Table 1.

Summary of recommendations for nutritional support for children during critical illness

Question	Recommendation	SIGN recommendation grade	Consensus	References used in synthesis of recommendations
In critically ill children, should nutritional status be assessed and what is the optimal method to assess nutritional status?	1.1: The assessment of nutritional status is recommended in critically ill children at admission and throughout their PICU admission	GCP	Strong consensus	[31–57]
	1.2: It is recommended to perform anthropometric measurements on admission and regularly during admission, and to express these measurements in z-scores, including weight, height/length mid upper arm circumference and head circumference in young children	GCP	Strong consensus	[6, 10, 48–55]
In critically ill children, when should enteral nutrition be commenced and how should it be increased?	2.1: It is recommended to commence early enteral nutrition within 24 h of admission unless contraindicated	D	Strong consensus	[58, 61, 64–69, 71]
	2.2: It is recommended to increase enteral nutrition in a stepwise fashion until goal for delivery is achieved using a feeding protocol or guideline	D	Strong consensus	[59, 60, 62, 63, 71, 72, 74–76]
In critically ill children on haemodynamic support (vasoactive medications, extracorporeal life support ECLS) does enteral feeding compared to no enteral feeding affect outcomes?	3.1: Early enteral nutrition is recommended in term neonates who are stable on ECLS	D	Consensus	[77–80]
	3.2: Early enteral nutrition is recommended in children who are stable on ECLS	D	Strong consensus	[82]
	3.3: Early enteral nutrition is recommended in term neonates who are stable on pharmaceutical haemodynamic support	GCP	Consensus	[83, 85, 86]
	3.4: Early enteral nutrition is recommended in children who are stable on pharmaceutical haemodynamic support	D	Strong consensus	[83, 85, 86]
	3.5: Early enteral nutrition is recommended in children after cardiac surgery	C	Consensus	[87–94]
In critically ill term neonates with umbilical arterial catheters and/or PGE1 infusions, does enteral feeding impact on adverse events?	4.1: Enteral nutrition should be considered in term neonates with umbilical arterial catheters	D	Strong consensus	[95, 96, 100]
	4.2: Enteral nutrition should be considered in critically ill term neonates on PGE1 infusion if managed in a critical care unit with adequate observation and monitoring	D	Strong consensus	[97–99]
In critically ill children what are their energy requirements?	5.1 In the acute phase, energy intake provided to critically ill children should not exceed resting energy expenditure	C	Strong consensus	[26, 101–104]
	5.2. After the acute phase, energy intake provided to critically ill children should account for energy debt, physical activity, rehabilitation and growth	GCP	Strong consensus	[105–113]
In critically ill children, what is the most accurate method of determining or predicting energy expenditure?	6.1 Measuring resting energy expenditure using a validated indirect calorimeter should be considered to guide nutritional support in critically ill infants and children after the acute phase	GCP	Strong consensus	[114 –119]
	6.2 Schofield equation (for age and gender and using an accurate weight) is recommended to estimate resting energy expenditure	C	Strong consensus	[120–125]
In critically ill children, what are the macronutrient requirements?
What is the recommended glucose intake?	7.1. Parenteral glucose provision should be sufficient to avoid hypoglycemia but not excessive to prevent hyperglycemia	D	Strong consensus	[126, 127]
What is the recommended lipid intake or type?	7.2: When parenteral nutrition is used, composite lipid emulsions, with or without fish oil, should be considered as the first-choice treatment	GCP	Strong consensus	[128]
What is the recommended protein/amino acid intake?	7.3a: For critically ill infants and children on enteral nutrition a minimum enteral protein intake of 1.5 g/kg/d can be considered to avoid negative protein balance	B	Strong consensus	[23, 24, 106–108, 129, 130]
	7.3b: There is insufficient evidence available to support the use of additional protein/amino acid intake during the acute phase of illness (Strong consensus)	D	Strong consensus	[131-137]
In critically ill children, do different feed formulas (polymeric vs. semi-elemental feed, standard vs. enriched formula) impact on clinical outcomes?	8.1 Polymeric feeds should be considered as the first choice for enteral nutrition in most critically ill children, unless there are contraindications	GCP	Strong consensus
	8.2 Protein and energy-dense formulations may be considered to support achievement of nutritional requirements in fluid-restricted critically ill children	B	Consensus	[138, 139]
	8.3 Peptide-based formulations may be considered to improve tolerance and progression of enteral feeding in children for whom polymeric formulations are poorly tolerated or contra-indicated	GCP	Strong consensus	[141]
In critically ill children, does pharmaconutrition (glutamine, lipids and/or micronutrients) impact on clinical outcomes?	9.1 There is insufficient evidence to recommend the use of pharmaconutrition in critically ill children	B	Strong consensus	[81,141–148]
In critically ill children, does continuous feeding compared to intermittent bolus gastric feeding impact on outcomes?	10.1: There is no evidence to suggest that either continuous or intermittent/bolus feeds are superior in delivering gastric feeds in critically ill children	B	Strong consensus	[70, 149,152]
In critically ill children, does gastric feeding compared to post-pyloric feeding impact on clinical outcomes?	11.1: Gastric feeding is as safe as post pyloric feeding in the majority of critically ill children	C	Strong consensus	[83, 150, 151, 153]
	11.2: Gastric feeding is not inferior to post pyloric feeding in the majority of critically ill children	D	Strong consensus	[150, 151, 153]
	11.3 Post-pyloric feeding can be considered for critically ill children at high risk of aspiration or requiring frequent fasting for surgery or procedures	GCP	Strong consensus
In critically ill children does routine Gastric Residual Volume (GRV) to guide enteral feeding impact on outcomes?	12.1: Routine measurement of GRV in critically ill children is not recommended	D	Strong consensus	[154]
In critically ill children, do prokinetics impact on clinical outcomes?	13.1: There is insufficient evidence to support the use of prokinetics in critically ill children to improve gastric emptying and feed tolerance	GCP	Strong consensus	[144, 145]
In critically ill children, when should Parenteral Nutrition (PN) be started?	14.1: Withholding parenteral nutrition for up to one week can be considered in critically ill term neonates and children, independent of nutritional status, while providing micronutrients	B	Consensus	[8, 9, 22, 25–27, 156]
In critically ill children, does the use of a feeding protocols impact on clinical outcomes?	15.1: Enteral feeding protocols are recommended to improve time to initiation of EN and nutritional intake	C	Strong consensus	[30, 59, 60, 62, 72, 74–76, 87, 90, 157–162]
	15.2: Enteral feeding protocols are recommended for high-risk populations to improve nutritional intake and reduce adverse events	D	Strong consensus	[30, 59, 60, 62, 72, 74–76, 87, 90, 157–162]