Nutritional Guidelines for Critically Ill Children Released

Guidelines on nutritional support therapy for critically ill children were jointly released by the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) on July 7.

"Children are especially susceptible to malnutrition," M. Molly McMahon, MD, president of ASPEN and professor of medicine in the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at the Mayo Clinic in Rochester, Minnesota, said in a news release. "These guidelines addressing the nutrition of critically ill children have never been more needed or relevant. Ultimately, this clinical guidance has the potential to improve medical outcomes and to decrease health care costs in this group of children."

"This group of vulnerable patients is distinct from healthy children with respect to their unique metabolic state, nutritional requirements, and risk of nutritional deterioration," Nilesh M. Mehta, MD, from the Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts, told Medscape Medical News. "The risk of both underfeeding and overfeeding is becoming evident, and hence a careful individualized approach to each patient is important." Dr Mehta is president-elect of ASPEN and lead author on the guidelines.

There is wide variation in approaches to nutritional support in pediatric intensive care units (PICUs) across the United States. Since the publication of the first nutritional guidelines for critically ill children in 2009, research on the nutritional needs of critically ill children has increased, but randomized controlled trials are still lacking. In addition, studies that have been conducted in adults have largely not been replicated in children.

Therefore, several questions remain unanswered as a result of the limited available evidence. Nevertheless, "some new and evolving themes have been illustrated," Dr Mehta said.

Dr Mehta and colleagues "reviewed and interpreted published results using a systematic approach, with a healthy balance between evidence and expert consensus," he explained. "Key areas addressed in these guidelines include the importance of assessing nutritional status, the challenges of determining energy and protein requirements, the feasibility of enteral nutrition [EN], a spotlight on the timing of parenteral nutrition, and the role of immunonutrition in critically ill children."

Assess Nutritional Status at Admission and During Illness

"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," the authors write.

"Malnutrition is associated with worse outcomes, and therefore, affected patients must be detected early for potential targeted intervention," Dr Mehta explained.

Those who receive timely intervention may benefit most from nutritional support therapy. Therefore, patients in the PICU should undergo detailed nutrition assessment within 48 hours of admission, and reevaluation of nutritional status at least weekly during hospitalization.

Having a skilled nutrition support team makes all the difference, the authors write. They recommend having a dedicated dietician available in the PICU to facilitate nutritional assessment, delivery of nutrients, and adjustment of the child's nutrition plan as clinical situations evolve.

The authors stress the importance of avoiding unintended caloric under- or overfeeding, which requires reevaluation of nutritional status at least weekly while the child is hospitalized.

The guidelines recommend measuring weight and height/length on admission to the PICU and using z scores for body mass index for age (weight for length, <2 y) or weight for age (if accurate height is not available) to screen for patients at extremes of these values. Children younger than 36 months need documentation of head circumference.

The authors also suggest using indirect calorimetry to determine the patient's energy requirements and develop the daily energy goal. If indirect calorimetry is not feasible for measurement of resting energy expenditure, the authors suggest using the Schofield or Food Agriculture Organization/World Health Organization/United Nations University equations without adding 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 [recommended daily allowances], which are suggested by the dietary reference intakes, should not be used to determine energy requirements in critically ill children," the authors write.

Recommended daily allowances were developed for healthy children and are likely to underestimate energy requirements in critically ill children.

EN Remains the Preferred Mode of Nourishment

"[EN; tube feeding] remains the preferred mode and is tolerated early in critically ill patients. The guidelines discuss current evidence for a variety of EN-related practices," Dr Mehta told Medscape Medical News. "The timing of parenteral nutrition [intravenous feeding] is being revisited, and early initiation in all patients is not recommended."

The new guidelines present strategies for optimizing EN in critically ill children.

"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," the authors write.

Protein Associated With Outcomes

"The energy and protein requirements in critically ill children are not the same as in healthy children, and are likely variable between individual patient groups. Protein requirements, in particular, need further examination," Dr Mehta explained.

The authors recommend a minimum protein intake of 1.5 g/kg per day, as randomized controlled trials have shown that protein intake higher than this threshold prevents cumulative negative protein balance. "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 children," the authors write. "Based on a large observational study, higher protein intake may be associated with lower 60-day mortality in children receiving mechanical ventilation."

"There is no demonstrated role of immunonutrients in this group. Overall, the guidelines provide some basic recommendations, which will need to be individualized for patients and titrated based on ongoing assessment," Dr Mehta said.

Role of Gastric Residual Volume Assessment Unclear

"Despite being commonly measured in many PICUs, the accuracy of [gastric residual volume (GRV)] as a marker of delayed gastric emptying has been recently challenged in adult and pediatric intensive care populations. Measurement of GRV has not been correlated with risk of aspiration in adult studies, and it is no longer recommended in the recent adult critical care nutrition guidelines," the authors write. "In the absence of pediatric trials, we cannot recommend discontinuing GRV measurement in the PICU, but the role of this practice is not clear and might impede EN advancement."

"There was no specific recommendation regarding GRV as an indicator of EN intolerance in this guideline. The use of GRV for this purpose was not recommended in the recently published adult guidelines, but evidence in pediatrics is not yet enough to firmly refute this practice," Dr Mehta explained. "However, the guidelines discuss emerging studies that have challenged the rationale and the role of GRV measurements as the only indicator of intolerance. Future and ongoing studies will help address this issue."

The authors have disclosed no relevant financial relationships.

J Parenteral Enteral Nutr. Published online July 7, 2017. Full text

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