SCCM Resource Library-Food for Thought: The Nuts and Bolts of Nutrition for Pediatric Critical Illness

Video Transcription

Hi, and welcome to the SCCM Congress. I'm delighted to present the speakers for the session, Food for Thought, the Nuts and Bolts of Nutrition of Pediatric Critical Illness.  Let's first start with Vijay Srinivasan, who is a pediatric intensivist at the Children's  Hospital of Philadelphia and assistant professor of anesthesiology, critical care, and pediatrics at the Perlman School of Medicine at the University of Pennsylvania.  He serves as the advisory dean to medical students at the Perlman School of Medicine, and in addition to his clinical responsibilities as a pediatric intensivist, Dr. Srinivasan  is actively involved in research and quality improvement programs in critical illness endocrinopathies and nutrition to improve outcomes in critically ill children.  He co-founded and co-leads the pediatric ICU nutrition team at CHOP in partnership with nurse practitioner scientists, nurses, and dietitians to enhance nutrition support  for critically ill children. His research focuses on stress hyperglycemia nutrition support in pediatric critical illness  with his published works being widely cited and recognized with awards from the Society of Critical Care Medicine, the American Society of Parental and Enteral Nutrition, and the  American Academy of Pediatrics. He is an elected fellow of the American College of Critical Care Medicine and a fellow of the AAP.  He serves as a member of the Pediatric Section Steering Committee and as an executive committee member of the AAP Section on Critical Care.  As chair of the SCCM Pediatric QI Subcommittee and the Pediatric Quality and Safety Subcommittee  for the AAP SOCC, he has developed an innovative webinar series to foster and grow collaboration  in quality improvement in patient safety across multiple pediatric intensive care units. He is a member of the Critical Care Congress Program Committee for SCCM and a member of  the Editorial Board for Pediatric Critical Care Medicine. Dr. Srinivasan will present in Gut We Trust, Feed Early and Feed Well.  Next up is Dr. Anne-Marie Brown, who completed her bachelor's at the University of Akron, her master's at Kent State University, and PhD in Nursing at the University of Akron.  She's an Associate Clinical Professor and Director, Acute Care Pediatric Nurse Practitioner Program at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta,  Georgia, and a Nurse Scientist at Children's Healthcare of Atlanta. Dr. Brown's research has primarily focused on nutrition in critically ill children and  she has collaborated with many colleagues nationally and internationally. Her recent focus has been on enteral nutrition delivery, intolerance, and pathways to optimize  nutrition therapy across the heterogeneous PICU population. Her clinical background is as a pediatric ICU NP where she held leadership positions for many years.  She serves on the boards of the Association of Faculty of Pediatric Nurse Practitioners, the Pediatric Section of the Society of Critical Care Medicine, and the World Federation of  Pediatric Intensive and Critical Care Societies. She is a committed educator, having directed two different acute care PNP programs, and  is passionate about the use of social media for professional networking and career development.  Dr. Brown will present, Feeding the Stomach in Critically Ill Children, Is BOLUS Better Than Continuous?  Lastly, for this session, we have Dr. Sharon Irving, who is an Associate Professor and Vice Chair of the Department of Family and Community Health at the University of Pennsylvania  School of Nursing. She has a clinical appointment at the Children's Hospital of Philadelphia in the Departments  of Nursing and Critical Care Medicine, where she maintains a clinical practice as a nurse practitioner in the Pediatric Intensive Care and Progressive Care Units.  The foundation of her work is nutrition therapy during and immediately following critical illness in infants and children.  As a PICU provider, Dr. Irving has focused her work in obtaining an interpretation of accurate anthropometric measurements, determining energy and protein requirements, optimization  of nutrition delivery, and monitoring tolerance of enteral nutrition in this population. She considers herself a participant in team science and partakes in an interdisciplinary  approach to teaching, clinical practice, research inquiry, and quality improvement initiatives.  She is co-author of the Comprehensive Nutrition Support Guidelines for Critically Ill Children  endorsed by the American Society for Parenteral and Enteral Nutrition and Society of Critical  Care Medicine, and is primary author on the Best Practice Recommendation for Nasogastric Feeding Tube Safety in Infants and Children endorsed by Aspen.  Her attention and diligence in pediatric critical care and in the field of nutrition has earned  her fellowships in the American College of Critical Care Medicine and the American Academy of Nursing.  In addition, she was named the 2019 Distinguished Nutrition Support Nurse by the American Society for Parenteral and Enteral Nutrition.  Dr. Irving will present Pre-Illness Nutrition Status and a Pathway to Nutrition in Critically Ill Children. Now on to the talks. Good evening.  It is my pleasure to be here with all of you to talk about the importance of enteral nutrition in critically ill children.  My sincere thanks to the organizers for inviting me to speak at this historic 50th and first virtual edition of the Annual Congress.  I have listed my disclosures, including my research grant support. I also serve in a voluntary capacity in national societies, including the Society of Critical  Care Medicine, the American Academy of Pediatrics, and the American Society of Parenteral and Enteral Nutrition.  I have no commercial or financial conflicts of interest relevant to this topic. My objectives for this talk are twofold.  One, to understand the rationale for early initiation of enteral nutrition, and two, to evaluate the association of adequacy of enteral nutrition with outcomes in critically  ill children. Or to put it more simply, feed early and feed well. Critical illness in children is a very dynamic state with metabolic flux.  Using the systemic inflammatory response as an example, this figure highlights the involvement of numerous organ systems with interrelated processes that affect nutrient  mobilization and utilization, with very important implications for nutrition therapy. Now critical illness ebbs and flows from the acute illness state to a more chronic illness  state, leading to either recovery or death. While traditionally, nutrition therapy during chronic illness is widely acknowledged to  play an important role in recovery, more recently, it is also becoming evident that nutrition therapy in acute illness can dampen and shorten the inflammatory response.  