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A Stepwise Enteral Nutrition Algorithm for Critically Ill Children Helps Achieve Nutrient Delivery Goals*

Hamilton, Susan RN, MS, CCRN, CWOCN1; McAleer, Diane M. RN, MS, CCRN, CPN1; Ariagno, Katelyn RD2; Barrett, Megan MPH1; Stenquist, Nicole BA3; Duggan, Christopher P. MD, MPH2; Mehta, Nilesh M. MD3

Pediatric Critical Care Medicine: September 2014 - Volume 15 - Issue 7 - p 583–589
doi: 10.1097/PCC.0000000000000179
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Objectives: To evaluate the impact of implementing an enteral nutrition algorithm on achieving optimal enteral nutrition delivery in the PICU.

Design: Prospective pre/post implementation audit of enteral nutrition practices.

Setting: One 29-bed medical/surgical PICU in a freestanding, university-affiliated children’s hospital.

Patients: 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.

Interventions: 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.

Measurements and Main Results: 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).

Conclusions: 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.

1Department of Cardiovascular/Critical Care Nursing, Boston Children’s Hospital, Boston, MA.

2Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA.

3Critical Care Medicine, Department of Anesthesiology, Pain and Perioperative Medicine, Boston Children’s Hospital, Boston, MA.

* See also p. 667.

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Supported, in part, by a grant from the Program for Patient Safety and Quality 2009 funding cycle at Boston Children’s Hospital.

Dr. Duggan served as board member for Grupe Danone, received royalties from UptoDate and People’s Medical Publishing House (book royalties), and received support for article research from the National Institutes of Health (NIH). His institution received grant support from the NICHD, the NIH, and the Gates Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Nilesh M. Mehta, MD, Bader 634, Critical Care Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail:

©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies