Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a “motor” of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
Highlights
There are direct nutritive and non-nutritive benefits of feeding patients with pediatric acute respiratory distress syndrome
The generally accepted strategy centers on the early identification of need for nutritional supplementation and early initiation of enteral nutrition (EN) targeted toward fulfillment of nutritional goals and implemented by a collaborative, multidisciplinary treatment team
Before we evaluate the role of immunonutrition to improve outcomes of pediatric acute respiratory distress syndrome (pARDS), fundamental questions regarding protein and energy requirements during pARDS remain: if delivery should be based on premorbid nutritional risk and if under, normo, or even overfeeding might be beneficial at different stages of illness
Summary
There are direct nutritive and non-nutritive benefits of feeding patients with pediatric acute respiratory distress syndrome (pARDS). Multiple retrospective studies demonstrate mortality benefit with improved adequacy of energy and protein provided during pediatric critical illness (Table 1) [2, 3, 36].
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