Early versus Late Parenteral Nutrition in Critically Ill Children

Jordan Alava, Mercer University College of Pharmacy

According to the American Society for Parenteral and Enteral Nutrition’s (ASPEN) guidelines for the nutritional support of the critically ill child, the preferred mode of nutrient provision is by enteral route if the child has a functioning gastrointestinal tract.  [1]

Per guidelines on pediatric parenteral nutrition, the time when parenteral nutrition should be initiated should depend both on individual circumstances and the age and size of the infant or child.  It is suggested that one day of starvation may be detrimental to small preterm infants.  The guidelines recommend that parenteral nutrition be initiated shortly after birth if it is clear that enteral feeds will likely not be tolerated.  [2]

Title: Early versus Late Parenteral Nutrition in Critically Ill Children
Design Multicenter, prospective, randomized, controlled trial; N= 1440
Objective To investigate whether withholding parenteral nutrition for one week in the pediatric intensive care unit (ICU) is clinically superior to providing early parenteral nutrition
Study Groups Early parenteral nutrition (n= 723); late parenteral nutrition (n= 717)
Methods Children (newborns to 17 years of age) who were anticipated to have a pediatric ICU stay of 24 hours or more and that received a score of two or more on the Screening Tool for Risk on Nutritional Status and Growth received treatment with either early parenteral nutrition or late parenteral nutrition.
Duration June 18, 2012 – July 27, 2015
Primary Outcome Measure New infection acquired during ICU stay and adjusted duration of ICU dependency
Baseline Characteristics There were no significant differences in characteristics between treatment groups at baseline.  Median age, weight, height, and body mass index (BMI) were similar between groups with approximately 58% males.
Results   Early Parenteral Nutrition (n= 723) Late Parenteral Nutrition (n= 717) p value Adjusted OR or HR (95% CI) p value
New infections, No. (%) 134 (18.5%) 77 (10.7) <0.001 0.48 (0.35-0.66) <0.001
Total duration of stay in pediatric ICU, days ± SD 9.2 ± 0.8 6.5 ± 0.4 0.002 1.23 (1.11-1.37) <0.001
Abbreviations: odds ratio (OR), hazard ratio (HR), confidence interval, standard deviation (SD)
Adverse Events Common Adverse Events: Hypoglycemia (9.1%)
Serious Adverse Events: Death: within eight days of admission to pediatric ICU (2.6%), during stay in pediatric ICU (4.5%), during hospital stay (5.2%), within 90 days after enrollment (5.3%)
Percentage that Discontinued due to Adverse Events: N/A
Study Author Conclusions Withholding parenteral nutrition for one week in the ICU was clinically superior to providing early parenteral nutrition in critically ill children.

The practice of early parenteral nutrition in critically ill children stems from the idea of fulfilling the nutritional needs of pediatric patients to ensure proper recovery, growth, and development.  This study helps to disprove this assumption by illustrating the benefits of delayed parenteral nutrition in this specific patient population.  Patients in the late parenteral nutrition group had fewer infections, less organ failure, and a faster recovery time than those in the receiving early treatment.  One limitation to this study was its lack of internal validity since the patients, parents, and ICU staff were not blinded to treatment assignments.

References

  1. Mehta NM, Compher C. A.S.P.E.N. Clinical Guidelines: nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr. 2009;33(3):260-76.
  2. Koletzko B, Goulet O, Hunt J, et al. 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S1-87.
  3. Fivez T, Kerklaan D, Mesotten D, et al. Early versus Late Parenteral Nutrition in Critically Ill Children. N Engl J Med. 2016.
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One thought on “Early versus Late Parenteral Nutrition in Critically Ill Children

  1. I had no idea that parenteral nutrition was a thing until I had a good friend explain to me what was happening to his son. I think it’s great that there’s ways to help these kids when they’re critically ill. I also appreciate you sharing this and talking about it in a way that I could understand. It helped me understand my friend a lot better.

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