Specifically, the gastrointestinal tract is a very important organ that modulates the critical illness state.  This figure depicts key factors that influence both function and dysfunction in the gut in illness.  Panel A on the left depicts the healthy gut with normal barrier function, while panel B on the right depicts the inflamed gut with impaired barrier function.  The absence of enteral nutrition, coupled with the pro-inflammatory state of critical illness, shifts the milieu to the right, resulting in feeding intolerance, immune dysfunction,  and organ dysfunction. In contrast, initiation of enteral nutrition, coupled with anti-inflammatory changes, shifts  the milieu to the left, facilitating feeding tolerance, improved immune function, and improved organ function. Good science demands good evidence.  In this context, study design assumes importance for establishing validity and strength, while the population studied provides the basis for generalizability and plausibility.  So till date, only a single randomized controlled trial has attempted to examine the question of timing of enteral nutrition initiation in critically ill children.  In this study, 120 subjects from one PICU were randomized to either early enteral nutrition within 6 to 24 hours of admission, or late enteral nutrition after 24 hours of admission.  After adjusting for severity of illness, malnutrition, and age, there were no differences in the primary outcome of PICU length of stay between the groups.  However, there was a trend towards lower mortality in the early enteral nutrition group. Our group completed a secondary analysis of nutrition support in the half-pint randomized  clinical trial that studied the benefit of tight glucose control in critically ill children with hyperglycemia.  The study enrolled over 600 subjects from 35 pediatric ICUs and incorporated a nutrition guideline that emphasized the use of early EN.  Nutrition data was prospectively collected in enrolled subjects, and the primary outcome was 90-day mortality.  We defined early EN as EN begun within 48 hours of study enrollment, corresponding to peak critical illness in this population.  After adjusting for age, body mass index z-score, inotropic support, severity of illness, reason  for ICU admission, and ICU site, we observed that early EN was associated with lower ICU mortality.  Early EN was also associated with more ICU free days, hospital free days, and ventilator free days, as well as less organ dysfunction.  The largest study of enteral nutrition therapy in critically ill children published in 2014 retrospectively enrolled over 5,000 subjects from 12 PICUs to study the impact of early  EN on PICU mortality. The analyses were adjusted with propensity scoring to account for the possibility that sicker kids are less likely to be fed enterally.  The investigators defined early EN as EN initiated within 48 hours of admission to the PICU, and examined the effect of early EN on the entire cohort, as well as the sub-cohorts  of well-nourished patients and those that were mechanically ventilated. Notably, early EN was associated with lower mortality in the overall cohort, as well as in the sub-cohorts.  Further, an increasing proportion of enteral nutrition relative to total energy at 48 hours  was also associated with a significant trend of lower mortality, highlighting a dose-response effect of early EN on survival.  Do these observations also hold true for disease-specific states in critical illness? Yes.  The timing of EN initiation on length of stay was examined in a retrospective study of children  with acute respiratory failure after adjusting for severity of illness and respiratory failure, with early EN being defined as EN begun within 72 hours of admission.  Notably, the majority of the cohort received early enteral nutrition, and early EN was associated with shorter PICU, as well as shorter hospital length of stay.  In another retrospective study of children with ARDS who were followed for seven days of illness, the impact of early enteral nutritional mortality was examined after adjusting for  severity of ARDS, illness severity, and adequacy of nutrition therapy. Early EN was defined as EN begun within 24 hours of onset of ARDS.  About a quarter of subjects received early EN, and early EN was associated with lower mortality.  The recently published surviving sepsis guidelines in children note the paucity of evidence for  timing of enteral nutrition in sepsis, but do favor early EN initiation within 48 hours of recognition of septic shock.  Similar evidence favoring early enteral nutrition is available in children who sustain traumatic brain injury.  A secondary analysis of data from a randomized clinical trial of therapeutic hypothermia  in children with traumatic brain injury enrolled 90 subjects from 15 ICUs to examine the timing of enteral nutrition initiation on mortality.  After creating four groups based on timing of EN initiation, ranging from no EN to EN delivered from 72 to 168 hours, EN initiation before 72 hours was noted to be associated  with lower mortality and favorable outcomes. In this retrospective study of over 400 children from five ICUs admitted with traumatic brain  injury, after adjusting for age, illness severity, ICP, and Glasgow Coma Scale scores, early  EN initiation within 48 hours was associated with lower mortality and shorter ICU and hospital lengths of stay.  Finally, in this retrospective study of nutrition practices in children supported on ECMO, after  adjusting for ECMO days, vasoactive agents, and renal replacement therapy, similar proportions  of survivors and non-survivors had EN initiated within the first seven days, but survivors tended to have earlier initiation of EN within 48 hours compared to non-survivors.  So when should we start EN? Based on all the available evidence, the SCCM and Aspen Guidelines for Nutrition Support  Therapy in Critically Ill Children suggest early initiation of enteral nutrition within 24 to 48 hours in all eligible patients.  So if early EN is good, then early PEN must be even better, correct? The landmark RCT by Fives, PIPANIC, published in 2016, examined whether a strategy of early  PEN initiated within 24 hours was superior to late PEN initiated after seven days. Over 1,400 subjects were enrolled with the primary outcomes being new infections and  PICU dependency. After adjusting for age, illness severity, malnutrition risk, and diagnosis, the two  groups were compared for the primary outcomes, and notably, the early PEN group had worse outcomes compared to the late PEN group.  So based on the evidence from this RCT, the SCCM and Aspen Guidelines for Nutrition Support Therapy in Critically Ill Children do not recommend early initiation of PEN within 24  hours of admission. Moreover, the optimal timing for initiation of parenteral nutrition remains unknown in the absence of sufficient evidence.  