Enteral Nutrition in the PICU: Current Status and Ongoing Challenges

Abstract

Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.

Keywords

pediatric critical care - enteral nutrition - pediatric nutrition

• References

• 1 Pollack MM, Wiley JS, Holbrook PR. Early nutritional depletion in critically ill children. Crit Care Med 1981; 9 (8) 580-583
• 2 Hulst JM, van Goudoever JB, Zimmermann LJ , et al. The effect of cumulative energy and protein deficiency on anthropometric parameters in a pediatric ICU population. Clin Nutr 2004; 23 (6) 1381-1389
• 3 Tume L, Latten L, Darbyshire A. An evaluation of enteral feeding practices in critically ill children. Nurs Crit Care 2010; 15 (6) 291-299
• 4 Mehta NM, Bechard LJ, Cahill N , et al. Nutritional practices and their relationship to clinical outcomes in critically ill children—an international multicenter cohort study*. Crit Care Med 2012; 40 (7) 2204-2211
• 5 Kyle UG, Jaimon N, Coss-Bu JA. Nutrition support in critically ill children: underdelivery of energy and protein compared with current recommendations. J Acad Nutr Diet 2012; 112 (12) 1987-1992
• 6 Mikhailov TA, Kuhn EM, Manzi J , et al. Early enteral nutrition is associated with lower mortality in critically ill children. JPEN J Parenter Enteral Nutr 2014; 38 (4) 459-466
• 7 Tume L, Carter B, Latten L. A UK and Irish survey of enteral nutrition practices in paediatric intensive care units. Br J Nutr 2013; 109 (7) 1304-1322
• 8 Hulst J, Joosten K, Zimmermann L , et al. Malnutrition in critically ill children: from admission to 6 months after discharge. Clin Nutr 2004; 23 (2) 223-232
• 9 Mota EM, Garcia PC, Piva JP, Fritscher CC. The influence of poor nutrition on the necessity of mechanical ventilation among children admitted to the Pediatric Intensive Care Unit [in Portuguese]. J Pediatr (Rio J) 2002; 78 (2) 146-152
• 10 Mehta NM, Compher C ; A.S.P.E.N. Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr 2009; 33 (3) 260-276
• 11 Rogers EJ, Gilbertson HR, Heine RG, Henning R. Barriers to adequate nutrition in critically ill children. Nutrition 2003; 19 (10) 865-868
• 12 Skillman HE, Wischmeyer PE. Nutrition therapy in critically ill infants and children. JPEN J Parenter Enteral Nutr 2008; 32 (5) 520-534
• 13 King W, Petrillo T, Pettignano R. Enteral nutrition and cardiovascular medications in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2004; 28 (5) 334-338
• 14 de Oliveira Iglesias SB, Leite HP, Santana e 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 (2) 233-239
• 15 Khlevner J, Antino J, Panesar R, Chawla A. Establishing early enteral nutrition with the use of self-advancing postpyloric feeding tube in critically ill children. JPEN J Parenter Enteral Nutr 2012; 36 (6) 750-752
• 16 Cook RC, Blinman TA. Nutritional support of the pediatric trauma patient. Semin Pediatr Surg 2010; 19 (4) 242-251
• 17 Abdul Manaf Z, Kassim N, Hamzaid NH, Razali NH. Delivery of enteral nutrition for critically ill children. Nutrition Dietetics 2013; 70 (2) 120-125
• 18 McClave SA, Martindale RG, Vanek VW , et al; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. 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.). JPEN J Parenter Enteral Nutr 2009; 33 (3) 277-316
• 19 Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P ; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27 (5) 355-373
• 20 Dhaliwal R, Cahill N, Lemieux M, Heyland DK. The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies. Nutr Clin Pract 2014; 29 (1) 29-43
• 21 Chellis MJ, Sanders SV, Webster H, Dean JM, Jackson D. Early enteral feeding in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 1996; 20 (1) 71-73
• 22 Briassoulis G, Tsorva A, Zavras N, Hatzis T. Influence of an aggressive early enteral nutrition protocol on nitrogen balance in critically ill children. J Nutr Biochem 2002; 13 (9) 560
