Table 2.
Comparison between American and European guidelines on paediatric intensive care nutrition support
| ESPNIC Recommendations (European Society of Paediatric and Neonatology Intensive care) |
SCCM and ASPEN recommendations (Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition) |
|---|---|
| Q1: In critically ill children, should nutritional status be assessed and what is the optimal method to assess nutritional status? | Q1A. What is the impact of nutritional status on outcomes in critically ill children? |
| Q1B. What are the best practices to screen and identify patients with malnutrition or those at risk of nutritional deterioration in the PICU? | |
| R1.1: The assessment of nutritional status is recommended in critically ill children at admission and throughout their PICU admission | R1A. 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. We recommend that patients in the PICU undergo detailed nutritional assessment within 48 h of admission. Furthermore, as patients are at risk of nutritional deterioration during hospitalization, which can adversely affect clinical outcomes, we suggest that the nutritional status of patients be re-evaluated at least weekly throughout hospitalization |
| R1.2: 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 | R1B. Based on observational studies and expert consensus, we recommend that weight and height/length be measured on admission to the PICU, and z scores for body mass index for-age (weight-for-length < 2 years), or weight-for-age (if accurate, height is not available), be used to screen for patients at extremes of these values. In children < 36-months, head circumference must be documented. Validated screening methods for the PICU population to identify patients at risk of malnutrition must be developed. Screening methods might allow limited resources to be directed to high-risk patients who are most likely to benefit from early nutritional assessment and interventions |
| Q2: In critically ill children, when should enteral nutrition be commenced and how should it be increased? | Q6B. When should EN be initiated? |
| Q4A. Is EN feasible in critically ill children? | |
| Q4B. What is the benefit of EN in this group? | |
| Q5A. What is the optimum method for advancing EN in the PICU population? | |
| R2.1: It is recommended to commence early enteral nutrition within 24 h of admission unless contraindicated | R6B. Based on expert opinion, we suggest that EN be initiated in all critically ill children, unless it is contraindicated. Based on observational studies, we suggest early initiation of EN, within the first 24–48 h after admission to the PICU, in eligible patients. We suggest the use of institutional EN guidelines and stepwise algorithms that include criteria for eligibility for EN, timing of initiation, and rate of increase as well as a guide to detecting and managing EN intolerance |
| R4A. Based on observational studies, we recommend EN as the preferred mode of nutrient delivery to the critically ill child. Observational studies support the feasibility of EN, which can be safely delivered to critically ill children with medical and surgical diagnoses, and to those receiving vasoactive medications. Common barriers to EN in the PICU include delayed initiation, interruptions due to perceived intolerance, and prolonged fasting around procedures. Based on observational studies, we suggest that interruptions to EN be minimized to achieve nutrient delivery goals by the enteral route | |
| R4B. Although the optimal dose of macronutrients is unclear, some amount of nutrient delivered as EN has been beneficial for gastrointestinal mucosal integrity and motility. Based on large cohort studies, early initiation of EN (within 24–48 h of PICU admission) and achievement of up to two thirds of the nutrient goal in the first week of critical illness have been associated with improved clinical outcomes | |
| R2.2: It is recommended to increase enteral nutrition in a stepwise fashion until goal for delivery is achieved using a feeding protocol or guideline | R5A. Based on 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 |
| Q3: In critically ill children on haemodynamic support (vasoactive medications, extracorporeal life support ECLS) does enteral feeding compared to no enteral feeding affect outcomes? | Q4A. Is EN feasible in critically ill children? |
| R3.1: Early enteral nutrition is recommended in term neonates who are stable on ECLS | NA |
| R3.2: Early enteral nutrition is recommended in children who are stable on ECLS | NA |
| R3.3: Early enteral nutrition is recommended in term neonates who are stable on pharmaceutical haemodynamic support | |
