Proefschrift Kerklaan

Evidence for the use of PN in the PICU

INTRODUCTION

For critically ill children who require an admission to the Pediatric Intensive Care Unit (PICU), nutritional support is advised as soon as possible to prevent or reduce catabolism, with the intention to enhance recovery while allowing normal growth 1 . The enteral route is preferred as it has been suggested that feeding via the gut maintains gut integrity and may reduce the risk of infection, in comparison with feeding via the parenteral route 1 . However, when only enteral nutrition (EN) is provided during PICU stay, caloric targets are often not reached. This is explained by intestinal dysfunction as part of the critical illness, the administered medication that affects the gastrointestinal tract, frequent interruptions of enteral feeding and the need for fluid restriction 2 . Hence, a caloric deficit quickly builds up in critically ill children, the severity of which has been associated with poor outcomes and impaired growth 3,4 . Children are particularly vulnerable for accumulating a pronounced caloric deficit as their relative energy requirements are 2-3 times higher than those of adults. Reaching the preset caloric targets is easier when parenteral nutrition (PN) is administered. However, feeding children via the parenteral route has shown to increase the risk of metabolic disturbances such as hyperglycemia and dyslipidemia and to be associated with more nosocomial infections 5 . Therefore, the question remains if, and when, PN should be initiated for critically ill children in the PICU. The currently available guidelines are not very specific on how energy requirements should be determined for critically ill children nor on how the caloric deficit should best be prevented. The European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines state that the initiation of PN depends on the clinical condition and the age and size of the infant or child 6 . These guidelines advocate to start PN in infants shortly after admission to PICU whenever EN fails, but in older children and adolescents longer periods of inadequate nutrition may be tolerated. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines make no specific recommendations for the use and dosing of PN for children treated in the PICU 1 . However, the A.S.P.E.N. guidelines state that for older children, a caloric deficit can be tolerated for up to one week. These different and rather non-specific recommendations have resulted in nutritional practices that vary widely among PICUs worldwide 7 . Therefore, we performed an up to date review to assess all available evidence from randomized controlled trials (RCTs), with hard clinical as well as surrogate endpoints, that supports the use of parenteral nutrition in children during critical illness.

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