Determining energy and protein needs in critically ill paediatric patients: A scoping review:Nutrition in Clinical Practice

Introduction : In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients. Methods : An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data. Results : A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated. Conclusion : This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter

Description of Ultra-Processed Food Intake in a Swiss Population-Based Sample of Adults Aged 18 to 75 Years.

Ultra-processed foods (UPFs) are associated with lower diet quality and several non-communicable diseases. Their consumption varies between countries/regions of the world. We aimed to describe the consumption of UPFs in adults aged 18-75 years living in Switzerland. We analysed data from the national food consumption survey conducted among 2085 participants aged 18 to 75 years. Foods and beverages resulting from two 24-h recalls were classified as UPFs or non-UPFs according to the NOVA classification, categorized into 18 food groups, and linked to the Swiss Food Composition Database. Overall, the median energy intake [P25-P75] from UPFs was 587 kcal/day [364-885] or 28.7% [19.9-38.9] of the total energy intake (TEI). The median intake of UPFs relative to TEI was higher among young participants (<30 years, p = 0.001) and those living in the German-speaking part of Switzerland (p = 0.002). The food groups providing the most ultra-processed calories were confectionary, cakes & biscuits (39.5% of total UPF kcal); meat, fish & eggs (14.9%); cereal products, legumes & potatoes (12.5%), and juices & soft drinks (8.0%). UPFs provided a large proportion of sugars (39.3% of total sugar intake), saturated fatty acids (32.8%), and total fats (31.8%) while providing less than 20% of dietary fibre. Consumption of UPFs accounted for nearly a third of the total calories consumed in Switzerland. Public health strategies to reduce UPF consumption should target sugary foods/beverages and processed meat

How to follow the guidelines, when the appropriate fluid is missing?

Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. Recently paediatric societies have produced evidence-based practice guidelines that recommend the use of balanced isotonic fluid when prescribing IV-MFT in both acute and critical paediatric care. Unfortunately, the applicability of these guidelines could be called into question when a ready-to-use glucose-containing balanced isotonic fluid is not available. The main objective of this study was to describe the availability of glucose-containing balanced isotonic fluids in European and Middle Eastern paediatric acute and critical care settings. This work is an ancillary study of the survey dedicated to IV-MFT practices in the paediatric acute and critical care settings in Europe and Middle East, a cross-sectional electronic 27-item survey, emailed in April–May 2021 to paediatric critical care physicians across 34 European and Middle East countries. The survey was developed by an expert multi-professional panel within the European Society of Peadiatric and Neonatal Intensive Care (ESPNIC). Balanced isotonic fluid with glucose 5% was available for only 32/153 (21%) responders. Balanced isotonic fluid with glucose 5% was consistently available in the UK (90%) but not available in France, Greece, The Netherlands and Turkey.    Conclusion: Ready-to-use isotonic balanced IV solutions containing glucose in sufficient amount exist but are inconsistently available throughout Europe. National and European Medication Safety Incentives should guarantee the availability of the most appropriate and safest IV-MFT solution for all children. What is Known:• Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care.• Balanced isotonic fluid is recommended when prescribing IV-MFT in both acute and critical paediatric care. What is New:• Balanced isotonic fluid with glucose 5% is available for less than 25% of the prescribers in Europe and the Middle East. Availability of balanced isotonic fluid with glucose 5% varies from one country to another but can also be inconsistent within the same country.• Clinicians who have access to a ready-to-use balanced isotonic fluid with glucose 5% are more likely to consider its use than clinicians who do not have access to such an IV solution

ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis

PURPOSE Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. METHODS A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. RESULTS 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations. CONCLUSIONS Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance

Quelles mesures sont conseillées en Suisse et dans le reste de l'Europe pour atteindre l'apport recommandé en vitamine D chez les enfants en santé ?: travail de bachelor

Introduction : Le développement et la croissance sont des phénomènes cruciaux pendant l'enfance. La croissance des os, des dents et leur fortification est importante dans cette étape de vie. Une déficience en vitamine D peut avoir des effets néfastes sur la croissance et le développement d'un enfant. Si l'apport recommandé n'est pas quotidiennement atteint ; des manifestations cliniques peuvent apparaître. Pour éviter cela, un taux sanguin en vitamine D dans les normes est nécessaire. Les recommandations actuelles varient selon l'âge mais sont difficilement atteignables lié à certains facteurs de risque. L'apport recommandé en vitamine D étant difficile à atteindre, différentes mesures sont proposées par les sociétés savantes. Actuellement, aucun consensus sur les mesures à prendre vis-à-vis de cette problématique n'existe en Suisse. But : Notre travail de Bachelor a pour but de regrouper les différentes mesures conseillées dans les pays européens et en Suisse pour atteindre l'apport recommandé en vitamine D chez les enfants en santé âgés de 0 à 18 ans. Méthodologie : Pour répertorier l'ensemble des mesures conseillées dans les pays européens pour atteindre l'apport recommandé en vitamine D chez l'enfant en santé, une revue systématique de la littérature sur les bases de données électroniques PubMed et CINHAL et sur le moteur de recherche Google a été effectuée. Sur un résultat de 40 articles, 15 ont été sélectionnés sur la base de leur titre puis 10 en lisant l'abstract. Après lecture complète des articles, 10 ont été retenus et trois ont été inclus sur référence soit un total de 13 articles. La qualité des guidelines sélectionnées a été déterminée à l'aide de la grille d'analyse AGREE II de la HAS (Haute autorité de santé). Pour l'extraction des données, des tableaux regroupant l'ensemble des mesures visant à atteindre l'apport recommandé en vitamine D ont été réalisés. Résultats : Le regroupement des mesures relevées dans nos articles a permis de définir cinq axes principaux : prévention, mesure du taux sanguin de vitamine D, supplémentation, exposition au soleil et mode de vie. Trois publics cibles ont également pu être distingués : enfants en santé - à risque - avec déficit. Plusieurs caractéristiques comme les seuils sanguins ou encore les facteurs de risque révèlent une certaine hétérogénéité dans les résultats. La mesure la plus recommandée consiste à supplémenter (sans forme déterminée) les enfants dès leur plus jeune âge. Sur la base de l'analyse qualité des guidelines, deux d'entre elles ont obtenu un résultat final négatif, deux modéré et une positif. Conclusion : Le manque de consensus évident impacte la prise en charge des enfants en santé au sujet de la vitamine D. La mise en place d'une supplémentation reste la mesure la plus recommandée et la plus efficace pour atteindre l'apport recommandé en vitamine D chez les enfants en santé âgés de 0 à 18 ans. L'alimentation est un axe peu abordé. La prévention dans le milieu pédiatrique pour sensibiliser les professionnels de la santé serait, selon nous, une mesure de prophylaxie efficace et nécessaire