So we can agree that early EN is good, but questions remain. How much energy and protein should be delivered, and by when during the course of illness?  And should this be exclusively through EN or PEN, or a combination of EN and PEN? So during critical illness, the question of how much energy to deliver becomes very important.  This figure shows changes in total energy expenditure and endogenous energy production in the acute stages of critical illness in the first few days.  During this phase, the risk of overfeeding with parenteral nutrition is very high, and early EN initiation is associated with favorable outcomes, as we have seen.  Once the acute phase gives way to the chronic phase to the right, the traditional paradigm has been to supplement EN with parenteral nutrition to prevent underfeeding and improve  clinical outcomes. But is this true? In other words, what does the evidence show? To answer this question, we turn to the first large Pediatric International Survey by Nilesh  Mehta, published in 2012. This study prospectively enrolled 500 subjects from 31 PICUs across the world with prospective  data collection for 10 days to study the relationship of nutrition practices with clinical outcomes. The analysis was adjusted for illness severity and body mass index z-scores.  Contrary to expectations, increasing delivery of energy as a combination of EN and PEN was not associated with lower 60-day mortality.  But surprisingly, increasing delivery of energy exclusively via EN was associated with lower 60-day mortality, highlighting the benefits of enteral nutrition adequacy in critically  ill children, even after adjusting for illness severity and nutrition status. So the data from this study suggests an alternative and improved paradigm to incorporate stepwise  increase in enteral nutrition delivery to achieve at least two-thirds of energy needs by a week following critical illness to improve recovery and outcomes.  In this retrospective study of children with ARDS who were followed for seven days of illness,  the impact of adequacy of EN delivery on mortality was examined after adjusting for severity of ARDS, illness severity, and adequacy of nutrition therapy.  Compared to survivors represented by the solid blue and red lines, non-survivors represented  by the dashed red and blue lines received lower median total energy and median percentage EN calories.  This retrospective study by Cheng-Si Ong examined nutrition adequacy in children supported on ECMO.  After adjusting for ECMO days, vasoactive agents, and renal replacement therapy, in multiple logistic regression analysis of factors associated with hospital mortality, EN adequacy  was independently associated with lower mortality. So based on the available evidence from observational studies, the SCCM and Aspen Guidelines for  Nutrition Support Therapy in Critically Ill Children suggest achieving delivery of at least two-thirds of prescribed daily energy requirement by seven days, preferably through  enteral nutrition. Lastly, but very importantly, we have the question of how much protein should be delivered to critically ill children.  The second Pediatric International Survey by Nilesh Mehta, published in 2015, examined the relationship of adequacy of protein in clinical outcomes.  This study prospectively enrolled over 1,200 subjects from 51 PICUs across the globe and collected nutrition data for 10 days.  The primary outcome was 60-day mortality, and the analysis modeled to include PICU characteristics, patient characteristics, and nutrient intake adequacy.  So this study observed that adequacy of enteral protein intake correlated inversely with 60-day  mortality, highlighting the importance of enteral protein delivery in critically ill children.  In the previous retrospective study of children with ARDS who were followed for seven days  of illness, the impact of adequacy of protein delivery on mortality was also examined after adjusting for severity of ARDS, illness severity, and adequacy of nutrition therapy.  Compared to survivors, the solid blue line, non-survivors with the dashed blue line had lower median total protein delivered over time.  So to answer the question of whether enteral protein or parenteral protein is more impactful, we turn again to the FIBRS study of early PN versus late PN in critically ill children  for the evidence. A follow-up analysis from the ZARCH CT examined the impact of specific macronutrients on the  likelihood of acquiring a new infection in the PICU and observed that parenteral amino acids in red appears to increase the likelihood of acquiring a new infection and cause harm.  In contrast, carbohydrates in blue appeared to confer protection while lipids in green had no impact on the likelihood of acquiring a new infection.  So in summary, numerous studies have highlighted that critically ill children have higher protein needs with increased turnover in protein.  Importantly, studies have highlighted the benefits of providing a higher percentage of protein via the enteral route. So how much protein is sufficient?  Based on all the available evidence, the SCCM and Aspen Guidelines for Nutrition Support Therapy in critically ill children recommend a minimum protein intake of 1.5 grams per  kilo per day and possibly even more to prevent cumulative deficits in protein balance during critical illness in children.  As I conclude my talk, I would like to reemphasize the importance of feeding the critically ill child early and feeding them well.  I hope that I have been able to convince you or at the very least whet your appetite for the importance of enteral nutrition therapy in critically ill children.  Thank you so much everyone for your time and attention. I look forward to answering your questions in the interactive chat session following or by email. Thank you.  Thank you for the opportunity to talk to you about an area of interest not just to myself  but to all of us in terms of optimizing enteral nutrition delivery in our pediatric ICU patients.  And that is whether bolus feeding is better than continuous feeding in this population. I have no conflicts of interest to report.  Our learning objectives are to describe the potential advantages of bolus versus continuous gastric feeding in the PICU patient and then utilize best evidence in the implementation  of bolus gastric feeding. Why is this a conversation? Why bolus versus continuous? We know one of our jobs is to optimize enteral nutrition delivery, that there are a lot of  barriers to meeting our target intake such as fluid overload, a patient that's in shock, feeding interruptions, and feeding intolerance.  So how can looking at bolus versus continuous help us address that? Well we know bolus is more physiologic.  Our stomachs are actually designed to be fed meals and there's actually increased gastric motility using bolus feeds compared to continuous.  