Optimal Enteral Nutrition Research Articles

Biomarkers and Functional Assays of Epithelial Barrier Disruption and Gastrointestinal Dysmotility in Critical Illness-A Narrative Review.

Enteral nutrition in critically ill children has been associated with improved clinical outcomes. Gastrointestinal dysfunction often impedes the timely initiation and advancement of enteral nutrition and can contribute to immune dysregulation and systemic inflammation. Therefore, assessing gastrointestinal function, at a cellular and functional level, is important to provide optimal enteral nutrition therapy and reduce the gastrointestinal tract's contribution to the inflammatory cascade of critical illness. In this narrative review, we present an overview of biomarker and functional assays for gastrointestinal dysfunction, including epithelial barrier disruption and gastrointestinal dysmotility, that have been considered for critically ill patients.

Optimal Enteral Nutrition Support Preserved Muscle Mass in Critically Ill Children.

Background Inflammation and immobility are the most relevant mechanisms that alter protein synthesis and increase protein breakdown. Protein catabolism is associated with morbidity and mortality in critically ill children. Objective To demonstrate the effectiveness of the routinely used enteral nutrition support guideline in preventing muscle breakdown in critically ill children. Methods A prospective cohort study was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital. Critically ill children (aged 1 month to 15 years) admitted to the PICU were enrolled. All patients were assessed for nutritional status and nutritional requirement. Enteral nutrition support following the guideline was initiated within the first 24 hours if no contraindication. The calorie target was defined either by direct measurement from indirect calorimetry or estimated from Schofield equation with protein target at least 1.5 g/kg/day. Anthropometric assessments and body composition measurements by bioelectrical impedance analysis (BIA) were examined at baseline and on the seventh day of the PICU admission. Results Sixty-three patients were enrolled in the study. The most common age group was 1–5 years old (38.1%). The length of PICU stay was 9.1 (SD = 12.7) days. Respiratory problems were the major cause of PICU admission (50.8%). Mechanical ventilation was required in 55.6% of the patients with the average duration of 6.3 (SD = 12.4) days. Undernutrition was found in 36.5% of the patients. Enteral feeding was the major route of nutrition support (95.2%). After the first week of admission, muscle mass was significantly preserved (p < 0.01). All patients received the nutrition support at their target energy and protein goal within the first week. The enteral feeding-related complication was reported in 1.6% of the patients. Conclusion Protein catabolism during critically ill period can be minimized by optimal nutrition support. Nutrition practice using the enteral nutrition support guideline was effective in helping critically ill children reach their target caloric and protein intake.

Taurine in Septic Critically Ill Patients: Plasma versus Blood.

Purpose: Sepsis and systemic inflammatory response syndrome (SIRS) encompass various problems throughout the body, and two of its major problems are the creation of oxidative substances in the body and decrease of the body's antioxidant capacity to deal with the stress and organ damage. Optimal enteral nutrition fortified with antioxidant or immunomodulator amino acid is a hot topic concerning sepsis in the critical care setting. Taurine plays a protective role as an antioxidant in cells that is likely to have a protective role in inflammation and cytotoxicity. Methods: In the present study, 20 septic patients and 20 healthy volunteers were enrolled. The blood and plasma taurine levels of the patients on days 1, 3 and 7 were measured. Blood and plasma taurine level and the correlation between them, organ failure, and severity of the disease were assessed. Results: Taurine concentrations in the plasma of the septic patients were significantly lower than control group, and the whole blood concentrations were significantly higher than those of the control group (P<0.001). There was not a significant correlation between the blood and plasma taurine levels in control and septic patients. In addition, there was not any correlation between the severity of the disease, organ failure, mortality, and plasma as well as the blood concentration of taurine. Conclusion: In septic patients, taurine concentration in plasma and blood are low and high, respectively. These concentrations are not linked to each other and not associated with the patients' outcome, and the disease severity, and organ failure.

Are Nutritional Guidelines Followed in the Pediatric Intensive Care Unit?

