A review of feeding intolerance in critically ill children

© 2018, The Author(s). Ensuring optimal nutrition is vital in critically ill children and enteral feeding is the main route of delivery in intensive care. Feeding intolerance is the most commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition, yet the definition for this remains inconsistent, nebulous, and entirely arbitrary. Not only does this pose problems clinically, but research in this field frequently uses feeding intolerance as an endpoint and the heterogeneity in this definition makes the comparison of studies difficult and meta-analysis impossible. We reviewed the use of, and definitions of, the term feed intolerance in pediatric intensive care research papers in the last 20years. Gastric residual volume remains the most common factor used to define feed intolerance, despite the lack of evidence for this. Healthcare professionals would benefit from further education to improve their awareness of the limitations of the markers to define feeding intolerance, and the international PICU community needs to agree a consistent definition of this phenomenon to improve consistency in both practice and research. Conclusion: This paper will provide a narrative review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children.What is Known?:• Feeding intolerance is a commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition.• There is no agreed definition for feeding intolerance in critically ill children.What is New?:• This paper provides an up to date review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children.• Despite no evidence, gastric residual volume continues to drive clinical bedside decisions about enteral feeding and feeding tolerance

Near-infrared spectroscopy after high-risk congenital heart surgery in the paediatric intensive care unit

Objective: To establish whether the use of near-infrared spectroscopy is potentially beneficial in high-risk cardiac infants in United Kingdom paediatric intensive care units. Design: A prospective observational pilot study. Setting: An intensive care unit in North West England. Patients: A total of 10 infants after congenital heart surgery, five with biventricular repairs and five with single-ventricle physiology undergoing palliation. Interventions: Cerebral and somatic near-infrared spectroscopy monitoring for 24 hours post-operatively in the intensive care unit. Measurement and main results: Overall, there was no strong correlation between cerebral near-infrared spectroscopy and mixed venous oxygen saturation (r=0.48). At individual time points, the correlation was only strong (r=0.74) 1 hour after admission. The correlation was stronger for the biventricular patients (r=0.68) than single-ventricle infants (r=0.31). A strong inverse correlation was demonstrated between cerebral near-infrared spectroscopy and serum lactate at 3 of the 5 post-operative time points (1, 4, and 12 hours: r=-0.76, -0.72, and -0.69). The correlation was stronger when the cerebral near-infrared spectroscopy was 60%, which was r=-0.50. No correlations could be demonstrated between (average) somatic near-infrared spectroscopy and serum lactate (r=-0.13, n=110) or mixed venous oxygen saturation and serum lactate. There was one infant who suffered a cardiopulmonary arrest, and the cerebral near-infrared spectroscopy showed a consistent 43 minute decline before the event. Conclusions: We found that cerebral near-infrared spectroscopy is potentially beneficial as a non-invasive, continuously displayed value and is feasible to use on cost-constrained (National Health Service) cardiac intensive care units in children following heart surgery

A national survey of sedation practice and clinicians’ attitudes regarding sedation-related research in the UK paediatric intensive care units

Aims: Research involving analgo-sedation is a priority for parents and professionals in paediatric intensive care, and current guidelines are based on low-quality evidence. Future research will require an understanding of current practice and research priorities of healthcare professionals. This survey aimed to identify perceived barriers to research, describe the current UK analgo-sedation practice and assess outcome priorities for future research. Methods: A 26-question web-based survey was emailed to all Paediatric Critical Care Society members (n=1000) in April/May 2021. Responses were analysed either by ‘unit’ or at the individual respondent level. Questions related to four patient categories: ‘infant (< 3 months of age) ‘paediatric’ > 3 months of age, ‘cardiac’ and ‘non-cardiac’. Results: Two hundred sixteen healthcare professionals responded and responses were available from 100% of the UK paediatric intensive care units (n=29) for all questions. Most units (96%, 28/29) routinely use scoring systems for sedation adequacy but few routinely screen for delirium (24%, 7/29). The most highly prioritised outcome measure was the duration of mechanical ventilation. Respondents were most likely to agree to randomise paediatric general intensive care patients to trials comparing two different alpha agonists and least likely to randomise neonatal cardiac patients to trials comparing benzodiazepines with alpha agonists. The most common perceived barrier to research was unit familiarity with a particular regimen, followed by the perception that parents would not provide consent. Conclusions: This study provides a snapshot of the UK analgo-sedation practice and highlights the importance of public involvement in planning future trials, as well as consultation work across the spectrum of stakeholder clinicians to maximise the acceptability of study design

Newly qualified Saudi nurses' ability to recognise the deteriorating child in hospital

Background: It is recognized that nurses' failure to recognize and respond promptly to deterioration in children's physiological status can result in increased morbidity and mortality. Aim: The aim of this study was to explore the ability of Saudi-educated, newly qualified nurses, working in paediatric wards, to recognize children's deterioration.Methods: A pilot study was carried out to assess nurses' responses to three clinical vignettes (deteriorating child, improving child and ambiguous scenarios). The nurses' ability to make a correct identification was captured using a 'Think Aloud' approach and quantified using a visual analogue scale. Results: Twenty-seven nurses in two geographical regions in Saudi Arabia participated. Only half the nurses (51·8%) correctly identified the deteriorating child vignette. Of those who could not, 37% were unsure and 11% responded incorrectly. No nurses correctly identified all three vignettes, and four nurses (15%) responded incorrectly to all vignettes. Conclusions: The recognition of the deteriorating child is complex, and even in non-stressful simulated scenarios using vignettes, many newly qualified nurses working with children failed to recognize clear signs of deterioration. A focused (culturally specific) educational intervention is being developed to target this, taking into account Saudi nurses' perceived education and training needs. Relevance to clinical practice: Newly qualified nurses working in paediatric wards frequently find it difficult to identify the deteriorating child