| R3.4: Early enteral nutrition is recommended in children who are stable on pharmaceutical haemodynamic support | R4A. Based on observational studies, we recommend EN as the preferred mode of nutrient delivery to the critically ill child. Observational studies support the feasibility of EN, which can be safely delivered to critically ill children with medical and surgical diagnoses, and to those receiving vasoactive medications |
| R3.5: Early enteral nutrition is recommended in children after cardiac surgery | |
| Q4: In critically ill term neonates with umbilical arterial catheters and/or PGE1 infusions, does enteral feeding impact on adverse events? | NA |
| R4.1: Enteral nutrition should be considered in term neonates with umbilical arterial catheters | NA |
| R4.2: 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 | NA |
| Q5: In critically ill children what are their energy requirements? | Q2C. What is the target energy intake in critically ill children? |
| R5.1 In the acute phase, energy intake provided to critically ill children should not exceed resting energy expenditure | R2C. Based on observational cohort studies, we suggest achieving delivery of at least two thirds of the prescribed daily energy requirement by the end of the first week in the PICU. Cumulative energy deficits during the first week of critical illness may be associated with poor clinical and nutritional outcomes. Based on expert consensus, we suggest attentiveness to individualized energy requirements, timely initiation and attainment of energy targets, and energy balance to prevent unintended cumulative caloric deficit or excesses |
| R5.2. After the acute phase, energy intake provided to critically ill children should account for energy debt, physical activity, rehabilitation and growth | |
| Q6: In critically ill children, what is the most accurate method of determining or predicting energy expenditure? | Q2A. What is the recommended energy requirement for critically ill children? |
| Q2B. How should energy requirement be determined in the absence of IC? | |
| R6.1 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 | R2A. Based on observational cohort studies, we suggest that measured energy expenditure by indirect calorimetry (IC) be used to determine energy requirements and guide prescription of the daily energy goal |
| R6.2 Schofield equation (for age and gender and using an accurate weight) is recommended to estimate resting energy expenditure | R2B. If IC measurement of resting energy expenditure (REE) is not feasible, we suggest that the Schofield or Food Agriculture Organization/World Health Organization/United Nations University equations may be used “without” the addition of 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 RDAs, which are suggested by the Dietary Reference Intakes, should not be used to determine energy requirements in critically ill children |
| Q7.1: What is the recommended glucose intake? | NA |
| R7.1. Parenteral glucose provision should be sufficient to avoid hypoglycaemia but not excessive to prevent hyperglycaemia | NA |
| Q7.2: What is the recommended lipid intake or type? | NA |
| R7.2: When parenteral nutrition is used, composite lipid emulsions, with or without fish oil, should be considered as the first-choice treatment | NA |
| Q7.3: What is the recommended protein/amino acid intake? | Q3A. What is the minimum recommended protein requirement for critically ill children? |
| Q3B. What is the optimal protein delivery strategy in the PICU? | |
| Q3C. How should protein delivery goals be determined in critically ill children? | |
| R7.3a: 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 | R3A. Based on evidence from RCTs and supported by observational cohort studies, we recommend a minimum protein intake of 1.5 g/kg/d. Protein intake higher than this threshold has been shown to prevent cumulative negative protein balance in RCTs. 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 patients. Based on a large observational study, higher protein intake may be associated with lower 60-d mortality in mechanically ventilated children |
| R3B. Based on results of randomized trials, we suggest provision of protein early in the course of critical illness to attain protein delivery goals and promote positive nitrogen balance. Delivery of a higher proportion of the protein goal has been associated with positive clinical outcomes in observational studies | |
| R7.3b: There is insufficient evidence available to support the use of additional protein/amino acid intake during the acute phase of illness (Strong consensus) | R3C. The optimal protein dose associated with improved clinical outcomes is not known. We do not recommend the use of RDA values to guide protein prescription in critically ill children. These values were developed for healthy children and often underestimate the protein needs during critical illness |
| Q8: In critically ill children, do different feed formulas (polymeric vs. semi-elemental feed, standard vs. enriched formula) impact on clinical outcomes? | NA |