• 23 Taylor RM, Preedy VR, Baker AJ, Grimble G. Nutritional support in critically ill children. Clin Nutr 2003; 22 (4) 365-369
• 24 Havalad S, Quaid MA, Sapiega V. Energy expenditure in children with severe head injury: lack of agreement between measured and estimated energy expenditure. Nutr Clin Pract 2006; 21 (2) 175-181
• 25 Hardy CM, Dwyer J, Snelling LK, Dallal GE, Adelson JW. Pitfalls in predicting resting energy requirements in critically ill children: a comparison of predictive methods to indirect calorimetry. Nutr Clin Pract 2002; 17 (3) 182-189
• 26 Mehta NM, Duggan CP. Nutritional deficiencies during critical illness. Pediatr Clin North Am 2009; 56 (5) 1143-1160
• 27 Schofield WN. Predicting basal metabolic rate, new standards and review of previous work. Hum Nutr Clin Nutr 1985; 39 (Suppl. 01) 5-41
• 28 World Health Organization. FAO/WHO/UNU Expert Consultation. Energy and Protein Requirements: Technical Report Series #724. Geneva, Switzerland; 1985
• 29 Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC; 2005
• 30 Irving SY. Patterns of Weight Change in Infants with Congenital Heart Disease Following Neonatal Surgery: Potential Predictors of Growth Failure. Philadelphia, PA: University of Pennsylvania; 2011
• 31 Irving SY, Mascarenhas MR. Nutritional deficiencies in pediatric critical illness. In: Stockwell J, Preissig C, , eds. Comprehensive Critical Care: Pediatric. Mount Prospect, IL: Society of Critical Care Medicine; 2012: 837-848
• 32 Kyle UG, Arriaza A, Esposito M, Coss-Bu JA. Is indirect calorimetry a necessity or a luxury in the pediatric intensive care unit?. JPEN J Parenter Enteral Nutr 2012; 36 (2) 177-182
• 33 Wakeham M, Christensen M, Manzi J , et al. Registered dietitians making a difference: early medical record documentation of estimated energy requirement in critically ill children is associated with higher daily energy intake and with use of the enteral route. J Acad Nutr Diet 2013; 113 (10) 1311-1316
• 34 Mehta NM, McAleer D, Hamilton S , et al. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2010; 34 (1) 38-45
• 35 Leong AY, Cartwright KR, Guerra GG, Joffe AR, Mazurak VC, Larsen BMK. A Canadian survey of perceived barriers to initiation and continuation of enteral feeding in PICUs. Pediatr Crit Care Med 2014; 15 (2) e49-e55
• 36 O'Meara D, Mireles-Cabodevila E, Frame F , et al. Evaluation of delivery of enteral nutrition in critically ill patients receiving mechanical ventilation. Am J Crit Care 2008; 17 (1) 53-61
• 37 McClave SA, Sexton LK, Spain DA , et al. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med 1999; 27 (7) 1252-1256
• 38 de Neef M, Geukers VG, Dral A, Lindeboom R, Sauerwein HP, Bos AP. Nutritional goals, prescription and delivery in a pediatric intensive care unit. Clin Nutr 2008; 27 (1) 65-71
• 39 de Menezes FS, Leite HP, Nogueira PC. What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition?. Nutrition 2013; 29 (1) 76-80
• 40 O'Leary-Kelley CM, Puntillo KA, Barr J, Stotts N, Douglas MK. Nutritional adequacy in patients receiving mechanical ventilation who are fed enterally. Am J Crit Care 2005; 14 (3) 222-231
• 41 Iben S, Rodriguez R. Neonatal necrotizing enterocolitis. In: Wyllie R, Hyams JS, Kay M, , eds. Pediatric Gastrointestinal and Liver Disease. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2011: 512-520
• 42 Teitelbaum JE. Indigenous flora. In: Wylie R, Hyams JS, Kay M, , eds. Pediatric Gastrointestinal and Liver Disease. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2011: 28-38
• 43 Leong AY, Field CJ, Larsen BM. Nutrition support of the postoperative cardiac surgery child. Nutr Clin Pract 2013; 28 (5) 572-579
• 44 Panchal AK, Manzi J, Connolly S , et al. Safety of enteral feedings in critically ill children receiving vasoactive agents. JPEN J Parenter Enteral Nutr 2014;
• 45 Mancl EE, Muzevich KM. Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr 2013; 37 (5) 641-651
