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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

Mehta, Nilesh M. MD1; Skillman, Heather E. MS, RD, CSP, CNSC2; Irving, Sharon Y. PhD, CRNP, FCCM, FAAN3; Coss-Bu, Jorge A. MD4; Vermilyea, Sarah MS, RD, CSP, LD, CNSC5; Farrington, Elizabeth Anne PharmD, FCCP, FCCM, FPPAG, BCPS6; McKeever, Liam MS, RDN7; Hall, Amber M. MS8; Goday, Praveen S. MBBS, CNSC9; Braunschweig, Carol PhD, RD10

Pediatric Critical Care Medicine: July 2017 - Volume 18 - Issue 7 - p 675–715
doi: 10.1097/PCC.0000000000001134
Special Article

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

1Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA.

2Clinical Nutrition Department, Children’s Hospital Colorado, Aurora, CO.

3Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, PA.

4Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX.

5Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

6Department of Pharmacy, Betty H. Cameron Women’s and Children’s Hospital, New Hanover Regional Medical Center, Wilmington, NC.

7Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL.

8Biostatistics, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA.

9Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI.

10Department of Kinesiology and Nutrition, Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL.

All authors completed both the American Society of Parenteral and Enteral Nutrition and Society of Critical Care Medicine conflicts of interest form for copyright assignment and financial disclosure. The authors of these guidelines have reported all potential conflicts or financial disclosures. There was no funding or contribution from industry nor were any industry representatives present at any of the committee meetings.

The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM) that possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.

These guidelines are being copublished by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) in the Journal of Parenteral and Enteral Nutrition (JPEN), 2017; 41:706–742.

For information regarding this article, E-mail: nilesh.mehta@childrens.harvard.edu

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies