ICAN: Infant, Child, & Adolescent Nutrition

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Nutrition Management of the Critically Ill Pediatric Patient : Minimizing Barriers to Optimal Nutrition Support Ana Abad-Jorge ICAN: Infant, Child, & Adolescent Nutrition 2013 5: 221 DOI: 10.1177/1941406413492821 The online version of this article can be found at: http://can.sagepub.com/content/5/4/221

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vol. 5 • no. 4

ICAN: Infant, Child, & Adolescent Nutrition

Evidence-Based Practice Reports

Nutrition Management of the Critically Ill Pediatric Patient Minimizing Barriers to Optimal Nutrition Support Ana Abad-Jorge, EdD, MS, RDN, CNSC

Abstract: Provision of optimal nutritional support to children in the pediatric intensive care unit (PICU) is important for optimizing nutritional management, yet challenging because of a variety of factors. Previous nutritional status, degree of malnutrition, and variability in disease states differ significantly among PICU patients. Although there are numerous benefits for enteral nutrition (EN) in critically ill children, obstacles exist within the PICU that prevent the initiation and delivery of appropriate EN and parenteral nutritional (PN) support. Evidence-based nutrition care guidelines have been established to promote optimal nutrition support practice in PICU patients, including identification of those at greatest nutritional risk, initiating EN or PN in a timely manner, and providing EN as the preferred nutrition support modality for children with a functioning gastrointestinal tract. Strategies can be implemented to minimize avoidable delays or interruptions to the optimal delivery of PN and EN, including establishing nutrition support guidelines to promote consistency in practice, promoting clear and consistent communication among the PICU team via direct communication,

unit rounds, and the medical record. The education of frontline PICU staff by trained professionals such as pediatric registered dietitians board certified in pediatric nutrition or nutrition support practice can also help promote improved nutritional support practice and outcomes. Specific strategies to optimize nutritional support and EN initiation and delivery at the author’s institution are also presented.

function of the cardiovascular, respiratory, and immune systems until the acute phase inflammatory response resolves.1-3 The American Society for Parenteral and Enteral Nutrition (ASPEN) has established evidence-based clinical guidelines for nutrition in the critically ill pediatric patient.3 However, obstacles often exist, which prevent timely and effective advancement of both parenteral nutrition (PN) and enteral nutrition (EN) support in these critically ill

“The provision of optimal nutrition support to critically ill infants and children is essential for effective overall care, management, and outcomes.” Keywords: pediatric nutrition support; pediatric critical care; PICU patient; enteral nutrition; parenteral nutrition

Introduction The provision of optimal nutrition support to critically ill infants and children is essential for effective overall care, management, and outcomes. Furthermore, optimal nutritional delivery sustains

children. Recent studies suggest, however, that some of these barriers may be avoidable. Often, opportunities for initiation and advancement of nutrition support in critically ill children are missed because of lack of standardization or institutional guidelines, the lack of adherence to established guidelines, and inconsistent practice among clinicians.4,5 The prevalence of malnutrition has remained consistent within the pediatric intensive care unit (PICU) over the past

DOI: 10.1177/1941406413492821. From Department of Nutrition Services, University of Virginia Health System, Charlottesville, Virginia. Address correspondence to Ana Abad-Jorge, EdD, MS, RD, CNSC, Director, Nutrition and Dietetic Internship Program, PICU Nutrition Support Specialist, Department of Nutrition Services, University of Virginia Health System, Park Place and Lane Road, Bos 800673, Charlottesville, VA 22908; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)