• 46 Yang S, Wu X, Yu W, Li J. Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice. Nutr Clin Pract 2014; 29 (1) 90-96
• 47 Sabatino A, Regolisti G, Maggiore U, Fiaccadori E. Protein/energy debt in critically ill children in the pediatric intensive care unit: acute kidney injury as a major risk factor. J Ren Nutr 2014; 24 (4) 209-218
• 48 Kyle UG, Akcan-Arikan A, Orellana RA, Coss-Bu JA. Nutrition support among critically ill children with AKI. Clin J Am Soc Nephrol 2013; 8 (4) 568-574
• 49 Larsen BM, Goonewardene LA, Field CJ , et al. Low energy intakes are associated with adverse outcomes in infants after open heart surgery. JPEN J Parenter Enteral Nutr 2013; 37 (2) 254-260
• 50 Khorasani EN, Mansouri F. Effect of early enteral nutrition on morbidity and mortality in children with burns. Burns 2010; 36 (7) 1067-1071
• 51 Brown A-M, Forbes ML, Vitale VS, Tirodker UH, Zeller R. Effects of a gastric feeding protocol on efficiency of enteral nutrition in critically ill infants and children. ICAN Infant Child Adolescent Nutr 2012; 4 (3) 175-180
• 52 Solana MJ, Sánchez C, López-Herce J , et al. Multichannel intraluminal impedance to study gastroesophageal reflux in mechanically ventilated children in the first 48 h after PICU admission. Nutrition 2013; 29 (7-8) 972-976
• 53 Ukleja A. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract 2010; 25 (1) 16-25
• 54 Horn D, Chaboyer W. Gastric feeding in critically ill children: a randomized controlled trial. Am J Crit Care 2003; 12 (5) 461-468
• 55 Horn D, Chaboyer W, Schluter PJ. Gastric residual volumes in critically ill paediatric patients: a comparison of feeding regimens. Aust Crit Care 2004; 17 (3) 98-100 , 102–103
• 56 Reignier J, Mercier E, Le Gouge A , et al; Clinical Research in Intensive Care and Sepsis (CRICS) Group. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 2013; 309 (3) 249-256
• 57 Poulard F, Dimet J, Martin-Lefevre L , et al. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr 2010; 34 (2) 125-130
• 58 DeLegge MH. Managing gastric residual volumes in the critically ill patient: an update. Curr Opin Clin Nutr Metab Care 2011; 14 (2) 193-196
• 59 Hamilton S, McAleer DM, Ariagno K , et al. A stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient delivery goals*. Pediatr Crit Care Med 2014; 15 (7) 583-589
• 60 Moore TA, Wilson ME. Feeding intolerance: a concept analysis. Adv Neonatal Care 2011; 11 (3) 149-154
• 61 Dickerson RN, Mitchell JN, Morgan LM , et al. Disparate response to metoclopramide therapy for gastric feeding intolerance in trauma patients with and without traumatic brain injury. JPEN J Parenter Enteral Nutr 2009; 33 (6) 646-655
• 62 Fraser RJL, Bryant L. Current and future therapeutic prokinetic therapy to improve enteral feed intolerance in the ICU patient. Nutr Clin Pract 2010; 25 (1) 26-31
• 63 Taylor SJ, Manara AR, Brown J. Treating delayed gastric emptying in critical illness: metoclopramide, erythromycin, and bedside (cortrak) nasointestinal tube placement. JPEN J Parenter Enteral Nutr 2010; 34 (3) 289-294
• 64 Skillman HE. Monitoring the efficacy of a PICU nutrition therapy protocol. JPEN J Parenter Enteral Nutr 2011; 35 (4) 445-446
• 65 Skillman HE. How you can improve the delivery of enteral nutrition in your PICU. JPEN J Parenter Enteral Nutr 2010; 34 (1) 99-100
• 66 Weckwerth JA. Monitoring enteral nutrition support tolerance in infants and children. Nutr Clin Pract 2004; 19 (5) 496-503
• 67 Hurt RT, McClave SA. Gastric residual volumes in critical illness: what do they really mean?. Crit Care Clin 2010; 26 (3) 481-490 , viii–ix
• 68 Lee H, Koh SO, Kim H, Sohn MH, Kim KE, Kim KW. Avoidable causes of delayed enteral nutrition in critically ill children. J Korean Med Sci 2013; 28 (7) 1055-1059
• 69 Prieto MB, Cid JL-H. Malnutrition in the critically ill child: the importance of enteral nutrition. Int J Environ Res Public Health 2011; 8 (11) 4353-4366
