Nutrition in the PICU

Abstract

Nutritional therapy is recognized as an important cornerstone in the management of the critically ill child. However, optimal nutrient delivery in the PICU is challenging and results in nutritional deterioration and negatively impacts on clinical outcomes. There is increasing evidence that energy and protein intake in the PICU are far lower than their estimated requirement during critical illness. Recent data show an association between decreased macronutrient intake and mortality in mechanically ventilated children. Hence, optimal energy and protein intake in the PICU needs to be prioritized. Enteral nutrition (EN) is the preferred mode of feeding in the PICU. Current evidence suggests benefit of early initiation of EN, followed by rapid advancement using a protocolized strategy and subsequent maintenance of uninterrupted EN. While the gastric route is preferred, patients at risk of aspiration or those who have failed gastric feeding may benefit from transpyloric feeding in centers with available resources and expertise. The role of routine prokinetics in the PICU is unclear. EN is probably safe in hemodynamically stable patients on a single vasopressor agent. Both avoidable and unavoidable barriers to EN exist, and need to be addressed by multidisciplinary commitment. Immunonutrition has been inadequately studied in critically ill children, and its role needs further clarification with the help of well-designed clinical trials. In the current era of limited evidence base for most nutrition practices, uniform consensus based strategies might be prudent. Protocols that provide guidelines for early initiation, rapid advancement and maintenance of EN in the PICU have been shown to improve the ability to reach nutrition goals and their use is associated with improved clinical outcomes. Future studies must examine strategies to optimize EN, improve protein intake to preserve lean body mass, role of supplementary PN, and clarify the role of immunontrition in the PICU.