Proefschrift Kerklaan

Chapter 9

In chapter 3 we have shown that VCO 2 measurements by the Servo-I® ventilator are more precise in determination of REE than the frequently used predictive equations in mechanically ventilated children weighing more than 15 kg. This provides a promising alternative to the limited available IC. However, for the large proportion of PICU patients weighing less than 15 kg this method is not sufficiently accurate due to the technical specifications of the sampling method. Chapter 4 Energy overfeeding is associated with worse outcome and is frequently observed in critically ill children. In a cohort of mechanically ventilated children, we found that the number of children identified as overfed ranged widely depending on the definition used. Even children with an energy intake below the presumed threshold to equilibrate nitrogen balance were identified as overfed, indicating inaccuracy of current definitions. The maximum caloric intake is likely to depend on the age and nutritional status of the child and the phase of critical illness. However, current definitions of overfeeding fail to take these factors into account, and are therefore not generally applicable to the PICU population. To prevent the detrimental effects of overfeeding, an age- and phase dependent definition of overfeeding is warranted, preferably based on hard clinical outcomes. Chapter 5 Provision of enteral nutrition (EN) in critically ill children often results in a pronounced caloric deficit, which is associated with poor outcomes and impaired growth. Use of (supplemental) PN helps reaching preset goals, but with the added risk of metabolic disturbances and an increased nosocomial infection rate. Chapter 5 reviews the available evidence from RCTs supporting the use of PN in critically ill children. Only six small RCTs were identified, showing a beneficial effect of increased or altered PN. However, these studies focused only on surrogate endpoints, such as nitrogen balance or inflammatory markers, underlining the lack of high-level evidence on clinical outcomes in critically ill children regarding the effect of timing, amount and composition of PN. Chapter 6 and 7 Evidence from high-quality RCTs in critically adults no longer supports early initiation of (supplemental) PN. To determine if a pronounced macronutrient deficit could also be tolerated in critically ill children, we performed an international multicentre RCT in 1440 critically ill children at nutritional risk. We found that withholding PN for oneweek in the PICUwas clinically superior to early provision of PN, with fewer new infections, shorter duration of intensive care dependency and shorter hospital stay. This beneficial effect was detected irrespective of the treatment centre, severity of illness, STRONGkids category, age and diagnosis on admission. The effect was even larger in children with the highest nutritional risk and in critically ill neonates.

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