Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

The aim of this editorial is to provide an adaptation of nutrition support recommendations for the overall population of critically ill children, to provide further refined recommendations for critically ill children presenting with COVID-19 or paediatric hyper-inflammatory syndrome temporally associated with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 (6) and Surviving Sepsis Campaign recommendations from February 2020 (7). These recommendations cover the acute, stable and rehabilitation phases (Table 1, Table 2)

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

Gastric point-of-care ultrasound in acutely and critically ill children (POCUS-ped): a scoping review

Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children. An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute). A total of 70 studies were included. Most studies ( = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion ( = 6), nasogastric tube placement ( = 5), hypertrophic pyloric stenosis ( = 8), and gastric insufflation during mechanical ventilatory support ( = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms. Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation. [Abstract copyright: Copyright © 2022 Valla, Tume, Jotterand Chaparro, Arnold, Alrayashi, Morice, Nabialek, Rouchaud, Cercueil and Bouvet.

Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations

Abstract: Background: Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective: To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design: The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results: The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions: We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions

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

NUTRITIONAL SUPPORT IN CRITICALLY ILL CHILDREN HOSPITALIZED IN INTENSIVE CARE UNIT

In critically ill children, optimal energy and protein intakes are associated with improved prognoses. However, their protein and energy needs have been determined on the basis of insufficient data. In clinical practice, resting energy expenditure (REE) is frequently estimated from prédictive équations, despite their probable lack of précision, instead of using indirect calorimetry measurements. Thus, the aims of this PhD thesis were twofold: to determine the energy and protein needs in ventilated critically ill children, and to evaluate available prédictive équations for estimating REE in this population. Our first study was conducted to investigate how much protein and energy are needed to equilibrate the nitrogen and energy balances of ventilated critically ill children on sedation and analgesia. From 402 daily measurements of total urinary nitrogen (TUN) and REE in 74 children, we found that TUN was elevated and REE was reduced during mechanical ventilation. Minimum intakes of 1.5 g/kg/d of protein and 58 kcal/kg/d were required in children up to 4 years old, whereas older children needed more protein. Our second work aimed to determine, based on our indirect calorimetry measurements, the biases of 15 prédictive équations, including recent équations specifically developed for estimating REE in ventilated critically ill children. Only the six équations of Talbot, Schofield, Henry and Mehta had a bias < 10% between 200 and 1000 kcal/d, but their précision was still unsatisfactory in young children. Following this work, we made a systematic review of the literature to document validation studies of prédictive équations in critically ill children. Of the 993 studies identified, 22 studies were included and involved 998 critically ill children and 2076 indirect calorimetry measurements. They assessed 21 prédictive équations, but only 6 équations were evaluated by at least three studies. The équation of Harris-Benedict clearly overestimated REE in a large majority of patients and should not be used in this population. The équations of Schofield and the tables of Talbot were the most accurate, but predicted REE within ± 15% of measured energy expenditure in only 53% of patients. Other analysed équations were either more imprecise or not assessed in a sufficient number of studies. In conclusion, this project precisely assessed the energy and protein needs of ventilated critically ill children aged 0 to 8 years and showed that most prédictive équations of REE are inaccurate, especially in the youngest children

Physicians' perceptions about managing enteral nutrition and the implementation of tools to assist in nutritional decision-making in a paediatric intensive care unit.

