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Enteral Nutrition Practices in Critically Ill Children Requiring Noninvasive Positive Pressure Ventilation
Matthew K Leroue1,2, Ryan J Good3, Heather E Skillman4
1Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO.
Insights
Critically ill children on noninvasive ventilation often receive early enteral nutrition, but less than half achieve adequate calorie and protein goals. Further research is needed to optimize nutritional support in this vulnerable pediatric population.
Area of Science:
- Pediatric critical care medicine
- Clinical nutrition
- Respiratory support
Background:
- Noninvasive positive pressure ventilation (NIPPV) is common in critically ill children.
- Optimizing nutritional delivery is crucial for recovery in pediatric intensive care unit (PICU) patients.
- Enteral nutrition (EN) is preferred but its timely and adequate delivery during NIPPV requires evaluation.
Purpose of the Study:
- To assess the practice of initiating and achieving goals for enteral nutrition in critically ill children receiving NIPPV.
- To identify factors associated with early EN initiation and nutritional adequacy.
Main Methods:
- Retrospective cohort study of 562 pediatric patients in a quaternary care PICU.
- Inclusion criteria: age >30 days, NIPPV for ≥24 hours, no prior invasive ventilation, able to receive EN at baseline.
- Outcomes: EN initiation within 24 hours, time to goal rate, nutritional adequacy (calories, protein), adverse events, and length of stay.
Main Results:
- 64% of patients initiated EN within 24 hours; 72% reached goal rate within 72 hours.
- Only 49% and 44% achieved adequate cumulative calorie and protein intake, respectively.
- Bi-level NIPPV and continuous dexmedetomidine were associated with decreased likelihood of early EN.
- 12% experienced at least one adverse event.
Conclusions:
- While early EN initiation is common in children on NIPPV, achieving nutritional goals remains a challenge.
- Less than half of patients met recommended caloric and protein targets during their PICU stay.
- Further research is necessary to establish optimal EN strategies for safety and efficacy in this patient group.
Objectives:
Evaluate the practice of providing enteral nutrition in critically ill children requiring noninvasive positive pressure ventilation.
Design:
Retrospective cohort study.
Setting:
PICU within a quaternary care children's hospital.
Patients:
PICU patients older than 30 days requiring noninvasive positive pressure ventilation for greater than or equal to 24 hours from August 2014 to June 2015. Invasive mechanical ventilation prior to noninvasive positive pressure ventilation and inability to receive enteral nutrition at baseline were additional exclusionary criteria.
Interventions:
None.
Measurements And Main Results:
The primary outcome was enteral nutrition initiation within 24 hours of admission. Secondary outcomes included time to goal enteral nutrition rate, adequacy of nutrition, adverse events (pneumonia not present at admission, intubation after enteral nutrition initiation, feeding tube misplacement), and lengths of noninvasive positive pressure ventilation and PICU stay. Among those included (n = 562), the median age was 2 years (interquartile range, 39 d to 6.8 yr), 54% had at least one chronic condition, and 43% had malnutrition at baseline. The most common primary diagnosis was bronchiolitis/viral pneumonia. The median length of time on noninvasive positive pressure ventilation was 2 days (interquartile range, 2.0-4.0). Most (83%) required continuous positive airway pressure or bi-level support during their PICU course. Sixty-four percent started enteral nutrition within 24 hours, with 72% achieving goal enteral nutrition rate within 72 hours. Forty-nine percent and 44% received an adequate cumulative calorie and protein intake, respectively, during their PICU admission. Oral feeding was the most common delivery method. On multivariable analysis, use of bi-level noninvasive positive pressure ventilation (odds ratio, 0.40; 95% CI, 0.25-0.63) and continuous dexmedetomidine (odds ratio, 0.59; 95% CI, 0.35-0.97) were independently associated with decreased likelihood of early enteral nutrition. Twelve percent of patients had at least one adverse event.
Conclusions:
A majority of patients requiring noninvasive positive pressure ventilation received enteral nutrition within 24 hours. However, less than half achieved caloric and protein goals during their PICU admission. Further investigation is warranted to determine the safety and effectiveness of early enteral nutrition in this population.
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