• 70 Brown A-M. A Comparison of Two Gastric Feeding Approaches in Mechanically Ventilated Pediatric Patients. A dissertation presented to the Graduate Faculty of the University of Akron in partial fulfillment of the requirements for the doctoral degree of Philosophy, 2014
• 71 Chen YC, Chou SS, Lin LH, Wu LF. The effect of intermittent nasogastric feeding on preventing aspiration pneumonia in ventilated critically ill patients. J Nurs Res 2006; 14 (3) 167-180
• 72 Lee JSW, Auyeung TW. A comparison of two feeding methods in the alleviation of diarrhoea in older tube-fed patients: a randomised controlled trial. Age Ageing 2003; 32 (4) 388-393
• 73 Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: observations from traditional and Bayesian random-effects meta-analysis. Clin Nutr 2013; 32 (1) 8-15
• 74 Antonelli M, Azoulay E, Bonten M , et al. Year in review in Intensive Care Medicine, 2007. III. Ethics and legislation, health services research, pharmacology and toxicology, nutrition and paediatrics. Intensive Care Med 2008; 34 (4) 598-609
• 75 Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Feeding tube placement: errors and complications. Nutr Clin Pract 2012; 27 (6) 738-748
• 76 Martinez EE, Bechard LJ, Mehta NM. Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study. Nutr Clin Pract 2014; 29 (3) 360-367
• 77 Pillo-Blocka F, Adatia I, Sharieff W, McCrindle BW, Zlotkin S. Rapid advancement to more concentrated formula in infants after surgery for congenital heart disease reduces duration of hospital stay: a randomized clinical trial. J Pediatr 2004; 145 (6) 761-766
• 78 Braudis NJ, Curley MAQ, Beaupre K , et al. Enteral feeding algorithm for infants with hypoplastic left heart syndrome post stage I palliation. Pediatr Crit Care Med 2009; 10 (4) 460-466
• 79 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 (4) 340-344
• 80 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. JPEN J Parenter Enteral Nutr 2005; 29 (3) 176-185
• 81 Mehta NM. Approach to enteral feeding in the PICU. Nutr Clin Pract 2009; 24 (3) 377-387
• 82 Skillman HE, Mehta NM. Nutrition therapy in the critically ill child. Curr Opin Crit Care 2012; 18 (2) 192-198
• 83 Fuchs S. Enteral nutrition. In: Reuter-Rice K, Bolick B, , eds. Pediatric Acute Care: A Guide for Interprofessional Practice. Burlington, MA: Jones & Bartlett Learning; 2011: 436-447
• 84 Mehta NM, Corkins MR, Lyman B , et al; American Society for Parenteral and Enteral Nutrition Board of Directors. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013; 37 (4) 460-481
• 85 Corkins MR, Griggs KC, Groh-Wargo S , et al; Task Force on Standards for Nutrition Support: Pediatric Hospitalized Patients; American Society for Parenteral and Enteral Nutrition Board of Directors; American Society for Parenteral and Enteral Nutrition. Standards for nutrition support: pediatric hospitalized patients. Nutr Clin Pract 2013; 28 (2) 263-276
• 86 Castro MG, Pompilio CE, Horie LM, Verotti CC, Waitzberg DL. Education program on medical nutrition and length of stay of critically ill patients. Clin Nutr 2013; 32 (6) 1061-1066
• 87 Wong JJ-M, Ong C, Han WM, Lee JH. Protocol-driven enteral nutrition in critically ill children: a systematic review. JPEN J Parenter Enteral Nutr 2014; 38 (1) 29-39
• 88 Gentles E, Mara J, Diamantidi K , et al. Delivery of enteral nutrition after the introduction of practice guidelines and participation of dietitians in pediatric critical care clinical teams. J Acad Nutr Diet 2014; 114 (12) 1974-80.e3
• 89 Kleinman RE. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009: 1423
• 90 Carcillo J, Holubkov R, Dean JM , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Rationale and design of the pediatric critical illness stress-induced immune suppression (CRISIS) prevention trial. JPEN J Parenter Enteral Nutr 2009; 33 (4) 368-374