrition does not improve intestinal permeability, nitrogen balance, or outcome in newborns and infants undergoing digestive-tract surgery: results from a double-blind. Ann Surg 2005; 241
Briassoulis G, Filippou O, Kanariou M, Papassotiriou I, Hatzis T. Temporal nutritional and inflammatory changes in children with severe head injury fed a regular or an immunoenhancing diet: a randomized, controlled trial. Pediatr Crit Care Med 2006; 7
Gottschlich MM, Jenkins M, Warden GD, Baumer T, Havens P, Snook JT. Differential effects of three enteral dietary regimens on selected outcome variables in burn patients. J Parenter Enteral Nutr 1990; 14
Marin VB, Rodriguez-Osiac L, Schlessinger L, Villegas J, Lopez M, Castillo-Duran C. Controlled study of enteral arginine supplementation in burned children: impact on immunologic and metabolic status. Nutrition 2006; 22
Papadopoulou A, Papazoglou K, Tsoutsou A, Papadatos J. Prospective, randomized trial on the efficacy of glutamine versus placebo-enriched peptide based feeds in critically ill children. J Pediatr Gastroenterol Nutr 2000; 2
Lambe C, Hubert P, Jouvet P, Cosnes J, Colomb V. A nutritional support team in the pediatric intensive care unit: changes and factors impeding appropriate nutrition. Clin Nutr 2007; 26
Petrillo-Albarano T, Pettignano R, Asfaw M, Easley K. Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit. Pediatr Crit Care Med 2006; 7
Gurgueira GL, Leite HP, Taddei JA, De Carvalho WB. Outcomes in a pediatric intensive care unit before and after the implementation of a nutrition support team. J Parenter Enteral Nutr 2005; 29
Briassoulis GC, Zavras NJ, Hatzis MT. Effectiveness and safety of a protocol for promotion of early intragastrical feeding in critically ill children. Pediatr Crit Care Med 2001; 2
Chaudhari S, Kadam S. Total parenteral nutrition in neonates. Ind Pediatr 2006; 43
Sandstrom R, Drott C, Hyltander A. The effect of postoperative intravenous feeding on outcome following major surgery evaluated in a randomized study. Ann Surg 1993; 217
Simpson F, Doig GS. Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 2005; 31
Gramlich L, Kichian K, Pinilla J, Rodych NJ, Dhaliwal R, Heyland DK. Does enteral nutrition compare to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004; 20
Dhaliwal R, Jurewitsch B, Harrietha D, Heyland DK. Combination enteral and parenteral nutrition in critically ill patients: harmful or beneficial? A systematic review of the evidence. Intensive Care Med 2004; 30
Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001; 74
Heller AR, Rossler S, Litz RJ. Omega-3 fatty acids improve the diagnosis related clinical outcome. Crit Care Med 2006; 34
Wichmann MW, Thul P, Czarnetski HD, Morlion BJ, Kemen M, Jauch KW. Evaluation of clinical safety and beneficial effects of a fish oil containing lipid emulsion. Crit Care Med 2007; 35
Wang X, Li W, Li N, Li J. Omega-3 fatty acids-supplemented parenteral nutrition decreases hyperinflammatory response and attenuates systemic disease sequelae in severe acute pancreatitis: a randomized and controlled study. J Parenter Enteral Nutr 2008; 32
Friesecke S, Lotze C, Kohler J, Heinrich A, Felix SB, Abel P. Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a randomized controlled trial. Intensive Care Med 2008; 34
Tappy L, Berger MM, Schwarz JM. Metabolic effects of parenteral nutrition enriched with n-3 polyunsaturated fatty acids in critically ill patients. Clin Nutr 2006; 25
Jordan I, Balaguer M, Esteban ME, Cambra FJ, Felipe A, Hernandez L. Glutamine effects on heat shock protein 70 and interleukins 6 and 10: randomized trial of glutamine supplementation versus standard parenteral nutrition in critically ill children. Clin Nutr 2016; 35
Larsen BM, Field CJ, Leong AY, Goonewardene LA, Van Aerde JE, Joffe AR. Pretreatment with an intravenous lipid emulsion increases plasma eicosatetraenoic acid and downregulates leukotriene b4, procalcitonin, and lymphocyte concentrations after open heart surgery in infants. J Parenter Enter Nutr 2015; 39
Lekmanov AU, Erpuleva UV, Zolkina IV, Rossaus PA. Study of glutamine solution use efficiency in pediatric patients with heavy thermic burns and concomitant injuries in the intensive care unit. Anesteziol Reanimatol 2013; 1
Larsen BM, Goonewardene LA, Joffe AR, Van Aerde JE, Field CJ, Olstad DL. Pre-treatment with an intravenous lipid emulsion containing fish oil decreases inflammatory markers after open-heart surgery in infants: a randomized, controlled trial. Clin Nutr 2012; 31
Chaloupecky V, Hucin B, Tlaskal T, Kostelka M, Kucera V, Janousek J. Nitrogen balance, 3-methylhistidine excretion, and plasma amino acid profile in infants after cardiac operations for congenital heart defects: the effect of early nutritional support. J Thorac Cardiovasc Surg 1997; 114
Chaloupecky V, Vislocky I, Pachl J, Sprongl L, Svomova V. The effect of early parenteral nutrition on amino acid and protein metabolism in infants following congenital heart disease surgery in extracorporeal circulation. Cor Vasa 1994; 36
Mehta N, Jaksic T. The critically ill child. Clin Nutr 2008; 4
Mehta NM, Compher C. Clinical guidelines nutrition support of the critically ill child. J Parenter Enteral Nutr 2009; 33
Kawagoe JY, Segre CA, Pereira CR, Cardoso MF, Silva CV, Fukushima JT. Risk factors for nosocomial infections in critically ill newborns: a 5-year prospective cohort study. Am J Infect Control 2001; 29
Roy S, Rigal M, Doit C. Bacterial contamination of enteral nutrition in a pediatric hospital. J Hosp Infect 2005; 59
Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R. Amino acids. In: Guidelines on Pediatric Parenteral Nutrition of the European Society of pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN). J Pediatric 2005; 41
Rubin LG, Sanchez PJ, Siegel J, Levine G, Saiman L, William R, et al
. Pediatric Prevention Network. Evaluation and treatment of neonates with suspected late-onset sepsis: a survey of neonatologists' practices. Pediatrics 2002; 110
Aba-Sinden A, Bollinger R. Challenges and controversies in the nutrition support of the preterm infant. Support Line 2002; 2
Ekema G, Falchetti D, Boroni G, Tanca AR, Altana C, Righetti L, et al
. Reversal of severe parenteral nutrition-associated liver disease in an infant with short bowel syndrome using parenteral fish oil (Omega-3 fatty acids). J Pediatr 2008; 43
[Table 1], [Table 2], [Table 3]