Feeding Critically Ill Pediatric Patients
New guidelines show nutrition in pediatric patients is not simple science.
Posted Jul 12, 2017
Critically ill patients are exceedingly vulnerable; critically ill pediatric patients, even more so. A myriad of factors can impact their condition. Of all of the possible considerations, it might seem that nourishment would be one of the most straightforward. But nutrition, particularly among this population, is quite complex. And, until recently, we lacked the comprehensive research necessary to establish guidelines, deliver the proper nutrition, and, ultimately, improve outcomes for these young patients. Thankfully, that is no longer the case.
Earlier this year, at the American Society for Parenteral and Enteral Nutrition’s Clinical Nutrition Week, I attended a presentation showcasing the findings of a national task force, chaired by Dr. Nilesh Mehta of Boston Children’s Hospital, that conducted a first-of-its-kind, exhaustive literature review on the importance of nutritional support therapy in cases involving critically ill pediatric patients (those ages one month to 17 years of age). This research paved the way for the newly released Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition, just published this week.
The American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine spearheaded the development of these guidelines. This team analyzed over 2,032 citations for relevance related to pediatric nutritional support, specifically looking at the data for critically ill pediatric patients with a length of stay greater than two or three days in a pediatric intensive care unit (PICU), admitting medical, surgical, and cardiac patients.
Among other things, the research found that:
- There is a significant gap in proper nutritional interventions, particularly among malnourished patients. This is deeply concerning as malnutrition is associated with adverse clinical outcomes including longer periods of ventilation, higher risk of hospital-acquired infection, longer PICU and hospital stays, and increased mortality.
- Early intervention makes a difference. Patients who receive a nutritional intervention in a timely manner may benefit most from the therapy. The new guidelines recommend that PICU patients undergo a detailed nutritional assessment within 48 hours of being admitted to the hospital.
- The timing and method of nutrient delivery is important. The new guidelines offer strategies to optimize enteral nutrition (tube feeding) during critical illness. The research also points to the benefits of a delayed approach to parenteral nutrition (intravenous feeding).
- A skilled nutrition support team is a key differentiator. One that includes a dedicated dietitian should be available on the PICU to facilitate timely nutritional assessment, and optimal nutrient delivery and adjustment to the patient’s nutrition plan as the clinical situations change.
Ongoing monitoring is critical to avoid unintended caloric under or overfeeding. Patients are at risk of nutritional deterioration during hospitalization, which can adversely affect clinical outcomes. The new guidelines, therefore, suggest that the nutritional status of patients be reevaluated at least weekly throughout hospitalization.
Determining how much nutrition is needed is an important factor. For example, optimal protein intake is closely related to positive clinical outcomes. The new guidelines provide recommendations on the minimum protein intake. However, it’s important to bear in mind that the use of RDA (recommended daily allowance) values to guide protein prescription in critically ill pediatric patients is not advised; these were developed for healthy children and often underestimate the protein needs during critical illness.
For most of us, getting nourishment happens almost without consideration. But for critically ill pediatric patients, careful attention is required. These new guidelines will ensure these young patients receive the nutrients they need, better enabling them to be on the road to recovery. Whether you are on the medical team providing care, or are a parent advocating for your child, these guidelines can help to keep you and your loved ones in good health.
Please CLICK HERE to access the full report and complete recommendations.