The American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) released Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Paediatric Critically Ill Patient at the end of last year.

Malnutrition in critically ill children is a huge concern.

These guidelines were based upon an exhaustive literature review on the importance of nutritional support therapy in cases involving critically ill patients aged one month to 17 years of age.

The research team, chaired by ASPEN president-elect, Dr Nilesh Mehta of Boston Children’s Hospital, analysed over 2 032 citations for relevance related to paediatric nutritional support, specifically looking at the data for critically ill paediatric patients with a length of stay greater than two or three days in a paediatric intensive care unit (PICU), admitting medical, surgical, and cardiac patients.

“In 2009, after conducting a comprehensive review, ASPEN issued clinical guidelines for critically ill paediatric patients. Up until that time, healthcare providers had no such assistance when providing nutrition support therapy to their youngest patients,” explained Debra BenAvram, ASPEN’s CEO.

“Thanks to Dr Mehta and his team, we have now updated that information. The strategic pathway indicated in the 2017 guidelines will help to deliver optimal nutrition and better outcomes for this particularly vulnerable population.”

Among the guidelines findings:

  • There is a significant gap in proper nutritional interventions, particularly among malnourished paediatric patients. This is deeply concerning as malnutrition is associated with adverse clinical outcomes including longer periods of ventilation, higher risk of hospital-acquired infection, longer PICU and hospital stays, and increased mortality
  • Early intervention makes a difference. Patients who receive a nutritional intervention in a timely manner may benefit most from the therapy. The new guidelines recommend that PICU patients undergo a detailed nutritional assessment within 48 hours of being admitted to hospital
  • The timing and method of nutrient delivery is important. The new guidelines offer strategies to optimise enteral nutrition during critical illness. The research also points to the benefits of a delayed approach to parenteral nutrition
  • A skilled nutrition support team is a key differentiator. One that includes a dedicated dietitian should be available in the PICU to facilitate timely nutritional assessment, and optimal nutrient delivery and adjustment to the patient’s nutrition plan as the clinical situations changeOngoing monitoring is critical to avoid unintended caloric under- or overfeeding. Patients are at risk of nutritional deterioration during hospitalisation, which can adversely affect clinical outcomes. The new guidelines, therefore, suggest that the nutritional status of patients be re-evaluated at least weekly throughout hospitalisation
  • Determining how much nutrition is needed is an important factor. For example, optimal protein intake is closely related to positive clinical outcomes. The new guidelines provide recommendations on the minimum protein intake. However, it’s important to bear in mind that the use of recommended daily allowance values to guide protein prescription in critically ill paediatric patients is not advised. These were developed for healthy children and often underestimate the protein needs during critical illness.

“Children are especially susceptible to malnutrition,” stated Dr Molly McMahon, president of Aspen and professor of medicine in the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at the Mayo Clinic (United States).

“These guidelines addressing the nutrition of critically ill children have never been more needed or relevant. Ultimately, this clinical guidance has the potential to improve medical outcomes and to decrease healthcare costs in this group of children,” she concluded.