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August 2013


Table 1. Common Diagnoses or Conditions Increasing Nutritional Risk in PICU Patients.1-3 • Cardiorespiratory illness  Congenital heart disease  Chronic lung disease or bronchopulmonary dysplasia  Cystic fibrosis with acute respiratory failure and infection • Trauma  Traumatic brain injury  Spinal cord injury  Burn injury—particularly in children with >20% body surface area burn • Respiratory failure or infection  Acute respiratory distress syndrome (ARDS) secondary to acute respiratory infection or sepsis  Children requiring extracorporeal membrane oxygenation (ECMO)  Hemodynamic instability—increased use of inotropic medications • Gastrointestinal disease and dysfunction  Short bowel syndrome with infectious complications  Biliary atresia  Necrotizing enterocolitis • Pediatric oncology with multiple gastrointestinal and infections complications • Diabetes mellitus—new onset • Neurologic or neuromuscular disease  Cerebral palsy with history of gastric tube feedings  Myelomeningocele with complications  Spinal muscular atrophy  Genetic syndromes requiring long-term nutritional support, that is, trisomy-18, cri-du-chat syndrome

30 years, with some studies indicating that up to 65% of patients are malnourished on PICU admission.3 Despite multiple advancements in both enteral formulations and medical technology, achieving nutrition support goals in previously malnourished pediatric patients still remains a major challenge within the PICU. On admission to the PICU, infants and children often have preexisting malnutrition and premorbid nutrition related conditions, which put them at increased nutritional risk. An overview of common disease conditions seen within the PICU that indicate increased nutritional risk are presented in Table 1. Additionally, further deterioration of nutrition status commonly occurs during the hospitalization because of the metabolic response to inflammation, injury, stress, or surgery. These conditions often prevent the

accurate calculation of energy expenditure using predicted energy equations3,4 putting critically ill children at risk for energy imbalances associated with both overfeeding and underfeeding. Barriers and challenges occur within the PICU that prevent optimal initiation and advancement of both PN and EN, thus preventing pediatric patients from reaching their nutritional goals. While some of these barriers are unavoidable due to the patient’s underlying clinical condition and status, other delays and barriers to the initiation of nutrition support are avoidable.3,5,6 When critically ill children have persistent or unavoidable EN interruptions, including gastrointestinal (GI) intolerances, PN may be used to achieve nutrition goals.5 However, PN initiation is often delayed as well because of fluid restriction and the use of multiple intravenous medications, which may account

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for most of the fluid volume delivered. Additional common reasons for not meeting optimal nutritional goals include interruptions for procedures and the concern for possible GI intolerance due to unstable cardiorespiratory status.2,4 Benefits of Enteral Nutrition and Current ASPEN Practice Guidelines Enteral nutrition provides a number of benefits to the critically ill pediatric patient. In general, EN is more physiological than PN, maintains the physiologic and functional integrity of the GI mucosa by nourishing the gut first, and thus prevents or decreases the risk for bacterial translocation.7 EN is also more cost-effective than PN and within adult patients it is associated with both decreased risk of infectious complications and length of stay, as compared with patients nutritionally supported with PN.7,8 The management of fluid and electrolyte balance is often easier when using EN; furthermore, EN may promote anti-inflammatory effects by decreasing cytokine production such as tumor necrosis factor and interleukin-6.9 Given the proven benefits of EN in adult critically ill patients, most PICUs have established institutional guidelines for the preferential use of EN over PN for nutrition support despite the fact that the benefits of EN in pediatric patients has not been established with prospective controlled randomized trials. The current evidence-based ASPEN nutrition support guidelines3 for critically ill pediatric patients include the following: (a) nutrition screening of admitted PICU patients to identify those with existing malnutrition, (b) nutritional assessment with development of a nutrition care plan for those children with premorbid conditions, (c) use of EN for critically ill children with a functioning GI tract, and (d) identification and prevention of avoidable interruptions to EN. However, the highest grading of the evidence for these guidelines is a grade C, which means that the evidence supporting the guideline is based on small, randomized trials with uncertain results. There is a

vol. 5 • no. 4


Table 2. Waterlow Criteria to Assess Malnutrition Status in Pediatric Patients 1-3 Years of Age.10 Acute (Weight/50% Weight for Height)

Chronic (Height/50% Height for Age)

>0.90

>0.95

Stage 1 (mild malnutrition)

0.80-0.90

0.90-0.95

Stage 2 (moderate malnutrition)

0.70-0.79

0.85-0.89