For critically ill children hospitalised in paediatric intensive care units, adequate nutrition reduces their risk of morbidity and mortality. Barriers may impede optimal nutritional support in this population. Moreover, physicians are usually responsible for prescribing nutrition, although they are not experts. Therefore, tools may be used to assist in nutritional decision-making, such as nutrition protocols. The objective of this two-stage qualitative study was to explore the perceptions of physicians about their management of enteral nutrition in a paediatric intensive care unit and the implementation of a nutrition protocol and computerised system. This study involved semistructured interviews with physicians at the Paediatric Intensive Care Unit of Lausanne University Hospital, Switzerland. Research dietitians conducted interviews before (stage one) and after (stage two) the implementation of a nutrition protocol and computerised system. During stage one, six junior physicians and five fellows were interviewed. At stage two, 12 junior physicians, 12 fellows, and five senior physicians were interviewed. Interviews were recorded, with data transcribed verbatim before a thematic analysis using a framework method. Three themes emerged from thematic analysis: "nutritional knowledge", "nutritional practices", and "resources to manage nutrition". During stage one, physicians, especially junior physicians, reported a lack of nutritional knowledge for critically ill children and stated that nutritional issues primarily depended on senior physicians, who themselves had various practices. All physicians were in favour of a nutrition protocol and computerised system. At stage two, interviewees stated that they used both tools regularly. They reported improved nutritional knowledge, more systematic and consistent nutritional practices, and increased attention to nutrition. The implementation of a nutrition protocol and computerised system by a multiprofessional team helped physicians in the paediatric intensive care unit to manage nutritional support and increase their attention to nutrition

How much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children?

Protein and energy requirements in critically ill children are currently based on insufficient data. Moreover, longitudinal measurements of both total urinary nitrogen (TUN) and resting energy expenditure (REE) are lacking. The aim of this study was to investigate how much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children on the basis of daily measurements of TUN, REE and protein and energy intakes. Comparisons were made with the guidelines of the American Society for Parenteral and Enteral Nutrition and the Dietary Reference Intakes. Children with an expected duration of mechanical ventilation ≥72 h were prospectively recruited. TUN was measured by chemiluminescence, and REE was measured by indirect calorimetry. Generalised linear models for longitudinal data were used to study the relation between protein intake and nitrogen balance and to calculate the minimum intake of protein needed to achieve nitrogen equilibrium. A similar approach was used for energy. Results were compared to the recommended values. Based on 402 measurements performed in 74 children (median age: 21 months), the mean TUN was high at 0.20 (95% CI: 0.20, 0.22) g/kg/d and the REE was 55 (95% CI: 54, 57) kcal/kg/d. Nitrogen and energy balances were achieved with 1.5 (95% CI: 1.4, 1.6) g/kg/d of protein and 58 (95% CI: 53, 63) kcal/kg/d for the entire group, but there were differences among children of different ages. Children required more protein and less energy than the Dietary Reference Intakes. In critically ill children, TUN was elevated and REE was reduced during the entire period of mechanical ventilation. Minimum intakes of 1.5 g/kg/d of protein and 58 kcal/kg/d can equilibrate nitrogen and energy balances in children up to 4 years old. Older children require more protein

Performance of Predictive Equations Specifically Developed to Estimate Resting Energy Expenditure in Ventilated Critically Ill Children.

To determine, based on indirect calorimetry measurements, the biases of predictive equations specifically developed recently for estimating resting energy expenditure (REE) in ventilated critically ill children, or developed for healthy populations but used in critically ill children. A secondary analysis study was performed using our data on REE measured in a previous prospective study on protein and energy needs in pediatric intensive care unit. We included 75 ventilated critically ill children (median age, 21 months) in whom 407 indirect calorimetry measurements were performed. Fifteen predictive equations were used to estimate REE: the equations of White, Meyer, Mehta, Schofield, Henry, the World Health Organization, Fleisch, and Harris-Benedict and the tables of Talbot. Their differential and proportional biases (with 95% CIs) were computed and the bias plotted in graphs. The Bland-Altman method was also used. Most equations underestimated and overestimated REE between 200 and 1000 kcal/day. The equations of Mehta, Schofield, and Henry and the tables of Talbot had a bias ≤10%, but the 95% CI was large and contained values by far beyond ±10% for low REE values. Other specific equations for critically ill children had even wider biases. In ventilated critically ill children, none of the predictive equations tested met the performance criteria for the entire range of REE between 200 and 1000 kcal/day. Even the equations with the smallest bias may entail a risk of underfeeding or overfeeding, especially in the youngest children. Indirect calorimetry measurement must be preferred