Point-of-Care Gastric Ultrasound Confirms the Inaccuracy of Gastric Residual Volume Measurement by Aspiration in Critically Ill Children:GastriPed Study

Introduction: No consensus exists on how to define enteral nutrition tolerance in critically ill children, and the relevance of gastric residual volume (GRV) is currently debated. The use of point-of-care ultrasound (POCUS) is increasing among pediatric intensivists, and gastric POCUS may offer a new bedside tool to assess feeding tolerance and pre-procedural status of the stomach content. Materials and Methods: A prospective observational study was conducted in a tertiary pediatric intensive care unit. Children on mechanical ventilation and enteral nutrition were included. Gastric POCUS was performed to assess gastric contents (empty, full of liquids or solids), and gastric volume was calculated as per the Spencer formula. Then, GRV was aspirated and measured. The second set of gastric POCUS measurements was performed, similarly to the first one performed prior to GRV measurement. The ability of GRV measurement to empty the stomach was compared to POCUS findings. Both GRV and POCUS gastric volumes were compared with any clinical signs of enteral feeding intolerance (vomiting). Results: Data from 64 children were analyzed. Gastric volumes were decreased between the POCUS measurements performed pre- and post-GRV aspiration [full stomach, n = 59 (92.2%) decreased to n = 46 (71.9%), p =0.001; gastric volume: 3.18 (2.40–4.60) ml/kg decreased to 2.65 (1.57–3.57), p < 0.001]. However, the stomach was not empty after GRV aspiration in 46/64 (71.9%) of the children. There was no association between signs of enteral feeding intolerance and the GRV obtained, nor with gastric volume measured with POCUS. Discussion: Gastric residual volume aspiration failed to empty the stomach and appeared unreliable as a measure of gastric emptiness. Gastric POCUS needs further evaluation to confirm its role

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

Nurses’ decision-making around gastric residual volume measurement in adult intensive care: a four-centre survey

Background: Despite increasing evidence of the potential inaccuracy and unwarranted practice of regular gastric residual volume (GRV) measurement in critically in adults, this practice persists within the United Kingdom.Aim: To explore adult intensive care nurses’ decision-making around the practice of gastric residual volume measurement to guide enteral feeding.Methods: A cross sectional 16 item electronic survey in four adult intensive care units in England and Wales.Results: Two hundred and seventy-three responses were obtained across four intensive care units with acceptable response rates for most [Unit 1 74 /127 = 58.2%; Unit 2 87/129 =67.4%; Unit 3 77/120= 64.1%; Unit 4 35/168 = 20.8%]. Most (243/273 (89%) reported measuring GRV 4-6 hourly, with most (223/273 82%) reporting that the main reason was to assess feed tolerance or intolerance and 37/273 (13.5%) saying their unit protocol required it. In terms of factors affecting decision-making, volume obtained was the most important factor, followed by the condition of the patient, with aspirate colour and appearance less important. When asked how they would feel about not measuring gastric residual volume routinely, the majority (78.2%) of nurses felt worried (140/273 = 51.2%) or very worried (74/273 = 27%).Conclusions: Factors affecting the nurses’ decision making around gastric residual volume were based on largely on fear of risk (around vomiting and pulmonary aspiration) and compliance with unit protocols. Relevance to clinical practice: Despite increasing evidence suggesting it is unnecessary, nurses’ beliefs around the value of this practice persist and it continues to be embedded into unit protocols around feeding.<br/

Association between protein intake and muscle wasting in critically ill children: a prospective cohort study

BackgroundSurvival from pediatric critical illness in high-income countries is high, and the focus now must be on optimizing the recovery of survivors. Muscle mass wasting during critical illness is problematic, so identifying factors that may reduce this is important. Therefore, the aim of this study was to examine the relationship between quadricep muscle mass wasting (assessed by ultrasound), with protein and energy intake during and after pediatric critical illness.MethodsA prospective cohort study in a mixed cardiac and general pediatric intensive care unit in England, United Kingdom. Serial ultrasound measurements were undertaken at day 1, 3, 5, 7, and 10.ResultsThirty-four children (median age 6.65 [0.47–57.5] months) were included, and all showed a reduction in quadricep muscle thickness during critical care admission, with a mean muscle wasting of 7.75%. The 11 children followed-up had all recovered their baseline muscle thickness by 3 months after intensive care discharge. This muscle mass wasting was not related to protein (P = 0.53, ρ = 0.019) (95% CI: −0.011 to 0.049) or energy intake (P = 0.138, ρ = 0.375 95% CI: −0.144 to 0.732) by 72 h after admission, nor with severity of illness, highest C-reactive protein, or exposure to intravenous steroids. Children exposed to neuromuscular blocking drugs exhibited 7.2% (95% CI: −0.13% to 14.54%) worse muscle mass wasting, but this was not statistically significant (P = 0.063).ConclusionOur study did not find any association between protein or energy intake at 72 h and quadricep muscle mass wasting

Framework for Research Gaps in Pediatric Ventilator Liberation

BackgroundThe 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence.Research QuestionWhat are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines?Study Design and MethodsWe conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children.ResultsSignificant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure.InterpretationAlthough pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be filled through high-quality RCTs, multicenter observational studies, and quality improvement initiatives