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Obstacles to meeting nutritional recommendations in a tertiary pediatric intensive care unit
Claire Morice1, Corinne Jotterand Chaparro2, Angelo Polito1
1Pediatric and Neonatal Intensive Care Unit, Pediatric Specialities Division, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland.
Insights
Critically ill children often miss nutritional targets due to clinical factors like ventilation and hemodynamic support. These barriers, particularly in the first 48 hours, impact adherence to pediatric nutrition guidelines.
Area of Science:
- Pediatric critical care medicine
- Clinical nutrition
- Evidence-based practice
Background:
- Optimal nutrition is crucial for critically ill children.
- Updated 2017 guidelines from the Society of Critical Care Medicine and ASPEN aim to improve nutritional support.
- Clinical barriers may impede guideline implementation in pediatric intensive care units (PICUs).
Purpose of the Study:
- To assess adherence to American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines in a PICU.
- To identify clinical barriers hindering the implementation of nutritional support recommendations.
- To hypothesize the impact of caregiver bias and clinical factors on guideline adherence.
Main Methods:
- Retrospective chart review of 533 children (1 month to 16 years) admitted to a PICU from July 2017 to January 2020.
- Evaluation of two ASPEN recommendations: feeding within 48 hours and meeting two-thirds caloric needs by day 7.
- Collection of nutritional and clinical data at admission, 48 hours, and 7 days.
Main Results:
- 75.4% of patients received feeding within 48 hours; barriers included invasive ventilation and hemodynamic support.
- 80.5% of patients met two-thirds of caloric needs by day 7.
- Invasive ventilation was the primary obstacle to meeting caloric goals at 7 days.
Conclusions:
- Adherence to ASPEN nutritional guidelines in a tertiary PICU is challenged by clinical factors.
- Hemodynamic instability and invasive ventilation are significant barriers, especially within the initial 48 hours of PICU admission.
- Targeted interventions may be needed to overcome these barriers and optimize nutrition in critically ill children.
Objectives:
Optimal nutrition is associated with positive outcomes in critically ill children. In 2017, the Society of Critical Care Medicine (SCCM) and the American Society of Parenteral and Enteral Nutrition (ASPEN) updated guidelines for nutritional support for this population. However, implementation of these guidelines may be delayed due to clinical barriers. We aimed to assess our practice against the recommendations of the ASPEN guidelines, hypothesizing that caregiver bias and clinical factors may hinder their implementation in our pediatric intensive care unit (PICU).
Methods:
We focused on two ASPEN recommendations: (1) feeding within 48 h (48H) of admission and (2) meeting two thirds of estimated caloric requirements after seven calendar days. All children aged 1 month to 16 years admitted to our PICU from July 2017 to January 2020 were eligible. Using a retrospective chart review, nutritional and clinical data were collected at the time of admission, at 48H, and 7 calendar days after admission.
Results:
A total of 533 patients were included. After 48H of admission to the PICU, 402 out of 533 (75.4%) patients received feeding. The following factors were associated with not reaching nutritional goals at 48H: invasive ventilation support, inotropic and vasoactive support, and extracorporeal life support. After 7 days, 95 out of 118 (80.5%) received two thirds of caloric needs. At 7 days, the main obstacle to meeting caloric goals was invasive ventilation.
Conclusion:
In a representative tertiary PICU, barriers to meeting ASPEN nutritional recommendations included hemodynamic instability or invasive ventilator support, especially within the first 48H of admission.
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