And that all sounds good, it's physiologic, but does it make a difference? And I'm going to share with you that I think that it does and that the evidence says that it does.  We also have the opportunity with bolus to decrease some of those interruptions, some of which are avoidable, some of which aren't.  Because if feeds aren't running all the time, then some of the other therapies that are needed such as beds, baths, turning, imaging, ICU rehab, we have time to do that without  interrupting feeds. It is more nursing intensive to have bolus feeds that have to be stopped and started  so we also want to justify to say it makes a difference to our patients before we increase that nursing workload.  Finally there's been kind of a dogmatic assumption that feeding bolus in a critically ill child would increase the risk of emesis and the dreaded adverse event of aspiration and I  will share with you that the science suggests otherwise. So let's talk about the migratory motor complex.  You can think of it as the housekeeper for our GI tract and if you haven't thought about  the MMC for a while, it's important to understand that the MMC only works during fasting periods in between meals.  So we almost completely obviate its function during continuous feeds and typically after somewhere between 30 to 90 minutes of a last meal through three phases of both muscle and  ciliary contractions, the remaining contents of the GI tract starting from the antrum of the stomach all the way through are propelled forward.  This includes not only residual food product, but also microbial debris, bacteria, white cells, etc.  And so it stands to reason that by eliminating the normal function of the MMC we may be changing the gut microbiome.  Next let's think about splanchnic circulation, that which provides circulation to pretty much the entire GI tract, which also includes the liver, the pancreas, etc.  We know that particularly in periods of low cardiac output that while under normal conditions the splanchnic perfusion gets about 25 to 30 percent of the total cardiac output, there  may be significant shunting away from this area during shock. We also know that not feeding the gut affects gut mucosal barrier.  So those things together can impair gut barrier integrity and gut permeability that affects digestion and absorption. How can how we feed impact this?  So while not our specific population, in a very low birth weight population, they looked at bolus versus continuous feeds and examined the splanchnic circulation using both Doppler  ultrasound and splanchnic NEARs and what they found were no differences in peak systolic velocity, or excuse me, they found significantly better peak systolic velocity or actually  enhanced splanchnic perfusion in the bolus group compared to the continuous group. In addition, they also found that there was increased end-diastolic velocity as well.  So bolus actually improves splanchnic perfusion, not decreased it, which is what has been a concern because this is our big fear, necrotizing enterocolitis.  In the Capriotti review article that I highlight here, they looked at NEC from a number of  perspectives, but they also included nutrition and they also looked at it from a prevention as well as a treatment perspective.  What they found was intermittent NG feeding compared to continuous was more physiologic, promoted normal cycles of GI hormones and contributed to a decreased risk to develop NEC.  Once NEC had occurred, bolus feeds improved gut motility, which we've already discussed,  and adaptation back towards normal and decreased hyperinsulinemia by providing periods of fasting.  A year ago at this meeting, we had our first major oral presentation around our new surviving sepsis pediatric guidelines.  In those, while they acknowledged an inadequate evidence base, they noted that for the patient in septic shock, enteral nutrition is the preferred approach, that gastric feeding  is preferred over post-pyloric. They recommended against routine measurements of GRV and routine prescriptions of prokinetic agents.  They suggested against specialized lipid emulsions, specialized micronutrient therapies, including vitamin D deficiencies.  They also made an important statement that EN, enteral nutrition, is not contraindicated in children with septic shock after adequate hemodynamic resuscitation where vasoactive  therapies are no longer being increased and in fact may be decreasing.  Being on a vasoactive is not an absolute contraindication to feeding the gut, and we know that even trickle or trophic feeds can help maintain that important gut barrier integrity.  It brings forth the question, given what we just talked about in terms of bolus improving  splanchnic circulation, it might be the better way to deliver EN in patients recovering from shock or at risk for shock.  So the next potential impact of bolus feeding I'd like to talk about is its anabolic function,  and that in this particular study they looked at neonatal pigs comparing bolus versus continuous  in a lab, and what they found were increased protein synthesis in both multiple types of muscle fibers as well as visceral proteins in the bolus group compared to the continuous  group. What does that mean for us? So one of the challenges for us to begin to translate this work into our peds ICU, and  there are folks working on this, is that we need bedside, rapid, easy, noninvasive ways to measure lean muscle mass.  Once we have that there are opportunities to look at bolus versus continuous feeds and see if we see what we've seen in piglet and neonatal models that there is enhanced protein  synthesis that appears to be stimulated by the rapid increase by bolus of an amino acid pool and the associated insulin surge that comes with it translating that AA pool into  actual anabolic processes and protein synthesis and it also results in important mRNA signaling.  These authors called for a need for pragmatic studies to compare protein anabolic action of continuous versus bolus but we need those methodologies.  So here then my questions that come from what we know so far is that does that mean that bolus could actually positively impact our ICU rehab helping to maintain strength, enhance  strength particularly for longer stay patients and related to that can it help improve post-ICU syndrome outcomes particularly those around strength.  An intriguing impact of bolus that I actually hadn't encountered before doing my lit search  for preparation for this talk was a potential impact of bolus feeds on gallbladder function.  In this neonatal study they looked at the impact of bolus versus continuous on gallbladder function in a seven day prospective crossover study.  The first phase the baseline was bolus feeding and then they went to continuous feeding for three days and then back to bolus feeding for three days.  They evaluated the gallbladder by ultrasound in phase A as a baseline then at the beginning  and the end of phases B and C. Remembering the timing of some of this would also coordinate with our migratory motor complex. Here's what they found.  On the left hand graph you can see the gallbladder contraction index on the Y-axis and those different days and phases on the X-axis and you can see from a baseline of a contraction  index of around 65% as soon as they went to continuous feeds gallbladder contraction essentially stopped.  Conversely as soon as they went back to bolus it returned to that normal baseline. On the right hand side you can see a curve that's almost inverse from the first one.  The bottom is still the timeline of the study, but the Y-axis is now the gallbladder volume.  So as soon as the gallbladder contractility went down it makes sense the gallbladder volume  increased and then started decreasing again once they went back to bolus feeding. So this causes me to ask two questions, a short term and a long term question for our population.  By using continuous feeds are we impairing optimal absorption and digestion of nutrients by basically negating gallbladder function and limiting bile excretion into the GI tract  to enhance fat soluble nutrients and vitamin absorption? And in the long term particularly for long term continuously fed patients are we potentially  negatively impacting the biliary tree setting them up for the increased risk of cholestasis and or cholecystitis in the future?  So with all of this in the background where are we at? What does this mean? In the most recent Aspen SCCM guidelines published in 2017 they acknowledged again with a weak  quality of data that gastric is the preferred site for enteral feeds, but that there was insufficient data at that time to recommend continuous versus intermittent feeding.  About a year ago some colleagues and I undertook a systematic review of this question to see if some additional data had really come on the scene since then and what we really found  was no. There was really almost no head to head continuous versus bolus feeding, particularly those that targeted timing and delivery of targeted nutrition markers.  So in between there was an important publication by Levantoum and colleagues in international publication describing the priorities for nutrition research in pediatric critical  care and among those high priorities were examining the impact of continuous versus bolus or intermittent enteral feeding on clinical outcomes.  So I found in my hunting an abstract I could not find and was unable to really contact  the authors of an abstract comparing continuous versus bolus Q3 hour feeds in the PICU a median  age of patients of about 11.5 months and they found that bolus achieved their maximum feed by 21 hours compared to 27 hours for continuous.  They found no difference between the groups in severity of illness and the sedation, muscle relaxant and inotropic usage.  Also importantly no difference in adverse events including emesis and aspiration. So next I want to share with you that after some intriguing single center pilot data suggesting  the bolus was superior in delivery of nutrition with an equivalent safety profile, a multicenter  team undertook a trial that's currently under review and I'm going to share some preliminary data here.  So on these slides that you see with the symbol, please not screenshot, share or otherwise make public this data until hopefully we have it published soon.  So in this continuous versus bolus NG feeding in mechanically ventilated pediatric patients  affectionately known as COBO2, our primary outcome was time to goal feeds and the delivery of energy and protein between groups.  Our secondary outcomes including examining safety measures of the incidence of ventilator associated infections. Now our goal here wasn't to define the still controversial events.  So what we did was those were as defined and reported by each participating hospital's infection control department, thereby each hospital served as its own control for that event.  But we did serially measure oxygen saturation index between bolus and continuous groups every three hours.  Our target population were medical PICU patients who were intubated within 24 hours of PICU admission and EN was started within 48 hours of admission.  The protocols were very nurse driven at the bedside. Both groups started at 1 ml per kilo per hour and advanced by 1 ml per kilo per hour every three hours to goal volume.  The difference was whether that was delivered continuously or over one hour on a feeding pump.  Once they achieved goal rate or volume, then if needed caloric concentration was increased one time a day until they were at final target feeding.  The protocols also included PRN constipation meds and standardized definitions of feeding intolerance.  So what we found were no significant differences in demographics or clinical characteristics of the groups.  We did not hit our target sample size, so we were a bit underpowered, but we still had what we believe are important results.  We also of note found no difference between the groups in nutritional status on admission, primary diagnostic category, or severity of illness.  We did find when controlling for the age groups because the infant group often takes longer to get to goal, so we controlled for that because they require caloric concentration,  is the boldest group was one and a half times more likely to meet goal feed and while I didn't share the specific data here, they deliver significantly more of the target energy  in K-cows and protein than the continuous group. The oxygen saturation index did not differ in that every three hour measurement between groups.  And we had no reported VAIs in either group at any site.  So where do we go from here? I hope I've left you with a growing body of evidence that bolus is in fact not only equivalently  safe to continuous, but may in fact be a superior way to deliver enteral nutrition in the critically ill pediatric patient.  There's a lot of work yet to be done and my recommendations would be that future work in this area needs to examine the splanchnic circulation via ultrasound and perhaps NEARS  in our population and along with that it's an opportunity to examine the timing of initiation of EN in cases of septic shock and patients with vasoactive infusions for other reasons  as well. That once we have real-time reliable ways to measure lean body mass that we need to  look at the effects of bolus versus continuous on that and subsequently and related to that effects potentially on early mobility and PEDS-ICU functional outcomes both at the time  of discharge from the unit but past that as a part of our PICS-P evaluations. I think we need to take a closer look at the effects on biliary and gallbladder function  in both the short and the long term as I mentioned and also the effects on pancreatic both endocrine and exocrine function.  We know some of the exocrine functions also contribute to the digestive process and that's really not been looked at yet, but it's an intriguing question based on the gallbladder  data and also the endocrine function falling back on the multiple studies that showed less hyperinsulinemia and glucose instability with bolus feeds over time.  We have to examine the effect of bolus versus continuous on the gut, lung, and brain microbiome axis.  With that I leave you with some of the VIPs in my world and contact information and I look forward to our Q&A session coming up in February. Thank you.  Hello, everyone, and thank you for attending this talk. My name is Sharon Irving. I'm an associate professor of pediatric nursing at the University of Pennsylvania School of  Nursing in Philadelphia, Pennsylvania, and I was asked to present on the pre-illness nutrition status, a pathway to nutrition in critically ill children.  I am honored to be able to present this information at this 50th celebration of SCCM. I have no disclosures and I bring you greetings from the School of Nursing at University of  Pennsylvania and Children's Hospital of Pennsylvania. So objectives for today, we will discuss nutrition status and the impact on illness in critically  ill children, and then we'll examine some of the data regarding nutrition status in that patient population and its impact on illness outcomes. The background.  So we know that nutrition status talks and gives us information on presentation at illness, what that child looks like, the response to in the course of illness, and the timing and  such of nutrition therapy and overall outcomes of critical illness. We know this from the literature.  We know this from anecdotal experiences, and we know this from conversation with our colleagues.  In my own work in 2018, we published an article that looks at the nutrition status in relation  to a cohort of patients that's global looking at pediatric sepsis, and we found that severe nutrition was associated with all cause ICU mortality.  But the reality is, what is nutrition status? How do we define it and how do we understand it?  So nutrition status in and of itself, I don't think you can put a finger on exactly a singular  definition of this, but it's used to describe nutrient intake to support the body's overall daily metabolic demands, that intake and utilization of such must be balanced.  It has to be void of any insufficiencies or excesses. In ideal conditions of nutrition status, it favors cell and tissue turnover.  Optimal status is fundamental for typical childhood growth and development. And how do we measure nutrition status?  We measure it in comparison to population standards for age and sex. And so again, no singular definitive definition, but at the same time, all of these things  together give us an idea of what nutrition status should look like for our patients. And so how do we measure it?  We look at anthropometrics initially, and that's used pretty globally as a measure of nutrition status.  We determine that, as I just mentioned, in terms of population standards using Z-scores and percentiles.  And oftentimes from a clinical standard, we also put in there some serum biochemical markers.  Consistency, accuracy, and frequency of these measurements is not universal. So therein lies a challenge for this to be a consistent way to look at nutrition status.  How do we determine if there's malnutrition and what those patients need? We use equations, we use estimation, and sometimes we will use indirect calorimetry.  But because this is not standardized, it creates challenges in how we define nutrition status.  And then when we talk about those serum biomarkers, they are influenced by inflammation and fluid balance.  So again, a challenge in getting a definitive definition of nutrition status and what that looks like.  So I use this chart to do some comparisons, because some places will use more of a percentile or Z-score, whereas they are aligned, and you can use either one, but when you look  at this and you look at where's the norm, it's right there in the middle. So when we are talking about the general population, we want them to be in this third to 97th percentile.  And as you can see, that puts them in the minus two to two Z-score for their age and sex and weight.  And within those parameters, we're looking at normal weight, normal height, normal weight for length.  It's when you get on either side of this very wide parameter that you begin to worry about, do I have a child whose nutrition status can impact what their overall illness can look  like and how we treat them? So there are risks. If you fall into any of those parameters that I just showed you on that chart that look  at over or under outside of the typically growing child, you are at risk for poor nutrition status at hospital admission, and that leads itself to risk during hospitalization.  And I want to be clear that I talk about nutrition status, both in malnutrition, which most of  us think of as the undernourished child and the really small child, but malnutrition is also present in obesity.  And if either of those presented at present or present in the child's initial presentation to us, they are at risk for increased hospital acquired infection, for decreased number of  ventilator free days, for increased PICU length of stay and for hospital length of stay. And what does that lead us to? They can have new morbidities.  They have an increased risk of mortality and they have decreased deterioration of their nutrition status when they are in our care.  And I will talk about that a little bit longer, a little bit later, excuse me. And then we also worry that they will have decreased overall function post their ICU  stay and or hospitalization. All of it relating back to poor nutrition status at hospital admission puts our patients  at risk for any of these kind of sequelae that can occur due to their course of illness. So let's dive into the literature a little bit.  In 2016, there was a systematic review that was done by a group out of Brazil, Costa and  colleagues, and they looked through the literature and wanted to see what are the outcome measures that relate to nutrition status.  They looked at hospital length of stay, duration of mechanical ventilation and mortality. Their study included patients that were less than 18 years of age.  They were all PICU patients and they had at least all of the studies had to have at least one of these outcomes identified that they measured. And so what did they find?  Out of initially 96 studies, they were able to narrow it down to seven studies. Only seven studies met their criteria.  And that was over the timeframe from 20, I'm sorry, from 1982 through 2012. Each of these studies had different types of assessment that they used, and it was based  on either the clinical condition, the body composition differences, or what was interesting to me is that one of the things that they found a difference across the studies is an  awareness of an importance of the measurements by the staff. What they also looked at and was able to find that there were unestablished practices for fat and muscle measurements.  