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Nutritional practices and their relationship to clinical outcomes in critically ill children--an international
Nilesh M Mehta1, Lori J Bechard, Naomi Cahill
1Division of Critical Care Medicine, Department of Anesthesiology, Pain and Perioperative Medicine at Children's Hospital Boston, Boston, MA, USA. nilesh.mehta@childrens.harvard.edu
Insights
Inadequate nutrition is common in mechanically ventilated children. Higher energy intake via enteral nutrition improves survival, while parenteral nutrition increases mortality, highlighting the need for optimized nutrition therapy.
Area of Science:
- Pediatric Critical Care Medicine
- Clinical Nutrition
- Intensive Care Medicine
Background:
- Energy and protein intake adequacy is crucial for critically ill children.
- Mechanically ventilated children in pediatric intensive care units (PICUs) often face nutritional challenges.
- Malnutrition on admission is prevalent, impacting clinical outcomes.
Purpose of the Study:
- To investigate factors affecting energy and protein intake adequacy in PICU patients.
- To determine the relationship between nutritional intake and clinical outcomes in mechanically ventilated children.
- To identify characteristics of PICUs associated with better nutritional delivery and patient outcomes.
Main Methods:
- International prospective cohort study of mechanically ventilated children (1 month to 18 years).
- Nutritional practices recorded for up to 10 days during PICU stay.
- Multivariate analysis to assess impact of nutrition and PICU factors on 60-day mortality and acquired infections.
Main Results:
- 31 PICUs across 8 countries enrolled 500 patients; 8.4% 60-day mortality, 22% acquired infections.
- Mean prescribed energy: 64 kcal/kg, protein: 1.7 g/kg; actual intake was 38% energy, 43% protein.
- Higher enteral energy intake correlated with lower mortality (OR 0.27); parenteral nutrition associated with higher mortality (OR 2.61).
- Units with feeding protocols had fewer infections (OR 0.18), independent of intake levels.
Conclusions:
- Nutritional delivery is often inadequate for mechanically ventilated children globally.
- Increased enteral energy intake improves 60-day survival; parenteral nutrition linked to worse outcomes.
- PICU feeding protocols reduce infection rates, emphasizing the importance of optimized nutrition therapy for critically ill children.
Objectives:
To examine factors influencing the adequacy of energy and protein intake in the pediatric intensive care unit and to describe their relationship to clinical outcomes in mechanically ventilated children.
Design, Setting, Patients:
We conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections.
Main Results:
31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (SD) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z-score >2 (13.2%) or <-2 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (SD) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p = .002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p = .008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p = .008), and this association was independent of the amount of energy or protein intake.
Conclusions:
Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children.
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