| R8.1 Polymeric feeds should be considered as the first choice for enteral nutrition in most critically ill children, unless there are contraindications | NA |
| R8.2 Protein and energy-dense formulations may be considered to support achievement of nutritional requirements in fluid-restricted critically ill children | NA |
| R8.3 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 | NA |
| Q9: In critically ill children, does pharmaconutrition (glutamine, lipids and/or micronutrients) impact on clinical outcomes? | Q8. What is the role of immunonutrition in critically ill children? |
| R9.1 There is insufficient evidence to recommend the use of pharmaconutrition in critically ill children | R8. Based on available evidence, we do not recommend the use of immunonutrition in critically ill children |
| Q10: In critically ill children, does continuous feeding compared to intermittent bolus gastric feeding impact on outcomes? | NA |
| R10.1: There is no evidence to suggest that either continuous or intermittent/bolus feeds are superior in delivering gastric feeds in critically ill children | NA |
| Q11: In critically ill children, does gastric feeding compared to post-pyloric feeding impact on clinical outcomes? | Q6A. What is the best site for EN delivery–gastric or small bowel? |
| R11.1: Gastric feeding is as safe as post pyloric feeding in most critically ill children | R6A. Existing data are insufficient to make universal recommendations regarding the optimal site to deliver EN to critically ill children. Based on observational studies, we suggest the gastric route be the preferred site for EN in patients in the PICU. The post-pyloric or small intestinal site for EN may be used in patients unable to tolerate gastric feeding or those at high risk for aspiration. Existing data are insufficient to make recommendations regarding the use of continuous vs intermittent gastric feeding |
| R11.2: Gastric feeding is not inferior to post pyloric feeding in the majority of critically ill children | |
| R11.3 Post-pyloric feeding can be considered for critically ill children at high risk of aspiration or requiring frequent fasting for surgery or procedures | |
| Q12: In critically ill children does routine Gastric Residual Volume (GRV) to guide enteral feeding impact on outcomes? | NA |
| R12.1: Routine measurement of GRV in critically ill children is not recommended | NA |
| Q13: In critically ill children, do prokinetics impact on clinical outcomes? | NA |
| R13.1: There is insufficient evidence to support the use of prokinetics in critically ill children to improve gastric emptying and feed tolerance | NA |
| Q14: In critically ill children, when should Parenteral Nutrition (PN) be started? | Q7A. What is the indication for and optimal timing of PN in critically ill children? |
| Q7B. What is the role of PN as a supplement to inadequate EN? | |
| R14.1: 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 | R7A. Based on a single RCT, we do not recommend the initiation of PN within 24 h of PICU admission |
| R7B. In children tolerating EN, we suggest stepwise advancement of nutrient delivery via the enteral route and delaying commencement of PN. Based on current evidence, the role of supplemental PN to reach a specific goal for energy delivery is not known. The time when PN should be initiated to supplement insufficient EN is also unknown. The threshold for and timing of PN initiation should be individualized. Based on a single RCT, supplemental PN should be delayed until 1 wEEk after PICU admission in patients with normal baseline nutritional state and low risk of nutritional deterioration. Based on expert consensus, we suggest PN supplementation in children who are unable to receive any EN during the first week in the PICU. In patients who are severely malnourished or at risk of nutritional deterioration, PN may be supplemented in the first week if they are unable to advance past low volumes of EN | |
| Q15: In critically ill children, does the use of a feeding protocols impact on clinical outcomes? | NA |
| R15.1: Enteral feeding protocols are recommended to improve time to initiation of EN and nutritional intake | NA |
| R15.2: Enteral feeding protocols are recommended for high-risk populations to improve nutritional intake and reduce adverse events | NA |
| NA | Q5B. What is the role of a nutrition support team or a dedicated dietitian in optimizing nutrition therapy? |
| NA | 5B. Based on observational studies, we suggest a nutrition support team, including a dedicated dietitian, be available on the PICU team, to facilitate timely nutritional assessment, and optimal nutrient delivery and adjustment to the patients |
NA not applicable, EN enteral nutrition, IC indirect calorimetry, PN parenteral nutrition, RCT randomized controlled trial, RDA recommended daily allowance