Some studies measured these parameters and others did not. And of the studies that measured the organic parameters, there was always alterations. So overall, what did they find?  There was no homeogeneity in the methods or parameters used to assess nutritional status.  So that brings us back to one of the problems that using nutritional status presents for us. We don't have a homogeneic way that we look at this.  Again, in the literature, looking at Lori Pichard and the group up at Boston Children's, they looked at 90 PICUs in 16 countries using an age range of one month to 18 years.  That resulted in over 1600 subjects who were measured weights. They had 91% of those at admission were only 72% where their weights were measured.  In their study, they found 18% were underweight, 15% were of normal weight, 15% overweight, and 13% obese.  Again, back to the chart that I utilized to show you that we have a range, but when you fall on either sides of those ranges, you may run into trouble.  Their findings, they had children that had hospital acquired infections up to 15%. And then they also were able to demonstrate that of those children, those that were underweight  and obese had increased risk of hospital acquired infection. Their underweight children, they had about 40%, overweight were about 19%, but the underweight  children had a 1.53 times increased risk of mortality in their study. And so what this is pointing out over here is if you're underweight, mortality was higher.  If you're underweight or overweight, you have an increased risk of infection, all clinically and statistically significant.  Another study, GRIPA done in 2016, again, a Brazilian study looked at duration of mechanical ventilation for these children based on nutritional status.  There was 72 children in their study and their age range was from four to 82 months. They measured weight if the child was less than 36 months of age, and they use medical  records for everyone else. They measured height or length for those children or a knee height who were less than six years of age. They calculated Z-scores on all of their children.  And they also looked at biochemical assessments of albumin and prealbumin. What were their findings? Malnutrition at PICU admission.  In the weight for age, they had 34%, height for age had 41%. They also found that the albumin and prealbumin were less than normal range, but were not  associated with an increased risk or an increased duration of mechanical ventilation. So when you look at the Kaplan-Meier curves from that study over here, where we're looking  at weight for age, it's associated with a duration of increased duration of mechanical ventilation that you see down here. The same thing with height for age.  But remember that height is more of a chronic malnutrition, a chronic issue where we now have stunting.  So in their study, if you had both weight for age Z-scores that were low, height for age Z-scores that were low, you had an increased prevalence of being mechanically ventilated  for a longer period of time. So in conclusion, their malnourished patients required that longer duration of mechanical ventilation.  They found no association between biochemical biomarkers and that duration of mechanical ventilation.  So again, inconsistency in how we utilize nutrition status and what it helps us to do with our patients.  Finally, back to Vala, who, that I mentioned earlier, an interesting study looking at deterioration of nutrition status that occurs during the child's ICU stay.  So in our care, no matter how they come to us, when they're in our care, how are we taking care of them and what are we able to determine about their nutrition status?  So they looked at children zero to 18 years of age who had a length of stay of at least five days. Their total number was about 579.  Their outcome for their study was to describe faltering growth during their PICU admission. They looked at weight, length or height that was measured at admission, and then they did  ongoing daily weights in their patients. They calculated Z-scores and they calculated using WHO standards.  Their outcome, as I said, was faltering weight, and they defined that as a Z-score decrease. Here's their results.  During PICU admission, they found a 10% decline in that BMI Z-score greater than one standard deviation. Okay.  28% had a decline of less than a half standard deviation, and 27% of the children in their study that were under two years of age had a wait for age Z-score decline of greater  than a half. In our care, our therapies, our treatments, our provision of nutritional therapy is causing a decline of the nutritional status of these children.  So what does that mean for us and what's our pathway forward? The current evidence tells us that malnutrition at illness presentation increases the risk  of suboptimal clinical outcomes in terms of hospital acquired infections, duration of mechanical ventilation, increased PICU or hospital length of stay, loss of muscle mass,  or that deterioration of their status. And that chemical biomarkers are more indicative of inflammation than they are of nutritional status.  And we should not use them as reliable markers, those chemical biomarkers being the common ones that people talk about of albumin and prealbumin. So what do we need to do?  We have to begin to direct our care and our research and our quality improvement to a standardization of appropriate assessment methodologies.  We need to work with our colleagues, both in neighboring ICUs and across the globe to create that standardization.  We need to use less reliance on current chemical biomarkers, because I hope I've been able to show you that in some of the studies that we're able to look at, it didn't help us.  We need to minimize that nutrition status deterioration that's happening when these children are in our care.  And then we need to develop a consistent approach to the provision of nutritional therapy for these children so that we can minimize this deterioration.  Again, going back to what do we need to think about and how do we need to think about these children?  So if these are our typically growing children in here, and these are the extreme ends, both  on the low end of overweight and then obese, we need to recognize that while these children that I've identified with the circles here are at higher risk, these children are at  risk as well. And at the very least, these children are at risk for a deterioration of their nutrition status while in our care.  So our forward pathway is to standardize how we continually measure this, how we feed them, and how we monitor what we're doing with these children.  With that, I thank you for your time and your attention, and I open it up to questions. And here are some abbreviated references for you. Thank you very much.