Energy expenditure in critically ill children

In critically ill children, optimal nutritional intake can improve recovery. During stay in the pediatric intensive care unit (PICU), both underfeeding and overfeeding have to be avoided. The assessment of energy requirements is difficult during critical illness because of lack of devices to measure it. In addition, energy requirements vary during the different phases of critical illness; i.e. the acute, stable and recovery phase. Energy expenditure is affected by the illness itself, but also by the conditions of the PICU such as mechanical ventilation, sedation, fever and the lack of physical activity. During the acute phase, energy intake has to be increased gradually while not exceeding resting energy expenditure (REE). The latter may be estimated using the Schofield equation or ideally be measured using a validated indirect calorimeter. After the acute phase, energy intake has to be increased to enable recovery and growth. The aim of this review is to give an overview of the current knowledge concerning REE in critically ill children and factors that may affect REE. The principles of measurement or calculation of REE will be described. The available evidence will be synthesized and practical recommendations will be provided for guiding energy intake during the different phases of illness

The impact of nutrition on clinical outcomes in the critically ill child

In critically ill children, appropriate nutritional support can improve short- and long term outcomes. When prescribing nutritional support, clinicians in Pediatric Intensive Care Unit (PICU) have to answer numerous questions. These include how much macro- and micronutrients to provide, when to begin nutrition and, which type of feeding should be preferred i.e. enteral or parenteral nutrition (PN). In case of enteral feeding, the PICU team has to choose between continuous vs. intermittent feeding, polymeric vs. semi-elemental formula. The different phases of critical illness and patient age, nutritional and clinical status at admission must also be considered. The impact of these different nutritional strategies on clinical outcomes must be assessed in well-performed randomized controlled trials. Due to the heterogeneity of the population, small sample size, ethical considerations and multiples confounding factors, interventional studies are rare in this population group, and nutritional guidelines often rely on observational studies, results of which describing worse clinical outcomes associated with overfeeding, poor nutritional status or vitamin D deficiency at PICU admission. In contrast randomized controlled trials have shown that withholding PN for one week in critically ill children may be of benefit. However, many questions still remain including the optimal macro- and micronutrients during the various phases of critical illness all of which require future studies. The aim of this review is to give an overview of the current available studies assessing the effect of different nutritional strategies on clinical and functional outcomes in critically ill childre

Refeeding syndrome and other related issues in the PICU

The objectives of this review are to describe the pathophysiology of refeeding syndrome, to synthesis the available evidence in critically ill children, and to provide practical recommendations for its prevention and management in paediatric intensive care units (PICUs). The refeeding syndrome appears in patients who have had a reintroduced and/or increase caloric intake after a period of restricted or no caloric intake. It is manifested by a decrease in one or many electrolytes (potassium, magnesium and/or phosphorous), a thiamine deficiency and/or sodium retention. Despite the lack of evidence, the patients most at risk for refeeding syndrome seem to be malnourished children and those with restricted nutritional intake for more than 7 days. On admission to PICU, nutritional status should be assessed, this should include anthropometric measurements (weight and height z-score, mid upper arm circumference and head circumference in young children) and a diet history. Indeed, nutrient intakes of the child prior to admission to PICU should be collected to identify whether the child’s intakes were decreased or inadequate in the weeks prior to hospitalization, including the number of meals and foods consumed per day. In children with low serum levels of potassium, magnesium and/or phosphorous, these imbalances should be corrected before nutrition support is commenced, along with supplement thiamine 100 mg per day. Current recommendations to avoid refeeding syndrome in critically ill children, are that energy intake should not exceed resting energy expenditure (REE) during the acute phase of critical illness and nutritional support must be increased progressively in a stepwise manner. Finally, the presence of a protocol to guide the timing and management of nutritional support in the PICU and the presence of a nutrition support team including a dedicated dietitian is recommended