A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child

Abstract

The prevalence of malnutrition among critically ill patients, especially those with a protracted clinical course, has remained largely unchanged over the last 2 decades.1,2 The profound and stereotypic metabolic response to critical illness and failure to provide optimal nutrition support therapy during the intensive care unit (ICU) stay are the principal factors contributing to malnutrition in this cohort. The metabolic response to stress, injury, surgery, or inflammation cannot be accurately predicted and the metabolic alterations may change during the course of illness. Although nutrition support therapy cannot reverse or prevent this response, failure to provide optimal nutrients during this stage will result in exaggeration of existing nutrient deficiencies and in malnutrition, which may affect clinical outcomes. Both underfeeding and overfeeding are prevalent in the pediatric intensive care unit (PICU) and may result in large energy imbalances.3 Malnutrition in hospitalized children is associated with increased physiological instability and increased resource utilization, with the potential to influence outcome from critical illness.4,5 The goal of nutrition support therapies in this setting is to augment the short-term benefits of the pediatric stress response while minimizing the long-term harmful consequences. Accurate assessment of energy requirements and provision of optimal nutrition support therapy through the appropriate route is an important goal of pediatric critical care. Ultimately, an individualized determination of nutrient requirements must be made to provide appropriate amounts of both macro- and micronutrients for each patient at various times during the illness course. The delivery of these nutrients requires careful selection of the appropriate mode of feeding and monitoring the success of the feeding strategy. The use of specific nutrients, which possess a drug-like effect on the immune or inflammatory state during critical illness, continues to be an exciting area of investigation. The lack of systematic research and clinical trials on various aspects of nutrition support in the PICU is striking and makes it challenging to compile evidence based practice guidelines. There is an urgent need to conduct well-designed, multicenter trials in this area of clinical practice. The extrapolation of data from adult critical care literature is not desirable and many of the interventions proposed in adults will have to undergo systematic examination and careful study in critically ill children prior to their application in this population. In the following sections, we will discuss some of the key aspects of nutrition support therapy in the PICU; examine the literature and provide best practice guidelines based on evidence from PICU patients, where available. While some PICU popu lations include neonates, A.S.P.E.N. Clinical Guidelines for neonates will be published as a separate series. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is an organization comprised of healthcare professionals representing the disciplines of medicine, nursing, pharmacy, dietetics, and nutrition science. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of nutrition support therapy. A.S.P.E.N. vigorously works to support quality patient care, education, and research in the fields of nutrition and metabolic support in all healthcare settings. These clinical guidelines were developed under the guidance of the A.S.P.E.N. Board of Directors. Promotion of safe and effective patient care by nutrition support practitioners is a critical role of the A.S.P.E.N. organization. The A.S.P.E.N. Board of Directors has been publishing clinical guidelines since 1986.6-8 Starting in 2007, A.S.P.E.N. has been revising these clinical guidelines on an ongoing basis, reviewing about 20% of the chapters each year in order to keep them as current as possible. These clinical guidelines were created in accordance with Institute of Medicine recommendations as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."9 These clinical guidelines are for use by healthcare professionals who provide nutrition support services and offer clinical advice for managing adult and pediatric (including adolescent) patients in inpatient and outpatient (ambulatory, home, and specialized care) settings. The utility of the clinical guidelines is attested to by the frequent citation of this document in peer-reviewed publications, and their frequent use by A.S.P.E.N. members and other healthcare professionals in clinical practice, academia, research, and industry. They guide professional clinical activities, they are helpful as educational tools, and they influence institutional practices and resource allocation.10 These clinical guidelines are formatted to promote the ability of the end user of the documen