Background: French (2014) and American (2017) pediatric guidelines recommend starting enteral nutrition (EN) early in pediatric intensive care. The aims of this study were to compare the applicability of the guidelines in the pediatric intensive care unit (PICU) and to identify risk factors of non-application of the guidelines.Methods: This retrospective, single-center study was conducted in a medical–surgical PICU between 2014 and 2016. All patients from 1 month to 18 years old with a length of stay >48 h and an exclusive EN at least 1 day during the PICU stay were included. The outcome variable was application of the 2014 and 2017 guidelines, defined by energy intakes ≥90% of the recommended intake at least 1 day as defined by both guidelines. The risk factors of non-application were studied comparing “optimal EN” vs. “non-optimal EN” groups for both guidelines.Results: In total, 416 children were included (mortality rate, 8%). Malnutrition occurred in 36% of cases. The mean energy intake was 34 ± 30.3 kcal kg−1 day−1. The 2014 and 2017 guidelines were applied in 183 (44%) and 296 (71%) patients, respectively (p < 0.05). Following the 2017 guidelines, enteral energy intakes were considered as “satisfactory enteral intake” for 335 patients (81%). Hemodynamic failure was a risk factor of the non-application of both guidelines.Conclusion: In our PICU, the received energy intake approached the level of intake recommended by the American 2017 guidelines, which used the predictive Schofield equations and seem more useful and applicable than the higher recommendations of the 2014 guidelines. Multicenter studies to validate the pediatric guidelines seem necessary.

NEED FOR FEEDS: EARLY ENTERAL FEEDING IN MECHANICALLY VENTILATED, CRITICALLY ILL PATIENTS

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Current guidelines recommend early enteral nutrition during critical illness within 24 to 48 hours of admission. The purpose of our study was to investigate the percent of patients admitted to our medical ICU (MICU) who received enteral nutrition within 48 hours of mechanical ventilation and to investigate barriers to administering optimal enteral nutrition. METHODS: We conducted a single-center, retrospective chart review of patients over the age of 18 who were admitted to the MICU in our academic community hospital in New York, NY and mechanically ventilated between July 1, 2019 and November 30, 2019. Patients who had nasogastric or percutaneous endoscopic gastrostomy feeding tubes placed prior to intubation, patients with tracheostomies, and those intubated for fewer than 48 hours were excluded. Contraindications to tube feeds were based on the ESICM 2017 clinical practice guidelines. An anonymous, electronic survey of internal medicine resident physicians was conducted to assess perception and knowledge of enteral feeding. RESULTS: Of 128 patients, 63 were excluded, the majority excluded due to length of intubation less than 48 hours. The average age of the included 65 patients was 68 years, 55% (36/65) male and 45% (29/65) female. The three most common admitting diagnoses were sepsis or septic shock 26% (17/65), respiratory failure 25% (16/65), and EtOH withdrawal 8% (5/65), Three patients had contraindications to tube feeds. Of the 62 included patients without contraindications to tube feeds, 85% (53/62) were started on tube feeds at any time and 61% (38/62) were started on tube feeds within 48 hours, and 15% (9/62) were not. Thirty of about ninety residents responded to the survey, of whom 77% (23/30) were “somewhat confident” starting tube feeds and only 13% (4/30) felt “confident in all aspects.” The reasons for not beginning enteral nutrition were lack of knowledge about correct formula 48% (14/30), timing of nutrition 45% (13/30), which patients require enteral nutrition 38% (11/30), and placing a nasogastric or orogastric tube 7% (2/30). CONCLUSIONS: Sixty-one percent of mechanically ventilated patients in our MICU were started on enteral feeds within 48 hours of intubation. Survey results from resident physicians suggest lack of knowledge and confidence as barriers to beginning enteral nutrition. Our survey was limited in sample size and in low survey response rate. CLINICAL IMPLICATIONS: This study demonstrates that many mechanically ventilated patients receive suboptimal enteral nutrition. In contrast to current literature, our study was limited to mechanically ventilated patients. Practitioner education and implementation of MICU nutrition protocol on admission would allow for improved guideline adherence and increase rates of enteral feeding. DISCLOSURES: No relevant relationships by Zein Kattih, source=Web Response no disclosure on file for linda kirschenbaum; No relevant relationships by Rebecca Mazurkiewicz, source=Web Response No relevant relationships by Rebecca Zweifler, source=Web Response

Achieving enteral nutrition during the acute phase in critically ill children: Associations with patient characteristics and clinical outcome

In the absence of methodologically sound randomized controlled trials (RCTs), current recommendations for timing and amount of enteral nutrition (EN) in critically ill children are based on observational studies. These studies have associated achievement of a higher EN intake in critically ill children with improved outcome. Inherent to the observational design of these underlying studies, thorough insight in possible confounding factors to correct for is essential. We evaluated the associations between EN intake and 1) patient and daily clinical characteristics and 2) clinical outcomes adjusted for these patient and clinical characteristics during the first week of critical illness with a multivariable mixed model. This secondary analysis of the multicentre PEPaNIC RCT investigated a subgroup of critically ill children with daily prospectively recorded gastrointestinal symptoms and EN intake during the first week with multivariable analyses using two-part mixed effect models, including multiple testing corrections using Holm's method. These models combined a mixed-effects logistic regression for the dichotomous outcome EN versus no EN, and a linear mixed-effects model for the patients who received any EN intake. EN intake per patient was expressed as mean daily EN as % of predicted resting energy expenditure (% of EN/REE). Model 1 included 40 fixed effect baseline patient characteristics, and daily parameters of illness severity, feeding, medication and gastrointestinal symptoms. Model 2 included these patient and daily variables as well as clinical outcomes. Complete data were available for 690 children. EN was provided in 503 (73%) patients with a start after a median of 2 (IQR 2-3) days and a median % of EN/REE of 38.8 (IQR 14.1-79.5) over the first week. Multivariable mixed model analyses including all patients showed that admission after gastrointestinal surgery (-49%EN/REE; p=0.002), gastric feeding (-31% EN/REE; p<0.001), treatment with inotropic agents (-22%EN/REE; p=0.026) and large gastric residual volume (-64%EN/REE; p<0.001) were independently associated with a low mean EN intake. In univariable analysis, low mean EN intake was associated with new acquired infections, hypoglycaemia, duration of PICU and hospital stay and duration of mechanical ventilation. However, after adjustment for confounders, these associations were no longer present, except for low EN and hypoglycaemia (-39%EN/REE; p=0.018). Several patient and clinical characteristics during the first week of critical illness were associated with EN intake. No independent associations were found between EN intake and clinical outcomes such as mortality, new acquired infection and duration of stay. These data emphasize the necessity of adequate multivariable adjustment in nutritional support research and the need for future RCTs investigating optimal EN intake.

Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study.

To investigate the barriers in administering enteral feeding to critically ill patients from the nursing perspective. Our objectives are to provide tailored interventions for addressing identified barriers and propose an optimal enteral nutrition (EN) practice in intensive care unit (ICU). Despite the availability of numerous verified clinical practice guidelines focusing on enteral feeding of critically ill patients, a wide gap remains between the guideline recommendations and actual nutrition performances. Underfeeding is also a global problem. Therefore, to further understand the reasons of the systemic iatrogenic underfeeding in ICUs, several potential issues are investigated. This research is a cross-sectional descriptive study. A total of 808 nurses were recruited from 10 comprehensive hospitals from different districts in China. The nursing staff demographic, the unit's EN management information and the Chinese version of barriers to enteral feeding critically ill patients questionnaire were the parameters used to collect data via WeChat app. Moreover, the collected data were analysed by descriptive and correlative statistical analysis methods. Results obtained by multiple linear regression showed that frequency of EN-related training, full-time ICU nutritionist, hospital level, specific protocols for enteral feeding and position were significantly influencing the enteral feeding of ICU patients. Enteral feeding barriers of ICU patients are at a moderate level and are influenced by multiple aspects. Hence, hospital departments should strengthen standardisation and systematic EN training, provide ICU full-time nutritionists and distribute medical resources and personnel rationally. Moreover, construction of a localised feeding process and exerting subjective initiative of clinical nurses from an evidence-based guideline are important. Multifaceted tailored interventions should be implemented to address these barriers. The findings of this study can be used to inform future intervention and guidelines aimed at addressing these barriers systematically and improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.

Providing optimal enteral nutrition support in the community.

