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Enteral Nutrition and Acid-Suppressive Therapy in the PICU

Impact on the Risk of Ventilator-Associated Pneumonia*

Albert, Ben D., MD; Zurakowski, David, PhD; Bechard, Lori J., PhD, RD; Priebe, Gregory P., MD; Duggan, Christopher P., MD, MPH; Heyland, Daren K., MD; Mehta, Nilesh M., MD

Pediatric Critical Care Medicine: October 2016 - Volume 17 - Issue 10 - p 924–929
doi: 10.1097/PCC.0000000000000915
Feature Articles

Objective: Enteral nutrition has been implicated as a risk factor for ventilator-associated pneumonia. We explored the prevalence of ventilator-associated pneumonia and its association with clinical and nutrition-related therapies in mechanically ventilated children.

Design: Prospective, multicenter, cohort study.

Setting: Fifty-nine PICU in 15 countries.

Patients: Children less than 18 years old, mechanically ventilated for more than 48 hours.

Interventions: None. Multivariable logistic regression to determine factors associated with ventilator-associated pneumonia.

Measurements and Major Results: Data are presented as median (interquartile range) or counts (%). We enrolled 1,245 subjects (45% women; 42% surgical), age 20 months (4–84 mo), and duration of mechanical ventilation 7 days (3–13 d). Culture-positive ventilator-associated pneumonia was diagnosed in 80 patients (6.4%); duration of mechanical ventilation for this subgroup was 17 days (8–39 d). Enteral nutrition was delivered in 985 patients (79%), initiated within 48 hours in 592 patients (60%), and via postpyloric route in 354 patients (36%). Acid-suppressive agents were used in 763 patients (61%). The duration of enteral nutrition (p = 0.21), route (gastric vs postpyloric) of delivery (p = 0.94), severity of illness (p = 0.17), and diagnostic category on admission (p = 0.31) were not associated with ventilator-associated pneumonia. After adjusting for enteral nutrition days, illness severity, and site, ventilator-associated pneumonia was significantly associated with mechanical ventilation more than 10 days (odds ratio, 3.7; 95% CI, 2.2–6.5; p < 0.001), PICU length of stay more than 10 days (odds ratio, 1.8; 95% CI, 1.1–3.1; p = 0.029), and the use of acid-suppressive medication (odds ratio, 2.0; 95% CI, 1.2–3.6; p = 0.011).

Conclusions: Ventilator-associated pneumonia was diagnosed in 6.5% of mechanically ventilated children in a heterogeneous multicenter cohort. We did not find a link between enteral nutrition duration or route of delivery and ventilator-associated pneumonia. In addition to duration of mechanical ventilation and length of PICU stay, the use of acid-suppressive therapy independently increased the likelihood of developing ventilator-associated pneumonia in this population. This association must be further explored in clinical trials.

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

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

3Department of Critical Care Medicine, Queen’s University and Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada.

4Harvard Medical School, Boston, MA.

*See also p. 1001.

Dr. Mehta received royalties from McGraw Hill Publishers (Editor of Textbook; Pediatric Critical Care Nutrition). Dr. Bechard is employed by Northeastern University and Nestle Nutrition and lectured for NASPGHAN and ASPEN. Her institution received grant support from the ASPEN Foundation and from the Academy of Nutrition and Dietetics Foundation. Dr. Priebe’s institution received grant support from AHRQ R18 HS021636. Dr. Duggan received royalties from Peoples Medical Publishing House and Uptodate and received support for article research from the National Institutes of Health. His institution received grant support from the NIDDK. Dr. Heyland received grant support from Nestle (quality improvement work) and lectured for Abbott (lectures). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies