Proefschrift Kerklaan

Introduction

Table 2. Perceived barriers to (early) enteral nutrition in critically ill children Barriers Facts Delayed initiation (Non)-invasive positive pressure ventilation

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Early enteral feedings are feasible, well tolerated, and cost- effective in mechanically ventilated children 60,61

Gastro-intestinal surgery Early enteral nutrition after small and large operations in children, including intestinal resection, is safe and feasible. It promotes rapid elimination of intestinal paresis, early activation of motor function, mucosal regeneration and early activation of absorptive function, thereby reducing infection rate and length of hospital stay 62,63 Use of vasoactive drugs Enteral nutrition in patients on vasoactive drugs improves

gut blood flow and is associated with no difference in gastro- intestinal outcomes and a tendency towards lower mortality 61 Available large RCTs in adults consistently showed no beneficial effect of GRV monitoring 64 , with a higher chance of achieving nutrient goals if GRV is not monitored 65 The accuracy of GRV measurement to predict enteral nutrition intolerance has not been studied in critically ill children 66 A reduced fasting protocol by use of clear fluids is safe and feasible 67 Auscultation of bowel sounds has limited clinical utility and should not be used to guide provision of enteral nutrition 68 Use of energy and protein enriched formulas might increase the chance of achieving caloric goals 69 . Interdisciplinary team interventions improve nutrition delivery 70

Interruption of delivery

High GRV

Procedures requiring fasting, including surgery and planned extubation Absence of bowel sounds Diagnosis dependent, often in cardiac or renal patients

Fluid restriction

GRV, gastric residual volume; RCT, randomised controlled trial

Early parenteral nutrition in critically ill children Evidence on the impact of (supplemental) parenteral nutrition on clinical outcomes in critically ill children is currently lacking 6 . Some nonrandomised studies, or studies with surrogate outcome measures, have pointed toward potential disadvantages of parenteral nutrition in this population. In a retrospective study of 204 nonsurgical critically ill children eligible for enteral nutrition provision, supplementation of parenteral nutrition was associated with a higher nosocomial infection rate than administration of enteral nutrition alone (34.0 vs.10.9%, P less than 0.001) 73 . The use of parenteral nutrition was one of the most significant predictors for nosocomial infections in a prospective cohort of 1106 cardiac PICU patients (odds ratio 1.2, 95% confidence interval 1.1-1.4) 74 . Use of parenteral nutrition has shown to be the single significant factor determining energy intake in mixed-effect modelling and is also identified as risk factor for overfeeding 1,75 , possibly because higher provision of energy is possible, while administration is less interrupted compared to enteral nutrition. In septic adolescents, metabolic side effects, such as enhanced endogenous glucose production and lipolysis, were

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