Nutrition protocols improve caloric adequacy in critically Ill children: a systematic review and meta-analysis

Malnutrition is common among critically ill children admitted to the Pediatric Intensive Care Unit (PICU). Despite established guidelines, real-world caloric delivery consistently falls short. Structured nutritional protocols have been proposed to close this gap, yet no prior meta-analysis has quantified their pooled effect on caloric adequacy specifically in PICU patients.

We searched through PubMed, Embase, the Cochrane Library, and Web of Science from January 2015 to March 2026. Studies enrolling critically ill children (≤18 years) in the PICU with a comparison group and at least one nutritional delivery outcome were eligible. The primary outcome was caloric adequacy. A random-effects model was used for pooling effect. Subgroup analyses, meta-regression, sensitivity analyses, and publication bias assessments were conducted.

Nine studies enrolling 1,992 children across six countries were included. Nutritional protocols were associated with a pooled mean difference of +21.98% in caloric adequacy (p < 0.001), with a substantial heterogeneity (I² = 73.9%). Both nurse-led (MD +19.16%) and non-nurse-led protocols (MD +23.95%) improved delivery without a significant between-group difference (p = 0.51). Study design was the dominant heterogeneity driver and explained 93.6% of between-study variance. The pooled estimate was robust across all sensitivity analyses, and trim-and-fill imputed zero missing studies.

Structured nutritional protocols meaningfully improve caloric adequacy in critically ill children, regardless of whether nurses lead their implementation. These findings support the wider adoption of protocolized feeding as a standard of care in PICUs globally.