Video Summary

The speakers discussed the importance of nutrition in pediatric critical illness and the impact of early initiation of enteral nutrition (EN). Dr. Vijay Srinivasan highlighted the benefits of early EN, including improved feeding tolerance, immune function, and organ function. He presented evidence from studies showing that early EN is associated with lower mortality and better outcomes in critically ill children. He also discussed the optimal timing for initiation of EN, which is within 24 to 48 hours of admission. Dr. Anne-Marie Brown spoke about the comparison between bolus and continuous gastric feeding in pediatric critical care. She presented evidence suggesting that bolus feeding is more physiologic and may have advantages over continuous feeding, such as improved gastric motility and decreased interruptions in feeding. She also discussed the potential impact of bolus feeding on gallbladder function and protein anabolic action. Dr. Sharon Irving focused on nutrition status in critically ill children and its impact on illness outcomes. She emphasized the importance of measuring nutrition status using anthropometrics and serum biomarkers. She highlighted the risks associated with malnutrition, including increased hospital-acquired infections, longer duration of mechanical ventilation, and higher mortality rates. She also discussed the challenges in determining nutrition status and the need for standardized assessment methodologies. Overall, the speakers highlighted the importance of early initiation of EN, the potential benefits of bolus feeding, and the impact of nutrition status on outcomes in critically ill children.

Asset Subtitle

Pediatrics, GI and Nutrition, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives Discuss the impact of pre-illness nutrition status on outcomes of pediatric sepsis Examine the evidence for pre-nutrition assessment and clinical pathway guidelines to optimize nutrition support in critically ill children Discuss the impact of timing and intensity of nutrition therapy on outcomes in critically ill children Review gastric physiology and evidence for bolus and continuous feeding in critically ill children

In Gut We Trust: Feed Early and Feed Well Vijay Srinivasan

Feeding the Stomach in Critically Ill Children: Is Bolus Better Than Continuous? Ann-Marie Brown

Pre-Illness Nutrition Status and a Pathway to Nutrition in Critically Ill Children Sharon Y. Irving

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area GI and Nutrition

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Enteral Nutrition

Year 2021

Keywords

nutrition

pediatric critical illness

enteral nutrition

early initiation

feeding tolerance

immune function

organ function

bolus feeding

nutrition status

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