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Abstract

Introduction: Despite evidence that delivery of more than 2/3 energy goal via the enteral route is associated with lower risk of mortality¹, energy delivery is often suboptimal in mechanically ventilated children. We aimed to describe nutrition practices and explore elements associated with improved EN delivery in this cohort. ¹Mehta NM et al, 2012 Methods: Daily nutritional practices in 524 mechanically ventilated patients, 1 month-18 years old, from 31 international PICUs were prospectively documented by dedicated dieticians. Details of energy prescription methods, stress factor application, timing and mode of energy delivery, and the use of EN adjuncts were collected. Practices associated with increased energy delivery (EN adequacy) by day 3 and 7 in the PICU were evaluated by univariate analysis. Agreement between commonly used equations to estimate energy requirements (EER) was assessed using Bland-Altman analysis. Results: 341/524 subjects received EN alone, initiated on average 1.6 days (range 1-11 days) post-admission. 12.9% and 32.9% of patients received more than 2/3 of prescribed energy goal by day 3 and 7 respectively. Delay in EN initiation (day 3, -16.66, p<0.001; day 7, -8.92, p <0.001) and duration of EN interruption (day 3, -0.82, p 0.02; day 7, -1.65, p 0.001) were inversely associated with EN adequacy on day 3 and 7 of PICU stay. Antacids, pro-motility agents, or post-pyloric feeding were used in most patients, but were not associated with increased EN delivery. Energy expenditure was determined in 99% of patients by either one of 10 different equations or regional energy intake standards, and indirect calorimetry (IC) was used in 1%. Of the equations used to estimate energy expenditure the WHO and Schofield equations were the most commonly used. Agreement between calculated EER by the WHO and Schofield equations showed a mean percentage bias of 2.0, and 95% CI of -47 to +52%. Stress factors were applied to EER in 39.7% of patients, at an average of 1.2 (range 0.1- 1.7). Conclusions: Energy delivery goals were not met by day 7 in a majority of mechanically ventilated children. Reliance on a variety of equations for EER, the use of stress factor, and absence of IC, may result in inaccurate energy prescription. Delayed initiation and subsequent interruptions to EN were associated with failure to reach EN goals. EN adjuncts were not associated with improved EN delivery. Accurate assessment of energy needs, early initiation and maintenance of EN and further research on effective EN adjuncts, may help optimize EN delivery in critically ill children.