Providing optimal enteral nutrition support in the community.

Individualizing endpoints in randomized clinical trials to better inform individual patient care: the TARGET proposal.

In practice, critical care practitioners individualize treatments and goals of care for each patient in light of that patient’s acute and chronic pathophysiology, as well as their beliefs and values. Yet critical care researchers routinely measure one endpoint for all patients during randomized clinical trials (RCTs), eschewing any such individualization. More recent methodology work has explored the possibility that enrollment criteria in RCTs can be individualized, as can data analysis plans. Here we propose that the specific endpoints of a RCT can be individualized—that is, different patients within a single RCT might have different secondary endpoints measured. If done rigorously and objectively, based on pre-randomization data, such individualization of endpoints may improve the bedside usefulness of information obtained during a RCT, while perhaps also improving the power and efficiency of any RCT. We discuss the theoretical underpinnings of this proposal in light of related innovations in RCT design such as sliding dichotomies. We discuss what a full elaboration of such individualization would require, and outline a pragmatic initial step towards the use of “individualized secondary endpoints” in a large RCT evaluating optimal enteral nutrition targets in the critically ill.

Enteral Glutamine Administration in Critically Ill Nonseptic Patients Does Not Trigger Arginine Synthesis.

Glutamine supplementation in specific groups of critically ill patients results in favourable clinical outcome. Enhancement of citrulline and arginine synthesis by glutamine could serve as a potential mechanism. However, while receiving optimal enteral nutrition, uptake and enteral metabolism of glutamine in critically ill patients remain unknown. Therefore we investigated the effect of a therapeutically relevant dose of L-glutamine on synthesis of L-citrulline and subsequent L-arginine in this group. Ten versus ten critically ill patients receiving full enteral nutrition, or isocaloric isonitrogenous enteral nutrition including 0.5 g/kg L-alanyl-L-glutamine, were studied using stable isotopes. A cross-over design using intravenous and enteral tracers enabled splanchnic extraction (SE) calculations. Endogenous rate of appearance and SE of glutamine citrulline and arginine was not different (SE controls versus alanyl-glutamine: glutamine 48 and 48%, citrulline 33 versus 45%, and arginine 45 versus 42%). Turnover from glutamine to citrulline and arginine was not higher in glutamine-administered patients. In critically ill nonseptic patients receiving adequate nutrition and a relevant dose of glutamine there was no extra citrulline or arginine synthesis and glutamine SE was not increased. This suggests that for arginine synthesis enhancement there is no need for an additional dose of glutamine when this population is adequately fed. This trial is registered with NTR2285.

The impact of implementation of an enteral feeding protocol on the improvement of enteral nutrition in critically ill adults.

The optimal delivery of enteral nutrition (EN) may improve clinical outcomes in critically ill patients; thus, optimal EN protocols should be developed. The purpose of this study was to evaluate the impact of implementing an EN protocol on the improvement of EN practices and on the clinical outcomes of critically ill patients. This was a retrospective study with prospectively collected data. Multidisciplinary working group developed an evidence-based EN protocol based on an extensive review of literature and existing guidelines. Subjects included patients consecutively admitted to the ICU who received EN for more than 24 hours. EN practices and clinical outcomes were compared before and after implementation of the protocol. A total of 270 patients were included, 134 patients before implementation and 136 after implementation of the protocol. EN was initiated earlier (35.8 vs 87.1 hours, p=0.001) and more patients received EN within 24 hours (59.6% vs 41.0%, p=0.002) after implementation of the protocol. The interval between starting EN and reaching the caloric goal was not different, but more patients reached the caloric goal after implementation (52.2% vs 38.3%, p=0.037). The post-implementation group was given more prokinetics and less parenteral nutrition. The incidences of diarrhea and gastrointestinal bleeding significantly decreased following implementation of the protocol. There was no difference in clinical outcomes including in-hospital mortality and length of hospital and ICU stay. The implementation of the EN protocol significantly improved the practices of EN and decreased complications in critically ill patients. Clinical outcomes were not different before and after implementation.

Process-Related Barriers to Optimizing Enteral Nutrition in a Tertiary Medical Intensive Care Unit.

Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients. We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori. Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure. Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients.

A Multi-Institutional Retrospective Study Suggests That Optimal Enteral Nutrition (EN) Influences Outcomes after Hematopoietic Stem Cell Transplantation in Children and Adults

A Multi-Institutional Retrospective Study Suggests That Optimal Enteral Nutrition (EN) Influences Outcomes after Hematopoietic Stem Cell Transplantation in Children and Adults

A stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient delivery goals*.

To evaluate the impact of implementing an enteral nutrition algorithm on achieving optimal enteral nutrition delivery in the PICU. Prospective pre/post implementation audit of enteral nutrition practices. One 29-bed medical/surgical PICU in a freestanding, university-affiliated children's hospital. Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of more than 24 hours who received enteral nutrition. Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing, and maintaining enteral nutrition in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, enteral nutrition interruptions, parenteral nutrition use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and postintervention cohorts. Time to achieving energy goal was analyzed using Kaplan-Meier statistical analysis. Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the preimplementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating enteral nutrition, or use of postpyloric feeding between the two cohorts. We recorded a significant decrease in the number of avoidable episodes of enteral nutrition interruption (3 vs 51, p < 0.0001) and the prevalence and duration of parenteral nutrition dependence in patients with avoidable enteral nutrition interruptions in the postintervention cohort. Median time to reach energy goal decreased from 4 days to 1 day (p < 0.0001), with a higher proportion of patients reaching this goal (99% vs 61%, p = 0.01). The implementation of an enteral nutrition algorithm significantly improved enteral nutrition delivery and decreased reliance on parenteral nutrition in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study.

Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs). Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis. Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P < .001) and hours per EN interruption (-1.65; P = .001) and was not associated with the use of algorithms, promotility agents, or postpyloric feeding. A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.

Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients

BackgroundTo successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument.MethodsThe content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n = 43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n = 17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability.ResultsWe developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 – 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of items (ICC’s range −0.13 to 0.70). The within group agreement, an indices reflecting the reliability of aggregating individual responses to the ICU level was also variable (ICC’s range 0.0 to 0.82).ConclusionsWe developed a questionnaire to identify barriers to enteral feeding in critically ill patients. Additional studies are planned to further revise and evaluate the reliability and validity of the instrument.

387 Enteral Nutrition and Use of Human Milk Fortifiers in Preterm Infants; An International Survey

Background and aims: Optimal enteral nutrition is of critical importance to preterm infants, but there is limited evidence on benefits and safety of different feeding regimens including use of human milk fortifiers (HMF). We sought to determine feeding practice and use of HMF in neonatal units from different countries and continents.Methods: An internet-based questionnaire was sent by email to a single neonatologist in 120 tertiary units in Australasia, Canada, Scandinavia and UK.Results: 111 units (92%) responded. Fifty-four units (49 %) had either a breast milk bank or access to donor milk (Australasia 2/24, Canada 6/25, Scandinavia 20/20 and UK 26/42). Enteral feeding was initiated in the first 24 hours of life in 42 units (38 %) if GA < 25 weeks, in 50 units (45 %) if GA 25- 27 weeks and in 81 units (73%) if GA 28-31 weeks. For infants with GA < 25 weeks 55 units (50 %) used 4-5 days minimal enteral feeding before grading up feeding volume. Target feeding volume was 160- 180 ml/kg/d in 62 units (56 %). Ninety units (81 %) routinely used a multi-component HMF. Most (85 %) used birth weight as criteria for which infants to be given HMF. Twenty-nine units added HMF when infants tolerated a feeding volume of 80-120 ml/kg/ day and 43 units waited until infants tolerated “full feeds” (≥150 ml/kg/day).Conclusions: This study examines key areas of uncertainty and shows that feeding practices demonstrate enormous variability. It provides data that will be useful in planning collaborative feeding trials.

How You Can Improve the Delivery of Enteral Nutrition in Your PICU

Dr. Mehta and colleagues 1 have provided an excellent opportunity for those of us who treat critically ill infants and children to examine and improve enteral nutrition (EN) delivery to our patients. Future research aimed at elucidating effective nutrition strategies to improve patient outcomes depends on early initiation and subsequent maintenance of optimal EN. If we are unable to reliably reach and sustain target intakes of EN, we will be unable to determine effects of specific EN therapies on patient outcomes. Many basic research questions in need of answers revolve around enteral feeding in the pediatric intensive care unit (PICU). When should we start EN? How should we administer EN? Are there advantages or disadvantages to specialized enteral formulas? Should initiation of EN be delayed until medical paralytic and vasoactive agents have been discontinued? What is the optimal amount of EN needed for trophic gastrointestinal effects? How is EN tolerance defined, and how can it be improved? When is the transpyloric route indicated? How do we define appropriate enteral intake targets? When should the goal rate be achieved? Which strategies will reduce intake deficits and ensure patients meet calorie and protein goals? How can we minimize the risks associated with enteral feeding? What nutrition and outcome benefits can be pursued through provision of optimal EN? Once we provide EN as an imperative therapy and use it to its fullest potential in the PICU, we can begin to examine the associated outcome benefits. 2 Other groups have reported their experiences with the inadvertent inadequate nourishment of PICU patients. 3-8 This publication is unique in that it focuses on a PICU population with a wide variation of ages and diagnoses (as is commonly encountered in a moderate- to large-sized PICU), exclusively looking at preventable obstacles to optimal EN during a 4-week period. What can you do to improve EN delivery in your PICU? Many of us who read the article by Mehta et al 1

Challenges to Optimal Enteral Nutrition in a Multidisciplinary Pediatric Intensive Care Unit

To describe nutrient intake in critically ill children, identify risk factors associated with avoidable interruptions to enteral nutrition (EN), and highlight opportunities to improve enteral nutrient delivery in a busy tertiary pediatric intensive care unit (PICU). Design, Setting, and Measurements: Daily nutrient intake and factors responsible for avoidable interruptions to EN were recorded in patients admitted to a 29-bed medical and surgical PICU over 4 weeks. Clinical characteristics, time to reach caloric goal, and parenteral nutrition (PN) use were compared between patients with and without avoidable interruptions to EN. Daily record of nutrient intake was obtained in 117 consecutive patients (median age, 7 years). Eighty (68%) patients received EN (20% postpyloric) for a total of 381 EN days (median, 2 days). Median time to EN initiation was less than 1 day. However, EN was subsequently interrupted in 24 (30%) patients at an average of 3.7 +/- 3.1 times per patient (range, 1-13), for a total of 88 episodes accounting for 1,483 hours of EN deprivation in this cohort. Of the 88 episodes of EN interruption, 51 (58%) were deemed as avoidable. Mechanically ventilated subjects were at the highest risk of EN interruptions. Avoidable EN interruption was associated with increased reliance on PN and impaired ability to reach caloric goal. EN interruption is common and frequently avoidable in critically ill children. Knowledge of existing barriers to EN such as those identified in this study will allow appropriate interventions to optimize nutrition provision in the PICU.

Approach to Enteral Feeding in the PICU

The pediatric intensive care unit (PICU) environment poses unique challenges to achieving enteral nutrition (EN) goals for the critically ill child. Nutrition support in the PICU is often in conflict with the complexity of care provided to acutely ill children. A significant proportion of eligible patients do not receive optimal enteral nutrition for avoidable reasons. Early institution of EN is recommended and the gastric route is preferred because of ease of administration and reduced costs compared with the transpyloric route. In patients with poor gastric emptying or in cases where a trial of gastric feeding has failed, transpyloric or postpyloric feeding may be used to decrease the risk of aspiration and to improve enteral feed tolerance. However, there is no evidence of benefit for routine use of small bowel feeding in all patients admitted to the PICU. The placement of blind nasoenteric feeding tubes can be technically challenging, is not without complications, and requires local expertise and experience for successful placement and maintenance. A protocolized approach to selecting the optimal route and advancing enteral feedings may optimize EN delivery. Institutional practice guidelines based on consensus, available evidence, and national guidelines may decrease time to reaching caloric goal, improve protein balance, and potentially affect clinical outcomes. The rationale and challenges to the delivery and maintenance of optimal EN, and strategies to achieve optimal EN during critical illness, are discussed.