The advice of Dr. Vijay Srinivasan regarding enteral nutrition in intensive care children is simple: “Feed early and feed well.”
Srinivasan, a pediatric intensive care physician at Children’s Hospital in Philadelphia, presented key evidence of this strategy at the Society for Critical Care Medicine (SCCM) 2021 Critical Care Congress Tuesday.
Nutritional therapy is known to play a key role in children’s recovery from chronic diseases. More recently, however, it has become clear that it can shorten and tame the inflammatory response in acute illness, Srinivasan explained.
Without enteral nutrition, the pro-inflammatory condition of a critical illness could lead to nutritional intolerance, immune deficiency and organ dysfunction, he said.
Only one randomized study has attempted to answer the question of the optimal timing of EN in critically ill children, Srinivasan said.
In this study, 120 children in a pediatric intensive care unit (PICU) were randomized to either an early EN (6–24 hours after admission) or to a late EN (more than 24 hours after admission). There was no significant difference in length of stay – the primary outcome – between the groups.
Srinivasan’s group examined the early EN in a secondary analysis of the randomized controlled trial of heart and lung failure pediatric insulin titration and published the results in Pediatric Critical Care Medicine last March.
“We observed that early EN was associated with lower ICU mortality,” he said.
In this analysis of 608 children, early EN was also associated with more days without an ICU, more ventilator-free days, and fewer organ dysfunction, he said.
According to Srinivasan, the largest EN study was conducted in critically ill children in 2014. Subsequently, 5105 children from 12 PICUs were included to investigate the effects of early EN on PICU mortality.
Early EN in this study was defined as 25% of enteral calories during the first 48 hours of PICU intake.
The results show that children who received an early EN died half as often as those who did not (odds ratio 0.51; P = 0.001).
“Remarkably, an increasing proportion of EN in total energy at 48 hours was associated with significantly reduced mortality, suggesting a dose-response effect of early EN on survival,” said Srinivasan.
The recently released surviving sepsis guidelines advocate early EN initiation, less than 48 hours after identification of septic shock in children with no contraindications to EN, noted Srinivasan. The guidance states that EN should be continued gradually until the nutritional goals are met.
All of the available evidence, contained in the SCCM and American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines for supporting the feeding of critically ill children, suggests that all eligible patients should be 24 to 48 hours after PICU Receive EN early admission, Srinivasan said.
Early PN not recommended
Although the evidence supports early EN, the results for early parenteral nutrition (PN) were not favorable.
A randomized controlled trial in 2016 showed that patients who received PN in the first 24 hours after admission had more infections and longer hospital stays than in the first 7 days after admission.
Given these findings, “the SSCM and ASPEN guidelines for nutritional support therapy in critically ill children do not recommend early initiation of PN within 24 hours of admission,” said Srinivasan, adding that “the optimal time for that Initiation of parenteral nutrition remains unknown “.
He explained why early PN results seem worse.
“Based on pre-planned secondary analysis, it appears that early intravenous amino acid exposure can be associated with significant harm,” he told Medscape Medical News. “Early intravenous amino acid exposure appears to lead to suppression of cellular autophagy – an extremely important process during the catabolic state of acute critical illness – and increased urea production, which leads to liver and kidney dysfunction.”
He said the long-term effects of exposure to intravenous amino acids are less clear.
Srinivasan addressed the question of how much energy to deliver and whether it should be all EN or PN or a combination.
Once the acute phase transitions to the chronic phase, traditional treatment has been to supplement EN with PN to prevent malnutrition and improve outcomes.
He highlighted a 2012 study that prospectively enrolled 500 subjects from 31 PICUs worldwide. The study showed that, contrary to expectations, an increase in energy intake as a combination of EN and PN was not associated with a lower 60-day mortality rate, but only with EN.
In summary, it can be said that early EN is preferred in seriously ill children as long as there are no contraindications.
“Once enteral nutrition is initiated, a gradual increase in energy and protein output to achieve the goals of an energy requirement of at least two thirds and a protein of more than 1.5 g / kg per day is about one week after admission to the intensive care unit extremely desirable, “he said.
“If necessary,” he added, “additional parenteral nutrition can be selectively provided starting approximately 3 to 5 days after the intensive course begins.”
Lauren Sorce, PhD, RN, co-director of clinical research in the intensive care unit at Lurie Children’s Hospital in Chicago, told Medscape Medical News that the early and well-fed policy is well known in intensive care units, but in a rush to stabilize children , Often not in the foreground Srinivasan’s talk was a fond memory.
“Once they are stable, it is important that we remind ourselves that it is time to start feeding,” she said.
She indicated that this is a major area of research as very few interventional studies are being conducted on pediatric nutrition. The level of evidence is often weak, so updated ASPEN and SCCM guidelines are essential tools for feeding strategies, she said.
Srinivasan and Sorce have not disclosed any relevant financial relationships.
Society for Intensive Care Medicine (SCCM) 2021 Congress for Intensive Care Medicine. Presented on February 9, 2021.
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com and was an editor for the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick
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