1034

Abstract

Introduction: Optimal nutrient delivery and the use of uniform feeding protocols have been associated with improved clinical outcomes in pediatric critical illness. We aimed to examine the prevalence of nutrition guidelines and protocols in PICUs across the world and identify variability in key practice parameters. Hypothesis: We hypothesized that feeding protocols are not routinely employed and consist of recommendations that are variable among institutions. Methods: Centers participating in a prospective nutritional study were asked to provide details of the nutrition support guidelines currently implemented in their PICU. Specific recommendations regarding feeding route, rate of advancement, contraindications, definition and management of intolerance and goals for enteral nutrition (EN) were compared between centers. Results: Of the 30 PICUs from academic centers in the international study, 9 (30%) from 3 countries reported using a nutrition guideline. EN was preferred in all the centers and recommended early in a majority of the centers, but contraindicated with ionotrope use or abdominal pathology. Uniform nutritional screening and measurement of energy expenditure were not specified in most guidelines. EN goals were volume-based and stepwise rates for advancement of EN were variable. Criteria for EN intolerance included: increased gastric residual volume (GRV) (7/9), abdominal distension (5/9), vomiting (5/9), and diarrhea (4/9). GRV threshold for stopping EN ranged from 2 to 5mL/kg or 2 to 4 hours of feed volume. A majority of the protocols defined a plan to address EN intolerance, which included reducing feed volume, post-pyloric feeding and use of prokinetics. Conclusions: Uniform nutrition guidelines were used in less than a third of all participating PICUs. A majority of the guidelines prioritize EN, soon after admission, with stepwise advancement to a specified volume goal and a plan to address intolerance. The definitions of EN intolerance are variable. Despite a lack of evidence, centers use variable GRV thresholds for stopping EN, and the indications for post-pyloric feeds and prokinetics are heterogeneous. Nutritional investigations to guide uniform evidence-based best practices in the PICU are urgently needed.